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Hello, everyone. We're just going to wait a minute or two for everyone to join. Okay. So welcome, everyone. Um, to the weekly mindedly surgical series. Uh, today we're going to talk about common ear, nose and throat presentations on a surgical take. Um, the format is going to be the same as, um as previously. So we're going to talk about the clerking we're talking. We're going to talk about breath, anatomy and pathology of the cases we discuss, um, disease and etiology. And then I'll take you for some investigations and initial management. That's important for the questions and potential complications. The key learning point. Artie, understand what the common presentations are the anatomy and that's relevant. And to understand the risk factors of common presentations. And then we're going to apply the skills that we've learned in indicated and questions. My name is Sharon Osbourne, one of the academic f y two doctors working in London, and I'm adjusting plastics and vascular surgery teaching research. Um, then this is just a quick, quick add. Um, we are collaborating with COPD me, a platform where you can get access to loads of educational videos. Um, which you can add to your portfolio. Um, help you build your career development point. All right, so let's let's get started. So you're on the surgical, Take your one of the F one. So we're going to keep this in mind as we go through, and we're only going to Do you think that are relevant to two F ones? Um, so obviously, in those scenarios you're not going to be the one operating, but you're going to be the one who's seeing the patient first and comes up with the initial plan. So the first case, um, is a 40 year old male he presents with pain, itch and scanty distract from his right ear. So when the patient like this presents to us, we have to think of some differentials. So in this case, um, what we're going to do is we're going to take the history, examine him, we're going to do some investigations which are relevant, and we're going to think about the differentials. So just a reminder. It's a man presenting with a pain in his right ear. Um, some itching and discharge. So some of the key differentials, um, would be otitis media with perforation or tightness. External otitis media is the middle ear information. Um, otitis external is the inflammation of the external ear Ramsey Hunt syndrome. What? It's caused by herpes virus for uncle, which is an abscess which forms in the ear from hair follicle infection. It could be a trauma. It could be dermatitis. Or it could be ear canal malignancy. So the key surgical questions to ask the patients who present with, uh, ear, nose and throat problems, um, are mainly ear pain and discharge. Um, we have to ask about the color of the discharge, the volume. Um, the smell is offensive Doesn't have a smell. Soul. Um, we should ask the patient if he or she or having any headaches. Is there any hearing loss? Tinnitus, which is, uh, this feeling of ringing in the ears. Um, do they have that ago so that they have this, um, spinning like sensation that experience, Do they have any difficulty breathing or swallowing? That's also going to be important. Um, we should also ask about systemic problems such as anorexia, weight loss, nausea, fatigue, fever and confusion. So this is pretty standard that questions that we use for the majority of patients that we see in patients in pain. We should use a sokrati structure, Um, and in this case, the past medical history and past surgical history. The important things are going to be immunocompromised, which can predispose patients to develop developing, um, problems with the ears, any trauma to the ear, or any history of eczema. And it's also important to ask about any family history. The social history important in here would be water exposure and these of coating bones, because that can all cause trauma to the ear. And we'll create this humid environment in the ear, which will, UM, which will essentially mean the bacteria are able to grow more freely. So going back to our case, um, our 40 year old gentleman, he has pain in his in his ear and discharge for three days, but it's not getting worse. So this is why he presented the hospital. It's mostly in front of his ear, and it's worse when he chews and the pain keeps him up at night, which is always a an alarming sign. And he he says that he hasn't had any recent trauma to his ear. His past medical history includes type one diabetes, rheumatoid arthritis and the medication. He takes his insulin for his diabetes and infliximab for rheumatoid arthritis, which is an immunosuppressive medication. He's a nonsmoker and a moderate drinker and swims three times a week. So looking at the the past medical history and the history that we've taken from the patient, you can see that they're already festival. There are some alarming features. So, like the pain, um, pain in his jaw associated with with the pain and the pain that keeps him up at night, despite then being no trauma that he remembers, um, he's also, and an email suppressant medication infliximab, Um and he's diabetic, which also means that he's more prone to have infections. And he also is a swimmer, which means he's going to have, um, repeated exposure to water in his ears, which again is a risk factor, as as I said before, for developing infections in the year. So we're going to examine our patient. Um, we're going to examine him using the otoscope, which you can see on