LBM 5 THT

STEP 11. Detritus Kumpulan leukosit dan bakteri yg mati dari epitel yg terlepas Hasil eksudat yg berisi leukosit, bakteri, bercak kuning yg berada canal2. ENT Ear, nose and throat. Sp. THTSTEP 21. Why he complaint get painful swallowing ?2. Why he feel that sensation of throat burning, fever and reduce appetite ?3. Why the result of the physical examinations for oropharyngeal statuse were tonsil T3-T3, hiperemic mucosa +/+, tonsil crypt widened +/+, detritus +/+ ?4. Why the result of the physycal examinations for pharynx were hyperemic mucosa, granulation in the posterior wall (-) ?5. Why he had taken medications but the symptoms still persisted ?6. DD ?7. Anatomy and physiology of larynx and pharynx ?8. Therapy ?9. What is the corelations between the patient history and the condition when the patient came to the doctor ?10. What are etiology that can caused his condition ?11. Risk factor about the case ?12. Complications ?STEP 31. Anatomy and physiology, histology of larynx and pharynx ?Anatomy

NasopharynxThe upper portion of the pharynx, the nasopharynx, extends from the base of the skull to the upper surface of the soft palate. It includes the space between the internal nares and the soft palate and lies above the oral cavity. The adenoids, also known as the pharyngeal tonsils, are lymphoid tissue structures located in the posterior wall of the nasopharynx.

The nasopharynx, oropharynx, and laryngopharynx or larynx can be seen clearly in this sagittal section of the head and neck.Polyps or mucus can obstruct the nasopharynx, as can congestion due to an upper respiratory infection. The eustachian tubes, which connect the middle ear to the pharynx, open into the nasopharynx. The opening and closing of the eustachian tubes serves to equalize the barometric pressure in the middle ear with that of the ambient atmosphere.

The anterior aspect of the nasopharynx communicates through the choanae with the nasal cavities. On its lateral walls are the pharyngeal ostia of the auditory tube, somewhat triangular in shape, and bounded behind by a firm prominence, the torus tubarius or cushion, caused by the medial end of the cartilage of the tube that elevates the mucous membrane. Two folds arise from the cartilaginous opening:

the salpingopharyngeal fold, a vertical fold of mucous membrane extending from the inferior part of the torus and containing the salpingopharyngeus musclethe salpingopalatine fold, a smaller fold extending from the superior part of the torus to the palate and containing the levator veli palatini muscle. The tensor veli palatini is lateral to the levator and does not contribute the fold, since the origin is deep to the cartilaginous opening.Behind the opening of the auditory tube is a deep recess, the pharyngeal recess (also referred to as the fossa of Rosenmller). On the posterior wall is a prominence, best marked in childhood, produced by a mass of lymphoid tissue, which is known as the pharyngeal tonsil. Superior to the pharyngeal tonsil, in the midline, an irregular flask-shaped depression of the mucous membrane sometimes extends up as far as the basilar process of the occipital bone, this is known as the pharyngeal bursa.

OropharynxThe oropharynx lies behind the oral cavity, extending from the uvula to the level of the hyoid bone. It opens anteriorly, through the isthmus faucium, into the mouth, while in its lateral wall, between the Palatoglossal arch and the Palatopharyngeal arch, is the palatine tonsil. The anterior wall consists of the base of the tongue and the epiglottic vallecula; the lateral wall is made up of the tonsil, tonsillar fossa, and tonsillar (faucial) pillars; the superior wall consists of the inferior surface of the soft palate and the uvula. Because both food and air pass through the pharynx, a flap of connective tissue called the epiglottis closes over the glottis when food is swallowed to prevent aspiration. The oropharynx is lined by non-keratinised squamous stratified epithelium.

