ENT Surgery - SurgEazy



This is an interactive on-demand teaching session aiming to provide medical professionals with an update on a range of topics relating to recurrent epistaxis and other ailments in children and adults. We will touch on suitable management, the underlying causes and considerations for allergies in nosebleeds. Participants will be posed questions and join in polls within the session, gaining the opportunity to discuss their answers with colleagues and the presenter for a comprehensive understanding. This session offers a unique chance to gain insights into these topics and leave with sound knowledge.
Generated by MedBot

Learning objectives

1. Provide a working definition of recurrent epistaxis and the common causes of it. 2. Explain the management for a patient with a prominent vessel on their septum. 3. Compare and contrast the management for a patient with a suspicious vessel vs. hereditary hemorrhagic telangiectasia. 4. Recognize the features of mastoiditis in a patient and the medical management required. 5. Describe how medications and conditions can predispose a patient to epistaxis.
Generated by MedBot

Related content

Similar communities

View all

Similar events and on demand videos

Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

okay? Yeah, we can see it. Thank you. Great. Like I was saying, my colleague was saying, Thank you. The introduction. Um, my name's the HEB. I'm one of the ent run through trainees in Kent on. I'm just gonna go through some SPS and some questions. Feel free to, you know, just ask questions in the chat and the, uh, they'll they'll be able to feed back the what you guys are saying in the chapter two to me, anyway. Okay. So it will begin. Put the first question. So there's a 78 year old female who presents to your emergency clinic with the history off recurrent epistaxis nose bleeding from the left nostril. Let me just move this away on examination that you notice that there's a prominent vessel on the septum. Um, and should patient to note has also got a peanut allergy. That's a picture of what you're seeing on examination. So the question I have for you is what management with you offer this lady in the first instance? No. Wait for, you know, it's to reply, and then we can Sure, rather. And 10. 1. Should we wait for the questions? Um, should we give about a minute and a half? Yeah. Cool. Cool. Okay, good. So the majority of you got the answer, right? So the answer is, see Nasalcort tree. And the reason for this is a 60% of you got just under 60%. Cut. That right? So well done to you guys. Um, there isn't. Is is because if you do see a prominent vessel that's on the septum, it's just such a simple and easy procedure to do. And you can do that in your clinic. Um, you do that with a silver nitrate stick, give them a little bit of topical anesthetic on the nose on, then you can just do that there. It takes a couple of minutes on. Really? The effects of this A really positive. A lot of the patients don't actually have another nose bleed, you know, for years to come, and some just never come back, which is great. So that would be the answer for this lady. I don't think holding the SP I would be a great idea here unless you're uncomfortable with cool tree. And there we go. That's the answer is See. Do you have any questions? area. There's a hand wrist. I think you need to write in the chat. If you have a question, please would have any questions in the chart, and we'll try to answer them or will pause it to, uh, stay sticky during our in between the session. Okay, Question, too, will stick on the topic. So you have a 78 year old female again. Same history presents to your emergency clinic with the history again over current episode axis from the left nostril. So it's unilateral. On this occasion, you notice not a prominent vessel, but you noticed what seen in this picture, which is a lot of the time, is mistaken for a prominent vessel. Now what would you do in this case? And there's a bonus question at the end is what is the diagnosis? But maybe wait until we finished with the first question before you answer that in the chat. And we started the pole for the second question. No, they put over the second questions out. That's a lot more mixed. Then the last question again, we'll give it a minute. Just over a minute, minute and a half. And again, any questions that you have about any of the questions, please, just right in the chapter on. Then we can discuss them at any point on for this one in particular. If you could write what you think that diagnosis also is in the chapter, Yeah, I've stopped it. They're just cause it wasn't the number participant or a movie too many in the chest. And I mean the people answering the questions, So it's just fine. So the right answer is D, and I think the majority of you got that right this time a little bit less 40%. And there's a bit of confusion with the next