CASE REPORT

CHRONIC RHINOSINUSITIS

Presentator: dr. Aras Amila Husna

Moderator: Dr. dr. Luh Putu Lusy Indrawati, M.Kes., Sp.T.H.T.K.L.(K).

Department of Ear, Nose, Throat, Head and Neck Surgery, Faculty of Medicine,
Public Health, and Nursing Gadjah Mada University,
Dr. Sardjito Yogyakarta
2022
Introdcution
Rhinosinusitis is a disease that is
often found and affects the quality of life
and health of individuals which in turn will
have an impact on economic
employment problems (Rosenfeld, 2015).
Rhinosinusitis is inflammation of
the paranasal sinuses and nasal mucosa,
which is characterized by symptoms of
nasal congestion, the presence of nasal
secretions from both anterior and posterior
nasal drips, accompanied by symptoms of
spontaneous facial pain or compression in
the sinus area and decreased or lost smell
(Rosenfeld, 2015).
Rhinosinusitis is divided
several types according to the duration of
symptoms felt by the patient based on the
classification made by the Task Force of
The American Academy
Otolaryngology-Head and Neck Surgery
(AAO-HNS), namely: acute rhinosinusitis,
subacute rhinosinusitis, chronic
rhinosinusitis, chronic rhinosinusitis acute
exacerbation, and recurrent
rhinosinusitis. Acute rhinosinusitis lasts no
more than 4 weeks. Sub-acute
rhinosinusitis, lasting between 4-12 weeks.
Chronic rhinosinusitis can last more than 12
weeks. Recurrent acute rhinosinusitis, is a
symptom experienced by the patient more
than 4 times a year, with total resolution
between attack intervals. Meanwhile, acute
exacerbation of chronic rhinosinusitis is a
sudden worsening of the symptoms of
patients, who have been diagnosed with
chronic rhinosinusitis, such as early
and symptoms before being given treatment
(Bailey, 2014).
Otherwise, based on EPOS 2020,
rhinosinusitis in adult 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 ± facial
pain/pressure; ± reduction or loss of smell
and either Endoscopic examination; - nasal
into polyps, and/or mucopurulent discharge
primarily from middle meatus and/or
oedema / mucosal obstruction primarily in
middle meatus and/or CT changes which is
of mucosal changes within the ostiomeatal
complex and/or sinuses.
Paediatric rhinosinusitis is defined as
presence of two or more symptoms one of
which should be either nasal blockage /
acute obstruction / congestion or nasal discharge
(anterior / posterior nasal drip) ± facial
pain/pressure, ± cough 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: mucosal changes within
the ostiomeatal complex and/or sinuses. For
epidemiological studies and general
practice, the definition is based on
symptomatology usually without ENT
examination or radiology (EPOS, 2020)
Meanwhile, Chronic rhinosinusitis
(with or without nasal polyps) in adults is
defined as presence of two or more
symptoms, one of which should be either
nasal blockage / obstruction / congestion or
nasal discharge (anterior / posterior nasal
drip): ± facial pain/pressure; ± reduction or
loss of smell; for ≥12 weeks (EPOS, 2020)
Task Force of The American
Academy of Otolaryngology-Head and
Neck Surgery (AAO-HNS) 1996 divides
rhinosinusitis symptoms into major and
minor symptoms in patients to facilitate
diagnosis. The major symptoms are: facial
pain; nasal congestion; nasal secretions,
either from the anterior or posterior nasal
drip; decreased smell function; the presence
of purulent secretions on examination; and
the presence of fever (in the acute
classification only). Minor symptoms
include: headache; fever (in all non-acute
classifications); bad breath; tooth ache;
feeling tired; cough; ear pain / feeling full /
pressure The AAO-HNS Task Force
changed the term sinusitis to rhinosinusitis
because the anatomy of the paranasal
sinuses and the nose are interconnected, so
infection from the sinuses can cause
disorders of the nose and also disorders of
the nose can develop into disorders of the
sinuses (Bailey, 2014).
