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Hello, everybody. Um, we'll get started in a few minutes, but just to say welcome. Um, also just a reminder that next week we have a double bill on both the Monday and Tuesday. Um, so make sure you check our Facebook page for the events and details if you're interested. Um, I'm just waiting for our speaker to join us. Um, and we'll probably start a few minutes just after eight. Just to give people a chance to join us. Thank you. Hello, everybody. Um, so crippled. I've just invited you to the stage. You can accept the invitation. Yeah. Hi. Hi. Um, we'll probably start just a little bit after eight. Just to give people extra chance to attend. Um, but yeah, just a reminder. There's a chat function to the right hand side. Um, So if you've got any questions that you'd like to ask either during the presentation or at the end, feel free to post in there, I'll be monitoring throughout. Um, and yeah, if you have any additional questions, just just ask, um, and that will give it a couple of extra minutes. No, I was just going to say Can you just test just to see if your slides are working properly, please. Thank you. Um, just share screen. Yeah. Can you see it? Yes, we can. Thank you very much. All right, a couple of extra minutes. I've got cases. So if people can use the chat function or stuff, that will be useful. Yeah, I know. They can definitely use the chat function. Um, yeah, it will be. Yeah. They can use the chat function to ask questions. And then, um, I can share it or just to make it easier for you. Or you can also check the chat yourself if you like. Um, and yeah, also, just to say this will be put on to meddle, And it will be put on to our YouTube channel as well if anybody wants to see it but wasn't able to see it this evening. Um, certificates will also be created using the medal link. Um, as well as the feedback form. Um and yeah. So next week, we've also got a double bill, as I previously mentioned. So on the Monday and Tuesday, um, we've got on Monday, um, e n t and airway emergencies. And then on the Tuesday we've got common ent procedures. Um, as I think, mainly outpatient. So somebody attending the ent department. But I think some also some surgical procedures as well. Um, but yeah, and I'll give people a couple of extra minutes. Okay, so I'll just start introducing. And then if we have more people coming at any point like I said, um, yeah, we've also got the chat function so high. I'm Gabriella. I'm currently an F one at Pool I'm the ent lead for mine the BLEEP. And basically, we're running a series of seminars slash webinars to try and help prepare F one F two s and anyone else who might be interested in ent to prepare them for a foundation job at F two level. So that's the benchmark that we're going for. Um, but like I said, anybody else's free to join. Um, this is the second in our series. Um, this presentation is going to be on pediatric ent, So common presentations, um, and yeah, I will hand over to cripple to talk. Hi, everyone. My name is Keppra and one of the CT two s in the East Midlands. Um e n t themed core training. So like, really says I'm going to be taking you through some common pediatric presentations that you'll see at sort of a s H 02 level if you have an ent job. Um, so I'll start by showing my slides. Um, I have got cases, so feel free to answer questions as they come up. Uh huh. Okay. Can you Can everyone see that? Yes, we can see. Okay, I can't see the chat function in my full screen, so you'll have to just interrupt me. Yeah, don't worry. I'll monitor it throughout. If anybody is, uh, nervous about speaking perfect. So the first case I've got for you. So you've got a two year old boy who is coming to a and B that you asked to see is coming with his mom. And she reports that he was playing in the other room and witness and she heard him make a choking sound and some coughing. And since then, he's been refusing to eat and drink on examination. He's drooling and has some mild kidney and tachycardia. So does anyone was the first diagnosis that jumps to your head. Unfortunately, I've got a foreign body. Yeah, exactly. So quite typical presentation for a foreign body. And your main concern in this case would be a particular type of foreign body. So yeah, like you said to have swallowed foreign body and your main concern would be a battery. So especially the small circle batteries Kids often get into them there in certain toys remote things like that. And the reason for this is because they're corrosive and they called liquid active necrosis. Um, so what would be your immediate management and this patient and any Can anyone mention any useful investigations? I've got somebody who has commented a chest X ray, someone else who's commented, honey. But it might have been. I'm not sure if that was the previous question of the current question. Uh, I've also got a B C d. Okay. I've also got flexible nose Oh, endoscopy for an investigation. Okay, so a B C D is always a really good start because obviously, if the airways are concerned, um, you'd want to involve your senior early, And if you're worried about foreign body, the only way to remove it is the theater. So you would try and prepped for theater. I wouldn't try and do a flexible nasal endoscopy in a child. First of all, they're very difficult to do in a child if you're not experience because of poor compliance, and you may risk upsetting the child and sort of making things a lot worse, especially if they're already drawing and choking and things like that, Um And, yes, chest X ray for an investigation. So, um, if they are stable enough and their airways not immediate risk, then most useful being direct direct chest X ray. Um, and this way you can see what sort of type of foreign body is. Especially when you don't have a