Rhinogenic & Odontogenic

Rhinosinusitis

Retno S. Wardani retno.wardani@ui.ac.id

Rhinology Consultant
ENT Department – Faculty of Medicine
University of Indonesia Jakarta
Dr. Cipto Mangunkusumo Hospital
 Rhinosinusitis
Rhinosinusitis = inflammatory
disease

Bacterial Rhinosinusitis occur in following

viral infection & allergic inflammation 1,2

How to control inflammation?

When to prescribe
antibiotic?
1)Van Cauwenberge P, Van Kempen M, Bachert C. Mechanisms of Viral & Bacterial Infections of the
Nose & Sinuses; Pediatric Nasal & Sinus Disorders, 2005;199:59-67
2)Fireman P. Diagnosis of sinusitis in children: emphasis on the history and physical examination. J
Allergy Clin Immun, 1992;90:433-36
Rhinosinusitis Symptomatology

Ostio Meatal
Complex (OMC)
 Epidemiological Clinical Definition Clinical Definition
Definition Adult Pediatric
ü Nasal blockage / ü Nasal blockage / ü Nasal blockage /
obstruction / obstruction / obstruction /
congestion congestion congestion
ü Nasal discharge ü Nasal discharge ü Nasal discharge
ü ± Facial pain / ü ± Facial pain / ü ± Facial pain /
pressure pressure pressure
ü ± Reduction or ü ± Reduction or ü ± Cough
loss of smell loss of smell
• Based on symptoms • AND either • AND either
• Validations by tele- ENDOSCOPIC ENDOSCOPIC
phone / interview SIGNS SIGNS
• No need for ENT
exam / radiology • AND / OR CT • AND / OR CT
• Question for allergic CHANGES CHANGES
symptoms
Fokkens W, Lund V, Mullol J et al. Rhinology 2012,vol 50 (Suppl
23):1-198
Rhinosinusitis
 Definition of Acute Rhinosinusitis
¢ Sudden onset
¢ 2 or more symptoms
l One of which should be either
• Nasal Blockage/Obstruction/Congestion Or
• Nasal Discharge (anterior/posterior nasal drip)
l ± facial pain/pressure
l ± reduction or loss of smell
¢ For < 12 weeks
¢ With symptom free intervals if the problem is recurrent
¢ With validation by telephone or interview

Fokkens W, Lund V, Mullol J et al. Rhinology 2012,vol 50 (Suppl

23):1-198
 Acute rhinosinusitis can be divided into:
common cold and post-viral rhinosinusitis
A small subgroup of the post-viral rhinosinusits
is caused by bacteria:
Acute bacterial rhinosinusitis (ABRS)
 Acute Rhinosinusitis

¢ Common cold / acute viral rhinosinusitis

l Duration of symptom less than 10 days

¢ Acute post-viral rhinosinusitis

l Increase of symptoms after 5 days or
l Persistent symptoms after 10 days with
l less than 12 weeks duration
 Acute Rhinosinusitis
Acute bacterial rhinosinusitis (ABRS)
Suggested by the presence of at least
3 symptoms/signs of:
l Discoloured discharge (unilateral predominance)
and purulent secretion in nasal cavity
l Severe local pain with unilateral predominance
l Fever (>380)
l Elevated ESR / CRP
l “Double sickening” (deterioration after an initial
milder phase of ilness)
Fokkens W, Lund V, Mullol J et al. Rhinology 2012,vol 50 (Suppl
23):1-198
 Common Cold
(acute viral rhinosinusitis)
&
post-viral rhinosinusitis

