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Catherine, it's on. I am an ent registrar in Essex, in the UK Thank you very much for having me here. Its privilege to help you guys hope all is well on. We are thinking of you aware, um, or wherever you are in the world, to be honest. So I'm going to do a talk today just on introduction or a revision of Atala. Gee, for some, um, depending on how much you already know, um, I'm going to first. We'll just start with the picture on. But since we're doing a lecture on apologies, this is Adam Pulitzer, who was a board in Hungary but trained in Austrian. Some say he's the father of autologous on most certainly the most influential person in the latter half off the 19th century. So okay, the ends today I'm going to talk about Ah, basic Atala. Gee, and some anatomy on, then I'm going to relate that Teo clinical relevance and application also help to remember things if you remember them, um, relating to clinical cases or technical pictures or images. So uh huh. First of all, what I want you to do is just spend, um about 20 seconds. Just looking at this image and seeing how many of these you can name if you have a pen and paper, or if you could just think in your head, um, which which ones you can name and then I'll go over them. It might be quite hard for some people if you have not looked at this, because it's not sort of always commonly tour, but it's quite helpful in the ENT, so going to the for some of the answers here. So the reason why I put this on is it's obviously your part of anatomy in V E N T. But it's important because when it comes to your clinical practice, it is to be able Teo describe where something is and you need to but describe where it is on the year on. Obviously, the year has the pinna we call this part has lots of different areas which will different in shape on do some parts of cartilage and some parts don't know. So such a Z a L0. B, which is the lobule is, doesn't have any cartilage. That's important, Teo note. When you're seeing patients so you can see they're helix is the part of the top, and then the anti helix is just below that on be triangular. Foster is the part sort of in the corner, at the top of well on the scale. Fire escape void. Foster A swell you can see going back is number four there, which is quite common place where you get pain a hemotomas. So you get big blood clots there for an injury, which I will go over shortly. So when you're describing where something is on the year, such as a laceration or pin hemotomas or a lesion on possibly for worried about cancer, you need to describe exactly where it is on the year. So this is a pen, a hemotomas one example off something that could be where we're saying is in the escape would force it, for example, most commonly, and this is usually caused by blunt injury on. But it's usually rugby players or some sports karate and taekwondo and things as well. On what happens is you get a bleeding under the skin, which disrupts the blood supply to the cartilage, because the pinna gets its blood supply from the skin. So if you have this blood clot dividing the skin from the cartilage, then the perichondrium cartilage. It's, uh, under cruise on that leads to cauliflower ear. So for us to see and t surgeons, it's important because it needs to be drained a soon as possible on usually, it could be a needle inserted to drain the blood out. Or you can put incision in which this one looks like, well, looks like it's a little cut, but you put a big incision in. Drain out the clot on. Put a pressure dressing on to prevent the blood clot forming again. Um, sometimes this could help into an abscess if it's left for a while, and that could be more serious on that construct Teo Road from the Perichondritis. So it's important that's treated adequately with proper drainage proper wash out on biotics. So going from the pinna now into the external auditory canal, this's signboard shape, so it's like an s shape, from the outer ear pinna to the tympanic membrane. The external one third is cartilage on, then Thean turn Ultram thirds is temporal bone, so this is important as the external part of the year is a little tougher, and then the internal part of the year. Canal is a little bit thinner on be damaged more usually so we don't go into the tympanic membrane on dumb. You can see him some more numbers. So I just thought I'd let you just quickly see if you can Name is many as you can. I'll just wait for about 10 2020 seconds. This is very important because obviously when you before Martosko pee and you look at the ear drum again, you need to build to you describe the tympanic membrane on. And if you see any abnormalities we need to we'll describe exactly where they are so that you conduct you meant this. So here's a diagram. Um, and here the answers. So we have the past flaccid er in the past tensor. So the the tympanic membrane is, um uh a layer off the past tense There is three layers on has a very fibrous layer, which makes it tougher on on in the name 10 sells, he gives that away. The past flaccid er is a small area in the superior part that in panic membrane, which is a bit thinner on sort of lax, that fibrous layer on But that's important because it can get retracted on it, sort of. It gives away a lot for the middle ear because it's thinner. It can get retracted. If there's anything abnormal going on in the middle ear, you can see the code of like they're the light reflex on. That gives you a good idea which side of the year you're looking into because the coated like is the anterior in barrier portion. We call it quadrant off the tympanic membrane. So on this here you can. If you contract right, guess which side of the year this is it. The Kona bloat is anterior inferior there. Then this must be the what? If so, thecal like interestingly, is just where the tympanic membrane, the angle of the tympanic membrane, is slightly slightly different at that part of the of the compounding member. And so when you shine, the Tosca pee scope in the light shines in, and it bounces off reflex in a certain way, a certain angle so you can see the bones of the cycles off the middle ear through the compounding membrane, because tympanic membrane generally is quite translucent and you can see a lot of structures through it so you can see the malleus. There you can see the short process of the malleus of manubrium. And the, um bro is thie on the point right in the middle on a top you can see just wear around the past last year is is the blood supply, which is called the vascular strip Onda. Um, on the previous image, you can see the round window, which is around where number seven is, and sometimes that could be more visible, and sometimes you can't