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DIAGNOSIS and MANAGEMENT
Acute bacterial rhinosinusitis CHILDREN
By:
Tutut SRIWILUDJENG T.
Dr. Wahidin Sudiro Husodo Mojokerto
Acute bacterial rhinosinusitis CHILDREN
By:
Tutut SRIWILUDJENG T.
Dr. Wahidin Sudiro Husodo Mojokerto
INTRODUCTIONRhinosinusitis is a condition which is a manifestation of the inflammatory response paranasalis sinus mucous membranes, which are usually associated with infection that can cause thickening of the mucosa and accumulation of mucus secretions in the sinus cavity paranasalis. So great is rinogen paranasalis sinus infections and rhinitis is often accompanied by changes in the sinuses, the term rhinosinusitis is now a term that is more sidukai for sinusitis, especially in children where the disease is seen as one of the same diseases (Bachert and Verhaeghe, 2002; Mulyarjo, 2002).Rhinosinusitis is an inflammatory disease with a high prevalence and likely will continue to rise. Due to quality of life of patients with this condition can be severely disrupted, it is important for doctors to be able to cope with having the correct knowledge about the definition, symptoms and methods of diagnosis rhinosinusitis.CRS is widespread and is estimated to about 10% hinga 30% of individuals in Europe. In the United States nearly 15% of the population have suffered from at least one episode of rhinosinusitis in his life (bachert and Verhaeghe, 2002; mulyarjo, 2002). In Indonesisa rhinosinusitis morbidity is not known with certainty.Rhinosinusitis generally starts from a viral infection, namely acute rhinitis, which often attack children. According to O'Brien (1998), 0.5 - 5.0% upper respiratory tract infections can suffer from complications of a bacterial rhinosinusitis acute (RSBA).RSBA treatment principle is to eliminate bacterial infection, reduce inflammation and symptoms of clogged nose and restore clearance mukosilier (mulyarjo, 2002). Rhinosinusitis is a disease of "medical" meaning medical therapy is the main treatment modality especially pda children. Act of surgery aimed at cases that are not responsive to maximal medical therapy or in case of orbital or intracranial complications.In this referat will be explained about the diagnosis and management of rhinosinusitis in children.1. AnatomySinus paranalis is a series that surround the nasal cavity. There are four pairs of sinuses paranasalis, namely the frontal sinus, sinus sfenoidalis, etmoidalis sinus and maxillary sinus. Maxillary sinus and sinus etmoidalis began to develop during the 3rd month of pregnancy until the 4th and already formed at birth. Maxillary sinus grew very rapidly until age 3 years later at age 7 years to 18 years of growth to happen again as it grows teeth. At the time of birth sinus air cells etmoidalis grow from 3-4 cells and develop into 10-15 cell precision at the age of 12 years, and became 30-40 when an adult cell. Sinus sfenoidalis grow at the age of 3 years and fully formed at age 12. Frontal sinuses started there at age 8 years and fully formed at age 18. Up to 5% in adults may get one or two sine frontalisnya not fully developed. Therefore, the absence of the frontal sinus which teraerasi well on radiological examination of young people do not need to be considered as a pathological condition (Rachelefsky, 1984; Rohr and Spector, 1984; Josephson and Roy, 1999).Although the anatomy of the sinuses in children is similar to the sinus in adults, the sinuses in children is much smaller so often makes clinical evaluation difficult. On examination of the nasal cavity appears the three projections of the lateral wall of the nasal cavity called konkanasalis. Drainage of the maxillary sinus, frontal sinuses and sinus etmoidalis (sinus - sinus anterior) is through Konka nasalis medius, while drainage of the sinuses and sinus etmoidalis sfenoidalis posterior (sine - sine the posterior) is through Konka nasalis superior (Josephson and Roy, 1999 .)The area is called the complex osteomeatal regarded as a place of major blockages that cause stasis of secretions and recurrent sinus disease. The anatomical area bordered by the anterior edge of Konka nasalis medius in the medial and leteral wall on the lateral nasal cavity.
2. Rhinosinusitis2.1 DefinitionRhinosinusitis is defined clinically as a condition which is a manifestation of the inflammatory response paranasalis sinus mucous membranes are usually associated with infection that can cause thickening of the mucosa and accumulation of mucus secretions in the sinus cavity paranasalis (Bachert and Verhaeghe, 2002).Most sinus infections are rinogen paranasalis and rhinitis is often accompanied by changes in the sinuses. The term rhinosinusitis as a combination of rhinitis and sinusitis seems appropriate to use in children, because both are ongoing disease, where the sinusitis is a continuation of rhinitis and rarely stand alone. Besides the clinical symptoms of rhinitis and sinusitis similar to each other so it looks as a whole the same disease (Mulyarjo, 2002; Bachert and Verhaeghe, 2002).