good history from the parents. You can see at what level it is. Um, you know, for example, if it's past already, um, and you can also look for signs of surgical emphysema. So, um, when you're worried about a button battery so you can see this typical double halo sign on a chest X ray, which is the pattern of the battery. So that's something you know, you know, you need to take the theater straight away and something you're worried about. Um, so it's quite distinct from other types of foreign body for example. Quite common. A coin, which would be a similar shape. But you wouldn't necessarily see this double halo pattern. You just see a circular, a pig foreign body. Um, so can anyone think of any risks of delaying the treatment in terms of complications? Okay, so particularly if it's a sharp foreign body or if it is a battery, you're worried about perforation, perforation of the esophagus. Um, and this can lead to quite a lot of severe complications such as mediastinitis through infection. So particularly if it is a battery, you need to act quite quickly. Um, and obviously, depending on the foreign body type, you'd be worried about airway obstruction. Um, just some comments on foreign bodies in other offices. So if you've got foreign bodies in the air, you've got the same sort of similar risks of local trauma. So, for example, perforating the tympanic membrane infection and local trauma to the ear canal, for example, sharp foreign bodies, um, with the air, the urgency depends on the actual material of foreign body. So if it's an organic material, so kids often put food and things like that in their ear, then you're worried more about infection. Um, but again, these these can wait, for example, till the next day for a lot of places like run emergency clinics. Um, and it's a lot easier with the use of the microscope and two hands rather than just one hand. And an otoscope in any so sometimes logistically can be easier to remove them in a sort of emergency clinic. Um, if it's something in a plastic bead, then that can wait a day or two as well. Sorry. Um, so it just depends on what the material is. And that's in the year. Because unless there's a tympanic membrane perforation, there's not really many places it can go, Um, and in the nose again, you're worried about local necrosis. So perforation of the septum. Um, obviously in the nose, you're worried about risk of it going further and then aspirating it or swallowing it, Um, an infection. Sometimes patients, especially pediatric patients, can put something up their nose, and their parents don't notice. And they often present with, you know, blocked nose. On. One side may be some nose bleed on that side and fowl smelling discharge, so that can be if there's something up there that no one's noticed. So any questions on foreign bodies before we move on to the next case? I don't have anything so far, but I will mention it at the end if anything comes through. Okay, so the second case, you've got a two month old child who's brought to any parents are worried about high pitched noise, especially when they're crying and laying down. And it's been going on for a few days. So when you go to examine this child, you hear Strider and here slightly. Take it, Nick. But nothing else on observations. So anyone named the most likely diagnosis I've got Laryngeal Malaysia. Yep. So, yeah, so laryngomalacia the key points. And this is the patient as well, and that it's usually a younger age. So in this case, they were two months old. Uh, so laryngomalacia is when the laryngeal cartilages are not matured. Um, so it can affect the epiglottis. And they're rich noise, um, and essentially means because the cartilage isn't mature, it's quite floppy. And when the child breathe it, the larynx flops into the airway on inspiration. So this causes an inspiratory stridor, which is worse on exertion because of the increased rate of breathing. So especially on crying and feeding, it's worse. Um, symptoms usually start around two weeks of age, typically around two months, and then they often self resolved by about two years once the larynx does mature it by itself. So this is if you look at our flexible nasal endoscopy, you have some typical features that tell you that it is laryngo Malaysia. So, um, if you look at the diagram, you've got a normal larynx and mature larynx, and then on the other side, you've got the laryngomalacia. Um, this is a flexible nasal endoscopy view, so you can see, like a curved what's typically called omega shape epiglottis. Um, I don't know if you can see my mouth mouth, but that bit, um and then you've also got enlarged a retinoid, so they're much bigger than they would be. And then this whole epiglottis larynx, it flops into this airway whole when you're when the child is on inspiration. So it flops into this area, which causes partial obstruction and the typical noise that you get. Um, so do you think based on that with their cry sound normal or abnormal, would it be horse or not. So based on what I've said, so it is the cry would actually sound normal. Yes, you would have stridor when the crime. It wouldn't be horse. And that's one of the things that can differentiate from other, more serious conditions, such as vocal cord palsies or group or epiglottitis and, um, in terms of management for this patient. So, like I said, it can resolve once the child matures and the allowance matures as they grow older. So in that case, you would just monitor, um, in outpatient clinics, you can. These Children often have reflux, so you can correct the reflux putting them on PPI. Yes. Um, you can also do sleep studies and things, um, depending on their symptoms. Um, certain patients need surgical intervention. So if, for example, they're having real difficulty if the airway obstruction is quite severe, is affecting their