really see that. And then also on number eight there, you can see that's where the eustation she would be, which is a tube cheaper. The structure which connects the middle ear, teo the back of the throat on. That's obviously important because the station tube doesn't work fluid and AARP can't escape from the middle ear on. But that can cause problems with ah otitis media. So some people get your station to have dysfunction as well. If they're on adults on some Children, obviously, how come it's where the Eustation tube doesn't rate the middle ear appropriately on most Children? Do you grow out of that? Because the on angle of the eustation. She changes his Children great. The black arrows on this image show the annual is, which is a fibrous structure, which goes around the tympanic membrane on down. It's usually deficient superior Leah's well, so here's another ridge, and this just shows some nice structures because this is quite translucent so you can see number one. You can actually see that the incus is there on day number two shows Really nice really nicely. The Eustation tube again on day number three does show the round window. Just about you can see that they're on before was just trying to highlight that this the anterior soldiers there, which means you can often not really see around the corner there so it be quite difficult to see or examine on them. But oscopy itself. Some patients have very difficult girls on the shape that there could be different, so it can be difficult to examine around the corner there, as I described with the s shape. So a Z mentioned before the panic membrane is too scored, just sort of divide it up into quadrants. So there's the four quadrants there on um mentioned earlier that the anterior fairy is where the light reflexes and again that can help you decide for which side it is on. You can see that it is this sort of interior soul, cause they're on the on the right hand side as well. There are some other important structures you could just see on. There is well on the posterior superior area. There is the nerves, according Tympani does run under the tympanic membrane there on That's nerve, which supplies taste Teo the A. Tear it either with tongue. So that's, um, area to avoid, for example, of doing anything with the tympanic membrane on, such as a government insertion that we try to avoid on the area because the nerves and the facial nerves around there as well. So this is, um, a panic membrane perforation. It looks traumatic. Someone's probably stuck in cotton blood in there, and it's caused a whole incident in panic membrane on. This is bleeding there. Define it. Membrane. Perforations are quite common. They generally heal up on their own. We generally advise water precautions, so I keep the year dry on. Let it heal up for about usually takes a couple of weeks on gum times. Antibiotic drops could be used if there's infection is a cause. Sometimes if there's a cute otitis media, so this fluid infection behind the eardrum behind it about a membrane can perforate G to the pressure. Um, but in general they can be small, and they heal themselves. Sometimes they may need an operation to help seal it as if there's a whole. It means that the tympanic membrane isn't waterproofed on. If it's not what proof, then water can get in and cause infection. And some patients with long standing to panic member and perforations can have ongoing discharge on. And that can obviously be very difficult for their air quality of life. So just quit briefly mentioning about the sensory innovation of the outer ear. The reason I put that on those just because it's there's a lot of nerves that do supply the pinna on do the extended auditory canal and the area of the tympanic membrane. As a result of that, the vagus nerve obviously, um, supplies other things as well. So the vagus nerve can mean that when patients when you examine patients ears in their ear canal and you could put a not a scope in on, but they could cough. And that's related to you. The vagus nerve, also with some patients. When they get sore throats, they can get Eric on. Do that's related to grasses were on Jonah on. Also, when you get pain in your, it could be really, really severe. Mostly some patients, when they have acute otitis external on it could be absolutely, you know, it could be horrible, horrible pain. Patients could be crying, screaming on. That's because of the nerve supply. The is very sensitive on Also, you probably felt it yourself when you're cold, weather on be cold, wind is blowing and it could be cause really sore. Eric Thebe Been is also important because if you ever want Teo do anything to the Pinna on such a pseudo seizure up a laceration of the Pinna, um, it's important. Teo, if you want to do a block and you can, you can do a block. It need to know where the nerves are coming so you could do a block with local anesthetic and the bottom of the air and the top of the air, and that generally to numb the whole of the pinna, making sure that you get all of the nerve supply that's supplying it. So the example The tree canal ear wax is healthy. Must remember that on. Do a lot of people get quite disturbed by having loads of ear, wax and area? And obviously, if it's completely compact, impacted in the year, it can cause problems with hearing. But in general, earwax is very healthy. It's protective, it's lubricating and its antibacterial an antiviral. So we try not to, you know, get rid of all the ear wax and patients. Is Thea. Other thing is, patients sometimes stick things in their ears on. That's very common. I'm sure you've done yourself cotton buds on. The problem with that is that if you put a cot but into your ear, it pushes the wax and and all the debris back into the year because the air canal ear canals, their self cleaning, they're amazing on. They have it my greatly function. So if you put a little pen mark on the inside of the ear canal over a period of time, the pen mark would migrate out on. But it's it's amazing, So putting anything into the year just pushes everything back in on day. The other thing to be aware of is patients don't have a wax. It can often mean that they have really dry. It's years on dissipation, have more wax and others on does actually being studies to show that wax is genetically determined. So depending on genetics, you might have different type of works as well. Some people have wet wax in some time. Some people have dry wax on Do this. Ah, this means that some people get quite distressed by the different types of work, so they have. But it is No, um, good. So now moving on to the middle, it, so you can see from this is a view from the external auditory canal on. Did you can see the tympanic membrane still on? It's