Case Report

Day/Date : Friday/October 15th 2021

Doctors on duty : Wulan/Bobby-Rini-Mizwar
Consultant :Bestari Jaka Budiman, MD,ORL-HNS(C), FICS

Department of Otorhinolaryngology, Head and Neck Surgery

Faculty of Medicine Andalas University/Dr. M. Djamil Hospital
Padang
 Identity of Patient
Male, 68 years old

Chief Complaint

Difficulty in breathing since a day before admission

 Medical History
Previously, two weeks ago patient felt something
stuck at the throat after ate fish. Four days later
patient felt pain in swallowing but didn’t took
medication. Ten days ago, patient felt difficulty in
swallowing, then patient was brought to private
hospital and hospitalized by ENT doctor for 4 days
and nasogastric tube was installed. Patient then
referred to outpatient clinic at private hospital in
Padang for got examination using fiberoptic
laryngoscopy but rejected
 Medical History
Four days ago, there was swollen at the neck and
getting bigger since 2 days before admission. And
patient felt difficulty on breathing since a day before
admission then patient was brought to emergency
room Dr. M.Djamil Hospital Padang
There was pain and difficulty moving the neck since 4
days ago
There were no pain and difficulty in opening the
mouth
There was hoarseness since a week ago
 Medical History
There were drooling and saliva mixed blood since 2
days ago
There was salty taste at the mouth since 2 days ago
There was no muffled voice
There was chest pain since a day before admission
intermittently
There were no history of diabetes mellitus and
hypertension
There was no history of trauma at neck
There was no history of toothache
There was no fever
 General Examination
General condition was moderately ill, composmentis
cooperative

BP : 131/80 mmHg
PR : 97x/min
RR : 25x/min
T : 36,4⁰C
SpO2 : 94%
 General Examination
Thorax
Inspection : symmetric movement, retraction (-),
hyperemic (+) at supraclavicula level
Palpation : crepitation (-), tenderness (+)
Auscultation : stridor inspiration (+), stridor expiration (-),
wheezing (-/-), ronchi (-/-)
 ENT Examination
Ear
Right :
Ear canal was wide, tympanic membrane was intact,
cone of light (+)

Left :
Ear canal was wide, tympanic membrane was intact,
cone of light (+)
 ENT Examination
Nose
Right Nasal Cavity
NGT was installed

Left Nasal Cavity

Nasal cavity was wide, inferior and middle turbinate
were eutrophy, septal deviation (-), discharge (-)
 ENT Examination
Throat
Pharyngeal arch was symmetric, uvula in the
midline, tonsil T1-T1 not hyperemic, posterior
pharyngeal wall was not hyperemic, there were no
prominence at posterior and lateral pharyngeal wall

Indirect Laryngoscopy
Epiglottic was edema, arytenoid couldn’t be
evaluated, vocal folds and ventricular band
movement couldn’t be evaluated, pyriform sinus
standing secretion (+/+) pus mixed blood
 ENT Examination
Neck region
Edema (+), hyperemic (+),
fluctuative (+), tenderness
(+), crepitation (-)
Regio submandibulanya mana
Aspiration (Neck Region)

Aspiration : pus mixed blood (+)

Pictures of Patient
 Laboratory Findings
Hb : 12.7 gr/dl SGOT : 44 U/L
Ht : 40% SGPT : 46 U/L
Leucocyte: 16.4700 /mm3 Ureum : 18 mg/dL
Trombo : 406000 /mm3 Creatine : 1.1mg/dL
Diff.count : 1/4/55/31/9 % RBG : 109 mg/dL
PT : 11.4” Na : 145 mmol/L
APTT : 23.8” K : 3,7 mmol/L
Cl : 111 mmol/L

Result : Leucocytosis, SGOT/SGPT decrease

 Thorax X-ray

Result :
 Cervical AP X-ray

Result :
CT-Scan Neck
CT-Scan Neck
CT-Scan Neck
 CT-Scan Neck

Result :
 Working Diagnosis
Working • Impending upper airway obstruction
Diagnosis cause by epiglottic edema
• Paratracheal abscess
• Suspected mediastinitis
ICD 10 • Upper airway obstruction (J98.8)
• Other abscess of pharynx (J39.1)
• Disease of mediastinum, not elsewhere
classified (J98.5)
 Management
Informed consent to perform incision and exploration
abscess and tracheostomy under general anesthesia 
patient and family were agreed
Consult to Surgery Department
Consult to Anesthesiology Department
Consult to Internal Medicine Department
Consult to Larynx pharynx subdivision
 Management
Therapy:
- O2 2 liters/minutes
- IVFD RL 1 kolf/8 hours
- Inj. Dexamethasone 3x5mg (IV)
- Inj. Ceftriaxone 2x2gr (IV)
- Metronidazole infuse 3x500mg (IV)
- Paracetamol 3x500mg (orally)
- Povidone iodine gargle 3x1cup
 Surgical Department

A: Suspected mediastinitis + Paratracheal abscess

P: Agree to joint surgery if between operations there was
findings up to the mediastinum
 Internal Medicine Department
A: Paratracheal abscess + Hypertension + Liver function
disorders

P: Risk for operation :

- Metabolic : Mild to moderate risk
- Pulmonary : Mild to moderate risk
- Haemostatic : stable
- Cardiovascular : low risk
Therapy : - Amlodipine 1x10mg (orally)
- UDCA 3x1 (orally)
Operating Video
 Operating Report
Patient was lying down on the operating table under
general anesthesia
Aseptic and antiseptic procedure
Performed lidocaine 2% infiltration at the front neck
Performed vertical incision 1-2 cm length two fingers
above sternal notch using blade no. 15  pus (+)
Opened layer by layer using clamp until trachea was
seen, while suction the pus
 Operating Report
Performed needle aspiration, air bubble (+), infiltrate
with sulfas atropin
Performed U shape inverted incision on trachea
Inserted tracheostomy tube number 7, filled cuff with
10 cc air, air passage was good, then fixated
Operation finished
 Post Operative Management
Trendelenburg position
Redressing 2x/day
Therapy:
- IVFD RL 1 kolf/8 hours
- Inj. Dexamethasone 3x5mg (IV)
- Inj. Ceftriaxone 2x2gr (IV)
- Metronidazole 3x500mg (IV)
- Paracetamol 3x500mg (orally)
- Povidone iodine gargle 3x1cup
THANK YOU
Followup pasien