BAB 1 PENDAHULUAN
Pendengaran merupakan salah satu dari pancaindera yang digunakan untuk berkomunikasi dan berinteraksi, baik antara sesama manusia maupun dengan lingkungan sekitarnya. Gangguan dengar akan mengurangi kemampuan menerima info inform rmasi asi dan dan berk berkom omun unik ikasi asi mela melalu luii suara suara,, sehi sehing ngga ga akan akan meny menyul ulit itka kan n pelaksanaan pekerjaan.1 Samp Sampai ai deng dengan an tahu tahun n 1995 1995,, World Health Organiza Organization tion memperkirakan secara secara kasar kasar bahwa bahwa di dun dunia ia terd terdap apat at
kuran kurang g lebih lebih 1! 1! jut jutaa orang orang
yang yang
mempunyai permasalahan dengan pendengaran yaitu sekitar " dari populasi keseluruhan keseluruhan.. Perkiraan Perkiraan angka angka ini naik pada tahun !!# yaitu sekitar $! juta orang, sekitar %& juta di antaranya berada di negara berkembang. 1 Pene Peneli liti tian an pada pada tahu tahun n !!$ !!$ diny dinyata ataka kan n bahw bahwaa kura kurang ng lebi lebih h & juta juta penduduk 'merika Serikat mengalami penurunan ambang pendengaran dan sebanyak &!" menderita gangguan dengar menetap yang terdiri atas $,(" pada usia 1&)$$ tahun, 1$" pada usia $5)($ tahun, 5$" pada usia (5 tahun, #" pada usia (5)%$ tahun, dan #1" di atas usia %5 tahun. 1 Sebagai negara berbentuk kepulauan, *ndonesia mempunyai 5 pulau besar dan lainnya pulau kecil. +enurut sensus nasional total populasi populasi sebesar !5 juta pada tahun !!!, didapatkan sekitar 1(,&" menderita gangguan pendengaran yang di antaranya ketulian !,$"-. 1
1
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BAB 2 TINJAUAN PUSTAKA
2.1 Anatomi
Secara anatomi dan fungsional, telinga dibagi menjadi # bagian telinga luar, telinga tengah, dan telinga dalam. /elinga berfungsi ganda, yaitu untuk keseimbangan dan untuk pendengaran. +embran timpani memisahkan telinga luar dari telinga tengah. /uba auditi0a menghubungkan telinga tengah dengan nasofaring.,#
Gambar .1. Telinga luar, telinga tengah, dan telinga dalam 2.1. 2.1.1 1
Teling linga a Lua Luarr
/eling elingaa luar luar terdiri terdiri dari dari auricu auricula la yang yang menghi menghimpu mpun n bunyi bunyi dan meatus meatus acustic acusticus us etern eternus us yang yang mengan mengantar tar gelomb gelombang ang bunyi bunyi ke membra membran n timpan timpani. i. 'uricu 'uricula la terdir terdirii dari dari beberap beberapaa bagian bagian yang yang terdiri terdiri dari dari tulang tulang rawan. rawan. +eatus +eatus acusticus eksternus meluas dari concha auricularis ke membran timpani. 2agian sepertiga sepertiga lateral saluran saluran ini berbentuk berbentuk seperti S, terdiri terdiri dari tulang tulang rawan dan dilapisi oleh kulit yang sinambung dengan lapisan luar membran timpani. # +embran timpani yang berdiameter lebih kurang 1 cm adalah selembar selaput yang tipis, jorong, dan setengah tembus pandang, terentang pada ujung medial tuba auditoria. +embran timpani bergerak sebagai reaksi terhadap getaran udara yang sampai padanya padanya melalui meatus acusticus acusticus eksternus. eksternus. Gerak membran
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dipersa dipersarafi rafi ileh ileh ner0us ner0us auricu auriculot lotemp emperal eralis, is, cabang cabang yang yang berasal berasal dari dari ner0u ner0uss mandibularis 3er0us 4 # -. Sebagian kecil membran timpani dipersarafi oleh ramus auricularis gangglion inferior yang berasal dari ner0us 0agus, saraf ini berisi beberapa serabut dari ner0us glossopharingeus dan mungkin serabut dari ner0us ner0us faciali facialis. s. Permu Permukaa kaan n dalam dalam membra membran n timpan timpanii dipersa dipersarafi rafi oleh oleh ner0us ner0us kranialis *. #
Gambar .. Bagian-bagian .. Bagian-bagian dari dari auricula telinga luar . 2.1.2
Telinga Te linga Te Tengah ngah
