ENT, OPHTALMOLOGY,

DERMATOLOGY

ENT
CASE 1
Women, A, 25 years came to the clinic
with chief complaints of hearing loss in
right ear since 1 year ago accompanied
by a purulent ear charged, smells,
sometimes pain and itching and
headache. No complaints of vertigo.
History of frequent ear probe, a history of
the same disease is often recurrent, a
family history of atopy denied.

ENT
Physical examinations:
General conditions: Good, not anemic. Height: 160 cm, Weight: 60 kg.
Vital signs are within normal limit.
Inspection
: Auricel normal
Palpation
: No edema and no tenderness of tragus and retroauricel
Otoskopi
: Right external acoustic meatus and right tympanic
membrane hyperemic, subtotal central perforation of right tympanic
membrane, mucoid secretions in right tympanic cavity and the external
acoustic meatus
Left acoustic meatus and left tympanic membrane normal
Faringoscopy : Within normal limits
Anterior Rhinoscopy
: Nasal cavity, nasal septum and nasal turbinate
normal
Laboratory examination
: Hb 14 g / dl, leukocytes 12,600 g%, LED
45 / 1 hour
Pure Tone Audiometry Examination :

Ear artery: Mild-Severe Hearing Loss Conductive (60 dB)

Ear Sinistra: Normal Hearing (20 dB)

Examination of vestibular function: no canal paresis

ENT
Chest X-Ray : Normal
Mastoid CT-Scan :

Diagnosis : Right Chronic Supurative

Otitis Media

Definisi
OMSK ialah infeksi kronis pada telinga
tengah dengan perforasi membran
timpani dan sekret yang keluar dari
telinga tengah terus menerus atau hilang
timbul, sekret mungkin encer atau kental,
bening atau nanah.
Berlangsung lebih dari 2 bulan.
OMSK adalah perlangsungan dari OMA.

Patogenesis
OMA ( fase oklusi tuba eustachius
fase hiperemis fase supurasi
fase perforasi fase resolusi)
OMSK
Faktor predisposisi

Kepatuhan pasien
Terapi tidak adekuat
Pertahanan tubuh lemah
Hygiene

Diagnosis

Klasifikasi
OMSK BENIGNA

OMSK MALIGNA

Perforasi sentral

Perforasi marginal atau atik

Peradangan terbatas pada

mukosa

Abses/fistel retroaurikular

Biasanya tidak mengenai tulang

Polip di MAE

Jarang menimbulkan komplikasi

Kolesteatom pada telinga tengah

Tidak terdapat kolesteatom

Sekret berbentuk nanah dab bau

khas
Ada bayangan kolesteatom pada
foto radiologi
Menimbulkan komplikasi fatal

Terapi
OMSK BENIGNA

OMSK MALIGNA

Konservatif atau medikamentosa

Operatif

Cuci telinga dengan H2O2 3% 3-5

hr

Simple mastoidektomi

Pemberian antibiotik tetes

Mastoidektomi radikal

Pemebrian antibiotik oral

(ampisilin)

Modified radikal mastoidektomi

Tes sensitivitas dan kultur otore

Miringoplasti
Timpanoplasti
Combined approach
tympanoplasty

Komplikasi oleh Adam dkk

ENT
Male, 18 years came to the clinic with
complaints of smelling reduced from
six months ago accompanied by nasal
congestion, thick mucus that are
ingested into the throat, sometimes
smells and headache. No complaints
of serial sneezing and nasal itching.
Previous history of the same disease
and a family history of atopy denied.

ENT

Physical examinations:
General conditions: Good, not anemic. Height: 160 cm, Weight: 60 kg.
Vital signs are within normal limit.
Inspection : The external nose normal
Palpation : No edema and crepitation, tenderness in the left and right
cheek

tenderness on the left and right orbital roof

Otoscopy : Within normal limits
Faringoscopy : Within normal limits
Anterior Rhinoscopy : hyperemic of nasal mucosa, congestion of nasal
turbinate, there is secret in bilateral of the middle nasal meatus and
nasal cavity

Laboratory examination

: Hb 14 g / dl, leukocytes 12,600 g%

ENT
Chest X-Ray: Normal
CT scan :

Diagnosis : Bilateral anterior ethmoidal sinusitis, Left posterior

ethmoidal sinusitis, Bilateral frontal sinusitis and Bilateral maxillary
sinusitis chronic

Pendahuluan
Sinusitis merupakan peradangan dari
mukosa sinus paranasalis
Plg sering pada sinus maksilaris dan
sinus etmoidalis.
Penyebab dan faktor predisposisi
ialah ISPA, deviasi septum nasi,
obstruksi KOM, infeksi gigi, dll.

