CASUALTY RHINOLOGY DIVISION

August – September 2021

REPORT Febby-Lia/Wulan/Mesi-Fateha
Identity & Chief Complaint

MALE, 21 YEARS OLD

Consulted from ophthalmology

department with chief complaint
of blurred vision on the left eye
since 3 hours prior to admission
 Swollen right cheek and neck with pain (VAS
• 5 was riding motor cycle at moderate
Patient
speed, using half-face helmet 3 hours prior to
admission
• Fell off from motorcycle  left face side
hitted the part of motorcycle
Medical
Medical
History
History
Blurry vision of left eye

Difficulty to open left eye

Swollen on left eye with laceration

History of left nosebleed

 No decrease of consciousness, seizure,
nausea, vomiting

No difficulty of breathing

Medical No bleeding from ear and throat

History
No history of visual impairment or using glasses

Patient was brought to Fatmawati Hospital

 referred to CMGH
 Compos mentis, moderately ill

No dyspnea, stridor, nor retraction

Physical
Examination Vital sign

• BP: 134/84
• HR: 87 bpm
• RR: 22 x/m
• T: 36,5 C
• O2 Sat: 99% (room air)
 Compos mentis, moderately ill

No dyspnea, stridor, nor retraction

Physical
Examination Vital sign

• BP: 134/84
• HR: 87 bpm
• RR: 22 x/m
• T: 36,5 C
• O2 Sat: 99% (room air)
 ENT Examination

Ear Throat
• Right - left: wide ear • Right nose: Wide nasal • Pharyngeal arch was
cavity, inferior turbinate
canal, no discharge or eutrophy, discharge-, symmetric, uvula in
cerumen, intact deviated septum-, good air the middle, Tonsil T1 –
tympanic membrane passage, clotting-, active T1 not hyperemic,
bleeding- clotting-, active
• Left nose: Wide nasal bleeding-
cavity, inferior turbinate
eutrophy, discharge-,
deviated septum-, good air
passage, clotting+, active
bleeding-
ENT Examination

- Frontal: excoriation (-), laceration (-), hematoma (-), edema (-), crepitation (-), deformity (-)
- Orbit: excoriation (-/+), laceration (-/+), hematoma (-/-), edema (-/+), crepitation (-), deformity
(-)
- Nasal: excoriation (-), laceration (-), hematoma (-), edema (-), crepitation (-), deformity (-)
- Zygoma: excoriation (-/+), laceration (-/+), hematoma (-), edema (-), crepitation (-), deformity
(-), malar depression (-)
- Maxilla: excoriation (-), laceration (-), hematoma (-), edema (-), crepitation (-), deformity (-),
floating maxilla (-)
- Mandible: excoriation (-), laceration (-), hematoma (-), edema (-), crepitation (-), deformity (-),
malocclusion (-)
Rhinopharyngolaryngoscopy CMGH
11/9/2021
 Laboratory
Laboratory Examination
Examination CMH
CMH
(September 11th, 2021)

 Hb : 16.3 mg/dl  Blood glucose : 113

 Ht : 45.1 %  Prokalsitonin : 0.05
 WBC : 15.530 u/l  CRP : 4.0
 Platelet : 264.000u/l
 Sodium : 136 mEq Antigen SARS-CoV2 : non reactive
 Potassium : 4.1 mEq
 Chlorida : 99.6 mEq PCR SARS-CoV2. : negative
 Thorax
Thorax X-Ray
X-Ray CMHCMH
(September
(September 11th,, 2021)
11 th
2021)

There
There were
were no
no radiological
radiological abnormalities
abnormalities of
of the
the heart
heart
and
and lungs
lungs
ENOPHTHALMOS ASESSMENT
 Facial
Facial 3D
3D CT
CTCMGH
CMGH
(September
(September11th,
11th, 2021)
2021)
 Working
Working Diagnosis
Diagnosis

- Traumatic optic neuropathy of the left eye (S04.019)

- Orbital Apex Syndrome left eye (H05.9)
- Left ethmoidal hematosinus (J32.2)
- Left ZMC fracture (S02.40)
- Blow out fracture of the left eye (S02.3)
 MANAGEMENT
MANAGEMENT

Report to Nina Irawati, MD, ORL-HNS, PhD :

 Intranasal corticosteroid 2x2 nasal spray on both nose
 Nasal saline spray 2x2 on both nose
 Suggest to report to Retno S Wardani, MD, ORL-HNS, PhD
for further treatment from Rhinology Division
 Consult to ENT-Plastic Reconstruction Division for ZMC
fractures management
 MANAGEMENT
MANAGEMENT

Report to Retno S Wardani, MD, ORL-HNS, PhD

Rhinology Division
 Plan for Trans-nasal endoscopic orbital decompression on
Sunday, September 12th 2021
 Antibiotics and steroids according to Ophthalmology
department
 PCR SARS COV-2 swab
 Consult to Internal Medicine and Anesthesiology
department for surgery tolerance
 MANAGEMENT
MANAGEMENT

