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Basically tells you all the dates on our six pm series out. I mean on Instagram. Um If I'm looking to my right, I've just basically got my ipad here. That's got my questions and stuff. So if you have any questions, just drop it down in the chat box and we'll try and get through it as we go along with the presentation. So I think we started off part one covering lots of the ears, lots of the nose and we're gonna move on to throat. Very common, very bread and butter of ent that you're actually gonna deal with is someone like this 21 year old female coming in complaining of sore throat. And when she's there with you, obviously, what you want to do is you want to do an A&E and make sure that they're stable or unstable. Her history is that she's come in with a three day history of a sore throat and pain is 10 out of 10. It's absolutely unbearable. She cannot manage to eat and drink at all. But when you ask her, what was her last thing that she managed to eat? She says she managed to eat some, uh, mcdonald's Nuggets. She's systemically well, otherwise. And her big question is when can I get my tonsils out? Um, anybody have a rough idea where I'm going with this in terms of ent problems. It starts with tea as well. That helps. No, no one tonsillitis. Yeah. Yeah. We're thinking about tonsillitis, aren't we? Um, obviously we're not at the point where we've actually examined her. So, thank you. But three things that I want you to think of when it comes to a tonsillitis is their bloods, their management. And do you discharge or admit them? Those are the three things that you need to know about tonsillitis patients under ent so very quickly, these are just some stages. So when you actually examine them, you are basically obviously, number one, you're looking in the oropharynx, you're having a look at their tonsils, you're looking at the size of it and this just helps you to understand what the stages are. Um It's known as the Broady grading scale. It's basically the percentage of um your oropharynx being occupied. Also, apart from that, you are also having a feel for their lymph nodes. You're having a look at, you know, things like their neck range of movement, the observations and also just to make sure that they've got no signs of Trismus um able to actually open them out and how their voice is actually presenting with you. And we'll get on to why this is just a grading system. But in an actual tonsilitis, what it can look like. Now, a grade four tonsillitis can look pretty scary, you might say. And people can think that it looks like a Quinsy. It takes a little bit of experience to have a look. It takes sometimes a little bit of a second person to come in and have a look. But don't be alarmed. A lot of patients with tonsillitis get a little bit alarmed because when they look inside their own throat and they see that their tonsils are so enlarged, they worry about choking. Now, just to let you know because sometimes that reassurance helps them when you're naturally eating and drinking anything, your tonsils will naturally move apart from each other. So try and reassure them that that does actually happen. Despite when you look at yourself in the mirror, it looks like it's almost kissing each other. That just means you've got big tonsils and they might just be enlarged. So tonsillitis, well done. Yes, we've got a nice cocktail and you should memorize this cocktail because if someone comes in with tonsillitis, this is a cocktail of medications that you are giving them and that's obviously they're allergic to something under the sun. Now, dexamethasone steroids, easy, benzylpenicillin or Clarithromycin. If they're allergic paracetamol and it is a concoction of analgesia, you will soon find that it pain is what keeps them in and this pain, that is their main concern. You want to give them paracetamol, Ibuprofen codeine a dila spray and to just for nourishment. Now, is there a scoring tool that we know, not specifically for tonsillitis, but there's a scoring tool for acute pharyngitis. There is a scoring tool just for like strep throat that people can commonly use. Does anybody know what they could be? Center school? Yeah. Absolutely brilliant. There's another one, let's see whether anybody else picks up on that when you do their bloods. I want you to do. Yeah. Fever pain. Absolutely brilliant. Yeah. Um, when you do their bloods, I want you to do all the basics. Your full blood counts, your eery, your LFT S, your CRP and your IM screen your infectious mononucleosis screen. And we need to think about any advice if they were glandular fever positive. Can anybody think of anything? And finally, what we were talking about earlier, her big question is, are they eligible for a tonsillectomy? Now, when it comes to a tonsillectomy, these are the numbers that unfortunately nice guidance have just come up with and you kind of just need to memorize or have in your head. I'll just look it up at that point in time. It is basically, if they've had seven cases, seven cases of tonsillitis in a year or five cases of tonsillitis for every year, for three years or three cases of tonsillitis every year for three years sounds like an absolute mouthful. But that's just guidance. Yes. So, if they are glandular fever positive, this doesn't change anything drastically. It's just your advice. Refrain from alcohol, no contact spots for at least six weeks because there's a risk of organomegaly like and your spleen rupturing. That is it. And the bottom picture in my bottom right here shows you just a very clinical example of a glandular fever positive patient. Um, those exudate foul smelling little bit of discharge otherwise, well, in themselves, some people can confuse this for a Quinsy Cos they're just a bit worried about it, but these are just inflamed tonsils with lots of exudates. Now, my favorite question, can they be discharged? So I'm gonna give you this first scenario and what the scenario is is a person with tonsillitis has a CRP of 210. They have glandular fever. They're po they've screened positive they're eating and drinking fine. Now, after your concoction of medications, their obs are all fine. Do you admit them or do you send them home? We will just give this just a few seconds. Oh, ok. Well, I think we have a clear win here. So someone with ACR P of 210 despite being glandular fever positive can go home, they can be discharged with safety netting advice. What is the criteria? The criteria is if they are eating and drinking and their observations are fine, they can go home and they can be discharged with safety netting advice. You'll obviously give them a prescription for their antibiotics and ensuring the most importantly of all analgesia, analgesia is the most important, do not shy away from giving someone codeine or if they need something a bit stronger because they will come back into your clinic because of pain. So always control their pain and give them the concoction that they need. So next one. So like everyone said, we've got fever pain score for strep pharyngitis. And this just basically