Based on the European Position
Paper on Rhinosinusitis and Nasal Polyps in
2020, the definition of chronic rhinosinusitis
(with or without nasal polyps) in adults is:
the presence of 2 or more symptoms, one of
which is the nose congestion / obstruction /
congestion or nasal discharge ± facial pain /
pressure, ± decrease or loss of smell for ≥12
weeks and questions about allergy
symptoms (sneezing, runny rhinorrhea,
itchy nose, itchy and watery eyes) should be
asked. Meanwhile, the definition of chronic
rhinosinusitis (with or without nasal polyps)
is: the presence of 2 or more symptoms, one
of which is nasal congestion / obstruction /
congestion or nasal discharge ± facial pain /
pressure, ± coughing during ≥12 weeks.
Chronic rhinosinusitis affects 5-15%
of the population in Europe and the United
States with an increasing prevalence with
increasing age, with a mean of 2.7% in the
20-29 age group and 6.6% 50-59 years.
After 60 years of age, the prevalence rate of
SSR decreases to 4.7% (Fokkens WJ et al.,
2012).
CRS is typically an adult onset
disorder with diagnosis most commonly in
the fifth decade of life.
Based on data from the Ministry of
Health of the Republic of Indonesia in 2003,
nasal and sinus diseases is in the order of 25
of the 50 main ranking disease patterns sinusitis. For diffuse CRS, the clinical
(Mustafa M et al, 2015). phenotypes are predominantly eCRS and
Chronic rhinosinusitis has non-eCRS, determined by the histologic
traditionally been classified into chronic quantification of the numbers of
rhinosinusitis with nasal polyps (CRSwNP) eosinophilic, i.e. number/high powered field
and without nasal polyps (CRSsNP). which the EPOS panel agreed to be 10/hpf
CRSwNP: chronic rhinosinusitis as defined (400x) or higher.
above and bilateral, endoscopically For secondary CRS, again, the
visualised polyps in middle meatus; and division is into localized or diffuse and then
CRSsNP: chronic rhinosinusitis as defined considered by four categories dependant on
above and no visible polyps in middle local pathology, mechanical, inflammatory
meatus, if necessary following and immunological factors. Chronic
decongestant (EPOS, 2020) rhinosinusitis without polyps can be treated
This definition accepts that there is with antibiotics and intranasal
a spectrum of disease in CRS which corticosteroids or with surgical techniques.
includes polypoid change in the sinuses However, it would be more effective if the
and/or middle meatus but excludes those background of chronic rhinosinusitis
with polypoid disease presenting in the conditions, such as allergies, was also
nasal cavity to avoid overlap. Moreover, it treated (Rosenfeld et al., 2015).
has become progressively clear that CRS is Complications if chronic
a complex disease consisting of several rhinosinusitis is not handled properly can
disease variants with different underlying occur intracranial, intraorbital or bone
pathophysiologies. disorders (Bailey, 2014).
The EPOS2020 steering group has Chronic rhinosinusitis produces
chosen to look at CRS in terms of primary greater quality of life impairment than
and secondary and to divide each into acute(24). Gliklich and Metson first
localized and diffuse disease based on demonstrated the impact of CRS on global
anatomic distribution. In primary CRS, the quality of life, finding that CRS had a
disease is considered by endotype greater impact on social functioning than
dominance, either type 2 or non-type 2. angina or chronic heart failure (EPOS,
Clinically localized primary CRS is then 2020).
subdivided into two phenotypes – allergic Patients who do not reach an
fungal rhinosinusitis (AFRS) or an isolated acceptable level of control despite adequate
surgery, intranasal corticosteroid treatment
and up to two short courses of antibiotics or
systemic corticosteroids in the last year can
be considered to have difficult-to-treat
rhinosinusitis (EPOS, 2020)
In the treatment of rhinosinusitis, it
encompasses the use of biological agents
and macrolides as above. With respect to
surgery, functional implies restitution of
physiology and is usually, though not
exclusively, applied to endoscopic sinus
surgery. It should fulfil the following
criteria: Creates a sinus cavity that
incorporates the natural ostium; Allows
adequate sinus ventilation; Facilitates
mucociliary clearance; Facilitates
instillation of topical therapies. In contrast,
a ‘Full FESS’ is defined as complete sinus
opening including anterior and posterior
ethmoidectomy, middle meatal
antrostomies (likely large), sphenoidotomy
and frontalopening.Extended endoscopic
surgery is used in the same context as ‘full’
but could also include extension beyond the
confines of sinuses i.e. skull base, orbit,
pterygopalatine and infratemporal fossa.
