CHAPTER 2 LITERATURE REVIEW 2.

1 Anatomy of a Tonsil With adenoid tonsil, lingual tonsil, lateral pharyngeal bands, tubaria tonsils and lymphoid follicles forming network distribution ring of lymphoid tissue known as Waldeyer ring. Waldeyer's ring is a defense against infection. Tonsils and adenoids is the most important part of the Waldeyer ring. Adenoids will experience regression at the age puberitas.1, 5 Tonsils are masses of lymphoid tissue located in the tonsillar fossa on both corners oropharynx. Bounded by the anterior tonsillar pillar of anterior muscle formed palatoglossus, posteriorly by the posterior pillars formed palatofaringeus muscle, medial part by oropharyngeal space, bounded laterally by the superior pharyngeal constrictor muscle, the superior part by the soft palate, the inferior part by the lingual tonsil. Lateral surface of the tonsil is covered by a thin alveolar tissue of the fascia pharyngeal tonsil and the free surface is covered by epithelium that extends into the pockets of the tonsils form known as kripta.1, 5 Figure 1. Anatomy Tonsil7 Crypt of the tonsils ranged between 10-30 pieces. Tonsillar crypt epithelium is a thin layer that is semipermeable membrane, so epithelial antigen serves as access either of the respiratory and digestive to get into the tonsils. Swelling of the tonsils will result in crypt so that the longer interested in participating. Inflammation and epithelial crypt increasingly loose and obstruction due to chronic inflammation and crypt resulting debris stuck in the crypt antigen tonsil.1, 5 Tonsil got bleeding from branches of the external carotid artery, through its subsidiaries, namely: external maxillary artery (facial artery) with tonsilaris arterial branches and ascending palatine artery internal maxillary artery to the descending palatine artery branches the lingual artery with the dorsal lingual artery branches asenden1 pharyngeal artery, 5 Source of bleeding under the polar regions tonsil: Anterior: the dorsal lingual artery Posterior: ascending palatine artery Among them: arteries tonsilaris1, 5 Polar region above the source of bleeding tonsils: ascending pharyngeal artery desenden1 palatine artery, 5 Figure 2. Bleeding Tonsil1 Tonsilaris artery runs up on the outside of the superior constrictor muscle and gives branches to the tonsils and soft palate. Ascending palatine artery, sending branches through the posterior pharyngeal constrictor muscle to the tonsils. Ascending pharyngeal artery also gives branches to the tonsil through the outside of the superior pharyngeal constrictor muscle. Dorsal lingual artery up to the base of the tongue and sends branches

to the tonsil, cords anterior and posterior cords. Or a descending palatine artery. gives the posterior palatine tonsil bleeding and soft palate from above and forming an anastomosis with a. ascending palatine. Veins form a plexus of tonsil join plexus of faring.1, 5.12 Lymph flow from tonsil area flows into a series of deep cervical lymph nodes (deep jugular nodes) under the superior portion of sternocleidomastoid muscle. The stream next to the nodes and the thoracic duct ends toward torasikus. Tonsils have only efferent lymph vessels and do not have afferent lymph vessels. Innervation of the upper tonsil gets the sensation of nerve fibers to V through the ganglion sfenopalatina and bottom of the nervous glosofaringeus.1, 5 2.2 Histology of Tonsils Microscopic tonsil has three components, namely connective tissue, interfolikuler network, network germinativum. A trabecular connective tissue that serves as an advocate for tonsil. Trabecular an extension to the tonsil capsule tonsil parenchyma. This tissue contains blood vessels, nerves, efferent lymphatic channels. Free surface of the tonsil is covered by epithelial statified squamous.1, 5 Germinativum network located at the center of tonsil tissue, the formation of a stem cell lymphoid cells. Interfolikel network consists of lymphoid tissue in varying degrees pertumbuhan.1, 6 On chronic tonsillitis lymphocytes infiltrate into tonsillar surface epithelium. Increased number of plasma cells in the subepithelial tissue and in the interfolikel. Hyperplasia and fibrosis formation of connective tissue parenchyma and lymphoid tissues resulted in hypertrophy tonsil.6 2.3 Physiology and Immunology of tonsils Tonsils are secondary lymphatic organs necessary for the differentiation and proliferation of lymphocytes which are sensitized. Tonsil has 2 main functions, namely: 1. Capture and effectively collect foreign objects 2. Place of production of antibodies produced by plasma cells derived from B1 lymphocyte differentiation, 5 Lymphocytes were observed in tonsillar B lymphocytes is Together with adenoid lymphocytes B ranged 50-65% of all lymphocytes in the two organs. T lymphocytes ranged from 40% of all tonsil and adenoid lymphocytes. Tonsil mature B lymphocyte cells function and then spread to the mucosal cells and lymphocytes terstimulus secretory glands throughout tubuh.1, 5 Antigen from the outside, in contact with the surface of the tonsils will be bound and taken mucous cells (M cells), antigen presenting cells (APCs), macrophages and dendritic cells are present in the tonsils to Th cells in the centrum germinativum. Th cells will then release mediators that stimulate B cells B cells form the immunoglobulin (Ig) M pentamer followed by the formation of IgG and IgA. Some B cells become memory cells. IgG and IgA passively diffuses into the lumen. When the low antigen stimulation would be destroyed by macrophages. When high concentrations of antigen will induce B cell proliferation in response centrum germinativum so tersensititasi to antigens, resulting in hyperplasia of cellular structures. Regulation of the immune response is a function of T lymphocytes that will control the cell proliferation and the formation imunoglobulin.1

