Morning Report

Monday, March 22th 2021

ONCOLOGY DIVISION
Date of entry : February, 9th 2021
Name : AP
Age : 16 years old
Gender : Male
Main Complain : Nose Bleeding
Explaination : Patient come to ENT Oncology division outpatient RSUP
HAM with main complaint nose bleeding. This complaint
appear about 3 months ago. The bleeding its about 10-
20cc. History bleeding on the nose was found in 6/2/21
and patient came to ER. The patient's complaints are felt
intermittent. The nose bleeds out spontaneously. The
epistaxis was stopped after perform anterior tampon.
History of nasal congestion (+), history of trauma (-).
• Previous disease : Denied

• Madication History : Denied

Status Presens
Sensorium : Compos Mentis
BP : 120 / 80 mmHg
HR : 80x/i
RR : 20x/i
Temp : 36,5oC
Localized Status
Ears Right Left

Ear lobe Normal Normal

Ear Canal open open

Tympanic membran Intact Intact

Nose Right Left

Rhinoscopy Cavum Nasi Open Open

Anterior
Septum Nasi Deviation (-) Deviation (-)

Konka Inferior Eutrofi Eutrofi

Tumor + -

Discharge + +

Throat

Orofaring Tonsil T1-T1

Faring Clear

Laringoskop Indirek : Hard to eximine

Physical examination of neck:

- There is no enlargement of the lymph nodes in the neck

Supporting examination
MSCT SCAN Paranasal Sinus (11/02/2021)
MSCT SCAN Paranasal Sinus (11/02/201)

EXAMINATION RESULT DESCRIPTION:

MSCT SCAN NASOFARING IV
• Paranasal sinus MCTS scan examination with soft tissue and bone window technique, no
intravenous contrast, axial sections of coronal and sagittal reconstructions.
• Post-contrast heterogeneous density mass appears on the right nasal cavity, which fills the
maxillary sinus, right ethmoid and bilateral spenoids following destruction of the surrounding
bone.
• Septum deviation to the left.
• Nasopharyngeal mucosa, oropharynx, both parotid are in good condition
• The cricoid, aretinoid, and thyroid cartilages are in good condition.
• There is no visible enlargement of the Lymph node colli region
• Both mastoid air cells are good

EXAMINATION DESCRIPTION:
• In accordance with the description of the sinonasal mass
MSCT SCAN ANGIOGRAPHY with intravenous contrast (24/2/2021)
MSCT SCAN ANGIOGRAPHY IV with intravenous contrast (24/2/2021)

EXAMINATION RESULT DESCRIPTION:

MSCT SCAN ANGIOGRAPHY IV with intravenous contrast
• A large enough hypervascular mass appeared to fill the nasopharynx to the
nasal cavity.
• Splenoid sinus with destruction of the surrounding bone accompanied by
pushing the nasal septum to the left by feeding the artery originating from the
right internal maxillary sinus.
• There was no other visible feeding of the arteries leading to the tumor mass
• Lingual artery, facial, ascending pharyngeal, superior thyroid, posterior
auricula, superficial temporalis right to the point.
EXAMINATION DESCRIPTION:
• Corresponding to the description of angiofibroma with arterial feeding originating
from the internal maxillary artery
Nasoendoscopic Examination

Appears that the

mass filling the
cavity of nose
 Examination Result Reference Value Unit
Hemoglobin 11,8 13 - 18 g/dl
Leukosit 6550 4000 – 11.000 /µL
Trombosit 247.000 150.000 – 450.000 /µL
KGDs 84 Mg/Dl
Laboratorium Renal Function Test
(05/03/2021) Ureum 11 19-44 mg/dl
Creatinine 0,63 0.7-1.3 mg/dl
Elektrolit
Natrium 140 135-155 mEq/L
Kalium 3,4 3,6-5,5 mEq/L
Klorida 105 96-106 mEq/L

