Ukkie - LBM 4 Painful Swallowing THT SGD 19

UKKIE modul tht lbm 4 (tonsilitis)
2013
M a n g b e w o k . t k - @s i m a n g b e w o k

Page 1
LBM 4 PAINFUL SWALLOWING

STEP 1
Detritus : hasil eksudat yang berisi leukosit, bakteri, dan epitel yang
terlepas di kanal berwarna bercak kuning.
Kripte : muara saluran limfoid yang dapat terlihat pada tonsil

STEP 2
1. Anatomi, fisiologi, dan histologi faring dan tonsil?
2. Mengapa pasien merasakan seperti sensasi terbakar dan nyeri telan pada
tenggorokan?
3. Mengapa pasien demam dan mengalami penurunan nafsu makan?
4. Apa interpretasi dari pemeriksaan orofaringeal : tonsil : T4/T4, mukosa
hiperemis, kripte melebar +/+, detritus +/+ dan pada faring ditemukan
mukosa hiperemis dan terdapat granul di posterior?
5. Causa detritus dan kripte (definisi, patofis)?
6. Obat warung apa yang kira-kira sudah dikonsumsi untuk mengurangi
gejala?
7. Pemeriksaan penunjang untuk menegakkan diagnosis?
8. Penatalaksanaan yang tepat untuk pasien tersebut?
9. DD?
10. Komplikasi yang dapat timbul dari diagnosis?

STEP 3
ANATOMI
Faring : berbentuk seperti corong, kurang lebih 15 cm, dibentuk oleh jar
fibromuskular

2013

Page 2
Nasofaring :
Batas depan : choanae
Atas : basis crania
Belakang : vertebra cervical yg dipisahkan facia prevertebralis
Bawah : palatum mole
Lateral : dinding medial leher
Ada bangunan ostium tuba eusthacii, adenoid, recessus faring

OROFARING
Atas : nasofaring
Depan : cavum oris dan uvula
Belakang : vertebra cervical II-III
Lateral : dinding medial leher
Bawah : tepi atas epiglottis
Bangunan tonsila palatine, fossa supra tonsilaris, tonsila lingualis
Laringofaring
Atas : orofaring
Depan : tepi blkg epiglottis
Belakang : dinding belakang orofaring
Bawah : porta esophagus

Ruang di sekitar faring:
Retrofaring : ada mukosa faring, fossa faringobulbolaris, sering
tjd supurasi, jk pecah abses retrofaring
Parafaring : dibagi 2 ruangan oleh os. Stiloid pre dan post
stiloid
Pre stiloid : gampang tjd supurasi
Post : banyak pemb darah

TONSIL
Ada cincin waldeyer : tonsil palatine, tonsil faringeal, tonsil lingual, tonsil
tuba

2013

Page 3
Tonsil palatine : ada di fossa tonsil, dibatasi pilar anterior : m.
palatoglossus, posterior : m. palatofaringeus. Panjang 2-4 cm.
masing2 tonsil 10-30 kriptus. Lateral ; m. konstriktor faring superior,
anterior : m. palatoglossus, posterior : m. pakatofaringeus, superior :
palatum mole, inf : tonsil lingua.
Vaskularisasi : a. maksila eksterna, a. maksila interna, a. lingualis cab
a. lingua dorsal, a. faringeal ascenden
Tonsil faringeal ; di dinding belakang nasofaring, tidak mempunyai
kripte
Tonsil lingual : di dasar lidah, dibagi 2 oleh lig. glossoepliglotika
HISTOLOGI
Pada nasofaring mukosanya bersilia dan epitel mengandung sel goblet, sedangkan
orofaring dan laringofaring mukosa tidak bersilia.
Pada faring banyak jar limfoid untuk proteksi.

Ada palut lender/mucous blanket di bagian nasofaring, di atas cilia, berfungsi
untuk menangkap partikel dari udara, mengandung lisozim. Bergerak ke posterior.
Terdapat otot2 sirkuler dan longitudinal.
Sirkuler : m. konstriktor faring sup, media, inf untuk konstriksi
Longitudinal : m. stiloideus dan m. palatofaring untuk melebarkan faring
dan mengangkat faring. Dipersarafi n IX.
Di palatum mole ada 5 pasang otot :
M. levator veli palatine menyempitkan isthmus faring, melebarkan tuba
eusthacii. Dipersarafi n X
M. tensor veli palatine mengencangkan anterior palatum mole dan
menyempitkan tuba eusthacii
M. palatoglossus menyempitkan isthmus faring
M. palatofaring

