LBM 5 THT

STEP 1
1. Detritus
- Kumpulan leukosit dan bakteri yg mati dari epitel yg terlepas
- Hasil eksudat yg berisi leukosit, bakteri, bercak kuning yg berada canal
2. ENT
- Ear, nose and throat. Sp. THT
STEP 2
1. 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 T3T3, 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 3
1. Anatomy and physiology, histology of larynx and pharynx ?
Anatomy

Nasopharynx
The 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 muscle

the 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 flaskshaped 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.
Oropharynx
The 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.
Laryngopharynx
The 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 ring
2. 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 into
1. pharyngeal tonsil, adenoid, which lies on the roof and posterior wall
of the nasopharynx
2. tubal tonsil which lies around the eustachain tube
3. palatine tonsil which lies between the anterior and posterior faucial
pillars
4. lingual tonsil which lies at the base of the tongue
These 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.

Physiology
Faring
- Respirasi
- Menelan
3 fase :
Oral bolus makanan dari mulut ke faring secara volunter
Pharingeal transfer si bolus melalui faring secara involunter
Esofageal secara involunter, si blous bergerak secara peristaltik, dari esofagus
ke lambung
- Protek terhadap infeksi benda asing masuk dibatukkan atau tersedak
- Persepsi rasa
Laring
-

Produksi suara
Syarat terjadi suara :
Aliran udara yg cukup adanya perbedaan tekanan udara. Dilihat dari glotisnya.
Ditentukan volume udara dan aliran udara di rongga dada
Sumber suara terjadi di plica vocalis
Resonator
Fungsi 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
minum
3. Why he feel that sensation of throat burning, fever and reduce appetite ?
Kurang makan = adanya pembesaran tersebut
Demam = adanya inflamasi
4. Why the result of the physical examinations for oropharyngeal statuse were tonsil T3T3, 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 postnasal 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 peradangan
Granulations (-) = menyingkirkan DD ( faringitis )
Adanya granulasi organ limfoid membengkak
6. Why he had taken medications but the symptoms still persisted ?
Tergantung penyebabnyaa apaa
Di skenario sudah terjadi pengulangan sudah resisten
Tonsilitis kronik indikasi tonsilektomi (absolut), dikasih obat saja tidak ampuh
7. 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 tonsil
Infeksi panas, gangguan menelan akibat pelebaran
8. 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 baik
10. 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 broadspectrum 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. Faringitis
Radang pada faring
Disebabkan virus maupun bakteri
Virus = adenovirus, HIV, common cold
Bakteri = streptococcus grup A, corinebacterium, archanobacterium, n.gonohhrea,
clamidia penumonia
Gejala nyeri tenggorokan, nyeri telan, demam, pembesaran KGB di leher,
leukosit meningkat

Terapi = analgetik, antibiotik(streptococcus = penicilin, alergi penicilin :

eritromicin)
c. Tonsilitis akut bakteri viral
Viral
EBV, hemofuilus influenza tonsilitis akut supuratif
Infeksi virus Coxs Chakie didapatkan luka2 kecil pada palatum dan tonsil
sangat nyeri
Terapi hanya istirahat, minum banyak, diberi analgetik dan antivirus
Bakteri
Disebabkan oleh kuman grup A streptococcus beta-hemoliticus = strep throat
Ada detritus akibat infeksi
Ada 2 : lakunaris folikularis
Folikularis = detritus jelas
Lakunaris = bercak jadi satu, membentuk alur dan bisa melebar membentuk
pseudomembran dan menutupi tonsil
Gejala demam, rasa lesu, tdk nafsu makan, otalgia
Terapi = antibiotik spektrum luas, antipiretik, obat kumur
11. 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 setahun
12. Complications ?
- Sinusitis
- Rhinitis
- OMA

STEP 4
STEP 5