Computer generated transcript

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

Good. I hope you all have had a very good day, either if you were working or you were not. Um Thank you so much for coming in and taking time to take this session, acknowledging the work that we are doing. Um So I think let's start with, with some basic rules. Um The name of the, they look very familiar, I believe. Um You, you all have attended the sessions before. So you basically know all the things that happened, but just to give you a brief overview of things. So the platform that we are using unfortunately does not allow us to um to allow the viewers to interact with us. The only form of interaction that we have is via chat. So I would really acknowledge if you want to have uh if you want, if you want to ask any questions, if you have any suggestions, if you have any queries, just put in the chart. And then myself and so will obviously after the session, we'll go through the charts and um we will be able to address everything that you uh every, every concern that you have one thing. Second thing before. Um you leave this session. So once we finish and before you leave the session, I will just put the feedback form live on the uh on the chat. Once you have finished the feedback form before leaving the session, your certificate will be issued and um, you'll, you'll, you'll have your certificate straight away. Um Yeah, so if, if you have any questions, if you have any queries, just put in the chat and then we'll go through uh the things um once, once we have finished with the with the session. So I think I'll hand over to Subash now from continue from here onwards and once the thing is done, I'll see you again then. Hi, thanks. I hope everyone is well and everyone had a very good day. So since everything has been told by uh myself, I am, so I'll be uh presenting today regarding the foreign body in Ent, I'll just briefly discuss the various foreign bodies that are in Ent and we'll just try to discuss the minimum management that we can do. I can you see my screen? Can I can I can your screen is visible? Ok. Yeah. Do you, do you want to, do you want to um run through the slides to see if the screen is working or not? I can see the foreign body in Ent. Yeah, it's working, it's working, right? Yeah. Yeah. Ok. Thank you. Thank you. So, moving ahead. Uh Foreign body is one of the most common uh one of the most common emergencies that we encounter in our daily practice. There are various types of foreign bodies that occur in ent because uh since the all the part of ear, nose and throat are exposed to outside environment, so uh and their presentation also depends on the mildest form to the most severe form. It can be very mild and it can be very life threatening. So all type of foreign bodies we get an ent these are a few of the common foreign bodies. I have taken a photo of these are the common foreign bodies that we see encountered in uh in our ent since there are three parts in ear, nose and throat. So I'll be discussing briefly all of them separately. Uh Just to give an idea how the foreign body might occur, how they might present and the way how do we manage it initially moving to the foreign body in here. So basically in here, the foreign bodies uh we usually see in two basic headings, they might be, they may be alive or they may be moving and the next one, they might be non living or not alive or not moving. So when uh uh it comes to the alive or moving foreign body, there may be any insect, any in any kind of insect, like small cocks or spider or any kind of insect. When it comes to non moving foreign body, they can be again divided into the vegetative or organic and then non vegetative and then I have made a special mention of Foreign Body Battery. This I'll just explain in a minute. So when we go to vegetative or organic, I have put them in separate heading because there is a reason to do it. The vegetative uh foreign bodies are like any vegetative uh things like cereals or any seeds, the lentils or the chickpeas, these kind of foreign bodies have a tendency to expand. These kind of foreign bodies have a tendency whenever they absorb water or whenever they are there for a long period of time, they have a tendency to expand which may lead to the symptoms getting worse. Whereas in the same si at the same time when the foreign bodies are non vegetative, like the beets or the pebbles or the collars. So they don't have a tendency to expand. So the symptoms might not progress within a short term uh short time frame. So, so in the order of the emergency of uh the management approach, also this is important and then there is a foreign body battery which I think is again one of the most emergency condition because battery have a pro property to uh distract the distract the you see the mucosal surface. So it might create problem whenever it is there for a long period of time. Hence, we need to take them out uh as soon as possible. So in the, in the uh view of this severity I have, I'll be discussing the foreign body separately. First of all, the battery. So in talking about batteries, first of all, if anybody will present with a battery, they will present with a history of uh battery put in the ear. Obviously, the most commonly uh coming patients will be kids and the parents will have a history that there was a battery he was playing with. And suddenly we can't see the battery. He might have put it in the ear. The the kid might present with bleeding, there might be pain if it's a late presentation. Once the tissue has started to degrade due to battery. If we go on