MANAGEMENT OF

RHINOSINUSITIS
Delfitri Munir
 Rhinosinusitis
 Rhinosinusitis is defined as inflammation of the nose and
the paranasal sinuses resulting in:
And either
≥2 MAJOR SYMPTOMS ENDOSCOPIC SIGNS of
• Polyps or
• Blockage/congestion • Mucopurulent discharge from middle
• Loss of smell meatus or
• Discharge anterior/postnasal drip • Edema/mucosal obstruction
primarily in middle meatus
• Facial pain/pressure
Or
CT CHANGES
• Mucosal changes within ostiomeatal
complex and/or sinuses

EAACI. Rhinol Suppl. 2005;18:1.

Fokkens et al. Allergy. 2005;60:583.
 Acute Rhinosinusitis
Viral rhinosinusitis/common cold
Acute rhinosinusitis/increase after 5 days
Acute rhinosinusitis/persist after 10 days
Symptoms

0 5 10 15
Days

Fokkens et al. EP3OS Guidelines. Rhinol Suppl. 2005;18:1.

Rhinosinusitis:
Intensity of Symptoms and Signs
 Acute rhinosinusitis  Adults

 Chronic rhinosinusitis  Children

 Recurrent acute rhinosinusitis

 Acute exacerbations of chronic

rhinosinusitis

Acute rhinosinusitis
Intensity of symptoms

Chronic rhinosinusitis
and signs

Recurrent acute rhinosinusitis

Acute exacerbation
of chronic rhinosinusitis

12
Weeks
 Sinus Cycle Leading to Rhinosinusitis

Secretions thicken, pH
changes
Secretions Mucosal gas metabolism
stagnate changes
Frontal sinuses

Mucosal congestion (often due Cilia and epithelium are

to viral rhinitis) or anatomic Ostiomeatal Ethmoid damaged
obstruction blocks air flow and complex sinuses
drainage
Change in host milieu
creates culture medium
for bacterial growth in
Ostium is Closed closed cavity

Maxillary
sinuses
Retained secretions cause
Mucosal thickening
tissue inflammation
creates further blockage
Bacterial infection develops
in the sinus cavity

Kennedy DW, et al. Ann Otol Rhinol Laryngol Suppl. 1995;167:22-30.

SAHP. Otolaryngol Head Neck Surg. 2000;123:S1-S32.
Anatomical Variants
 deviated nasal septum
 concha bullosa, paradoxal
 ethmoid bulla
 other middle turbinate anomalies

 Agger nasi cells

 Haller cells
Underlying Diseases:
 asthma
 cystic fibrosis
 ciliary dysmotility
 immuno-compromised:
 chemotherapy
 transplant
 immuno-deficiency
Other Etiology of Rhinosinusitis

 Dental, periapical abcess

 Cystic fibrosis
 Occupational irritants and allergens
 Drug induced, rhinitis
medicmentosa
 Atrophic rhinitis
 Fluticasone furoate

Afinitas INS pada reseptor glukokortikoid pada paru-paru manusia

Relative receptor affinity (RRA)

3000

2500

2000

1500

1000

500

0
Fluticasone Mometasone Fluticasone Beclometha- Ciclesonide Budesonide Dexamethasone
furoate furoate propionate sone-17- active
monopropionate principle

Valotis A, Högger P. EAACI. 2006, Abstract 780

Bioavailabilitas rendah
Fluticasone Furoate

25

Bioavailability of currently used INS 20%

20
% bioavailability

15
11%
10

5
0.5% 0.5% 0.5%
0
Fluticasone Fluticasone Mometasone Budesonide Flunisolide
furoate propionate furoate

Bryson HM, Faulds D. Drugs 1992;43:760–75.; Daley-Yates PT, Baker RC. Br J Clin Pharmacol 2001;51:103–5.; Daley-Yates PT et al. Eur J Clin Pharmacol 2004;60:265–8.; Allen A et al. Clin Ther 2007;29:1415–20.
 Angka Kejadian Epistaksis
Angka kejadian epistaksis pada penelitian 6–12 bulan
Study MF % BDP % TAA % FP % FF % Placebo %
duration
6 bulan1,2 9 8-15 8
(blood in the (9) (2-9) (1-2)
nasal mucosa)
12 bulan3 20 8
3 bulan4,5 17-19 23 17 11
12 bulan6* 11 6
*Durasi pengobatan tidak dispesifikasi, termasuk 513 pasien yang diobati selama ≥ 1 thn

1Van As A et al. J Allergy Clin Immunol 1993;91:1146–54; 2Banov CH et al. Ann Allergy 1994;73:240–6; 3 Rosenblut A et al. Allergy 2007;62:1071–7; 4 Drouin M et al. Ann Allergy
Asthma Immunol 1996; 77: 153 – 160; 5Mandl M, et al. Ann Allergy Asthma Immunol 1997; 79: 370 – 378; 6Baldwin CM and Scott LJ. Drugs 2008;63:1723–39

15
 Biopsi Nasal
Baseline dan setelah 12 bulan pengobatan dengan FFNS

Setelah pengobatan 12 bulan, ada pengurangan yang bermakna pada infiltrasi sel
inflamasi sub-epitel dengan FFNS dibandingkan dengan MFNS. Sama seperti MFNS, FFNS
menunjukkan tidak ada tanda atropi mukosa.

Fokkens et al. Am J Rhinol Allergy. 2012 ;26(1):36-44