Documente Academic
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Oleh
Ismi Cahyadi
Nama : dr Ismi Cahyadi SpTHT-KL
TTL : Cirebon, 10 Mei 1983
Riwayat Pendidikan
- Pendidikan Dokter FK Unjani lulus 2007
- Pendidikan Dokter Spesialis FK UNPAD 2012-
2016
Riwayat pekerjaan
- Dokter umum RSUD Waled 2012
- Dokter Spesialis THT-KL RSUD Waled s/d
Sekarang
• Infeksi
Ear pain • Foreign body
• Trauma
• Sindrom Meniere
Vertigo • Vertigo perifer
4
EXTERNAL EAR ANATOMY
• Auricle
5
AURICLE
Lobule
– Skin
– Areolar tissue
– Fat
Auricle (excluding lobule)
– Elastic cartilage
– Subcutaneous tissue (minimal)
– Skin
• Loosely adherent
posteriorly
• Tightly adherent anteriorly
6
EXTERNAL AUDITORY CANAL
STRUCTURES
• S shape, 2,5 cm from concha – tympanic membrane.
• Segments :
– Cartilaginous segment : 1/3 lateral
Cartilaginous canal : 0,5-1,0 mm thick, hair follicles
(+), sebaceous and ceruminous gland (+).
– Bony segment : 2/3 medial
Bony canal : 0,2 mm thick, continous to TM, devoid
of skin appendages
7
ADNEXA AND SECRETORY SYSTEM
The adnexae and secretory
system of the skin of the
external auditory canal
contains many:
• Hair cells,
• Sebaceous and apocrine
glands
9
INFECTION OF THE PINNA
• Most Common: Celulitis & Erysipelas
• Bacterial infection that usually
follows:
− abrasion,
− laceration, or
− ear piercing
• The auricle is red, swollen, painful,
and tender to manipulation
10
INFECTION OF THE PINNA
• Etiology:
– Cellulites : Staphylococcus or Streptococcus
– Erysipelas : group A β-hemolytic Streptococcus
• Treatment:
Rapid treatment with oral or IV antibiotics if insufficient
Response.
First choice: Penicillin
12
HERPES ZOSTER OTICUS
(RAMSAY-HUNT SYNDROMES)
• Facial Nerve Paralysis:
– Sensory
– Sensory + motor
– Sensory + motor + auditory
symptom
• MRI other cause of facial
nerve paralysis
• Treatment:
– Valacyclovir, famciclovir,
acyclovir
13
HERPES ZOSTER OTICUS
(RAMSAY-HUNT SYNDROMES)
Treatment
14
PERICHONDRITIS AND CHONDRITIS
• Bacterial infection of
perichondrium or cartilage of
the auricle
• Symptom:
painful, red, and swollen and
drains serous or purulent
exudates.
The surrounding soft tissues of
the face and neck may be
affected.
15
PATHOGENESIS OF PERICHONDRITIS
16
Sumber: K.J. Lee, 2003; Cummings, 1993 Deformity
PERICHONDRITIS AND CHONDRITIS
Treatment
• Advanced stage :
− Hospitalized with aggressive
intravenous antibiotics
using ceftazidime or
fluoroquinolones and local
treatment.
− Topical antibiotic
− irrigation with indwelling
catheters may be tried.
18
INFECTION OF EXTERNAL AUDITORY
CANAL
19
ACUTE LOCALIZED OTITIS EXTERNA
(FURUNCLE)
Furuncle
20
ACUTE LOCALIZED OTITIS EXTERNAL
(FURUNCLE)
Symptoms Treatment
• Localized pain • topical and systemic
• Pruritus antibiotics.
• Hearing loss (if lesion • If a localized abscess has
occludes canal) formed:
• Discharge is not usually − incision and drainage
present until the abscess and
ruptures. − topical antibiotic
ointment with or
without oral antibiotics.
21
DIFFUSE OTITIS EXTERNA
“Swimmer's Ear”
22
DIFFUSE OTITIS EXTERNA
• Factors : trauma to the
meatal skin, invasion by
pathogenic organisms.
• Organisms :
– Staph. Aureus,
Pseudomonas
aeruginosa,
– Basillus piosianius , Esch.
