CORRELATION OF INCREASED SINUSITIS AND URBAN AIR POLLUTION

*Sunali S. Khanna1 and A. S. Gharpure2

Department of Oral Medicine and Radiology, Nair Hospital Dental College, Maharashtra, Mumbai
2
Nair Hospital Dental College, Maharashtra, Mumbai
*Author for Correspondence
ABSTRACT
Increased level of air-pollution in urban areas throughout the world has led to
deplorable effects on health of the inhabitants of metropolitan cities. High levels
of Sulphur Dioxide (SO2), Nitrogen Dioxide, (NO2), Ozone (O3), Carbon
Monoxide (CO), Ammonia (NH3) and Particulate Matter (PM10) in developed
regions have skyrocketed respiratory disorders, notably maxillary sinusitis. The
high incidence of chronic maxillary sinusitis in Mumbai has caused great
discomfort to the people affected. Lack of proper air pollution regulation and
general unawareness has escalated the problem. The fact that its cure depends
not only on improved medical treatment but also on reduction of environmental
air pollution should be brought to the forefront. The promotion of awareness in
the general population coupled with execution of comprehensive environmental
programmers is the need of the hour.
Key Words: Chronic Maxillary Sinusitis, Air Pollution and Urban Population
INTRODUCTION
Air pollution is defined as the introduction of chemicals, particulates, or
biological materials into the atmosphere that cause discomfort, disease, or death
to humans, damage other living organisms such as food crops, or damage the
natural environment or built environment. Urbanization and rapid growth and
development have catalyzed a multifold rise in levels of pollution in our
metropolitan cities. Increased consumption of fuels to meet the ever increasing
demands of the growing population coupled with increased industrial growth has
adversely affected the air quality, especially in commercial hubs like Mumbai.
Increase in automobiles, factories and domestic activities have chocked the city of
its clean and pure air. This has led to people suffering from a host of diseases
ranging from rhinitis, sinusitis to increasing risks of more severe problems like
cerebrovascular, ischemic heart diseases, heart rhythm, heart failure, chronic
obstructive pulmonary disease, and respiratory infection (Dominici et al., 2006).

The association that air pollution leads to serious negative impacts on health has
already been demonstrated (Shrivastava & Kumar, 2002).

AIR QUALITY MONITORING

Air quality data generated by the Central Pollution Control Board (CPCB) for
2007 under the National Air Quality Monitoring Programme (NAMP) presents
deadly facts about air pollution levels in Indian cities. The revised National
Ambient Air Quality Standards (NAAQS) has set the limit for the five gaseous
pollutants namely, Sulphur Dioxide (SO2), Nitrogen Dioxide (NO2), Ozone (O3),
Carbon Monoxide (CO), Ammonia (NH3) and Particulate Matter (PM10).
Growth of agriculture sector, industries and associated developmental activities
are generally leading to a rise in the emission of these gasses (Seiler & Crutzen,
1980). During 2007 only 2 per cent cities have low air pollution on the basis of
PM10 levels. In about 80 per cent of cities (of a total of 127 cities/towns
monitored under the NAMP) at least one pollutant exceeded the annual average
ambient air quality standards. This has serious public health implications (Centre
for Science and Pollution in Indian Cities Air Pollution, 2013). In the city of
Mumbai, the levels of SO2 and NO2 are within limits, as of the year 2008, thanks
to the more stringent rules set by the government, regarding purity of petroleum
fuels and more conversion of cars to CNG gases. However there has been an
exponential rise in PM from 2006 to 2008 which it a cause of great concern
(Central Pollution Control Board, India, 2013).
PREVELANCE OF MAXILLARY SINUSITIS
The presence of pollutants in air is known to cause respiratory diseases in people,
especially children. Air pollution is known to be a contributing factor in the cause
of sinusitis (Roberts, 2007). It is estimated that 134 million Indians suffer from
chronic sinusitis, the symptoms of which include, but are not limited to,
debilitating headaches, fever and nasal congestion and obstruction. The National
Institute of Allergy and Infectious Diseases' (NIAID) estimate does not even take

into account those of us who suffer from acute sinusitis. Among Indians this
disease is more widespread than diabetes, asthma or coronary heart disease.
One in eight Indians suffer from chronic sinusitis caused by the inflammation of
the nasal and throat lining, which results in the accumulation of mucus in the
sinus cavity, and pressure build-up in the face, eyes and brain. Various studies
show that the urban population is more prone to maxillary sinusitis mainly
because of higher occupation and industrial air pollution in cities as compared to
rural areas (Lewis et al., 1995). Thus, this disease is likely to be higher in
Mumbai given the pollution levels and unhealthy lifestyle of its citizens. (The
National Institute of Allergy and Infectious Diseases, 2013)

