LBM 3

Dok, hidung anak saya bau...

STEP 1
Rhinoskopi: px.hidung. ada dua yaitu rhinoskopi anterior (melihat bag.depan hidung)
dan rhinoskopi posterior (melihat bag.belakang) butuh kaca nasofaring yang telah
dihangatkan
STEP 2
1. Anatomi, fisiologi, histologi organ penghidu!
2. Mengapa pada paseien mengeluh hidungnya keluar ingus dan bau pada sisi kiri
sejak 5 hari yang lalu?
3. Mengapa pada pasien didapatkan mimisan?
4. Mengapa setelah diberi obat pileknya habis, hidung masih tetap berbau?
5. Patologi dari organ penghidu!
6. Jelaskan interpretasi konka hiperemis -/+, sekret mukoserous -/+, mukosa
hiperemis -/-, benda asing -/+!
7. Bagaimana cara px.rhinoskopi anterior?
8. DD (pemeriksaan penunjang, prognosis, komplikasi)!
9. Penatalaksanaan!

STEP 3
1. Anatomi, fisiologi, histologi organ penghidu!
Anatomi:
Nasus/hidung ada 2 bagian nasus internus dan eksternus (tulang yaitu os nasal dan
kartilago nasi lateralis, kartilago alaris mayor et minor)
Nasus dipisahkan oleh septum nasi yaitu os.vomer, os.ethmoidal, kartilago septi nasi.
Batasnya:
anterior: nares anterior
Belakang: nares posterior
Atap: os.frontal, os.ethmoidal (foramina cribosa di lamina cribosa sebagai tempat
keluarnya fila olfactory), os.sphenoidal.
Lateral: concha nasalis (superior, media, inferior) dibawahnya meatus nasi
Dasar: palatum durum (lamina horizontalis os.palatini dan proc.palatini os.maxila)

Vaskularisasi: plexus kiesselbach/area litle a.sphenopalatina (cabang dari

a.maxilaris interna), a.ethmoidalis (cabang a.ofthalmica), rami septi nasi cabang dari
a. Labialis superior.

Sinus paranasal: normalnya berisi udara. Muaranya di dinding lateral hidung

Fisiologi:
Fisiologi

Fungsi hidung adalah :

1. Jalan napas
2. alat pengatur kondisi udara (air conditioning)
3. penyaring udara
4. sebagai indra penghidu
5. untuk resonansi suara
6. turut membantu proses bicara
7. refleks nasal
Sebagai Jalan Napas ;

Inspirasi udara masuk melalui nares anterior naik ke atas setinggi konka media
turun ke bawah (nasofaring) aliran udara berbentuk lengkungan atau arkus.

Ekspirasi udara masuk melalui koana mengikuti jalan yang sama dengan
inspirasi tetapi bagian depan aliran udara memecah sebagian melalui nares
anterior da sebagian lain kembali ke belakang membentuk pusaran dan bergabung
dengan aliran dari nasofaring.

Pengatur Kondisi Udara ;

Untuk mempersiapkan udara yang akan masuk ke alveolus paru.

Cara:

a. Mengatur kelembaban udara . fungsi ini dilakukan oleh palut lender(mucous

blanket). Pada musim panas, udara hamper jenuh oleh uap air, penguapan dari
lapisan ini sedikit, sedangkan pada musim dingin akan terjadi keadaan sebaliknya.
b. Mengatur suhu. Karena banyak pembuluh darah di bawah epitel dan adanya
permukaan konka dan septum yang luas, sehingga radiasi dapat berlangsung
secara optimal. Dengan demikian suhu udara setelah melalui hidung kurang lebih
37 derajat celcius.
Sebagai Penyaring dan Pelindung.

Berguna untuk membersihkan udara inspirasi dari debu dan bakteri dan dilakukan
oleh : a. rambut padavestibulum nasi, b.silia , c.palut lender (mucous blanket). Debu
dan bakteri akan melekat pada palut lender dan partikel besar akan dikeluarkan oleh
refleks bersin. Faktor lain : enzim yang dapat menghancurkan beberapa jenis bakteri,
yang disebut lysozyme.

Indra Penghidu

Yaitu dengan adanya mukosa olfaktorius pada atap rongga hidung, konka superior,
dan sepertiga bagian atas septum. Partikel bau dapat mencapai daerah ini dengan
cara difusi dengan palut lender atau bila menarik napas dengan kuat.

Resonansi Suara.

Penting untuk kualitas suara ketika berbicara dan menyanyi. Sumbatan hidungakan
menyebabkan resonansi berkurang atauhilang, sehingga terdengar suara sengau.

Proses Berbicara

Hidung membantu pembentukan kata-kata. Kata dibentuk olh lida, bibir, dan
palatum molle. Pada pembentukan konsonen nasal (m, n, ng) rongga mulut tertutup
dan hidung terbuka, palatum mole turununtuk aliran udara.

Refleks Nasal

Contoh :iritasi mukosahidungmenyebabkan refleks bersin dan nafas terhenti.

Rangsang bau tertentu menyebabkan sekresi kelenjar liur, lambung dan pancreas

Buku Ajar Ilmu Kesehatan THT, FK UI

Membran olfactory (100.000 epitel) sel olfactory fila olfactori (4-25) untuk
rangsang kimia nempel di mukus yang dihasilkan oleh gl.bowman.