LaryngopharynxThe laryngopharynx, (Latin: pars laryngea pharyngis), is the caudal part of the pharynx; it is the part of the throat that connects to the esophagus. It lies inferior to the epiglottis and extends to the location where this common pathway diverges into the respiratory (larynx) and digestive (esophagus) pathways. At that point, the laryngopharynx is continuous with the esophagus posteriorly. The esophagus conducts food and fluids to the stomach; air enters the larynx anteriorly. During swallowing, food has the "right of way", and air passage temporarily stops. Corresponding roughly to the area located between the 4th and 6th cervical vertebrae, the superior boundary of the laryngopharynx is at the level of the hyoid bone. The laryngopharynx includes three major sites: the pyriform sinus, postcricoid area, and the posterior pharyngeal wall. Like the oropharynx above it, the laryngopharynx serves as a passageway for food and air and is lined with a stratified squamous epithelium. It is innervated by the pharyngeal plexus.

The vascular supply to the hypopharynx includes the superior thyroid artery, the lingual artery and the ascending pharyngeal artery. The primary neural supply is from both the vagus and glossopharyngeal nerves. The vagus nerve provides a branch termed "Arnolds Nerve" which also supplies the external auditory canal, thus hypophayrngeal cancer can result in referred otalgia. This nerve is also responsible for the ear-cough reflex in which stimulation of the ear canal results in a person coughing. Pharyngeal lymphatic ring(waldeyer lymphatic ring):1. inner ring2. outer ring

Applied anatomy of pharynx, Wang Peihua, Department of Otorhinolaryngology,9th peoples hospital, School of medicine, Shanghai Jiaotong University.

Tonsils are lymphoepithelial organs at the opening of the upper aerodigestive tract. From above downwards, they can be divided into1.pharyngeal tonsil, adenoid, which lies on the roof and posterior wall of the nasopharynx2.tubal tonsil which lies around the eustachain tube3.palatine tonsil which lies between the anterior and posterior faucial pillars4.lingual tonsil which lies at the base of the tongueThese lymphoid organs developed from the epithelium of the primitive oronasal cavity, the mesenchymal stroma and lymphoid cells then infiltrate these areas. Although the tonsils are present at embryonal stage, they only acquire their typical structure in the postnatal period. They begin increasing rapidly in size between the first and third year of life, with peaks in the third and seventh year. They involute slowly at early puberty. In contrast to other lymphoid aggregates, tonsils do not filter lymph.The palatine tonsil is supplied by the facial artery, ascending pharyngeal artery, lingual artery and the maxillary artery. Venous drainage is by the lingual and pharyngeal veins.

PhysiologyFaring Respirasi Menelan3 fase :Oral bolus makanan dari mulut ke faring secara volunterPharingeal transfer si bolus melalui faring secara involunterEsofageal secara involunter, si blous bergerak secara peristaltik, dari esofagus ke lambung Protek terhadap infeksi benda asing masuk dibatukkan atau tersedak Persepsi rasaLaring Produksi suaraSyarat terjadi suara :Aliran udara yg cukup adanya perbedaan tekanan udara. Dilihat dari glotisnya. Ditentukan volume udara dan aliran udara di rongga dadaSumber suara terjadi di plica vocalisResonatorFungsi koordinasi dan kontrol Respirasi pintu udara pernafasan Proteksi penutupan epiglotis Deglutisi mekanism penutupan epiglotis

2. Why he complaint get painful swallowing ?Adanya invasi kuman patogen menyebar lewat limfogen ke faring dan tonsil (inflamasi) tonsil = hipertermi, edema, pembesaran nyeri telan, sulit makan dan minum3. Why he feel that sensation of throat burning, fever and reduce appetite ?Kurang makan = adanya pembesaran tersebutDemam = adanya inflamasi4. Why the result of the physical examinations for oropharyngeal statuse were tonsil T3-T3, hiperemic mucosa +/+, tonsil crypt widened +/+, detritus +/+ ?

