REFERAT RHINOSINUSITIS RHINOSINUSITIS KRONIS ALERGIKA
Diajukan untuk memenuhi sebagian persyaratan pendidikan profesi dokter
Pembimbing : dr. Dony Hartanto, Sp.THT, M.Kes
Disusun Oleh : IDA WULANDARI RISA AGUSTINA
J500050028 J500050035
KEPANITERAAN KLINIK ILMU PENYAKIT THT FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH SURAKARTA 201
1
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BAB I PENDAHULUAN
Sinusitis dianggap salah satu penyebab gangguan kesehatan tersering di dunia. Data dari DEPKES RI tahun 2003 menyebutkan bahwa penyakit hidung dan sinus berada pada urutan ke-25 dari 50 pola penyakit peringkat utama atau sekitar 102.817 penderita rawat jalan di rumah sakit. Survei Kesehatan Indera Penglihatan dan Pendengaran 1996 yang diadakan oleh Binkesmas bekerja sama dengan PERHATI dan Bagian THT RSCM mendapatkan data penyakit hidung dari dari 7 propin propinsi. si. Data Data dari dari Divisi Divisi Rinolo Rinologi gi Depart Departeme emen n THT RSCM Januar JanuariiAgustus 2005 menyebutkan jumlah pasien rinologi pada kurun waktu tersebut adalah 435 pasien, 69%nya adalah sinusitis. 1 Manusia mempunyai beberapa rongga di sepanjang atap dan bagian lateral rongga hidung. Rongga rongga ini diberi nama sinus yang kemudian diberi nama sesuai sesuai dengan dengan letaknya letaknya : sinus sinus maxillaris, maxillaris, sinus frontalis, frontalis, sinus sinus sphenoidal sphenoidalis is dan sinus sinus ethmoidalis ethmoidalis (sinus paranasalis). paranasalis). Seluruh Seluruh sinus sinus dilapisi dilapisi oleh epitel saluran saluran pernapasan yang mengalami modifikasi dan mampu menghasilkan mukus dan bersi bersilia, lia, sekret sekret disalu disalurka rkan n ke dalam dalam rongga rongga hidung hidung.. Pada Pada orang orang sehat, sehat, sinus sinus terutama berisi udara.2 Penyebab utamanya ialah infeksi virus yang kemudian diikuti oleh infeksi bakteri. Secara epidemiologi yang paling sering terkena adalah sinus etmoid dan maksil maksila. a. Yang Yang berbah berbahaya aya dari dari sinusi sinusitis tis adalah adalah kompli komplikas kasiny inyaa ke orbita orbita dan intrakranial. intrakranial. Komplikasi Komplikasi ini terjadi terjadi akibat akibat tatalaksana tatalaksana yang inadekuat inadekuat atau faktor predisposisi yang tak dapat dihindari. Sampai saat ini sinusitis maksila kronis masih merupakan masalah dan merupakan subjek yang selalu diperdebatkan, baik mengenai etiologi, keluhan, diagnosis maupun tindakan selanjutnya. 3 Berbeda dengan sinusitis akut, sinusitis kronis biasanya sukar disembuhkan dan hasil pengobatan sering mengecewakan, baik untuk dokter dan terutama untuk penderita. Penderita biasanya mempunyai
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predisposisi berperan dalam timbulnya penyakit ini, seperti deviasi septum, polip kavum nasi, tumor hidung dan nasofaring serta alergi. 6 Menurut Lucas seperti yang dikutip Moh. Zaman , etiologi sinusitis adalah sangat kompleks. Hanya 25% diseb isebab abka kan n
oleh leh
infe infek ksi, si,
sele selebi bih hnya nya
75% dis disebab ebabk kan
oleh oleh
aler alerg gi
dan