Finally, radical also includes significant
removal of inflamed / dysfunctional
mucosa (EPOS, 2020)
CASE REPORT
A 72 year old woman was referred
from a hospital in Yogyakarta to the ENT
HNS clinic of Dr. Sardjito, with complaints
of nasal blockage since 7 months ago.
Complaints are accompanied by facial pain
in the left, runny nose, and mucus in the
throat. Nasal congestion, smelly breath, and
decrease sense of smell denied by patient.
The patient has no history of itchy nose and
eyes, watery eyes or sneezing in the
morning. Complaints in the ear and throat
were denied by the patient. Patient has
Diabetes Mellitus, Hypertension and an
allergy to NSID. She has history of dental
cavities, sealed by dentist 3 years ago, but
the tooth missed now. History of smoking
and hypertension denied by patient
On physical examination, the
patient's general condition looked good,
compost mental awareness, blood pressure
120/80 mmHg, pulse rate 88x / minute,
breath rate 20x / minute and temperature
36.80C. On otoscopy of the right and left
auris, CAE was seen within normal limits,
the tympanic membrane was intact. On the
anterior and posterior rhinoscopy
examination, there was minimal
mucopurulent secretions in the right nasal
cavity. Minimal posterior nasal drip
especially found in the left posterior pharynx
on oropharyngeal examination. Indirect
laryngoscopy did not show any
abnormalities. On palpation of the face,
facial pain was found in the left maxillary
bone.
 Nasoendoscopic examination
showed mucopurulent discharge in the left
nasal cavity.
From the CT scan, there is isodense
lesion with opacification/ calcification
fulfilled maxillary sinus.
Based on history, physical
examination and investigation, our patient
was diagnosed with Chronic Rhinosinusitis
Maxillaris Sinistra. The patient was then
planned for polypectomy and FESS surgery.
DISCUSSION
Rhinosinusitis can result from a
viral infection of the nose that results in
inflammation and / or viral infection of the
adjacent sinuses. One possibility is the
development of negative atmospheric
pressure in the sinus cavities and a
decrease in the partial pressure of oxygen.
There is also excessive mucus production
with or without plasma transudation. This
can cause malfunction or complete
cessation of movement of the cilia lining
the sinuses which will cause static of
mucus and blockage of the osteomeatal
complex (KOM). The environment in the
sinuses will support the growth of
pathogenic organisms. Therefore, the
development of rhinosinusitis is mainly
due to blockage of the osteomeatan
complex (Masood, 2007).
There are three elements that
contribute to the pathogenesis of
rhinosinusitis, namely: narrow sinus ostia,
dysfunction of the ciliary apparatus, and
thick sinus secretions. The narrow diameter
of the sinus ostia regulates the stage of the
obstruction. Obstructed ostia include
factors that cause swelling of the mucosa
and factors that cause direct mechanical
obstruction. Of these several causes, upper
respiratory tract infections (ARI) and
allergic inflammation are the most frequent
and most important (Soetipto, 2007).
Previously, the hypothesis in sinus
disease was that the drainage pattern of the
paranasal sinuses was dependent on gravity,
but it is now clear that mucociliary transport
mechanisms are essential in sinus drainage.
The metachronous coordination of ciliated
columnar epithelial cells propels the
contents of the sinus immune flow to the
sinus ostia naturally. Impaired function of
the cilia causes fluid accumulation in the
sinuses. Poor ciliary function can be caused
by the loss of ciliated epithelial cells
(Soetipto, 2007).
Sinonasal secretion plays an
important role in the pathophysiology of
rhinosinusitis. The mucus that lines the
paranasal sinuses is composed of a thin
periciliary layer, which allows mobility of
the cilia, and a thick gel layer, which is at the
end of the cilia. This mucosal immune
stream contains mucoglycoproteins,
immunoglobulins, and inflammatory cells.
Changes in water content in the mucosal
layer can impair ciliary motility. Excess
mucus production can floods the
mucociliary drainage system, resulting in
retained secretions in the sinuses (Soetipto,
2007).
