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I, if we go for it now. Yeah, we're at 35 people. It's 22 minutes past seven. So. Right. Perfect. Perfect. Uh, right. Yeah, welcome guys. Thanks for joining this evening. Um, oh, I've got a heater turned on. I can turn that off and you might hear better. Um, yeah, thanks for, thanks for joining this evening. So, uh, I understand you've been having a few weeks of these, uh, kind of overview lectures, uh, some of the evenings. So tonight's topic is ent, so it's not one of the, it's not one of the, the kind of biggest topics for third year. But, um, I think it's fairly logical and intuitive one. So it's, uh, I don't think it takes, takes the most work either. So, um, yeah, we'll get through a lot of the content will obviously not cover everything in. Uh, it'll probably be about 4550 ish minutes. Um, but, uh, we'll kind of get briefly through everything. I'll just be sharing some kind of tips that I found useful, uh, for going through Ent. Uh, yeah. So, oh, that was an exercise. Sorry. So, yeah, we'll be going through some ay stuff, uh, of a wee bit at the start about history taking, which isn't very common in the ENT, but just in case, um, and then we'll kind of just chat through some of the examinations and some tips for them as we go through, uh, the topics for a NT, uh, which are listed there. So hearing loss is the big one. and then the rest of the topics are, are a bit smaller, a bit quicker to get through. Uh So in terms of, uh taking a history and ent, I haven't seen it come up in an a station before. Um, but I have been, I do remember having a tutorial on it before. So, uh it's definitely something that is within the realms of possibility, uh Even if it is unlikely. Um So, uh what I found in third year was, uh compared to 1st and 2nd year where all the histories, you kind of had a bit of a script for, uh from your CSC booklets and you could just kind of bash through the questions you learned off. Uh, in third year, there's a couple of new specialties. Uh and you don't have that same kind of list to go through. Um So obviously, it'll just be the, the same standard uh structure to your history as any other, uh as any other topic. Um For a history representing complaint, something I came across first, uh when being taught about ent history taking is this stopped approach and it can be used in any, for any, uh, history but, uh, any presenting symptom, if you ask them about duration. So when did, when did the symptoms start onset? Was it a sudden onset or was it gradual, uh, progression? How has it changed with time? Has it got any worse and then timing, uh, asking them about, uh, is it constant or is it intermittent? Um, and within that you can kind of ask about exacerbating relieving factors kind of things, anything that brings it on, anything that helps to get rid of it or is there a particular timing to or pattern that they've noticed, uh to the symptom? Uh So some specific questions, uh, and if the anti history does come up, you'll probably not need to go through all the symptoms of ears, nose and throats like you would in another, uh, in another body system. But, um, if there's, uh, some presents with some sort of ear issue, there's four questions you'll definitely want to ask, um, hearing including tinnitus within that, which is a ringing in the ears, uh, then ask them about pain ortalia, um, ask them about any discharge from the air and then asking them about balance, uh, nose related, uh, questions to ask. So, rhinorrhea, uh or kind of discharge from the nose snotty, uh blowing the nose all the time, uh, postnasal drip as well is kind of a similar thing. But at the back of the nose. Um Then has there been any changes to their smell? Uh Have they felt noticed any kind of nasal congestion? So blocked nose, um and any facial pain then for throat, uh you'd want to ask about any pain, particularly, uh asking any pain with swallowing, um any issues with swallowing, uh and any hoarseness and then just kind of general symptoms. Uh So fever, if someone has a fever, you might be suspecting an infection of some sort of weight loss, you might be thinking uh worried about some kind of malignancy. Um So just kind of general uh symptoms then as well that you think are relevant to ask. Uh And it's a bit of a, it is a bit of a scale uh history taking in terms of knowing what to ask when the, the history is a bit more vague. And it's one that's uh I mean, I still don't feel hugely confident with it. So it's something that you probably won't feel hugely confident with at any stage while you're a student, but it's just about practicing and you do notice that you'll start to get, you will start to get a bit better at it. Uh With practice, that's the main thing really with, with your history taking then uh NS surgical specialty, obviously. So you want to ask about any previous surgeries in your past medical history, um particularly thinking of any uh previous ear surgeries or tonsillectomy or something like that. Um Then family history, if someone presents with hearing loss, it would be relevant uh to ask them about anyone else in the family. Uh social history, smoking and alcohol are big, big risk factors for head and neck cancers. So you definitely don't want to be missing, missing out that one. And then again, if someone presents with hearing loss, uh occupation and hobbies can be relevant with noise exposure for that one. Um But yeah, don't be too worried about learning off a script for something like a nt history, it is unlikely to come up. But if it does just kind of know roughly what kind of symptoms you'd ask about for each, each different part of a nt. Uh So the first topic we'll go through is hearing loss. Uh So the big question that you want to, you want to try to answer in