very translucent, as we saw in the The photos on this is just showing again some of the some of the anatomy you can see behind the area. Obviously doing a lot oscopy can actually give away a lot. So just looking in here with your daughter scope can actually give you a lot of information. Even what's going on behind the batting membrane So this is the middle ear. So we have the oscal's there on. You can see it's nice enough to me. Here you have the Malia's Think it's in the stapes on day obviously transmit sound from the tympanic membrane into the into. In a year on, there are two, um, muscles. There s so we have the smallest muscle in the human body is just a pedia muscle. It's around six millimeters in size on, um, thespians muscle and tens of Simponi. Both use really to dampen sound so that your ears s so if anything loud noise comes and it can dampen it that damage the very can't necessary prevent any sudden, sudden loud sounds it can help to dump in vibrations. It usually is set off, and muscles really set off around, I think, 85 decibels. Thesis. A pedia muscle is innovative by a branch of the facial Nerve to this is important for the anatomy on. But if there's any damage to the facial nerve in along this branch, it can cause something called high produces, which is where patients feel. That loud sounds could be very distressing because there's not this dampening of the sounds on dtaps attempt Any muscle connects to the malleus. And that's innovated by branch of the trigeminal nerve. Yeah. So, um, the injury, um is basically consists of two parts which is the body labyrinth and the membranous labyrinth on, um, the inner ear is within the Petrous part of the temporal bone on the body Labyrinth Ables a copier. Rest of you, all the semi circular canals on they both. They also they all contain fluid called peregrine. The member of this labyrinth lives within the bony, not rinse on dc'ing taints Copley a duck. The semi circular ducks the each cooler and the sexual on they contain and he looked fluid on there. On this image, you can see they're two openings into the inner ear, which is the over window on do the round window on the over window. The stapes Clinically, this part of the air, the inner ear is important in some some diseases, such as many years, disease on many as diseases. It deserves to be in the area. And it's characterized by Bert ago tinnitus. Andi hearing loss on it's thought to be caused by an excess accumulation off the endolymph in the membranous leverage. So just going to briefly go over a year examination because it's important for your your practical examinations. Eso So your examination is important to have the patient position in the right in the right way, so either they'll be Saturn chair on you be using not a scope on Teo Sam in, but you need to look at the patient front on First of all, so you need to look. That's the symmetry of the ear, the pin in from from from external part on, Do you need to you look at the preauricular area. So in front of the year and in front of the Pinner, need to look at the picture itself on on. Did you see looking for any abnormalities on any any, um, changes to the skin, any changes to the cartilage? And again, as I described forward, just put another image there just exactly where there's any abnormality in your documentation. So then you want to look postauricular so behind the pinner on around that region there that could be lymph nodes on is the area where the mastoid is on. I mentioned a bit later on, but we look for a tickly important any anti years master writers. Um, so you also want to look for scars as well on go looking for for scars behind years. Well, it might be suggestive of, um, previous mastoid surgery on. Also, uh, people may have had a previous operations of previous excisions to that to the Opana. And there are other ways of going and doing surgery to the middle ear, which you can involve scars around the front as well on around where the tragus is. So when you're doing your tosca pee, you need to make sure that you pull the pinna service. An adult need to pull the pitcher, um, up in back on in Children, you do. It's slightly more back rather than up on. Do you need Teo? Make sure you got a good view of the tympanic membrane on the external auditory canal. So the extraordinary external auditory canal. You need to look to see if there's any stenosis or any narrowing of the external auditory canal. Is there any erythema? Any readiness is any debris? Is there any discharge? Um, Andi, is it tender? One of the really important, really good things. Teo, do you when you examination actually is to press on there tragus on be pressing on the tragus if they've got otitis external. So they got an infection of the external auditory canal that usually causes pain on Be pulling the ear canal is well can cause pain on patients, often drug jump when you do that. And that could be quite good diagnostic for, uh, you take six tona. And that could decide sometimes between otitis external and internal media. There's loads of discharge and, you know, then you need to look at the tympanic membrane on Be again, as I mentioned previously, mentioning all the parts of the anatomy and checking that they're all clear, I will talk a little bit about certain things to look for. But you need to make sure that you can see the tympanic membrane has no perforations. Is it bulging? Um, is it is it is it got diagnosed like reflex that suggests that the compounded membrane isn't isn't bulging. Is there any fluid behind the ear? Can you see that behind the tympanic membrane on do you need to look in the attic, which is the superior part, which is where I mentioned before in the past. Flaccid er at the top part of it impacted membrane. Need to check that there is no retraction on do that. There isn't any debris carrot in on buildup of any skin cells there, and I mentioned that later on. But that's suggested with the Colestid Tomer, and that's very important to make sure you look there. And also you can see. See if you can see that all schools you could mention that they they look intact on. Then you need to think about further tests on. But I'm going to talk about weaning and weather's test, which could be done if you're if you do GP or, you know, done by the bedside with a tuning fork. But also, if you're in a in a clinic in Ent Clinic, we do and audiology tests on dumb. There are many other tests that you can do are go over those detail now, but hearing test is important, and if there's any hearing loss, then it's important to decipher whether this is conducted hearing loss or sensory new hearing loss. So this is just ah really in weather's, uh, test on. But this is important to learn for if we