ketida ketidakse kseimb imbang angan an pada pada sistim sistim saraf saraf otonom otonom yang yang menimb menimbulk ulkan an peruba perubahan han- perubahan pada mukosa sinus. 3 Alergi adalah salah satu faktor prediposisi prediposisi dalam patogenesis patogenesis sinusitis sinusitis maksila kronis, yang mengakibatkan edema mukosa dan hipersekresi, keadaan ini akan menimbulkan penyumbatan muara sinus mengakibatkan stasis sekret. Hal ini sebagai medium infeksi yang akhirnya menyebabkan sinusitis kronis. 2 Penyakit alergi adalah suatu suatu penyimpang penyimpangan an reaksi tubuh terhadap paparan bahan asing yang yang menimb menimbulk ulkan an gejala gejala pada pada orang orang yang yang berbak berbakat at atopi atopi sedang sedangkan kan pada pada kebanyakan kebanyakan orang tidak menimbulkan menimbulkan reaksi apapun.3 Gangguan Gangguan alergi pada hidung ternyata lebih sering dari perkiraan dokter maupun orang awam, yaitu menyerang sekitar 10 % dari populasi umum.4 Prev Prevale alens nsii rini riniti tiss alerg alergii telah telah dike diketa tahu huii berv bervar aria iasi si anta antara ra 5 – 10 % panduduk diberbagai kota di dunia. Insiden rinitis di Bandung 1,5 % , di Sub Bagian Alergi-Imunologi Bagian THT FKUI/RSCM selama setahun 1992 adalah 1,14 % dan di RSUP H. Adam Malik Medan tahun 1993-1994 sebesar 16,44%. 5 Rinitis alergi dapat ditegakkan berdasarkan anamnesis, bila terdapat 2 atau lebih gejala seperti bersin-bersin lebih 5 kali setiap serangan, hidung dan mata gatal, ingus encer lebih dari satu jam dan hidung tersumbat, maka dinyatakan positif. Hampir 50 % diagnosis rinitis alergi dapat ditegakkan dari anamnesis saja. Oleh Oleh karena karena faktor faktor alergi alergi merupa merupakan kan salah salah satu satu penyeb penyebab ab timbul timbulnya nya sinusi sinusitis tis maksila kronis, maka perlu dilakukan tes kulit epidermal berupa tes kulit cukit (Prick tes, tes tusuk).
7
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BAB II TINJAUAN PUSTAKA
1. Defi Defini nisi si Sinu Sinusi siti tiss
Rhinosinusitis kronik didefinisikan sebagai suatu inflamasi dari hidung dan mukosa sinus paranasal dengan durasi lebih dari 12 minggu. Sinusitis diberi nama sesuai dengan dengan sinus sinus yang terkena. Bila mengenai mengenai beberapa sinus dise disebu butt mult multis isin inus usit itis is.. Bila Bila meng mengen enai ai semu semuaa sinu sinuss para parana nasa sali liss dise disebu butt pansinusitis.
Sinusi Sinusitis tis adalah adalah radang radang mukosa mukosa sinus sinus parana paranasal sal.. Perdefin Perdefinisi isi,, sinusitis kronis berlangsung selama beberapa bulan atau tahun. Sinusitis kronis berbeda dari sinusitis akut dalam berbagai aspek, umumnya sukar disembuhkan dengan pengobatan medikamentosa saja. Pada sinusitis akut, perubahan patologik membrana mukosa berupa infiltrat polimorfonuklear, konges kongesti ti vaskul vaskular ar dan deskua deskuamas masii epitel epitel permuk permukaan aan,, yang yang semuan semuanya ya revers reversibe ibel. l. Gambar Gambaran an patolo patologik gik sinusi sinusitis tis kronik kronik adalah adalah komple kompleks ks dan irreversibel irreversibel.. Mukosa Mukosa umumnya umumnya menebal, menebal, membentuk membentuk lipatan-lipat lipatan-lipatan an atau pse pseud udop opol olip ip..