helps decide whether you have antibiotics or not. And we've got our center score. Reason I point this to is because sometimes it's good to have this behind your mind because people come in to you with the indication that they need antibiotics and you're fairly certain with your clinical examination that they do not, this just solidifies that and you can use that as well to explain the rationale behind this. So moving on to a 30 year old that's also come in now with sore throat. So Raj doesn't look good and he doesn't feel good at all. He has a three day history of sore throat and he's been unable to eat and drink. He tried some soup and he just could not swallow it at all. Um To be honest, he looks a little bit rubbish. Um He's got a slight fever, he's got a bit of a lock jaw. He can't open his mouth very much. So the most that you can get him to do would be this, it would be about and anything more really hurts him and he's like about to cheer up. He's got one sided sore throat, which is a little bit worse and hot pot voice a bit parx and tachy. And yes, someone has already tried to get in front of us and guess what it is. So, indeed, so this is what you look at when you look at his mouth. Indeed. Those are red flag symptoms for your Quinsy. So those are your classical symptoms for your Quinsy, your peritonsillar abscess and basically a peritonsillar abscess is and can be a complication of your tonsillitis. You've basically got pus that's collecting in your peritonsillar space. Now, my advice to you is when you're looking at it because this is more of a clinical diagnosis, not all the patients will present with those key red flag symptoms. It'll be based on what you see and their oropharynx. Now where you put this is known as a Sims retractor, that silver thing where you put that, I would like you to always put it directly where you think the midline is and the midline of the mouth and see whether that uvula is displaced almost based on the fossa that you have. So the right and the left and try and see whether one side is larger than the other. And if you definitely think that there is a collection, don't never be shy of asking for a second opinion because sometimes they could just have, you know, nobody's mouth is equal on both sides. It's based on clinical symptoms. So it's based on what you see in the oropharynx. So management wise, very similar concoction, dexamethasone, benzylpenicillin. But you add metroNIDAZOLE cost for anaerobic cover and also just in case you're going to manage them and how you manage them is one obviously, antibiotics cover and analgesia that we were talking about. But aspiration and incision and drainage. That is basically what it is. Aspiration is literally putting a little bit of lidocaine spray on on the side that you are going to aspirate. Some people do put some lidocaine injections in there. It just depends who you learn from and, and then after that, just giving them a few minutes and you literally put a green, green syringe needle and you stick it in there and you try and collect your pus after you have gotten that. And you're quite certain where it is, you basically take a little scalpel and you cut it by a tiny amount and you let that free flow drain. You ask them to gargle and spit out anything. So that is basically a Quinsy. So now my case for you is we've got a Quinsy and he is basically less off ba Raj. He is basically refusing an aspiration and an incision and drainage can they leave and go home with antibiotics? That's his question. He's not eating and drinking like you know, CRP is 100 and 20. Can they go home? What do we think? Come on. A few, few more canals are definitely ok. Yeah. So it's obviously not the best polls because I can only give a select few options. But what I'm going to say is that there are two things obviously in this scenario. Number one, you need to understand and you need to talk to him and find out what he actually understands from his, you know, diagnosis at the Quincy. And you need to explain to him the risks of leaving. Number one, something like a Quinsy, which is basically pus collecting in your peritonsillar space can go and become a retropharyngeal abscess. It can become a deep seated neck space infection if left, if untreated. And this is in the worst case possible, which can also cause an airway compromise, which can also cause a deep seated infection from your neck up to your brain even. So you need to explain all of this. Obviously, number two, which I know you would. Number two, we would obviously try and persuade and admit him. That is the ideal scenario. But in the event that you cannot and you are fairly certain that this is a Quinsy and he's not eating and drinking. I would say this is a self discharge form and if he understands the risks, so moving on to someone that has vomiting blood. So he's a 14 year old and Ron doesn't look very good at the minute and his friend Harry doesn't feel like he's equipped to actually help him because he's three days post tonsillectomy and he started spitting up specks of blood and then he's progressed to fill up a huge bucket and now he feels faint and lethargic and now it's stopped though. So he's ok. He's just got a bit of a sore throat. What do you think this is very common, common complication following a tonsillectomy? Um, it's the most common, but it's also the most serious. So in my trust, what we tend to do is that each post tonsillectomy bleed. Yep. Exactly. Goes on an M and M based on it and we actually do count because it falls on the part of the mortality of it. So, next big question is, is it a primary or a secondary hemorrhage? And people have used that word hemorrhage? Yes. So what defines a primary hemorrhage is within the 1st 24 hours after your surgery? And a secondary hemorrhage is any time after the most common time that people see this incidence is basically day four to day nine. So my question for you is, for example, it's ever so slightly different. The question itself. But let's try this. It's a patient that's come in five days, post tonsillectomy. He presents with a post tonsillectomy bleed, sorry for the aggravation. But on examination, he's not actively bleeding and his oropharynx, he's hemodynamically stable what do you do with him? You're seeing him literally, let's say you're seeing him in the clinical Decisions Unit. He's in front of you in the surgical clinical decisions unit. Yeah. So we've got really mixed answers right now. So I will say this something that I've learned as well as something and this has actually happened. This um this case was a real case that happened to one of my colleagues and uh how he dealt with it was different. So what I'm going to advise you is that any person that's come in with a post tonsillectomy bleed gets admitted even if they're not bleeding, even if they're hemodynamically stable because it's the most common, most serious complication and any signs of the bleeding could mean that there is a herald bleeding, it could mean that you could bleed later as well and they need to at least be observed at least for 24 hours and taking it from there. So