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Summary

Join Fiona, a medical professional from the South Hospital, for an informative on-demand session. She discusses ENT (ear, nose, and throat) related pathologies, particularly those that present in emergency situations. While she steers clear of airway topics, Fiona covers intriguing subjects, such as epistaxis, tonsillitis, facial nerve palsy, and nasal traumas. Despite not being an ENT expert, Fiona leverages her nine-week placement experience in medical school under ENT specialists. With interactive multiple-choice and open-answer questions scattered throughout, she keeps the session engaging and invites professionals with ENT experience to share insights. An apt fit for doctors aspiring to expand their medical knowledge, especially in handling ENT emergencies.

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Description

Screws, scalpels and suspicious ooze - A foundation Drs guide to surgery

A 6-part teaching series aimed at foundation doctors and final year medical students. Covering high yield topics from selected surgical specialties with essential tips and tricks useful for all foundation placements.

The hybrid event will take place in Great Western Hospital academy seminar room 2 and online via medal 18:00 - 19:00

  1. 1/10/24 - General surgery + wound review/dressings
  2. 3/10/24 - Urology + catheter conundrums
  3. 8/10/24 - Peri-operative care
  4. 10/10/24 - T+O + MSK radiology interpretation
  5. 15/10/24 - ENT + nosebleeds
  6. 17/10/24 - Neurosurgery + EVDs

Learning objectives

  1. By the end of this presentation, attendees should be able to differentiate between anterior and posterior nosebleeds.
  2. Participants should be familiar with quick and effective measures for managing nosebleeds in various contexts.
  3. Attendees will understand the indications for admitting a patient with nosebleeds, with a focus on recognizing hemodynamically unstable patients.
  4. Medical professionals should be able to identify the key causes of facial nerve palsy and their relationship to the field of Ear, Nose, and Throat.
  5. The audience should feel comfortable assessing and managing nasal traumas, including understanding when to escalate management.
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Computer generated transcript

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

And then just get you expensive. Mhm. Yeah. Ok, great. So sorry, everyone um had a bit of a technical difficulties there. Um I'm Fiona, I'm one of the F two S at South Hospital. Um And today I'm gonna be doing a presentation on uh ent sort of onco related pathologies, um things that will come in acutely slightly sort of emergency related, but sticking away from the airway stuff because I know you've had a presentation from Han already um related to anesthetics. Um If we start with a signing in on the mentee, hopefully this will work and just for a couple of questions throughout and it would be really great if people could try and answer the questions, there's a couple of multiple choice, a couple sort of open answer. Um And I might sort of shout out some questions in, in between, um which you're more than welcome to put answers on the chat. Um And we'll see how we go and hopefully, hopefully that people have logged into the mentee and move on and I'm gonna start with a caveat, which is that I have not done an ent job. However, I did a total of nine weeks on ent placement at medical school. I did six weeks in my fifth year, um which I spent largely with the Sh Os who did the on call work and I really enjoyed it. They let me get involved. But this is just to say I'm by no means an expert and actually haven't done it as a job as an F one or an F two. So just bear with me and if people have done it as jobs or have experience of doing it elsewhere, um please feel free to, to chime in at the end um uh with anything that you want to add, hopefully this will be useful. And so the things that we're going to try and cover today are um epistaxis looking at how you should approach that, how you can manage that from identifying the bleeding source and controlling that. And we're going to look at the typical presentations of tonsillitis and its potential complications and primarily Quinsy and a bit of an understanding of how you might be expected to manage these as an sho differentiate the key causes of facial nerve palsy, which you might be thinking is that that acute to an ent problem or an ent emergency. But actually, I think it's a presentation that comes up in association with some serious conditions and I think it encompasses some of them quite nicely. So we'll touch on that and then we'll do a bit about nasal traumas and how to assess them when to escalate them. Essentially. Cool. So we'll start with sepsis, nosebleeds. And they're often trivial but can be life threatening. People can bleed really heavily from them, especially old comorbid patients who are on anticoagulants, et cetera. Most commonly, they are idiopathic but can be traumatic as well. And typically the place that people bleed from is little's area or kissel's plexus, which is an area on the anterior septum. It's where the anastomosis of the branches of the internal and external carotids are. And it can essentially, it's an area that's sore, quite exposed to trauma and prone to bleeding. And the risk