Mekanisme penghidu:
Substansia yang dapat menguap dan larut air tangkap sel olfactory diteruskan
silia secara difus berikatan dengan protein reseptor ada yang melipat keluar
(bau berikatan) dan kedalam akan terbentuk 3 sub unit substansi tapi hanya 1
yang berikatan yaitu sub unit alfa aktivasi adenil siklase berikatan dengan
 trifosfat adenosin intraseluler berikatan deng cAMP buka kanal ion Na
depolarisasi Na ke sitoplasma sel reseptor n.olfaktorius SSP
3 syarat odhorant: harus larut dalam udara, lipid (berikatan dengan resptor silia dan
n.olfactorius), larut air (odhorant larut dalam mukus dan silia olfactorius)
Fungsi DIJELASKAN
1) Respirasi: untuk menyaring udara dari vibrisa, menyesuaikan suhu luar dan dalam
2) Fungsi penghidu
3) Fonetik: resonansi suara untuk proses bicara melalui konduksi tulang
4) Fungsi statik dan mekanik: meringankan beban kepala dan proteksi terhadap
trauma dan pelindung panas
5) Reflek nasal: iritasi mukosa hidung bersin

Histologi:
Penghidu: epitel olfactorius dilengkapi kel.bowman untuk hasilkan sekret. Ada 3
macam sel: basal, olfactory, sustentakular. Letaknya di concha superior, atap hidung,
dan atas septum nasi

Mukosa: yang melingkupi hasilkan mukus

Epitel respiratori: epitel silindris psudokompleks bersilia dan bersel goblet goblet
untuk menghasilkan mukus dan membuat gumpalan serta silia untuk mendorong
supaya keluar
2. Mengapa pada paseien mengeluh hidungnya keluar ingus dan bau pada sisi kiri
sejak 5 hari yang lalu?
Foreign Body in the Nose Symptoms

Fortunately, most people (adults) can and will tell their doctor about an object's
presence in their nose.

Typically, foreign items in the nose result in complaints of pain or difficulty

breathing through that side of the nose.
Nasal bleeding is also a common symptom of a foreign body in the nose because
the tissues of the nose can be easily scratched. Much of this blood can drip down
the back of the throat and be swallowed. Because blood is quite nauseating, the
person may vomit, which can appear black or bloody, depending on how long the
blood remains in the stomach. It is important to distinguish vomiting swallowed
blood from vomiting because there is bleeding in the stomach.
The nasal space connects to the back of the mouth, so it is also possible for an
object to be pushed back into the throat. Individuals may swallow the object or
choke on it. Complaints ofchoking, wheezing, difficulty breathing, or inability to
talk should prompt an evaluation of the entire nose and throat in addition to the
lungs so that foreign bodies will not be overlooked. Gathering information in
regard to what kind of foreign object it may have been will assist the health care
practitioner to determine if an X-ray will show the object (the object is
radiopaque such as metal) or if it will not show up on an X-ray.
 Some individuals, especially children, who are motivated to place something in
their nose might also think it is fun to put something in the other side of their
nose as well as in one or both ears. A doctor will check all the likely places if there
is a suspicion of additional foreign bodies. Moreover, children have been known
to place objects in their younger siblings nose, ears, and other places.
Infection is another common symptom of a foreign object in the nose. Lost or
forgotten tissue paper is a common source of such a problem. This scenario is not
uncommon in adults and children. People will typically complain of continuing
nasal discharge from one side of the nose. Many of these people have been
treated with one or moreantibiotics. Unfortunately, antibiotics alone will not
cure this condition until the object is removed. In addition, the sinuses are all
connected to the nasal passages. Because a foreign body in the nose will
frequently become infected and block the drainage sites of the sinuses, sinusitis
(especially repeated episodes or chronic sinusitis) should also raise the question
of a foreign object inside the nose.
Although a person can usually sense the presence of something out of the
ordinary in their nose, it may be confused with nasal congestion, so small objects
or torn tissue paper can easily go undetected.
A foul odor can be a sign of a foreign body that has been in the nose for a period
of time. The object can manifest itself by producing bad breath or a foul odor
from the nose, possibly linked to a nasal discharge associated with the foreign
object.
The skin under the nose may become raw from the continuous discharge or from
frequent wiping. Impetigo is an infection of the skin that is commonly associated
with this problem. Impetigo typically appears as a raw rash with faint yellow,
crusty material over it. Impetigo just in this area must prompt a thorough
evaluation of the nose to ensure that the nose is clear.

http://www.emedicinehealth.com/foreign_body_nose/page2_em.htm#foreign_bod
y_in_the_nose_symptoms

Nasal Drainage
Another common symptom of a foreign body in the nose is nasal drainage on the
affected side of the nose. The fluid draining from this nostril may be clear or grey. In
some cases, it may have a bad odor. This is usually the sign of an infection.

http://www.healthline.com/health/foreign-body-in-the-nose#CommonItems2

Benda asing terjebak di daerah rongga hidung sehingga menimbulkan mekanisme

peradangan sel sel radang berkumpul peradangan, sehingga didapatkan sekret
mukoserous yang menyebabkan bau. Bau ditimbulkan dari sekret mukoserous yang
berasal dari debris sel-sel peradangan dari mukosa rongga hidung karena adanya benda
asing.
Benda asing yg menimbulkan peradangan menimbulkan sel radang yg hasilkan sekret
yang menyebabkan hidung bau