Septin and the Bactroban, so we'll talk through that on. The answer to this bonus question was a registry hemorrhagic telangiectasia, which we'll discuss. Surely. So when you see this type of splattered pattern where there's not one clear vessel, um on you can see it's kind of almost a tissue in its in its nature. It's quite actually dangerous or futile using nasal courtroom on this because these vessels tend to be a lot deeper, um, on continue to bleed and just continue to bleed when you try to stop it, so In this case, if you see something like that, you need to be discussing this with the Sr Sr before you do anything, because, um, it's quite difficult to actually stop a bleed with someone who has hay change tea. This is, you know, this is like one of the really difficult. When a patient they changed, you have the nose bleed on. They commonly do because that's one of the areas which is affected by a change to the peanut allergy part. By the way, the reason that's in there is because next Septin cream as peanut oil in it. So if you ever prescribe that commonly prescribed just to soothe the nose and people who do have recurrent nose bleeds without a prompt, prominent vessel, you can give them they accept and cream. So that would be the right answer if for the previous question, if there was nothing on examination, Bactroban cream is the is the cream that lots of people rightfully put is what you've given patients who have a peanut allergy on. In this case, I wouldn't do nasal courtroom. So just a quick run through on recurrent epistaxis on the common causes off this in Children and actually adults as well. The most common cause is actually nose picking. So direct trauma from the fingernail. Now there's lots of other causes. Another key one is allergy on. The reason why nose bleed is becoming more frequent, actually, outside is, which is which it is is because of lots of patients now being on things like blood, blood thinning medication, high BP. And as as we get older, all of these things become worse. Just the mucosal lining in the nose starts to wear away. The vessels become more leaky. Um, blowing your nose at that point as well, all of these things can can contribute, um, interesting things to note things like cocaine and drug use anything inhaled through the nose. Chemical irritant PSAs. Well, so cleaning products and things, all of these can predispose you to having a pistol cyst. Um, now hereditary hemorrhagic, telling me they don't spend too long on this because that's a bit of a, you know, more detailed question. But the reason that this is just a n'importe want to think about is because in the disease is, um, you need to be able to diagnose it. quite early on, especially for a patient like this comes through with a nosebleed. One of the ways to do that is they get a petition rash around the lips. That's a really common place. You'll get it on your palms as well get like the spotted pattern. Um, and also, you'll see that in the nose, and it's caused by these. You get these, avian. Ah, these arterial venous kind of malformations. So if the vessels you keep trying to cauterize it and it just keeps on tracking back, Um, and there's a lot of different things that now the clever things that we can do to to stop it, um, that we don't really need to go into it on the slide anyway. Uh, yeah, Any questions about that or shall we live on? Sorry. And she's gonna have to propose you there. I just seen that our sponsors come in. Matthew. He just has. It's shama top. Uh huh. So, yeah, I think we've finished with the recurrent epistaxis start of things so we can move on on the third question moving off of the nose. Have a five year old who presented your emergency clinic with his parent. He has a history of a cough, a fever on bilateral ear pain on on examination. And one of his is You see this and it's similar on both ears. Okay. Yeah. Uh huh. Okay, So the majority of you got this one, right? So well done. So the answer is be a Titus media. So this is a middle ear infection, which we'll talk about in a bit more detail later. Okay, So this five year old now the father says it's been five days and the pain isn't getting any better. The same patient as the one we've just had. How would you treat this child Things. People are a lot more comfortable with the is than they are with the notes stuff building. Yeah, that's perfect. So the answer to the question is D on. In this case, you would start giving the patient some antibiotics. All the other points are relevant in a case like this with the tightest media. But in this case of a patient like this comes to you was that five days and it's nothing is getting better. And they haven't had any antibiotics or anything. Then it would be time to start some antibiotics. Onda. Now the father tells you that they've been using your antibiotics, which you've prescribed for three days, and there's no improvement whatsoever. The