factors for epistaxis are hypertension, blood thinners, NSAID yeast coagulation disorders. And broadly speaking, they can be classified into anterior and posterior bleeds, which is useful to be able to differentiate between because it will affect the sort of management and bleeding control measures that you can use. And so in anterior bleeds, the bleeds will typically be from little's area. Um and you might be able to see the bleeding point when you examine them. Um when they present, the blood will usually run through one nostril, they'll be able to tell you whether it's coming from the right or the left nostril um unless it's coming from both. Um and they won't describe sort of blood going down the nasopharynx, going down the back of the throat. Um Whereas in posterior bleeds, you probably won't be able to see a bleeding point. Um, just because it will be much higher, much further back, the blood might run down both nostrils or as a result of that, or they'll describe sort of a sense of swallowing blood. Um So when you examine them, very important to look at the back of the nasopharynx, so get a tongue depressor, get a torch and make sure you can depress their tongue fully and look properly at the back because it will, it will affect what you're going to do next and also ask them about swallowing blood and they might be able to tell you that. Oh, so this is just a demonstration of where wax um plexus um and area is so it's that area in orange um there cool. So uh I think this we have the next question is on the. So let me just see if I can change it, hopefully if people have it up on their phones. Is it working? Great. So, um just quickly, what things are you going to think about when you're first approaching a patient with Epistaxis? Um That's not really anyone answers be as broad or niche as you like. Oh, yeah, great. Thank you. Or I can read it out. It's 1538 3752. Nice. Yeah. Great. Daphne Wharton. I give it a couple of minutes, a couple more seconds. Anyone else has any suggestions? Yeah, perfect. So all really great. Suggestions. So broadly speaking, you need to start with an A to E approach because you need to consider the need for recess. It might be that they, they're hemodynamically stable and it's a, it's a small slow bleed. Um but you need to establish how much blood has been lost, resuscitate if required. Do they need a transfusion? Do you need to reverse their anticoagulation? Take a full set of bloods, look check their HB. But also are they someone who you think might have a heavy, sort of, have they had heavy bleeding which now stopped? But at high risk of a rebleed? So, do you think it's worth putting in sort of too wide or cannular kind of thing? Um, you can try conservative measures first. Although a lot of people, if they've been at home or been with paramedics and brought in or been to the ed, they probably will have tried that already. So, pinching the soft part of the nose and leaning forwards for 10 minutes, you can put ice on sort of the forehead or the nose or I've seen people do it at the back of the neck as well, which sometimes can help to slow bleeding. Then if at that point, you're able to try and identify a source of bleeding. So for that, you're gonna use nasal specks which are a little usually metal, um, sort of four sets which you can put in one n at a time. Hold open the nostril, use a pen toch and have a look, try and look typically to the anterior septum because that's where your bleeding point is most likely to be. And that's the area that you can feasibly cauterize if you can see it. So if you can identify a bleeding point, then you can try and do something about it if you can't see a bleeding point. Um but you think it's an anterior bleed, you can pack it. Um, so that could be with rapid rhinos of what a lot of trust use. And I'll show you some pictures in a minute. But for anyone who's not seen them, they look a little bit like tampons, but you inflate them with a syringe just with air. If you can see a slight of bleeding, you can use silver nitrate, watery sticks, they look a bit like long match sticks and you just very gently rub the end over the sort of bleeding point. Um I was taught to do it in sort of a spiral shape. You don't need to make a massive area around the bleeding point, but just enough to get the bleeding point and a little bit of mucosa around it to try and stand the bleeding. And you, there are packs for posterior bleeds. So if you can't see a source of bleeding and you think it's posterior, you can do posterior packing. I think they typically have two lumens, but I could be wrong. Um, and then people who have sort of severe bleeding that doesn't seem to be resolving with any of those measures or they have packing, which you take out and they rebleed. So you have to repack and then they rebleed and it might be that they're considered for artery ligation. Um, does, uh, I would ask, I don't know if, can you see a child? Yeah. Does it, does anyone know what the vessel that you ligate or you can put it on the men? Because it's the option to write? No fine. So it's the sphenopalatine artery usually that they ligate. Um I never saw anyone who went to have that done. Um, once saw a patient who they were talking about doing that for, but often the other measures are successful and then you should think about whether they need admitting. And so things that people might