Case Report Session

Tinnitus et causa Serumen Prop

Tutor : dr. Ismelia Fadlan, Sp. THT-KL

Intan Karnina Putri

G1A217112
intankarniceputri@gmail.com
Preface
01 Serumen
Merupakan campuran dari material sebaseus dan hasil
sekresi apokrin dari gland. seruminosa

02 Serumen Prop
Predisposisi: Produksi serumen banyak, penggunaan cotton
bud

03 Gejala serumen prop

Rasa penuh, gatal, tinnitus, bau tak sedap, nyeri pada telinga

04 Tinnitus
Serumen impaksi dapat menjadi penyebab tinnitus disertai tuli
konduktif , 2,1% dalam penelitian ACTA.
Case
 Identity

“
Adress: Desa Karya Bakti
Masuk Poli: 24 September 2018
“

Tn. G
21 y.o.
 Clinical History
Telinga Kanan berdenging sejak ±1 minggu sebelum masuk rumah sakit.

01 Pasien mengeluh telinga kanan

Telinga Terasa Penuh
berdenging sejak ± 1 minggu SMRS.
Rasa berdenging dirasakan setiap waktu
Pasien juga mengeluhkan adanya
dan menetap dengan intensitas yang
lembut dan rendah. Sifat bunyi didengar 02 penurunan pendengaran pada telinga
kanannya karena telinga terasa penuh
seperti suara berdenging. Bunyi denging yang terasa bersamaan dengan keluhan
tidak bertambah ataupun berkurang baik telinga berdenging sejak ± 1 minggu SMRS
di pagi atau malam hari. Sebelum keluhan
terasa, pasien membersihkan telinga
kanannya menggunakan cotton bud Kebiasaan

Keluhan tidak disertai rasa pusing

Keluhan Berdenging
Pasien mengatakan keluhan
04 berputar, namun pasien mengeluhkan
rasa stress yang meningkat akibat
bunyi berdenging yang didengarnya.
03 berdenging pernah sesekali
dirasakan setelah membersihkan
Pasien memiliki kebiasaan
mendengarkan musik dengan volume
telinga dengan durasi berdenging yang
yang tinggi menggunakan handsfree
kurang dari 1 menit.
Riwayat Pengobatan: Sejak ± 2 hari SMRS pasien berobat ke FKTP diberikan obat tetes
 Vital Sign
Respiratory Rate

20 x/menit

Heart Rate Blood Pressure

83x/ minute 130/80 mmHg

Kesadaran Temperature

Compos mentis 36,5 celcius

 Telinga Hidung Tenggorok
Your Picture Here Laring
Kanan/Kiri Kanan/Kiri Kanan/Kiri Kanan/Kiri
Gatal :-/- Rinore: - / - Sukar menelan: - Suara parau: -
Korek : + / - Buntu: - / - Sakit menelan: - Afonia: -
Nyeri :-/- Bersin: - Trismus: - Sesak nafas: -
Bengkak : - / - Dingin/lembab: - Ptyalismus: - Rasa sakit: -
Otore :-/- Debu rumah: - Rasa ngganjal: - Rasa ngganjal: -
Tuli :+/- Berbau: - Rasa berlendir: -
Tinnitus : + / - Mimisan: - Rasa kering: -  
Vertigo : - / - Nyeri hidung: -    
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Anamnesis
- Anemia : (-)   - Retraksi suprasternal : (-)
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- Sianosis : (-)   - Retraksi intercostal : (-)
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Easy to change colors, photos and Text.
- Stridor inspirasi : (-)   - Retraksi epigastrial : (-)
 Daun Telinga Kanan Kiri Membrana Timpani Kanan Kiri