Coli / mixed.
23
OTITIS EKSTERNA DIFUSE (ACUTE)
Humidity
Foreign body Weather
Long and narrow EAC
Hearing Device Skin disorder:
Drug alergy Dermatitis
Psoriasis
DM
Occlusion Immunocompromise
Apopilosebaseus
Ear wax
High pH (alkali)
Bacterial Proliferation • pH 4-5
Trauma
• Ig
• Lisozim
Otitis Eksterna 24
Source: K.J. Lee, 2003
I. Preinflammatory Stage
earliest stage
• mild erythema and minimal
edema
• small amount of clear or
slightly cloudy exudate
moderate stage
• pain and itching increase
• edema and a thicker canal
• more profuse exudate
26
Severe Stage
severe inflammatory
• Increased pain and obliteration of the
lumen of the canal
• profuse greenish-gray, purulent exudate
• edema of the canal skin
• small white papules on the surface of the
canal skin
27
TREATMENT
• Most common pathogens: P. aeruginosa and
S. aureus
• Four principles
– Frequent canal cleaning
– antibiotics
– Pain control
– Instructions for prevention
Necrotizing (Malignant) External
Otitis
• DM, immunocompromised
• Etiology: P. aeruginosa
• OE + Skull base osteomyelitis →spread
• Progression:
1.EAC →Santorini fissures and timpanomastoid →
retromandibular fossa
2.Deployment to the stylomastoid and jugular
foramens
3.Lateral sinus thrombosis
4.Apex of the petrosal (mel the vascular or fascia, not
the cell water
30
Diagnosis Necrotizing External Otitis
History
• Persistent otalgia
• Persistent, purulent otorrhoea, granulations
• Diabetes mellitus, advanced age,
• immunocompromised state
• Cranial neuropathy(ies)
Physical Examination
• Granulations in external canal
• Purulent discharge seen
• +/- cranial neuropathy, especially cranial nerve VII
31
Clinical: Granulation on Posterior wall of EAC, paralysis n. VII, IX - XI,
severe pain
Stadium:
Soft tissue and cartilage
Temporal bone erosion
Extension to the intracranial
32
Culture
• Pseudomonas sp
• Pseudomonas aeruginosa
Radiology
• Nuclear (gallium technetium)
• CT with contrast
• MRI with contrast
33
NECROTIZING (MALIGNANT) EXTERNAL OTITIS
Treatment Necrotizing External Otitis
Medical
• Hospital admission
• Intravenous antibiotics Anti-Pseudomonas antibiotics
(6 weeks or more)
• Daily cleaning, debridement
Surgical
• Excise granulations
• +/- middle ear exploration
• +/- mastoidectomy
• +/- facial nerve decompression
• +/- temporal bone resection if no response
34
NECROTIZING (MALIGNANT) EXTERNAL OTITIS
PLUS
PLUS
Added intravenous
antipseudomonals :
Ceftazidime (Fortaz) or Cefepime (Maxipime)
Ciprofloxacin or levofloxacin
Piperacillin/tazobactam (Zosyn) plus :
gentamycin or tobramycin or amikacin
Imipenem or Meropenem
35
Bullous External Otitis
• Very painful condition
• Vesicles or bullae are noted in the bony portion of the
external canal& hemorrhagic vesicles
• Etiology : Pseudomonas
• Treatment :
otic drops
avoid packing and irrigation
36
Bullous Myringitis
• Viral infection
• Confined to tympanic membrane
• Primarily involves younger children
Symptoms
• Sudden onset of severe pain
• No fever
• No hearing impairment
• Bloody otorrhea (significant) if rupture
Bullous Myringitis: Signs
• Inflammation limited
to TM & nearby canal
• Multiple reddened,
inflamed blebs
• Hemorrhagic vesicles
Bullous Myringitis: Treatment
• Self-limiting
• Analgesics
• Topical antibiotics to prevent secondary
infection
• Incision of blebs is unnecessary
FOREIGN BODIES
• A variety of foreign • Any objects small enough
bodies may be discovered to enter the EAC can
in the EAC become prospective
foreign bodies
• Diagnosis : easy using the (animate, inanimate, or
operating microscope and mineral objects)
a small blunt hook
• They may cause
• Found most frequently in symptoms of irritation,
the pediatric age group pain, and hearing loss
or in mentally retarded
patients
LR/EO 40
a . Sand particles can be seen
along the anterior wall of
EAC
– The main harm by a foreign body in the EAC is caused by its careless
removal!
