Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello and welcome to session five of the Ulster University Surgical Series. My name is Michael and the topics for today are ent and ophthalmology. I have the pleasure of being joined by fellow committee member Joseph Tan, who's going to take ophthalmology and I'm going to tackle the ent core conditions. So just a quick disclaimer as always that the UU Surgical Series is a peer led revision series for educational purposes only. And the design and delivery of these materials is carried out by medical students and as such shouldn't be taken as professional medical advice. Whilst the materials have been designed as accurately as possible. It's possible that some of the materials might be out of date by the time the content is accessed. So, kicking off the session today, we'll start with a review of the gross anatomical structure of the ear, nose and throat in the eye as they relate to the core conditions. And this won't be detailed as there's, there's quite a lot to cover here. Then we will review the definition presentation and management of the T ent and ophthalmology core conditions. And here are some of them on the right now. I want to note here that there are only one or two ophthalmology core conditions for two year and those would be the ones that are covered in this session. I'd just like to advertise the Neurology and Ophthalmology Society in a couple of weeks time. We'll be doing a more in depth revision session on lots more ophthalmology conditions. So keep an eye out for that and hopefully these two sessions will support one another. And then as always, we'll we'll finish by having a look at some practice. Um single best answer questions. So ear, nose and throat, I thought we'd look at each of these individually. So doing ear, anatomy and ear conditions, nose, anatomy and nose conditions, and then throat, anatomy and throat conditions. So the gross anatomical structure of the ear, it can be split up into three external middle and inner and thinking about the anatomy in this way, helps us when we come to think about what can go wrong in each of these areas and and what conditions patients can present with. So, kicking off with the external ear, the external ear itself can be divided up into two substructures. First is the auricle, which is this cartilaginous structure that you see from from the outside and then the external acoustic meatus, which is in here. Now, the article functions to direct sound waves towards the external acoustic meatus. So all those external signs are almost funneled down by the article and all, all the structures in the article are are cartilaginous except from the earlobe. Then looking into the air, you come into the external acoustic mutus, which basically extends from the outside world right up to the point of the tympanic membrane. And the outer third of is is made of this cartilaginous material as you can see here and then the inner two thirds are formed by the temporal bone. OK. See see there and bone compared to cartilage, then you meet the tympanic membrane, colloquially known as the eardrum. And it is the innermost part of the external acoustic mutus. It's a connective tissue structure that's connected into the temporal bone by a fibrocartilaginous ring around the outside and immediately behind the drum is the later process on the handle of the malleus as you can see here. And this is what you'd see if you looked into the ear with an otoscope. Um and we'll come to those small bones in a minute. Now, the tympanic, the tympanic membrane is thin um can be easily perforated by trauma or infection. Um and particularly otitis media where fluid will build up behind the eardrum and increases the pressure behind it. So we'll come to that shortly. And these are the important structures in the external ear. So moving immediately behind the eardrum, we come to the middle ear and it has two main areas as well. The first is the tympanic cavity and this is on the medial side of the eardrum and it contains these little bones, the auditory obstacles, ok. These are the smallest bones in the body. Um They are the malleus, the incus and the sties, ok. These, these words mean hammer anvil and stirrups are named after their she and the purpose of these small bones is to aid conduction. So as the tympanic membrane vibrates that vibration conducts through the mala through the incus and through the STIs into the internal ear. And that's, that's the function of those. The second part of the middle ear is the epitympanic recess. And it's the space that the malice you can see here that the Malala extends up into and that little space contains mastoid air cells. Ok. So last week, we moved to the inner ear and the inner ear is, it's an amazing structure, but it can get quite complicated and we'll just cover the basics now. So the inner ear is located within the petrus part of the temporal bone. As you can see here, it's kind of it's kind of nestled into the bone of the skull. And in brief, the the main parts are firstly, the bony labyrinth and the bony labyrinth consists of the vestibule, the cochlea and the semicircular canals. Ok. Within these is a structure known as the membranous labyrinth. And this includes cochlear duct. It contains semicircular ducts, saccule and uric. And together this is all known as the vestibular apparatus and its function is to um, control our, our balance. So it is, this is really interesting stuff. It's, it's quite in depth. We're not going to cover it. Now, I'd encourage you to read up a little on it in your spare time. But um, it's unlikely that the intricacies of vestibular physiology are going to come up in the exams. But just knowing, being aware of these structures is probably enough in brief how sound works is sound vibrations will come in from external world. Um They'll, they'll cause a vibration of the tympanic membrane and and this causes oscillation or, or vibration that transmits through those auditory osc those little bones we mentioned before, this movement is transmitting the sound waves from the tympanic membrane through the bones. And to this area here, the oval window of the external ear or of sorry of the internal ear. Then the job of the inner ear, this quite complicated apparatus is to convert those mechanical vibrations into electrical signals. Ok. And it does this through quite a complex pathway that involves all sorts of fluids, um like Perilymph endolymph. And it can get quite confusing. But I think the main takeaway and what I really want you to know is that the purpose of the apparatus is to turn mechanical