Blok special sense

1. GROUP 14
Modul “Smelling“
Tutor : dr.Abdul Mubdi

2. Group 14
11020150009 Aulia Amani
11020150024 Nada Nahda
11020150033 Ainun Jariah Muliadi
11020150059 Nur Zamzam Azizah
11020150065 Afrilia Chaerunnisa
11020150081 A. ST. Zuraidha P.A
11020150089 Indah Chintya Maharani
11020150096 Muhammad Rizky Hidayat
11020150109 Reza Novriadi Khautsari
11020150119 Asyaratun Qamila

3. SKENARIO I
A 52-year-old man came to THT with a complaints of reduced inhabitants
experienced since 1 week ago. Previously patients often complained of
his bad breath smelling. History of pain at the base of the nose, often
headache accompanied by greenish yellow-thick snot since 2 years ago.
On examination of the nose found piles of dried snot.

4. 1. HOW DOES THE OLFACTORY
TRACK OCCURS ?

6. 2. WHATARE THE ETIOLOGY
OF HYPOSMIA ?

7. ETIOLOGI HIPOSMIA
Hyposmia can be caused by obstruction of the nose, as in
allergic rhinitis, vasomotor rhinitis, atrophic rhinitis, konka hypertrophy,
septal deviation, polyps, tumors. Can also occur in some systemic
diseases, such as diabetes, kidney failure and liver failure and the use of
drugs such as antihistamines, decongestants, antibiotics, antimetabolites,
anti-inflammatory and antithyroid.
Arsyad Efiaty Soepardi, et al. 2012. Textbook of health science ear nose throat danleher.jakarta: FK UI. Seventh
edition. Page 136.

8. 3. WHATARE THE
DISEASED CAN CAUSE
HYPOSMIA?

9. DISEASES THAT CAUSE HYPOSMIA
Rhinitis
Konka
hypertrophy
Septum
deviation
Polyps
Trauma
Capitia
Tumor
Raviv JR, Kern RC. Chronic Rhinosinusitis and olfactory disfunction.In: Hummel T, Lussen AW, editors. Taste and smell. Vol
63. Switzerland: Karger; 2006. P. 108-24.
Wrobel BB, Leopold DA. Olfactoryand sensory attributes of the nose. Otolaryngol Clin N Am 2005; 38: 1163-70.

10. 4. WHAT CAUSED THE
PATIENT HAVE RUNNY
NOSE ?

11. The cause of runy nose in general is :
Human rhinovirus
(HRV)
Specific chronic
infections by other
germs
Deficiency of iron and
vitamin A
Progress Environment Chronic sinusitis
imbalance of estrogen
hormone
Collagen disease that
includes autoimmune
disease
Hereditary
Suparanasi on the nose
and paranasal sinuses
Blood type
1
1110
7
4
98
65
32
Adams GL. Boies : Buku Ajar Penyakit THT. 6th ed. (EGC PBK:, ed.).; 1997.

12. 5. WHYTHE COLOR OF
MUCOUSE IS YELLOWAND
GREENISH ?

13. trauma, localized local
infection, further effects
of surgery, radiation &
subsequent
inflammation
normal ciliary activity
in the human nasal
mucosa
stops
ciliated stratified
epithelium is
transformed into a
flat epithelium
The cleaning &
debris ability of the
cilia ↓
The mucosa
glands atophy
subepithelial
tissue fibrosis
Disfunction of
surfactant
the frequncy
of the cillia
movements ↓
Mucus
retension
Blood supply in
adequat
(necrosis)
Decompetiton
proces +
microorganism
toxin
Smell-green-
yellow secrets
Soetjipto D, Mangunkusumo E. Hidung. Dalam : Buku Ajar Ilmu Penyakit Telinga Hidung Tenggorok. Edisike 3. Jakarta : FKUI, 1997; 91-3, 113-4
Sayed RH, Elhamd KA, Kader MA. Study of Surfactant Level in Cases of Primary Atropic Rhinits. J Laryngol Otol 2000; 114 ; 254-0

14. 6. WHYTHE PATIENT HAVE SMELLS
BAD BREATH ?

15. • Bacterial sinusitis (Streptococcus pneumonia and
Haemophilus influenza) develops mostly out of acute
viral sinusitis
• When purulent mucous is produced, a typical odour
appears
• bacteria are able to produce VSCs (volatile sulphur
compound), a clear association to halitosis is
available.
Sinusitis
• Foreign bodies in the nasal cavity can produce a foul
odour as well.
• Also a cleft palate can be the origin of bad breath.
• Atrophic rhinitis with bacterial surinfection causes
malodour too. This can be caused by tumor
rescetions, radiotherapy or overuse of decongestives
or cocaine.
Nasal
causes.
Bollen CML, Beikler T. Halitosis : the multidisciplinary approach. 2012;(September 2011):55-63.
doi:10.1038/ijos.2012.39.

