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One. So just some housekeeping before we begin, I'm sure you will be familiar with this if you have attended our previous session. But please use the chat to us. Any questions and the session will be recorded in the slides and recording will be sent out via metal. So please fill in our questionnaire and attend up to six, attend six out of 10, sorry, six out of eight sessions to get free R CS affiliate member for 15 lbs and for our social, please. Um, just a disclaimer that this is apa session by medical students. So please bear with any mistakes next back, please. So before we begin, I'll just get everyone to fit in a few polls which I will get out now and there should be about six polls, but please pull this up. You just give it like a minute or so just where you basically fill it up. Yeah, yeah, for those people who just joined, um, please fill up the post that we have just put on the chart and we will begin shortly after and yeah, also please scroll up down to all six polls. Um Some of the poles have may have been hidden. So just do a quick scroll up the chat box just to see what uh anything you have missed out. We're just waiting for a few more responses, right? So that's great. Uh Well, there's someone still filling in but yeah. Um So while you guys fill in the polls or whoever hasn't filled it in yet, I'll just cover some of the lesson objectives so I can just go through that while you are doing that. So we will be covering these three cases today. Um Just to learn more about the key anatomical bits in surgery. So we have a cataract surgery case. We have a gourmet surgery case and we have a thyroidectomy. Um We'll be going through a quick tour through the following points here. Um The pathophysiology, clinical features, investigations, management, anatomy and complications of the condition and the surgery. And we'll be keeping everything light and interactive next slide, please. So here's just a quick introduction to ent surgery and ophthalmology. Um for ent surgeons, their role is quite self, self explanatory. So they focus on the ears, nose and throat region of the body. They also known um by a variety of names depending on where you are from in the world and they can be known as or Lagos or oral Lagos. Fun fact, these names are all derived from Greek and can be quite a mouthful to pronounce. So, auto meaning e laryngo, the structures of the neck and rhino into the nose. For, for simplicity, sick, I will be referring to them as ent surgeons. Um The specialty itself is very competitive as a crossover from other medical and surgical specialties such as neurosurgery max effect and plastic surgery. And they also deal with a long list of conditions which is seemingly inexhaustible from malignancy, er glue year in pediatric patients and cosmetic rhinoplasty or nose job, as you might know the common term. Um ophthalmologists, eye eye specialist, it is also a very competitive job with high impact work affecting quality of life as vision and sight is a really important part of our senses. And there is also quite a crossover between medical and surgical fields due to the drugs and techniques used to treat eye disease. And also ophthalmologist usually treats patients of all ages from the youngest neonate to the oldest patient on the geriatric ward. So, next slide please. So I have included um a non exhaustive list of common specialty cases done by both specialties. On the ent side. They usually work on the head and the neck and we have a right and we have a wide range of cases here. We have ent oncology for surgeons, interested in head and neck cancers. We have tonsillectomies or the removal of tonsils, thyroidectomies for thyroid removal and insertion for glue and various other procedures. Um I won't go into too much detail regarding that. Um on the ophthalmology side, they usually work on the eye itself. So we have cataract surgery to remove cataracts, pretty self explanatory and we have LASIK surgery to correct myopic vision. I will not be going to again, too much detail regarding this, but there are many more vision salvaging procedures that ophthalmologists can do. So. Next slide, please. So tonight, imagine yourself as a medical student having an 8 a.m. start in theaters. Um Next slide please. You go to the morning introduction round and you meet the team shown here. Um You introduce yourself and you prepare for the first case to start in theaters. Next slide, please. So while you wait around, you watch the team set up and you hear that you see these retractors on the floor under some blue drapes, you choose either to pick up the drops instrument or inform the theater. So this is a start to our interactive poll. So please answer the poll and we will select the most popular answer and this will take us into a unique adventure pathway. I'll just get the poll right now and that it up. Um Just put your answer in the post. Don't worry, it's all, it's all anonymous and we'll choose the most popular answer. Give it a few more seconds. Um Just for people who just join. So I think everyone's pretty unanimous in this answer. So um everyone has chosen inform the theater. So you decide to say retractor on the floor and the theater picks it up done. Um And she thank you for doing the right thing. You see some students pick up and break the sterile for you around the DRS. So the main takeaway from this short event will be always to keep away from the scrub by all times, especially if you are not scrubbed in as a medical student. And this is really to maintain the sterility of the equipment and to ensure that all instruments are accounted for during the case. So at this point, your supervising consultant hops in and invites you to the next theater to observe a cataract surgery. And I shall now hand you over to Joseph who will be covering the case. Hello, everyone. I hope you can hear me. I'm Joseph and I'll be uh going through cataract surgery today. So let me get back onto the slideshow. All right, there we go. So today we'll be learning about what cataracts are. Um what is done during cataract surgery, some of the complications of cataract surgery as well as to learn a bit about the anatomy of the eye in general. So, um in terms of cataract surgery and cat, so what cataracts are, it's where the lens of the eye gradually aac they are cloudy and they believe this is because the fibers of the lens over time sort of denature and degrade and the sort of build up and because it gets cloudy, it makes it more difficult for lights to reach the back of the eye. And this is why some of the symptoms of cataracts, you get progressive blurring of vision, you get a glare when you're looking at lights as well as colors appearing a bit dull. Um, in terms of some of the risk factors for cataracts, um, usually it's due to um age related changes. So at the moment, I think around over 70% of people aged over 85 develop cataracts. Um, so the main, the main risk factor is age but, uh, other risk factors include diabetes. Um, you can get it with long term, uh, steroid use, corticosteroid, use, uh, UV, exposure, smoking and ocular trauma. And sometimes you might want to control these risk factors to slow down development. So you could, uh, stop smoking, you could have good glycemic control. Um, and that kind of thing, I guess, um, in terms of cataract surgery itself, um, some people might call it fatal emulsification, but it's basically what happens. So what involves is breaking down and removing the cloudy lens using ultrasound, take that out and then implant a new artificial lens. And in terms of when you would do cataract surgery, er, for cataracts, it's when the symptoms of cataracts interfere with patients activities of daily living. So there's actually no minimum level of vision required to have