need admitting for obviously hemodynamically unstable or requiring transfusions or anemic with the amount of blood that they've lost. Um Think about the sort of a lot of the population that you see will be old frail. People who are on blood thinners and just be sensible, don't send them home in the middle of the night kind of thing. But um because if they rebleed, they'll just come back in, in the middle of the night. Um Yeah, fine. Um And then NASO and NASEPTIN we'll talk about very quickly, but I'll just show you a picture. So these are what the packs look like. The Rapid Rhinos and the top two images. And then the silver nitrate quarter sticks are the, the long matchstick looking things on the back. They're sort of maybe 20 centimeters long. And the stem is plastic. So you can slightly bend them to try and get to the area essentially that you want to cauterize a bit more easily. And then this bottom right picture is nasal, which is a bioabsorbable. It's a bit like sponge. You can cut it up and it's essentially is packing, but it dissolves in the nose. So they don't need it removed. You can send people home with it and it applies sort of internal compression to the area to try and help them stop bleeding. So the way that I saw this mostly used and I don't know whether this is the same in other trusts was after people had the packing removed, which is typically at 12 to 24 hours after it's been put in, you deflate, deflate the rapid Rhino, gently remove it and then use nasal after you've tried to cauterize an area. So they would then try and identify a bleeding point, cauterize if they could and then get a bit of the nasal pore, cut it up into strips, coat it in naseptin, which I'll tell you a bit about in a minute and insert it into the nasal packing and then they could be sent home with that um because the packing doesn't need to be removed. Naseptin is um chlorhexidine and Neomycin. Um And it's like a cream and they, the um was doing placement on, they always coated the Nasacort in that. Um So it's sort of like an antiseptic um cream to just try and assist in healing, prevent infection, things like that. The most important thing about naseptin is that it contains peanut oil. So you need to ask people if they have an allergy to nuts because you can't give it to them and if they do fine, uh we'll move on. So next question, um I'll read it out. A 78 year old man comes to the Ed with a right sided nose bleed that started three hours ago and has bled studly since he doesn't feel any blood going down his throat and first aid measures don't work. He's stable and still has fresh blood coming from his right nostril. And you do think you can see a point of bleeding when you have a look and can't see any blood in the nasal pharynx. So what is the most appropriate next step? Um And this is all if people are able to see that. Oh, sorry. Yeah. So anyone who can't see the options are silver nitrate, quarter vessel ligation packing with ribbon gauze or NASEPTIN. Um And I see if there's any more. Yeah. So it looks like most people have gone for the silver nitrate core which Yeah. Ideally, you would go for that first. If you can see a bleeding point, you want to try and control the bleeding point directly. So that's what you go for first and you can do packing. But usually you try to pack when there isn't a bleeding point that you can identify and often places we use rapid rhinos. I don't think I saw ribbon gauze being used particularly. Um but that might be a just sort of preference and cool we'll move on. So we're going to talk about tonsillitis now, which is a very common ent presentation. I guess that most, most often is probably managed in the community. But it is something that you could see as an acute on call presentation either because they're very sick or because they have a complication of it. So I thought it was easiest to talk about tonsillitis and then we'll talk about the complications. Typically, it's viral rather than bacterial and associated with upper respiratory tract infections. But people can develop secondary bacterial infections sort of later down the line. Um Can the bacterial causes a sort of Hemophilus, pneumococcus um but also group group, a beta hemolytic strep. So strep genies um and those are, are sort of involved in the more severe infections that you see. Um fine. So this is a very good demonstration of what tonsillitis, bacterial tonsillitis will typically look like and with the sort of exudate erythema inflamed tonsils and fine. So, we'll move on and symptoms and signs of tonsillitis. I'm sure a lot of you are probably aware of. Um, so fever, sore throat, dysphasia, or pain on swallowing, um, as well. Actually Trismus, um which is lock jaw and just feeling generally rubbish. And then when you examine people, um, enlarged inflamed tonsils, bilaterally white tonsil are exudate, particularly if they're bacterial. Viral, generally wouldn't have an exudate and then tender lymphadenopathy, sort of usually anterior cervical lymphadenopathy cool. So and the way in which you would approach tonsillitis is dependent on whether you think it's viral or bacterial really. So the way in which most people sort of stratify is the scoring system. So there's fever pain or central score. I think central score is the older one. A lot of places use fever pain now, which is easier to remember because it's a pneumonic. So