patient's here is actually now protruding forwards, and there's a swelling behind the left ear. Now, what would you do in the initial side of things? I can't seem like answers there a little bit unfair we'll talk about Okay, so be correct. Answer, I would say is in it in the initial instance, is to admit the patient. Okay, yes, you would need to involve your seniors at some point, but at this point, with just a history off protruding A, we know the most likely diagnosis, which will let me just check. That's about the next question. Okay, so the likely diagnosis would be something called mastoiditis, which is on here emergency. But the reason you don't call your do a senior straight away or initially it is because you know how to order your you should. We'll talk about the management that an S H o can provide for this patient, and basically it's IV antibiotics. So you're just improving the antibiotics. There is a discussion about when CT heads are done, obviously, because that's what we're ADH in. You don't always do that in Children, but that is definitely a discussion that can be done. Um, and in this case, emergency chromic. It's I've never seen them before. Um, but you can, in some instances, place grommets to relieve pressure if the pressure is going backwards, which is what happens in Mastoiditis. So let's just get understanding of a bit of your anatomy and how this is all working. So in that picture, the green parts, the external air, the blue part with your articular chain is your middle air on. Then the orange part. There is your inner ear, which has got your cochlea on your balance centers. Um, all in that area, connecting to your nerves. Now a diet is media is very common in Children. Classic history is that they had a flu like symptom of had they had flu like symptoms. What happens is the eustation tubes, which is small tubes that connect this middle ear area. This is actually in the eustation tube. It's not labeled on that opens up in your post nasal space. Um, just, you know, in the back of your throat essentially help to dream that area and keep the pressure in that area equal. And when you pop your ears and things like that, you're actually contracting and relaxing your eustation tubes and just equalizing pressure. If that becomes inflamed, there can. Bacteria can get into that space in the middle here, and then that fluid is welcome to doctor to build up, and it can't come out and then that can get infected on. If this pressure here keeps building, sometimes it comes through your tympanic membrane on out. Um, so that would be a superlative with the fusions. The effusion builds up, and then it comes out. And that's why sometimes you can get lots of mucking that canal as well of the air. Um, but it's actually if they come in with this classical history, Um, I treat it as a a Titus media now that can also precipitate on a tight 6 10 over. That's a conversation that for another day on, then this is the mastoiditis type picture where you get this distinct swelling that ear itself. You'll see one of them is like like that and Children. It's a lot more obvious where it's actually being pushed for words. It's not just, um, like tenderness on examination, it should be read on. There should be a bit of a body swelling for it to be a proper mastoiditis on. If you conceive in this picture, you can see what we have in the temporal bone that sits behind the ear is it has, like these air cells on these. The pockets of air within the bone on these can get fluid insider, because the pressure's too much and it starts at your road into that bone, and then that becomes full of fluid and infection. And that's what actually mastoiditis is. This could be come quite serious, because this can then spread from their different areas where you can get abscesses in your neck. People get abcesses towards the brain as well. Eso they do need to be admitted and monitored. Now, if they start to display signs of intracranial pathology, then you definitely be thinking about getting the CT's and MRI's and things like that, um, about any questions about asteroid itis or otitis media. And if not, we can. The antibiotics of choice is always, you know, the classical answer for that is you have to check your trust guidelines. Generally, something that has an aerobic cover is a good idea. But yeah, that's you know it's okay. Honestly, it depends wherever you are. They always use different things. Okay, so the next question we have a 20 year old female patient who presents to your emergency department with the two day history of a sore throat is able to eat and drink. But on examination, you notice that the tonsils are really swollen. They're enlarged on their covered in Exodus eight. The CRP is 100 the white cell count of 13, and it's a neutrophilic white cell count on the liver function test is normal. What is your initial management? So there's a quick question. If you just seen a