Refleksi Kasus Otomycosis
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REFLEKSI KASUSOTOMYCOSIS
Reza Syahputra
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Kasus
IdentitasNama: Bapak SUmur: 67 tahunAlamat: Sumpium RT 005/RW003
KU: Gatal pada telinga kanan sejak 2 minggu yang lalu
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Riwayat Penyakit SekarangGeneral Telinga Hidung Tenggorokan
Panas (-), Lelah (-),
Penurunan pendengaran (-), Cairan (-), Gatal AD (+)Nyeri (-)Telinga kanan mumpet (+)
Epistaxis (-), Pilek (+), Mumpet (-)
Batuk (+), Nyeri (-)Odynophagia (-), Dysphagia (-)
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Riwayat penyakit dahulu
Otitis media sinistra with perforation sebulan yang lalu di obati dengan antibiotic
Obat tetes vital pada CAE dextra dan korek dengan cotton bud
Riwayat allergy disangkal Riwayat operasi THT disangkal Riwayat trauma: Dulu ada bom meledak
deket AD
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Riwayat penyakit dahulu
Riwayat DM (-), HTN (-), Merokok (+) Gizi bagus
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Resume anamnesis
Bapak S datang dengan keluhan utama gatal-gatal pada telinga kanan disertai dengan rasa mumpet pada telinga kanan, pilek dan batuk. Riwayat DM, Alergi, trauma disangkal.
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Diagnosis differensial
Otomycosis Chronic otitis externa Cerumen prop Otitis media
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Pemeriksaan fisik
Keadaan umum: compos mentis, gizi baik
Telinga Inspeksi AD & AS: Bengkak(-), Trauma(-),
Hematom(-) mastoid bengkak (-) cairan (-)malformasi(-), Inflamasi (-), Mastoid bengkak (-)
Palpasi AD & AS: Nyeri tekan tragus(-) Nyeri tarik pinna(-), Nyeri tekan mastoid (-)
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Pemeriksaan OtoscopeD S
PerforasiCentral
Debris putih
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Pemeriksaan Rhinoskopi anterior
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Pemeriksaan Oropharyng
T1T1
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Pemeriksaan Garpu tala
Rinne: AD (+) AS (+)
Weber: Tidak ada lateralisasi Schwabach: AD memendek
AS memendek
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Diagnosis Kerja
Otomycosis canalis auditorius externus dextra disertai otitis media supuratif kronis inaktif
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Management
Aural toilet – menghilangkan debris dan kering
Krim miconazole di aplikasikan dengan cotton bud 3 kali sehari
Edukasi:Liang telinga di jaga tetap keringJangan sering korek2 dengan cotton budControl dalam seminggu
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Prognosis
Bonam = 90% response bagus terhadap krim miconazole (Alnaweish S et al, 2011)
Bisa kemungkinan untuk rekuren Bisa menyebabkan komplikasi bila tidak
di tangani: perforasi membran tympani, trombosis mikotik dan membran tympani menjadi avaskuler
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Terima kasih
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Pembahasan
Definisi otomycosis:“Otomycosis is a fungal infection of the skin of the external canal. Although fungi may be the primary pathogens, they are usually superimposed on chronic bacterial infection of the external canal or middle ear” – Bailey, 2006
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Pembahasan
Tiga komponen yang membantu pertumbuhan fungus yaitu: moisture, warmth and darkness
Penyebab paling sering ada lah oleh Aspergillus sp. dan Candida Albicans (dermatophytes – keratinase)
Bersifat non pathogen selama terdapat keseimbangan antara sistem pertahanan tubuh dengan berbagai organisme tersebut
4 macam pathogenesis: OCTA (Obstruksi, Cerumen, Trauma, Asam)
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Faktor predisposisi
- -Daerah tropis: CAE jadi lembab- - Diabetes Mellitus
- Pemakaian antibiotik/steriod jangka panjang- Gangguan imun berat- Wanita hamil : Kenaikan Estrogen dan Progesterone- Stress- Pemakaian tetesan kuping- Renang
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Kenapa tempat tropis?