Swab PCR (15/03/2021) : Negative

• Diagnose : Angiofibroma Nasofaring Juvenile

• Planning : Surgical extirpation of the tumor with Degloving

Operation Report (18/3/2021)
• The patient is in supine position on the operating table with the infusion and ETT attached.
• Disinfection area with povidone iodine in dilution with NaCl 0,9%
• Landmarks is made in the frenulum area by making tiles, infiltration is carried out with pehacain on the left-right sub labial to
tuberosity left-right maxilla.
• An incision is performed on the sub-labial mucosa starting from the one-sided maxillary tuberosity until the periosteum.
• Periosteum luksir up to the left-right canine fossa.
• The nasal mucosa is incised around the lower edge of the anterior and lateral apertura nares piriformis, the septum is cut from the
anterior nasal spine to nasofrontal suture.
• Inserted 2 catheters each in the left-right nares and removed the sub labial, pulled superiorly to glabela.
• Determined the location of the tumor mass through the apertura piriformis and oral cavity. Found tumors filling the nasopharynx.
• Once identified, entered the elevator through apertura piriformis and the mass of the tumor is released from the sticky area assisted
by the finger from oral cavity.
• After removing, the tumor mass is obtained with approximately 8 x 5 x 2 cm, sent to the PA department RSUP.H. Adam Malik.
• Perform palpation on the area where the mass came from and also endoscopic examination for ascertaining no more mass left.
• Control bleeding.
• The operation area is washed with 3% H2O2 and physiological NaCl.
• The septum is stitched with the number 8 method and alternating mattress stitches.
• Sub labial incision sutured
• A bellocq and anterior tampon were attached
• Bleeding (+) 1300 cc, Blood transfusion PRC 1 bag and WH 1 bag during surgery
• The operation is complete
Durantee Operation
 Post Operative Therapy

• IVFD RL 20gtt/i macro

• Inj. Ceftriaxon 1000 mg / 12 hour

• Inj. Dexamethason 1amp / 12 hour
• Inj. Tranexamic Acid 500 mg / 6 hour
• Inj. Ketorolac 1amp / 8 hour
• Inj. Ranitidin 1amp / 12 hour
 Care Plan
• Observation of the vital sign
• Observation of general circumstances of the patient
• Observation of post operative complication
Follow up (19/02/2021)
• S : Headache (+), pain in the nose (+)
• O : BP : 120/80

Nose Right Left Lab result Reference Value Unit

Rhinoscop Nasal cavity tampon tampon
y Anterior attached attached Hemoglobin 8,0 13 - 18 g/dl
Nasal septum tampon tampon leukocyte 8550 4000 – 11.000 /µL
attached attached
Platelet 194.000 150.000 – 450.000 /µL
Turbinate Inferior tampon tampon
attached attached

• A : Angiofibroma Nasofaring Juvenile

• P :- Post Surgical extirpation of the tumor with Degloving 18/3/2021
- PRC transfusion (2 bags)
Follow up (20/02/2021)
• S : Pain in the nose (+)
• O : BP : 110/80

Nose Right Left Lab 19/3/21 Result Reference Value Unit

Rhinoscop Nasal cavity tampon tampon
y Anterior attached attached Hemoglobin 8,0 13 - 18 g/dl
Nasal septum tampon tampon Leukocyte 8550 4000 – 11.000 /µL
attached attached
Platelet 194.000 150.000 – 450.000 /µL
Turbinate Inferior tampon tampon
attached attached

• A : Angiofibroma Nasofaring Juvenile

• P :- Post Surgical extirpation of the tumor with Degloving 18/3/2021
- PRC transfusion (2 bags) -> Ongoing
Follow up (21/02/2021)
• S : Pain in the nose (+)
• O : BP : 110/80

Nose Right Left Lab 19/3/21 Result Reference Value Unit

Rhinoscop Nasal cavity tampon tampon
y Anterior attached attached Hemoglobin 8,0 13 - 18 g/dl
Nasal septum tampon tampon Leukocyte 8550 4000 – 11.000 /µL
attached attached
Platelet 194.000 150.000 – 450.000 /µL
Turbinate Inferior tampon tampon
attached attached

• A : Angiofibroma Nasofaring Juvenil

• P :- Post Surgical extirpation of the tumor with Degloving 18/3/2021
- Post PRC transfusion (2 bags)
- Repeat Blood Test post transfusion
Thank You