/elinga tengah terdiri dari suatu ruang yang terletak antara membran timp timpan anii dan dan kaps kapsul ul telin telinga ga dalam dalam,, tulan tulang6 g6tu tula lang ng,, dan dan otot otot yang yang terda terdapa patt didalamnya beserta penunjangnya. 2atas6batas superior ca0um timpani menjadi epitimpanum, mesotimpanum dan hipotimpanum. 7ipotimpanum adalah suatu ruang dangkal yang terletak lebih rendah dari dari memb membran ran timpa timpani ni.. Perm Permuk ukaan aan tula tulang ng pada pada bagi bagian an ini ini tampa tampak k sepe seperti rti gambaran kerang karena adanya sel6sel udara berbentuk cangkir. 8inding ini menutupi bulbus jugularis. +eso +esotim timpa panu num, m, diseb disebela elah h medi medial al diba dibatas tasii oleh oleh kaps kapsul ul otik otik,, yang yang letaknya lebih rendah daripada ner0us fasial pars timpani. Suatu penonjolan yang melengkung pada bagian basal kokhlea terletak disebelah medial mebran timpani dan disebut promontorium. 8i dalam promontorium terdapat beberapa salu salura ran n beri berisi si saraf saraf6sa 6saraf raf yang yang memb memben entu tuk k ple pleus us timp timpan anic icus us.. 8iseb 8isebela elah h posterior promontorium pada bagian superior terdapat foramen o0ale dan pada bagian inferior terdapat foramen rotundum yang keduanya terletak pada dasar
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:oramen rotundum terlindung dari penglihatan karena bagian ini terletak pada bidang melintang sebelah anterior suatu tepi penonjolan dari promontorium. :orame :oramen n rotund rotundum um ditutu ditutupi pi oleh oleh suatu suatu membra membran n yang yang tipis tipis yaitu yaitu membra membran n timpani sekunder. 2agian 2agian anteri anterior or saluran saluran fasial fasial pars pars timpan timpanii ditand ditandai ai oleh oleh penonj penonjola olan n berbentuk pengait di ujung posterior saluran otot tensor timpani, yaitu prosesus kohklearifo kohkleariform rm yang mebuat mebuat
tendon tendon muskulus muskulus tensor tersebut tersebut membelok membelok ke
lateral ke dalam telinga tengah. Saluran muskulus tensor timpani berjalan ke depan ke dalam permukaan superior tuba ;ustachius dan merupakan tanda batas anterosuperior mesotimpanum. Pada dinding anterior mesotimpanum mesotimpanum terdapat orifisium orifisium timpani timpani tuba ;ustachius pada bagian superior dan membentuk bagian tulang dinding saluran karo karotis tis asen asende den n pada pada bagia bagian n infe inferio riorr. 8ind 8indin ing g ini ini bias biasany anyaa meng mengala alami mi pneumatisasi yang baik dan dapat dijumpai dijumpai bagian6bagian tulang yang lemah. 8alam 8alam epitimp epitimpanu anum m terdapat terdapat inkus inkus dan maleus maleus.. 8i bagian bagian superio superior r epitim epitimpan panum um dibata dibatasi si oleh oleh suatu suatu penonj penonjola olan n tipis tipis os petros petrosus, us, yaitu yaitu tegmen tegmen timpan timpanii yang yang merupa merupakan kan kelanj kelanjutan utan tegmen tegmen mastoid mastoid poster posterior ior.. Pada Pada bagian bagian anter anterio iorr terd terdap apat at bagi bagian an ampu ampula la kana kanalis lis supe superi rior or,, dan dan lebi lebih h ante anterio riorr ada ada gangglion gangglion genikulatum. genikulatum. 8inding anterior terpisah dari maleus oleh suatu ruang yang ang semp sempit it,, yang yang dapa dapatt diju dijump mpai ai muara uara sel6 sel6se sell udar udaraa yang yang memb membua uatt pneumatisasi pangkal tulang pipi.
Gambar .#. Membran .#. Membran Timpani Timpani
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terdiri dari maleus, inkus dan stapes. +aleus dan inkus bekerja sebagai satu unit, memberikan respon rotasi terhadap gerakan membran timpani melalui suatu aksis yang merupakan suatu garis antara ligamentum maleus anterior dan ligamentum inkus pada ujung prosessus bre0is. Gerakan ) gerakan tersebut teteap dipelihara berkesinambungan oleh sendi inkudomaleus. Gerakan rotasi tersebut diubah menjadi gerakan seperti piston pada stapes melalui sendi inkudostapedius.
