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Hello, everybody. Welcome to this evening. Uh, we'll give it a few extra minutes just to allow other people to join. Um, Just to say, before we start just in general housekeeping stuff, I'll be monitoring the chat throughout. So if anybody's got any questions they want to ask, you can either say them to the end, or you can ask, um but the relevance slide. Hello? Hey, um, on, then? Yeah. Just to get your certificates at the end, you will need to complete the feedback form, which I will generate, and then we'll automatically be sent to you. Um, Andi, this talk will also be posted on the medal site, so that usually takes a couple of days to process on. Then I will add it to YouTube once it's processed. Um, but yeah, Otherwise, if you've got any questions, um, my older is breaking up. Oh, dear. I'll post it in a message is Well, just to make sure it's clear for everybody. Also, just to say that today is the beginning of a double bill. So we're having ent emergencies today and then tomorrow at seven PM, um, will be having comedy and T procedures a zoo. Well, um, so feel free to register for that one, too. It's on our Facebook event. Um, I could post the Lincare a swell. Um, can you see my slides? We couldn't see your size. You want to try again? There's a little box that the, um that should be on your screen at the bottom, along with your microphone on your camera, which says Present now? Yeah. It's no letting me right out. Sorry, guys. Mm. If it still doesn't work, what I conducive. You send me your slides earlier so I can just share that my screen. And then, if you is your sound, really? According to say next light. But I can do that if we need to. Yeah. Sorry. I'm not sure why it's not coming up. That me just Yeah, I think unfortunately, we try one more thing. Got technology? Yeah. Yeah, I think unfortunately we might have to do that. I'm sorry about that. Oh, sure. Why? I want now You have Peter to do that and say Okay. Yeah, that's fine. I'm just trying to get it up at the moment. You using a mask? Because sometimes you have to give it permission to show your screen as well. Yeah, I am using my back. Yeah, I I did give it permission to use anything. Um, men's means that I let me try one more thing, actually, with my work. Sorry, guys. Uh huh. It's strange. I've never actually had this problem for We've used this a couple of times. Usually it's working. Okay. This my back that work in? Yes, that's working. Well done. Sorry. It might look slightly different cause I've had to download it elsewhere, but let me know how it is. And, um, anybody has any questions, right? I also, um I won't be able to look at the chart function. I don't think what? I go through it. I'll be the chat functions and work. Think Thank you. Um, so sorry about that, guys. They always take a little bit of a bulge. Begin with my name's Merrin. I'm currently an f Y one. Um, Norfolk in Norwich University Hospital. I'm an academic F one with my research project in in T on. It's something that I'm interested in pursuing a career in. I'm hoping that things presentation to be quite interactive. I'm get you guys answering some questions on day and hopefully make a little bit more interesting for you. So here is a range off different topics that I think can't is key and T emergencies. Unfortunately, with time, I'm not going to do them all today. But the topics I don't cover should be cross covered in other minor blips sessions. So if you love onto those, then all of these should be covered within the mind that I think this is quite a good extensive list for exams, but also for emergency ent situations that you might have a in teaching your doctor. So moving on to so you our neck. The first case. So a six year old boy is brought in by his mother. Any department. He has had flu like symptoms and ear pain for the last couple of days, but day has become feverish and increasingly sleepy. On examination, you realize his irregular mastoid silk asses lost. His pinna has been pushed down and forward, and he has a bogey a Dema off the mastoid on a Tosca pee, there's a red bulging tympanic membrane. Does anybody know what I think this might be? You got one. Answer mastoiditis lovely. Well done. Exactly. Mastoiditis. So mastered itis is a common cut. Well, a rare complication of acute otitis media. That's where the infection spreads to form an abscess in the mastoid air spaces off the temporal bone. Um, they're percent presentation I gave you in the case. Very typical. You get this tender body swelling over the mastoid is you can see in this picture been a push down and out and then on a Tosca pee can either have to findings. You'll either get a bulging and ara thumb Metis tympanic membrane. Or if this is perforated, you might have passed in the external acusticus meters Now, so, um, managing these patients, you need to admit them. You need to blood, give them IV antibiotics. Um, analgesia. Does anybody know what you would say for what? Antibiotics. You've