vibrations into electrical sounds which can be conducted down this nerve and into the brain. So now we've got an overview of the anatomy. Let's have a look at some of the conditions in the ear. So the first thing I want to talk about is otitis and this is inflammation of the ear as the name might suggest you can have on your core conditions list. There are two separate ones. There's Otitis Externa which refers to inflammation of the external ear and otitis media which is inflammation of the middle ear. Um So these are two separate conditions, but we're just going to tackle them together because there are many similarities. Now, the most common cause of both is bacterial infection with otitis externa. Um common causative organisms are pseudomonas and staph aureus. And then in media, you get Hemophilus influenza strep pneumonia and staph aureus as well. Again, the presentation for both is quite similar, patients might complain of ear pain or discharge. Sometimes they'll say they've woken up and there's some fluid from their pillow. Um the ear is often quite itchy, maybe some temporary hearing loss. If the ear becomes blocked with fluid, they might be systemically unwell with fever and things like runny nose, sore throat and a cough. So, on examination, then typically you see a bulging red tympanic membrane, um particularly in the case of otitis media. The bulging is suggestive that there's fluid in that middle cavity and it's putting pressure on the eardrum as you can see here on the right. Um That's quite classic of Otitis media, Otitis Externa. You might see a little bit of erythema and redness around the oracle that external part of the ear and you might see some reddening around the tympanic membrane or along the lining of the external acoustic meatus. But you probably wouldn't see this bulging, right. This bulging is quite suggestive of otitis media. There might be puss or discharge. In some cases, you might go in and see that the eardrum is actually perforated because of the pressure behind it. This on the left is a nice normal one. This is what you'd expect to see. It's a nice healthy, thin looking tissue, there's a little cone of light, it's nice and shiny and you can see the lateral process of the malleus just in behind on examination of their neck, they might also have some lymph nodes up as well. And with this clinical picture, you can usually make the diagnosis clinically if you really wanted to, you could take a swab of any pus or anything to determine the organism. So how do we manage it? Um The big thing to know about both otitis externa and media is that most cases are going to resolve on their own. Um But for externa, you need to avoid some of the exacerbating factors. So swimming is a big cause. There's lots of bacteria in swimming pools and it just sits in the external air. So um you need to keep that air dry and avoid things like that. And it can usually be managed with simple pain relief over the counter stuff like paracetamol and ibuprofen. If not resolving with that, you can think about some things like topical antibiotics and if the air is really inflamed, you might have a think about steroid drops for media. Again, most cases are going to resolve on their own within three or four days. Now, if the patient's systemically unwell with fever or, or you really just don't have a good feeling about it, you can consider antibiotics. Amoxicillin would be first line and then um in, in an allergy, allergy to penicillin, you would turn to Clarithromycin when you would refer to ent for admission is if a child is presenting with um significant symptoms and a temperature of 38 or more or maybe in younger Children like 3 to 6 months. If their temperature was over 39 you'd be wanting ent to have a look and that's to avoid some, some of the complications. So big things Otitis media with a fusion where you can get more fluid accumulation in that ear and you're at higher risk of eardrum rupture, you can have some temporary hearing loss with this maybe labyrinthitis where it's disturbing that vestibular apparatus and causing dizziness and rare but serious complication is mastoiditis where the infection is spreading to that mastoid process and the bone in. And here you would really, really need ent or pediatrics input. So, here's another condition that was on the list that you just needed to know the principles of this is cholesteatoma. So what this is is a collection of proliferating squamous epithelial cells in the middle ear. And we don't really know what causes this. Um There may be thought to be both acquired and congenital components. And the current understanding is that when there's dysfunction of the eustachian tube and maybe an anatomical variant in it or um some physiological dysfunction that this can cause a retraction of the tympanic membrane. Ok. Almost imagine um like a hoover in the inner ear that's sucking the the tympanic membrane in. And as that eardrum gets sucked in and those cells are proliferating, they start spreading and growing into nearby structures. So how do they present? Typically, there is a foul smelling discharge from the ear and they will have hearing loss on that side. And if these cells have started invading into other structures like bone or even into the the hearing apparatus and the nerves, the patient might be experiencing infective symptoms, they might be in a lot of pain, they might have vertigo and if it spread into the facial nerve, they might have a facial nerve palsy and that would be quite serious invasion. So, diagnosis is usually with a CT of the head and this is kind of what it looks like. There's the, if you're looking inside the ear on otoscopy, you might see a bit of a sort of ulcerating mass on the wall of the ear canal. And you might see a little bit of retraction on the eardrum might be quite subtle and definitive treatment of this. All you need to know is that it's with surgical removement of the cholesteatoma by an ent surgeon. Ok. So that rounds off the ear anatomy and conditions. Now we move on to the nose. So again, the nose can be divided into external and internal. And there's a lot of complicated structures in the nose. So we'll stick to the basics on the external nose. There is a bony component and a cartilaginous component. The bony bit is the bit at the top, the superior part closer to the orbits and it has contributions from the nasal bone, the maxilla and the frontal bone of the skull then down lower is the cartilaginous component. And it has lateral cartilages, alar cartilages and a septal cartilage which is in the middle. Um So the skin over the bony part is, is thin