Hidung bau (foeter et nose) yg baunya dlm skenario terjadi karena pembusukan biji
jagung

Mekanisme peradangan karena benda asing transudasi awalnya sekretnya serous,

jika menetap beberapa hari akan menjadi media yg baik sbg perkembangan bakteri
sekret mukopurulen

Benda asing peradangan tetapi karena ada biji jagung tsb, sekret tersumbat
sekret mukopurulen bau
Diberi obat antipilek, bau hilang namun setelah obat dihentikan jd bau lagi

Benda asing luka rongga hidung luka, dijadikan untuk perkembangan bakteri
dilawan oleh sel-sel pertahanan tubuh sekret bau dari bakteri dan sel-sel tubuh
sendiri

Inflamasi pembengkakan mukosa hidung sekret tdk bisa keluar ulser, sekret tdk
bisa keluar bau busuk

Biasanya ditemukan di anterior vestibulum / meatus inferior sepanjang dasar hidung

Benda asing jg bisa sebabkan epistaksis inflamasi pembengkakan pd hidung

spina septum tajam terjadi pd spina itu sendiri maupun pd concha

Awalnya anak pilek, karena ada biji jagung, sekret tdk bisa keluar bercampur dengan
sel-sel peradangan bau

Keluhan pilek, berawal karena sekret mukoserous tdk ada perlakuan ekstraksi
sekret mukopurulen. Diberi obat pilek tdk sembuh karena tdk mengobati etiologinya

Bau karena sumbatan bisa dari benda asing, tumor partikel bau tdk mencapai daerah
mukosa
Robert T.Sataloff, Michael M,Johns III, Karen M. Kost

o Keluar ingus: corpus alineum jatuh di meatus nasi inferior di concha inferior
yang banyak sel goblet yang mengandung garam fisiologis dan garam
natrium corpus alineum dibiarkan hipersekresi sel goblet mukus
berlebih
 o Bau: corpus alineum dari bijian mudah mengembang membusuk
corpus alineum jatuh di meatus nasi inferior di concha inferior yang banyak
sel goblet yang mengandung garam fisiologis dan garam natrium corpus
alineum dibiarkan bau karena akumulasi dari mukus yang mengandung
garam fisiologis

organik degradasi bakteri

3. Mengapa pada pasien didapatkan mimisan?
Epistaksis

Trauma
Epistaksis dapat terjadi setelah trauma ringan, misalnya waktu mengeluarkan ingus
dengan kuat, bersin, mengorek hidung atau sebagai akibat trauma yang hebat, seperti
terpukul, jatuh dan sebagainya. Selain dari itu iritasi oleh gas yang merangsang, benda
asing di hidung dan trauma pembedahan, dapat juga menyebabkan epistaksis.

Buku Ajar Ilmu Kesehatan THT, FK UI

CHAPTER 45 Epistaxis
Daniel B. Simmen,
Nick S. Jones
Key Points
Epistaxis is the most common otolaryngologic emergency.
The most common etiology of epistaxis is idiopathic, followed by primary
neoplasms and traumatic or iatrogenic causes.
The management ranges from resuscitation, through visualization, and cautery,
nasal packing, and surgery (either endoscopic or external), to embolization.
Terminal branches of the external and internal carotid arteries supply the mucosa
of the nasal cavity, with frequent anastomosis between these systems.
Various anastomoses on the ipsilateral side between the internal and external
carotid systems exist as well as crossover to the contralateral side.
The philosophy of management for epistaxis is: (1) establish the site of bleeding,
(2) stop the bleeding, and (3) treat the cause.
The majority of posterior idiopathic bleeds are from the septum, usually from the
septal branch of the sphenopalatine artery.
Endoscopic bipolar diathermy treats most cases of epistaxis.
If a bleeding point cannot be found, ideally the nose is packed with an absorbable
hemostatic agent that produces minimal mucosal trauma.
Endoscopic sphenopalatine artery ligation (ESPAL) has replaced the need for
posterior nasal packs, other than in an emergency situation to control profuse
bleeding.
The branching pattern of the sphenopalatine artery is complexmost commonly
there are two or three branches medial to the crista ethmoidalis, sometimes even
more.
 Persistent posterior epistaxis can be controlled by percutaneous embolization of
bleeding arteries.

Epistaxis is the commonest otolaryngologic emergency, affecting up to 60% of the

population in their lifetimes, with 6% of cases requiring medical attention.[1] It has been
estimated that nosebleeds affect 108 per 100,000 population per year.[2] In England and
Wales an average of 10.2 per 100,000 patients with nosebleed are admitted, for an
average stay of 2.9 days, in a 3-month period[3]; and in the United States 17 per 100,000
or 6% of patients with nosebleed are admitted.[4] There are peaks in incidence for patients
both younger than 10 years old and older than 40 years.[4-6] The etiology of epistaxis in
the majority of patients is idiopathic,[7] followed in frequency by primary neoplasms and
traumatic or iatrogenic causes.