the picture in here, and that essentially helps us visualize the ear, canal and the ear drum and look inside of the year. Um, so we're going to use the otoscope, and this is what we see. So the tympanic membrane is completely obscured, so it will be behind all the structures here, so you can't see the tympanic membrane. There's a lot of redness and swelling of the ear canal and some versed looking discharge inside of the ear canal. And then when we look at his, um, external ear, um, it looks like there is some skin inflammation called cellulitis affecting the ear. The external pinner, um, it extended to touch and his ear is actually cauliflower shaped. We examined his cranial nerves, and the examination is normal bilaterally. And he does have this pain in his temporomandibular joint. So for our patients who presents with with those symptoms um, the most important thing to do, um, is to know what to do initially and then what? I want to refer him to a specialist specialist center. So, looking at this, um, looking at this ought oscopy view. Um, we can quite confidently, um, diagnosed patient with an external ear infection. So the way we're going to manage his external ear infection is, um, we're going to prevent so we're going to advise him on the oral. Toilets were going to ask him to not use codeine buds. And we're going to, um, ask him to avoid, um, avoid water exposure. Um, and he might need some micro suction if necessary. If the patient had eczema, then we'll have to manage this. And if there are any polyps, we have to address that as well. But for our patient, we're going to advise him or a toilet. Um, if it was a simple external ear infection, we advise topical antibiotics, but because his external ear the peanut is involved, we're going to, um, advise him to take our antibiotics. Um, And if there is a canal inflammation, we also advise the patient to use steroid jobs. So those are all pretty simple measures to to treat external ear infection. However, it is really important when you're an F one, seeing the patient intake to know when to refer to ent. So if the patient's presenting the longstanding disease, um, if he develops complications or if there is a middle or inner ear and involvement, then this is something that would have to refer to e n t straight away. So what is this about six. Turner? Um, it's an infection of the external ear. It's a very common condition, mostly caused by an organism called pseudomonas. UM, it is caused because of the interruption of the wax formation, which is usually caused by watch exposure, trauma or a blockage. And that leads to inflammation and bacteria overgrowth. And the risk factors include hot, humid climate, swimming, their polyps and trauma. And the symptoms the patient might be presenting with is, um, as in as in the case with our patient is going to be worsening air pain, feeling of fullness, pure and discharge. And sometimes patients might complain of hearing loss, and this feeling of ringing in the ear is called tinnitus. So just to just to recap, the reasons why we prefer to ent is if the disease is just not going away. Um, and we also have to refer if the patient developed what we call malignant or 56 10, which I'm going to talk to you about. In a second, the patient developed involvement of his bone or the mastoid process, which is a bone in itself that weren't referred to ent as well. If there's any intracranial spread, and again, if there's any inner or inner involvement, would have to refer. So simple. Case advertised external We mostly treat with with oratory little advice, um, type of antibiotics or antibiotics, that there is an pin involvement and some steroid drops. However, in the case of our patients, we are worried about the condition called malignant otitis external. Um, this is a condition which is caused by extension of otitis external into the mastoid process, which is just behind the bone. And the temporal bone, which is again, is very close to to here. Um, and the risk factors are immunocompromised. So, for example, inflicts them up in case of our patient or conditions such as diabetes, which cause immune compromise. Um, the symptoms would be severe air pain and headache. The difference in the way we're going to treat those patients is that those patients will need urgent CT head scan. So when the patient comes in and we are worried, um, that's the external ear infection is not so straightforward. So, for example, in our patient, he's presenting withdrawal pain, which is not a normal feature of the of the otitis external. He also does have pain at night, and we know that he does have risk factors to develop. Malignancy is external. Um, so this is something that we need to bear in mind. So for our patient, we need to order an urgent CT scan and in here on the right, you can see the the arrows. Um, the black arrow is pointing to the involvement of the of the temporal bone. Um, because of the spreading infection from the external air so you can see on the other side this looks completely different, and this is full of the inflammatory fluid. But also, I have to examine the cranial nerves to see for, um to check for any cranial nerve involvement. In particular the seventh cranial nerve, the facial nerve which runs in proximity to the temporal bone in the external ear. Um, and the management would be to refer to the ent urgently because those patients will need the bride mint. So we have to get get rid of all those all those inflammatory fluid, and they will need IV