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okay, SBA format on this. Every one congestant Iraq through the pole. And if you have got any questions, just put them on the chat will get to every single one of them as we go along the chit oral. All right, I'm going to just put a hand over to laughter. Did it start of them? Oh, hi, guys. And that's all coming back on the days that happened when you joined yesterday. And we're gonna do part Torto part series on the ENT for finals today we would be talking about We split a session into too hot now slots. So the top one, I would go do it on on peripheral bat ago was quite common. And it tends to pop up in medical Bible, especially empty cues. And then we'll talk about some facial palsy. It's, um, different types of different causes. Information about pools. He's in the second half an hour on Botox, leaving on. So this is the same schematic beard I showed you guys yesterday. So I remember the artery is basically anything involved from the pinner up to the tympanic membrane A the middle ear is this cavity in between which, between a tympanic membrane between around and over windows. And then today we're going to looking. Mawr acts up being in their ear, which involves the best of you'll on the copy. Oh, on the you trickle, which are they Organs of hearing on balance. And it will be looking at the nerves and world of stable branch. In a copy of that PSA would be some SBA. It's on on one in her ex ology. Okay, so just a bit been asked me before. We sort of dive in and we don't go to bed. And that fixed it will make more sense that probably you see any in here will make more sense once you understand that, um, roughly one goes on me. So as you can see here, the facial nerve is very close by to the festival a copy and on in the vestibule, a copy nerves, actually two separate branches. So it's the vestibular branch which is associating. Where was it called with balance on Got the cochlear branch, which associated period. Now this is really important because certain pathology within the inner ear that we're going to later actually involves certain branches, which why you might have issues of dizziness but not necessary hearing it's because it's involving one branch as well. Is that so? This is the stemming circular canals, so that's all. So the weight is a picture, your seventh cycle canals, and you imagine a hose pipe being a member anus labrum. So that's like in a choo. And then you've got a casing around the outside, and that's what bony lab room. And the reason this is really important because in certain conditions of giving us the semi circular canals and where the pathology are, you got free of them. Got the anterior posterior you got. The lateral semi circular canals on the concrete is involved with the hearing, and it's basically a a a lot of the whole of the organ. So the seven second canals to copy and the you trickle or have something called Endolymph. We've been the members labrum, and this is really important will come onto a bit later, so that's generally what it looks like. Kind of looks like a funny looking snail, but this is what's involved your hearing on balance, say, having pulled about that, let's move on to our first SBA so believe me. Get the pool ready. So you're asked to see a simple viral gentleman, Edie, He's been reporting feeling quite lightheaded, which were some readings head on the nose. This especially when he's like turning around, especially in bed at night, on the vertigo and the business in the vertical he describes last for about seconds. Minutes. He doesn't report any other hearing or your hearing loss or any tennis is on. It's got no neurological symptoms, wonder clinicians. That ends up being a big full pipe, which ends up becoming positive. So I'll give you guys like a minute Latif. So we'll fill this one out, and that makes you gain for the same answer, which is good. Give you 15 more seconds. Cool. Say the vast majority of you've actually gotten for BPPV said benign paroxysmal positional better gay, which is the the credit cards? Um, so I will talk about it all. That why this is BBB What pathology is in next slide. So would be give you sort classical medical scenario, the antique you snore essentially relatively oldest person who notices it gets like pretty bad dizziness on turning the head on a swelling that uh, they tend to do a rectal pike, which tends to be positive on that. Basically a positive, big full pipe classes. Basically, when you place the patient on sitting up right and you basically know their head, what's looking at you on? If it's on the side that the, uh, that big PBS president, then they'll start getting rotation of my stack ms, which improve with time. So some of you want to be put many years. So the reason it's not many ads kids Many years it's an association with pen movements and actually associated with Tenet Ear's hearing loss of a little fullness so upset that sensation of fullness inside your ear on and the viral labrum Vitus. The business pattern tends to last a lot longer than seconds to a minute intensive. Also, they also mentality be's the reasons I keep straight snore Mix of CT had a lack of focus on neurological desk. They're kind of plot, I said. It's not really a strike, so well done, guys, um, say you could be be It's a fortune. The most common cause of best go present in people on. Like I said, the the name kind of gives away, so it's benign, so it's nothing sort of molecular. Nothing, too concerning parents is more means that it's a lot dependent on the wrong. Placing off what we call motor can get a little crystals that get lodged in the semi circular canals on the main place of the semi circular main patients crystals get logical. Answer your posterior canal, which is why people can't notice that when they're turning their heads around, that's it at night. In bed on this, basically called is quite intense. Oh, go back over the next five after I finish this, but basically causes quite intense, short lived episodes of vertigo, which tends to, uh, and that's a characteristic beaches of it is. It tends to get better with time. The nystagmus he gets rotational on, but there are, and it's usually quite self limiting, so it does usually improve with time, so you don't really need to do anything about it. So going back to addict all pipe test. Essentially, if you picture myself so your picture yourself on a patient is saying on the table, sitting up on it. So you got so many seconds, so you got you got patients bed. You've got patients sitting up in bed. Basically, what you do is you stand in front of them, hold the head. What's the kitty? You have more say, looking for tried degree