PRESENTASI 

KASUS
BANGSAL 2
28 NOVEMBER 
2017

Garnis Swanenghyun
IDENTITAS PASIEN

• Nama : An. IBP

• Tanggal Lahir : 23 Juni 2001
• Usia : 16 tahun
• Jenis Kelamin : Laki-Laki
• Alamat : Sukoharjo
• Pekerjaan : Pelajar
• Agama : Islam
• Masuk RS : 23 November 2017, via Poli THT
• Tanggal periksa : 24 November 2017
KELUHAN UTAMA

Bengkak di leher kanan sejak 2HSMRS

RIWAYAT PENYAKIT 
SEKARANG
– ± 2 HSMRS pasien merasakan bengkak pada leher kanan. Keluhan disertai nyeri
dan sakit bila membuka mulut serta nyeri bila menelan. Bengkak dirasa hanya
sebesar telur puyuh dan berwarna kemerahan. Keluhan demam dan kesulitan
bernafas disangkal. Beberapa hari sebelumnya, pasien mengatakan bahwa gigi
pasien sakit karena ada gigi yang berlubang. Pasien hanya meminum obat anti
nyeri yang dibeli di apotek.
RIWAYAT PENYAKIT 
SEKARANG
– HSMRS keluhan menetap. Bengkak dirasa semakin membesar dan terasa
semakin nyeri. Pasien masih tidak bisa makan. Keluhan demam dan kesulitan
bernafas disangkal. Pasien dibawa ke poli THT RSUD Ir. Soekarno Sukoharjo.
RIWAYAT PENYAKIT 
DAHULU
– Riwayat penyakit serupa (-)
– Riwayat penyakit gigi (karies gigi, dll) (+)
– Riwayat infeksi telinga (-)
– Riwayat infeksi saluran pernafasan atas (-)
– Riwayat hipertensi (-)
– Riwayat diabetes mellitus (-)
– Riwayat dislipidemia (-)
– Riwayat alergi (-)
RIWAYAT PENYAKIT 
KELUARGA
– Riwayat penyakit serupa (-)
– Riwayat hipertensi (-)
– Riwayat diabetes mellitus (-)
– Riwayat dislipidemia (-)
– Riwayat alergi (-)
KESAN UMUM

– Keadaan Umum : sedang

– Kesadaran : compos mentis, E4V5M6
– Nutrisi : kesan cukup
– Skala nyeri : 3-4
VITAL SIGN

– Tekanan Darah : 110/80 mmHg

– Nadi : 80 kali/menit
– Respirasi : 20 kali/menit
– Suhu : 37°C
PEMERIKSAAN FISIK

KEPALA LEHER
•Mata : pupil isokor Ø 3 mm/3mm
•RC +/+, RK +/+, CA -/-, SI -/-
–Mulut : caries (+) pada molar 2 kanan bawah
–Leher : oedem (+) hiperemis (-), teraba massa berfluktuasi (+) KGB tidak
membesar
PEMERIKSAAN FISIK

Telinga
Right Lef
Auricula normal normal
Plannum mastoideum normal normal
Gld. Lymphatica normal normal
Canalis auditorius externus Discharge (-) Discharge (-)

D S
Within Normal Limit
PEMERIKSAAN FISIK

Hidung
D S
Right Lef
Discharge Perdarahan (-) (-)
Hiperemis (-)
Cavum Nasi Hiperemis (-)
Clott (-)
Conchae Edema (-) Edema (-)

Septum Normal, deviasi (-) Normal, deviasi (-)

Tumor (-) (-)

PEMERIKSAAN FISIK

Oropharynx
Right Lef
Palatum Normal
Uvula Normal
Lingua normal
Palatine Tonsils T1 T1
Posterior wall normal
Dalam batas normal
PEMERIKSAAN FISIK

PULMO
DEPAN Kanan Kiri
Inspeksi Simetris (+), KG(-), jejas (-)
Palpasi FT ka=ki, krepitasi (-), pengembangan simetris
Perkusi Sonor (+) sonor (+)
Auskultasi Vesikular +/+, suara tambahan -/-

Belakang Kanan Kiri

Inspeksi Simetris (+), KG(-), jejas (-)
Ekspansi paru simetris, nyeri tekan (-),
Palpasi fremitus ka=ki simetris
Perkusi sonor (+) Sonor (+)
Auskultasi Vesikular +/+, suara tambahan -/-
PEMERIKSAAN FISIK

COR
Inspeksi IC tidak terlihat
Palpasi IC tidak teraba
Perkusi dbn
Auskultasi S1-2 reg murni, bising (-)

ABDOMEN
Inspeksi Distended (-), jejas (-)
Auskultasi Peristaltik (+) normal
Palpasi Defense muscular (-), NT (-)
Perkusi Timpani
PEMERIKSAAN FISIK

