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Dalam keadaan fisiologis sinus biasanya steril. Secret yang diproduksi dalam sinus dialirkan ke

rongga hidung oleh silia. Pada individu yang sehat, aliran secret dari sinus selalu searah, hal ini

untuk mencegah kembalinya secret ke sinus. Saat terjadi edema pada mukosa maka ostium akan

tersumbat yang kemudian menyebabkan obstruksi aliran saluran secret dengan tekanan negative,

yang mengarah pada infeksi bakteri.

Retained mucus, when infected, leads to sinusitis. Another mechanism hypothesizes that because

the sinuses are continuous with the nasal cavity, colonized bacteria in the nasopharynx may

contaminate the otherwise sterile sinuses. These bacteria are usually removed by mucociliary

clearance; thus, if mucociliary clearance is altered, bacteria may be inoculated and infection may

occur, leading to sinusitis. ( Cherry et al, 2004)

Data are available that support the fact that healthy sinuses are colonized. The bacterial flora of

noninflamed sinuses were studied for aerobic and anaerobic bacteria in 12 adults who underwent

corrective surgery for septal deviation.Organisms were recovered from all aspirates, with an

average of 4 isolates per sinus aspirate. The predominant anaerobic isolates were Prevotella,

Porphyromonas, Fusobacterium andPeptostreptococcus species. The most common aerobic

bacteria were S pyogenes, S aureus, S pneumonia, andH influenzae. In another study, specimens

were processed for aerobic bacteria only, and Staphylococcus species and alpha-hemolytic

streptococci were isolated. Organisms were recovered in 20% of maxillary sinuses of patients

who underwent surgical repositioning of the maxilla. (Brook et al, 2013)

In contrast, another report of aspirates of 12 volunteers with no sinus disease showed no bacterial

growth. Jiang et al evaluated the bacteriology of maxillary sinuses with normal endoscopic

findings. Organisms were recovered from 14 (47%) of 30 swab specimens and 7 (41%) of 17 of

mucosal specimens. Gordts et al reported the microbiology of the middle meatus in normal

adults and children. This study noted in 52 patients that 75% had bacterial isolates present, most

commonly coagulase-negative staphylococci (CNS) (35%), Corynebacteriumspecies (23%),and S aureus (8%) in adults. Low numbers of these species were present. In children, the most

common organisms wereH influenzae (40%),M catarrhalis (34%), and S pneumoniae (50%), a

marked difference from findings in adults. Nonhemolytic streptococci andMoraxella species

were absent in adults.

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The frequent involvement of anaerobes in chronic sinusitis may be related to the poor drainage

and increased intranasal pressure that develops during inflammation. This can decrease the

mucosal blood flow and depress ciliary action, thus reducing the intrasinus oxygen tension. The

lowering of the oxygen content and pH supports the growth of anaerobes. (Brook, 2005)

Most cases of acute rhinosinusitis are caused by viral infections associated with the common

cold. Mucosal edema leads to obstruction of the sinus ostia. In addition, viral and bacterial

infections impair the cilia, which transport mucus. The obstruction and slowed mucus transport

cause stagnation of secretions and lowered oxygen tension within the sinuses. This environment

is an excellent culture medium for viruses and bacteria. (Ann M. Aring and Miriam M. Chan,

2011)

Usually, the margins of the edematous mucosa have a scalloped appearance, but in severe cases,

mucus may completely fill a sinus, making it difficult to distinguish an allergic process from

infectious sinusitis. Characteristically, all of the paranasal sinuses are affected and the adjacent

nasal turbinates are swollen. Air-fluid levels and bone erosion are not features of uncomplicated

allergic sinusitis; however, swollen mucosa in a poorly draining sinus is more susceptible to

secondary bacterial infection.

Contrary to earlier models of sinus physiology, the drainage patterns of the paranasal sinuses

depend not on gravity but on the mucociliary transport mechanism. The metachronous

coordination of the ciliated columnar epithelial cells propels the sinus contents toward the natural

sinus ostia. Any disruption of the ciliary function results in fluid accumulation within the sinus.

Exposure to bacterial toxins can reduce ciliary function. Approximately 10% of cases of acute

sinusitis result from direct inoculation of the sinus with a large amount of bacteria. Dental

abscesses or procedures that result in communication between the oral cavity and sinus can

produce sinusitis by this mechanism. (Brook,2005).