exams and also for general, you know, general clinical practice, because it is quite helpful. If you don't have a, you can do a hearing test. So if a patient has, um, normal hearing, then with weather's test, which is way, hold the shooting for usually 512 30 tuning fork in the middle on the forehead. This allows for bone conduction and four airconditioning and most normal, normal hearing. You would hear the sound central. You wouldn't hear louder on one side or the other, however patient his his own louder to one side. So let's say to the right side then that would be conducted hearing loss in the right ear. Onda. If it's louder, um, lot of the right and and and that sort of got hearing loss on the right here. Then it would be suggestive that is conducted hearing loss in the right here. So then you need to do really is Testa's well on release testes where you put the June it for, um, on the mastoid region behind on. Did you let the patient here it first normally? Um um, normally, So it's a conduction, so it's just outside the Pinna years. It would be normal at conduction on. It should be louder with their conduction than bone conduction. Bone conduction would be in the mastery region, So if the patient hears louder with their conduction, that's normal on with the knees test, we say that positive test is normal. So if they're conduction is louder than bone conduction, then that is positive, and that's normal. However, if they've got bilateral central neural hearing loss, then it may be positive bilaterally because it's the same. So then, if it's negative, that means bone conduction is louder than AARP condition, so it would be louder behind the air on the mastoid process here. Then that would be that would be conducted hearing loss in this right here. So that would be if the weather's was louder in the right ear on greenies. Test was negative on the right, but positive on the left, and you would have conducted hearing loss in the right side. It's good idea to watch video on House has done as well in practice doing it because it's it's a really useful, so it's a sudden censoring. Your hearing loss is something very important to pick up in patients. That it could be quite common on be reason we need to pick it up early is because we usually treat patients with some steroids to try and help improve their hearing. It's what it's is usually unilateral on and off when we don't find a cause. But there are causes on. There can be things like bio oil infections, people co bit of we found that patients have seemed to be getting hearing loss with the viral infection. Such a scope did Onda. Also. That could be a basket of causes immune mediated causes. And it's important to exclude these causes, which could be reversible to help improve their hearing. So we would normally do an audiogram. But as I mentioned before, you can do any weather's test, which condition for whether something is 17. Your hearing loss or conducted hearing loss on dearly. Had audiogram on consider bloods. To rule out any immune mediated or vascular causes on, we would usually get an MRI scan of the internal Do tree be eight hours. Teo Check If there's any abnormality on atomic Lee on Ben, management is to start steroids seems possible. Studies have shown that it is better to start the steroids sooner and which method they're given by, uh, so you can give them orally. I've written here prednisolone 1 mg poking around the day, usually up to 60 mg, But you can give it if it's patients. Can't have steroids were really such a sleeve. Got poorly controlled diabetes. You can give injections into the tympanic membrane. Onda uh, some. Some people would give anti virals as well, such as this. I could be in case there is a viral cause, so just going to talk a little bit about some application off autologous A and acute air conditions and some sort of emergency. So here this is a list of few things. Obviously, there's lots of many, many other things. This is a more common things, such as otitis external, which I did already mentioned. We'll go over that a bit well, foreign bodies and here's quite common in Children or Children with learning disabilities. On do acute otitis media is obviously very common and typically seen in GP. Practice is on. On day, we're more important, but the rarer conditions for ent is things like master notice on down pain in my toe. My sensory some knots up on set sent in your hearing loss of vision would cause the these reported because they need to be treated. Quote quite early on to try and prevent, uh, improve the symptoms and prevent any complications. So you're just going about otitis external. Fantastic stone is very common on, but it's inflammation of the skin of the external auditory canal. It's important to know about pre disposing fact. And so, as I met you before, uh, you know some patients you don't have healthy wax on go swimming. A lot are more predisposed to getting otitis external, and some people get it quite common often and could be very, very debilitating. Actually, it's very, very painful and get discharged from the ear canal. Some people who are immunocompromised eso such as, you know, talk to diabetes, can be predisposed to any infection, so as a result they can get a more episode of it touches external. The other thing to keep in mind is if the patient is having recurrent um, otitis external well, having a recurrent discharge from the air canal on they've got, they are immunocompromised or talk to diabetes it's important Teo considered malignant otitis external, which is which is a deep seeded infection which can spread through the bone, could be very serious. Um, I'm ready to go over that in this in this lecture, but it is something to keep in mind, especially older patients. Well, so there are different causes of different, uh, bacterias and fungus is that can cause, um, otitis external. Most commonly, it's bacterial on. Do you could be such a staff sergeant caucus bacterias or pseudomonas. There was also reacted causes extreme. It's quite common dermatitis on patient who have psoriasis. Normally, they would have another other parts of the body, or you see it on the outside of the areas. Well, fungal fungal causes of otitis external very typically very itchy on day shift a little. Describe having having Great Year on D, actually some pictures in a moment, but there's sometimes a very distinct, uh, look inside the egg. Now, when there's a fungal infection is Well, um, acutely. Patients have a lot of pain and swelling and could be very, very, very painful. Um, on, um, if it's more chronic that generally this irritation and just general discharge, it's important to decide where exactly what the cause of the attacks external is, because it does