MECHANISM OF ACTION OF POLLUTANTS

Pollutants may contribute to sinusitis through several mechanisms. Deposition of
irritant particles in the mucous blanket during respiration can increase the
relative concentration to which the mucous membrane is exposed, resulting in
direct chemical and physical irritation. This subsequently promotes the
inflammatory process. (Trevino, 1996) The irritant effects of these chemicals may
also induce neurogenic inflammation through vasodilation, tissue oedema, and
leukocyte influx. Specifically, neuropeptides such as substance P from
unmyelinated sensory fibers have been implicated (Nadel, 1991). Pollutants may
also impair muco-ciliary clearance through alterations in mucus viscosity,
inhibition of ciliary function, and increases in epithelial permeability. The typical
chemical components of outdoor pollution have been shown to increase
neutrophil counts in nasal lavage specimens (Peden et al., 1995). The mucus
plays a role in filtering these foreign particles. Sometimes air pollution can
irritate the mucous membrane blanket and the cilia that move it. The saturation of
harmful particles can cause inflammation and swelling. This disruption of the
mucus can have an effect on the draining sinuses and they may become clogged
and obstructed which can lead to sinusitis. Furthermore, harmful particles that
remain in the nose and sinuses can irritate the delicate lining and cause damage
to them. This also results in lowered functional capacity, making the distal part of

the respiratory tract more vulnerable to high concentration of these gases

(Caldern-Garcidueas et al., 2001). Sulfur dioxide is known to cause nasal
congestion in pediatric patients along with increase in both mast cells and
lymphocytes in nasal lavage fluids. Ozone gas causes nasal congestion, increased
levels of histamine, neutrophils, eosinophils, and mononuclear cells in nasal
lavage fluid. Formaldehyde in sufficient concentrations causes upper airway
irritation (Koltai, 1994).

DIAGNOSIS AND TREATMENT OF MAXILLARY SINUSITIS

The clinical diagnosis of maxillary sinusitis in based on the various symptoms
presented. The most common symptoms involve nasal discharge, fullness of face
and pain on bending forward. Intraoral symptoms include pain in the premolarmolar teeth on the affected side and sometimes, paresthesia/anesthesia of the
gingiva and mucosa. On certain occasions, a patient may complain of expansion
of the alveolar process of maxilla and problems with the dental occlusion.
Although patients may have disturbances of the maxillary sinus, they frequently
first seek professional dental service in the belief that the pain they experience is
of dental origin. Symptoms of maxillary sinusitis are divided into two components,
major factors and minor factors. Major factors include facial pain, facial
congestion/ fullness, nasal drainage/discharge, postnasal drip, nasal obstruction,
hyposmia/anosmia, fever and purulence on nasal endoscopy. Minor factors
include headache, maxillary dental pain, cough, halitosis, fatigue, ear pain,
pressure or fullness, fever. Fever is a major factor only in the acute stage. Either
two major factors, or one major and two minor, are required for a diagnosis of
sinusitis (Miloro, 2004). Various investigations can be performed to aid in
diagnosis of sinusitis. Nasal endoscopy is one such useful procedure. Purulence
on nasal endoscopy is diagnostic of sinusitis (Carson et al., 1994). Radiography is
one of the best investigations to study Maxillary sinusitis (Varonen et al., 2000).
Computed Tomography (CT) is the examination of choice to evaluate sinusitis
(Anzai & Yueh, 2003 and Mafee et al., 2006). However, the problem with CT is
the high level of exposure and cost to the patient. Alternatives to CT such as OPG