Standardized tonsillar hypertrophy grading scale. (0) Tonsils are entirely within the tonsillar fossa. (1+) Tonsils occupy less than 25 percent of the lateral dimension of the oropharynx as measured between the anterior tonsillar pillars. (2+) Tonsils occupy less than 50 percent of the lateral dimension of the oropharynx. (3+) Tonsils occupy less than 75 percent of the lateral dimension of the oropharynx. (4+) Tonsils occupy 75 percent or more of the lateral dimension of the oropharynx.Wang RC, Elkins TP, Keech D, Wauquier A, Hubbard D. Accuracy of clinical evaluation in pediatric obstructive sleep apnea. Otolaryngol Head Neck Surg. 1998;118:6973.

Widen crypt:

The human palatine tonsils (PT) are covered by stratified squamous epithelium that extends into deep and partly branched tonsillar crypts, of which there are about 10 to 30. The crypts greatly increase the contact surface between environmental influences and lymphoid tissue.The tonsillar crypts often provide such an inviting environment to bacteria that bacterial colonies may form solidified "plugs" or "stones" within the crypts. In particular, sufferers of chronic sinusitis or post-nasal drip frequently suffer from these overgrowths of bacteria in the tonsillar crypts.[medical citation needed] these small whitish plugs, termed "tonsilloliths" and sometimes known as "tonsil stones".Barnes, Leon (2000). Surgical Pathology of the Head and Neck (2nd ed. ed.). CRC Press. p. 404.Detritus:Infiltration of bacteria on the epithelial tissue lining the tonsils will cause an inflammatory reaction in the form of the release of polymorphonuclear leukocytes to form detritus. This detritus is a collection of leukocytes, dead bacteria and epithelial apart. Clinically this detritus filling kripte tonsils and appear as yellowish spots.Staf Pengajar Ilmu Penyakit THT FKUI. Buku Ajar Ilmu Kesehatan Telinga Hidung Tengorok Kepala Leher Edisi ke 6 Cetakan ke 1, Balai Penerbit FKUI, Jakarta, 1990.Granule in the posterior wall:Acute pharyngitis Looks at mucosal thickening and hypertrophy of the lymph nodes underneath and behind the posterior pharyngeal arch (lateral band). The existence of the uneven mucosa of the posterior wall of the so-called granular.Staf Pengajar Ilmu Penyakit THT FKUI. Buku Ajar Ilmu Kesehatan Telinga Hidung Tengorok Kepala Leher Edisi ke 6 Cetakan ke 1, Balai Penerbit FKUI, Jakarta, 1990.

5. Why the result of the physycal examinations for pharynx were hyperemic mucosa, granulation in the posterior wall (-) ?Hyperemic mucosa = adanya peradanganGranulations (-) = menyingkirkan DD ( faringitis )Adanya granulasi organ limfoid membengkak

6. Why he had taken medications but the symptoms still persisted ?Tergantung penyebabnyaa apaaDi skenario sudah terjadi pengulangan sudah resistenTonsilitis kronik indikasi tonsilektomi (absolut), dikasih obat saja tidak ampuh7. What is the corelations between the patient history and the condition when the patient came to the doctor ?Riwaya berulang selama 2 bulan terakhir, akan mengikis jaringan limfoid dan epitel berubah jaringan parut mengkerut adanya pelebaran crypt tonsilInfeksi panas, gangguan menelan akibat pelebaran8. What are etiology that can cause his condition ? Higiene mulut si pasien (adanya sisa2 makanan kuman2 berkembang disitu) Tonsilitis karena virus (adenovirus) = 70%. Bakteri 30%(streptococcus hemoliticus, streptococcus viridas, streptococcus piogenis, pneumococcus, hemofilus influenza) 9. Risk factor about the case ? Rangsangan yg menahun (merokok = zat2 yg ada di rokok, suka makanan yg pedas2) Pengobatan radang yg tidak adekuat Higiene mulut yg kurang baik10. DD ?a. Tonsilitis kronik

