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Hello, my name is me. I'm one of the, oh, I was going to say, yeah, whatever, but I'm not, I'm an fy one in Ent currently and Eximer as well. So I did my finals in around like what February time, January time. This will be kind of your whistlestop tour of Ent. I know Ent isn't generally very high yield in finals, but it definitely does come up and they do get quite specific. So I'll try to cover what I think is the highest yield stuff and then gloss over or somewhat talk about the other things that can sometimes come up. Um Any questions I've got the chat up. So you're more than welcome to just type things in there as you go along. Um, ok, so let me just get slice change. This is kind of what we're going to be covering today. So we'll go by ears, nose and throat because that is the acronym and some miscellaneous stuff at the end, which does come up because we did get an audiogram in our finals. But to start things off easy, we'll just start off with there is or autolog and I don't know if anyone who's listening has actually had the ent placement, but don't be frightened by not knowing what these terms or words mean if you haven't had the placement at all anyway. Ok. So just to start off anatomy of your ear, if you don't install this, you're not going to the rest of it. So you kind of got your outer ear, which is everything from what you can see up to your membrane. So your tympanic membrane or your eardrum, then everything, your eardrum and your ossicles and then your inner ear is your labyrinth, which is like the semicircular canals and that snail looking thing, the cochlear, um this will be mainstay for everything else. Your most common presentation that you will get either in GP or in hospital or in your finals will be or Titus media and you can get it with or without a fusion. This is just an infection in the middle ear. So behind the tympanic membrane. But before it kind of hits your inner ear, I wouldn't get too bogged down with symptoms. To be honest, the main thing is you've got ear pain, which isn't necessarily discharging and you've got malaise symptoms and a flu pro. So like snotty nose, sore throat, feeling a bit unwell, very common in Children just because they have small it ears. That would kind of make you think you've got a Hepatitis media going on. Glue ear is basically a colloquial term for when you've got an effusion, effusion is essentially when behind your typ panic membrane. During the infection, you get a lot of pus building up and it doesn't drain. So it basically stays there and you get really muffled hearing. And so it feels like you've got blue in your ear. It happens a lot in Children, not so much in adults. So if you see with effusion in an adult, we get a bit concerned because you think that something in this post nasal space ie between your ear and your nose has cancer growing in it. And that's causing your Eustachian tube to basically not drain that fluid in your inner ear away because there is a mass there. So that's the main red flag you need to be aware of with investigations wise, always go bedside bloods and then imaging. If it's relevant, I'd get into the habit of it just before, before like acies to be honest, essentially do their see how systemically well they are, examine them and look in their e some people are quite well. You don't have to be systemically unwell your external ear ie of the ear that you can see should look completely normal. But when you do an oscopy on them, you kind of see a very bulging red, angry looking tympanic membrane. And with an effusion, people describe it as dull or that you can see fluid behind it or bubbles behind it, which indicates that there's a lot of fluid sitting there, effusions don't really develop acutely. It has to be a build up of fluid after a while. So that people might say I've had an ear infection and now it's, I've got really weird hearing for like two weeks after it. That would be more in line with that. Here are two pictures of what it kind of looks like on oscopy. I wouldn't get bogged down because it's very hard to sometimes tell the difference between effusions and not an effusion. But the idea is, you understand, when it looks angry. So this is bulging. It's got that little dimple in the middle and it's quite red because that's what an om would normally look like. Um You wouldn't always treat it conservatively pain relief. It should sometimes just resolve by itself. You kind of go the medical route of antibiotics once they're systemically unwell. So fevers tachy, all of that or if they're really, really young and it's bilateral or if their symptoms are just not resolving after a while or if their TMS have puffed. So the tympanic membranes popped. Any of those would kind of warrant you towards Comox 12. It's not a defined, it's not on the nice guidelines. Exactly. It's very Patan, but I would say these are the things that would lean you more towards starting some antibiotics. If they are inpatient, it would be slightly different. And then if it does last, then you get a grot insertion for blue ear, that's just a little device that sits in your tympanic membrane creates a hole in it and the fluid comes out this way, you don't have to get them removed. They just kind of fall out and then leave your ears. So that's kind of the overall thing with the main thing that you would have to think about as a complication is mastoiditis. Um I've included this image here. Can you guys see my mouse or do I have to describe this more? We can see your mouth? Ok, great. So this is your ear and this bone here is your mastoid bone. So you can kind of see it cushions and surrounds the ear canal um with Children if you've got an infection here and the pressure builds up with the fluid because the kind of architecture of your bone is slightly different. It's very easy for the fluid here to kind of push and make its way into your mastoid bone. And you essentially have an infection of your bone ie osteomyelitis and it's in the mastoid region. So the mastoid region, I have a picture next. It's just behind your ear, it's a little bony bit. Um And it happens more in Children, essentially, you get a boggy red region behind your ear and you get ear pointing. So your ears instead of sitting flat against your head, kind of start sticking out or forward. And they are quite unwell, to be honest, in this situation, you'd kind of do your sepsis, six vibes. So you do blood cultures, you would do a CT head just to see if there's a collection or build up within the brain. And if you're concerned about meningitis, you do an LP. Um, usually, then you'd keep them nil by mouth and you'd keep pumping IV antibiotics through them. But if they are not improving, you'd go for surgery essentially. Um, this is what it looks like and it happens quite a lot. We've drained many of these ent and I've got to see quite a few as well. So this would be red flag. Absolutely. Must be in hospital. Absolutely. Must be senior reviewed. Um, nothing to do in GP. It would come in. Um, then you've got your Otitis externa. So this is everything after your TMS outside to your external canal. Um, it's usually caused by pseudomonas. Um, this is quite important. Um, because it changes why you don't use something like Coamoxiclav because it doesn't get covered by for Pseudomonas. Essentially. Um, your risk factors are diabetes because I don't actually ask why it's probably just the sugar and stuff. To be honest, diabetes, any kind of change to the humidity of your ear. So, swimming and water sports, eczema and psoriasis because if it peels as in there is a skin break in your ear and maybe you touch it or something is more easily able to get into the skin around the ear. So eczema psoriasis is a big one or foreign body that's made trauma inside your ear tract and now something has gone in. So any of those would be a risk factor, you basically just see mock in your ear canal or your external auditory canal as in this hole gets completely shut or gets smaller essentially. So you'd examine this, do an otoscopy if you can, if you can't do an otoscopy, that's obviously a sign that's really bad because you can't even fit the otoscope through the air. You would take some swabs. So if the antibiotic cover comes out different, you can obviously adjust it, you'd microsection there. So you could just basically suction out all of this for symptomatic relief. And if the whole ie the canal is really, really small, you have a poke p put in, it essentially looks like maybe this big, tiny little thing of like cotton. It basically acts like a tampon. So it goes