and then overlying the cartilage part in the inferior nose is thicker and it's got sebaceous glands. Um and that skin extends into the vestibule of the nose. And those nose hairs have a have a important function. They filter air as it enters the respiratory system trying to keep particles and things out of the airway. All right. So let's look at the internal nasal cavity. So the nose is a respiratory organ, but it's also an olfactory organ and it has a nasal skeleton which houses the, the cavity itself. And this nasal cavity has a couple of important functions. So the first, it warms and humidifies air as you breathe in, it warms the air. Um, it removes and traps any germs or pathogens or particles that you've breathed in. And it also contributes to the sense of smell and picks up smells and, and transmit those to the brain through the olfactory nerves. Then lastly, it drains and clears the paranasal sinuses and the lacrimal ducts, which we'll have a wee look at in a moment, the vestibule is the anterior part of the nose. Ok. This part in here and it's a respiratory region and it is lined with mucous secreting cells. And as you can see here, um con air like mucosal, bony mucosal folds that humidify air by increasing the surface area on the inside of the nose. So air is held in the nose for longer when you breathe in through the nose. These folds, their purpose is to slow that flow. Keep air in the cavity for longer and warm it up in the process. And then that superior part is the olfactory region, which as you can see, um the olfactory bulb, one of it's our first cranial nerve sitting along the rem plate. And those little nerve fibers extend down into the olfactory region of the nose. And that's how we pick up smells at the back of the nose. It's important to or the back of the nasal cavity is the artery tube opening. And that's also known as the eustachian tube that we discussed before and that connects the nasal cavity to the middle ear and it's a common route for infection spread. So this is why quite often when we have a common cold, it can affect um the upper airway and it can be a sore throat or a runny nose. And that will also mute our hearing a little bit as well. It's because these, these structures are all connected by the Eustachian tube. Now, I want to also briefly cover the paranasal sinuses. And these are useful because these are a common site for infection spread. And we can often feel congested here during an upper respiratory tract illness. And again, the functions of the paranasal sinuses. We have, we have four groups. We have the maxillary here and here we have frontal up top and then in behind, we have ethmoidal and sphenoidal sinuses. The functions are to humidify the air again and warm it up as we breathe in. They also have immune properties and can fight infection um and try and stop that from getting lower into the respiratory tract. Then they also play an important role of making the skull lighter. So these are, these are sacks of air. Um and the skull can be quite heavy on our shoulders. But by having these air filled spaces, it takes some of the weight off and then they also have an important role in phonation in the, the resonance of our voice. So you'll notice that um when we are sick and when we're congested, we almost our voice changes a little bit and all of us gets a bit meter and a little high pitched because um we're congested in these sinuses. So now we have the basics of nasal anatomy. Let's look at the condition that's on the list for two years. So, rhinosinusitis and polyps. So, rhinosinusitis is inflammation of that nasal mucosa and or the paranasal sinuses. Um and that can be split up into acute or chronic. If it's over 12 weeks, we would call that a chronic rhinosinusitis and then polyps is it's its own condition, but quite commonly, it's a complication of chronic rhinosinusitis and it's growth of the nasal mucosa. Um and it's associated with anything that's um chronically inflamed inside the nose. So, what causes it? There are a couple of different buckets you can put the causes into versus infection that can be viral or bacterial. You can get inflammation of the nasal cavity with allergic disease such as hay fever. Um, we'd call that allergic rhinitis. I think we've probably all experienced that at one stage, you can have a mechanical obstruction. So a foreign body um trauma or, or if you've got existing polyps that can cause inflammation. And then another biggie is smoking. Ok. So that constant irritation of smoke in the nasal cavity um can cause inflammation how do these patients present? Well, congestion is a big one. Sometimes they'll have nasal nasal discharge or even running, which we'd call rhinorrhea. Um If those, those sinuses are congested, they might experience facial pain or a sense of pressure over the face. Um anosmia, which is the loss of smell and difficulty breathing through the nose, especially if there's polyps blocking that, that flow of air. And you'd investigate these patients with by examining the nose with a nasal endoscope or otoscope. And then for specialist camera testing, you do nasal endoscopy if symptoms persist after the initial treatment. And that would typically be managed by an ent surgeon or someone appropriately trained. And to diagnose this acute diagnosis of this is is clinical. Um and the things you're looking for sudden onset of nasal obstruction, that would be a very obvious clue. If they said they've had some trauma or um something's been lodged up there, particularly in a child. They can lodge things in their nose if they are presenting with discolored nasal discharge, um or facial pain or pressure and maybe an altered sense of smell. If they've got any of these things, typically two or more, you you can probably diagnose acute rhinosinusitis clinically for a diagnosis of chronic rhinosinusitis, it requires that nasal endoscopy. Ok. So usually patients will present with an acute episode. It won't, it won't improve with the treatment. And then you would be referring to ent for a closer camera test. So how do you manage these patients? As with a lot of upper respiratory tract infections and inflammation. It's the milder cases are usually self-limiting. You'll get away with some pain relief. You might want to think about some nasal irrigation where you um do toileting of the nose to wash it out and get rid of any debris. And you could prescribe in general practice something like a decongestion spray which would try to open up the airways a bit and, and resolve the inflammation if symptoms are really persistent and you think there's maybe a bacterial