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The first part of the ent session yesterday. And I'll be kind of continuing on from where she left. Um So obviously, for us, thanks to all our partners, for all the support. So these are just so sort of the learning outcomes for today. So there's a bit of anatomy that will be going over. Um uh the innervation of, of muscles, mainly. Basically, we'll be talking about cranial nerve five and cranial nerve seven talk a bit about tonsils, tonsillitis, um the complications of tonsillitis and some important red flags in E ND. So this is kind of just a recap uh of the viscerocranium and the T MJ joint. So the viscerocranium is made of the pa nasal bones, the palatine bones, the pa lacrimal bones, the zygomatic bones, the maxilla and inferior nasal contra and the unpaired vomer. Uh Some sources out there also include um the mandible as part of the vis cranium. But that honestly depends. I know grace doesn't include the mandible as part of the facial skeleton and the T MJ. Just briefly, it's basically a hinge type joint and the articular processes involved in it are the articular tubercle of the temporal bone, you can see that and the mandibular f uh fossa is visible right here and you can see the head of the mandible, the mandibular condyle just kind of going up and forming the T MJ. And the temporomandibular joint is really important for mastication for moving the jaw, having chew food. Basically, that's one of the it's important functions. OK. Now, talking about the muscles of facial expression. So the muscle of facial expression are listed below the, the occipitofrontalis right here. The orbicularis oculi here, which is two parts, the bl part and the orbital part. So the BP part is the part that's closer like on top of the eyelids almost. And the orbital part is the part kind of orbiting as the name suggests the eye, then you got the orbicularis oris around the mouth. You've got the bucinator, you've got the mentalis and you've got the platysma and the function of all of these muscles is basically, again, like to help you with movement of your jaw, open and closing. Um They like a bit, the main opening closing is done by the muscles mastication, but they do kind of support its function. They also help in the movements of the lips and the eyes and forming all kinds of facial expressions and they're all innervated by CN seven, which is the seventh cranial nerve, which is the facial nerve and an interesting fact. Uh So there's a buckle fat pad right here. Uh as you can see in the diaphragm and in cases of malnutrition, there's a loss of the fat uh from the buckle fat pad, which kind of caused, which is what causes hollowed out cheeks. So that's why you see hollowed out cheeks in people who might be suffering from malnutrition. Yeah. Um So this is the muscles of mastication. These are the main muscles involved in opening and closing the jaw. So first talking about the muscles that help in closing the jaw, the three of them, the maor which elevates the jaw, the temporalis, which elevates and retracts the mandible as well. Uh and the medial Pacho which also helps in elevation. So you can see all three of them kind of what their function is, how they move to help with closing the jaw and to open the jaw. There's one main muscle that you need to know which is the lateral pid and it protracts the mandible and depresses the chin. So it helps in opening the mouth like that. And their main function, as I said, the muscle of mastication. So they help in chewing, they help in speech and the all of them are uh innervated by the third branch of the trigeminal nerve, which is the mandibular branch of the trigeminal nerve. So, talking about facial palsy because we've talked about uh kind of the facial uh muscles and their innervation. So there are a few instances where the facial uh which can cause facial palsy. Um you know, the facial nerve can be damaged because of temporal bone trauma and paro surgeries. I think ESA might have gone over a bit of that yesterday. And, but what we're gonna discuss today is Bell's Palsy, which is an Idiopathic syndrome. So there's no particular cause to it that we know of and it causes damage to the facial nerve and it presents as unilateral lower motor neuron, facial nerve palsy. So what it means by lower motor neuron, basically, if there's a lower motor neuron uh lesion, then the forehead is also involved. And if there's an upper motor neuron lesion, then the forehead is spared. So you can still move the forehead freely. And that basically just has to do with the innervation of the forehead. So the forehead is innervated bilaterally by both uh parts of the brain. So that's why um, it's spared um in upper motor neuron, facial palsies. Um And how you manage Bell's palsy is basically within, you aim to give prednisoLONE, which is um, you know, to help with the condition within about 72 hours of the symptoms, onset of the symptoms. And you'd also wanna assess and see whether you wanna give them eye drops