BIODATA

NAMA : Dr. Kiagus Yangtjik , SpAK

ALAMAT : Jln.Sersan Sani No. 3440 Kel. Sukabangun

Palembang

TEMPAT/ TGL.LAHIR : Palembang, 18 Mei 1951

AGAMA : Islam

PEKERJAAN : PNS

EMAIL : kiagus99@yahoo.com

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Management Rhinosinusitis in children

KIAGUS YANGTJIK

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Sinusits & Rinosinusitis

1. Embriologis mukosa sinus lanjutan dari mukosa hidung

2. Sinusitis hampir selalu didahului oleh rinitis

3. Gejala Obstruksi nasi, rinore dan hiposmia dijumpai pada rinitis dan sinusitis

• Rhino-sinusitis is an inflammation of the mucous membrane of nose and paranasal sinuses

American Academy of Otolaryngology-Head and Neck Surg,1996

Kids = Adults

• Children are susceptible to 6-8 episodes of nasopharyngitis (viral) per year (adults endure 1-4 episodes)

– 2-5% of these episodes may be accompanied with bacterial infections

• Rhinosinusitis in pediatric population is different than in adults

Wald ER, Guerra R, Byers C. Pediatrics. 1991; 87 129-133

Aitken M, Taylor JA, Arch Pediatr Adolesc Med 1998;152:244-258

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Anatomy

• Maxillary Sinus – first to develop at day 65 of gestation – seen on plain films at 4-5 months – slow expansion until 18 years

• Ethmoid Sinus – develop in third month of gestation – ethmoids seen on radiographs at one year – enlarges to reach adult size at age 12

• Sphenoid Sinus – originates in fourth gestational month from posterior part of nasal cavity – pneumatization begins at age 3 – rapid growth to reach sella by age 7 and adult size at age 18

• Frontal Sinus – begins in fourth month of gestation from superior ethmoid cells – seen on radiographs at age 5-6 – grows slowly to adult size by adolescence

Rhinosinusitis

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ISPA pada anak 6-8 kali / tahun

5- 10%

Rinosinusitis

Rinosinusitis bacterial Akut

2 – 10%

Viral rinosinusitis

90-98%

Clasification

• Acute: symptoms often inseparable from URI and include rhinorrhea, daytime cough, nasal congestion, infrequent low-grade fever, otitis media, irritability and headache. Key in diagnosis of sinusitis is persistence beyond 7-10 days or worsening of symptoms at around 7 days – Severe Acute Sinusitis: purulent rhinorrhea, high fever, periorbital edema

• Recurrent: complete resolution between episodes and 3 or more episodes in six months or more than 4 episodes in one year

• Subacute: signs and symptoms lasting three weeks to three months • Chronic: signs and symptoms lasting longer than three months

AAP. 2001

Rhinosinusitis per Symptoms/Signs (requires 2 Major Factors, or 1 Major & 2 Minor)

–Facial Pain / Pressure –Nasal Obstruction / Nasal Congestion –Nasal or Post-Nasal Discharge /Purulence –Hyposmia / Anosmia –Cough not due to Asthma

• (in children only)

Minorinor Factors

–Headache

–Fever

–Halitosis

–Fatigue

–Dental Pain

–Cough (in adults)

–Otologic symptoms

Mayor Factors

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Why pain ?? Air trapped within a blocked sinus, along with pus or other secretions may cause pressure on the sinus wall that can cause the intense pain of a sinus attack.

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Etiologi Bacterial

• Acute : Sterptococcus pneumoniae 33%

Haemophilus influenzae 25%

Moraxella cataralis 20%

Streptococcus pyogenes (betahemolitic) 5%

• Cronis Sterptococcus pneumoniae

Haemophilus influenzae

Moraxella cataralis

Streptococcus pyogenes (betahemolitic)

Anaerob bacterial (peptostreptococcus,fusobacterium)

Pseudomonas

Acute RS : Bacterial versus Viral

Signs / Symptoms more likely Bacterial than Viral:

• Symptoms worsening after 5-6 days, or persisting more than 10 days, or out of proportion to those typically associated with viral URI

• Unilateral Midfacial, Periorbital or Forehead Pain

• Pain worsened by bending over or Valsalva, “Toothache”

• Unilateral purulent Rhinorrhea

• Poor response to Decongestants

• Facial Swelling, Conjunctival Injection, Meningeal or other Signs of spread outside of the sinus(es)

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7–10 Days 3 Months

Viral

Aerobes Resistant Aerobes, Anaerobes & Fungi

Causes of Rhinosinusitis – Time Course

0

20

40

60

80

100

Time

Perc

en

t o

f P

ati

en

ts

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Duration of Symptoms in Viral URIs

1 2 3 4 5 6 7 8 9 10 11 12 13 14 0

10

20

30

40

50

60

70

Day of Illness

Fever

Sore Throat

Cough

Nasal Drainage

Perc

ent

of

Pati

ents

Wit

h S

ymp

tom

s

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Pathogenesis

• Ostia obstruction creates increasingly hypoxic environment within sinus

• Retention of secretion results in inflammation and bacterial infection

• Secretion stagnate, obstruction increases, cilia and epithelial damage become more pronounced

• Most common inciting event is viral URI

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Shortcut to acute sinusitis micro.lnk

Sinus and Allergy Health Partnership Otolaryngol Head Neck

Surg 2004:130:1 17

Sinus & Allergy Partnership. Otolaryngol Head & N Surg 2004; 130:1 18

Acute Bacterial Rhino sinusitis - Treatment

Antibiotics x 2 weeks

Amoxycillin clavulanat (90mg/KgBB)

(10 – 14 h) ?