Klasifikasi
Sinusitis akut : < 4 minggu
Sinusitis sub-akut : 4 minggu 3
bulan
Sinusitis kronik :> 3 bulan

Keluhan dan gejala

Sinusitis akut & subakut : demam,
cephalgia, lesu, ingus kental yg berbau
dan dirasakan mengalir ke daerah
nasofaring, hidung tersumbat,nyeri pada
daerah sinus yg terkena
Maksilla : nyeri pada rahang atas
Etmoid : pengkal hidung dan kantus medialis
Frontal : dahi atau seluruh kepala
Sphenoid : verteks, oksipital, nelakang bola
mata

Keluhan dan gejala

Sinusitis kronik : nyeri kepala
terutama pada pagi hari,dll.

DIAGNOSIS
Anamnesis
Rhinoskopi anterior mukosa konka
hiperemis dan edema, sekret
mukopurulen pada rongga hidung
Rhinoskopi posterior mukosa pada
nasofaring (post nasal drips)

PEMERIKSAAN PENUNJANG
Transiluminasi sinus yang
terinfeksi dan berwarna suram atau
gelap.
X-ray posisi Waters, PA, dan lateral.
CT-Scan sinus paranasalis potongan
coronal

PENATALAKSANAAN
Sinusitis Akut
Antibiotik 10-14 hari
Dekongestan lokal berupa obat tetes
hidung
Analgesik untuk menghilangkan nyeri

Sinusitis subakut
Pungsi dan irigasi sinus maksilaris
Tindakan pencucian Proetz

PENATALAKSANAAN
Sinusitis kronik
Antibiotik 2 mingu
Tindakan pembedahan radikal :
Caldwell-Lus, atmoidektomi
Tindakan pembedahan tidak radikal
: Bedah Sinus Endoskopik Fungsional

KOMPLIKASI
Osteomielitis dan abses subperiosteal
Kelainan orbita (edema palpebra,
selulitas orbita, abses orbita, trombosis
sinus kavernosus)
Kelainan intracranial (meningitis, abses
ekstradural, atau subdural, abses otak)
Kelainan paru (bonchitis kronik,
bronchiectasis)

OPHTALMOLOGY
CASE 1
A 66 year old man was diagnosed as Senile Cataract
+ Diabetic Retinopathy ( ODS ), based on these
findings :
History: A chief complain of decreased vision on
both eyes, aware since
8 months ago and
worsened for the past 4 weeks. Vision appears to be
white, hazy smoke-like and seems to be clearer during
night time. There was no history of using spectacles
for distant vision, and neither of red eyes or trauma of
the eye balls. There is a history of hypertension for
about 10 years with improper treatment, diabetic
mellitus is not known and neither in family history.

OPHTALMOLOGY
Physical findings: General state :
Mild / Good nutrition / Conscious
Vital signs : BP = 180/90 mmHg;
Pulse = 80 x/mnt, Breathe=
20x/mnt; Temp = 36,7o C
Ophthalmology findings :
VOD = 3/60; could not be corrected
VOS= 1/60; could not be corrected

OPHTALMOLOGY
Eye
Palpebra
Cilia
Bulbar
conjunctiva

OD
Normal
Normal
Normal/ Hyperemic(-)
/

OS
Normal
Normal
Normal/
Hyperemic(-)

Palpebral
conjunctiva
Cnea
COA
Iris
Pupil

Clear
Normal
Dark brown, crypt(+)
Round, central, light

Clear
Normal
Dark brown, crypt(+)
Round, central, light

Lens

reflex (+)
Opaque

reflex (+)
Opaque, dense

Posterior Segment :
FOD : fundus reflex (+), Optic nerve : fine edge, CDR 0,3, A/V :
1/3, Macula : fovea reflex(+), peripheral retinal : dot-blot
hemorrhage 4 quadrant
FOS : fundus reflex (+), Optic nerve : fine edge, CDR 0,3, other
details are difficult to evaluate due to dense cataract.