Teling linga a Dala Dalam m
/eling lingaa dalam dalam atau atau orga organ n 0esti 0estibu bulo loko kokh khlea learr berh berhub ubun unga gan n deng dengan an penerimaan bunyi dan pemeliharaan keseimbangan. /elinga /elinga tengah yang tertanam di dalam pars petrosa, salah satu bagian tulang temporal, terdiri dari kantong6kantong dan pipa6pipa labirinthus membranaceus. Sistem selaput ini berisi endolimfe dan organ ) organ akhir untuk pendengaran dan kesimbangan. =abyrinthus membranaceus berupa selaput yang diliputi oleh perilimfe terbenam di dalam labyrintus osseus. #
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Gambar .$. Telinga Dalam =abyri =abyrintu ntuss osseus osseus telinga telinga dalam dalam terdir terdirii dari dari tiga tiga bagian bagian,, yaitu yaitu kohkle kohklea, a, 0estib 0estibulu ulum m dan kanali kanaliss semisir semisirkul kularis aris ossei. ossei. =abyri =abyrinth nthus us osseus osseus menemp menempati ati hampir seluruh bagian lateral pars petrosa pada os temporal. # okhlea okhlea merupa merupakan kan bagian bagian labyrin labyrinthu thuss osseus osseus yang yang berben berbentuk tuk seperti seperti keong, berisi ductus cochelaris, bagian telinga dalam yang berhubungan dengan pendengaran. okhlea membuat ,5 putaran, mengelilingi sumbu tulang yang disebu disebutt modiol modiolus us dan berisi berisi terusan terusan6ter 6terusa usan n untuk untuk pembul pembuluh uh darah darah dn saraf saraf putaran kokhlea basal yang lebar menyebabkan terbentuknya promontorium pada dinding medial ca0um timpani. # 4estibulum merupakan ruang yang kecil dan jorong berisi utriculus dan sacc saccul ulus us,,
bagi bagian an6b 6bag agia ian n
pera perant ntii
kese keseim imba bang ngan an..
e
ante anteri rior or
bersinambungan denga cochlea dan tulang, ke posterior
0est 0estib ibul ulum um
dengan canalis
semisi semisirk rkul ulari ariss osse osseii dan dan deng dengan an fossa fossa cran cranii ii post posteri erior or melal melalui ui a>ue a>uedu duct ctus us 0estibuli.# analis semisirkularis ossei terbagi menjadi kanalis semisirkularis anterior, posterior dan lateralis yang berhubungan dengan 0estibuum labyrinthi ossei. ana anali liss semi semisir sirku kula laris ris ossei ossei terle terleta tak k poste posterio riorr terh terhad adap ap 0esti 0estibu bulum lum yang yang merupa merupakan kan tempat tempat bermua bermuarany ranyaa canalis canalis semisir semisirkul kulari ariss ossei. ossei. etiga etiga terusa terusan n ditemp ditempatk atkan an tegak tegak lurus lurus terhad terhadap ap yang yang lain. lain. 8engan 8engan demiki demikian an stereom stereometri etriss mereka menempati tiga bidang. # =abyrintus membranaceus terdiri dari urutan6urutan kantong6kantong dan pipa6pipa yang saling s aling berhubungan dan terbenam di dalam labyrintus la byrintus osseus. 8i
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=abyrintus membranaceus terdiri dari tiga bagian utama, yaitu # ?triculus ?triculus dan sacculus, sacculus, dua kantong kecil di dalam 0estibulum 0estibulum labyrinthi labyrinthi • • •
ossei yang saling berhubungan. /iga ductus semisirkularis di dalam kanalis semisirkularis ossei. 8uctus cochlearis di dalam cochlea. ?triculus ?triculus dan sacculus sacculus masing6masin masing6masing g mempunyai mempunyai daerah6daerah khusus dengan dengan epitel sensoris sensoris yang dienal dienal sebagai makula makula utriculi dan makula makula sacculi. +acula +acula utricu utriculi li terdapat terdapat pada pada dasar dasar utricu utriculus lus,, sejajar sejajar dengan dengan dasar dasar craniu cranium, m, sedangkan sedangkan makula sacculi teratur 0ertikal 0ertikal pada ddinding ddinding media sacculus. Sel6sel rambut didalam makula memperoleh persarafan dari serabut bagian 0estibular ner0us 0estibulocochlearis.