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Ok. So, hi, everyone. Thank you for attending today's session. So, this week we are on Ent and Max Fax week and we have University of Dundee presenting. So, my name is Prudence. I'll be the moderator today and I'm one of the educational coordinators. So today is session one. We have ESSA from Dundee who will be presenting um session one of this week. So I'll hand it over to you now. Hello, everyone. Um Thank you so much for joining us. Um So, yeah, we'll just get started. Um So firstly, thank you to our partners. Um Here we have kind of like all the learning outcomes that we're gonna go through today. So we're gonna go through the ear, um the nasal cavity, um prostate gland, like salivary glands and all that. So I'll just start. So firstly, we have um the anatomy of the ear. So the ear is basically divided into three parts, uh the outer ear, middle ear, and inner ear. So the outer ear can uh consist of the auricle, um and the ear canal, which also is also known as the external acoustic mucus and basically the function of the outer ear is to capture and direct sound waves uh towards the ear canal. And then um yeah, and then we move on to the middle ear which contains like the tympanic membrane. And um its main function is to transmit uh vibrations uh throughout the middle ear uh throughout the sorry, sorry. So the middle ear also consists of the tympanic membrane and also the three bones, it's called uh they're also called the um auditory ossicles. And uh they basically transmit vibrations to the inner ear. Um That's what I was meant to say. Um And then the inner ear consists of the semicircular canals and also the cochlear. Uh the cochlear has uh functions in hearing and the semicircular canals have functions in balance. Um Yeah. So that's basically the anatomy. Um And then, so this is the tympanic membrane. Um And it lies uh at the distal end of the ear canal as we saw just now. And it's a connective tissue structure, it's covered uh with skin on the outside and it has a mucous membrane on the inside. And um it has um a translucent like it's translucent which allows us to uh be able to see um the structures within the middle ear um through otoscopy. And then, yeah, so you can use the cone of light um which is this um it's shown on the little image over there and you can use the position of that to kind of orientate uh which ear you're in. So, for example, in the right ear, your cone of light will be in the five o'clock position and then in your left ear, it would be in the seven o'clock position. Um So yeah, that's your tympanic membrane. Um And then, so we're just gonna start uh uh with the certain conditions. And so we'll start with otitis media uh with effusion, which is also known as glue ear. So, glue ear is uh a condition where fluid uh accumulates in the middle ear. Uh it's more common in kids and it has like a peak incidence uh around uh two years of age. So basically, um the reason why kids uh are more likely to get glue ear is because they have really large like adenoids and this can block the eustachian tube. Um glue ear is also the most common cause of hearing loss in kids and it also predisposes them to developing acute otitis media. So, these are some of the risk factors. So, for example, if you're a male, um if you have siblings who have had blue ear, um it happens in winter and spring more um could be due to upper respiratory tract infections which are more common during these times. Uh bottlefeeding in supine positions, attending daycare, parental smoking, and also craniofacial abnormalities such as cleft palate. All of these can predispose kids to or people in general to having glue ear. Um So yeah, so these are some of the symptoms. So you have conductive hearing loss and this in turn can lead to like poor school performance, behavioral p problems, speech delay. Um obviously, cause kids can't communicate um like these problems, like the fact that they can't hear so well. So these are some ways that um this can manifest. Um they might also like tug at their ears a lot. So that's another sign to look out for. Um in terms of signs, you will see uh you could see middle ear effusion. So this is rare but it can be seen um as like bubbles behind the ear. Um you could have a dull uh tympanic membrane color. Uh your tympanic membrane can be retracted and you will also have the loss of the light reflex. So the cone of light that we saw just now can be lost. Um And then you would also, so investigations how you would investigate glue ear. So oscopy obviously to view um the tympanic membrane, uh you you you can use renas and webers. So it will show bone conduction over air conduction which is conductive hearing loss and then it would let electrolyse to the affected ear. Um The audiometry would show mild conductive hearing loss and you would get flat tracing on toma tympanometry. And then the one in red is basically some of the red flags um that can, that would require you to kind of refer um patients on. So unilateral glue ear, um especially in adults. Um This can indicate like um maybe a tumor, um compressing on the eustachian tube. Um weight loss, fever, night sweats, any neck clamps if they have unilateral epistaxis or unilateral nasal obstructions, if you have any of these um symptoms, you should refer um the patient on. Um Yeah. And then, so for management, usually most um blue ear incidents