hearing loss is conductive versus censoring your own hearing loss. So there's a couple of clinical tests we'll go through in a second to, to help you answer that question. Uh But conductive hearing loss is just any issue with the transmission of sound uh as it enters the ear canal uh through the lytic membrane, the oles of the middle ear and then uh to the oval window. So any issue in that uh in that kind of length of, of the ear uh will cause a conductive hearing loss and then sensory neural hearing loss is any issue with the cochlea or the cochlear nerve carrying the, the impulse to the brain. So in terms of uh ent examinations for, for Os, they're all demonstrated on the portal. So uh I don't know if that, if that link works on the slides, but I'm sure you'll be able to find it on the portal. No bother anyway. But there's, there's very good videos that are organized by Mr Rohana, who's the guy who, who organizes the, the stations for the OSK for ent. So, I mean, if whatever he kind of says or, or suggests to do those videos, I would, I would go with that. Uh because if he's setting the station as well, then you'll not be going wrong if you just follow his advice. Um But the test using hearing loss, uh firstly, the crude hearing test uh is just a very uh non sensitive test for determining if there is any hearing loss. If there is hearing loss, then uh you can use the tuning fork test. So R and webers to determine if it's a conductive or sensory neural hearing loss. So current hearing test again, you can watch the video on the portal to get the full, the full run through of it. It would be much better than me talking through it. Um Just a couple of tips, you'll obviously you'll end up standing behind the patients who just remember to explain uh the station fully to the patient from in front of them first and then uh tell them that you're going around behind them in terms of occluding, hearing in one ear. I remember being told in, in CSE to ask the patient to put a finger over the tragus uh and push it over the ear canal and uh rub it around er on the, on the video on the portal. Uh They suggest just using a piece of paper folding too and roughing it. So I would go with that uh if that's what they're suggesting on the portal, but if you have kind of a suitable alternative, I'm sure there wouldn't be any issues. Um And then in terms of kind of defining or quantifying the hearing loss is a bit like using a Snellen chart for visual acuity where you're trying to determine the smallest line that they can read uh with crude hearing interest, you're trying to determine the, the quietest uh voice that they can hear. So you start with your whisper. If they can't hear that, then go to normal voice and then to the loud voice uh to try and quantify very crudely what the hearing loss might be. And then the Rennie's and Weber's test for, determine if it's uh if it's conductive or sensory neural hearing loss. The Rennie's test, uh it seems like I remember being told to strike the tune and fork and then you hold it behind the ear in the Mastoid process um and ask the patient to wait until it rings out and they can't hear it anymore. If you do that, you'll probably be waiting a couple a minute or two for it to, for it to ring out. So on the portal, what they suggest and what I definitely recommend you do instead is just hold the, the chin and fork behind the ear in the ma process, then bring it in front of the ear and ask the patient which one's louder uh behind or in front of the ear. And the normal result is in front of the ear with air conduction. Uh if it's louder with the bone conduction behind the ear, then that implies a conductive hearing loss. And then Weber's test is the tuning fork in the middle of the forehead as just asking the patient to hear this equally on both sides or is it louder on one side? Um It's a wee bit more complicated to interpret the sensory neural hearing loss is, is fairly straightforward to, to understand it's just it's gonna be louder on the side that doesn't have the hearing loss. Um But then the conductive hearing loss is just the opposite way round. So it'll be louder on the side, which, which does have the hearing loss. Um And that's just a wee a kind of memory aid to remember which ones which Weber's test. If you imagine shooting the web on someone's forehead, then you've got Weber's test if you find that useful. Um So this table just kind of documents the the results you expect from the test and the different types of hearing. Also, I wouldn't advise just trying to learn the table off. Uh It will be much easier for you in exams to, to kind of logically think through things if you understand the table. So uh yeah, just knowing Rennie's test, the, the only abnormal result in Rennie's test is with the conductive hearing loss. Um sensory neural hearing loss, both air conduction and bone conduction will be reduced, but it'll be in proportion to each other. So it'll still stay a normal test with the air conduction being louder. And then Weber's test, as I was describing on the last slide, uh sensory neural loss is very intuitive, lateralized to the good ear and then conductive hearing loss, it's the opposite goes to the bad ear. So to remember the the causes of conductive hearing loss, I don't have any kind of handy mnemonic or anything for for that. So I think the easiest way that I found to remember it is if you just think of the anatomy of the ear and think what could be obstructing the the conduction or transmission of sound from when it enters the the external of meatus until it gets the oval window uh through the stapes. So uh issues with the outer ear that can cause hearing loss. So, thinking of earwax uh foreign body uh or else Otitis Externa, which is an infection of the outer ear. So you get a, a