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Okay, So, yeah, the lining objectives today, um, for the session. Oh, to give you practical tips on explanations to help your daily practice on all your understanding if you're a student, not to manage Curatola. Gee, conditions on emergencies to avoid pitfalls. Inpatient management on to other son the safe triage of ent patients. Um, I I just want to say that, um, I'll try my best to stay within the time limits, but I think that I don't want to take away from the value of the session. I want to make sure that everyone gets a smudge out, but it's possible, So I'd rather go a reasonable pace on. Of course, if anyone has any other commitments, feel free to leave. Um, I've posted been linked to the feedback form already on, but when you fill in the feedback form, you'll get your certificates. Um, so I just want to do a pre session quiz. Initially, it's a very, very quick one. You just have to use your phone or, um, scan the QR code to get onto the actual questionnaire. Um, alternatively, tear will post the link in in here in the chat as well. She come get the key. Well, codes. So I'll give you two minutes to do that. And then I'll carry on most other people still coming into the room. Um, I will, because I'm Requip someone else. If it's possible to have the slides because I'm recording the session, you'll be able to access reporting. I can also send out the slides. That's fine. We're just going to send the link to the cuisine. Now. I'm just checking that you gave me some insisted. It's really quick quizzes. It might be very easy for some of you more telling you for others, depending on how much anti done. But hopefully it gives us an idea where everyone's that. I'm going to give it one more minute, and the more you're going, okay, we're gonna move on now. So, um, first he just in overview of this of the session, this is just another view of everything that will be covering, um, in this session in the form of a diagram, we're gonna structure of the session, looking at the conditions of the external air, moving inwards towards the inner ear with some practical bit throwing in. Um, so the things that will be discussing are diseases of the external ear on the extended external auditory canal, both common conditions and emergencies. And then we'll talk about things that could happen in the middle year on. Then finally, we'll talk about in airport blooms a swell. So the first thing I want to do is cover the very basics the formalities and conventions of how to examine a near. So the first thing is how to hold the otoscope. So the way to hold the otoscope is to hold it like a pencil, using the same hand on the side of the year that you're examining. So if you're examining the right ear, you want to use your right hand. Um, you want to hold it like a pencil in order to straight in the air Canal so that you can actually see properly. You want to pull the pinna, which is external year up and back on to be quite gentle with it, because it can be painful. If you're examining a child, you want to pull the down and back. The covers over here, um, are on the slide because there are different sizes, typically trying to use a larger one, Um, if you can. If the if, the year. What is big enough to allow that otherwise, if the person has gotten really, really swollen here, then you might have to use a smaller one, then just the very basics to set the scene for the rest of the session. This is a view off the tympanic membrane on. We're gonna look at the important landmarks off this in panic remembering. So for the first, this here on the left hand side, I want to make the sessions lightly interactive so that you're not bored. So if you guys type into the chats what, you think this is pointing Teo, and we'll see what people think on dumb. See if you can see if you just read them out because I can't hardly see that. Exactly. So somebody says which are Oh, you didn't actually specify which are all because therefore it's the top left. Sorry. I thought you could see my cancer. It's the top left. So we have not solved Amillia eso this one, actually, Is that mean we want with this one is the past Basseterre On. Then we've got here on the top, right? We've got the money is I'm then at the Boston here on the left hand side, we have the pause 10 psa on, then Finally, the last one remaining is just the cone of life. So when you're you're signing your prescription, there should be seeing that you're not going to see such a perfect image. Usually, um, this is a lovely image, but generally speaking, if you know what you're looking for, then there's more of a chance that you will, um you asked me find the appropriate things. And the other thing that you want to look for when you're looking into near with the notice scope is if there's a foreign body or any wax buildup, you want to look at the skin of the external auditory canal and you want to make sure that there's, um, no discharge or anything like that that could suggest infection. So now we're just gonna talk briefly about the cheating for tests, their key to most of the hearing issues related to this teaching session, um, out. And so, um, again, that's it on those two main ones that we use, which are Renese. And we was test. This diagram was just here to help you, um, see what I'm talking about. So Renee's test is used. Um, Teo, in conduction with the best test is to decide whether someone's got a hearing loss on whether it's sensory neuro, all conductive hearing loss. It's quite a basic test, but actually it helps you understand what's going on if you know how to do it. So the tuning fork that's used is a five fold purse, um, tuning fork on D. I want to mention that the runny test is, um, unusual in the sense that if you say that the test is positive or if you see it documented that the release test is positive, that means that it's a normal finding on D tells you the air condition, so that then the sound traveling the normal way, which is through the air into the ear. Violating panic membrane on, then into the activating the copier is better than when the cochlea stimulated directly by putting the tuning fork over the mastoid process. So a positive Renee's is normal. Um, use the air condition is best in bone conduction, which is normal. Onda um, that we've is test is a test to see if there's any problem, Um, with the with the copier in some cases. So, for example, the way that you use it is that you, um, we'll hit the cheating fork on your elbow on your knee and then put it in the center off the top of the head, just like in the