saturations or causing respiratory distress. Then you would, um, do an area epiglottic plasty or an epic last capacity or in severe cases would be a tracheostomy just to relieve the airway obstruction. Um, so, in terms of the topic aryepiglottic party, they often have tight folds between the epiglottis and the retinoids. So the area epiglottic last is essentially just cutting the fold. The band that's holding the epiglottis so it just releases it. Which means it can sort of spring back into a more and the topical position rather than being pulled in. Um, any questions about that? Not currently. But, um, like I said again, I'll let you know the end if I get anything through. Okay, So moving on to the next case, um um, three year old comes into any. She's had a 48 hour history of noisy breathing agitation and Pyrex sick. There is no history of cough. However, there's a harsh inspiratory Strider. The patient has sat leaning forward and drooling, and she has a temperature of 39 38.9. So, in this case, what do you think you're most likely? Diagnosis is Are you more worried about this patient than the last one? I had a very quick response, which was epiglottitis. Yeah, perfect. And anyone know the common organisms. So yeah, Epiglottitis. The most common one is haemophilus influenza. Uh, this is because of the vaccine. It is decreasing, um, in incidents, but other ones can be staph aureus. Beta hemolytic strep, strep pneumonia. Um, what would you have in terms of your differential diagnosis for this? So essentially a child who's come in with an acutely horse voice? I'm breathing difficulties. I've got anaphylaxis. Yeah, that could be one. Also. Croup. Foreign body bacterial. Tricky Isis. Um, I can't see anything. Okay, so, yeah, the most common sort of thing to differentiate is croup. Um, this tends to be in younger Children. It's got quite a characteristic barking cough, um, and is usually more of a viral picture and self limiting. So it's also caused by a virus with parainfluenza. Um also, severe tonsillitis can cause this, but there will be more of a pro dermal history, so it won't be as acute. Um, onset. And obviously there'll be complaints of a sore throat and not able to eat and drink and things like that. Anaphylaxis is also one that I didn't think about, but and then also deep space neck infections can also happen in Children. So, like preferential abscesses, Retropharyngeal abscess is how would you manage this patient? So, in patients with hepatitis, you want to avoid upsetting them. So if you've got high suspicion and they are drooling. They are, you know, leaning forward, respiratory distress, that sort of thing. Um, you don't want to try and examine them because it will only agitate them. It will make them cry, um, can cause them to go into lowering your spasm, which you know is a lot worse than the current situation. They can also aspirated a lot of this pool saliva that they have not been able to swallow. That's just sitting in their mouth. So, to be honest, you don't really want to do much other than just make a prep for theater. You also wanna involve your seniors seniors very early. So be registrar, consultant, ent surgeon. Or so you want to involve a pediatric kinesis because this patient is going to need some kind of airway securing. Um, one thing you can do is just If they're not too distressed and will tolerate having a mask on, then giving adrenaline nebulizers can help. Um, and then, um just arrange for immediate transfer to theater so that you can undergo an intubation. They can also get IV access and bloods and things there, and obviously the Ent team can have a look inside and confirm if they if it is a dermatitis or not. Um, and the idea of this is just doing it all in a very controlled environment and with the airway secured because trying to do this in any of your biggest worry is to lose the airway. Um, so the next case, this one is probably quite a simpler one. So you've got a older child, a six year old child who comes in with a three day history of progressive sore throat, been struggling to eat and drink because of the pain, and has been generally just feeling unwell. Um, she's finding it difficult to talk and has a low grade temperature On examination. You can feel some cervical lymph nodes and you look into her oropharynx and it looks like this. Anyone know the diagnosis? I got tonsillitis times to Yep. So, yeah, so back to your old ones like this is the most common one. Especially if you're seeing the typical white spots pass. Um, viral tonsillitis. Also infectious mononucleosis caused by Epstein Barr virus is the other common one. You're less likely to get this sort of puss on top. There be more um, just in large red tonsils. Sometimes they can have a sort of extra day on the outside. Um, another one could be also a Quincy. So peritoneal abscess. But there are some slight things that may tell you if it is a Quincy rather than a tonsillitis. So, um, it's more of a swelling in the peritoneal space rather than the tonsils itself. Often it's unilateral. So you would have the uvula deviated to the opposite side. Um, the patients complain of trismus, so this is painful opening of their mouth, so they may not even be able to open their mouth well enough for you to examine them. Um, and they've got this typical hot potato voice. So the voice you kind of make when you've got something hot in your mouth, whereas in tonsillitis they don't tend to have that, Um, and the reason they get the trismus is because of the abscess past being in the peritoneal, a sweat space, it irritates the muscles. So you get pain on opening your drawer and stretching of those muscles. Um, one of the most common organisms causing tonsillitis. So this is viral and bacterial. I've got strap streptococcal strep. Yeah, a lot stronger. Yep. So strep Argenis is the