swelling of the epithelium and a and a discharge which can obstruct the, the, the sound waves. Um and then middle ear structures. Uh So a perforated tympanic membrane, uh tympanic membrane is named as such because it's like a drum skin. So if there's a perforation in it, it's not going to be able to uh to catch the sound waves uh as efficiently as it should. Um acute tit media is infection of the middle ear. So you get uh a collection of pus and a bulging on the tympanic membrane. Um and that'll inhibit the tympanic membrane from, from vibrating as it should with the sound. Um And then similarly, with the titus media with effusion, uh it's a fluid collection in the ear, not in the setting of infection. Uh And it's like a, a sticky fluid that'll suck the eardrum in. Uh And again, it won't allow it to resonate with the sound as it should. Autocross is a stiffening of the, of the ossicles in the middle ear. Um So the ossicles work like levers from the tympanic membrane to, to then eventually the scapes will push on the, on the oval window to transmit the sound to the cochlea. Um So if you have a stiffening of those levers, uh you're going to have a hearing loss and that's a genetic condition Uh So that's a genetic cause of conductive hearing loss. And then aoma it is a proliferation of squamous cells in the middle ear. So, uh and it can, it can erode through the structures that are uh around it. So it can erode through sic or the topa membrane again, causing conducive fear and loss. And then you station tube dysfunction, uh station tube is to regulate the, the or equate the pressure in the middle ear with the outer ear. Um So if the eustachian tube is obstructive uh for, for any reason, then you lose that uh balance of the pressure. And again, it'll affect how the, how the lymphatic membrane resonates. So some exam kind of pointers, if you're doing MC QS, we things to, to look for in, in the questions that can point you to a diagnosis. Swimmers with uh ear pain, uh fever or um conductive hearing loss or discharge. Uh swimmers would point you to otitis externa. Swimming is a big risk factor for it. Another thing, exams look out for with Otitis externa is uh people with diabetes or uh immunocompromised, compromised patients. Uh They've uh a high risk of or they have some degree of risk of like an initis externa which is a condition. It's a wee bit like cholesteatoma, but it acts a lot faster in that it can erode through uh surrounding structures. So that requires emergency management. So if you see uh diabetic or an immunocompromised patient uh with uh kind of disproportionate uh severity of infection in their ear. Then you're going to in an M CQ, then you're going to want to, if there's an answer for emerg immediate referral to ent that's the one you probably wanna go uh going to want to go for. Then uh hence, for a perforated tympanic membrane, any kind of recent trauma with the, with the ears, like a slap on the side of the ear or um a recent acute media with discharge that implies that the pulses built up and burst through the tympanic membrane. Uh They would both be pointers for a perforation. Um And then acute oitis media looking for signs of infection, uh pain fever, uh upper respiratory tract infection is the main uh cause of acute media. So any kind of coral symptoms alongside it or preceding it, uh you'd be thinking of that and then if it comes up on an exam and ask you about the most common bacterial cause of acute media, like uh quite a few other upper respiratory tract infections, it's a streptococcus pneumonia. Um Then for titus media with a fusion, uh it's also commonly called glue ear, uh you might recognize it by more, it's very common in Children. Um But if you see it uh a unilateral of titus media with effusion in an adult, then that's a red flag for risk of a nasopharyngeal cancer. Uh So that's uh potentially a like a tumor that's obstructing the eustachian tube and then you get a fluid collection in the middle ear. So that's the worry there uh autos sclerosis, as I, as I was saying, is the genetic cause of conductive hearing loss. So look out for family history tends to present in patients, late teens, twenties, early thirties, kind of age. And then cholesteatoma, if there's someone who comes uh presents with smelly discharge, says foul smelling discharge from the ear, then you should immediately be thinking cholesteatoma. And then if you do your runs and webers and you determine a sensory neural hearing loss, then uh there I do have a mnemonic for that one. If you're a mnemonics kind of person that might be useful. Uh So just thinking of this TNT stick on the right of the slide, um Obviously, loud noises can cause hearing loss. So the TNT with its fingers in its ears should be thinking, don't make deafness inducing TNT. Uh So stands for degeneration, which is uh Presby sis. So that's old people with hearing loss. All the old people with hearing aids. That's why the mens, which we'll chat more about with vertigo. Um Some drugs which can cause sensorineural hearing loss, aminoglycoside antibiotics. So your Gentamicin, Neomycin, the ones that end in M ICI N as opposed to M YC in which are the macrolides like Erythromycin, Azithromycin, it's not them, it's the aminoglycoside antibiotics. Uh and the diuretics are associated with it as well. Um And yeah, infections that can cause it. Labyrinthitis, which is an infection of the, the whole of the inner ear. We'll chat about that more with vertigo as well. Uh Any kind of CNS infection can have these kind of neurological uh symptoms. So, meningitis and cephalitis and then herpes zoster virus, that's like a, a shingles, uh infection of the eighth cranial nerve can cause its dysfunction. Uh tumor, acoustic neuroma will talk more about that alongside facial nerve palsies. Uh