into your ear and then you give the drops over it. So it essentially feeds the drops deeper into your ear canal when it's completely shut. Um You would keep your ear dry to prevent anything else going crazy in it. Um So Vaseline on a bit of cotton wound and plug your ears and this is the mainstay would be Ciprofloxacin drops or it's called Cetraxal, the brand name. Um And you'd plus minus dexamethasone in the drop. Um That just helps with the swelling essentially. Um, but this would be what you would answer in your questions. What do you give them? It would be Cipro drops always. Um Hopefully that makes sense. Your red flags that you want to consider here or things that would be, oh, maybe we should admit them to hospital would be if you've got cranial nerve palsy if you've got pice cellulitis. So that's when this cartilaginous part of your ear gets really red and you can't really see the little grooves in it anymore because it's so swollen. If it's completely stenosed or if it's just not resolving, essentially, they usually get admitted into hospital in like a surgical ec you'd have a low threshold for concern or to be concerned. Sorry, if they're immunocompromised if they have diabetes or if they're quite old. Um Essentially this means that they are more likely to develop what we call neo e or necrotizing oe similar to mastoiditis in that it just spreads towards another bone and causes osteomyelitis. Um Any of these three risks factors and them being quite unwell would make me think this guy needs like a proper look in the ears and maybe a scan just to see if this is happening. If it is, that would be senior led. So, yes, you do CT head, you'd have IV antibiotics and you'd maybe have a longer antibiotic course. So these would be your red flags to look out for in exams because you would not answer. Cipro drops if they have one of these, you'd probably say they need to be admitted. Um, this is technically an infection if you're out of air. Um, could anyone tell me what looks different about it or what is different about it? Even in the truck you'd have to unmute. That's totally fine. Mhm. No, not sure. That's totally fine. I'm not really sure what it is but it looks like there's like black dots. Yeah, perfect. Exactly. So these black dots are spores. Um So that makes this fungal oe. Um So fungal oe just looks a bit creamier. That's not really going to be as helpful. Sometimes people say it looks like cream cheese, but these are the spores. So usually when we're taking referrals while are like, can you see black spores um that will basically make the diagnosis otomycosis or basically fungal oe. Um And it's often due to people having oea lot using a lot of drops and now you've got like an opportunistic infection of this basically. Um And so you kind of do things slightly differently because obviously your Cipro drops are not going to help with anything fungal, usually with microsection and get as many spores out as we can and use clotrimazole drops and you would continue the treatment once it's resolved, it's resolved, you can treat treatment for two more weeks. But the main thing is if you, if you're seeing spores or the questions are anything about spores or maybe they've had antibiotic drops all the time and suddenly this is not responding to antibiotic drops. And you've got a new thing. I would start thinking fungal oe, basically just to touch on. And this is also an ear which is slightly swollen. Does anyone know what this might be hazard? A guess as to what it might be. Again, I'm not sure who's had replacements and who hasn't just like uh boxes here or something? Oh, sorry. I like a cauliflower. You know, like a almost this would cause cauliflower ear if this happened repeatedly or if it wasn't treated properly. So this is a pin of hematoma. This is kind of what's going on. So you've got your skin layers, you've got your cartilage here, this blue bit and you've got your perichondrium. So your perichondrium is the bit that surrounds the cartilage for whatever reason, usually due to trauma and or rugby or rugby plus trauma, you get bleeding between your cartilage and your perichondrium. Like this, the reason this is dangerous is because this creates pressure in a very tight space and that pressure can start impinging on blood vessels, supplying your ear and then you might start getting a bit of necrosis as a result. That is why this is an emergency. So you get bleeding, bleeding between your perichondrium and your car, you risk avascular necrosis to your pinner. And then if you do have that, you often get cauliflower. So this immediately goes to hospital to be seen by ent to be drained essentially. So, analgesia antibiotics have contaminated, but I've never seen one that we've had to give antibiotics for, to be honest, um, usually just aspirate or drain it. So you can either puncture it with a needle and suck out the blood or you basically cut it open and you stitch it. There's loads of different ways to close and every ent surgeon will tell you that their way is the best that doesn't actually matter at this stage. The main thing is you aspirate and you drain it if it happens again. So the blood recollects either because of the way you stitched it closed, did not drain it properly and, or create enough pressure to keep the blood from basically filling that space again. Um, you would consider taking it to theater to have a proper wash out under general anesthetic, but that would be like a third line, but no imperial. They might examine you on that. So, drain drain again. Consider refractory case do under ga in theater. Ok. You've got CC comes up a lot on past med. It's really not that important to be honest. Um Essentially you have a squamous cell growth in your middle ear. It's always on the attic of the ear canal. So it's always like, oh, you see a mass that looks kind of like wax but superior, it's noncancerous. But it's important because it invades local structures. It's associated with palate. That's why it kind of comes up a lot in year five because of peds. Think about it if you've got foul smelling discharge because of this weird growth kind of just causing problems and a conductive hearing loss. So in your external canal, it has got nothing to do with your nerves. There's obviously something blocking in front of your tympanic membrane. It will cause a conductive loss and it's very rarely bilateral. So I would say unilateral and the management is just surgical removal, it doesn't grow that fast, but it obviously does need to be dealt with before it starts impinging on other things. There is a bit of pathophysiology on how it kind of develops. So it's essentially like this attached onto your eardrum. You basically have a pocket and your cells decide to proliferate in this little pocket. But you can see it's very close to a lot of different things. If you don't want irreversible hearing loss. When it starts impinging on this region here, you need to cut it out. You can just get symptoms related to vertigo related to the things it's impinging. So vertigo and palsies and hearing loss. But the main thing is seeing it and deciding to take out rather than the symptoms it necessarily causes because they can all present slightly differently. Um sudden hearing loss. So anything can be sudden hearing loss, to be honest, but this sudden hearing loss is kind of unexplained by anything else and it's unilateral and it's sensory neural. So you always ask the GP to do Webers and Rs and then ask them to clarify if it's sensory neural or not. If it is sensory sensory neural, there's some evidence to show that the quicker you get pred, the better your hearing comes back essentially, um You need to rule out things that actually cause the hearing loss though. So like head trauma, ear surgery, if they've got an infection, if they've got any kind of neurological symptoms or infectious symptoms, that kind of needs to be investigated. First, if that's completely out of the picture, you've got what we call sudden onset hearing loss. Um, you start them on pred, this does come up in exams and it's a reducing dose. So you start big, reduce small, you kind of get them to come in for an audiology assessment and then another one in a few weeks time just to see if you're better, a bit more specialist. But if they come back later and they're still a lot better, you can consider in some trusts to inject the tympanic membrane with steroid and that's got some evidence behind it. But I don't think that will come up in your exam mainly just the pred. Um, BPPV, again, fan favorite of ENT and passed and finals. Um, it is one of the most common