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I got rather Hello? Hi. Um, on. Welcome, everybody else. High alerts. How are you? I'm fine, thank you. I'm good. Quick. Look, um would you be able to try just sharing the screen with your slides just because we have a bit of an issue yesterday just where it took a couple of attempts to get the slides going. Yeah, I try, but does that seem okay, Gabrielle? Yeah, I know that. It's very it's definitely working. Uh huh. I also like how you used the mind, the bleed longer. First speaker so far to have done that. So okay, way if you're released, will start when you were a few minutes. But, uh, just if this drags Liz time to get healed, so I'll turn it off now. Yeah. Just to say before we begin, I'll be posting in the chat function. Um, I will want to the travel team throughout. So if people want to ask questions, it'll feel free to do so on. I'll interject when you finish speaking, but I can also some save the questions until the end as well. If anybody wants to ask anything in particular, um, we also have the feedback function, which is basically a feedback form. So for anyone that wants to, um, to get the certificate you need to fit in the feedback form on, then it will automatically generate a certificate to you. Um, and also just to say that this will be, um it will after a couple of days because it takes a couple of days from medal to process. It will be personal call medal first in 2 to 3 days as a catch up recording. And then afterwards we'll be put on to our YouTube channel. It just takes a little bit of time to process. All right, since it's seven o'clock, I'll just start introducing and then we'll probably have more people join a sweet go on behind my name's Gabriella. I'm the ent lead for mine. The BLEEP We've been organizing a serious of webinars to help people who were going into F two s h o T level basically prepare for being the ent s h O. As it may not necessarily be a topic that's covered in medical school that much So I've been organizing a serious of speakers to come and cover really important topics. Ritual hopefully stand you're in good stead for your s h o job in ent. Um, like I said, just a bit of housekeeping. Um, there's a feedback form in the main chap. Please fill it house at the end. We really do value your feedback and go through it. And we also send it to the presenters a swell to help them develop on. Reflect for the next time, um, on you won't get the certificate for attending unless you fill out the feedback form. Um, we've been hosting these events on cheese days at seven PM Uh, we have a couple more to go next week and the week after, um and yet so this week session is being hosted by the lovely Alex Bell. Um, and it will be on common ent procedures and skills will be really useful for you going forward, especially because you're expected to act a lot more in an independent capacity anyway, aren't won't fill out. If you want to ask any questions, just put them in the messages box, and then I will pick up on it on. Do, um, ask. But at some point, you may be more appropriate to ask the questions when Alex is finished speaking. So don't worry if I don't answer immediately, and they can also be a little bit of a lag. I've noticed a little bit of a timeline between you answering a question on it, popping up on the screen. Anyway, thank you very much to Alex for agreeing to coming to do this talk. Um, I will need myself in turn. My Yeah, that the breaking up just a little bit? No. Yeah, unfortunately, noticed a little bit. I think you might might be tender. Yes, it's just a little bit. I don't know what happened because it was okay at the beginning when you were talking to me, but for some reason, it's coming through a little robotic. It's It's an event. I just tried to change. My wife, I think often have put that spoke Spanish name. Right? The only guys in the last Is this any better? I'm sorry. No, it's coming out sick. Uh, let me just try the other one more time. Just with me. Does that make any difference? I'm afraid. No, I think. Okay, Um, I just don't because I think I can't watching your wife. I go on the side and you seem to be jumping in. And I was well, oh, well, let's come back in a being 100% with anybody else be able to comment in the chat. How is sounding because I've run out of having issues as well, Jeanine Competitive and the Trans? I just try. Woman's like going every, maybe from just any other thing I could suggest is perhaps if you've got the days are available to go off three G, it's a pain. I don't know what yes, just I'm just trying to go. What is that given moment? Does not need anything, I'm afraid. Know it's still coming through is very readable. I'm I don't know whether it's due because that's three different networks. I've just tried just wondering whether it's my that. No, actually, just my It's very strange because it sounded fine when you join the chop initially. Sorry, everybody. These things happen. Um, hardware, is she? But it's very stiff. Yeah. No, it's very odd. Just because when Alex was here at the beginning of the chap, it was very it sounded okay. I think I'm coming through bright unless racks may, you know I just try back. You know that's leaving. Come, block. Follow. Jeez, everybody, these things happen. Um, if we call and get the sound to work properly, what we'll have to do potentially is just reschedule for another time. Really? Sorry, guys, but yeah, unfortunately, these things happen. Let's give alexin other chance to see whether she comes back. Okay? And you bet took that. Yeah, it's working. Fine. Ah. Okay. Please to interrupt me if it if it goes again, that's really odd. No, very strange. But I know it sounds absolutely fine to me. Anyone moment to just to make sure that it sounds okay on the board cast. Well, just try not to move too much. Yeah. No, it's not good. I don't know. You moved, and now it's Yeah, on. Is it so the same? Yes. That's why we do it again. Going? I'm very still. Yes. No, it's working. Go on. But let's give this a go. I'm gonna put my slides up now. Thanks for being patient. Everybody on again. No worries. You just interrupt me. If the sound changes, it's all okay. Finally. Welcome to this event. Thanks everybody for being patient like I said, I'm just uninterested in to begin with. My name's Alex. I'm currently working as an ent education fellow in Self Manchester, and tonight we're going to become covering Kameni and see procedures as part of my role. Obviously, I teach fourth year medical students you're rotating through that ent block at the hospital, but I'm also on the ent rotor, the Shor rotor, and have been since August. So I should hope that I'm qualified by now to teach you about some of the stuff you're expected to cover on core. I just put my sides up and we'll get started. I think it's fairly obvious it would be really difficult for me to cover. Every single possible ent procedure that you may or may not be asked to do is an S H O. In in one hour. I'm and it's also quite difficult for me to teach you some manual skills via the mid ality of a presentation like this. So I've done my best to try and stuff this presentation through some with some practical tips, and generally I focused on three core procedures, and that's being some Quincy Aspiration Foreign body removal on pen a hematoma. Drainage. I'm not expecting people to recall every single step after, you know, an hour's worth of teaching for each of these procedures. But what I'm really hoping to do is that to try and give you that theoretical background and a little bit of familiarity with some of the ent equipment, just so when you want first few weeks of your ent placement, you're actually a little bit. So when the know about things. And it makes it much easier to pick that stuff up once a richest arise teaching you Like I