post tonsillectomy bleed uh and the pictures down there in the bottom, you know, it's not the clearest of images, but what you kind of see is just very common. Um oropharynx is what it looks like with those scar tissues over there, postectomy and at the top, it's a bit dramatized, but that's what you could see in terms of a bleeding. So how do you deal with them? And I always, when I ask you later, I want you to say a to E always A to e because this can be an airway compromise and it's extremely important for you to remember how to start cos the problem could just be an airway, examine the oropharynx cannulate and get some bloods. Make sure you get a group and save as well. Um Keep them nil by mouth with I VT running and get, start them on antibiotics and hydrogen peroxide gargles and you can start them on IC acid. It, especially if you know, obviously they are profusely bleeding at a time, not controlling it. You're worried about it. But if they're so unstable, you would start something like the major hemorrhage protocol, give them analgesia as well. And like you said, you would escalate to your registrar. So I would discuss with your ent registrar and anesthetics and or both uh because you'd want them to be aware because if they are actively bleeding with your cells, normally, what your registrar would do is take them into the theater and they would cauterize it. So, it's known as an arrest of a post tonsillectomy bleed if they are fairly stable and it's a very small bleed and you're able to see the opening, your registrar yourself might be comfortable with cauterizing this on the ward. This doesn't happen very commonly, but it can, most of the time you would take them to the theater. So now we've got a 33 year old that you've seen that has come in with funny breathing. So my question for you is, can you give me examples of funny breathing noises for some of your patients? Oh, we've gotten it straight to the point. Yes. Strider. Strider is definitely one. Any other common? Yeah. Wheeze anything else that you can think of? I'll just, I'll ask for one more and then I'll leave CTA Yes. Exactly. Certa is one as well. Thank you. So, speaking of Stridor, because someone has actually mentioned it. Um What do you do? Patient in front of you? Has Stridor. What are you gonna do when you see it? And it's all right, you're allowed to be honest in that point in time. Um You have a stridulous person in front of you at the minute and the sound, I'm obviously not the best person to do. Bear in mind. But what it could be is something like obviously, there are different phases of a Stridor. But what Stridor is is number one, an airway emergency. Number two, it's basically a very high pitched sound that's caused by a turbulent airflow through an obstructed airway and this could be at any either level. So if you think about it based on which part of the airway it is, we give you a bit of an idea if it's an inspiratory strider, expiratory or biphasic sprier. Yes. Oh, obviously, thank you very much. You guys know exactly what to do. You will do ABCD E now it's a bit of a problem because in ABCD E you've got a problem in the airway immediately. So what's the things that you can do for them in a, in their airway to assist them? II respect the person that said all of them. That, that's a true answer. Yes, you can definitely give them oxygen. Beautiful. But under airway, what I was thinking was like, what are some of the airway maneuvers that you could do? Some of the airway adjuncts that you can use to support their airway. And the really common simple maneuver that you could do is just tilt your head, lift their chin jaw thrust if they were, you know, unconscious and would actually be able to tolerate them. Um Airway adjuncts that anyone knows that we can use. Yep. Brilliant head tilt, chin lift, jaw thrust. Thank you. Any adjuncts or things that you know, that are fairly simple. Yeah. NP. Yeah, I would be mindful of things like a gazelle because you just don't know about the pathology just yet. Obviously, if they are unconscious and you have to and that's the way to do it. I understand. But if they are conscious, you just might want to just be a little bit more cautious about that. So number one, obviously protect the airway as best as you can while you're there, get anesthetics and ent as soon as you can because if this thing goes out very quickly, you will not be equipped as a junior doctor to actually manage it immediately give them oxygen. Like one of our uh people here have said nebulized adrenaline is something that you can do for them to just help. So it's one mil of one and 1000 and you solve that with four mils of sodium chloride and start them on some dexamethasone, just giving them some systemic steroids might just help with any swelling that's going on at that point in time, candidate and take off some bloods check. So in the meantime, while somebody is actually having Stridor, if they're comfortable and they're conscious with, you don't be afraid to examine them as long as they're comfortable with it and they're all right, check. Look at their oropharynx, have a feel around their neck, do a proper neck examination. Um If you're able under ent we would obviously do a flexible nasoendoscopy. And this is that picture on the right. You'd be looking at the vocal cords, you'd be looking at the epiglottis, you'd be looking for any signs of any pathology, deep seated infections, abscesses, inflammations, foreign bodies. And then you'd consider imaging. This is all just dependent on what the cause of the stridor that you think it is. Um I think one of the Stridor cases that actually sat with me the longest was um a gentleman that came in 30 odd something. Um struggler, I was asked to see him about 10 o'clock at night, um conscious but was not stable, you would say um still talking to you uh fairly on the edge anesthetics were there. We did a flexible nasoendoscopy. But actually the first thing that we noticed was when we first did the oropharynx was that it looked like a Quinsy, but we couldn't persistently say, and he had a bit more pain on just the right side. And actually what we found out after CT imaging, it was actually just the peritonsillar abscess that had grown to a massive size and it caused this airway compromise and they needed to be taken to theater to do this drainage and it slowly resolved in itself after that. So always think about the cause behind it. Uh When things actually go south, I've only seen one of this, but obviously, they will sometimes they can be taken to theater to do a tracheostomy, a temporary tracheostomy or more emergent scenarios. You can do things like a quicker thyroidectomy. So when you think about causes, I want you to always think about things like the um surgical thieves because this just really helps you after all, the ent is a surgical topic. So think about the infective causes. We've got clos epiglottitis. Ludwig's angina, any abscesses and like I said, quinsy inflammatory are things like your angioedema and your anaphylaxis malignancies and trauma very simply put. And obviously, there are just