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Laporan Kasus

Tumor Cavum Nasi


/0ntitas Pasi0n
Nama : Tn. JE
Usia : 26 tahun
P00rjaan : Supir tru
amat : Tuungagung
Suu Bangsa : Jawa
Tg p0risa : 24 Nov 2011
No r0gistrasi : 110xxxxx
namn0sa
K0uhan Utama
B0njoan /i hi/ung iri
namn0sa Khusus
Pasi0n m0ng0uh muncu -0njoan /i /aam hi/ung
s0ja 1 tahun yang au. B0njoan awanya muncu /i
s0-0ah iri, 0mu/ian s0main -0sar /an m0ram-ah
hi/ung -agian anan s0ja 4 -uan yang au.
B0njoan yang s0main -0sar m0m-uat hi/ung t0rasa
t0rsum-at /an susah -0rnafas. Pasi0n saat ini -0rnafas
/0ngan muut.
Cairan 0uar /ari 0/ua hi/ung s0cara t0rus m0n0rus
/aam jumah minima, -0rwarna putih -0ning aga
0nta. Cairan yang 0uar /ari -agian iri 0-ih -anya
/aripa/a s0-0ah anan. B0rsin--0rsin 0-ih /ari 5 ai
-ia /ingin /an t0r0na /0-u /isanga o0h pasi0n.
Mimisan /ari hi/ung iri 1 -uan yang au.
Pasi0n m0ngataan ti/a p0rnah m0ngaami
mimisan s0-0umnya, /an ti/a m0ngaami
mimisan agi s0t0ahnya.
Pasi0n m0ng0uhan mata iri m0nja/i a-ur
s0ja 5 -uan yang au.
Pan/angan a-ur ti/a -0ra-ut, ti/a s0p0rti
m0ihat tirai, ti/a siau, ti/a nrocoh, /an ti/a
a/a pan/angan gan/a.
S0main ama s0main a-ur, hingga pasi0n
0hiangan p0ngihatan 3 -uan yang au.
Pasi0n ti/a m0ng0uhan a/anya -atu, /an
panas s0-0umnya, s0rta ti/a a/a 0uhan
pa/a t0inganya.
P0nurunan -a/an yang progr0sif -0-0rapa
-uan ini /isanga o0h pasi0n.
Riwayat P0ngo-atan
Pasi0n s0-0umnya -0ro-at 0 /ot0r sp0siais
THT, /iminta foto CT-scan, 0mu/ian pasi0n
/iruju 0 RSS. Pasi0n -0um /i-0rian o-at
/an ti/a m0ngonsumsi o-at s0n/iri.
Riwayat P0nyait Dahuu
Pasi0n m0ngau p0rnah jatuh saat SD, /an
m0ngaami ua parah pa/a -agian panga
hi/ung.
Riwayat Penyakit KeIuarga
0rgi (-), tumor (-).
Riwayat SosiaI
Pasi0n -00rja s0-agai supir tru yang
s0ring m0nga/aan p0rjaanan jauh.
T0man-t0man 0rja pasi0n m0rupaan
p0roo.
namn0sa Umum
T0inga
Gata - / -
Kor0 t0inga - / -
Ny0ri t0inga - / -
B0nga - / -
Otor0 - / -
Lama : -
T0rus m0n0rus : -
Kumat-umatan : -
Cair/0n/ir/nanah: -
Tui - / -
Tinitus - / -
V0rtigo -
Mua -
Muntah -
Mau jatuh -
Mua m0nc0ng - / -
namn0sa Umum
Hi/ung
Rinor0 + / +
Lamanya : 1 tahun
T0rus-m0n0rus : +
Kumat-umatan : -
Cair/0n/ir/nanah : cair
Campur /arah/-au: -
Hi/ung -untu + / +
Lamanya : 8 -uan y
T0rus-m0n0rus : +
Kumat-umatan : --
B0rsin - / -
Dingin/0m-a- : -
D0-u rumah : -
B0r-au -/-
Mimis0n -/+
Ny0ri hi/ung /an 0paa -/+
Suara s0ngau +
namn0sa Umum
T0nggoro
Suar m0n0an -
Sait m0n0an -
Lamanya : -
Fr0u0nsi : -
Yang t0rahir :
Ba/an panas -
Lamanya : -
Fr0u0nsi : -
Yang t0rahir : -
Trismus -
Ptyaismus -
Rasa m0ngganja -
Rasa -0r0n/ir -
Rasa 0ring -
namn0sa Umum
Laring
Suara parau -
Lamanya : -
T0rus m0n0rus : -
Kumat-umatan : -
fonia -
S0sa nafas -
Rasa sait -
Rasa m0ngganja -
Status g0n0rais
K0a/aan umum : -ai
K0sa/aran : compos m0ntis
Gizi : cuup