• Macrolides (30% resisten thd S Pneumonia)

• TMX –SMT (30-40% ) resisten S. Pneumonie & H.Influenza)

• Doxycyclinne no recomend to child

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© The Author 2012. Published by Oxford University Press on behalf of the

Infectious Diseases Society of America. All rights reserved. For Permissions,

please e-mail: journals.permissions@oup.com.

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PERBAIKAN 3-5 HR PERBAIKAN 3-5 HR

PERBURUKAN 3 – 5 HR

LANJUTKAN 5-7 HR

GANTI ANTIBIOTIKALANJUTKAN 5 -7 HR

PERBURUKAN 3 – 5 HR

• CT/ MRI

• CULTUR SINUS/MEATUS

PERBAIKAN PERBAIKAN

RESIKO RESISTEN

RESIKO RESISTEN

1. UMUR < 2 TH

2. SDH MENDAPAT AB

SEBELUMNYA

3. SDH DIRAWAT

SEBELUMNYA

4. ADA COMORBIDITAS

5. IMMUNOCOMPROMISE

REFER SPESIALIS

LANJUTKAN 5-7 HR

LANJUTKAN 5-7 HR

ALGORITMA TATALAKSANA ACUTE BACTERIAL RINOSINUSITIS

GEJALA

1. MENETAP (>10HR)

2. BERTAMBAH BERAT (>3 – 4HR)

3. PERBURUKAN/PENY.LAIN (. 3-4 HR)

ANTIBIOTIKA 2SC

YATIDAK

ANTIBIOTIKA 1ST

PENGOBATAN

SIMTOMATIK

Chow A W et al. Clin Infect Dis. 2012;cid.cir1043

List of Antibiotics

1st Line

• Amoxicillin

• TMP-SMX

• Erythromycin

2nd Line

• Clarithromycin

• Azithromycin

• Augmentin

• Cephalosporins

• Levofloxaxin

• Clindamycin

• metronidazole

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Chronic Rhinosinusitis

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Chronic Rhino sinusitis - Symptoms

Usually less - no pain

Symptoms for > 12 weeks

Nasal obstruction

Nasal/Post nasal purulnt discharge

Cacosmia

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Chronic Rhino sinusitis - Signs

Mucopus in the meati

Nasal mucosa congested

X-ray show fluid level or opacity

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Diagnosis of CRS

• Physical examination – Endoscopy or anterior rhinoscopy

• Purulent drainage

• Edema or erythema of the middle meatus or ethmoid bulla

• polyps

• Sinus CT scan – Mucosal thickening

– Air-fluid level

Meltzer et al. JACI 2004;114:155 25

Microbiology of Chronic Rhinosinusitis

• Not well defined because of differences in culturing techniques, prior use of abx

• S. pneumoniae, H. influenzae, M. catarrhalis

• S. Aureus, coagulase negative staph, anaerobes

• Fungi

Meltzer et al. JACI 2004;114:155 26

Medical Management of Chronic Rhinosinusitis

• Antibiotics

• Corticosteroids

• Decongestants

• Muco-evacuants

• Antihistamines

• Non-pharmacologic treatment

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Chronic Rhino sinusitis - Treatment

• Surgical

– Open-depends on the site

• Caldwell-Luc Operation

• Osteoplastic flap

– Endoscopic-FESS

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Surgery for Rhinosinusitis

• FESS

– enlarge sinus ostia

– correct anatomic deformities (septal deviation, concha bullosa)

– create a common cavity for nasal drainage

– ventilate sinuses

– >85% improvement in selected series

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FESS

• Functional Endoscopic Sinus Surgery

• ? Funtional

– resume the normal function of sinus

• drainage

• ventilation

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FESS-complication

• Local – Bleeding – Adhesion – Mucocele – Stenosis – Recurrence

• Orbital – Orbital haematoma – Diplopia – Blinding

• Intracranial – CSF leakage – Meningitis

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Complications of Rhino sinusitis

• Local – Mucocele

– Osteomyelitis-Pott’s tumor

• Orbital – Orbital cellulitis

– Orbital abscess

– Cavernous sinus thrombosis

• Intracranial – Epidural abscess

– Subdural abscess

– Intracerebral abscess

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Chronic Rhinosinusitis: Which Antibiotic to Use?

-No antibiotic is approved by FDA for CRS

-We use similar abx as ABRS

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Antibiotics for Chronic Rhinosinusitis

• Appropriate duration is not well defined

• AAAAI and ACAAI Joint Task Force

– treat for 3,4 or 6 weeks

– continue abx for at least 1 week after the patient is symptom free

• Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery

– treat 4 to 6 weeks

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Adjunctive Therapy

• Dekongestan dan antihistamin :

Tidak ada obat Dekongestan baik oral maupun lokal dan

Antihistamin direkomendasikan untuk rinosinusitis akut bakterial (low moderate)

• Kortikosteroid :

Dapat diberikan rinosinusitis dengan riwayat atopi (low

moderate )

• Irigasi :

Hanya untuk dewasa pd ABRS (weak low moderate )

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Nasal Irrigation

• Improves mucociliary function

• Decreases mucosal edema

• Decreasing inflammatory mediators

• Clearing mucus

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Prognosa rinosinusitis

• Dengan tatalaksana yang baik dan optimal tindakan operasi jarang dilakukan pada anak

• Kekambuhan sangat tergantung dari Etiologi dan faktor predisposisi

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Summary

• Acute rhinosinusitis is usually related to infection – Antibiotic management is first line

• Chronic rhinosinusitis is usually related to inflammation – Further characterization of the condition is important

(nasal polyps)

– Exploration of underlying allergy is important

– Management is challenging

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Thank you

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