at all because they won't be able to close their eyes. So it can cause dryness and infections and all kinds of problems. And then then you have Ramsay Hunt syndrome, which is basically the herpes zoster, uh sorry, the varicella zoster virus which also causes chicken pox infecting and affecting the facial nerve. Um And the presentation is basically the same as Bell's palsy. The only difference is that you'll see kind of a painful and tender vesicular rash in or around the ear. And in fact, it can even spread, you know, uh to the anterior two thirds of the tongue and the heart palate sometimes. And how you manage. That is basically you again, you wanna use prednisoLONE and eye drops, but because it's a viral infection, you're also gonna wanna give them acyclovir to kind of uh hold back the varicella zoster. And like I said, there's just a note again pointing out that in upper motor neurone lesions, stroke, uh you know, the forehead will be spared while in low motor neurons, there will be no forehead sparing and this is how facial paralysis is basically scored. So what is the House Brackman facial paralysis scar? You grade them from 1 to 6 and how this is helpful is that helps in guiding the treatment for facial paralysis. So for example, like in uh Bell's Palsy and even in Ramsey hunt, if the grade is four or above. So four or 56, you'd want to consider eye drops because there's incomplete eye closure talking about uh CN seven. So don't worry too much about all the details of the labelings. This is just to kind of show you the path of CN seven and how it moves. So the CN seven originates from the posterior border of the bones and then it runs through the internal acoustic mutus, which is kind of shown there in the diagram if you can see just above the sphenoid sinus that you can see it. Um After that, it exits through the stylomastoid foramen um um and enters the pa parotid gland from where it forms the parotid plexus, which gives rise to the five terminal motor branches which are temporal, zygomatic buccal marginal mandibular and cervical. And this is just a pneumonic to help you remember the branches of the facial nerve. And another important thing to note is that before, just before exiting from the internal acoustic meters, the CN seven also gives off a uh branch known as the corda tympani which kind of joins uh with the CNV uh V three right here. You can see it, it's, it joins CNV three and it supplies uh the anterior two third taste buds of the tongue. So that's sensory innervation and it also uh provides parasympathetic innervation to the sublingual and submandibular glands. So that's that in the diagram. So that's an important branch uh that it gives off. Yeah, talking about the trigeminal nerve. Now, so the trigeminal nerve originates from the pons and then uh it's present inside a dural recess, which is known as the trigeminal cave in the temporal bone. Um and it's sort of present there as a ganglion basically. And this ganglion then gives rise to three branches. The ophthalmic nerve which exits the cranium through the superior orbital fissure. The maxillary nerve, which will exit through the foramen rotundum and the mandibular nerve, which will exit through the foramen ovale. And they're just basically in a line one after the other in the skull. If you can see uh it's there in the picture. Yeah. And then we're gonna talk a bit about the external carotid artery. So the external carotid artery arises from the common carotid artery and it gives rise to six arteries uh which are the superior thyroid, the lingual, the facial, the ascending pharyngeal, the occipital and the posterior auricular artery. Um and after it gives off these arteries, it then splits to form two terminal branches which are the maxillary artery and the superficial temporal artery. And there's a pneumonic again to just kind of to help you remember these different branches and the external carotid artery is responsible for supplying the external structures of the head and neck. And another important thing to remember is that as it's giving off these branches, it does run deep to the parotid gland. So the retromandibular vein, so the retromandibular vein, um it also runs deep to the parotid gland and it's formed by the merging of the superficial temporal and maxillary veins which you can see in the diagram. So just uh anterior to the ear, you can see there's formation of the retromandibular vein and it runs deep to the parotid gland. And once it reaches the inferior pole of the parotid gland, it's going to divide. So it divides into two branches, which is the anterior and posterior branch. Now, the anterior branch basically joins the facial vein to form the common facial vein which will eventually empty into the internal jugular vein. And the posterior branch will join with the posterior auricular vein. And that together empties into the external sorry, which forms the external jugular vein, which will then drain into the subclavian vein. So there's a simplified diagram as well, just to