angle and he basically drop their head on down to the down Teo down to the bad. Essentially. What happens if it's If that's what it crystals are said The crystals are lodged in the right posterior semi circular canal. What? You tend to get 1 2010 to observe in a positive dix Hallpike their whole pipe test. Is there nystagmus basically going around in circles which for equal rotational nystagmus. So that's kind of like you're investing in the investigation of choice. But that makes sense. Yeah, Good, eh? So you ask your main sort investigation of choice and what you'd like to do at that point if they are, I have a positive Dix Hallpike test. If you do something called Epley maneuver Now, the principle behind this maneuver is your basic moving the head in a way to try and dislodge those crystals from the posterior semi circular. Now I'm moving it back into what we call the ambulance, which is the big opening where they can't well, it didn't cause any problems on um, there's basically a way to do it. Published YouTube hard to hard to do one, but probably won't be asked to do it in your actual medical finals, but it's just good to know. But this maneuver, essentially, what is Talk to the patients when they have a a Q attack bpp be it so that they can. They self treat themselves at home. Um, other source stuff that you can do for you can give him some festival rehab, excited court or next. Size is it's basically when they come into they see a fib. You know, basically, and they get told on the different sort of exercise is to try and get used to the idea bpb and get the trying to retrain that big brain to do the episode so they get with BPPV on the main thing, really is the boys, uh, vestibule symptoms like prochlorperazine and beat a history in a lot of evidence out there on a clinical research which shows that this doesn't really have any effect with BPPV, the main, the main sort mainstay of treatment to really that Epley maneuver on giving patients reassurance and let him know house still intact When they do get in the tag, you can also the surgery, but it's a really extreme. Not so. It's a little thing and basically involves destroying the inner ear. So you basically inject the interim with toxic drug gentamicin or steroids on basically destroy, it said, thus preventing you from getting BPPV, but also means that you also lose. Hearing in that ear is well, the main thing is, um, as we go through the different cases at all off dizziness, a peripheral vertigo. It's really important when you are like seniors, patients or even in your excuse up the skis. It's really important that you mentioned driving ability. Drug. Essentially, they're having attacks that can't be predicted. They have been formed EBL eight, generally speaking, So it's really important that you get on and estacion like this and your skits, importantly, mentioned importance of not driving until the dizziness. Episodes are predictable on that she can be managed when they do. Come on. Um, what's the question? What's differently, particular. This kind of interchangeable terms of where to go from or the medical term for dizziness. I did. But the thing is, did you miss? Tend to eat more? The laymen terms of patients tend to use the bitterness one a day for for different. The different being said they're feeling lightheaded. They might prefer that's being busy with Byetta. Go is the actual formal term of when perfectly the room is spinning around you or century. You are spinning in that room that extent. So yeah, so that acceptance Rubini cool. I'm single case to it, so you have to see a 45 year old woman presents a business, and she reports that each episode last that minutes hours. She also reports the sensation of fullness and elect a result of some self reported hearing loss. And tennis is. She doesn't think there's any triggers to this, but she does report that she had the 20 year Pakis three cigarettes drinking cigarettes and drinks about 15 years and uncle per week. They have gone and done a quite comprehensive examination on your really is essentially positive bilaterally. But the weather's was it called weapons test us lateralize is to the right. Yeah, give you go, stay more seconds. I just think it's a nice mix of everything. Okay, I could be five more seconds. They will stop in there. Cool. So the vast majority of you put many years, which is correct. The some of you will say, but one of the others, it's best it been your ICS accusing. You're over there. Okay, we'll talk about why it's many years on day, like I mentioned earlier. So basically many years has this sort characteristic signs off or fullness, which is basically on a sensational Your is being blocked tentative, which is like a ringing noise hearing loss. I'm busy Nestle Bass ago on Well, is that the other characteristics sign that points this towards being a many years and the fact that the elected the episodes from minutes to hours rather than days like you get with that provide tests or best of the new writers? Um, the reasons are you using the robot? It's good accusing the Romans. It doesn't. It doesn't degrade, is associate with a sensor in your hearing loss, and and it's normally start the first port call that you do best gate for where the patient does prevent like this. But given the fact that she's also reported other side's a little bit on but on Was it called and tinnitus and hearing loss that kind of points more toward many years. Disease, eh? So many years and that makes sense. So many is quite interesting conditions. So remember when I said, you know, you got yours or a hose pipe? But you remember this number, and then you got your your casing around that Who's the bony labrum? So inside the members, like I'm very elaborate, basically, just fluid called and I live on that's a really important fluid. It's basically when you move your head, that fluid moves I/O in an hour. The same exactly canals and through the food. Uh, vestibular in general, what happens in what happened in many years? Basically, you've got too much of that fluid in the in the area on people think too much about fluid is probably read and why people feel like they've got that sensation along fullness. So that's that's a blockage in the air. There are some association with this being being so good associate with a high salt diet, so people poor diet, scan Teo, be associated home many years and The main thing really about the birthday is the episode. Vertical tend to occur from minutes to hours on the comedy effects people from about aged eight H 2060. You mentioned earlier like this, the common symptoms of vertigo that lasted minutes, hours, nausea and vomiting, tinnitus or Filner's and then the