depend on what treatment you give on day, really making sure to treat it properly so that it clears up on. But, um, I will mention later, a little bit. But one of the most important things to remember is that for otitis external, most of the time, the best treatment is topical treatment. So that's such a drops rather than aural antibiotics. If there is, if it's suggested to be bacterial, topical drops are the most important thing for for the treatment and also being able to clean the air out well, which is which is what we do or not off with my perception. So this is, um, fungal, uh, to my cosis on. You can see there that this very distinct spores on do you do often see this on, but it is obviously diagnostic of fungal infection on the reason it's important to pick this up when you examine year is because if you give anti bacterial drops such a ciprofloxacin, then it can actually make a fungal infection. Worse on a fungal infection needs a longer course of treatment to really clear it up. So even after the after the symptoms have gone, this should be treatment given extended after that period to make sure it's probably cleared up and it doesn't come back. So um, to sometimes, if you're not sure what the diagnosis is, you can do a swab. Send it to the microbiology lab on, but they will tell you exactly what the organism is. So management wise, we see patients in the ENT, and they referred to us if they've been treated by the GP and that the symptoms are still not resolving on down times with this. Symptoms are so severe in the year it's completely blocked up with discharge. They might need microsection in, which is getting the air out with them. With the Huber on Do that's really effective and not seeking cleaner on Deborah or discharge or the bacteria eso we we would then give topical antibiotics is the patient should be treated with on that could depend on what the microbiology swab has. Steroids can help because that can reduce the inflammation in the air canal. Um, that can particularly help with symptoms on it. Also, the juice in the information helps for the year drops to go in on. Treat the infection more deep. That's deeper in some patients. We, the canal could be so swollen that it drops will be able to get in the air canal so a Pope WIC might be indicated, which you can see on the image there. And this is a little sponge on Let's put inside the ear canal. It's hard when you put it in, and then it it's ah gets larger with with water, so such a tampon on do you can administer drops through? It's a little sponge. It soaks up the drops that helps the drops to go be administered all the way in into them in a part of the year. Canal generally remove it's time after after one or two days on. But what precautions as well for patients, Teo prevent to been any further reflection on boil a bunch of biologics. Give a very rarely allergies. You is important and results. It's very painful, as I mentioned before, so this is just showing my construction with a microscope. We do this very commonly. Use the microscope to examine the year, which also gives us a better image on, but also for very careful. My perception. You see, the gentleman in the picture looks like he's in a lot of discomfort. So when when they advertise extender, it can be sore. But in general, it's not. It's not. It shouldn't be too painful. Um Onda, uh, red flags to look for it was a much before completely snows Ear Canal s. So this would need, um I need some treatment with the pope Quick pen or a picture. Say, Like to sometimes the the infection can spread to the pin it on out to the face, and this may require IV antibiotics, so my may require admission in the hospital on day. Chronic supportive otitis media is where you can get this ear discharge on. But this may need more antibiotics and may need a further investigation. Friends and going on in the middle. A big, big, uh, red flag is a cranial nerve palsy in particular, facial nerve palsy. This could suggest a more deep seated infection on Batticaloa. I mentioned before, um, in patients who are immunocompromised or elderly patients, and they've been having this three sentence for a long period of time that we would say. Typically, the symptoms off this necrotizing artistic stone or malignant noticed extender is severe pain, which could be worse at night when they're lying on lying on their side. They could be really painful. So, as I mentioned, or antibiotics generally not useful topical antibiotics on be aware of, they could be a fungal infection on. Also, don't miss a foreign body in the mail. So this is just to show you another tympanic membrane. But here you can see that there's some white patches on the on the stomach membrane, and this is to find a sclerosis on. But most commonly is caused by damage, some scarring on the on the table, I remember, and and this could be caused by either by having had previous governments ast child previous perforations, um, and previous infections. Generally it's harmless generally doesn't cause any problems, but for some people, it can cause it can cause upset, conductive changes in the hearing. But generally we would just leave up, look down. So cholesteatoma is very important to pick up because this is, um, a, uh this is a buildup of skin cells of debris and carotids, which, um, is benign. It's not cancer, as the name might suggest, but it can cause erosion to important structures in the middle ear. On dialysis, you tomer occurs in the middle. It when the year is not working normally, and it's not allowing the my greatly function, and it's not allowing the cells just to move in and move out of the year on. They instead just build up on this Concordes erosion Teo into important structures, including through the bone on Drew the ossicles On. In these images, you can see they're in the in the superior part of the tympanic membrane, which is, I mentioned, where the parts flaccid a region is. You can see this this buildup of debris in character and that's suggestive off cholesteatoma on cholesteatoma is generally diagnosed acyclovir. Khaled diagnosis. Generally, patients will have ongoing discharge on do, um, some hearing loss conducted hearing loss on Do you may see this on examination. You may know we'll weigh. See this? An examination. Um, other things to look out for are more chronic changes of the ear canal. Such a polyps, a swell maybe suggestive of chronic changes, suggestive cholesteatoma and um, Cholesteatoma is important to treat on degeneration. We would treat it surgically on by. Our master rejected me. There are lots of different methods on do. A CT scan can help, but generally the diagnosis is clinical. So, um, make sure that patients do you have a hearing test is Well, um, with