PATOLOGI KEPALA DAN ORGAN

INDERA

Dr. Resti Arania Sp.PA

 CURRICULUM VITAE
Nama : Dr. Resti Arania Sp.PA
Alamat : Perum. Bukit Kencana II blok MM09 Jl. P. Antasari , B. Lampung
Lahir : Jakarta, 2 Januari 1971
Pendidikan :
SD : Jakarta
SMP : SMPN 41 Jakarta
SMA : SMUN 28 Ragunan, Jakarta
S1 Kedokteran : FKUI, Jakarta, lulus 1995
Spesialis : Patologi Anatomi, FKUI, Jakarta, lulus 2009
Status : Menikah 2 anak (suami Ir. M. Syarifuddin)
Pekerjaan : 1995- 1999 : dokter PTT Muba, Sum Sel
2001 : PNS Sum Sel/ RS Kayu Agung, OKI
2004 : staf dokter umum SMF Kebidanan RSUD A. Moeloek, Lpg
2010 skr : Ka. Instalasi Lab. Patologi Anatomi RSUD A.
Moeloek
Praktek : Klinik & Lab PA Terdia Jl. Teuku Umar 106D, Tj. Karang (jam 15.00
18.00)
TELINGA
 TELINGA SKDI 2012
Otitis eksterna 4A
Otitis media akut 4A
Otitis media serosa 3A
Otitis media kronik 3A
Mastoiditis 3A
Miringitis bullosa 3A
Benda asing 3A
Perforasi membran timpani 3A
Otosklerosis 3A
 Anatomy and Physiology of the Ear

Divided into three anatomic parts

 TELINGA
FUNGSI pendengaran dan
keseimbangan.
Penyakit dan trauma gagal :
komunikasi
reaksi
keseimbangan
 Anatomy and Physiology of the Ear

Sound waves enter the

ear.
Travel to the tympanic
membrane.
Sound waves set up
vibration in the ossicles.
Vibrations transmit to the
cochlear duct.
At organ of Corti,
vibrations form impulses.
Travel to the brain via the
auditory nerve.
Normal Tympanic Membrane
Benda asing Impacted Cerumen
Biasanya pada anak Yellowish oily substance
found in outer ear
May present as:
Wet: a sticky brown color
Dry: a grayish flaky
substance
Can become impacted
External Auditory Canal
Foreign Body
Serumen prop/Impacted Cerumen
Risk factors include:
Abnormal ear canal shape
Diseases that cause increased cerumen
Improper use of cotton swabs
Symptoms may include:
Pressure or fullness in the ears
Ringing in the ears
Loss of hearing
 Labyrinthitis
Feeling of vertigo or loss of balance after an
ear infection or upper respiratory infection
Other symptoms may include:
Ringing in the ears
Loss of hearing
Vomiting
 Meniere Disease
Endolymphatic rupture creates increased
pressure in the cochlear duct
Damages organ of Corti and semicircular canal
Patients will likely experience:
Severe vertigo
Tinnitus
Sensorineuronal hearing loss
 Otitis Externa and Media
Infection resulting from bacterial growth in the
ear canal
Externa: outer ear
Media: middle ear

More common in children than adults

Signs and symptoms may include:

Edema and erythema
Diminished hearing acuity
Inflamed, bulging tympanic membrane
Otitis Externa
Acute Otitis Media
Serous Otitis Media
Hemotympanum
 Perforated Tympanic Membrane
Ruptured eardrum
Signs and symptoms include:
Loss of hearing
Blood drainage from the ear
Pain
Results from:
Foreign bodies in the ear
Pressure-related injuries
Diving-related injuries
Tympanic Membrane Perforation
Partial
Tympanic Membrane Perforation
Near Total
HIDUNG
 HIDUNG SKDI 2012
Furunkel pada hidung 4A
Rhinitis akut 4A
Rhinitis vasomotor 4A
Rhinitis alergika 4A
Rhinitis kronik 3A
Rhinitis medikamentosa 3A
Sinusitis 3A
 Anatomy and Physiology of the Nose