show you the anterior posterior division, what they join when what they form uh to kind of simplify it and help you understand what I'm talking about. So, moving on to the oral cavity. So the oral cavity is divided into two parts by the upper and lower dental arches, which is formed by the teeth. Uh and the, the first part is the vestibule, which is the space between the teeth and the ginger wave and the lips and the cheek. So it goes kind of all around in a horseshoe uh horseshoe shape, kind of just anti it to your teeth and between your, between your lips and teeth basically. And then you've got the mouth cavity proper, um which is bordered by a roof which are formed by the hard and soft palate. So you can see that in the diagram and it's got a floor, a floor and then it's got the cheeks and the tongue feels most of the cavity proper. So when your mouth is closed, it's f almost fully occupied by the tongue. And one important thing, uh actually, we'll discuss that in the next slide. So we're gonna talk, yeah. So we're gonna talk about the oral cavity and tongue innervation. So the cavity is basically innervated by the trigeminal nerve. The roof is innervated by the second branch of the trigeminal nerve, which is the max maxillary branch and the floor of the mouth and the cheeks are innervated by the third branch of the trigeminal nerve. And the tongue itself has sensory innervation and motor innervation. So the sensory innervation is by is also split. So the anterior two thirds get the sensory innervation from the third branch of the trigeminal nerve, same as the floor of the mouth and the cheeks basically. Uh but like I mentioned before, the taste for the anterior two thirds of the tongues comes from the ca corda tympani from the facial nerve. And the posterior one third of the tongue is supplied by the glossopharyngeal nerve, which is the ninth cranial nerve. And that provides the sens sensory and taste innervation. For the posterior one third, talking about tongue motor innervation, all the muscles of the tongue are innervated by CN 12, which is the hypoglossal nerve, except for the palatoglossus, which is innervated by the 10th cranial nerve, which is the vagus nerve. And another important things I want to talk about is that all the muscles of the soft palate are innervated by the vagus nerve, except the tensor Veli pentin, which is innervated by the mandibular nerve. Now, that's important uh because uh it can you kind of test the clinically, you test the leal by asking a patient to kind of open their mouth and say, ah and if the muscles on each side are functioning, normally, the palate will elevate evenly in the midline. So the uvula will be in the middle, it won't deviate to either side. But if there's a problem on one side, the palate won't properly elevate on that side basically. So it will kind of uh de the uvula will deviate away from the normal side. That's what's important to remember. So if there's a problem with elevation on this side, but this side's elevating better, then the uvula is gonna kind of be tilted towards the normal side and away from the side that has a problem and that's in contrast to the tongue. So if there's an e ever any damage to the 12th cranial nerve, then the tongue tends to deviate towards the side of the lesion, right. So what's important to basically remember is if there's a problem uh with the uh with the 10th cranial nerve, when you open the mouth, the uvea will deviate away from the abnormal side. If there's a problem with CN 12. The tongue will deviate towards the abnormal side. Ok. Moving on to the tonsils. So the tonsils are basically masses of lymph tissue that are found in the pharynx. And there are a couple of tonsils actually. Um there's a pharyngeal tonsils which are located at the roof of the nasopharynx. You have two tubal tonsils which are found at the opening of the station tubes. So they're present kind of in a pair. Uh You have the palatine tonsils which are found in the tonsillar bed, which is in between the palatoglossal and the palatopharyngeal arch. So you can kind of see it right here. Uh kind of at the tip here. That's what it means by being in between the palatoglossal and the palatopharyngeal arch. And they called the lingual tonsils, which as the name suggests, they're located in the submucosa of the posterior one third of the tongue, which is again showed here by uh the diagram and they tend to form a ring shaped structure. If you look into the mouth, they can form a ring. Uh and this ring shaped structure is known as the walders ring. Um and these tonsils are classified as mucosa associated lymphoid tissue. Uh So they contain T cells, B cells, macrophages, whatever you would associate with kind of the lymphoid immune system. And they have an important role in fighting uh in fighting infection and they form the first line of defense against all pathogens entering through the nasopharynx or the oropharynx. Uh So the tonsils are very, very important when it comes to infection control. So, talking