a self limiting disease

 Radiologic Examination
¢ PNS Plain x-ray is not recommended
l diagnosis of acute uncomplicated RS should be
made on clinical grounds alone
(EP30S 2007, American College of Radiology, 2000)
lPlain x-ray technically difficult to perform
¢ CT Scan recommended on:
l Severe disease
l Immunocompromised patients
l Severe complications (orbital & intracranial)
l For guiding surgical treatment
 Radiologic Appearance of Plain Sinus X-ray
in Pediatric Acute Rhinosinusitis
Radiologic ABRS (+) ABRS (-)
Appearance
Frequency % Frequency %
Normal 3 18.8 13 81.2
Mucosal thickening 6 66.7 3 33.3
Opacification 5 71.4 2 28.6
Mucosal thickening +
9 47.4 10 52.6
opacification
Mucosal thickening +
1 100 0 0
air fluid level
Opacification +
2 100 0 0
air fluid level
All appearance 3 100 1 25
Suprohaita, Retno S. Wardani, Zakiudin Munasir, Bambang Supriyatno, Damayanti R.
Syarief, Clinical Symptoms & PNS Plain X-ray Compare to Nasoendoscopy
Examination As Diagnostic Criteria In Pediatric Rhinosinusitis, Jakarta, 2009
 Radiologic Appearance of
Pediatric Acute Rhinosinusitis
Radiologic Sensitivity Specificity
Appearance % 95%CI % 95%CI
Mucosal thickening 64 47 - 79 58 42 - 73

Opacification 67 50 - 81 56 40 - 71

Air-fluid level 18 8 - 34 95 84 - 99
Mucosal thickening +
44 28 -60 67 52 - 81
opacification
Mucosal thickening + air fluid
level
13 4 - 27 95 84 - 99
Opacification + air fluid level 15 6 - 31 98 88 – 99
Suprohaita, Retno S. Wardani, Zakiudin Munasir, Bambang Supriyatno, Damayanti R.
Syarief, Clinical Symptoms & PNS Plain X-ray Compare to Nasoendoscopy
Examination As Diagnostic Criteria In Pediatric Rhinosinusitis, Jakarta, 2009
3: Coronal CT scan demonstrating bilateral maxillary
(arrows). The degree of sinus inflammation is more Figure 5: Coronal CT scans
Rhinogenic Maxillary Sinusitis
nt in the right sinus. Concha bullosa or nasal septal bullosa (superior arrows) w
arrows). Note that there is m
are not noted. caused by Septal Deviation & Concha Bullosa
of the maxillary sinus than
concha bullosa demonstrat
compared to the left concha

!
: Coronal CT scan demonstrating right middle concha
Odontogenic Maxillary Sinusitis
Odontogenic Maxillary Sinusitis
 HOW TO CONTROL
INFLAMMATION
&
WHEN TO PRESCRIBE
ANTIBIOTIC
Correlation Between Antimicrobial
Use & Bacterial Resistance
 ANTIBIOTICS

21
R Setiabudy, WHD April 7, 2011
 Prevention of Antibiotic Resistance
¢ We have reached a CRUCIAL TIME:
l Rise of antibiotic resistance
l A steady decline in the rate of
discovery of new antibiotics

CONCEPTUALLY NOVEL THERAPEUTIC

STRATEGIES AGAINST MICROBIAL INFECTION
 Antibiotic Prescribtion Indication
Rhinosinusitis & Asthma – Bronchitis
 Ant i b i ot i c P r es cr i b t i on Ind i cat i on
R hi nosi nusi t i s & O t i t i s Med i a

Ostiomeatal
Eustachia
Complex
n Tube
(OMC)

Nasopharynx -
Adenoid
 Adenoid
David S. Parsons
Hypertrophy

Ventilation & Drainage

Disturbance

Eustachian OMC
Tube
OTITIS MEDIA RINOSINUSITIS

Parsons DS, Wald ER. Otitis media and sinusitis: similar disease.
Otolaryngol Clin North Am, 1996;29:11-25
 Antibiotic for Bacterial Infection Only
Microbiological Result Frequency

No growth 9 (20,9%)

Purulent secretion should not be used to

assess the need for antibiotic therapy
à discoloration & thickening is related to
presence of neutrophils, not bacteria.

Suprohaita, Wardani RS, Munasir Z, Supriyatno B, Syarief DR, Clinical

Symptoms & PNS Plain X-ray Compare to Nasoendoscopy Examination As
Diagnostic Criteria In Pediatric Rhinosinusitis, 2009
Antibiotic Prescribtion Indication

S E V E R E S Y M P TO M S
for at least 3-4 consecutive days at the initial time
• Fever at least 390 C
• Purulent nasal discharge
 DO NOT TARGET THE PATHOGEN DIRECTLY
à enhance immunomodulatory molecules /
host defence mechanism
à to eliminate the pathogen
Glucocor'coids+Suppress+Inflamma'on+but+Spare+
Innate+Immune+Responses+in+Airway+Epithelium+
Robert'P.'Schleimer'Proc'Am'Thorac'Soc'Vol'1.'pp'222–230,'2004'