It's a benign tumor which can impinge on the eighth cranial nerve, uh any kind of neurological cns lesion. Uh So, stroke MS, if it happens uh around uh a part of the brain associated with hearing, then that can cause sensorineural hearing loss, um and noise induced hearing loss as well and then uh trauma. So a basal skull fracture which happens to uh affect the cochlea or the secular cochlear nerve. So, the last point on sensory neural hearing loss, if you see in an exam, sensory neural hearing loss that's occurred over less than 72 hours, then that's an indication that they need an immediate ent referral. Um So it's usually an idiopathic cause um and the management of steroids. But the main thing to remember there is just sensory neural hearing loss that's occurred over less than 72 hours. You're gonna need to uh have an immediate ent referral. So, otoscopy, in terms of ent clinical skills, this is uh the one that's, that does require a bit more skill rather than just knowing the steps of the station. Um So the main thing with it is make sure you know how to turn on an Osco. So you can see on the right hand side slide uh the wee green button under the doctor's thumb. Uh You just press that down and twist the black bit round. Uh You might hear the odd horror story of someone who goes into an O station for otoscopy or ophthalmoscopy and they don't know how to turn it on. So just don't be, don't be that person um and other things to, to look out for. Uh don't forget to do your inspection. I think a lot of the time when there, there's kind of a more skilled focused station, you forget the simple things. So don't forget inspection. If you want a couple or a few things to, to mention on inspection, you can just say looking for any scars, hearing aids, skin changes, uh particularly that's around the, the external of metus. Um And then you can watch the video of course on the portal to go through the the whole uh kind of routine of it. Um But other things be be gentle, of course, when you're, when you're using uh the Osco, but also be confident it can take a bit of uh kind of wiggling around to, to get a proper view of the Tympanic membrane. So, so be confident enough to, to, to go looking, but just be gentle as you do it basically. Um And then if you want a few things to say, to comment on the external acoustic meatus as you're entering the ear, uh you can just comment on redness. Is there any wax or um any discharge or pus? And then when you're seeing the tympanic membrane, if you're doing it on a simulated patient in an ay, it's very likely to be a normal tympanic membrane. So it's usually described as a pearly gray appearance. Um and other things you can say presence of normal landmarks. So you can see there the the kind of three landmarks on the tympanic membrane, the lateral process of the malleus, the handle of the malleus in the middle. Uh and then the light reflex is in the bottom corner under the the side of the lateral process of the malleus. So I wouldn't get too concerned with, with kind of knowing all the detail of the tympanic membrane. But just so you have a few things to say, if you do have to do, you have to do oscopy in your oscopies. Um And also stating negatives can be a useful thing just to, just to say a few more things look like, you know what you're talking about. Uh So on a normal tympanic membrane looking at no redness, no bulging the tympanic membrane, um no perforation. Uh And then LA I can't remember if it was last year or the year before. For third years, there was a uh an autoscopy station with uh with a mannequin. Uh So for that, they obviously could give you a diseased tympanic membrane. So uh cutis media, um you'll see it there on the left, it's very red and inflamed and there's a bulging tympanic membrane. So you, you lose the normal landmarks of the tympanic membrane because of the bulging um dentis media with a fusion, you get this golden brown appearance uh and a sucked in tympanic membrane. So you get a very prominent lateral process um and then perforated tympanic membrane, you just get a, a very obvious hole uh in it. Uh And then this, this one as well. You can see that there's some tympanal sclerosis around the bottom of the tympanic membrane, but that's a fairly clinically insignificant finding. Um But it might just be something to comment on if, if you happen to see it, but I wouldn't get too worried about being an expert and looking at tympanic membranes just kind of know your your routine for the otoscopy and look like you're confident doing it. So that's hearing loss done. That's the, that's the kind of big topic of, of ent done. Um So moving on to onto vertigo, uh if someone presents a nasty with uh dizziness, the main thing you want to determine uh is does this patient have like a a lightheadedness feeling like they're about to faint uh darkness coming over their vision. In which case you're thinking this dizziness sounds like syncope or do they have a room spinning sensation? Um Feeling like everything's moving around them is often associated with nausea and vomiting. And that's when you're thinking along the lines of vertigo. So two kind of categories of causes of vertigo, there's central causes, which is any cns lesion that affects the brain stem where the uh where the nucleus of the, of the vestibular nerve is or the cerebellum, which coordinates uh balance. So any lesions in, in either of those structures that can be caused by just here, kind of general cns lesions of stroke, MS space occupying lesion. Um and then there's peripheral causes uh and the four main peripheral causes to know about. And I have found that they are the ones that come up more commonly in MC HS. So, uh and sometimes you can be asked to kind of differentiate between what which peripheral cause might be