said, I suppose, in terms of formal objectives will be going through those three key procedures on I should hope by the end of this session you should be able to recognize some of the common indicate indications for each but maybe more importantly, the ability to identify some red flags symptoms that might make you think you need to phone your boss before doing the procedure. And finally, like I said, just to be familiar with some of the major steps in each, it's probably relatively important for me to mention some of things I won't be covering your next session in this Siris is obviously on efforts Axis. So I know my colleague will be able to cover that in much more detail than myself. And so I left that out of this session equally. There's a couple of course skills that you use really frequently as an ent S h o. One of them is using the salt big microscope in clinical rooms to look in people's ears. So that's got sort the eyepiece and the lamp so you could do handheld procedures. I'm on the other is three use of a flexible knees and a scope. So for anybody who's not familiar, that's just a piece of kit with a very thin fiberoptic camera that we use to thread to the back of the nose at the post nasal space and look down at the larynx. I hope I'm not disappointed. Anybody not covering them, but essentially both of those skills really hands on on. There's very little point we're going through it with you without you having the equipment in front of you. Every single anti S H O joins their post not knowing how to do that and is proficient within a few weeks, so I really wouldn't worry about about reading up on that sort of thing. So without further ado will talk about Quincy. Drainage. Probably spent the most amount of time on this just because it's such a common procedure that crops up on call. I'm probably covering some old ground. Really, because I know you will have gone through this in some of this presentations. But as you're aware, Quincy is a parry tonsil abscess on. We use those two terms interchangeably on. More after than that, it's a sequelae of acute tonsillitis. So generally proposed pathophysiology is that you get a bit of necrosis of that tonsil tissue, and then you get separation or the production of Puss and that collects in that tight space next to the tonsil. And it's kind of that peri tonsils spaces bound by your tonsil. A capsule immediately pharyngeal wall, actually with just sort of superior constrictor anteriorly. You've got a lot of glasses and posteriorly platter pharyngitis. One of the key skills for any anti S. H O is again differentiating tonsillitis from Quincy, and it it could be really frustrating in those first few months when you're constantly accepting referrals from GP into a a with query Quincy and they arrived in. It's sort of bog standard tonsillitis again in probably covering old ground. But the key symptoms to differentiate the two and usually people who have a bad Quincy have quite awful trismus, and that's obviously difficulty opening their jaw. And that's simply because you've got a collection, of course, in the mouth, causing local information, particularly of your medial pterygoid muscle, which is clearly a a muscle, a faster cation. And so it's all that inflammation tenses that muscle. It's very different. Difficult to open the jaw. For the most part, people with Quincy have a union actual pain or at least some asymmetry in the pain. And they often have that typical hot potato for us to to allow that congestion at the back of the throat. I wouldn't attempt a impression. I've learned my lesson from a year of teaching her, but I'm not very good at it, but I'm sure you could hear a YouTube clip. But essentially it's meant to be, You know, if you eat something very hot and you're trying to breathe around the food, it's that sort of feature, I suppose, and then clearly the definitive point that separates the two is Theopylline of the peri tonsil a space. So if you have a little look at this picture, there is clearly infection in the back of the throat, isn't there? You can see a rhythm, a on this clear enlargement of the tonsils and actually it is quite a symmetrical. So any anti we often great tonsils on how big they are so great for tonsils are away in the midline. And I agree that on the right side that looks like a Grade four tonsil. But actually on the left, the tonsils quite small. But what's key from different agent? Differentiating this from Quincy a slight, you know, you can see the anterior tonsil pillars is perfectly well maintained, and the curve it your easel there and actually that shaded area that I've just puts up is your peri tonsil. A space on that looks like a concave, and there's no edema. Compare that with this picture where you can see obviously DeMarlo us of that demarcation. It looks fluctuance almost, and you can see that the uvula is push right over to the other side. Just where the mention there is a sort of condition called peri tonsil a cellulitis. And essentially, that just means you've got a demon in the periodontist, the region without a collection of puss, and it often precedes a Quincy. They're very difficult to differentiate clinically and realistically, if you see anything, regardless of whether you think that might be simple senior. So you litis you need to treat it as a Quincy, and you're off to need to put a needle in it. You'll remember that your neck is made up of lots of fascial layers in pre trick your prevertebral fascia. And in between all those layers, that is what we call potential space is obviously if you leave a Quincy completely untreated, that inflammation and post transfer trans locate down into the neck into some of these potential space is, and you can get a possible for parapharyngeal abscess or deep that space neck abscess as a result. And usually those people will present with very obvious next. If nous for the same reason that Quincy causes trismus, a parapharyngeal abscess can inflame particularly your sternocleidals asteroid, and that can give you that sort of torticollis appearance, usually people with abscesses but systemically on well on a very late Sinus. Obviously, airway compromise. It's difficult because people who present with Quincy do tend to have very tender cervical lymphadenopathy and may say the next if this people with some slight is equally can present, you know, with sepsis, I suppose, the point that I'm trying to make it. If you've got any concerns that this is more than a simple Quincy for any of those reasons in the first instance, when you're just starting out with worthwhile speaking to register on later, you'll get used to scope in those patients to rule out power for angina abscess with any abscess. The obvious treatment is to drain the pus because, you know, systemic antibiotics will only work so far. And the way that we do that most frequently is by attaching a needle to a syringe, porcine out in the peri tons of space and drawing off course on. This is the sort of typical equipment that you need for that. So you can see on the very left I've got sort of blue box, and for people you've got good eyesight might be able to read that on the top. That's what we call Kofi no cane spray, and inside that box it's got a little vial on. The solution in that vial is essentially a mix of lidocaine, so it's very good for Topic Lee numbing a mucosal surface. And it also is mixed with adrenaline, which is excellent for causing vasoconstriction stopping bleeding. So we use it across the Siris of procedures in the anti inside that boxes usually got a little nozzle with a sort of spray cap on that you can attach to the vial so you can use a spray next to that on the picture, you can see you've got a tongue depressor, followed by 10 mil syringe, and then finally, the needle on the end. You can see it's got sort of white bass, so that