2.2 IncidentsRhinosinusitis is a common disease encountered in everyday practice. CRS is widespread and is estimated to about 10% to 30% of individuals in Europe. In the United States nearly 15% of the population have suffered from at least one episode of rhinosinusitis in his life (Mulyarjo, 2002; Bachert and Verhaeghe, 2002).Actual incidents of child rhinosinusitis may be very high and largely unknown. If a CRS is an inflammation of the mucous lining of the nose and sinuses paranasalis, it can be said that CRS can occur at any upper respiratory tract infection (Saragih, 1985 quoted by Jonathan B, 1991). But in children where the sinus cavity is relatively small paranasalis with paranasalis sinus ostium size is relatively large, then there is no retention of secretions, so that despite the rhinitis due to viruses that can spread to the mucous layer paranasalis mukosasinus contained in the sinus cavity will be quickly removed by cilia movement. Therefore, in children aged 2-3 years clinical problems rarely arise. Infection of the sinuses paranasalis more likely in older children, however this does not mean that the incident paranasalis sinus infections in children less frequently than adults because children are more often exposed to upper respiratory tract infections than adults (Climent, 1981 quoted Jonathan B, 1991, Rockville, 2000).Menururt Ballenger (1985) rhinosinusitis in children often occurs at the age of 40-10 years. Medium Becker, et al (1989) states that CRS increases in children above the age of 4 years and the majority between the ages of 7-12 years.According to Hayes (2001) upper respiratory tract infections in children caused by viruses do not always develop into RSBA, but RSBA ranks fourth disease is diagnosed in children aged 15 years or younger in age.2.3 PathogenesisSinus ostium paranasalis plays an important role in the pathogenesis of rhinosinusitis. Normal ostium diameter less than 2.5 mm. Acute rhinitis that occurs because of a viral infection caused edema of the mucosa and this can cause pembuntuan ostium in 80% patients (Roos K, 1999 cited Mulyarjo, 2000). Pembuntuan this will cause a decrease of oxygen in the sinus cavity and occurs hypoxia. Hypoxia causes dysfunction of cilia that inhibits drainage of the sinus cavity. When the healing of acute rhinitis, pembuntuan darainase ostium will disappear and return to normal. If there are predisposing factors such as anatomical abnormalities, pembuntuan ostium will settle and drainage disruption lasts longer (Rohr and Spector, 1984; Mulyarjo, 2002).Mucus produced by the normal sinus mucosa contain antimicrobial and very few nutrients so that will complicate the growth of germs. This mucus will always be excluded from the sinus cavity by cilia movement through the sinus ostium. When the ostium deadlock will occur so that the flow resistance of mucus to accumulate in the sinus cavity. Hypoxia also causes mucus gland dysfunction resulting in changes in the quality and quantity of mucus in the sinus cavity. Secretions become more viscous as well as changes in pH so that it becomes a fertile medium for bacterial growth (Roos K, 1999 cited Mulyarjo, 2002).Accumulation of thick secretions also cause damage to the mucosa and ulceration and damage to cilia. Because they served cilia push the mucus out of the sinus cavity lining, the damage to some of cilia would interfere with the task due to the increased accumulation of secretions. In this condition there was an acute bacterial rhinosinusitis (RSBA) is fulminant. Germs breed and many proteolytic enzymes released by leucocytes which became more severe mucosal damage. Metabolic acidosis occurs because tertimbunya lactic acid, and the defense declined antimokrobial. Colonization of bacteria increases and so the damage becomes more severe. These changes occur grandual (Mulyarjo, 2002).When pembuntuan ostium and the ongoing buildup of secretions within the sinus cavity is not resolved, then the process into sub-acute and chronic phase. This occurs when handling RSBA inadequate or there are other factors that cause sinus drainage and ventilation, especially in complex osteomeatal (Mulyarjo, 2002).Maxillary sinus is the most frequently affected by rhinosinusitis is mainly caused by anatomical structures. Maxillary sinus ostium is a winding canal with a length of several millimeters. This canal connects with the meatus medius maksial antrum to form a complex osteomeatal. In addition, maxillary sinus base is lower than the base of the nasal cavity, so that the maxillary sinus ostium is in the superior part of the maxillary antrum. Secretions can terdrainase spontaneously from maxillary sinus into the nasal cavity when the head in an upright position, drain secretions cilia must work out with the superior direction against the force of gravity. It is not surprising that most cases of rhinosinusitis on maxillary sinus, and after that etmoidalis sinus, frontal and sfenoidalis (Slavin, 2002).Factors that may predispose the occurrence of rhinosinusitis are: (Rachelefsky, 1984, Rockville, 1999; Slavin, 2002).2.3 Udem nasal mucosa: upper respiratory tract infection allergic rhinitis, non-allergic rhinitis, smoking, swimming.2.3 mechanical obstruction: hipertofi adenoids, septal deviation rice, Konka bullous, rice polyps, trauma, foreign bodies, neoplasms.
Common factor is the upper respiratory tract infection by the virus allergic rhinitis. Nasal mucosal edema are characteristic of acute infections or allergic rhinitis resulting ostium obstruction, decrease work paranasalis cilia in the sinuses and increased mucus production and viscosity. Ritis non-allergic may experience similar effects with allergic rhinitis.Physiological factors may be predisposing factors affected rhinosinusitis. For example, a cigarette that has a profound effect because it can increase production mukusdan slow cilia movement.This is based on the fact that shows that children who live in the wild house where one or both parents smoke, have an increased incidence of respiratory disorders and chronic rhinosinusitis. Swimmers also have a high incidence of rhinosinusitis may be caused by contaminated water entry of chemicals or bacteria into the sinuses (Slavin, 2002).Mechanical obstruction also can be a predisposition for individuals to get rhinosinusitis. Some circumstances, such as adenoid hypertrophy, septal deviation rice, Konka bullous, rice polyps, trauma, foreign bodies, and neoplasms should be ruled out by endoscopic examination in patients with recurrent rhinosinusitis (Slavin, 2002).
2.4 Classification and Clinical Symptoms2.4.1 ClassificationClassification of rhinosinusitis is based on the long duration of disease on clinical symptoms. According to The American Academy Of Pediatrics (AAP), 2001, CRS classification is as follows:• Acute bacterial rhinosinusitis (RSBA): infection lasts less than 30 days, with mild symptoms or beratdan a continuation of a viral infection (acute renitis).• RSBA recurrent (recurrent rhinosinusitis): several episodes of bacterial infections, each of which less than 30 days and separated by asymptomatic intervals of at least 10 days.• Chronic rhinosinusitis (CRS): inflammation lasting more than 90 days and there are residual symptoms of cough, rinore and clogged nose.