OPHTALMOLOGY
Lab findings, biometry
Diagnose : ODS Mature Senile Cataract
+ Diabetic retinopathy
Treatment plan :
Cataract extraction + IOL implant ( Intra
Ocular Lens ) ODS
control blood glucose and pressure

ANATOMI MATA

Anatomi lensa
Cembung ,tebal 3,5-5 mm,
D 6,4-9 mm ,
Transparan, avaskuler,
persyarafan(-)
.Kapsul antor,postor,
semipermiabel
(air,elektrolit),elastis
.Korteks antor,postor
.Nukleus, dewasa keras
.Epitel subkapsul antor,1
lap sel kuboid,ekuator
(mitosis) serabut
lamelar (ukuran
>,kelenturan<)

Komposisi lensa
66 % air,umur >,air <,elastis <(presbiopia)
33 % protein,water soluble (crystalline,81%)
water insoluble (urea soluble/in)
Mempertahankan transparansi
Umur tua (katarak)
crystalline (51%)
water insoluble >
Bersifat antigen
Elektrolit , K 120 mM, Na 20 mM, Ca 30 mM

Fungsi lensa
Refraksi , menfokuskan objek jauh ke
retina.Relaksasi M siliaris
.Zonula zinn teregang
.D/ Ant-Post minimal
Akomodasi, menfokuskan objek dekat ke
retina.Kontraksi M siliaris
.Zonula zinn kendor
.Lensa cembung
(kapsul elastis,lensa lentur)

Angka kebutaan di
Indonesia
Survei kesehatan 1993-1996
Angka kebutaan 1,5 %
Penyebab utama kebutaan :
Katarak
: 0,78%
Glaukoma
: 0,20%
Kelainan refraksi : 0,14%
Penyakit(usia >) : 0,38%

Pemeriksaan kelainan lensa

1.Uji tajam penglihatan(visus)
2.Pemeriksaan lensa
. Pupil dilebarkan dg midriatikum
. Lampu celah(Slit lamp)
. Oftalmoskop (Red reflex/ refleks
fundus )
. Lup
. Lampu senter

Kelainan Lensa
Katarak : . Kongenital . Polaris
antor,postor
. Lamellaris(zonularis)
. Nuklearis
. Didapat . Senilis(degeneratif)
. Komplikata
. Traumatika
. Sekunder
Dislokasi : . Sublukasi
. Luksasi

KATARAK
Kriteria lensa katarak

Perubahan protein
Edema
Nekrosis
Serabut robek
Oxygen uptake <

Penyebab katarak
Kongenital : . Herediter
. Infeksi intra uterin,TORSCH
. Sindroma,Down S
. Idiopatik
Didapat : . Umur tua(Age related cataract)
. Infeksi
. Metabolik
. Toksik
. Trauma

Pembagian Katarak

Morfologi . Kapsular
. Nuklear
. Subkapsular . Lamellar
. Kortikal
. Sutural
Maturiti . Insipien
. Imatur
. Matur
.Hipermatur
Umur .Kongenital
. Infantil
. Yuvenil

.Presenilis
. Senilis

Katarak kongenital
Klinis : Lensa keruh (leukokoria)
. Parsial total
. Unilateral bilateral
Th/ .Indikasi operasi . > 2mm
. Sentral
> Operasi
segera
. Padat/keruh
( < 2 bl )
. Tu/ unilateral
> Mencegah ambliopia deprivasi,supresi
Penyulit : . Uveitis fakoanafilaktik
. Glaukoma sekunder
. Katarak sekunder

Katarak pd Anak
Penyebab .Kongenital
.Didapat
Th/ . Tergantung umur
. Operasi ,mencegah ambliopia
perbaikan visus
. Follow up (tidak terlalu
mendesak)

Katarak senilis

Penyebab kebutaan utama di Indonesia

Age-related cataract
Bentuk :
. K.Nuklear,
Nukleus makin besar,sklerotik,
putih kekuninganan > coklat > khitam
/K.Nigra, Brunescent nuklear cataract
.K.Kortikal,
Penyerapan air > lensa cembung,miopisasi
Bentuk .cuneiform, coronary