a cataract operation and it's usually based on personal, er, decision. So you have a joint decision between the patient and the surgeon based on your own personal circumstances, if it's really affecting you in a day to day life. Um Another reason you might have cataract surgery is if the cataract hinders the monitoring and the treatment of any coexisting conditions that might be affecting the retina or the back of the eyes. So, in terms of the anatomy and so we're just gonna talk a little bit about the anatomy of the eye to start off with. So you've got the cornea here at the front. Um So the cornea and the lens, as well as I guess, the um the aqueous humor, er all work together to er focus the light onto the back of the eye onto the retina. So the lens accounts for around 30% of the refraction and the cornea does make the jab about 70%. Um the lens itself uh in the middle here uh sits in this little depression, uh which is called the hyaloid fossa uh between the IRS here and the uh vitreous Hema. And it's suspended uh by these suspensory ligaments to connect to aci muscle bacillary body. And what happens is the ciliary muscles contract. Um This relaxes the suspensory your ligaments and that makes the lens more spherical. So you can increase the focusing power of the lens. So you can focus on nearby objects in terms of other structures in the eye. And you've got the iris here. And what that does is it can change the shape and the diameter of the people, which is this little hole here to control the amount of light that uh goes into the eye. Um The area between the cornea and the iris is the um anterior chamber and the area between the iris and the lens is a posterior chamber. And these all filled with um aqueous Hema and in terms of like a clinical point of view um in the condition of glaucoma. Um what happens is the um er trabecular meshwork, um it's blocked and that um stops the drainage of aqueous humor. It builds up in the er anterior chamber and that causes an increase in intraocular pressure and that can sometimes cause pain and glaucoma. Um in terms of other structures of the eye, uh the retina at the back has all your photoreceptor cells. Um the macular er and especially the foer um has a high density of cells and these are the ones that you need for color vision. Um Yeah. And then the sclera and then the choroid is the uh filled with connective tissue as a and vascular tissue, I guess with all your blood vessels and all the inflammation goes by the optic nerve to the brain. All right. Uh And now we're gonna look a bit further at the anatomy of the lens itself. So the lens has um I guess for three different parts, it's got the nucleus in the center, it's got the cortex and I guess it has the capsule um there and it has two poles, the anterior pole and the posterior pole. And what, and what's the significance of these different parts is that different types of cataracts can form in the three different parts. You got, you can get nuclear cataracts, you get cortical cataracts and you can get cataracts uh sub uh just below the capsule. OK. So now I guess we can move on to our patient Vignette. So here we have, er, Missus Charlotte Kelman who is 76. Um, she's been complaining of reduced vision, particularly, er, difficult at night, uh, especially when she's driving because of lights, give her glare and starburst as you can see in the picture here and it's really affecting her day to day life. Now, uh, she can't read her books, she really enjoys reading and she can't read. And, um, it's, yeah, really affecting her day to day life in terms of her past medical history. She has type two diabetes adder's disease and hypertension in terms of medications. She's on hydrocortisone and fludrocortisone for Addison's disease, Metformin for diabetes and amLODIPine for her BP, uh, in social history. She's a retired secretary. She lives alone in a bungalow, she's, and she smokes around 15 a day since she was 18. So you can see in these pictures here, what someone with the cataracts, how they might view the world and, and what the images might look like, compared to someone who has a normal lens. So before we move on to the surgery, uh, just a little bit of a content warning. Um, some people get a little bit freaked out, er, by eye surgeries and looking into the eyes. So that's completely normal. Um, if you do feel a bit woozy, er, feel free to pop out the room, grab a drink or a snack or, or, or just take a, take a break and come back when you feel ready. So I guess we can move on to the surgery now. Oops. So, um, cataract surgery usually it's uh with local anesthetic. So they inject that into the eye. So you numb the eye so you don't feel pain. Um, but that does mean the patient can hear sounds and they can sort of move the rest of the body. So they, er, told to keep the head still and keep their body still as much as possible. Uh, it's quite difficult. Uh, I've seen a few cataract surgeries. Um, it's very tempting to be, but you have to keep it as still as you can. So after they've injected like an anesthetic, uh they make a primary incision so they can insert the instruments into the eye. And what the first thing they do is they insert viscoelastic, um, some kind of viscous type of uh fluid. So, the question is, what is the purpose of inserting, uh this type of viscous kind of fluid into the eye right now. So, is it a to stabilize the anterior chamber by keeping it maintained and pressurized? Is it to uh protect the corneal endothelium from intraoperative trauma or is it c to open up the capsular back? So, I guess uh I think there should be a polyp right now and you can vote on what you think the answer is. Actually, I can't see the problem right now. So Reagan is answers coming in. Yeah. Um we have about seven answers. So we'll just give it a couple more seconds and we can. Ok. And I'll just let you know. Right. So I think um 85% of people have stabilized anterior treatment by keeping it maintained and pressurized. Ok. We'll go for that then. So, yes, there that is correct. The consultant smiles on those heads. So what it does the visco elastic, it because of its viscosity helps to um maintain the shape of the anterior chamber. So when you're prodding around, um it doesn't collapse the, the eyeball or the anterior chamber. Yes. So it allows the surgeon room to maneuver the different instruments in the eye. Um and we can go back and look at the other options. So if you put b it would actually easily be correct. So the viscoelastic it helps to protect the inside of the cornea er from the ultrasound energy you can imagine from the ultrasound energy, it's quite intensive. So it helps to protect the inside of the cornea, er, from that ultrasound energy, er, by coating the inner surface of the corneal endothelial cells. And if we go back to see, er, opening the capsular bag, um, no, we er, not yet because we've not removed the cataract er, yet. So we don't need to open up that space yet, but we will do it later on in the, er, procedure as well as I'll show you later to open up that bag. So we can insert the artificial lens, right. So after you've inserted the viscoelastic, you perform something called capsular hexa. So what it that does is where a circular opening is made in the um in the capsule, um the bag that's holding the er ca er the lens and the cataract in so that er the surgeon can access or remove the nucleus and the cortex of the lens. So remember before, when I was er showing you the picture of the anatomy of the lens with three different layers, the nucleus and the cors of the two middle layers. So usually you remove those two layers that keep the er capsule intact. Uh So that's what capsulorhexis does. Um So now er after you've er made a little opening in the capsular bag, so you can reach the nucleus and the er cortex