LR/EO 43
Instrument used in the removal of aural foreign bodies
Dhillon RS, East CA. An Ilustrated colour text: Ear, Nose , Throat and Head and Neck Surgery. 2 nd Edition. Hartcourt .2000.
LR/EO 44
important
• The removal safely done under direct visualization, preferably under an operating
microscope with the patient in a supine position
• Instruments helpful for this task (alligator forceps, ring curettes, and hooks)
• Inanimate objects located lateral to the isthmus of the canal are removed with an alligator
forceps or by placing a hook or ring curette behind it and pulling it out
• Suctioning with Frazier suction catheters is useful in removing an object with a smooth
surface that is hard to grasp
• Objects located medial to the isthmus of the canal are more difficult to remove and may
require local or general anesthesia
LR/EO 45
TRAUMA
CAUSATIVE
Mechanical and
thermal factor
Causative
Chemical injuries
Agents
Pressure changes
12/30/2018 47
External Ear Trauma
12/30/2018 48
THE EXTERNAL EAR
12/30/2018 49
BLUNT TRAUMA
• The most common complication → auricular
hematoma .
• Failure to recognise and treat → deformity of the
pinna “cauliflower”
• Management
Needle aspiration under sterile conditions
Pressure dressing
Recurs within 48 hours → formal incision
and drainage
12/30/2018 50
12/30/2018 51
SHARP TRAUMA
Lacerations of cartilaginous
framework
Management :
Minimal debridement and
suturing of the perichondrium
and skin
12/30/2018 52
EXTERNAL EAR
• Exposure of extreme outer temperatures
Varying degrees of thermal injury
First degree burns and frostbites
Redness
Swelling
Highly sensitive to touch
Second-degree thermal injury
Blister formation
• Exposure to extreme hot or cold
Irreversible damage to the underlying cartilage
Necrosis and severe deformity
12/30/2018 53
EXTERNAL ACUSTICUS
CANAL
Initial management :
• Local conservative treatment
• Gentle washing and application of
antibiotic ointment
Prevent secondary infection.
12/30/2018 54
EXTERNAL ACUSTICUS
CANAL
• The most common in children
Foreign body (FB) impaction
Unsuccessful attempts at removal
• Types of trauma
Abrasions
Lacerations
• Management
Eardrops containing antibiotics →
preventing secondary infection
Aminoglycoside → avoided
12/30/2018 55
Middle Ear
12/30/2018 56
EPIDEMIOLOGY
TM is much more
traumatized than the
Inner ear
1.4-8.6 per 100,000
Men > Women
Children are curious
12/30/2018 57
Tympanic Membrane
12/30/2018 58
Traumatic TM Perforations
Compression Injuries
Barotrauma
Penetrating Injuries
Thermal Injuries
Lightning/Electrical Injuries
12/30/2018 59
Traumatic TM Perforations
The majority heal spontaneously.
No infection → no antibiotics
Conservative therapy → prevent a secondary infection
Eardrops containing gentamicin → avoided
Tympanoplasty → a persistent perforation
In welding spark injuries, perforations of the difficult to
heal
12/30/2018 60
MIDDLE EAR TRAUMA
Associated with TM or Inner ear or
Temporal bone trauma unless
Iatrogenic
Ossicular discontinuity
Facial Nerve Injury
Chorda tympani Nerve Injury
12/30/2018 61
MIDDLE EAR TRAUMA
Otic barotrauma
• Rapid changes of external pressure
Airplane flight
Diving
Explosion
• Rupture of fine blood vessels in the middle ear → hemotympanum.
• Prophylaxis of barotrauma during airplane flight depends especially on
proper eustachian tube function.
Valsalva manoeuvres
Topical nasal
Systemic decongestants
A preventive myringotomy with ventilation tube insertion.