causes of vertigo, but you very rarely see in hospital because it basically gets managed as an outpatient. Um So the main thing is you move your head and it triggers even though you're sitting still after you've moved your head, the whole room starts spinning. Um You really need to clarify whether how the dizziness is presenting. If it's lightheadedness or like, it's not exactly fitting that exact description. I would start thinking of other things. But if it's your classic head moved whole room is spinning even though I'm still 20 32nd duration, that is more BPPV. Um And you basically check by doing the dick hole pike maneuver. The dix Hallpike maneuver essentially involves leading the patient down quite quickly while supporting them. And you notice that they have a bit of a nystagmus with it in a specific direction. If that is positive, that's basically bait for BPPV. And then you have to go into doing the maneuver. You can do this as GP and what should we do on it? Just so you know what the hell is going on? Um You can have to like sometimes repeat it a few times in the community, but most of the time it's successful and you can consider these rehabilitation exercises just involve moving your head weirdly in specific directions. Um Oh, it's like there you go. I've now summarized the other ones, the other vertigo causing things that come up a million times on passed on this. So, vertigo, I would say in past paper questions pretty much never comes to ent as an emergency because it's very rare that vertigo that's caused by the ear is going to be that urgent. It's usually a long chronic problem dealt with as an outpatient if they are systemically unwell and they have vertigo, it pretty much is never a peripheral cause ie like peripheral nerves, it will basically be a central cause ie neuro. So I would go to them. So just to roughly go over these men's disease is long term is essentially because you've got too much endolymph in this cochlear part of your ear. So too much fluid and it just starts swelling and causing you issues, vertigo because it's obviously to do with the crystals in your semicircular canals. That's why you get the feeling of fullness in your ear because there's just too much liquid dancing around this cochlear and hearing loss because it also involves the cochlear. So cochlear is more hearing, these are more the balance, the fluid in all of it is swelling too much. So you get all of it, you usually get these attacks that last for like hours to days and is a chronic picture. That's pretty much be many years disease. The main thing is you'd use betahistine. That's the only thing that betahistine should be used for. Even though it's a bit of an abuse drug. Betahistine would be for many years. You can use these other things. Prochlorperazine comes up a lot on past med as like symptomatic relief, like short term, you've got your vestibular neuronitis then and labyrinthitis. The main difference is vestibular neuronitis. IE is only impacting the vestibular nerve ie you should only get balance problems. You shouldn't get hearing problems. It usually happens after an infection and then suddenly they've got these weird balance symptoms. The thing that comes up I've seen is the hints exam. So a hints exam, I'll google it. It's basically a collection of movements that you do to clarify if it's a neuro cause I ea stroke, a posterior circulation, stroke, I think, or if it's actually vestibular neuronitis, you just need to see if there's a what they call a corrective Sicard. So you hold the patient's head, you move it and their eye moves and then it flicks back that tells you it's a peripheral cause I believe so reassuring. Either way we don't really do much for this. It goes away by itself. Um You give pro prochlorperazine as symptomatic relief, nothing else really. And labyrinthitis, it's the labyrinth. So you get the hearing and you get the balance problems. Um you again do the hints exam again, you give prochlorperazine for short term symptomatic relief and then it basically goes to ent outpatient clinic and then it becomes a senior review thing. But they should basically these two go away. Only this would be chronic and really seen as an outpatient. Hopefully, that makes sense. I know, I really hated doing this when I was in finals. And then I think this is the last ear slide. The sort of about is, but acoustic neuroma and vestibular smas are the same thing. I figured that out way too late. Um It's essentially a tumor of your Schwann cells that surround your vestibular cochlear nerve. Um You get sensory neuro hearing loss, vertigo for severe kind of sounds like men years. But obviously, it's a mass, it is slow growing. So it is managed as an outpatient. You'd basically have an MRI head once you make it to ent clinic and then they decide whether it's actually causing you that many problems. Do you have to cut it out or if it is, then they'd cut it out? Um Nothing all that fancy there, to be honest. Um OK, any questions from you guys before I actually start questioning you instead, I think this is the longest part is ear stuff. Sadly, if not, then I will move on to the actual questions. So I pick these handpicked these from past med for a reason. So there's logic behind this, an eight year old boy presents to the ed with three day history of right sided atalia and otorrhea on further questioning, his father believes he has a middle ear infection as he suffered from these in the past ie on examination, he's pyrexial tender behind his right ear, his right ear appears more prominent than his left ear oscopy of the affected ear reveals an erythematous tympanic membrane with a visible tear and purulent discharge. Given the likely diagnosis. What is the usual first line management? It should say ABCD E but it doesn't, but you get the gist if you want to just pop in the chat, what you would think? Um Absolutely fine if they're obviously not. Right. That's fine. Mhm. Mhm. Or you can pick multiple, I don't really mind because I would probably also pick multiple disease guys. You can't be shy. You have to give me one answer. I think there's been some in the chart. Oh, they are. I don't see him. Oh, sorry, babe. Can you read them up for me? Yeah. So, um, so that's uh ea b ea. Oh, we've gone different. Yeah. Good. This is good. I wanted it to be different. So the answer is a, I'll go through why it's not B or E. Um So the idea is this patient had, um, potentially a bit of mastoiditis because they, they talked a bit about the, you know, that is being pushed forward, which yes, would normally you want to investigate that as a CT head. Absolutely. This kid would probably have a CT head. However, the question is first line management. So you would have to start the IV antibiotics always, even if the mastoiditis isn't there and the CT confirms there's no mastoiditis. You would have had to have started them on antibiotics because it's just so dangerous to leave them without the reason it's a, not b, is because they're systemically unwell and they, even though it's popped and you're thinking, oh, maybe they can have oral antibiotic. It's just the fact that they've got a mastoiditis brewing and a mastoiditis is quite severe. You would not be ok with oral antibiotics. It's just not going to solve it. You just need IV antibiotics. So that's the logic behind it. But the I chose it was because you are thinking a few different things, but we don't know what's best. So it's always IV antibiotics, then they would probably have a CT head to confirm and or deny and then you'd kind of go that route. Does that make sense? Sorry, I clearly don't have access to the chart. So you're going to have to tell me if anyone has problems. OK, good. Next question. Then this is from 2021 written paper that caused probably a fight between me and my friends on Weis. Um So this is a 40 year old lady attends Ent outpatient clinic with a series of vertigo episodes spanning three years. Each episode is preceded by a feeling of fullness in her left ear. The attacks last for several hours and leave her with left sided tinnitus and deafness. She sometimes vomits during the attacks. An audiogram shows left sided sensorineural hearing loss. What is the most likely diagnosis? Actually, I don't think we would have beefed over this. I think we would have beefed over something else. Mhm. If you just let me know what's being said in the chat so far, just see. We see. Yeah. Good. So, yes, exactly. That you wouldn't really be thinking which else? This one is actually sometimes how easy it can be or nice it can be in. Um And then this question, so 76 year old man seen by