# +asing6masing ductus semisirkularis pada stu ujungnya mempunyai sebuah ampull ampullaa atau peleba pelebaran ran dengan dengan daerah daerah sensor sensoris, is, yakni yakni crista crista ampull ampullaris aris.. @igi @igi tersebut tersebut berfungsi berfungsi sebagai sensor yang mencatat gerak endolimfe endolimfe dalam ampulla sebagai akibat rotasi kepala dalam bidang pipa tertentu. Sel rambut pada crista ampull ampullaris aris,, seperti seperti yang yang terdap terdapat at pada pada makula, makula, berhub berhubun ungan gan dengan dengan serabut serabut neur neuron on sens sensor oris is prim primer er yang yang bada badan n seln selny ya terd terdap apat at di dala dalam m gang ganggl glio ion n 0estibulare.# 8uctus cochlearis adalah sebuah pipa buntu yang berbentuk ulir dan terikat erat pada dinding luar dan dinding dalam canaliculi cochlea oleh crista spiralis. Pipa ini yang berbentuk segitiga terletak antara lamina spiralis ossea dan dinding luar luar canalic canaliculu uluss cochle cochleae. ae. 'tap 'tap ductus ductus cochle cochlearis aris dibent dibentuk uk oleh oleh membra membrana na 0estibularis dan dasarnya oleh membrana basilaris dan bagian luar lamina spiralis ossea. @eseptor rangsang pendengar adalah organum spirale corti yang terletak pada membrana basilaris . pda orgnum spirale corti terdapat sel rambut yang bereaksi teerhadap getaran yang ditimbulkan pada endolimfe oleh gelombang
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•
/uli /uli kokl koklea, ea, yaitu yaitu apab apabil ilaa gang ganggu guan an terd terdapa apatt pada pada resep resepto torr atau atau mekani mekanisme sme pengha penghanta ntarr pada pada koklea koklea.. 2iasany 2iasanyaa diseba disebabka bkan n aplasia aplasia,, labirinitis, intoksikasi obat ototoksik atau alkohol. Pada tuli koklea ini terjadi suatu fenomena rekrutmen dimana terjadi peningkatan sensitifitas pendengaran yang berlebihan di atas ambang dengar. Pada kelainan koklea pasien dapat membedakan bunyi 1 d2, sedangkan orang normal
•
baru dapat membedakan bunyi bunyi 5 d2. 5 /uli retr retrok okok okle lea, a, yaitu aitu apab apabil ilaa terd terdap apat at gang ganggu guan an pada pada ner0 ner0us us 0estibulokoklearis atau satu dari area pendengaran di lobus temporalis otak. Pada tuli retrokoklea terjadi kelelahan fatigue- yang merupakan adaptasi abnormal, dimana saraf pendengaran cepat lelah bila dirangsang terus terus meneru menerus. s. 2ila 2ila diberi diberi istirah istirahat, at, maka maka akan akan pulih pulih kembali kembali.. /uli /uli retro retroko kohk hklea lea dise diseba babk bkan an oleh oleh neur neurom omaa akus akusti tik, k, tumo tumorr sudu sudutt pons pons serebellum, mieoma multiple, cedera otak, perdarahan otak, dan kelainan otak lainnya. 5
?ntuk membedakan tuli koklea dan tuli retrokoklea diperlukan pemeriksaan audiol audiologi ogi khusus khusus.ya .yang ng terdiri terdiri dari dari audiom audiometri etri khusus khusus,, audiom audiometri etri objek objektif, tif, pemeriksaan tuli organik, dan pemeriksaan pemeriksaan audiometri anak. 5
2.3 "i!iologi Pen#engaran
Getaran suara ditangkap oleh daun telinga telinga yang diteruskan diteruskan ke liang telinga dan mengenai membran timpani sehingga membran timpani bergetar. Gelombang suara yang bertekanan tinggi dan rendah berselang seling menyebabkan gendang telin telinga ga yang yang sanga sangatt peka peka terseb tersebut ut menek menekuk uk kelu keluar ar6m 6masu asuk k seiram seiramaa deng dengan an
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pengungkit tulang6tulang pendengaran juga turut berkontribusi dalam peningkatan tekanan gelombang suara.( Gerakan stapes yang menyerupai piston terhadap jendela o0al menyebabkan timbulnya gelombang tekanan di kompartemen atas. arena cairan tidak dapat ditekan, ditekan, tekanan tekanan dihamburka dihamburkan n melalui dua cara sewaktu sewaktu stapes menyebabkan menyebabkan jendela o0al menonjol ke dalam yaitu, perubahan posisi jendela bundar dan defleksi membrana basilaris.