12/30/2018 62
MANAGEMENT
Depend on etiology
Audiologic examinations,and impedance
testing
An accurate diagnosis
Surgical intervention
12/30/2018 63
Inner Ear
12/30/2018 64
ANATOMY
12/30/2018 65
ETIOLOGY
Blunt Trauma
Penetrating Trauma
Barotrauma
12/30/2018 66
LONGITUDINAL FRACTURES
70% of Temporal
Bone Fractures
Lateral Forces along
the petrosquamous
suture line
15-20% Facial
Nerve involvement
EAC laceration
12/30/2018 67
TRANSVERSE FRACTURES
20% of Temporal
Bone Fractures
Forces in the
Antero- Posterior
direction
50% Facial Nerve
Involvement
EAC intact
12/30/2018 68
PENETRATING TRAUMA
12/30/2018 69
BAROTRAUMA
Rapid pressure fluctuations with the inner ear
Air travel or SCUBA diving
“the bends”
12/30/2018 70
PHYSICAL EXAMINATION
Basilar Skull Fractures
Periorbital Ecchymosis
(Raccoon’s Eyes)
Mastoid Ecchymosis
(Battle’s Sign)
Hemotympanum
Raccoon’s Eyes. Bluish discoloration of the
peri-orbital region (Periorbital Ecchymosis)
12/30/2018 71
Hemotympanum (blood in the middle ear)causes a Ruptured tympanic membrane and blood in
bluish discoloration of the drum the ear canal (surgeon's view)
12/30/2018 72
Battle's Sign. Bluish discoloration of the Traumatic cochlear hemorrhage
post-auricular region (Mastoid Ecchymosis)
Cerebrospinal fluid (CSF) otorrhea Oblique left temporal bone fracture line crossing the mastoid
process, into Henle's spine and the external auditory canal
(surgeon's view)
12/30/2018 73
PHYSICAL EXAMINATION
Pneumatic Otoscopy
12/30/2018 74
IMAGING
HRCT
MRI
Angiography / MRA
12/30/2018 75
HRCT
12/30/2018 76
Sudden Hearing Loss
• SSHL didefinisikan sebagai gangguan
pendengaran sensorineural ≥30 dB pada 3
frekuensi bersebelahan
• Onset ≤ 3 hari
• Sebagian besar kasus penyebab pasti?
• Prognosis bervariasi
• Perawatan : infus dan/atau intratympanic
kortikosteroid
• Kejadian tahunan SSHL 1 kasus per 5000-10.000
penduduk pasien yang mencari pertolongan
medis
• Jumlah kasus sebenarnya? pulih spontan
• 10-15% kausa oleh infeksi, trauma, neoplastik,
imunologi, intoxikasi, gangguan peredaran
darah dan kausa neurologis
• Sebagian besar kasus (85-90%) Idiopatik ;
infeksi virus, gangguan pembuluh darah,
pecahnya membran intracochlear dan
penyakit autoimun telinga dalam
Vertigo
Syndrom Meniere
Definition
81
Lee, KJ, Essential Otolaryngology Head & Neck Surgery, 9th ed, McGraw-Hill, 2008
Introduction
• French physician
• Published in 1861
Johnson J, Lalwani AK. Meniere’s . Ballenger’s Otorhinolaryngology Chapter 20. 2003 BC Decker Inc.
Pathophysiology
• Exact pathophysiology of Ménière disease is
controversial
Merchant SN, Adams JC, Nadol JB Jr. Pathophysiology of Meniere's syndrome: are symptoms caused by endolymphatic hydrops?.Otol Neurotol.
84
Jan 2005
Pathophysiology
86
Hain TC. Meniere’s disease [online] 2008
Pathophysiology
• Attacks of hydrops probably are caused by an
increase in endolymphatic pressure, which, in
turn, causes a break in the membrane that
separates the perilymph (potassium-poor
extracellular fluid) from the endolymph
(potassium-rich intracellular fluid).
87
Hain TC. Meniere’s disease [online] 2008
Pathophysiology
• The resultant chemical mixture bathes the
vestibular nerve receptors, leading to a
depolarization blockade and transient loss of
function. The sudden change in the rate of
vestibular nerve firing creates an acute
vestibular imbalance (ie, vertigo).