One of two primary

entry points for oxygen
Nasal septum:
separation between the
nostrils
Turbinates: layers of
bone within each nasal
chamber

Jones & Bartlett Learning

 Anatomy and Physiology of the Nose

Frontal sinuses are

above the nose.
Paranasal sinuses
Cavities within
several bones
associated with the
nose
 Epistaxis
Nosebleed
Anterior Posterior
Bleed fairly slowly More severe
Self-limiting and resolve Often cause blood to
quickly drain into the throat,
causing nausea and
vomiting
 Foreign Body
Most likely to be seen in pediatric patients
Pressure in the nasal passage can cause:
Tissue necrosis
Inflammation
Swelling
 Rhinitis
A nasal disorder that is most common during
childhood and adolescence
Generally caused by allergens
Signs and symptoms may include:
Nasal congestion
Itchy runny nose and eyes
Postnasal drip
 Sinusitis
Patients experience thick nasal
discharge, sinus and facial pressure,
headache, and fever.
Infection occurs when an obstruction
or growth blocks the paranasal sinus.
Nasal Polyp
Nasal polyp

CT Scan - Sinusitis
Allergic Rhinitis
Nasal Septal Perforation
Nasal Bone Fracture
Deformitas os nasal
Septal Hematoma
 Keganasan
Epitelial sinonasal/ karsinoma sinonasal

kelenjar/ adenokarsinoma
 The Neck
Anterior part of the
neck include:
Thyroid and cricoid
cartilage
Trachea
Muscles and nerves
Major blood vessels
 The Neck
Other structures: Lower cranial nerves
Vagus nerves Brachial plexus
Thoracic duct Soft tissue and fascia
Esophagus Various muscles
Thyroid and
parathyroid glands
Neck Masses
Internal View of the Oral Pit at 3.5 weeks
26-day embryo

Figure from Ten Cates Oral Histology, Ed., Antonio Nanci, 6th edition
 The pharyngeal apparatus

pouch
arch

groove/cleft

membrane

2 34
1

esophagus

Branchial arches form in the pharyngeal wall (which has lateral plate mesoderm sandwiched
between ectoderm and endoderm) as a result of lateral plate mesoderm proliferation and
subsequent migration by neural crest cells

The Developing Human by Moore & Persaud

 Anomalies of the head and neck

Congenital auricular sinuses and cysts

Branchial cysts

Branchial sinuses

Branchial fistula
Dermatlas

Branchial vestiges
(cartilaginous or bony remnants)

Branchial cysts

Dermatlas
 MATA SKDI 2012
1Benda asing di konjungtiva 4A
2 Konjungtivitis 4A
3 Pterigium 3A
4 Perdarahan subkonjungtiva 4A
5 Mata kering 4A
6 Blefaritis 4A
7 Hordeolum 4A
8 Chalazion 3A
9 Laserasi kelopak mata 3B
10 Trikiasis 4A
11 Keratitis 3A
12 Xerophtalmia 3A
 Anatomy and Physiology of the Eye

Oculomotor nerve
(third cranial nerve)
Cause motion of the
eyeballs and upper
eyelids
Optic nerve (second
cranial nerve)
Provides the sense of
vision
 Anatomy and Physiology of the Eye

Eye structures
Sclera (white of the
eye)
Cornea
Conjunctiva
Iris
Pupil
Lens
Retina
Converts light impulses to
nerve signals
 Anatomy and Physiology of the Eye

Anterior chamber:
between lens and
cornea
Filled with aqueous
humor
Posterior chamber:
between iris and lens
Filled with vitreous
humor
 Anatomy and Physiology of the Eye

