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All right. Hello everyone. Thank you for joining us. Uh I'm just gonna give a few minutes uh to allow people to trickle in. So we'll give it around five minutes or so and then we can, we can start. So, yeah. Yeah. Hello everyone. Thank you for joining us. We're just gonna give it a couple of minutes and then we'll, we'll start. So in four minutes we'll, we'll get, we'll uh we'll begin. Yeah, that's fine for me. Is that ok? Yeah. Uh or actually we can go ahead. Now. What do you think you? Yeah. Yeah, that's fine. Let's, let's get started. Ok. So, hello, everyone. Good afternoon. Thank you for joining us today on a Saturday and giving up an hour of your time. My name is Rashad. I, one of the founders of the teaching frontier, essentially teaching frontier. We're, we're a group of president doctors with various grades and various specialties come together to provide a wide range of teaching topics covering medical and surgical and aim to prep you for UK MLA and also foundation slash spe specialty training overall. Uh We'll also frequently offer specialized lectures uh delivered by experienced registrars and consultants within the field and we do have a few lined up as well. Uh Today is an example of that. So without further ado, it's my pleasure to introduce our speaker today, Miss Wood, she's a highly skilled, a registrar with deep commitment to both patient care and education. Uh beyond her medical expertise, she's also a passionate educator and also been actively involved in teaching and mentoring. Uh In addition to her passive medical career, she's also a title holder for Miss Africa UK, 2023 uh using her platform to advocate for cultural representation, empowerment, and social change. So once again, thank you for joining us today, MS and I'll leave the floor to you. Thank you so much. That was a lovely introduction. So, um hello, everyone. Um Unfortunately, I cannot see um at the moment who is here, who is not here. So we'll be doing this as a lecture format where um I'll be kind of giving you the bit size information and you've got a chat option. Um So hopefully, I have got my phone on as well with some, if you have questions to go through the chat, um it's quite a long um topic for, for an hour, but we'll cover what we can. And my second slide is basically the outline of our emergencies of today. So in ent we have to look at all three different um parts of it. So these are the emergencies that our foundation doctors whenever they join our ent department, they tend to have to deal with quite independently actually. Um, obviously they are supported at the beginning but then quite when they go on through the weeks, um, they, they are able to manage ATA or foreign bodies. Um, so starting with nose. Um, yeah, your throats and foreign bodies as well. So I'll go through the theory of things. There'll be procedures as well, but obviously you won't be able to cover all the different parts of the, of the um emergencies. But I'm sure we can, if you enjoy this lecture, we can definitely come back to do other bits and Bobs around Ent. So, um well, OK, I guess the first question already with the slides we provided. So, um unfortunately, the slide will this um presentation will be available for you to view and review at any time on the middle website? Oh, thank you, Rachel for replying to that. So, right. So we'll start as a case by case basis and then I will be talking through some theory um concepts during the presentation through the case as well. So we have Missus epi as you can imagine is I'm not too creative, but that's the name at the moment. And 75 year old female presenting with left axis. I have put in board here, all the risk factors of AP axis. So this patient has been newly started on home Oxygen for CO PD. She's got a past medical history of COPD, but also hypertension. She takes medications, but she's also on clopidogrel and in family history, I've tried to put in something about rheumatological conditions. She lives in a care home and she is worried about her nose bleeds. So this is just to give you an idea how patients present to us in, in A&E and these are the patients who will need to potentially have to stay with us. Because if the is not, is not sorted, it's not settled. There are so many risk factors there that we need to make sure they're all corrected before they can go home. So to talk about the nose, a little bit of anatomy, we do have a very common area where nosebleeds normally happen. And that's the anterior part of the septum. It's called the little's area. So that you can see there in the picture is the uh oh I, yes, I don't know if you can see my um uh mouse, but this is where the anterior part of the septum is. And this is where there's a congregation of thin small ended vessels and that's where the nose will tend to bleed from a couple of more reasons. It's not only because we have small vessels that are joining there, but also because this part of the anterior nose is directly open to the atmosphere. So this is the driest part of our nose. And that's why if the mucosa is dried. Plus you have those friable vessels there. Plus people are picking their nose. So it's more likely to bleed from there. So this is about the vessels, the arteries and the bleeding. However, why have I written some veins? Dream to Sagittal sinus. Why is that important? If somebody can type in uh on the chat? Why am I worried about that? About the venous drainage from this part of the nose? I'm just looking at my chart to see if anyone will respond. Mm mm mm. Yes. Thank you, Amelia. Thank you. Perfect. Yes, Emilia. So exactly the reason why I'm worried about this area is because if you have infection at the tip of the nose, oh in that area, the drainage will go from this, these veins and straits can go intracranially. So that's why we call the danger zone of the face, the triangle danger zone of the face. Um So it's high, it has high infection risk intracranially, so well done. So how to assess these patients when anyone comes in with epistaxis, you want to assess it as an a two week approach in an a two week approach. Um Any emergencies. That's how you do. So a for airway that helps because it makes you remember that you need to check the oropharynx. I know that the nose is bleeding but we need to check the back of the throat. Why? Because of clots and if the clots, if there are clots from the posterior part of the nose that are dangling there. Patient can easily aspirate on it. On the other hand, if you can see a clock but no dripping from the front, you might think, oh, it's a posterior bleed. So that gives you an idea of how to manage that. And then you move on with your B for breathing. C also think of this as an upper gi bleed. We may think that um a nose bleed is just a small nosebleed, but actually we have to think of it like an upper gi bleed, put in the large cannulas, get your bloods done, check all the vital signs. The good thing around positioning is in summary, we want the patient to be sat up forward, encouraged to spit out rather than to swallow. Because what happens when you swallow so much blood is that you vomit and when you vomit again, you have the risk of aspiration for your first aid measure. Make sure that if especially when you're getting a phone call, you're getting a phone call that in A&E high ent I've got um 75 year old Missus