cause underlying that you could consider antibiotics such as ent and a steroid spray for the nose. And then as I said, if there's no improvement after these initial treatment steps, you'd query. If there's something else going on, you, you'd refer to ent for nasal endoscopy and get a really good look. So the patients that have chronic rhinosinusitis, these patients tend to get regular nasal irrigation, they'll almost always have a decongestion spray on them and you'd advise them to avoid their triggers. So if they are smokers, you really need to counsel on smoking cessation. Um if it's an aller allergic cause like hay fever, you'd want to get rid on top of that with antihistamines, et cetera, then if there's severe symptoms and you think there's maybe obstruction, you could consider surgery. And again, this would be managed by ent specialist and the two, some types are functional endoscopic sinus surgery. And if the cause is obstructive polyps, you would do a polypectomy. Some of the complications we want to avoid in the acute. Do you know the nasal cavity is very close to a number of other important structures? The eyes are right there. Um And the skull is very close by. So some of the acute complications would be periorbital cellulitis for that infection. Infection is spreading up to um the orbits. Chronic, chronic rhinosinus patients can get what's called a mucocele. It's just a collection of that mucus in the cavity, um which would need to come out as that poses a very uncomfortable obstruction. And then some of the, the complications from sinus surgery can include bleeding, infection, orbital hematoma and you can get um injury to the orbits or the anterior skull base as well. Ok. So we've covered that useful little nasal condition. That's something you'll come across lots in general practice and ent now we move over to our throat anatomy. So, starting with the pharynx. Now, the pharynx is commonly referred to as the back of the throat. Ok. And it's split up into three parts. You have the nasopharynx at the top, which is continuous with the nasal cavity that we discussed earlier. And it's lined with a ciliated pseudostratified columnar epithelium and mucous secreting goblet cells to keep that area moist, moving on down. Then we have the oropharynx located between the soft palate and the superior border of the epiglottis. And it, the structures there include the posterior part of the tongue are lingual tonsils or palatine tonsils. Then lower down we have what's called the laryngopharynx or some texts will, will refer to as the hypopharynx. And this is between the superior border of the epiglottis and the inferior border of the cricoid cartilage. And it continues, it gets to that point and then continues as the esophagus. A quick note on the epiglottis just here, the epiglottis is quite an elastic, almost leaf shaped cartilage and it covers the opening of the larynx. So the larynx, um the pharynx comes all the way down here to the laryngopharynx and then becomes the larynx down into the airway. Um And then the anterior continuation is done at the esophagus. When we swallow, there is a risk of food going down into the larynx into the airway because these two tubes are so close together. So the purpose of that epiglottis is um to cover the opening of the airway when we swallow. So that food and liquid go into the esophagus rather than into the lungs. I just want to note here that there are, this is just a gross anatomical structure of the throat. There are lots of intrinsic and extrinsic muscles of the FX that are useful to have a look at. But you could do a whole session on these on, on their own and it would be a really long session. So we'll not cover those today, but do have a look at those in your own time. So, moving down the respiratory tract, we come to the larynx or sometimes known as the voice box and it's located in the anterior neck. It's a very important part of the respiratory tract. It has important roles in phonation, obviously, with our vocal cords sitting in this area, um it's involving the cough reflex and also these cartilaginous structures serve an important protective role for our respiratory tract as well. The larynx is a really complex structure. Um I certainly found it quite difficult to learn. We'll cover the basics. Now. Um Let's start on the outside. The outer larynx is formed by a skeleton of cartilage and muscle. Um And it's these muscles and these cartilage that allow the larynx to move up and down with speech and with swallowing and for protection. And there are some subsections of the internal laryngeal cavity. There's the, if you look over to this, this diagram here, it splits it up quite nicely. So this is as if you've sliced the larynx in half, you have the supraglottis, the glottis and the subglottis super meaning above, sub meaning below. Ok. So that's easy to remember. The supraglottis is the space between this epiglottic cartilage we discussed earlier and the vestibular folds in here. Then the glottis is the important area that contains the vocal fold, the vocal folds, two important pieces of cartilage that come together um to assist in our speech and then subglottis, the area beneath the glottis um goes from the inferior glottis to the inferior border of the cricoid cartilage. OK. This diagram up here shows you, it gives you a good idea of where the cricoid cartilage sits. As I said, the larynx is really complex. There are lots of internal structures, lots of muscles around the outside that are beyond the scope of this presentation. What I want you to know at the moment is the supporting structures on the outside. OK. And you've got a series of unpaired, unpaired cartilages. Um and some of the subsections of the internal larynx and, and kind of the borders of those. And lastly, I just wanted to touch quickly on the tonsils, which will be really relevant when we come to, to discuss tonsillitis in a few moments. Um So what are the tonsils? They're, they're collections of lymphatic tissue located in the pharynx and they have a really important role in first line defense against infection of the nasal or oral cavities. Um There are four groups to be aware of. There is the fron jail tonsil. You have one of those, you have 22 tubal tonsils, two palatine tonsils and one lingual tonsils. And they're arranged in a ring kind of like this and that's sometimes known as old Irish ring and the tonsils contain T cells, b cells and macrophages. And that's how they um attack pathogens that get in through the nasopharynx or the oropharynx. You commonly associate tonsils with just these ones, the ones that