yeah, I've just read the question eso. What I would say is, in foundation yes, it's very rare that has an F one year ever any anti but usually has an S h o R N f two If you see a query mastoiditis on, you're confident it's a mastoiditis. The Children tend to be quite unwell, I would say, if you recognize did admit them and Start IV antibiotics because that's what's actually going to help the child in management. So whenever you have a patient and you think always this mastered, I just isn't it safer to say it is? Start them on treatment and then get the registrar to confirm it. That's the safest way rather than, um, being in our ng registrar might be in his own clinic or her own clinic that they might be in theater on that. So it's it's, you know, it's a bit of a difficult one. Um, yeah, there is a role as mentioned previously. There is a role for CT heads in cases of MASTOIDITIS. Um, but it's one of those things that, um it's a difficult, And if there's no intracranial pathology and the child actually gets better on antibiotics, then you don't really need to do anything on. And then it's a case off. Can you get an MRI? Because an MRI will show soft tissue better. But if it's you know, really significant, you can also see where the abscess is tracking. If you do a CT head a lot better than in an MRI. If you have some bone erosion as Well, these things are all the things that CT head is better for. Um, Then an MRI. Let's get back down to the question. Um, back to the pole for a question six. The answer, as most of you said, is send them home with Orlando. Got X. A general rule of thumb is obviously treat the patient and not the numbers on it. Yeah, we'll talk about about this next question. And what's the difference between the two patients? So questions seven. Same patient. But the main thing here is that they're not able to eat and drink. Um, so hopefully this is going to be a quick question. Polls opened. Yeah, 30. We're going to move on to have turkey it for a few more questions. Um, yeah. I'm glad everyone was paying attention in the last one on most, most people got this one, right. So admit that this patient on give them IV antibiotics. Now, the main differences of the patient is not able to eat or drink. You can't send them home with tablets because they want all of the tablets. Okay, so that's kind of the main difference between the two patients that we look at the previous can go back. Um, if we look at the previous question, only difference is one was able to eat and drink, and one wasn't able to eat and drink. And that's kind of your It's a good guideline for telling you how sick a patient is. If they're managing to eat and drink because they need antibiotics, that's what's gonna make them feel better. In 95% of the cases, you don't need your registrar. You won't think about until ectomy right now. Um, hot tonsillectomy Zarah kind of topic of debate. But it's very, very rare for you to do the ms and you don't do them. Just the general tonsillitis is. Anyway, I wouldn't send this one home. Next question continuing on now, this patient, we have to look carefully. They're not able to eat and drink. Um, on the blood. The CRP of 100 white cells of 13 lft show a raised a low p and a raised a lot e. So these are liver function tests on a similar picture where you've got the bilaterally and large tonsils with some extra date on them. Now, what would you say is the diagnosis in this case. Great. So again, the majority of you got this one right, which is a good sign. And there is infectious mononucleosis, also known as glandular fever. Now, with this, the I'd say the actual management. Let me see. I don't want to say that we're discussing Yeah, So the actual management, I'd say, is the same as your tonsilitis. Pay patient in an A Any setting on demand as an inpatient setting you give them the steroids will give them the antibiotics and pain killers. Because with infectious mononucleosis, you can also get a secondary bacterial infection on top of it. Um, even though a lot of the times we all know that it's a viral infection that's causing this, which is next in bar virus. Um, so there's always this question on why do we give antibiotics? And it's just because it helps them to actually feel better. And it prevents a secondary bacterial infection, and sometimes they already have that second repacked urine infection. Now there is a specific monos pot test that you go are mononucleosis test you can do for glandular fever, which is a blood test which are any should be doing if they think that, um, and a good end. But they don't always. Which is why I didn't put that on this and defeat the point of the question. The other thing is, is that the liver function test is most of you spotted is the main kind of driving factor floor. This question is that if you have deranged liver function tests on a don't like to start picture, it's going to be most likely, um, and be a