K.Subkapsular postor/cupuliform
Std dini K.nuklear,K.kortikal(gamb piring = K.komplikata

Stadium Katarak Senilis

K.Insipien
Keruh tdk teratur,kortek ant,post
Poliopia,Shadow test/Iris shadow (+)
K.Imatur
Intumesen:Air >,lensa bengkak,kapsul tegang,Artificial Myopia
KOA(BMD) dangkal Glaukoma phakomorfik
Iris shadow (+)
K.Matur
Keruh difus,ukuran lensa N, KOA N
Deposit Ca > perkapuran > lensa sangat putih
Iris shadow (-)
K.Hipermatur , K.Morgagni
Korteks mcair,lensa mkerut warna kuning
KOA dalam
Shadow test pseudo iris shadow (+)
Penyulit : uveitis fakotoksik, glaukoma fakolitik

Katarak Komplikata

Penyakit intraokuler
. Iridosiklitis,khoroiditis(uveitis antor,postor),
. Glaukoma (K.Vogt)
. Ablasio retina,retinitis pigmentosa,miopia >
.Tumor intra okular,iskemia okular
. Paska bedah mata
Penyakit sistemik
. Diabetes Melitus (K.Diabetes), Galaktosemia
. Hipoparatiroid,tetani infantil ( Ca<), nutrisi
. Miotonia distrofi
Rokok
Th/ operasi , visus < , penyulit

Katarak Traumatika
Lensa keruh k/ trauma
tumpul(vissius ring),tajam, radiasi,
kimia, IOFB, metallosis(siderosis,
calcosis), listrik
Monokular katarak
Penyulit : Glaukoma,uveitis
Th/ Visus < , penyulit

Katarak Sekunder
After cataract
Pos-op operasi ECCE,/fakoemulsifikasi
Wedl /bladder cell Soemmering ring
Elschnig pearls
Penebalan kapsul posterior
Th/ . Visus <,penyulit
. Kapsulektomi post
. Laser

Operasi Katarak
Indikasi :. Tajam penglihatan(visus)
. Penyulit
Anestesi: . Lokal , GA (anak, takut,neurosis)
Tehnik : . ICCE
. ECCE
. Fakoemulsifikasi
Persiapan : Visus,anel test (+)
infeksi (-), TIO N
Keadaan umum

Extracapsular cataract extraction

1. Anterior
capsulotomy

2. Completion of
incision

3. Expression of
nucleus

4. Cortical cleanup

5. Care not to aspirate

posterior capsule
accidentally

6. Polishing of posterior
capsule, if appropriate

Extracapsular cataract extraction ( cont. )

7. Injection
of
viscoelastic
substance

8. Grasping of IOL and

coating with viscoelast
substance

9. Insertion of inferior
haptic and optic

10. Insertion of superior

haptic

11. Placement of haptics

into capsular bag
and not into ciliary
sulcus

12. Dialling of IOL into

horizontal position

AFAKIA

Lensa tidak ada

Iris trimulans,KOA(BMD) dalam
Umum hipermetrop +10D,Add+3D(Ako-)
Afakia monokuler anisometropia
Penatalaksanaan :
. Tes toleransi
. Kaca mata
. Lensa kontak
. IOL /peudofakia
(P = A 2,5 L 0,9 K )

Dislokasi Lensa
Subluksasi lensa
Sebagian zonula zinn putus/lemah
Penyebab : Kel kongenital(sindroma
Marfan,Marscesani)
Kel didapat (trauma)
Keluhan : miopia,astigmat,diplopia
Penyulit : Glaukoma
Th/ : Koreksi km max,operasi ekstraksi
lensa(glaukoma)

Dislokasi Lensa
Luksasi lensa
Luksasi anterior . Visus <,lensa di
COA,glaukoma
kongestif
. Operasi ekstraksi lensa (TIO < )
Luksasi posterior . Visus <,lensa di C
vitreus,uveitis
fakotoksik
Glaukoma fakolitik
,hipermetropia
+10D
.Th/ Ekstraksi lensa(penyulit),
Th ( - ) (absorpsi)

OPHTALMOLOGY
A 20 year old woman was diagnosed with anterior
uveitis, due to:
History taking :
Major complaint was red and painful right eye,
which since 1 week prior to visit, first symptom was
mild pain which developed progressively until
admitted. She also complaint of excessive tearing,
glare and blurred vision on her right eye. No
previous history of trauma, systemic illness nor
ocular surgery. No history of spectacle uses and
other ocular diseases.