some idiotic or genic causes. So this is a picture just for your knowledge about what Ludwig's Angina is and Ludwig's Angina is basically the few celitis of the base of the floor which can cause this. And it's just something that's good to have a, well, just know what, what it presents like. And this is epiglottitis, obviously not as common anymore. What you see at the top right corner in B is obviously inflamed, epiglottitis, lots of bleeding, lots of inflammation anywhere. This is a normal sign of what an F NE looks like. This is an X ray of your um lateral neck. And it basically, it's supposed to show you the thickening of the epiglottitis and your aryepiglottic falls. It's meant to show you a bit of a thumb sign if you can see that, but again, not the most common. So does anybody have any questions so far? Anything whatsoever we're going to go to the next topic you would say because we've, and I've tried to make them into like solidified, like versions of each other if that makes sense, but we'll see how we get on. So we're gonna move on and we're gonna talk about neck clubs. People don't like neck lumps. And whenever anyone comes in with a neck lump, it's a bit of a, it's just a bit of an annoying thing. Really cos where do you start? Where do you end? So let's just approach neck lumps. What it is is basically a swelling within your neck. I want you to find out whether it has it been an acute thing, a gradual thing, any triggers with it and any associated symptoms with it, because obviously that's what helps you find out a little bit more about what this neck lump even is red flag symptoms. Obviously, very important to remember, dysphasia, dysphonia and your bee symptoms. Your B symptoms are things like your fever, your weight loss, your night sweats, clinical features that you might also just wanna make sure is obviously the swelling itself. What does it look like? What does it feel like? What is the skin changes around it? Do they have any pain with it? How's this swallowing with it? Is it affecting them in any sense or way? Are they systemically well with this any discharge? And you'd examine it thoroughly. So you'd obviously start, you know, we'll go through this very quickly, but you do a proper neck examination, lymph node examination and just a general systemic examination to make sure that there aren't any lumps or bumps anywhere else. And also for a neck lump, always look inside your throat, have a look at the oropharynx, oral cavity. And if you're under the ent, you'd be able to do a flexible nasoendoscopy to ensure that there's no like a foreign body, there is no deep seated abscess anywhere that's causing anything and your investigation. So it's like normal bloods that you think to do. You can do a flexible nasoendoscopy. An ultrasound is normally what we do um with a fine needle aspiration, if there is something to actually drain it and you would refer to the appropriate interventional specialist to help you do that or your radiologist and it would take things from there. So your differentials is where it comes in. And I like to think of it as two things you want to break it down to anatomy and a surgical sleeve. And that just basically, um, gives you a better idea about what this lump is actually going to be. So if we do this exercise where I try to explain to you where it goes based on the anatomy and the zones of your neck. So zone one is just how you start doing a lymph node exam in med school, you start with your submental, you go up to your submandibular, your tonsillar space and your preauricular that is zone one. What's common in zone one is your um citti. It's basically inflammation of your salivary glands. You've got dental problems and sub man gland tumor can also present there. Now, level 23 and four is basically we turn your neck and I want you to think about um your stenocladum mysid if you divide this into thirds. So one third, two thirds, three thirds, that's your 23 and four, very similarly, lymph node pathology is very common in all three of these. And but in level two, you can have your pa to tail lump there in level five. So level five is your posterior fossa is behind your Stenomys. And you can find that lymph nodes are there, lipoma cystic hygromas and level six is back looking forward at where your thyroid is and your midline is things like your thyroid elosal cysts and your dermoid cysts. So I feel like that's a better idea of understanding, you know, where things can present. And when you're actually calling ent, which level of your neck are you actually talking about? It gives them a better idea over the phone. So we saw a lot of lymph nodes pathology over there but causes behind the lymph nodes pathology. That's when you use your surgical sleeve. Number one is reactive, could be tonsillitis, abscesses or stomach infections. Quite common to have your lymph nodes to start reacting towards that infective could be viral or bacterial. We've got TB E HIV CMV, things like that inflammatory. Your Sjogren's your rheumatoid, your sarcoids and your neoplastic obviously divide it to benign and malignant. And um think about whether it is it your primary or is it your secondary of something? And if so where is your primary congenital? Are things like your cysts and your cystic hygroma and your endocrine obviously be mindful. I know you are, but right in the midline, you want to be aware of thyroid nodules, goiter. It's really important. These are the associated features that you'd want to know a little bit about. So those is my consideration of how you'd approach neck lumps. So now we're moving on to sinusitis. What sinusitis is, is basically inflammation of your paranasal sinuses, ent calls it rhinosinusitis. And that's just because inflammation of your nasal cavities almost always occur with sinusitis. So, sinus sinuses just reminding ourselves of the three most common ones. We've got a frontal, we've got a ethmoid around the corner and we've got a maxillary in our cheeks. Clinical features of it. Very simple. It's like having a runny nose, but it's persistent and it causes facial pressure and facial pain. It can reduce your sense of smell. And although it's very similar to viral illness symptoms most of the time often because it's been induced by viral symptoms. It can cause systemic symptoms like fevers, coughs and sore throats. Now, obviously, there are complications for anything and sinusitis can lead to very deadly complications. Can anyone give me an idea of what the complications could be? Um s I've mentioned a little bit so sometimes systemically with sinusitis, people can become really unwell with it. They can be, yeah. Orbital cellulitis. Oh, I wasn't even going there, but that's great. Yes. Or periorbital cellulitis is one. Um, they can present as tachycardic, a pyrexial, they can be unwell with it. They can become a little bit. Anybody want to finish my sentence for me. It's when they will need to be admitted. They might need IV antibiotics, fluids. Mait. Yeah, mait. Yeah. Also just simple things like sepsis. Yeah, meningitis, sepsis. Yes, intracranial complications and a bit of