( Pada jalur pertama, gelombang tekanan mendorong perilimfe ke depan di kompartemen kompartemen atas, kemudian kemudian mengeliling mengelilingii helikoterma, helikoterma, dan ke kompartemen kompartemen bawah, tempat gelombang tersebut menyebabkan jendela bundar menonjol ke luar untuk mengkompensasi peningkatan tekanan. etika stapes bergerak mundur dan mena menari rik k jende jendela la o0al o0al ke luar luar,, peri perilim limfe fe meng mengal alir ir ke arah arah yang yang berla berlawa wana nan n mengubah posisi jendela bundar ke arah dalam. ( Pada Pada jalur jalur kedua, kedua, gelomb gelombang ang tekana tekanan n frekuen frekuensi si yang yang berkai berkaitan tan dengan dengan penerimaan suara mengambil jalan pintas. Gelombang tekanan di kompartemen atas dipind dipindahk ahkan an melalu melaluii membran membranaa 0estib 0estibula ularis ris yang yang tipis, tipis, ke dalam dalam duktus duktus koklear koklearis is dan kemudi kemudian an melalu melaluii mebrana mebrana basilar basilaris is ke kompar komparteme temen n bawah, bawah, tempat gelombang tersebut menyebabkan jendela bundar menonjol ke luar6masuk bergantian.( +embra +embran n basilar basilaris is yang yang terletak terletak dekat dekat teling telingaa tengah tengah lebih lebih pendek pendek dan kaku kaku,, akan akan berg berget etar ar bila bila ada ada geta getara ran n deng dengan an nada nada rend rendah ah.. 7al 7al ini ini dapa dapatt diibaratkan dengan senar gitar yang pendek dan tegang, akan beresonansi dengan nada tinggi. Getaran yang bernada tinggi pada perilimfe skala 0estibuli akan melintasi membrana 0estibularis yang terletak dekat ke telinga tengah. Sebaliknya
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Gambar .5 Proses terjadiya pendengaran pendengaran aren arenaa orga organ n corti corti menu menump mpan ang g pada pada memb membra rana na basil basilar aris, is, sewa sewakt ktu u membrana basilaris bergetar, sel6sel rambut juga bergerak naik turun dan rambut6 rambut tersebut akan membengkok ke depan dan belakang sewaktu membrana basilaris menggeser posisinya terhadap membrana tektorial. Perubahan bentuk mekanis rambut yang maju mundur ini menyebabkan saluran6saluran ion gerbang meka mekani niss di sel6se sel6sell rambu rambutt terb terbuk ukaa dan dan tert tertut utup up secar secaraa berg bergan anti tian an.. 7al 7al ini ini meny menyeba ebabk bkan an peru peruba baha han n
pote potensi nsial al
depo depola laris risasi asi dan dan
hipe hiperp rpol olar arisa isasi si
yang yang
bergantian. Sel6sel rambut berkomunikasi melalui sinaps kimiawi dengan ujung6 ujung serat saraf aferen yang membentuk saraf auditorius koklearis-. 8epolarisasi sel6sel rambut menyebabkan menyebabkan peningkatan peningkatan kecepatan kecepatan pengeluaran pengeluaran Aat perantara perantara mereka yang menaikan potensial aksi di serat6serat aferen. Sebaliknya, kecepatan pembentukan potensial aksi berkurang ketika sel6sel rambut mengeluarkan sedikit Aat perant perantara ara karena karena mengal mengalami ami hiperp hiperpolar olarisas isasii sewakt sewaktu u membra membrana na basilar basilaris is bergerak ke bawah-. Perubahan potensial berjenjang di reseptor mengakibatkan perubahan kecepatan pembentukan potensial aksi a ksi yang merambat ke otak. *mpuls kemudi kemudian an dijalar dijalarkan kan melalui melalui saraf saraf otak otak statoac statoacust ustiku ikuss saraf saraf penden pendengara garann- ke medulla oblongata kemudian ke colliculus. Persepsi auditif terjadi setelah proses sensori atau sensasi auditif.(
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Gambar .(. aras .(. aras Persyara!an Pendengaran
2.$ Etiologi
Penyebab tuli sensorineural dibagi menjadi 2.$.1. Ko%lea
Penyebab tuli sensorineural yang berasal dari koklea terdiri dari a. =abirin =abirinitis itis oleh oleh bakteri bakteriBB 0irus0irus=abirinitis adalah infeksi pada telinga dalam labirin-. eadaan ini dapat ditemukan sebagai bagian dari suatu proses sistemik atau merupakan suatu proses tunggal pada labirin saja. =abirinitis bakteri sering disebabkan oleh komplikasi intra temporal dari radang telinga tengah. Penderita otitis media kronik yang kemudian tiba6tiba 0ertigo, muntah dan hilangnya pendengaran harus waspada terhadap timbulnya labirinitis supuratif.