that's fever within the last 24 hours and purulent tonsils. And I always want to say absence for a cough a but it's not, it's attend rapidly so quick presentation from onset and then inflamed tonsils, severely inflamed tonsils and then no cough or corr. And then the central score is very similar but tonsil legs today, absence of cough, anterior survival, lymphadenopathy and a fever and with fever pain, a score of 4 to 5 is a good indication that they might have a streptococcal infection. And at that point, you would be more likely to get some antibiotics. Essentially which is usually phenoxyethyl penicillin or Clarithromycin. And obviously, people who have severe systemic infections should be admitted. Um but also GPS might send in patients who have severe problems swallowing because of the pain just because they will struggle to manage at home with oral intake and things like that. And you should be able to assess the need for a tonsillectomy um while there in. So as we come to our next question, which is a nine year old girl who comes to the GP with sore throat, difficulty swallowing a hoarse voice and nausea. She has red swollen tonsils and painful glands in the neck. She has had two episodes of tonsillitis the previous year and she is currently too unwell to attend school. Does she meet the criteria for tonsillectomy? So you might be thinking that this, oh, that was an extra question, never mind. Um, not directly relevant to starting to sort of acute management of tonsillitis. But actually, if you're seeing patients out of hours and they ask you, they say, oh, I've had so many episodes of tonsillitis. Well, I have a tonsillectomy. It's good to be able to know and not give people false hope essentially. Um So we've got a pretty even split so far. Yes. No. Ok. So, oh, ok. So the tonsillectomy criteria actually really harsh, you have to have an awful lot of episodes of tonsillitis to qualify for a tonsillectomy. So seven episodes in the last year. Or five episodes per year in, for two years or three episodes per year for, um, for five years. Um, or if you have one that's enough for, for a tonsillectomy, but those episodes all have to be sort of debilitating and prevent normal function. Um, so actually it's an awful lot of tonsilitis. You have to have to get a tonsillectomy. Um, cool, we'll move on to Quinsy. So, Quinsy is a peritonsillar abscess, um which typically it's a failed resolution of tonsillitis. So usually tonsillitis that's prolonged and then sort of 5 to 7 days after they might develop a collection of pus in the peritonsillar space, people will have swelling of the soft pat um and symptoms of tonsillitis, but usually sort of unilateral pain. So they'll be able to tell you unlike the tonsillitis where they have a sore throat that they have unilateral throat pain, they might also have drooling. So, and which is sort of an indication that they might progress to struggle with their airways because of the swelling. Usually the uber is displaced, so away from the side of the Quinsy just because of the displacement of the anterior arch. Um And sort of people typically say they have fat or offensive breath. Um and you can use the Liverpool Quinsy score um in the assessment to sort of establish how likely quiz is going to be. And I've just written it here because ii remember what they are otherwise, but a unilateral sore throat will score you three points. Trismus or lock jaw will score you two points. Hot potatoes voice, which you'll hear a lot when describing Quincy that scores you one point. And male also scores you one point. If you score three or less or less than three, then it's unlikely to be a Quincy. But four plus is felt likely to be a Quinsy. People with Quincy should be admitted if they come in because they'll require intervention. Yeah. So the management of a Quinsy involves treatment with IV antibiotics. They'll need quite significant pain relief and then they need surgical aspiration or incision and drainage. And so the way I always saw this done was lidocaine spray to the throat. They have such in hand because you're gonna produce at least a little bit of blood and probably some little bit of pus as well. Um And then they always use an IV cannula. So a gray cannula usually connected to a syringe and some of the sort of guidelines I read suggested putting a bit of tape at one centimeter from the end of the cannula to try and stop people inserting them too far and damaging sort of further back structures. But I never actually saw that being done. But they use this sort of three pronged approach typically to try and aspirate as much as possible. And then the aspirate should be sent for M CNS. And then there are sort of additional complications for quinsy to be aware of which are retropharyngeal and parapharyngeal abscesses. So, retropharyngeal abscesses are sort of dorsally to the um, to the quinsy. So they, they will fit. If you look in the mouth, you'll be able to see sort of swelling of the pharyngeal wall on one side at the back of the throat and it's quite a severe severe complication and people might just develop respiratory, just stress. They can get torticollis, which is where you get sort of spastic contraction of the stone or quite a mastoid to that side. So they'll end up with their chin towards one shoulder and they'll have quite severe neck pain, which is usually worsened by movement. And