your colleagues one month previously complaining of right ear and discharge. He was diagnosed with oe and started on ear drops. He was next seen by an out of hours doctor one week ago who prescribed more antibiotic drops and traMADol. He's traMADol. Wow. Ok. He has come to see reporting that his symptoms aren't any better. The pain is becoming unbearable. He has a past medical history of type two diabetes hypertension. He's on all these meds, no allergies. He's never smoked, rarely drinks on examination. There's debris in the right ear canal, but the tm remains visible. There's no erythema of his pinna or mastoid swelling, an examination of his cranial nerves are normal. What is the most appropriate course of action in this case? We've got C and DC and D. Of course, you're thinking along the right lines, definitely C and D if you could pick both. Um But the reason why it would be d let me just make sure I change it. Here we go. The reason why it's D is because this man has the risk factors for a neck oe. Um So he's not responding to his antibiotic drops and he's got type two diabetes and he's quite old. So that's already two. And yeah, he's just not getting better essentially. So we would swab them once they've come in and we've seen it, we probably would swab it. But the main thing is that he comes into hospital, we review it and we see if there is neck oe because if it has started to go into his temporal bones, he needs a scan is up and he needs like all sorts of additional care and he can deteriorate quite quickly, especially if it's quite a while. So refer to ent first think of the swabs later just because that's the red flag. So red flags you deal with as a red flag y first and then you deal with everything else. Good, well done. So now we're on to the nose Rhinology. This is much shorter than the ear part of the presentation is much longer than everything else. So this is essentially anatomy and epistaxis I think comes up the most in finals, either as an Aussie Station and or in Britain's, to be honest, and in life actually. So this is the anatomy, this area here, the green circle I've kind of been like circled is it's a Plexus. So Kaiser Pax Plexus, but I've only ever heard it referred to as little's area and I have confirmed the other same thing. It's basically a very vascular region at the front of your nose, which is the common site of a bleed. Um with epistaxis, you don't really, I'm not going to be patronizing with what causes a nosebleed. It's usually just trauma. This is kind of the pathway to think about with management. So the main thing is always first aid, you pinch the soft portion of the nose, not the hard. So you always slide down from hard on to soft and then hold it there for 20 minutes continuously. You don't get to cheat and check if it's still bleeding, it has to be continuous. You lean forward, some people either suck on ice or ice on the back of the throat and then you spit out blood clots that come in your mouth because if you swallow them, you can start feeling a bit sick and suddenly now you're also vomiting. So that's first aid. If first aid fails. Um usually it comes into GP who kind of refers it to us because first aid measures are failing or after five minutes of not holding your nose, it starts bleeding again, usually ends up in A&E or acu of some kind. If you then can see where the point is like the point in your nose that is bleeding. Um You would consider core. So this is a silver nitrate stick, it looks like a massive matchstick. Um you essentially put blue spray or co phenyl canine up the nose to numb it and you look with AFA fum is a nasal scope. Um I have a picture of it later and you basically just zap away at this. Um, it's quite fun to do afterwards. You just give them some Epin cream. So it's got chlorhexidine and neomycin just to treat it and prevent any infection and then they be on their merry way. The problem is is if first aid fails and you cannot see where it's bleeding because it's just that much blood, then you consider anti packing. It's basically like a big tampon. You lube it up and you put it up the nose and then there's a little balloon at the end that you inflate that just creates pressure. And usually once a pack is in, you review it after 24 hours. So they're also called rapid dry nose, but it's called anterior packing. Um If anterior packing fails, ie you can also put two in. So one on each nostril, but it's really painful. So if you can avoid it and it's only one nostril bleeding, avoid it. And if that fails, ie once your anterior pack is in, you can still see blood really gushing fresh blood at the back of the throat. You're thinking that the bleed point is not actually here, it's actually back here. Anterior pack would probably only hit around this region and you need something at the back here, it's very rare. But if it does happen, you do a posterior pack, it looks exactly the same. It's just a bit longer and it has two balloons. So one balloon to inflate the back and one balloon to inflate the front. Um, if all of that fails, then your seniors will basically take them to theater for an artery ligation. It's usually the sphenopalatine artery. Um, but that's a senior L discussion. Essentially what I would remember as final students is be more wary about people who are obviously on anticoagulants or have clotting disorder. Usually just for safekeeping, you would have them in hospital or under surveillance. If packing is needed, you would usually send off for things like a hemoglobin, a group in safe just in case and a clotting just in case they have a clotting condition that they are not aware of and get IV access to make sure that they are pumped full of fluids to make sure they don't dehydrate. This is essentially the pathway you need to be aware of. This is kind of what it looks like. So Silber Corry, this is kind of the aftermath. It just looks a bit fluffy. This is that nasoscope that I was talking about. So both these little prongs will go in one nostril and then you let go gently to basically have a good view. You can put an Orosco up there or you just look with a torch this is an anterior pack. So one balloon here and this is a posterior pack with two balloons to inflate and then artery ligation is artery ligation. Hopefully, that makes sense. Your other nasal trauma. Emergency thing that you want to consider is a nasal septal hematoma. Um essentially similar to pin hematoma between the perichondrium, the cartilage pressure, similar thing you'll get avascular necrosis if you don't deal with this. So all of them are basically the same, just different parts of the body. Um You get a bilateral, as you can see in this picture, boggy and fructuous swelling. So it has to feel kind of like a balloon or a bit like a cushion. Um and it's always medial and it's usually bilateral. It would be very, very, very, very rare for it to not be bilateral. Um essentially incision and drainage just like a pin of hematoma. Um Usually it's under ga but that's a bit questionable depending on the trust. And if your nasal fractures are present, I didn't think nasal fractures were that important, but I've added it in here because I have seen some questions on it on past med where if there is a nasal fracture present, you essentially manipulate it under anesthetic, it can be local or it can be general in around 7 to 14 days. So not straight away because you need swelling to go down, but not beyond 14 days because that's when it starts healing and then you are never going to be able to manipulate it properly. Usually your hospital will have a nose fracture clinic to deal with that. Um You've then got sinusitis, it doesn't come up that much. I don't think essentially it's you've had a cold. So rhinorrhea, blocked nose, um, reduced sense of smell. The main thing is that when you lean forward the infection because it spread to your sinuses. When you lean forward, it triggers pain because it's usually in your mix in the sinuses here and you get like this viral prom. Generally speaking, you do not do anything for this. You very much do analgesia and see if it just goes away by itself and if the pain is managed, the pain is managed, you don't routinely ever really give antibiotics. Um Nice guidelines say though if it's been longer than 10 days, then to consider a nasal steroid. Um and not on nice guidelines. They kind of advise against it, but it has come up sometimes as like a red herring in questions as a nasal decongestant. So otra you'd have to use a short course because the data around it is not as good and it can like interfere with how your turbinates or these fluffy things