to manage this condition, it should be emergency management. We should, we try, we should be trying to take it out as soon as possible to take it out. We can try use the forceps, we can use the probe, we can take it out in the clinic and we can or we can uh if, if uh require, if it's a kid who is not allowing us to take it out in the clinic, we might need to take him to the theater. So maybe sedate him and then maybe take it out. But we should make sure that once it is taken out, we should examine the external audit canal carefully. We should examine the tympani membrane carefully because there might be chances that battery might have caused some damage to the overlying epithelium of the external adit canal and the skin and the t membrane, sorry. And we must always examine both the side to see if the kid by any chance have put the foreign body on other side as well. The next foreign body is in the category of alive and moving foreign body. So it can be any form of insect, it can be any form of insect that we see it might go in the ear. There will be a history of the insect going into the ear. It usually uh is a case when anybody is lying in the ground or those kind of cases, the insect might go into the ear. There might be a complaint of something is moving in the ear and there might be a complaint of pain. Sometimes the patient might complain of bleeding as well if the inside attacks cause some trauma in the ear. Regarding uh the management of this kind of foreign body in the ear. As soon as the patient comes, it's not as much emergency condition as the battery, but it's also a urgent condition because the insect might go inside and might injure the tympanic membrane or might injure the middle layer. So we should try to take action as soon as possible. If it's mobile. If it's moving, we should try our best to make it in mobile first, which can be done by putting olive oil in the ear, maybe warm line, maybe local anesthesia. So this will make sure that the insect is suffocated or it, it might uh it may die and then it will not move. So we that will ensure that it will not travel or it will not move around sometimes showing a bright light in the ear. Also, we have seen that showing a bright light in the ear. The insects are attracted towards the light and they spontaneously come out of the ear. And after that, obviously, we need to take it out uh with the forceps or we need to take it out uh with any other instrument like Johnson Hon probe. As we can see here, obviously, it is not a for like insect foreign body, but this is the Johnson Hon probe with the r in the top. So we might be able to take it out with the uh forceps or this probe and we can use succin as well. So again, in this foreign body, we should always remember to see the axonal injury canal, the tympanic membrane because it might have been injured by the insect and always make sure that we examine the both sides. This is uh this is therefore for every cases of the foreign body, the next condition is a little bit of less emergency than the previous two. It's a vegetative foreign body. I would say we can keep it under the early treatment maybe within a week. We might be, we should be able to take it out. It, uh, it doesn't need to be very much emergency condition. But uh, since there is a chance that it might swell up, which might cause pain and we should make a patient aware that since it's a vegetative foreign body, it might swell up, it might increase the pain. Same thing when the phone patient comes to us, we should examine the years and then we should try to take it out in the clinic or maybe we should try to take it out in the theater if required. This is the picture of a probe that I was talking about. So what does this probe does do is at the tip of the disk, we can see the ring like uh uh structure. So it just slightly curve down what, so what it does, we can go behind the foreign body and try to pull it out. So this is one of the way of taking out the foreign body apart from suction and the other uh forceps, uh obviously forceps, we won't be able to use in uh the foreign body which are circular. So it will only push the foreign body inside, it won't take it out. That's why it's very important. First of all, to see the shape of the foreign body, try to visualize the shape of the body, foreign body and then only make a plan because if we try to take out a foreign body which is a circular or round with the forceps. The only thing it will do is it will push the foreign body inside and we might not be able to take it out. So then better option might be to go behind this foreign body with a option on probe. And sometimes even that is not possible if it's completely impacted, then we might need to try other methods. Like we might need to try suction. We might need to try to find out a way a hook or something like that. Mhm Then the another one is non vegetative. There might be beads or there might be pebbles, there might be anything uh that is non vegetative can go into the ears. And this this kind of patients are usually not emerge emergency condition and this kind of patient can wait for uh up to two weeks. Obviously, we need to take them out as soon as possible. But looking at our case load, this kind of patient can wait and then we can take them out. So one thing we should know is we should not try to attempt very hard or we should not try to do multiple attempts because we should always remember beyond the foreign body behind the foreign body, there is a very delicate structure which we call tympanic membrane. And beyond that, there are ossicles and even more uh important