Anotia/mikrotia/makro - - Sulit dinilai, karena Sulit dinilai, karena

Hiperemis
tia tertutup serumen tertutup serumen
Sulit dinilai, karena Sulit dinilai, karena
Keloid - - Retraksi
tertutup serumen tertutup serumen
Bulging
Sulit dinilai, karena Sulit dinilai, karena
Perikondritis - - tertutup serumen tertutup serumen
Kista - - Atropi
Sulit dinilai, karena Sulit dinilai, karena
tertutup serumen tertutup serumen
Fistel - - Sulit dinilai, karena Sulit dinilai, karena
Perforasi
Ott hematoma - - tertutup serumen tertutup serumen
Sulit dinilai, karena Sulit dinilai, karena
Liang Telinga Kanan Kiri Bula
tertutup serumen tertutup serumen
Atresia - - Sulit dinilai, karena Sulit dinilai, karena
Sekret
+ tertutup serumen tertutup serumen
Serumen prop +
Padat, tidak berbau, Sulit dinilai, karena Sulit dinilai, karena
Refleks Cahaya
coklat kehitaman, agak Padat, tdak berbau, coklat tertutup serumen tertutup serumen
keras kehitaman, agak keras Retro-aurikular Kanan Kiri
Epidermis prop - - Fistel - -
- Kista - -
Korpus alineum -
Abses - -
Jaringan granulasi - -
Mastoid - -
Exositosis - - Hiperemis, Bengkak

Osteoma - - Pre-aurikular Kanan Kiri

Furunkel - - Fistel - -
- Kista - -
Hiperemis/edema/sem -
pit Abses - -
 Hidung
Rinoskopi Anterior Kanan Kiri Rinoskopi Posterior Kanan Kiri

Vestibulum nasi Sekret (-), Hiperemis (-), Sekret (-), Hiperemis (-), bisul
bisul(-), krusta (-), polip (-) (-), krusta (-), polip (-)

Kavum nasi Sekret (-), hiperemis (-) edema Sekret (-), hiperemis (-) edema
Kavum nasi Sekret (-), hiperemis (-), Sekret (-), hiperemis (-), mukosa (-) mukosa (-)
edema mukosa (-) edema mukosa (-)

Selaput lender dbn dbn

Selaput lender Dbn Dbn

Septum nasi Deviasi (-) Deviasi (-) Koana Sulit dinilai Sulit dinilai

Lantai + dasar hidung Dbn Dbn

Septum nasi Deviasi (-) Deviasi (-)
Konka inferior edema (-), hiperemis (-) edema (-), hiperemis (-)

Meatus nasi inferior Sekret (-) Sekret (-) Adenoid Sulit dinilai Sulit dinilai

Massa tumor  - -
Konka media edema (-), hiperemis (-) edema (-), hiperemis (-)

Meatus nasi media Sekret (-) Sekret (-) Transiluminasi Sinus Kanan Kirii

Polip - - Sinus Maxillaris dbn dbn

Korpus alineum - -
Sinus Frontalis dbn dbn
Massa tumor - -
 Faring
Faring Hasil

Uvula Bentuk normal, terletak

ditengah, permukaan rata,
Mulut edema(-), hiperemis (-)
Palatum mole hiperemis (-), benjolan (-)
Pemeriksaan Hasil Pemeriksaan
Dbn Palatum durum Hiperemis (-), benjolan (-)
Selaput lendir mulut
Bibir Sianosis (-), kering (-) Plika anterior Hiperemis (-)

Lidah Atrofi papil (-), tumor (-) Tonsil Dekstra : tonsil T1

Sinistra : tonsil T1
Gigi Karies (-)
Plika posterior Hiperemis (-)
Kelenjar ludah Ptyalismus (-)
Mukosa orofaring Hiperemis (-), granula (-)
 Laring
Pemeriksaan Hasil Pemeriksaan

Pangkal lidah Hiperemis (-), Edem (-)

Epiglotis Tidak dilakukan
Valekula Tidak dilakukan

Plika ventrikularis Tidak dilakukan

Tidak dilakukan
Plika vokalis
Tidak dilakukan
Komisura anterior
Tidak dilakukan
Aritenoid
Tidak dilakukan
Massa tumor Tidak dilakukan
Sinus piriformis Tidak dilakukan
Trakea Tidak dilakukan
 Kelenjar Getah Bening Leher
  Kanan Kiri
Regio I Dbn Dbn
Regio II Dbn Dbn
Regio III Dbn Dbn
Regio IV Dbn Dbn
Regio V Dbn Dbn
Regio VI Dbn Dbn
area Parotis Dbn Dbn
Area postauricula Dbn Dbn
Area occipital Dbn Dbn
Area supraclavicula Dbn Dbn
 Tes Penala

