Pemicu 3

Blok Penginderaan

Kelompok 3
14 Agustus 2018
Kelompok 3
• Tutor : dr. Chandra
• Ketua : Yunita Halim (405140132)
• Penulis : Erika Juniartha T. (405150002)
• Sekretaris : Lidya Octalia L. (405150047)
• Anggota :
• Ryan Juliansyah (405130048)
• Mike J. Wanane (405130198)
• Ignatius Daniel S. (405150028)
• Felita Wiyasih (405150052)
• Louis Regan (405150077)
• Cessy Christy (405150096)
• Reyhan Fahriasandy (405150130)
• Fitria Ramadhana H. (405150145)
• Haraka Nabda P. (405150178)
Apakah Anakku Tertular?
Seorang perempuan berusia 28 tahun beserta anakanya yang berumur 4 tahun datang berobat ke poli umum
karena keluhan di telinga.
Ibu mengeluhkan telinga kirinya sakit sejak 2 hari yang lalu. Dia mengatakan kira-kira 5 hari yang lalu di dalam
telinganya terdengar suara berisik, seperti kemasukan serangga. Kemudian dia pun mengoleskan minyak tawon
pada kapas lidi dan dimasukkannya ke dalam lubang telinganya dengan harapan serangga akan keluar. Sejak
saat itu, suara berisiknya hilang, tetapi telinganya menjai sangat gatal dan mengeluarkan cairan bening yang
encer, sehingga dia pun menjadi semakin sering membersihkannya. Kira-kira 2 hari yang lalu telinganya mulai
terasa sakit dan tadi pagi dia pun mulai merasakan sakit berdenyut pada telinganya.
Ibu juga membawa anaknya berobat karena telinga kanan anaknya mengeluarkan cairan lagi sejak 2 hari yang
lalu. Ibu mengatakan seminggu yang lalu anaknya pilek dan beberapa hari kemudian telinganya pun berair.
Cairan yang keluar agak kental seperti ingus, yang setiap kali dibersihkan akan keluar lagi. Seingat ibu, pertama
kali anaknya mengalami seperti ini ketika berusia 2 bulan, tetapi pada saat itu keluhan terjadi hanya di telinga
kiri dan tidak pernah berulang pada telinga kiri hingga saat ini. Pada saat berusia 8 bulan, telinga kanan keluar
cairan dan terus menerus berulang terutama ketika anaknya pilek, hingga saat ini. Seingat ibu, dia sudah 6 kali
membawa anaknya berobat karena keluhan pada telinga kanan ini.
Ibu menanyakan kepada dokter, mengapa telinga ibu dan anak sama-sama berair, tetapi mengapa setiap kali
pilek keluar cairan dari telinga anaknya sedangkan ibu tidak demikian? Dokter menjelaskan setelah melakukan
pemeriksaan THT rutin terhadap kedua pasangan tersebut.
Apakah yang dapat Saudara pelajari dari kasus tersebut?
Mind Map - Inflamasi pd aurikula
- Mastoiditis

- Ototis eksterna
OTALGIA
- Benda asing
- Perforasi membran timpani
- Otitis media (akut, serosa,
KELUHAN TELINGA kronik)
OTOREA

- Otitis media (akut, serosa,

kronik)

PEMERIKSAAN
Otoskopi, timpanometri, CT san/
MRI telinga, kultur cairan telinga
Learning Issues
1. Menjelaskan Anatomi Telinga
2. Menjelaskan Histologi Telinga
3. Menjelaskan Fisiologi Pendengaran
4. Menjelaskan Infeksi Telinga Luar (Inflamasi pada aurikula, Herpes Zoster
pada telinga, Fistula preaurikula, Otitis Eksterna, Benda Asing, Serumen
Prop)
5. Menjelaskan Infeksi Telinga Tengah (Otitis Media Akut, Otitis Media
Kronik, Otitis Media Serosa, Mastoiditis, Miringitis Bullosa, Perforasi
Membran Timpani, Timpanoskerosis, Kolesteatoma, abses Bezold)
6. Menjelaskan perjalanan N. Facialis pada os temporal
7. Menuliskan resep sesuai gangguan
ANATOMI
Bagian Telinga