Maximal activity of the tonsil between the age of 4 to 10 years. Tonsil began experiencing involution at puberty, so the B cell production decreased and the ratio of T cells to B cells are relatively increased. On recurrent tonsillitis and inflammation crypt epithelial reticular changes stratified squamous epithelium that resulted in the destruction of immune cell activity and reduce antigen transport functions. This change lowers the local activity of system B cells, as well as lowering the production of antibodies. B cell density on the centrum germinativum also berkurang.1 2.4 Chronic Tonsillitis 2.4.1 Definition of Chronic Tonsillitis Chronic tonsillitis is a persistent inflammation of the tonsils due to an acute or subclinical infection recurring. Size parenchymal hyperplasia due to enlarged tonsils or fibrinoid degeneration with tonsillar crypt obstruction, but can also be found relatively small tonsils due to the formation of the kronis.1 sikatrik, 3 Brodsky explains the duration and severity of throat pain difficult to explain. Usually sore throat and painful swallowing is felt more than 4 weeks and sometimes can menetap.1 Brook and Gober was quoted as saying by Hammouda4 explain chronic tonsillitis is a condition that refers to the enlargement of the tonsils as a result of recurrent tonsil infections. 2.4.2 Etiology Etiology of this disease can be caused by repeated attacks of acute tonsillitis cause permanent damage to the tonsils, or damage may occur if the phase resolution is not perfect. In patients with chronic tonsillitis types of germs that often is Streptococcus beta hemolyticus group A (SBHGA). In addition there is Streptococcus pyogenes, Streptococcus group B, Adenovirus, Epstein Barr, Herpes virus even. 12 2.4.3 Risk Factors for Chronic Tonsillitis So far there has been no complete studies on the involvement of genetic and environmental factors as risk factors for disease tonsillitis kronis.7 a. Age Epidemiological data indicate that chronic tonsillitis disease is a disease that often occurs at the age of 5-10 years and young adults aged 15-25 years. In one study, the prevalence of Group A Streptococcus is a career that is asymptomatic: 10.9% at age less than 14 years, 2.3% aged 15-44 years, and 0.6% aged 45 years or older. According to research carried out in Scotland, the age of patients with chronic tonsillitis is the most common age group of 14-29 years, which amounted to 50%. While Kisve on research to obtain data that 62% of patients with chronic tonsillitis is the age group of 5-14 year.7 b. Sex In the study conducted at the Hospital of Sarawak in Malaysia obtained the data 657 patients with chronic tonsillitis, and was found in 342 men (52%) and 315 women (48%). In contrast to research conducted at the Hospital of Pravara in India, of 203 patients with chronic tonsillitis, as many as 98 (48%) are male and 105 (52%) sex wanita.7 2.4.4 Pathophysiology