diagram, Um, and then ask the patient whether hear the sound. A normal finding would be that they the sound is the same in both ears. But if the sound is specifically louder, and one here that might suggest that there's a problem going on, but you need the result of the brain is test in combination with it to understand what's actually going on on in the release tests. After you run the after you bring the, um, tuning fork, you put it on the back off the head over the master of process on, then ask them when they have stopped hearing it on. Then, when they say I can't hear anymore than you put it in front of the ear about the level that you can see in the top right hand side of the diagram on then, um, awesome. If they can still hear it, and they should be able to still hear it. It was really, really valuable. If, um, healthcare practitioners or healthcare professionals know how to use training for tests on, document them because this will just help me out in your practice. And it's such a simple way off making sure that you're comfortable with what's going on. I've put this crown here because ah, good way of remembering. Which is which is that? W kind of looks a bit like a crown. It's It's at the top of the head if you have a patient. He has. I'm sorry to jump in again. It looks like the slides are not moving forward. Okay, soon. I wish I did. You currently seeing We can see the slide with the with way burn the rainy test? Yes. Yeah, I'm just going forward in a moment. So and the the Weavers test if if a patient has a turban or you can't put the the gene for it on the top of the head, you campus on the forehead as well. Okay, so on this slide, I just want you to kind of take what we said so far on. See if you can work out what's going on here. If anything. So you've got a ring knees, which is positive bilaterally. That means it's normal. Air condition is best of them bone conduction in both ears on then we was a central. So if any, if people just right in the in the chat what they think is going on here and what this might represent, Revis is a big we visibly one at the top and reduces the pink. So we're getting lots of normal, normal, normal, which is great. Yeah, so that's perfect. I'm gonna move on them. So yes, this could This could be normal hearing. I suppose at this point, this represents the limitation of this test because it's not a really detailed a test. It won't tell you if there is bilateral sensory neural hearing loss. Um such as, for example, AIDS related hearing else, which is also called press be accuses, which we will discuss. But if there is, um here hearing loss, that symmetrical in both is then this test will come back normal because, um, ways we're lateralize. So if you do suspect that, then we need to get a formal hearing test. So the next thing we'll just go over it. Starting from the external ear. We'll talk about the examination of the external ear quickly so that we can move on to the more interesting bits. So let's examine that year you want to inspect the whole of the pinner. A swell is in front of him behind the Pinner. In case there are scars from surgery or any other obvious things going on. You want to look at the pin of for inflammation. Skin changes experience in swellings deformities, and you want to make sure that you also palpate so you want to pop it over the tragus on over the mastoid and feel the lymph nodes around the area. If you, um, you want to ensure that you pop it because it can tell you very specific things, For example, if you palpate over the triggers on that's tender, that's very sensitive for telling you that the patient might have the titers. It's Turner, um, if you palpate over the mastoid and it's tender and there are other features and it could be muscle itis, but we'll discuss that slightly later on. So first of all I just want to talk about and benign skin needs n's you might see. Most commonly, most lesions of the external ear are benign on what you can see in this, uh, set of pictures is on the far left that that seborrheic dermatitis. Very common skin condition. It's benign. Patients will come into all kinds of places with it. Um, in the middle here, we've got separate kerotosis, which is also a benign lesion Onda on the far right. We've got an epidermal cyst, which is also benign. One of these things are just got to be aware of. I don't want to go into them too much because they're not really within the the remit of the time that we have. But they're here to tell you that the vast majority off things that you see on the external ear will be benign. But it kind of leaves me onto my next slide, which is about a squamous cell carcinoma. So this is the first thing I I really want people to take in. I've had this in because I've when I was working on any anti, I had a patient here. Uh, this wasn't recognized on did up with really advanced milligrams. See, this is rare. I just want to put this out. But it's good to be aware of it, because once you see it, I don't think you can forget it. So squamous cell cancer on the on the skin of the year on the Pinner could look like a wound or a sore. It's it happens because there is one of the areas that's exposed to the sun and to the elements and ultraviolet radiation on. So it's important to be aware of it. Whatever setting you're right, if you're a student or if you're practicing and I want the thing I want to say Here is just If you do see this kind of appearance, then you want to refer this to the the ent or dermatology, according to your local centers, um, to the week to week weight clinic. So it's a two week wait referral. It requires biopsy, and it it may require surgical intervention. I'm want to talk about perichondritis very, very common presentation to any urgent care centers on TNT. It's three information of the perichondrium, which is a layer of connective tissue that surrounds the cartilage on did. It can lead to really, really severe deformity on. That's because the perichondrium has a poor blood supply on um when it's inflamed and infected, it can peel away from the skin on. Therefore, the actual cost is resistant. Spots apply. Um, a very common cause of this is an infected cartilage here, piercing on do the most caused glass of organism, for that is pseudomonas, but it can be caused by other things, like trauma blows to the ear. If someone place contact, sports or or gets assaulted, or and all the reasons like that, there's also some also immune, cause is. But and we won't talk about that at the moment because they're quite uncommon and not as severe is this. In terms of presentation, this