88
Hain TC. Meniere’s disease [online] 2008
Pathophysiology
• Physical distention caused by increased
endolymphatic pressure also leads to a
mechanical disturbance of the auditory and
otolithic organs
• Utricle and saccule irritation → nonrotational
vestibular symptom
89
Hain TC. Meniere’s disease [online] 2008
Pathophysiology
• This physical distention → mechanical
disturbance of the organ of Corti
• Distortion of the basilar membrane and the
inner and outer hair cells → hearing loss
and/or tinnitus
90
Hain TC. Meniere’s disease [online] 2008
Pathophysiology
91
Hain TC. Meniere’s disease [online] 2008
92
Etiology
• Disorders that may give rise to elevated
endolymphatic pressure include metabolic
disturbances, hormonal imbalance, trauma,
and various infections (eg, otosyphilis and
Cogan’s syndrome [interstitial keratitis]
Paparella MM, Djalilian HR. Etiology, pathophysiology of symptoms, and pathogenesis of Meniere's disease. Otolaryngol Clin North Am. 93
Jun
2002;35(3):529-45
Physical Examination
• Depending upon the phase of disease
• During remission, physical examination findings
may be completely normal
• During an acute attack, the patient has severe
vertigo
• Significant distress
• Elevated blood pressure, pulse & respiration
• Significant nystagmus may be present
94
Hain TC. Meniere’s disease [online] 2008
Evaluation of vertigo
• The Dix-Hallpike positional test → Nystagmus
• The Romberg test generally shows significant
instability and worsening during acute attacks
when the eyes are closed
95
Hain TC. Meniere’s disease [online] 2008
Evaluation of hearing loss
• Audiologic testing is more accurate
96
Probst-Grevers-Iro, Basic Otorhinolaryngology, 2006
Complications
• Injury due to falls
• Anxiety regarding symptoms
• Accidents due to vertigo spells
• Disability due to unpredictable vertigo
• Progressive imbalance and deafness
• Intractable tinnitus
97
Other problems to be considered
include the following
• Trauma • Basilar meningitis
• Endocrine abnormalities • Brainstem tumors
• Hyperlipidemia • Neoplasms (eg, acoustic
• Diabetes neuroma)
• Congenital anomalies • Toxic or pharmaceutical
• Autoimmune injury to the vestibular
problems/inner ear apparatus
inflammation • Vascular infarction of the
• Otosclerosis labyrinth (usually associated
with unilateral hearing loss)
• Perilymphatic fistula
• Electrolyte imbalance
98
Hain TC. Meniere’s disease [online] 2008
Differentials Diagnosis
• Anterior Circulation Stroke • Migraine Headache
• Arteriovenous Malformations • Neurosyphilis
• Basilar Artery Thrombosis • Otitis Media in Emergency Medicine
• Benign Positional Vertigo in Emergency • Polyarteritis Nodosa
Medicine • Posterior Cerebral Artery Stroke
• Brainstem Gliomas • Skull Tumors
• Cerumen Impaction Removal • Rheumatoid Arthritis
• Ear Foreign Body Removal in Emergency • Temporal Lobe Epilepsy
Medicine • Transient Ischemic Attack
• HIV-1 Associated CNS Conditions: • Vestibular Neuronitis
Meningitis
• Viral Encephalitis
• Hypothyroidism and Myxedema Coma in
Emergency MedicineI • Viral Meningitis
• ntracranial Hemorrhage
• Labyrinthitis And Related Conditions
99
Hain TC. Meniere’s disease [online] 2008
Differentials Diagnosis
100
Bailey, Byron et al: Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins2006
Work Up
• Should be directed • Audiometry
at differentiating • Brainstem auditory evoked
the disease from potentials
other causes on the • Transtympanic
basis of associated electrocochleography (ECOG)
symptoms
• Electronystagmography
(ENG)
• Otoscopy
• Caloric testing/ENG
101
Hain TC. Meniere’s disease [online] 2008
Treatment
• In the emergency department (ED) is based on
symptomatic relief of the clinical findings
• Surgical therapy for Ménière disease is
reserved for medical treatment failures
102
Pharmacologic Therapy
Vestibulosuppressants
• meclizine, droperidol, prochlorperazine,
diazepam, lorazepam, alprazolam
Diuretics and diureticlike medications
• hydrochlorothiazide and triamterene,
hydrochlorothiazide, acetazolamide,
methazolamide)
103
Hain TC. Meniere’s disease [online] 2008
Pharmacologic Therapy
Steroids
• probably by reducing endolymphatic pressure
orally, intramuscularly, or even
transtympanically
Aminoglycosides
• toxic to the vestibular (balance) end organ
104
Sajjadi H. Medical management of Meniere's disease. Otolaryngol Clin North Am. Jun 2002
Pharmacologic Therapy
Histamine agonists
• betahistine (Serc) → increasing circulatory
flow to the cochlear stria vascularis?