Report to Mirta Hediyati R, MD, ORL-HNS, PhD

ENT – Plastic Reconstruction
 Plan of Elective ORIF to repair ZMC fracture and orbital
floor with Ophthalmology department
 ENT
ENTSurgical
Surgical Report
Report 1. Continuing the procedure from opthamologist
ER
ER OR
OR (September
(September1212th ,, 2021
th
2021 )) 2. Insertion of adrenaline tampon: Nacl 1:4 with
xylocain gel in left nose for 10 minutes.
3. Evaluate left nose : mucosal edema around the
middle meatus, mucus mixed with blood
coming out of the middle meatus and
sphenoethmoid recess  Suction & evaluate
until the nasopharynx normal.
4. Uncinectomy & Middle meatal antrostomy
the superior wall of maxilla prolaps to anterior
closing the natural ostium maxilla.
5. Evaluation: there was ethmoid anterior bone
trapping to the medial wall of orbita
fragmented bone was release. The ethmoid
anterior bone to posterior ethmoid bone was
crushing prolaps to anterior, medial wall of orbit
(lamina papiracea) fragmented. All the ethmoid
tissue & bone was removed from nasal cavity
8. A stent was placed to hold the 6. Reconstruction of medial wall of orbit by
reconstruction of the lamina papiracea realignment the fragmented lamina papiracea
fragments using 1/2 netcel wrapped in a bone returned to medial wall of orbit
hand scoon. 7. Sphenoidotomy OCR & plane of sphenoid
couldn’t be identified
 Opthalmology
Opthalmology Department
Department
13-14
13-14 Sept
Sept 2021
2021
O: A:
Right eye -Post Transnasal endoscopic orbital
-Normal movement decompression & medial wall orbit
-Visual Acuity: 6/9 ph 6/6, IOP 11 reconstruction D-1 due to traumatic optic
P: normal neuropathy & orbital apex sindrome
Cb: normal
C: clear -Post repair of partial thickness palpebral
CoA deep, cell (-), flare (-) superior and inferior ruptured
I/P round, central, light reflex +, P:
- Metyl prednisolone 4x 125 mg IV (for 5 days)
konsensual +
- cendo LFX 6x1 drop on left eye
L clear
- Fenicol zalf 3x1 applic on left eye
V/F papil round, clear border, CDR
- Clindamisin 2x300 mg PO
0.3-0.4, aa/vv 2/3, RM +, normal
- Natrium diclofenac 2x50 mg
retina
- Ranitidin 2x150mg IV
Left eye
- CaCo3 1x500 tab PO
Covered by gauze
- Folic acid 1x5 tab PO.
 Opthalmology
Opthalmology Department
Department
15
15 Sept
Sept 2021
2021
O: A:
Left eye -Post Transnasal endoscopic orbital
-Cb Subconj bleeding +, C decompression & medial wall orbit
clear, COE deep, trace cell, no reconstruction D-3 due to traumatic optic
flare neuropathy & orbital apex sindrome
-Visual Acuity: NLP, IOP 16 -Post repair of partial thickness palpebral
-Palpebrae: ptosis, edema of superior and inferior ruptured
superior and inferior palpebra P:
- Metyl prednisolone 4x 125 mg IV (for 5 days)
-Pupil: edema, spasm, multiple - cendo LFX 6x1 drop on left eye
prolene suture - Fenicol zalf 3x1 applic on left eye
- Clindamisin 2x300 mg PO
- Natrium diclofenac 2x50 mg
- Ranitidin 2x150mg IV
- CaCo3 1x500 tab PO
- Folic acid 1x5 tab PO.
ENT-Rhinology Follow Up 13-14th Sept
ENT-Rhinology Follow Up 13-14 th
Sept 2021
2021
))

S : Pain VAS 3, no blood stained

saliva, nasal congestion
O:
Left Nose : nasal pack attached 0/
2, active bleeding-
Throat: Symmetrical pharyngeal
arch, uvula in the middle, T1T1
tonsils, posterior wall hyperemic-,
no active bleeding nor clotting
ENT-Rhinology Follow Up (13-14th Sept
ENT-Rhinology Follow Up (13-14 th
Sept 2021)
2021)

P:
-Ampicilin sulbactam
A:
4x150 mg iv
-Post optic nerve
-Tranexamid acid 3x500
decompression per
mg
nasoendoscopy and
advanced FESS D-1 for - Plan for nasal pack
traumatic optic neuropathy removal on sept 15th 2021
at Rhinology division
-Post repair of partial
outpatient clinic
thickness palpebral superior
and inferior ruptured
 ENT-Rhinology Follow Up 15th Sept
ENT-Rhinology Follow Up 15 th
Sept 2021
2021

S : Pain VAS 2, no blood stained saliva

O:
Left Nose : Wide nasal cavity, maxillary ostium covered by prolapse periorbital tissue,
no structure of ethmoid sinus, medial wall of orbit reconstruction covered with fibrin,
sphenoid ostium opened, minimal clotting, no active bleeding
A:
-Post optic nerve decompression per nasoendoscopy and advanced FESS D-3 for
traumatic optic neuropathy
-Post repair of partial thickness palpebral superior and inferior ruptured
P
-NaCl 0,9% 1 spray every 2 hours from 6 am to 6 pm
-INCS 2x2 spray
-Tranexamid acid 3x500 mg
-Plan to discharge
-Control to ENT Rhinology division outpatient clinic on 29th Sept 2021
THANK YOU