then parapharyngeal abscesses, actually, symptom wise are very similar to quinsy or tonsillitis, but often they'll have neck swelling and they might develop stridor as well. So I think the parapharyngeal space is the space between sort of, it's laterally to the peritonsillar space and but behind the mass, very close to the carotid sheath. Um and you can do CT S or um intra oral ultrasounds to try and determine the presence of abscesses or collections back, right? And then this is just some pictures to sort of demonstrate the difference between tonsillitis and quinsy because I think I remember from being on a NT placement, they got a lot of referrals in re Quinsy, which ended up being tonsillitis, which obviously it's better to be sure, but just to demonstrate. So you can see on the picture on the left, that's tonsillitis. You can see the X day, the uvea actually weirdly does look displaced, but actually, you can see the midline of the tongue and it's not displaced and the anterior arch is clearly visible with the tonsil behind it. Whereas the picture in the middle, you've got sort of the displacement of the anterior arch demonstrated by the arrows and the uvula is displaced to that left side of that patient's mouth because that tongue depressor is in the midline. And so I just thought that was quite a good demonstration of the difference. Cool. So 17 year old boy is brought into Ed by his dad. He had a tonsillectomy a week ago and noticed fresh bleeding in his throat this morning, which has now stopped. He is hemodynamically stable on examination. And you can see the old bleeding point in the tonsillar fossa, but no active bleeding at the moment. What would be the most appropriate next step. So again, it's on. So the options are discharge home with safety netting advice, discuss with the ent reg for immediate return to theater or admit for observation. So I'll give you a OK. Right. So everyone's gone for the same option. And now this has made me slightly nervous and because actually, I think the answer to this is admit for observation. And so all patients who have a post Tosi bleed should be admitted for 12 to 24 hours is the guidance that I've seen whether or not the bleeding has stopped if they're not heavily bleeding. Some places advise use of hydrogen peroxide gargles and which can stop slow bleeds and prevent re bleeds. Um, they shouldn't swallow hydrogen peroxide but they can gargle it and, and ideally, you should make them know by mouth until they're reviewed by a senior. Actually, post tonsillectomy bleeds can be divided into primary and secondary bleeds. Primary bleeds are within 24 hours, usually prior to 12 hours from, from their operation. And those are the ones that need immediate return to theater. Always. Um Secondary tonsillectomy bleeds are typically 5 to 10 days POSTOP. So like this, this boy and actually, they're usually the result of a wound infection and they can require a return to theater, but don't always, but they should always be monitored in case they do because they have potential for extreme sort of extreme blood loss. They can lose a lot of blood. Great. We'll move on to the next question. So we're going to talk about facial nerve palsies and we'll start with the question which is not a feature of facial nerve palsy. So the options are inability to fully close the eye, the ability to raise the eyebrow on the affected side, unilateral facial dr or increased sensitivity to sound. Um So which of those is not a feature or not? We'll say cool, great So yeah, and ability to raise the eyebrow on the affected side isn't a feature of facial nerve palsy. And this is why the differentiation between upper motor neurone and lower motion, urine palsies is really important because a differential diagnosis for a facial nerve palsy is stroke or tia, but actually one is upper motor neurone. So you should be able to differentiate that on the examination. It might not always be easy but up and urine lesions are hopefully not teaching people sort of things they already know. But you get dual supply of the forehead and up and motoneuron lesions won't, will cause forehead sparing because that supply is still able, basically able to reach the area and the motor supply. Whereas lower motor neuron lesions knocks off that supply. So they can't, they'll have paralysis of their forehead. Um fine. So facial nerve palsy is a oh sorry, facial nerve palsy is a um cranin nerve seven palsy, which is only known as Bell's palsy when it's idiopathic. So Bell's palsy is a diagnosis of exclusion. There are other causes of facial nerve palsy, which a lot of them are related, which you should rule out. And you can't technically call it Bell's palsy until you've ruled out the other causes. Um Does anyone oh, I can't see the chat but II was gonna say, can anyone give any suggestions about um possible causes of patient that palsy excluding Bell's palsy? Great. Mhm. It's not much cheaper. Yeah. Nice. So, broadly speaking, I've divided them into infection, malignancy, trauma, idiopathic. So idiopathic would be great and nice. So, we're going to talk mainly about the infection ones here. Um, but parotid malignancies, um, the tract of the cranial nerve seven can be affected by those and infections, mastoiditis, necrotizing otitis, externa, acute otitis media and Ramsay hunt or herpes zoster opticus can all cause, um, cranial seven palsies. So