classics or empty Q. Question is, when you get drop attacks, especially in the elderly, so drop attacks it basically, when people suddenly just like collapse and then they get up again. But like a few seconds later, and there's no real light reason for it. For some reason, men many years associate that that tends to be one of those NTG questions that getting your finals about what this could be in terms of management. Does anyone have any ideas how you manage someone many years, just write a shot? Um, saying Mom, it's so how How does grommets work? Freddie said. They tend to work by ventilating the middle ear. So the issue here is the issue here is really a problem with the inner ear. So you got too much fluid. It would been the member. Let's remember. That's what I remember. Last lab room in the inner ear. The government would have really improved. Got be testing. Yeah, I agree. And they also How would you do with, like, the tennis is aspect of that. Said your poncho up with you mean sorry. I didn't quite get that Ready? Um, steroid. Yeah, you can. Is it more than last resort thing into panic? Steroids? Very kind of also ruins that. Here's what I can't destroy that here. Yeah. Yes. The surgical options tend to be quite a lot. Yes, I did. Yes. A surgical options tend to be kind of, uh, loss, actually. Last line to any business of episodes that you get. Despite what the pathology is, surgery is pretty much a loss. Absolutely lost a little there, so stuff. But you can't be before, uh, conservative year, which is but conservative, which is a bit big because there are some that you can do, which doesn't necessarily involve giving tablets, but it can make your life easier. Yeah, Said lacy gym diet. Yeah, we did. Yeah. Try and prevent that fluid from building up. Yeah. Distract themselves. No valsalva maneuver weight work because the valsalva believe it's the principle point. It basically opens up your eustation two, which allows the middle ear to drain. The pathology isn't in the middle ear. We'll be in the interest. I wouldn't really work with the with many ads. Um, I mean, you guys will send a pretty good A. Pretty good suggestions I'll do is I'll be on to this. Yeah, arresting the tax yet really good. So basically changes to die. It's really important. So make sure that your doctor, pretty much a healthy diet so late soul I'll call free, caffeine free and also smoking cessation. Well, it's really good in terms of attacking the hearing loss. Hearing aids are really good. So you have behind the ear hearing AIDS, which can try and amplify and something hearing loss that I've got terms with tinnitus say I think I mentioned so distraction techniques are really good. There's a really good leave that by ent UK, which kind of which we kind of get to our patient for many years and helping to deal with the tinnitus. Just spotting too strong here. That's a lifelong, attentive Yeah, a masking devices, really good to hear this white noise masking devices, but you're quite good for tinnitus. In terms of the DMSO, it's kind of similar to what you do with BPPV can give a vestibular rehab. Exciting is to try and get the toe become more used to their tax, and it doesn't become as aggravating as it once did that also managing to be two episodes, Antiasthmatic said. Also, when they do have some happen, more attacks they can have be to histine as well. From a psychological perspective from ignored a double piece, a CBT is really good and stuff, but mine from this is also really good as well. It kind of helps and put them that eases well, what they're having their tax and also makes um less fearful about the seed. And, like I said on the surgery, kind of like a last minute last last resort. Not really any clinical benefit shown in the literature, but a stuff you can do in terms of surgery. There was a similar to what you do. You pee pees. It can destroy the inner ear by injecting of interesting it with steroids or gentamicin or any other sort of toxic drugs or yeah, that's pretty much what you do. So it's kind of like you kind of have to approach it from a holistic profile. Save you, like, kind of think about what the patient's main issues on you Try and talk with each one know bit. You kind of have a nice, all complete way of attacking many years. Yeah. You can use prochlorperazine. Yeah, at an anti emetic use for dizziness. Yeah, uh, awesome. Case number free Shurtz and bet you're a woman who reports business episodes that last day at a time she imports. It's starting after you have a cold. A few days? A few weeks ago. Sorry. Did you find each other side to be quite dependent? Debilitating. And it lasts for a day at a time. She doesn't report any hearing loss. Know tinnitus. Um, I will create a pole for you guys. Give me a sec. Oh, it's so excited. What you think is going on. Interesting. So I'll give you five more seconds, but remained of you to participate. And then we'll we'll talk about what's going on. Say 543 to one. Cool or Interpol there. So, interestingly, actually, most of you but Bible Akron fighters. But in this case, it's actually best doubling. Your writers say we tend to like in to change these things quite a lot, but they're actually two very similar. But there's actually one main difference between these two syndromes. So the labyrinth, it's basically the part that injury, which houses thecal clear on do the best of you, also basically houses organ of hearing and organ of balance. So when you get viable labrum fighters, yeah, you get the business that last for babies. But you also get hearing loss associated with it, but a copy is effective by it's open information of the labrum. Where's the best? England New rightist don't want to mention the start at all. It's really important to remember that there's two different branches that the best thing Lebranchu off training that day, and there's a copy of Branch pregnant, but they have been in a best deal. In the right is when you have inflammation of the best develop branch only. So what you tend to get is you tend to get the stiffness that last the babies at a time, but you don't get any hearing loss, so that's really important is also some that comes up empty kids kind of catch you up. So just knowing that's a big difference for important eso. Like I said, best thing when you write it involves the best of the branch of the best diplococcus, you know? But which, for those and long absence business, but not necessarily any hearing impairment. Uh, yeah. Is that Yeah. So lab invited space, new writers plus hearing loss. But they both had that here. They both have that dizziness that last for a day. A time from Alice days. Let me sent. I think so. But vestibule, your