(Orthopantomography) and Walters View are preferred because of their lower

cost and patient exposure. Radiographic appearance of maxillary sinusitis shows
primarily an increase in mucosal edema. There may be presence of opacification
in the lining. Sometimes a thickened hyperplastic mucosa can be appreciated. On
certain occasions radio-opaque fluid in the affected sinus may be appreciated
(Wald et al., 1981). A study done verifying the authenticity of OPG in diagnosis of
maxillary sinus infection showed that the mean sensitivity and specificity of
panoramic radiography were 81.0% and 85.6%, respectively. In another study,
chronic maxillary sinusitis was studied in 37 patients, out of which 32
demonstrated radiographic changes (Cho & Jung 2008.) Thus, radiographic
examination is sufficient in diagnosis of maxillary sinusitis keeping in mind its
cheap cost and lower exposure level.
Antibiotic medications are used to treat acute sinusitis. Suitable antibiotics
include sulfa antibiotics, amoxicillin, and a variety of cephalosporins. These
medications are usually given for about two weeks, but may be given for even
longer periods of time. Decongestants, or the short-term use of decongestant nose
sprays, can be useful.
Acetaminophen and ibuprofen can decrease the pain and headache associated
with sinusitis. Also, running a humidifier can prevent mucus within the nasal
passages from drying out uncomfortably, and can help soothe any accompanying
sore throat or cough. Chronic sinusitis is often treated initially with antibiotics.
Steroid nasal sprays may be used to decrease swelling in the nasal passages. If an
anatomic reason is found for chronic sinusitis, it may need to be corrected with
surgery. If a surgical procedure is necessary, samples are usually taken at the
same time to allow identification of any organisms present which may be causing
infection Prevention involves the usual standards of good hygiene to cut down on
the number of colds an individual catches. During the winter, it is a good idea to
use a humidifier. Avoiding exposure to cigarette smoke, identifying and treating
allergies

may

help

prevent

sinus

infections.

Otolaryngology-Head and Neck Surgery, 2013)

(American

Academy

of

CONCLUSION
A complex environmental problem like air pollution when ignored beyond a limit
has far reaching effects on the health of the population. Several studies have
proved that improved air quality shows lower prevalence of sinusitis
(Bhattacharyya, 2009). It is of importance that we tackle such grave issues with
swift and effective measures. The united efforts of the community would curb the
ill-effects of pollution and will help to reduce the severity, if not completely
eliminate, environment related disorders like maxillary sinusitis.
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Cho BH & Jung YH (2008). The value of panoramic radiography in assessing
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The National Institute of Allergy and Infectious Diseases (NIAID). Available at
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Trevino RJ (1996). Air pollution and its effect on the upper respiratory tract and
on allergic rhinosinusitis. Journal of the American Medical Association
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Wald IR, Milmoe GJ, Bowen A, Ledesma-Medina J, Salamon N & Bluestone
CD (1981). Acute Maxillary Sinusitis in Children. New England Journal of
Medicine, 304 749-754.

HUBUNGAN PENINGKATAN SINUSITIS DAN PENCEMARAN UDARA PERKOTAAN

*Sunali S. Khanna1 and A. S. Gharpure2
1
Department of Oral Medicine and Radiology, Nair Hospital Dental College, Maharashtra, Mumbai
2
Nair Hospital Dental College, Maharashtra, Mumbai
*Author for Correspondence
Abstrak
Peningkatan tingkat polusi udara di daerah perkotaan di seluruh dunia telah
menyebabkan efek buruk pada kesehatan penduduk kota-kota metropolitan.
Tingginya kadar Sulfur Dioksida (SO2), Nitrogen Dioksida, (NO2), Ozon (O3),
Karbon Monoksida (CO), Amonia (NH3) dan Particulate Matter (PM10) di
daerah-daerah maju telah meningkatkan gangguan pernapasan, terutama sinusitis
maksilaris. Tingginya angka kejadian sinusitis maksilaris kronis di Mumbai telah
menyebabkan ketidaknyamanan besar kepada orang-orang yang terkena dampak.
Kurangnya regulasi polusi udara yang tepat dan ketidaksadaran umum telah
meningkatkan masalah. Fakta bahwa pengobatan tidak hanya bergantung pada
peningkatan perawatan medis tetapi juga pada pengurangan polusi udara
lingkungan harus dibawa ke permukaan. Promosi kesadaran pada masyarakat
umum disertai dengan pelaksanaan programmer lingkungan yang komprehensif
merupakan hal yang dibutuhkan pada saat ini.
Kata Kunci: Sinusitis Maksilaeris Kronis, Polusi Udara dan Penduduk Perkotaan
PENDAHULUAN
Polusi udara didefinisikan sebagai pengenalan bahan kimia, partikulat, atau bahan
biologis ke atmosfer yang menyebabkan ketidaknyamanan, penyakit, atau
kematian pada manusia, kerusakan organisme hidup lainnya seperti tanaman
pangan, atau merusak lingkungan alami maupun buatan.
Urbanisasi serta pertumbuhan dan perkembangan yang cepat telah memicu
kenaikan berlipat ganda dalam tingkat polusi di kota-kota metropolitan kita.
Peningkatan konsumsi bahan bakar untuk memenuhi tuntutan pertumbuhan
populasi ditambah dengan peningkatan pertumbuhan industri juga berdampak
buruk terhadap kualitas udara, terutama di pusat-pusat perdagangan seperti
Mumbai. Peningkatan automobil, pabrik dan kegiatan domestik telah merusak
kebersihan dan kemurnian udara kota. Hal ini menyebabkan orang menderita
sejumlah penyakit mulai dari rhinitis, sinusitis hingga peningkatan risiko masalah
yang lebih berat seperti masalah pada serebrovaskular, penyakit jantung iskemik,
irama jantung, gagal jantung, penyakit paru obstruktif kronik, dan infeksi saluran