causing the vertigo. So this wee table is quite a useful. I used to one for uh for determining what the cause might be. So, if it's a persistent vertigo, uh then you're thinking an infective cause. So, vestibular neuritis or labyrinthitis, uh we'll chat in the next slide about about the difference in them and why one causes hearing loss and not the other. Um And then intermittent causes of vertigo, you're thinking uh benign paroxysmal positional vertigo, which is the stones in the semicircular canals. Um Or else Meniere's disease, uh which again, we'll chat about in the next slide. So, uh things that wouldn't point towards a labyrinthitis or vestibular neuritis, if it's an acute onset or if there's a concurrent or preceding viral upper respiratory tract infection. So your coral symptoms alongside it, then you'd be thinking that's more like to be a cause. Uh labyrinthitis affects the entire of the inner ear structure of the cochlea and the vestibular system. So that's why with labyrinthitis, uh you get a loss of hearing and you can also remember that with the, the l for labyrinthitis and loss of hearing and then vestibular neuritis just affects the vestibular nerve and the uh the vestibular system, it doesn't affect the cochlea. So you get no loss of hearing with vestibular neuritis. Uh And then BPPV, as I was saying, is the stones and the semicircular canals. Um So it's often you can imagine uh if you've got stones kind of irritating the canals, if you move your head, uh that tends to cause the, the vertigo. So often these people, they don't necessarily have the vertigo if they just lie down at rest and let it settle. Uh But if they move their head, then it'll come on. The main thing to remember with it is the Dix Hallpike test which is to diagnose if you remember D for Dick Hallpike and to and diagnose uh versus the Epley maneuver, which is the one to treat. So, dick Hallpike, which is where you tell turn the patient's head 45 degrees and then uh lie them back. There was a video of it in the OS uh either last year or the year before uh for third years. And the, the kind of main comment on it from the examiners was that students didn't describe the sign correctly. So the signs rotatory nystagmus, it's just kind of one of those bits of lingo you need to to learn off. But um yeah, that's, that's kind of most of what you need to need to know about it. You don't need, as far as I'm aware, you don't need to be able to, to do a dick Hallpike or, or do an maneuver. Um So yeah, when it came up a couple of years ago in a, it was, it was a video of it and you just describe the sign and then Meniere's disease, it's a triad. So you get these parts, these small attacks of uh sensory neural hearing loss, vertigo and tinnitus. Um and the management of it. Sorry, I didn't mention the management of the labyrinthitis and fib neuritis. So it's the same for, for the infective causes and for many years in the setting of in the acute setting. Um So you use labyrinthine sedatives. Uh So that's uh drugs which kind of dampen the uh the brain stem input from the vestibular system. So, prochlorperazine, which is a dopamine antagonist and or else an antihistamine uh and then on the facial nerve palsy. So the the main feature that you need to be able to distinguish in a facial nerve palsy is is it an upper or motor uh neuron lesion? Uh that's, that's causing the facial nerve palsy. So you can learn the physiology and anatomy and all that crack. If, if you want um the easiest way to remember is just upper, is upper sparing. So, uh an upper motor neuron lesion doesn't involve the forehead, whereas a lower motor neuron lesion will involve the forehead. Um and then got a pneumonic for some of the for the key causes for facial nerve palsy as well. Uh Mr Bits sounds like a strange and creepy guy and if you look at the the guy with facial nerve palsy, uh he also looks a bit strange and creepy. So if that helps you remember the pneumonic happy days. If you're not a mon person, no worries. Um So causes the only the only upper motor you're on causes in this pneumonic and kind of the big ones, uh MS and stroke. Uh And then the R for Ramsay Hunt syndrome that is uh again, your herpes zoster uh kind of shingles infection of the facial nerve this time. Um We'll look at it more in the next slide. Bell's palsy is the most common cause of facial nerve palsy. It's idiopathic uh and then infective causes. So uh oh sorry. So an infection around uh the middle ear where the, where the facial nerve uh passes very close to. So uh imatis media or a malignant metiti externa it that infection, severe infection in uh patients with diabetes or immunocompromised patients can erode through surrounding structures. Uh and then some tumor causes acoustic neuroma which will come to you in a couple of slides, uh a malignant parotid tumor. So, if someone has a parotid tumor and it's causing a facial nerve palsy, that's an indication that it's very likely to be uh to be malignant. Uh whereas usually product tumors are benign and then cholesteatoma, that's again, the, the proliferation of squamous cells in the middle ear which can erode through uh surrounding structures and then a traumatic cause. So a uh basal skull fracture, uh or else uh an iatrogenic cause. So if someone's had an operation on their ear or their parotid glands, uh places where the facial nerve crosses, uh it's at risk of being damaged by the surgeon. So some exam tips for facial nerve palsy if you're in a nosy and there's a facial nerve palsy and you're asked, asked about management, no matter what the cause is, you can mention uh protect the eye. So uh patients with a facial nerve palsy, they can't blink and their eye can dry out. So they're at risk of an exposure to keratopathy. So, uh remembering to protect the eye taping