Epit Epitel el
perm permuk ukaa aan n
tamp tampak ak
meng mengal alam amii
desk deskua uama masi si,,
regenerasi, metaplasi, atau epitel biasa dalam jumlah yang bervariasi pada
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menyel menyeluru uruh h terdapa terdapatt infilt infiltrat rat sel bundar bundar dan polimo polimorfo rfonuk nuklear lear dalam dalam lapisan submukosa. 10 Etiologi Etiologi dan faktor predisposisi predisposisi sinusitis sinusitis kronis cukup beragam. Pada era pre-antibiotik, sinusitis hiperplastik kronis timbul akibat sinusitis akut akut beru berula lang ng deng dengan an peny penyem embu buha han n yang yang tida tidak k leng lengka kap. p. Dala Dalam m patofisiologi sinusitis kronis beberapa faktor ikut berperan dalam siklus peristiwa peristiwa yang berulang. berulang. Polusi Polusi bahan kimia menyebabka menyebabkan n silia rusak, sehingga sehingga terjadi terjadi perubahan perubahan mukosa mukosa hidung. hidung. Perubahan Perubahan mukosa mukosa hidung hidung dapat juga disebabkan oleh alergi dan defisiensi imunologik. Perubahan mukosa hidung akan mempermudah terjadinya infeksi dan infeksi menjadi kronis kronis apabila apabila pengobatan pengobatan pada sinusitis sinusitis akut tidak sempurna. sempurna. Adanya Adanya infeksi akan menyebabkan udem konka, sehingga drainase sekret akan terganggu. Drainase sekret yang terganggu akan menyebabkan silia rusak dan begitu seterusnya. 2 Sinusitis kronik adalah sinusitis yang terjadi lebih dari 8 minggu. Pada sinusitis kronik, rongga di sekitar lubang hidung (sinus) menjadi merada meradang ng dan bengka bengkak. k. Ini mengga menggangg nggu u draina drainase se yang yang menyeb menyebabk abkan an lendir lendir menumpuk. menumpuk. Kondisi umum seperti seperti ini disebut disebut juga rinosinusitis rinosinusitis kronik. Daerah sekitar mata dan wajah mungkin akan terasa bengkak, sakit wajah atau sakit kepala. Sinusitis kronik dapat disebabkan oleh infeksi, tetapi juga dapat disebabkan oleh adanya polip hidung atau septum hidung yang bengkok (menyimpang). 8
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2. Anat Anatom omii Sinu Sinuss Para Parana nasa sall
Secara Secara embrio embriolog logik, ik, sinus sinus parana paranasal sal berasa berasall dari dari invagi invaginas nasii mukosa mukosa rongga hidung dan perkembangannya dimulai pada fetus usia 3 – 4 bulan, kecuali sinus sfenoid dan sinus frontal. Sinus etmoid dan maksila telah ada sejak anak lahir, sedangkan sinus frontalis berkembang dari sinus etmoid anterior pada anak yang berusia kurang lebih 8 tahun. Pneumatisasi sinus sfenoid dimulai pada usia 8 – 10 tahun dan berasal dari bagian posterosuperior rongga hidung. Sinus – sinus ini umumnya mencapai besar maksimal pada usia antara 15 – 18 tahun. 2 Manusia mempunyai sekitar 12 rongga di sepanjang atap dan bagian lateral rongga udara hidung; jumlah, ukuran, bentuk, dan simetri bervariasi. Sinus – sinus ini membentuk rongga di dalam beberapa tulang wajah dan diberi nama sesuai sesuai : sinus sinus maksilaris, maksilaris, sfenoidalis, sfenoidalis, frontalis, dan etmoidalis. etmoidalis. Yang terakhir terakhir biasanya berupa kelompok – kelompok sel etmoidalis anterior dan posterior yang saling saling berhub berhubung ungan, an, masing masing – masing masing kelomp kelompok ok bermua bermuara ra ke dalam dalam hidung hidung.. Seluruh sinus dilapisi oleh epitel saluran pernapasan yang mengalami modifikasi, dan mampu menghasilkan mukus, dan bersilia, sekret disalurkan ke dalam rongga hidung. Pada orang sehat, rongga terutama berisi udara. 2
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Pembagian sinus paranasalis : 11 a.