glandular fever caused by HPV because I can also affect the liver and the spleen, and we'll talk about that again a bit later. So question nine. You have a 20 year old female patients, Same patient, really, and you could just see how many different presentations you can have for the same patient. But this time on examination, you see that the tonsils are both slightly enlarged my next day, but the uvula is deviating towards the left and both daughters air enlarged CRP again is 100 white cells of 13 liver function test this time is normal. What do you think is going on? All right, while we do that one ounce of some of the questions that on the chat. So what? This call's outbreak of rash. So with mononucleosis, the thing about rashes if you give them amoxicillin for some reason, it's really only amoxicillin that causes a proper outbreak of rash. Although there are other antibiotics which have been reported, which is why nobody really gives amoxicillin in tonsillitis is this is why they give penicillin V because in case it is, then it doesn't tend to cause a rash. So we still treat the mononucleosis financially, fevers with antibiotics. But just avoid amoxicillin because that content to give a potential rash all over the body. Next question for mono. Do we admit patients from primary care use the same, um, kind of line of thinking as a tonsillitis for infectious mono? Treat that very, very similarly in the sense that give them oral antibiotics. If they can tolerate oral antibiotics, then they don't need to be admitted, and they don't need to be even seen by anyone else in primary care. If you've made that diagnosis, send them over the antibiotics on analgesia and they should be okay. The only thing I would do is a repeat blood test of the liver function test if that's off in the next six weeks. And again, if that's, you know, not got better than that needs to be investigated. Um, on yes. So we'll talk about we haven't spoken fully to talk about it. So the reason why you're advised to avoid contact sports and glandular fever is because you can get a pattern splenomegaly and which your organs get more swollen. And then if you have any contact with that, it just puts you at risk of any injury to those organs. Different thing. But differentiating between bacteria tonsillitis on Benzie Quincy is it swollen mass which we'll discuss in a second? It will be quite obvious how we do friendship between them on good. Most people got this question right. That's the right side of Quincy. So what happens is that you get this, um, very good until, uh, abscess. That's another word for Quincy. So you get this abscess, that's it's just on top of your tonsils. So if this is your this is your left tonsil, let's in my left arm. So your abscess will be about here, just sitting on top of it. Okay, um on. Then we'll come to that in a description in a second. So now we have a patient, 70 old female, different patient, two days drifts or throat, not able to eat and drink left side, a tonsil swelling with exudate. What do we think is the most likely diagnosis? That's a unilateral swelling of a tonsil. I'd probably say, What's the most important diagnosis? Um, but yeah, I think most of you picked up on that anyway, in the insist, which is good. If I could refined the question, I would make the inflammatory markers a lot lower or change it to what the underlying mechanism off the infection could be. All right, great most of you have on to that question right again. It is a tonsil sec squamous cell carcinoma. These in the most like he's the most common types of cancers that you'll find in your tonsils, which are malignant. On the only one really that you need to discuss, we'll know about, um so what can happen in patients with this is that you can get these unilateral swelling's off the tonsil, or you can get his unilateral tonsilitis is on any elderly patient who gets either Quincy or a unilateral tonsillitis. Really? You need to investigate them in the two week wait cancer clinics. And normally what you do is you wait for that to settle down the infection on, but they should be reviewed on a proper to equate history Taken an examination done on Bastable biopsies taken a swell. And in this case, you could take a you do tonsillectomy for a biopsy. Some people take one, but most people take both. Okay. And I think this is the last question about tonsils. Um, what is the reference or guidelines that we used correct criteria wise for tonsillectomies. And I can tell you there's three made up Answer is, uh, literally nothing to do with with anything, really, as they're just from the chat. The main reason why you want to think about Tonsils CC in that last question was basically because of the age and the fact that it was unilateral on. Then you have to look at SEC being the most common type of cancer, especially the questions that we have in our In the example that we gave, um, from a B c. D. That's