Fungi are abundant in soil or sand that contains decomposing vegetable matter. This material is desiccated rapidly in tropical sun and blown in the wind as small dust particles. The airborne fungal spores are carried by water vapours, a fact that correlates the higher rates of infection with the monsoon, during which the relative humidity rises to 80%.
Then the environmental temperature exceeds 100° F and relative humidity exceeds 70%, the skin tends to become macerated predisposing this structure to infection (Satish H.S et al, 2013)
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DONT APPLY OIL
Unless indicated for example to soften cerumen in action of aural toilet. Disturb the lipid acid environment of CAE
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Apopilosebaceous unit
Apocrine Hair follicle Sebaceaous gland
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Cerumen
In health, the external auditory canal is well protected and self cleansing structure but several factors, either singly or in combination, predispose the ear canal to otitis externa. Absence of cerumen may lead to infection for two reasons.
1. Act of cerumen removal may be traumatic and lead to breaks in the fragile external auditory skin.
2. Cerumen serves as antimicrobial role through physically protecting the extemal auditory canal skin, establishing a low ph, inhospitable enviroment for pathogens, and producing antimicrobial compounds such as lyzosyme so that its absence leaves the canal vulnerable to infection. Cerumen maybe removed physically by cleaning or through syringing but water in the canal both macerates the underlying skin and raise the pH of the canal.
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Anatomy CAE
Superior adalah fossa cranialis media Posterior adalah tympanic bone, yang
memisahkan CAE dengan mastoid Anterior fossa glenoidalis of TMJ dan
parotid gland Inferior, Infratemporal fossa
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Pathophysiology
Obstruction of the drainage of glands into the follicular canal and subsequently into the external canal is the primary factor in the pathogenesis of external otitis.
This obstruction intracellular oedema Inflammatory response to increased
environmental temperature and humidity Uncomfortable sense of fullness which leads to
sense of itching . Scratch and this act disrupts surface epithehum
allowing contamination by surface microbes
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Pathophysiology
That sets the stage Usually sets for bacteria, so superimposed otitis
externa. Fungi sometimes set the stage Pre-inflammatory: the set stage Inflammatory: Lumen narrowing, serous secretion Chronic: Hyperkeratosis and acanthosis Many cases of otomycosis are actually mixed
bacterial and fungal infections , the most common bacterial isolates being Staphylococcus aureus , Psuedomonas species and Proteus species.
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Differensiasi antara OE
OED Otomycosis• Otalgia + fullness• Nyeri• Oedema (+)• CAE menyempit dan hyperemis
• TM Hyperemis
• Gatal• Debris (+)• Rasa penuh pada telinga•Otorrhea•Titik-titik Putih/Hitam/abu-abu
• TM Normal
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Otitis externa
Diffuse Furunculosis Chronic Maligna (necrotizing) Otomycosis Eczematous
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Antimycotic
Specific: Myconazole, clotrimazole, nystatin dll. Non-specific: solusi acidifying and dehydrating:
Asam boric 2%Aluminium sulfat-kalsium asetatGentian violet (di toleransi dengan baik oleh pasien dengan cavitas mastoid)Metacresyl acetate (pakai microscope)
Antibiotik dan steroid tidak dapat membantu menyembuhkan otomikosis tetapi akan meningkatkan pertumbuhan jamur khususnya Candida.
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Bagaimana dengan OMSK?
Tanpa tanda-tanda inflamasi (nyeri, discharge, bengkak mukosa)
Bila ada discharge wet/draining form acute
Prognosis: baik bila kering, bisa biasanya tanpa keluhan
Apakah perlu tympanoplasty? (Paper patch)Monitor untuk infeksi rekuren dan cholesteatoma Bahan dari fascia temporalis/perichondrium auricle/irisan tipis cartilago fibrin glue
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Otitis media
Acute/Recurrent Otitis media with effusion (OME)
acute(3w)/subacute(3m)/chronic ~ HL(Adults: SAS, Tumors)
Chronic Suppurative otitis media (CSOM/OMSK)
Chronic otitis media with cholesteatoma (primary acquired cholesteatoma/Secondary acquired)
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Terima kasih
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Pemeriksaan Otoscope