Decisions about the optimum therapeutic intervention and timing are often made on an ad
hoc basis, and most units do not have a protocol (systematic algorithm) for the
management of epistaxis,[8] despite a 2005 published protocol aimed at junior doctors.[9]
However, this protocol does not contain the timing of surgical intervention. The
management of a patient with epistaxis ranges from resuscitation, through direct
visualization and cautery, nasal packing, and surgery (both endoscopic and external) to
embolization.

Vascular Anatomy

The nasal cavity is extremely vascular. Terminal branches of the external and internal
carotid arteries supply the mucosa of the nasal cavity with frequent anastomoses between
these systems (Fig. 45-1). The anterior nasal septum is the site of a plexus of vessels
called Little's or Kiesselbach's area, which is supplied by both systems.
Figure 45-1. Latex-injected human skull showing the functional vascular anatomy
of the nasal mucosainternal and external artery supplies with rich anastomoses in
between and also crossover anastomoses.
(Courtesy of the Institute of Anatomy, University of Z?rich, Switzerland.)

The terminal branches of the external carotid artery that supply the nasal cavity are the
facial artery and the internal maxillary artery. The facial artery supplies the superior labial
artery, which enters the nose and supplies the anterior nasal septum. The internal
maxillary artery courses within the pterygopalatine fossa and terminates in the
sphenopalatine, descending palatine, pharyngeal, infraorbital, and posterior superior
alveolar arteries. The branching of the sphenopalatine artery when it enters the nasal
cavity is a key point in the understanding of the management of posterior nosebleeds. The
sphenopalatine artery enters the nasal cavity through the sphenopalatine foramen and then
divides into conchal (posterior-lateral) and septal (posterior-medial) branches.[10,11] The
descending palatine artery courses through the greater palatine canal and becomes the
greater palatine artery, entering the nose through the incisive foramen, where it supplies
the anterior inferior septum and anastomoses with medial branches of the sphenopalatine
artery. Importantly, the vidian artery has a significant anastomosis between the internal
carotid artery and a branch of the sphenopalatine artery and therefore with the external
carotid system (Fig. 45-2).
Figure 45-2. Endoscopic view of an anatomic, injected specimen showing the
vidian artery along the floor of the right sphenoid with the ball probe anastomosing
the internal carotid (asterisk) with the sphenopalatine artery system (plus sign).

The internal carotid artery supplies the nasal mucosa via the ethmoidal branches of the
ophthalmic artery. The ophthalmic artery is the first branch of the internal carotid artery.
The posterior ethmoidal artery passes through the posterior ethmoidal canal into the
anterior cranial fossa and divides into lateral and medial branches, supplying the superior
part of the posterior septum and lateral nasal wall. The anterior ethmoidal artery enters
the nasal cavity through the anterior ethmoidal canal and passes anteromedially to the
area of the anterior skull base (Fig. 45-3). Where it crosses the anterior ethmoid roof to
reach the fovea ethmoidalis and cribriform plate, a nasal branch supplies the anterior
superior part of the septum (Fig. 45-4) and its other branchthe anterior meningeal
arteryenters intracranially.
 Figure 45-3. Internal and external artery supply with rich anastomoses in between
and also crossover anastomoses: lateral nasal wall (A), external nose (B), and
septum (C).
(Adapted from Zuckerkandl: Anatomie der Nasenh?hle, Taf. XIII, 1892.)

A fundamental aspect of the understanding of the vascular anatomy and its

importance to epistaxis is the fact that various anastomoses on the ipsilateral side between the
internal and external carotid systems exist as well as crossover to the contralateral side. The
rich anastomoses underlie the importance of a strategy to address the most distal site of any
bleeding (Figure 45-5).

Figure 45-5. Endoscopic view (A) and computed tomography scan (B) of a
cavernous hemangioma arising from the olfactory cleft on the right side that has
caused a severe epistaxis.

The maxillary sinus ostium serves as the dividing line between anterior and posterior
epistaxis. Anterior bleeding is usually easier to access and is therefore less dangerous.
Posterior epistaxis is more difficult to treat because visualization is more difficult and
blood is often swallowed, making it more difficult to gauge the amount of blood loss.
The term posterior bleeding is all too often used incorrectly to label bleeding that
cannot be visualized with a head lamp. It transpires in many cases that endoscopic
examination shows the bleeding to be located high on the septum.

Epistaksis: di rongga atas hidung di vaskularisasi oleh a.ethmoidalis anterior et

posterior cabang a.opthalmica dan a.carotis interna
Di rongga bawah di vaskularisasi oleh a.spenopalatina cabang a.ethmoidalis
externa masuk rongga belakang hidung di concha superior.

Anastomosis cabang arteri: a.spenopalatina, a.ethmoidalis anterior, a.labialis

superior, a. Palatina mayor plexus kieselbach trauma epistaksis anterior
 Etiologi: local (trauma ringan, infeksi, neoplasma, kel.kongenital) dan general
(kel.darah, penyakit sistemik, infeksi)
Anak benda masuk rusak epitel yang dibawahnya ada lamina propia yang kaya
akan vaskuler anastomosis di depan membentuk plexus kieselbach epistaksi
anterior
Epistaksis posterior a.ethmoidalis posterior yang berasal dari a.carotid interna
cabang a.ophtalmica

Benda masuk (hidup) local inflamation nekrosis karena vaskulernya konstriksi.