and you ins er you inject a balanced so er solution between the cortex and the capsule to separate them and this is known as hydro dissection. What that does? It helps to make the rest of the lens er, pretty er pretty mobile out. So, um you can sort of start to break it down and remove the different pieces, but then the surgeon stops at you and he asks you where in the lens are cataracts more common. So, remember those three areas, the nucleus, the cortex of the subcapsular. The surgeon asks you which of these three areas um are cataracts more common? Is it than a the nucleus B the cortex or C subscap? Sorry, subscapular. So I guess there will be another polyp and you can vote on the answer. Give it about 30 seconds. Ish more. OK. Sure. Yeah. So I think most people have both had fallen nucleus. All right, we'll go for that. Then the n the more central one and that is correct. So nuclear cataracts, the ones in the center are the most common and they're usually age related, which um is the biggest risk about type of cataracts. So your typically na the typical sign of progressive loss of vision and decreased color perception. If we go to the other ones, the second most common is the cortical ones from the cortex. Um and they usually develop a lot quicker with cataracts. So when N cataracts is a very gradual progressive um loss of vision, maybe over quite a few years. Whereas cortical cataracts are a lot quicker and they are more common in people who have diabetes, uh who have ocular trauma, who smoke, who have a lot of UV exposure and a in African Americans. And the least popular um, of the phrase or least common I should say is subscapular. Um, so these develop a faster, sorry again than both the needle and the cortical cataracts. And these are associated with diabetes and long term corticosteroid use moving on. So now that you've opened, made a little hole in the capsule bag to reach the er nucleus and the cortex of the lens, you can start to break it down with something called fac emulsification. So, here you've got this er facial probe and you've got some chopper instruments and the cataracts you with the ultrasound energy is broken down in smaller pieces. Um, so you er, yeah, so it's easier to take it out, I guess. So, um, as you aspirate the last bits of the, um, of the cataract of the cortex, as you take it out, the surgeon asks you, how do, how does the lens usually get its nutrients? So, is it a via the long posterior ciliary arteries? B via the anterior ciliary arteries or C via the aqueous humor? So, there'll be another poll and I, if you could vote on your answer, that would be great. Thanks. So that's about a minute. So I think most people have onset via the aqueous humor. You'll be correct. You're very good today. Uh you're answering all the questions correctly. So yes, the, the lens obtains its nutr from the a by pass diffusion from perhaps from um nine weeks to four months. Uh The um so I guess nine weeks to four months, whilst the baby is a fetus inside the mother's womb, the lens is actually supplied by the hyaloid artery. But these regress by the time the fetus is born at which time is, um it gets its nutrients from the aqueous fe if we go back and look at the other two arteries, so the long posterior oci arteries, they supply the choroid, uh the I and the ai body uh which is where they uh join together with the anterior aci arteries. Um And if we go to the anterior ciliary arteries, these supply the other structures in the eye. So the conjunctiva, the sclera, the rectus muscles which er move the eyeball and the aci body moving on. And so, as I mentioned before, and this time you insert viscoelastic again. Um and this is inserted into the capsule bag because you remove the cataracts and the lens, it's inserted the capsule bag to open it up. So it creates space for you to insert the artificial lens. And it also helps to maintain the er structure because it's quite viscous. It helps a bit of the structure of the area as you insert your lens. Um now we're inserting the artificial lens. So you can see nice and shiny. Um So how you slip the correct lens, you need to calculate the power of your lens uh which is something known as biometry. So you what you do for this, you measure the curvature of the cornea er and you use uh ultrasound to measure the length of the eye. Um you do this before the operation, these values are then all put into a formula to calculate the power of the lens. And I guess the surgeon selects to correct power of lens to put in. So most lens in the NHS are multi focal, so they only correct vision for one distance. Um So usually they correct it for long distance. So you patients often still need glasses if they want to um for near vision. Um but in private clinics, you can get multifocal awareness so you can uh those can change and correct it. Uh correct it for both far and near distance, which is a bit better. But I guess the near the local ends er are, have been used longer and they're a lot cheaper to which is why they're used in the NHS. And last but not least what you do is then you remove the viscoelastic er, and then you refill the anterior chamber with the bone and salt solution and then you give them antibiotic drops. Um um I guess prophylactically er, to prevent an infection. All right, er, postoperatively um shower here. Er, we'll need to have a clear shield as shared in this picture, er, placed over the operated eye, er, to protect it and it should be a one at night for, er, five nights. Um, then she'll, may be given a course of topical steroids and topical antibiotic drugs to, to take for four weeks and then she'll usually come back to clinic four weeks later to be seen. Or she can also go to a local optometrist as well. Depends on the area, I guess. Um what I will say is these surgeries are very, very, very quick and usually take 30 minutes to perform. And so they're performed as a day case. And um in the PVI, surgeons can do seven or eight of them um in one day. So they have very high turning there in terms of the complications. So during the operation, you might have a posterior capsule rupture. So the um the capsule might rupture um causing with the hole and that might cause a vitreous femur, which is uh from the vitreous chamber um on the back of the eye to escape into the capsule or for cataract fragments to escape into the vitreous femur. And it's a lot harder to er grab the bits of cataract fragments if there's a skit into the vitreous chamber. Um Other complications after the operation, the cornea bit at the front might react badly, it becomes swollen and hazy. Um there's an increased risk of retinal detachment. Um There's an increased risk of endophthalmitis, which is infection of the tissues or the uh fluids inside the eye and that might cause vision loss. Um There's increased risk of something called cystoid macular edema, which is where fluid might accumulate at the macular. Um and there's also a risk of um further cataracts in the future or the back of the uh capsule becoming cloudy again and they might need further operations for that. So now as you end your week long attachment in ophthalmology, you start your new attachment in ent. Um However, most of the ent operations happen at Saint John's. So you have to make the trek over to Livingston on the train to see some more surgeries. So I'll pass you over to Pat who will talk a little bit more about gruit, make your joke. Um Great. So I'll be talking about uh Graetz also known as otitis media of fusion. So, um and how we, sorry um we're talking about glue air, which is otitis media of fusion and how they're treated with Gratz and Laryngotomy. So it's a relatively short surgical procedure. So this will not be long. So the relevant Rinos toy that we'll be looking at um will just be the symp membrane, the middle