picture is a good illustration of it. You get quite a characteristic appearance where you've got an inflammation off the cartilage of the year, but the actual ear lobe itself, the bit without any cartilage in it this bad. Um, the area is red, swollen, hot, um, really tender on. And you This requires prompt antibiotics. I've seen quite a few of these that don't get they get antibiotics, but they don't get the right antibiotics, and typically it's it's super floxin that's required, but you you should check your local guidance, but it needs to be something that can cover for Pseudomonas because that is the most causes of organ organism. If there's also an untapped, tightest external going on at the same time on, then the actual ear lobe becomes involved. Then you might need to add on another antibiotic to cover for skin infections. If things get out of hand and it develops into an abscess, then it might require surgical intervention. So I'll show you a picture of what that would look like. This is without an abscess. It's just the parrot Perry Chondritis, which come at this point, be treated with antibiotics. This is what it would look like if there was an abscess. Onda, um, I think it's an appearance. That's that's quite characteristic. It's swollen. It looks fluctuance. If you felt that it would be soft, it looks like there's an area of the spot that past might be coming out or on. This is something that you're trying to avoid when you're managing Perichondritis, because once it gets to this point, it may be that there is a permanent deformity, depending on how much cartilage has been, UM, has been across basically, so the landing puts, I think, are important for this. On relevant are not to miss. Take this for simple skin cellulitis, it needs appropriate and spotted cover. It might need theater. If there's an abscess, you should refer a lot patients with this condition. If you suspect that there might be an abscess buts if there isn't an abscess on it, if it if it looks really, then the patient can just have antibiotics and then a further review. So any patient with an abscess should be admitted under anti refer to ante a any hour of the day or night. If you are working as an anti shor practitioner, then you want to keep the patient Will be i'ma on discussed this with your Reg. Um, if it's severe, the patient will have IV antibiotics and stay overnight. This is, ah, image that I've just put in to illustrate how the deformity that can happen if this is left too late. It's a permanent deformity. It can really affect people's people's mental mental health and well being, especially if they're younger patients, so this is not the most thrilling aspect of the anti. But it's an important one on did. It's something that people call about and ask about all the time. So I felt it was important to mention, um, I won't take Long s so if if someone has issues with wax buildup, But the first thing I need to say actually is that earwax is very normal, that yourself cleaning typically nothing needs to be done about. It works. But if it's a persistent issue, if it's, um, impacted on causing the patient problems, then you can treat this by prescribing sodium bicarbonate year drops for about five days, usually or olive oil literally a few drops of, ah, warm olive oil to soften the wax on, then that should solve the problem. If that doesn't work on. But, uh, the wax is very, very impacted, then you can refer them to ent for micro suctioning. I just want to say that sometimes people are say that their patients got hearing loss as a result of earwax, and that's unusual unless it's very, very, very impacted. So that's probably not the cause of your patients hearing loss unless it's extremely impacted in the year. Um, Syringing is performed in some places, but it's got to be done safely. The advice generally is that if there's a perforation, you should avoid doing it. But obviously, if there's a lot of, um, build up, then it's not possible to really, uh, know whether there is a perforation. So what are advice? Would be to, um, just refer for my prescription in if it gets to that point? Um, at this point, are there any kind of burning questions that people have? Just typing the chats? Uh, on we can address the otherwise we'll just carry on. Um, so the next thing I want to talk about this foreign bodies in the ear very, very common. If you were you working in or around the anti in any capacity you hear about this a lot. Children put things into their ears. They put things into every orifice, but they put things into the ears all the time. Um, sometimes this tiny hearing aids will fall into people's is on. But, um, generally speaking, it's not a a massive emergency problem. If there's, ah, live insect or something in here then advising people to put a bit of oil in the air will kill the insect on. But that will help with the distressing symptoms of people experience. Because it could be really distressing. Really, really loud on kids. Confuse, quiet, upset When that happens, the learning point for this slide is that a foreign body in the air isn't an emergency. Usually on it can be just referred. A routine in to clinic to anti clinic If wherever you all you don't have the tools to get rid of it, Um, you're unable to about it. It is an emergency if the foreign body is corrective. So if we're talking about But, um, Bacitracin we're talking about chemicals, you know, things that could potentially be corrosive. Then you want to Herget you refer this patient to ent. So that's the take home message here. Okay, So attached external test 16. That is an inflammation of the external district in al. And as you can see in this diagram, um, it can cause the main thing actually is itching. So people complain of a niche year. Um, they can get intelligent and pain. They can get swelling of the exam right external auditory canal. A red nous. They can end up with a conductive hearing loss on Do. Sometimes you can get lots of debris inside the ear canal. Um, with the tightest external, uh, you know, it's a standard method of examining. Inspect that year, palpate and then use notice scope. Um, you might find the things that I just mentioned when you look inside the year, um, you if you use the training fall, you would find that the patient had potentially could have a conductive hearing loss. The treatment here is Teo. The steps here are, firstly to actually, if you look into the air and there there's a lot of debris, Um, there there's wax in the way. Then you want to do your best to try and remove it, whether you have access to instruction