Benda masuk (benda mati) ulserasi

Gambaran meatus, plexus kieselbach

4. Mengapa setelah diberi obat pileknya habis, hidung masih tetap berbau?
Obat pilek: dekongestan farmakodinamik: mengkonstriksi vaskuler di hidung
supaya tidak memproduksi mukus.

Tertahannya sekresi mukus, jagung yang mudah membusuk, ulserasi sekret bau
busuk fungsi dekongestan untuk mengurangi bau busuk obat tidak diminum
bau lagi.

5. Patologi dari organ penghidu!

1) Anosmia: hilangnya penghidu bisa parsial maupun total. Etiologi: kongesti di
nasal, rusak n.olfactori.
2) Hiposmia: berkurangnya sensitivitas penghidu.
3) Disosmia: kesalaha persepsi penghidu troposmia (ada objek salah interpretasi)
dan pantosmia (tidak ada objek bisa membau pre-epilepsi)
6. Jelaskan interpretasi konka hiperemis -/+, sekret mukoserous -/+, mukosa
hiperemis -/-, benda asing -/+!
Kel.di rongga hidung kiri.
Konka hiperemis, sekresi mukoserous, corpal di kiri
Tidak ditemukan mukosa hiperemis
7. Bagaimana cara px.rhinoskopi anterior?
 Ekstraksi: forsep alligator masuk hidung dibuka saat diluar.
Px.rhinoskopi anterior:
Pakai lampu kepala Spekulum Cek konka superior, media, inferior. Cek sekret
(kental, encer untuk melihat prognosis), mukosa.
8. DD (pemeriksaan penunjang, prognosis, komplikasi)!
Foreign Body in the Nose Overview

The nose is a surprisingly deep space that extends directly back into the face. A
relatively small portion of the nasal cavity is visible by looking into the tip of the
nose. In the back of the nose, the space turns downward and connects to the back of
the mouth.

Only the imagination limits the objects and circumstances that result in things
getting stuck inside of the nose.

Common objects found in noses include food material, tissue paper, beads, toys,
and rocks.
Most cases of foreign bodies in the nose and nasal cavity are not serious and
occur in toddlers and children from 1-8 years of age. Children develop the ability
to pick up objects at about the age of 9 months, so foreign objects in the nose
are much less common in children 9 months of age or less.
An object that is simply stuck in the nose and not causing other symptoms can
usually wait until morning or the following day for removal. The object does,
however, have to be completely removed quickly and without discomfort and
danger.

In addition, an object stuck in the nose has the potential to dislodge and travel into
the mouth where there is the danger of swallowing it, or even worse, inhaling it into
the lungs, which may block airflow.

The subject of this article is foreign objects in the nose and it is not intended to cover
toxic chemical inhalants toxins that injure the nasal cavity, trauma to the nose, or
foreign bodies traveling through the nasal cavity into the lungs.
http://www.emedicinehealth.com/foreign_body_nose/article_em.htm#foreign_bod
y_in_the_nose_causes

SINUSITIS AKUT

Etiologi
Penyebab sinusitis akut ialah (1) rinitis akut (2) infeksi faring, seperti faringitis,
adenoiditis, tonsilitis akut (3) infeksi gigi rahang atas M,, M2, M3, serta P, dan P2
(dentogen) (4) berenang dan menyelam (5) trauma, dapat menyebabkan perdarahan
mukosa sinus paranasal (6) barotrauma dapat menyebabkan nekrosis mukosa.

Gejala subyektif
Gejala subjektif dibagi dalam gejala sistemik dan gejala lokal. Gejala sistemik ialah
demam dan rasa lesu. Lokal pada hidung terdapat ingus kental yang kadang-
kadang berbau dan dirasakan mengalir ke nasofaring. Dirasakan hidung
tersumbat, rasa nyeri di daerah sinus yang terkena, serta kadangkadang
dirasakan juga di tempat lain karena nyeri alih (referred pain). Pada sinusitis
maksila nyeri di bawah kelopak mata dan kadang-kadang menyebar ke alveolus,
sehingga terasa nyeri di gigi. Nyeri alih dirasakan di dahi dan di depan telinga.

Rasa nyeri pada sinusitis etmoid di pangkal hidung dan kantus medius. Kadang-
kadang dirasakan nyeri di bola mata atau di belakangnya, dan nyeri akan
bertambah bila mata digerakkan. Nyeri alih dirasakan di pelipis (parietal).

Pada sinusitis frontal rasa nyeri terlokalisasi di dahi atau dirasakan nyeri di seluruh
kepala.

Rasa nyeri pada sinusitis sfenoid di verteks, oksipital, di belakang bola mata dan di
daerah mastoid.

Gejala obyektif
Pada pemeriksaan sinusitis akut akan tampak pembengkakan di daerah muka.
Pembengkakan pada sinusitis maksila terlihat di pipi dan kelopak mata bawah, pada
sinusitis frontal di dahi dan kelopak mata atas, pada sinusitis etmoid jarang
timbul pembengkakan, kecuali bila ada komplikasi.

Pada rinoskopi anterior tampak mukosa konka hiperemis dan edema. Pada
sinusitis maksila, sinusitis frontal dan sinusitis etmoid anterior tampak mukopus
atau nanah di meatus medius, sedangkan pada sinusitis etmoid posterior dan
sinusitis sfenoid nanah tampak ke luar dari meatus superior.