antibiotics. And this is the just a picture showing how malignant it is. External might look like, So you can see this. Um, there's a lot of pure and discharge. There's a redness. And, um, there's this characteristic appearance called the College. So that's how the pain I would look like in somebody with in whom we suspect malignant otitis external. So just so you don't get confused, it's not. Cancer is just this progression of the time It's external, which affects the master prices and temporal bones. Um, but it's just called malignant otitis external. Um, so I just want to briefly talk about the anatomy whilst we added. So you understand, Um, what we are talking about when we talk about the extent of the year, maybe a year and in the ear infections. So on the picture on the left, you can see a simple diagram of the of the year. So the outer ear consists of the pin er and the auditory canal, also called an ear canal. So the external, um, ear infection is going to affect this part of the ear canal and dinner in the middle ear, as you can see in here, consists of the malleus in case and stapes, and then the inner ear consists of the cochlea and the semicircular canals, and this is essentially the way that the sound will travel. And then all those organs are responsible for allowing us to hear, um, looking at the pictures at the bottom. Um, this is what you'd see using the artist scope, looking inside the air, um, in a healthier. So what we should see is the malleus. So this bone over here then incus which is this bone over here, and then this is the eardrum, and you should see the light reflex. Okay. And this is, um, just next to it at the bottom of the screen, we can see the view using the otoscope of somebody who has a middle ear infection. It's the middle ear being here very close to the to the eardrum. Um, when we look at it from the outside, we can see that again. We have the malleus and Incas, and we see stapes in here, but you can see that there are some retracted pockets and there's a lot of thick fluid in here, and that is suggested. The middle ear infection, which we'll talk about in in a second and the during at the top is just a It's just an extent that here's the thinner, um, and a different different parts of it. But I don't think we have to get into this into a lot of detail. All right, so we're going to use meant a meter today, the same as last week. And I'm just going to show you the code and give you a second to log in. So the code is at the top of the screen. I hope you can all see it. And the code is 6130, 5447. So I'll give you a second to to login. Um, the first question is, what is the most common positive pathogens of the times? Six. Turner. So I'll give you a minute or two. Slogan. Perfect. So we have somebody already joining Perfect. So I'll just give you Give you a minute. So the deposit answers are two pneumonias staph aureus, staph epidermidis and strep pneumoniae. Me, let's say for a few more people to join, because we'll do a couple of questions on on that topic. Perfect. So so far we have 19 people. Let's let's wait for a minute or two longer. All right? So the majority of people, um said that the positive organism is pseudomonas, which is the correct option, the correct option. So the most common organisms causing external ear infection is in fact pseudomonas. All right, well done, guys. The next question, um, is a question that we is the case that we spoke about just nice. A 40 year old male presents with ear pain and discharge for three days. Complaints of headaches draw pain at night. What are we going to do for him? What is the best management plan for him? Are we going to advise him to do all the toilet use? Topical antibiotics? Are we going to refer him to a ent or are we going to discharge and just bear in mind that the question asks, What is the best management plan? All right, Perfect. So just to just to recap, um, in this case, because the patient does have the worrying features associated with the airplane and discharge, including the jaw pain at night, um, headaches. This is going to warrant an ent referral because we are worried about potentially malignant. It is external, but you're right. We're going to advise him or a toilet we're going to give him topical antibiotics. Um, but we are also going to refer him to an ent, which is going to be, um, the best management plan for him, um, to look into the suspected malignant otitis external. All right, And, uh, on that topic, what is a malignancy and 60 now? So the options are localized infection, not responding to first line treatment or extension advertised exterior into the mastoid and temporal bones or 60 in a secondary to metastatic disease. Or it directs your secondary to multiple 60 an infection. And perfect. Um, a vast majority of the right option. Well done. Malignant sized external is the extension of the external ear infection into the mastoid and temporal bones. And in somebody in whom we're suspecting, malignant is external. What is the imaging do we have to do? Is it high resolution CT? Is it an MRI or is it an ultrasound scan? Very high. So well done, guys. It is a high resolution CT, and this is the image imaging that I showed you on the slide. I can go back to it in a second. All right, I will get back to this in a sec, so well done. It is a high resolution CT. So just to go back to the presentation, we go back. Um, just here, um, on a slide when I told you about the malignancy in six. Turner. Just to recap, the patient needs an urgent