2.4.2 Clinical Symptoms• RSBARSBA Symptoms often preceded by upper respiratory infections (ARI) because firus with rinore clear. ARI symptoms generally improved itself in 5-7 days. If symptoms do not improve after 7 days RSBA diagnosis should be considered (Josephson and Roy, 1999; Mulyarjo, 2002).RSBA clinical symptoms can be classified into major and minor symptoms symptoms. Major symptoms: clogged nose, purulent nasal mucus, pain in the region face (cheeks, forehead, nose), disruption of smell. Minor symptoms are: cough, febrile, slimy throat, headache, sore teeth, halitosis (Josephson and Roy, 1999; Bachert and Verhaeghe, 2002; Mulyarjo, 2003).• SSRSSR is defined as a sinus infection that settled in paranasalis for 90 days or more. Often this becomes a challenge for physicians to make the diagnosis of rhinosinusitis due bervariasidan symptoms are often nonspecific (Josephson and Roy, 1999).The signs and gelaja SSR in children generally include nighttime cough, rinore, clogged nose, postnasal drip, headache. According to Josephson and Roy, (1999), a number of other symptoms may dapt not mislead doctors in ensuring the diagnosis of rhinosinusitis (Table 1).
Chronic rhinosinusitis Acute rhinosinusitisPurulent nasal mucus RinoreCough recurrent facial painFebrile headacheCough postnasal dripUdem poriorbita nose CoughingSore throatMild febrileAsthmaPain in the face / eyes / teeth
Table 1. The symptoms of rhinosinusitis (Josephson and Roy, 1999).
2.5 DiagnosisDiagnosis of acute rhinosinusitis or chronic rhinosinusitis with a diagnose clinically established a careful and complete physical examination. Many common diseases that have similar symptoms of rhinosinusitis. ARI because of viruses and adenoiditis are the two most common diseases that may be difficult to distinguish from patients with rhinosinusitis in children. It is difficult to distinguish acute respiratory infection with rhinosinusitis in the early stages of disease. ARI is the emergence Often predisposisiuntuk rhinosinusitis (Josephson and Roy, 1999).According to Cohen R, 1999 cited Mulyarjo (2002), rhinosinusitis in children is often controversial. Often there is over diagnosis thereby increasing the use of unnecessary antibiotics. Kadan difficult to distinguish viral infections with bacterial rhinosinusitis. ARI is a disease that most children receive, but only less than 5% only which is a bacterial rhinosinusitis.Based on the latest pedoamn from AAP (2001), the diagnosis of rhinosinusitis based only on clinical criteria for both mild and severe radiological examination only to confirm the diagnosis.• Clinical featuresRSBA in children suspected when: O'Brien, 1998; Hayes, 2001) Colds> 10 days Mucus thick yellow / green cough continues, especially at night Gejal Other: fever, headache (on a weight) and halitosisAccording Mulyarjo (2002), the diagnosis is established based RSBA: Colds persist or worsen> 7 days, especially after treatment with free drug The combination of major and minor symptoms. According to Bachert and Verhaeghe (2002) obtained 2 or more major symptoms or 1 major symptom and 2 minor symptoms Rinoskopi anterior: presence of mucosal edema, hyperemia and the presence of secretions mukopurulen Symptoms that may be of particular sinus (maxillary sinus: pain in cheek or graham, sinus etmoid: pain between the two eyes, the frontal sinuses: pain in the forehead, sinus sfenoidalis: severe pain in the center of the head or occipital)
• Physical ExaminationPhysical examination RSBA in children are found: (Suyitno, 1996) nasal mucosa edema and hiperemis purulent discharge in the meatus medius mucosa, nasal cavity or nasopharynx breath smelled but not found signs of pharyngitis, abnormal teeth and foreign bodies in the nasal cavityPhysical examination is less describe RSBA specificity in children, especially children under the age of 10 years• transilluminatesThis examination helps lift maxillary rhinosinusitis diagnosis in children with the shadow of differences between right and left maxillary sinus where the sick sinus provide more gloomy shadow. This examination is only to help the diagnosis, especially in children over the age of 10 years (Suyitno, 1996).
• RadiographyWith Waters position we can evaluate the maxillary sinus. X-ray picture is often found on maxillary rhinosinusitis in children are: Thickening of the mucosa of more than 4mm dim or dark picture on the maxillary sinus Air fluid levelsHowever sometimes the picture mucosal thickening, a grim picture of the sinuses do not always describe rhinosinusitis, especially in children younger than 1 year. Because the form is still small maksilia sinus and soft tissue shadow on the cheek gives grim / dark (Suyitno, 1996).
• CT-ScanWith the CT-scan obtained more detailed information about sinus paranasalis and abnormalities in complex osteomeatal. Thus CT scan can diagnose more precisely, only the higher cost and not smua hospitals have CT-scan devices (Josephson and Roy, 1999).• MRIMRI is superior to menggambartakan examination of soft tissue abnormalities in the sinus paranasalis. However, because the examination is limited to disorders of bone structure. MRI is not is not an option a survey tool to evaluate acute rhinosinusitis and chronic rhinosinusitis (Josephson and Roy, 1999).
2.6 MicrobiologyThe actual picture rhinosinusitis microbiology obtained from studies where taken from the sinus by way punksi antrum or by direct sampling of the affected sinus during surgery (Slavin, 2002)In a study of 76 adults who experienced failure with medical treatment of rhinosinusitis and scheduled for surgery, aerobic bacteria found in 76.3% of cases and anaerobic bacteria in 7.6% cases. Similar results were also obtained in children. Wald et al, 1989 quoted by Slavin (2002), conducted a study of 40 children with non-allergic chronic rhinosinusitis. The results obtained positive sinus aspirates in 58% of the sample, with the dominant bacteria Streptococcus pneumonia, Haemophilus influenzae, and Moraxella Catarrhalis. There is no anaerobic bacteria were isolated in children who do not have this allergy. Similar results were obtained in the study of chronic rhinosinusitis in children with respiratory allergy.According to the AAP (2001), Lippincott (2002), Slavin (2002), and Lampl (2003), bacteria that commonly cause acute bacterial rinoinuitis is Streptococcus pneumonia (30-40%), Haemophilus influenzae (20-30%), Moraxella Catarrhalis (12-20%) and Streptococcus pyogenes β Hemolyticus (3%). These germs are bacteria that are commonly found in cultured bacteria, in addition to the germs that are rarely encountered such as Staphylococcus aureus and anaerobic germs. Anaerobic germs into play when the sinus cavity oxygenation dwindle. The more progress in the process increasing the population of anaerobic bacteria. In chronic rhinosinusitis is more dominant role anaerobic (Lampl, 2003).