name s a recent history. Or like a bio on this kind of puts the history of being more effective. Such inflammatories. That kind of rules out the salt. Best initial name in the stomach use drinks, uh, some basal insulin, But, um, does that all make sense? So basically, yeah, best thing when you write to sit still want to be due to the information back. Still in their attention, her off that viral pasture on. But it's really important. Just remember that lab Vitus is hearing, plus dizziness. Where best of in your itis is basically just dizziness on its own. And you tend to get a prolonged so isolated episodes of vertigo, which lost what least a day at a time on it kind of precipitate pace. Viral infection. So with this on, so managing it, you tend to give himself sure so in terms of diagnosing them intense, mostly based on history on day, there's not really any investigations that you do to solve ruin thing L. The management really would be to do a short course of anti emetics up about 3 to 4 days. It's basically so that we don't want a downgrade the best. If you don't want to start sedate the best develop system. We kind of want to get used to the fact that it's been irritated. So I think the as your body and confuse the fact that it's been It's been irritated, comfortable, tolerant business at states and the business that should come from less less worth. The patient, basically, and then, if they're like, really cute young, well, not vomiting up everywhere on down on that, unable to tolerate border, that's basically a bit of IV fluids, and I'd be antiemetics just them toe get some sort of fluid intake. In the past they're getting neck. You have said so. It's best English. One open accusing your Oh, yes, so best thing which one over is the name we tend to use for these things? Accusing me Rome was more the layman's term for it, but it's what you call a vested. It's basically the same thing. Yeah. Does that all make sense? There is one more case. We'll warm or warm or peripheral. Better go condition that I'd like to discuss, but I don't have a case for it. But I think we'll be good to be. Guys are replied and chat to say I'm a I'm a 25 year old and that present it's got a long history of migraine since Onda come in on basically complaining. Dizziness on my symptoms is that you know, I've got a headache. I had an aura of this headache, just vomiting everywhere. What would be your primary diagnosis? I try to bear aspirin but hasn't really helped. Yeah, it, I agree, is a migraine. But what kind of migraine is it? Space occupying nations to can present like that. It's more central course for for best ago. But, uh um, so basically it's something called a best develop migraine. I don't have you guys heard of it, but essentially, it's the migraine. Which, kind of localized to the festival is into the system on Don't really understand how it works and the pathophysiology behind it is. But they think it's kind of similar to what I think is going on with normal migraines, where they think certain parts of brain on our basic constricted and so that causes that sort of a headache and why you get so vocal symptoms and, well, sometimes migraines. Uh, why would you give aspirin? Take it the pain killer. And if you get a high dose that also causes bay, the dilation say, improves blood supply, Teo. Different parts of the brain. Which is why you give it to people with migraines so you can give up to 800 mg. Actually, for people migraines. That's what we used to get a D on space occupying Sorry, space occupying lesions. It's also a valid answer, but that tends to be associated so early. Warning. Bomb it sitting on depend. It tends to be sexually early morning bombing thing, and also you might get some sort of fake one urological deficits. Well, if it is causing that much of a master bet. Uh, but that will make sense. Cool. Perfect. So I think that's the end of all best about business. There are other and stuff that can cause birth to go. So what kind of central cools of the vertigo can get just probably chat. Oh, just talk about it. So someone somebody mentioned space up lesions. So anything else apart from space? Optical lesions? Yeah. Strike yet? Accusing your roommates. Yeah. Yeah, I'll call drugs. Yeah, great. There's one war. It's kinda is it is a new law. Wonderful condition. Yeah, M s exactly. Yeah. And, um, let's see. Yeah. So I guess it's really important sometimes. Like it's presenting symptom. It's bad to go, so they might not necessarily have that neurological deficits here on what would you see? What would you want to be walking with your life choice investigations? So it's t T or Ameri, Which would you go for? You get a choice. I had unlimited resources. Me and the teachers say ct is good. CT is good, but it will be MRI in this case because basically, you can be what we call t one waiting, teach you waiting so you could look at a different views of the brain. This would be a different views of the brain on different veins. Kind of pop up on on the MRI. It's really easy to see your characteristic sclerotic patches. The basic white patches on the brain, which is kind of your life's over hallmark of diagnostic features. M s one of them. All right, so it's been easy to see on the MRI, but now it's become a cirrhotic and different areas. The brain becomes cirrhotic, uh, which is which is the hallmark of which is why it's this gold gold standard. The choice for investigations. Yeah. Yeah, that's good. All right, on this is just a, uh, at being sprained. Here you go. Thanks. A break. Uh, room to do mental. Well, being can be tough. Be fine, maybe. Yeah. So you got a patient that All right. Say, before we talk about facing their pools, even different types of, uh, conditions that could call this patient that pulls if it's really important. Just like no longer. That's me. So what I'll do for the festival? 