%
=abirin =abiriniti itiss dapat dapat diseba disebabka bkan n oleh oleh bakteri bakteri atau atau 0irus. 0irus. =abiri =abirinit nitis is bakteri bakteri supuratif- mungkin terjadi sebagai perluasan infeksi dari rongga telinga tengah melalui fistula tulang labirin oleh kolesteatom atau melalui foramen rotundum dan dan foram foramen en o0al o0alee tapi tapi dapa dapatt juga juga timb timbul ul sebag sebagai ai perlu perluasa asan n infek infeksi si dari dari meningitis meningitis bakteri melalui cairan yang menghubun menghubungkan gkan ruang subaraknoid subaraknoid denganruang perilimf di koklea, melalui akuaduktus koklearis atau melalui daerah kribrosa pada dasar modiolus koklea. %
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#. =abirin =abirinitis itis kronik kronik supura supuratif tif yaitu terlibat terlibatnya nya labirin labirin oleh bakteri bakteri dengan dengan respons inflamasi jaringan sudah dalam waktu yang lama. eadaan ini biasanya merupakan suatu komplikasi dari penyakit telinga tengah kronis dan penyakit mastoid. % $. =abirin =abirinitis itis fibrose fibroseus us yaitu suatu respons respons fibroseus fibroseus di mana mana terkont terkontroln rolnya ya proses inflamasi pada labirin dengan terbentuknya te rbentuknya jaringan fibrous sampai sa mpai obli obliter terasi asi dari dari ruan ruanga gan n labir labirin in deng dengan an terbe terbent ntuk ukny nyaa kalsi kalsifi fika kasi si dan dan osteogenesis. Stadium ini disebut juga stadium penyembuhan.% =abirinitis 0iral adalah infeksi labirin yang disebabkan oleh berbagai macam 0irus. Penyakit ini dikarakteristikkan dengan adanya berbagai penyakit yang disebabkan 0irus dengan gejala klinik yang berbeda seperti infeksi 0irus mumps, 0iru 0iruss influ influen enAa, Aa, dll. dll. Pada Pada labi labirin rinit itis is 0iral 0iral biasa biasany nyaa telin telinga ga yang yangdi dike kena naii unilateral.% Pada Pada labirin labiriniti itiss akut akut serou serouss- mikroo mikroorg rgani anisme sme penyeba penyebab b S. pneumo pneumoni, ni, Streptokokus dan 7emofilus influenAa. Pada labirinitis kronik mikroorganisme penyebab biasanya disebabkan campuran dari basil gram negatif, Pseudomonas, Proteus dan ;.coli. % Gamb Gambara aran n klin klinik ik deng dengan an adany adanyaa gang ganggu guan an 0esti 0estibu bula larr dan dan kuran kurangny gnyaa pendengaran didapati juga pada abses serebellum, miringitis bulosa dan miringitis hemoragika. Pemeriksaan telinga yang teliti diperlukan pada kasus ini
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6
'min 'mino oglik gliksi sida da
stre strept ptom omis isin in,,
neom eomisin isin,,
kanam anamis isin in,,
genta entam misin isin,,
/obramisin, /obramisin, 'mikasin dan yang baru adalah 3etilmisin dan Sisomisin. 6 Golo Golong ngan an mac macro roli lide de ;rit ;ritro romi misi sin n 6 'nti 'ntibi biot otik ik lai lain n klo klora ramf mfen enik ikol ol .- 8iuretik :urosemid, ;thyrynic acid, dan 2umetanides #.-
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.- Presbikusis neural /erjadi atrofi pada sel6sel saraf di koklea dan pada jalur hantaran suara ke saraf pusat. Dadi gangguan primer terdapat pada sel6sel saraf, sementara sel6 sel rambut di koklea masih dipertahank dipertahankan. an. Pada tipe ini, diskriminasi diskriminasi kata6 kata relatif lebih terganggu dengan hanya sedikit gangguan sel rambut. #.- Presbikusis metabolik strial presbikusis/erjad erjadiny inyaa atrofi atrofi pada pada stria stria 0askul 0askulari aris, s, dimana dimana stria stria 0askul 0askularis aris tampak tampak menciut menciut akan tetapi masih memberi skor diskriminasi diskriminasi yang bagus bagus terhadap terhadap suara walaupun proses degenerasi degenerasi menyebabka menyebabkan n ketulian ketulian sedang hingga berat. $.- Presbikusis mekanik presbikusis konduktif koklear/erjadi /erjadi oleh karena penebalan dan pengerasan membran basalis basa lis koklea. d. /uli mendadak /uli mendadak merupakan tuli sensorineural berat yang terjadi tiba6tiba tanpa tanpa diketah diketahui ui pasti pasti penyeba penyebabny bnya. a. /uli /uli mendad mendadak ak didefi didefinisi nisikan kan sebagai sebagai penurunan pendengaran sensorineural #! d2 atau lebih paling sedikit tiga frekuensi berturut6turut pada pemeriksaan audiometri dan berlangsung dalam waktu kurang dari tiga hari. *skemia koklea merupakan penyebab utama tuli mendadak, keadaan ini dapt disebabkan oleh karena spasme, trombosis atau perdarahan arteri auditi0a interna. Pembuluh darah ini merupakan suatu end
