CASE REPORT

BY :
ENDRO TANOYO FUAD ANSHORI YOHANES AGUNG P. YANUAR ADI KURNIA INDERA NOOR A. ABDUL SYUKUR

PATIENT IDENTITY

Name Age Sex Adress Occupation Last studied

: Mr. H : 60 years old : Male : Bayan, Purworejo : Farmer : SD

ANAMNESIS
Chief complaint : obstructed right and left nostril Present Ilnessess: Since 1 year before, this patient complains obstructed right and left nose. Obstructed nose is felt continually. Patient complained of frequent runny nose(+), yellow-green nasal mucus, the nose smells(+), especially on waking up. Patient frequent experienced colds when exposed to dust(+), sneezing(+), itching of the nose(+). Pain is felt on the nose, on the right cheek and left(+).

Patient also complained of frequent cough (+), feels a lot of mucus in the throat (+), and often swallow mucus. Patient has no complaints on the ear (-) & sore throat (-), fever (-) and a history of tooth extraction (-). History of treatment: patients always to seek health care if the patient has complaints like this, and experienced temporary improvement.

 Past Illnesses :
Denied history of trauma History of dust allergy (+) History of asthma denied History of itching in the skin denied Denied a history of hypertension and diabetes mellitus History denied bleeding nose

 Family History :
No family history of similar illness Dust allergy history denied History of asthma denied History of itching in the skin denied Denied a history of hypertension and diabetes mellitus

RESUME ANAMNESIS
Nasal obstruction (+) on the right & left nose Rhinorrhea (+) Pain on nose and around cheek (+) Sneezing (+) Itching on the nose (+) Smell from the nose (+) Dust allergic (+) Cough (+)

PEMERIKSAAN FISIK
Status Generalis : KU : Good, CM, adequate nutrition VS : BP : 130/90 mmHg P : 88/mnt RR : 24/mnt T : 36,7 C

 Ear
Kanan Kiri

Ear Examination: Auricle Normal CAE laceration(-), Cerumen(+)N, Oedema(-) Tymphanic Membrane redness(-), Normal

Nose
Kanan Kiri

Mass (+) mucopurulen Discharge (+)

Posterior Rhinoscopy : no Examination

Throat

Throat Examination: Mucosal layer normal, redness(-), Ulcer(-), Tonsils normal

DIAGNOSIS
Chronic Rhinosinusitis with Bilateral nasal polyp

Treatment
Ceftriaxone Metronidazole Dolak 3 x 30mg Metilprednisolone Aldisa 2 x 1 Natrium diklofenac

PLAN Ro SPN Allergic test Pro op Sinus : Polipectomy Anthrotomy Medial, Ethmoidectomy PROGNOSIS Dubia ad bonam

Anatomy

Paranasal Sinus Drainage

Vascularization and Innervation

Nasal Polyp

DEFINITION
Nasal polyps is the mass of benign / sessile stemmed from the nose-clear pale yellow, single or multiple, and stemmed from the mucoperiosteal tissue or mucoperichondrial and filled with edematous stroma and inflammatory cells (Bailey, 2004) Histologically, polyps are edematous nasal mucosa tissue (Brown, 1997) Nasal polyps that prolapse is part stemmed from the mucosa of the nose / paranasal sinuses, and is not a neoplasm (Bhargava, 2002)

 Mass intracelluler fluid accumuluation swell :

Vascular tissue Polysacharide deposite Sodium Absorption ion Cl -

 Nasal Polyp characterized by chronic eosinophils inflammation: eosinophil + mast cell+neutrophil cytokine & other mediators sodium Uptake polyp water retention

Etiologi (Scott Brown,1997)

Bernoulli phenomen Polysacharide change Vasomotor imbalance Infection Allergy

TIPE POLIP
Anthrochoanal maxilar anthrum choana sometimes up to nasopharynx - single - children and young adults - dumbell appearance Ethmoidal - multipel - bilateral - tend to protrude forward - any ages - grape like

Clinical Symptoms (Scott Brown,1997)

Nasal obstructionp main complaint Rhinorea, Sneezing Hyposmia/anosmia Post nasal drip Headache Epistaxis

Clinical Signs
Outer Nose : broad face, frog like Anterior Rhinoscopy : polyps appear smooth, pale colors like pearl, shiny, not painful to the touch(Bhargava, 2002)

Diagnosis
Major factor
Facial pain / pressure Nasal obstruction / blockage Nasal discharge / purulence / discolored postnasal drainage Hyposmia / anosmia Purulence in nasal cavity on examination Fever ( acute rhinosinusitis only)

Minor factor
Headache Fever (all nonacute ) Halitosis Fatigue Dental pain Cough Ear pain / pressure / fullness

DIAGNOSIS
GEJALA KLINIS : 1) Nasal congestion 2) Sneezing 3) Discharge 4) Expansion of the nose 5) anosmia 6) Snoring / breathing through the mouth 7) Dizziness, epiphora, PND rarely 8) Talk impaired (Bhargava, 2002)

