- A 38-year-old man was admitted to the hospital after falling from a roof and sustaining head injuries including a right ear tympanic fracture. - Imaging showed right os temporal and maxillary fractures as well as a suspected incus dislocation. - The patient was consulted by neurology, ENT and plastic surgery and monitored during his hospital stay. Elective surgery was planned to repair his facial bone fractures.

1. Day/ date: Sunday Morning / Dec 18th 2016
Doctors on duty: Arfiza, MD / Robert, MD / Dewi, MD/ Ayi, MD -
Iman, MD/ Tara, MD
Consultant on duty:
Harim Priyono, MD, ORL-HNS
Plastic Reconstruction Division Consultant on Duty
Dini Widiarni W., MD, ORL-HNS, PhD
Casualty Report

2. Identity
Male, 38 years old
Consult from Neurology
Department with suspected
Os Tympanic fracture and
Otalgia

3. Medical History
• History of fell off from the house roof with a height of
approximately 4 meters.
• He was unconscious and didn’t remember the
mechanism of how he fell.
• He had clear watery discharge from his right ear around
2 table spoon and stopped spontaneously. History of
ears discharge before the accident was denied. There
was pain on the right ear (VAS 3-4)
• There was blood mix with stickie mucus discharge from
his nose about 1 table spoon and stopped
spontaneously. History of nasal congestion, decrease of
smelling, and epistaxis before the accident were denied.
• There was no difficulty in opening his mouth.
• There was no discharge from mouth, no dyspnea

4. • There was no history of runny nose, and sneezing.
• There was no pain when swallowing, difficulty
swallowing, and chocking
 General condition: moderately ill
 Compos Mentis
 Dyspnoe (-) Stridor (-) inspiration and retraction (-).
 BP : 110/70mmHg RR: 20x/min
T : 36,5 HR: 88 x/min
O2 Sat : 99%
Medical History

5. Physical Examination
General condition:
moderately ill
There was dyspnea, no
stridor and no retraction
Vital sign:
• BP : 110/70mmH
RR : 20x/min
• T : 36,5
HR : 88 x/min
• O2 Sat : 99%

6. ENT Examination
• Right ear:
wide ear canal, there was laseration on one
third posterior of the ear canal at quarter right
area with central perforation of the tympanic
membrane with uneven borderline
Left ear:
• wide ear canal, no discharge, no cerumen,
intact tympanic membrane
Ear

7. ENT Examination
•Right nostril: wide nasal cavity, inferior turbinate hypertrophy,
there were clotting, there were no discharge nor active bleeding
•Left nostril: wide nasal cavity, inferior turbinate hypertrophy, no
secretion, right deviated septum
Nose
• Pharyngeal arch was symmetric, not hyperemic, uvula in the
middle, tonsil T1-T1 not hyperemic, posterior pharyngeal wall not
hyperemic, wide oropharyngeal space
Throat

8. ENT Examination
HALO TES : Negative
• Tuning Fork Test :
• Rinne Test :
• Right ear : Negative
• Left ear : Positive
• Weber Test : Lateralisation to the right ear

9. Local Examination
 Frontal region: lacerations -, excoriation -, hematoma -, edema
-, deformity -, crepitation –
 Right Orbital region : excoriation -, hematome + at right
inferior palpebarae, edema -, deformity -, crepitation -
intercanthal distance 1,5 cm -1,5 cm
 Left Orbital region: laceration -, excoriation -, hematome -,
edema -, deformity -, crepitation -, intercanthal distance 1,5 cm
-1,5 cm
 Nasal region: laceration -, excoriation -, hematome -, edema -,
crepitation -, deformity -,

10. Local Examination
Left Zygomatic region: laceration -, excoriation -, hematome -,
edema -, deformity -, crepitation -, malar depression –
Right Zygomatic region: laceration -, excoriation -, hematome
-, edema +, deformity +, crepitation +, malar depression -
Right Maxillary region: laceration 2 x 1 cm, excoriation -,
hematoma -, edema +, deformity -, crepitation - , floating maxilla
-
Left Maxillary region: laceration -, excoriation -, hematome -,
edema -, deformity -, crepitation -, floating maxilla -
Mandible region: laceration -, excoriation -, hematoma -,
edema -, deformity -, crepitation -, malocclusion -

11. ENT Examination

12. Working Diagnosis
Multiple fracture of facial bones (S02.92)
Post bloody discharge from the right ear (388.69)
Laseration of the right ear (S01.311A)

13. Management
Reported to Dini Widiarni, MD, ORL-HN, PhD:
1. Plastic reconstruction division of ENT Department will follow
up
2. Suggestion: 3D CT Scan of the facial bones and CT scan of
mastoid without contrast
3. Avamys nasal spray 2x2 puff
4. Dexamethasone 3 x 5 mg po
5. Kemicetin applied on the right ear canal

14. CT Scan of the Mastoid
October 18th 2016

15. CT Scan of the Mastoid
October 18th 2016

16. CT Scan of the Mastoid
October 18th 2016
- Right os temporal fracture
- Multiple fracture of the Anterior et lateral wall of the right maxilla
- Multiple fracture of the anterior wall of the external acustic canal with postero-
inferior dislocation of the fracture fragment
- Suspected of maleo-incudo junction dislocation dd/ fracture
- Konsolodation on the external acustic canal and tympanic cavity of the right
ear dd/ Bleeding, fluid collection
- Hematosinus of the right maxilla and right ethmoid
- Minimal thickening of the mucosa of the left maxilla sinus

17. Chest X-Ray Examination
October 18th 2016
- Lung and Heart
within normal
limit
- No Fracture at
costae

18. Cervical X-Ray Examination
October 18th 2016
- Straight cervical
- Osteophyt on the
anterior C5 apex
- No fracture at
cervical vertebrae