Sinus Maksila Sinus maksila merupakan sinus paranasal yang terbesar. Saat lahir sinus
maksil maksilaa bervol bervolume ume 6 – 8 ml, sinus kemudian kemudian berkem berkemban bang g dengan dengan cepat dan akhirnya mencapai ukuran maksimal, yaitu 15 ml saat dewasa. Sinus maksila berbentuk segitiga. Dinding anterior sinus ialah permukaan fasial os maksila yang disebu disebutt fossa fossa kanina kanina,, dindin dinding g posteri posteriorn ornya ya adalah adalah permuk permukaan aan infra-t infra-temp empora orall maks maksil ila, a, dind dindin ing g medi medial alny nyaa iala ialah h dind dindin ing g late lateral ral rong rongga ga hidu hidung ng,, dind dindin ing g superiornya ialah dasar orbita dan dinding inferiornya ialah prosesus alveolaris dan palatum. Ostium sinus maksila berada di sebelah superior dinding medial sinus dan bermuara ke hiatus semilunaris melalui infundibulum etmoid. Suplai darah terbanyak melalui cabang dari arteri maksilaris. Inervasi mukosa sinus melalui cabang dari nervus maksilaris. b.
Sinus Frontal Sinus Sinus fronta frontall yang yang terleta terletak k di os fronta frontall mulai mulai terbent terbentuk uk sejak sejak bulan bulan
keem keempa patt fetu fetus, s, bera berasa sall dari dari sel sel – sel rese resess ssus us fron fronta tall atau atau dari dari sel sel – sel sel infundibulum etmoid. Ukuran sinus frontal adalah 2,8 cm tingginya, lebarnya 2,4
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caro caroti tiss inte intern rna. a. Iner Inerva vasi si muko mukosa sa disu disupl plai ai oleh oleh caba cabang ng supr suprao aorb rbit ital al dan dan supratrochlear cabang dari nervus frontalis yang berasal dari nervus trigeminus. c.
Sinus Etmoid Pada orang dewasa sinus etmoid seperti piramid dengan dasarnya di
bagian posterior. Ukurannya dari anterior ke posterior 4,5 cm, tinggi 2,4 cm, dan lebarnya 0,5 cm di bagian anterior dan 1,5 cm di bagian posterior. Sinus etmoid berongga – rongga, terdiri dari sel – sel yang menyerupai sarang tawon, yang terdapat di dalam massa bagian lateral os etmoid, yang terletak diantara konka media dan dinding medial orbita. Sel – sel ini jumlahnya bervariasi antara 4 – 17 sel (rata – rata 9 sel). Berdasarkan letaknya, sinus etmoid dibagi menjadi sinus etmoid anterior yang bermuara di meatus medius dan sinus etmoid posterior yang bermuara di meatus superior. Sel – sel sinus etmoid anterior biasanya kecil – kecil dan banyak, letakn letaknya ya dibawah dibawah perlek perlekatan atan konka konka media, media, sedang sedangkan kan sel – sel sinus sinus etmoid etmoid posterior biasanya lebih besar dan lebih sedikit jumlahnya dan terletak di posterosuperior dari perlekatan konka media. Di bagian terdepan sinus etmoid anterior ada bagian yang sempit, disebut resessus frontal, yang berhubungan dengan sinus fronta frontal. l. Atap Atap sinus sinus etmoid etmoid yang yang disebu disebutt fovea fovea etmoid etmoidali aliss berbat berbatasa asan n dengan dengan lamina kribosa. Dinding lateral sinus adalah lamina papirasea yang sangat tipis dan membatasi sinus etmoid dari rongga orbita. Di bagian belakang sinus etmoid posterior berbatasan dengan sinus sfenoid. Supl Suplai ai dara darah h bera berasa sall dari dari caban cabang g nasa nasall dari dari arter arterii sphe spheno nopa pala latin tina. a. Inervasi mukosa berasal dari divisi oftalmika dan maksilaris nervus trigeminus.