5, 10 minutes. If It's kind of talk to you about what innovates I don't pathway population that through the head using a schematic, and then they'll make it a bit easier to understand why certain things go wrong with the patient. But certain conditions in terms of innovation said lot of Asian of controls the muscles of facial expression. So you know when you do like a credit, for example, you get to, like, scratch the rise pop out of cheese. Um, it's all based on the muscles, so that then that term of branches and facing that control of that it was a controlled with posterior belly die grass tree style of Ohio it on the COPD. It's muscles, the COPD. It's muscle with basically really tiny muscle that connects to the stapes, and it basically prevents 100 juices. Because basic constance, when the lab noises present that prevents the overstimulation off the over one day by the state piece. So basic, protected from being exposed to rely on the reasons in terms of Century and provides a little small patch off skin. Just the entrance to the extent of your Jimmy. Eight hours and then I donated guys like yesterday but, um But talk about this branch water cooler tympanies that provides some taste sensation to anterior to the the tongue, and it's very runs really close to the middle ear, so it's become invincible. Fill it impact membrane and then, from a parasympathetic point of view, kind of supplies and waste. The glands, the head neck include something nebulous, sublingual, slightly glands. The nasal polyp time found you that weeks the glands that like more gland as well. So as you can see, there's no side being a lot stop in the head and neck. Which why, when we do, you have problems right in the neck. This tends to be the last one that goes, Say, this is that it's really complicated said Wait. Still understand all of it and less meat dyskinetic. All right, So essentially, what you've got here is, uh, basically like this picture of like, teach me ask you, I think a really good picture. But it kind of just like it's just kind of just showed the parkway There. Problems off where starts in the ponds to it's tender branches on in the face. So it's actually it's there is a build up of two routes and got motor. It's got Central Room X join and then the basic gives us a great petrosal which we look at the left supplies Terry or Ghost Terrio, Palatine Daniel, which makes your supplies lack of glance allergic to produce tears. Then you go down there some medicine down Trista pds so that basically innovate since the Pts possible which prevents heart rate juices and then you move down to about like the posterior original nerve, which provides some sort of sensation to your ear you got noted by gastric, provides the, uh, innovation two plus the gastric muscle. When you go in there to start the high road, which provides information to style muscle on, I think and see. Here's where you got this branch. The corner tympani, which provides taste sensation that as well as in abates the Southern Nebula glad sublingual gland. And it kind of ends up in this or burn the five roots here. So the time of motor branches, which supplies the muscle, the facial expression. Now it sounds really complicated, but if you get a rough idea that this facial kind of has a lot of important branches were in the head neck like this will make the rest of the SBA. It's a lot easier to understand, and then, in terms of remembering, like the five temper Branch ears I remember is like a separate bit, my child. So temporal zygomatic back or mandibular And that's a bicycle. But that's pretty much a pathway. Does that all make sense? That boy move on to the SBA is Uh huh. Seeming they want to do is a good answer. So we'll leave on that, okay, Until next. SBA. All right, So you've been on 30 and 40 year old who presents a one day history of weakness on the left side of the face. She also notes, um, inching possibility Rush around. There is she's unable to create the right that's quite distressed. And the observation that war before previously felt well, what would be your primary diagnosis is So this is what you see when you look at our face on. This is what you see. When you look at her is, um should acceptable. Interesting, interesting mix of 32 ounces. We'll give you 10, 15 more seconds. Okay. I could be funneled seconds and then Well, there will be even okay for the pool there. So the vast majority, actually Ramsey Hunt would choose the diagnosis here. But I also like some of you put bells palsy in the some of you put that clothing otitis external there, we'll talk about why, uh, this is this, um So the reason this is really a brandy hunt is because what you can see here, if you look at this image right, the the basic crossed it big vehicles and which is kind of characteristic off a ground cellars zoster infection on this is normally found. So around the it's in grams of pants and you tend to find a trusted musicals or even like fresh, beautiful zar like yellow blebs. You tend to find that around the air we can find out on the inside of the mouth, and it kind of follows the distribution off the facial on de sensually. This alongside a paralysis on probation. There, on the same side is pretty much your capitalistic all marked signs for anti hunt syndrome. Now, some of you put you can also get a hearing loss as well, cause I can mention the facial nerve gives off a branch of noticed a PDS, which basically prevents hyper A juices. So what happens is you can basically don't get any control off any of the, uh, what's it called off the sounds that being conducted fruit out of middle ear so you can get some hearing loss. President. Absolve this. Um, so the reason is that or keep strikes. Got a low protein, urine palsy. So remember one of the cardinal signs of low motion little urine palsy, foreheads, forehead sparing. So in this case, and the consultants images not able to get a left eyebrow, uh, which is indicative all found that it's a low back in your multi. The reasons, not Bell's palsy, is because Bell's palsy intensity idiopathic in nature. We don't really know what causes there. It can be a little post viral thing. In her case, she's got characteristic vehicles on the inside here, so it's gonna be point toward the diagnosis of the county, huh? And the reason it's not expired the context and she has been reporting any. So was it called any ear discharge of pain in the air? Um, him? That all makes sense. I will move on, Teo walk around the hunt. And so, essentially, if you want to get Ramsey heart or you want to get Bell's, you watch. Get Bell's because the problem is it's around 200. That should quite bad being about 20% of people don't actually end up getting a normal resolution of the facial nerve. They have a lasting, long lasting patient there. And essentially, if you think of it, is a shingle, the complete by a facial nerve palsy that essentially what Randy Hunt is. And it's caused by the same virus that causes chicken pox and shingles said about So it's off the virus. Remember this virus? The reason cause the shingle that's once you get exposed to chicken pox. Virus basically hides in the dorsal ganglion toe of your cells of your nerves story. And then when you become immunosuppressed or, you know, when you come older on dear taking stuff, only thing that's press it reactivates, and it basically is that she was like picture in the In the case of Brandy Heart, despite of space behind the genetically ganglion, which is basically the big ganglion, not facial