2.7 TherapyThe principle of management of rhinosinusitis include the treatment and prevention of infection, improved patency otium sine, repair and menkan mucociliary airway mucosa inflammation. Medical management of rhinosinusitis is a phased approach. Once the diagnosis rinosinuitis established, therapy with antibiotics is generally a first-line therapy (Moesges, 2002). Ostium Pembuntuan inus needs to be eliminated with decongestants for sinus drainage back to normal.According Moesges (2002), treatment with antibiotics is often times based on experience because of the difficulty of obtaining reliable specimen for culture. Most importantly, the selection of antibiotics should be based on the prediction of its effectiveness, potential side effects, and price. To RSBA recommended antibiotic therapy 14 days diving.Lately a number of studies published stating that the need for antibiotic therapy is still uncertain. Effects greater damage can occur by the emergence of side effects from drugs that balanced with the beneficial effect of oral antibiotic therapy. Therefore, some researchers estimate the end of antibiotic therapy (Moesges, 2002).According to the Rockville (1999) RSBA potential to become a serious illness sehigga needed antibiotics to prevent complications. But the excessive use of antibiotics can increase the incidence of side effects, bacterial resistance to antibiotics and treatment costs (Watson et al, 1999; Rockville, 1999; Garbutt et al, 2001; Lampl, 2003).Based on the bacteria that often cause RSBA, then the first-line antibiotic is amoxicillin (Josephson and Roy, 1999; Clients, 2001; Lampl, 2003). According to the AAP (2001), the election is because the antibiotic amoxicillin are relatively safe and affordable price. This option is done mainly to attack the pertaman RSBA which have never been treated with antibiotics. To RSBA a history of recurrent or maybe day after amoxicillin antibiotics less effective, for the second-line antibiotics may be an alternative. If the suspected existence of germ-producing β-lactamase enzymes, the combination of amoxicillin and klavulanat acid can be used. For patients hypersensitive to penicillin can be used katrimoksazol, makrolid or doxycycline, but the latter drug is not recommended in children. Antibiotics are given 10-14 days ahrus (Mulyarjo, 2002).According to the AAP (2001), about 80% of children with RSBA improved with amoxicillin treatment. Lippicott (2002) reported the same thing at 90% of cases, and Hayes (2001) melapoekan 91.2% of cases.Fenilpropanolamin or systemic decongestants pseudoephedrine may improve ventilation and restore sinus mucociliary function. While topical decongestants may be useful in the early stages of the disease process rinosinuitis, but the use of this topical decongestants should be limited to three smapai 5 days (Josephson and Roy, 1999; Lampl, 2003).Surgical therapy in patients with rhinosinusitis children aimed at recurrent rhinosinusitis and chronic rhinosinusitis who are not responsive to maximal medical therapy and when there are complications such RSBA orbital or intracranial complications (Josephson and Roy, 1999; Mc Clay, 2001).
2.8 Complications of Acute Bacterial rhinosinusitisSinus paranasalis limited by the brain and cavum orbit in lateral, superior and posterior, so that the spread of infection can cause intracranial or orbital complications of life-threatening. Orbital complications are usually caused by direct spread of infection from the sinuses through the lamina papiracea etmoidalis.
Orbital ComplicationsSelusitis preseptalSelusitis orbitalSubperiosteal abscessOrbital abscessCavernous sinus thrombosisBlindness
Intracranial complicationsMeningitisEpidural abscessSubdural abscessBrain abscessAnterior wall of frontal sinus osteomyelitis
Systemic ComplicationsToxic shock syndromeSepsis
Table 2. complications of rhinosinusitis (Josephson and Roy, 1999).
SUMMARYRhinosinusitis is a common disease encountered in everyday practice. anatomical factors cause children vulnerable to obstruction of sinus ostium, causing ketidaklancaran nasal secretion and increases bacterial growth.Diagnosis of acute and chronic rhinosinusitis, especially Diagnosis based on clinical history and clinical examination. Medical treatment plays an important role in the handling RSBA, with the aim to kill the germs that cause, opening the sinus ostium and restore the function of cilia. Surgical therapy is intended for cases that are not responsive to medical therapy or if there is intracranial or orbital complications.
LiteratureAmerican Academy of Pediatrics, 2001. Clinical PracticeGuidelme: Management of Sinusitis. Pediatrics: 108 (3): 798-808.Bachert C, Verhaeghe of Pediatrics, 2002. Differential Diagnosis of Rhinosinusitis. Enhancing the Treatment of Rhinosinusitis Family Practice Recertification. 24 (1) 8-13.BallengerJJ, 1995. Infectio paranasal sinuses. In Ballenger JJ. Deseases of the Nose, Throat, Ear, Head and Neck. 13 Ed. Philadelphia Lea & Febiger. 205-217.