the class retirement prior to surgery, we always do a hearing test to make sure we know what the hearing is before we do Any operations on that area of the of the eggs, we go into the middle ear. So for my body's just teo much time left. But just Teo be aware of foreign bodies in the air is common and Children unfortunately on. But the important thing to remember is if it's but, um, battery in the year that needs to come out. And that's a real real emergency, because button batteries anywhere in the body can erode through anything it's in in touch with in in. It's touching on because really severe damage, we say, with insects we drawn and with oil before removing them so that kills them stops and moving around on dumb. It's important to get paid your patient, your child's parents inside because the first attempt is the best attempt at removal. So acute types, media and schedule briefly mentioned quite common. Um and and so I said mentioned, seen a GP quite often on that's information of the middle area of the new closer on. It's generally and Children on. They could be really upset. They get a fever. You know, Talagi a pain discharge if the eardrum is perforated and there's some of the common organisms, so that's Australian. Other image off the Qvar touches media. You can see it's bulging, it looks angry. It looks erythematous on, but looks like you know you could always pop, which sometimes it does on that often gives the patient relief from the symptoms. So with your test media generally is, a patient is observed with oral antibiotics on lots of energy. Easier. However, the same plans we do. We do treat this with a government insertion, so that would be, ah, eating a little cut in the tympanic membrane and putting a little government in to help drainage on. This could be done because this is a government here, um, on this could be done because it rarely acute otitis media could need to acute mastoiditis on This isn't spread of the infection beyond the mucosa with middle ear. So that goes to the Mastoid region on be quite severe because it can spread to see make the patient very unwell. Uh, I'm John. Because the septic, however it is often wrongly diagnosed. Eso the typical presentation off mastered itises. The pinna is just pulled forward slightly on. That could be a loss of the folds behind the pinner. The nice thing called the soldiers on. Do you can see on this picture there? It's very, very thin, itches and bulging on. Do this open, often extreme tenderness. The hand year patient will generally have fever. You have been well, see, it's always the case on. They may have had a previous ear infection. Otitis media. Sometimes it could be mistaken for a lymph node when there's tenderness over the master region behind the behind the year there, there's another imaged Arabic you talk to specific and keep Austin artists so that the treatment really is IV antibiotics aboard spectrum antibiotics analgesia Here on, we do consider taking the patient to the Attorney for drainage of the puss on government insertion to help the middle ear drain. Sometimes you did you imaging, but that does depend on different surgeons on down. Uh, sometimes it's done prior to surgery, So I think I'm just about on time That, for questions, is a bit of a a whirlwind tour off basically common Atala gene. There there will be other lectures on more, more detailed otology Onda. Uh, very interesting area. Three years is fascinating. And when you learn about the anatomy and how how sounds transmitted through the through the year, it's it's it's fascinating, and some of the operations that could be done now in the ENT is amazing where patients can be awake and having an operation done. Teo improve, for example. There are secular chain, so the small bones in the air and they can suddenly get their hearing back. So it's a very rewarding area. So, please, if you got any questions, please show, uh, doctor, did they have you in the chart? Um, I just view of thumb. But if there's someone that wants to ask a question over the course of the spinous, well, if no one does, then I'll just read the ones out on the chart. Okay, they? Yeah, that's good. Um, so the first question we had was Is there a treatment for dry? It? G is so it depends on what the cause of it is. So I mentioned before that fungal infections is It's one of the causes of dry each year. But generally that's it year, and there would be discharged for dry it years. It could be expert for, you know, it could be other skin condition dermatitis, for example. You could be, you know, allergies. Teo Teo. Things that cause irritation to the skin would be the same. It's causing irritation to the air. Eso Sometimes we advised, if it's just acceptable dry, you can use olive oil, which is commonly used to help with earwax. So using olive oil in there and sometimes just using a cream, um, that you would use for your skin. You can use on a cot in bed without putting the cotton, but all the interior you could just do it around the entrance of the canal. Yeah, they think that the, um, the next question is from Abdullah, and it says, Why is the 40 why 40% have no dominant pathogen in a fungal infection. Why 40% have no dominant pathogen informal infection. So I would think, probably microbiologist, we have more information about the specific percentage, but, uh, generally, actually, with is you don't always have a dominant pathogen. And that's because obviously, there are between eStick and especially fungal infections on. Sometimes we don't find a pathogen. It's all right. So as we don't find a pathogen, actually, on this on the swap, Onda really was sort of treating it blindly. And you can have multiple pathogens causing otitis external, for example. And so I did about a percentages of exactly about the exact pathogens. Unfortunately on this is when people, when a public is needed and why So Pope Week is needed when three year canal is various to know so that the air canal is narrowed. And it means that when you put drops in there won't they won't bill to go into the air canal properly because it's so tight because the air canal is so swollen, so pope, which just helps to open up the now on it, soaks up the drops when you put them in on. That means that the drops or soaked up all the way through into the middle part of the of the external auditory canal s, so it allows the drops to go away in rather than just sitting on the outside when it's when it's to nosed, and that this is like a sponge and it basically absorbs the drops away on its length. It's about the pope weeks. There could be different sizes, but you can sometimes, but two in, but they're generally a couple of centimeters in length and adequate for the holes in length of