nerve. And then it kind of pops out at times a minute suppression or stress convention. It was also associate with milk allergen wanting 100 juices been hearing loss, neuropathic pain and also tinnitus as well. Um, the main thing with France the hunt syndrome is you need to try and grade or any sort of face. From there. You'll see if you need to be able to grade how bad their facial palsy years on. That's using. Assistant called the House back in school, which, uh, well well, see now what is her house pregnant Score based on what's described in this pin that Yeah, there you are in complete like pleasure. Still quite obvious. Disfiguring weakness and asymmetry of the face, including her forehead and mouth, give you 10 more seconds. Cool, Cool. A day is not okay, so kind of a mixed buried results. I mean level majority of you able majority of you can be, say great for it is a great pull pull be, but quite believe also about three. Well, so what we'll do is we'll talk about why it's a painful palsy. It's the fact that she's not able to claim to right alongside some more today symmetry about weakness of the forehead. So I kind of family puts. That's great for and really important of. This is knowing what it's a great. It's a difference between the different too great freedom. Great for basically a difference between reading off one juvie or no, on the reason that that she's not even close your eyes and she'll need artificial tears. You need really good that I care. So they use it like lubricates at night and taping all I shot on day and often want to review the while to make sure they don't get carried, tightest and get blindness of them, is all of that. What would do is we'll talk about what, actually, individual hospital in scoring is so basically split into free things. So it's been two forehead pies and mouth on one, if normal for each one of these parameters on Day six, it's basically total price is there's no movement at all with my forehead, the eye or the mouth. Generally speaking of the ones that they ask you about the antique you is whether it's a four or no, and you basically need to know what for, is on the scale for you, Teo based you know what one is what for? It's for what six is on. Everything else is basically a range of spectrum in between. So one, like I said, it's completely normal in terms of liars, forehead and now Ah, four grade four words. Basically, when you have incomplete I closure, it also means that you kind of got this asymmetrical mouth as well. At rest on. It also means that you've got basically an obvious weakness of your forehead, so you're not able to let your eye brows up for anything like that on. Like I said, the main importance of this is to make sure whether it kind of friendships that's the house seriously is. And also, what do you need a lot more to do with you or no, Um, which is pretty much the rationale behind the house back in school. And it's also a really good way of, well grading when there's any improvement in the patient's symptoms. After you start treatment for the world so you can great and using the house back in school and hopefully the guy from one of it is like four or five a one by the end of our body and in their treatment. Generally speaking of your scoring, the house broken 45 or six. You do have generally poor prognosis on, but it's just something to be aware of, I know, but we don't really get that that get that. I was called that function, but on been terms of management's it's really acyclovir. So you want to start here? I didn't have been three days of that symptoms appearing, So look, you can start to up to a week, but the evidence and then you start a free day that you tend to get some sort of reasonable improvement outcome. We will also give him some prednisolone is well, so you get 1 mg for kilogram, said Maxixum. Roughly about 60 mg alongside of PPI, say alongside some maps, Old time's up lines up, so to protect stomach bastard taking such high doses of steroids. So you give that prednisolone part about a week, and then after we get them weaning down by 10 mg five or 10 mg every day until it goes back to zero, it can also be unbelievably painful as well. So getting really good out of the easier. So you know, it would be still working out that wh a pain ladder on you might be using, you know, or a morphine codeine 12 for people like this on. Like I mentioned about the eyes, the eyes are really important. That's making sure that they have good I care. So, you know, using artificial tears using like really, which is basically like a lubricant, like a look in that you can put in your eyes at night. And then you take that shot and it also an ophthalmology. Reviews well, because then some people really, really bad facial nerve palsy they can get get, get something done called a pass off, which is basically where they are Super. The islands shop to protect the eye, which bit hurts, though I being dry and no so imagine shingles, but much in shingles in your face. The shingles in general is quite painful for patients. Could it cause it's sort of neuropathic pain that you mentioned on that face, though their whole face is gonna hurt or defensible? Nerve aspect of it's going to hurt around the ears and the eyes will be dry would be quite painful. And also, if they get on the inside the mouth. They won't be able to eat and drink. Ah would walk I dearly. So we go back to this. Ideally, you basically, if you think of any sort of. Generally speaking, it's from four on words. But if you think like a great three but like they could do a bit of artificial tears because they're blanks, not complete what is covering of it's very weak. Then you'd still start, like if that being pragmatic have been quite practical. When you started, could you know about them, was banned to sing on their part way, and it will be lost marginality. I mean, if you find a way to the back of facial, uh, go for. But it's quite difficult blocker patient there, but also means that we need to come in right quite regularly. There's no long last the anesthetic that you can give them. Andare last for that long about them. Have to come in a few few hours, unfortunately, but, uh, yeah, I yeah, it's a good idea, but I think practically it's quite hard to implement. So it's normally given some neuropathic stuff like I'm a trip clean as well and gabapentin help them with the neuropathic pain that they get a lot of side start working on that. But the H A letter? Oh, yeah. I mean, even they weren't in patient will be difficult. Well, I just I can't imagine any sense wouldn't come in on the nerve block in the face. And there have been a bit annoyed. This is also quite difficult, Remember, like a lot