EKSTREMITAS

Edema (-), CRT <2 detik, akral Edema (-), CRT <2 detik, akral
hangat, nadi kuat hangat, nadi kuat

Edema (-), CRT <2 detik, akral Edema (-), CRT <2 detik, akral
hangat, nadi kuat hangat, nadi kuat
PEMERIKSAAN FISIK

TAMPAK DEPAN TAMPAK SAMPING

PEMERIKSAAN PENUNJANG

DARAH RUTIN 23-11-2017

Hasil Nilai rujukan Satuan

Hb 13.7 11.7-15.5 g/dL

Hct 40.8 35-47 %

Trombosit 294.000 154.000-386.000 Sel/mm3

Eritrosit 5.29 3.80-5.20 Sel/mm3

Leukosit 20.000 4.500-12.500 Sel/mm3

PEMERIKSAAN PENUNJANG

– Trabekulasi tulang
tampak baik
– Tampak kelengkungan
vertebra cervical
melurus
– Pedikel intact, DIV tak
menyempit
– Trachea ditengah, tak
terdeviasi
– Tak tampak
spur/osteofit di
corpus VC
PEMERIKSAAN PENUNJANG

X-Foto Vertebra Cervical, AP/Lat

Kesan:
– Gambaran paraspinal musculospasme
– Tak tampak kelainan trachea
DIAGNOSIS

• Abses Mandibula
TATALAKSANA

– Diet lunak
– IVFD RL 20 tpm
– Inj. Ceftazidin 1gr/12jam
– Inj. Metronidazole 500mg/12jam
– Inj. Metilprednisolon 125mg/12jam
– Inj. Ketorolac 30mg/8jam
– Inj. Ranitidin 50mg/12jam
ABSES MANDIBULA
DEFINISI

– Abses mandibula merupakan salah satu infeksi pada leher bagian

dalam (Deep Neck Infection), disertai dengan pembentukan pus
pada daerah submandibula.
– Umumnya sumber infeksi pada ruang tersebut berasal dari proses
infeksi dari gigi, dasar mulut, faring, kelenjar limfe submandibula.
ETIOLOGI

– Kuman penyebab biasanya campuran kuman aerob dan anaerob

– Kuman aerob yang paling sering ditemukan adalah Streptococcus sp,
Staphylococcus sp, Neisseria sp, Klebsiella sp, Haemophillus sp
– Sedangkan kuman anaerob tersering adalah Bacteroides melaninogenesis,
Eubacterium Peptostreptococcus
PATOFISIOLOGI

– Bakteri masuk ke dalam jaringan yang sehat, terjadi infeksi. Sebagian sel mati
dan hancur meninggalkan rongga yang berisi jaringan dan sel-sel yang terinfeksi.
– Sel-sel darah putih melawan infeksi, bergerak ke dalam rongga tersebut, setelah
menelan bakteri, sel darah putih mati dn membentuk nanah yangg mengisi
rongga.
– Akibat penimbunan nanah, maka jaringan disekitar akan terdorong jaringan dan
tumbuh di sekeliling abses dan menjadi dinding pembatas.
SIGN AND SYMPTOMS

Signs of Deep Neck Infections Signs of an Impending Airway Disaster

– Swelling below the inferior border of the – Stridor (a raspy noise while breathing)
mandible
– Tracheal deviation
– Swelling of the floor of the mouth
– Inability to tolerate secretions
– Difficulty swallowing
– Swollen tongue
– Difficulty talking
– Pain while swallowing or pain out of portion – Raised tongue or floor of mouth
to swelling – Muffled voice (“hot potato” voice)
– Trismus out of proportion to swelling
THERAPY

First line: Penicilin VK 4x600mg and metronidazole 2x500mg for 7 days

– Or Clindamycin 4x300mg for 7 days for patients allergic to penicillin
In life-threatening infections: Penicillin G Na 4 million units every 6 hours
intravenously with Metronidazole 500mg every 12 hours intravenously
– Or Clindamycin 600mg every 8 hours intravenously for patient allergic to
penicillin
ANGINA LUDWIG
DEFINISI

– Ludwig’s Angina refers to inflammation, cellulitis, or an abscess, generally of

dental origin, that involves the sublingual, submental, and submandibular space.
– Patient present with pain, drooling, dysphagia, submandibular swelling, and
trismus.
– Penyebab angina ludovici adalah trauma bagian dalam mulut, infeksi lokal pada
mulut, karies gigi, terutama gigi molar dan premolar, tonsillitis dan peritonsilitis,
trauma pada ekstraksi gigi, angina vincent, erysipelas wajah, otitis media dan
eksterna serta ulkus pada bibir dan hidung. Jika infeksi berasal dari gigi, organism
pembentuk gas tipe anaerob sangat dominan. Jika infeksi bukan berasal dari gigi,
biasanya disebabkan oleh streptokokus
– Tanda-tanda dan gejala ludwig’s angina adalah selulitis, nyeri tenggorok dan
leher, disertai selulitis yang berkembang pesat atau pembengkakan di daerah
submandibula, yang tampak hiperemis dan keras pada perabaan. Demam, sakit
gigi, malaise, disfagia dan napas berbau trismus, merupakan gejala yang umum.
Peradangan ruang ini menyebabkan kekerasan yang berlebihan pada jaringan
dasar mulut dan mendororng lidah ke atas dan belakang dengan demikian
dapat menyebabkan obstruksi jalan napas secara potensial
TERAPY