pernapasan (Dominici et al., 2006). Hubungan bahwa polusi udara menyebabkan

dampak negatif serius pada kesehatan telah dibuktikan (Shrivastava & Kumar,
2002).

MONITORING KUALITAS UDARA

Data kualitas udara yang dihasilkan oleh

Central Pollution Control Board

(CPCB) untuk tahun 2007 di bawah National Air Quality Monitoring Programme
(NAMP) menyajikan fakta-fakta mematikan tentang tingkat polusi udara di kotakota India. National Ambient Air Quality Standarts (NAAQS) telah menetapkan
batas untuk lima polutan gas yaitu, Sulfur Dioksida (SO2), Nitrogen Dioksida
(NO2), Ozon (O3), Karbon Monoksida (CO), Amonia (NH3) dan Particulate
Matter (PM10). Pertumbuhan sektor pertanian, industri dan kegiatan pembangunan
yang terkait umumnya mengarah ke peningkatan emisi gas-gas tersebut (Seiler &
Crutzen, 1980). Selama tahun 2007 hanya 2 persen kota yang memiliki polusi
udara rendah berdasarkan tingkat PM10. Pada sekitar 80 persen dari seluruh kota
(total 127 kota / kota dipantau di bawah NAMP) setidaknya satu polutan melebihi
standar kualitas udara ambien rata-rata tahunan. Hal ini memiliki implikasi serius
pada kesehatan masyarakat (Centre for Science and Pollution in Indian Cities Air
Pollution, 2013). Di kota Mumbai, tingkat SO2 dan NO2 pada tahun 2008 masih
berada dalam batas standar, berkat aturan yang lebih ketat yang ditetapkan oleh
pemerintah mengenai kemurnian bahan bakar minyak bumi dan lebih banyak
konversi bagi mobil menjadi gas CNG. Namun telah terjadi kenaikan
eksponensial dalam PM pada tahun 2006 hingga 2008 yang menjadi masalah
besar (Central Pollution Control Board, India, 2013).

ANGKA KEJADIAN SINUSITIS MAKSILARIS

Kehadiran polutan di udara diketahui menyebabkan timbulnya penyakit
pernafasan pada masyarakat, terutama anak-anak. Polusi udara diketahui menjadi
faktor penyebab dalam timbulnya sinusitis (Roberts, 2007). Diperkirakan 134 juta
orang India menderita sinusitis kronis, dimana gejala yang termasuk meliputi sakit
kepala hebat, demam dan hidung tersumbat dan obstruksi. Perkiraan The National

Institute of Allergy dan Infectious Diseases (NIAID) tidak memperhitungkan

mereka yang menderita sinusitis akut. Di antara orang-orang India penyakit ini
lebih tersebar luas daripada diabetes, asma ataupun penyakit jantung koroner.
Satu dari delapan orang India menderita sinusitis kronis yang disebabkan oleh
peradangan pada lapisan hidung dan tenggorokan, yang menimbulkan akumulasi
lendir di rongga sinus, dan peningkatan tekanan di wajah, mata dan otak. Berbagai
studi menunjukkan bahwa penduduk perkotaan lebih rentan terhadap sinusitis
maksilaris terutama karena kependudukan dan polusi udara industri yang lebih
tinggi di kota-kota dibandingkan dengan daerah pedesaan (Lewis et al., 1995).
Dengan demikian, penyakit ini cenderung lebih tinggi di Mumbai mengingat
tingkat polusi dan gaya hidup tidak sehat warganya. (The National Institute of
Allergy dan Infectious Diseases, 2013)