of it intracranials. Well, so you have to go quite deep, Teo. Know, block area. We can deal. Gets isolated like parts, but will be quite this school, Generally speaking technically, um, because that will make sense in the hospital in scale. So the main things really like mint earlier. It's one. It's normal. Six is tender promises and forth. The one you really care about. It basically is the one. We can't close your eyes. I can't really make your face and got that exhibit tree arrest moving on. So you got a six. They got a 75 year old because that's a unilateral weakness of its mouth. Have a CT had no strike. They should have a large bilateral lumps in cyberspace. Just tmj. He reports that TMJ being the temporomandibular joint. He reports These lumps have been there for a long time, and he actually got them investigated early this year. Report people nine. He's also got a four year pap 40 pack year history of smoking as well. What would be your primary diagnosis? It's just Oh, cool. Uh huh. Yeah. Started off trusting. We'll give you 10 more seconds. Interesting. So, I mean, people have gone come mixed that I with this one or pull ups pull it felt So how, um, Say I think people just about the war fins tumor where can you see it? You can't say you just about put warnings for which is the correct answer. But I see some here, but it it's staying on something. Probably walking is so this is like kind of tough one to it. I've been washing guys and it might be a bit of a hard, but what you get you think it's really important that you do kind of a difference in between all the stuff about two minutes. So the readings of warnings to s a a walking student also clearly they bake benign behind lesions, But the war fins tumor tend to be so the one that's social or men that smoke. So that's kind of like our interesting Have a seat. You question, old man, that's makes, like 50 years by 20 a day on, he presented bilateral lunch, said, It's been done on this shows that it's benign, so he had. The academics should be benign, but what's your head? Doctor? Did not be a war fins tumor where, where we're clear, more name, but they don't be more, you know, actual where you need actual in origin intensive one brought it on. There's also ah, higher chance of actually more for Neymar becoming cancers as compared to a walk in two months. Now, some of you but Protestant while process day and the I agree you can because they can get bilateral prostate that can call it bilateral masses. The reason it's not the case here is it doesn't really, uh, it doesn't really large to a science that it can start compressing a patient there where the walking stupid that we can. So basically, the Wolf Instruments store tumor is still blind tumor, but basically I think it's bigger and bigger. It kind of compresses different parts of the off the off the so it tends to grow on the table. The projects at the very top of the mandible, uh, join. And it can cause a compression, which causes an isolated life individual branch off the off the temporal financial because individual individual branches occupation there to be a paralyzed on, um, should do bells palsy like severely Patrick Nature of experience patients in terms on between morning and then, yeah, you guys all right can can call special process. That's into that a little bit, comes lignin. Get something called the next kid. Clear what the cost in a while that basically rides his opinion just a little bit more about the walk INS TV It's It's kind of like thinking less common behind prostitute are the new kind of accept that temp sent a prostitute with. That's the most common bilateral benign prostate tube that could it could be because the only run six decades are in their fifties. Yeah, fifties and sixties, and it's twice a couple men, tens of percent. So hey, let's project swelling can be associated with. It was temporary, social long term. It's working like a mentioned earlier cause a professional process by compression has managing and see kind of basic to kind of watch and wait and see where it goes. Well, we can do a CT proficient for expecting me, which quite good recurrence rates actually less than 5%. So it's quite good in terms or warnings to becoming negative. It's actually less than 1% of tumors off the extremely complicated as a poster for 3 to 4%. Does that make sense or more friends? Tumor? Uh, I'm seeming to guess that Teo, the last case I think we go So you got a 50 year old gentleman has got history. Why is it so? She was smoking. We'll go back. Why is it so? She was thinking I should have it. It's just one of those things. I think it's I should have the answer. It's just one of those treatments that is essentially, it's working and what we do to them about that smoking kind of generally speaking, for everybody damages difference or self off ways. It might be that the protein based it's just more like more damaged by thinking I shouldn't I mean, I don't really notice for this. Sorry uh, any other questions on warfarin? So we're going to this case, but generally people walk instruments. Remember, old man smoking? That's your cream. She That's your, like, characteristic. No person could be guys. Uh, trend, was that Okay, Maybe I'll stop there now. So maybe you put all just a bit, except you put neckties in a tight external. But some of you will separate cluster tumors that people's Crestor table in this case, the oldest and she necrotizing times Exanta. And I'll tell you why. Um saying But anyway, I was like, Listen to yesterday's chapter on someone actively a classic standard. It's really associate with poorly controlled diabetes or any signs of like, you know, suppression. So being really poorly controlled, diabetic kind of makes him, you know, suppressed to a while. So it kind of pretty high risk of developing necrotizing right extent. Have you look at this image that what you can see essentially is this's thing here, The polyp? Can you see my mouth? So that thing here is a polyp on. It's formed of granulation tissue on. That's not your Hallmark Sign for neck tightening in tight. Six. Dinner in and in patients with this condition on that basically represents where the infections kind of eat and freely the cartilaginous ear canal, and it's gone into the temple boat on into the mastoid. So that's basically what you're seeing there, and they have. You also look at it. You can kind of see it kind of it with lots of white sort discharging stuff, and that's basically the infection. That's that's the active type 16, and that's all there on. You can see this So neck Tyler times extent it's coming. So eating away in two different aspects of the cartilage and, well, that's what been the