you see when they're all swollen and inflamed. Ok. When you open the mouth, the, the fal tubal and lingual tonsils aren't as obvious. The ones that you can usually see are these big ones here at the back, either side of the uvula and those are your palatine tonsils and those are the ones that are relevant for tonsillitis. So finally, we move on to conditions of the throat. Ok. So I'm starting with two really important conditions. They're um, quite similar. So I thought we'd tackle them together and they're so common if I had to venture a guess, I, I'd say that pharyngitis would be the most commonly occurring presentation to, to GP. And you'll see this so much in your placement. So it's really useful to be able to recognize these cases. So we'll start with pharyngitis, which as the name suggests, is inflammation of the pharynx or the back of the throat more often than not. It's a viral cause. And it's been associated with Epstein Barr adenoviruses, enteroviruses influenza if it is a bacterial cause. The most common one is grip by strep. And we know that these present with a sore throat. If it's painful to swallow, the, the throat is red and inflamed when we look inside. And in some cases, the lymph nodes might be raised as well. So I think all of us have probably suffered from this at some stage. So we know what it's like. No, you can usually make this this diagnosis clinically just based on the history and the clinical features. But if you are to do some investigations, you can do a group, a strep antigen test or a throat swab if you're suspecting other bacterial causes. But nine times out of 10, these aren't required. So laryngitis then can present very similarly. Um as the name suggests, inflammation of the larynx or further down the vocal cords. And again, the most common cause is viral. And rhinovirus is often the culprit, other bacterial causes, you might come across would be homophilic strep pneumonia or staph aureus. And you can also get laryngitis from noninfectious causes. So you can have an irritated larynx maybe due to smoke or some other toxic exposure. You can get laryngitis in an allergic reaction. Um, traumatic laryngitis is quite a common one. You call it singer's throat. Um, if anybody is a singer and they know how it feels when they've been, um, we've been doing a lot of singing and they, they, they know that the voice can get tired and the voice can, can change in ways or if you've been at a concert or something and you've been shouting and we all know that feeling where um we've been speaking at loud volumes and really working our larynx and, and that can be sore the next day, you can get reflux laryngitis. Remember the close relation of the esophagus to the larynx and sometimes reflux um acids will come up the esophagus and fall back down into the airway and irritate the larynx. Then some other rarer causes like fungal causes um can be associated with candida albicans. Um but II have yet to see one of these causes but it can happen. So a patient has presented to you with symptoms of either pharyngitis or laryngitis. What are you going to do for them? So as is the case with loads of these upper respiratory tract infections, supportive care is really the mainstay of treatment. So getting on top of the pain with good analgesic relief and symptom control. So you might prescribe a throat spray like diam or that can be bought over the counter. Um Pharyngitis is, is usually self-limiting and it will go away on its own. The body's quite good at dealing with it. You do have an option to provide a delayed prescription of antibiotics. And what that means is that say to the patient, look, take this antibiotic just to have, try not to take it for two or three days, see if it resolves on its own and if it doesn't then start on the antibiotic and, and patients and from what I've seen on my placements are, are usually quite open to trying this with laryngitis. Again, the key is supportive care, good analgesic relief. Um quite often the the voice box is strain. So we talk about vocal hygiene, good voice rest, no shouting or minimal singing. If, if that's what you've been doing in your spare time, good hydration and trying to avoid caffeine for a couple of days typically helps as well. You can consider it mucolytic drugs. And what this does is is break up the mucus down, down in the airway. Now, what we tend to do if we have mucus, we'll, we will try to clear our throat or cough it up and by clearing the throat and coughing that irritates the, that irritates the larynx more. So by using mucolytics and getting those, those um mucous clumps in our, in our lungs broken down into smaller pieces. We'll be less likely to start coughing and trying to clear our throat, which is good um and helps the larynx rest if it's necessary and symptoms aren't improving on their own, you need to start thinking about an underlying cause and um and treating that appropriately. So, if you identify a bacterial cause antibiotics, if it's a fungal cause antifungals and so on, and there are local guidelines for each of these. Alright. So now let's have a think about tonsillitis. Tonsilitis is inflammation of the palatine tonsils. All right. It's really common and it's really important to be able to recognize a case of tonsillitis because if untreated, um it can have some complications. So what are the top causes more often than not. It's a viral cause. And some of the viruses are Adenovirus rhinovirus influenza. And in a smaller number of cases, it's going to have a bacterial cause and group a strep is probably the most common these patients present with. Again, as you can imagine, throat pain, difficulty swallowing and they might have a bad taste in their mouth, particularly if there's pus and exigent from the tonsils. The lymph nodes might be swollen and tender and they might feel feverish on examination. Then you look in the back of the throat with a tongue depressor and a light, you'll typically see red, swollen, angry looking tonsils really enlarged. They might have yellow puss and exuded, streaming off of them. As you can see in this picture here, this is quite a classic case that you might see they might have lymph nodes enlarged in the neck and they might have a temperature. So, one of the big considerations for tonsillitis is is it a bacterial cause or is it a viral cause? Now knowing the probability it's most likely going to be a viral cause in the majority of cases. But the center criteria is useful in primary care to determine if a bacterial cause is likely. And therefore, if you should be giving antibiotics to the patient. So if two or more of