• has not been approved by the US Food and
Drug Administration (FDA)
105
Phillips JS, Prinsley PR. Prescribing practices for Betahistine. Br J Clin Pharmacol. Apr 2008
Surgical therapy
• Endolymphatic sac decompression or shunt
placement
• Vestibular nerve section
• Labyrinthectomy
• Intratympanic injection of medications such as
gentamicin or steroids
Wetmore SJ. Endolymphatic sac surgery for Ménière's disease: long-term results after primary and revision surgery. Arch Otolaryngol Head
106 Neck
Surg. Nov 2008
Diet and Activity
Dietary measures
• Avoiding foods with high sodium content
(pizza, preserved foods, smoked fish)
Activity restriction
• dangerous tasks (eg, especially climbing
ladders) should be avoided
107
Prevention
• Caffeine • Foods with high
• Nicotine cholesterol or
• Chocolate, which has triglyceride content
shown to be a potent • Foods with high
trigger substance carbohydrate content
• Tobacco • Excessive sweets and
• Alcohol, particularly red candy
wine and beer
108
Prognosis
• Patient presentation and progression of
Ménière disease vary widely
• In general, the patient’s condition tends to
spontaneously stabilize over time
• However: many patients are left with poor
balance and poor hearing
109
Minor LB, Schessel DA, Carey JP. Ménière's disease. Curr Opin Neurol. Feb 2004
Epistaksis
INTRODUCTION
111
VASCULAR ANATOMY
113
ETIOLOGY
LOCAL SYSTEMIC
• Trauma: digital, fractures • Hypertension
• Nasal sprays • Vascular disorders
• Inflammatory reactions • Blood dyscrasias
• Hematologic malignancies
• Anatomic deformities
• Allergies
• Foreign bodies
• Malnutrition
• Intranasal tumors • Alcohol
• Chemical inhalants • Drugs
• Nasal prong O2 • Infectious
• Surgery
Dhingra PL, Diseases of ear nose and throat. 4th ed. Elsevier;2008 117
Differences Between Anterior And Posterior Epistaxis
General status
Local status
• Determine :
Anterior or posterior
Right or left cavum nasi
Duration of bleeding
Quantity of blood loss
121
MANAGEMENT
124
networkmedical.co.uk
ELECTRIC CAUTERIZATION
125
NASAL PACKING
sehha.com
The traditional anterior pack of petrolatum gauze (0.5 72-inch) coated with an
antibacterial ointment is firmly packed in a layered fashion toward the
posterior choanae after decongestion and local anesthesia placement
127
Newer nasal packing materials
expand several times in
volume with hydration, making
placement easier for the
physician and patient
hydroxylated polyvinyl acetal
(Merocel) and polyvinyl alcohol
(Expandacell, Rhino Rocket)
128
networkmedical.co.uk
POSTERIOR NASAL PACKING
Indicated :
failing anterior nasal packs or
who upon evaluation have
known posterior bleeding
Preoperative procedure :
– Require careful instruction to the
patient
– Intravenous access and mild
sedation
129
networkmedical.co.uk
POSTERIOR NASAL PACKING
www.bes.de/rhinologie/epistaxiskatheter 130
LIGATION OF ARTERIES
• Patient education
• Keep the nose moist
• Avoidance of digital manipulation,airborne irritants,
smoke
• Control of allergies
• Tappering amount of nasal spray
• Intranasal surgical technical refinements
Krouse Jhon, The Unified Airwayd Conceptual Framework In: Otolaryngologic Clinics of North America 2008 134
Allergic
Inflammation Snoring
Rhinitis
135
Krouse Jhon, The Unified Airwayd Conceptual Framework In: Otolaryngologic Clinics of North America 2008 136
Starling Resistor model
W.T. McNicholas, The nose and OSA: variable nasal obstruction may be more important in pathophysiology
than fixed obstruction, Eur Respir J 2008 137
- Nasal mucosal congestion
- Mucous secretion
NASAL OBSTRUCTION
IMPAIRED SLEEP
138
QURESHI AND BALLARD.JACI 2003.645-649
140
Bailey BJ, Head & Neck Surgery-Otolaryngology, 4th editon, Lippincot Williams & Wilkins, Philadephia, 2006.