Epi who is here with a nose bleed. In the meantime, while you're going to see the patient, what you can tell them is to make sure there's anterior nose, pressure, eyes to the bridge of the nose and control the BP. If the patient has high BP, because obviously, that would be driving the nose bleed. But these are things we can instruct to um our A&E colleagues. You have to take a good history, especially about which side was bleeding first. Was it dripping out in the front first or did you taste the blood first again? That gives you an idea. Is it anterior or posterior? So this, these are the kits I thought, depending on the levels you're at, I thought I could uh show some basic pictures. Always make sure you have a stick ball. It's always handy, make sure you have your PP as well. So your um um aprons gloves, this is your dicum speculum and this is you have to learn how to um hold that. This is your headlight that we like using and that's your tongue depressor. So these are the equipments that we'll need to manage to examine the nose and the throat. So, I mean, I have few scenarios in how status is managed. Let's think of this one. This is scenario number one, you've done your FBC, you've done your clotting because obviously we want to see if the patient has any clotting abnormalities. Maybe the patient was on Warfarin and Warfarin. Um or I nr normally is range 2 to 3, maybe six. So do we need to reverse that? So these are all the medical managements you can think of before you decide to pack the nose or do something surgically about it. You want to also get grip and save as well as I said, treat this in it as an A BG eye bleed. So after you've thought medically, then you optimize the patient medically, then you want to start doing procedures. You've used the serum speculum to have a look at the bleeding point. What you can use if it's bleeding a lot. The first thing that you can use is a gauze and you soak it in transin Amic acid like in the picture. And then if you're not ent you may not have this um um forcep T forcep that the doctors using in the picture. So you would literally put the gauze in and tell the patient to hold it there for about five minutes. And that's what we tell uh patients who are waiting in A&E. And thankfully, by the time we come there, we can then examine the nose because we have stemmed the bleeding. Next, once I know that actually the bleeding has now reduced, I can actually examine, we will use section and the next step we can do is cautery. So this is Cay. Um you can see the picture here. It looks like a mag stick, but I should have probably put a la lot. The, the actual pictures, which is, it's, it's longer, it's about 15 centimeters a stick like a ruler length and it's got silver nitrate coated on its end and the silver nitrate will basically seal off the blood vessels. So you can, once you put in that gauze and the trans cinnamic acid, it has reduced the bleeding. You can see where it's bleeding from, especially if it is in the little area, which is a more common area, then you paint it using that culture. Stick on one side only you don't never do it on both sides. The reason being, does anybody know why, why do we not do cautery on both sides or if you are not sure what cautery is or if you haven't done it, why wouldn't you want to buzz the vessels on both sides of your cartilaginous septum? Yes, exactly. Thank you, Angel. Yeah. Oh, I've se to hematoma risk sep to perforation. Thank you. So, not really septal hematoma. Um, but septal perforation, but we've missed a step. Why do we have settled perforation is because if we are cauterizing one side of the nose, you're, you're missing out the vessels that are feeding the cartilage. So the cartilage is depending on the other side. Now, if you do the other side as well, there's no blood vessel going to the septum, there's necrosis and then there's septal perforation. So that's why we say do not, um, cauterize on both sides. Um, I'm not going to go through the, um, procedure itself. Um, but you want to put some local anesthetic around first because it actually burns and then, um, you, you will also leave a stain. So we tell patients we we give a gauze um to patients but just know that it doesn't stain their lips. There are some precautions we say for patients not to do after quarter. So we don't want them to have hot foods, anything hot, to dilate the vessels. We don't want to increase the impression in the face. So all of this, we say to not do for 48 hours. And then after we cauterize it, it does build, it's kind of an acidic ph. So then we put naseptin, which is a cream, it's antiseptic and also it prevents bleeding and it keeps it moisturized because don't forget it's the dryness that makes it bleed. So, nectin has peanut oil in it. So you have to check for peanut allergy if you're going to prescribe someone a Aspin. But if you're a GP, if you're turned to be a GP, that's the, that's the thing you will be doing when patients come to you with a nosebleed, you want to contact Ent first. You will basically say apply as four times a day, 10 days. See if that settles. Obviously, you will examine the nose first and then you'll see that. Oh, that's a dilated vessel there. Maybe it's bleeding from there and then you can give that EPIN cream on its own. If that doesn't settle. That's when you, er, refer to Ent, then after core. So these are the simplest me, uh measures then after the core, you can also put a dissolvable nose pack, it's called a nasal pole. It's a very spongy material. It's got a protein uh matrix in it and it helps to extend the bleeding further and you can then discharge the patient home. So this is quite a lifesaver because the next step is actual packing with a balloon pack or a tampon pack. So we use the balloon one, which is called rapid Rhino, which is the more favorable one. And so that you would use in case your co tree is not working, in case your uh gauze with transam acid is not working and the patient is BP is getting lower, tachycardic bleeding a lot in front of you, then you might not be able to control it with the other measures. So then you just need to pack. So this um anterior pack packing is done in this manner where you're actually you're not pushing it up, ok? You're not pushing the pack up to the brain. Basically, that's what we don't want to do. You're gonna push it str head straight, you're gonna push it down and basically down the floor of the nose and you don't want most of it to be outside like this picture. Uh You want it to be sitting well inside like in this picture here and that will be using pressure to help stopping the bleeding. You leave that in there for about 24 hours. Patient have to be admitted. You don't let the patient go home with this. They have to be admitted. If it stops the bleeding, that's great. You leave them, maybe some oozing might be expected. But if it stopped most of it, you just leave it. It is very traumatic for the patient. Um So you leave it and then the next day you remove, you assess, you see if you can cauterize a bidding point, then you put your nasal pole and then you discharge. But obviously discharge is uh checking to make sure the patient has somebody at home, et cetera. So that's the next step up. Now, if that's not working, what we do is something called posterior packing. So if we realize that the bleeding is not from this part here, the anterior, but