CT scan, and this is a CT scan. Just over here. Perfect. Well done, guys. All right. And now let's move on to the second case. So the second case is, um, is a six year old boy who presents with difficulty hearing in his right ear. He has had an ear infection one month ago, and he's otherwise well, but his mom is really worried about him. So they come to a and B to see you. So the difference was in here, um, for for air pain and difficulty hearing, um, not resolving after after an infection, it could be arthritis, medium perfusion, otitis, external or trauma. So approach. The case is going to be the same as as always. We're going to take history. We're going to examine, we're going to investigate, and we're going to think about differential, which we have already done. So our six year old boy um suffers from recurrent ear infections, but they usually resolve very quickly and they don't need any any medical. Um, input. His last ear infection was one month ago, but he is still having some difficulty difficulty hearing. And it's otherwise. Well, um, he doesn't have any significant past medical history, and he was born at term without any complications. So we're going to examine him. He is systemically well, his right ear is not painful, and his external auditory canal is normal. But then we take the otoscope and we look at his tympanic membrane. So in here you can see the external ear canal. It looks normal. But then when we look at the membrane, it's not as, um as nicely looking. Um, as the membrane that I showed you on previous slides, Uh, when I talked to you about the anatomy, it looks very dull. And when we examine his hearing, he does have conductive hearing loss on the right side. So just to go back to the slide, um, I just briefly mentioned that there are two or three actually different types of hearing loss. It can be conductive, which we can see in him and that's usually caused by fluid in the allergies. Foreign objects wax in the ear or ruptured eardrum. Um, there can also be censored. Neural hearing loss caused by toxins. Loud noise, Um, and also seen an aging. And it can also be a mixed picture, which is usually seen in viral disease. Had trauma or genetic disease. So our boy presents with with conductive hearing loss. So we did some investigations for him. Um, but mostly it's it's important to bear in mind the same as the extent that your infection, um, this presentation, um, his problem is usually a clinical diagnosis. So what we're going to do is we do the history we examined, and we think, or I think we know we know what it is. So the membrane looks still and he does have, um, conductive hearing loss on the right side. Um, we're going to supplement our clinical diagnosis with two simple tests. The first one is a pure tone audiometric, which I'm not going to talk about it in detail, but this will show us that he does have conducted hearing loss and we can also do it in parliamentary, which will which will reduce um, membrane compliance Essentially meaning that the membrane is not as flexible and doesn't, um it doesn't move as freely because there's something blocking it. And this is just a trace that you'll see on an impediment trace. This is a type B trace. Um, so the membranes essentially stiff, Um, in an adult, um, if somebody presents with with a similar problem would have to ask or add flexible nasal endoscopy to our investigations to include to exclude a mass in the postnasal space. But in a child who presents with a hearing loss one month after the infection, we're going to take the history examine, and we're going to do the two simple death. So the Puritan audiometry, um and it's in parliamentary. So essentially, what this patient presented with, um is a clue here. So our patient has the tightest media with infusion and the reason why Why we know this is because he presents with the classic symptoms and he does have difficulty hearing um, it is a month after, um, in your ear infection. Um, and he does have this conductive hearing loss. And on the auto oscopy, we see this classical classic view of a dull um eardrum, which is essentially in keeping with otitis media effusion. It's also called the blue here, and the reason why it affects Children is because they have a short and immature eustacean tube. It's it's wider and shorter, and the angle is different in adults. So it's quite quite common for for kids to get that, um, it results and build up of inflammatory fluid in the middle ear. So the section dollar showed you before where the where we have the eardrum and all the malleus think it's just a piece of the bones. Um, it does cause conductive hearing loss because those little bones cannot cannot move to transfer the signed because of all this, um, a fusion in the middle ear. The risk factors include bottle fed Children, parent of smoking, A to pee down syndrome and cystic fibrosis. So how do we manage? Um, yeah, um, in 50% of Children, it will resolve in three months, so we manage it. But what we call active surveillance, which essentially means that we watch and wait and see if the kids is getting better. And are there any Are there any complications that we worried about anything, but 50% of cases would just go away on their own in, uh, in three months. When we have to start worrying is there's no resolution after three months. So our our patient presented, um, with hearing difficulty after one month since the infection. So he's still within that three month window. So if it doesn't resolve after three