needle is a 16 gauge needle on because obviously pluses. Very viscous. So trying to aspirate that with a really thin needle it is near impossible because of the resistance, you'll find some seniors prefer to use a cannula because you can obviously get 14 gauge cannulas, which is the orange ones, and and so they attach the needle to the syringe in the same manner. But it's a bit fiddly because you've got to get rid of certain things, like the needle safety and and the and plastic tubing and what not finally, on the ends. I've got a sample part on a cup of water on things that I haven't put in this picture of things like a vomit balls you definitely need, and obviously your light source, which is usually a headlight that you carry around with you so hard to do it. Communication with this procedure is really can will come on to that in a slide ulcer. Usually just take verbal consent after explaining the procedure. Position is really important. As you're aware. You know, if someone's coming towards you with a needle, patients have a tendency to try and draw back from from insertion. So what you want is them upright but also with their head resting on something solid. So usually that's you know the bad sat up or a chair with a head rest, and you also don't want to be crouching down, appearing into someone's mouth. You want to have the bad high enough that you're just looking directly in the eye height. Once you position them, you can put your head so John PPA. Get your equipment ready, and then, essentially, you're gonna ask the patient to open their mouth with your nondominant hand. Use your tongue depressant Too sweet talking out the way I'm with you or the hand you're going to spray some of that co phenol spray around the area of the Quincy. I usually then ask people to try and hold that solution in the back of their throat for a long as possible. Because really, you want to keep the solution in contact with the Quincy and sort of an exercise as much as you can. It's important to warn patients, and you may try some of that spray at some point yourself that co venous cane spray is very, very bitter, and sometimes it's well, spraying it. They inhale. It'll bit and it makes him cough. You just got to warn them and just ask them to try and suppress that reflex. A space out as long as they've hold, held it for a few minutes. You can let them spit out into a bowl, swallow it that's safe, a swell, and I usually do it into two sort of separate squirts. Just so on. They get used to that sensation of holding the fluid in the back. Next steps is to insert the needle, so back in the same position, mouth open. Sweet the tongue out the way with the left hand on. With your right hand, you'll be holding the 10 mil syringe with the needle on the end inserted into the periodontist space and aspirate. Once you've aspirated a much a possible and all the prices come out, you can take that instrument out, and you just give the patient a glass of water and ask them to rinse and spit into a formidable and you can empty. That puts some pulling to a part to send to microbiology, just to talk a bit more detail about exactly how to do things. It's important to know exactly where you want to make that puncture site. So the landmark that's commonly quoted in sort of text, books and things is the point of interception between horizontally, the line that skin is the base of the uvula unversity, the line that is, um, on the board, the medial border of your molars on where that line treatment into sex is where you want to put your first puncture site. Usually I'm You'd like to put that needle about one centimeter depth and you want to keep it fairly in the such little planes. They're not wandering off naturally immediately. Yeah, it's difficult, Isn't it too? Estimate. How much? One centimeter is when you got a needle in somebody's mouth. So a technique that some s h o Z use is they had touch the needle to the end of a syringe I should use. She would, but they leave on the safety cap. That's usually on the needle before you take it off packaging. But what they doing it or what I've done in this picture is remove the safety cap cut off one sent to me from the end and then popped it back on. So essentially you can only put that into the tissue one centimeter because then it gets caught on the hilt of the needle protector. The theory behind that is that your common quart it is about 2.5 centimeters posterior and natural to the peri tonsil. A space on a theoretical risk is that you could hit that that artery I've never seen it. Don't. I've never even heard of it done. I think it's mostly a theoretical risk, but when you're beginning, I think it's reasonable to use a safety needle just like this. It's important to give the post time to feel the syringe, because it's not like blood where you get immediate flashback. It's viscous, so it takes time to get into the syringe. If you're struggling to get anything, you congenitally address the needle angle, so withdrawing slightly and then reinserted, and then you can take the needle out completely. If you know if you're not going at you look. Usually it's worthwhile trying a couple of times, but just adjusting your position so you can see on that original picture. There's three stars you could try a bit superior immediately or inferior lateral e. And because obviously, if there's a tiny collection of push, you might just miss that with your needle, and it's worthwhile having another go off the patient control aerator. Final thing to say about technique is obviously with your non dominant hand. You're holding the tongue depressor, so with your dominant hand, you know Onley need to hold the syringe, but also withdraw the plunger and sorry you forgive my nails looking for from that bitch of what? That's how I hold it so that I've got one finger that can pull the plunger. We'll talk about some hiccups that you might come across when you're doing a Quincy aspiration. A really common response to your explaining what you're going to do to a patient is sudden panic. You want to put a needle in my mouth or what to do in that situation. I think it's quite simple, really. You just need to communicate with them. Essentially, you need to reassure them that you do this procedure you know, every day in an E. It's very common in a low risk. Try and be explicit about exactly what you're going to do, so they know what to expect. And they trust what you're doing when they've got their eyes closed and they're not watching. What I think is really important. That I like to do is formulate communication plan because when you've got an instrument, it's wars mouth. You can't tell you to stop because I can't verbalize, so I usually say, if you really need me to stop to tops on the bed and I'll take everything straight up. It's also good to go into the procedure with the caveat that this might just be simple edema, and you might have something called a dry top where no puss comes out. Just so they're aware that's a possibility and also to explain the, you know, the, um, so theory behind wanting to try again. If you don't manage to get anything a second possible hiccup, you go into examined somebody in a any on a soon as you look in the mouth. You know, that's exactly Quincy. But the problem is the patient has such severe trismus that you can barely open their mouth. Well, I think we all recognize that trying to do a procedure in those settings is asking for trouble. Because you've got a really poor view on the patient isn't gonna be able to tolerate it. For the most part, people who are coming in with a Quincy you tend to prescribe everybody the same thing, and that's those set of drugs that I just put in that box of the bottom, one of them being dexamethasone on the most stress. That's a 6.6 mg IV step dose, and it tends to help with the inflammation. Enough done