it or using lubricating eye drops, uh is an important management point and a simple one to mention. Um And then Ramsay Hunt syndrome, you can see it on the middle left photograph there. Uh So it's a facial nerve palsy and they get this vesicular rash, uh the kind of herpetic looking rash around the external acoustic meatus. Um And they can also get a neuralgic pain uh with it. And the management of that is prednisoLONE and Acyclovir. Uh And then Bell's palsy uh is the most common cause idiopathic and the management is is prednisoLONE. So, steroids and protect the eye as well. Uh And then, as I was saying, the carotid tumor, if it causes a facial nerve palsy, there's a high risk of malignancy and then acoustic neuromas. So they come up strangely commonly in MC Qs considering their very rare and they, they're uh they're managed by very specialist surgeons. So, uh but yeah, they seem to come up. So some, some things that get asked, sometimes they are benign tumors of the Schwann cells. They occur at the cerebellopontine angle. So that's just meaning the, the point where the cerebellum meets the pons of the brainstem. Uh and they're associated with neurofibromatosis type two. And as you can see on the, on the wee uh images on the left, on the top one, the facial nerve and the vestibulocochlear nerve if you remember your anatomy from second year, they originate from the brainstem. Uh So as they pass from the brainstem to the ear, they cross uh that kind of cerebellopontine angle area uh where an acoustic neuroma occurs. So they can uh an acoustic neuroma can put pressure on those nerves and cause their dysfunction. Um And then invest if you're asked about an investigation when you're suspecting on neuroma. MRI brain is the, the gold standard investigation for. So, epistaxis, it's the uh fancy term for nose bleeds. Um Some M CQ tips for it. Uh If they ask you about the most common site to bleed, it's little's area. So if you just think about uh I'm sure no one picks their nose here. But if you were to pick your nose, it seems intuitive to use the little finger. Uh so little finger for Li's area. And then uh if you, if it's bleeding from a single nostril, they're probably suggesting an anterior bleed. Uh so near uh near to the nostrils itself and then if they're bleeding from both nostrils, they're probably implying that it's a posterior bleed and that affects the management as you'll see in the next slide. Uh And then also in MC QS, if there's recurrent or prolonged nose bleeds, uh then you want to start thinking about uh any kind of coagulation issues to consider anticoagulant medications and doses. Um So if someone's been regularly on warfarin, you might be wondering about their ir, um, and then checking bloods as well for thrombocytopenia or coagulopathies. And then in terms of management of epistaxis, um, you to, to obviously most nose nose bleeds will just resolve themselves, uh, with patients at home using this, uh, kind of thing on the right, pinching the nose and leaning forward, uh, nosebleeds that require management if they've been happening for more than 10 to 15 minutes if they're severe. So, if someone's hemorrhaging out of their nose, you're not gonna wait for the 10 to 15 minute mark. Uh or somebody, if someone's hemodynamically unstable, then those are all indications for, for intervening. Uh So, as I was saying, in the last slide about anterior versus posterior uh nose bleeds. If it's an anterior bleed and on anterior rhinoscopy, you can observe a bleeding site, then uh you can use nasal cautery. So just a silver nitrate stick, uh touch it on the bleeding site and that'll cauterize it. Uh A wee points on anterior rhinoscopy. I haven't got a slide on it in, in this because I didn't really have any points to add to it. Uh But you can watch it on the, on the portal uh and it did come up uh last year or the year before. Um And I've kind of got a wee screenshot in of about that station later on. Uh So we'll chat about it then. But yes, so that's for an anterior bleed and then a a posterior bleed, uh or if there's no bleeding site observed, then you obviously can't go, go in with the with the nasal cautery and kind of go waving it around. So in that case, you will use nasal packing. So either nasal tampon or, or gauze to try and tampon out the tampon up the the bleeding point. And then you may have come across naseptin cream, uh which isn't used to stop a nose bleed, but once a nose bleed has been stopped, then you can use naseptin bleed to, to try and reduce the chances of it bleeding again. Um So the the kind of main M CQ point for, for it is that it's contraindicated in peanut and soya allergy, particularly the peanut allergy uh seems to come up often enough. So just, just bear that in mind in MC Qs and then sinusitis, uh the kind of cut off point between acute and chronic is at 12 weeks and uh symptoms of it. Uh If you think back to those symptoms, I was chatting about to ask around uh rhinology, uh nose kind of history questions. So causes nasal congestion, uh nasal discharge, uh facial pain and they can get a a tenderness over the sinuses if you were to press on, on their face over the sinuses, uh and they get a loss of smell as well. Um And so acute sinusitis is associated with a viral upper resp tract infection. Uh like like all ent infections basically. Um And so the vast majority of them are viral. So usually it doesn't, it doesn't require treatment. Uh I'm sure many of you guys have had sinusitis in the last year or two if you've had a common cold or something and then you get that kind of facial pain uh with it. Um But yeah, if it's, if it's lasted for a long time or it's very severe, then it, then it may uh require management. So, symptoms greater than 10 days. Uh then you can use intranasal steroid spray to