Otitis 3: Eksterna - Patofisiology

Trauma to the ear hole, the accumulation of keratin, or changes in pH can affect the occurrence of inflammation and infection. One study revealed that the bacteria have aerobe share of 91%, anaerobe four percent (4%), and also a mix of infection-four percent (4%). Organism is found most often among others have Pseudomonas aeruginosa (50%), Staphylococcus aureus (23%), anaerobe and gram negative organisms (12.5%), and yeast such as Aspergillus and Candida (12.5%). Increase of pH of pond water can be trusted to make infection may be more severe.

Predispositions Factors
Factors specific predisposes as follows:
a. Changes in skin pH is usually acid canalise be bass.
b. Changes in the environment, especially a combination of increased temperature and humidity.
c. A trauma is often mild or swim because of excessive ear cleaning.

Symptom and alert
Symptoms arising in otitis external diffuse, among others:
a. Redness on the outside of the ear (pinna) and ear hole that used to feel very sore.
b. Scaly skin that is good in and around the ear hole when flake.
c. Discharge from the ear and a little thin like pus.
d. Droop when the ear or jaw
e. At the time of ingest felt pain in the throat
f. Some people also lost their hearing

A diagnostic
a. Press painful tragus
b. Great pain
c. Most of the swelling wall canalise
d. Secret slightly
e. Hearing normal or slightly reduced
f. The absence of a fungus disease
g. There may be a painful adenopati regional press

Otitis external diffuse usually very painful
Stroma covering the bones in the third hole in the ear is very thin so that it allows only minimal swelling. So subjective interference experienced patients are often not comparable with that observed disease investigator.

Clinical manifestations
Eritema skin, secret a greenish skin edema and ear hole is a classical signs of otitis diffuse acute. Stench of secret not occur. Otitis external diffuses can be divided into 3 stages, namely:

a. Stadium "Pre inflammatory"
Stadium began with the loss of this layer of fat is normal and can be caused by the entry of water during the swim, wear clean cotton wool, and pry into your ear hole with the tools blunt. When the fat layer disappears at the time the weather is hot and humid air from the womb corneum increased stratum so that edema occurred intracellular. Edema is caused secret expenditure through orifisum apopilosebasea and layers of fat.
When exposed to hot and humid weather and long time the skin of the ear hole is not protected masers experience and reasonable ekfoliasi of cells epistle of the stratum corneum will not occur. This will cause a tickle, so try to minimize it with a paw or rub the cycle until there were: itching, Lucifer (itch scratch cycle). This will cause trauma to the stratum corneum, and there were predisposes for infection.

b. Stadium acute inflammation
Stadium this happens in 3 levels, namely: light, medium and heavy.
1. Lightweight
At the stadium, the patient experienced malaise when the light touches the tragus or concha moving. On examination the ear skin vagina will appear eritema and edema. When found a layer of clear secret not smell or accumulation of materials rekfoliasi or both. Ear drum looks less shiny.
2. Medium
Found itchiness and pain that are. Lumen ear hole partially closed by edema and exudate. Appear mass "debris" seropurulen cover the lumen and edema can also be seen there is currently little auricular, but does not have adenopati.
3. Heavy
On a more serious cases, patients complain of severe pain when chew and manipulated outside the ear. Although the helix does not seem involved, have found a clear edema periaurikuler and closing the lumen of the ear hole. Secret seropurulen a gray or green and exfoliated the visible mass in the lumen. Skin of the ear hole appear edema, and thick as can be seen papula, especially on top of the rear wall.
There is a decrease in the characteristics of the skin on the wall behind your ear hole (convex sagging), with a smooth and convex. This decrease extends membrane tympani. Otoskopi on using the enlargement, then can be seen papula white milk protruding from the surface and the surface, can also vesicle grayish organized by regions eritema.
Histopatologi showed the infected epidermis, and edema. Gram negative bacillus mainly pseudomonas species culture can almost 100% of your ear like this. When infected solved, it will appear papula small and pustule arising from secret purulent. In many circumstances this neutrofil complications can be obtained from the results secrete undelete it.

c. Stadium chronic infections (inflammation chronicles)
Besides the ear skin of leaves vary in degree, will thick (hiperkeratosis, acanthuses) and edema, which extends into the ear so that will orificium going refinement of the vagina and the ear hole of the ear, and abrasions on the laserasi lobe and conch. Dry mass and exfoliated often closed ear hole and can be found also secret colored gray or brown greenish and the smell fills recesses timpani.
Ear drum is not shiny and thick. Culture of the ear hole would result in the growth of gram negative bacillus (especially Proteus) and sometimes found fungi. Undelete will showed that the colored cells epistle basil and a very large amount.