or whether you have access to a little talk, all the jobs and horn on D. If not, and if you are unable because there is so full of stuff, then then refer the patient to ent because they need to have this kingdom up. Otherwise it won't. The antibiotics won't be helpful. Little if they can't get to the right place. The thing to do is to if you can look into the ear and you're happy that the antibiotics can actually be delivered to the right place is you want to take us walks, um, on to make sure that whatever you grow is sensitive. So the antibiotic that you prescribed on do the first line here is topical antibiotics, usually a topical. A combination of antibiotic and steroids started to reduce the inflammation on the antibiotics actually address the infection. Also, analgesia, because it can be very, very painful, cause pain not only in the air, the triggers will be very tender, but also it can extend into the jaw. Um, you want to ask the patient to keep that I there is dry. Often it happens as a result of them swimming on developing the infection on Avoid scratching. We're using any cotton buds that might traumatize the area more. Um, the take home message here is really to use topical antibiotics. Um, I think a lot of patients over fed because they they been given or Aleve um, antibiotics. And this just went treat the infection. It's topical antibiotics that they need. I'm if they guys it anti. Then they will, um, be given topical antibiotics as well. Okay, so the next bit here is that malignant or necrotizing a test external. So this is a Nimer ginseng tea. It's a really solitary or ear emergency. It describes a spread of infection from the external ear canal into the mastoid and the temporal bones, so it causes osteomyelitis, which is infection off the bones. Um, this is usually caused by pseudomonas but can be caused by other, um, bacteria. It's can be fatal. Um, on the problem with it is that the presentation could be quite insidious. It's not necessarily an extremely dramatic presentation. One thing that will alert you that there might be something going on is if someone has a target or extreme facial pain. That's really distribution it what you see on your examination findings, despite them having been on topical antibiotics, um, patients might be in so much pain that they can't sleep when you actually look inside. There. Here, um, you might find that there are polyps in the actual ear canal. You might find that there's areas of skin that looked granulated. Um, on when you do a cranial nerve exam. If you find cranial nerve abnormalities on you suspect this, then that's very serious, because it suggests that the infection is so bad that it spread into the bones, and I started to effects the nerves. So the investigations you can you do blood. You check blood glucose because poorly controlled diabetes is a big risk factor for this on you do some imaging, but ultimately the treatment is that they need up to be admitted. They need IV antibiotics, and they need to have strict blood glucose control. So the learning point I want everyone to take home here is that if, um, you see a patient who's got who's had, um, a course of topical antibiotics, you've looked at the you've looked at the, um CNS, and it's the right antibiotic that you're that you're giving the patients elderly or that immunocompromised or they've got poorly controlled diabetes. Um, and they they might have severe facial pain that might not. Then you any you're thinking about necrotizing noticed external. Then you need to refer them, Um, anyone who you think has has it needs to be referred to me reviewed and possibly need to be admitted and it's I've written this list of patients to be aware of because you should have a lower and that's a little threshold for suspecting that they might have an owy and bus. All the patients can also get, and then we'll. But it's wrapped. Um, it's just going back to this. I just want to say that you want to make sure that the patients actually have the right treatment, because again, if they had a toast is external and have just had or antibiotics and they're young for it and, well, then they probably don't have any, even if they are in a lot of pain. Um, so this is a slide about traumatic panic member and perforation. So I'm just talking about a hornet to panic membrane that year drum caused by trauma rather than by infection on. That could be either a direct flow, direct trauma by someone putting something into the air costs and bother or something, or by blunt force trauma. So in this case, the first thing that you need to do is to rule out a significant injury or significant trauma. So you want to take a a TLS approach, especially if you're assessing patient initially, a soon as they've had this trauma. Um, this patient it once you've excluded all of this, you can look inside there. You can do tuning for tests. Um, Andi Ultimately, that from an anti point of view, a traumatic some panic membrane Perforation doesn't need a referral because most impact member and perforations will just heal on their own. It takes up to two months, but most of them will heal on their own. The only reason why they would might need ent referral is if they develop infected ear. If it's discharging, um, on day, despite topical antibiotics, it's not improving. Then they might have to be seen by anti eventually or if, um, the perforations persistent and it doesn't heal. Then they might need an elective repair of the ear drum. So that's why I put in this gets like the top things are to be aware of serious injuries. What we're talking about is interpectoral bill. It bleeds temporal bone fractures, other skull base fractures if a patient's got check behind there. If they've got any bruising behind that end, and it may be because of the serious injury other than that you can just treat an infection with topical ear drops on referred to ent if there's a persistent perforation but last longer than two months. So I put this light here because this is a kind of thing that you might find. If there's a panic remembering perforation, so does anyone. Can anyone right in the chat? What kind of hearing loss you would expect to see with a tympanic membrane perforation? But, I mean, what would it be? The ducts of hearing loss or sensory neuro hearing loss conductive? Yes, if people saying conductive. Okay, so baring that in mind, conductive hearing loss, you're looking up meaningful test again. If you were, um, doing turning fork test on a patient like this, then what? What would you expect to see so many is? What would you expect? You've got