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perkembangan gelang basal, sehingga gelang kokhlea hanya satu sa tu setengah putaran dari yang seharusnya dua setengah putaran, dimana gelang tengah dan dan apik apikal al meny menyatu atu.. 8ige 8igene nesis sis orga organ n corti corti meny menyeba ebabk bkan an gang ganggu guan an 6
pendengaran. elainan ini diwariskan sebagai trait autosomal dominan.9 etu etulia lian n Sche Scheib ibe, e, dimana dimana labiri labirin n tula tulang ng berkem berkemban bang g penu penuh h namu namun n pars pars inferior berwujud gundukan sel6sel yang tidak berdiferensiasi. e lainan ini
6
diwariskan sebagai trait utosomalresesif .9 etu etulia lian n 'lea leand nder er,, dima dimana na tula tulang ng labi labirin rin berkem berkemba bang ng dengan dengan penu penuh h namun pars inferior. 'plasia yang berat ditemukan pada organ corti dan sel6sel gangglion putaran basal koklea di dekatnya. 2erakibat ketulian
6
frekuensi tinggi. 8i luar itu, labirin menbran dan tulang tampak normal. 9 .- /uli /uli kongenital kongenital dengan dengan asal non non genetik genetik @ube @ubela la yang yang masi masih h meru merupa paka kan n sala salah h satu satu peny penyebab ebab ters terser erin ing g dari dari tuli tuli kongenital non6genetik adalah rubela campak Derman-. 3amun dengan adany adanyaa 0aks 0aksin in rube rubela la yang yang terak terakhi hir, r, peny penyak akit it ini ini khus khusus usny nyaa dapa dapatt dielirninasi dielirninasi nantinya. nantinya. Dika seorang wanita terkena campak Derman selama tiga bulan pertamakehamilannya, maka besar kemungkinan bahwa bayinya akan akan mengala mengalami mi ketuli ketulian an sersor sersorineu ineural ral dalam dalam derajat derajat tertent tertentu. u. 'nak 'nak dengan rubela kongenital dapat pula menderita cacat lain, seperti cacat jantung,
retardasi
mental,
dan
kebutaan.
Pemeriksaan
patologi
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seperti seperti pegunu pegunung ngan an 'lpen 'lpen.. Ganggu Gangguan an penden pendengara garan n benifat benifat campur campuran, an,
6
sensorineural dan konduktif. 9 #.- /uli /uli genetik genetik didapat didapat atau atau lambat lambat /uli /uli sensori sensorineu neural ral yang yang bersifa bersifatt progresi progresif, f, sifat gene genetik tik dari dari tipe tipe hilangn hilangnya ya pendengaran ini memberikan bersamaan klinis berlebih terhadap tipe ketulian sensorineural lain. 8iagnosis benar tergantung anamnesis primer secara cermat dari masalah yang berhubungan dengan kejadian anggota keluar keluarga ga lain. lain. 8iagno 8iagnosis sis sering sering ditega ditegakka kkan n dengan dengan meniad meniadaka akan n semua semua kemungkin kemungkinan an penyebab penyebab ekstrinsik, ekstrinsik, hanya sisa6sisa penyebab penyebab intrinsik6 intrinsik6 khususnya, ketulian genetik6 kemungkinan yang paling mungkin. etulian biasanya bilateral dan memikirkan suatu penyakit autosomal dominan. 8apat timbul pada masa anak6anak atau masa dewasa yang dini dan akan berkembang hebat selama sisa hidup penderita. etulian genetik progresif ditandai adanya bilateral, umumnya datar atau konfigurasi sensorineural berbentuk6tasin pada audiogram dengan diskriminasi hampir baik. +ungkin +ungkin tidak adanya organ Corti dan sel ganglion ganglion spiralis pada putaran putaran
6
basal, dan paling penting, degenerasi tak teratur dari 0askularis stria.9 Peny Penyak akit it page paget. t.
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terlindung terlindung oleh letaknya letaknya yang di tengah. Dika tulang tulang temporal temporal patah, biasanya biasanya disertai gangguan gangguan lainnya. lainnya. :raktur :raktur longitudina longitudinall tulang temporal temporal
biasanya biasanya
menyebabkan telinga berdarah dan terjadi gangguan pendengaran konduktif. :raktur trans0ersal tulang temporal sering menyebabkan cedera labirin dan saraf facialis karena karena garis fraktur melintasi apeks petrosus atau labirin. labirin. Cedera labirin mungkintidak begitu berat dengan ketulian total. 9 /rauma /rauma akustik akustik agaknya agaknya meerupakan meerupakan penyebab penyebab ketulian ketulian sensorineural sensorineural yang paling umum. etulian sensorineural disebabkan oleh kerasnya suara maup maupun un laman lamanya ya papa paparan ran.. Occupa Occupatio tionl nl "a!ety "a!ety and Health Health #dmini #dministra stratio tion n