would cases would resolve on their own. So you would wait for about three months, just um monitor. Um And for kids, you can also do the autoinflation or valsalva maneuver where this is where you basically um pinch their nose closed and ask them to blow. So it kind of um equalizes the pressure in both ears. Um If um after three months, symptoms are not like resolved, you can treat with like nonsurgical or surgical options. So the non surgical option would include like um so bend bone anchored hearing aid. So this is not like um it's similar to other hearing aids, but instead of being inserted into the ear canal or held um behind the ear, it's attached to like a soft band and it's worn on the head. Um And then f uh surgically you can do m myringotomy and grammar insertion. Um And this, the picture basically shows what uh the grommets look like. And um tea tubes, tea tubes are similar like they have the same purpose as grommets. Uh but they are like t shaped and they would have to be surgically removed. Cause grommets uh will fall out spontaneously but tea tubes won't um and they stay in a lot longer than grommets do. Um Yep. Um Yeah. And then the next uh condition we have is pera perforated tympanic membranes. So, these are some of the causes. So it could be due to infections which is commonly um it's a complication of otitis media with effusion. Uh it could be iatrogenic. Um it could be bar trauma or direct trauma. So, barotrauma, maybe, you know, s scuba diving if you go scuba diving, stuff like that, direct trauma. So cotton buds or head injuries, um the signs and symptoms. So it could be incidental. So it could be incidentally found. Um the person might have no symptoms at all. So, asymptomatic they would have og um AA so like pain um discharge. Um the patient also have conductive hearing loss. Um Recurrent otitis media is also a sign um that your tympanic membrane could be perforated. Um And then, so the management for perforated tympanic membrane is um usually it's conservative. So small perforations tend to heal spontaneously. So the only advice is just um avoid getting water into the ear. Um um you could consider hearing aids, but um usually you would just leave it. Um and if they're having um more than um three infe so you can also repair it surgically. So they're having like if a patient is having more than three infections a year. Um You can consider um myringoplasty, which is the one like if the person is having recurrent otitis media, you can do laryngoplasty. Um Yup. Um, we'll just move on to the next one. So the next one is uh pinna hematoma. So this is basically caused by direct trauma to the external ear and you can see in the upper right, um cona, that's what it looks like. So it, it's said to have kind of like a cauliflower um appearance, cauliflower ear. So it just becomes really swelled up and red. Um And this is like an emergency because the blood supply to the underlying cartilage can become impaired. And if left untreated, you can basically disrupt the supply and cause avascular necrosis of the pinna. And yeah. So investigations for this, it's usually clinical diagnosis. So you would do like an inspection, uh palpate the ear, you can do an otoscopy to um look if there's any injuries in the middle ear. Um and one of the most important things to do is to rule out temporal bone fracture. So the way in which you do this is um basically looking for any hearing loss, any facial nerve injuries. So any facial nerve palsy um vital signs. So if you can see in the picture like it's post auricular like bruising, um that can indicate like there's bleeding or pain, the eyes again around the eyes like it's dark. Um Yeah, so this needs a same day assessment by ent and you need to do incision and drainage um within 24 hours um to prevent cauliflower ear. Um Yeah. So the uh the steps for the um incision and drainage is stated on the slides. Um And if the hematoma is small enough, you could just do a needle aspiration. Um Yeah. So next, we're just gonna move on to the anatomy of the nasal cavity. So the nasal um um yeah, the n nasal cavity is made up of five bones. And this, this is the vomer palatine maxillary ethmoid. And um so, well, yeah, there's five bones. Um and then the, the nasal cavity is also divided into three parts. So it's divided into the vestibule, the respiratory region and the olfactory region. So the vestibule is kind of like the opening uh uh surrounding the um external opening to the nasal cavity. And then you have the respiratory region which is um lined by ciliated pseudostratified epithelium. And then you have the olfactory region which is located at the apex of the nasal cavity and it's lined by olfactory cells with olfactory receptors. Um The cavity also has um the nasal contra um and this uh the function of this contra is basically to increase the amount of inspired air that is coming into contact with the cavity walls. So, basically what it does is it disrupts the laminar flow, um makes it slow and turbulent. And so the air will spend longer um time in the nasal cavity so that it can be humidified and then the contra um c uh will project into the nasal cavity and it creates four pathways uh which are called mutases. And there's four mutases. There's the inferior mutus, the middle muts, um the superior muts and the sphenoethmoidal recess. So the inferior Mattis is between the inferior contra and the floor of the nasal cavity. The