now that alongside of fact, they have a recurrence of ear discharge. For weeks prior on, we've had a pain, but then get any treatment for this also points to sign that this is probably more next time. Times external rod and cholesteatoma When cholesteatoma, you tend to get pain less diarrhea is a painless ear discharge, which is why it's more next time being tight exam. In this case, Robin Classy a timer. Well, I do agree like classical have left untreated on diagnosis can cause atrial and facial of privacy is because of where it conveyed, but like I mentioned, intend to be essentially painless discharge on dependence of air pain rules that sort simple Bell's palsy and well. So that's why on Like I mentioned about Ramsay, hunted German tense involved with musicals, you tend to see those three calls on the air on the inside of the or anywhere in the facing the distribution, which is why it's naptime type external. Um, he met good talking bit more about next time he attacked externally. It's actually a really serious condition, so we tend to see, like one of these pop up every week on the ENT. But it's actually quite like for life threatening. It's got around 20% mortality rate on it. It's basically involvement or like the skull basic cause of that. The reason sector, I think, basically involved the skull by same pathogens that called low times six dinner on like a mentioned earlier presence of the Hallmark presence. We like regulation tissue taken see on a Tosca pee. That's more likely Nobody, you know, suppress that anyone has got a that you had previous chemo. I know it's really a poorly controlled diabetic. On the most common organisms, that you tend to see you next time. You're at 6. 10 and I have a pseudomonas aeruginosa, which isn't a normal flora, that which is a part of the whole floor of your air canal on also fun guy. So if you ever see you like pseudomonas on it is what we kind of have to take that seriously because that's not gonna be there. But it's probably like a precursor that I'm good about that being next. Lighting otitis External. Yeah, meaning on. So these are some of the investigations that you could do a CT temporal bones. So if you can see the CT image of the right basically as concede here, this's the entrance to the ear canal, but you can see like the master weed, which is normally have like black stuff. Here is, uh, basically what grade out, which implies that it's thought parcel from your fluid going on in the actual mastered cavity as well as that. This is this blood. But here's the entrance to your exam told you canal, and you can kind of see here that it's not existed, but it's also it's kind of non existent, and it's just full of fluid, which is all the discharge that you get from times Exanta, a necktie, the entire six donor, um, other stuff that you can do for them to have an investigation. So you want to get a baseline MRI with contrast, so that basically allows you to sort of compare how well treatment's working for these patients. When you do some routine talk about your eyes as well as the air stopped. The reason you stopped the loud it's still target the pathogen, a bulge in the neck tightening and tight external would be D C like a polyp or any sort granulations issues. So it's really good boat biopsy that involves to confirm that it's granulations tissue. And it's not like a cancer or something like that that's causing that sec. That's causing invasion of the end. Master wouldn't temporal bone and as well is that the other thing? That's really important. So I'm having blood. So here started basically your prognostic factor, So your sa it's improving that then that's a sign that but then it kind of tightens extent. It's improving as well. That's what's done on place, weekly basis to see with the new treatment response to treatment or not in terms of managing it's patients. It kind of want to do IV antibiotics, but they they're they're long states. It can be up to about 6 to 12 weeks of IV antibiotics and regular salt microsection inning, and they were really good. And, um, do you see a swell, um black and mentions well said that they're not really bad patient and Protestants. They'll need that. So, like care Well said Artificial tears. I live at night. You take that I shut night and it's found reviews be any side of the current tight it's or whether they need to pass up, which faithfully suited it, and it shut petechiae. You haven't got to mention it. This is the one condition where if you put these patients in the hyperbaric oxygen chamber with IV antibiotics, it tends to have a better it tends to promote. It provides a synergistic response to anybody that biotics That antibiotic worked really well when you put these patients in the hyperbaric chamber as to why, I don't know if that's like, basically it's quite knuckle, a form of like research, but there's any two centers in the UK that do it. But I noticed, like, really good, like outcomes for patients that are placed in a barrel in chamber with the antibiotics for this. So it's pretty cool stuff. So that is basically next time the otitis external, they already questions deep enough, a lot slide. Um, yeah, that is when all slight. And I'm You guys have got to be careful that great. But I'm also around because what going questions I can answer. So Okay, good. Loved. You want to just tell them about smaller? Oh, yeah. Sorry, guys. Yet tomorrow, before you guys sign off on, I've got a p l s. So if we could pay Spain to my session to seven. PM that we agree, it would be on head neck pathology. So common sort of head neck stuff. So from, like, firings, toe thyroid, more projects that, uh, it'll be at seven. PM you guys conjoined. It will be great. It's just I don't anticipate a pure running. Uh, Okay, that's right. And they asked me Really? Oh, yeah. I know. I I I'll just send that you back link one last time, and, uh, he's just We would really appreciate it If you could just take a minute to fill it in. Yeah. Really? Appreciate you get from me back. Somebody about Yes. It really helped, actually. So So getting rid of those questions that still about leaving a B C D. Um, so, yeah, be back to be helpful for lousing sold about the beach. That should we go along? Yeah. Um, we'll say call it any questions for me? Uh, well, it's like, yes. So guessing. There's no questions. Laughed. I guess we can end it here Where I and see every once more at seven. Good. Good question. Easy. But yeah, If you guys could be a few, that will be great. Much appreciated. Oh, all right. All right. Thanks, everyone for attending again. I'm gonna end here and see you tomorrow. Yeah, yeah, yeah. The ultimate simply, uh, thank you for listening him