try and dampen the inflammation around the sinuses. Uh Or else you can, or you can also give a delayed antibiotics, prescription at that stage if or if the infection doesn't get any better or, or worsens over the next few days. Uh and then tonsillitis uh comes up more commonly in Pedes. So, uh it's probably not as likely to come up this year for you, but still on the anti topic. So it could come up um You again, usually viral cause. Um if it is a bacterial cause. Uh and then cios you, what's the most likely bacterial cause? It's group a strep. Uh and the, the kind of main exam point for tonsillitis uh is determining the likelihood of bacterial infection and hence whether, whether it warrants antibiotics or not. So the two scores used for that there's center criteria or fever pain. Uh They make questions so that it will, it will fit for either criteria that you use. So you don't need to learn both. Um I, I'd probably, well, I learned fever pain just because it's a mnemonic itself. So it kind of uh helps with remembering it a bit better. Um But whatever you prefer, uh both are equally viable and they, they make questions that fit both criteria. So, so yeah, I just learned one and then neck lumps. So this is our last topic. So uh I think the the easiest way I find to kind of think about neck lumps is if you consider midline neck lumps and then your lateral neck lumps. So uh midline, I mean like uh truly midline. So thyroid lumps will obviously be anterior on the neck um and towards the midline, but I've still put them in as lateral over there. So midline neck lumps, you're thinking uh either thyroglossal cyst, which is the one that moves when a patient sick or tongue out um or dermoid cyst, which is like a, an issue with the uh obliteration of some of the folds from embryology. Uh and they're the ones that can contain hair or teeth or, or skin and different things in them. Um and then your lateral neck lumps. Uh So lymph nodes uh they can of course uh swell with, with infection. So any kind of head and neck uh infection or upper respiratory tract infection, then your cervical lymph nodes can, can uh and turn into kind of more prominent lumps under the skin uh and then tumor as well. So, primary ie uh lymphoma uh or else uh secondary. Uh So, in which case, you'd have to go looking for for a primary site that's metastasized to the lymph nodes. Um and then salivary glands will look at the kind of common causes for submandibular and parotid glands, uh swelling on the next slide. Uh and same with thyroid lumps that'll also occur more anterior on the neck compared to um compared to like the the lymph nodes or the branchial cyst. The branchial cyst tends to come at the towards the top of the sternocleidal mastoid muscle. Um So some exam tips for uh for neck lumps. Uh again, the thyroglossal cyst uh moves with the tongue. So uh remember in your neck lumps, examination, if you're asked to do it to use your your special tests uh for thyroglossal cyst of moving the tongue. Um the dermoid cysts as I was saying that can contain hair, teeth, skin, uh and then your lateral uh neck lumps. So, lymph nodes, if you, if you there's kind of other signs of infection, uh so your upper respiratory tract infection signs titus media or an eye infection, then that might lead you to uh to thinking of a lymphadenopathy uh secondary to infection uh or the bee symptoms. So your fever, weight loss, night sweats, uh those would would suggest ly lymphoma um and particularly night sweats. If you see that in the question, it's basically always either referring to lymphoma or like TB or something like that. So, in this case, with the neck lumps, you'd be, you'd be worried about lymphoma. Uh and then salivary gland enlargements. The common causes for submandibular gland would be a stone in either the gland or the duct. Uh and parotid, the most common cause is mumps. Um If it is a tumor causing it, it is usually benign. But as I was saying, on the facial nerve palsy slide, um if if it does cause a facial nerve palsy, then that would be worrying for a malignancy and then thyroid uh lumps. So can either be a diffuse or a nodular goiter. So if a diffuse goiter, you're thinking of those kind of autoimmune diseases from endocrinology. So, like your graves disease or hashimoto's. Um and if it's a nodular goiter, then if it's multinodular halt on radio iodine scan scan, that basically just means it's taking up iodine and it's, it's an active uh piece of thyroid tissue. Uh that would be less worrying for malignancy, it's probably benign. Um but a solitary nodule with no radioiodine uptake. So it's lost its function as thyroid tissue. Then that's more worrying for a malignancy. Um and then neck lumps examination. Uh So again, just remember before you dive in to, to actually examine for neck lumps, remember your general inspection and the inspection of the neck. So things you can comment on in your general inspection, uh body habits and clothing would relate to if there's potentially a thyroid lump. Um If the patient looks uh like acutely unwell or like they've got uh an infection, then you might be thinking about lymphadenopathy secondary to some uh upper resp tract infection or something like that. Uh And then if they're cachexic, you might be worried about uh a lymphoma. So there are just some, some uh things just to, to say, cause a are a bit of a show. So just having a few things up your sleeve to say for each station is handy. Um And then inspection of the neck, specifically looking for any obvious lumps, uh scars, skin changes uh are just handy things to, to be able to, to, to shout out. Um And then when you move on to palpation, you just need to learn your areas to palpate. Um uh and then just verbalize them in the exam as you're going through each of them, uh get