Otitis 3: Eksterna - Patofisiology

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.

Histopatology
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
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.

PROGNOSIS
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).

CONCLUSION
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

Management
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

DIAGNOSIS
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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Peritonsiler abscess (PTA / Quinsy) 5

Peritonsiler abscess is an infection that started from the outer surface that extends into the inner layer of soft tissue. Exactly pathophysiology of PTA is unknown. However, several theories attempt to explain the mechanism of the PTA, and the theory was widely accepted that the occurrence of an abscess peritonsiler tonsil inflammation spreading from there. Abscess formed between tonsila Palatina and the capsule, usually in the superior region. It is then believed that the abscesses originated from an acute episode include tonsilits growing soft tissue around the area (Mehta, 2007). Other Mecanisme happened is the emergence of necrosis and pus in the capsular area, which then clog the Weber glands, minor salivary glands found in the living and working peritonsiler help clean up debris from the tonsils, resulting in secretions and forming abscesses (Gosselin, 2008).
Superior and lateral regions tonsilaris fossa is loose connective tissue, the infiltration into the potential supurasi posters peritonsil occupy this area, so look swollen palate molle. In the early stage (stage infiltrates), in addition to swelling, the surface looks hiperemis. If the process continues, the area is more soft and yellowish color. Tonsils pushed to the middle, front and bottom, and swollen uvula pushed to the contralateral side. If the process continues, inflammation of the surrounding tissue will cause irritation of the m. Pterigoid internal, resulting in trismus. Abscesses may rupture spontaneously, may occur to the pulmonary aspiration (Fachruddin, 2002).

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Peritonsiler abscess (PTA / Quinsy) 4

Some microorganisms that can cause acute or chronic tonsillitis can also be a PTA-causing organisms. Aetiology peritonsiler abscess most frequently encountered is a species of aerobic and anaerobic gram-positive are usually found in the culture, usually bacterial beta-hemolytic Streptococcus group A. The next most common is from Staphilokokus groups, pneumococcal, and Haemophilus. And other microorganisms that can be found in the culture including Laktobasillus, groups such as filamentosa shaped Actinomyces sp., Mikrokokus, Neisseria sp., Diphtheria bacteria, Bacteroides sp., And some bacteria other non-sporulation (Gosselin, 2008). Sometimes the infection continues to be tonsila cellulitis difusa of the palate extends tonsila mole. Continuation of this process causes abscesses peritonsilaris. These disorders can occur quickly, with the beginning of tonsillitis, or the end of the course of the disease of acute tonsillitis. This can happen even if given penicillin. Usually unilateral and more frequently in children older and younger adults (Adams, 1997).

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Peritonsiler abscess (PTA / Quinsy) 3