these features are present, you're going to consider an antibiotic. So, is there a history of fever? Is there a pus and exit from the tonsils. Is there an absence of a cough and is there tender, tender, enlarged lymph nodes in the neck? If there are two more of those, an antibiotic might be a safe option. In viral cases, usually analgesia and some sort of symptom relief delam spray is is enough and this um the body will deal with the virus on its own. And then if indicated by a centaur criteria, you could consider antibiotics and pen V is, is usually first line. If indicated, you might need a referral to ent for surgical management and removal of the tonsils if um it's really problematic. And one of the topics exam seems to like are indications for tonsillectomy. So if you have seven or more episodes in a year or you have five or more episodes per year for two years or three or three or more episodes a year for three years. Those are typically um particularly in Children. Those would be indications for removing the tonsils because they are consistently problematic. Other indications would be if you think there's a malignancy, um if there's causing difficulty breathing or if you've had two previous peritonsillar abscesses and these are all things that would mean ent would be, would be thinking of removing the tonsils with tonsillectomy. Now I've mentioned there peritonsillar abscess and I just want to touch on this for a moment because it's an important complication to be aware of. So, in untreated tonsillitis or persistent tonsillitis, you become at risk of what's called a peritonsillar abscess, also known as Quincy. This is an abscess that just grows at the back of the throat. It's often, it's often confused for, for tonsillitis. Um, but this is a really dangerous complication. It's if you imagine it's an abscess growing at the back of the throat and very slowly will start closing off the airway and this needs incision and drainage as soon as possible. All right, the final core condition in the ent segment of this session is infectious mononucleosis. Um, pally known as glandular fever. So this is, it's a clinical syndrome most commonly caused by EBV. And that's, that accounts for about 80 to 90% of cases. It's sometimes called kissing disease because the disease is present in saliva and it's transmitted through exchange of saliva like in kissing. The clinical features are usually throat pain. It might be fever, fatigue. Um There might be some enlarged lymph nodes and then splenomegaly in severe cases. Um usually adolescents and Children deal with the symptoms a bit better. And for glandular fever in adults, the symptoms are a little more severe. So, investigations you're gonna do a full blood count. Um and lymphocytosis is shown in 70% of these results. And then there's a couple of special tests that you need to be aware of for diagnosing infectious mononucleosis. So, some of the antibody testings you'll do, you'll send away a monospot test and a Paul Bunnell test. Now, a monospot test introduces the patient's blood to horse blood. And if there are heterophile antibodies present, there'll be a reaction to the horse's red blood cells. So, heterophile antibodies are produced by the body in response to active glandular fever infection. So, these tests are good for identifying the presence of, of those antibodies and therefore confirming the diagnosis. There are also some um EBV antibodies you can send away for, you can test for IgM, which can, which suggests an acute active infection. And then I GG which would suggest that you've either had the infection before and you're now immune to it. How do you manage these patients again? Like a lot of the other conditions, they're usually self-limiting, which is good. Um And the illness will tend to subside within two or three weeks. And some of the advice you need to give patients are keep on top of your pain relief, stay well, hydrated, avoid alcohol. And then really important as we we discussed earlier, there's a, a risk of splenic rupture, you need to avoid contact sports. Um So things like rugby um or any of those sports, in fact, probably all sports is better because you're at increased risk of splenic um of the spleen rupturing, um which is really serious. Ok, folks that brings us to the end of the ent anatomy and core conditions. Thanks for staying with us so far. Some of the things we didn't cover that I encourage you to read up on are the physiology of hearing muscles of the FX and the larynx. And then one of the conditions we didn't cover that is in the T year conditions list is head and neck carcinoma just because this would have made the session very long. But there is a good two year P bl case and some lectures that cover this in good detail. So I'd refer you to those. Now I'm going to pass over to Joseph who's going to walk us through some ophthalmic anatomy and the core conditions for two year. And I'll rejoin you back at the end for some practice. Questions. See you then, hello folks. We now come to the ophthalmology section of the talk. We begin with anatomy. As always the eye is our specialized sensory organ for sight to do. So it detects light that enters our eye through the pupil, hitting the retina, light gets converted to electrical signals, which is sent via the optic nerve to our brain. Regarding the eyeball itself, we divide the anatomy into three layers, outer middle and inner layers. We also need to orientate ourselves to anterior and posterior ends of the eye. This being the anterior and this being posterior. With that in mind, let us begin exploring the layers of the eye. The outer layer of the eye consists of the sclera and cornea. The sclera is the white of the eye and is a tough fibrous connective tissue that contains the contents of the eye highlighted here in blue. It is also the site of attachment for the extraocular muscles. These are the muscles that move the eye moving anteriorly. We have the cornea which is a transparent outer layer of tissue that covers the iris and pupil. This contrast with the sclera which is opaque. The cornea is actually where most light refraction occurs with the lens only fine tuning this refraction where the sclera and cornea meet the cornea sclero junction is called the limbus. The limbus has a population of stem cells which supplies the cornea as it is avascular itself. This is where the conjunctiva is found. There are two parts with the first part covering the anterior sclera before doubling back on itself and covering the inside of the eyelid. These two parts are called the bulbar and palpebral conjunctiva respectively. We