a bit of an uncommon one is ap puffy tumor, which we'll talk about in a second. So examination wise, I want you to obviously have a look inside your nose, see what the discharge looks like, palpate their sinuses. They might have pressure or pain with the flexible nasoendoscopy so that you can see through like in the nasal spaces to see what the discharge looks like. But always, always, always for sinusitis, do a dental check because dental abscesses get missed. Um, neuro and cranial nerves are because of the complications that we mentioned earlier. So what p puffy tumor is, it is very rare, but it's basically the forehead of your frontal bone having osteomyelitis and it's associated with having a subperiosteal abscess in itself. So, we've talked about what sinusitis is, but how do we manage it? And management is basically a few things. Number one, it's about understanding what's acute, what's chronic and what is recurrent. So, acute sinusitis happens following a common cold and what an acute sinusitis is is that you have an increase of symptoms after five days and it is the persistence of those symptoms for over 10 days, but under 12 weeks. So it's basically symptoms that have extended for 10 days that has acute sinusitis. A chronic sinusitis is per symp symptoms that have persisted for longer than 12 weeks without any resolution. And the recurrent sinusitis is having at least four of these episodes um with si of annual episodes of sinusitis without any symptoms in between those periods. So, if I were to ask you predisposing factors, so someone that can come in with like chronic sinusitis, any idea what you know, would be risk factors or factors that they could come in with, that make them more likely to get sinusitis. And simple things can be like um having allergic rhinitis, having a history of atopy. Anybody else can think of something very common. Something that we as doctors always try and advise people not to do asthma. Yes, smoking, beautiful. So it is things like that obviously taking account um if they're immunocompromised as well, if they have any signs of ciliary impairment. Um and my next big question is imaging. So for imaging, what imaging is considered gold standard for sinusitis? A Yep recreational drug use definitely is. So I'll give you guys just a few seconds. It's a bit, it's a bit varied over there. So I'll stop you now because I've been a little bit, been a little bit mean there is actually no gold standard imaging for sinusitis. Number one, it is a clinical diagnosis. Number two, imaging is really used when you're concerned about complications. So when you're thinking about complications, that's when you think about the different types of imaging that you would use in the sense for something like a periorbital cellulitis, you would think about a CT head and a CT orbit. If you're thinking about, you know, just like a deep seated neck infection that may have been caused by the sinusitis, then you would think about that appropriately. Now, how do we start managing an actual sinusitis is by understanding, where are we right now? Acute, chronic and going from there? Number one, if you're under 10 days, it is likely because of the viral symptoms, it is likely viral and it is self resolving and it is annoying and you just have to reassure them. It is things like giving them a nasal decongestant. This is like your Atra spray, analgesia and nasal douching. And obviously, if they're a little bit, no, by that, you can try things like um your topical nasal steroids. So these are things like your mometasone, your fluticasone sprays. So for an acute sinusitis, you would think about 14 days of your nasal steroids for a chronic, it can go up to three months. We obviously would not, this is not ideal, but this is something that might help people antibiotics. Huge question. So if it's after 10 days and it is obviously not resolving in itself and it looks more and more like a bacterial sinusitis. These are classified as symptoms of over 10 days. Discolored, discolored purulent nasal discharge. They are febrile, they have a high CRP. These are all signs that it could lead to bacterial sinusitis and then you start them with antibiotics. Um this would just be phenoxymethylpenicillin or doxy. Um If they were allergic and you would just continue with the decongestant and the topical nasal steroids, you would admit if the complications do arise with them and if it was recurrent and it was becoming a problem affecting quality of life, they can be considered for affair. So, one second, let's start our cases just to like solidify what we've learned. Somebody's got sinusitis for six days. The abs are stable. They're managing their pain pretty well. With paracetamol and Ibuprofen. Would you give them antibiotics? They're complaining like they're like, oh, it's been six days. It's been absolutely shit. I can't take this anymore. I just want this to be done. Versus someone that's complained of it for 13 days. Increased pain. They're bit feverish, they're a bit persistent. They can't sleep, they can't rest, they can't even drink. What would you do for them? Would you consider antibiotics then for them? Yeah. These are obviously guidelines, right? So, if someone comes see you at day nine and it looks like a full blood s sinusitis, a green discharge. They're, and well with it just because I've gone and said 10 days only at 10 days, can you think about antibiotics? Doesn't mean that it's clinical. So, always take it person to person. I know you will. But it's good to just understand when and why? Why are you considering something like this? If that makes sense? So, because someone has already mentioned it. Let's talk about periorbital cellulitis. And this is basically an umbrella term used in ent. And what we're thinking about is that this is just means swelling around the orbit and the eyelid and it's broken down to preseptal and orbital, which is postseptal. What is really important is how you want to classify it and what sta not stage, what type are we at? This is a Chandler classification and it talks to you about the different types. So I want you to pay attention to this and my explanation because we've got a few questions coming up after this that I really like you to get correct. So just to bring your idea to obviously what is normal right over there and let's talk about the first type. It is a preseptal cellulitis. So what is demarcating this border is something known as the orbital septum? So just circling my mouse over here, this thin line over here, an orbital septum is basically just a fibrous layer that forms the anterior boundary. And its basic function is to actually reduce the spread of infection from your preseptal to your postseptal space. So what is preseptal cellulitis? It is cellulitis confined to your eyelid basically, and it is confined to anterior of your orbital septum. Next, we have type two. This is your orbital cellulitis without abscess. So it has now entered the orbit. So your cellulitis is involving your orbit and it's obviously using your postseptal tissues. If that makes sense. Your next one is orbital