n0mia : conjungtiva an0mis (-)
Na/i : 80 x/m0nit
P0rnafasan : 20x/m0nit
Muntah : -
Nistagmus : -
Par0s0/parais0 n.fasiais: -
P0m0risaan Fisi
Status oais T0inga
P0m-0ngaan -/-
Futuasi -/-
Fist0 auris ong0n -/-
nfitrat/a-s0s -/-
Ny0ri t0an -/-
ME :
Hip0r0mi -/-
E/0ma -/-
P0ny0mpitan -/-
Furun0 -/-
Fist0 -/-
S0r0t -/-
Granuasi -/-
Poip -/-
Ko0st0atoma -/-
Fo0tor -/-
M0m-ran timpani :
Warna putih,
r0trasi (-),
P0rforasi -/-
Pusasi -/-
RC +/+
Status oais T0inga
T0s garpu taa:
T0s Batas tas-
Batas Bawah:
norma
Rinn0 : +/+
W0-0r : ti/a a/a
at0raisasi
Swa-ach : N/N
Status oais Hi/ung
D0formitas -/-
H0matoma -/-
Kr0pitasi -/-
Ny0ri -/-
Rinosopi ant0rior :
V0sti-uum:
0/0ma(-), rusta(-),
s0r0t(-)
V0sti-uum 0/0ma -
/-, /ischarg0 -/-,
us0rasi -/-
Kavum nasi :
Luas m0ny0mpit
Muosa hip0r0mi -/-
Massa -/+
S0r0t +/+
Kona 0/0ma -/-
pucat -/- hip0r0mi -/-
S0ptum /0viasi +/-
F0nom0na pa mo0 -/-
Status oais Hi/ung
Rinoskopi posterior
Ti/a -0rhasi
/iauan
Transiuminasi
SF T/T
SM T/T
Status oais T0nggoro
Paatum
mo0:paraisis -/-
Uvua /0viasi -/-
Tonsi : T1 / T1
Hip0r0mi -/-
D0tritus -/-
Kriptam00-ar -/-
rus ant N/N
rus post N/N
Faring
E/0ma -
Hip0r0mi -
Granua -
L0n/ir -
Status oais T0nggoro
aringoskopi indirek
Hipofaring /-N
Epigotis /-N
Supragotis /-N
rit0noi/ /-N
Kor/avoais /-N
R0gio coi :
p0m-0saran KGB -/-
T1 T1
P0m0risaan P0nunjang
RadioIogi
CT-Scan 0paa : M0nyoong
a/anya tumor /i cavum nasi /an
masiaris anan
R0sum0
B0njoan /aam hi/ung
s0-0ah iri (+),
p0rmuaan haus, tampa
una, warna sama
/0ngan ona. S0main
ama s0main -0sar
/aam 1 tahun ini.
Hi/ung t0rasa t0rsum-at
/an susah -0rnafas.
P0nonjoan /i panga
hi/ung iri (+).
Suara s0ngau (+)
Ny0ri /i /a0rah wajah /an
0paa -agian iri.
P0nurunan visus (+).
Lingungan 0rja p0roo
(+).
P0m0risaan P0nunjang:
CT-Scan : m0nyoong
a/anya tumor /i cavum
nasi
Diagnosa
Tumor Cavum Nasi
Panning
Diagnosa
Biopsi
T0rapi
M0nunggu hasi
Panning
KE
M0nj0asan 0pa/a pasi0n m0ng0nai
p0nyait yang /i/0rita, yaitu t0rja/i tumor
pa/a rongga hi/ungnya.
M0nj0asan -ahwa p0nanganan 0-ih
anjut aan /iauan pa/a ahi onoogi,
/0ngan r0ncana p0nanganan awa yang
aan /iauan a/aah -iopsi yang aan
m0n0ntuan t0rapi s0anjutnya.
T0rima Kasih
Dhingra PL. Dis0as0 of Ear, Nos0, an/ Throat, 4
th
0/.
T0rapi
Kan0r maxiary sinus, usuay surg0ry with or without ra/iation
th0rapy.
f canc0r is in th0 0thmoi/ sinus, usuay ra/iation th0rapy an//or
surg0ry.
f canc0r is in th0 sph0noi/ sinus, tr0atm0nt = nasopharyng0a
canc0r, usuay ra/iation th0rapy.
f canc0r is in th0 nasa cavity, usuay surg0ry an//or ra/iation
th0rapy.
f canc0r is in th0 nasa v0sti-u0, usuay surg0ry or ra/iation
th0rapy.
For inv0rting papioma, usuay surg0ry with or without ra/iation
th0rapy.
For m0anoma an/ sarcoma, usuay surg0ry with or without
ra/iation th0rapy an/ ch0moth0rapy.
For mi/in0 granuoma, usuay ra/iation th0rapy.