um ears space and the Eustachian tube, the middle ear space is basically just that little kind of um rectangle area between the tympanic membrane and the the the eustachian tubes. Uh This is relevant because in glue year. And this can be caused by many different things such as ear infections or eustachian tube dysfunction or um other allergic or respiratory infections. Basically, fluid accumulates um in the middle ear space and blocks off the Eustachian tube. And normally the Eustachian tube will drain into our um nasal area. This means that the air pressure inside is equal to the air pressure in our uh it's, it'll be the same as the one in our outside environment. So when this is blocked up, the, when the station tube was blocked up, the air cannot escape and it will eventually be reabsorbed by the tissue surrounding it. This causes negative pressure inside the middle ear chamber and this will pull in the eardrum leading to a retracted eardrum. Uh So otitis media of effusion or blue ear can lead to hearing difficulties. There are other symptoms such as uh a sensation of fullness or ear popping. And in some severe cases, there can also be um balance problems. However, typically patients don't really go to their GP and say that, you know, their ear is popping, balance problems and then turn out to have glue ear, mainly they'll the the symptom that they'll be presenting with is just hearing loss. Um So in the next few slides, there will be some surgical pictures. So if you feel a bit, um faint dizzy, feel free to leave and come back later, right? So the investigations for glue ear in a GP practice, normally, you would have an otoscopy done. So, um an otoscopy would show a retracted eardrum due to the negative pressure as explained before as well as some a colored fluid inside. Uh Some hearing tests may also be done such as Rs and Webers. And this would show a conductive hearing loss. And in secondary care, sometimes tympanometry can be used as well and this would show a rigid eardrum due to the fluid accumulation behind it. So um not every single person with glue will get gro surgery. So the indications are different for Children and adults. So for Children, the um glue ear must have persisted for a period of at least three months from the date that the problem was first identified by A GP and the child must be three years or older and there must be evidence of delay in speech development or education or behavioral um behavior attributable to the hearing loss or a second disability such as uh Down syndrome Turner syndrome or Cleft pet. So if they meet the criteria, they will be referred on to secondary care for um uh to, to assess if they need any surgery for adults. If they have significant negative middle ear pressure, measured on two sequential appointments and significant ongoing associated pain or unilateral middle ear effusion where a postnasal space biopsy is required to exclude an underlying malignancy. They will also be referred, right. So the surgery itself um basically, there's really only three main steps, uh which is to make an incision into the tympanic membrane, um, place the grommet into the incision. And that's basically it, it's not a very complex procedure at all. And it is commonly done in an outpatient setting, although sometimes it may also be done in a uh general theater suite. So, um, top care for gro surgery, blood and discharge is normal for a day or two after the operation. Should this persist? Um The patients should be told to get in touch with a healthcare professional and normally um a follow up appointment is scheduled at six weeks after the operation to assess um the patient's hearing and the patency of the gro as of all um sur surgeries, there's a risk of infection and this is normally treated with antibiotic, ear drops in patients who complain of excessive discharge. They have the option to have the grommets removed. The grommets will allow the ear to drain so that the fluid inside comes out. However, in some patients, it is quite excessive to the point where um it affects their life. So in those cases, they, they can ask for the grommet to be removed. And another complication is a failure of the eardrum to heal. In which case, a surgery called um myoplasty can be performed. And this is basically just surgery to repair the eardrum. Um Yeah. Oh yeah. And of course, there's also the risk of recurrence some patients can maybe get clear once in their life, get grommet surgery and be done with it. Some other patients may have 56 or seven or more. Um Grommets inserted, right. So the patient for today is Alex Blogs. Uh He's age six, his presenting complaint is uh hearing loss. So his parents report that um Alex seems to be having difficulty hearing and they first noticed it after Alex had a cold around four months ago. Initially, um they thought it was due to a cold but saw a GP after the hearing loss persisted for around a month where they got a diagnosis of glue ear. They presented three months later to the GP with the hearing loss still persistent and they were referred for consideration of groma and Zhi Alex's past medical history is there's not much of note, he's had a few ear infections in the past and he's up to date with his vaccinations and has no allergies. There is no family history of any sort of hearing disorder. And upon examination, the otoscopy shows an amber colored fluid behind both eardrums and a tympanic membrane appears to be retracted and rings and webers indicate bilateral conductive hearing loss, right? So we're moving on to the shoes, your own adventure. So, Alex is now due for a surgery and before the operation begins, the consultant surgeon asks you what type of anesthesia should be used for the procedure, which would you use for Alex, give you guys a few minutes to answer. How are you doing, Reagan? So I'm just letting like dancers come in. But so far, I think most people have said local anesthesia. I think we'll probably end the poor right now. So I think the majority has, have voted for local anesthesia. Ok. Unfortunately, this is not correct. Um We need to consider the age of the patient as well. Um Given that Alex is still quite young, I would say that from, from what I've read, they tend to use general anesthesia. More um local anesthesia can be used in adults and is mainly used in adults, but they also have the option to go for general if they want to. Right. Let's not go to the next one. Um So the next question, the consultant surgeon shows you the blade that she'll be using for the laryngotomy. Uh Sorry if I didn't explain this earlier, the laryngotomy is literally just making the incision. Um Should she be making the decision using a uni directional or bidirectional sweep action? Well, it's about a minute and I think most people have voted for unidirectional suite. Ok. Um That's correct. Um If I go back to the image, I appreciate that the image is not of the best quality. But if you can see um where my cursor is, this blade only will, it only has a blade on one side, the other side is actually blunt. So the correct answer is to do a unidirectional sweep if you were to do a bidirectional sweep. Um And this is, well, in theory, only, um you could potentially be causing damage to the tissue because of the uh through blunt trauma. And theoretically, this could cause hemorrhage in the ear, which would obstruct the facial field, making your job much more difficult. So obviously, we don't want to do that. And even though it's a theoretical risk, we normally do it. You need a directional sweep, right? Um The last question for this one. So the consultant surgeon has inserted the grommet in the incision, the spr turns and asks you when will be removing the grommet. So there seems to be a 5050 split between. Oh, never mind. It's ok. Um I think one minute has passed but