Lacrimal apparatus
Secretes and drains
tears from the eye
Tears moisten the
conjunctivae.
 Conjunctivitis
Conjunctiva
becomes inflamed
and red.
Often starts in one
eye and spreads to
the other eye
Often caused by Courtesy of John T. Halgren, M.D., University of Nebraska Medical Center

bacteria, viruses,
allergies, or foreign
bodies
 Conjunctivitis
Assessment and management
Rule out life threats or dangers to the crew.
Perform general assessment of vision.
Viral conjunctivitis resolves on its own
Bacterial conjunctivitis: topical antibiotic
Allergic conjunctivitis: topical antihistamine
 konjungtivitis
Conjunctiva
Cornea
Iris / Ciliary body
Lens
Retina
Choroid
Histology:
Conjunctiva
Conjunctiva
Epithelium, goblet cells
Stroma
Topographic zones
Tarsal (palpebral)
Fornix
Bulbar
 Histology:
Cornea
Epithelium
Nonkeratinizing, 5-layered
Bowmans layer
Thick collagenous layer
underlying the basal cell
basement membrane
Stroma
Collagen lamellae secreted by
fibroblasts interrupted by large
artifactual clefts
Descemets membrane
Endothelium
Single layer of cuboidal cells
 Corneal Abrasion
Painful
Due to superficial trauma to the cornea
If discomfort does not resolve, patient should
be seen in the emergency department.
 Corneal Abrasion
Assessment and management
Symptoms include:
Pain
Sensitivity to light
Tearing
Lubrication can alleviate some pain.
Taping the eyelid closed can keep the eye from
drying out.
 Corneal Abrasion
Assessment and management (contd)
Invert the eyelids to expose the source.
Look for a foreign body in the eye.
A topical anesthetic may relieve symptoms.
If movement of the eye causes discomfort, cover
both eyes.
 Keratitis virus
Herpes simpleks
Inflammation of the Eyelid (Chalazion
and Hordeolum)
Oil glands and oil
ducts may become
blocked, causing:
Chalazion: swollen
bump or pustule on
the external eyelid

Francoise Sauze/Photo Researchers, Inc.

Hordeolum (stye):
red tender lump in
the eyelid or the lid
margin
Inflammation of the Eyelid (Chalazion
and Hordeolum)
Often painful
Hardeolum : radang akut kelopak mata
Kalazion : radang granulomatosa
(kronik) ada keterlibatan kelenjar
sebasea Meibom dan Zeis tersumbat
(kebocoran/ ekstravasasi lipid ke
stroma).
chalazion histopatologi
 hardeolum
hardeolum
 Glaucoma
Group of conditions that lead to increased
intraocular pressure
Usually treated with eye drops to reduce
ocular pressures
 Hyphema
Bleeding into the
anterior chamber of
the eye
Obscures vision
Blood clotting is a
concern.
Can cause a rise in
intraocular pressure
 Hyphema
Assessment and management
Pain and blurred vision is likely.
Blood may be visible.
If no contraindications, transport upright.
Other medications with antiplatelet effects should be
avoided.
An anxiolytic may facilitate transport.
 Iritis
Inflammation of the iris
Acute causes include:
Trauma
Irritants
Chronic causes include:
Autoimmune diseases Biophoto Associates/Photo Researchers, Inc.