In the acute otitis external diffuse the picture looks hiperkeratosis epidermis, parakeratosis, acanthuses, erosion, spingiosis, hiperplasia stratum corneum and stratum germinativum, edema, hiperemis, infiltration leukocyte, necrosis, necrosis focal followed in the dermis of healing fibroblast and apparatus gland decreased, the activities secretaries gland reduced.
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Peritonsiler abscess (PTA / Quinsy) 9

Complications that can arise in the abscess is peritonsiler (Fachruddin, 2002):
1. Spontaneous abscess rupture, causing hemorrhage, or pulmonary aspiration pyernia.
2. Spreading infection and abscess to the area, causing parafaring abscess parafaring.
3. If there is spreading to the region may lead to intracranial sinus thrombus Cavemosus, meningitis and brain abscess.
4. Nephritis, peritonitis, mediastinitis.

Most of the patients treated with antibiotics and adequate drainage in the area will return abscces recover within a few days. A small percentage of complaints indicates a further abscess, and it is necessary tonsilektomi action. In addition, if the patient reported back pain throat complaints that persist after incision and drainage is appropriate, action may be indicated tonsilektomi (Gosselin, 2008).

1. Peritonsiler abscess (PTA) is an infection that occurred in the area - the area around tonsila Palatina caused by aerobic and anaerobic bacteria.
2. Pathophysiology of PTA is certainly not known, but one thing is widely agreed that the occurrence of an abscess is associated with inflammation of the tonsils previous events.
3. Management is done in cases of abscess peritonsiler with adequate antibiotics when the stadium infiltrates. Arise when the abscess is incision and should be followed by drainage tonsilektomi action.
4. Complications that can arise due to inadequate handling and complete. As if there is an appropriate treatment, the prognosis would be good then.
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Peritonsiler abscess (PTA / Quinsy) 8

Handling peritonsiler abscess include hydration, pain, and antibiotics are effective to overcome Staphylococcus aureus and anaerobic bacteria. Fine needle aspiration is an effective treatment in 75% peritonsiler abscess in children and is recommended as primary therapy unless there is a history of recurrent tonsillitis, or abscess before it peritonsiler measure is immediately tonsilektomi (Bailey, 2005).
In the infiltration stage, given high doses of antibiotics, and symptomatic medications. Also need to gargle-gargle with warm water and cold compresses on the neck. Appropriate choice of antibiotic depends on the results of cultures of microorganisms in the needle aspiration. Penicillin is a "drug of choice" in peritonsilar abscesses and 98% effective in cases when the combicated with metronidazole. Dosage for penicillin in adults is 600 mg IV every 6 hours for 12-24 hours, and children 12500-25000 U / kg every 6 hours.
Initial dose metronidazole for adult maintenance dose of 15mg/kg and 6 hours after initial dose with intravenous 7.5 mg / kg for 1 hour was given for 6-8 hours and not exceed 4 grams / day (Fachruddin, 2002).
If formed abscess, requiring surgical drainage, either by needle aspiration technique or with incision and drainage techniques. Difficulties may arise in ascertaining whether associated with acute cellulitis or abscess formation which had actually been hesitant happen, needle size 17 can be inserted (after application with anesthetic spray) into the three locations that seemed most likely to produce pus aspirations. If pus is found by accident, this method may be sufficient for drainage followed by antibiotics. If the amount of pus were found, and insufficient drainage with this method, a further incision and drainage can be done (Adams, 1997).
Incision and drainage technique requires local anesthesia. First pharynx sprayed with topical anesthetic. Then 2 cc Xilocain with adrenaline 1 / 100, 000 injected. Knife tonsila no 12 or no 11 with tape to prevent deep penetration used to make the incision through the mucosa and submucosal polar near the tonsilaris fossa. Place of incision is the most prominent areas and soft or in the middle of the line joining the base of uvula with the last molar on the side of dull aching Hemostat is inserted through the incision and gently stretched. Tonsila suction should be provided to collect pus issued. In older children or young adults with severe trismus, surgical drainage for abscesses peritonsiler possible after the application of fluid cocaine 4% in the incision area and regional areas and the fossa ganglion sfenopalatina Nasalis. This is sometimes reduce pain and trismus. Children younger require general anesthesia. Tonsilektomi recommends immediate (tonsilektomi quinsy) feel that this is a safe procedure that helps perfect drainage of the abscess if tonsila removed (Adams, 1997).
When tonsilektomi performed with acts of abscesses drainage tonsilektomi it is called "a chaud", when tonsilektomi performed 3-4 days after darinase abscess tonsilektomi called "a tiede" and if tonsilektomi performed 4-6 weeks after the drainage of abscesses tonsilektomi called "a froid ". Tonsilektomi generally performed after the infection quiet, ie 2-3 weeks after the drainage of abscesses (Fachruddin, 2002).
If there is trismus, then to overcome the pain, given analgesia (local), with novocain injected xylocain or 1% of ganglion sfenopalatinum. This ganglion is located at the rear of the lateral from concha media. Sfenopalatinum ganglion nerve has branches Palatina anterior and posterior media that send branches to aferen nerve tonsil and palate molle on the tonsils. The most appropriate area for the incision got inervasi from Palatine branch m. trigeminal ganglion sfenopalatinum passing. Then the patients recommended for surgery tonsilektomi (Fachruddin, 2002).
Tonsilektomi an absolute indication to people who suffer from recurrent abscess or abscess peritonsilaris which extends to the surrounding tissue. Peritonsil abscess has a large tendency to relapse. Until now there has been no agreement on when tonsilektomi done peritonsil abscess. Some authors recommend 6-8 weeks later tonsilektomi considering the possibility of bleeding or sepsis, whereas others recommend immediate tonsilektomi (Adams, 1997).
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Peritonsiler abscess (PTA / Quinsy) 7