now move on to the middle layer. Its main function is for vascularity and to provide nutrients to the eye. It is also called the uvea or vascular tunic. Because of this, it consists of three layers itself. The choroid, the ciliary body and the iris highlighted here, the choroid is a thin but highly vascularized area and is responsible for the majority of the blood flow for the eye. It continues anteriorly before thickening and becoming the ciliary body. The ciliary body is responsible for aqueous human production and contains the attachments for the lens by the zonular fibers, these small wispy looking fibers that hold the lens in place. The ciliary body also contains the ciliary muscle. And together with the zonular fibers can change the shape of the lens when contracting this is called accommodation and is used to change the focus of the lens when looking at objects far away or close up in conditions such as myopia, the lens is unable to accommodate appropriately and glasses are used to correct this. Finally, the middle layer extends to the iris. The iris is responsible for eye color and that has an opening in the middle, the pupil, smooth muscles within the iris can change the size of this opening or the aperture of the pupil to control the amount of light entering the eye. Last but not least we have the inner layer. This is made up of the retina. The retina itself is a very complex topic but broadly speaking, there are two layers of the retina, the outer layer and inner layer. The outer layer is called the pigment layer and that extends fully anteriorly in the eye due to the pigment, it assists the choroid with absorbing light to avoid scattering in the eye. Otherwise we wouldn't get a clear picture but no vision is detected by this layer. The neural layer is where that occurs. It contains the photoreceptors necessary for sight. There are two types rods and cones with rods being for vision. In low light and cones being for colors. The macular is where visual acuity is best with the middle of it. The fovea being where the greatest concentration of cones are. When we talk about macular degeneration, it is the loss of these photoreceptor cells. And therefore, visual acuity that often occurs due to age. The neuro layer does not continue fully anteriorly stopping at the ora serrata. I now want to talk about humor and the chambers of the eye. The eye is divided into three chambers, the anterior chamber, posterior chamber and vitreous chamber. The vitreous chamber is filled with vitreous humor which is mainly there to hold the shape of the eye. Some refraction also occurs here. The aqueous humor, the other type is produced by the ciliary body. It flows out from the posterior chamber to the anterior chamber where it is then drained past the trabecular network through the canal of sle and eventually draining back to venous circulation. This is clinically relevant as glaucoma is a condition where this drainage is affected. We are now going to discuss some common conditions with the eye. The only core condition listed for ophthalmology is conjunctivitis. However, I decided to also talk about glaucoma and cataracts as these are very common conditions you are likely to encounter on clinical placement. Conjunctivitis is literally inflammation of the conjunctiva. It is the most common cause of an acute red eye and there are three types bacterial viral and allergic. The three types will have differences in presentation and treatment. So it is important to distinguish between them. However, signs and symptoms common to all of them include a red sore eye with some discharge. The eye can also be described as being itchy or feeling gritty. This table summarizes the main differences between the types. Importantly, bacterial conjunctivitis has what is called a purulent discharge as seen in image in the previous slide. It often starts in one eye but symptoms quickly occur in the other. A common presenting complaint is the patient waking up with their eyes stuck due to discharge in viral conjunctivitis. The discharge is more thin and watery often being accompanied by signs of a general viral infection. In allergic types. The symptoms can be seasonal coinciding with classical allergy. Symptoms, often both eyes are affected simultaneously with uncomplicated conjunctivitis. All times are self limiting, usually being restricted to five days or so. However, we tend to treat bacterial conjunctivitis with chlorophenol topically. First for severe infections, chloroquinol such as Ciprofloxacin, eye drops can be used as well. Be careful with prescribing chloramphenicol to Children under two years of age. Chloramphenicol and its metabolites are actually toxic in high enough levels. Usually a functioning liver and kidneys will metabolize this safely. But in neonates, there is a risk that they would be unable to process the drug and eventually have a reaction to the build up physically. Their skin will turn in ash and gray color and it is fatal if not treated. So, referral for specialist advice is needed in these cases in viral conjunctivitis, supportive management is what is recommended, warm compresses and washes can be used on the eye along with lubricating tears to manage symptoms. Both types of infective conjunctivitis are highly contagious. So good hand washing should be recommended as well. Allergic conjunctivitis is usually managed alongside other allergy symptoms. So, oral antihistamines are often used, sometimes only eye symptoms are present and there are antihistamine, eye drops available. There is also a special case to refer someone who wears contact lenses. This is because they tend to grow more nasty infections and will need more intense management. Two types of bacterial conjunctivitis also need to be seen by ophthalmology. Those are gonococcal and chlamydial conjunctivitis. Usually the symptoms are a bit more severe and longer lasting up to two weeks in some cases. And there may be history of sexual contact if so, they will need swabs of their eye to confirm infection. And a referral to ophthalmology. I mentioned earlier that glaucoma is a condition affecting aqueous humor, drainage. What happens is aqueous humor is not draining but is still being produced with more volume within a finite space. There comes an increase in pressure, this back pressure then pushes on the optic nerve which can damage it. This can lead to irreversible damage to the optic nerve and permanent loss of vision. You need three characteristics to officially diagnose glaucoma. There needs to be raised intraocular pressure, but you also need to have optic disc cupping and visual