months, um, there are two main options. So it's either a nonsurgical option, which essentially is a hearing aid in session, or a surgical option where we do a myringotomy which essentially, um, is making a little puncture in the tympanic membrane so you can see it in here. This the tympanic membrane, This is a, uh you can see there's a little puncture that we made, so we will pierce it to equalize the pressure inside and outside of the tympanic membrane to let some of this gunky fluid to drain. Um, and then where we put when we made a little hole, we put a gram it so you can see it in here. It's a little tube, which has nobody inside, and we stick it in the in the member in the tympanic membrane will essentially allies for drainage, and it equalizes pressure and the help of hearing and will help the child recover. If this does not work, if the disease is persistent and we have to insert the grommets twice, then we have to consider, um, removing the some of the adenoid tissue. So just recapping the anatomy, you have the extended care of the ear canal, the eardrum here where we would put the grommet in which you can see in here. Um And then what we can also do is we can approach the the other side of the eustation tube. So we have the opening of the eustation tube near the middle er in in a year. And this is where we put the grommet in the proximity of the of this opening of the eustation tube. But then on the other side of your station tube, which is essentially kind of above you're above your throat. You have this big adenoid tissue and the really the way to to help equalize the pressure and and help the child with hearing if they need in multiple government insertions, we can remove this adenoid tissue and that will help and that will help with keeping the eustation tube patent and will improve the hearing. All right, um, well, we have to worry about, however, um is when a patient presents with their pain, um, or a hearing loss, um, affecting the middle ear. We always have to bear in mind another differential called cholesteatoma. So this essentially is going to be discovered on the history and examination. So whenever a patient presented a difficulty hearing ear pain and ear discharge, we take a history. We look with the otoscope and you can see different views in here. So you have the normal tympanic membrane on the top, then the blue here on the top, right at the bottom left, you can see external ear infection. You can see all of those dilating blood vessels in the ear canal and the normal tympanic membrane, slight redness. And then what we can also see is, um, what we call it, call it a cholesteatoma so you can see it at the bottom. Right in here. Um, essentially is, um it's the presence of those abnormal, um, cells and debris in the ear, um which are made of characterizing scream as epithelium in the inner in the middle ear, which can also extend to the mastoid process. It's a chronic, superlative, all otitis media, so it's one of the complications. But it's not a cancer, even though the name suggests so. But the problem is it can cause erosion, and it can destroy the bone, which can then, um, create an environment which is very conducive of infection. Um, and this does warrant routine referral to ent. So the features, um, what's going to help us decide whether that it's a cholesteatoma or not? Is the view on the auto oscopy. So you can see and hear this carrot and plug, and the patients are going to complain of full foul smelling this judge, um, on on the history and those patients again, we'll need a CT of the temporal bone and mastoid process because there's a risk that this will extend into either the bones of the skull. All right, so let's go back to a mental meter and just quickly recap what we've learned. So it's the same the same code, and we just have a couple of questions on that, so I'll give you a second to go back to 20. So again, the code is 61305447. And the first question is, um, we have a six year old boy with difficulty hearing after an ear infection one month ago. He's otherwise well, And what are we going to advise him? So the opinions are quite, um, divided on this one, so I'll just give you a second. Okay, so the options are quite divided, but you did get the the right option. The majority of people which is monitored for a resolution of Bolivia and try to optimize his hearing. And so he presents after the infection has resolved over a month ago. And he's, well, we're not suspecting that his ongoing infection, What we are expecting is that he does have this, um, complication, which is a glucose. Essentially, um, so there's no need to give him antibiotic jobs. Um, there is no need to refer him to ent for consideration of Grandma's, because, um, he's still within this three month period. So we're going to wait, wait for three months and then see if it has not resolved. Then we can think of referring him to ent, and he does not need an urgent going to refer at the moment. So we're going to monitor for resolution of the Gloria and try to optimize his hearing. And what is a risk factor for otitis media with the infusion? So what are what are the risk factors for having a glue here? Yeah, give me a minute. Perfect. Um, so again, majority of people get the answer, right? It's a to be, um, So having a history of of A to be asthma allergies does increase your risk of having, um, otitis media with the infusion. All right, so now imagine that a 45 year old male presents with otitis media of infusion. Um, What tests going to perform