main one. And then Epstein Barr virus is the most common viral one you can get a viral tonsillitis and then a secondary bacterial tonsillitis. So that's something to be aware of. Um, and in terms of management of this patient, I've got antibiotics, oral antibiotics, pen V as well. Yeah. So antibiotics, Um, so, yeah, it's usually a pen. V, um, you would give antibiotics, even if you think it's viral. Because, like I said it, um, you can get secondary bacterial infection on top of a lot of these pair of times, patients will come in having had some oral antibiotics, and it's not been working, So they come in with worsening symptoms, so they may need IV antibiotics. In that case, um, they may need IV fluids if they're not able to eat and drink anything. Obviously, pain killers. Um, benzidine. So def Jam also is really useful. Um, it's NSAID and local anesthetic, and you can get it in a gargle or in kids. A spray version is really useful, so you can give it to them just before they eat and drink as well so it helps with their oral intake. And you just wanna do a mono spot, Glandular fever, blood test as well just to confirm if they do have glandular fever or not, um, anyone know what? What you would advise if they did have glandular fever in terms of management and cautions to take so glandular fever you get, you know, it's the infectious mononucleosis. You can also get hepatomegaly. So you want to warn them if it does come back positive not to, uh, do any contact sports or anything like that because you're more at risk of, um, trauma to the liver because of the hepatomegaly and splenomegaly as well. So your risk of splenic lacerations and ruptures. I've got no kissing of exports and penicillin as well. Yeah, exactly. Um, so just a little bit on the guidelines for tonsillectomy, which is really useful to know, because patients will always come into A and E and be like, Can I just get my tonsils out? So it's useful to know the guidelines. So we follow the Scottish guidelines, Um, which state that if you've had seven episodes per year, or if you've had in the last year or if you had five episodes a year for two consecutive years or three episodes a year for three consecutive years. Um, so they're quite strict. In terms of that, there are some sort of more relative criteria. So if you're getting recurrent Quincy so usually it's if you've had two queens ease that will make you eligible for a tonsillectomy. Um, sometimes if there is a worry of a tonsil asymmetry. So, for example, so for this reason, you'd want to do it for diagnosis and histology just to rule out anything malignant in adults, this is more likely a sort of a sec, uh, malignancy in smokers and things. But in Children, it may be more of a lymph malignancy. Um, if they are having obstruction so in, if the tonsils are so enlarged that there obstructing, um, also obstructive sleep apnea can help. And another relative indication is if they're allergic to the penicillin antibiotics and they don't respond well, so they have a couple of episodes of tonsillitis, but it takes them a longer time to recover. Or they get a lot sicker and sepsis than things because they can't have the, um, guideline, antibiotics, then it may be safer in this patient to just take their tonsils out. Um, any complications of having tonsillitis anyone can think of? Yeah, I've got a phthisis media. Um, not necessarily. So one of them would be a Quincy repair a tonsil. That abscess. Um, they can also rarely develop into a deep space, uh, infection so spreading of the infection into the retropharyngeal spaces. Um, if they're not eating and drinking, make them with dehydration and then also because it is a bacterial infection, they are at risk of developing sepsis. Um, and like someone mentioned earlier, So you're just a point to avoid amoxicillin if you're suspecting Epstein Barr virus because they can cause, uh, Redmond syndrome, which is a type for a hypersensitivity reaction and rush. Okay, So the next case, um, we've got a six year old child who's been referred in by the GP. He's had three days of Kreisel symptoms and left sided otalgia. He has been treatable oral antibiotics, but now is feberal. And there is a swelling behind his ear. So what do you think the GP is concerned about? I've got bursitis. Uh, yeah. Several mastoiditis. Yeah. Perfect. So mastoiditis and this can be secondary to acute otitis media, um, common symptoms, depending on the age of the child. You know, especially if their nonverbal they may be pulling at the ear will have otorrhea. So, like discharge coming from the ear, um, fever, excessive crying. And in rare cases, if it's severe enough, you may have mentioned gettik symptoms. So an examination What would you expect to find? This is a big clue. I've got hot and swollen, um, post auricular swelling and erythema. And then I've also got a swelling and tender mastoid as well. Yeah, so the most important thing is this is the swelling. A lot of patients who have just otitis media well, the GP will often say they have mastoid tenderness and be worried about mastoiditis. But in a lot of cases, it's not. So you'll have because of the swelling behind the ears of post auricular swelling. You have anterior displacement of the Penis, so it's often useful just to look at the child face on and see if one of their ears is pushed forward. Essentially compared to the other one. Um, the swelling will often be red tender fluctuation. Um, as it looks in this picture. Uh, they may also have lymphadenopathy in the area. Cervical post curricula. Um, and then one of the a good sign as well to differentiate it from any other post auricular swelling is they often won't have the posterior skin crease of the year. So usually there should be an ear skin crease there. Um, if you can see the mouse, which is then obliterated, so that