Sumbatan Jalan Nafas Atas
Pendahuluan
• Kegawatdaruratan di bidang THT-KL
FARING
DIAGNOSIS
145
Anamnesa :
Dispneu
145
Riwayat penyakit
146
• Onset dan berat stridor
• Progresifitas
• Fluktuasi gejala
• Posisi dan gerakan yang meringankan / memperberat
146
Pemeriksaan Fisik
147
• Keadaan umum
• Tanda vital(T,N,RR,S)
• Beratnya kelainan pernafasan & kebutuhan
penanganan jalan nafas
149
Etiologi pada anak
Akut kronik
Inflamasi Supraglotis Subglotis
Croup Atresia koana Stenosis,web
Epiglottitis Stenosis Massa
Masa, kista Benda Asing
Trauma Trakea
Glottic Benda Asing
Laryngomalasia Stenosis
Benda Asing Masa
Paralisis pita suara Trakeomalasia
Papillomatosis Kompresi Vaskular
150 150
Bailey, Byron J.;Head & Neck Surgery - Otolaryngology, 4th Edition. 2006
Etiologi pada dewasa
Akut Kronik
Inflamasi -Tumor
Croup - Kongenital
Supraglotitis - Post Trauma
Angina Ludwig - Inflamasi
(Wagener Granulomatosis Relapsing
Benda Asing Polikondritis, Sarkoid)
Trauma - Idiopatik
Bailey, Byron J.;Head & Neck Surgery - Otolaryngology, 4th Edition. 2006 151 151
Tindakan Emergensi Lain Pada SJNA
152
152
Intubasi Endotrakeal
153
153
KRIKOTIROIDOTOMI
154
154
155
155
Perasat Heimlich
156
.
158
A Kalan,M Tariq. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures in Postgrad Med J 2000;76:484–487
Emergency unit of ENT-HNS dept. Hasan Sadikin
Hospital May 2012-August 2012
12 cases of nasal foreign body of 55 total case of foreign body in ENT regions
(21,8%)
Percentage
Ear canals 25,6%
Esophagus 34,6%
Pharynx 9%
Bronchus 9%
159
12 cases of nasal foreign body
• screw=1 case
• beads=4 case
• plastic toys= 4 case
• marbles=1 case
• button batteries=1
• Nail=1
160
161
DEFINITION
ANORGANIC ORGANIC
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011163
CLASSIFICATION
A Kalan,M Tariq. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures in Postgrad
164 Med J 2000;76:484–487
Modul Hidung, Benda Asing. Kolegium Ilmu Kesehatan THT-KL. 2008
Common sites of impaction of foreign
bodies in the nasal cavity
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011
Pathology
• Inert FB may remain in the nose for years without
mucosal changes.
• Inanimate objects initiate congestion and swelling
of the nasal mucosa ulceration, mucosal erosion,
necrosis and epistaxis.
• The retained secretion, decomposed foreign body,
and ulceration foul fetor
• Vegetable FBabsorb water from the tissues and
evoke a very brisk inflammatory reaction..
A Kalan,M Tariq. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures in Postgrad
167 Med J 2000;76:484–487
Pathology
A Kalan,M Tariq. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures in Postgrad
168 Med J 2000;76:484–487
Pathology
• Button batteries:
– Severe destruction of the nasal mucous.
– Composed of various types of heavy metals:
mercury, zinc, silver, nickel, cadmium, and lithium.
