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Nama : Dr. Cita Herawati Murjantyo, Sp THT-KLTempat/tgl lahir : Yogyakarta, 15 MaretPekerjaan/jabatan :

Staf Medik Fungsional RS Kanker DharmaisBagian THT – RSI Bintaro

Riwayat Pendidikan FormalSpesialis THT, FKUI/RSCM-1998Sedang pendidikan S3, Universitas Gajahmada Yogyakarta

Riwayat Pendidikan TambahanEndoscopic & Skull Base Surgery, Masterclass, Milano 2003OSAS Obstructive Sleep Apnea Syndrome/SNORING, Singapore General Hospital, 2006Head & Neck Course, Singapore General Hospital,2007European Allergic Course, Greece, 2008

PERANAN AUGMENTIN PADA TERAPI RHINOSINUSITIS

Cita HerawatiRS Premier Bintaro

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Anatomy of the sinus

Osteomeatal Complex

United Airway Disease Integrated Airway System

Same histologic & physiologic organ

Same pathology mechanism

Same analogy & hypothesis careful analysis &

interpretation

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Rhinosinusitis Definition

AAO definition-Defined as an inflammation of the nose and sinuses

Rhinosinusitis Include nasal airway

inflammation (Rhinitis)

Rhinosinusitis Symptoms

A rhinosinusitis task force in 1997 "major" criteria facial pain nasal obstruction Hyposmia purulence on examination fever

"minor" criteria Headache Fatigue dental pain cough

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Viral Infection Self Limiting Disease Unless There Is Secondary Bacterial Infection

Viral infections

Most common predisposing factors for sinusitis in children

Day care important risk Reduce viral exposure among children

Prevention Hand washing

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Distinguishing ABRS from ARS caused by viral upper respiratory infection

91. Rosenfeld RM, Andes D, Bhattacharyya N et al. Clinical practice guideline : Adult sinusitis. Otolaryngology Head & Neck Surgery; 2007; 137:S1-S31.

Term DefinitionAcute rhinosinusitis

Up to 4 weeks of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction, facial pain-pressure-fullness, or both:• Purulent nasal discharge is cloudy or colored, in contrast to the clear secretions that

typically accompany viral upper respiratory infection, and may be reported by thepatient or observed on physical examination

• Nasal obstruction may be reported by the patient as nasal obstruction,congestion, blockage, or stuffiness, or may be diagnosed by physical examination

• Facial pain-pressure-fullness may involve the anterior face, periorbital region, or manifest with headache that is localized or diffuse

Viral rhinosinusitis(VRS)

Acute rhinosinusitis that is caused by, or is presumed to be caused by, viralinfection. A clinician should diagnose VRS when:a. symptoms or signs of acute rhinosinusitis are present less than 10 days and the

symptoms are not worsening

Acute bacterial rhinosinusitis(ABRS)

Acute rhinosinusitis that is caused by, or is presumed to be caused by, bacterialinfection. A clinician should diagnose ABRS when:a. symptoms or signs of acute rhinosinusitis are present 10 days or more beyond

the onset of upper respiratory symptoms, orb. symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial

improvement (double worsening)(Adapted from ref 1)

Classification by Duration of Symptoms ACUTE – lasting up to 4 weeks, with total resolution of

symptoms

SUBACUTE – persisting more than 4 weeks, but less than 12 weeks, with total resolution of symptoms

CHRONIC – 12 weeks or more of signs / symptoms

RECURRENT ACUTE – 4 or more episodes per year, with resolution of symptoms between attacks

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AAcute Bacterial Rhinosinusitiscute Bacterial Rhinosinusitis2007

Fokkens W, Lund V, Mullol J, et al. Fokkens W, Lund V, Mullol J, et al. RhinologyRhinology 2007 (Suppl 20): 12007 (Suppl 20): 1--136. 136. web:web: www.rhinologyjounal.comwww.rhinologyjounal.com / / www.ep3os.orgwww.ep3os.org