middle maters is between the inferior and middle contra. The superior Matis is between the middle and superior contra and the sphenoethmoidal recess is um superior and posterior to the superior contra. Um Yup. So the function of the nasal cavity is basically like I said to warm and humidify, inspired air. It removes and traps any like pathogens and particulate me matter from inspired air. Um It's also responsible for um smell and it drains and clears all like the paranasal sinuses and lacrimal ducts. So, as you can see in the picture, we have four paranasal sinuses. So, um they're all paired. So, frontal sinus, you have two frontal sinus, um ethmoid sinus, maxillary, sinus and sphenoid sinus. Um So, the para nasal sinuses are clinically relevant in the transphenoidal surgery, which is also known as endoscopic transsphenoidal surgery. And this is because like the sphenoid bone um has a very close anatomical relationship with the pituitary gland. Um And the pitu pituitary gland sits in the sella turcica of the sphenoid bone and the pituitary gland can be accessed surgically bypassing the instruments through the sphenoid bone and uh the sphenoid sinus. So, yeah, um Next we're gonna move on to the Kaiser backpack. It's also known as little's area. So it's made up of um the anastomosis of these five arteries. So, the anterior ethmoid artery, the posterior ethmoid artery, the sphenopalatine artery, greater palatine artery and superior labial artery. So, um the kel box plexus is located in the anterior nasal septum. It uh supplies uh blood to the anterior, inferior quadrant of the nasal septum and it's a very vascular area. So, um epistaxis can quite commonly occur from this area. So, nosebleeds and um yeah. Um so that we're gonna move on. That's the next thing I wanna talk about. So, nosebleeds, epistaxis. So these are basically the causes. So it can be idiopathic uh trauma. So, nose picking nose blowing, insertion of foreign objects, fractures, hypertension, cocaine bleeding disorders. All of these can cause um nose bleeds. Um There are two types. So, anterior nosebleed, which is the more common type, um which is caused by a rupture in the Kaiser plexus or the toes area. So, 80% of nosebleeds are anterior, um posterior bleeds are caused by the rupture of a sphenopalatine artery which is a branch of the maxillary artery. And so management is always in a stepwise approach for um nose bleeds. So first you would do first aid. So you would pinch the fleshy part of the nose um here and then lean forward um ice pack compression and then if let's say the bleeding doesn't stop. Um And you go to secondary care. Um So you would do resuscitation. So ABCD E approach, um the first thing you would, the uh the next thing you would do is try to slow or stop the flow. So, using ice or topical vasoconstrictors, um and then you would use a Rhinoscopy or nasal endoscopy to investigate the source of bleeding. And basically, then you would move on to um uh use um direct or indirect therapy. So you could use silver nitrate co three if you can identify um an interior bleeding point, uh or you can use indirect therapy. So nasal packs, foley catheters, basically. Um there's pictures, I've put some pictures of um the packs and catheters and yeah. So this is basically you can use the nasal packs and foley catheters if to compress um areas which are difficult to identify. So, bleeding areas that are difficult to identify, you could use them. And if all measures fail, then you would do a spen palatine artery ligation. Um endoscopically, yeah, and we'll then move on to nasal sepal hematomas. So this is um a very important complication of nasal trauma that should always, always be looked for and ruled out um because it can cause irreversible septal necrosis um which in turn, um can cause c nose deformities, which is shown in the picture. Um So basically septal hematomas is the development of a hematoma between septal cartilage and the overlying perichondrium. And it's like um often associated with trauma. And yeah, uh head trauma should also always be ruled out. Um when you have a patient presenting with septal hematomas. So it can present as like a sensation of nasal obstruction or just pain. And basically, it will look like um it's basically bilateral red swellings arising for from your nasal septum and it can present unilaterally, but most commonly, it tends to present bilaterally. Um So sometimes a deviated septum can look similar and the way you can differentiate a deviated septum from a septal he hematoma is by gently probing it. And so in septal hematomas, they tend to have very boggy feeling while deviated septum would have more uh firm feelings. Um Yup. And then the management is basically um urgent surgical incision and drainage. Um So, within 24 hours uh to prevent uh septal necrosis, IV antibiotics. So, usually amoxicillin and um splints and quilting sutures. Um Yeah. Ok. Um That we're gonna move on to the salivary glands. So there's three salivary glands. That's the protid gland, the submandibular gland and sublingual gland um as shown in the photo. So the biggest gland is the carotid gland. It's located superficial to the mandibular Remus. Um It is uh its blood supply is by the posterior auricular and superior temporal arteries and its blood uh venous drainage is by the retromandibular vein, it's innervated. So it has a few innervation. So it's sensory um innervation is through