why it was Tom test. You see, I mean, as a bit means of a bacterial tonsillitis there because technically, it would be a bacteria tonsillitis, which are a viral tonsillitis that would predispose you from had to having, um, you get that infection. But that was because of the cancer that you get. And that's why you only got it on the one side. And so it was a bit of a harsh question. It's important, really important to think when you get to that age, it's not that common to get tonsillitis. So think about cancer if you got a hostage. Um, the difference of dance easy BCC Don't worry about it. I don't even think you can get a B, b, c, c and your and your total. That was just thinking. I just put in the question, Um good. The pole. We shall conclude for this question. 11 s o 50% of you got this right. I don't know what the other 50% we're guessing, but I don't know what tm is that it's made up. So see, and then oh, MFS dance or like the max extreme signed criteria. That's the one that you should know about. Well, we'll learn about today on this is a Scottish criteria that's pretty much used in the in the UK We don't really use our own nice, nice guidelines for this. We use the sign criteria, which we will, um, talk about here. So let's just quickly run over the sign criteria. Eso at just the general rule for this is that if you have seven tonsillitis infections in one year, you should be referred for a half tablet on Select to me. If you have five infections each year for two years or five and five, then you should also have a tonsillectomy. And then, if you have three years for three consecutive years, three infections and three consecutive years, you should also have one be referred for a tonsillectomy and then two episodes of Quincy or more. We'll also predispose. It was actually one or more, Um, or more than one, I think. Is there right in the right phrase for that full call off? Are you for it? Until it to me as well, um, generally about tonsillitis if they admit them when they're not able to eat and drink IV Antibiotics IV steroids There's a big debate on the show. It just be one shot of dexamethasone. A should be regular on IV fluids. At least give the one shot is what I would say on def. I don't have any other kind of risk factors they don't get, you know, make some hallucinate at night and things like that I would say Just give it to them. Um, then going back to the glandular fever, I think we covered most of TB. The infection Epstein Barr virus can affect your liver function because that causes the patches. Splenomegaly. Now you can catch this virus 4 to 6 weeks before it presents is an infection. Eso just know that's probably not They didn't just catch it into the week before something they call it a long time before on Dad Vice. No contact sports for six weeks. Post infection because we discussed your organs are more at risk of being damaged. If this is, the case, should also do an abdominal examination as well, and feel for participating vaguely. For patient like this comes through, um, for antibiotic use in tonsillitis. A swell. It's important to know fever, pain or the center or criteria. On day. It's kind of these two risks. Stratification. Things that have that have been done would show you. Is it likely to be a structure couple infection? It's more for use in in the in the primary care, rather than if they get to the hospital in the hospital. No eating and drinking, then IV antibiotics. If they come to you on there, really been paying to send them home with four and six? Um, fine. And then Quinton, we discussed, is the Parodontal abscess, which requires drainage on. I think that's a nice pictures of it. It was Well, yeah, So this is your tonsillitis picture. It's difficult on examination, but you get you kind of can tell. In the end of Colangelo, few of us tonsillitis you get more of a plaque great type film on your tonsils in glandular fever. You also to do a neck examination because you tend to get a lot more lymphadenopathy and the neck your feel. Lots of the nodes around the neck Now Quincy. That's a nice picture of a Quincy. You get this swelling on top of that statue of tonsil, and then you can see this big swelling on top. That's where you're That's where your, um, abscesses forming. And then you drain it. Tip typically with the needle your sticks. Give them some local anesthetic. Stick a needle in this area here, actually just on top of the molars. So it's no, actually, as media is quite lateral on, don't start there and try and drain that now, since some cases you can also put a small nick with it with a scalpel. Just cause a little incision there on drain all the puss. Usually patients can go home if they come in the morning. The evening will keep them in overnight. Same as a tonsillitis. Um, on you get them home. Okay. Any questions about that cool move on? Next question. Nearly though. No, I think I just ruined that question. Ah, if