19. CT Scan of the brain
October 18th 2016

20. CT Scan of the brain
October 18th 2016
- Right zygomaticus fracture, infero-latero-antero
wall fracture of the right orbita, comminutive
fracture at the postero-latero-inferior right maxilla
sinus wall, right maxilla lateral wall and tympanic
part of the right temporal
- Bilateral haematosinus especially at the right
ethmoid
- Bleeding at the right external acoustic canal
- No subdural/ epidural/ subarachnoid bleeding and
intra parenchimal cerebri / cerebelli
- Soft tissue swelling at the right face region

21. (October 18th , 2016 06.00 AM)
Neurology Department
S : Adequate contact. There was
pain on the right ear
O : BP : 110/70 HR : 70x/min
RR : 18 x/min T : 36.6
O2 saturation: 98%
Eyes: normal shape and size of the
pupil
Cranial nerve : No sign of Paresis
Motoric: 55555 I 55555
Sensory: within normal limit
Autonomy: within normal limit
A :
- Comossio cerebri
- Os Tympanic fracture
- Multiple fracture of facial bone
- Elevation of liver function test
P:
-Consult to Plastic Surgery department
-Consult to ENT-HNS department
-IVFD NaCL 0,9 % 500 cc / 12 hours
-Ketorolac 3 x 30mg
-Ranitidine 2 x 50 mg
-Extrace 1 x 400 mg

22. (October 18th , 2016 09.15 AM)
Plastic Surgery Department
S : Right facial swollen since 22
Hours before admission, there was
history of fell off from the house roof
with unknown mechanism of how he
fell. There was history of
unconsiousness after the accident,
there was history of ear and nose
discharge,
O :
A: clear, C spine under controled
B: Spontaneous breathing (20 x/minutes)
C: TD 110/70 mmHg, HR : 88 x/ minutes
D: GCS 15
A :
- Right zygoma bone fracture
- Comossio Cerebri
P:
-Hospitalized by the Plastic Surgery
department
-Plan for elective ORIF
-Ceftriaxon 2 x 1 gr IV
-ketorolac 3 x 30mg stopped and
changed into oral form : Mefinal 3 x
500 mg po

23. (October 18th , 2016 16.15 PM)
Neurology Department
S : Adequate contact.
O : BP : 110/70 HR : 76x/min
RR : 20 x/min T : 37
O2 saturation: 98%
Eyes: normal shape and size of the
pupil
Cranial nerve : No sign of Paresis
Motoric: 55555 I 55555
Sensory: within normal limit
Autonomy: within normal limit
A :
- Commosio cerebri
- Right Os Tympanic fracture
- Multiple fracture of facial bone
- Elevation of liver function test
P:
-Round with Tirza A, Neurologist, PhD:
There was no indication for hospitalizing
the patient in neurology department. If
ENT-HNS department or Plastic Surgery
department will hospitalize the patient,
ENT-HNS / Plastic surgery department can
take over as a captain and neuro-trauma
division will follow up
-17.15 PM  Plastic surgery department
as a captain

24. (October 19th , 2016 16.15 PM)
Neuro-trauma division
S : Adequate contact.
O : BP : 130/80 HR : 78x/min
RR : 18 x/min T : 36.7
O2 saturation: 99%
Eyes: normal shape and size of the
pupil (3mm/3mm)
Cranial nerve : No sign of Paresis
Motoric: 55555 I 55555
Sensory: within normal limit
Autonomy: within normal limit
A :
- Commosio cerebri
- Right Os Tympanic fracture
- Multiple fracture of facial bone
- Elevation of liver function test
P:
-Ceftriaxone 2 x 1 gr IV
-Mefinal 3 x 500mg po
-Ranitidine 2 x 50 mg IV
-Extrace 1 x 400 mg IV

25. (October 20th , 2016 08.00 AM)
Neuro-trauma division
S : Adequate contact.
O : BP : 130/80 HR : 78x/min
RR : 18 x/min T : 36.7
O2 saturation: 99%
Eyes: normal shape and size of the
pupil (3mm/3mm)
Cranial nerve : No sign of Paresis
Motoric: 55555 I 55555
Sensory: within normal limit
Autonomy: within normal limit
A :
- Commosio cerebri
- Right Os Tympanic fracture
- Multiple fracture of facial bone
- Elevation of liver function test
P:
-Ceftriaxone 2 x 1 gr IV
-Mefinal 3 x 500mg po
-Ranitidine 2 x 50 mg IV
-Extrace 1 x 400 mg IV
Round with Yetti Ramli, Neurologist, PhD:
- Neuro-trauma division will not need
further follow up

26. (October 20th , 2016 07.00 AM)
Plastic Surgery Department
S : there was pain ( VAS 1-2)
O :
A: clear, C spine under controled
B: Spontaneous breathing (18 x/minutes)
C: TD 120/80 mmHg, HR : 85 x/ minutes
D: GCS 15
A :
- Right zygoma bone fracture
without any functional lesion
P:
-Plan for elective ORIF
-Ceftriaxon 2 x 1 gr IV
-Mefinal 3 x 500 mg po
-Ranitidine 2 x 50 mg IV
-Extrace 1 x 400 mg IV
-Operation tolerance

27. (December 20th, 2016 07.00 AM)
Plastic Reconstruction Division , ENT Dept
S : Pain VAS (1),
O : CM, there were no dyspnea,
stridor and retraction
BP : 120/80 HR : 78x/min
RR : 24 x/min T : 36.7
O2 saturation: 99%
Local examination :
Zygoma Region : There was malar
depression, oedema +, pain on
palpation +, deformity +
A :
• Multiple fracture of facial bones
(S02.92)
P:
• Plan for ORIF according to
Plastic Surgery Department

28. Thank You