apart from the standard tests which are used in Children. So what do we need to do? A flexible nasal endoscopy, a CT head, MRI head or a mastoid bone X ray. Okay, so again, a little bit divided on this one, But the majority of people got the answer weight, which is flexible nasal endoscopy. So in this case, I did tell you that middle ear infections are quite common in Children because of the of the eustation tube being underdeveloped, and because of this anatomy, they tend to get it often. But in adults who get a digital media, we are worried, Um, if they develop a medium perfusion that they might have cancer. So what we have to do is to do this flexible nasal endoscopy to look. If there's any mass in the in the postnasal space causing this obstruction and causing the eustation tube blockage the CT head, I think you might have you might have been confused with the cholesteatoma. So in patients who do have cholesteatoma So this current unplug, um, near the tympanic membrane, they need CT head to check for extension to to the mastoid process. But for adults who come with blood here, we have to do flexible nasal endoscopy, all right, And this we're going to leave for later. So let's just go back to the last case. All right, So our last case is a 36 year old male who presents with a nosebleed which started one hour ago. So we have to think, what happened? What could be the possible causes of, um of those bleeds? So some possible differentials could be no Strama, which is fairly obvious hypertension, which can cause bleeding from the nose. Um, some medication. So blood thinning medications, um, anticoagulants, um, anti platelets can cause bleeding from the nose as well. Um, foreign bodies having cardiomyopathy. So problems with clotting. Um, malignancy, which is the one that's, uh, that we cannot miss and use of cocaine can cause those beads. So again, we're going to approach the case. The same as always. We're going to take history, examine do appropriate investigations and rule out the differentials. So our case are 36 year old guy presented with a nosebleed which started one hour ago during a boxing class after being punched in the face. So we kind of have our have our answer. Um, to what happened? Um, 100 on the on the silver platter. Um, but the bleeding, um, he can't stop it and now feels dizzy. He didn't lose his consciousness, and he's never had a bad nose bleed like this before. He said it was perfectly fit and well, doesn't have any past medical history. And there's no family history of coagulopathy thing. We examine him and he is feeling dizzy, but he's still talking to us. Um, he's not confused. He's able to obey commands and his eyes are open. So GCS is 15 and 15. There is someone going bleeding from the right nostril and the nose does look swollen. And when we look inside of a notice, we can see the visible, a visible bleeding point, the interior part of the septum. On the right side, we look inside of his mouth, and there is no evidence of blood in the pharynx. His BP is 100 over 17, his heart rate slightly raised, 205. Respiratory rate is normal at 16, and the temperature is 36.3. We do some blood tests because we worry that if he's losing blood, his hemoglobin might be low enough that he might need a transfusion. However, hemoglobin is 89 um, so he's not at the usual threshold of 70 where we think about transfusing. But obviously there's ongoing bleeding. Then it's perfectly assigned to do. A group is safe. Um, take group and safe bloods and cross match some blood for him. If there's ongoing bleeding, his clothing comes back as normal and his electrolytes are normal as well. Um, so epistaxis is bleeding from the nose. Um, is a very common thing, but actually, you can lead to a very serious hemorrhage. So we have to be very cautious when dealing with a patient who presents with a nosebleed. Um, 90% of cases are caused by anterior bleeds. So on the diagram on the right side, you can see this, um, space called Little Area, also called the Capsule Backs. Plexus is located in the anterior septum, and it's where five different arteries are just amazing. So it's a it's a very vascular bit of the nose. So if there's any injury or there any other causes to cause nosebleeds, it's going to come from from here. In 90% of cases, in 10% of cases would be, um, from the posterior nasal cavity, um, mostly from a sphenopalatine artery, which is you can see in here in the back the things that we have to look out for. If somebody presents with the bleeding and this is associated with a facial pain or ear pain without any trauma, then we are worried about suspected nasal pharyngeal tumour, so it's always really important when somebody presents with a nosebleed to ask them about facial pain or ear pain. But obviously, if there is a trauma, then it's a complete, different story. So the way we manage those patients, um, it's very important to approach all the cases as if they were severe until proven otherwise. So we approach all the cases using a two year approach to stabilize them. They might need some blood. They might need some fluids. We have to get him stable. Um, in somebody who presents with a nose bleed, it would not stop. We have to escalate your senior straight away. And if we are really worried, then we might need a doctor. His airway trained, um, to help with that, to make sure that the airway is protected, we might resuscitate with blood products. And if there is a posterior blood Sorry, the posterior bleed. A lot of blood can be