PATHOGENESIS
Ciliary & epithelial damage Change of the host milieu. Bacterial become pathogenic Changes of the mucosal gas metabolism Change in the composition & pH of secretion

Inflammation of the lamina propria

Stagnation of secretion

Increased mucosal thickness Ostium Occlusion

Inhibition of ventilation & drainage

Radiology Examination
(Scott Brown 1997)

Ro SPN Head CT scan

Therapy
conservative - corticosteroid - Antihistamin - Antibiotic polipoid with suspected sinusitis - Decongestan Operation - Polypectomy - Sinuscopy - Caldwell-Luc - Ethmoidectomy

Thank You

POLIP NASI
Suatu pertumbuhan edematus dari mukosa saluran napas bagian atas dapat tumbuh dari semua bagian mukosa kavum nasi dari sinus ethmoidalis, cenderung multipel (Ballantyne, 1979)

Etiologi
ada 2 tipe 1. Simpel : gambaran oedem dan hipertropi sub mukosa stroma jaringan fibrosa dengan cairan serosa pada interseluler. Permukaan ditutupi epitel kolumner bersilia p epitel transisional dan skuamosa a. allergik : Sensitivitas inkomplet terhadap alergen mutipel, eosinofilia + plasma sel ada jumlah besar b. vasomotor: serupa dengan alergi, tidak ditemukan gejala alergi

c. Infeksi - akut

: bakteri atau virus : influensa, single, lembek, sedikit hemoragi

- kronik non spesifik : multipel - kronik spesifik : mudah pecah, strawbery d. Mixed infeksi alergi : infeksi sekunder pada alergi vasomotor 2. Neoplastik a. Benigna : neurofibroma, fibroma, glioma dsb b. Maligna : carsinomatous, sarkomatous, sakit, timbul pendarahan, fragil

Teori Pembentukan Polip

1. Teori Alergi Alergi & polip hidung p persamaan histologis terutama edema & eosinofilia dalam darah & sekret hidung 2. Teori Infeksi Inflamasi kronis p infeksi kuman 3. Teori Obstruksi Mekanik Obstruksi mekanik p deviasi septum, hiperplasi & hipertrofi konka inferior atau media p teori fenomena Bernoulli p peran penting pembentukan polip.

4. Teori Gangguan Saraf struktur polip tidak ada serabut-serabut saraf sensoris, vasomotor dan sekreto-motoris 5. Teori Supurasi Sinus polip hidung timbul akibat supurasi sinus 6. Teori Pembuluh Darah & Limfe polip timbul karena perubahan pembyuluh darah dalam mukosa hidung, serta infeksi yang berulang akan menyebabkan periflebitis & perilimfangitis

Proses pembentukan polip diduga melalui 2 tahap yaitu : 1. Tahap awal terjadi pertumbuhan mukosa berupa edem dan infiltrasi sel-sel radang seperti eosinofil dan neutrofil, yang disebabkan oleh alergi, infeksi, gangguan vasomotor & kombinasinnya 2. Tahap kedua mukosa yang udem tersebut akan menonjol ke kavum nasi karena pengaruh mekanis dari lingkungannya yaitu tekanan negatif.

Faktor penyebab Faktor pendukung (aspirin intolerance, infeksi, cystic fibrosis) (Ig E dependent reaction)

Nerve damage

Degranulasi mast sel

Denervasi vasomotor

Pelepasan histamin

Kenaikan permeabilitas vaskuler

Oedema

Polip Gambar 1. Etiopatogenesis Polip nasi (Mygind N, 1981)

Pembentukan Menurut Histologi

1. Polip Edematus Masa putih mengkilap, jernih, seperti buah anggur paling sering ditemukan. Mikroskopis tampak sedikit jaringan fibrous longgar terdapat pada ruangan yang penuh cairan edern 2. Polip Fibrous Masa putih keruh kurang mengkilap Mikroskopis jar. Fibrous lebih banyak daripada cairan edemnya. 3. Polip Vaskuler Masa kemerahan Mikroskopis jaringan dominan adanya jar. vaskuler disertai gambaran edema perivaskuler. Becker. Wet at. 1994 p Massa bertangkai atau tak bertungkai pada mukosa nasal atau sinus disebabkan oleh inflamasi.

Nasal Polyposis
Pathophysiology: The pathogenesis of nasal polyposis is unknown. Polyp development has been linked to chronic inflammation, autonomic nervous system dysfunction, and genetic predisposition. Most theories consider polyps to be the ultimate manifestation of chronic inflammation; therefore, conditions leading to chronic inflammation in the nasal cavity can lead to nasal polyps.

 Most studies suggest that polyps are associated more strongly with nonallergic disease than with allergic disease. Statistically, nasal polyps are more common in patients with nonallergic asthma (13%) than with allergic asthma (5%), and only 0.5% of 3000 atopic individuals have nasal polyps.