give thumb to a bit of a mean question on, but so the antibiotic choice. You want something that can cross the blood brain barrier in case mastoiditis further spreads? Uh, the general antibiotics of choice would be caff trucks own and metronidazole. However, you'd always use trust guidelines. And that's something that, for exams is really um, that's a good thing to say, sort of. I would consult trust guidelines because it might be different in different hospitals. If after 24 hours of I antibiotics, there's no improvement. This is when you then do ct of the temporal bones on. Do you have a low threshold to do a court go mastoidectomy because of the risk of complications. So the key complications with mastoiditis mastoid abscess, intracranial spread and meningitis. Yeah, eso Now moving on. If anybody has any questions, by the way, just tuckman the chat box and what that meant to be shot down. So, uh, this is a slightly more simple one, and I've not really got a history for it. But what do people think this is? I've got a fractured nose. Lovely. Does anyone know what? Um, chemo anage mint for this would be I've got a nasal fractured deviation is well for, um, diagnose it on realignment as the answer to what you do. Pretty. Um All done, guys. Um, so, um, initial manage, we can split, um, nasal fractures into initially any management and then the anti management. So initially, if this is being seen in a you want to rule out head injury. Does this person have a lower GI CS? Did they lose consciousness? Things like that All out facial fractures so you can look for patterns of bruising. You can examine and feel the bones of the face and look for things like hemorrhages in the eye and also rule out septal hemotomas, which we will touch on an MBA little bit. After you've ruled out these key things, you then want to refer for Ent Emergency Clinic. Often there's a misconception, but actually we don't need to do any imaging for people with nasal fractures. So after seven days, ent will then see them in their emergency clinic. The reason we wait seven days is because you need to wait for the inflammation off the fracture to go down on. Then we can do a manipulation under German anesthetic or local anesthetic. Um, this needs to be done within 28 days. Um, this is unless there's an issue with the septum or any complication of a nasal fracture. This is usually a purely cosmetic procedure on, actually, is just done for the patient going on to a septal hemotomas. So a septal hematoma is where you is often caused by trauma to the hose on. It's where you get shearing forces from the trauma, which then tear these blood vessels on. Then the human homer forms in the potential space between the two layers. As you can see here, usually it presents read on bilateral swelling, but it it can be unilateral. They might present with a nasal blockage on for pain. When you feel it s 01 of my registrars once explained it to me that it feels like a squishy trampoline. And so that's often quite diagnostic when you actually feel it, Um, you can also then do a needle aspiration with a wide bore needle to diagnose this and it'll you're aspirating a broad, bloody or serosanguineous fluid. But after needle aspiration or that will initially improve it, you then have to go on to manage it. Due to the risk of this recurring. So what you then do to manage the septal hematoma. This is not something that an s h O would be expected to do on their own. And you need to involve any anti registrar and incision and drainage would occur under general anesthetic. You're them Pack the nose with, uh without car. Gated drain. Depending on the procedure, it's often good, too. Then cover this with antibiotics, um, for risk of infection. And if when you drain it, you think there's likely an infection, send cultures off. It's always best practice to make sure the antibiotics were using a targeting the right in section. All of these patients need a follow up within 23 weeks. And the main reason we follow these patients up is because some quite serious complications except or hemotomas so you can get a vascular necrosis of the septal cartilage on do this can lead to septal perforation, as you can see in this photo here, the hole in the nose, which in turn, might lead to a saddle nose deformity. Um, other key, uh, complications. Aricept abscess. The risk with the septal abscess is the nose is a danger area on, but it can lead to intracranial spread by the venous drainage off the midface. And this can actually lead to a cavernous science to emphasis. So really serious outcomes on definitely ones we want to look out for. Um, make sure we monitor case three. So we've got an eight year old boy who father brings him into the GP. He's had a blocked nose with yellow discharge and a frontal headache for the last two weeks. But Dad's now concerned because he's developed this readiness and swelling around his eye on examination. His feverish his left eyelid is red tender and swollen, and he's not able to fully open his eye. He