he should rule all of those out. Um And then I've just got a little diagram to sort of demonstrate that. So low emotion and facial nerve palsy. So the forehead is affected. So they will have paralysis of that forehead, drooping of the eyelid. And so they will often can't close their eye completely loss of the nasal labial fold. And then I realized one of my other options was increased sensitivity to sound. So people do get hyper ais with facial nerve palsy and that's because of the involvement of the tens pa and Stapedius. I think um, they have supply from training and seven if my memory says me correctly. Um Right. So what the ones I wanted to talk about were acute oitis, media, mastoiditis and a ati externa. So, acute media is an infection of the middle ear. So behind the eardrum and usually people will have atalia quite severe ear pain, often without discharge from the ear. But if the tympanic membrane perforates due to the sort of build up of pressure behind it, then they can get discharge of pus from the ear. And if they perforated their eardrum, they may well have hearing loss as well. And on examination, they'll get this sort of bulging tympanic membrane that would be erythematous. So you can see that picture on the right, that's acupan membrane. And actually, it usually resolves within three days if without antibiotics. But people who have a persistent acute titus media and should be given antibiotics. I think it's usually amoxicillin or if they're systemically unwell, um they should have antibiotics. Um then mastoiditis is sometimes a complication of acuity media, but that describes an abscess in the mastoid air cells of the temporal bone and and people will get this tender boggy swelling that you can see in this picture here in over the sort of mastoid process of the ear. Patients will be septic, they'll be really unwell and then I haven't got a picture of this, but the pinner is often displaced sort of forwards and inferiorly. So the ear is sort of pushed forwards with the swelling and they'll require IV antibiotics and usually a ct of the temporal bone as well to look, to look for sort of temporal bone involvement and then necrotizing otitis externa will I quickly say about otitis externa, which is an infection of the external auditor meatus. So that's up to the eardrum. It's often um sort of itchy. People describe it as irritating, they'll have quite superficial pain and sort of tender exteriorly. So if you pull on that pinner or push on the tragus, often that's painful and they often have discharge from the ear as well. And that's in acute otitis externa and people who do swimming and things are more likely to be prone to that. And necrotizing otitis sterna is also known as malignant otitis externa. And that's typically from non resolving acute otitis externa and they get pain out of proportion, they'll have purulent artoria and then sort of necrotizing and granulation tissue in their auditor me. So you can see in this picture there, there's some granulation tissue in there and it looks really quite swollen and the people who are at highest risk of this come back. Um I can't go back now because my keypad doesn't like people who are at highest risk of necrotizing enteritis. Externa are people who are immunocompromised and diabetics and they're at really high risk and then there's a risk of spread to the temporal bones with exercising. A TS externa causing osteomyelitis. And so they can get skull base or temporal bone osteomyelitis, which is why it's important to do a ct temporal bone and they should be treated with IV antibiotics. Cool. So management of facial nerve palsies really kind of depends on ultimately the cause. Um usually people will need um a way to manage eye closure. Often they can't fully close the eye. So they should have artificial tears and also be instructed to take their eyes closed at night to avoid sort of damage, um, treat the underlying cause. And if you've excluded all other possible causes and it is truly does seem to be a Bell's palsy, then treatment with high dose pred is, is the first line of treatment and some places will give us cyclovir as well, but it doesn't sound like there's very good evidence um for that, um, giving pre within 72 hours of um, so the onset of does increase the and sort of um recovery rate for VN. So it is important to try and treat them early if you can and then they need that dose of steroids needs to be a weaning dose to stop it. Um Great, I'll move on to nasal trauma which will come up quite quickly. So, nasal fractures make up 40% of all facial injuries typically following trauma and I wanted to talk about it because of the complications of it. So, septal hematomas, CSF leak, Analia and septal deviation, which can cause some nasal obstruction. And the most important one I think to talk about is septal hematoma is key. They need prompt treatment because the risk of having a septal hematoma untreated is that it becomes an abscess, which can obviously make them very sick or septic, but also can lead to necrosis and then they can get collapse of the septum which leads to people get saddle nose deformity. I think I've got a picture of those. Yeah. So you can see this one diagram here shows a septal hematoma and um the, the hematoma will be visible on both sides. So that would be it will these sort of bulging and erythematous on both sides and often