00 55 1010 1515HariHari

Sym

ptom

sS

ympt

oms

1212MingguMinggu

Common Common ColdCold

Acute Viral Acute Viral RhinosinusitisRhinosinusitis

GejalaGejala meningkatmeningkat > 5 > 5 harihari

GejalaGejala menetapmenetap > 10 > 10 harihari

Rhinosinusitis Spectrum Based on Disease Duration

Acute Rhinosinusitis

Subacute Rhinosinusitis

Chronic Rhinosinusitis

4 weeks 12 weeks

Acute Recurrent Rhinosinusitis3x in 6 months or 4x in 12 months

Free of symptoms between episodes

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2007

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Sym

ptom

s In

tens

itySy

mpt

oms

Inte

nsity

Symptomatic TreatmentSymptomatic Treatment + + Corticosteroid intranasalCorticosteroid intranasal±± oral antibioticoral antibiotic

Common Common ColdColdAcute Viral RhinosinusisitisAcute Viral Rhinosinusisitis

Acute RhinosinusitisAcute Rhinosinusitis

Acute Rhinosinusitis TreatmentAcute Rhinosinusitis Treatment

Pathogenesis of ABRS changes from acute to chronic

In acute maxillary sinusitis S pneumoniae, H influenzae, and M catarrhalis predominate

In chronic maxillary sinusitis anaerobic bacteria are the main isolates

Peptostreptococcus, Fusobacterium, and pigmented Prevotella and Porphyromonas

β-Lactamase–producing bacteria were isolated in 46% of the patients

142. Brook I. Bacteriology of Acute and Chronic Frontal Sinusitis. Arch Otolaryngol Head Neck Surg. 2002;128:583-58.

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Chronic rhinosinusitis (CRS)

Symptom-based diagnosis may be unreliable

Patient with “sinus all the time,” chronic headache and facial “pressure,” plus “stopped up” nose; has had “innumerable” courses of antibiotics and 3 sinus operations by 2 different physicians

Computed tomography is the gold standard

Predisposing Factors In Chronic rhinosinusitis (CRS)

Host Factors Systemic Allergic rhinitis Immunodeficiency IgG subclasses IgA

Genetic/congenital cystic fibrosis, ciliary

dyskinesia

Local Anatomic obstruction Gastroesophageal reflux

Enviromental factors Microorganisms viral illness (children in

daycare) Pollutants cigarette smoke

Medications Rhinitis

medicamentosa

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Possible Strategies for Treating CRS

CRSCRS

Infectious

Allergy

TreatEtiology–– Allergen AvoidanceAllergen Avoidance– Antibiotics– Surgery

TreatEtiology–– Allergen AvoidanceAllergen Avoidance– Antibiotics– Surgery

IL-5, IL-4IL-8, IF-GM-CSF

IL-5, IL-4IL-8, IF-GM-CSF

AttenuateInflammation– Steroids– Immunotherapy– Antileukotrienes– Macrolides– Who knows what else?

AttenuateInflammation– Steroids– Immunotherapy– Antileukotrienes– Macrolides– Who knows what else?

Anatomic

Antibiotics in CRS

Should be based on culture results Endoscopic directed culture of purulent

secretions from the nasal vestibule or middle meatus correlate well with maxillary tap results

S. aureus, Anaerobes & Gram negative Pseudomona Aeruginosa

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Antibiotics

First-line amoxicillinamoxicillin--clavulanateclavulanate cephalosporin second-or third-generation

Second-line For adults The respiratory quinolones ciprofloxin, levofloxacin, gatifloxacin, and moxifloxacin

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AugmentinTM - Reliable efficacy in ABRS

The Sinus and Allergy Health Partnership (SAHP) guidelines 7 Recommend any of the following as initial therapy in adults with mild disease who have not

received antibiotics in the previous 4 to 6 weeks: amoxicillin-clavulanate, amoxicillin, cefpodoximeproxetil, cefuroxime axetil or cefdinir

Several guidelines include amoxicillin- clavulanate as a first-line/second-line treatment option (France, Germany, USA, Spain, UK, Belgium, Netherlands, Finland, Canada) 8

217. Poole MD, Portugal LG. Treatment of rhinosinusitis in the outpatient setting. Am J Med 2005;118 (7A):45S–50S.8. Klossek JM, Federspil P. Update on treatment guidelines for acute bacterial sinusitis. Int J Clin Pract 2005; 59 (2): 230–238

Conclusion

CRS is multifactorial Treatment is based on patient’s

predisposing factors Therapeutic options Prevent & treat etiology Reduce inflammatory response

Surgery Exhaustion of medical option Certainty of diagnosis

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Thank you9 April 2011