a, um, conductive hearing loss. Let's say it's in the right ear. Yes, it was saying Negative. Renee's on. Then what about weepers? Yeah, it's a little extra nice, right? So that's right. So school, um, so you'd have ah, right sided conductive hearing loss. You'd have a negative Weaver's on the right, and then the negative. Renee's on the rights, and then the week would lateralize to the side with the conductive hearing loss. So that's great. Okay, so this we've already discussed. About what sense? All good, cause this, um, this is a picture off a facial nerve. Palsy is just something to be aware of in any patient with, uh, when you're thinking about serious. Yeah. Um, problems. In any air emergency, the problem will be involvement off. If there's a cream that involvement, then you've got a serious problem on your hands. Potentially. So this is what we've been the client. The next thing I want to talk about is a tightness media. So I says, media is, ah, group. It's a Would you describe a group of inflammatory diseases of the middle ear? Um, you've got a cute as this media, which is acute inflammation of the middle ear. Um And then the way that that tends to present is, um, with your pain, mainly if it's most common in Children. So Children will be potentially pulling the air crying, not sleeping or eating well, they could have a fever. But if pain is a talk, um, top thing that happens. Um, if you look inside the ear. Then you'll see a bulging, angry looking ear drum. Uh, this condition doesn't need emergency intervention. It just needs supportive treatment that just needs analgesia. Staying hydrated, typically. Antibiotics. I've seen them used at all, though having looked at the evidence or it, antibiotics like amoxicillin can help with improving pain. Interestingly, but not necessarily how long the child has a tightness. People testes media. So initially I would avoid antibiotics and just give analgesia. So within the otitis media group, there are two main subtypes I'm going to talk about. So one is it has a cure. Titus Media, which have discussed the other, is a tightest media with effusion or army, also called blue. Here on, that's when there's a collection of fluid in the middle ear without evidence of acute inflammation. So talk about that next. So, um, that Isis Media with a fusion or P, where it's the most common cause of hearing loss and Children on. But, um, persistent malaria is linked to probably station two dysfunction, so there's issues with the ventilation and the pressures in the middle ear. It could be caused by a low grade viral about your, uh, infection. Um, on the other thing that we think makes it persistent is if the child has a lot of adult. But the child typically has, um, large, enlarged adenoids or infected and annoyed. So that's why that's one of the treatments to do another. Order it to me. The issue with this is that if it lasts for a long time, it can really affect Children's development. They don't they can't hear, so they don't do well at school. They struggle to communicate and things. So you want to sort this out if you if you see it in the community, you can refer it if the if the child has persistent and blue here, Teo Anti, who will look into perhaps doing surgery in the future if it's required, it can cause damage to the tympanic membrane so it can cause a conductive hearing loss. Um, because it thickens it in Panic member and if it goes on. But you know, the main main thing that I really want to flag up is that unilateral blue here in adult is a red flag. So you want to know if you've seen you natural blue here in adults, so you see unilateral, um, the tightest media with an infusion in only one ear. Then you want to refer this patient TNT urgently. You should have a higher um, you should suspect this mornin in people of Chinese descent, because it tends to be more calmer. But in any adults who has the union natural blue where they should be referred to ent urgently on, I think that's the most important part of this slide nasopharyngeal concert. That could be the cause. And it could be including the eustation tube, which is why they got the earlier in the first place. So to summarize, you want to, um, when it comes to acute otitis media, you want to ever heard in the refer people who you suspect might have mastered itis, which will discuss, um, people who have persistent or recurrent attacks this media because they might need surgery. This is usually Children, um, on adults with Kordech discharging years on you. You can discharge patients with acute otitis media because, um, it's not a dangerous. It's not a dangerous condition. Unless it develops a complication, you can just safety net the the kids with acute otitis media to come back. If they show any signs of being systemically unwell, will have mustard. Isis. Um, if you see you natural, Gloria in an adult, that's the red flags. So you need to refer that to urgent anti. This is just picture of acute otitis media. It's just ah, a near that looks angry. Bulging eardrum looks dull. Quite a classical. Um, appearance on this is the kind of thing that you would see if you notice in someone's here who had a clear on go again. If you see this in an adult on only on only one side you want through further um, this is a gram. It which is used to treat um Libya happens quite often in kids on. But if you look into someone's ear and see this, this is a normal appearance. The grommet will migrate naturally out of that year. Don't need to do anything about it. Just leave it alone. Sometimes people try to put out. So the next thing that we're going to talk about is mastoiditis. Um, at this point, are there any major major questions? No. Seems to be going good masters. So, um, acid itis so massive itis is a nymphomaniac off the with the mastoid lining on the air cells. Um, it's usually due to a spreading bacterial infection. Um, it's preceded by a tightness media. It's a complication off acute Tyson's media, but and he gets a lot of referrals, rightly so for suspected mastoiditis. But I suppose why I want to say here is that, um, Children with mastoiditis for anyone with Master Isis is systemically unwell. Um, so they are feverish. They might be psychotic. Um, they might be septic, but they they're really unwell, systemically unwell. Their blood's will be deranged on did. It is not just a case of the patient having a bit of tenderness of the mastoid. Um, if they're totally well and have a base of tenderness over the mastoid, then it's unlikely to be mastered itis. Unless they are. They've had attack of acute otitis media. You