about tonsillitis as the name suggests. So it's basically infection of the tonsils. And when we're talking about tonsillitis, we're usually talking about infection of the palatine tonsils. Those are ones that you usually see. So the ones right here, right? Um And so it's uh can be viral or bacterial and the presentation is usually a sore throat, a fever of about more than 38 °C. Um, you will find dysphagia. So, you know, there'll be, you know, um problems with uh eating and stuff, they'll find it difficult to swallow. Uh You'll have nasal congestion, you can have headache, earache, cough, and when you examine the patient, you'll see inflamed tonsils, you might also see cervical lymphadenopathy. So, basically, the cervical lymph nodes will be inflamed like and you know, they'll be visible and you'll be able to feel them at least and purulent tonsils. So they'll be kind of exuding kind of like a pus. Uh an important point to note is that uh absence of cough and presence of pustular tonsils indicates a bacterial cause. So, if you get a patient who's not coughing and they have pustular tonsils, then they're much more likely to have a bacterial tonsillitis than a viral tonsillitis. However, what really helps in differentiating kind of uh kind of whether to give antibiotics to a patient who has come in with tonsillitis or not is the scoring systems which are the center criteria and the fever print criteria. Um So, uh I've listed them both here, the center and the uh fever pain criteria. Um I think the fewer pain criteria came later on, it's considered to be more sensitive than the uh center criteria. But um honestly, both are used and both are fine. Um One second. Yeah, I'm sorry. Uh And how, so like I said, the management usually, uh the management is reassurance, fluids, paracetamol, uh or Ibuprofen to help with pain. Um And antibiotics can be given if, like I said, if the center of your pain criteria are high enough. So each, basically in the center criteria and the fewer pain criteria, each point, each kind of criteria gives you one point. So if a patient comes in and they have, let's say we're doing fewer pain criteria. So if they have purulence and fever, uh and they have severely inflamed tonsils, but they didn't attend within three days and they have a cough, then you'll give them three points. And if a patient scores four and above in the fever pain criteria or three and above in the center criteria, you'd want to give them antibiotics basically. And yeah, and if a patient scores two or about two or three, basically in the, in the fever pain criteria, then we give them backup antibiotics. So there's no criteria for giving backup antibiotics in the center criteria. But there is in the fever pain one. And that's also why I think a lot of people prefer the fever pain criteria. Um and the differentials for tonsillitis is glandular fever. Uh and you'd see a classic triad of a sore throat, pyrexia fever and lymphadenopathy. Uh but a classic, a key difference is the presence of severe fatigue. So you will see, you will see fatigue a bit in tonsillitis, but you'll see severe fatigue and glandular fever. And you might also see splenomegaly. Uh and that is worrying because what can happen is that the patients can get abdominal pain because of the rupture of the spleen and that's an emergency. So if the patients come in, um and they have kind of with signs of kind of tonsillitis, but they have splenomegaly and they have abdominal pain. Then that's an emergency. You wanna send them to A&E immediately. And another point about glandular fever is that you never wanna give amoxicillin for it ever because if you give amoxicillin, it doesn't help with anything because uh it's viral. And secondly, it causes a horrible rash all over the body. So you wanna avoid giving um amoxicillin for it. And another differential is deep, deep space infe uh neck space infections, which we'll discuss a bit later. So, talking about tonsillectomy. So tonsillectomy is the removal of the palatine tonsils. So, because those are the ones that are usually involved in tonsillitis. And according to nice patients that meet all the criteria listed below should be considered for tonsillectomy. So the sore thoughts are due to tonsil tonsillitis. Obviously, uh, symptoms have been occurring for at least a year. The episodes of sore throat are disabling and prevent normal functioning. However, I think one of the most important ones is the second point that's listed here is the person has seven or more episodes of sore throat per year. Five more episode, such episodes in each of the preceding two years. So five in each of the last two years and three or more in each of the preceding three years. So either seven in last five each in two, last or three each in last three years. So that's the major criteria for tonsillectomy and sorry. And there are other established indications like recurrent febrile convulsions which we know are secondary to tonsillitis, obstructive sleep, apnea, stridor or dysphagia, recurrent