in your nose work. But it has come up a question. So I've just mentioned it here. Nasal douching. That's basically a glorified way of saying squirting will show up your nose to clean it. Um And only consider antibiotics if it's been like over 10 days or it's like senior led decision, they are very systemically unwell. So always analgesia then steroid if you're going to do anything and then nasal decongestant, that's very important. Um You'll find out why later. Um there you got your periorbital cellulitis. So technically, this is eyes, but the reason why it's not eyes is because of what causes it. So it's an infection anterior to your orbital septum. I've concluded this picture here. Your orbital septum is this that line there. And periorbital cellulitis is in front of that septum. We are scared about orbital cellulitis when it is behind the septum because it can really start impacting your eye movements and then obviously your optic nerve and that's when it is truly opal periorbital cellulitis usually arises from trauma to the skin. So if anything about like they had a nick in their skin and now they got an infection, it's a bit more reassuring. We're thinking periorbital cellulitis, but a complication of sinusitis that we just talked about or this frontoethmoidal sinus, which is here and kind of by your nose is that it can become orbital cellulitis because you can see the sinuses there, it goes behind the orbital septum and then we're a bit scared. So you get a swollen orbital region. It usually happens in kids, you get proptosis of the eyes moving out a little bit pain on eye movement, some double vision things like that. Um Essentially we want to rule out orbital cellulitis. So you get opal involved straight away for an in depth eye examination to really assess their eye movements and ability to see because you're not going to be carrying around a shot, do obs on them if they are really in well sepsis six and you always do a CT orbits or sinuses to assess if it's in the orbit or if it's not once that's come back, we're fairly happy. Um However, you should also, if it's confirmed periorbital cellulitis, which often happens in Children, you have a very, very low threshold for giving them a CT head. If their symptoms are for some reason, not getting better despite starting them on antibiotics or if the inflammatory markers start rising because we start thinking that in this infection, you are now creating an abscess which is not draining. I think we had a child who came in with peri confirmed preorbital cellulitis. They were completely fine. Their CT orbits were fine. We started her on an IV antibiotics and her CRP went from 10 to 30 which is very, very minor in the grand scheme of things. But our R was like CT head straight away and she had the biggest abscess in her head ever. Like the stuff that you can't miss as a med student. It was a bit insane. Um So management would be ivory antibiotics. Um You can consider nasal steroids and decongestants but again, if they are acutely unwell, it would be IV antibiotics and then you supportively manage them. Ok. Oh, is this the last slide for? No? Yes. So foreign body common in Children, kids with learning difficulties because they've got sensory issues or psych patients the whole lot. Um, usually you need a collateral history or a witness. Usually mum saw them put something up their nose. Um, if you don't have any of that, then you usually get unilateral nasal foul discharge, um, problems with inhaling on one side of the nose. Um, if it's a battery or if it's organic, ie like a bug, um, see them sooner because it can cause problems and infections a lot more quicker than if it's a bead. Essentially use a third to come again or an sco just to look up as high as you can. Um, and then you kind of go through this in terms of management. So I don't know if anyone knows what a mother's kiss is, is essentially where you hold the child on one bit of their nose and mum like forces breath through their mouth, like blows in and it basically creates pressure to shoot the thing out. Sometimes it works really, really well. Um So you'd ask them to do that. Usually if you're waiting to see them, ask if they've done this, otherwise you remove under direct vision, you get all these weird devices and you start scoping it out. But try doing that on a five year old and they will hate you. Um, if it's really like not coming out, it's going to cause a problem and you actually have seen it go up there and the child is telling you it's up there as well. You would basically get them in for a general anesthetic to be removed and in theater which you want to avoid if you can do basically. OK. What time are we on? Not too bad questions, any questions from anyone else before I go on to the questions, you'll have to tell me um because I can't see the chat it. So this is a 21 year old woman presenting to Ed with a three hour history of continued epistaxis. She was training with a university rugby team when she collided with another player. X ray confirmed she has not broken her nose. However, there is still profuse bleeding in spite of compression, you are unable to identify the bleed site. What is the most appropriate initial management option? Mhm. Got a couple of days. Be great. OK. So anti incision. Yes. Don't be fooled by an ice pack. Don't get me wrong. It is important. But realistically if she's been bleeding for three hours and she's compressed and it's still bleeding and you literally can't see anything. It will be an antiac insertion. You don't do silver nitrate because you can't identify the bleeding site. You'll be going wild in their nose and that's a bit crazy. Um So you'd leave it cool. Then you've got a 37 year old man presents to GP with headache and nasal discharge that's been present for six days. On further questioning, he describes the headache as frontal pressure pain which is worse on bending forward. He denies having a cough or generalized malaise. His heart rate is fine, frustrate is fine. His BP is fine. His temperature is fine. His past medical history of asthma controls it with an inhaler. Given the most likely diagnosis, which of the following is the correct management plan for this man. He was a mom, right? Yeah. Would it be a Hey. Yeah, good. Well done. So red herrings in this one would be I basically chose this question because it was a very similar to past paper question which we did actually argue over. It's because of the fact that it's only been six days. So not 10 days, they're systemically very well. Um And you would avoid things like steroids and nasal decongestants if it's less than 10 days and she's not systemically well, so you wouldn't consider antibiotics. So therefore basically pop them up on some painkillers and make sure that they're drinking really well and then review. Um Sorry, can I ask a question about the previous one for that? Yeah. Did you say you put that in for 24 hours? Yeah. So you basically pop it in, you inflate it and once it's inflated, you usually have to keep it in for 24 hours before attempting to deflate for it. Cause for it to bleed that you're going to admit. Yeah, you meet the patient and then wait 24 hours and then you take it out. Yeah. Ok. Um So there's a guy actually right now in AM and he's not happy about that because we haven't got in the bed. So he has to just wait in a, it's a bit sad. Um But sadly, yeah, once the pack is in, you have to keep it in for 24 hours. Um ok, like it wouldn't be a pack in, in a quickly out ever. Cool. Um And then this one, so a 37 year old man presents with nasal obstruction. This is a bit mean, but this is more of a teaching point and presents with nasal obstruction and loud snoring. He has noticed these symptoms get gradually worse, have gotten gradually worse actually. For the past two months, his left nostril feels blocked while his right feels clear and normal. No history of epistaxis systemically. Well, on examination, large nasal polyp can be seen in the left nostril. What is the most appropriate action? I actually didn't teach this, but I use this as a teaching point because I don't think it was worth a slide. Um So how is it your guesses and say a OD A or D? Ok. Cool. So that's why I chose this. So thanks for answering that. Um So it's actually ec um and this you will get used to ino me because I where they have like 50 questions on the same thing. A unilateral nasal polyp is cause for concern for the following reasons. Um polyps or like enlarging in the nose is usually your turbinate, blocking things in your nose and it usually swells up bilaterally if you've got like if you are ill and