Repeated infections and blockages in the tonsil crypt debris resulting in increased stasis and antigen in the crypt, as well as a decline in the integrity of the epithelial crypt making it easier for bacteria to enter the tonsil parenchyma. Bacteria that enter into the tonsillar parenchyma will result in tonsil infection. The tonsils are normal bacteria rarely found in crypt, but can be found in chronic tonsillitis bacteria multiply. Bacteria that live in the tonsillar crypt a source of recurrent infections of the tonsil.1, 12 Due to recurrent inflammatory processes arising in addition to the mucosal epithelium, lymphoid tissue is also eroded. As a result, the process of healing, lymphoid tissue scarring replaced. This network will contract so kripti widened. This seems clinically kripti filled by detritus, which is a collection of leukocytes, dead bacteria, and epithelial apart. This process extends to penetrate the capsule and finally arises equipment with surrounding tissue tonsilaris fossa. In children, this process is accompanied by enlargement of the lymph glands submandibula.12 2.4.5 Clinical Symptoms Clinical symptoms of chronic tonsillitis preceded symptoms of acute tonsillitis, such as sore throat that does not go away sempurna.1, 4 clinical symptoms of chronic tonsillitis, namely: 1) Sense of a lump in the throat. In a study of epidemiological aspects of chronic tonsillitis, 41.3% of patients complained of a lump in the throat as the chief complaint; 2) Halitosis or bad breath. Halitosis caused by debris stuck in the tonsil crypt, which then can be the source of subsequent infection. In a 2007 study in Sao Paulo, Brazil, 27% of patients complaining of halitosis; 3) Swallowing disorders, obstructive sleep apnue, and voice disorders (due to enlarged tonsils) .2,3 2.4.6 Physical Examination On physical examination, the enlarged tonsils can be found in a variety of sizes with a dilated blood vessels on the surface of the tonsils, which damaged crypt architecture as sikatrik, exudate on tonsil crypt, sikatrik on pillars, and enlarged lymph nodes submandibula.1, 12 Enlarged tonsils may vary. According to Thane and Cody, enlarged tonsils divided into T1: the medial border of the anterior tonsillar pillar pass through the uvula distance anterior pillars; T2: the medial border of the tonsils through the anterior pillar distance to -uvula-uvula distance anterior pillars; T3: tonsil medial border pass -uvula distance anterior pillar to pillar distance anterior -uvula; T4: the medial border of the tonsils through the anterior pillar -uvula distance until the uvula or more. Research conducted in Denizli Turkey than 1,784 school children aged 4-17 years of data obtained tonsil size, include T1: 1,119 (62%), T2: 507 (28.4%), T3: 58 (3.3%), T4 : 2 (0.1%) .2,3 Figure 3. Tonsil size (A) grade-I Tonsillar hypertrophy tonsils. (B) Grade-II tonsils. (C) Grade-III tonsils. (D) Grade-IV tonsils (kissing tonsils) 7 2.4.7 Diagnosis Difficulty of diagnosing chronic tonsillitis is due to the lack of specific diagnostic tests and non-invasive to date. For frequent or typical cases, additional investigations, such as

photos Roetgen cavity, CT-scan and nasal endoscopy (nasofibroskopi), is not so necessary to confirm the diagnosis, but the diagnosis is useful to step aside as a result obstuksi nasal rhinitis, polyps, septal deviation, turbinate hypertrophy, stenosis, and others. Serous otitis media can be assessed through timpanometri.13 The main diagnosis points for microbiological diagnosis is the presence of mixed bacterial flora in the structure, often including anaerobic agents. It can be found in the sample raised surgikal Bajah and the sample. Bacterial flora closely resembles that found in the normal flora of the tonsil surface is usually considered as a commensal organism. Recurrent infections by Streptococcus pyogenes and Streptococcus A pyogen others also found in chronic cases, which makes these cases resemble the recurrent tonsillitis mikrobiologis.13 Currently, immunological deficits in chronic tonsillitis still can not be proven. Even so, there are strong theoretical local congenital immune deficiency, in which the children with chronic tonsillitis existing hereditary factors, usually caused by opportunistic agents (anaerobic). Lack of focus on the body and other infections improvement after adenotonsillectomy confirm this theory. In these cases, humoral and cellular immune deficiency, and surface immunoglobulin deficiency is not considered local. Changes were found in the tonsil epithelium could be the cause and effect of infection kronis.13 2.4.8 Treatment Management of chronic tonsillitis divided into medical treatment and therapy pembedahan.1, 5.12