look in the security times, this media, they are are becoming systemic. Lien. Well, they've got tenderness over the mastoid. It's it's boggy. You can feel that there's something going on. It's a Demetrius. It doesn't necessarily have to be a fairly flat you that year doesn't have to necessarily be protruding like in this photo and buts There there are some early signs such as, Well, be a demon. It will feel a bit. It will feel swollen over the last story on. In that case, then definitely those patients need to be referred urgently need to be admitted because muscle duchesses is really serious and it used to actually kill a lot of Children. But no, Everyone with a bit of tenderness of the mustard has this. Um, sometimes the eardrum will perforate with the attacks. This media that might relieve the pain of little bit and you might see discharge in the But if you if you if the child's or the person is in a lot of pain there systemically unwell, they've got the fever, that tachycardia, then that suggests that they need to be admitted. So this is for the speaking about, um, and treatment of this. It needs to be IV antibiotics. They need a master debts mean ultimately, but the fasting they need us to be admitted to hospital under ent half some resuscitation on do have IV antibiotics. So the learning point here is just that all patients with suspected mastoiditis should be referred urgently for any anti assessment and whether that's in the community or in the hospital on patients with mustard Isis do need admission. But the way that they present is that they are systemically unwell and purely having a slight bit of tenderness of the master. It doesn't mean that person has mastered Isis. Um, hopefully that will make sense. Um, the next thing is cholesteatoma very common also, and the ENT might have heard about it during your studies. It's It's a destructive and expanding growth consisting of characterized from Billy Epithelium in the middle ear. All the mastoid. Um so I'm going to just talk you through the presentation using these pictures. So the picture of this man holding his nose is meant to tell you that that could be really unpleasant smell. So a parent might say that the child has a really horrible smell coming out that Yeah, and if that um, happens in conjunction with these other things and they might have a cholesteatoma. So this picture with the black background at the bottom right hand side shows a perforation on it shows a bit of debris, a swell, and that suggest that there could be a cholesteatoma going on. Um, on the left hand side, the woman who Oh, the picture of the year is just trying to tell you that there might be a hearing loss is conducted hearing loss on then above that, there is a picture over a tract ID to panic membrane. So if you look at that picture, I hope you can see it. It's the ear drum. Doesn't look like the initial eardrum that we looked at earlier. The eardrum is kind of sucks in, um, Andi, that's called your attraction. Look it. He also has a bit of debris in it, but it's the retraction pocket that's really suspicious. Also on the left. Here, you can see a polyp on if you see a polyp in the attic area, which I'll show you in a second. That's also very suspicious for cholesteatoma. Um, cholesteatoma it is. Uh huh. I'm unlike what the name suggests. It's not a malignant tumor or anything, but it can cause significant issues because they can erode tissues around them. What they expand. They can destroy the bones of the middle ear. Onda. They can become infected, and they can cause chronically discharging is. So they are something that needs to be dealt with. Um, but they're not necessarily something that will need surgeon inpatient admission or anything like that. So when you look inside someone's ear, you might see some attic protraction. You might see the preparations of the polyps that we spoke about. The complications of Cholesteatoma, as we've spoken about, are erosions into the temporal bone. But you cannot should get even more serious complications such as meningitis. You can get intracranial abscesses in really severe cases. Sepsis, facial nerve palsy is all the stuff that happens when the skull base is invaded by your infections are too advanced. Um, it's a clinical diagnosis, but imaging continues to look a disease. It's stent. Usually that's more to plan surgery, though, on the definitive treatment is a muscle destiny. So the learning point that I just want people to take home is that it doesn't necessarily need inpatient treatment or an overnight referral. But if you see something that looks like the next light I'm going to show you, then they patient doesn't need anti follow up on assessment, so you want to arrange an urgent outpatient. The anti For now, So if you see this kind of appearance, um, you especially in the top of this, this top bit that you can see that is obviously abnormal. That's the attic. If you see something like this in the attic, it's It's probably cholesteatoma on da Good way to remember this is never trust at it crust. So take her message. Never trust at a crust. Next thing I'm going to talk about is, um, press the accu sis. So this is just progressive sensory neuro hearing loss that happens with age. Very common. Um, it's due to a loss of hair cells. Um, that happens as we age in the copy here on, but it usually happens in the from the ages. 60 to 65 ish is progressive, but it's symmetrical. So usually people come in, they say, I'll keep turning the TV up a ladder louder. I can't really hear it. Um, Andi that the otherwise fine, you look inside the ear, everything's normal. You do a training for test their normal Um, but of course, this is because the hearing loss is symmetrical. So unless they're hearing is really, really bad and which you will have noticed because you're fasting at them. The tuning forks are normal. Doesn't necessarily mean that the hearing is normal. So if someone complacent this kind of thing, then the thing to do is just to, uh, refer them for an audiology. We'll tell them to go and get a hearing test. The next steps would be a hearing aid. There's nothing else that can really be done. Um, so the learning queens are that this is not an emergency progressive, uh, hearing loss that is the same in both years. When do tuning fork test cystometric a while? There's no abnormality on the tuning fork test. It's not an emergency. Don't, uh, you don't need to worry about it. Um, especially this age group. You just need to refer them. Well, tell them to go todo a GE, get hearing tests and then from then on the minute to be seen in