there used to be a 5050 split, but I think most people are going for six months now. Ok. No one's typed anything in the shot. Have they? No, not that I can see. All right. So, um the spr smells easily. Actually, it's neither of them. So grommets aren't removed, they usually follow up themselves, although we can remove them for, for um the typical patient, we won't remove them and we'll just let them follow up themselves. And this is usually around 6 to 18 months different for every person. Um Yeah. And the only reason we'd be removing them on purpose would be if there was successive discharge. All right. See. So, um, that's a surgery done. And as you exit theater, another consultant sees you and says, ah, a medical student just who I needed, she pulls you into another theater and ask you to scrub up. So I'll be passing it on to, um, my colleagues Reagan and Julia now to present their case on thyroidectomy. So, moving on to case three where I do this and I will be cover covering a total thyroidectomy. I'll just give them, give it a few seconds so it slight to go up. So um next slide, please. So, a thyroidectomy is defined as a procedure um to remove either partially or totally the thyroid gland. If it's not total, it can be known as a subtotal thyroidectomy or hemithyroidectomy if half is removed. Um This is seen on the diagram on the right here, um which I got from Cancer Research UK, which shows various forms of lobectomies and thyroidectomy. Um So the technique really involves open surgery with a fascia structure surrounding the thyroid is dissected from superficial to deep. So it's basically dissected from the skin down to the thyroid wet room. Um Behind the thyroids, there are parathyroid glands and these are responsible for calcium regulation in the body and these are usually preserved during the surgery as seen on this, as seen on the image on the right. Um by cancer research UK. There are quite a few techniques to this though as as there are approaches where they go in through the mouth or the oral cavity. So it's called a transoral thyroidectomy if that's the case, and they pass a scope through the mouth to remove the thyroid without external scarring. But today, we'll be just covering the open approach where they go in um through the anterior aspect of the neck. Um The procedure is generally performed under general anesthetic and there are few indications for a thyroidectomy here. So imagine your patient comes in with a standard mass in their throat. Um as shown at the bottom right hand corner can see here how on this image, you can get compression over the structures of the neck. And if it compresses the airway, you get airway obstruction, which needs to be cleared as soon as possible. Um If it starts to compress on the esophagus, you can get swallowing problems or dysphagia and these and as such, these are indications for total thyroidectomy. As you can imagine how life threatening these symptoms can be. And this can even happen as a result of non cancerous thyroid disease. So, it's, it's not only the malignant thyroid disease that causes this presentation. Another indication of the surgery uh as I mentioned earlier would be cancer of the thyroid. There are some guidelines, but the key points are basically targeted towards papillary and Folli and follicular cancer with a primary tumor, greater than four centimeters with metastases to lymph nodes or distant sites. Um I think it's, it's also fair to include tumors which are smaller than four centimeters of a papillary and follicular type, but with abnormalities in the contralateral low. So you remove as much, uh you basically treat the cancer aggressively by removing the whole thyroid. There's also this subtype of thyroid cancer called medullary carcinoma, which basically calls for the entire thyroid to be removed if it's discovered. Um regarding non malignant disease, this can include hyperthyroidism, not responsive to medical therapy like your anti thyroid drugs. Um I think some examples can include carbimazole and proper thyroid uracil or PTU if you have heard of it before or patients with contraindications to radioactive radioactive iodine like pregnant patients or patients who simply choose not to receive um radioactive therapy at all. Um Patients with severe eye disease can also be included as radioactive iodine can worsen eye disease. Next slide, please. So, er regarding contraindications, er pregnancy is not an absolute contraindication, but you must always err on the side of caution and have an MDT or multidisciplinary discussion with your anesthetic colleagues. Should they have any contra contraindications for general anesthesia? And this can include things like allergies, er allergies and maybe even fetal risks to anesthesia depending on the stage of their pregnancy. Um some absolute contraindications to a tho uh a thyroidectomy can include uncontrolled preop preoperative hyperthyroidism. So, something called a thyroid stone where someone's thyroxine levels through the roof and they are experiencing severe symptoms. Um Another contraindication would be locally advanced anaplastic carcinoma, which is a very aggressive cancer. So, the cost to benefit ratio is low for intervention as it's basically a 7 to 14% 5 year survivor survival rate. And this, this really brings into account whether you're gonna just place the patient at extra risk to no benefit at all. Uh smaller tumors as well. Um is also another contraindication as remove, as if you imagine removing the whole thyroid, you'll basically need to replace uh someone's thyroxine levels. Um So in smaller tumors, a part, a partial resection like a lobectomy or hemithyroidectomy would be preferred. And as I've mentioned earlier, the long term sly or long term effect of this surgery would be lifelong thyroid replacement therapy with thyroxine. So, next slide, please. So again, I'm aware that this tutorial attempts to cover as much anatomy and surgery as possible. So I wouldn't go into much depth regarding the medical path of physiology or clinical features of disease. Um broadly speaking, there are two different types of thyroid disease and they can be divided into malignant uh or the cancerous type or, and the non malignant type or the noncancerous type. So, malignant thyroid disease can present with goiter, um which is a swelling in front of the neck and very and some nodules which you can feel on patients with thyroid disease. There are quite a few subtypes of malignant thyroid disease. Um including papillary carcinoma, which is the most common. About 70% of cases presented with this. Um, follicular medullary anaplastic and lymphomas and symptoms are, are really variable and they can present with a huge variety of symptoms. And some of the common ones include neck swelling, symptoms of hypo hypothyroidism, especially encode nodules. Um I wouldn't go into much detail regarding that lymph adenopathy can also be another symptom or this is basically a fancy term for lymph node swelling. You can also get hoarse voice, pain, problem swallowing and difficulty breathing. Um Regarding non malignant thyroid disease, um it can present as goiters or varying number of nodules or diffuse swelling of the thyroid. Um This can be caused by many things including iodine deficiency, autoimmune conditions and the list is really endless, to be honest. Um, symptoms can again include hypo hypothyroidism, neck swelling and pain. Um One thing to note, however, would be regarding thyroid nodules is that co nodules or nodules that don't overproduce thyroid hormone are more worrying and are more likely to be malignant. So I've just included some images on the right hand side with a patient with a goiter on the top part and a patient with, with um active eye disease seem in the bottom part. Next slide, please. So, regarding the