REFLEKSI KASUSOTOMYCOSIS

Reza Syahputra

Kasus

IdentitasNama: Bapak SUmur: 67 tahunAlamat: Sumpium RT 005/RW003

KU: Gatal pada telinga kanan sejak 2 minggu yang lalu

Riwayat Penyakit SekarangGeneral Telinga Hidung Tenggorokan

Panas (-), Lelah (-),

Penurunan pendengaran (-), Cairan (-), Gatal AD (+)Nyeri (-)Telinga kanan mumpet (+)

Epistaxis (-), Pilek (+), Mumpet (-)

Batuk (+), Nyeri (-)Odynophagia (-), Dysphagia (-)

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

Riwayat penyakit dahulu

Riwayat DM (-), HTN (-), Merokok (+) Gizi bagus

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.

Diagnosis differensial

Otomycosis Chronic otitis externa Cerumen prop Otitis media

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 (-)

Pemeriksaan OtoscopeD S

PerforasiCentral

Debris putih

Pemeriksaan Rhinoskopi anterior

Pemeriksaan Oropharyng

T1T1

Pemeriksaan Garpu tala

Rinne: AD (+) AS (+)

Weber: Tidak ada lateralisasi Schwabach: AD memendek

AS memendek

Diagnosis Kerja

Otomycosis canalis auditorius externus dextra disertai otitis media supuratif kronis inaktif

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

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

Terima kasih

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

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)

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

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)

DONT APPLY OIL

Unless indicated for example to soften cerumen in action of aural toilet. Disturb the lipid acid environment of CAE

Apopilosebaceous unit

Apocrine Hair follicle Sebaceaous gland

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.

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

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

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.

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

Otitis externa

Diffuse Furunculosis Chronic Maligna (necrotizing) Otomycosis Eczematous

Pemeriksaan KOH?

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.

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

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)

Terima kasih

Pemeriksaan Otoscope