16. 7.WHY DO THE PATIENT
GET HEADACHE?

17. Sinus headache
Sinuses are air-filled spaces inside forehead, cheekbones, and
behind the bridge of your nose. When they get inflamed, usually
because of an allergic reaction or an infection, they swell, make
more mucus, and the channels that drain then can get blocked. The
build-up of pressure in sinuses causes pain that feels like a
headache
Ref: WebMD Medical Reference Reviewed by Neil Lava, MD on 3/, 2016

18. 8. RELATION OF THE EACH
SYMPTOMS ?

19. Host Factors :
•Ages, Genders, and etnis
•History of acute rinosinusitis
•Infection of tooth
•Allergic rhinitis
•Diabetic mellitus
•Asthma
•Disorder of nose anatomy
•Congenital disorder
Agent factors:
•Bacteri
•Virus
•Fungi
Envirotment factors:
•Pollution
•Cold air
Rinosinusitis
Nose
Inflamation Nasal congestion, mucus on the
nose
Anxious Perseption of sensory
smell disorder
Ineffective
airway hygiene
CP : Infection

20. 9.HOW TO DIAGNOSE
PATIENT ?

21. Anamnesis
Is there a
nose
blockage? Is there a
tenderness in
the nasal
basin or not?
Has your
nose ever
been
injured?
Do you have
any history of
allergies?
Has there been
a previous
history of
nasal disease?
Is there a seasonal
change in your
symptoms? If so,
which season is
the worst?
Have you ever
had a doctoral
medicine
before?
1. Bickley, Lynn S. BATES Buku Ajar Pemeriksaan Fisik & Riwayat Kesehatan.Edition 8.2012.page.162-163
2. Sofyan, Ferryan. Anatomi Hidung dan Sinus Paranasalis.2016.page.10-11. Acses from USU Repository

22. Con.
Anamnesis
Do you
have other
prior history
of illness?
Was there a history of
previous drug use?
• antihistamines,
• decongestants,
• antibiotics,
• antimetabolites,
• anti-inflammation
• antithyroid
Does your family
or your nearest
person have the
same illness as
you? If yes, how
often do you
meet that person?
1. Bickley, Lynn S. BATES Buku Ajar Pemeriksaan Fisik & Riwayat Kesehatan.Edition 8.2012.page.162-163
2. Sofyan, Ferryan. Anatomi Hidung dan Sinus Paranasalis.2016.page.10-11. Acses from USU Repository

23. PHYSICAL EXAMINATION
Inspection
Anterior rhinoscopic examination
1. Bickley, Lynn S. BATES Buku Ajar Pemeriksaan Fisik & Riwayat Kesehatan.Edition
8.2012.page.162-163
2. Sofyan, Ferryan. Anatomi Hidung dan Sinus Paranasalis.2016.page.10-11. Acses from USU

24. PHYSICAL EXAMINATION
Palpation
1. Bickley, Lynn S. BATES Buku Ajar Pemeriksaan Fisik & Riwayat Kesehatan.Edition
8.2012.page.162-163
2. Sofyan, Ferryan. Anatomi Hidung dan Sinus Paranasalis.2016.page.10-11. Acses from USU

25. SUPPORTING EXAMINATION
X- RAY
1. Bickley, Lynn S. BATES Buku Ajar Pemeriksaan Fisik & Riwayat Kesehatan.Edition
8.2012.page.162-163
2. Sofyan, Ferryan. Anatomi Hidung dan Sinus Paranasalis.2016.page.10-11. Acses from USU
Waters Position

26. SUPPORTING EXAMINATION
X- RAY
1. Bickley, Lynn S. BATES Buku Ajar Pemeriksaan Fisik & Riwayat Kesehatan.Edition
8.2012.page.162-163
2. Sofyan, Ferryan. Anatomi Hidung dan Sinus Paranasalis.2016.page.10-11. Acses from USU
PA Position

27. SUPPORTING EXAMINATION
X- RAY
1. Bickley, Lynn S. BATES Buku Ajar Pemeriksaan Fisik & Riwayat Kesehatan.Edition
8.2012.page.162-163
2. Sofyan, Ferryan. Anatomi Hidung dan Sinus Paranasalis.2016.page.10-11. Acses from USU
Lateral Position

28. 10. DIFFRENTIAL
DIAGNOSIS PATIENT ?