does have a have no change in his vision. What do people think this is? I've got pre or brittle cellulitis. Brilliant. Can anyone tell me why they think it's pre orbital cellulitis rather than orbital cellulitis? I've also got peri orbital cellulitis. I've got no change in vision is being the reason why I previous is Parry. Ah, couple extra person for you over till cellulitis. Well done, guys. William S O preseptal, pre orbital cellulitis s O. This can be of this is a complication of acute Sinus sinusitis. It can also be a complication off nasal or eye trauma. So this is something to ask about in the history in the case that I just gave you there. The block nose, yellow discharge, frontal headache. Those key symptoms of acute one Sinus isis. So should be ringing alarm bells in your ear. So examination you want to do I movements. Look at the people usually acuity, color, vision, an interior rhinoscopy. Um, any guys are absolutely right. The reason we want to look at all of these things is to work out whether it's preseptal orbital cellulitis so that everything that swelling and I pain can often happen in both. Um, but actually the issues with the eye happened in orbital cellulitis instead. So you often get pain with the eye movement proptosis on. They may have issues with, um, vision impairment. I wouldn't get overly caught up on this, but it's something to be aware off, eh? So this is the channel is classifications of, and it kind of links the more together. So you got preseptal cellulitis or little cellulitis, Some periosteal abscess or little abscess, cavernous Sinus thrombosis. And I think being aware of this classifications of the different stages is quite helpful to make you realize partly why we're so interested in working out where this classification is. Orbital cellulitis is more likely to lead Teo visual loss. Which is why we need to, um understand quickly on dumb act on this appropriately. So management of preseptal so ideal itis. So whatever happens, you want to involve the Ent team, the pediatric team and the ophthalmologist. It's important to involve all of these teams early so that you can, um, if anything happens, or there any complications it could be act on promptly. IV antibiotics. Um, I was looking at mine, and my trust suggested I've become oxcarb. But I've also discussed it with other people and they've suggested kept track so in a metronidazole instead. So again, I would trust use your trust guidelines when you're looking at this, uh, manage the patients with nasal decongestions and nasal Do shing on. This is particularly if they the cause is likely to be acute Sinus sinusitis because it will help with that. If there's no improvement in 24 hours or if these patients develop neurology, you want an urgency he had done on. Then if there's still no improvement with IV antibiotics or you're concerned about anything, surgical drainage is theocracy in. This could be either be an internal set surgical drainage or external, so now moving on to conditions of the throat, so leaving on tip airway emergencies So I think this is one of the key key topics that are really important to cover on do Airway, as you know, is the first part of a NATO reassessment. And if in a row, way is compromised, this is the thing that's going to kill patients first. So and usually go to assess these patients. If you're on the ward and an alarm bell gets called called or anything like that, first of all, you want to know the recess status of this patient. Um, that sounds like it's taking away from assessing the patient. To begin with that I've seen in scenarios where, UM, you're doing in a tree assessment a patient becomes unresponsive on actually knowing whether or not they want to be resuscitated. Really important. A prompt review of the patients. So doing, um, pulled learning about that. Allergies Medications past medical history. Last meal on events surrounding their illness can be helpful on discussing that the nurse who's been looking after them can often tell you all of this information rather than you searching through their notes on. Then begin your atria cess mint. So, um, the way these patients might present cyanosis seesaw breathing. So this is where you get paradoxical respiration. The anterior chest is pulled in and down as the abdomen expands, and this is a key sign of respiratory failure. Use of expect accessory muscles, diminished breath sounds, strider and stir to or two people know the difference between these two. Yes, don't worry. There's always a little bit of a delay. Unfortunately, between people typing or medal and the answers, I'll wait. See if anyone does. No, it's fine in, Go ahead and explain the difference. It's okay. So Strider is, ah, high pitched inspiratory noise, and that's due to obstruction off the larynx. Um, where a stir total is a low pitched inspiratory noise. Do two obstruction off the or, if I drink, so it's just just depending on where your obstruction is, depends on whether it's a high pitched or a low pitch noise and