your ear canal. But I mean, you would you would learn to do this in in any anti clinic when you when you get a chance to, uh, to go teo any anti clinic and the J how to do it. But it's, um, something which patients refer. Patient referred to ent for this, for my perception and poke with putting in because the drops that the GP or any of the other doctors give where be adequate. So which one is the best on safe method of cleaning? Here section worry syringing. I think most ent surgeons would say yes, suctioning So in my suctioning, syringing is less in favor in the UK now because there has been some some complications from it. For example, they're perforations, and sometimes I've seen patients where your syringing Concordes and ear infections and damage to the canal and damage to the eardrum. My perception is what we do in clinic is very well controlled. We use a microscope on be, obviously, section out a lot of debris very carefully. So personally, I would just say Work section. So what can we use for is here but are good if you've got a relax and it's causing you problems. As I said, earwax is healthy and it's really good for your ear. You should you should have a wax in. You know you shouldn't try and get it all out. But if it's causing problems with compassion impaction, it's causing problems with discomfort or or hearing loss. Some patients have so much wax in there that they see is causing the problems with hearing olive oil drops on dumb Ah, I mean, all of all drops I would probably recommend is the is the most the most effective. But sodium bicarbonate drops is well, help to soften the wax and help your ears here it's natural migrated function of removing debris in wax. Been obviously, if that If that doesn't work and you need to be a patient to try that, then patient could be referred to my perception ing well. You can go get and see my perception. People who do just clean up wax, yeah, but don't stick anything in because they said it just pushes everything back into the canal, which is a way to the middle, and then it just causes more problems. So do we prescribe oral antibiotics when there is spreading of infection, for instance, swollen lymph nodes in the neck so local antibodies would be just Focalin flexion? So yes, so when this, when this spreading infection, if they're swollen lymph nodes in the neck sometimes that could just be drainage from from the year on doesn't necessarily mean that the infection is spreading from the skin spread on the skin. But if there's any cellulitis, say, like just erythema readiness and swelling spreading to the skin of the face or the ear. Oh, the Pinna, then, um, or antibiotics or even I be intravenous. Antibiotics should be considered a so the infection spreads because it will see means it's a bit more severe, and it leads to some stronger treatment. So, local antibiotics, yes, that would be topical drops generally used for otitis external. So, you know, infection of the year canal on DTaP. It'll antibiotics are most effective if it's just in the year now, so can you kind of said to be offered you in the market? Suction. I've never given it to any patients that are really it's It's not gonna work if they put lots of debris in the area because it won't get there. You can give them. You can give up in a block you can give us. Or you can give them a ninja action into the Air Canal, which we do sometimes give for operations. And if we are doing an injection into the tympanic membrane and that does run on the echo, know, But, um, then the needles a bit sore anyway, and it could sting. So generally we don't offer that maybe some people do, but I don't do it personally. And then topical spray wouldn't really work because I'm you. Ah, you've got some. Generally, it's painful. It is because it's an infection. So the topical spray won't work on it shouldn't be painful. Otherwise on my perception is quite well controlled on, but it could just leave it loud on, sometimes bit uncomfortable in the tympanic membrane. If there's any debris pushing on pressing on the tympanic membrane, that could be a bit sore. But generally it's it's well tolerated. Um, so was going quite a lot. So, um, it is it is it Is it a drainage procedure? So, uh, government is insertion off a ventilator e tube, which goes in the tympanic membrane Onda. What you first will do is you would put a little urine operation generally done in a general anesthetic, But some people do do under local anesthetic on it's for typically, glue here for Children who have, um, otitis media with infusion on do it. It's involves putting a little cut. We call a myringotomy. It's a little cut into the tympanic membrane Onda. This is under a microscope, so it's quite small cut. And then we put the little gourmet it, which was, which is, um, one of my previous images on. We put the little government in to the tympanic membrane so allows for fluid to drain out on prevent the glue accumulating in the middle ear. Generally, the government comes out. We say generally about 12 months, it would say in, But some patients, it comes out earlier. So it just your body, your ear. Soria's, as I mentioned before it in with my greatly system, it just basically extremes the garment itself and doesn't even moving. It just drops out, falls out. Sometimes it doesn't even moving, Um, and sometimes it needs repeating because patient can get more blue here on day. Need another government. But essentially, is the drainage procedure Exactly. And sometimes we actually do it when patients have got acute otitis media when they've got, um, acute infection in the middle ear on that allows us to drain or any puss that might be in the middle ear on prevents it's spreading any further. So weather and Renee's test. I think the best thing really you can do is to you can watch. I've got a tuning fork here, but you can watch a video on YouTube expensive tests, but basically what is the what river weather or rainy test is? Check testing where hearing loss is sense. Renewal hearing also conducted hearing loss. So generally you hear sound louder through AARP conduction. So, um, when you have, uh, weapons test, which is the one that you put on the forehead here, generally you should hear sound equally on both sides on D if there's a problem with conductive. So let's say a patient has ah has otitis external where they have a problem with the conduction of air. Three. The bones through the tympanic membrane. Then this would be a muffled to see would be muscled with air condition so you would hear bone conduction louder in that year. But you would hear air condition louder and that if you have a conductor period loss here. So if a patient presented with some hearing loss and they said it came right