fluctuant, the difference between that and deviation is, is you need to look at both sides. So a deviated septum will be concave on one side where it's deviated. Whereas hematoma will have this swelling on both sides. And you can see here, this is the hematoma on both sides here. And this is a sort of a demonstration of the saddle nose, um, deformity, um, fine. So people with nasal trauma, um will present and the things that you need to find out really is what trauma they've had to their nose and whether they think there's a change of shape and result because they might just have a nose feed and have had trauma to the nose. Um Hopefully people have a good idea of what their nose looked like before. And if there's a lot of swelling, it might be difficult to tell. But don't, you can't, you can't assume essentially that that nose was straight in the first place. Um So knowing whether it's actually different for them is quite useful and often they'll have associated epistaxis, um, significant swelling. Um, and they might have features of coexisting fractures. Um So bruising black eyes, et cetera, people who have developed CSF leaks will have continuous clear watery rhinorrhea from the nose, which to confirm that it's CSF you can send a sample, I think a beta two transferrin or Tau protein samples to the lab. And a lot of the time, see athletes can be managed conservatively. Um The guidelines I've seen have sort of indicated that it would usually be conservative unless there's features of meningism or neurological symptoms or signs. Um And then the, the examination when someone's had a nasal trauma is best to do sort of standing above and behind them. So you can look down the nose from the bridge to the tip and look for any deviation. You should palpate the facial bones for any coexisting fractures and then assessing the eye movements can be useful as well. Um Orbital wall fractures, apparently the second most common hypo fal fracture and people's eye movements can be affected in those. So they can get diplopia, I think on upward gaze and some gaze restriction as well and then rhinoscopy. So looking up the nose to see if they've got any septal deviation or hematoma there and then doing a CT to assess for any facial fractures or sinus fractures as well and can be helpful fine uh and then managing uh nasal fractures um if they're uncomplicated, so they don't have septal hematomas. Um then they can typically be returned to the ent clinic. Often I know where I did my placement they brought them back about a week later and for manipulation and because often the swelling has gone down, so it's easier to sort of assess after sort of 5 to 7 days. Um, but from 4 to 6 weeks, the bones in the nose will start to fully heal. So you might not be able to manipulate. And I only ever saw it done under local anesthetic, but you can have it done under general anesthetic as well. And you need to advise them to refrain from contact sports for at least two weeks. And the way that they do it is digital pressure. So they always stood above and behind and used their thumb to sort of sort of almost push the nose out towards the chin and then would use pressure to try and straighten it and then ask the patient midway, I guess what's the benefit of doing it on the local? Is that midway through, you can ask the patient to get up, have a look in the mirror and say when they think that that has straightened back to what it normally is and it can look quite brutal to be done. It does sometimes require a bit of force. Oh, so we'll go to the back to the learning points. Um which hopefully people got you got something from. So the main things I wanted you to take away was that epistaxis, you need to start with an at e approach. General principles. Of first aid, identify a bleeding point, control a bleeding point with packing quarter ligation and think about anticoagulation, whether you need to reverse it, whether you need to admit them and be able to recognize tonsillitis. So typically sore throat, fever, absence of a cough and exudate on the tonsils when it's bacterial and using the scoring systems, fever, pain and to try and sort of establish the likelihood of it being bacterial and whether they need antibiotics and then how Quinsy differs and how you can assess the Quinsy and um manage those because often it is the sho who does the drainage of Quin. Um and then post tonsillectomy bleeds as well knowing that they need to be erred on the side of caution. Essentially, they should be observed because they're at high risk really. Um And then facial nerve palsies, lots of causes of which Bell's palsy is one of them, but some severe infections um can, can be responsible and so worth knowing about those. Um And then nasal traumas, essentially, the main thing is if they have septal hematoma, you need to let the reg know because it needs something doing about. Um Right, that's the end. I put some resources up there because there are some really, really good resources out there. En TSH O is a great website, I think it's made um by U Ks H Os and registrars and maybe some consultants as well. Um I think up in York and Humber area. The ENT UK guidelines are pretty good and teach me surgery is pretty good as well. And then the Oxford Hamburg do have an ent surgery and head and neck cancer one which, um, if you have NHS email, you can access that through your institution. It.