OPHTALMOLOGY
Pemeriksaan Fisik : Keadaan Umum
: Sakit sedang / Gizi baik/ sadar
Vital sign : TD = 120/80; Nadi = 80x/mnt;
Pernapasan= 20x/mnt; Suhu= 37,1oC

Pemeriksaan Oftalmologi :
Visual Acuity :
OD : 3/60 Counting finger
OS : 20/20

Intraocular Pressure : OD : Tn OS : Tn

OPHTALMOLOGY
Structures of the
eye
Palpebra
Cilia
Konjungtiva bulbi/

OD

OS

Normal
Normal
Hyperemis,

Normal
Normal
Normal/ normal

Konjungtiva

conjunctival

palpebral

injection (+),
pericorneal injection

Cornea

(+)
Slightly hazy,diffuse

Clear

Keratic Precipitate
COA

(+)
AC (+), flare grade

Normal

Iris

(+2)
Bombae Segmental

Brown, crypte(+)

Pupil

posterior synechiae
Irregular shape

Round, light

OPHTALMOLOGY
Posterior segment :
FOD : Due to unclear media, posterior
segment could not being evaluated
FOS : red reflex (+), fine edges of
optic nerve, CDR normal, fovea reflex
(+).
Laboratory findings : Leucocytosis
( 14.000 /ul ), elevated ESR/LED

OPHTALMOLOGY
CASE 3 :
Seorang Wanita 60 tahun didiagnosis dengan Glaukoma
absolut berdasarkan :
Anamnesis :
Kedua mata tidak bisa melihat yang dialami sejak 6 bulan
yang lalu, awalnya pasien sering merasa sakit kepala sejak
2 tahun yang lalu, kemudian penglihatan kabur pada
kedua mata dan perlahan lahan tidak bisa melihat,
riwayat mata merah (+), gatal (-), berair (+), kotoran mata
berlebih (-), nyeri (-), silau (-), berair (+). Riwayat berobat
(-), Riwayat operasi (-), Riwayat penyakit yang sama
dalam keluarga(-), Riwayat HT (-), Riwayat DM (-).

OPHTALMOLOGY
Pemeriksaan Fisik :
Visus
VOD: 0
VOS : 1/-
Tonometri :
TOD = 0/5,5 = 0/7,5 = 2/10 = 59,1
mmHg
TOS = 0/5,5 = 0/7,5 = 2/10 = 59,1 mmHg

OPHTALMOLOGY
PEMERIKSAAN

OD

OS

Palpebra

Edema (-)

Edema (-)

Apparatus Lakrimalis

Lakrimasi (+)

Lakrimasi (+)

Silia

Normal

Normal

Konjungtiva

Hiperemis (-)

Hiperemis (-)

Bola mata

Normal

Normal

Mekanisme muskular

Normal ke segala arah :

Normal ke segala arah :

Kornea

Jernih

Jernih

Bilik Mata Depan

Dangkal

Dangkal

Iris
Pupil

Coklat, kripte (+)

Coklat, kripte (+)

Bulat,middilatasi (-),

Bulat, sentral, mid

RC (-)

dilatasi RC (-)

OPHTALMOLOGY
Oftalmoskopi
FOD : refleks fundus (+), papil N.II
batas tegas, CDR 1,0, a/v = 2/3,
nasalisasi (+), makula refleks fovea (+)
kesan normal, retina perifer kesan tipis.
FOS : refleks fundus (+), papil N.II batas
tegas, CDR 1,0, a/v = 2/3, nasalisasi
(+), makula refleks fovea (+) kesan
normal, retina perifer kesan tipis.

DERMATOLOGY
CASE 1:
A man, 30 years old diagnosed with seborroic
dermatitis, based on :
History Taking :
A man, 30 years old came to the hospital with the
chief complained red spot,with yellow scale on
scalp, face, nasolabial folds and chest since one
week ago and getting more itch if sweating and
eat spicy food. There is no Family history with
the same disease. There is no allergic history
and no drug consumption before.