you see these two turbinates, we are not worried but they always swab bilaterally. So we are not that concerned. A unilateral nasal polyp is query cancer until proven otherwise. So it's basically a suspected pathway. So you have to refer them to ent they would have a look, they would usually biopsy it or a senior will come and review it and then decide whether it doesn't necessarily mean it is cancer, but it has to be query cancer until proven. Otherwise, only unilateral in adults would rethink about this and you will get used to it after you finish your passed because they love that topic to death. Ok. That's your nose done. Hopefully. Now we're on. So, laryngology or Pharyngolaryngeal, whoever wants to be pedantic about it and this is your bread and butter of ent, especially at finals tonsillitis. So you get inflammation of your tonsils due to an infection as you know. Yeah. Yeah. It can be viral. Yeah. Yeah. It could be bacterial. I'm sure you're sick to death of like central score and like fever pain. You know, the symptoms, you get a sore throat, you get your malaise change in voice. Can't swallow, can't drink swollen neck trismus is the inability to open your jaw. Um The main thing is the exam. So there's a third exam. You can grade the tonsils or have a thing on the next page. You do a neck exam, you know, a lymph node examination as well. For the sake of it, you'd also do an otoscopy because you can, everything is kind of linked. So they might also have an ear infection that you need to deal with and then blood wise, your FBC S use and ease because these people often if it's really bad, aren't eating and drinking that well. So you need to see if they're dehydrated CRP S as like your infectious marker. And a glandular fever screen is quite important if they are looking a bit suspicious. Um mainly because obviously we start antibiotics. Some with glandular fever, oftentimes they get a rush. But also does anyone know why glandular fever is important? It's mainly in PSA that I'm talking about. Something about. You have to give them a piece of advice if they come up as glandular fever. Yeah. Brilliant. Exactly. So you get a big spleen with glandular fever. So you have to avoid contact sports for six weeks. Sometimes we just slap this blood test on top just to make sure it's not that, um and that would be the advice, but that comes up in PSA a lot. So save yourself the five seconds of Googling on the BNF. It is avoid contact sports for six weeks. Um Any time this comes up. Um So conservative Diam is basically a local anesthetic spray you can use on your throat. It's underrated, to be honest, you should use it more. And the antibiotic of choice is usually phenoxy methyl Benzyl penicillin, phenoxymethylpenicillin, not Benzyl. So, or pen, um you would start this in community based off the center score or fever pain. I has a whole thing about it and I won't bore you with that. Um But you would admit them into like hospital if they are unable to drink or eat. Um They're not improving on this course of antibiotics or if you query Quinsy, which will go into an end later slide, this is tonsillar grading. Um So usually when we see patients in hospital, I would say we usually see usually 3 to 4, to be honest, over two. because as you can imagine if your tonsils are almost touching, which I have seen, um you're basically not going to be able to drink much. Um So this is the type of tonsil reading a Quinsy then is a complication of tonsillitis um whereby you get a collection between in your peritonsillar space. Essentially the main things, everyone thinks hot potato voice which you sharp roof out brush because it's like you've got a hot potato in your mouth. Um But the other things I would look for is uvula deviation. So, not necessarily the dangly bit of your uvula, but the base of the uvula has that moved from the midline because that points you towards an asymmetrical oropharynx. So, IUD when you look in your mouth, it's not symmetrical. That is much more. We're thinking of Quinsy. The investigations would have been the same as tonsillitis, you know, look in the mouth, grade the tonsils, um, assess how well they are. Do your obs and things like that, the basic stuff. Um, the management is slightly different. So if you don't drain that, it's not going to respond to antibiotics. Really, you do need to drain it. So you just need to pop a needle in and suck the drug out. Basically, you give analgesia adequately because it hurts a lot. Um, you give them IV antibiotics because they obviously can't swallow and you need something to go straight in. Um, and IV DEX. So the DEX is usually if they've got Trismus, so they've got a lot of swelling around their throat so they can't open their mouths, dex. So basically, just bring the swelling right down because it's just a steroid. Um, this would be the main thing, but the mainstay, if it says mainstay of management, it's in and so incision and drainage of this. Um, this comes up in like what's the word virus? Um, just learn it. It does come up sadly and you might be asked about it. Um, yeah, then a complication of tonsillectomies which comes up as your ent emergency would be a post tonsillectomy bleed. It is the main complication that we care about. A primary bleed is within 24 hours. POSTOP. So most hospitals will keep their patients for 24 hours so that the primary bleed is caught in hospital and a secondary bleed is later, it's more associated with an infection. They're usually a bit unwell. Um Things like that. So only 48% of people get that and only a small percentage of that percentage ends up in theater for a big hemorrhage. Um It is more likely in adults, that's why we try to get tonsillectomies in kids. Um and don't be fooled by like a small bleed in their aa frying, which looks like nothing. It's usually a herald bleed ie is heralding the fact that you're going to have a bigger bleed. Um Every tonsillectomy bleed, post tons bleed is an emergency and needs to be seen by a senior on ent do not leave it in GP. You have to send them in and we will review them essentially. Ok. Ok. So assessment obviously, please follow that. Always answer that in a first for everything. If it's a severe bleed or a primary bleed, you basically swinging back to theater ASAP. So 06 hours post tonsillectomy, go back to theater um because you are in a nice window where you can do that whilst you're awaiting theater, typical things wide access, send off your FBC, send off a coagulation screen, send off your group and save. This is all like ay stuff. Um And if you really want to look good and if this does come up, which I really doubt but you can to stop the bleed and whilst you're awaiting theater, so this will never be the first thing you do, but it's what you do in the interim is you can get adrenaline patties. So you basically get go soak it in adrenaline and like poke it and pressure onto the tonsil. If you're not going to gag them to basically stop the bleeding as fast as you can. If it's not that severe, you kind of go for IV Tranexamic acid. Um And these h2o 2 Gargles and so ice at the back of the neck. It will be senior reviewed. Um But they then decide whether that this, these combination of two things has caused, um has stopped the problem enough or whether there's an infection and you want to add on some antibiotics. Um The main thing is under 24 hours back to theater after 24 hours TX and these gargles. Um This kind of fluffy stuff is more for if you want to get in Aus, if it comes up um, this is a picture of something but I want you to essentially tell me if your, if you would admit this or not, if you saw this and they said, oh, I've had my tonsils taken out recently, like two days ago. Would you admit this or would you not admit this? Mhm. Absolutely. So, like it looks relatively normal, but there might be like a tiny bit of bleeding on the left. So, and a tiny bit of bleeding, then you'd wanna bring them in. That's yeah, I was just looking at it and I was like, oh, it does look a bit like a bleed, it's not a bleed. Um This is actually normal post tonsillectomy appearance. So do not be put off. It's just sloughing and if it looks like this, it is good, you wouldn't pick this off or anything because you probably caused the bleed in the first place. But if someone said I've had a tonsillectomy this week and this is what their throat looks like. That is a normal healing sloughing appearance. So this would not be cause for concern. Ok. This is your head and neck cancer pathway. This comes up in what does it come up in mock acies for finals and it comes up in finals, um often very vaguely. Um