MEKANISME AKSI DARI POLUTAN

Polutan dapat menyebabkan sinusitis melalui beberapa mekanisme. Deposisi
partikel iritan dalam selimut lendir selama respirasi dapat meningkatkan
konsentrasi relatif pada selaput lendir yang terkena, sehingga menimbulkan iritasi
fisik dan kimiawi secara langsung. Hal ini kemudian mendorong proses inflamasi
(Trevino, 1996). Efek iritan bahan kimia tersebut juga menyebabkan peradangan
neurogenik melalui vasodilatasi, edema jaringan, dan influks leukosit. Secara
spesifik, neuropeptida seperti substansi P dari serabut sensorik tidak
termyelinisasi telah terlibat (Nadel, 1991). Polutan juga dapat mengganggu mucociliary clearance melalui perubahan dalam

viskositas lendir, penghambatan

fungsi silia, dan peningkatan permeabilitas epitel. Komponen kimiawi khas polusi
luar ruangan telah terbukti meningkatkan jumlah neutrofil dalam spesimen secret
(Peden et al., 1995).
Lendir berperan dalam menyaring partikel-partikel asing. Kadang-kadang polusi
udara dapat mengiritasi selaput lendir dan selimut silia yang memindahkan
partikel-partikel tersebut. Saturasi partikel berbahaya dapat menyebabkan
peradangan dan pembengkakan. Gangguan lendir ini dapat memiliki efek pada
pengeringan sinus dan dapat menjadi sumbatan dan hambatan yang dapat

menyebabkan timbulnya sinusitis. Selanjutnya, partikel berbahaya yang tetap

berada di dalam hidung dan sinus dapat mengiritasi menyebabkan kerusakan pada
lapisan halus. Hal ini juga menimbulkan penurunan kapasitas fungsional,
membuat bagian distal dari saluran pernapasan lebih rentan terhadap tingginya
konsentrasi gas-gas ini (Caldern-Garcidueas et al., 2001).
Sulfur dioksida diketahui menyebabkan hidung tersumbat pada pasien anak
seiring dengan peningkatan sel mast dan limfosit dalam cairan lavage nasal. Gas
ozon menyebabkan hidung tersumbat, peningkatan kadar histamin, neutrofil,
eosinofil, dan sel-sel mononuklear dalam cairan

sekret nasal. Formaldehida

dalam konsentrasi yang cukup menyebabkan iritasi saluran napas atas (Koltai,
1994).

DIAGNOSIS DAN PENGOBATAN SINUSITIS MAKSILARIS

Diagnosis klinis sinusitis maksilaris di didasarkan pada berbagai gejala yang
muncul. Gejala yang paling umum meliputi nasal discharge, rasa penuh wajah
dan nyeri pada saat membungkuk ke depan. Gejala intraoral termasuk rasa sakit
pada gigi premolar-molar pada sisi yang terkena dan kadang-kadang, paresthesia /
anestesi dari gingiva dan mukosa. Pada saat-saat tertentu, pasien mungkin
mengeluh perluasan prosesus alveolar rahang atas dan masalah dengan oklusi
gigi. Meskipun pasien mungkin memiliki gangguan dari sinus maksilaris, mereka
sering lebih dulu mencari layanan gigi profesional dengan keyakinan bahwa rasa
sakit yang mereka alami adalah berasal dari gigi.
Gejala sinusitis maksilaris

dibagi menjadi dua komponen, faktor mayor dan

faktor minor. Faktor mayor meliputi nyeri wajah, sumbatan/kepenuhan pada

wajah, nasal drainase /discharge, postnasal drip, sumbatan hidung, hyposmia /
anosmia, demam dan nanah pada endoskopi hidung. Faktor minor termasuk sakit
kepala, sakit gigi rahang atas, batuk, halitosis, kelelahan, sakit telinga, tekanan
atau kepenuhan, demam. Demam merupakan faktor mayor hanya pada tahap
akut. Adanya dua faktor mayor, atau satu faktor mayor dan dua faktor minor,
diperlukan untuk penegakan diagnosis sinusitis (Miloro, 2004). Berbagai
pemeriksaan dapat dilakukan untuk membantu dalam mendiagnosis sinusitis.