tells you it's more likely a mastoid rather than something happening just behind the air like a lymph node. Um, and then when you examine the ear inside so you can see red bulging tympanic membranes. So signs of acute otitis media um, you may also have swellings in other areas, so it's common for the infection to spread to the occipital area. Sternocleidomastoid. Um, and as with any ear infection, there may be a facial nerve palsy. So it's important to check for that. Um, any other differential diagnosis of post auricular swelling have already said one. And what investigation would you want to do on this child? Yeah, I've got an MRI. Okay. So, in terms of differential diagnosis, so you can have post auricular lymphadenopathy uh, like I mentioned, and that post auricular fold will be present because it's more posterior. You can also have trauma. So it's a scratch, uh, an insect by which may cause just a local swelling and also things like boils. Cysts can also happen behind the ear, so it's important to rule those out. Also on the other things. Looking inside the ear, it's less likely you would find signs of acute otitis media. Um, so we'll look more normal on internal examination. Um, and in terms of investigations, the easiest and quickest would be, and the best one for mastoiditis would be a contrast CT of the temporal bones. And what you'll see is obliteration of the mastoid cells. So, as you can see on the left here, so this the right side is the normal mastoid. So because the air cells they will be black on CT, and obviously tissue is gray. So on the left side you can see it's all obliterated, so there's not really any black at all there. It's all either swollen or pass or filled with something that is an air, Um, and sometimes you can also get some periosteal abscesses, so you can look out for those. Uh huh. And how would you want to manage this child? I've got mastoidectomy, uh, sort of. I wouldn't jump to that straight away. IV antibiotics are the next couple of answers. Yeah. Yeah. So you would want to give IV antibiotics. So you want to admit the child? Obviously do baseline bloods and things IV antibiotics. You also want to give ear drops if indicated, and then if they're not responding, you would do a cortical mastoidectomy on the patient. Um, and the reason we worry about mastoiditis is that it can be quite a severe infection. So although it's just usually a complication of, uh, quite common ear infection, it can have quite severe complications. So just do two purely the location of the mastoid. It's very close to a lot of other structures, as you can see this diagram so you can have extracranial complications, so involvement of the ear itself will cause hearing loss. Um, your facial nerve goes through quite closely, So your facial nerve palsy is, and also like I said, it can spread locally within the planes so you can have a sternocleidomastoid abscess and also occipital abscesses and then intracranial complications So you can develop a venous Sinus thrombosis, uh, meningitis, um, and then epidural and subdural abscesses and even cerebral abscesses, so just purely by spread of infection. So this is why it's something that needs to be monitored quite untreated. Quite carefully. Um, so the next case child presents with a lump in the midline of their neck. The mom mentioned it's been there for some time, but it's gotten a lot more painful and bigger in the last two days. The lump moves on swallowing and protrusion of the tongue. There is your clues. So what's the top? No basis. I've got a thyroglossal cyst. Yep. So this is the most one of the most common next swellings in Children. I think it's the most common congenital one as well. Anyone know the pathology, the embryo, logical origin of how you get thyroglossal duct cyst. I've got thyroglossal duct cyst, which is not, um, yeah, question Mark. I was going to guess pharyngeal pouch, but I don't know if that's the right answer or not. Something so pharyngeal pouch is different, so it's essentially a congenital remnant of so in M biological development your thyroid develops from around the base of the tongue, and then it then descends along. Can you see this tract? So it says thyroglossal tract and then decide descends in front of the high thyroid and then in front of you, and then where the natural level of the thyroid is in front of the trachea in adulthood. So when this track doesn't quite obliterate, you can develop a cyst and swelling. They're, um So the common things to differentiate from other types of neck low is because it is attached to the tongue. When you protrude your tongue, there will be it will move upwards. So if you stick your tongue out and move upwards and also when you swallow because again it's attached to the thyroid. So if you think about thyroid examination and moves on swallowing, so with this and also it's midline. Um, so those are the things that you sort of look for. I was just going to say on an answer here, which is the failure of the thyroglossal duct to obliterate? Yeah, essentially, Yeah, that's what um and then it can get acutely infected. So in this case, they've had it for a while, and, um, it's got worse in the last couple of days. It can get a sort of acute infection on top and become a lot worse. Um, any idea what investigations you would do that will help? Because there's quite a lot of neck lumps that can present. I've got bloods. TFT s as well. Yeah. Yeah. So you don't do TFT s. Um, sometimes your radioiodine scan, um, and an ultrasound of your neck. And the reason you do the ultrasound is a to look at the consistency and also to check because sometimes the thyroglossal cyst maybe the only functioning thyroid tissue you've got, which you obviously need to know before you plan on removing the cyst because you don't want you need to know if the patient