So I've introduced the three kind of head and neck cancers, obviously, only one is really ent um but this is the nice guidelines for red flag symptoms that will warrant a two week wait referral. Um, so I've included all of them. However, I would probably say this is ent, I would say the middle one is Max Vax and then the right one would be endos surgery. Um, but be aware of all of these because if it is a station of history, you're taking you kind and they're saying I've got neck pain, um, you kind of, or I've got a neck lump, you kind of want to rule out thyroiditis symptoms, either by location and or symptoms. Oral symptoms, hear and then hear hoarseness of voice. The minute it's unexplained, hoarseness of voice. You are sending them off to be seen basically. Um, this would basically be it. Um, the middle one, I did say Max Fox, but it really depends on your trust. Um, clarify your symptoms, um, rule out other symptoms. That's roughly how you would take a neck lump history. And your first investigation usually, once this comes to hospital under the two week week pathway is a fine nasoendoscopy. Um, oh, sorry, a flexible nasoendoscopy, they just pop it in to have an actual look to see if there is a mass or not, if there isn't a mass. And we're still a bit concerned. You do some form of imaging, that's all senior led, but you absolutely would need to be able to pick up this in an osk or in a written exam and identify these as red flags for a cancer pathway. That's the most important part. No one cares if you haven't identified the exact thyroid cancer. Right now, I've included this because that's what everyone uses to describe neck lumps, the American head and neck society levels. So you'll often hear like neck lump in zone level two or level three. And I thought it was top to bottom initially is actually not, this is the diagram and this is a description of the areas and this is what a lump in those areas could mean. So if you are at a loss, always say lymph node because a lymph node can be in all of those places. But if you want like a bit under your belt as to what to say, there's a few different things. It could be like Pati, it could be sialadenitis, it could be dental, that would be max fx. There's all that like thyroglossal cyst and things like that that you can learn. Um But I think learning it based on the anatomy is quite helpful. Um Just a glance over this, don't commit this to memory, but the more you understand the anatomy, the easier you'll just be able to recall it rather than memorizing it. Um And we talk about foreign bodies every single time. I'm sorry, but sometimes people eat them um who takes care of this problem, which is an emergency defense differs by trust, but you will never go wrong by saying ent or upper gi how we do it is upper airway. If they say it feels like upper airway, II can feel it right here or I'm coughing a lot or they're coughing up blood because of something stuck there. And if they are saying it feels like it's stuck in their chest, it may be lower. Gi realistically red flags would be that they can't breathe. The item is sharp. Um, so think like bones or a needle and battery ingestion, which we'll talk about a little bit. Um You need to immediately remove a battery because it can cause a burn. And if it burns, you can cause an ulcer and if it causes an ulcer, you can cause a perforation, you can make fistulas with weird things around there and it's very problematic. Um If you do ever swallow a battery or know someone who sold a battery, start eating honey because the honey will coat the battery and prevent erosion from the acid and or alkali that is leaking. Investigation is a, you do a flexible nasendoscopy to see where it is. And then you would consider if you can't see it. Um a lateral neck, X ray or frontal neck, you usually do a lateral as well. You cannot rule it out if it's negative. Um, always go off of the symptoms, but you would pretty much always get imaging involved because if you are going to go in there with a rigid esophagoscope, which is basically a glorified metal tube that goes into your mouth under sedation and they can put prongs through it to lift things out. Um, even if the imaging is negative, there's a lot of stuff that's radio lucent ie it won't get picked up on an X ray. But if there's patients saying they've got something stuck in, they've probably got something stuck there. Um, that would be the mainstay of this kind of stuff. Um I think I have a question on it later, but we'll see and I'm going to only really briefly touch on supraglottitis, epiglottitis. I'm sure you're sick to death of epiglottitis from peds last year. Supraglottitis happens in adults. It's just slightly different as to where it is anatomically and the infectious organisms essentially you get difficulty swallowing, change to your voice or maybe stride or you're quite unwell if it's an emergency. A always, always, always like secure the airway, don't examine them, you know, get into your anesthetics to see them first, always get reviewed by seniors and then once they are stable, you basically do sepsis, six vibes on them, um start them on some IV, start them on dexamethasone, start them on nebulizers, some fluids. Um Once they're stable, you can do a ford nasoendoscopy. And this little fluffy thing is your um epiglottis that's very, very swollen. Um Normally it's very skinny. Um Again, this is very senior L so I don't think it's really that worth it all. You really need to know is that it's an emergency and to not examine their throat. Ok. Questions from you guys and, or we shall continue and go on to the actual questions. I think we're almost done actually. Um, so this is from the 2022 bits of paper tip. And so a 76 year old female ate fish and chips three days ago presented to the ENT on call from GP reports. Ongoing non resolving throat, pain and pain on swallowing. She has not coughed up any blood. Her abs are all cool and her examination is unremarkable. What would you do next and tell me what you put in the chart? I've got a couple of CS yay. Brilliant. OK, good. Um This is the one that we argued over Asprin last year. Um We were between at the time X ray and a laryngoscope, but now that I work in and I read that I was literally like, who would do a laryngoscope? You just don't do a laryngoscope at all. You were doing esophagoscope, but very rarely would you ever go in with esophagoscope without any form of imaging? So even though imaging can be non conclusive, you would still image because let's say if they've got what she's got a fish bone, if she's got a fish bone, I want to know, you know, is it the anterior, is it in the posterior wall? Is it really wedged in? Is it not really wedged in, where is it? And an X ray can be really helpful with that. Before I go in with an esophagoscope, a laryngoscope is basically only released for anesthetics to visualize the vocal cords. I think you have a living anatomy session on it in like year one and two, but you just don't use it. So that's the clarification on that question. Um This question, a 43 year old woman had tonsillectomy one week ago. She presented to her GP one week later because she's noticed a small amount of blood pooling in her mouth from this morning. She believes the blood is coming from the wound site. GP examines her mouth and throat sees no obvious source of bleeding. Her abs are normal. What is the most appropriate next step for the GP to take? Got a couple of bees. Oh, bees. Oh, I'm glad I talk to you guys that it's a and the reason it is a, it absolutely would be b had the tonsillectomy not been a week ago. So if the tonsillectomy was in 24 hours, you're in the window where operating is basically needed and bleeding that soon after the operation is quite concerning. So basically, we don't want to do the in between. You want to send them straight back to theater. This is one week later. Um And so it's still an emergency and it definitely you still need go to hospital for ent review. But because it's been a week. You are closer to the idea of an infection over the wound site or bleeding, necessarily not having to be managed in theater ie we can start you on IVT Xa and the Gargles and see the vibes. It is of course, reassuring that she has gone to GP and not seen the bleeding. But at the end of the day, she had a bleed post tonsillectomy. So it's mainly timeframe that will dictate surgical exploration immediately. Versus let's try a few things first and see how it goes before considering taking them to surgery if that makes sense. But if literally the question said six hours ago, you would be correct with