here, I have a problem with my hearing if you did so, they got hearing loss on this on this on this area right here. If you put the weather weather's test with gene for in on the forehead, there on the sound was her louder on the right side. Then that would be That would be a conductive hearing loss because the patient has a conducted hearing loss which means that the sounds heard better through the bone there. And, um, that is because any other sound around is is prevented from coming in because the patient has conducted hearing loss there and that that's how I think of it. Because if you have dampening of the sound from any other external sounds, then you're here. Here's a better there on Do you generally could do weapons and Renee's test together, which would confirm your diagnosis of center in your hearing loss, all conducted hearing us on as image before with the knees test, which involves the tuning fork being put just outside the air Canal. It's difficult for me to show exactly how you do it to. You need to watch videos because there is a particular way of holding the training for but generally air air. Air condition should be louder, so it should be louder here than it should be behind the mastoid, and that would be a normal test. Air condition was louder than bone conduction, and we would say that is a positive test if it's louder here. So if the patient has, um, a negative hearing test and they would here negative redness tests, and they would hear it louder bone. And that would be because they have a conductive hearing loss. So the sound is not going through being conducted through normally. So they're hearing it louder through the bone because the sound travels directly through the bone on day to the um, to the middle area and to the uh to the nerves on. Then that means that if there's a conductive hearing loss, patient will hear a loud on the bone. So I think assistant card death patients respond to Web Renese testing bone conduction. So it depends on what the cause of the of the deafness is. So if a patient patient could be different, obviously different reasons, so they can have conducted hearing loss or center in your hearing. And also depending on what the cause of their symptoms that their their hearing loss are and what the symptoms are there, then they will have either a positive or negative, you know, really, Sweeney's test, depending on So they got bone conduction, then they would respond. Teo Weber Minis test for bone Conduction If they've got central neural hearing loss to be questioned about censoring your hearing loss, then the sound won't be transmitted through bone all through through a so they wouldn't respond. They've got complete center in your hearing loss and they wouldn't hear anything because even though the sound is transmitted through the bone, it wouldn't be transmitted through Teo to their nerves. And B and B sense wouldn't be sensitive sensitive. But the thing is, the patients can hear, or it can be transmitted from one side to the other. Actually, so if patients have one sided hearing loss, they can you can transmit it sounds the other a so that can get confusing. And actually, audiogram, we do take that in consideration. So we do use masking, which allows us to, um, the mask one side. So we're just testing. We're just testing one side of one year because sometimes the other it can take some of the sounds of patients here his sound but actually coming from the other A. Yeah, that's a That's a good question. What is more dangerous? Um, perforation of the past last Fastenal past tensor, the more common and perforations the past tense. A result. It's a bigger area, Um, and actually in the superior area of the tympanic membrane. There's more, more important structures on it's It's a strain on the image before you've got the nerves. The facial nerve, um, recorded tympani nerve, which one superior portion so generally would be more worried about that? That it also depends on the size and past Lassiter Perforation might be suggestive off cholesteatoma or something pathological going on in the middle ear. I think I wanted the question about the wax already, so we reckon. And then drops are such a lot of oil generally, um so otitis so otitis meats can otitis lead to deafness. So was the any infection can spread and need to deafness. Um, otitis. Six. External is more the external ear canal, but that can cause problems with conducted hearing loss because the economic apiece to nose. But that would be temporary generally, but that can spread through the bone and lead it, you know, serious deafness. Otitis media, um, is infection. I'll see of the middle ear on that can lead Teo deafness and all or a little you know, any any. Any problems with the years. Pathology of the year's can essentially lead to deafness if it spreads to the wrong places. But the bones in the bones in the middle ear convey damaged with cholesteatoma or with their total media, which can lead to obviously problems with the transmission of the sound through the bones. Um, Andi ear infections can spread to the inner ear. A swell on calls cause problems with deafness and mean a malignant otitis external can spread along the bone on bone lead to brain access is on very, very serious complications. I think we may have to stop the questions on, but I can make a note of the ones that are left over because I concede of people, um, quite interested. They're very interested in this. Um, tell me in a special, any questions that the other people have had, and I couldn't I tried answer them afterwards because there are quite a lot of there are quite a lot of questions. So to answer, So yes, definitely saw make a lot of the ones that are left over, and hopefully we can answer them in your next session. Thank you so much. We do have a second like the starting, um, in a couple of minutes. But is that anything else? you would like to say before we and the cool? Um, no. I think if you do get generally in medical school road, many elections. Vnt. So it is important to try and get as much of all with this you can, because in my medical school, in it in the UK ent is very minimal teaching. But it's huge part of off, you know, clinical practice. And particularly you think you're doing general practice family, medicine, things. That ent is a big part of that. So do you try? And the trying to learn about an obsessive, an excellent specialty of anyone's interested in joining us went once you start working. Thank you so much. Like them. It was amazing, Lecter. Uh, just everyone I want to be. Do you have a second? Just I think so. I will end the cool. And if you confused for your joint once again Thank you so much. Katherine. You're welcome. Thank you dot Thank you so much.