CASE REPORT

CHRONIC RHINOSINUSITIS

Moderator
dr. Bara

Presenter
Group 15203
Anditta Syifarahmah 11/317216/KU/14464
Girhanif Amri Yunda
Habib Huud Fadlan
Sofia Zachra Faiza
Stefani Melisa Karina
Nova Yuli Prasetyo

Department of Otorhinolaryngology Head and Neck Surgery

Faculty of Medicine, Universitas Gadjah Mada Dr. Sardjito General
Hospital
Yogyakarta
2016

Introduction
Chronic rhinosinusitis (CRS) is a common disease with significant
morbidity and health care cost1. Chronic rhinosinusitis is one of the most
common conditions treated by primary care physicians. Each year in the
United States, CRS affects one in seven adults, and is diagnosed in 31 mil-
lion patients2. (epidemiologi Indonesia)
Even though both mortality and morbidity of
CRS are low, it may result to lower QoL compared to patients with Chronic
Obstructive Pulmonary Disease (COPD), diabetes and Congestive Heart
Failure (CHF) in terms of pain, vitality, and social function 3.
 The term sinusitis is defined as inflammation of the paranasal
sinuses while rhinitis is the inflammation within the nasal
cavity.Inflammation of the sinuses rarely occurs without concurrent
inflammation of the nasal mucosa; therefore, rhinosinusitis is a more
accurate term for what is commonly called sinusitis 2. The term
rhinosinustis is more accurate term to coin the disease as the
development of sinusitis is frequently preceded by the inflammation of
nasal mucosa4.

Until recentlu rhinosinusitis was usually classified based on the duration

into acute, subacute, chronic, and recurrent acute (Figure 1) 5. The
American Academy of OtolaryngologyHead and Neck Surgery defines
subtypes of rhinosinusitis based on the duration of symptoms: acute,
subacute, recurrent acute, and chronic. The duration of acute
rhinosinusitis is up to 4 weeks, sub acute occurs at least four weeks but
less than 12 weeks, recurrent is defined as 4 or more episodes per year
with complete resolution between episodes, each episode lasts at least 7
days, while chronic persists for 12 weeks or longer 2.

The definition from EPOS 2012 for rhinosinusitis is inflammation of

the nose and the paranasal sinuses characterised by two or more
symptoms, one of which should be either nasal blockage / obstruction /
congestion or nasal discharge (anterior/posterior nasal drip), with or
without facial pain/pressure reduction and with or without reduction or loss
smell5.
The patophysiology of CRS..
The etiology of CRS remains poorly understood. Progress in basic
science coupled with technologic improvements in endoscopy, imaging,
and surgical technique have gradually improved our ability to diagnose
and treat rhinosinusitis.3 There are several known factors contributing in
the development of CRS, viral upper respiratory infection is the most
common precursor to bacterial rhinosinusitis followed by sinus obstruction
from the mucosal edema of inhalant allergies and by anatomic factors,
Less frequent causes include nasal polyps (e.g., the aspirin triad of
aspirin sensitivity, asthma and nasal polyps), the hormone-based turbinate
edema associated with pregnancy, medication side effects topical
vasoconstrictors or cocaine, mucosal edema from use of oral
antihypertensive drugs, antiosteoporosis agents or hormone replacement
sprays), mucociliary dysfunctionassociated with cystic fibrosis and
immune deficiencies1.