structures inside. So we should always be careful, do not try very hard because if the foreign body is to be uh is to is to come uh with our effort, it will come in one or two. Go. We do, we don't, we don't need to do multiple attempts or then we'll only do harm then good. So it's very important to see that. It's very important to know that now is the time to call the senior or maybe a colleague and a different pair of hands or different pair of eyes may help. So calling the help is always important because we have seen many cases being attempted uh for foreign body removal. They have come back, come to us with a perforation in that impairing membrane with a uh laceration in the external uter canal and then foreign, there are a few cases, you know, the foreign body is being pushed into the media layer because of the multiple attempts. So it's always better to call for help in the early, early in the at the earliest rather than when it's the when the harm has been done next, we will be moving to the foreign body throat. So this is another one of the very important uh places in our ent or in our body where the foreign body can impact broadly. I have divided them into two categories. One I have kept airway and another esophagus, we can say air, uh one is air pipe and one is food pipe. So the for foreign body in airway can be anywhere from the larynx to uh below, up to the level of the bronch. Uh bronchus, the various foreign body can be as I have seen here. This is a septine, this is an insect, this is uh tip of the uh the pen tip and this is the bluish uh some uh things with the kids and the same thing with EHA. It can be different kind of foreign body like it can be coin as seen here. It can be chicken bone, it can be other artificial tensor. So these kinds of foreign body can be in the throat, in the area and its and they might they will have different presentation if we are to discuss about them. So first of all, we'll discuss foreign body area because this is one of the most uh one of the uh most emergency condition, most urgent condition in an practice. And it can be life threating at many of the times or at most of the time. I would say. So if we look at our respiratory uh system, if we look at a general uh overview of our respiratory system, there is only a one channel up to the carina and from there, it leads to the two different channels or two different bronchi. So location wise it with the location, it shows the severity of the foreign body in the airway. If the foreign body is in the single most channel like if the foreign body is in the vocal cords, if the foreign body is obstructing the vocal cords. So what it will do is first of all, it will completely obstruct the airway. First of all, there won't be anything to breathe in. And next thing, what will happen to the rea uh as a reaction to the foreign body in the vocal cord, the larynx will go into spasm and this kind of uh cases are absolute emergency. So sometimes we have seen the patient might not even get a time to reach hospital. After that re you trachea is a bigger structure. Trachea has bigger lumen and smooth structure. So the foreign body being impacted in trachea is very rare. Although if the foreign body gets there and if it's completely obstructing the lumen, it might cause season of breathing, then comes the bronchus. This is the most common place where the foreign body in airway loss or uh goes into. So when it comes to Bronchus, one of the few things that make us that gives us time is there are two bronchus, the right and the left. So whenever a foreign body comes into one of the bronchus, it gives us some time because the patient might be who is able to breathe from the other lungs. But in the same time, the lungs where from which is obstructed, might collapse and they are seized. But at least it will give us some time. Mostly the foreign body will lodge into the right side of the Bronchus. Because as you can see in the picture here, the right side of the bronchus is more vertical and more wider. So anything that goes inside will directly go into the right side of the Bronchus. So that we have seen the foreign body usually loss in the right side of the bronchus. And in this side of foreign body, the usual picture uh rather than coming with a stridor or breathing, uh with a falling to the patient usually comes with the uh with the difficulty, difficulty in breathing. And then when doing examination, we might be able to see there is a collapse in the lungs and then retrogradely, we we'll find out that there is a foreign body. So the presentation, if we talk about the foreign body uh presentation in the area, it can be acute and it can be chronic if the foreign body is is in the vocal cords is in the subglottis is in the trachea of certain area. The for the presentation can be very acute. The patient may complain of shortness of breath and then uh the patient might be uh in a very uh bad situation. Patient might feel it very difficult to breathe and the saturation might be low at the same time. If a foreign body is lost in the one of the bronchus, most probably the right bronchus, the patient will come with a complaint of difficulty in breathing, the saturation getting low. Uh And when doing the auscultation, chest examination, we might not hear any sound in one side of the lungs, right side of the lungs, the left side of the lungs would look fine. And usually the, the, uh the most important thing is the history. Uh because it's most common in kids. There is a history that the, the parents will give a history that uh the kid was playing with a foreign body, maybe peanuts