it's from one of those vessels from the back, your pack might not be reaching that and you can't see where it's bleeding from. So then this is something where you have to call your seniors to do. I don't expect any juniors to be doing this. It is again, very traumatic. However, what we can also do is I if you have packed one side with a rapid Rhino, you can pack the other side that can provide some more pressure management. So it's called Conal packing. If that doesn't work, then we think of posterior packing post, you packing it, it is with a catheter, a normal catheter, a urinary catheter, you put it um through the nose, bring it through the mouth, inflate the balloon and then pull the balloon back so that it provides pressure at the back. So it's quite traumatic for the patient. If that doesn't work, then we need to go to theater and we need to ligate one of the arteries more commonly is a spinal um S pa ligation. So for no, this is the main thing, which is why I've spent some time on it. But this is a little flow chart. I've done that helps to um first of all, um help you to know where to go from here. So you've checked all your blood tests. You've checked if it's not Warfarin, that's high. You've checked if it's not Heparin, that's been given in too many much doses. You've reversed everything. You sectionally examined the nose, you see an un to your point that's bleeding. If you don't see it, you pack, if you see it, you can try cauterizing if that's unsuccessful, then you pack complications of packing. It is an a foreign body in its on its own. So you don't do it. You don't leave it in for more than 48 hours if you are planning to, because every time you deflate it, it starts bleeding, then you start on antibiotics and uh the uh blockage of areas around that can happen as well. So just make sure that we check on patients every day with their PAX in. So that's about epistaxis. Any questions on that I will keep going because I always realize I've spent 20 minutes on this. We have got quite a few. Um, ok, so the next emergency for nose is sept hematoma. So I think it was, uh Emily, yes, you mentioned septa hematoma before. So this is what it looks like. When you're looking at the nose, you can see like two cherries looking at you. Sometimes people make, um, uh, can be confused that it's the septum if you have a deviated septum. But um most of the time the the patient will have locked nose, there's a history of trauma. So what we need to do is we need to incise and drain this because for the same reasons, blood is not going to reach the cartilage, the vessels is not going to reach the cartilage. You'll have abscess, you have infection and then um then you have perforation, necrosis, sorry. Uh septum necrosis. So that's why you want to drain septal hematomas straight away. So if any causes you, patient coming in with aba broken nose, but I can see something in the nostril. Can you come review? Yes, you need to go review. However, if they call you and say patient has broken their nose, it's deviated, then you can actually say, ok, we'll see them in a week's time because we want the swelling to settle down before I can assess if the bones have been deviated or not. And if I can manipulate the nose back in place. I do need to review that patient after one week. So too early is not good for nasal bone fractures. So that's about the nose. Um Again, if you've got any questions, if you in, put that on here, otherwise I'll be moving on to ears. I think ears and throats are the biggest part of, of the lecture today. Da da, no, no questions. OK. So for the ear, this is our ear. It's nice to know what, how to describe the different parts. Because when there's a laceration, you want to describe this, using these terms, the lobule is the one that will be very relevant in a moment. This is your eardrum. OK. Uh The three layers of the eardrum. Um One of the part which is called part flaccida here, that's where we get worried that you can get debris that's collected at the top end here. So these are emergencies again, same reasons as for the septal hematoma. This is it e hematoma here. So rugby players um they present with that a lot. So this has to be in size. So I will make an incision just here and then I will release the blood, the blood will come out and then I will stitch in two dental walls to apply pressure so that it does not reaccumulate. So that's uh an ear hematoma that you would want to see today. Now, that's an ear laceration so sorry, you want to make sure that you bring together the skin because you want to protect the cartilage. You don't want to see any cartilage that's outside. The next condition is otitis externa. So this is the one that you will be seeing as GPS um and medical students and you will come across that a lot. So, otitis externa, otitis means ear, external means external. Um So it's the ear canal that is um infected and inflamed. So this case is more, you'll see progress. That's why I started it as a case. So you've got a 50 year old who's presenting with pain and discharge. You want to check a few things for this patient. Is it a simple infection? Oh, these are risk factors. Your history should be based on risk factors. Do they have diabetes? Because diabetes increases your risk of infections. Are they are medications that are bringing down the immune system? Are these swimmers? Do they wear earplugs? Do they have hearing aids? What is causing them to have so many infections? Then you will examine the patient. You will check for discharge. You'll check if uh, if uh the ear canal is tight, you want to, if you can go in and have a look, you'll see if there's any perforation in the eardrum. You look at this attic area that I mentioned here, you'll look if there's any gratulation here and then you want to check the mastoid as well because uh you get worried about mastoiditis. So your investigation for this case would be to get an ear swab because then you can pick out which bug is affecting the patient to manage this. Always think of lifestyle, medical surgical. So lifestyle make sure that they don't get any water in there. So we say to patients take a cotton wool, dip it in Vaseline, put it in the ear ball and then and then shower. So don't let any water to go in. Don't go swimming at the moment. If you are go, if they are competitive level, then have some special ear plugs made. And then how we actually manage it in, in ent is we like to suction all this um uh debris out because we want the ear drops to go in. We do not like giving oral antibiotics. We like to give ear drops and then we say keep the ear dry. So this is what? So now if you see an eardrum like this, do you think eardrops will go in? We it it's a question if somebody can uh reply to me. So what can we do to allow um drops to go in this tight edematous swollen ear canal? Cause we want to give drops. We don't want to give tablets if anyone knows what we can use. Good, good. Thanks for trying. So I've got a uh so yes, so we want to get something in there, Milly the issue is at the moment. Nothing will want to go in because it's so tight. Thank you, Angel. Um But um thanks, thanks, thanks so much for trying. Yes, we want to put a week a week is like again, it's like a, a tampon like the nose one. It's um the picture is the picture there. It is, this is the pe it's basically a piece of condensed cotton and it goes in, it