me. But otherwise it's eight. And that's the reason I included that question. And this is a 45 year old shipyard worker with hyperthyroid well managed gourd presents to GP with hoarseness of voice for six weeks. He's smoked 10 cigarettes per day for the last 15 years. On examination is BMI is fine. His baby is fine, sorry, it's fine. Temperature is fine, respiratory is fine and his sats also are fine. Um This is the result of his thyroid function tests. Um Which aspect of this patient's history most strongly indicates the need for urgent ent referral. Got a ne A&E good. OK, good. That's kind of what I want you as to choose. But it is a as you can see, a lot of people also chose e the reason why he is not as important here for the referral is because yes, he smokes, but he has smoked for many years. Um, and had the hoarseness of voice not cropped up. I wouldn't even be thinking about that. Um, it's the hoarseness of voice itself. That is the red flag and the fact that he's had that hoarseness of voice for six weeks only, even though he smoked for much longer, that is what would make me concerned. So that specifically, rather than, and feeling quite new onset compared to the fact that he smoked for a lot longer. So it's the new onset hoarseness voice rather than the smoking. The smoking still makes me concerned. It adds to the picture. But similarly, there's a lot of people who present with hoarseness of voice without smoking and I'd be still more concerned because of the horse's voice if that makes sense. But good thinking generally, um this is the miscellaneous part. So it's just a few bits and Bobs. So Weber and Ryans comes up all the time. You can answer questions and finals based on Webers and Ryans, sometimes you don't even need to read the question. I don't encourage that but that you can um RNAs is, or Ryans is the one where you do in front and behind the ear and then Webers is um the middle. I just remember it because Weber's is symmetrical like the w symmetrical. So then I just think it has to be in the middle um line of symmetry. Um And then Rines as rins, this is, I'm not going to do too much on this, but it essentially will just tell you whether air condition is better than bone conduction. And based on the combination of results, you can figure out whether you've got conductive hearing loss or sensory neural hearing loss. The thing I must tell you however, is what positive rines means. So positive rines means that air conduction is better than bone conduction, ie normal hearing. They will not tell you in finals, air conduction is better than bone conduction. They will tell you the patient had bilateral positive and certainly you're stuck thinking what the hell does positive mean? Does that mean positive for pathology or does it mean positive for they can hear if there is hearing, which hearing? So please learn that positive Rs means air conduction is better than bone conduction, which is normal because that came up in our finals very horribly and audiology. This is an audiogram. This also came up in our finals. You will often have a key. So this little bit at the bottom and really no one uses this or like learns it. We get off the tics page every single time we are asked to interpret this unless you are an audiologist. Um This is just to make you aware. So you've got one color for right ear, one color for left ear. Um and one like basically denotes bone conduction and one denotes air conduction. Um This is a normal audiogram because the lines are symetrical and they're quite high up ie they can hear quite well. Um This is someone who can't hear high frequencies um and it's in both ears. So this little bracket um oh, not both ears, it's in one ear but it is air conduction and bone conduction. So the air conduction and bone conduction goes down at higher frequencies, denotes sensory neural hearing loss. And so I spelled that wrong on the pot. I'll change that. You've then got conductive hearing loss where you've got what you call a bone air gap. Ie this is the bone and it's conducting better than the air. Um because you are able to hear better here and you are getting more hearing loss when it's sensory neural. Um No, when it's through the air, that's where you get this. Um So the idea is you're conducting better through bone than through the air because something is blocking the air. So when you've got a bone air gap, this is conductive hearing loss. Um and this always comes up press by you basically just hearing loss with old age, even though I'm pretty sure I have this now. Um basically is a bilateral hearing loss, um sensory neural at high frequencies. Um I wouldn't die over these because often you can figure out what the hearing loss is based on the symptoms, which is what I did in finals rather than looking at the audiogram. But this is just so you don't get freaked out when you do see an audiogram in your exam and you're thinking what the hell they are usually not too bad and you can often diagnose it based off symptoms. I wouldn't be too worried. And then a quick note in trachys and Larry. So a tracheo for a laryngectomy, this is how it's anatomically different. So this is a regular throat. This is a throat with a tracheostomy in it. So the whole ostomy is whole into your trachea. So tracheostomy and a laryngectomy. So the whole voice box has been cut out and anastomose to the surface. So the outside literally goes through into your trachea. Um The reason why these are different is this. So, trachea are usually short term ish. Um You can have long term trachea. It really depends, but indications would be like upper airway obstruction. So something is going on up here, they can't breathe. So therefore, we have to create a hole here and then they go down. That's the typical using a pen and then shoving it through and somehow creating a whole in an emergency. That never happens, trauma to your face and neck to preserve the airway. Like we have someone, one of our patients had like a big car crash accident, mold face basically has to have a tr because you can't breathe otherwise until this is plastically fixed. Basically, neuromuscular disease. I think like motor neuron disease. If they lose tone of the muscles around here, they still need to breathe, they need to get rid of all this dead space. So you go through here or if you are in it for over 10 days, they start thinking of giving you a tracheostomy just because it makes the dead space of breathing shorter. So you kind of get your lungs and you breathe straight out here. You can have percutaneous, which is what they do in it. Basically with selling this technique or you go to surgery and you do it and it's quite a fun surgery to be in. Um, if you get to do it, do it, it's a bit fun. And for your laryngectomies, this is more the reason why you'd ever have to cut out the whole whole voice box is because you've got cancer on it or cancer impeding into it or you've had radiotherapy to that area and your voice box for some reason is fried, you just cut it all out and then basically it's brought to the front. Um, this is kind of how a trucky tube would sit. So you've got a cuff here, you breathe through this. When you've got a laryngectomy like this, you have a special type of tube. You can get different caps on top and you can get speaking valves. So basically, if you cover that, you can start speaking and it just manipulates the air in your throat a bit differently. The only thing I'd be aware of because it comes up in images and instruments in your os is sometimes they will give you a tracheostomy tube. You just need to be familiar with the fact that this is the cuff. So this is what gets inflated and keeps it inside. You've got these little flaps which are often sewn into the skin, sub, particularly just so it stays in place and you would inflate it with this thing here. And it's usually gone in a tube that you can take out and pop back in. If this is fenestrated, ie this has holes in it. It's basically one designed to help you speak. Because if you can imagine there's a cuff here and air is only going out here and your vocal cords are here, you can't speak unless air gets pushed up this way. So if this has holes in it or fenestrations, it forces the air upwards and you can speak. There's a lot more to the science of it, but that's the basics of it and that's all you'd really need to know for images and instruments. Um So that is the end. Thankfully, there are no questions about the tracheostomies feedback is very much appreciated. I know you guys have busy days and joining a lecture at the end of the day is probably the last thing you want to do. So I.