Case Report

Day/ Date : Saturday/ January 5th 2019

Doctors on duty : Jenny/Nadya-Rimel-Wahyu-Amy
Consultant : Dolly Irfandy, MD, ORL (C), FICS

Department of Otorhinolaryngology Head and Neck Surgery

Faculty of Medicine Andalas University/Dr. M. Djamil Hospital
Padang
 Identity of Patient
Female, 42 years old

Chief Complaint
(alloanamnesis)
Decrease of conciousness since 12 hours before
admission
 Medical History
Decrease of conciousness since 12 hours before
admission
Patient was inwarded at Painan hospital in surgery
department for a day and got therapy Asering IVFD 16
drops/m, ceftriaxone 2x1 gr (IV), Ranitidine 2x50 mg (IV),
Analtram 2x1 tab, KSR 2x1 tab, and pronalgess suppos.
Because of there was no improvement, patient referred
to Dr. M. Djamil Hospital with diagnosis tumor at
colliregion DD/ limfoma maligna DD/ nasopharyngeal
carcinoma
There was history of nasal blocking
 Medical History
There was lump in the left neck since 6 months ago and
right neck since 2 months ago
There was history blood came out from the nose since a
month ago, intermittently especially from the left nostril,
stop spontaneously
There was fullness sensation at left ear
There was buzzing at left ear
There was difficulty and pain in swallowing, patient
could only drink liquid
There was intermittent severe headache
 Medical History
There was history of decreasing body weight, 5
kilograms in past 6 months
There was no double vision
There was no history of difficulty and pain in opening
the mouth
There was no hoarseness
There was no numbness at the cheek
There was no lump at groin or armpit
There was no prolong cough
There was no weakness at extremitas
 Medical History
There was no history of eating salted fish
There was no history of smoking
There was no history of cooking with firewood
There was no history of consuming alcohol
There was no history of trauma at head and neck
There was no seizure
There was no history hypertension and diabetic mellitus
Patient worked as cleaning service
 General Examination
General condition was severe ill, somnolen (GCS 13)
BP : 120/ 80 mmHg
RR : 19 x/ min
PR : 94 x/ min
T : 36.7 oC

Thorax : retraction (-), stridor (-), Wheezing (-), rhonkhi(-)

 ENT Examination
Ear
Right :
Ear canal was wide, tympanic membrane was intact,
sclerotic, cone of light (+) decrease

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

Left nasal cavity :

Nasal cavity was wide, inferior and middle turbinate was
eutrophy, septal deviation (-), discharge (-)

Rhinoscopy posterior : could not be performed

 ENT Examination
Throat
Pharyngeal arch was symmetric, uvula in the midline,
tonsil T1-T1 not hyperemic, posterior pharyngeal wall
not hyperemic
 ENT Examination
Neck region :
Right neck
Level I - II : mass (+), 40 x 40 x
16 mm in sized, hyperemic (-),
solid, fixated (+), tenderness (-)
 ENT Examination
Neck region :
Left neck
Level II-III-V : mass (+), 70 x 40
x 16 mm in sized, hyperemic (-),
solid, fixated (+), tenderness (-)
Pictures of the Patient
 Laboratory Finding
Hb : 12.7 g/ dl PT : 13.7 s
WBC : 11.530/ mm3 APTT : 36.3 s
HT : 39 % Na : 137 mmol/l
PLT : 482.000/ mm3 K : 3,4 mmol/l
RBG : 132 mg/dl Cl : 103 mmol/l
Ur : 16 mg/dL SGOT : 60 u/l
Cr : 0,5 mg/dL SGPT : 87 u/l

Result : Leucocytosis , thrombocytosis, ↑ PT, hypokalemia,

↑ SGOT and ↑ SGPT
Thorax X-Ray
Brain CT Scan
Brain CT Scan
 Working Diagnosis

Working • Decreased consciousness ec suspicious

Diagnosis Nasopharynx tumor with intracranial
infiltration
ICD 10 • Malignant neoplasm of nasopharynx (C11.9)
 Management
Consult to neurology department
Biopsy preparation if general condition is stable
Join inward with oncology subdivision
 Neurology Department
A/
- Decrease of consciousness and bilateral N.VI parese
+ sign of increasing intracranial pressure sign
suspicious intracranial SOL
- Bilateral tumor at regio coli suspicious ca
nasopharynx
 Neurology Department
P/
– Inward at neurology department
– Head elevation 30°
– O2 4L/m
– Brain CT without contrast
– Th/ IVFD NaCl 0,9% 20 drop/m
Inj. Dexamethasone 4x5 mg (IV)
Paracetamol 3 x 500mg (orally)
Sucralfate susp 3xI tbs
 Neurosurgery Department
A/
– Cerebellum space occupying lesion
– suspicious carcinoma nasopharynx

P/
– Join inward with neurosurgery department
 Follow Up (Oncology Subdivision)
S : Alert (+), blood came out from nose (-)
O: moderately ill, compos mentis cooperative,
colli region: mass (+), hyperemic(-), fixated (-)
A: suspicious nasopharyngeal tumour with intracranial
infiltration
P: prepare to biopsy at ORL-HNS outpatient clinic
Reconstruction of Nasopharynx CT Scan
Reconstruction of Nasopharynx CT Scan
Reconstruction Nasopharynx CT Scan
Reconstruction Nasopharynx CT Scan