– Liberation of thes substances causes intense
local tissue reaction and necrosisseptal
perforations, synechiae, constriction, and stenosis
of the nasal cavity.
A Kalan,M Tariq. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures in Postgrad
169 Med J 2000;76:484–487
Pathology
A Kalan,M Tariq. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures in Postgrad
170 Med J 2000;76:484–487
BUTTON BATTERIES
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Easily fit into nose
Low-voltage electrical, electrolysis-induced release of sodium
hydroxide and chlorine gas.
Rapidly cause severe chemical burn & painful
Septal perforations, saddle nose deformities
Sri Herawati JPB. Impacted foreign body in nasal cavity In Folia Medica Indonesiana, Vol. 40 No. 3 July – September 2004 p. 139-142
Nancy Sculerati. Foreign bodies of the nose. In Pediatric Otolaryngology-4th edition, 2003, p.1032-1036
171
• Damage to the nasal mucosa has previously been
reported after as few as 3 hours, with damage
leading to perforation after 7 hours.
• Liquefactive necrosis alkaline contents leak out
Alice K Guidera, Hans R Stegehuis. Journal of the New Zealand Medical Association, 30-April-2010, Vol 123 No 1313
172
173 LIVING NFBs
A Kalan,M Tariq. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures in Postgrad Med J 2000;76:484–487
LEECH
• Primarily in tropical areas; Mediterranean, Africa and Asia
• Blood – sucking, hermaphroditic parasite
• Drunk polluted water localize in the mucosa of the oropharynx, nasopharynx,
tonsils, esophagus or nose but rarely in larynx
• Symptom: bleeding from nose (88%), foreign body sensation (80%) and nasal
obstruction (74%)
• Dribbled tobacco juice into the nostrils to relieve suction leeches
Prakash Adhikari MS. “Experiences of Single Technique in Removing Nasal leech Infestation: An analysis of 25 cases”. The Internet
Journal of Otorhinolaryngology 2009 : Volume 9 Number 2
RHINOLITH
a greyish irregular mass, usually along the floor of the
175
nose that feels bony, hard.
Exogenous, endogenous; blood clot, dried purulent
debris encrusted with mineral salt.calcium, magnesium,
phosphate, or carbonate
Initially symptomless, and later cause nasal
obstruction only if they become enlarged.
Radio-opaque.
Nancy Sculerati. Foreign bodies of the nose. In Pediatric Otolaryngology-4th edition, 2003, p.1032-1036
Symptoms and signs
A Kalan,M Tariq. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures in Postgrad
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Examination of the nasal cavity
A Kalan,M Tariq. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures in Postgrad
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Immobilize the young patient
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PHYSICAL EXAMINATION
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011
179
WORKUP
180
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011
WORKUP
Radiographic examination
Plain films
Computed tomography
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CT-Scan
182
Differential Diagnosis
• Epistaxis
• Sinusitis
• Polyps
• Tumor
• Upper respiratory infection (URI)
• Unilateral choanal atresia
183
PRETREATMENT
184
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011
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PRETREATMENT
185
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011
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PRETREATMENT
186
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011
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The FB removal success depends on:
• patient’s cooperation
• doctor’s ability
• type of FB
• previous manipulation
• visibility and depth of the FB
• available equipment
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011
188
INSTRUMENT
Head lamp
Killian‘s speculum
Hemostats
Aligator forceps
Bayonet forceps
Hooked probes
Wire-loop
Suction
Rigid/flexible nasopharyngoscope
36
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011
SPECIFIC REMOVAL TECHNIQUES
Direct instrumentation
Balloon catheters
Positive pressure
Suction
Glue
Posterior displacement
Magnet
Irrigation
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011 190
DIRECT INSTRUMENTATION
Easily visualized, nonspherical, and nonfriable
Instruments: hemostats, alligator forceps, hooked probes or
bayonet forceps.
Friable and spherical foreign bodies
Difficult use this technique
Friable → tear
Spherical: difficult to grasp and posterior displacement.
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011
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DIRECT INSTRUMENTATION
Nancy Sculerati. Foreign bodies of the nose. In Pediatric Otolaryngology-4th edition, 2003, p.1032-1036
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Terima Kasih