Tonsilitis

The most active phase of tonsils is between age 3 to 10 years and after that involution begins. Although hyperplasia of tonsils is not a disease, these organs are found to have a higher incidence of pathogenic bacteria around the poorly-drained tonsillar crypts resulting in tonsillitis. Majority of childhood tonsillitis are caused by group A ]-haemolytic streptococcus (GABHS). Its frequency and serious consequences such as acute rheumatic fever and glomerulonephritis make this an important infection. Viral causes are also common including coxsackievirus, herpesvirus and Epstein-Barr virus. However, it was found that with recurrent attacks of tonsillitis, the type and number of organisms changes from a commensal to greater varieties of bacteria and thus requiring different broad-spectrum antibiotics. Therefore the use of throat culture to arrive at the diagnosis is inaccurate.Clinically, the patients presented with sorethroat, fever and malaise. Physical examination may nor may not show enlarged tonsils, but exudates, erythema are seen. Cervical lymph nodes may be enlarged and tender.Definition of recurrent acute tonsillitis is varible. We take more than 4 episodes in one year or 7 episodes in 1 year, 5 episodes per year for 2 years or 3 episodes per year for 3 years .Recurrent acute tonsillitis and chronic tonsillitis can give rise to peritonsillar abscess. Further spread of the infection beyond the peritonsillar space and lateral aspect of tonsillar fossa can lead to parapharyngeal space abscess. In addition, children under age 3 with tonsillitis are more susceptible to retropharyngeal space infection. Affected children will present as irritability, fever, difficulty in breathing and torticollis.The most common drug used to treat tonsillitis is amoxicillin. But with increasing resistance, the use of beta-lactamase inhibitor i.e. augmentin or unasyn may be needed. Only 32% responds to medical treatment with 6 months prophylaxis or a prolonged course of 30-days antibiotics.Decision for surgical intervention in patients with recurrent tonsillitis should be individualized. When treating paediatric patients, surgeon should have good communication with parents and provide full explanation of the procedure. Always ask for family history of bleeding tendency and other medical problems. Cervical XR should be done for children with Down's syndrome.ACUTE TONSILLO PHARYNGITIS EXUDATIVE, CAPITOL MEDICAL CENTER COLLEGES INC., CORRAL, Priscilla Chantal M.

b. FaringitisRadang pada faringDisebabkan virus maupun bakteriVirus = adenovirus, HIV, common coldBakteri = streptococcus grup A, corinebacterium, archanobacterium, n.gonohhrea, clamidia penumoniaGejala nyeri tenggorokan, nyeri telan, demam, pembesaran KGB di leher, leukosit meningkatTerapi = analgetik, antibiotik(streptococcus = penicilin, alergi penicilin : eritromicin)c. Tonsilitis akut bakteri viralViralEBV, hemofuilus influenza tonsilitis akut supuratifInfeksi virus Coxs Chakie didapatkan luka2 kecil pada palatum dan tonsil sangat nyeriTerapi hanya istirahat, minum banyak, diberi analgetik dan antivirusBakteriDisebabkan oleh kuman grup A streptococcus beta-hemoliticus = strep throatAda detritus akibat infeksiAda 2 : lakunaris folikularisFolikularis = detritus jelasLakunaris = bercak jadi satu, membentuk alur dan bisa melebar membentuk pseudomembran dan menutupi tonsilGejala demam, rasa lesu, tdk nafsu makan, otalgiaTerapi = antibiotik spektrum luas, antipiretik, obat kumur11. Therapy ? Istirihat bicara dan bersuara 2-3 hari Menghirup udara lembab Menghindari iritasi laring dan faring (merokok,makanan yg pedas) Antibiotik bila ada peradangan dari paru harus di kultur dulu Sumbatan laring trakeostomi Tonsilektomi indikasi : berulang 3x dalam setahun12. Complications ? Sinusitis Rhinitis OMA

STEP 4STEP 5