the auriculo uh auriculotemporal nerve, sympathetic innervation is through the superior cervical ganglion. And the parasympathetic is through the. So um cranial nerve nine to the alter ganglion and then auriculotemporal uh nerve, which is the branch of um CNV three. Um Its secretions are transported to the oral cavity uh via stent's duct and it will open it. Uh stents duct opens into the oral cavity at the second upper molar. And um the parotid gland has um an important anatomical relations that pass through the gland. So it has the facial nerve and the five terminal branches of the facial nerve. Um the external carotid artery and the retromandibular artery. So one way um I've put the pneumonic there. But one way to remember the terminal branches of the facial nerve is by using the pneumonic to tanz by motor car. So to Zanzibar, not Tanz oh, there's a mistake in the slides. Um but to Zanzibar by motor cars. So there's temporal zygomatic buccal mandibular and cervical. Um Yup. And then we move on to the sublingual gland. So the sublingual gland is the smallest and most deeply uh situated gland. It's located medially uh on the floor of the oral cavity and it's located underneath the tongue. Um Its blood supply is uh by the sublingual and submental arteries and it's drained by the sublingual and submental veins. It's uh innervation. So, the parasympathetic innervation is through the corda tympani branch of um the facial nerve. And um the sympathetic supply is through the superior cervical ganglion. And the secretions are transported to the oral cavity via the minor sublingual ducts of ravinus or duct of ravinus and they open out onto the sublingual fold. Um And then we move on to the submandibular gland and the submandibular gland is located below and behind the ramus of the mandible. It is uh again, uh it's supplied uh by the cemental and sublingual artery and its venous drainage is through the facial and sublingual vein. Its innervation is sympathetic, innervation is called a tympani branch of facial nerve and sympathetic is through superior cervical ganglion. Uh The secretions is transported to the oral cavity from the small ducts. So the ravenous ducts to the Balin duct, then to the submandibular duct um to the sublingual papillae. Yeah. Um and finally, we have uh salivary gland tumors. So, salivary gland tumors tend to be uncommon. Um but when they do occur, the parotid tumors are the most common type. Um most of the time they tend to be benign. So, um there's a little fun fact, 80% of salivary gland tumors are within the parotid gland, out of which 80% of these are benign and out of this uh benign, 80% are pleomorphic adenoma. So, that's a little like um easy way to remember, um the most common type of salivary gland tumors. Um So, theoric adenomas are the most common type. Uh They're benign. Uh but they can transform to become malignant. Um tumors of the submandibular and sublingual glands tend to be malignant when they do occur. Um So there is um yep. So the clinical features would be pain of the affected gland. I don't know why the slide. Um Yup. So there's a spelling mistake but there's pain of the affected gland and obviously swelling, it would be swelled up. Um And with parotid tumors, uh malignant parotid tumors, facial nerve palsy can occur. So, um yeah, so lots of um taste in the anterior tooth, third of the tongue, uh facial paralysis. Um Yup. So how do we investigate salivary gland tumors? So, they can be investigated by um ultrasound fi uh ultrasound, guided fine needle aspiration. Um And for staging of the tumors um is by CT so for local relations or um MRI for deep lobe of the protid or relations with the cranial nerve and the management is by surgical rea uh resection. So it can be a superficial or total peridectomy resection with or uh without cervical lymph node clearance and with or without uh adjuvant radiotherapy. So, usually in the early stages, uh you can't really differentiate a benign tumor from a malignant one. which is why most of the time you resect um the tumor, whether it's benign or not. Um and if it's an adenoma, there is risk of malignant transformation if it's left alone. Um One of the things that to look out for um is that a facial nerve, uh retromandibular vein and external carotid artery can uh be damaged during per peridectomy. So it's uh it's important to look out for the structures and be aware. Um Yup. Um And I think honestly that is all, it's a really short talk, but if you guys have any questions or anything, just feel free to put it in the chat box. And yeah, great. Thank you, Jessica. That was very helpful. Um So we can see if anyone has any questions. Um In the meantime, I will just send everyone a feedback form in the chat. And if you fill this in, that will be really helpful for us and also for Sica and also on completion of that, um you will receive a certificate of attendance. So um that will be beneficial as well. So if no one has any questions, um the slides will also be uploaded um by the end of this week as well. And we also have um part two of um the ent session which will cover more of max fax uh tomorrow at 6 p.m. as well. So please stay tuned for that and join us if you're available. Um Otherwise I think we can conclude it here. So once again, thanks very much for attending and thank you Jessica for presenting today as well. Yes, thank you everyone. Thank you and have a good rest of the day. Yeah.