management of thyroid disease, this includes a full history and exam of um of basically the patient. Um, investigations include bloods. So we look at the thyroid function tests and any whether there are any um thyroid, a autoantibodies circulating in the blood. And that can really indicate whether it's an autoimmune or um some other cause an ultrasound if nodules are found. So we want to look at what's in the nodule, whether they are hard, whether they are irregularly shaped. And this can point us towards the diagnosis. Um We can also do a technetium or radioisotope uptake scan if we find that, that T the TSH is suppressed and this can really pick up um pick up um sources of thyroid hormone secretion, we can also do a fine needle aspirate if we want to investigate um the tumor lesion um to a greater detail where we stick a needle into the thyroid and suck out basically a small um collection of cells which we can look at under histopathology. We can also perform a diagnostic surgery where a direct biopsy can be taken and the thyroid can be removed at the same time. So, treatment is really decided on the type of thyroid disease. But if the thyroid is overactive, you can give anti thyroid medications, radioactive iodine radio or chemotherapy if there is malignancy or just straight up removing the thyroid via surgery, which we will be talking about in detail this time. Next flight, please. So now for some relevant anatomy, um the thyroid lies at the level of C five to T one on the vertebral level. So that's around the front portion of your neck and it sits in front of the trachea. It's located in front of the thyroid cartilage and has two lobes. Um and the center part of the thyroid here, um as shown in the diagram on the left is known as the isthmus. There are four parathyroid glands that sit immediately posterior or behind the thyroid gland itself and these regulate calcium levels within the body, as mentioned earlier. There are also two branches of the recurrent laryngeal nerve that supplies the muscles of speech within the neck. And we will go into more detail regarding the implications of this further in the top. And you can see that the recur that the recurrent laryngeal nerve is located um just surrounding the, the the posterior aspect of the thy of the thyroid in tracheia are seen on the diagram on the right side regarding arterial supply of the thyroid. It's supplied by branches from the common and external carotid arteries and the subclavian artery. Um Some of the branches include the superior and inferior thyroid artery and the thyrocervical trunk. And these are located behind the thyroid as seen in the diagram on the left. So sorry, on the right. So next slide, please. So just let me introduce the patient. We have Mrs Laureen scope age 59. Um She presented with a two month history of neck swelling and symptoms of hyperthyroidism with sweating, anxiety, mood swings, insomnia, et cetera. Um She has multiple nodules palpated within the thyroid gland. But she is usually well. She works as a restaurant owner and has a past family history of hyperthyroidism. Regarding investigations she has been through most of them and her uptake scan shows multiple hot nodules showing overproduction of thyroid hormone in multiple regions as seen on the right side. Um, she eventually got a diagnosis of toxic multinodular goiter and she wishes for definitive treatment without radiation as she doesn't like the idea of radioactive iodine. And the surgeons have basically seen her and deemed her eligible for a total thyroidectomy. Next slide, please. So before the procedure starts just a quick visceral content warning. Uh next slide, please. So here we are, the team has confirmed the patient's identity and everyone is ready to go. Um The surgeons have marked the incision sites and have cleaned the patient of iodine prep and has draped the patient. Next slide, please. So we we are just seeing Mr Scope. Now she is positioned in the reverse Trendelenburg position. And this is basically a fancy term from for when someone's angle with their head facing upwards, the incision is marked up with two finger breasts above the sternal notch as seen in the image that put down here. Next slide please. So they make an incision and they retract um the layer of skin above um the the most superficial layer of skin and the first muscle layer within the fascial plate is visualized. The consultant asks you on whether you know which these muscles are and you wreck your brains and come up with either the SCM or the platysma muscle. Um I'm just gonna get the poles up and you can leave your answers on the pole, right? So I think it's been about a minute now. Um I'm just gonna end the pause right now, but I think most people are going for the platysma muscle. So, yes, the the consultant agrees with you and the it's so um on the superficial muscles of the neck, there are multiple layers of fascia and muscles within this region of the body. The most superficial muscle is the platysma which constitutes the sheet like layer of muscle, which aids in facial expression by lowering the the lower lip, um depressing the man mandible and tenses the skin of anterior neck, as seen in this image. The se M or sterno cleidomastoid sits behind this layer of muscle and it's more responsible for neck turning. There are other muscles deeper to this layer such as the higher and the sternal, higher overlying the thyroid. And these are known as the strap muscle, the strap muscles which we will be covering more on that later. Um The case carries on or the consultant dissects down to these deeper muscles. Next slide, please. So, moving deeper, the thyroid. No, sorry. Um So these are the strap muscles that I mentioned earlier. Um They are exposed and separated with a dissection down into the midline raphe onto the thyroid and the straps are swept laterally of the gland. So there the dre muscles are basically swept to left and right side of the thyroid and the thyroid is then exposed. So next time, please. So, moving forward or moving deeper, um the thyroid is exposed and pushed towards the midline. So the midline is on the right side of the slide here and it makes these two structures visible behind the thyroid. And this is quite an important anatomical landmark and the consultant arts, which vessel she's pointing to with the blue instrument or bipolar. Um These are two choices, either the internal jugular vein or the common carotid artery. I just put the pulse up right now and just give it a few. It's about 30 seconds for the rest of the answers to flow in slowly, right ending the poles about now. So I think most people have selected the internal jugular vein. So, unfortunately, the rich dryly states that you should revise your anatomy and this is not the internal jugular vein. Um I mean, I appreciate this question. It might be a bit hard because in actual, um when you are looking at the actual thyroid surgery itself, you can see the pulsations of the vessels involved. So, next slide, please. So, uh next, next again. So regarding the vessels of the neck, the carotid sheath runs posterior and lateral to the thyroid and this is um on the right hand side, this is ac seven level transverse section of the neck and within the carotid, within the carotid sheath, we have the common carotid artery, the internal jugular vein and the vagus nerve and the and the common carotid artery runs medial to the internal jugular vein. A good way to remember. This would be the thing in terms of how important the vessel is. The more important, the more you would think that the structure will be tucked away towards the mid line to protect it more. So hence, as the carotid artery directly supplies the brain, it will be one of the most important structures within the neck and will be further deeper within the