Pada rinoskopi posterior tampak mukopus di nasofaring (post nasal drip).

P.penunjang
Pada pemeriksaan transiluminasi, sinus yang sakit akan menjadi suram atau gelap.
Pemeriksaan transiluminasi bermakna bila salah satu sisi sinus yang sakit, sehingga
tampak lebih suram dibandingkan dengan sisi yang normal.

Pemeriksaan radiologik yang dibuat ialah posisi Waters, PA dan lateral. Akan tampak
perselubungan atau penebalan mukosa atau Batas cairan-udara (air fluid level)
pada sinus yang sakit.

P. mkrobiologik
Sebaiknya untuk pemeriksaan mikrobiologik diambil sekret dari meatus medius atau
meatus superior. Mungkin ditemukan bermacam-macam bakteri yang merupakan
flora normal di hidung atau kuman patogen, seperti Pneumococcus,
Streptococcus, Staphylococcus dan Haemophilus influenza. Selain itu mungkin
ditemukan juga virus atau jamur.

Terapi
Diberikan terapi medikamentosa berupa antibiotika selama 10-14 hari, meskipun
gejala klinik telah hilang. Antibiotika yang diberikan ialah golongan penisilin.
Diberikan juga obat dekongestan lokal berupa tetes hidung, untuk memperlancar
drenase sinus. Boleh diberikan analgetika untuk menghilangkan rasa nyeri.

Terapi pembedahan pada sinusitis akut jarang diperlukan, kecuali bila telah terjadi
komplikasi ke orbita atau intrakranial; atau bila ada nyeri yang hebat karena ada
sekret tertahan oleh sumbatan.

SINUSITIS SUBAKUT

Gejala klinisnya sama dengan sinusitis akut hanya tanda-tanda radang akutnya
(demam, sakit kepala hebat, nyeri tekan) sudah reda.
Pada rinoskopi anterior tampak sekret purulen di meatus medius atau superior.
Pada rinoskopi posterior tampak sekret purulen di nasofaring. Pada pemeriksaan
transiluminasi tampak sinus yang sakit suram atau gelap.
Terapinya mula-mula diberikan medikamentosa, bila perlu dibantu dengan
tindakan, yaitu diatermi atau pencucian sinus.
Obat-obat yang diberikan berupa antibiotika berspektrum luas, atau yang sesuai
dengan tes resistensi kuman, selama 10-14 hari. Juga diberikan obat-obat
simtomatis berupa dekongestan lokal (obat tetes hidung) untuk memperlancar
drenase. Obat tetes hidung hanya boleh diberikan untuk waktu yang terbatas (5
sampai 10 hari), karena kalau terlalu lama dapat menyebabkan rinitis medika-
mentosa. Selain itu, dapat diberikan analgetika, antihistamin dan mukolitik.

Tindakan dapat berupa diatermi dengan sinar gelombang pendek (ultra short wave
diathermy), sebanyak 5 sampai 6 kali pada daerah yang sakit untuk memperbaiki vas-
kularisasi sinus. Kalau belum membaik, maka dilakukan pencucian sinus.
Pada sinusitis maksila dapat dilakukan tindakan pungsi irigasi. Pada sinusitis
etmoid, frontal atau sfenoid yang letak muaranya di bawah, dapat dilakukan
tindakan pencucian sinus cara Proetz (Proetz displacement therapy).

SINUSITIS KRONIS

Sinusitis kronis berbeda dari sinusitis akut dalam berbagai aspek, umumnya sukar
disembuhkan dengan pengobatan medikamentosa saja. Harus dicari faktor
penyebab dan faktor predisposisinya.

Polusi bahan kimia menyebabkan silia rusak, sehingga terjadi perubahan mukosa
hidung. Perubahan mukosa hidung dapat juga disebabkan oleh alergi dan
defisiensi imunologik. Perubahan mukosa hidung akan mempermudah terjadinya
infeksi dan infeksi menjadi kronis apabila pengobatan pada sinusitis akut tidak
sempurna. Adanya infeksi akan menyebabkan edema konka, sehingga drenase
sekret akan terganggu. Drenase sekret yang terganggu dapat menyebabkan silia
rusak dan seterusnya.

Gejala subyektif
Gejala subyektif sangat bervariasi dari ringan sampai berat, terdiri dari:

- gejala hidung dan nasofaring, berupa sekret di hidung dan sekret pasca nasal
(post nasal drip).
- gejala faring, yaitu rasa tidak nyaman dan gatal di tenggorok.
- gejala telinga, berupa pendengaran terganggu oleh karena tersumbatnya
tuba Eustachius.
- adanya nyeri/sakit kepala.
- gejala mata, oleh karena penjalaran infeksi melalui duktus naso-lakrimalis.
gejala saluran napas berupa batuk dan kadang-kadang terdapat komplikasi di paru,
berupa bronkitis atau bronkiektasis atau asma bronkial, sehingga terjadi penyakit
sinobronkitis.
- gejala di saluran cerna, oleh karena mukopus yang tertelan dapat
menyebabkan gastroenteritis, sering terjadi pada anak.
Gejala obyektif
Pada sinusitis kronis, temuan pemeriksaan klinis tidak seberat sinusitis akut dan tidak
terdapat pembengkakan pada wajah. Pada rinoskopi anterior dapat ditemukan
sekret kental purulen dari meatus medius atau meatus superior. Pada rinoskopi
posterior tampak sekret purulen di nasofaring atau turun ke tenggorok.