2013

Page 4
M. azigos uvula memperpendek dan menaikkan uvula
FISIOLOGI
Fungsi menelan
3 fase :
ORAL bolus di mulut berjalan ke faring, volunteer
FARINGEAL transfer bolus melewati faring, involunteer
ESOFAGEAL bolus bergerak peristaltic dari esophagus keg aster,
involunteer

tenggorokan?
Invasi bakteri pertahanan utama : tonsil , karena terdapat jaringan limfe
virulensi tinggi inflamasi tonsil edem tonsil membentuk cincin ,
susah menelan nutrisi berkurang , kelemahan . mengobstruksi tuba
eustacii juga kurang oendengaran .
Bias juga menyebar menjadi otitis.
Sensasi terbakarinflamasi tonsil dan mukosa di orofaring
Nafsu makan
Karena ada nyeri di tenggorokan , nyeri telan nafsu makan menurun

Derajat tonsil:
T0 T4
Pada scenario T4 sehingga mengobstruksi makanan, nyeri telan
Jika kronis tidak ada nyeri telan

Di no 2


2013

Page 5
Hiperemis mukosa ada peradangan, dilatasi pemb darah
Detritus adanya peradangan tonsil penumpukan leukosit,
bakteri mati, epitel mati. Terlihat bercak kuning
Kriptus muara sal limfoid terisi detritus lama kelamaan tjd
pengerutan
Granula pembengkakan organ limfoid faring
Ada bakteri/virus menginvasi mukosa faring, tjd inflamasi local,
kuman /bakteri mengikis epitel, jar. Limfoid bereaksi
pembendungan infiltrate leukosit PMN
Stadium awal : hiperemi, edema, sekresi banyak. Awal eksudat
serosa, menebal, kering menempel di dinding faring
Derajat tonsil
T0 : Tonsil sudah diambil
T1 : Normal
T2 : Pembesaran tonsil tidak sampai linea media
T3 : hipertrofi mencapai garis tengah sesak napas
T4 : pembesaran tonsil lebih dari linea media, mengganggu deglutio

Es tidak bersih banyak bakteri inflamasi pada tonsil
Chiki MSG jd Iritan di tonsil ..

Tonsil dibungkus oleh kapsul di fossa tonsil , di tonsil banyak jar limfe yg
disebut folikel, tiap folikel pny kanal yang bermuara pada perm tonsil.
Muara tersebut terlihat muara yaitu kripte.

2013

Page 6
Folikel peradangan tonsil membengkak membentuk eksudat yang
mengalir dalam kanal keluar ke kripte terlihat kotoran putih/ bercak
kuning (Detritus)

gejala?
Hanya mengatasi simptomnya saja
Paracetamol, ibuprofen
Antibiotic

CT Scan
MRI
Biopsi
Darah rutin : leukositosis, Hb turun
Uji swab untuk mengetahui bakteri

Farmakologi : antibiotic cefadroxil 1 minggu, analgesic, antipiretik,
kortikosteroid
Non farma : edukasi, minum air putih, pengontrolan makanan

GOLONGAN ANTIBIOTIK ? GENERASI?SEDIAAN..

9. DD?
TONSILITIS
Tonsillitis akut
o Viral : haemophillus influenzae
o Bacterial : streptococcus beta hemoliticus
Tonsillitis membranacea
o T. diphteri Corynebacterium diphteri

2013

Page 7
Demam, nyeri kepala, nyeri telan, badan lemas
o T. septic strep hemoliicus
o T. angina plaut Vincent bakteri spirochaeta
o T. karena kelainan darah leukimia
o Proses spesifik luas dan TB
Kronis

Tonsilitis diphteri
Dari sal pernapasan atas, usia 10 th
Ada 3 gejala :
Local : membrane semu, pembesaran limfe / bull neck
Sistemik : Demam, nyeri kepala, nyeri telan, badan lemas
Eksotoksin : jantung miokarditis
Diagnose : gejala local, px mikrobiologi


11. Batasan operasi pada anak2?

2013

Page 8
STEP 7

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:

2013

Page 9

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 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.

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.

2013

Page 10

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
thepostnatal 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.

2013

Page 11
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.

tenggorokan?

Bacteria and virus enter the body through the nose
and mouth
Bateria and viruses are filtered
in the tonsils
tonsils work by surrounding bacteria and
virus with white blood cells
Precipitating factors
Age
Sex
Race
Unhealthy Lifestyle
Environment
Predisposing Factors
Cold
loss of sleep
constipation
infection and inflammation causes
enlarge tonsils
Signs
Red and swollen tonsils and uvula
Redness of throat
Presence of purulent materials
Tenderness on the jugulodiagastric
lymph nodes
Gray furry tongue
Symptoms
Sore throat
Dysphagia
Fever
Earache
Loss of appetite
Constitutional symptoms

2013

Page 12
emedicine.medscape.com

Virus; Bacteria; Group A beta hemolytic streptococcusActivation of macrophages by
IFN- production of endogenous pyrogen IL-1, IL-4, IL-6, TNF-endogenous pyrogens
enter the systemic circulation and penetrate hematoencephalic barrier reacts to the
hypothalamusEffects of endogenous pyrogen on hypothalamic cytokines causethe
production of arachidonic acidand prostaglandins Prostaglandins stimulate the cerebral
cortex (behavioral response) leptin causes stimulation of the
hypothalamussuppressed appetite.
ACUTE TONSILLO PHARYNGITIS EXUDATIVE, CAPITOL MEDICAL CENTER COLLEGES INC.,
CORRAL, Priscilla Chantal M.