W. Becker Nouman HH. Pfaltz CR, 1989. Ear, Nose and Throat Siseases 3rd Ed. New York. Theme Medical Publishers. 224-253.Garbut JM et al, 2001. A randomized, Plaeebo Antimierobial-Controlled Trial of Treatment for Children with Clinical Diagnosed Acute Sinusitis. Pediatrics, 107 (4): 619-625.Hayes RO, 2001. Pediatrics Sinusitis: When it's Not Just a Cold. Clinician Reviews: 1 (10) :52-59Jonathan B, 1991. Comparative Test maxillary sinusitis treatment in children with Diathermy and Irrigation. End of Work Pathology Laboratory SMF Dr ENT Medical Faculty Airlangga University. Soetomo.Josephson G, Roy S. 1999. Pediatrics Rhinosinusitis: Diagnosis and Management. International Pediatrics, 14 (1): 15-21.Klein GI, 2001. Treatment Guidelines for Acute Rhinosinusitis Infect Med, 15 (10F): 26-33.Lampl KL. 2003. The Role of OTC decongestants in the Treatment of Rhinosinusitis. http://www.medscape.com/viewprogram2685. Download date 09/26/2003.I. Lippincott, 2003 Sinusitis Pediatrics. Medical Treatment http://www.emedicine.com/ent/topic/612.htm 144 k10.11.03 Download date 11/10/2003.McClay JE, 2001. Sinusitis Pediatrics, Surgical Treatment http://www.emedicine.com/ent/topic/612.htm 144 k10.11.03 Download date 11/10/2003.Mosges R, 2002. Medical and Surgical Management of Rhinosinusitis. How Much Treatment Is Required?. Enhancing the Treatment of Rhinosinsitis. Family practice Recertification; 24 (1): 14-18.Mulyarjo, 2002. Rhinosinusitis and Penatalaksanannya. Symposium management of rhinosinusitis and otitis media. Surabaya. 1-8.Mulyarjo, 2003. Diagnosis and management of rhinosinusitis in children. Rhinology Symposium Abstract Update. Bali. 56.O'Brien KL, et al 1998. Acute Sinusitis-Principles of Judicious Use of Antimicrobal Agents. Pediatrics, 101 (1): 174-177.Rachelfsky GS, 1984. Sinusitis in Children. Diagnosis and Treatment. Clin Rev Allergy, 2: 397-408.Rockville, 1999. Diagnosis and Treatment of Acute Bacterial Rhinosinusitis summary, Evidence Report / Technology Assesement (9). http://www.ahrg.gov/clinic/epcsums/sinussum.htm.download dated 02/22/2004.Rohr A.S and Spector SL. 1984. Paranasal Sinus Anatomy and pathophysiology. Allergy Rev Clin 1984; 2: 387-395.Slavin RG, 2002. Rhinosinusitis Epidemilogy and Pathology. Enhancing the Treatment of Rhimosinusitis Family Practice Recertification, 24 (1): 1-7.Suyitno S, 1996. Maxillary sinusitis in children at Dr. Manuscript Collection Semarang Kariadi annual Scientific
2. Rhinosinusitis2.1 DefinitionRhinosinusitis is defined clinically as a condition which is a manifestation of the inflammatory response paranasalis sinus mucous membranes are usually associated with infection that can cause thickening of the mucosa and accumulation of mucus secretions in the sinus cavity paranasalis (Bachert and Verhaeghe, 2002).Most sinus infections are rinogen paranasalis and rhinitis is often accompanied by changes in the sinuses. The term rhinosinusitis as a combination of rhinitis and sinusitis seems appropriate to use in children, because both are ongoing disease, where the sinusitis is a continuation of rhinitis and rarely stand alone. Besides the clinical symptoms of rhinitis and sinusitis similar to each other so it looks as a whole the same disease (Mulyarjo, 2002; Bachert and Verhaeghe, 2002).
2.2 IncidentsRhinosinusitis is a common disease encountered in everyday practice. CRS is widespread and is estimated to about 10% to 30% of individuals in Europe. In the United States nearly 15% of the population have suffered from at least one episode of rhinosinusitis in his life (Mulyarjo, 2002; Bachert and Verhaeghe, 2002).Actual incidents of child rhinosinusitis may be very high and largely unknown. If a CRS is an inflammation of the mucous lining of the nose and sinuses paranasalis, it can be said that CRS can occur at any upper respiratory tract infection (Saragih, 1985 quoted by Jonathan B, 1991). But in children where the sinus cavity is relatively small paranasalis with paranasalis sinus ostium size is relatively large, then there is no retention of secretions, so that despite the rhinitis due to viruses that can spread to the mucous layer paranasalis mukosasinus contained in the sinus cavity will be quickly removed by cilia movement. Therefore, in children aged 2-3 years clinical problems rarely arise. Infection of the sinuses paranasalis more likely in older children, however this does not mean that the incident paranasalis sinus infections in children less frequently than adults because children are more often exposed to upper respiratory tract infections than adults (Climent, 1981 quoted Jonathan B, 1991, Rockville, 2000).Menururt Ballenger (1985) rhinosinusitis in children often occurs at the age of 40-10 years. Medium Becker, et al (1989) states that CRS increases in children above the age of 4 years and the majority between the ages of 7-12 years.According to Hayes (2001) upper respiratory tract infections in children caused by viruses do not always develop into RSBA, but RSBA ranks fourth disease is diagnosed in children aged 15 years or younger in age.2.3 PathogenesisSinus ostium paranasalis plays an important role in the pathogenesis of rhinosinusitis. Normal ostium diameter less than 2.5 mm. Acute rhinitis that occurs because of a viral infection caused edema of the mucosa and this can cause pembuntuan ostium in 80% patients (Roos K, 1999 cited Mulyarjo, 2000). Pembuntuan this will cause a decrease of oxygen in the sinus cavity and occurs hypoxia. Hypoxia causes dysfunction of cilia that inhibits drainage of the sinus cavity. When the healing of acute rhinitis, pembuntuan darainase ostium will disappear and return to normal. If there are predisposing factors such as anatomical abnormalities, pembuntuan ostium will settle and drainage disruption lasts longer (Rohr and Spector, 1984; Mulyarjo, 2002).Mucus produced by the normal sinus mucosa contain antimicrobial and very few nutrients so that will complicate the growth of germs. This mucus will always be excluded from the sinus cavity by cilia movement through the sinus ostium. When the ostium deadlock will occur so that the flow resistance of mucus to accumulate in the sinus cavity. Hypoxia also causes mucus gland dysfunction resulting in changes in the quality and quantity of mucus in the sinus cavity. Secretions become more viscous as well as changes in pH so that it becomes a fertile medium for bacterial growth (Roos K, 1999 cited Mulyarjo, 2002).Accumulation of thick secretions also cause damage to the mucosa and ulceration and damage to cilia. Because they served cilia push the mucus out of the sinus cavity lining, the damage to some of cilia would interfere with the task due to the increased accumulation of secretions. In this condition there was an acute bacterial rhinosinusitis (RSBA) is fulminant. Germs breed and many proteolytic enzymes released by leucocytes which became more severe mucosal damage. Metabolic acidosis occurs because tertimbunya lactic acid, and the defense declined antimokrobial. Colonization of bacteria increases and so the damage becomes more severe. These changes occur grandual (Mulyarjo, 2002).When pembuntuan ostium and the ongoing buildup of secretions within the sinus cavity is not resolved, then the process into sub-acute and chronic phase. This occurs when handling RSBA inadequate or there are other factors that cause sinus drainage and ventilation, especially in complex osteomeatal (Mulyarjo, 2002).Maxillary sinus is the most frequently affected by rhinosinusitis is mainly caused by anatomical structures. Maxillary sinus ostium is a winding canal with a length of several millimeters. This canal connects with the meatus medius maksial antrum to form a complex osteomeatal. In addition, maxillary sinus base is lower than the base of the nasal cavity, so that the maxillary sinus ostium is in the superior part of the maxillary antrum. Secretions can terdrainase spontaneously from maxillary sinus into the nasal cavity when the head in an upright position, drain secretions cilia must work out with the superior direction against the force of gravity. It is not surprising that most cases of rhinosinusitis on maxillary sinus, and after that etmoidalis sinus, frontal and sfenoidalis (Slavin, 2002).Factors that may predispose the occurrence of rhinosinusitis are: (Rachelefsky, 1984, Rockville, 1999; Slavin, 2002).2.3 Udem nasal mucosa: upper respiratory tract infection allergic rhinitis, non-allergic rhinitis, smoking, swimming.2.3 mechanical obstruction: hipertofi adenoids, septal deviation rice, Konka bullous, rice polyps, trauma, foreign bodies, neoplasms.