29. Sinusitis
Definiton
• Sinusitis defines as mucul inflammation of paranasal sinus. Sinusitis
mostly caused by rhinitis, so that can be called rhinosinusitis.
Etiology
• Some etiology and predispotition factors are Upper Respiratory Tract
Infection cause by virus, rhinitis, nasal polip, abnormality anatomy
structur such as septum deviation or concha hypertrophy, obstruction of
osteo-meatal complex, tonsil infection, immunologic abnormalitiy, ciliary
dyskinesia, and cystic fibrotic.
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Indonesia; 2016.

30. Patofisiology
Location of
organs that form
OCM is near
Edema
mucous that face
each other will be
combined
lead to
obstruction of
ostium
negative
pressure
happened in
cavum sinustransudation, start
with serous
•can be recover in few days
without medical treatment.
the secret that
accumulated inside
sinus
microorganisms
grow and bacterial
multiplication
secret become
purulent
bacterial acute
rhinosinusitis
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Indonesia; 2016.

31. Symptoms
• Mostly syptoms of sinusitis are nasal congestion,
• face pain,
• purulent secret
• usually post nasal drip happen
• Fever and weakness
• Pain pressure in sinus area is characteristic of acute sinusitis
• In chronic sinusitis, the symptoms is not specific, sometimes one or
two symptoms that happen : chronic headache, post nasal drip, post
nasal drip, chronic cough, throat disorder, ears disorder caused by chronic
obstruction of tuba Eustachius, pulmonary disorder such as bronchitis or
bronchiectasis. In child, post nasal drip can cause gastroenteritis.
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Indonesia; 2016.

32. Diagnosis
• Physical examination : anterior and posterior rhinoscopy, naso-endoscopy is
the most important to make a proper diagnosed.
• Specific sign is a pus in meatus medius (maxillary sinusitis, anterior and frontal
ethmoidal) or in superior meatus (posterior ethmoidal sinusitis and sphenoidale).
In acute rhinosinusitis can found mucuos edem and hyperemic.
• Support examination using CT-Scan is the most important. CT-scan is gold
standard to diagnose sinusitis because can evaluate anatomy structural of nose
and sinus, evaluate the disorder inside nose and sinus overall. Microbiological
test can be do with take a secret from superior/medial meatus to give a specific
antibiotic.
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Indonesia; 2016.

33. Treatment
• the first line therapy in acute bacterial sinusitis to
remove the infection and mucous swolling also
can remove the ostium sinus obstruction
Antibiotic and
decongestant
• In case of antibiotic resistance
Amoxicillin-kluvanat
or cephalosporin 2nd
generation
• antibiotic given for 10-14 days despite the
symptoms disappearAcute sinusitis
• antibiotic given based on gram negative bacteria
and aerob bacteria.Chronic sinusitis
other treatment necessary are analgetic, mucolytic, topical/oral steroids. Antihistamin
not given routinely because anticholinergic effect can make secret become thick.
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed. Fakultas Kedokteran
Universitas Indonesia; 2016.

34. NASAL POLYP

35. DEFINITION
Nasal polyps are a soft, white or grayish mass present in the
nasal cavity. Polyps come from swollen nasal mucosa that
contains a lot of interseluler fluid and then pushed into the
nasal cavity by gravity. Polyps can arise from any part of the
nasal or bilateral nasal mucosa or sinuses.
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Indonesia; 2016.
Dhingra. Disease of Ear, Nose and Throat. 4th ed. Elsevier

36. • Nasal Polypi are non-neoplastic masses of oedematous nasal or sinus
mucosa.
They are divided into two main varieties:
• (a) Bilateral ethmoidal polypi.
• (b) Antrochoanal polyp.
Dhingra. Disease of Ear, Nose and Throat. 4th ed. Elsevier
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Indonesia; 2016.

37. ETIOLOGY
inflammarory
conditions of
nasal mucosa
(rhinosinusitis)
abnormal
composition of
nasal mucus
(cystic
fibrosis).
disorders of
ciliary motility

38. Various diseases associated with the
formation of nasal polypi are:
Chronic rhinosinusitis
Asthma
Aspirin intolerance
Cystic fibrosis.
Allergic fungal sinusitis
Kartagener's syndrome
Young's syndrome.
Churg-Strauss syndrome
Nasal mastocytosis
Dhingra. Disease of Ear, Nose and Throat. 4th ed. Elsevier
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Indonesia; 2016.

39. Pathophysiology
Hipersentivity
reactions
mucosal edema
in the meatus
medius region
the stroma will
be filled by the
intercellular fluid
the puffy
mucosa
becomes
polypoid
the swollen
mucosa is
enlarged
it will descend
into the nasal
cavity while
forming the stalk
Polyp
Dhingra. Disease of Ear, Nose and Throat. 4th ed. Elsevier
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Indonesia; 2016.