then going on to management. So this's really good to know, not just for ent, but that 80 for your B l s u R A. L s really important to know. So involve the anesthetic and medical team immediately. If you think someone's airways compromised, it's not the ent team that should be called. It's the anesthetic team that need to be there. You want to put a 15 liter, non rebreathe oxygen mask on them? Does anybody know what you do if you had a laryngectomy or a track us to meet in situ? So if if someone's got a tube in the throat, it's importantly, put the oxygen both over there mouth on. Go over that that other airway. So over the track us to decide. I could've been saying, Would you in shape A. And I think will allow you to answer the question. Would you? In Jamaica and I will come onto that. We will get this, but yeah, that's a very good That's something that you might move Teo eventually. But in your initial management, if someone has a track us to me, you'd put the 15 m normally breathe mask over their mouth, and then you also get, uh, you can get Children's masks and you can put that over the track loss to me site. And that means you're giving oxygens two both of their airways, um, maneuvers that you might do for people he thinks gone airway. Obstruction ahead tilt and lift on a draw thrust Because this will just open the airway up. You can use airway a junks so you can use the nasal pharyngeal that you've got here. When you put in a nasal pharyngeal, it's really important you put it. Um, thank you straight into the nose. Don't put it up because it can cause a lot of damage. Um, on also or four in jail. So the way to measure or for angio airway adjunct would be from the midpoint of the sizes to the angle of the mandible. The important thing to know with an aura for angina airway is if your patient is conscious, they usually won't tolerate this. And this is when you have to use a nasal pharyngeal their way. If what you can then do for to manage these patients is give them a realized adrenaline on. This is one in 1000 adrenaline that you'd give thumb on also IV dexamethasone on what this does is it can help relax the airway on improve their breathing. Um, but nebulized adrenalin will work immediately. The dexamethasone will take a little bit of time to work. Another thing that you can then do, and this will come later on. Depending on the course is give them IV antibiotics. If you think this is an infectious cause that's causing them to lose their airway, um, then start the IV antibiotics early because they take a little bit of time to work. So coming onto the cause is we've got you've got inhaled foreign bodies, and this is a really key anti emergency and something that will be covered in some of your other sessions. Blame the airway. So episodic axis, another really key issue. Vomiting, secretions, soft tissue, swelling, local mass effect. So, for example, cancers of the larynx and cancers in the neck cause this laryngeal spasm on depressed levels of consciousness. So I think this initial management is the key thing that you should really all know. Onda New guidance has suggested that the innocents should always be the first point of cool in an airway emergency, not the anti T. The ent team will get called if there's difficult anatomy, which means that intubation is going to be difficult. So in patients, the knee situs when they're involved. If all of the things that you've done so far in eight in your process of managing the airway has not worked. They will go and intubate the patient. But if they were worried that actually, they won't be able to intubate the patient because of an upper airway obstruction. For example, if your patients had an anaphylaxis and they've got a really swollen airway, the niece, this might not actually be able to relate those patients very well on this is where the anti would get involved again. This is not something because the nest a job would be involved in, and you'd get your senior help immediately. But they might then consider doing an emergency track, your ostomy. And if the pain when the patient becomes more stable, they might perform a flexible nasal scope. Just have a look at what's happening, but actually, most of the time it's the anesthetist that will deal with these situations. If it can't be dealt with on the ward just to go into a bit more information about tracheostomy, it's something I definitely struggled with getting my head round at university a little bit, So a track, your ostomy is used for multiple reasons, just like I've spoken about an emergency to secure, maintain a safe airway if there's an upper airway obstruction, but it can also be used for other reasons. So weaning off until a shin and I t. U airway protection on long term ventilation in some patients How it's done. So Ah, horizontal incision is made midway between the Cricoid and Suprasternal Notch, and usually this's. We create a window in the cartilage between the 2nd and 3rd track your ring straps, then divided in the midline. The tubes