Endoskopi

hidung adalah salah satu prosedur yang berguna. Nanah pada

endoskopi hidung adalah diagnostik sinusitis (Carson et al., 1994). Radiografi

merupakan salah satu pemeriksaan terbaik untuk mempelajari sinusitis maksilaris
(Varonen et al., 2000). Computed Tomography (CT) adalah pemeriksaan pilihan
untuk mengevaluasi sinusitis (Anzai & Yueh, 2003 dan Mafee et al., 2006).
Namun, masalah dengan CT adalah tingginya tingkat paparan dan biaya bagi
pasien. Alternatif untuk CT seperti OPG (Orthopantomography) dan Walters
View lebih disukai karena biaya yang lebih murah dan paparan yang lebih rendah
bagi pasien.
Penampilan radiografi sinusitis maksilaris terutama menunjukkan peningkatan
edema mukosa. Mungkin ditemukan opasifikasi (kekeruhan) pada lapisan.
Kadang-kadang penebalan mukosa hiperplastik dapat dijumpai. Pada saat-saat
tertentu cairan radio-opak pada sinus yang terkena mungkin juga dijumpai (Wald
et al., 1981). Sebuah studi yang dilakukan untuk memverifikasi keaslian OPG
dalam diagnosis infeksi sinus maksilaris menunjukkan bahwa sensitivitas rata-rata
dan spesifisitas radiografi panoramik adalah 81.0% dan 85.6%. Dalam studi lain,
sinusitis maksilaris kronis diteliti pada 37 pasien, 32 diantaranya menunjukkan
perubahan radiografi (Cho & Jung 2008) Dengan demikian, pemeriksaan
radiografi sudah cukup dalam mendiagnosis sinusitis maksilaris

mengingat

murahnya biaya dan eksposur yang lebih rendah pada pemeriksaan tersebut.
Terapi anntibiotik digunakan untuk mengobati sinusitis akut. Antibiotik yang
sesuai meliputi antibiotik sulfa, amoksisilin, dan berbagai sefalosporin. Obat-obat
ini biasanya diberikan selama sekitar dua minggu, tetapi dapat diberikan untuk
jangka waktu yang lebih lama. Dekongestan, atau penggunaan jangka pendek dari
semprotan hidung dekongestan, dapat berguna.
Acetaminofen dan ibuprofen dapat mengurangi rasa sakit dan sakit kepala yang
berhubungan dengan sinusitis. Penggunaan humidifier juga dapat

mencegah

lendir dalam saluran hidung kering hingga menimbulkan ketidaknyamanan, dan

dapat membantu mengurangi sakit tenggorokan atau batuk yang menyertai.
Sinusitis kronis sering diobati awalnya dengan antibiotik. Semprotan hidung
steroid dapat digunakan untuk mengurangi pembengkakan di bagian hidung. Jika

ditemukan alasan anatomi pada sinusitis kronis, mungkin perlu diatasi dengan
pembedahan. Jika prosedur bedah diperlukan, sampel biasanya diambil pada saat
yang sama untuk memungkinkan identifikasi organisme yang dapat menyebabkan
infeksi.
Pencegahan melibatkan standar kebersihan yang baik untuk mengurangi jumlah
pilek yang tangkapan individu. Selama musim dingin, penggunaan humidifier
merupakan ide yang baik. Menghindari paparan asap rokok, mengidentifikasi dan
mengobati alergi juga dapat membantu mencegah infeksi sinus. (American
Academy of Otolaryngology-Head and Neck Surgery, 2013)
KESIMPULAN
Masalah lingkungan kompleks seperti polusi udara, ketika diabaikan melampaui
batas dapat

mencapai efek yang jauh pada kesehatan penduduk. Beberapa

penelitian telah membuktikan bahwa peningkatan kualitas udara menunjukkan

prevalensi yang lebih rendah dari sinusitis (Bhattacharyya, 2009). Penting bagi
kita untuk mengatasi masalah serius tersebut dengan langkah-langkah cepat dan
efektif. Upaya bersama dari masyarakat akan mengekang efek buruk dari polusi
dan

akan

membantu

mengurangi

keparahan,

meski

tidak

sepenuhnya

menghilangkan penyakit/gangguan terkait lingkungan seperti sinusitis maksilaris.

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