will need biopsy and treatment life long or if they can function without the cyst if they've got functioning. Thyroid and management of this. Um, so in this case, the acute infection can be treated with antibiotics. Um, and you want to do an elective excision once the inflammation infection is settled down and this is called a systems procedure. Um, and this is you would exercise not only the cyst, but you also take a bit of the hyoid bone and the tract out. So if I go back to the picture, it's often connected to the high road bone and the track. So you would take out this. You would incise in front of the cyst, so the neck incision and then follow the tracks back until you get to the high road. And then you would take off the bit of the high road that it's attached to. Um, this is just because if you don't do that, it can reoccur. The recurrence rate is a lot worse in um, when you don't take up the high point that combined is called a system of procedure, um, and then differential diagnosis of neck lumps. So just going through. Because neck lumps are quite complicated and they present, um, can present similar in similar ways. Um, it's often useful just to have a symptom of how you sort of go through things. So I found quite a useful one, so it can be. Some people do it by location. Some people do it like by pathology, and then this one I found quite useful. So to look at if it's a cystic or a solid lesion. So, for example, cystic. Then you can split it into, um if there midline, um, most common ones thyroglossal duct assist and then a dermal insist, and then if the lateral, their bronchial cyst. So these bronchial sisters, the other really common one. Um, and this is again a congenital thing. And it comes from, um, remnants of the second floor and your arch in, uh, geological development. Um, and again, it can get infected, but it does present a little bit later than thyroglossal duct cyst. So it's normally sort of, uh, late teen years. It starts to present and become a problem. You can also in this in the younger age, you can have vascular malformations, lymph angiomas and then looking at the more solid types of neck lumps. Uh, they can just be a reactive nodes from an infection lymph colitis, lymphoma. But you also look for lymph nodes and other places like Exelon, groin, um, and then some other ones. Uh, more common in adults, I would say, is like So, thyroid lesions, um, famous teratoma neuroblastoma, that sort of thing. But in Children the most common ones. Thyroglossal duct cyst. Like I said, mid line. And, um, the easiest way to differentiate is so it moves on protrusion of the tongue and swallowing. And then the other common one is the bronchial cyst, which is usually on one side. I think this is the final case. So your call to the emergency department to review four year old child who's been unwell for three days, and she's developed swelling of her left eye. How do you want to examine this patient? What sort of things would you want to consider? An examination? Yeah, I've got the you a, um a TUI assessment. Uh huh. Yeah. So what What's your, like, main? Sort of. So you know, you you've been asked to come and see someone a swelling of their eye. What's your main sort of e n t worry with someone who's got and unilateral advice? Well, uh, is the I read. I've got query N A I query cellulitis as well. Um, I think I might know, but I don't want to spoil it. So everybody. So your main concern with someone you've been asked to see a child with an eye swelling is sinusitis because this can spread. So you want to start by doing a full examination. So obviously, take a history check if they're systemically well or unwell, and then I like to sort of split it up into three sections. So doing an eye exam for the nose exam and then just a general sort of neuro exam. Um, so on I you want to look at their eye movements if they have proptosis so, you know, bulging of the eye, Um, you want to check their color vision? Um, bearing in mind, a lot of these things will be a lot more difficult in Children. So you can, because the red color is the heart. First one to go, you can just show them something red and ask them what color this is. You know, this would work in our patient because they're about four years old, so they would most most likely know colors. If they're a bit older, you can use the issue. Our plates, which are, you know, the ones with the numbers, um, and the two different colors. Um, you can also use the snow and chart, or, if it's a child, just hold up your fingers and ask them how many you're holding, Um, and then signs of ophthalmoplegia. And this is just to assess their vision and severity of what's going on. And then you want to do a nose examination. So, like I said So sinusitis is our main issue. We want to work out if we've been asked to see this patient in any is if this is a primarily I think so. Then we would appropriately refer onto ophthalmology or, um, if it's cellulitis, then to pediatrics or whoever, but or if it's a ent related thing, so I want to do. And, uh, you could do a nasal endoscopy. If you think you can do one, you don't usually need to do the full nasal endoscopy. Just look in there, um, nasal passages, or just do an anterior rhinoscopy and just look inside the nostrils so looking for signs of sinusitis. So turban inflammation, congestion. So signs of blocked nose, Um, and any puss or anything like that. So any thick sort of snotty discharge that's coming out? Um, that's supposed to say swab, not swap. So if there is any discharge, then take the microbiology swab of that so that would be useful later on. And then you want to do a new neurological exam. So try and do to the best, uh, review ability, depending on the age and compliance of cranial nerve exam. Looking for signs of meninges. Um, so, you know, first phobia