really hurts when we put it. I say sorry, it's gonna be really painful. And then I do it straight away. I like to dip it in some hydrocortisone because it helps to reduce the swelling and then straight away I put in some ear drops then always make sure that patient comes back in two days or from Friday to Monday. It's fine. Why? Because again, it's a foreign body. You don't want to get further infections. So going back to the type of antibiotics that we like. So we like to have an antibiotic and a steroid. So there's Gentisone HC, there's Ciloxan. Ciloxan has got ciprofloxacin in it. Uh There's a spray we don't really like that. Do you mind getting questions that if there's a perforation? Can I give Gentisone? Because gentamicin is phototoxic? But then there are school of thoughts that say papers say that actually the purse is more autotoxic than the drops. So we might as well use the drops. So we'd still do it. So this is how we suction using the small section, uh zar section. We've got fine tips. Um and we use a microscope to suction it very carefully, right? Um I think that's what Otitis Externa. So that's your bread and butter of ent for, for sh Os for junior doctors as resident doctors. Um So you thought you were treating this patient? However, two days later they come back to you, doesn't anybody know what condition this is? Ok. Um Just looking for for diagnosis. Good point. Thanks. Thanks for trying hematoma. I can see why you, you're saying this because it looks a bit the same as the previous picture. But actually this whole ear is inflamed and infected. This is actually peanut cellulitis. Ok? So this history is exactly this patient came in with an outer ear infection. You gave them drops, it did not get better. Instead the whole ear is now red. So this is called Pulis, again, assess the patient in a three manner in case the patient has sepsis, you want to give IV antibiotics for this patient. Just make sure that you mark it and make sure that um the infection is decreasing with time. So this is a patient. You want to admit, some consultants might say we can go home with oral ciprofloxacin because oral tablets, ciprofloxacin have the same by availability of IV. But you know, if you see the patient is very unwell or is well with it, you can decide that anyway, this is pedo cellulitis and there is another condition, another ent emergency um condition. But you can see this lobule if you remember the first slide of the er said, remember lobule, the lobu is bad. Has anybody heard about what do we call inflammation of cartilage? Perfect. Thank you. Is Yasmin. So perichondritis. Exactly. So when the lobule is spared, then we're thinking perichondritis. So cartilage inflammation and the difference between penis cellulitis and perichondritis. You can see here one is the whole penal, the other one is spares. Penis, cellulitis is mostly because you had an infection in the external ear canal, it spread whereas perichondritis is more penetration. So like piercings, you can see the bugs are different. One is uh staph, that's why you can use flu Acilin like citti anywhere else in the body. But for per chondritis, it's more likely pseudomonas. So then you use Cipro facin tablets and you can also put in the ear. So pros is in ear drops, you have to re remove piercings, et cetera. Just make sure none of these infections have any abscess. The case if you have conditions where all the cartilages are inflamed, just remember it can also be an autoimmune condition. So this is called relapsing, polychondritis. So if you have both penis and the nose because there's cartilage there, so then think of autoimmune condition, but we don't see that often at all. So same patient. So we go back to this one. So remember they came to you with Otitis Externa, you gave drops that didn't work. A few days later, it come back to you. And then they've got this ear showing penitis. You admit them, give them two days of IV flucloxacillin gets better. You send home. However, they come back again. Two weeks later, they had the same problem. But this time, you hadn't taken a good history. This time you realized the patient has diabetes, the patient is immunosuppressed. And when you look again in the ear, you can see the whole eardrum is kinda gone and the pain is so bad. I've already written the condition's name, but that's when you start getting worried about malignant otitis externa or nec necrotizing otitis externa. So these are in your elderly population who have diabetes or immunosuppressed and the pain is just a lot compared to what you can see, which means that the bones are affected inside. So then you want a CT scan. So the skin for the ear, it's actually a CT temporal bone. It's because the he has an extension from the temporal bone. So the external ear canal, bony part is temporal bone. So you want a ct temporal bone and that will show that there is a little bit of erosion here if you can see that. Um 00 dear, sorry. Uh one right here. Yeah. So that's your malignant or necrotic. So that and these patients need to stay in the hospital until their pain are managed and they have, they need a long term IV antibiotics. So some places have outpatient antibiotic therapy because the patient cannot stay in hospital realistically for 5 to 6 weeks. But these patients need at least six weeks of IV antibiotics. According to your microbiology, um guideline guidelines in your area. And if there's an abscess, obviously how that has to be drained surgically. But things we worry about are anything that's going in the brain. So, skull base Osteomyelitis, cerebral abscess, meningitis. So this starts getting serious here when the infection is going into the bones. So I think this is unfortunately our patient who has been really unlucky, but um you've hopefully that's covered quite a few conditions. Um One of the other otitis externa is to do with recurrence. So they keep coming with you to you with ear infections and you're thinking, what am I doing wrong? You check your sample and you're like, let me send a swab when you send it. What could it be? What could be another cause of otitis externa? What kind of microorganism could it be? Yes. Perfect. Yasmine. Exactly. Exactly. Amelia as well. So yeah, it could be fungal. So let's not forget sometimes you can actually see gray or hyphy. Um when you look under the microscope, it's actually a piece of art but not really. Um It's not nice for the patient um because it's very annoying to get rid of. Um so you need it to take for a long time. Two weeks, six weeks, uh sometimes you can squirt in some cream and this cream tr trid cream, you can squirt it in there. Um You leave it and then you ask patient to come and see you in, in a month of time um or three weeks, but that's got steroids, antibiotics and antifungal as well. So that's the external ear. Uh So I can hear my voice from my phone. I'm just trying to let's take care. Um middle ear now. So we've looked at the external ear. So this is what was the problem for the previous conditions, all this outside. Now, what happens when you have problems here? Middle so otitis media, this part and if you realize this is your back of your nose, this is your eustachian tube. So what is a big trigger factor for anything accumulating into this media compartment? Like you can hear I got now what can travel up or what can affect the back of the nose? Exactly. Thank you, Amelia. So