Efficient mucocilliary
clearance

113
DO NOT TARGET THE PATHOGEN DIRECTLY
à enhance immunomodulatory molecules /
host defence mechanism
à toCell. eliminate
Mol. Life Sci. Vol. 64, 2007
the pathogen Review Article

Mookherjee, Hancock,
Figure 3. Anti-infective Cationic
properties hostpeptides.
of cationic host defence defenceCationic hostpeptides: Innate
defence peptides protect against pathogen
either directly antimicrobial or by selectively boosting host immune responses. (a) Certain host defence peptides that are prese
immuneconcentrations
regulatory peptides
or are highly as direct
salt resistant exhibit a novel approach
antimicrobial for
properties either by treating
disrupting the bacterial membr
infections Cell.
targeting intracellular Mol.
components Life (b)
of the pathogen. Sci.
Most 64 (2007)
cationic host defence922
peptides–induce
933 a variety of responses in h
Ant i b i ot i c P r es cr i b t i on Ind i cat i on
O d ont ogeni c Max i llar y Si nus i t i s
Maxillary Sinus Puncture
Maxillary Sinus Puncture
Maxillary Sinus Puncture
Orbital Complication of Rhinosinusitis
 Orbital Abscess of
Odontogenic Origin
1. the maxillary premolar and
molar teeth
• the maxillary buccal plate à
posteriorly into the
pterygopalatine & infratemporal
fossae à the orbit through
inferior orbital fissure
• the posterior maxillary wall to
enter the maxillary sinus
2. through the valveless anterior
facial, angular & ophthalmic
veins
 fissure (Fig. 4). The patient was placed on intravenous clinda- FIG. 5. Case 3. Extensive periocular swelling of the left upper
and lower eyelids.
mycin and observed closely. On the second day of hospitaliza- ODONTOGENIC ORBITAL
ODONTOGENIC CELLULITIS
ORBITAL CELLULITIS 31 31
tion, the patient’s vision deteriorated to 20/400 OS, with
ocular motility had significantly improved. Bacterial cultures ob-
development of a left afferent pupillary defect and complete
tained from the orbital abscesschi-square or Fisher exact test was used to evaluate
yielded no organisms.
external ophthalmoplegia. She underwent emergent drainage of
categorical data.

Odontogenic Orbital Cellulitis

the orbital abscess through a sub-brow incision. Twenty-four
hours later, the patient’s vision returned to 20/20 OS and her Patient 3. An 18-year-old black man was admitted to an
outside hospital for intravenous antibiotic treatment after 24
RESULTS
afferent pupillary defect resolved. The left globe proptosis and
hours of progressive left upper and lower eyelid swelling. revealed
A review of the literature The 40 cases of odontogenic
1–30
patient was seen 3 days priororbital
by ancellulitis.
oral surgeon,However,
who diag-only 21 patients had adequate
nosed a left maxillary second ophthalmologic
molar abscess. examinations
However, to thebe included for statistical anal-
ysis (Table,
patient did not fill the oral antibiotic http://links.lww.com/A359).
prescription given to him Including the 3 cases
at that time. On the second day presented in this the
of admission, article, a total
patient wasof 24 patients were analyzed
evaluated by an ophthalmologist.withOnregards to visual
examination, outcomes and gender (12 men, 12
the patient’s
left upper and lower eyelids were swollen shut. Marked prop-
tosis was present, along withFIG.
a tight
5. orbit
FIG.Case
and
3. complete
5. Case Extensive external
periocular
3. Extensive swelling
periocular of theofleft
swelling theupper
left upper
ophthalmoplegia (Fig. 5). Uncorrected
and lower visual
eyelids.
and lower acuity was NLP
eyelids.
OS with an amaurotic pupil. Emergent canthotomy and can-
tholysis was performed at the bedside and the patient was
transferred for further management.
chi-square Dilated
chi-square funduscopic
or Fisher
or Fisher ex-
exactexact test test
was wasused used
to evaluate
to evaluate
amination showed a combined central data.
categorical
categorical retinal
data.artery occlu-
ODONTOGENIC ORBITAL CELLULITIS 31
sion and central retinal vein occlusion. Orbital CT showed left
maxillary and ethmoid sinus opacification, left-sided RESULTS RESULTS
orbital
FIG. 2. Case 2. Proptosis of the left globe with inferior emphysema with reticulation of A the fat,
review and
of tenting
the of
literature
A review of the literature the leftrevealed
revealed 40 cases of odontogenic
40 cases of odontogenic
displacement. globe (Fig. 6). The patient underwent
orbital
orbital emergent
cellulitis.left
cellulitis. 1–30 1–30maxillary
However,
However,only only
21 patients had adequate
21 patients had adequate
ophthalmologic
ophthalmologic examinations
examinationsto be to
included for statistical
be included anal- anal-
for statistical
ysis (Table, http://links.lww.com/A359).
ysis (Table, http://links.lww.com/A359). Including the 3 the
Including cases
3 cases
Ophthal Plast Reconstr Surg, Vol. 24, No. 1, 2008
FIG. 4. Case 2. Parasagittal (A) and coronal (B) MRI shows presented in this
presented in article, a total
this article, of 24ofpatients
a total were were
24 patients analyzed
analyzed
retromaxillary soft tissue swelling with extension in the orbit via with with
regards to visual
regards outcomes
to visual and gender
outcomes and gender(12 men, 12 12
(12 men,
the inferior orbital fissure (arrows).