There are three well-known criteria of diagnosis for rhinosinusitis

namely by EPOS (2012), The Task Force (2007) and PERHATI-KL(2007)
guideline. Based on EPOS, chronic rhinosinusitis is diagnosed by
assesment of the symptoms and examination. Subjective assessment of
rhinosinusitis is characterised by two or more symptoms, one of which
should be nasal blockage / congestion / or stuffiness and nasal discharge
of postnasal drip (mucopurulent discharge) with or without facial pain /
pressure / headache and with or without reduction / loss of smell and
either endoscopic signs of nasal polyps, and/or mucopurulent discharge
primarily from middle meatus and/or oedema/mucosal obstruction
primarily in middle meatus; and/or CT changes with mucosal changes
within the ostiomeatal complex and/ or sinuses 5. Based on Task Force,
symptoms associated with rhinosinusitis are divided into major and minor
groups. Symptoms that are classified into major criteria : facial
pain/pressure/fullness, nasal obstruction/ blockage, nasal or postnasal
discharge/purulence, hyposmia/anosmia, fever (only in acute
rhinosinusitis). Symptoms that are classified into minor criteria : headache,
fever, halitosis, fatigue, dental pain, cough, ear pain/pressure/fullness 1.
Physical finding that can be found on rhinosinusitis by anterior rhinoscopy
are swelling, redness and pus. Pharyngeal examination conducted to find
post nasal discharge and oral examination to exclude dental infection 1,5.
Rhinosinusitis can be diagnosed if there is two or more major sign and
symptoms, and two or more minor signs and symptoms, and nasal
purulence on examination1. In PERHATI-KL guideline, rhinosinusitis
includes the same symptoms as mentioned by The Task Force and EPOS
and rhinosinusitis is classified as chronic if it is longer than 12 weeks.
 Chronic rhinosinusitis has very typical symptoms and physical
findings, most patients can be effectively treated without the necessity of
nasal endoscopy, radiographic studies or bacterial culture.

The heterogeneity of the disease is very wide, which include

CRSwNP, CRSsNP, allergic fungal rhinosinusitis (AFS) and CRS associated
with other systemic disease. Symptoms may be mild with little effect on
QoL or may result in significant health problems and loss of productivity.
As such , the treatment strategies should be based on individual patient
problems. These treatment strategies include topical and systemic
medications. (infection and drug resistance 2013)

There are review that found nasal saline irigation to be beneficial

and well tolerated in treatment of CRS, although nasal irigation is not as
effective as an intranasal steroid, evidence suggest that it is useful adjunct
(grade of recomendation A)(BMJ 2012 and EPOS). Intranasal saline has
been shown to be beneficial in both unoperated and postoperative
patients. High volume, low pressure irigation have demonstrated
superiority over other methods of delivery (infection and drug resistance
2013). It is unclear whether isotonic or hypertonic solution is a better
option for saline irrigation, on the basis of symptom score and QoL,
hypertonic solution may be a better initial choice however if local adverse
effect develop, transition to an isotonic solution would be recommended
(co-Otolaryngology 2013). There is some solution like sodium hypochlorite
(NaOCl) (grade of recommendations B) and xylitol (Grade of
recomendation A) which may be used for nasal irrigation (Epos).

There is strong recommendation to use intranasl corticosteroids

(sprays or drops) as the primary medical treatment for CRS (LOE 1; Grade
of recommendations A) (EPOS). All type of steroid has same clinical effect
on treatment of CRS (BMJ 2012). The effect of corticosteroids may be
mediated by reduction in eosinophil activity in the mucosa. The delivery of
steroid to the affected area may be substantially limited with topical
application, especially in CRS with mucosal oedema and spray solution
may distribute little further than the nasal cavity. There is no suficient
evidence about the best methods for delivery the topical corticosteroid
(BMJ 2012, EPOS). The current status of FEES surgery may be affect the
penetration of corticosteroid, before such surgery distribution of the
snuses is thought to be poor regardless of the mode of delivery (BMJ2012).

Oral antibiotics are the most commonly prescribed medication for

CRS and remain a manstay treatment (Infection and drug resistance
2013). The use of antibiotics for the treatment CRS may be considered in
secondary care (BMJ 2012). Long term antibiotic treatment should be
reserved for patients where nasal corticosteroids an saline irrigation has
failed to reduce symptoms to an acceptable level. A number of open
studies using macrolides have shown a response rate of 60%-80%. Level
of evidence for macrolides in all patients with CRSsNP is Ib and grade of
recommendation C, indication exist for better efficacy in CRSsNP patients
with normal IgE the recommendation A. Other choices such as long term
treatment with doxycycline or TMP-SMX could turn out to be promisng
alternatives and further studies are warranted (EPOS).