any upper respiratory tract infection, any virus will come up will make this yeast to be very sticky and then the drainage won't have any mucus or layer will produce some sort of fluid. But if this tube is now blocked, then you have fluid that appears uh sorry that accumulates here, that fluid can be infected and that causes acute oitis media, especially in Children because in Children, that tube is not at such a nice gradient, it's flatter. So if it is flatter, it doesn't drain nicely. So unfortunately, Children have more risk of getting Otitis media. So you have to speak louder because they have hearing loss, they're touching their ear. But let's not forget we have to check facial nerve because you have a facial nerve that runs in there as well. So just make sure ask, can you raise your eyebrows? Can you puff your cheeks out? Can you smile? These are all functions of your cranial nerve, seven facial nerve. So otitis media, sometimes we don't give antibiotics. Sometimes we do give antibiotics depending on how and where the patient is. But for this one, you give tablet antibiotics, this is what it looks like. It's a bulging eardrum, it's red, it looks angry. So this is an acute otitis media again. Unfortunately, that child comes in and you saw this and you're like, oh, let me give you some amoxicillin and go home. But two days later they come and you have a look again. This time, the patient is not eating, is not drinking, is lethargic is. And then you look behind her ear and you see, oh it's like this. What is this condition? The ears pushed out. Yes. Emily mastoiditis. So this is a condition that we want the patient to stay in hospital because it is an emergency. So, mastoiditis, we get worried because it's connected to the brain. We don't want um any brain abscess infection. So we want to treat this, assess patient A to e make sure they are not septic. You can try with IV antibiotics at the beginning. Give it 48 hours max. If that's not getting better, then we go in surgery. We try to remove and, and um, remove any pus. But before we do that, we get a scan and everything. So these patients need, at management, we need IV antibiotics and we'll need to stay in the hospital. So if they're better, if they are not better, then we have to, um, go to surgery with them. We'll incise, we'll drain it, we'll get a swab of the pus. We may also put in a grommet in here because then if any pus wants to collect it comes out. So that's something that we do as well. Right. So that's about the infection. And the last part I think about hearing is sudden loss of hearing is also an emergency. So typically I went to bed, woke up. I cannot hear anything from my right side. When I went to my GP, they did a Rene and Webers test Rene's and Webers test. I hope, uh, you, you probably know what they are and we found out that it's sensor renewal, hearing loss. So you want to check there's no head trauma, there's no infection, there's no pain, no discharge, there's nothing else. It's just the hearing loss. So then this is something that we just term it sudden Centenary, neural hearing loss. And we think it could be because of a virus for that. We give steroids and we want to see the patient as an emergency level. We, we, we, we ask um GPS to give steroids uh because we feel that maybe that will help to get the hearing back. Some guidelines say to give antivirals but not all guidance says that. Um but we want to see those patients into our ent clinic because we want to get an MRI of the internal audit mutus. So that's our whole ear apparatus um as our in our outpatient. So it's something someone we will, we will treat them initially, but we want to see them again in our ent clinic. So this is for example, guidance about a unilateral, by the way, this is all one side. If it's both sides, we have to think more. Uh But yeah, that's one of them. And then I think, yeah, this is the last one, actually four years. So facial palsy. Um so I like to describe it as facial palsy but not Bell's because I'm sure you hear Bell's palsy a lot. Oh, that's more common that you hear a palsy means a weakness of the nerve, a facial palsy when you see a patient with a weakness, don't describe it as Bell's palsy straight away. You want to describe it as a facial palsy, but then you want to make sure it's not a stroke, it's not trauma, it's not something else. So you, you will check um all these components, most of these patients will probably have a CT head to make sure it's not a stroke and then you get to run you and you will say, oh, patient come in with one sided facial weakness. CT scan is normal. Is it Bell's palsy? Can we refer the patient to you? So when you see the patient, you examine the ear, make sure there's no vesicles because we have something called Ramsay Hunt syndrome. When you look into the ear, you can see vesicles. So that's the virus herpes zoster and that can lead to the facial nerve being affected and the and therefore affecting the um facial nerve um territories for this. You need to understand facial palsy. You want to really understand the pathway of facial nerve, it comes from the stylomma. So foramen and then turns blah blah blah and then go through the middle ear. So any infection of the middle ear, you can get facial palsy, any trauma to the middle ear, you can get facial palsy. So if you follow that path and then it comes down and then it goes through the parotid. So any parotid problem, you get facial palsy and then it goes, it divides into five parts. So it's nice to read around the pathway of the facial nerve um but when everything is normal, we don't find any reason, then we call it Bell's palsy. So in ent what we like to do is we like to document what kind of p it is? Sorry. The grade. So we have for example, grade one is normal function whereas grade five is severe basically at rest. So this patient here, the picture is a size, it is at least uh is at least a grade five because at rest, I'm assuming this is at rest. No, actually she's trying to spine. So it would be a four or five. Um oh, it could be six as well. But anyway, this is dynamic. So you'll assess the patient in front of you. So Bell's palsy, you want to make sure you give some steroids as well to try and help similar reasons. As for the sudden he sudden hearing loss, you want to review these patients. Again, the very important thing about face palsy of the eyes, you can lose your eyes if you don't look after it. If the patient has bells palsy and you forgot to say, make sure you close your eyes with a tape at night before you go to bed, you will have coronal ulcers. If that's happening already, you need to get ophthalmology involved. So what we do is we make sure we prescribe eye ointments, eye drops. So I think eye drops during the day, eye ointment at night, tape, the eye shut that's a very big part of Bell's Palsy management. If the eye doesn't shut. Ok. And then your steroids and everything and your follow ups. So that was a run through around. Yes. Again, I think I would take this lecture as these are the, all the points and all the topics I have to read rather than, um, oh, this is everything that I need to know. Um, so it's a bit of a, Yeah. So we've got, um, if there's any burning questions around ears, I'm happy to take, gives me a minute to stop talking to. Ok. Oh, ok. Yeah, I hope that was self uh, self explanatory. A bit of, of the, the