Common factor is the upper respiratory tract infection by the virus allergic rhinitis. Nasal mucosal edema are characteristic of acute infections or allergic rhinitis resulting ostium obstruction, decrease work paranasalis cilia in the sinuses and increased mucus production and viscosity. Ritis non-allergic may experience similar effects with allergic rhinitis.Physiological factors may be predisposing factors affected rhinosinusitis. For example, a cigarette that has a profound effect because it can increase production mukusdan slow cilia movement.This is based on the fact that shows that children who live in the wild house where one or both parents smoke, have an increased incidence of respiratory disorders and chronic rhinosinusitis. Swimmers also have a high incidence of rhinosinusitis may be caused by contaminated water entry of chemicals or bacteria into the sinuses (Slavin, 2002).Mechanical obstruction also can be a predisposition for individuals to get rhinosinusitis. Some circumstances, such as adenoid hypertrophy, septal deviation rice, Konka bullous, rice polyps, trauma, foreign bodies, and neoplasms should be ruled out by endoscopic examination in patients with recurrent rhinosinusitis (Slavin, 2002).
2.4 Classification and Clinical Symptoms2.4.1 ClassificationClassification of rhinosinusitis is based on the long duration of disease on clinical symptoms. According to The American Academy Of Pediatrics (AAP), 2001, CRS classification is as follows:• Acute bacterial rhinosinusitis (RSBA): infection lasts less than 30 days, with mild symptoms or beratdan a continuation of a viral infection (acute renitis).• RSBA recurrent (recurrent rhinosinusitis): several episodes of bacterial infections, each of which less than 30 days and separated by asymptomatic intervals of at least 10 days.• Chronic rhinosinusitis (CRS): inflammation lasting more than 90 days and there are residual symptoms of cough, rinore and clogged nose.
2.4.2 Clinical Symptoms• RSBARSBA Symptoms often preceded by upper respiratory infections (ARI) because firus with rinore clear. ARI symptoms generally improved itself in 5-7 days. If symptoms do not improve after 7 days RSBA diagnosis should be considered (Josephson and Roy, 1999; Mulyarjo, 2002).RSBA clinical symptoms can be classified into major and minor symptoms symptoms. Major symptoms: clogged nose, purulent nasal mucus, pain in the region face (cheeks, forehead, nose), disruption of smell. Minor symptoms are: cough, febrile, slimy throat, headache, sore teeth, halitosis (Josephson and Roy, 1999; Bachert and Verhaeghe, 2002; Mulyarjo, 2003).• SSRSSR is defined as a sinus infection that settled in paranasalis for 90 days or more. Often this becomes a challenge for physicians to make the diagnosis of rhinosinusitis due bervariasidan symptoms are often nonspecific (Josephson and Roy, 1999).The signs and gelaja SSR in children generally include nighttime cough, rinore, clogged nose, postnasal drip, headache. According to Josephson and Roy, (1999), a number of other symptoms may dapt not mislead doctors in ensuring the diagnosis of rhinosinusitis (Table 1).
Chronic rhinosinusitis Acute rhinosinusitisPurulent nasal mucus RinoreCough recurrent facial painFebrile headacheCough postnasal dripUdem poriorbita nose CoughingSore throatMild febrileAsthmaPain in the face / eyes / teeth
Table 1. The symptoms of rhinosinusitis (Josephson and Roy, 1999).