after about a half A Now that your is really relaxed and you can reattempt the procedure, it's worth mentioning. Often you can get side tracked with the patients. If you're you know, you've got busy on call, and sometimes that patient has to wait. Try not to leave it too long for two reasons. Firstly, obviously, that the stories tend to wear off after a few hours. But secondly, sometimes they moved up to the ward on speaking from experience of trying to drain a Quincy on awarded sort of four AM in the morning, where stuff will by the bedside, and it's very poor lighting. It's just not ideal. You're better in an any cubicle way. You've got space to put your equipment, unless ing you put the needle in, you got some puss, but when you look back, it's quite a lot of fresh blood leaking from the puncture site in the mouth. Well, this is normal, you know. What do you expect when you put a needle into a very inflamed area? As long as it's not spurting arterial blood, you have nothing to worry about on it can continue beyond a few Vince's, which sometimes makes patients a bit panicked. You just need to reassure them. You can just ask them to stop rinsing for a minute so the blood has a chance to caught. I'm three erotically. You can use some of the treatments that we use for post on selection. You bleed so things like hydrogen peroxide, gargle or dilute adrenalin solution. But it's really I've never seen that required, or I've certainly never had to do that before the last bone. Quincy. So what to do after you've done the procedure? Well, if it's successful, it's actually really satisfying because most patients feel so much better almost immediately and often they're able to eat and drink after about 20 minutes. And if the tolerating oil intake and they console antibiotics their observations of stable, most of these patients can go home without follow up. Naturally, if you've got any concerns that then that not really improved clinically or their observations, there are four. They're not drinking, then you will need to keep them in overnight. If a patient has had two confirmed episodes of Quincy and specifically, that means you've put a needle in and drawn puffs off, then. Actually, those patients that cope what do qualify for a tonsillectomy? As for the sign guidance. So it's worthwhile either consenting them or, you know, listing them, or at least sending them to her, um, consultant, that clinic to discuss it further. The other slip side is you occasionally see elderly patients with Quincy, and that should start to ring alarm bells because it's not for a common above 40. If that's the case, it's worthwhile booking them in follow up into a two week weight clinic just to re examine them. What's all the information settled? A rule out underlying malignancy in terms of alternative procedures that do the same thing you'll find. Some clinicians prefer incision and drainage of a Quincy. So essentially that just means instead of putting a needle into the peri tonsils space, you're making a shallow incision around that area, and it come be considered necessary if you've already punctured it and it's really accumulated. Obviously, the key difference is that the use of the scalpel because it's a little bit more invasive, you can't really get away with the use of coffee, and I'll spray gain spray alone so Often you have to inject the mucosa with local anesthetic because you're not catching that person in the syringe. It just falls into the mouth so often you need a a assistant with suction to hunt. And sometimes you can dissect that plane if the patient cantata rate it. And it's not something I do regularly. But sometimes it does very trust trust. Can't Grainer basically said that this very low evidence to support one mattered over the other? But as you'd expect, I think really Cumulation is less likely with instant incision and drainage. But it's obviously a little bit more painful. That's it for Quincy. Let me just double track time, Okay, so let's talk about foreign body removal. I find this very satisfying part of the job, and generally you tend to get the best stories from it. Really, I would strongly encourage everybody to start a foreign body hall of fame like I have our trust where you can record the weird and wonderful things that you removed from Aricept noses. It's actually whilst interesting. You know, you're dealing with a difficult patient cohort. We often associate foreign bodies with Children, but you've got to remember the adults that you see a swell. And that's people with learning difficulties, people who have inserted it on purpose because of mental health issues or very on looking adults, usually with insects. I'm sure most of you know by now a red flags for foreign body in removal of things like corrosive foreign bodies like back trees. Somebody found you from media triage with a query battery foreign body, and that needs to be top of the priority. And if you can't remove it straight away than you need to start putting the wheels in motion for removal in two G A. Um, naturally, there's a risk of our compromise with any foreign body and either the nasal cavity, theoretically, but more commonly in the throat. If you've got any concerns about that, you would obviously speak to your register all or get in touch with anesthetics. Occasionally, you come across situations where there is a suspected foreign body, but you can't necessarily see it on examination. And usually the story goes, you know a child or patient was was unsupervised. You came back, and they were with some objects that they could have put in their nose or that is, or, you know, child comes home from nursery and says, Oh, I put something in my nose today. I'm essentially When you come across that situation, you may need to make a decision. Is this unlikely? Can I leave this and see if it, you know it gets worse and safety net them always is something that I need to take further and investigate on. Think about examination on the general anesthetic on this sort of three key features that can help you make that decision. The first is how likely it is that foreign body to be in that cavity without you being able to see it on examination. I'm most Children that put things in their nose a relatively young so between sort of two and four, and they really do have very small nasal cavities. Sometimes patients are concerned parents are concerned. They put something large in there. But for the most part, it's, um, and large objects won't even fit in the nasal vestibule, which is the front of the nose. Most foreign bodies get lodged between your inferior turbinates and your septum, so if you can see a child's inferior turbinates and there's no signs of trauma and it doesn't appear to be anything beyond it is unlikely for a foreign body to be in there. I say that but recently was embarrassed because at seeing a young girl you'd complimentary Health Institute really on a Caries had told me that she put a long plastic so rod in her nose I summoned with the throat a coma. I couldn't see anything. I I said I'd scope just to kind of appeased and genuinely to this day. I don't know how she put it in there, but she really got this piece of plastic lodged is actually behind or kind of just adjacent to middle turbinates. I only sleep don't know how she got to that far. But I suppose the point of that story is to stay. I'm you know, you need to consider all options and just be sensible. It's probably better to error on the side of caution and be flippant and send everybody home. Other things that are overseen keeping with a true foreign body being somewhere a symptoms of discharge. So in the nose that will be unilateral rhinorrhea, particularly if it's foul smelling or if they've got new nasal congestion in the years that you know bad off to rear or hearing loss. And obviously, if it's any chance