Pemeriksaan mikrobiologik
Biasanya merupakan infeksi campuran oleh bermacam-macam mikroba, seperti ku-
man aerob S.aureus, S.viridans, H.influenzae dan kuman anaerob
 Peptostreptokokus dan Fusobakterium.

Diagnosis sinusitis kronis

Dibuat berdasarkan anamnesis yang cermat, pemeriksaan rinoskopi anterior dan
posterior serta pemeriksaan penunjang berupa transiluminasi untuk sinus maksila
dan sinus frontal, pemeriksaan radiologik, pungsi sinus maksila, sinoskopi sinus
maksila, pemeriksaan histopatologik dari jaringan yang diambil pada waktu
dilakukan sinoskopi, pemeriksaan meatus medius dan meatus superior dengan
menggunakan naso-endoskopi dan pemeriksaan CT Scan.

Terapi
Pada sinusitis kronis perlu diberikan terapi antibiotika untuk mengatasi
infeksinya dan obat-obatan simtomatis lainnya. Antibiotika diberikan selama
sekurang-kurangnya 2 minggu.

Buku Ajar Ilmu Kesehatan THT, FK UI

1. Bagaimana penanganan pada pasien tersebut?

Indications and Contraindications for Removal

Nasal foreign body removal may be attempted by an experienced clinician if the
object can likely be extracted. If doubt exists about the reasonable probability of
extraction, an otolaryngologist should be consulted. Repeated attempts at removal
may result in increased trauma and potential movement of the item into a less
favorable location. Mechanical removal of a foreign body should not be attempted if
the item appears to be out of range for instrumentation.
Removal should not be performed without adequate sedation in an uncooperative
patient whose head cannot be securely and safely stabilized. Ideally, nonmechanical
techniques such as positive air pressure should instead be attempted in these
patients.

Removal Techniques
Several removal techniques are available, and the choice of a particular method
depends upon the type of nasal foreign body (NFB), the supplies available, and the
clinician's comfort with each removal method. For easily visualized, nonspherical,
non-friable objects, most clinicians prefer direct instrumentation. If the object is
poorly visualized or spherical or cannot be successfully removed by direct
instrumentation, balloon-catheter removal is a preferred method. For large,
occlusive NFBs, positive pressure techniques are commonly used.