Recent interest for biofilms has been sparked by a potential role for biofilms in this process, with

a significant body of evidence implicating them in inciting sinonasal inflammation. Biofilms are

clearly present on the sinus mucosa of Chronic rhinosinusitis (CRS) patients, and their presence

there is associated with severe disease characteristics and surgical recalcitrance. (Foreman A et

al, 2012). Bacterial biofilms consist of a complex, organized community of bacteria, which are

encased in an exopolysaccharide matrix they have produced and anchor to both biotic and abiotic

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surfaces.Biofilm bacteria exhibit an altered phenotype with respect to growth rate and gene

transcription.This configuration allows the bacteria for the evasion of host defenses and

decreased susceptibility to antibiotic therapy, but this process maintains the ability to deliberately

release planktonic bacteria, resulting in recurrent acute infections. (Zhou Bing, 2012)

Several different techniques were employed to visualise biofilms. Arguably the most convincing

method was fluorescence in situ hybridization, since this provides contrast between bacterial

DNA and host cells. Biofilms on mucosal surfaces appear as punctate staining (bacterial cells),

occasionally with some diffuse coloration, suggestive of extracellular nucleic acids. (Robert C.

Shields et al, 2013). Biofilms or biofilm-forming bacteria have been associated with

unfavourable outcomes following functional endoscopic sinus surgery (FESS). For example, the

presence of biofilms on paranasal sinus mucosa was correlated with persistent mucosal

inflammation and requirements for lengthy post-surgical follow-up periods.

The presence of bacterial biofilms in CRS patients (with/without nasal polyps) both before and

after endoscopic surgery (ESS) has been identified by advanced techniques and is associated

with an increased likelihood of unfavorable outcomes in ESS. However, the impact of biofilms

on mucosal inflammation is not fully understood. Given that patients with CRS with nasal polyps

(CRSwNP) usually have bilateral nasal polyps in the middle meatus, which may form in the

nasal cavity or paranasal sinuses, this unique character may facilitate the growth of bacteria, such

asStaphylococcus aureus. Furthermore, patients with CRSwNP are associated with a high risk of

the development of asthma. In addition, the polyp tissues usually contain a lot of eosinophils and

Th2 cytokines, such as IL-5 and IL-13, and histimine, which may promote fungal infection.

However, whether the presence of biofilm is associated with any specific clinical characteristics

in patients with CRSwNP has not been explored, particularly in Chinese patients. (Zhou Bing,

2012)

http://www.ncbi.nlm.nih.gov/pubmed/?term=Shields%20RC%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Shields%20RC%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Shields%20RC%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Shields%20RC%5Bauth%5D

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1. Cherry JD, Shapiro NL, Deville JG. Sinusitis. In: Feigin RD, Cherry JD, DemmierGJ, Kaplan SL, eds.Textbook of pediatric infectious disease. 5

thed. Philadelphia, PA:

WB Saunders; 2004:201.

2. Brook, Itzhak. 2005. Bacteriology of Acute and Chronic Ethmoid Sinusitis. J ClinMicrobiol. 2005 July; 43(7): 34793480.

3. Ann M. Aring and Miriam M. Chan, 2011. Acute Rhinosinusitis in Adults. AmericanAcademy of Family Physicians. 83(9): 1057-1063.

4. Brook, Itzhak et al. 2013. Acute Sinusitis.http://emedicine.medscape.com/article/232670-overview diakses pada 7 September

2013.

5. Foreman, A., Boase S. Psaltis A., Wormlad PJ. 2012. Role of Bacterial and Fungalbiofilms in Chronic Rhinosinusitis.Curr Allergy Asthma Rep. 2012 Apr;12(2):127-35

6. Zhou Bing. 2012. Clinical and histopathologic features of biofilm-associated chronicrhinosinusitis with nasal polyps in Chinese patients. Chinese Medical Journal.

2012;125(6):1104-1109

7. Robert C. Shields, Norehan Mokhtar, et al. 2013. Efficacy of a Marine BacterialNuclease against Biofilm Forming Microorganisms Isolated from Chronic

Rhinosinusitis.PLoS One. 2013; 8(2): e55339

http://emedicine.medscape.com/article/232670-overviewhttp://www.ncbi.nlm.nih.gov/pubmed/22322439http://www.ncbi.nlm.nih.gov/pubmed/22322439http://www.ncbi.nlm.nih.gov/pubmed/22322439http://www.ncbi.nlm.nih.gov/pubmed/?term=Shields%20RC%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Mokhtar%20N%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Mokhtar%20N%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Shields%20RC%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/22322439http://emedicine.medscape.com/article/232670-overview