cellulitis with a sub sorry with a subperiosteal abscess. And this is basically number one, it's obviously postseptal. All right. Number two, your abscess has formed but it is confined to your um subperiosteal space. Basically. Sorry about that. It's confined to your orbital periosteum. Next is your intraorbital abscess. And what this is is basically an abscess which is in the intraconal part of your globe. And it's actually in between your extraocular muscles. So it's in between your intraorbital muscles here, followed by the next stage, which is your cavernous sinus thrombosis. So this is obviously, it's quite rare, but it's obviously the most serious in the sense that you formed a clot in your cavernous sinus. And also this normally presents as bilateral as bilateral um perorbital cellulitis with you'll see your intracranial complications. So, and also your eye complications, protos ophthalmoplegia and your neurological signs. So, in terms of pathophysiology, let's think about it as two ways. So we've got our preseptal, our preseptal is confined to our eyelid and that is obviously the exterior. So I want you to think of it as it could be things like an insect bite, just trauma, uh genic, just as you know, max back surgery or even eye surgery that can happen. Things like your orbital cellulitis is likely to happen following um sinusitis, your frontal and modal sinuses, especially pathology leading to an abscess there um important to know that your normal causative organisms can be things like your strep pneumonia, your haemophilus influenza and your staphylococci. Yeah, this is for my questions. Come in which channel classification is a, I'll reiterate it as we go. But hopefully you guys remember it. So one is confined to your eyelid. Yeah, anterior to your septum two is basically you are obviously diffuse cellulitis within your orbit. Three is you've got an abscess that sits underneath your orbital periosteum. Four is you've got it in between your intraorbital muscles and five is you've basically got cavernous sinus, thrombosis, bilateral signs, intracranial complications. Ok. Now, if I were to ask you what is B and then we'll discuss very quickly. Ok. So that's a bit cheeky of me, but I think it's just good to understand. So let's talk about B do you see how that erythema is actually just confined to her upper eyelid? Whereas in A, that erythema that redness has spread down to the maxillary just under here. Yeah. So B is Chandler classification one is com it's to the eyelid and A is two. It has just spread. It's an orbital cellulitis. I can't tell for certain, obviously with just that, that it could be three or four that would need some imaging to help us diagnose that. So, clinical features and examination and I've just divided it into three parts to help us think about your eyes and these are just the eye signs that we've talked about and the clinical features of it, ophthalmoplegia, diplopia, any pain in your movements, proptosis, visual acuity and color vision, red and green tends to go first. So you need to have a look at that and fundoscopy, a nose examination, obviously having a nasoendoscopy doing and fending through the nose and taking a culture and sensitivity of the discharge and a neuro exam because of the complications that we've talked about. So red flags, any signs of compromised vision, you'd always want to err on the side of caution of a preorbital cellulitis and obviously, things like sepsis, meningitis, cavernous, sinus, thrombosis, things that you've, you guys have already be like beautifully thought about. So how do you manage them? Number one ae this is after all, an A and a survival guide, but sepsis six, because you always, this just helps us go through things like bloods, lactates blood cultures, I VT things like this and most of the time they could present a septic with you. Imaging is your CT orbits and your sinuses. This is when you'd use it for them. This is gold standard. Ophthalmology is extremely important, especially for Children that present like this and they're not gonna tolerate you trying to look into the eye, get an ophthalmologist, but getting an ophthalmologist for a child should not um delay, you know, as treating them. So non surgical includes a few things, antibiotics as per as your local guidelines. Hydrocortisone. You would still give them a ster treating for sinusitis, things like nasal decongestants, steroid, nasal drops and nasal douching. This is again, just to help clear out any of the sinuses and collections that's probably feeding into the cellulitis. And your surgical options are two things. We've got a uh external frontoethmoidectomy that you can see at the top here. Um If anybody is curious, it is a lynch howard incision that they commonly use. Um You can either do with an external and endoscopic procedure and this is just to show you what it can look like that scar. Uh The bottom one, a lateral cany is because if you're considering or worried about orbital compartment syndrome. So my next question for you guys, these are CT orbits. So let's start off easy, which is a normal CT orbit. So I just will go through with you guys. Obviously, we've got our noses here and our sinus passages here and our two globes here. And this is your orbital septum that you're looking at here. So, very interesting. Let's go keep going, guys, keep going. This will make you and I'll, I'll give you the right answer as we go along with it. Indeed. B is your normal CT orbit? So with that said, which one do you think is your preseptal cellulitis? Yep. Absolutely beautiful. So A is your preseptal cellulitis? So if you can see just here, you can see that thickness here compared to this on your right side here, that would be your preseptal, it's just above anterior of your globe. And in C you can obviously see that inflammation and this abscess that is formed here within that is your orbital citti and C. So now my next favorite question is this, which facial palsy is likely an upper motor neuron lesion? So just the thing just think about the patient who's basically obviously, both of them are trying to use their facial like features on this side and the affected side is here. Yes, beautiful. Yes. We think B is definitely an upper motor neuron lesion and A is a lower motor neuron lesion. Because if you look at here, a, we're looking at an isolated left sided facial palsy. Now, facial palsy is a huge thing and just obviously coming into this talk, let's talk about Bell's palsy because that's very common for Ent. So Bell's palsy is normally a diagnosis of exclusion. It is a dysfunction of your cranial nerve causing facial weakness on the ipsilateral side and is most commonly known as being idiopathic examination wise. I want you to examine the ear because it's really important to have a think, see whether they've got any signs of infections, any signs of mastoiditis, you know, you querying necrotizing otitis externa or cholestatoma. Um And if they have vesicles in their ear, you're considering something like Ramsay hunt syndrome. When you want to think about their parotid. I want you to think about