dysphagia secondary to enlarged tonsils. Um And if they get abscess formation, so bad tonsillar abscess or if they're unresponsive to standard treatment, then you'd also want to consider a tonsillectomy. We don't regularly do tonsillectomies nowadays and that's because there are complications associated with it as well and you can manage it with antibiotics quite well on most of the times. Um complications usually primary, which are the ones that start in less than 24 hours of the pro procedure is basically hemorrhage. So 2 to 3% of patients will get uh primary hemorrhage and it's usually due to inadequate hemostasis. And pain is a very common, obviously, pain is there. And tonsillectomy, if anybody gets a tonsillectomy, that's very well known. Uh you know, people who've got tonsillectomies will often tell you about the pain, uh and how they got medication for it. Um, and then secondary is basically 24 hours to 10 days after the tonsillectomy and it's the same. So again, you can get hemorrhage, but this time, it's usually due to an infection. So secondary hemorrhage is usually due to infection and again, pain. So again, it's hemorrhage and pain, but the cause for hemorrhage is different and the management for the bleeding usually is through ABCD. E obviously, you have to do ABCD. That's the first line. You give antibiotics if it's because of an infection and the secondary cause and you do give do hydrogen peroxide gargles, you dissolve hydrogen peroxide in water and ask the patient to gargle with it. And that kind of helps with hemostasis and stopping the bleeding. Yeah. Uh So, oh and also one more thing. Uh primary hemorrhage, usually if primary hemorrhage happens, usually kind of rush the patient back to the theater because they're still there. And you wanna uh it's due to an um inadequate hemostasis, you wanna deal with that immediately. Um complications of tonsillitis. So first is peritonsillar abscess, which is also known as Quinsy and as the name suggests peritonsillar. So it's around the tonsil. So it's basically an abscess around the tonsil. Um, and the presentation is the severe throat pain, which is lateralized to one side. You'll have difficulty swallowing and speaking and they have a hot potato voice. So it's kind of like if somebody's got a hot potato in their mouth, that's how it's usually described. And they're trying to talk, uh, you see the deviation of the uvula to the unaffected side. And that's a pretty, pretty clear indication of uh quinsy. If you see the uvula being deviated to another size by a big mass in the neck. Uh Chism which means difficulty opening the mouth. They'll have difficulty moving their neck maybe. And they have systematic systemic features like fevers, chills and malaise and the treatment is drainage. So you wanna drain the abscess and then you wanna give the patient antibiotics. And the second uh complication is deep space infection. So, the two most important ones are parapharyngeal abscess, which is infection in the parapharyngeal space. Uh I've shown a diagram to show where the parapharyngeal space exactly is. And there's retropharyngeal abscess which we'll discuss in the next few slides. And um yeah, yeah. So here it is. So before we dive into retro fungal abscess, we'll discuss uh the retropharyngeal space. So it's the retropharyngeal space is the largest and it's the most important interfacial space in the neck. Uh It's located between the visceral part of the prevertebral layer of deep cervical fascia and mu pharyngeal fascia surrounding the pharynx superficially, that sounds like a lot of random words. But if you look at the diagram here, uh you'll be able to kind of see where the uh retro space is. So the prevertebral layer of the deep cervical fascia is right, the yellow part up there and the buccopharyngeal fascia um surrounding the wait one second, sorry, sorry. The prevertebral fascia is the blue one, sorry, um right there. And then you've got the buccopharyngeal fascia, which is kind of the yellow part right at the bottom, which is um a bit post posterior basically. And in between those two spaces, you can see you've got the retropharyngeal space. Um and the retropharyngeal uh space consists a lot of, of a lot of connective tissue, loose connective tissue between the uh visceral part of the prevertebral layer and the buccopharyngeal fascia. Um So, uh and it also another important point is that the true retropharyngeal space ends at the upper thoracic spine where the alar fascia joints and fuses with the visceral fascia. So, if you look at the diagram above, you can see that the alar fascia is kind of the red line running along and that and the buccopharyngeal fascia. So, between the allo fascia and the buccopharyngeal fascia is the true retropharyngeal space. And that kind of closes off here and joints, the buccopharyngeal fascia which closes off the true space and but just behind the true fang face uh space, you have the danger space as it's uh commonly called sorry. And it runs all the way to the posterior