Tes Pendengaran Kanan Kiri

Tes rinne - +

Tes weber Laterasisasi ke kanan (sakit)

Tes schwabach memanjang Sama dengan pemeriksa

Pemeriksaan Penunjang: Tidak Dilakukan

Differential Diagnoses

Serumen Prop Tinnitus Subjektif Idiopatik

Epidermis Prop

Korpus Alineum
 Diagnose

“
Tinnitus et causa Serumen Prop “

Mr. H
58 y.o.
 Work-Up and Management
TERAPI NON-MEDIKAMENTOSA
TERAPI MEDIKAMENTOSA
Jika serumen lunak, Ear
R/ phenol Glyserol 1-2 gtt
Toilet/ Evakuasi Serumen
2x/hari
KIE
A B
• Menjelaskan mengenai penyakit
yang diderita D MONITORING
• Menjelaskan untuk tidak mengorek C • Pantau KU
telinga dgn cotton bud • Pantau TTV
• Menjaga Personal Hygiene
• Menjaga telinga agar tidak
• Pantau Keluhan Telinga
kemasukan air • Pantau Ear Toilet
• Kurangi penggunaan handsfree
Discussion
 TINNITUS?
Insert the title of your subtitle Here

Tinitus adalah salah satu bentuk gangguan pendengaran berupa sensasi suara tanpa
Definisi adanya rangsangan dari luar, dapat berupa sinyal mekanoakustik maupun listrik.

Subjektif Objektif Pulsatil & Non

suaranya hanya suaranya juga Pulsatil
dapat didengar dapat di dengar Bersamaan
oleh penderita oleh pemeriksa dengan denyut
saja dengan auskultasi jantung/ menetap
di sekitar telinga

Sebanyak sepertiga dari populasi seluruh dunia setidaknya

pernah mengalami tinnitus sekali seumur hidup. Prevalensi
Epidemiologi Tinnitus di
dunia diperkirakan sekitar 10,1 % - 14,5% dan sering terjadi
pada usia 10 – 70 tahun.
 Etiology

Kelainan Somatik daerah Leher dan Kelainan psikogenik

01 Rahang 06

02
Kerusakan N. Vestibulocochlearis
0706 Akibat Obat-obatan

03 Akibat kelainan vaskular 08 Akibat Gangguan Mekanik

04 Akibat Kelainan Metabolik 09 Akibat Gangguan konduksi

05 Kelainan Neurologis 10 Sebab Lainnya

 Pathophysiology
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 Treatment

ER Management Post- Op Follow-Up

• IVFD RL 20 gtt/ m • Inj. Ceftriaxone 1x2 gram

Appendictomy • Inj. Ranitidine 2x ½ ampul
• Inj. Ceftriaxone 1x2 gram
Laparoscopic • Inj. Ketorolac 3x 30mg
• Inj. Ranitidine 25mg/ml
• Inj. Ondansetron 2mg/mL • Histologic Work-up need
• USG • Bed Rest 24 hours

 
Anatomi
&
Fisiologi
Definition & E
pidemiology
Appendicitis is defined as an inflammation of the inner lining
of the vermiform appendix that spreads to its other parts.
This condition is a common and urgent surgical illness with
protean manifestations, generous overlap with other clinical
syndromes, and significant morbidity, which increases with
diagnostic delay.
.
The incidence of appendectomy appears to be declining due
to more accurate preoperative diagnosis.Despite newer
imaging techniques, acute appendicitis can be very difficult to
diagnose. The percentage of misdiagnosed cases of
appendicitis is significantly higher among women than among
 Pictorial Explanation

Distention
causing
Ischemia

mucus
obstruction
Distention

Gangrene

Appendiceal Appendiceal distension Irritation of parietal Perforation,

obstruction/early peritoneum (localised) localised/generalis
appendicitis – ed peritonitis,
visceral peritoneal mass
irritation
 Symptoms