structures of the neck and therefore its media to the jugular vein. So the importance of identifying this landmark is so to prevent major hemorrhage is if you can visualize the structure, the less likely you'll be able to damage it by accident. Regarding the internal jugular vein, it runs lateral um to the common carotid. So within the thyroid, we have usually three sets of veins draining to each lobe of the thyroid. And these are creatively called the superior middle and inferior thyroid veins as seen on the right on the lower right diagram. So now the case carries on as a consultant ligates the draining veins from the from the thyroid while removing the connective tissue around the thyroid and the superior P of the thyroid is flipped downwards or inferiorly. So, um, the entire thyroid here is flipped down as seen through the arrows that I've put in onto the diagram on the lower right side. So it's flipped downwards and I'll be handing over to Julius. We'll be covering the next part of the case. Perfect. Thank you very much Reagan and good evening everyone. My name is Juice and I'll be taking you through the last part of this surgery. So like Reagan said here, we can see the super poles have been flipped inferiorly. Uh a vessel has been already clipped and ligated. But my takeaway for you from this side is actually quite simple, but could earn you some brownie points with the surgeons. And that is the color differences. So you can see that the parathyroids or somewhere of like a yellowish or brownish tinge or the trachea can be anywhere from pink, tan to sorry, pale pink to tan, white. And obviously, as you can imagine, we want to uh be aware of those structures and not damage them. And in the next slide, we'll see another structure which is quite important to be aware of. And that is of course, the recurrent laryngeal nerve, which we've mentioned previously and just to orientate you again, we can see that the thyroid has been moved to the patient's side here. We can see the the same parathyroid at the same ligated vessel and actually another ligated vessel near the, what the surgeons have outlined as the anticipated course of the recurrent laryngeal nerve. And we want to stay clear of that. But um and why, why do you want to stay clear of that? Well, in the next slide, we can see that we learned that the recurrent laryngeal nerve supplies all but one of the intrinsic muscles of the larynx. So the uh consultant turns to you and asks you which intrinsic muscle of the larynx does? The recurrent laryngeal nerve not supply? And we have an option of four and one of them is supplied by a different nerve. So let's just get the, the pole up and give you guys a minute to answer. We'll just give it about 15 sorry, 30 seconds more, right? I think the uh the majority have gone for cricothyroid. Perfect. Thank you very much. And actually, in the next slide, I'm going to build up the suspense and not tell you what the answer is just yet. So I'm going to speak to you shortly just in general about the intrinsic muscles of the, of the larynx. So there's nine of them and they're split into various groups depending on their actions. Uh but the uh function in general is to move the vocal cords in order to produce speech. And just for context, the extrinsic muscles of the larynx on the other hand, move the high bone. And so as as we learned all but one are innervated by the liver and laryngeal nerve. And in the next slide, we'll go over which one that is. So it's not the, it's not this one. And I know uh you can see a scary table there. Don't worry, no one wants to go through tables at this time of the evening. These are just for your uh purpose of, of revision or for, for your own interests when you can go through over the slides after this. But so it's not the um fro Arno because that is indeed uh supplied by the recurrence, but just to quickly go over the action, this one is responsible for low pitch sounds. Next slides, please. OK. So this one, the vocalis um again, recurrent laryngeal. So not this one next slide please. The posterior cricoarytenoid that's responsible for opening the glottis. But again, not the answer that we're looking for. And finally, the one that most of you went for the cricothyroid. Yes, indeed, that is supplied by the external laryngeal nerve and this muscle is responsible for generating a hype ultrasound. So in the next slide, just to put that on to visual context, we can see that the recurrent laryngeal comes from inferior as we'd expect. And then the superior laryngeal nerve, specifically the external branch of the superior laryngeal comes superiorly and then supplies that cricothyroid muscle. And all the other remaining eight intrinsic muscles of the larynx are supplied by the recurrent laryngeal. So that's why it's a key important structure to identify. And in the next slide, just to go back to the operation, we can see that the thyroid is now being dissected of the trachea. And in the next slide, we can see that, yes, it's been nicely dissected of the trachea. We can see that white tone of the trachea. And we can see a landmark that Reagan has talked about the common carotid artery. And we can also see at the top the uh shaded in sort of pink that right rhyd muscle that we spoke about. And in the next slide, going back to the recurrent laryngeal nerve, not only have the surgeons identified it here just visually, but now they're also new stimulating it just to be uh absolutely sure that this is indeed the uh recurrent laryngeal nerve and that we've got the right structure and we're going to stay clear of it. And the way that this works is there's actually an electromyogram end of your tube in the patient's throat. And that is used to detect the vocal cord movements uh as the recurrent laryngeal nerve is being stimulated. Ok. So, in the next slide, now that we're absolutely sure that we have the recurrent laryngeal nerve there, we can see the yellow brownish tinge of the parathyroid. Now we're able to establish this sort of safe line of, of release. And so we're not going to dissect any closer to the recurrent laryngeal nerve not any closer to the parathyroid because we need to preserve the parathyroid as well as this blood supply. So we're going to dissect along that line dash line of release. OK. And in the next slide here, after we safely, safely dissect on that line, all that's really left to do at this stage is to um uh dissect and clip all the remaining vessels connected to the inferior pole of the thyroid and resect the thyroid. And the very final step is if we can move to the next slide is closing the fascia over and leaving a space inferiorly to prevent a hematoma forming and impinging on the trachea. And this mention of a hematoma brings us nicely to talk about the early complications of the surgery. So the uh hematoma can occur in just around 2% of cases. So it's, it's not already common, but it can be very serious. So it's a collection of, of blood in the dead space that we've left because obviously, we've removed something there is space left. And if blood pools there in such a sensitive area close to the trachea, then of course, we could have something that would lead to area obstruction. And in such cases, the wound may need to be reopened and the uh uh blood or a clot will have to be excised. Next up. Of course, we've talked about the uh sorry, still on the same slide, we've talked about the recurrent laryngeal nerve a lot. So even despite all those steps to identify it and to trace its course and to neurostimulate, it, damage can still occur and it can lead to palsies. The classic textbook example would be a hoarse voice after an operation. But uh the degree of the palsy can vary. And in most severe cases, the uh vocal cords uh can close and of course, that's not good for your uh passage of