FEES or functional endoscopic sinus surgery is currently the

principal form of surgery practised widely by ENT surgeons for chronic
rhinosinusitis. These endoscopic procedures on some or all sinus groups
with the specific aim of restoring ventilation and mucociliary clearance
within the sinuses. EPOS conclude that level 2 and level 3 evidence
supports FEES as safe, effective, and appropriate for CRSsNP and CRSwNP
where medical interventions have failed. ESS is more likely to be effective
in managing nasal obstruction and facial pain than postnasal drip or
Hyposmia and is associated in significant improvements in generic as well
as disease specific quality of life outcomes (EPOS). Although a 2006
Cochrane review noted that some RCT have found no significant benefit
associated with FEES when compared with medical therapy (BMJ 2012).

Case Report
Initial Presentation

A 53 year old woman came to the ENT clinic in Soeradji Tirtonegoro

hospital with the chief complaint of nasal blockage since 4 months ago.

History

The complaint of nasal blockage had been suffered since 4 months

ago. The complaint was also accompanied by thick and yellow nasal
discharge. The discharge was also reported to have foul odor. She also felt
a painful sensation on frontal and maxilla region during sujood. She also
had complaint regarding her olfactory function; she was unable to smell
and identify any odor. The symptom was worsen when she was exposed to
allergen, presumably dust. She frequently experienced itchiness on her
nose, watery rhinorrhea, sneezing, and nasal blockage, especially in the
morning. There was no cough, fever, sore throat, difficulty or pain during
swallowing and no ear complaint either from the patient. Previously, she
had history of common cold and was improved by taking over-the-counter
medication. Currently, she had uncontrolled hypertension. The last time
she took medicine for her hypertension was 6 months ago. She confirmed
the presence of allergy history within her family.

Physical Examination
Mucopurulent discharge, hyperemic and edema was seen during
inspection by anterior rhinoscopy examination. Upon palpation, there is
facial pain around the cheekbones and frontal region. Trans illumination
examination was not performed, due to limited equipments.
Postnasal discharge can also be observed in the examination of the
oropharynx.
Dental caries was found bilaterally on 1st and 2nd upper molar. The ear
was within normal limit. Patient came with generally good condition,
compos mentis and able to communicate effectively. The result of vital
sign examination was 120/80-mmHg blood pressure, respiratory rate 24
times/minute, body temperature 36,5C, and heart rate 80 times/minute.
Diagnosis
The diagnosis of this patient is Chronic Maxillary and frontal
Rhinosinusitis based on the anamnesis and physical examination.
Treatment
Treatment for this patient was klindamycin 300 mg for two times
daily, pseudoephedrine 30 mg + terfenadine 40 mg for two times daily.
Patient was refered to dentist and the patient iwas asked to follow up after
one week.

Plan

Patient is asked to return to the clinic for follow-up after one week
and to discuss further plan of action depending on the condition after
treatment.
DISCUSSION

The patient is diagnosed with Chronic Maxillary and frontal

Rhinosinusitus bilateral based on the anamnesis that the patient
experiences this condition for 4 months with symptoms bilateral nasal
congestion, facial pain around the cheek bones and forehead, anterior and
post nasal drip, and foul smelling nasal discharge.

The patient fulfilled the criteria of diagnosis of Chronic

Rhinosinusitis according to Task Force and Perhati KL guideline, but the
patient did not undergo CT-scan or endoscopy to qualify for the criteria by
EPOS.

The treatment for CRS

Reference :

3. Lalwani AK.Acute & Chronic Sinusitis. In Current Diagnosis &

Treatment in Otolaryngology-Head & Neck Surgery, 2nd
edition.Lange 2007: chapter 14

5. W.J. Fokkens, V.J. Lund, J. Mullol et al., European Position Paper on

Nasal Polyps 2007. Rhinology 45; suppl. 20: 5-108.

2. AAFP 2011

1. AAFP 2001