clinic and have hearing AIDS, if that's appropriate. This is in direct opposition to a unilateral hearing loss, which is what we'll talk about next. So a sudden onset sensory neuro hearing loss. So this is, um, this is when the cochlear, suddenly the sudden failure of the cochlea in a previously normal year, it tends to happen within a 72 hour window. So the definition is that this this is a cute This has happened in the last three days. Um, it's happened. Suddenly. The patient's suddenly become aware of a reduction in their hearing in one ear. Specifically, they might have to notice. And Burt ago they might not On when you examine them, you do. You're tuning for tests on D. Um, Renese is normal bilaterally. Weaver's will lateralize to the opposite side on. But when you look into that ear, there's no abnormality that you can see. So at this point, you should be thinking, Okay, maybe this is a sudden onset sensory neuro hearing meals. Um, it's we don't we don't know exactly what the cause of this is. There are different theories, some that there's a viral cause. Vascular causes that. Really? No, But we know that from the research that steroids high dose steroids Um ah, the most important factor here. So high dose steroids. Some people use 40 mg once a day in the morning. Other people in the center that I've worked will use 1 mg Picula gram up to a maximum of 60 mg in the morning as well. On Do, uh, give that for 5 to 7 days, you can consider anti virals. However, the evidence is limited. It's not massively convincing. But, you know, some people do use thumb. Most important thing. Those steroids, Um, I personally give PPI cover, especially if the elderly on I I prescribe it. The started in the morning because it tends to keep patients up at night. Um, you just need to explain to the patient where you're giving them steroids. In the last majority of cases, patients would rather take take the medication because this can have a really drastic impact on people's lives. Um, and I've seen patients are really young thirties and forties who haven't been started on started soon enough, although that their doctor there GP or whoever saw them did suspect censoring your hearing loss, and that's why they were in clinic. The clinic appointment took a while on day haven't been treated. Um, Andi. It's unlikely that if we give them stories of that point that it's going to make any difference. So the learning point is start started. Assume it's possible if you have seen someone on the The features that we just spoke about happened. You've looked into the air. It's normal. You've done tuning Forks on D. This suggests, since when you were hearing those just, um, start the steroids and then refer them to clinic. They need a naughty A gram and then just follow up. But there's not really much then it that anyone conduce after this point because at that point you've done all that. That can really be done. But there are other options in terms of injecting steroids in certain centers, but the most important things to start them on all those steroids, these patients can be discharged. They don't need to be seen by anti. It's all. Actually, they can be prescribed the stories by any of the stuff that see them GP or you destroy forever They are on. Then they can be discharged, but with the anti follow up, because we want to see how things are going on if there's any improvement. So, having said what you just said, um, this is just illustrating that in diagram form that if there was ah sensory neuro hearing loss on the right side, then you would have a normal air condition normal, really sesame or more conduction on both sides, and then the we processed with lateralized to the opposite side. Um, so one of the last things that I'm going to talk about is, um, it's a logical cause of dizziness. This is because a lot of patients are referred to ent for dizziness, but the term dizziness itself is very, very non specific and means different things to different people. So you want to know from a patient who comes in complaining of dizziness? What do they mean? Is it rotator e birth ago? That means that is, does that mean that the whole world is spinning around them? Does? Are they complaining off dizziness when they stand up? Which could be postural hypertension, hypertension, is it when they're turning over in bed and then the world is spinning around them, which could be BPPV, um, or is it happening at rest? Um, you want to know when exactly is happening on? Do you want to know what the associated symptoms are? So if there's, for example, unilateral hearing loss of feeling of like fullness in that ear, Um, and tennis is on one side, then it could be a nausea. Vomiting could be many years. Um, really depends on what the associated symptoms are. You also want to know how long do the symptoms last? Because for the ear related causes off dizziness, um, the duration really matters. If it's lasting a few minutes whenever they turn their head, it's much more likely to be BPPV. If it's happening over a period of hours, it's much more likely to be many s disease on. If it's, um, happening for it started suddenly and it's happening for weeks or even months. Then it could be acute. Number and titers could be Mr Bulus urine itis, depending on the other symptoms. Eso this light is really just to tell you how important the history is on how how non specific the term dizziness kiss other causes of dizziness, neurological cardiology, related multi factorial issues. What if there are a million or not so good on also psychological causes? Um, so the leading point here is dizziness is non specific. History is key. There are no ear related causes of dizziness that require emergency inpatient admission. Apart from if patients have, um, really, really severe symptoms, nausea and vomiting from things like Labyrinth, isis or Be could be V. But in that case they would know and they're elderly, for example. There are falls risk than then. They might need admission just from that point of view, but that wouldn't, um, typically come under anti anyway, if you do suspect an ear related cause of dizziness and, um, you can refer to outpatient and see kidding, but just take a really thorough history. Initially, I've decided to just mention one specific cause of dizziness on. The reason for that is because it's it's very common. Seen a lot in any seen a lot of GP surgeries on. It's very satisfying because anyone can actually make the patients better on that speaking TV. Um, I I've had in my time lots of referrals about it, and it's one of the very few conditions that I