or bit and he swallowed the foreign body. The patient uh the kid coughed immediately but they didn't see any foreign body around. So that is very much that should raise our suspicion that it might have been aspirated. Another thing would be the kid was playing with the foreign body, but now they can't find the foreign body. So that might be another uh history which might point to us the foreign body being aspirated. Another thing uh uh One of the presentation could be chronic, presentation could be, the kid might present with recurrent chest infection which is getting recurrent and there is no obvious other obvious pathology found out. So that might be one of the case of the foreign body inhalation and then that might require further evaluation for foreign body. So in talking about management, if the foreign body is obstructing the airway completely, then it's absolute emergency. We should make every effort to take the foreign body out as soon as possible because uh that won't give us much more of time. Then we might need to do if it's lost in the bronchus or if it's not completely obstructed in the airway, then we might get time to do a scan to find out where exactly the foreign body is. And then we can plan our procedure. The foreign body is usually removed with rigid bronchoscopy or tracheoscopy. So what we do as you can see the instrument here, there are various channels. So one of the channel is a breathing uh for ventilation. So once we are doing the procedure, the ventilation is also going on from one side. And there is a part from where we put a telescope and uh forceps with which we just grab the foreign body and take it out. So this kind of instrument is required because we might, we have to make sure that patient is breathing at the same time, we are doing our procedure because there is no intubation to in place. And after the foreign body is removed, it should be made to make sure that we should examine everything completely, the airway completely and we should manage the lung condition if required if the history is suggestive of the foreign body in the airway, but they scan so that there is no abnormality or everything is uh clear. So it's a good idea that we should go for diagnostic bronchoscopy because there might be foreign body which has not produced any symptoms till now and might later produce the symptoms. This is one of the maneuver that I think everybody should know, everybody should be able to do it. There are various videos of this maneuver being done in the youtube and over the internet. So I would recommend everybody to practice this maneuver. This is a heli maneuver whenever anybody aspirates a foreign body. So we should be able to do this one. uh This there are various steps to do it as shown in the figure this is being done in the adults and this is being done in the kids. And it can also be done when we are alone and we experience something can be done, then this can be lifesaving sometimes. So I would recommend if we can go through it, uh the video of it and it would be helpful uh be the situation arise. Then after that comes the foreign body esophagus. So foreign body esophagus can be anything that we that can be swallowed. Mostly we see it's going me mid bone or meat bullous or artificial denture, but it can be anything as seen in the picture, it can be breast. So this is the case I found uh with the internet here, we can see it's a fox. So so it can be anything the with the presentation patient usually present with the history of foreign body uh being swallowed and they complain of difficulty in swallowing pain in the throat. And when you, when you do examination, there will be tenderness in the esophageal area at the check esophageal grove. When we do the endoscopy, you will see the pulling of the saliva in the per uh the p from sinus area. And on doing x-ray on scans, usually the x-ray is enough, we might do CT scan as well. We should be able to do uh in lateral view. Both of the views are very important. The the lateral view is more important to find out whether the foreign body is in the airway or is in the esophagus. Esophagus is just adjacent to the trachea as soon here and uh just adjacent to the vertebra as shown here and the airways here. So we need to see, we need to just find out whether it is in the airway or the esophagus. So this is the foreign body here and once the it is it is clear the scan, then we need to take it out with the maybe with the RS or a flexible Issy, we usually do is for sar foreign bodies and then flexible Issy is reserved for, is done for the non SRP ones like the meatballs and anything like that. There are few instances in which patient might give a history of foreign body inhalation, but we might not be able to see those foreign body in the scans. The the these are mostly the foreign bodies. If they are bone, fish, bone, which are not calcified. We usually don't see fish bone in the skin. We usually don't see meat boluses in the skin. So uh if we don't see the clear sign of these in the scan there, sometimes we can just have an idea like uh if the foreign body is there, there might be the uh increase in the diameter of the esophageal area. So this is one of the things which might point, ok, the foreign body might be there or there might be the straightening of the lumbar lo dosage, uh extending of the sorry, the spine curvature, the curvature will get straightened. So these two can give rough idea that foreign body might be there. And then in this kind of situation, if the if the clinical features are suggestive and if the uh scan show something like this, then we might need