slides and, and what I'm talking about especially the main points. So the last part is throat, um, throat as well as what everybody's getting at the moment. Throat, pain, sore throat, tonsillitis. Um So this is more what we're gonna talk about again. Something another bread and butter of ent, it's also important to know anatomy. So you've got, uh, the uvula, the dangly bit in the middle. You've got the, those folds. Can you see this is anterior and this is posterior. Forget the picture. Go into the mirror. Have a look at your own throat, please. At some point after this, have a look, find where your palatopharyngis fold is, find where your palatoglossal fold is. Have a look at your tonsils. You can even grade your tonsil size. We'll look at that in a moment, but this is important when we examine patients. So Mr Ti, he comes in with a sore throat, he cannot eat or drink. He's got a low grade fever and has high temp uh high heart rate. GP said boom, there's exudate on your tonsils, your tonsils look big tonsillitis. I'll give you treatment. Uh Pen V penicillin. V is the oral penicillin, uh choice for nonpenicillin allergic patients. But if somebody's calling Ent II, do want to know why are you calling me as in? Is there something more serious? So I want to know some red flags. Does anybody know what red flags am I worried about? Anything to do with the throat? Any conditions? So think of worse conditions like epiglottitis or abscesses. What are the points that you get worried about for the throat drooling? Tripod position? Good. Very good. I really, yeah, so that's about drooling. Anything else. Stride or? Perfect the breathing stridor respiratory distress. Great. Um There's just one last one and it has to do with abscesses. Neck abscesses with movements starts with at. That's ok. Perfect. Yeah, Christmas. Perfect. So these are the four things that you want to check if somebody is ringing Ent because of a tonsillitis. There must be something else. So you want to ask red flags breathing difficulty drooling Christmas or the lethargic, any voice change. So infection don't forget a two E sepsis. Six A airway or the drooling how are they sitting the tripod position, as you described? How is the hydration? They haven't drank anything? They must be dehydrated. They must, BP must be low. Heart rate must be high on the septic check, blood culture check lactate. I mean, a lot of patients come in with tonsillitis. You do want to get all these numbers and we do give them IV fluids and everything, even if they are talking to you normally as well, they're not half collapsed. So they may compensate well if they are young. So this is how you grade tonsils. So in my documentation, I like to write. So if your tonsil are hiding between the two pillars, it's a grade one. If it's out of the two pillars, you can see the pillars are here. If it's out of it, it's grade two. If it's more than midline, this is midline. If it's more than midline, then it's a three. If they are touching, it's a four. So most patients. So this one is a grade three, this is a grade three. So I will comment on the grade if there's erythema, if there's exudates, where is the UVR in the middle, is it not in the middle? What about those areas here? The peritonsillar areas, it's here. OK. This is the peritonsillar area. This and this and what else do you need to examine? You need to examine the neck because we've got lymph nodes in the neck. So we want to see if the nodes are affected. So this is something you read about where the nodes are found. But mostly the node I'm interested is here. It's called jugular gastric node. And this is the one you can feel for yourself. When you have a cold, it goes up. But range of movement is important. Can you move your neck from side to side, up and down? Why is that? Why is neck movement important in somebody with an infection of the throat? What condition? Uh am I excluding? It might be a bit difficult? I think unless you've, you've had it before, but that's ok. And I thank you for trying really um meningitis. I see where you're coming from because of uh neck stiffness. Good. That would be um a medical one that I'm thinking of deep neck space infections. We'll come to it. Thank you. Perfect. Thank you, Jasmine. Yes. But yeah, I can see where you're coming from remedy. So for your tonsillitis, IV fluids, IV ben Benzylpenicillin is what we give for tonsillitis. The fluids also really helps we give fluid. It drives down the tachycardia, settles the patient. You give IV antibiotics and we like to give a bit of steroids because steroids cures everything. So, steroids will reduce this inflammation. So three things we give and painkillers. The reason why they come to you is because they're in pain. So don't forget to give regular painkillers. We did an audit recently in my hospital and everybody gets fluids, bed pen and steroids, but only about 40% got regular painkillers. And we were like, this is the reason they came to the hospital. We are not treating them for that. I know if we treat the anti the infection, it will go down but we still need to give the regular painkillers. Uh your bloods will you do your blood test full blood count, white cell count. C RP. If the lymphocytes are high, it could be viral. It could be glandular fever. Glandular fever is caused by E BV virus. And that you'll know this because you'll see literally the, the lymph nodes are up a lot like when you feel the neck. So always examine the neck, ok, with throat stuff, always examine the neck. So when you feel the neck, you'll feel walls everywhere and to you, even before the blood test, you might say, ah, I think that's going to the fever. If it's glandular fever, you don't want patients to be playing in contact sports because the spleen has got lymphoid tissue. If your lymph nodes are swollen in your neck, it will be swollen in the spleen. If you are going to do boxing, you get hit in your tummy, you're gonna have a splenic rupture and you are in a life threatening life threatening position. So you don't want that to happen. If it's neutrophils are high, then it's more likely that it's bacterial. So then you don't need to worry about that, but we do what we call a glandular fever screen um that comes back to confirm if it's glandular fever or not. So, this is also a blood test that you have to do. Uh normally through the course of the day, if the patient is feeling better, they can eat and drink. We do discharge them on the same day with oral tablets, but these tablets are very big. So they have to be able to eat and drink before you can let them go home. Well, Mr was like, yeah, came in, got the tablets. Got IVS I said him home with me but then he comes back two days later, he comes back with this. What is this condition? Give me the side as well? Yes. Yes. Amy, thank you. So it is a Quinsy. It's got an s but anyway, I II know what you mean. So it's a right sided Quincy. Ok. So this, do you remember? I said was a Uvella, is it in the middle? No, it's not in the middle. It's to the side. It's deviated peritonsillar areas. Can you see this? This is fine, but this feels full, this looks fullness. So we describe it as a fullness, right? Peritonsillar fullness. Ok. So this is a right sided peritonsillar abscess, which is equals to right-handed. Uh Quincy patient has Christmas. They can't open their mouth, voice might change. They say hot potato voice