of something dangerous, like a blade or a battery, then you much more careful ruling that out and other things. And I suppose in the grand scheme of things, when you're just starting, you're just gonna throw in your register and let them make that decision. But those are some things to consider with every foreign body. Obviously we the goal is turned me. That, and the key to removing foreign bodies is choosing your equipment wisely. You want to kind of have a preamble about what equipment you're going to use, the last thing you want to be doing in the middle of trying to remove a foreign bodies fiddling around in your bag, wishing that you've got something else out earlier. So we'll go through some equipment and and some of the corresponding appropriate for embodies. So the first one you can see these forceps on the left there called crocodile forceps or cloak really crocs. They have a very delicate I'm so force that end at the tip on a really quite thin shafts of the great, forgetting things up a very narrow spaces. They're very good if you've got an edge to catch on to. So, for example, paper fabric or on the right, you can see that's a hearing a dome. And they have this brilliant, so thin rim that you can just grasp onto. The problem, obviously, with beads is that you can't really get a good purchase on a bead with forceps, so you have to use something else on. On the very left you can see the hand is holding something called a works hook. Essentially at the end of that hook, you've got thin 90 degree angle, bit of plastic. So that's fantastic. Forgetting beads out because essentially you can slide the pro, pass the beads and then twist the orientation of the wax hook so that 90 degree hook is sitting behind. Now the posterior aspect of the bead and you can drag it out. That way, you can use that second probe, which is called a Jobson Horn probe in the middle in a similar way, but one and you can see it's got a kind of circular component on an angle, and again that could be used dragging upstrokes. And then finally, you can use a subscription. I'm if you suspect you're not gonna be able to pull something out in one go and it's just gonna break off, For example, bits of food, the instructions bringing because you just whoever it all out. Obviously every single clinical area has scription, including any and of the ward. So usually, if you look at this picture on the very right hand side, that's just suction tubing you can hook up to any section on the wall and then in the middle. That is our typical suction prove that we use in, You know, looking at is mostly, you can see it's a lot more delicate than something like a young he sucker, Um, but it's great. You just hold it like a pen and look things up on the very far side on the left. That's what's called a foreign body removal remover. Ironically, you can see it's a little bit different from the suction in the middle, because it's got that signing little blue piece of is only site ruber on the end, and essentially that Blue better is like a suction cook, so it's designed to be able to latch on to round objects around for embodies and pull them out. The reason it doesn't get used very much is because actually that blue component at the end, it's quite big so often for kids. Um, you know, you were two or three. It doesn't really fit in the nostril, but it's something to consider if a child is older. Let's talk about the technique from removing a foreign body from the nose, because I think that's probably a little bit more complex in the air. First stage is to try a procedure called Mother's Kiss. Um, essentially, if you haven't heard of it. The premise is that you use apparent, Um, and they position the child either on a bed or kind of cradle in their arms. And when one of their hands, they include the contralateral nostril on the other side, too, where the foreign body is, they take a deep breath in, and then they form a seal around their child's mouth with them out. And then they shot the exhale on essentially, that sharp exhale of air force is the child to close. That got us the of and circulates up through the nasal cavity. And if you're blocking your beside the air, pushes against that foreign body gets in the nose on offering, it can come shooting out most of the time. When you called from Edie triage, they will have tried this. But it's always worthwhile trying it again when you get to the room, just in case they're not quite manage the technique, and you could try a couple of times. Obviously, if that's um successful, then you need to proceed with trying to take this out with an instrument. Best position to do that, or at least in my opinion, is having that child supplying on the hospital sheets on the bed. Ideally, you want to stop the child flail in their arms around so you can use the size of that sheet to almost swaddle the child and keep their arms. Took 10 My registrar calls or a baby burrito on. Then you probably want at least or three staff members, including yourself. So usually I have the parent holding the limbs underneath the sheet, and you kind of want them to be in the airline of the child to try and settle them and then Usually I got a nurse to hold the head because I know they'll be a little bit more firm. What's really case is just making sure to communicate with a little three of you very clearly. And what I usually say is two parents, at least often Children get very scared when we try and take things out for nose area, and so they get upset. But what I'm doing shouldn't hurt them. What we want to do is do this very quickly in one swift movement to keep them in that position as little time. It's possible, but for that to work, I need them to be really, really still. And so we all need to be quite firm to be kind on. Get this out and get this over with, and usually that kind of triggers them to be a little bit more sensible about trying to keep the child. Com. Is that you? Then you can prop your head light on on approach with your chosen instrument, and usually that's when they start to cry. What's really important, particularly if you're using a probe, is to make sure if you're holding the probe like a pen, you stabilize the rest of the hand on your on the child's face. It just means if the child's had moved, your hand moves with it instead of having that probe hung in free air. Essentially, where it could slip is so again hiccups that you might come across often. By the time you get down to where you need to see these patients, the world on his wife has tried to get this foreign body out, particularly if you're accepting referrals from sort of external hospitals. Another from parents will say, Oh, can you just put to sleep to get out? My typical response is just to try and explain what actually having a G A would entail. So that means that we've got to put a drip in the back of this kid's hand and that's a needle. And they don't like having in, more importantly than not allowed to eat anything for six hours before the operation. And obviously we try and do Children's first Children first on an emergency, less but a share that emergency list with every specialty in the hospital. So sometimes other operations will take Preston. The flipside is if you're trying and the kid is extremely distressing. You're not. You just feel like it's impossible. Then you have to recognize where to draw the line. You don't want to get this kid a complex about coming into hospital. Obviously, if it's a long standing for everybody, it's usually buried in either lots of wax or not so granulations tissue, and particularly if there's lots of infection around the area that could be extremely difficult to remove without some anesthetic on an equally it could be painful. And those were all indications to just list for G A. Another situation that you tend to come across in sort of emergency