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arteri arteri oftalmi oftalmiku kuss berasa berasall dari dari arteri arteri karoti karotiss intern interna. a. Yang Yang pentin penting g ialah ialah arteri arteri sphenopalatina dan ujung dari arteri palatina mayor. Bagian depan dan atas dari rongga hidung mendapat persarafan sensoris dari nervus etmoid anterior yang merupakan cabang dari nervus nasosiliaris, yang berasal dari nervus oftalmikus (nervus V – 1). Rongga hidung lainnya sebagian besar besar mendapatkan mendapatkan persarafan sensoris dari nervus nervus maksilla maksilla melalui melalui ganglion ganglion spheno sphenopal palatin atina. a. Gangli Ganglion on sphen sphenopa opalat latina ina disamp disamping ing member memberika ikan n persara persarafan fan sensoris juga memberikan persarafan vasomotor/ otonom pada mukosa hidung. Ganglion ini menerima serabut – serabut sensoris dari nervus maksila (nervus V – 2), serabut parasimpatis dari nervus petrosis superfisialis mayor, dan serabut – serabut simpatis dari nervus petrosus profundus. Ganglion sphenopalatina terletak di belakang dan sedikit diatas dari ujung posterior konka media
3. Fungsi Sinus Paranasal
11
Beberapa teori yang dikemukakan sebagai fungsi sinus paranasal antara lain : a. Sebagai pengatur kondisi udara ( air conditioning )
Sinu Sinuss berfu berfung ngsi si seba sebaga gaii ruan ruang g tamba tambaha han n untu untuk k mama mamana nask skan an dan dan mengatur kelembaban udara inspirasi. Volume pertukaran udara dalam ventilasi sinu sinuss kura kurang ng lebi lebih h 1/10 1/1000 00 volu volume me sinu sinuss pada pada tiap tiap kali kali bern bernafa afas, s, sehi sehing ngga ga dibutuhkan beberapa jam untuk pertukaran udara total dalam sinus b. Sebagai panahan suhu (thermal insulators )
Sinus paranasal berfungsi sebagai (buffer) panas, melindungi orbita dan
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Sinus Sinus mungki mungkin n berfun berfungsi gsi sebaga sebagaii rongga rongga untuk untuk resona resonansi nsi udara udara dan mempengaruhi kualitas udara. Akan tetapi ada yang berpendapat, posisi sinus dan ostiumnya tidak memungkinkan sinus berfungsi sebagai resonansi yang efektif. e. Sebaga Sebagaii pereda peredam m peruba perubahan han teka tekanan nan udara udara Fungsi ini akan berjalan bila ada perubahan tekanan yang besar dan mendadak, misalnya pada waktu bersin dan beringus. f. Memb Memban antu tu pro produ duks ksii muku mukuss Mukus yang dihasilkan oleh sinus paranasal memang jumlahnya kecil dibandingkan dengan mukus dari rongga hidung, namun efektif untuk membersihkan partikel yang turut masuk dalam udara. 4. Pato Patofi fisi siol olog ogii
Dalam patogenesis penyakit alergi termasuk rinitis alergi, dapat dibedakan ke dalam fase sensitisasi dan elisistasi yang dapat dibedakan atas tahap aktifasi dan tahap efektor.20 Fase sensitisasi
Semua mukosa hidung manusia terpapar oleh berbagai partikel seperti tepung sari, sari, debu, debu, serpih serpih kulit kulit binatan binatang g dan protei protein n lain lain yang yang terhir terhirup up bersam bersamaa inhalasi udara napas. Alergen/ antigen yang terdeposit pada mukosa hidung tersebut kemudian diproses oleh makrofag / sel dendrit yang berfungsi sebagai fagosit dan sel penyaji antigen (APC) menjadi peptida pendek yang terdiri dari atas 7-14 asam amino yang berikatan dengan tempat pengenalan antigen dari komplek MHC klas II. Sel APC ini akan mengalami migrasi ke adenoid, tonsil atau limfonodi. Pada penderita atopik, reseptor sel T (TCR) pada limposit Tho
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mempunyai bakat alergi (atopik) dan presentasi alergen oleh sel-sel penyaji antigen (APC) kepada sel B disertai adanya pengaruh sitokin IL-4 memacu sel B untu untuk k memp mempro rodu duks ksii IgE IgE yang yang teru teruss bert bertam amba bah h juml jumlah ahny nya. a. IgE IgE yang yang diproduksi berada bebas dalam sirkulasi dan sebagian diantaranya berikatan dengan reseptornya (FCE-RI) dengan afinitas tinggi dipermukaan sel basofil dan sel mast. Sel mast kemudian masuk ke venula postkapiler di mukosa yang kemudian keluar dari sirkulasi dan berada dalam jaringan termasuk di mukosa dan sub-mukosa hidung. Dalam keadaan ini maka seseorang dikatakan dalam keadaa keadaan n sensit sensitif if atau atau sudah sudah tersen tersensit sitisa isasi. si. Dalam Dalam fase fase ini seseor seseorang ang dapat dapat belum mempunyai gejala rinitis alergi atau penyakit yang lain, tetapi jika dilakukan tes kulit dapat memberikan hasil yang positif.