and um you want to incise and drain that. So you will give everything like we said, we also add metroNIDAZOLE as well. We add an extra antibiotic but you give analgesia steroids, antibiotics, fluids. And then you can put a needle in and you can aspirate that pus or we can make a cut with a scalpel. And if the patient smokes, you have to tell them to stop smoking. So this is everything we need. We don't need that. That was me just doing a quiz some some other time. But this is a needle that we use. You literally poke it. Take the pus out, patient will feel so much better if you don't want to um if they come in again because it can recollect. So people have different practices. Sometimes we go in and we anesthetize this is what dentists use. We use the same thing. We put the anesthetic and then we make a cut, we make a cut, make a cut around here and then we use dot to go into the CT and open up, the patient will hate you, but you will relieve a lot of the symptoms. And this is a ton depressor. By the way, this is a special tone depressor that we use in ent, right? So we did that. We did that for the patient. Uh Yeah, he had the quiz and drained it. I did not. No, I actually as aspirated it. I didn't drain it, but then he comes back to me and this time he's got this one side of the neck is wonky. Obviously, it's not the um, that child is young, but the neck is now pulled to one side. Severe sore throat, cannot eat or drink anything, cannot even talk to you. Patient is septic, unwell trid or breathing, cannot breathe even that. So, this is an unwell patient. I'm worried about this patient and this is what we call an impending airway disaster triad where you have a rapid onset aphagia, severe dysphagia. So really sore throat cannot eat or drink anything, rapido set voice change, systemically unwell septic. Oh maybe that's a bit of a time, but we're almost there. So this is an airway disaster triad that we worry about and this is what we call deep leg space infection. So what has happened is the infection spread from the tonsils into those areas here, parapharyngeal, the purple one or the retropharyngeal, the yellow one. So basically, the infection has come from the tonsils into the neck spaces. There is a danger zone that connects the back of the mouth to the thorax. You don't want infection to go there because it will be in your heart area like all the mediastinum medialis is what will happen. So anyway, before it goes there, it normally forms into parapharyngeal or retropharyngeal abscess. So that's why the patient cannot move their neck. And that's when you're worried about it. So this patient, you want early anesthetic review, they probably will have to go to theater to get it drained. They will have to go to theater to get it drained. Uh, admit nil by mouth theater and the antibiotics IV fluids. You can do a flexible nasoendoscopy, which is our bread and butter that we do. We have a look through the nose, we pass a thin camera through the nose into the throat and um there we go, this is what we see. We see the this is normal. This is the voice box. But can you see this bulge? This is bulge is not meant to be here. OK. This is meant to be like this, but this bulge means there's something going on once you see that you also want to do an urgent ct neck with contrast. And then you can see, I know it might be difficult for you at this stage but compare both sides. You can see there's fullness, there's some stuff here, but there's nothing here. So something is pressing. So that's the abscess. OK. So going back to flexible nasoendoscopy. Now this is your, this is a lovely picture. I love seeing that. Um but these are your vocal cords, OK? This is a vocal cord closed, but this is where you breathe in. This is your epiglottis. This is the tongue. So this is anterior and this is posterior. And this part here is your, is a the food pipe. That's why it's opening. But you've got the piriform fossa here and then it's like a fernel and these two ferns that drains into the food pipe here. So you shouldn't be seeing a B here, you should be seeing all open. So this patient needed to go to theater. Um and we have to closely monitor them because these, any abscess can recollect. So you went to theater, you want to make sure they are in the hospital, they're fine, they are improving. But then he's like, well, it all happened because of my tonsil. Can I um take the tonsils out? So in the UK, we have uh categories, um we have conditions before we can operate. So now it's changed to one previous screen. Actually, if you've had one previous screens, you can have a tonsillectomy, but you do have to talk about the complications of tonsillectomy because it's not straightforward. So he had his tonsillectomy, but then he comes back with tonsillectomy bleed. This is another emergency supposed to take me bleed. It's a clot. So the clot is the bleeding. Ok. So he presents to ed with postectomy bleed six days later. So again, treat this as an upper g bleed, resuscitate, put cannulas group and save if the patient is stable and the clot is there, we can leave it there. We just make sure we have to start management with IV antibiotics. Why? Because this bleeding is actually because of an infection. So we have two types of bleed. One is primary, one is secondary primary that happens on the day of surgery or the next day, which means that there's a problem with the surgery like we didn't tie things off properly. But if it happens five days or more later, that's because of infection. So that's why we tell patients, make sure you're eating, make sure you're drinking. Because if you don't, there'll be bacteria will be set at the back of your throat and it will form infection and then infection will cause you to bleed. So you admit this patient, you give them uh near by mouth, in case you have to go theater, you give them antibiotics, you give them transamin Amic acids, IV analgesia. Um And hopefully that settles if they start bleeding. Uh And then you basically put a uh gauze there and then you literally uh go to theater within the next hour. Um I think that's about now, I think this is about it. Um in terms of tonsillectomy and throat. This part, I mean, I've already taken five more minutes. I think it will take another five minutes. Now, it's more about for re bodies. So this one is a food bolus um very common. So especially for people, uh patients around Christmas time, you might hear that a bit more meats get stuck. They feel like it's still there. It hasn't gone down, but then they can talk to you they can swallow, they can eat, but it still feels it hasn't gone down for this. I would say it's a scratch. I don't think there's anything there, but we still see them, we still look down with a scope and then we, we send them home. However, if they are drooling, if they're set forward, if they're like retching, then you're sure that, yeah, there's something there ent can treat until the sterol. Not if it's below that, then we have to refer to, um, then we have to refer to um gastroenterology. So make sure there's no bones or sharp elements in it. So make sure you take a good history and you ask whether there was any bones in the fish or in the chicken. Do they have problems with swallowing already? Do they have a pouch, red flags, as we said, with the drooling, breathing problems? And the big one is the esophageal perforation. So any bone