clinic is if you see an older child who's put something in that ear, usually toe it checked. Um, you can find that very cooperative, their position grand to the microscope. But as soon as you touch that foreign body in the air with solve, yelping out in pain and you can't tolerate it is you're aware that deep portion of your ear canal, the bony cow. It's just a very thin she of skin across the temporal bone, and it's exquisitely sensitive, as is your tympanic membrane. And if they've pushed a foreign body and so deep that it's touching one of them. Even if you just touch the edge of the foreign body with your instrument, it's obviously moving, and that's really uncomfortable. In that situation, I would usually just try and get a registrar to come and give me 100. You know, they might persist, Um, or alternatively, just listening for an elective G A revival finally, comes his scenario. Unfortunately, it's 2 a.m. and you can't get the speed I want to do next. Well, it shouldn't make a difference to your decision, but for the most part, to am your red destroys off site and asleep. And so it's about making a decision whether to phone and we'll bring them in. We'll leave things still the next day on. It sometimes depends on where things are. So, for example, if you find a kid that's got a bead on it, see you. Actually, a beat is an inert substance, so it's perfectly reasonable to send them home and bring them back to your so rapid access for emergency clinic to try and take that out with a senior around. Yeah, the nose is slightly different, so there is a theoretical risk that they could a spray that bleed that be again. I've never seen that happen, but it's a possibility, so we like to try and get those out as soon as possible. Really, if you can't do it yourself and the heading towards being put, you know, put to sleep on the emergency list for an examination under anesthesia and foreign body removal so you could do that by the sending them home and bring them back following morning about 6 a.m. or just admitting them. If it's really late at night, you need to make sure you very explicit with how they need to fast before the anesthetic. You need to phone theater coordinator. You need to phone anesthetics and form of the plan, and then you need to sort organize with the Pedes team whether they're gonna be admitted or whether space have more award in the morning pre op. What to do after you finally got the beat out well is traumatic for everybody, isn't it? A particularly for you if it's sort of 3 a.m. but often the child's crying. The parents are crying, so you know you just need to try and calm everybody down. Let the child be taken into the parents arms and, ideally, before they move, just need to double check that there's no residual foreign body there. I'm had a case a few months ago where I thought I'd remove most of the foam that a child important is his nose, wasn't really wasn't sure and so eventually ended up listing in for G A. And actually, when they scoped him, there was so much more in there. But more than that, they scoped the other side and found a piece of bark. So you don't want to send people home and have thumb represent six months later with being a lot of bloody corollate discharge from the nose. More importantly, with the air, you just need to make sure you don't need to give him some drops to cover for infection. It's tempting to give the parents the foreign body back, but you're asking for trouble. I usually tell them to take a picture of it, Um, for that to remember things. Okay, probably about 10 minutes left of people come back with me. The last thing I want to talk about is Penny hematoma. Drainage less commonly comes up on core. But it is one of those things that you need to be able to recognize and treat. I got I'm sure you guys remember this from med school, but pen a hematoma forms is a result of direct penetral, Mama. So we'll see a lot of patients who have been involved in contact sports presenting with this and you have sharing forces that essentially strip the perichondritis, um, from the underlying a vascular cartilage. In doing so, you tend to tear the peri chondral vessels. They obviously bleed, and blood collects in that plane between those two layers on. You can see that demonstrated in this picture down here. Um, as a result, you've disrupted the blood supply to the cartilage, tend to get a bit of pressure and vascular necrosis, and then you got remodeling of the fiber Bless very irregularly. So people get that deformity known as a college flower. Here, if untreated, pretty simple to spot, really defining features of that fluctuate Penis welling. Sometimes it's a bit arithmetic over there. I'm for the most part, there's a history of trauma. We do see some people with spontaneous seen the time is what It's very uncommon, and usually they're on anticoagulants. Um, most likely those people bump themselves and not from realized, for the most part in a hemotomas are on the anterior surface of the Pinna, obviously, because that's more exposed. But occasionally you do get this, then posteriorly as well. It's worth examining for there's not really brainier had flags. In terms of differential diagnosis, you'll find that if a patient comes in with this, you tend to get called from Edie Triaged to say, We've got opinions home. Can you come down to sort out? Well, actually, if you've had enough head trauma to cause a pen, a hematoma, the you are at risk of intracranial complications. And as soon as you say that you've accepted that patient, they are your responsibility. But whether that's to try and slow out somebody else to come in to assess them or deciding whether they need to see it, he had, except there's just something to think about asking the triage nurse very specifically. Do they have any concerning signs from head from a head injury point of view? So, you know, similar took a Quincy, I guess. What we need to do with the pen. A hematoma? What you need to drain it on. And they idea is that you clear out that blood. You, um, reunite that perichondritis with the cottage on. Really? What you want to do with the pen or hemotomas not let the blood collect again. So the way to do that is to apply external pressure on both sides of the Pinna to keep those two. Um, so there's two layers pushed together. Yeah, I've just popped some of the equipment that you'll need from a pen. A humidifier? It's a little bit fiddly. Essentially on the end. On the left, you've got a straight needle, and I come to this in a minute. But some dental syringes at some dental roles as well. A scalpel to make a decision in the hemotomas. On this at the bottom is two components of something called a dental syringe that they using Max fax a lot. Essentially, you load it with a local anesthetic cartridge. The benefit of using it. It has got very thin needle. I'm also the needle's quite long, so it's really helpful for port in anesthetic in. And then you've got some color accident toe. Wash the area a syringe to irrigate the the capsule and then, obviously everything that you've got in your wound. Pack sterile gloves. A drape galley popping a little tray. When you open out that wound pack, you're very careful not to touch your side, and you can open your equipment on to it, and that becomes your sterile field. There's two ways to anesthetized that when you're doing any procedure, not just been a hematoma. Your pin lacerations, whatever the first is one that tends to be recommended in in some textbooks, and that's a pin a block, so a bit like things like ring blocks or fascial blocks. The point is to try and block the nervous entry to to the body component. And obviously you've got several nerves feeding the pinna things from your cervical plexus like greater regular lesser occipital. And then you've obviously got the branches of your mandibular