2.5 DiagnosisDiagnosis of acute rhinosinusitis or chronic rhinosinusitis with a diagnose clinically established a careful and complete physical examination. Many common diseases that have similar symptoms of rhinosinusitis. ARI because of viruses and adenoiditis are the two most common diseases that may be difficult to distinguish from patients with rhinosinusitis in children. It is difficult to distinguish acute respiratory infection with rhinosinusitis in the early stages of disease. ARI is the emergence Often predisposisiuntuk rhinosinusitis (Josephson and Roy, 1999).According to Cohen R, 1999 cited Mulyarjo (2002), rhinosinusitis in children is often controversial. Often there is over diagnosis thereby increasing the use of unnecessary antibiotics. Kadan difficult to distinguish viral infections with bacterial rhinosinusitis. ARI is a disease that most children receive, but only less than 5% only which is a bacterial rhinosinusitis.Based on the latest pedoamn from AAP (2001), the diagnosis of rhinosinusitis based only on clinical criteria for both mild and severe radiological examination only to confirm the diagnosis.• Clinical featuresRSBA in children suspected when: O'Brien, 1998; Hayes, 2001) Colds> 10 days Mucus thick yellow / green cough continues, especially at night Gejal Other: fever, headache (on a weight) and halitosisAccording Mulyarjo (2002), the diagnosis is established based RSBA: Colds persist or worsen> 7 days, especially after treatment with free drug The combination of major and minor symptoms. According to Bachert and Verhaeghe (2002) obtained 2 or more major symptoms or 1 major symptom and 2 minor symptoms Rinoskopi anterior: presence of mucosal edema, hyperemia and the presence of secretions mukopurulen Symptoms that may be of particular sinus (maxillary sinus: pain in cheek or graham, sinus etmoid: pain between the two eyes, the frontal sinuses: pain in the forehead, sinus sfenoidalis: severe pain in the center of the head or occipital)
• Physical ExaminationPhysical examination RSBA in children are found: (Suyitno, 1996) nasal mucosa edema and hiperemis purulent discharge in the meatus medius mucosa, nasal cavity or nasopharynx breath smelled but not found signs of pharyngitis, abnormal teeth and foreign bodies in the nasal cavityPhysical examination is less describe RSBA specificity in children, especially children under the age of 10 years• transilluminatesThis examination helps lift maxillary rhinosinusitis diagnosis in children with the shadow of differences between right and left maxillary sinus where the sick sinus provide more gloomy shadow. This examination is only to help the diagnosis, especially in children over the age of 10 years (Suyitno, 1996).
• RadiographyWith Waters position we can evaluate the maxillary sinus. X-ray picture is often found on maxillary rhinosinusitis in children are: Thickening of the mucosa of more than 4mm dim or dark picture on the maxillary sinus Air fluid levelsHowever sometimes the picture mucosal thickening, a grim picture of the sinuses do not always describe rhinosinusitis, especially in children younger than 1 year. Because the form is still small maksilia sinus and soft tissue shadow on the cheek gives grim / dark (Suyitno, 1996).
• CT-ScanWith the CT-scan obtained more detailed information about sinus paranasalis and abnormalities in complex osteomeatal. Thus CT scan can diagnose more precisely, only the higher cost and not smua hospitals have CT-scan devices (Josephson and Roy, 1999).• MRIMRI is superior to menggambartakan examination of soft tissue abnormalities in the sinus paranasalis. However, because the examination is limited to disorders of bone structure. MRI is not is not an option a survey tool to evaluate acute rhinosinusitis and chronic rhinosinusitis (Josephson and Roy, 1999).
2.6 MicrobiologyThe actual picture rhinosinusitis microbiology obtained from studies where taken from the sinus by way punksi antrum or by direct sampling of the affected sinus during surgery (Slavin, 2002)In a study of 76 adults who experienced failure with medical treatment of rhinosinusitis and scheduled for surgery, aerobic bacteria found in 76.3% of cases and anaerobic bacteria in 7.6% cases. Similar results were also obtained in children. Wald et al, 1989 quoted by Slavin (2002), conducted a study of 40 children with non-allergic chronic rhinosinusitis. The results obtained positive sinus aspirates in 58% of the sample, with the dominant bacteria Streptococcus pneumonia, Haemophilus influenzae, and Moraxella Catarrhalis. There is no anaerobic bacteria were isolated in children who do not have this allergy. Similar results were obtained in the study of chronic rhinosinusitis in children with respiratory allergy.According to the AAP (2001), Lippincott (2002), Slavin (2002), and Lampl (2003), bacteria that commonly cause acute bacterial rinoinuitis is Streptococcus pneumonia (30-40%), Haemophilus influenzae (20-30%), Moraxella Catarrhalis (12-20%) and Streptococcus pyogenes β Hemolyticus (3%). These germs are bacteria that are commonly found in cultured bacteria, in addition to the germs that are rarely encountered such as Staphylococcus aureus and anaerobic germs. Anaerobic germs into play when the sinus cavity oxygenation dwindle. The more progress in the process increasing the population of anaerobic bacteria. In chronic rhinosinusitis is more dominant role anaerobic (Lampl, 2003).
2.7 TherapyThe principle of management of rhinosinusitis include the treatment and prevention of infection, improved patency otium sine, repair and menkan mucociliary airway mucosa inflammation. Medical management of rhinosinusitis is a phased approach. Once the diagnosis rinosinuitis established, therapy with antibiotics is generally a first-line therapy (Moesges, 2002). Ostium Pembuntuan inus needs to be eliminated with decongestants for sinus drainage back to normal.According Moesges (2002), treatment with antibiotics is often times based on experience because of the difficulty of obtaining reliable specimen for culture. Most importantly, the selection of antibiotics should be based on the prediction of its effectiveness, potential side effects, and price. To RSBA recommended antibiotic therapy 14 days diving.Lately a number of studies published stating that the need for antibiotic therapy is still uncertain. Effects greater damage can occur by the emergence of side effects from drugs that balanced with the beneficial effect of oral antibiotic therapy. Therefore, some researchers estimate the end of antibiotic therapy (Moesges, 2002).According to the Rockville (1999) RSBA potential to become a serious illness sehigga needed antibiotics to prevent complications. But the excessive use of antibiotics can increase the incidence of side effects, bacterial resistance to antibiotics and treatment costs (Watson et al, 1999; Rockville, 1999; Garbutt et al, 2001; Lampl, 2003).Based on the bacteria that often cause RSBA, then the first-line antibiotic is amoxicillin (Josephson and Roy, 1999; Clients, 2001; Lampl, 2003). According to the AAP (2001), the election is because the antibiotic amoxicillin are relatively safe and affordable price. This option is done mainly to attack the pertaman RSBA which have never been treated with antibiotics. To RSBA a history of recurrent or maybe day after amoxicillin antibiotics less effective, for the second-line antibiotics may be an alternative. If the suspected existence of germ-producing β-lactamase enzymes, the combination of amoxicillin and klavulanat acid can be used. For patients hypersensitive to penicillin can be used katrimoksazol, makrolid or doxycycline, but the latter drug is not recommended in children. Antibiotics are given 10-14 days ahrus (Mulyarjo, 2002).According to the AAP (2001), about 80% of children with RSBA improved with amoxicillin treatment. Lippicott (2002) reported the same thing at 90% of cases, and Hayes (2001) melapoekan 91.2% of cases.Fenilpropanolamin or systemic decongestants pseudoephedrine may improve ventilation and restore sinus mucociliary function. While topical decongestants may be useful in the early stages of the disease process rinosinuitis, but the use of this topical decongestants should be limited to three smapai 5 days (Josephson and Roy, 1999; Lampl, 2003).Surgical therapy in patients with rhinosinusitis children aimed at recurrent rhinosinusitis and chronic rhinosinusitis who are not responsive to maximal medical therapy and when there are complications such RSBA orbital or intracranial complications (Josephson and Roy, 1999; Mc Clay, 2001).