CRS was a syndrome with a
multifactorial aetiology resulting from a
dysfunctional interaction between various
environmental. factors and the host immune
system. It was, however, very unclear
which environmental and host factors were
important even in the population at large, let
alone in an individual CRS patient. In
healthy individuals, the mucosa serves as a
relative barrier modulating interaction with
the host immune system, promoting
tolerance and symbiosis as well as
preventing or limiting inflammation. In
patients with CRS, the barrier is penetrated
with resultant chronic inflammation leading
to, in many cases, tissue remodeling and
clinical symptoms (EPOS, 2020)
Rhinosinusitis in adult 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 ± facial pain/pressure; ±
reduction or loss of smell and either - nasal
polyps, and/or mucopurulent discharge
primarily from middle meatus and/or
oedema / mucosal obstruction primarily in
middle meatus and/or CT changes which is
mucosal changes within the ostiomeatal
complex and/or sinuses (EPOS, 2020)
Chronic rhinosinusitis (with or
without nasal polyps) in adults is defined as
presence of two or more symptoms, one of
which should be either nasal blockage /
obstruction / congestion or nasal discharge
(anterior / posterior nasal drip): ± facial
pain/pressure; ± reduction or loss of smell;
for ≥12 weeks (EPOS, 2020)
In this patient. There is a chief
complaint of nasal blockage since 7 months
ago. Complaints are accompanied by facial
pain in the left, runny nose, and mucus in the
throat. On the anterior and posterior
rhinoscopy examination, there was minimal
mucopurulent secretions in the right nasal
cavity. Minimal posterior nasal drip especially
found in the left posterior pharynx on
oropharyngeal examination.
Nasoendoscopic examination showed
mucopurulent discharge in the left nasal
cavity. From the CT scan, there is isodense
lesion with opacification/ calcification fulfilled
maxillary sinus.
Complaint in the patient, fullfill the
criteria of chronic rhinosinusitis based on
EPOS 2020. There is a nasal blockage,
runny nose, and facial pain. In making the
diagnosis, apart from physical examination,
several supporting examinations can be collection of fungal debris usually within a
used. Nasal endoscopy is a simple, fast and single sinus. The maxillary and sphenoid
relatively inexpensive examination sinuses are most commonly affected. By
method to perform. Currently, paranasal definition, there is no invasive component to
sinus CT scan is still considered the gold the fungal colonization.
standard for diagnosis of chronic There is a reported female pre-
rhinosinusitis (Wuister et al, 2014). disposition has high as 2:1 and others have
Nasoendoscopy and CT scan suggested this but not to the same strength of
supported the diagnosis of Chronic association. Fungal ball is a condition that
Rinosinusitis. affects most in the fifth and sixth
Chronic rhinosinusitis is not always decade(206) with reported means of 55 years
caused by an infectious process by certain and 56±14 years. In a systematic review of
microorganisms as in acute rhinosinusitis. isolated maxillary and sphenoid sinus
There are three main factors known as opacifications, the reported age range was
pathophysiological factors for the 38-59 years for the maxillary sinus and 38-
occurrence of chronic rhinosinusitis, 57 years for the sphenoid sinus (EPOS,
namely host factors, environmental factors, 2020)
and microbial factors.(Bailey, 2014). DeShazo’s initial criteria and
Based on EPOS 2020, CRS divided description is still accurate for fungal ball
into Primary CRS and Secondary CRS. which is ; 1) Radiologic evidence of sinus
Possible classification for unilateral CRS in opacification with or without associated
primary, divided into two category, Type 2 flocculent calcifications; 2) Mucopurulent,
which is Allergic Fungal Rhinosinusitis and cheesy, or clay-like material within a sinus ;
Isolated Rhinosinusitis. And unilateral CRS 3) A matted, dense conglomeration of
in Secondary CRS, divided into hyphae separate from but adjacent to sinus
odontogenic, tumor, and fungus ball. respiratory mucosa, 4) A chronic
The suspected etiology in this case inflammatory response of variable intensity
is fungus ball. The patient was 72 years old, in the mucosa adjacent to fungal elements.
immunocompetent, had no had no history This response includes lymphocytes, plasma
of dental cavities, from the CT scan there is cells, mast cells, and eosinophils without an
heterogen isodense lesion filled the left eosinophil predominance or a
maxillary sinus. granulomatous response. Allergic mucin is
Fungal ball Is a concretion or absent on hematoxylin-eosin-stained
material; 5) No histologic evidence of
fungal invasion of mucosa, associated
blood vessels, or underlying bone
visualized microscopically on Gomori
methenamine silver or other special stains
for fungus. On radiology assessment,
“calcifications” and erosion of the inner
wall of the sinus are the two features most
diagnostic for fungal ball(221). Although
the term “calcifications’ is used, they are
probably more accurately referred to do as
hyperdensities as they represent trace metal
elements in the fungus (EPOS, 2020).