swelling in their parotid in the elderly. It could be something like malignancy. Those could be one of the signs. Um Obviously, you're looking for any signs of abscess and for the eyes, you want to check for the occlusion of the eyes, are they able to actually close it completely. So these are just some of the clinical features and in terms of a scoring tool, the scoring tool that we use is known as House Brackman. And it grades by severity and this just helps over time in terms of progression and severity or deterioration of disease. Really, it helps. Um I won't go through too much of it. It's just a very important point is that grade four would basically say that your eye closure has been compromised. So red flag signs are things that you were looking out for in your clinical features. So things like Atalia carotid swelling trauma, if they've had, it might need urgent surgery for decompression. And if they had other neurological symptoms, did they actually have Bell's palsy or did they have an upper motor neurone cause which you need to investigate further how you would manage them is steroids within 72 hours of onset for seven days, up to 60 mg, give them acyclovir, acyclovir is a bit of a gray. It depends on your local policy and what your ent uh guidelines are and eye drops. So it's very symptomatic and reassurance and follow up, which leads me to my next question. What percentage of patients with Bell's palsy recover without any treatment do you think? And this is just something that's really important when you want to reassure your patients. Oh, we got. It's a bit a bit mixed there. It is actually 75% of patients recover so they can recover in 2 to 3 months. Some can take up to nine months to recover. But 75% of your patients will recover without any treatment, steroids increase this by 85% if given within 72 hours of onset. Um And if your patient has not recovered by three months, this is just because it's a good estimate, we would obviously make sure that they're reviewed and you would just do an MRI of the artery miosis if you're concerned about something like a cholestatoma infections, things like that, and you would refer them to a specialist facial nerve clinic. This could be for SMES or reanimation, things like that in case they actually had persistent damage in this other 25%. So this is again, just a very general differential diagnosis for facial droop, which I will not go through. I think you guys can go through the sides and just have an idea. I just wanted to cover Bell's palsy very quickly. We're just gonna go through something like foreign bodies in Ent. So yes, history is always so so important. So this is a bit of a joke, Paul. But I think that it's something that is actually so exciting. Sometimes the types of things that you will find in mostly kids ear, but also adults, to be honest. So you guys can actually just find out for me or try and find out if you want to. What was the weirdest thing that I've actually taken out of a person's ear history is so important. You obviously want to know what have the exactly shoves in there. Clinical features are simple things like letia, irritation, hearing loss, bleeding and sometimes people can just be asymptomatic, but then just come for a review and you've just seen something there, examination is just so important and it's so difficult with little ones and yes, the goal of it is you want to remove it. So number one, you need support, especially with little ones. You need mum to actually hold them down or you need a proper ent nurse to give you a hand. So these are a pair of crocs, they've got a little, a little clipper at the end and your headlight is so important. You need a little bit of luck because sometimes you only have a few goes in a patient. Um, theater is always an option for kids, especially if you confirm that you've seen something in there and there's absolutely no chance getting it from them, but bear in mind it should not be our first go because putting a child through anesthetic for this has its own risk. Now, when you get triaged for something inside a year, it does not have to be reviewed the same day unless it is a button battery. It can be booked in for the next day or when they're actually available as long as it's not causing them too much discomfort. But after removing a foreign body, what do you do? Oh. So people found the macaroni. Yeah, that was pretty weird. II will be admit I was quite impressed at that child. But actually for me, it was, I'd taken out the sycamore seed from this darling kid that I thought it was quite cute to put in because he just thought that that little seed could just sit at the tip of his ear. So I removed it and I said, all right, let's look inside your ear once more to make sure. And he cried and cried and I was like, no, we have to. And he had something else in there. Reexamine, do not trust your patients always reexamine after taking it out and always look at both ears, not just the one that they think that they put stuff inside noses. You'll often find kiddies coming and parents saying that, oh, I didn't really see this. They were playing with something and then they've just been having these features and I think they've shoved something up their nose, really, really try and get as detailed a history as you possibly can. Features are well, red features, red five features that you should be concerned about is a unilateral one sided nasal discharge, crustiness of that nose. Any bleeding, that's one sided, especially in a young kid with a history that's a bit 5050. Any pain or discomfort always are on the same side of caution and see them on the same day because obviously anything in the nose can cause potential airway obstruction and ask them to do mother's kiss. It's basically holding the unaffected nostril in your nose and blowing more, blowing air in the mouth and trying that to see whether they can dislodge it, examinations where it gets trickier. It's one thing getting something out of somebody's ear, it's nothing to hold down a kid and look inside their nose. You need good visualization support and a lot of it you can try otra drops to help and slowly just dilate to let something come out. But things that you would use is suctions to just try and get it. If you first can, that comes over here, which you use to open the nasal prone, the nasal um to open your nasal flares and you can use the J and horn. So these little scoopers here might help you so you can theater always consent them for looking into both nostrils. Again, something was missed by accident. Cos we only looked into the one nostril and they had shoved up peas in both their nostrils. And finally, we've got foreign bodies and throats. Um I'll only be like five maximum 10 minutes overdue. So if you don't mind bearing with me, that would be great. And if not, please, please, uh just before you go, thank you so much for attending. Just fill up our feedback form. So foreign bodies and throats sounds a bit chaotic, sounds a bit unrealistic, but it does happen and as things like an esophageal foreign body that we need to be concerned about. So