Arthritis
Irritable bowel disease
Crohn disease
 Iritis
Assessment and management
Red area surrounding the iris, cloudy vision, or an
unusually shaped pupil
Focus on history.
Acute iritis may respond to topical corticosteroids.
Chronic iritis should be referred to a specialist.
 Papilledema
Swelling or inflammation of the optic nerve
Patients experience:
Headaches
Nausea
Temporary vision loss or narrowing vision fields
A graying in the field of vision
 Papilledema
Can be caused by: Other causes:
Abscess Meningitis
Tumor Fever
Inner ear infection Hypertensive crisis
Lung infection Chronic high blood
Dental infection pressure
Guillain-Barr syndrome
 Retinal Detachment and Defect
Potential result of blunt
eye trauma
Assessment and
management:
Generally painless
Produces:
Flashing lights
Specks
Floaters
Requires immediate
medical attention
 Cellulitis of the Orbit
Periorbital cellulitis Orbital cellulitis
Presents as a painful, red, Medical emergency
swollen eyelid Risk factors:
Risk factors: Sinusitis
Insect bites Tooth infections
Upper respiratory Ear infections
disorders Trauma
Trauma Sinus infections
 LAIN LAIN
Pterigium/Pinguecula : degenerasi/
fibrosis stroma konjungtiva, hub. Sinar
matahari/ solar elastosis
Fibroplasia retrolental (prematurity
retinopathy) : bayi prematur, high
oxigen therapy
Phtisis bulbi (end state) : trauma,
atrofik
 Jenis-Jenis Tumor pada Mata
1. Retinoblastoma
2. Tumor Palpebra
3. Tumor Orbita
4. Tumor Metastasis
 Retinoblastoma
Retinoblastoma merupakan tumor ganas utama intraokuler
yang ditemukan pada anak-anak, terutama pada anak usia
dibawah 5 tahun. Tumor berasal dari jaringan retina
embrional. Tumor ini bersifat herediter.(40%)
Gejala Klinis:
1. Leukokoria
2. Strabismus
3. Mundurnya visus sampai buta
4. Proptosis
5. Memberi kesan lebih besar dari mata yang lainnya
retinoblastoma
 Tumor Palpebra
Tumor palpebra merupakan tumor eksternal karena
menyerang bagian palpebra.
Gejala Klinis:
1. Karsinoma Sel Basal/ basalioma/ ulcus rodent:
keropeng pada palpebra
2. Karsinoma Sel Squamosa: adanya bercak putih kusam
pada daerah konjungtiva
3. Melanoma: tahi lalat
4. Adenokarsinoma: tumor kelenjar
BASALIOMA
 Tumor Orbita
Orbita merupakan rongga yang berisi bola mata dan
jaringan lunak.
Gejala Klinis:
1. Proptosis
2. Nyeri
3. Gangguan pergerakan mata
4. Turunnya penglihatan sampai buta
5. Penglihatan Ganda
6. Merah pada mata
 Tumor Metastis
Jenis tumor ini merupakan penyebaran dari
sel-sel tumor ganas dari bagian tubuh lain ke
organ mata.
Gejala Klinis:
1.Proptosis
2.Penglihatan terganggu
3.Peninggian tekanan bola mata
 Pemeriksaan Penunjang
1. Fundus Okuli/ oftalmoskop
2. X-Ray
3. biopsi (insisi, jarum/ sitologi)
4. USG
5. TUMOR MARKER (melanoma)
Nasopharyngeal Carcinoma

Dr. Resti Arania Sp.PA

 epidemiologi
Rare in the US, more common in Asia
High index of suspicion required for early
diagnosis
Nasopharyngeal malignancies
NPC/KNF (nasopharyngeal carcinoma)
Lymphoma
Salivary gland tumors
Sarcomas
 Anatomy
Anteriorly -- nasal cavity
Posteriorly -- skull base
and vertebral
bodies
Inferiorly -- oropharynx
and soft palate
Laterally --
Eustachian tubes and
tori
Fossa of Rosenmuller -
most common location
 Anatomy
Close association with skull base foramen
Mucosa
Epithelium - tissue of origin of NPC
Stratified squamous epithelium
Pseudostratified columnar epithelium
Salivary, Lymphoid structures
 Epidemiology
Chinese native > Chinese immigrant > North
American native
Both genetic and environmental factors
Genetic
HLA histocompatibility loci possible markers
 Epidemiology
Environmental
Viruses
EBV- well documented viral fingerprints in tumor cells
and also anti-EBV serologies with WHO type II and III
NPC
HPV - possible factor in WHO type I lesions
Nitrosamines - salted fish
Others - polycyclic hydrocarbons, chronic nasal
infection, poor hygiene, poor ventilation
 Classification
WHO classes
Based on light microscopy findings
Type I - SCCA (squamous cell carcinoma)
25 % of NPC
moderate to well differentiated cells similar to
other SCCA ( keratin, intercellular bridges)
 Classification
Type II - non-keratinizing carcinoma
12 % of NPC
variable differentiation of cells ( mature to
anaplastic)
minimal if any keratin production
may resemble transitional cell carcinoma of the
bladder
 Classification
Type III - undifferentiated carcinoma
60 % of NPC, majority of NPC in young
patients
Difficult to differentiate from lymphoma by light
microscopy requiring special stains & markers
Diverse group
Lymphoepitheliomas, spindle cell, clear cell and
anaplastic variants
 Classification
Differences between type I and
types II & III
5 year survival
Type I - 10% Types II, III - 50%
Long-term risk of recurrence for types II & III
Viral associations
Type I - HPV
Types II, III - EBV
 Etio-Patogenesis
NPC is the commonest epithelial cancer
in adults.
The detection of nuclear antigen
associated with Epstein-Barr virus
(EBNA) and viral DNA in NPC type 2
and 3, has revealed that EBV can infect
epithelial cells and is associated with
their transformation.
 The aetiology of NPC (particularly the
endemic form) seems to follow a multistep
process, in which EBV, ethnic
background, and environmental
carcinogens all seem to play an important
role.
In adults, other likely etiological factors
include genetic susceptibility,
consumption of food (in particular salted
fish) containing carcinogenic volatile
nitrosamines.
 CLINICAL COURSE