inserted, the cuffs inflated on. Then the tube is secured to the skin again. This isn't something that you guys need to know how to do, but it is good to sort of understand the procedure on the anatomy of it. I'm just going to go over different types of track, your ostomy is and things to be aware off. So I think this is quite helpful. So the two pictures they have hit a cuff on DNA on cuffed track kiosk to me. So a cuff Dracula's to me is where there's a soft balloon around the distal end of the tube, which seals the airway. Now these are often used in the first seven days of having a track. Yours to me in situ or if it's really important that we're protecting this airway. For example, if there's high risk of bleeding or aspiration toothies patients of vomiting lots if they've got, um, severe bleeding, you want this coughing's. It protects the airway. Also, if positive ventilation is required for these patients, the uncuffed is very rarely used in the queue, setting for the reasons I've just given that can be used in the long term for patients with an effective cough and gag reflex on day long time, helpful because it helps to manage secretions a little bit more. So the next few things I'm going to speak to you about is fenestration. So, as you can see here, some of these track yours to me. Tubes have holes in them, so these holes will allow for speech for these patients, which is important if patients are going to have to track yours to me in long term, whether it does increase the risk of aspiration if someone has a finished rated track close to me to put in. If you're concerned about the airway and they're going to need emergency ventilation, you can remove the fenestrated one and put the nonfenestrated one in. This will mean that they can't talk for that period of time but has no openings. So is that for emergency ventilation on? Then Just bring that this picture clearly so you can have an inner cannula in the tube. There is something called a single cannula where you don't have the end of one. But this is actually very rarely used due to the rest of blockage. So the inner cannula is really helpful and useful because you can remove it and clean it. And this reduces your risk of blockage on D helps create more safe away. If you guys get the opportunity, ent wards will have, um, load of track your ostomies. You can often speak to track your stomach nurse on. Actually, I think it's quite helpful to have a look at all the different types of track yours to me and see them because I think it helps you remember them a lot more. And seeing it kind of make it helps to treat your understanding of off what what they do and how it works. So they want to keep complications of track, your ostomy so saying with a lot of different things. Bleeding infection. As with most procedures, airway obstruction, they can dislodge. They can cause the pneumothorax have done incorrectly. And you can get a persistent track your could. Cheney's fistula. I was just going to Osco. Um, are there any contraindications? Very coughed apparatus. So a cough track your ostomy is opposed to a non catheter or a fenestrated one. That's one of the questions from the chapped. Um, good question. So from my knowledge, I don't think there's any contraindications to a cuffed rather than an uncuffed. I think the the often less comfortable I'm so in the long term you It might be easier to use an uncuffed track, your ostomy, and also it will help with being able to clear secretions. But I don't There's no contra indication to it. So you you could you could use that anytime that make sense. So that's why it's preferred in the emergency setting. How about since is your question? I'm with the fenestration, so the fenestration is almost additional 0.2. The cuff tore the uncuffed, but the it will mainly be the oncologist tubes that fenestrated but not always, um, going on two complications management of a track us to me. So I called the seen ent surgeon on Denise test yet again. If we're worried about an airway issue, we want any stress involved In case you're going to tap toe intubate these patients you're going to do your A to reassessment on when assessing the track. Yours to me site. You want to look at it, see what it looks like. See if it's looks bummed up. Feel if there's any air coming out from it on DC the way it's moving, all patients should have what we call a blue block box by the bedside on Do This blue box will go with Track your stomach patients wherever they go in the hospital in case there's an issue with the airway in the blue box, they'll be a track us me tube the same size undersize below. On this one mean, if there's an issue with their tube, you can put a new one in on If the the whole that this tube used to go in his issue. In kink, you can put a smaller tube in to help create an airway, a track you'll dilator so you can open up if you need to. Two of the key emergencies I wanted to discuss with you is one. What happens if the tubes dislodged, so if it becomes dislodged, you want to lie