number one, always a to e them, you want to make sure that they are a stable patient, you want to make sure that the airway is not compromised as well. But when we come looking at it from an ent point of view, we need to think about the anatomy based on where it is. Yes. So if you um if you sorry Fran sorry to disrupt, if you fill up the feedback form, you do get a certificate of attendance. So what's really important when you think about ent in this is basically levels of intervention and where your anatomical landmarks are. So if you think about anything obviously from the side of the amount to where your cricopharyngeus muscle is, and this is basically just a um muscle that sits just below your Adam's apple at this level or basically above your vocal cords that this is likely an ent intervention, anything past this up to your um aortic arch level is likely a gastroenterology problem and anything further than that, you would just discuss with interventional radiologist. So, history and clinical features obviously take a history from them. What were they doing at the time? You know? Um, are they concerned about something? Um, are they having any types of dysphasia which we will go through a little bit? Are they unable to swallow their own secretions or the liver? Um, is it painful, swallowing at all? Is it just a sensation of something in their throat? And do they, are they complaining of, you know, front or back or chest pain and they unstable with it? Are you querying a perforation with this? Are you, are you query um feeling surgical emphysema at any point? So my first tip is ask them to sip some water in front of you. Obviously, if they're not able to even swallow the saliva, it will be very difficult. And you understand that. But what happens when they sip some water, if they sip some water and immediately regurgitates everything in front of you, it's likely that this is within the top bit. So it's within the ent level and there is some sort of stricture pouch, malignancy, something that's going on that you can see through flexible nasal endoscopy if they sip some water and it's fine for 1015, 20 seconds. And then it comes out, this is likely a gastroenterological problem that you're thinking about and it's good to have this in the back of your mind. So, just other clinical features, check whether they've got pain and you're querying a perforation. Is it painful of occurring a sharp foreign body, um, aphasia or drooling and feeling for emphysema, noticing any torticollis or any Christmas. And these are the things that you'd look out for and examine them, examine them very, very carefully and get some support if you're worried about their airway. Obviously, imaging is really important just depending on the level and what you're thinking about doing it. Plain X ray films can be very important just and very useful for just normal hazards. Actually, you'd see and management gets divided into medical and endo endoscopical. So let's start with medical things that you can try fizzy drinks. You've all heard it before, but it does work because why fizzy drinks actually help to dilate your esophagus and this actually helps Buscopan, Ivy Buscopan. So you can use this about it's a 20 mg bolus up to five times. Um You're supposed to try it. IV Glucagon actually helps to relax your smooth muscle of both your mid and your distal esophagus. And it actually does help in most cases. It just again, depends on the type of foreign body we're thinking about and some people use prokinetic like uh Dodon or metoclopramide. Um studies vary depending on their usefulness. But now talking about endoscopy. So what is considered non urgent things like coins can be observed for 12 to 24 of there in your esophagus, objects that are in within your stomach that are about 2.5 centimeters and disc or batteries in your stomach without any gi injury. Not so urgent can be done the next day. Urgent endoscopy, which has to be done within 24 hours at least is a near complete or a complete esophageal obstruction. Again, just depends whether the patient is stable or unstable with it. If you have a food bolus without any complete obstruction, and if you have a foreign body, that's not sharp point, it shock points that are in your stomach and your doen because this likely can cause things like your perforations and any magnets with an endoscopic reach. Again, just depends where they are when you actually image them x-ray and objects that are over six centimeters in length, which are above your proximal duodenum. So emergency ones that you want to be mindful for is anything that's sharp and long or super absorbent. Um lithium or button batteries are obviously more of an emergent endoscopy things just because of the lead of necrosis that it could do if it leaks and any signs of airway compromise. Uh very quickly, dysphasia is a, a topic of its own. But it's very good to just be aware when it comes to ent because you share approaches for dysphasia between ent gastro neurology and you always work with your salt team. I just want you to have an idea about how to think about it. I want you to think about where the anatomy of the dysphasia. Is, is it higher up or is it with the initiation of your swallowing? Is it just this feeling of this lump that's there? But actually, no persistent problems with the swallowing or is it lower down? And you're thinking it's more esophageal? And if so if it is esophageal, it's likely to be gastro and if it's oropharyngeal it's likely to be ent, but lots of MDT S for dysphasia and you can obviously refer them accordingly. But if it's a gastro and esophageal thing, you would think about mechanical obstruction versus motility. If so you'd quantify this as either nonprogressive or either intermittent or progressive. And this gives you a better idea of what you think is going on. Sorry for running a few minutes late. Um, thank you. Thank you very much. Uh, does anybody have any questions whatsoever? I'll just send the feedback form again. I would really, really appreciate if you could fill up the feedback form and, uh, join us for next week. I think it's next week. On Thursday we've got the psychiatric emergencies and if you just need to brush up on a few things, especially different types of, er, sections or different types of capacity involvement, a mental health assessment, this would be a really good refresher for you. Uh, does anybody have any questions? I will try my very best to answer things. Thank you guys. Thank you very, very much. Like I said, we've got six more sessions to go. We'd really appreciate if you guys keep joining us, it would be absolutely amazing. Um We've enjoyed making the series. Uh Both my colleague and I uh so how you can get the slides. Um It will get added on to uh metal's like on demand content and then you can like rewatch it yourself. And I think, I think that's a way of keeping it somewhere on metal. No worries. Thank you very much, everyone. No, I hope you guys have a good evening. Thank you very much. You guys take care just please, please follow up the feedback form. I really appreciate it. Thank you.