field losses. Increased intraocular pressure alone is called intraocular hypertension. Once again, there are two main types of glaucoma, primary open angle and acute closed angle in primary open angle, glaucoma. The issue is in the trabecular network, draining the aqueous humor from the anterior chamber. Acute closed angle is when the issue is with the iris stopping aqueous humor from draining from the posterior chamber. This is one of the few ophthalmic emergencies and should be managed as soon as possible. The differences are outlined beautifully in this diagram here. Finally, we come to cataracts. The word itself means waterfall and this is to describe the white opaqueness that starts to develop in the lens compared to white water patients present with blurred vision and increased sensitivity to glare. You can sometimes physically see the blurred lens and they will have a reduced red reflex. The only management is surgery. The procedure is a very satisfying one. An incision is made through the cornea and the capsule that contains the lens is carefully opened. Once opened, the lens gets dissolved via phacoemulsification and aspirated out. Then the new artificial lens is put in place over time. The capsule, the only remaining part of the lens can itself get blurry. This is managed with something called yag laser capsulotomy. This is a very common procedure that you are likely to encounter on placement. And that's it. We talked through a very quick tour of the eye starting with the basic anatomy. We then discussed some common conditions. And finally, there is an SBA practice question. At the end, there are a lot of things that we didn't talk about including the physiology of vision, extraocular muscles, visual fields and visual pathway. These are all really important topics to cover, but we decided not to talk about them in this talk. I do strongly recommend that you look him up. You also notice I didn't go into as much detail with the other two conditions, glaucoma and cataracts. Uh This is mainly because they are not second year core conditions. But if you'd like, please read up on them as they are very interesting and very common. Finally, if you have any questions, you know where to find us, I'll now hand you back to Michael to finish up. Thanks for listening. All right. Thanks to Joseph for walking us through those eye conditions and now is a good time to have a look at some practice questions. So pause the video now and have a read through this question and give it a go. Alright, so hopefully you noticed from the case that this is um a patient presenting with otitis media and we know that because of the pale bulging tympanic membrane and that's suggesting that there's fluid in behind that eardrum. So given the likely diagnosis and the history of what's the most appropriate first line management. Well done. If you selected c analgesia, now you might think about oral antibiotics. But because the, the, the stem suggests that she does not have a fever that she's systemically well. And really, it's only a 24 hour history of, of ear pain. Um, and, and, and minimal other symptoms. Really a good place to start is analgesia. And remember we're trying to manage these as conservatively as possible. Well done if you got that right. All right. Pause the video now and have a go with this one. All right. So the answer to this question is a a cholesteatoma well done if you've got this right. So the patients presenting with some of those key things you're listening out for foul smelling discharge and on otoscopy, you can see a retracted tympanic membrane. Remember a cholesteatoma causes the air jump to retract inwards and those cells then start proliferating elsewhere for me, a cholesteatoma and you can see the, the white mass on examination. So well done. If you've managed to get this one question, three, pause and have a go. Ok. So here is a young child who has been brought to the GP sore throat lasting for three days, no cough, no problems breathing, swallowing and a temperature of 39.2 red swollen tonsils with white exudate and no palpable nodes. So, what's the most appropriate management for the patient? Hopefully at this stage, you're thinking, OK, this is maybe tonsillitis, um signified by the white a date. And hopefully, you're thinking in the back of your head of your centaur criteria. And already here you have an absence of cough and history of fever. So there's already the two that would probably warrant a prescription of antibiotics. So that rules you down to oral antibiotics or IV antibiotics. And hopefully, because this is the GP and we're in the community you've selected B oral pen V for seven days watch and wait. There are probably too many features to suggest that this will go away on its own. But yet we're still probably not. We don't have enough history to determine whether a tonsillectomy is indicated. And a difflam spray, you could always prescribe alongside your antibiotics. But um definitive management here would be for oral pen V well done if you got it right. And finally, here's an ophthalmology question to have a go at all. Right. So hopefully from the stem of the question, you're thinking that this patient might have an infective conjunctivitis. So, an important part of the question is determining whether you think it's bacterial or viral. And because in the stem, the discharge is purulent, you might be more suspicious of a bacterial cause. No, with this um being a short course of illness, you might think that, ok, it's maybe an uncomplicated case of bacterial conjunctivitis. So, in light of that, the most appropriate option would be c and well done if you got that right. Well, folks, that brings us to the end of our presentation as always, thank you so much for watching. We'd love your feedback on the session which you can provide via medal. And thank you to Joseph for walking us through the ophthalmic conditions. Just want to advertise again that the Neurology and Ophthalmology Society will be running a more in depth revision session for all things eyes in a couple of weeks time. So look out for that and it will be one not to miss. We're approaching the end of our surgical series and our final session will be released on the 13th of March and Joseph is going to walk us through the short list of orthopedic core conditions for two years. We hope that this was a useful recap and just to remind you that you can access any of the other recordings via med all at a time that's convenient to you as you come up to exam revision. So for me, it's a thank you very much and I hope to see you in our series finale. Bye for now.