Th0 prognosis (chanc0 of r0cov0ry) an/
tr0atm0nt options /0p0n/ on th0 foowing:
Wh0r0 th0 tumor is in th0 paranasa sinus
or nasa cavity an/ wh0th0r it has spr0a/.
Th0 siz0 of th0 tumor.
Th0 typ0 of canc0r.
Th0 pati0nt's ag0 an/ g0n0ra h0ath.
Wh0th0r th0 canc0r has just
-00n /iagnos0/ or has r0curr0/ (com0
-ac).
Stag0
The foIIowing stages are used for nasal
cavity and ethmoid sinus .an.er:
Stage 0 (Car.inoma in Situ)
n stag0 0, a-norma c0s ar0 foun/ in th0
inn0rmost ining of th0 nasa cavity or
0thmoi/ sinus. Th0s0 a-norma c0s may
-0com0 canc0r an/ spr0a/ into n0ar-y
norma tissu0. Stag0 0 is aso
ca0/ carcinoma in situ.
Stage I
n stag0 , canc0r has form0/ an/ is foun/
in ony on0 ar0a (of 0ith0r
th0 nasa cavity or th0 0thmoi/ sinus) an/
may hav0 spr0a/ into -on0.
Stage II
n stag0 , canc0r is foun/ in two ar0as (of
0ith0r th0 nasa cavity or th0 0thmoi/
sinus) that ar0 n0ar 0ach oth0r or has
spr0a/ to an ar0a n0xt to th0 sinus0s.
Canc0r may aso hav0 spr0a/ into -on0.
Stage III
n stag0 , canc0r has spr0a/ to any of th0 foowing:
Th0 0y0 soc0t.
Th0 maxiary sinus.
Th0 roof of th0 mouth.
Th0 -on0 -0tw00n th0 0y0s.47
Canc0r has spr0a/ to on0 ymph no/0 on th0 sam0 si/0 of th0 n0c
as th0 canc0r an/ th0 ymph no/0 is 3c0ntim0t0rs or sma0r.
Canc0r has aso spr0a/ to any of th0 foowing:
Th0 nasa cavity.
Th0 0thmoi/ sinus.
Th0 0y0 soc0t.
Th0 maxiary sinus.
Th0 roof of th0 mouth.
Th0 -on0 -0tw00n th0 0y0s.
Stage IV
Stag0 V is /ivi/0/ into stag0 V, VB, an/ VC.
Stage IVA
n stag0 V, canc0r has spr0a/ 0ith0r:
to on0 ymph no/0 on th0 sam0 si/0 of th0 n0c as th0 canc0r an/ th0 ymph no/0 is arg0r than 3c0ntim0t0rs -ut not arg0r than 6 c0ntim0t0rs; or
to mor0 than on0 ymph no/0 on th0 sam0 si/0 of th0 n0c as th0 origina tumor an/ th0 ymph no/0s ar0 not arg0r than 6 c0ntim0t0rs; or
to ymph no/0s on th0 opposit0 si/0 of th0 n0c as th0 origina tumor or on -oth si/0s of th0 n0c, an/ th0 ymph no/0s ar0 not arg0r than 6
c0ntim0t0rs.
an/ canc0r has spr0a/ to any of th0 foowing:
Th0 nasa cavity.
Th0 0thmoi/ sinus.
Th0 0y0 soc0t.
Th0 maxiary sinus.
Th0 roof of th0 mouth.
Th0 -on0 -0tw00n th0 0y0s.47
Canc0r has spr0a/ to any of th0 foowing:
Th0 front of th0 0y0.
Th0 sin of th0 nos0 or ch00.
Front parts of th0 su.
Th0 -as0 of th0 su.
Th0 sph0noi/ or fronta sinus0s.
an/ canc0r may hav0 spr0a/ to on0 or mor0 ymph no/0s 6 c0ntim0t0rs or sma0r, anywh0r0 in th0 n0c.
Stage IVB
n stag0 VB, canc0r has spr0a/ to any of th0 foowing:
Th0 -ac of th0 0y0.
Th0 -rain.
Th0 mi//0 parts of th0 su.
Th0 n0rv0s in th0 h0a/ that go to th0 -rain.
Th0 upp0r part of th0 throat -0hin/ th0 nos0.
Th0 -as0 of th0 su.
an/ canc0r may -0 foun/ in on0 or mor0 ymph no/0s of any siz0, anywh0r0 in th0 n0c.47 Canc0r is foun/ in a ymph no/0 arg0r than 6 c0ntim0t0rs.
Canc0r may aso -0 foun/ anywh0r0 in or n0ar th0nasa cavity an/ 0thmoi/ sinus.
Stage IVC
n stag0 VC, canc0r may -0 anywh0r0 in or n0ar th0 nasa cavity an/ 0thmoi/ sinus, may hav0 spr0a/ to ymph no/0s, an/ has spr0a/ to organs far
away from th0 nasa cavity an/ 0thmoi/ sinus, such as th0 ungs.