Unilateral hearing loss from a middle ear

effusion is the most common finding.
Another common presenting complaint is
a neck mass resulting from regional
spread.
Large or exophytic lesions may cause
nasal obstruction or epistaxis.
As the tumour enlarges, adjacent cranial
nerves may become involved.
 Clinical Presentation
Often subtle initial symptoms
unilateral
painless, slowly enlarging neck mass
Larger lesions
nasal obstruction, deafness
epistaxis
cranial nerve involvement (ptosis, diplopia, sulit
menelan)
 Clinical Presentation
Xerophthalmia - greater sup. petrosal n
Facial pain - Trigeminal n.
Diplopia - CN VI
Ophthalmoplegia - CN III, IV, and VI
cavernous sinus or superior orbital fissure
Horners syndrome - cervical sympathetics
CNs IX, X, XI, XII - extensive skull base
 Clinical Presentation
Nasopharyngeal examination
Fossa of Rosenmuller most common location
Variable appearance - exophytic, submucosal
NP may appear normal
Regional spread
Usually ipsilateral first but bilateral not uncommon
Distant spread - rare (<3%), lungs, liver, bones
 Radiological evaluation
Contrast CT with bone and soft tissue
windows
imaging tool of choice for NPC
MRI
soft tissue involvement, recurrences
CXR (chest x-ray)
Chest CT, bone scans
 Laboratory evaluation
Special diagnostic tests (for types II & III)
IgA antibodies for viral capsid antigen (VCA)
IgG antibodies for early antigen (EA)
Special prognostic test (for types II & III)
antibody-dependent cellular cytotoxicity (ADCC)
assay
higher titers indicate a better long-term prognosis
CBC, chemistry profile, LFTs
 Treatment
External beam radiation
Dose: 6500-7000 cGy
Primary, upper cervical nodes, pos. lower nodes
Consider 5000 cGy prophylactic tx of clinically
negative lower neck
Adjuvant brachytherapy
mainly for residual/recurrent disease
 Treatment
External beam radiation - complications
More severe when repeat treatments required
Include
xerostomia, tooth decay
ETD - early (SOM), later (patulous ET)
Endocrine disorders - hypopituitarism, hypothyroidism,
hypothalamic disfunction
Soft tissue fibrosis including trismus
Ophthalmologic problems
Skull base necrosis
 Treatment
Surgical management

Mainly diagnostic - Biopsy

consider clinic bx if cooperative patient
must obtain large biopsy
clinically normal NP
Surgical treatment
primary lesion
 Treatment
Surgical management
Primary lesion
consider for residual or recurrent disease
approaches
infratemporal fossa
transparotid temporal bone approach
transmaxillary
transmandibular
transpalatal
 Treatment
Surgical management

Regional disease
Neck dissection may offer improved
survival compared to repeat radiation
of the neck
Radiasi eksterna
 Treatment
Chemotherapy
Variety of agents
Chemotherapy + XRT - no proven long term
benefit
Mainly for palliation of distant disease
Immunotherapy
Future treatment??
Vaccine??
 Conclusion
Rare in North America, more common in
China
40% overall survival at 5 years
careful otologic, neurologic, cervical and NP
exams
Three WHO types - all from NP epithelium
Types II, III - better prognosis, EBV assoc.
Treatment is primarily radiasi