In >95% of patients with acute appendicitis,

A L PAIN
anorexia is the first symptom, followed by
OMIN
abdominal pain, which is followed, in turn, by ABD
vomiting (if vomiting occurs).
Abdominal Pain is the prime symptom of acute
EXI A
R
appendicitis. Classically, pain is initially diffusely centered
in the lowerepigastrium or umbilical area, is moderately ANO
severe, and is steady, sometimes with intermittent
cramping superimposed.After a period varying from 1 to
ITI NG
12 hours, but usually within 4 to 6 hours, the pain
localizes to the right lower VOM
quadrant
ANOREXIA nearly always accompanies appendicitis. It is so
constant that the diagnosis should be questioned if the patient is
AT I ON
not anorectic.
OB STIP
vomiting occurs in nearly 75% of patients
obstipation beginning before the onset of abdominal pain
 SIGNS
-Temperature elevation is rarely >1°C
-Pulse rate is normal or slightly elevated
-Tenderness often is maximal at or near the McBurney point
-Direct rebound tenderness
-indirect rebound tenderness

-The Rovsing sign—pain in the right lower quadrant when palpatory pressure is exerted in the left lower
quadrant
-Muscular resistance to palpation of the abdominal wall roughly parallels the severity of the inflammatory
process

-psoas sign - indicates an irritative focus in proximity to that muscle

-obturator sign of hypogastric pain on stretching the obturator internus indicates irritation in the pelvis. The
test is performed by passive internal rotation of the flexed right thigh with the patient supine.
Laboratory Findings
Mild leukocytosis, ranging from 10,000 to 18,000 cells/mm3, usually is
present in patients with acute, uncomplicated appendicitis and often is
accompanied by a moderate polymorphonuclear predominance.
White blood cell counts are variable,however. It is unusual for the
white blood cell count to be >18,000 cells/mm3 in uncomplicated
appendicitis. White blood cell counts above this level raise the
possibility of a perforated appendix with or without an abscess.
 Imaging
• Imaging studies: include X-rays, USG, CT
• Xrays of abd are abnormal in 24-95%
• Abnormal findings include: fecalith, appendiceal gas, localized paralytic ileu,
and free air
• Abdominal xrays have limited use b/c the findings are seen in multiple other
processes
• CT: best choice based on availability and alternative diagnoses.
• In one study, CT had greater sensitivity, accuracy, -predictive value
• Even if appendix is not visualized, diagnose can be made with localized fat
stranding in RLQ.
• USG: Low Cost, simple, not invasive, can use for suspect pregnany. In acute
appendicitis showns an intact submucosal layer and fluid-filled lumen
 Alvarado’s score
Value Manifestations
1 Migration of pain Symptoms
1 Anorexia
1 Nausea and/or vomiting
2 Right lower quadrant Signs
tenderness
1 Rebound
1 Elevated temperature
2 Leukocytosis Laboratory values
1 Left shift in leukocyte
count
 Once the decision to operate for presumed acute appendicitis has
Treatment
been made, the patient should be prepared for the operating room.
Adequate hydration should be ensured, electrolyte abnormalities
should be corrected, and pre-existing cardiac, pulmonary, and renal
conditions should be addressed. A large meta-analysis has
demonstrated the efficacy of preoperative antibiotics in lowering the
infectious complications in appendicitis. Most surgeons routinely
administer antibiotics to all patients with suspected appendicitis