– Securing an airway is the initial objective: doing tracheostomy

– One should have a low threshold for doing an awake tracheostomy under local
anaesthesia to secure the airway before inducing anaesthesia. Transoral
intubation may be hazardous and is often unsuccessful. Fibreoptic intubation
requires skill and experience and may cause nasal/nasopharyngeal bleeding
– Nebulised adrenaline (1ml 1:1000 adrenaline diluted to 5ml with 0.9% saline)
and intravenous dexamethasone (controversial) has been suggested to create
more controlled conditions for flexible nasotracheal intubation. It is important to
note that after incision and drainage, there is often even more swelling which
may compromise the airway on day 1-2 after the surgery pharyngeal bleeding
TERAPY

– Early aggressive empiric intravenous antibiotic therapy targeting gram-positive and

anaerobic organisms should be employed.
– Incision and drainage: Ludwig’s angina starts as a rapidly spreading cellulitis without
lymphatic involvement and generally without abscess formation. There is absolute
consensus that drainage is indicated when there is a suppurative infection and/ or
radiological evidence of a fluid collection or air in the soft tissues.
TERAPY

– However one of the main controversies in management of Ludwig’s angina is whether

surgical drainage is always indicated in the earlier stages of the infection. In the
authors’ experience, a more aggressive surgical approach should be followed in all
cases i.e. early tracheostomy and empiric placement of drains in the affected spaces
after removal of the underlying cause. It must however be noted that this combined
medical and surgical protocol is dictated by surgical/anaesthesia/intensive care
logistical problems often experienced in developing world practice.
– Drainage may be intraoral and/or external, depending on the spaces involved. The
submandibular spaces are drained externally. If sepsis extends both above and below
the mylohyoid muscle, through-andthrough drains extending between the oral cavity
and the skin of the neck may be inserted.
– Computed tomography (CT) scans give precise anatomical information without field-of-view limitations14.
Thus, they show in more detail the deep and often multiple cervicofacial spaces involved in a complex
infection. Mediastinal and intracranial involvement can also be shown clearly on CT scans. Abscess formation
can be differentiated from cellulitis when intravenous contrast is administered14. However, there are
drawbacks of CT imaging including artefacts caused by amalgam fillings, radiation exposure and adverse
reaction to intravenous contrast. Magnetic resonance imaging (MRI) produces better soft tissue detail then
CT. In 2001, Munoz et al. compared MRI versus CT in the initial evaluation of acute infections involving the
neck in 47 patients. They found MRI superior when looking at lesion conspicuity, number of spaces involved,
extension and source of infection. In complex cases, MRI with gadolinium contrast can be used to assess
epidural space involvement and infection extending to the skull base16. However, MRI remains expensive
and is not easily available in the UK, particularly on an emergency basis. It can be difficult for claustrophobic
or anxious patients to tolerate, which has implications where timely treatment influences their recovery. Ariji
et al. found that CT and MRI could both clearly demonstrate the different pathways of odontogenic infection
through the neck17.
– A dental panoramic tomogram (DPT) is the plain radiograph of choice as it can identify the source
of infection and show the position of a tooth in relation to surrounding structures. It also shows
the general condition of the patient’s dentition and can be taken despite trismus15. A DPT will
only provide an image in two dimensions and does not show soft tissue swelling or fluid
collection. Ultrasonography is rapidly becoming the imaging modality of choice for neck space
infections. It is a non-invasive technique useful in showing superficial soft tissue oedema and
abscess formation. It is the best way to differentiate an abscesses from cellulitis14,16. Ultrasound
(US)-guided needle aspiration can be used to drain small, uncomplicated collections. Although
quick and well-tolerated, US scans are limited by depth of the sound-wave penetration and bony
anatomy14. Bassiony et al. imaged 42 fascial spaces in 16 patients with cervicofacial infection. Of
those, US imaging showed the same 32 spaces, but could not detect involvement of masticator,
parapharyngeal or lingual spaces. Lingual space involvement can be difficult to image as the ul
– Ultrasonography is useful to evaluate the initial superficial lesion that may be
amenable to imageguided aspiration. If deep fascial spaces are involved, MRI
should be or intraspinal involvement is suspected. However, due to ease of
access in a time-constrained situation, a CT is generally sufficient to assess
odontogenic infection involving the neck.considered, especially if intracranial