a. Medikamentosa Medical treatment is aimed to overcome infections, both acute tonsillitis and acute exacerbation of chronic tonsillitis. Antibiotics are given appropriate culture. Penicillin type antibiotics is the antibiotic of choice in most cases. In the case of repeated increases bacteriological changes that need to be given alternatives to the type of penicillin antibiotic. In the enzyme -lactamase-producing bacteria have antibiotic stable to this enzyme, such as amoxicillin clavulanat.1, 5.12 b. Operative Formerly tonsillectomy is indicated for the treatment of chronic and recurrent tonsillitis. Currently, the main indication is more obstruction tonsillar hypertrophy. Obstruction resulting in impaired swallowing or breathing disorder is an absolute indication. However, the relative indication of tonsillectomy in non-emergency circumstances and the need for an age limit in this state is still a perdebatan.1 According to The American Academy of Otolaryngology - Head and Surgery (AAOHNS), clinical indication to perform tonsillectomy: 5.7 1. Absolute indications Swollen tonsils that cause airway obstruction, severe dysphagia, sleep disorders, and cardiopulmonary complications. Abscess peritonsil who do not improve with medical treatment and drainage.

 Tonsillitis that cause febrile seizures. Tonsillitis who need a biopsy to determine the anatomic pathology. 2. Relative indications Occurs 3 episodes or more tonsil infections per year with adequate antibiotic therapy. Halitosis due to chronic tonsillitis that does not improve with medical therapy. Chronic or recurrent tonsillitis in Streptococcus career that does not improve with antibiotic resistant -lactamase. 2.5 abscess Peritonsil 2.5.1 Definition and Etiology Peritonsil abscess occurs as a result of complications of acute tonsillitis or infection derived from Weber mucous glands in the upper pole of the tonsils. Infecting organism is usually equal to the germs that cause tonsillitis. Usually unilateral and more often in children and older adults muda.8 2.5.2 Pathogenesis Peritonsilar abscess is an inflammatory process that affects not only the unilateral tonsillar parenchyma but also peritonsilar network, which at the time of an acute episode adenotonsilitis, the bacteria causing the infection spreads through the network to the tonsillar capsule in sekitarnya.9, 10,11 Abscesses are usually located in the potential space between the tonsil capsule with the area around the pharyngeal muscles and is most often found in patients with infections berulang.10 2.5.3 Pathology Superior and lateral fossa area tonsilaris a loose connective tissue. Therefore supurasi infiltration potential space to occupy peritonsil common area so that it looks soft palate swollen. Peritonsil Abscesses can also form in the inferior part, but jarang.8, 11 At the beginning stage (stage infiltrates), in addition to swelling of the surface also looks hyperemia. If the process continues, the area is more soft and yellowish. Tonsils pushed to the center, front, and bottom. Swollen uvula and pushed to the side kontralateral.8 If the process continues, the inflammation in the surrounding tissue will cause irritation of the m. pterigoid internal, causing trismus. Abscesses may rupture spontaneously, so it can happen aspirations to paru.8

2.5.4 Clinical Symptoms In addition to signs and symptoms of acute tonsillitis, there is also odinofagia (painful swallowing) are terrific, typically on the same side and ear pain (otalgia), vomiting (regurgitation), halitosis (foetor ex ore), lots of saliva (hypersalivation), voice nasal (rinolalia), and sometimes difficult to open the mouth (trismus), and submandibular gland swelling with pain tekan.8 When there is pain in the neck (neck pain) and or limited neck movement (limitation in neck mobility), it is because the lymphadenopathy and inflammation of the neck muscles (cervical muscle inflammation) .8