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Fase elisitasi 1.
Tah Tahap akt aktifas ifasii
Pada seorang atopik yang sudah sensitif/ sensitif/ tersensitisa tersensitisasi si jika terjadi paparan paparan ulang
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ini adalah adalah terbent terbentukn uknya ya mediat mediator or lipid lipid yang yang tergol tergolong ong dalam dalam newly newly formed formed seperti prosta prostagla glandi ndin n D2 (PGD2) (PGD2),, leukot leukotrie rien n C4 (LTC-4 (LTC-4), ), platelet mediators seperti
activating activating factors (PAF) dan exositosis granula sel mast yang berisi mediator kimia yang disebut pula sebagai preformed mediator seperti histamin, tryptase dan bradikinin.20 Histamin merupakan mediator kimia penting yang dilepaskan sel mast karena histamin dapat menyebabkan lebih dari 50% gejala reaksi alergi hidung ( bersin, bersin, rinore, rinore, hidung hidung gatal dan hidung tersumbat tersumbat ). Histamin Histamin mempunyai efek lang langsu sung ng pada pada endo endote tell
yait yaitu u
meni mening ngka katk tkan an perm permea eaib ibil ilit itas as kapi kapile lerr
yang yang
menyebabkan proses transudasi yang memperberat gejala rinore. Ikatan histamin pada reseptor saraf nocicetif tipe C pada mukosa hidung yang berasal dari N-V menyebabkan rasa gatal di hidung dan merangsang timbulnya serangan bersin. Efek histamin pada kelenjar kelenjar karena karena aktifasi aktifasi reflek parasimpatis parasimpatis mempunyai mempunyai efek mening meningkat katkan kan sekres sekresii kelenj kelenjar ar yang yang menyeb menyebabk abkan an gejala gejala rinore rinore yang yang serous serous.. Sela Selain in itu itu hist histam amin inee juga juga meny menyeb ebab abka kan n geja gejala la hidu hidung ng ters tersum umba batt karen karenaa menyeb menyebabk abkan an vasodi vasodilat latasi asi pembul pembuluh uh darah darah mukosa mukosa hidun hidung g terutam terutamaa konka. konka. Gejala yang segera timbul setelah paparan alergen disebut reaksi fase cepat atau
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eosinofil eosinofil dari tengah tengah ke tepi dinding dinding pembuluh darah dan mulai berikatan berikatan secara revers reversibe ibell dengan dengan endote endotell yang yang mengal mengalami ami inflam inflamasi asi (rolling) yang yang diikut diikutii perlekatan pada dinding pembuluh darah yang diperantarai oleh interaksi molekul adesi adesi endote endotell sepert sepertii ICAM-1 ICAM-1 ( inter dan VCAM VCAM-1 -1 inter cell cell adhesi adhesi molecul molecul-1 -1 ) dan (vascular cell adhesi yang bersif bersifat at spesif spesifik ik terhad terhadap ap perlek perlekatan atan sel eosino eosinofil fil karena karena sel molekul-1 ) yang eosino eosinophi phill mengek mengekspr spresi esikan kan VLA-4 VLA-4 yang yang akan akan berika berikatan tan dengan dengan VCAM-1 VCAM-1.. ICAM-1 juga diekspresikan oleh sel epitel mukosa hidung penderita RA yang mendapatkan paparan alergen spesifik terus-menerus dan menjadi dasar konsep adanya minimal persistent yang terliha terlihatt pada pada rinita rinitass alergi alergi persistent inflamation inflamation (MPI) yang terhadap tungau debu rumah (TDR) dalam keadaan bebas gejala (Suprihati, 2006). Eosin Eosinofi ofill pertam pertamaa kali kali diluki dilukiska skan n oleh oleh Paul Paul Erlich Erlich 1879 1879 berdas berdasark arkan an perila perilaku ku spesif spesifik ik terhad terhadap ap pengec pengecatan atan.. Sekara Sekarang ng eosino eosinofil fil dengan dengan peran peran proproinflamasi dan peran pentingnya pada penyakit alergi kronik semakin jelas dikenal dan merupakan subyek penelitian dasar dan terapi. Eosinofil berasal dari sumsum tulang berupa progenitor, kemudian berada dalam darah tepi dan juga ditemukan di mukosa hidung penderita rhinitis alergi. Dalam darah tepi eosinofil merupakan