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/uli /uli akibat bising mempengaruhi mempengaruhi organ Corti di koklea koklea terutama terutama sel6sel rambu rambut. t. 8aera 8aerah h yang yang perta pertama ma terk terken enaa adala adalah h sel6se sel6sell rambu rambutt luar luar yang yang menunjukkan adanya degenerasi yang meningkat sesuai dengan intensitas dan lama paparan paparan.. Stereo Stereosili siliaa pada pada sel6sel sel6sel rambut rambut luar luar menjadi menjadi kurang kurang kaku kaku sehingg sehinggaa mengur mengurang angii respon respon terhad terhadap ap stimulas stimulasi. i. 8engan 8engan bertam bertambah bahnya nya intensitas dan durasi paparan akan dijumpai lebih banyak kerusakan seperti hilangnya stereosilia. 8aerah yang pertama kali terkena adalah daerah basal. 8engan hilangnya stereosilia, sel6sel rambut mati dan digantikan oleh jaringan parut. Semakin tinggi intensitas paparan bunyi, sel6sel rambut dalam dan sel6 sel penunjang juga rusak. 8engan semakin luasnya kerusakan pada sel6sel rambut rambut,, dapat dapat timbul timbul degenerasi degenerasi pada saraf saraf yang yang juga juga dapat dapat dijum dijumpai pai di nukleus pendengaran pada batang otak. 1#
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pendengaran dengan '28 secara efisien dibantu dengan membaca ucapan bibir, mimik dan gerakan anggota badan, serta bahasa isyarat untuk dapat berkomunikasi. 8isamping itu, oleh karena pasien mendengar suaranya sendiri juga sangat lemah, rehabilitasi suara juga diperlukan agar dapat mengendalikan 0olume, tinggi rendah dan irama percakapan. 1 2.$.2 &etro%o%lea
a. Penyakit +eniere Penyebab pasti penyakit +eniere belum diketahui. Penambahan 0olume endolimfe diperkirakanoleh adanya gangguan biokimia cairan endolimfe dan gangguan klinik pada membran labirin. 1$ Gejala klinis penyakit ini disebabkan adanya hidrops endolimfe pada koklea koklea dan 0estibu 0estibulum lum 7idrop 7idropss yang yang terjad terjadii mendad mendadak ak dan hilang hilang timbul timbul
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umumnya berkembang lambat. +eskipun demikia, neuroma akustik dapat pula menyebabkanketulian mendadak atau suatu sindrom mirip6meniere. 9 2.' Diagno!i!
.5.1. 'namnesis Pasien Pasien6pa 6pasien sien yang yang mengala mengalami mi penyak penyakit it teling telingaa dalam dalam mengelu mengeluhka hkan n gangguan pendengann, tinitus, dan gangguan kese imbangan. (angguan )en#engaran. 2eberapa faktor dalam anamnesis sering kali
emberi kesan tipe gangguan pendengaran yang dialami pasien. Pasien dengan ketuli ketulian an sensor sensorine ineural ural untuk untuk nada nada tinggi tinggi akan akan mengu menguraik raikan an ketida ketidakma kmampu mpuan an mendengar seorang pembicara wanita atau mengalami masalah dengan kata6kata tertentu berkonsonan tinggi seperti f, s, atau th *nggris-. 'dalah penting
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sebab sebab yang tida tidak k berh berhub ubun unga gan n deng dengan an sistem sistem kesei keseimb mban anga gan. n. Dika Dika pasi pasien en mengatakan mengatakan bahwa ia mengalami mengalami gangguan kesadaran atau merasa akan pingsan pingsan selama serangan pusing, maka lebih dimungkinkan suatu etiologi non60estibular. 8alam anamnesis, adalah penting mendapat data akurat mengenai waktu awitan, sifat6sifat fase awal pusing, akti0itas pasien pada saat awitan, lamanya gejala dan akhi akhirn rny ya
masa masa
pemu pemuli liha han. n.
Perj Perjal alan anan an
peny penyak akit it
juga juga
dipe diperj rjel elas as
deng dengan an
mendapatkan anamnesis frekuensi kekambuhan. Secara klasik, pusing 0estibular menimbulkan sensasi berputar baik pada pasien sendiri atau lingkungannya. Pada kasus yang lebih kronik dan pada kasus pusing perifer bilateral, pasien hanya dapat merasa mabuk atau amat goyah. Gejala pusing 0estibular sering pula disertai gejala somatik. Pasien akan mengeluh mual berat dan terkadang muntah pada saat serangan pusing 0estibular. Pasien dengan gejala6gejala 0estibular
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Gambar .%. Garpu /ala Peme Pemerik riksa saan an ini ini meru merupa pakan kan tes tes kualit kualitat atif. if. /erdap rdapat at bebe beberap rapaa macam tes penala, seperti tes @inne, tes He Heber, ber, dan tes Schwabach.$,
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/es Heber
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tungga tunggal. l. linis linisii harus harus melaku melakukan kan uji Heber bersam bersamaa uji lainny lainnyaa dan tidak tidak boleh diinterpretasi secara tersendiri.9 /es Schwabach ?ji Schwabach membandingkan hantaran tulang pasien dengan pemeriksa. Pasien Pasien dimint dimintaa melapo melaporka rkan n saat penala penala berget bergetar ar yang yang ditemp ditempelk elkan an pada pada
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