2.5.5 Diagnosis In the physical examination found a swollen soft palate and tonsils extension to the center line or more so swollen uvula and pushed to the contralateral side, may be palpable fluctuations. Swelling peritonsil picture can be seen in Figure 4, unilateral erythema, edema, and protrusion left tonsil and soft palate kiri.10 But if there is trismus may be hard to check all faring.8, 10 Figure 4. Peritonsilar abscess kiri3 Diagnostic procedures to perform needle aspiration (needle aspiration). Aspiration of purulent material (purulent) is a distinctive sign, and the material can be sent to dibiakkan.10 2.5.6 Diagnosis Peritonsil infiltrates, tumor, abscess retrofaring, parafaring abscesses, internal carotid artery aneurysm, mastoid infection, mononucleosis, salivary gland infections, dental infections, and adenitis tonsil.8 2.5.7 Therapy In stage infiltration, given the high dose antibiotics and symptomatic medication. Also need to rinse his mouth with warm water and a cold compress on the neck. Antibiotics were given penicillin or ampicillin 600000-1200000 unit / amoxicillin 250-500 mg or 3-4 x 3-4 x 250-500 mg cephalosporin, metronidazole 3-4 x 250-500 mg.8 If an abscess has formed, do puncture the abscess regions, then incision to remove the pus. The incision is in the most prominent areas and soft, or in the middle of the line connecting the base uvula with the last molars. Intraoral incision and drainage is done by slicing mucosa overlying absess, usually placed in the folds supratonsilar. Drainage or aspiration of a successful cause symptoms improved immediately pasien.8 Then the patient is recommended for tonsillectomy surgery. If done in conjunction with the so-called tonsillectomy abscess drainage "a chaud". When tonsillectomy was performed 3-4 days after drainage of abscess tonsillectomy called "a tiede", and when tonsillectomy 4-6 weeks after drainage of abscess tonsillectomy called "a froid". In general, infection after tonsillectomy done quietly, ie 2-3 weeks after drainage abses8. Tonsillectomy is an absolute indication to people who suffer from recurrent peritonsilaris abscess or abscess that extends the space surrounding tissue. Peritonsil abscess has a great tendency to relapse. Until now there has been no agreement when tonsillectomies performed on peritonsil abscess. Most authors recommend tonsillectomy 6-8 weeks later, after the acute episode is resolved, given the possibility of bleeding or sepsis, while others advocated tonsillectomy segera.10 2.5.8 Complications Ialah8 possible complications: 1. Abscess ruptured spontaneously, resulting in bleeding, pulmonary aspiration, or piema. 2. Propagation of infection and abscess to parafaring area, resulting in an abscess parafaring. Then spread to the mediastinum can occur causing mediastinitis.

3. In the event of propagation to the intracranial region, can lead to thrombus cavernous sinus, meningitis, and brain abscess. A number of other clinical complications can occur if the abscess diagnosis peritonsil ignored. Severity of complications depends on the speed of progression of the disease. To that required treatment and intervention since dini.8 CHAPTER 3 CASE ILLUSTRATION IDENTITY PATIENT Name: Mr.. U Age: 48 years Gender: Male Address: Gang Atlas II, Lapai, Padang No.. MR: 828 509 HISTORY TAKING A male patient, aged 48 years, admitted to the ENT ward Hospital Dr. M. Djamil Padang from the date of June 21, 2013 with, Main complaints: Painful swallowing repeatedly increasing since 4 months ago. History Disease Now: Painful swallowing repeatedly increasing since 4 months ago. Swallowing pain patients have experienced since 2 years ago, the frequency of more than 5 times. Sometimes accompanied by painful swallowing or a lump feeling in throat pain, fever is not too high, as well as cough and cold. Patients 1 month ago had been treated in the wards ENT Hospital Dr. M. Djamil Padang with abscess diagnosis peritonsil the left, and has done abscess incision. Patients go home with the repair, and was given antibiotics and analgesics. Patients feel pain in the left ear 1 month ago. voice murmured, much saliva, or breath smelled nothing. Difficult to open my mouth nothing. Feels fluid flow in the throat is not existing. Shortness of breath is not there. No vomiting. Headache or pain in the joints there. Weight loss nothing drastic. Patients often sleep snoring, but the patient can not recall when the patient is asleep snoring. History breathes through the mouth there. History suddenly could not breathe during sleep there. Appetite good patient, but patients sometimes be difficult to eat due to pain when swallowing food. History of discharge from the ear, hearing loss, or ringing in the ears is not there. History of nasal congestion, diminished sense of smell, and out of the nasal secretions or blood no. History of pain in the forehead, cheeks, bridge of the nose and no.