swallowed, and not much can be seen coming out. So this is why it's important to at first with all the cases as if they were severe. All right, so what do we do when somebody presents a nose bleed? The initial management will be to keep somebody set up set forward, then ask them to apply the compression, the manual compression to their nose for 20 minutes. If you're not able to do so, then you have to do it essentially, pinch their nose for 20 minutes and ask them to lean forward. Um, we can use some ice to stimulate faith in construction so we can put some ice on the nose. If the bleeding continues, we can use this special piece of kit to inspect the septum so it just keeps it open. If there is any visible and your bleeding point, then we can cauterize a silver nitrate so you can see and hear a little stick of a silver nitrate at the at the end. If there are any visible bleeding points, we can just cauterize them, and hopefully that will stop the bleed. Um, if that does not help, we can use adrenaline psychosis, which again will cause, um, localized phase of constriction so the vessels will shut time and we can put that inside of the nose, and we also have to look into your firing. So there's a lot of blood, um, in the in the firing, that means it could be an posterior bleed all right, So if this does not help, we have to think about some further management. And probably at this point, we might need to. You need to call the ent doctors to send us a hand. Um, so there is no bleeding points identified. We can cauterize it with silver nitrate bleeding continues, and there are some things that we can do so we can do anterior packing with the nasal pack, which you can see in here on the first picture so we can put a nail back. If this does not help, we can put the nasal packing the contralateral nostril, the one that's, uh, even if it's not bleeding. Because that was, um, pressure helps compress the vessels. If the bleeding is ongoing and there is a blood in or referring, so we're suspecting the posterior bleed, then we can do a posterior packing so you can see it in here on the picture number two. So you put the folic catheter all the way up to up to the throat, um, roof of the throat and then inflate the folic catheter. And then again, we can do it in one nostril or two nostrils just stop the bleeding. Now, if this fails, then we can think about surgical ligation or radiological embolization bleeding vessels. But that's going to be done by, um, by a specialist in the operating theater. All right, so before we move on to the summary, I have two last questions for you. All right, so I'll just give you a sec to join. And the first question is a 60 year old presents with no past medical history. Um, he presents with unprovoked bleeding from the nose. So no trauma and it is associated with facial pain, and he does have some ear pain. What do you think is the most like because? And what are you worried about? So are we thinking about illicit drug use? Are we thinking about the use of angioedema? Are you thinking about rhinosinusitis? Do you think it's idiopathic so we don't know why it happened, came out and I was all right, So in this case, well done. We are suspecting nasal pharyngeal tumor. So in a patient who comes in with a nosebleed and has associated facial pain and an ear pain without any trauma, then we always have to think it could be a nasal pharyngeal tumor, and we have to refer to ent. And what agent is most commonly used in quarter rising for nosebleeds? Is it, um on and chloride sodium bicarbonate seven. I trade or hydrogen from might. Perfect. All right, So, everyone good. This one, right? It is silver nitrate, and this takes us to the end of our mental meta presentation and brings us to the summary of the session. So we have learned about some common, um, e n t problems that you might encounter on the surgical Take, um, just to recap the otitis external. Well, mostly present with ear pain and the discharge. Um, we mostly made diagnosis clinically. But if we're thinking about complications such as malignant type of external, then we need to refer to ent for a high resolution CT scan. Management of simple device external includes prevention, oral toilets, topical antibiotics and some steroid drops. Um, all otitis media effusion can present with conductive hearing loss. And the characteristic feature is that the tympanic membrane will be adult on examination. It was present for more than three months. Then we have to think about further medical surgical treatment. Um, and then finally, nosebleeds can be caused by, um, a lot of different things. If it presents with facial pain or ear pain, we have to think about cancer. And with that, the ent 90% of cases would be Ontario bleeds in all cases should be treated is TV until proven otherwise. And just to remind you, you can read more on mindedly dot com for surgery. And I'll be very grateful if you could fit in the feedback form so we can know what you liked and what you didn't like and what you like us to do in the future. Um, so I'll let you scan the feedback feedback code. And if you have any questions, just put them in the chat, and I'll answer them shortly. But please, please do fit in the feedback from I just put it on here. Mm hmm. All right. So let me just move this perfect. All right? So let me move the feedback for Okay. So are there any questions? So the date and the time for next presentation for peri operative complications is next Monday, Same time. So next Monday, eight PM