2013

Page 13
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".

2013

Page 14
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.

gejala?

Diagnosis of tonsillitis is based on a medical history and a physical exam of the throat.
An accurate medical history is needed to find out whether tonsillitis is recurrent, which
may affect treatment choices.
If your symptoms suggest strep throat, your doctor may want to confirm this diagnosis
by doing a throat culture. Strep throat is more likely if 3 or 4 of the following signs or
symptoms are present:
Fever
White or yellow spots or coating on the throat and/or tonsils (tonsillar exudates)
Swollen or tender lymph nodes on the neck
Absence of coughing or sneezing

2013

Page 15
If a strep infection is suspected, your doctor may do a rapid strep test or a throat
culture or both. Both of these tests can be done in a doctor's office. You may want to
discuss the advantages and disadvantages of each test to see which test is appropriate.
The results of these tests will determine whether antibiotic treatment is needed. These
results combined with an accurate medical history will be considered in deciding whether
surgery to remove the tonsils (tonsillectomy) is recommended.
If the Epstein-Barr virus, which can cause mononucleosis, is suspected as a cause for the
tonsillitis, a test for mononucleosis may be done.
http://www.emedicinehealth.com/tonsillitis-health/page6_em.htm


http://www.nzdl.org/

9. DD?

2013

Page 16

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.

2013

Page 17


2013

Page 18

Tonsillectomy or adenoidectomy is indicated only if the patient has had any of the
following problems:
repeated bouts of tonsillitis;
hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive
sleep apnea;
repeated attacks of purulent otitis media;
suspected hearing loss due to serous otitis media that has occurred in association with
enlarged tonsils and adenoids;
and some other conditions, such as an exacerbation of asthma or rheumatic fever.
emedicine.medscape.com

1. Infection:
Recurrent, acute tonsillitis (>6 episodes per year or 3 episodes per year >2 years)
Recurrent acute tonsillitis associated with other conditions
Cardiac valvular disease associated with recurrent streptococcal tonsillitis
Recurrent febrile seizures
Chronic tonsillitis that is unresponsive to medical therapy associated with
Halitosis
Persistent sore throat
Tender cervical adenitis
Streptococcal carrier state unresponsive to medical therapy
Peritonsillitis abscess
Tonsillitis associated with abscessed cervical nodes
Mononucleosis with severely obstructing tonsils that is unresponsive to medical therapy
2. Obstruction:
Excessive snoring and chronic mouth breathing
Obstructive sleep apnoea or sleep disturbances
Adenotonsillar hypertrophy associated with
Cor pulmonale
Failure to thrive
Dysphagia
Speech abnormalities
Craniofacial growth abnormalities
Occlusion abnormalities
3. Other:

2013

Page 19
Suspected neoplasia-asymmetric tonsillar hypertrophy
There are different methods of tonsillectomy including the use of a cold knife, hot knife,
diathermy, laser and harmonic scalpel. The operation lasts for about one hour. Postop,
the patients recover rapidly and can resume tonsillar diet immediately. Most important
is to look out for post-op bleeding. Postoperative haemorrhage ranges from 0.5-2%. No
significant immunological consequence has ever been documented. Changes in speech
or velopharyngeal insufficiency are mainly temporary. In general, nearly all our patients
can be discharged safely from hospital three days after the operation.

Tonsillectomy Complications:
Peritonsillar abscess.
Acute otitis media.
Lancefield's GABS can cause rheumatic fever, Sydenham's chorea, glomerulonephritis
and scarlet fever.
Streptococcal infection may cause a flare-up of guttate psoriasis.
Enlarged and chronically infected tonsils interfere with children's sleep.
Complications of tonsillectomy include otitis media and haemorrhage which can be
very difficult, especially where there is an undiagnosed bleeding tendency such as
haemophilia. Altered taste sensation has been reported.
Patients who have had tonsillectomy are more susceptible to bulbar poliomyelitis.
Smithard A, Cullen C, Thirlwall AS, et al; Tonsillectomy may cause altered tongue
sensation in adult patients. J Laryngol Otol. 2009 May;123(5):545-9. Epub 2008 Jul 30.

BACTERIA vs VIRAL

These symptoms are generally mild in viral infection and very severe in bacterial infection.

2013

Page 20


Ukkie - LBM 4 Painful Swallowing THT SGD 19

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ukkie - LBM 4 Painful Swallowing THT SGD 19

Uploaded by

Copyright:

Available Formats

UKKIE modul tht lbm 4 (tonsilitis)

You might also like