Information from patients is needed to make the diagnosis peritonsiler abscess. Patients had a history of pain in the esophagus is one that supports peritonsilar abscess. History of acute pharyngitis and tonsillitis accompanied by a lack of comfort in unilateral pharingeal (Steyer, 2007).
The diagnosis is rarely in doubt if the inspector saw a large swelling peritonsilaris, pushing past the midline uvula, with edema of the palate molle and protrusion of tissue from the midline. Palpation if possible to distinguish abscess from cellulitis (Adams, 1997).
In the investigation can be done:
1. Laboratory tests such as complete blood, electrolytes, and blood culture. Which is the "gold standard" for diagnosing abscess peritonsilar is by collecting pus from the abscess using a needle aspiration (Jevuska, 2007).
2. Radiological examination in anteroposterior position only shows "distortion" of the network but not useful for certain locations who abscess (Daley, 2007).
3. On CT scan can be seen on the tonsils hipodens areas that indicate the presence of fluid in the affected tonsils besides that it also can be seen in an asymmetrical enlargement of the tonsils. This examination can help to plan the operation (Daley, 2007).
4. Ultrasound, a technique is simple and noninvasive and can help in distinguishing between cellulitis and the beginning of the abscess. This examination can also determine a more focused selection before surgery and drainage for sure.
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Peritonsiler abscess (PTA / Quinsy) 6

Typically, complaints emerged in patients with a history of acute pharyngitis with acute tonsillitis (Gosselin, 2008). Classic symptoms begin 3-5 days time from onset of symptoms until the occurrence of abscesses around 2-8 days. Patients usually experience odinofagia complaints (pain swallowing) is good, so difficult to do tests because it is difficult to open his mouth and dehydration can also occur, vomiting (regurgitation), halitosis (foeter ex ore), "hot potato voice", a lot of saliva (hipersalivasi), nasal voice (rinolalia) and difficult to open the mouth (trismus), headache, weakness, fever, and swollen glands submandibula with tenderness. Patients also may experience pain when moving the neck (Fachruddin, 2002).
Some patients also have ipsilateral otalgia during swallowing. Trismus, which appears on all of the cases of several degrees of severity, suggesting an inflammation of the lateral wall of the pharynx and muscle pterigoid. Because inflammation of the muscles and cervical lymphadenopathy, sometimes patients also complain of neck pain and limited neck motion. The doctors should be more wary of the PTA, when seeing patients with symptoms of inflammation of the pharynx that persist despite antibiotics have been given adequate preparation (Gosselin, 2008).
On physical examination can be found in various conditions, from acute tonsillitis with unilateral asymmetric pharynx until the occurrence of dehydration and sepsis. Used by most patients experiencing tremendous pain. Oral examination will find eritem mucosa, palate, mole appeared swollen and prominent in the future, may be felt fluctuations. Uvula swollen and pushed to the contralateral side. Swollen tonsils, hiperemis, maybe a lot of detritus and pushed toward the center, front, and bottom (Fachruddin, 2002).
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