Pharynx is divided into nasopharynx, orofaring and laringofaring. Nasopharynx is part of the pharynx that lies above pallatum molle, which is part orofaring located between palate molle and hyoid bone, while laringofaring part of the pharynx which extends from the hyoid bone to the lower boundary of cartilage crikoid (Ballenger, 1997). Orofaring open to the oral cavity in the anterior pharyngeal pillars. Pallatum molle (vellum palati) consists of muscle fibers are supported by fibrous tissue which is covered by mucosa. Protrusion on the median dividing it into two parts. Forms such as cones, located disentral called uvula. Two columns made up of tonsils tonsilar Palatina anterior and posterior. Glossoplatina and pharyngopalatina muscle is the largest muscle that make up the pillars of the anterior and posterior columns. Tonsils located between the basin palatoglossal and palatopharyngeal (Steyer, 2007).
Plika triangularis (tonsilaris) is a thin fold of mucosa, which covered the anterior pillar and some and some anterior surface of the tonsils. Plika semilunaris (supratonsil) is the upper folds of the mucosa which unites the two pillars. Supra tonsil fossa is the size of the gap varies over the tonsils, located between the anterior and posterior pillars. Tonsil consists of a protrusion of the circular or circular like cripte containing lymphoid tissue and surrounding connective tissue there. Amid the estuary there cripta mucous glands (Ballenger, 1997).
Tonsils and adenoid are the most important part of the Waldeyer ring lymphoid tissue surrounding the pharynx. Tonsils are located in the sinuses tonsilaris between the anterior and posterior pillars faussium. Faussium tonsils are one on each side is orofaring lymphoid tissue that is wrapped by a clear fibrous capsule. The inner surface of the membrane covered by stratified squamous epithelium which is attached. This epithelium extends into the open surface kripta tonsils. Kripta numbered 8-20 on the tonsils, usually tubular and is almost always extends from the tonsils to kekapsul the outer surface of the tonsils. The bound m.konstriktor faringeus superior, so depressed every time swallowing. m. palatoglusus and m. palatofaring also pressing the tonsils.
During the embryonic period, tonsils pharyngeal pouch formed from the second sebegai endodermal bud from the cell. Shortly after birth, tonsils are irregular and grow until it reaches the size and shape, depending on the number of network limphoid (Steyer, 2007).
Structure around tonsilla Palatina (Jevuska, 2007):
1. Anterior
In the anterior part is tonsilla Palatina palatoglossus Arcus, can extend for a short distance below it.
2. Posterior
There posteriorly palatopharyngeus Arcus.
3. Superior
In the superior near palate molle. Here tonsilla joined the lymphoid tissue on the lower surface of palate molle.
4. Inferior
In a third of the posterior inferior tongue. Here, together with tonsilla Palatina tonsilla lingualis.
5. Medial
In the medial part of the oropharynx space.
6. Lateral
There lateral capsula separated from the superior m.constristor pharyngis by loose areolar tissue. V. Palatina externa walked down from the palate molle in this loose connective tissue, to join the plexus venosus pharyngeus. Lateral to the superior pharynges there m.constrictor m. styloglossus and a.facialis arch. A. The internal carotid is located 2.5 cm behind and lateral tonsilla.
Palatina Tonsilla get vascularisasi from: tonsillaris ramus which is a branch of the facialis artery; the branches of a. Lingualis; a. Palatina ascendens; a. Pharyngea ascendens. While innervasinya, obtained from N. Palatinus Glossopharyngeus and minor nerve. Lymph vessels in the nl. Cervicales profundi. The most important node in this group are jugulodigastricus node, which lies below and belakangangulus mandibulae.

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Peritonsiler abscess (PTA / Quinsy) 2

Peritonsiler abscess (PTA) is the infectious disease most often occurs in the head and neck. A combination of aerobic and anaerobic bacteria in the peritonsilar area. Which could potentially place the abscess is a pillar area tonsils anteroposterior, inferior Piriform fossa, and superior palate (Mehta, 2007).
According to Gosselin (2008), peritonsiler abscess (PTA) is a pile of pus that is localized on the peritonsiler network formed as a continuation of supuratif tonsillitis. The alternative explanation that the PTA is an abscess that is formed from a group of salivary gland in supratonsiler fossa, known as the Weber glands. Because composed of loose connective tissue, severe infections in these areas can quickly lead to purulent material.
Peritonsil abscess formed due to the spread of infectious bacterial organisms to one's throat loose aereolar room around the pharynx causing abscess formation, where the infection has penetrated tonsil capsule but remains within the limits of pharyngeal constrictor muscle.

Epidemiology
Peritonsiler abscesses can occur at the age of 10-60 years, but most often occurs at the age of 20-40 years. In children is rare except in those who decreased immun system, but the infection can cause airway obstruction is significant in children (Mehta, 2007). These infections have the same proportion of men and women. Evidence indicates that chronic tonsillitis or multiple experiments using oral antibiotics for acute tonsillitis predispose people to develop peritonsiler abscess. In America sometimes incident -
sometimes approximately 30 cases per 100,000 people per year, are considered almost 45,000 cases each year (Gosselin, 2008).

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