The goals of rhinosinusitis therapy,
both acute and chronic, are to control
infection, reduce tissue edema, facilitate
drainage, maintain patency of the sinus
ostia and break the pathological cycle that
leads to chronic rhinosinusitis (Bailey,
2014).
As for chronic rhinosinusitis, there
are goals to achieve and maintain clinical
control and prevent complications. A
controlled condition is defined as the stage
where the patient has no symptoms or
symptoms that are felt by the patient not to
interfere, and if possible together with a
healthy or nearly healthy mucosa and only
requires local treatment (Bachert et al,
2014).
Treatment for chronic rhinosinusitis
includes topical intranasal steroids, oral
antibiotics, topical antibiotics, nasal
irrigation, oral steroids or a combination of
oral antibiotics and steroids (Bose S et al,
2016).
Treatment of chronic rhinosinusitis
begins with topical steroids. In cases of SSR
without polyps, nasal irrigation can also be
done. If there is no improvement after three
months or worsening occurs, antibiotic
therapy should be considered. If treatment
pharmacologically ineffective, so surgery
should be considered. However, after
surgery, pharmacological treatment of nasal
irrigation, oral and topical steroid therapy
and antibiotic therapy should be continued
(Kluczyński L et al, 2018).
At present, nasal irrigation is
recommended as a component of standard
therapy for chronic rhinosinusitis. Daily
saline nasal irrigation can reduce symptoms
and improve quality of life in patients with
chronic rhinosinusitis. Intranasal
corticosteroid therapy remains the first line
in the management of chronic rhinosinusitis
and this therapy is combined with nasal
irrigation with isotonic saline (Sedaghat
AR, 2017).
Endoscopic Functional Sinus
Surgery (BSEF) is a minimally invasive
surgical technique performed on the
paranasal sinuses using an endoscope that
aims to restore mucociliary clearance in the
sinuses. Endoscopic Functional Sinus
Surgery can be performed in chronic
rhinosinusitis with and without nasal
polyps, which do not resolve with maximal
medical therapy, as well as an approach to
removing benign and malignant
tumors.The principle is to open and clear
the area of the osteomeatal complex that is
the source of blockage and infection so that
ventilation and sinus drenage can smoothly
return through the natural ostium. The
advantages of Functional Endoscopic
Sinus Surgery that can be obtained are the
absence of facial scars, shorter hospital
stays and maximum visualization (Lund et
al, 2010).
Indications for Functional
Endoscopic Sinus Surgery are divided into
absolute indications and relative
indications. Absolute indications such as
tumor, chronic rhinosinusitis,
complications, encephalocele,
cerebrospinal fluid leakage. While the
relative indication is chronic rhinosinusitis,
headache accompanied by facial pain,
recurrent sinusitis, nasal polyps, and sinus
mucocele, epistaxis control (Patel et al,
2016).
CONCLUSION
A 72 year old woman was referred
from a hospital in Yogyakarta to the ENT
HNS clinic of Dr. Sardjito, with complaints
of nasal blockage since 7 months ago.
Complaints are accompanied by facial pain
in the left, runny nose, and mucus in the
throat. On physical examination, the anterior
and posterior rhinoscopy examination, there
was minimal mucopurulent secretions in the
left nasal cavity. Minimal posterior nasal
drip especially found in the left posterior
pharynx on oropharyngeal examination.
Nasoendoscopic examination showed
mucopurulent discharge in the left nasal
cavity. From the CT scan, there is isodense
lesion with opacification/ calcification
fulfilled maxillary sinus.
Patient diagnosed with Chronic
Rhinosinusitis Maxillaris Sinistra. The
patient was then underwent surgical
management of FESS.
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