DERMATOLOGY
Physical examination : status present : mild pain/
good level of nutrition/ compos mentis
Vital Sign : T = 120/80mmHg; N = 80 x/minute, P=
20x/minute; S= 36,7o C
Dermatology status :
Regio scalp, facialis, nasolabial fold, trunk
Effloresensi : mild scale, papule, makule eritematous, yellow
crusts
Another examination : KOH (-)

Diagnose : seborroic dermatitis

(seborrheic erythroderma).

Prognosis : dubia.

DERMATITIS SEBOROIK
Peradangan kulit yg sering terdapat
pada daerah tubuh berambut,
terutama pada kulit kepala, alis
mata, kronik dan superfisial.
Akibat peningkatan aktivitas kelenjar
sebasea, kemungkinan akibat
adanya pengaruh hormon

Dermatitis seboroik
Seboroik kepala
Pada daerah berambut dijumpai skuama
yang berminyak dengan warna kekuningkuningan sehingga rambut saling lengket
Kadang ditemukan krusta (Pityriasis
oleosea), kadang-kadang skuamanya
kering dan berlapis-lapis dan sering lepas
sendiri disebut Ptyriasis Sika. Pada bayi
Cradle Cap.

Dermatitis seboroik
Seboroik muka
Pada daerha mulut, palpebra, sulkus
nasolabialis, dagu
Makula eritem dan skuama berminyak
berwarna kekuningan

Seboroik badan
Daerah presternal, intraskapula, ketiak,
intramamma, umbilikus, kruris
Makula eritem dgn skuama bermeinyak
berwarna kuning

Dermatitis seboroik
DD
Psoriasis
Ptyriasis rosea
Tinea

Tindakan umum
Hindari faktor predisposisi sprti stress emosional,
makanan berminyak dan sebagainya
Terapi Topikal : sampo yg mengandung sulfur atw
as. Salisil dan selenium sulfida 2% 2-3x seminggu
slama 5-10 minggu
Sistemik : anti-histamin

Ptyriasis Rosea
A woman, 28 years old diagnose withpityriasis
rosea, based on :
History taking :
A woman, 28 years old came to the hospital with
chief complain redness on chest and back area
since 1 week ago after cleaning the house.
Firstly there are only 2 wide lesion with thin
scale on the margin then spread into some small
lesion on the back with a mild itchiness. There is
no family history of the same complain, no
history of allergy and no history of medication.

Ptyriasis Rosea
Physical examination : General status :
Mild illness/ Well-nourished / Conscious.
Status Vital : BP = 120/80; HR = 80
x/m, RR= 20x/menit; Tax= 36,7o C
Dermatology status :
Trunk & vertebrae region
Efflorescence : herald patch, erythematous
papule, thin scale
Laboratory test : KOH (-), wood lamp (-)

VITILIGO
A woman, 30 years old, diagnosed with
vitiligo, based on:
History taking :
A woman, 30 years old came to the hospital
with the complaint of whitish spot like
white milk, well-defined border in the face
since 2 months ago. There is no history of
injury. She has a family history of the same
complaint and no history of atopic and
medication.

VITILIGO
Vital sign : BP = 120/80; HR = 80
x/menit, RR= 20x/menit; Tax= 36,7o C
Dermatology status :
Location: Face region
Efflorecensce : Hypopigmented macules
Laboratory test : KOH (-), wood lamp
(-)

VITILIGO
Suatu kelainan berupa makula
berwarna putih (hipopigmentasi),
mengenai 1% penduduk di dunia.
Idiopatik, teori :
Teori neurogenik
Teori rusak diri (self destruction theory)
Teori autoimun

Vitiligo
Makula hipopigmentasi
Makula yang amelanotik
Macam2 vitiligo :
Vitiligo lokal
Vitiligo segmental
Vitiligo generalisata

VITILIGO
Anamnesis & Pemfis
Pemeriksaan tambahan (untuk
menghilangkan diferential diagnosis
lainnya, cont. Pityriasis versikolor)

VITILIGO
Terapi
Psoralen photochemotherapy
Fototerapi psoralen topikal
Kortikosteroid topikal (betametason
0,1%)
Skin grraft