they're moving their neck, and then a GCS. So what, given that examination, what would be the more worrying signs? So I think I've got an answer already. That's good for this. So I've got vision loss being something that's important. Yeah, I've got Are they systemically? Well, it was for the previous question, but I think it's still relevant to this as well. I've got query preseptal cellulitis as well. Yeah. So worrying signs would be a visual loss proptosis so bulging. So if there's so much edema and stuff that I won eyes sort of popping out almost ophthalmoplegia so not able to move there. I, um and then meninges. Um because then you're worried about of systemic spread, and then in it. So you're in a child. Obviously you don't want to do cts that often. But what would What sort of things would you need to do an urgent even overnight CT scan for again. So this is an answer to a previous question, but I think they're still relevant. So I've got proptose iss sepsis, vision loss as well. Yeah. So, um, in kids, So if you're unable to examine them, So, for example, this can be because you just they're not compliant at all. Or if the swelling is so bad that you can't they can't open their eye at all, then you're not able to determine if they have visual loss or not. So that would warrant a CT if you have worries of the underlying abscess, Um, if you've got worries of cabinets, Sinus thrombosis. So this will be where the ophthalmoplegia comes in because your cavernous that Sinus, if you remember, has got, um, yeah, cranial nerves 346 and then parts of the Ukrainian over five. And then if there is evidence of managers and more intracranial abscess, um, and then in terms of surgical intervention, a lot of similar worrying signs. So if their vision is decrease, if there if the prognosis does progress despite being on antibiotics, Um, so obviously with this patient, you wouldn't if if they're stable, enough to not warrant an urgency t You know, it's the middle of the night or, uh and they're okay, and they don't use theater overnight. You would put them on antibiotics and see how they get on. So if they're getting progressive procto sis, Um, also, if there is no response at all to the antibiotics or if they have had a CT and there is a drainable fluid or collection, Um, this is Chandler Grade three or four. I'll go through the channel grades in a second, Um, or if there's some kind of a typical picture or something like that that needs a biopsy. So the two approaches to draining this surgically. The most common easy one is something something the external approaches in this picture there. That's called Lynch our incision, Um, and it's the sort of quickest, most easy approach. You can also go internally using endoscopic Sinus surgery through an ethmoidectomy. Um, and you would just make this incision and drain any pass collection, anything like that. Um, so in terms of the management options, we've touched on this a little bit already, so obviously it's an infection. You would do sepsis. Six as you would usually resuscitate fluids. Um, that sort of thing. Analgesia do any swabs. It's for any partial discharge. So because usually the pathology is coming from a sinusitis, giving decongestions can make a big difference. So doing saline douches? Um, giving a Triveen. Also giving intranasal steroids can help, um, the information CT scan. And then you would also want to involve ophthalmology just to take care of things in the eye. Um, and then finally do surgical management. So the pathology, the most common ways you get periorbital still use that cellulitis or precept cellulitis or any type of ice swelling so it can be insect bites can be trauma. Um, a lot of times this can happen after ophthalmology procedures, dental procedures, dental procedures. So sometimes you can get this in. Adults who have had some kind of tooth extraction or affairs procedure can come with complications, but the most common one in Children of a specific age is Sinus coming from sinusitis, and this is usually the front ethmoid Sinus Sinus, um, and the way this is just by local spread. So if you think of where the Sinuses are, they all sort of below your maxillary Sinuses. You've got your ethmoid Sinuses. And sometimes if there is breach of Lamictal preparation, which is just a really thin cartilage in between your Sinuses and your eye it the infection in the past from the Sinus can just breach that. And then, um, the way to classify this is a channel of classification. So this is just used for, um, to assess the severity. So you're grade one would just be a preseptal cellulitis. So this one you just manage with antibiotics and decongestions and see how they get on. You can also get an orbital cellulitis without an abscess. Um, and then when you get to sort of channel classification three. So you've got a sub for osteo abscess, which is confined to confined to the periosteum. That's when you want to think about doing surgical intervention. So for anything, grade three or above, then grade four is your intraorbital abscess. And then grade five is your full blown cabinet. Sinus Sinus time, bro. Sis, um, ideally want to operate before it develops into that. And then again, there's quite a lot of complications, which is why we worry about this similar to my story itis just purely by local spread. So, like I said, you can get a subperiosteal orbital abscess. So you you're jeopardizing the either vision. Um, permanent visual loss. You can get a motility disorder of the eye. Um, systemic spread can develop meningitis, cabinet, science, some bruises, and then you can also in this case as well get intracranial spread or subdural spread. So forming an abscess and that's it for me. Does anyone have any questions? No, that was a lot of information, but I have a couple of I think I've got one or two