the patient flat with their neck extended as far as possible, you can then use the track. You'll dilators to part this off tissue and then suction, so you can either get the suction on the ward. Or you can get a finger suction per pet, which you can hold it. The end of new construction bits out from on a lot. Off the blue boxes will have a suction tube like that in it, a swell, and then you want to insertion you cheap and inflate the cuff. If you're concerned about airway obstructions again, you want to suction to remove secretions or plug. Um, if there's a blockage, you want to remove the inner cannula. And this is why, when I was discussing whether you have a single or double cannula, this is the benefit of having a double cannula so that you can, um, use the inner one and clean that off. You could then perform flexible names and just go pee to ensure that the tubes in the correct location. If none of this is working, you want to deflate the cuff. Onda, Um, and attractive intubation is still possible in these patients. Lots of people don't think it is. But you can intubate people beyond this point on this war Enjoy that. They haven't airway. And this is why you want to get the and he's just involved really on. So going back a little while ago now. But someone suggestion in the chat of Can you intubate these patients? Yes, absolutely. On It should be something that you do you think about if you're really concerned. So now, going on to the next case. So post tonsillectomy bleeding. So POSTOP length talks a lot. Talks a lot. Sorry. Got tonsillectomy bleed can either be less than 24 hours and this is called primary or over 24 hours and this is secondary. A second rebleed usually occurs between 4 to 9 days. Some think that sometimes comes up in exams but also really important to be aware off if separate cents to you with a small bleed following a tonsillectomy is that a small, self limiting bleed can actually lead to a larger bleed and something that you should be aware off how you manage to these patients. So you'd want to admit them all. Patients, even if it's a small bleed, you want to admit, and you want to inform your senior as soon as possible. The reason for this is because off the high risk of a major hemorrhage, because of being cautious with this. Actually, one in 20 people get re admitted after tonsillectomy on day one in 100 return to theater because of that bleed. So how you want to manage them? Eight. We assessment. As always, make sure that this bleed isn't causing them to have an airway issue. Make sure it's not causing them to be hemodynamically. Compromise. Do you want to look at their BP? The heart rate respirator, things like that. You want to get to cannulas in them. You on IV fluids IV analgesia years andare. It's not on here, but you also want to get them some IV antibiotics is well, just in case. Ice packed the neck might help with the bleeding. Getting these patients know by mouth in case you need to take them to Theatre on. Then, although I put it's plus and minus. If you can get hold of it on the ward, most patients will have tranexamic acid on hydro peroxide goggles, and these work really effectively and should be used in these patients. Topical adrenaline is used not very much on when I say top of adrenaline. The way this is done is gauzes So dren Elin. And then you can use forceps on base on the bleeding site. This is usually only done if the bleeding is severe coming on toe. Another case for you guys. Almost done. Now a 35 year old man presents with sore throat, painful swallow and reduced drawer motion on examination. Extensive. Everything on soft palate swelling has a deviated deviated deviated up to the unaffected side. Does anyone know what they think this might be? I've got periodontist a abscess. I've got Quincy, another periodontist or abscesses. Well, brilliant. While done, guys on before I move on. Does anyone know what the word is for? Reduced drawer motion? That's the medical term. I've got trismus brilliant model. Um, yeah. So Quincy or peri tonsil abscess. Exactly. Right. Well done, guys. Um, presentation Severe sore throat again. Aphasia Some people describe as a hot potato voice. And so imagine someone speaking like they've got report eight. Oh, in her mouth. Trismus say at that the issues with their drawer on a deviated uvula. Management of this, this is actually something that has ah, ent s h O. There quite often are involved in Perry tonsil abscess drainage, and it can either be with the needle aspiration or incision and drainage. You want to cover all of these patients with antibiotics yet again using trust guidelines. But you probably want something board spectrum on also analgesia, because these patients will be in quite a significant amount of pain. Um, finally moving onto deep next space infections. So they're two different types of deep next base infections. There's a power of foreign gl obsess, which is where infection spreads the potentials pasta lateral to the potential space postal up troll to the