a, get a pattern that you do consistently. So uh I usually go like submental and then move backwards towards occipital. And then you can go down your anterior and posterior cervical chains and supraclavicular. And then I'd usually come to thyroid at the end or anterior neck at the end. So at that stage, you can remember your special test. So sticking out the tongue uh and feeling for any lump moving for a thyroglossal cyst or else as swallowing water for, for any thyroid uh swellings or lumps. Uh And then the last thing for a neck lumps, examination is remember your uh three Ss, three CS and three keys for describing a lump. Uh They're quite easy to, to forget one or two of them because they all start similar letters. Uh So, so yeah, just, just practice kind of saying, saying those out loud uh a few times to get them into your head. Uh And then if something like this did come up, those would just be free marks for you if you had them learned off. So that's, that's us through all the, all the content we're going through. It's obviously not uh completely covering everything for ent um But it's hopefully something useful uh for each of the, each of the kind of topics within it. Uh So here's a screenshot from, I can't actually see the top of my slide. So I'm not sure what year this is from, but I'm sure you will be able to see. Um But it's from the AUS stations one of the last few years. Uh So this one was ear examination on a mannequin. Uh So they could uh put in a, a diseased tympanic membrane uh for you to comment on in that case. Um And then this is the one I was talking about with the Dex Hallpike uh and describing the, the signs. So the main thing to come from, this is basically that it's saying that students uh weren't describing the rotatory stag signs. So that's just if you watch through each of the videos on the portal and get used to the language that's that the doctors are using to, to describe things, then uh hopefully I'll just kind of roll off the tongue in an exam setting. And then this station uh was this was Anterior Rhinoscopy and a hearing assessment. So this is quite a high, quite a high fail rate uh for an OSK station. 18%. So, well, don't, don't be freaking out at that. That doesn't mean that 18% of students failed the OS because you can, you can fail. Uh I'm not sure how many stations you have from third year, but there's, there's quite a few uh stations that you can fail and still pass. But um yeah, I I'm, I'm guessing that was probably contributed to by students just not, not uh going over anterior rhinoscopy before. It's something I don't even know if I was really aware of it in the third year. Um So yeah, get onto the portal and, and watch the videos and make sure that you've covered each of the examinations. Uh It's more about having breadth of knowledge than, than being an expert in anything. So just make sure you cover everything. Um And then yeah, just to go over some, some resources that are handy for studying the portal. Uh, as I've been saying, it's great for acies. Uh There is some useful stuff in them if you want to, if you want to watch them, but I just wouldn't rely on it completely. Um And then zero to finals, I think is the best thing for covering all the content. And then a stop is a useful website and there's a textbook for it. It's the most useful textbook I've come across for AKI. So I'd definitely recommend getting it because you'll get three years, use out of it between now and final year. Um And it goes through all those kind of a topics that weren't covered in 1st and 2nd year. And you, you know, I remember feeling really unsure about them doing third year Aussies. So I definitely would recommend that. Um Yeah, and then to finish some ay tips, usually one ENT station. So don't, don't freak out about ENT, but just make sure that you kinda cover each possible thing that might come up. Um Don't listen too much to predictions. I've heard quite a few predictions over the last few years and I don't know if any of them have been right. So, don't, don't be studying based on predictions you hear from friends. Um and then instructions, uh sometimes you'll get a quite a long instruction outside a station like a long kind of blurb scenario bit with a few steps to go through. If your mind's spinning at the start of a station and you can't, you can't kind of remember everything it says, just remember to be calm, uh get the kind of main gist of the scenario and just know the first, the first step that they're asking you to do, uh because the instructions are always in the station. So if you know the first thing you need to do, you can just go in, uh get that uh over and done with and then you can check the instructions again uh to go through your next uh the next parts of the station. And then lastly, if you feel like you're, you're never going to learn all the content in time, which I always did do around this time in the last couple of years. Uh I think everyone feels that way and the vast majority of people do pass in the end. So don't be, don't be freaking out, but a bit of a bit of stress is, is always good for us. You getting through everything in time. Um And then lastly good luck everyone and hope, hope exams go well this year. And thanks, thanks for joining us this evening. If you thank so much Ryan, feel free to shout out or email me. I think my email is in the uh like timetable thing. Yeah, so Ryan Mills just in the timetable um that hopefully your lead um peer tutors have sent them to you. So I just put the link to the feedback in the group chat. So it would be really appreciated if you fill that in. Also, it will give you access to the slide. So yeah, we finished a bit early. So I hope everyone will have a lovely evening. Ok. Thanks Bianca. Thank you so much Ryan. All right. No worries.