Sobotta Vol-3 Ed 15
Auricula

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Auricula

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Auricula

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Telinga tengah dan dalam

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Tymphany Membrane

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Tulang Pendengaran

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Sobotta Vol-3 Ed 15
Tymphany Cavity

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Sobotta Vol-3 Ed 15
Sobotta Vol-3 Ed 15
Tuba Auditiva

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Telinga dalam

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Sobotta Vol-3 Ed 15
Bony Labyrinth

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Membranous Labyrinth

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Sobotta Vol-3 Ed 15
Sobotta Vol-3 Ed 15
Sobotta Vol-3 Ed 15
HISTOLOGI
Ear
• The external ear, which receives sound waves
• The middle ear, in which sound waves are transmitted from
air to fluids of the internal ear via a set of small bones
• The internal ear, in which these fluid movements are
transduced to nerve impulses that pass via the acoustic
nerve to the CNS.
• In addition to the auditory organ, or cochlea, the internal ear also
contains the vestibular organ that allows the body to maintain
equilibrium.

Junqueira's Basic Histology Text and Atlas, 13th Edition

External Ear
• Is an irregular, funnelshaped plate of elastic cartilage, covered by tightly
adherent skin, which directs sound waves into the ear.
• Sound waves enter the external acoustic meatus a canal lined with stratified
squamous epithelium that extends from the auricle to the middle ear.
• Near its opening hair follicles, sebaceous glands, and modified apocrine sweat
glands called ceruminous glands are found in the submucosa
• Cerumen, the waxy material formed from secretions of the sebaceous and
ceruminous glands, contains various proteins, saturated fatty acids, and
sloughed keratinocytes and has protective, antimicrobial properties.
• The wall of the external auditory meatus is supported by elastic cartilage in its
outer third, while the temporal bone encloses the inner part

Junqueira's Basic Histology Text and Atlas, 13th Edition

External Ear
• Tympanic membrane or eardrum  consists of fibroelastic connective
tissue covered externally with epidermis and internally by the simple
cuboidal epithelium of the mucosa that lines the middle ear cavity.
• Sound waves cause vibrations of the tympanic membrane, which
transmit energy to the middle ear

Junqueira's Basic Histology Text and Atlas, 13th Edition

External Acoustic Meatus

Junqueira's Basic Histology Text and Atlas, 13th Edition

Middle Ear
• The middle ear contains the air-filled tympanic cavity, an irregular space that
lies within the temporal bone between the tympanic membrane and the
bony surface of the internal ear
• Anteriorly, this cavity communicates with the pharynx via the auditory tube
(also called the eustachian or pharyngotympanic tube)
• Posteriorly with the smaller, air-filled mastoid cavities of the temporal bone.
• The simple cuboidal epithelium lining the cavity rests on a thin lamina
propria continuous with periosteum.
• Entering the auditory tube, this simple epithelium is gradually replaced by
the ciliated pseudostratified columnar epithelium that lines the tube.