questions from earlier in the presentation that just didn't get the opportunity to ask from before. Do you know, do you do a mono spot in everyone? Or how do you know who to suspect for this when holding off on antibiotics? Um, so it's usually easier to do on everyone. Um, just because if you're taking blood, you may as well. Um, and a lot of the time, it's difficult to differentiate If it is a bacterial tonsillitis. Like I said, you'd get more sort of the spotty posture ALS, whereas with the viral tonsillitis, you don't. But like I said, you can how it depends when they present in there sort of, um, infection stage So you can have had you could have had a, uh, viral infection and then had a secondary bacterial infection, so I wouldn't necessarily. Even if you're very convinced it's e B V, I wouldn't hold off on antibiotics. I would treat them all with antibiotics anyway. But it's just with the added court precautions of, um, it will take a lot longer to recover if it is viral, because it can take about six weeks. So they may feel a bit sort of rubbish for a bit longer than you would expect with just tonsillitis. So a bacterial tonsillitis would usually feel a lot better within sort of 48 hours of antibiotics. And on completing the course, um, they'll be pretty much back to normal as an EBV because it is a virus, it takes longer. So it's just so you can manage patient expectations and give them the precautions of, you know, avoiding contact, sports and things like that. Great. My worry is that when we give them penicillin antibiotics and it turns out to be EBV, so the penicillin V is okay. It's just the amoxicillin. So the most hospitals check your local guidelines. But most hospitals will suggest penicillin V, um, all benzyl penicillin. If it's IV for tonsillitis, so you can give that it's just amoxicillin, which causes the hypersensitivity. Great. Are there any other questions at all? I'll give you? Um, but yeah, just I've got There's also a streptococcal scorecard from BMJ. Best practice for the use of antibiotics. Um, any other questions at all? I'll give you a couple of minutes as well. Um, I just wanted to say thank you so much crude party for giving up your time to come and do this presentation. It was really, really informative. I felt like I learned a lot just from reading the slides and you're presenting. So thanks again, thank you so much for giving up your time on a Tuesday evening to come and do this for us quickly. Glad it was useful. It was very useful again. Thank you so much. Um, I just had one additional question which wasn't necessarily related to the presentation, but we always have a few keen beans in the audience who are keen on E N. T. And I noticed that your Ms Brown bat? Yeah. So I was just wondering if you could tell us about because I could see that you were on a theme DNT post, is that correct? Yeah. Tell us a little bit about how you got there and what you've had to do. Obviously not. Yeah, like a condensed version. Yeah. So with I know that in some places that are run through, I'm not sure if they're still running a finish. Yeah, it was only pilot. Yeah, so you can get a themed rotation. So I picked an ENT theme rotation, and what that means is part of my two years I get one year of those two years will be ent. And then, um, the other rotations will be something related. So also helps in your s t three applications for ent because you get points for certain surgical specialties you've done rotations in. So I had, um, cardiothoracic surgery, plastic surgery, and I'm currently doing general surgery. But upper gi guy. So, um, not only there sort of related, and I've had to have transferable skills, but they also give you points for your ST three applications. Um, and then in terms of the exam, so you obviously have to do the same MRCs part a. And then I did the Don's part B which, uh, I preferred to the MRCS part because it is just head and like focused, and it all seems very relevant. And you don't have to learn about specialties you're not really interested in. Um, so yeah, and I think once you've kind of done an ent job even as an f two, it the revision for the exam is a lot easier because it's a lot of these things that I've talked about today. You'll have a lot of these cases. You may seem some of the CT scans and all these presentations, Um, and it will make a lot of sense and just, you know, you won't have to think about it as much. You won't be as much of a vision because it will be something that you've done on your job. You know? How do you stop and epistaxis? Well, if you've done that every day on call, then you know exactly how to do it. And it's not really revision as such almost become second nature. So I think just doing an ent job definitely makes a big difference for your exam. And I Yeah, I try and do the exam. Once you've done an ent job, I think it will make a lot easier in terms of provisions. Yeah. Thank you. Yeah, that was a really good answer. Thank you so much again for giving up your time. It was a really, really informative presentation. Just some other housekeeping stuff. Um, everybody should have gotten a feedback link. Um, either via email. And it's also posted in the chat if you didn't get the email link, Um, and that should automatically generate a certificate if it doesn't feel free to message us on the mindedly Facebook group or email us as well. Um, as far as I can see, there are no other questions. So I'm going to Yeah, I'm going to close down just the presentation. Um, but again, also, thank you very much to everybody who's attended, and thank you so much. For all the answers and the questions that you had, it makes it a much more engaging, an easier presentation when we have people who you know, happy to contribute. So thank you so much as well. Um, and take care. Bye, everybody. Thank you.