nasopharynx or retropharyngeal abscess, which is where infection spreads to the potential space anterior to the prevertebral fascia. I wouldn't get overly worked up about. That is just to know there are different dude up. Two times key things to look out for are sore throats in the absence, often abnormal or a pharyngeal examination so often you can't see very much when you look inside there throats, severe neck pain or stiffness on signs of airway compromise. And this is thinking back to what we were discussing previously. You cyanosis your stride or your third toe, reduce consciousness things like this to investigate these patients you want to do bloods. They're probably going to have significantly raised inflammatory my mark markers blood cultures to look sensitivity on an urgency. Teaneck, with contrast, if you conceive in this image in both of them. Actually, there's quite significant airway compromise because of the infection pressing on the airway. Uh, I don't know if you guys can see my cursor that I'm moving, but they're way being the back but in the middle, and you've got this infection pressing on it. Um, so obviously, that's what quite concerned about these. And it's a serious ent emergency for that reason, because there's a rapid deterioration often in these patients, causing airway compromise and poor outcomes. So initial management, yes, again, an earlier seen it in put you wouldn't be expected to deal with this on your own and you want a lot of help. You want to nurse the patient patient at 45 degrees on, they definitely shouldn't be lying on their back. Broad spectrum antibiotics. The reason you won't mess is because often the cause of deep next base infections of calling microbial nephew. You want some think that targets all of these things humidified oxygen with saline can help on. Then you want a low threshold for intubation for these patients because of the risk by away. You then likely likely to go on surgical management on a low threshold for this as well. Um, and that's also Ari. That was a very whistle top. Um, talk. Does anybody have any questions? A tool? Give them a moment. I'm sure you questions Yeah, for those who weren't here earlier. If you go to the feedback chat, I've put a message there saying provide feedback and you would have consent and email. Hopefully, um, to your inbox is saying provide feedback as well. And that's how you get your certificates. Otherwise, just to give you a bit of a oh, I've got that was been Thank you very much. Thank you so much. Sorry. On then? Yeah. No, I just thought since we always gets, um, keen beans on, we have a few. I think we end up with a few medical strings. Also, joining these talks a swell. Do you just want to tell us a little bit about the academic foundation program that you're on on? Dumb? Any details about the project that you're working on? Yeah, I'm absolutely So, um oh, I'm doing, um, f p n or itch, which I get a four month block in my second year s o. This made it. My block is between November and April off my second year on grease. I chose to do it in or itches because I get to choose my topic. I found with anyone who is interested in ent and an academic ent. I'm more than happy for you to contact me. I've found it difficult cause lots of F p programs you can choose necessarily the project you want to do. Often they're decided for you in advance. For there's a list that you can choose from. Where's the Norichika? If you find a surprise, you can do it and whatever you want to do it in. So my research project is, um, to do with identifying people with smell and taste loss following head injury. Eso head injury is, um, often forgotten, cause of smell and taste loss, but something that actually significantly impacts on people in the long term. So, yeah, but if anyone wants to contact me about anything I've spoken about today or about an academic ent route or anything, come more than happy to discuss with you guys might emails. Great. Know. So we don't have any questions that have come up, but again, feel free to ask them otherwise. I'm just gonna say thank you so much for coming and agreeing to give this talk. It's been really, really interesting and also really concise. A swell, which is important, I think, Um, on very interactive as well. Um, yeah, I can't see any. Like I said, Any questions coming through, but yeah, again. General health keeping certificates. This video will be posted on meddle in a couple of days. It just takes some time to process on. Then it will be put up on YouTube after that. Um, and we've also got two more at seven pm We have common ent procedures Um, and also, I was wondering, um, I'm as the anti lead from mine. The BLEEP. We're always looking for authors and other contributors as well. Im so interested in contributing an article. Feel free to get in touch as well. Other than that, thank you very much on thank you all for attending a swell. It's been a really useful talk on. I will leave it there so by everybody and have a good evening. Thanks, guys.