Junqueira's Basic Histology Text and Atlas, 13th Edition

Middle Ear
• The tympanic membrane is connected to the oval window by a series of
three small bones, the auditory ossicles, which transmit the mechanical
vibrations of the tympanic membrane to the internal ear
• The three ossicles are named for their shapes the malleus, incus, and stapes.
• The malleus is attached to the tympanic membrane and the stapes to the
membrane across the oval window.
• The ossicles articulate at synovial joints, which along with periosteum are
completely covered with simple squamous epithelium.
• Two small skeletal muscles, the tensor tympani and stapedius, insert into the
malleus and stapes, respectively, restricting ossicle movements and
protecting the oval window and inner ear from potential damage caused by
extremely loud sound.
Junqueira's Basic Histology Text and Atlas, 13th Edition
Internal Ear
• Located completely within the temporal bone, where an intricate set
of interconnected spaces, the bony labyrinth, houses the smaller
membranous labyrinth.
• The embryonic otic vesicle, or otocyst, forms the membranous
labyrinth with its major divisions
• Two connected sacs called the utricle and the saccule
• Three semicircular ducts continuous with the utricle
• The cochlear duct, which provides for hearing and is continuous with the
saccule.
Internal Ear
• The bony and membranous labyrinths contain two different fluids
• Perilymph fills all regions of the bony labyrinth and has an ionic composition
similar to that of cerebrospinal fluid and the extracellular fluid of other tissues,
but it contains little protein.
• Perilymph emerges from the microvasculature of the periosteum and drains
via a perilymphatic duct into the adjoining subarachnoid space. Perilymph
suspends and supports the closed membranous labyrinth, protecting it from
the hard wall of the bony labyrinth.
• Endolymph fills the membranous labyrinth and is characterized by a high-K+
(150 mM) and low-Na+ (16 mM) content, similar to that of intracellular fluid.
• Endolymph is produced in a specialized area in the wall of the cochlear duct
and drains via a small endolymphatic duct into venous sinuses of the dura
mater.
Junqueira's Basic Histology Text and Atlas, 13th Edition
Hair cells
• All hair cells have basal synapses with afferent (to the brain) nerve
endings but are of two types
• Type I hair cells have rounded basal ends completely surrounded by an
afferent terminal calyx
• Type II hair cells are cylindrical, with bouton endings from afferent nerves

Junqueira's Basic Histology Text and Atlas, 13th Edition

Junqueira's Basic Histology Text and Atlas, 13th Edition
Cochlear duct
• The cochlear duct itself forms the middle compartment, or scala
media, filled with endolymph.
• It is continuous with the saccule and ends at the apex of the cochlea.
• The larger scala vestibuli contains perilymph and is separated from
the scala media by the very thin vestibular membrane (Reissner’s
membrane) lined on each side by simple squamous epithelium
• Extensive tight junctions between cells of this membrane block ion diffusion
between perilymph and endolymph.
• The scala tympani also contains perilymph and is separated from the
scala media by the fibroelastic basilar membrane.

Junqueira's Basic Histology Text and Atlas, 13th Edition

FISIOLOGI
Mekanisme konduksi suara

Sobotta Vol-3 Ed 15
Human Physiology_ From Cells to Systems - Lauralee Sherwood
Human Physiology_ From Cells to Systems - Lauralee Sherwood
Human Physiology_ From Cells to Systems - Lauralee Sherwood
Human Physiology_ From Cells to Systems - Lauralee Sherwood
Human Physiology_ From Cells to Systems - Lauralee Sherwood
Human Physiology_ From Cells to Systems - Lauralee Sherwood
Otitis Externa (4A)
• generalized condition of the
skin of the external auditory
canal that is characterized by
general oedema and
erythema associated with
itchy discomfort and usually
an ear discharge

ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition

Etiology
• Secondary bacterial infection
• major feature of the disease
• Treatment of otitis externa is
often with topical medications
and sensitivity to these can
actually exacerbate the condition
• A recent review concluded that
using topical agents which
include neomycin are most
likely to cause sensitivity,

ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition

 Pathology
• Pre-inflammatory stage • Chronic Inflammatory
• the protective lipid/acid balance • otitis externa is characterized by
(normal pH 4–5) of the ear is lost and thickening of the external canal skin
the stratum corneum becomes and fibrous canal stenosis
oedematous, blocking off the • Acquired atresia of the external ear.
sebaceous and
• disruption of the epithelial layer and
invasion of resident or introduced
organisms.
• Acute inflammatory
• with a progressively thickening
exudate, further oedema, obliteration
of the lumen (mild, little or no
obliteration; moderate, subtotal
obliteration; severe, complete
obliteration) and increasing pain.ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition
Diagnosis
• Otitis externa is a clinical
diagnosis based on the
following symptoms and signs:
• pain, itch, oedema and erythema
of the external auditory canal
with purulent otorrhoea and
debris in the meatus

ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition

Management
• Aural toilet
• Toilet remains the most effective single treatment for otitis externa
• irrigation of the ear canal is effective for the removal of debris
• The sensitivity of the bacteria to the antibiotic in topical medication
does not seem to influence outcomes
• There is no evidence for the efficacy of systemic antibiotic therapy for
uncomplicated diffuse otitis externa
Foreign bodies in the ear (3A)
• The foreign bodies found most commonly in the ear are, in order, cotton
wool, insects, beads, paper, small toys and erasers
• Foreign bodies in the external auditory meatus are most commonly
seen in children who have inserted them into their own ears.
• Children may present asymptomatically, or with pain or a discharge
caused by otitis externa.
• Adults are often seen with cotton wool or broken matchsticks which
have been used to clean or scratch the ear canal.
• Live insects in the ear, commonly small cockroaches,
• are annoying due to discomfort created by loud noise and movement.

ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition

Management

ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition

Management
• Living insects should first be killed by instilling oil into the meatus to drown them
before removal
• Irregular/soft graspable non-living objects (dead insects, cotton wool, paper,
small toys) may be removed with a pair of crocodile forceps.
• Organic objects (beans, etc.), which may absorb water, swell and cause pain,
should not be syringed.
• Button batteries should not be syringed as they may leak on exposure to water.
• They should be removed urgently.
• Inorganic round/smooth non-graspable (beads, erasers).
• Smooth, firm, rounded objects, such as beads or toy gun pellets, are difficult to grasp and
can easily be wedged deeper into the meatus
• Syringing is safe and is often successful, but may fail with tightly impacted foreign bodies

ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition

Complication
• In general, these are limited to lacerations of the canal skin and otitis
externa.
• Rarely, facial nerve palsy may occur secondary to leakage of alkaline
material from a button battery and necrosis of the surrounding
• Canal wall lacerations are present in 48 percent of cases where prior
attempts at removal by other health care professionals have failed.
• Damage and perforation of the tympanic membrane, and even
ossicular chain dislocation or fracture may occur.

ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition

Bullous myringitis (3A)
• Bullous myringitis (myringitis bullosa haemorrhagica) is the finding of
vesicles in the superficial layer of the tympanic membrane.
• The vesicles occur between the outer epithelium and the lamina
propria of the tympanic membrane
• More detailed histology has not been described.
• An infection by influenza virus or by Mycoplasma pneumoniae has
been suggested as the aetiological agent
• Bullous myringitis occurs in all age groups but children, adolescents
and young adults are more frequently affected

ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition

Symptoms
• Sudden onset of severe, usually unilateral, often throbbing pain in the
ear is the most common presentation
• The symptoms usually set in during or following an upper respiratory
tract infection
• A bloodstained discharge can be present for a couple of hours
• A hearing impairment (conductive and/or sensorineural) is common
in the affected ear.

ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition

SIGNS
• Otoscopy reveals blood-filled,
serous or serosanginous
blisters involving the
tympanic membrane and
sometimes the medial aspect
of the ear canal
• A serosanginous secretion
can be seen if the blisters
rupture.
• The tympanic membrane is
intact.
ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition
Diagnosis
• Bullous myringitis is based on physical examination.
• Vesicles in the superficial layer of the tympanic membrane are present.
• The main differential diagnoses are acute otitis media, herpes zoster oticus or
Ramsay Hunt syndrome.
• Inspection of the ear using a microscope is essential for diagnosis.
• Pneumatic otoscopy and tympanometry help determine whether the middle ear
contains fluid.
• Clinical evaluation of the cranial nerves and, in particular, the facial nerve must be
carried out for to distinguish from herpes zoster oticus or Ramsey Hunt syndrome.
• A serologic sample for herpes zoster is of value in cases with sensorineural hearing
loss and may be of help in the differential diagnosis.

ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition

Management
• In cases without middle ear affection and without sensorineural
hearing loss, only analgesics are recommended
• When the middle ear is affected, antibiotics can be used as in the
treatment of acute otitis media
• In children less than two years of age  treated as acute otitis media
• Antibiotics have also been recommended in cases with sensorineural
hearing impairment
• Complete recovery of the sensorineural impairment within three
months occurred in between 60 and 100 percent of affected patients
treated with amoxicillin, however, this study was not controlled
ScottBrowns Otorhinolaryngology Head and Neck Surgery 7th edition