antrostomy, total ethmoidectomy, and extraction of the dis-

eased molar along with an orbitotomy for excision of necrotic
orbital fat and drainage of multiple, loculated intraorbital ab-
scesses. Preoperative intravenous
FIG. 5. Case antibiotics
3. Extensive (vancomycin
periocular swelling ofand
the left upper
ampicillin/sulbactam) were continued. Orbital cultures ob-
and lower eyelids.
tained at the time of surgery grew !- and "-hemolytic Strep-
tococcus, Staphylococcus (coagulase negative), and Prevotella
chi-squareThe
buccae (Bacteroides). orpatient’s
Fisher vision
exactremained
test was used to evaluate
unchanged
categorical
postoperatively, data.tissue signs resolved.
but all soft

RESULTS
Literature Review. A Medline search was performed
FIG. 4.
all Case
forFIG. 2.A Parasagittal
4. Case
relevant review (A)literature
ofdating
the
2. Parasagittal
articles and
(A)
backcoronal
and (B) MRI
torevealed
coronal
1966, 40
using shows
(B)cases
MRI of
Med- odontogenic
shows
Yousef, OH. Odontogenic Orbital Cellulitis,
retromaxillary
ical Subject
the inferior
soft tissue
retromaxillary
orbitalsoft
Heading
orbital
the inferior fissure
orbital
blindness, and paranasal sinuses. All articles were re-
swelling
tissue
cellulitis.1–30with extension
swelling
terms:
(arrows).
fissure
ophthalmologic
tooth,
(arrows).
examinations
in 21
with extension
However, only
infection,
theinorbit via had
the orbit
patients
eye, orbit, viaadequate
to be included for statistical anal-

Ophthalmic Plastic andviewedReconstructive

antrostomy, presented
total
antrostomy,
for calculation
in this article,
ethmoidectomy,
total
of ethmoidectomy,
visual outcome. and
Surgery
ysis (Table, http://links.lww.com/A359). Including the 3 cases
for specific data required for statistical
anda extraction
totalextraction
Continuous
analysis
of 24ofpatients were
theof dis-
the
variables dis-analyzed FIG. 6. Case 3. Coronal (A) and axial (B) CT reveal left maxillary

2008(24);1: 29–35
easedeased withalong
molarmolar
along regards
with toanvisual
an orbitotomy outcomes
for excisionandof gender
necrotic (12 men, 12 and ethmoid sinus opacification, left-sided orbital emphysema
were analyzed with orbitotomy for excision
using the unpaired Student t test. The of necrotic with reticulation of fat and tenting of the left globe.
orbital fat and
orbital fat drainage
and drainageof multiple, loculated
of multiple, intraorbital
loculated ab- ab-
intraorbital
ESS FOR ORBITAL ABSCESS

Courtesy of Dr. Damayanti Soetjipto

TERIMA KASIH