know that can be instantly just sorted. Um, and but by doing a maneuver, So um, a PPV is benign. Uh, positional Paris is more worse ago. It's, um the problem is that there's a calcified stone, tiny stone loose in the air in the semi circular canals on it's causing issues with balance. It's in the wrong place, and people come in. They have brief periods of less ago whenever they move on the effective side on they feel, is if the whole world is spinning around them when they turn their head often it's when they turn in bed. Each episode usually only lost a minute or less than a minute on. They could have nausea and vomiting as a result. So in this situation you want to do a full neuro exam. You want to rule out all the medical causes because sometimes patients were referred as this without actually having had three investigations on. But the symptoms of vertigo can actually be part of lots of other problems, as we've spoken about. So that could be a posterior circulation stroke while other things going on. Uh, so this is a diagnosis of exclusion, but if you have experience all the other causes annual very happy that it's worth that. It's BPPV. Then you conduce some maneuvers. So, um, the Dex whole pike is a diagnostic test on the airplane maneuver. Is ah, treatment essentially. So the the learning point is that you need to exclude the medical causes. It's a diagnosis of exclusion. You can't make it unless you get scared of everything else. It's not dangerous. It doesn't need Sergent if Earl to the anti uncle um, it's patients could be seen in clinic routinely, But at the same time, if you're confident that, um, you can also try and do the afternoon for on, then they could be discharged. If it works, it really, really works on. Patients are amazed, So just show you a quick diagram. The best way of really knowing how to do this is actually just by watching YouTube video or seeing it happen in your life. But the driver will help a little bit. So this is a dictation. All pike. Remember, Dicks is diagnostic. So what you're doing is you're turning to the patient's gonna have get vertigo when they turn their heads on me to a particular side on. In this maneuver, you will. In this test, you'll turn the patient's head to one side on, then lay them down on the edge of off a bet on as a patient's going down to the side that's affected. There's a lag period. You look at them, you could you wait for up to a minute on? Then you see this down beating, uh, rotary nystagmus. So you've seen the stagnants that either going around and round on. Then it settles. And then as a patients coming back up, the nystagmus comes back again, um, and starts going in the opposite direction on the more times that you do this, it'll happen less and less and less so it fatigues. Um and so that's a big sign that this is actually the ppd. In that case, you can then try and do an Epley on. Essentially, What you're doing is, um, if you think about what's happening, there's a stone somewhere and you're trying to move it, so you keep the patients head still, as you're telling them, Teo, do certain maneuvers on the idea is that you're trying to turn the stone around and moving out the the place that's causing them to have their symptoms. So I just advised, If you're interested in this, if you want to see how it's done, then just watch YouTube video after the call, or whatever is convenient for you having done it before it is. I think it's the most satisfying thing that you can do, because it could be really, really effective. Instant me on. You get instant gratification, So thank you for sharing with us to this long. I just wanted give you a summary and take home points. So if there's nothing else that you take away from the session, I want you to take home the fact that if you're suspecting sensory neuro hearing loss in any context, it's important to start steroids early. The earlier the better. The longer you leave it, the less likely it's going to help on. The more likely it is that the hearing will never return. Um, otitis external. The biggest thing is, they need topical antibiotics. Know Orel, usually a combination of a antibiotic and a storage drop. Um, such a side of dexterity is and a C cetera. It depends on your department, and you want to make sure when you look into someone's ear that has a test, it's turned out that there's actually enough space for the drops to go in. So if there's no side debris or whatever, you can try either to remove it or you can try Teo refer. That's a anti because if the topical antibiotics aren't going to get in this, you can prescribe the drops, but it znachko be effective. So they need to clear out before they're salted acute otitis media and Children. It settles with that algesia. If it's persistent, you can consider antibiotics helps with pain it doesn't help with outcome on Do Unilateral blue here in adults have has to be investigated urgently by ent Um, it's a red flag for, um ah nasopharyngeal conserve area will. So the last thing is, I'd be really grateful if you guys could do this procession quiz just to see if this has been helpful. If we've covered right kind of things in it, um, and will help me to change the rest of the sessions. Thank you for attending. Thank you for your time. Thank you for giving up your evening to come to the session. I hope it's been useful. My top priority is that hopefully I can give some useful bits of advice from my own experience. We've got some more sessions coming up. We're gonna have some access extraneous and some surgical training is delivering them. Lets us know what you're thinking. The feedback Once you feel the feedback form in, you'll be able to automatically get your certificate of attendance. Given that this is now an international teaching session, I should look quite good on your portfolios. Um, again, Just thank you for your time. Um, if you have any further questions that I haven't been addressed, I'll go through the chat and try and answer them. If I can't on to them and they're beyond me, then I will also get Miss Morgan T help. How fast the fresh is an email you back? Um, Andi, I'll just keep the screen on for now. To people that need to scum the code. Thank you for coming up. It's been useful on I hope this to your future sessions. Thank you very much. Somebody's asking Where's the feedback form? So that feeling the feedback for me is I will send, um You think I've already sent to earlier on in the chapel? Send it again. Let me send it to you. I'll just stop recording now. This one to you. If you have anything that you'd like to add, um, feel free