anyone who didn't see the answer, how many terminal branches does the facial nerve her good? Most of you got this right. Good to see that that they have Five terminal branches will go through the acronym on on how to learn it. But generally your facial nerve just does this. It's a good way just to think about it. It's just your hand on your face um Now it says, Why does the uvula bend to the left? Is because if there's a pressure on the right side, like in that picture, let me see if I can actually get the picture. Uh, if there's that pressure on the left side, it's pushing everything on, especially the uvula to the left side. No, it's in the picture, but do if you if you understand what I mean. That's one of the big signs on if it is actually a Quincy on. Okay, though it's five. So the acronym Zebra bug until zebra bucket. My cat. It's the temporal zygomatic buckle, marginal mandibular and cervical branches off the facial nerve on which supplies your facial muscles. Okay, couple more questions before we round up. So which nerve is likely injured in a sub mandibular gland? Excision. They like this and then suck you world. Hi, guys. Well, while we're doing the question, we just have a small form assessing our serious itself on with love. If you could fill it in. And if you're enjoying the Siris so far with like some feedback on it too, will send the feedback link in a bit. A swell Thank you so much. Okay, so this is very closely contested, but we've just about got the right answer. So well done, everybody. It's the marginal, manipulative one of the branches off the facial nerve on this is really important to know in a sub mandibular gland excision because it's pretty much gonna be you'll come across this nerve if you make your incision wrong. So what you want to do Is this this never. It sticks really close to the actual mandible, and it comes around like that on what you tend to do is you put two fingers and you're making your incision on and you make it two things away from the mandible about two centimeters, the two fingers. And that helps you to avoid the marginal mandibular. Another landmark for that nerve. So you avoid it is the facial artery, which the man marginal mandibular nerve is superficial to, um so yeah, you'll know if you're in the right. I mean, the facial never sued. Is the fish artery superficial to that? So you'll know you're in the right lane. Next question we'll just mention is well that for that last question that that supplies basically the lower lip. So you, if you've injured up, it's you're going to get uneven. Smile. So this is important in any Styron to me. Um, when you're trying to remove the thyroid glands, there's one nerve that the surgeon will always try to locate in particular and try not to damage. Okay, good. The majority of you got this one, right? That is the recurrent laryngeal nerve. So this so the branch off the, uh, the branch of Vegas. Tough on. Essentially, it's really important because it supplies the majority off the muscles. Um, in the lyrics, um, and the voice box Essentially. So if this is damaged on one side, you get a change in the voice. It becomes a lot more breathy, a swell on horse on. If you damage both sides, you could actually completely stop their airway from working, Um, which would be a disaster. So it's really important when you're doing a total thyroidectomy that you locate their recurrent laryngeal nose and you test it before to make sure that it works. Um, and the only muscle doesn't supplies the cricothyroid muscle, which is like the the classical question that they'll ask you potentially an emcee cues on the superior laryngeal nerve is also located. It's up there, like the superior lobe off the off the thyroid's. That's kind of the region, which will come across the periodontal nerve. This never supplies the upper sensation above the vocal cords on and also the cracker thyroid. So if you damage that, you can get a change in voices well, but it's less kind of catastrophic, like the recurrent I'm Jule now is the main one, not the damage and the final question a day. We will keep it nice and light. What is the smallest own that you'll find in the head and neck? Let's finish this one on the high. Okay, it was a close one again, but we've edged it, and we've all got it right. Majority of us have, and that's the stapes, and that's your smallest love on it. In the secular chain, it also the smallest bone you'll find in the body. There's three bones in your cyclic chain, which you have your malleus, which it touches to the incus, which is known to be like, um, one of those iron shapes, Um, and then the stapes, which connects to the funland, um, to the round window, and it transmits the vibrations to your copy on Believe that was the last question. Anyone have any questions? Cool. Thank you so much. If you guys have any questions, please least oop it in the job we have, I have attached a form that