nervous. Well, the way to do it is usually with what's preferred is to use that dental syringe. So that's the same one I showed you before, but it's just loaded up, and can you see I put some cartridges on here often what we use in these solution called lignospan. It's got a mix of local, an adrenal adrenal in on day local anesthetic in it. Essentially, you insert that, um lignospan around the air by using to puncture sites. So to begin with, you're put the needle in the inferior portion just underneath the low, and then you turn a lot your long needle very superficial e up towards pre auricular tracheal area and then is you're withdrawing the needle. You you inject local the way down that tract, but you don't take the needle out completely when there's just the tip in, you change the orientation and you tunnel again towards postauricular area and inject local anesthetic as you come out and then you can take the needle out and you do the same from the top. And then you create this sort of diamond area of local anesthetic. Infiltration on that will give you completely non pen I've done correctly. The short cut way is to just infiltrate some local anesthetic around the actual hemotomas around a laceration. So usually you could just found some some local, very superficial ian this skin across the pinna on around that sort of area gonna be really careful not to put the local anesthetic into the human told me That's very tender, and it doesn't obviously know anything. I'm only thing to mention is theoretically, your pinner is an extremity, so, you know, theoretically meant to use I'm local anesthetic, this car adrenalin in it for that area, whether people do well, do you know how it comment on? But if you, if you want to use local, is that it's probably worth just getting your registrar sign off with adrenaline eyes. So technique again. Communication and concern to key well usually have these patients lying back on a bed with the head tilt tilt. It's like slightly away, just like if any of you have drained abscesses in general surgery. Always a good idea to point incontinence pad down. I know it's not very glamorous, but it's quite a massive procedure, and actually, you're going to soak the patient's close. If you don't put something down, you can then prepare the air of was sort. Of course, that's a dean and then use a drape around the pen itself, forming your sterile field so a bit like what you do with the catheter. You know, you tear out a circle of drape and do the same and then just kind of hanging over the pen and you can put your anesthetic industry as we discussed. And finally you can make an incision. So your incision is usually the lateral edge of that area fluctuance. And you kind of follow the contour of the heel X axis. It heals nicely that way. What you then want to do is just manually evacuate the hematoma. So you just kind of milking that area fluctuance towards your incision. And then you chondroit some saline and your temple syringe and just irrigate out that, um, cavity that you've left. And it's probably easier if I show you the picture. Really, once you've evacuated the blood Like I said, you want to sandwich that area to keep those two layers in contact. And so you use a dental roll. Which of those roles of kind of like condensed scores. They use in dentistry a lot on both sides of the pinna, and essentially, you're kind of almost throwing a mattress suture through the two, so you're going to thread you a straight needle through the dental sort through the dental role through the pen it directly through the car, such through the dental roll on the other side and then back. And then you're gonna tie it about quite tightly. I I think I was an F one when I first was told this, and it seems quite daunting to thread and heat of through someone's, you know, the cartilage of someone's Pinnock, um, pleat Lee. But actually, if you don't your local anesthetic, well, they honestly don't feel anything on, and it's actually not as tough as you would expect. You then do the same sort of stitch on the other pole of the dentals Vental Roll on. Then you can dress it. I'm I could distributing to think of things to troubleshoot with Penny hemotomas actually quite a simple procedure. Once you've made your incision occasionally, if you've not made your incision in the right place, you might not be able to evacuate that blood. The mud could be a few reasons you have. You made that incision deep enough. You know, it does need to go past the perichondrium. Have you made the incision to naturally so over an area of a demand rather than fluctuations. And also, you've got to remember hemotomas to solidify. So is it just really tough You? Do you need to put a bit more pressure when you evacuating? If you've done all those things, then I don't know why that would be happening. It's probably worth chatting to a boss about after you finished. Generally, what you want to do is apply a bit of a pressure bandage. So if you make a slit in this kind of stuck Gore's and fold that over the Pinna, you can put a head bandage over the top on, secures in place. Basically, tell the patient they can't sustain any more head trauma and give thumb seven days of prophylactic or real antibiotics just cause you've been filling them cartilage and usually we use ciprofloxacin. You want to see them again in yourself Emergency Access clinic in a couple of days just to reassess it and make sure it's not really cumulated. I'm just wondering if we've got time to do this. Uh, no. That's certainly fine just because we had a bit of a delay to begin with. So I think just doing a few quick tips because Yeah, it's title crispness, I think. Should be fine. If there's anyone who wants to go has somewhere to be, then obviously feel free to exit. Um, but yeah, everyone else he wants a sec very much. Well, it's only five minutes. So gone. It's Let me just sign off. I think it's got a bit. Yeah. Trying. Uh, how does that sound? Yeah, yeah, Unfortunately, it's come back. I think you have to maybe get it up on your screen on, then exit and then re enter again. Sorry, everybody, it's Yeah, It's history and things sometimes, but you know, it's you. Yeah, it's the one does movement. Technique? Yeah. What? Revolted. Still, I'll come out and yeah, yeah. In the meantime, if people would like Teo, if they've got any questions that they want to ask about, anything from the past Couple of slides? Uh, well, just the presentation is a whole feel free to put it in the chat books on a loss. Cataracts. Um, do you want to try again? Let me just because Okay. You know, I don't know whether you want to put it in the chat. Absolutely friends. Okay, let's crack on before it goes again. So last five minutes. Now, just some very brief ticks tips on some really simple procedures that you might be asked to do, which take, you know, literally a day to master really in terms you occasionally will get called for ent at from a D rather to suture in a laceration. If you consume your anywhere else on the body, then you can also suture in a laceration. The key is to anesthetized the Pinera's we've discussed so either just with some local anesthetic around the area or the pen a block of it's big, and then you want to use those teeny tiny suits is so usually five or six of something non absorbable, like a Flonase or silk on. The problem with the pen is is you really don't have frame which tissue before you get scar sledge. So very often you'll be able to see coccygeal wound. You need to make sure when you're closing that wound that you're covering the cartilage. Otherwise, you're leaving them very liable for vulnerable to sort of perichondritis like problems. The other things mentioned. I hope you can see my mouse. Sometimes you get lacerations that completely completely through the hell ical rim on when it's kind of hanging