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Hist Histam amin in meru merupa paka kan n medi mediat ator or utam utamaa terja terjadi diny nyaa bers bersin in.. Bers Bersin in umum umumny nyaa merupakan gejala RAFC, berlangsung selama 1-2 menit pasca terkena pacuan alergen alergen dihubung dihubungkan kan dengan dengan degranulasi degranulasi mastosit mastosit (terlepasnya (terlepasnya histamin), histamin), dan hanya kadang-kadang terjadi pada RAFL. Bersin disebabkan stimulasi reseptor H1 pada ujung saraf vidianus (C fiber nerve ending). Peptida endotelin-1 yang dioleskan pada mukosa hidung menyebabkan bersin. 15 2. Gatal-gatal (pruritus) Gatal-gatal merupakan kondisi yang mekanismenya tidak sepenuhnya diketahui dengan baik. Diduga berbagai mediator bekerja pada serabut saraf halus C tak bermyelin (unmyelinated ) dekat bagian basal, epidermis,atau mukosa, mukosa, yang Dapat menimbulkan rasa gatal khusus, yang disalurkan secara lambat sepanjang neuron
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kombinasi proses penurunan permeabilitas vaskuler, hipersekresi kelenjar mukosa hidung ipsilateral, dan akibat refleks kelenjar mukosa hidung kontralateral. Pacuan hidung dengan leukotriene dan bradikinin juga menyebabkan beringus melalui mekanisme peningkatan permeabilitas vaskuler dan hipersekresi kelenjar. Mediator lain yang juga berperan pada proses beringus(ECP,PAF,LTC4,Substance beringus(ECP,PAF,LT C4,Substance P dan VIP). 15 4. Buntu hidung (nasal congestion) Buntu hidung pada rinitis alergi merupakan kemacetan aliran udara yang tidak menetap, tetapi terjadi temporer akibat kongesti sementara yang bersifat vasodilatasi vaskuler. Mekanisme vasodilatasi ini diperantarai reseptor-H1, yang berakibat pelebaran cavernous venous sinusoid dalam mukosa konka, sehingga
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Perubahan/polarisasi sel Th0 menjadi sel Th1 atau Th2 dipengaruhi oleh jenis antigen yang merangsang, dosis antigen, tipe sel penyaji antigen yang terlibat, lingkungan mikro sitokin yang ada dan sinyal kostimulator yang diterima sel T serta faktor genetik. Pada infeksi intrasel dihasilkan satu set sitokin yang disebut sitokin tipe 1 yang diproduksi antara lain oleh sel Th1 yaitu IFN-∂ dan IL-2. Penelitian lebih lanjut ditemukan berbagai sitokin lain seperti IL-4, IL-5, IL-9 dan IL-13 yang diproduksi oleh sel Th2. Sitokin IFN-∂ dianggap sebagai prototipe sitokin Th1 sedangkan IL-4 merupakan protipe sitokin Th2. Pada individu yang atopik, sel T CD4+ (Th0) cenderung akan mengalami polarisasi menjadi sel Th2 yang akan melepaskan kombinasi khas berbagai sitokin yang disebut pula sebagai sitokin tipe 2 antara lain antara lain IL-3, IL-4, IL-5, IL-
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meru merupa paka kan n sumb sumber er utam utaman anya ya adal adalah ah sel-s sel-sel el dend dendri ritt yang yang memp mempro rose sess dan dan menyaj menyajika ikan n antige antigen n terlaru terlarutt ( soluble pada sel sel T. Sel Sel dend dendrit rit meru merupa paka kan n sel sel soluble ) pada penyaji antigen kunci yang mengaktifkan sel T naive dan dapat dikatakan sel dendrit merupakan pengatur diferensiasi sel Th1. Peran tersebut terutama setelah dendrit mengalami maturasi akibat paparan mikroba atau sinyal bahaya kuat yang lain lain . Sel dendri dendritt yang yang sudah sudah matur matur berkur berkurang ang kemamp kemampuan uan endosi endositos tosisn isnya, ya, sedang sedangkan kan kemamp kemampuan uan presen presentas tasii antige antigenny nnyaa mening meningkat kat dengan dengan mengub mengubah ah ekspresi reseptor, berada di limfonodi regional dan meningkatkan produksi sitokin imunoregu imunoregulator lator termasuk termasuk IL-12. IL-12. Sinyal Sinyal bahaya bahaya ditransduk ditransduksikan sikan oleh tool tool like like