40. Clinical manifestation
symptoms
a sense of
blockage
in the nose
Hyposmia
or anosmia
Headache
nasal
discharge
sneezing
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Muslim Indonesia; 2016.
Dhingra. Disease of Ear, Nose and Throat. 4th ed. Elsevier

41. Sign
• On anterior rhinoscopy, polypi appear as smooth, glistening, grape-like
masses often pale in colour.
• Often they are multiple and bilateral.
• Long-standing cases present with broadening of nose and increased
intercanthal distance.
• Nasal cavity may show purulent discharge due to associated sinusitis.
Dhingra. Disease of Ear, Nose and Throat. 4th ed. Elsevier
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Indonesia; 2016.

43. TREATMENT
Conservative
• Early polypoidal changes with oedematous mucosa may revert to normal
with antihistaminics and control of allergy.
• A short course of steroids may prove useful in case of people who cannot
tolerate antihistaminics
Surgical
• Polypectom
• Intranasal ethmoidectomy
• Extranasal ethmoidectomy
• Transantral ethmoidectomy
• Endoscopic sinus surgery
Dhingra. Disease of Ear, Nose and Throat. 4th ed. Elsevier
Prof. Dr. Efiaty Arsyad Soepardi ST-K. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorokan. 7th ed.
Fakultas Kedokteran Universitas Indonesia; 2016.

44. Rhinitis
“It is the Inflammation of the nasal mucouse membrane
“
Tille LP. 5 Minutes Consults Medicine.; 2006.

45. SIGNS & SYMPTOMS
• Nasal stuffiness and congestion • Rhinorrhea usually clear
• Pruritus of nose, eyes and palate • Sneezing, often
paroxysmal
• Injection and watering of eyes • Postnasal drainage
• Mouth breathing
• Fatigue or malaise
• Dark circles under eyes, “allergic shiners”
• Transverse nasal crease from rubbing nose upwards
Tille LP. 5 Minutes Consults Medicine.; 2006.

46. CAUSES
• Inhalant allergens:
◊ Perennial: house dust mites, molds, animal dander,cockroach
◊ Seasonal: tree, grass and weed pollens
◊ Occupational: latex, plant products (such as baking
flour),sensitizing chemicals
RISK FACTORS
• Family history
• Repeated exposure to offending antigen
• Exposure to multiple offending allergens
• Presence of other allergies, e.g., atopic dermatitis,
asthma, urticaria
• Non-compliance to appropriate therapeutic measures
Tille LP. 5 Minutes Consults Medicine.; 2006.

47. • Eosinophils predominate ◊ Basophils
◊ May see mast cells
• • Nasal mucosa
◊ Submucosal edema but intact without
evidence of
• destruction
◊ Eosinophilic infiltration
◊ Granulocytes to lesser extent
◊ Increased amount of tissue water
with poor staining
• of ground substance
◊ Congested mucous glands and
goblet cells
PATHOLOGICAL FINDINGS
Tille LP. 5 Minutes Consults Medicine.; 2006.

48. Tille LP. 5 Minutes Consults Medicine.; 2006.

49. Tille LP. 5 Minutes Consults Medicine.; 2006.

50. TREATMENT
• ntihistamines (H1 antagonists)
• Decongestants
• Physiologic saline solution may be comforting
• Steroids
• Leukotriene antagonist
• Anticolinergic
Tille LP. 5 Minutes Consults Medicine.; 2006.

51. 11. THERAPYAND FIRST
TREATMENT FOR PATIENTS
WITH OLFACTORY
DISORDERS?

52. Any treatment of olfactory disorders must first treat the specific causative abnormality
if it has been identified from diagnostic tests, history, and physical examination.
Local nasal and/or sinus conditions  saline lavage, decongestants,
antihistamines, antibiotics, and/or nasal and systemic steroids, if
applicable.
Polyps and sinus disease that are resistant to medical management 
surgically addressed to remove the conductive defect.
Endocrine disturbances may be addressed by administration of the
deficient hormone, as with hypothyroidism. Control of diabetes mellitus
may slow neural degeneration of the olfactory system.
 It is now known that olfactory training is safe and effective therapy for
postinfectious olfactory loss.
psychiatric evaluation and treatment may be warranted.
Example :
Reference : Donald Leopold, MD. 2016. Disorder Taste and Smell. Medscape. 15 January.
(http://emedicine.medscape.com/article/861242-overview#a5)

53. THANK YOU