apart. By that, the first suture that you want to throw is in the heel ical rim, particularly the most lateral aspect. As long as you can align the helical rim, then everything else falls into place, and it looks really nice. But if you if you start sort of halfway across Concord Bowl, then by the time you get to the hell a call room you've got, the edges don't quite match. So that's the most important thing to mention, and then you just get bring them back in seven days or so for suture of people. Get the GP to do it. Pope wicks Super simple soups. Very often you will see people with very severe otitis external so severe that they're canal will almost be completely stenosis. Shots, obviously the best treatment for it, I said. External is topical drops, but there's no way a drop is gonna, you know, get into the canal if it's that's the nose. So the best thing to do with that is to try and open it up with a little sponge. And that's what a week is essentially so you can see on that bottom picture. I'm just grasping a dry WIC there. That's what it looks like when it comes out of its packaging. It's essentially a very small condensed sponge, almost like a parent, and when you put water on it, it just expands up on that picture of the top is what it looks like. After you put some drops in the ear canal, it just expands up like a soft sponge. The way to put it in is to grasp, as I've shown here. So what the sort of, um then and I guess, with usually crocs. And then you want to align the tip of that wick with the middle of the Lumen, which is usually obvious. And then he wants with movement. You push the weekend. You can imagine if you've got it. I 16 about severe pushing a hard bit of cotton toe open your canal that's already friable is extremely painful. I'm I hope it's not just me, but genuinely patients. Sometimes you know, gas, power in agony and often people crying. The thing is, if you don't do it, it's never going to resolve. If you put some drops in straight away, then, obviously, that softens the sponge, and that can help a little bit. But essentially just need to apply that with pain killers. Once that happens, if you put the weekend, you need to take out in about two or three days. If it's over the weekend, you just need to make sure they got the first appointment on Monday or you bring them back. So of sooner. Generally, as the air canal gets better, it opens up, and often those weeks just fall out home. And then, finally, thing I know this seems incredibly trivial, but I've been called to quite a few embedded earrings this year, and you look like it the day of when you have to find your registrar cause you can't get an earring out. Often it happens. The eat. This situation tends to rise with kids because they're not checking the hearing back. A soft in is, maybe they should be on. They oversee he'll really Well, I'm what I would suggest is, you know that blue box of coffee and I can't spray. Like I said, it's got a little vial of that local anesthetic, an adrenalin in Essentially, If you just dunk some cotton ball in that and then you just hold it on the area and kind of so called those caps off. It tends to just locally know meant, which is excellent. And then you can just kind of gently tease out something like an embedded hearing back like this. Occasionally you see people and I in a while that airing back is stuck on the front of the airing, and they physically can't get it apart. And you, you've tried them almost trying that any triage nurses tried. I'm so by the time you turn up, it's a little bit inflamed because it's so difficult to get your a gloved hand around those two components. What you can use is the's sort of forceps that called mesquite eclipse and usually have them on the Ent ward because they use them a lot for valve changes with track your stories. Um, essentially, it's like an artery clip that they would use is in surgery. It's got a a ratchet on, so you just attach it to something and then you can lock it. So if you attach one rescue to clip toe the back of the hearing one McKee's musky to clip to the front one big pool, and it usually comes apart. I'm that kind of concludes things. I hope for most of you that was a least little bit helpful. And I hope it just has made you a little bit more familiar things, I suppose, from my point of view to conclude, I just want to important you that the majority of the into procedures including all the ones we've talked about today a really low risk. So they sound occasion. When you first hear about it, they sound complex, but actually you pick. Pick up the hunger if it really easily, and you look great when you had so any with your kit because no other specialty conduce those procedures, and they're completely clueless until you come in and sort out. And that's really satisfying on for any of you that are interested in the anterior you like. A said, have the jobs you'll find that generally is a COBOL ent seniors, a really approachable if you have got any concerns, particularly with people who have a Quincy just found them, and because they much rather know about potential concerns than not and find out your two days later when somebody's really, um well, last thing to say, particularly for half ones, enough to show you interested in surgery. I would recommend you keeping a log book of the procedures that you performed less. So now they've changed or the guidance. But when I was in, uh, for one, there was still a component on course surgical training. So self assessment, that was, um, essentially said something like, You know, your skills are both those of your peers. And if you've got a log book full of procedures like the ones we've just talked about, that signed by your supervisor at the end is a great thing to put in your surgical CV, and that's everything from May. So my God, Brianna said, Please do pop things in the questions, if you if you want in the chart, if you got any questions, that was excellent. Thank you very much for coming to give the talk, but it's given what really practical, useful information. I think I'm just to say on the topic of procedures, um, based change. I think they changed the cool surgical criteria Lost year, but it's actually more in favor procedures than it was before. And if you've performed a small procedure or if you've assisted in a procedure as well. So whether that's a procedure like you mentioned in taking out the foreign bodies. But also, if you have a cyst in theater, that's a really good thing towards your portfolio. I'm not getting any questions, period the moment. So I'm going to say please also little questions now or yeah, forever. He gets too. So, um yeah, no, there's nothing coming through. Um, but yeah, just to say thank you very much, Alex, for coming to give the tour of giving up your time. It's been really useful. And I think it's been also really good to see the types of equipment that you use on the bits and pieces that you need to take around with you because, um, get a lot of theoretical knowledge talked worse, but not necessarily practical knowledge, which is really good. Um, I know that s h o xyz currently some kind of national quality improvement project. Teo teach people these skills before they start their s h O mutation, but it's not necessarily uniformed across the country. Yeah. Uh, yeah, No, I don't think there's any questions. So I'm going to close the presentation on. I'm going to say once again, thank you very much. Alecks on do that. There is a feedback form that's both in the chat and also on the feedback linked to the side. Um, you do take your feedback quite seriously in terms of trying to see the gaps and to see if we need to put on any talks in the future to fill those gaps. So do you let us know? But yes, thank you very much for attending everyone. A swell on. Have a nice evening. Thank you. Bye.