air. So, tracheostomy may be required in severe cases to open up the airways. Thyroid storm is basically lifethreatening thyrotoxicosis. So, despite the fact that we've removed the thyroid, uh thyrotoxicosis can still occur due to um as, as a single event due to removing the thyroid or, or rather the thyroid hormones or can be released during the operation. And that can manifest as hyperorexia, tachycardia and tachypnea. The patients ventilating themselves and hyper perspiration. And if left untreated, this can lead to cardiac failure. Fortunately, this complication is rare because most patients prior to the operation would have been on some antithyroid medication. Already, other complications are, of course, we're dealing with a highly sensitive anatomical area. And despite being very thorough and identifying uh structures around, of course, there can be some damage to them. So the esophagus, drea the lungs and the sympathetic chain and moving on to the next slide, we have our intermediate and late complications. So, again, if the parathyroids are damaged, this can result in hypocalcemia. So management of course, be replacing the calcium, but we have to be sure to check the magnesium as well cause there's no point in replacing calcium if your magnesium is low as well. So we might need to replace both. Um Soma and chiro leaks are again, accumulations of fluid in the dead space that we've left. So they look and they're managed the same. But the difference is that is SOMA is an accumulation of uninfected serous fluid. Whereas Kyo is composed of fats, lymph and free fatty acids formed in the intestine and pick up by lacteal lymph vessels. And again, they're, they're managed in the same way by either watchful waiting, if they are not impacting their airways or the patient uh lifestyle, uh or they would eventually go away on their own or if they are increasing in volume rapidly or if they are indeed impeding on the trachea, then we would aspirate them. So that brings us to the end of this surgery and we'll now go over some MC QS from the whole evening. Thank you. Yeah. All right. Um So now we're starting the MC Keys. So the first MCC key that we have is from the cataract surgery case. So we've got a 45 year old woman here who attends eye casualty, complaining of blurred vision and glare from bright lights. Uh She has a history of asthma, polymyalgia, rheumatica and gout, the ophthalmologist finds a lens, opacity in her left eye that's located just deep to uh to the lens of the individual axis. So which of these is the strongest risk factor for subscapular cataracts? Remember those of the cataracts they develop really, really quickly. So, is it a myotonic dystrophy? B myopia C, ocular trauma, D corticosteroid yeast, le allopurinol yeast. So I'll give you 30 seconds to a minute to um wait on your, on the answer. How are we doing? Very good. So, I think most people have went for corticosteroid use and you would be correct. It is cortico therapy. So, here on the right, uh, it's just a picture of what you might see of a subscap, subscapular cataract. So, yeah. So it's subscapular cataracts. Uh, the two main you have to remember are diabetes and long term corticosteroid use. Uh If you remember the nuclear cataracts were the er, more of the age related ones and the cortical uh, cataracts. This can be caused by stuff like, um, it can be caused by diabetes as well. It can be caused by ocular trauma, UV, exposure, smoking and other things. So I guess we'll move on to M CQ number two. Um, so this is regarding the complications of cataract surgery. So, which of these is not a, a recognized complication of cataract surgery. Is it a posterior capsule rupture? B, macular degeneration, C, cystoid, macular edema D endothal mitis or E retinal detachment. So, I'll give you around a minute to, uh, to vote on what you think it is. We will just give it about 15 seconds more. Ok. Sure. So, yes, I think most people have went for macular degeneration. And again, you will be again, and the main risk factor for macular degeneration is age related. So as you get older, you, you can get uh macular degeneration. All the other rest of the uh all the other conditions here are complications. So now I'll pass on to PAP to do the M CT. Right. Right. So um Alex, our, our patient from the um glory case has now grown up and is attending medical school um in an ent clinical skill session. His peers perform a otoscopy on him and see something interesting um as shown in the image. Uh What do they see? Give you guys a few seconds to put some answers in. Are we doing Reagan? So that's about the minute up. I think most uh I mean, it's quite a mixed bag to be honest, but I think the on some of the greatest majority is tympanosclerosis. Uh Yeah, that is right. This is tympanosclerosis. It's basically, yeah, that's it. I say scarring of the eardrum. It can be seen after grandma insertion sometimes not always. Um and there are some other causes as well, but it's an entirely benign condition, doesn't really affect you in any way at all. Just apart from, I suppose you could say cosmetics, but you don't really see that every day. So, yeah. Um it's just scar tissue doesn't really have any significance, but it can look a bit worrying if you don't know what it is. Right. I can get on for now. Fantastic. An ultimate question, which complications of thyroidectomy can be prevented by prophylactic measures. You've got recurrent RDU nerve injury, thyroid storm hyperglycemia, Horners syndrome, or pneumothorax. So that's about one minute up. I think most people have one for a thyroid stone. Great. And that is the correct answer. So the other answers are all all related to the complications resulting from disturbing the anatomy. So, although we would think that those could be prevented by measures such as um well studying your anatomy and, and being a, a good surgeon. Option B is the one which can be prevented by prophylactically uh treating the patient with antithyroid medication such as the two examples I've given there in the slides. Thank you. So, this is the final question. Um which of these patients, which of these patients is most suited for thyroidectomy in their treatment plan or just get pull up right now? Yeah, I think that's about a minute. So I think most people have went for B um But unfortunately, the answer is e so um so yeah, I'm going through the answers. The patient has the indications for total thyroidectomy and this includes a relatively large tumor four millimeters and medullary carcinoma. Um Option A has two extensive disease and anaplastic carcinoma progresses too quickly for any surgical treatment to benefit the patient. For option B, we want to stabilize the patient first. As uncontrolled thyroid disease is a contraindication to general anesthetic. For option C A thyroid lobectomy will be preferred to preserve function as this patient has a small tumor with no evidence of metastases and option D will not be eligible. Now as the, as the patient has a potential contraindication anesthesia and some MDT discussion will be needed to decide if the risks outweigh the benefits. So just to cap it all off, next slide, please, these are, this is just a quick summary of the three cases this evening. Um I'll just leave you to read through it real quick. Um When, when I get the slides out after the tutor after this tutorial. So next slide, please. So thank you everyone for listening. Today. We have another session on general surgery next week on the eighth um at 7 p.m. So stay tuned for that. Also, please. Next slide, please also just fill in, please fill in our feedback form through this QR code and this will also be sent out after the after the tutorial. We really need feedback to improve our work and it really helps us. 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