All attempts at removal can be complicated by mucosal damage and bleeding. In

addition, all failed attempts can result in posterior displacement of the NFB.
Direct instrumentation
This technique is ideal for easily visualized, nonspherical, nonfriable foreign bodies.
Previously described instruments include hemostats, alligator forceps, and bayonet
forceps (see the video below). Friable and spherical foreign bodies are particularly
difficult to remove with this technique; friable objects may tear, and spherical
objects may be difficult to grasp, resulting in posterior displacement.
Hooked probes (eg, a right-angle hook) can be used for objects that are easily
visualized but difficult to grasp. The hook is placed behind the NFB and is then
rotated so that the hook angle is behind the bulk of the object. The object is then
pulled forward.[9] One author reported using a flexible endoscope to visualize the
NFB and then using it as a hook to pull out the object.[11] This technique, referred to
as the "hook-scope" technique, may be useful provided that the patient is extremely
cooperative and the clinician is highly adept at flexible nasopharyngoscopy. A recent
case report described the use of a smooth metallic wire grasped by a hemostat to
create a snare, which was used to dissect adhesed tissue planes adjacent to the NFB
and then pull the NFB anterior with the leading snare edge posterior to the foreign
body.[12]
Interestingly, some authors have suggested using the combination of direct
instrumentation to grasp an object while having a balloon catheter (see next
paragraph) placed behind the object to prevent posterior displacement during
removal attempts.
Balloon catheters
This approach is ideal for small, round objects that are not easily grasped by direct
instrumentation. Authors have used Foley catheters (eg, 5-8 French) or Fogarty
catheters (eg, No. 6 biliary or No. 4 vascular), and the Katz Extractor Oto-Rhino
Foreign Body Remover (InHealth Technologies, Calif) is also an option.
The biliary Fogarty catheter has been preferred over the vascular Fogarty catheter by
some authors because its balloon is firmer and theoretically less prone to rupture.
Regardless of catheter type, the technique is similar. First, the balloon is inspected,
and the catheter is coated with 2% lidocaine jelly. Then, with the patient lying
supine, it is inserted past the foreign body and inflated with air or water (2mL in
small children and 3mL in larger children). After inflation, the catheter is withdrawn,
pulling the foreign body with it. (See the illustration below.)
Use of a Fogarty catheter to remove a nasal foreign body.
Positive pressure
Large, occlusive foreign bodies are especially amenable to the positive-pressure
technique. Several techniques have been developed to expel NFBs by force provided
in the form of positive pressure. The least invasive form, "forced exhalation," can be
accomplished by occluding the unaffected nostril and asking the child to blow hard
out of his or her nose. If this fails, the positive pressure can be applied by either the
parent's mouth ("parent's kiss"[13, 14] ) or a bag-valve mask.
With either method, a tight seal is formed around the child's mouth, while avoiding
the nose. The unaffected nostril is then occluded, and a forceful puff of air is
provided. When the bag-valve mask is used, the Sellick maneuver can be considered
to prevent esophageal air insufflation.[15]
If these techniques do not completely remove the object, they may at least dislodge
the object more anteriorly and allow for removal using the previously described
techniques.
Another positive-pressure technique delivers air into the unaffected naris with the
patient's mouth closed. In this method, the patient is placed on his or her side
(foreign-body-side down), and the delivery device (known as a Beamsley Blaster)
provides high-flow oxygen (10-15L/min) into the unaffected naris. To set up the
Beamsley Blaster, one end of oxygen tubing is connected to the oxygen source and
the other end is connected to a male-male oxygen tube adaptor that is placed in the
patient's unaffected naris.
Self-limited, subcutaneous, periorbital emphysema has been reported as a
complication of NFB removal via intranasal positive pressure.[16] Positive-pressure
techniques also have the risk of causing barotrauma to the airway, lungs, or the
tympanic membranes, and clinicians should avoid using large volumes of forced air.
To the best of our knowledge, these latter complications have not been reported.
Suction
This technique is ideal for easily visualized, smooth or spherical foreign bodies. The
catheter tip is placed against the object, and suction is applied at 100-140mm Hg
(readily supplied by standard medical suction equipment). A strong seal is important
for success of this technique, and authors have recommended using a Schunk neck
suction catheter with its plastic umbrella tip or a Frazier suction catheter with a
segment of pliable tubing connected to its tip for a strong seal with the foreign body.
Glue
This method is ideal for easily visualized smooth or spherical foreign bodies that are
dry and nonfriable. A thin coat of cyanoacrylate adhesive is placed on the tip of a
wooden or plastic applicator, which is then pressed against the foreign body for 60
seconds and removed. Without full cooperation of the patient, the nasal mucosa can
be easily injured by misplaced glue.
Posterior displacement
Rarely, a foreign body may be so posterior that the above techniques will not work.
In these cases, after consultation with a specialist, it may be necessary to induce
further posterior displacement of the object into the oropharynx for removal. Of
course, this requires general anesthesia, endotracheal intubation, and esophageal
occlusion.
Magnet
A case report demonstrated successful removal of a loose ball bearing from a nasal
cavity using a household magnet.[17] The authors believe that a strong magnet may
be especially useful to remove button batteries, which are associated with mucosal
edema and significant bleeding with direct instrumentation, making visualization
especially difficult.
Irrigation
This technique has been strongly criticized for carrying a significant risk of aspiration
or choking. The authors do not recommend the use of this method; however, it will
be reviewed so that clinicians can be aware of its existence. The irrigation technique
is performed by forceful squeezing of a bulb syringe filled with 7mL of normal saline
into the unaffected naris.
http://emedicine.medscape.com/article/763767-overview#a8

Hidung bau dan epistaksi

o Trauma
o Neoplasma
o Kel.kongenital
o Rinolit
o Rhinitis atrofi
o Rhinitis bakteriae
 o Penyakit sistemik
local (trauma ringan, infeksi, neoplasma, kel.kongenital)
general (kel.darah, penyakit sistemik, infeksi, Hay fever dan Demam tifoid)
KELAINAN HORMONAL!!
IDIOPATIK DAN GENETIK!

9. Penatalaksanaan!

Vasokontriktor dan anestesi topikal Ekstraksi: forsep alligator masuk hidung

dibuka saat diluar.
Tampon epistaksis
Komplikasi ekstraksi!!

STEP 5
ETIOLOGI
 HIDUNG
BERBAU,
EPISTAKSIS

DD

GENERAL LOCAL

STEP 7
1. Anatomi, fisiologi, histologi organ penghidu!
Anatomi:
Fisiologi:
Fungsi DIJELASKAN
Histologi:
2. Mengapa pada paseien mengeluh hidungnya keluar ingus dan bau pada sisi kiri
sejak 5 hari yang lalu?
o Keluar ingus:
o Bau:
3. Mengapa pada pasien didapatkan mimisan?
Epistaksis:
Gambaran meatus, plexus kieselbach
4. Mengapa setelah diberi obat pileknya habis, hidung masih tetap berbau?
Obat pilek:
5. Patologi dari organ penghidu!
6. Jelaskan interpretasi konka hiperemis -/+, sekret mukoserous -/+, mukosa
hiperemis -/-, benda asing -/+!
7. Bagaimana cara px.rhinoskopi anterior?
8. DD (pemeriksaan penunjang, prognosis, komplikasi)!
Hidung bau dan epistaksi
o Trauma
o Neoplasma
o Kel.kongenital
o Rinolit
o Rhinitis atrofi
o Rhinitis bakteriae
o Penyakit sistemik
local (trauma ringan, infeksi, neoplasma, kel.kongenital)
general (kel.darah, penyakit sistemik, infeksi, Hay fever dan Demam tifoid)
KELAINAN HORMONAL!!
IDIOPATIK DAN GENETIK!
9. Penatalaksanaan!
Komplikasi ekstraksi!!