receptor (TLR) yang diekspresikan pada sel dendrit dan sistem imun lain. Sinyal bahaya ini cenderung memacu respon imun Th1 dengan memacu sel dendrit untuk
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Sitokin Th2 diduga merupakan inhibitor IL-12, tetapi hubungan antara sitokin Th2 dengan IL-12 sebenarnya lebih kompleks. Misalnya IL-4 dan IL-13 akan akan meneka menekan n produk produksi si IL-12 IL-12 bila bila kedua kedua sitoki sitokin n tersebu tersebutt ditamb ditambahk ahkan an saat saat stimulasi monosit tetapi preinkubasi yang lama dengan kedua sitokin tersebut (IL4 dan IL-13) IL-13) akan memicu memicu produk produksi si IL-12 IL-12 yang yang tinggi tinggi.. Mediato Mediatorr lain yang penting pada penyakit alergi, yaitu PGE2 dan histamin, ternyata juga mempunyai efek menekan produksi IL-12. Heterogenitas sel Th (Th1 dan Th2) sekarang dapat diterima secara luas karena perbedaan tersebut menjelaskan penyimpangan imunitas yaitu hubungan timbal timbal balik balik antara antara imunit imunitas as humora humorall dan selule selulerr dan menjela menjelaska skan n terjad terjadiny inyaa penyakit alergi sebagai akibat produksi berlebihan oleh sel Th2. Sementara itu
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Antigen yang membangkitkan reaksi hipersensitivitas tipe segera disebut alergen. Antigen Antigen yang membangkitkan membangkitkan reaksi hipersensiti hipersensitivitas vitas adalah protein protein atau zat kimia yang terikat protein terhadap mana individu atopi bersangkutan terpapar secara kronik. Pemaparan antigen sebelumnya sebelumnya secara alami merupakan merupakan faktor penti penting ng yang yang akan akan menent menentuka ukan n tinggi tingginya nya kadar kadar IgE spesif spesifik. ik. Secara Secara umum umum
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Reaksi imunologi yang terjadi ini tidak menguntungkan tubuh. Reaksi ini dapat bersifat sementara atau menetap tergantung dari daya eliminasi Ag oleh tubuh . 20
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peningkatan p C02 dan gangguan PH serta pembengkakan mukosa hidung dan akhi akhirn rnya ya menu menuru runk nkan an fung fungsi si pemb pember ersi siha han n muko mukosi sili liar ar (Bus (Busqu quet etss ,200 ,2006 6 ; Ballenger , 1994; Wilma ,2007). Obstruksi ostium sinus menyebabkan retensi lendir dan menurunkan kandungan oksigen, peningkatan pCO2, menurunkan pH, mengurangi aliran darah mukosa. Pembengkakan membran mukosa juga akan
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b. b.
Aler Alergi gi : reak reaksi si ale alerg rgii terj terjad adii di jal jalan an naf nafas as dan dan cav cavit itas as sin sinus us yan yang g
meng mengha hasi silk lkan an edem edemaa dan dan infl inflam amas asii di memb membra rana na muko mukosa sa.. Edem Edemaa dan dan inflam inflamasi asi ini menyeb menyebabk abkan an blokad blokadee dalam dalam pembuk pembukaan aan cavita cavitass sinus sinus dan membuat daerah yang ideal untuk perkembangan jamur, bakteri, atau virus.
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