to do a visit esophagoscopy as well, which would be a diagnostic uh esophagoscopy. After the foreign body, we would move to the next uh and the last segment of our uh ear, nose and throat, which would be the nose. So these uh nose, foreign body are again one of the most common uh type of foreign body that we see in our day to day clinical practice. They are mostly in kids. They are mostly unat and they can be anything that is around the kids, they can be color, they can be pebbles, they can be anything that is around the kids. So it doesn't, uh, need, uh, uh, because kids have a habit to explore themselves. So they have a tendency to put it in their nose, put it in there. So it can be anything again. Uh, uh, as, uh, if the foreign body is there in the nose, if it's battery, it's an emergency. So, what we do is, uh, once the patient present the, the patient will uh kids will present with a history of foreign body put in the nose, they might have other symptoms like nose block pain, bleeding and nasal discharge. One of the finding that we need to understand is if a kid presents with foul smelling discharge from a nose, unilateral nose for a long period of time, say 2 to 3 months, then it's most of the times it's foreign body until proven otherwise. So you should be careful if a foreign uh if a kid is presenting with a foreign smelling discharge from the nose that it's most likely foreign body uh in the nose and we need to see him, we need to scope him. We need to take the foreign body out. Ok. So management plan the nose, foreign body. If it's battery, we have to remove it immediately. If there are other foreign bodies, then also we need to be early on the management of foreign body nose because they have a tendency to get aspirated backwards examination. We need an endoscopy. Most of the time the scans are not required, they can be removed in the office with a job on probe. As we can see here, we can go just behind the foreign body and pull them out. We can do them uh with the forceps as well if we are able to hold the foreign body. And after that, as uh we did before, we need to examine the other nostril as well for the foreign body. So in this way, we can take out the nose, foreign body. And then after that, we see the nose, if there is any bleeding, if there is any sign of infection, then we might treat that as well. I'd like to mention at the end, uh this is my last slide. So in this one, I would like to mention regarding the foreign body battery, why? Who have I have emphasized this? Uh It's so much because the battery has a lithium ion and it spontaneously leaks alkaline solution. Whenever it's in at uh whenever it is attached to the moisture and whenever the alkali is released into the body, it slowly degenerates the mucosal surface, it slowly degenerates the cells of the body or tissue of the body. Hence, this is very, this can lead to complications. Now, suppose if it is in the nose, it might lead to the damage of the septum, it might lead to the damage of the septum leading to a septal perforation. If it's in the ear. It might lead to the perforation of the drum, uh and uh excoriation or erosion of the exit canal. The most serious complication occurs. If it is in the airway, if it is in the subglottis, it will erode the surrounding area which will lead into subglottic stenosis. And the patient might end up in lifelong trst toy or he might require a very big laryngotracheal resection, which is a very weak surgery. And similarly, if it is in the aha, it might lead to the perforation of the AHA. So these kind of foreign bodies, the batteries have to be given utmost importance whenever there is a history that is suggestive that injection of the batteries, it has to be taken out as soon as possible as as soon as possible. And uh usually uh if there is a metallic thing, then we might get confused between whether it is a coin or a battery. So there are a few things we need to be careful in other scans uh to suggest that it is better because battery will have double ring. Always here we can see in the figure we can see here. So what actually comes and if we see something circular metallic, it might be battery. So you should always be careful, you should try to differentiate whether it is battery or not. We can do it by looking at the scans, we can do it by taking the history on laterally scan the bottom batteries are wider than the coin. So in this way, we have to differentiate whether it is battery or a coin. The reason to differentiate is coin can stay for a day, but batteries should be taken out as soon as possible. So we need to know if it's battery or not and if it's battery, then we might need to take it out as soon as possible. So with this slide, uh my presentation comes to end. Thank you everyone for uh listening to my presentation. I would be very happy to answer if there are any questions. Thank you so much. So, thank you so much for such a wonderful session. Again, I think it was very informative for me. So having worked in the ent department for more than 10 months, I think there were still a few things that I was uh not sure about. So I think, I think your lecture has made a lot of things, things appear in my head. If anybody has any questions, uh we are happy to answer your, your concerns. Thank you so much, Aku for the acknowledgement. Thank you. A yes. So I think we have a question in the chart. So a short has a chat. Yeah. Ok. OK. Ok. OK. Um So I can see the question uh from ASU uh Kumar. Uh So the question is, how do we assess the extent of TM perforation? What possible complications are possible? So if we are talking in