 History of recurrent bleeding of the gums or patches appear without apparent cause bluish skin no. History ketulangan no. Past history of disease: History toothache or no cavities. History sneezing more than 5 times in the morning or when exposed to dust, animal dander, or no cold weather. History coughing old no. Family history of disease: No family member suffering from infectious diseases. No family member suffering from malignant disease. Work History, Social Economy and Habits: Patients a driver. Lives with his wife and 2 children in a permanent home. No electricity, water from taps. History smoking 6 cigarettes / day 30 years ago. However, the patient stopped smoking since 15 years ago. Patients usually brush my teeth 2 times a day, using toothpaste to brush my teeth every time. PHYSICAL EXAMINATION Generalists status General Condition: Good Awareness: Composmentis cooperative Blood pressure: 130/80 mmHg Pulse rate: 92 x / min Breath frequency: 20 x / min Temperature: 37.8 0C Systemic examination Head: No abnormalities detected. Eyes: not anemic conjunctiva, sclera jaundice not. Neck: Not found enlarged lymph nodes. Thoracic Lung Inspection: symmetrical chest movement right and left. Palpation: fremitus right and left alike. Percussion: Sonor. Auscultation: vesicular breath sounds, and wheezing rhonki no. Heart Inspection: ICTUS cordis is not visible. Palpation: ICTUS cordis palpable medial 2 fingers LMCS RIC V. Percussion: Limit the heart within normal limits.

Auscultation: regular rhythm, no noisy. Abdomen Inspection: No bulge. Palpation: Supple. Liver and spleen not palpable. Percussion: Timpani. Auscultation: Bowel (+) normal. Extremities: Akral warm, well perfused. No edema. Status ENT localist Ear Abnormalities examination Dekstra Sinistra Ex ears. Congenital None None Trauma None None Inflammation None None Kel. Metabolic None None No Pain No drag Tragus tenderness None None Quite the ear canal wall and airy (N) Pretty roomy roomy enough Narrow Hyperemia None None Edema None None No mass No Secretions / wax There is / is not None None Smell Color Number Type Tympanic membrane White Whole Color White shiny shiny Light reflex (+) 5 o'clock (+) direction at 7 No bulging None No retraction None Atrophy None None Number perforation perforation Type Quadrant Edge -

Tympanic membrane images

Signs mastoid inflammation None None Fistula None None Sikatrik None None No tenderness No No Pain No word of Rinne tuning fork test (+) (+) Schwabach Just the same as with the examiner examiner No Weber lateralization Conclusion Normal Normal Audiometric Not done Not done Tympanometry Not done Not done Nose Abnormalities examination Dektra Sinistra External nasal deformity None None Congenital abnormalities None None Trauma None None Inflammation None None No mass No

Paranasal Sinus Dekstra examination Sinistra No tenderness No No Pain No word of Anterior rinoskopi Abnormalities examination Dekstra Sinistra Vestibule Vibrise There There Inflammation None None Enough rice cavity field (N) Quite roomy roomy enough Narrow Field There secretions / no No No Location Type Number - There is no No odor No

