Case Report

Day/ Date : Friday/ November 16th 2018

Doctors on duty : Eko/Suci/Akhyar-Redza/Danu-Amy
Consultant : Effy Huriyati, MD, ORL(C), FICS

Department of Otorhinolaryngology Head and Neck Surgery

Faculty of Medicine Andalas University/Dr. M. Djamil Hospital
Padang
 Identity of Patient
Male, 55 year old

Chief Complaint
Difficulty in breathing that getting worse since
3 day before admission
 Medical History
Difficulty in breathing since 4 month ago and getting
worse since 3 days before admission. 3 weeks ago
the patient complained of the same and went to
RSUP dr M Djamil hospital and was recommended a
tracheostomy but the patient refused, when the
tightness was severe then the patient was brought to
the hospital and ready for tracheostomy
There was hoarseness since 6 month ago
There were no pain and difficulty in swallowing
There were no pain and difficulty in opening mouth
There was no drooling
 Medical History
There was no history of prolonged cough
There was no sweating at the night
There was no decrease of body weight more than 10
kgs
There was no history of bloody sputum
There was no history of regurgitation
There was no lump at the neck
There was history of smoking for 40 years, 2 pack per
day
 Medical History
There was history of drinking alcohol more than 3
times a week
There was no swelling another part of body
There was no history trauma of the neck
There was no history of malignancy in family
There was no fever, cough and cold
Patient was a truck driver
 General Examination
General condition was moderately ill, composmentis
cooperative
BP : 130/ 80 mmHg
RR : 28 x/min
PR : 104 x/min
T : 37.2 oC
SO2 : 97%
Thorax
Inspection : retraction (+) suprasternal, intercostal and
epigastrium
Auscultation : stridor inspiration (+), rh (-/-), wh (-/-)
 ENT Examination
Ear
Right :
Ear canal was wide, tympanic membrane was intact,
cone of light (+)

Left :
Ear canal was wide, tympanic membrane was intact,
cone of light (+)
 ENT Examination
Nose
Right :
Nasal cavity was wide, inferior turbinate and middle
turbinate were eutrophy, discharge (-), septal
deviation (-)

Left :
Nasal cavity was wide, inferior turbinate and middle
turbinate were eutrophy , discharge (-), septal
deviation (-)
 ENT Examination
Throat
Pharyngeal arch was symmetric, uvula in the
midline, tonsil T1-T1, hyperemic (-), posterior
pharyngeal wall, hyperemic (-)
 ENT Examination
Indirect laryngoscopy
Epiglottis and arytenoid edema (-), hyperemic (-), left
ventricular band and vocal cord: mass (+), irregular
surface, necrotic tissue (+), limited movement, glottis
rim was open partially, pyriform sinus : standing
secretion (-)

Neck region
There was no lymph node englargment
 Laboratory Finding
Hb : 13,9 g/dl Ureum : 27 mg/dl
Leuco : 9.730 /mm3 Creatinin : 1,2 mg/dl
Thrombo : 207.000 /mm3 SGOT : 34 u/l
Ht : 43 % SGPT : 40 u/l
PT : 11,1 “ Natrium : 140 mmol/L
APTT : 36,1 “ Kalium : 3,9 mmol/L
RBG : 118 mg/dl Chloride : 104 mmol/L

Result : Normal limite

chest x-ray
 Working Diagnosis

Working • Upper airway obstruction grade III caused

Diagnosis by suspicious laryngeal tumor

ICD 10 • Other specified respiratory disorders

(J98.8)
• Malignant neoplasm of glottis (C32.0)
 Management
Informed consent for tracheostomy in local
anesthesia  patient and family agreed
Th/ - IVFD RL 20 drops/min
- Ceftriaxone 2x1 gr (IV)  skin test
- Dexamethasone 3x1 amp (IV)
- Ranitidin 2x1 amp (IV)
 Tracheostomy Report
1. Patient lying down on the operating table
2. Performed aseptic & antiseptic procedure on
operating field
3. Performed infiltration anesthesia with Lidocaine on
operating field
4. Incision on the operating field 2 finger above
suprasternal fossa with blade no 15, continue with
blunt dissection layer by layer until trachea
 Tracheostomy Report
6. Performed aspiration  air bubble (+)
7. Performed n shape incision on trachea ring 2-3
8. Tracheostomy canula was inserted
9. Cuff was inflated
10. Air passage was good
11. Tracheostomy canula was fixated
12. Operation finished
Evaluation post tracheostomy
S : Difficulty in breathing (-),
O :BP: 120/70,HR: 82x/’, PR : 22x/’, SO2 : 99 %
Thorax : retraction (-), stridor (-/-), wheezing -/-,
ronchi -/-
A : post tracheostomy caused by airway obstruction
grade III caused by laryngeal tumor suspicious malignant
P : - Patient inward in ENT-HNS department
- Consult to larynx-pharynx sub division
- Suction regularly
- Th/ - RL 20 gtt/min
- Ceftriaxone 2x1 gr iv
Patient’s breathing video
Informed consent for
tracheostomy