regard to the foreign body in the ear, the perforation because of the foreign body in the ear. Uh uh the extent of the uh more than extent of the perforation, we just uh uh see the percentage of the tympanic memory that is involved in the perforation. So we can divide in uh in terms of the percentage, how much of the total area of the tympanic membrane is perforated. So it might be 1020 30%. And uh now going into your next question, what possible complications are possible? Mostly if it is traumatic per uh perforation of the tympanic membrane. There are very good chances that it will heal spontaneously. But if not, then the perforation may be there. It might lead to recurrent ear infection. It might lead to hearing uh loss. It might uh lead to various uh like the patient might not be able to do various things like he might not be able to go to swimming, he might not be able to go to diving. So these are the possible complications that might occur if there is perforation that stays in the depending membrane. You're most welcome doctor. No bye. So I can see another question from uh colleague cad. Are there any guidelines regarding the preferred method for of extraction for, for embodying the figures uh like when to switch to open surgery? So usually uh uh usually we are very rarely go into the uh open surgery for the foreign body in the esophagus because the esophagus lies in the Mediastinum. So if we do the surgery in that area, and there are chances, uh, that if the perforation is there, if it leaks, then it might lead to the very severe complications. So we try to do it as much as possible with the flexible scope or maybe rigid scope. And most of the times we are able to take it out, there are some instances when the foreign body is impacted, like it is impacted in the layer of the esophagus. If it is impacted uh within the esophagus, the mucus mucus surface of the esophagus. And those are the instances, mostly the fish bones and mostly the soft chicken bones. Those are the instances when we think of going into the open approach for the open surgery. And again, the open surgery is a complicated and after that, the patient might need to give the uh nutrition anywhere uh from anywhere else or parenteral nutrition for a long period of time and then it will increase the hospital stay. So we try rather not go to open surgery directly. Hope uh that answers your question, Khali, right. So I think these are all the, all the questions that we have for today. Thank you so much Abash again, for such a beautiful uh and informative session. And thank you everyone for taking the time to attend this thing. Uh OK, so we have one more, one more question from Ven. So, uh so, OK, so how do you treat the hearing loss due to no weakness? OK. So, but if we are talking, uh so there are different kind of hearing loss that might occur because of the nerve weakness. If this is of sudden onset, it has occurred uh suddenly within a day or two, we say the 71st, 72 hours of the golden uh period because within that time, the chances of recovery is 80% is and which drops to 20% days after that. So in that time, we do steroids, we do high dose oral steroids, maybe intravenous steroids and then maybe intratympanic steroids after that, if the hearing loss is of long duration of uh time, maybe two or three months, then there is very less we can do. And there are chances that the hearing might not come back. Then the options that are left for us is hearing aid. And if uh and then other implants, maybe cough ear implants or those kind of treatment, I hope that answers your question be right. So I have made the feedback form like for all of you, once you have finished the feedback, the certificates will be available automatically. And then next session will be on 23rd of this month, which will be regarding hearing loss. And the speaker for that session will be one of the other um ent uh clinical fellows that we have tia, we have, we have one more question. So that's very good question. Uh Bet. Are there any instances where oop foreign bodies are pushed into the stomach? If cannot be? Yes, yes, we do that. Uh a lot more of time. So the foreign body is very down in the esophagus and the foreign bodies are big uh sharp foreign bodies or maybe the chicken bone which are impacted down. So sometimes taking them from the esophagus might injure the esophageal lumen or, and in those instances, we decide to push them inside the mark or sometimes the meatballs is big ones which are impacted in the esophagus, which might be very difficult to take them out, especially because there is a cricoid cartilage, cricopharyngeal junction. So those kind of uh cases we push the foreign bodies down. Hope uh that answers your question, Benedict does, right. So as I was saying, the next session will be on 23rd of this month, which will be regarding hearing loss. And um the session will be run by um D bia again. She has done one session with us previously. Um You guys might remember her. Um I will start advertising the session from this evening after this session and I really hope to see you all in the next session then. OK. Thank you very much for providing me the opportunity to present a few of the things that I know and thank you so much So thank you. It was very informative. The session was very helpful for me and I believe for everyone who has attended it. Thanks so much for very happy to hear that. Thank you very much. So we say bye for now. Yeah, so that will be it for today and uh we'll see you again on 23rd of this month now, same time. Ok. Take care. Bye bye bye, bye, see you. Thank you. Bye bye.