Inferior turbinate Eutrofi Size Eutrofi Pink Color Pink Slippery Slippery Surfaces Edema None None Konka media Eutrofi Size Eutrofi Pink Color Pink Slippery Slippery Surfaces Edema None None Simply septum straight / straight Quite Enough deviation straight Slippery Slippery Surfaces Pink Color Pink Spina None None Krista None None Abscess None None No perforation No There is a mass / no No No Location Form Size Surface Color Consistency Easily swayed Vasoconstrictor influences -

Figure rinoskopi anterior

Rinoskopi Posterior (nasopharyngeal) Abnormalities examination Dekstra Sinistra Simply Koana field (N) Pretty roomy roomy enough Narrow Field Mucosa Pink Color Pink Edema None None Granulation tissue None None Inferior turbinate Eutrofi Size Eutrofi Pink Color Pink Slippery Slippery Surfaces

Edema None None There adenoid / no No No The mouth of the eustachian tube secretions Closed No No Mucosal edema None None There is a mass / no No No Location Size Form Surface Post Nasal Drip Yes / No No No Type Figure rinoskopi posterior

Mouth and oropharynx Abnormalities examination Dekstra Sinistra There trismus / no No No Uvula edema None None Bifida None None Soft palate and pharyngeal arch Symmetry / Symmetry Symmetrical not Pink Color Pink Edema None None Spotting / exudate None None Pharyngeal wall Pink Color Pink Slippery Slippery Surfaces Tonsil size T2 T2 No color No hyperemia hyperemia Uneven surfaces are flat Kripti estuary widens widens Detritus None None Exudate None None Adhesions to the pillars None None Peritonsil Pink Color Pink Edema None None Abscess None None There tumor / no No No Location Form Size Surface Consistency Dental Caries / root None None No dental caries impression

Tongue Color Pink Normal forms No deviation No mass Figure oropharynx (mouth)

Indirect laryngoscopy Abnormalities examination Dekstra Sinistra The dome forms the epiglottis Dome Pink Color Pink Edema None None Edge of the flat / no longer Average No mass No Ariteniod Pink Color Pink Edema None None No mass No Symmetrical Symmetrical Movement Ventricular band Pink Color Pink Edema None None No mass No Plica vocalist Color White White Symmetrical Symmetrical Movement Medial edge of Average Average No mass No Subglottic / tracheal Massa None None No discharge No Pyriform sinus mass None None No discharge No Mass Valekulae None None Secretions (type) None None

Image

Neck Lymph Nodes Examination Inspection: Do not look for signs of enlarged cervical lymph nodes. Palpation: There is a palpable presence of enlarged cervical lymph nodes.

LABORATORY EXAMINATION Routine blood examination (June 15, 2013) - Hemoglobin: 13.5 g / dl - Hematocrit: 38% - Leukocytes: 10.900/mm3 - Platelets: 259.000/mm3 Impression: Leukocytosis

RESUME 1. Anamnesis Painful swallowing repeatedly increasing since 4 months ago. Painful swallowing had experienced since 2 years ago, the frequency of more than 5 times. Sometimes accompanied by a feeling lump or pain in the throat, a fever is not too high, as well as cough and cold. One month ago the patient had been treated with a diagnosis of abscess peritonsil the left, and has done abscess incision. History of pain in the left ear 1 month ago. No history of snoring. Voice murmured, much saliva, or breath smelled nothing.

Difficult to open my mouth nothing. Shortness of breath, vomiting, felt liquid running down the throat, and drastic weight loss does not exist. 2. Physical examination Of the physical examination, the temperature was found afebrile. Both enlarged tonsils of patients with T2/T2 size, color pink tonsils, tonsil surface flat, and estuarine kripti widened. 3. Job Diagnosis History of chronic tonsillitis with abscess tonsillectomy pro peritonsil the left. 4. Additional Diagnosis: None 5. Differential Diagnosis: None 6. Prompts examination 7. Therapy o Conservative: Inj. Ceftriaxon 1 x 1 gram Betadine garg 3 x 1 o Operative: Tonsillectomy 8. Prognosis o Quo ad Vitam: Bonam Quo ad o sanam: Bonam

9. Advice o Avoid foods and beverages cold. o Maintain mouth hygiene o Consumption of adequate nutrition