2.8 Complications of Acute Bacterial rhinosinusitisSinus paranasalis limited by the brain and cavum orbit in lateral, superior and posterior, so that the spread of infection can cause intracranial or orbital complications of life-threatening. Orbital complications are usually caused by direct spread of infection from the sinuses through the lamina papiracea etmoidalis.
Orbital ComplicationsSelusitis preseptalSelusitis orbitalSubperiosteal abscessOrbital abscessCavernous sinus thrombosisBlindness
Intracranial complicationsMeningitisEpidural abscessSubdural abscessBrain abscessAnterior wall of frontal sinus osteomyelitis
Systemic ComplicationsToxic shock syndromeSepsis
Table 2. complications of rhinosinusitis (Josephson and Roy, 1999).
SUMMARYRhinosinusitis is a common disease encountered in everyday practice. anatomical factors cause children vulnerable to obstruction of sinus ostium, causing ketidaklancaran nasal secretion and increases bacterial growth.Diagnosis of acute and chronic rhinosinusitis, especially Diagnosis based on clinical history and clinical examination. Medical treatment plays an important role in the handling RSBA, with the aim to kill the germs that cause, opening the sinus ostium and restore the function of cilia. Surgical therapy is intended for cases that are not responsive to medical therapy or if there is intracranial or orbital complications.
LiteratureAmerican Academy of Pediatrics, 2001. Clinical PracticeGuidelme: Management of Sinusitis. Pediatrics: 108 (3): 798-808.Bachert C, Verhaeghe of Pediatrics, 2002. Differential Diagnosis of Rhinosinusitis. Enhancing the Treatment of Rhinosinusitis Family Practice Recertification. 24 (1) 8-13.BallengerJJ, 1995. Infectio paranasal sinuses. In Ballenger JJ. Deseases of the Nose, Throat, Ear, Head and Neck. 13 Ed. Philadelphia Lea & Febiger. 205-217.
W. Becker Nouman HH. Pfaltz CR, 1989. Ear, Nose and Throat Siseases 3rd Ed. New York. Theme Medical Publishers. 224-253.Garbut JM et al, 2001. A randomized, Plaeebo Antimierobial-Controlled Trial of Treatment for Children with Clinical Diagnosed Acute Sinusitis. Pediatrics, 107 (4): 619-625.Hayes RO, 2001. Pediatrics Sinusitis: When it's Not Just a Cold. Clinician Reviews: 1 (10) :52-59Jonathan B, 1991. Comparative Test maxillary sinusitis treatment in children with Diathermy and Irrigation. End of Work Pathology Laboratory SMF Dr ENT Medical Faculty Airlangga University. Soetomo.Josephson G, Roy S. 1999. Pediatrics Rhinosinusitis: Diagnosis and Management. International Pediatrics, 14 (1): 15-21.Klein GI, 2001. Treatment Guidelines for Acute Rhinosinusitis Infect Med, 15 (10F): 26-33.Lampl KL. 2003. The Role of OTC decongestants in the Treatment of Rhinosinusitis. http://www.medscape.com/viewprogram2685. Download date 09/26/2003.I. Lippincott, 2003 Sinusitis Pediatrics. Medical Treatment http://www.emedicine.com/ent/topic/612.htm 144 k10.11.03 Download date 11/10/2003.McClay JE, 2001. Sinusitis Pediatrics, Surgical Treatment http://www.emedicine.com/ent/topic/612.htm 144 k10.11.03 Download date 11/10/2003.Mosges R, 2002. Medical and Surgical Management of Rhinosinusitis. How Much Treatment Is Required?. Enhancing the Treatment of Rhinosinsitis. Family practice Recertification; 24 (1): 14-18.Mulyarjo, 2002. Rhinosinusitis and Penatalaksanannya. Symposium management of rhinosinusitis and otitis media. Surabaya. 1-8.Mulyarjo, 2003. Diagnosis and management of rhinosinusitis in children. Rhinology Symposium Abstract Update. Bali. 56.O'Brien KL, et al 1998. Acute Sinusitis-Principles of Judicious Use of Antimicrobal Agents. Pediatrics, 101 (1): 174-177.Rachelfsky GS, 1984. Sinusitis in Children. Diagnosis and Treatment. Clin Rev Allergy, 2: 397-408.Rockville, 1999. Diagnosis and Treatment of Acute Bacterial Rhinosinusitis summary, Evidence Report / Technology Assesement (9). http://www.ahrg.gov/clinic/epcsums/sinussum.htm.download dated 02/22/2004.Rohr A.S and Spector SL. 1984. Paranasal Sinus Anatomy and pathophysiology. Allergy Rev Clin 1984; 2: 387-395.Slavin RG, 2002. Rhinosinusitis Epidemilogy and Pathology. Enhancing the Treatment of Rhimosinusitis Family Practice Recertification, 24 (1): 1-7.Suyitno S, 1996. Maxillary sinusitis in children at Dr. Manuscript Collection Semarang Kariadi annual Scientific
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