mediastinum at the level of the diagram. So the danger space runs much, much lower and it, that's why it's called the danger space because the infection and the danger space can spread all the way to the mediastinum, uh which can be really, um it can be very, very troubling and very dangerous. Uh So there are some red flags of retrophin abscess. So there'll be a sore throat in the absence of abnormal oropharyngeal examination. So if you look into the throat, everything's fine, but uh they still got a sore throat for some reason. Uh So that should make you think about retros. You've got, they've got severe neck pain or stiffness. Um They've got any signs of airway compromise such as Stridor, dyspnea, drooling or dysphonia. Um You know, you wanna think to order to find you abscess and that's even more worrying because there's an airway compromise, you'll see torticolis. So that's as you see, uh in the image kind of the head is stuck to one side, that's what torticolis is, chest pain. So, like I said, if the infection is in the D space and it spread to the mediastinum, it can cause mediastinitis, which is basically inflammation of the mediastinum and that's really, really dangerous because it has a 50% mortality. Uh there's also an inability to tolerate, tolerate oral secretions. So, like I said, uh you know, uh difficult for them to swallow and there's also Trismus. So they get a sorry, they get Trismus. So they got a lock jaw. And the usual investigation for retro fungal abscess is act scan. With contrast, you can see the abscess more clearly and you'd wanna manage it by surgical draining. So whenever this is an abscess, the first thing you wanna do is drain it and then you wanna give antibiotics. So, Ceftrixone and metroNIDAZOLE are the ones that are usually given for it. Uh talking a bit about dental infection. So what's important to talk, what we're gonna talk about is Ludwig's Angina. So it usually occurs in people who are immunocompromised or older uh as a complication of dental infections like cavities. Uh and it's basically a kind of cellulitis that uh starts kind of at the floor of the mouth and then it spreads to the soft tissues of the neck. So it spreads into the sublingual and the submandibular space as well. And that's dangerous because it can spread further into the parapharyngeal and retropharyngeal spaces, encircling the airway and cause air compromise, that kind of constricts with the infection and the inflammation. So it's really dangerous and sort of this is the last slide. So just talking about the red flags of ent. So there are quite a few red flags uh when it comes to the er, you wanna think about, there's unilateral persistent unilateral hearing loss, there's sudden onset of hearing loss, there's discharging ears, especially in the immunocompromised. You wanna think about malignant ortis externa, there's pa pain in the ear, uh there's facial nerve palsy, like we talked, there's Bell's palsy, for example, even uh bleeding from the ear is uh so discharge also, I'm talking about bloody discharge as well. That's also a red flag nose. You wanna think about blood stain mucus. Again, if there's blood coming out of ear, nose, throat, that's worrying. Um, you get facial pain, uh, especially if it's unilateral and it keeps getting worse, then that's worrying. You get orbital symptoms. Uh, you've got sinusitis in immunocompromised people because that can be fungal. Um, if the CSF leak, you'd be worried about some sort of cranial fracture. Uh, and the throat, uh, if there's dysphonia, there's dysphagia, there's adephagia, there's pain, the pain in the throat can actually radiate to the ear. So that's why ear pain is even more important because the throat pain can spread there. And any persistent growing lump is, uh worrying and I would say that the throat ones are especially really important, but because again, they can compromise the airway and airway compromise is a big, big emergency. You wanna uh deal with that as soon as possible. Uh Yeah, and that's my presentation. That's about it. Um Thank you for listening. I'll hand it back to prudence now. Great. Thanks, love and that was helpful. Um Definitely good revision for me. Um So does anyone have any questions? They can just and put it in the chart if they have any? And in the meantime, I will send a feedback form out and this should be in the chat now. So if you um everyone don't mind filling it in, please, that will be really helpful for LA and for us as well. And um after the completion of the feedback form, you will receive a certificate of attendance as well. So that will be really helpful for you all. Um So yeah, if no one has any questions, um our next week we'll be covering urology. So that will be on next Tuesday and Wednesday at uh at 6 p.m. So if you all are um free, please attend our next week session. Um Yep. So if no one has any questions, um Thank you Lavan once again for the presentation. Thank you for having me. Thank you. So I hope everyone enjoys the rest of the day. Thank you. Bye.