Appendectomy :
1-open appendetomy
2-Laparoscopic appendetomy
Open Appendectomy:
For open appendectomy most surgeons use either a McBurney
Open
(oblique) or Rocky-Davis (transverse) right lower quadrant muscle- Appendectomy
splitting incision in patients with suspected appendicitis. The incision
should be centered over either the point of maximal tenderness or a
palpable mass
Laparoscopy
2. Laparoscopy:
 Appendectomy
Laparoscopic appendectomy usually requires the use of Laparoscopy
three ports. Four ports may occasionally be necessary to
mobilize a retrocecal appendix. The surgeon usually stands
to
the patient's left. One assistant is required to operate the
camera. One trocar is placed in the umbilicus (10 mm),
and a second trocar is placed in the suprapubic position.
Some surgeons place this second port in the left lower
quadrant. The suprapubic trocar is either 10 or 12 mm,
depending on whether or not a linear stapler will be used.
The placement of the third trocar (5 mm) is variable and
usually is either in the left lower quadrant, epigastrium, or
right upper quadrant.
The mortality from appendicitis in the United States has
steadily decreased from a rate of 9.9 per 100,000 in 1939
PROGNOSIS
to
0.2 per 100,000 today. Among the factors responsible are
advances in anesthesia, antibiotics, IV fluids, and blood
products. Principal factors influencing mortality are whether
rupture occurs before surgical treatment and the age of the
patient. The overall mortality rate in acute appendicitis with
rupture is approximately 1%. The mortality rate of
appendicitis with rupture in the elderly is approximately 5%
—a five
fold increase from the overall rate. Death is usually
attributable to uncontrolled sepsis peritonitis, intra-
abdominal
abscesses, or gram-negative septicemia. Pulmonary
embolism continues to account for some deaths.
Case Analyzes
 Summary Analyzes
Mr. H 58 y.o.

According to the With the physical

anamnesa of the examination ,
patient with symptoms laboratory finding, and
and signs has found USG

Alvarado’s Treatment Medication Appendectomy

Laparoscopy
Post-op
Pre-OP
Score
Score 9 for the patient Antibiotic Pain Killer
mean have a high IFVD Antibiotics
likehood appendicitis Anti H-2 Histamine Anti H-2 Histamine
IVFD
Bed Rest
 References

1.Shrestha, S. Anatomy of appendix and appendicitis. [diunduh dari: http://medchrome.com/basic-

science/anatomy/anatomy-appendix-appendicitis/], 2011
2.Faiz O, Blackburn S, Moffat D. Anatomy At A Glance. Edisi Ketiga. England: Oxford, 2011
3.Riwanto I, Hamami AH, Pieter J, Tjambolang T, Ahmadsyah. Usus Halus, Apendiks, Kolon, dan
Anorektum. Dalam: Buku Ajar Ilmu Bedah Sjamsuhidajat-De Jong Ed. 3. Jakarta: EGC, 2007
4.Snell, Richard S. Anatomi Klinis Berdasarkan Sistem. Jakarta: EGC, 2008
5.Kevin P. Lally, Charles S. Cox JR. Dan Richard J. Andrassy. Appendix on Chapter 47 in Sabiston
Textbook of Surgery 17Ed. New York: Saunders, 2004
6.Sulu, Barlas. Demographic and Epidemiologic Features of Acute Appendicitis. Dalam: Appendicitis – A
collection of essays from around the world. InTech, 2012. [diunduh dari:
https://www.intechopen.com/books/appendicitis-a-collection-of-essays-from-around-the-world]
7.Craig, Sandy. Appendicitis. [diunduh dari: http://emedicine.medscape.com/article/773895-overview],
2017
8.Brunicardi C, Anderson DK, Billiar T, Duhn DL, Hunter JG, Mathews JB, Pallock RC. The Appendix on
Chapter 30 in Schwartz’s Principles of Surgery 9th Ed Ebook. New York: McGraw-Hills, 2010
9.Anonymous. Appendicitis Type. http://www.appendicitissymptoms.org.uk/appendicitis-types.htm
10.Old JL. Imaging for Suspected Appendicitis. [diunduh dari:
http://www.aafp.org/afp/2005/0101/p71.html#afp20050101p71-b15]
11.Vanjak D. Analysis of Scores in Diagnosis of Acute Appendicitis in Women. [diunduh dari:
www.ncbi.nlm.nih.gov/pubmed/10356580]
12.Dudley H.A.F. Appendisitis akut. Dalam: Hamilton Bailey Ilmu Bedah Gawat Darurat Edisi 11.
Yogyakarta: Gajah Mada Univ Press, 1992
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