history, make sure that you touch and examine the neck. What am I looking for when I examine the neck? And I'm looking for like as if I'm walking on snow. What am I? That's maybe my last question of the day. What condition is that called? E have I lost everyone? No, that's ok. Um So it's, it is the surgical emphysema that I've, I've kind of written. Oh, thank you for trying. Sorry. What is the specific issue in if, if, if present in me, I'm not Sure. Oh, fine. Ok. So thank you. Now I see what you mean. So some patients might be sticking things in or hiding things. So we have quite a few um quite a few patients who come in swallowing folks nice. Um Things like that. So that's why we want to know if there's a sharp element how careful we have to be. So yeah, thank you for that. Um But mainly we want to know what you have swallowed really? So yeah, we, yeah, I think, yeah, the last one II it was a folk which um we had to get our gastro team to help us with. Um So we want to know any risk factors of what could be there because we don't know until we have a look with the camera. Um So surgical emphysema, um surgical emphysema is what I was trying to say when you're palpating the neck. If you have puncture your food pipe, then there'll be air in the soft tissue around your neck. So surgical emphysema and if you drink anything, it will be a very severe pain from your chest, going to the back in your tachycardia and your septic. So then you know that you've puffed the food pipe and this patient will be very, very unwell. So these are examples of this is a fish bone here you take it. The investigation is chest X ray, lateral neck X ray. You want to to get a neck, X ray and that's a fish bone. And this one, you can see that air somewhere that's not meant to be. This is surgical emphysema, ok? This black line is air, there shouldn't be air here, ok? And then you have swelling of the soft tissue. You, you may not see there's a bone like this fish bone probably wouldn't, it cannot, it may not be there. But once you see this swelling like here cos it's meant to be only half a vertebral body, but this is almost a full vertebra body, all this length. So that's telling me there's something there. So sometimes they are not all radio opaque. So you can't see the furry body, but the soft tissue is swollen. Then you're like and also you lo lose that cervical loos, it's kind of straight. Then you know, there's something there and we need to go to theater and have a look uh food bolus. So if it's so that's not to do with bones, that's to do with a piece of meat that's got no bone. If we think that it's there, it's not moving. You can give me a bromide. Uh you can give Glucagon Erythromycin that helps to, to flush it down. Um If the patient is very distressed, then we need to take to theater to try to take it down. Um The other foreign bodies that can happen is in the ear, this is the ear insects, you have to take it out on the same day. If it's a button, battery chemicals take it out on the same day within the next, like, literally it's an emergency because it will corrode and it will, um, destroy your structures. So any button batteries, any organic living things, they have to be taken out very, er, soon in the nose you can have mother's kiss. So you basically close one nose and then you tell parents to blow to one nose and try to remove whatever there is. But make sure that you, if the child has too many goes from junior um, staff, then it may be difficult for you as a specialist to come and have a look. So you might need to book theater if the child is not cooperative aspiration and another foreign body issue, this is a coin in the middle of the throat. So yes, that can happen too. So we need to go to theater to remove those. The main thing for aspiration is you want a chest X ray because the chest X ray can show collapse. If one side is completely wiped out, you won't see the object. But you know that there's something that's blocking this bronchi. Ok. So then you can go to theater to have a look. The patient is having cough, chestiness, wheezing, there's something there. If the mom says I give the nuts, I turned around child was coughing no nuts. So then we know that um, they, they must have aspirated, come to A&E we need to have a look in the future. So this diagnosis, I think one of the earlier we mentioned epiglottitis. So epiglottitis is, is a condition again an emergency. We don't want to do anything with the airway until we have secured airway. So we ask a anesthetist to come and help and to secure the airway. But this is a leaning forward, drooling, high fever, unwell child, um horse voice tridal uh is a late sign. So these are cases we are worried about uh you want to intubate that patient. So this is a normal uh epiglottis, but this is your epiglottitis. Ok. So this, when you see this, there should be this. Ok? So there should be a tube going. You can't be seeing this and without an airway because that patient will arrest very soon if there's no airway. Um So you want to do sepsis, six blood culture, get anesthetist, um IV, antibiotics, IV, steroids, IV, antibiotics, IV, steroids, our friend, um adrenaline nebulizers will help as a temporary measure to just give us some time so that we can intubate the patient, but it's not a definite management and then they have to not eat or drink anything until we can see this improve. Ok. So that's epiglottitis in this has reduced because we take vaccines now. But um in adults that there's something called supraglottitis, which is everything else. Otherwise that looks red and swollen. So, for example, this looks red and swollen. After treatment, it becomes like this, which is normal. So you can do a CT, but normally we, we have a look every day. They are admitted, we give them IV antibiotics, IV steroids. Um And then we repeat the scope every day to have a look if it's getting better. Um Well, that's it really. Um, that was a very quick tool into the different emergencies of entity. Um I hope that give you a broad idea of, of what we deal with and um if that's something you would want to come and work in or you would want to explore as a career or um that helps for you to get better at your current job. So, thank you very much. If there are any questions, I'm happy to take them. Oh, yeah, feel back side. Yes, please. Can you feel back this? You're welcome, please do this feedback. Thank you. So if in doubt um oh, I had a punch line, I forgot IV antibiotics and IV steroids. OK. Well, no questions. Thank you very much on a Saturday. I well done everyone. Thank you so much and thank you also missus, we for joining us. Uh I've learned a lot personally. So thank you guys and thank you guys for joining us. Yeah, giving up an hour and 15 minutes on a Saturday. Uh and we're planning to do a lot of these. So possibly we will have few sessions as well with this, with it. And also we have a couple lined up for 2025. So this is the last session for 2024. Uh We're gonna start again in 2025 in January. Uh We have a few sessions lined in. We'll continue to advertise on the page and also on the Instagram page uh in March, we have, we have a big session uh presented by a cardiac surgeon consultant uh from East Midlands. Uh So stay tuned for that one. Oh yeah, thank you guys for joining us. And if there's no last minute questions, I hope you guys have a great weekend. Thank you. Thank you guys.