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I think, um uh, most important to cover stages because they're a bit trickier. So we're going to go over otology audiology rhinology some of the Farren, Farren, geology and laryngology and head and neck. So that's going to be adjust the sort of the lump, like the cancerous, um, or neoplasms in the head and neck rather than just all head and neck lumps. I think we sort of know those quite well from third year and fifth year. Um, and then final year, we tend to kind of forget about those details. Um, so, yeah, let's get started with otology. Um and we're going to start with some anatomy. So you've got your out here, which is everything from the Pinner, uh, the auditory Metis up to the tympanic membrane, middle air, everything from behind the tympanic membrane, um, to the bones and the, um, have a stimular organs. And then once we get to inner ear, it's the cochlear, um, and the acoustic nerve. And then we've got just a bit more of the anatomy of the Pinner there, and we've also got an image of an otoscope. And first question just to the audience. If anyone would like to answer the question. Which side of here do we think this image is showing? And how do you know? I hope to get any answers or anyone to mute people have answered in the chat. Oh, sorry. Christ, you let me escape. It was a health that with them just reading answers. Uh, they said right side because of the cone of light. Yeah, precisely. Um so the cone of light is usually at five o'clock position in the right here. Or we can think about it as just being on the right side and the left side. The cone of light is going to be at seven o'clock or on the left side. Next question. So 38 year old presenter, 38 year old swimmer Sorry with a background of Type one diabetes presents is GP with a one week history of ear pain, redness, Tintin's and discharge Question one. What's the most likely diagnosis? Only one can if you can, um, use. Or if you can just type in the chat for her reef to let me know. Getting otitis. Six. Turner. Yeah. Oh, tie 16. We've got a few aunts there. And what other features. Can we see on examination any guesses? If not, that's all right. We'll go through it. So, otitis external, uh, we can just think about it as an information of the extent external auditory canal, and it can be classified as primary and secondary. So with finals, especially in paces, you want to just classify all of your answers as well as you can. So whether that's with management, you know you're conservative. Medical, surgical. Um, pathophysiology can do primary secondary, any sort of classification you can think of while you're doing your notes or your revision. Um, practicing with friends is going to one. Help you remember your answers and to it's going to really make you look like you know what you're talking about with the exam in it that then it'll just make you look a lot slicker. So primary X 026 terna. Um, we usually think about that as a change in the environment of air canal or break in the skin. So that can be, um, things like increased humidity. Um, with swimmers in particular, breaks in the skin as well. Um, so a cotton bud use can cause minor trauma and also just eczema. So if you it might be that you'll be using the cotton buds to, you know, to get it as well. And everyone who's eczema is the itch that rashes. And if that cause a break in the skin, you've sort of got an opening your skin to allow the infected organism to get in. Um, secondary. It's usually in the context of otitis media with perforation of the eardrum. Other risk factors, um, that we haven't discussed yet. Foreign body is so particularly in Children who like sick things in, that is, and the nose is, um and also diabetes mellitus responsible organisms. Uh, most commonly, it's bacterial, so pseudomonas and staphylococcus are the most common. Um, and if antibiotic treatment fails, then you might consider, um, fungal uh, causes such as a specialists in candida. And then other things we can see on examination include narrowed inflamed ear canals and discharge. And it's usually, um, kind of creamy. And I think I've read custard like as well in some textbooks. Um, and that's usually indicative of bacterial infection. Um, if you see black discharge, think aspergillus, and that's more indicative. Fungal infection treatment is always topical antibiotics, which is usually ciprofloxacin drops, and steroids, which usually dexamethasone or antibiotics, won't work. In these patient's. You need direct therapy of the antibiotics and straight into the ear unless the case is very mild, in which case it might help. But to be honest, the answer will always be topical. Antibiotic ear drops, some red flags and things to look out for times you might want to escalate to senior or even the n T E N T team. Sorry if there's complete acute stenosis of the ear canal. So sometimes this swelling can get so severe that the, uh, canal just closed off. If there's Pinner or facial cellulitis, if there's any sign of abscess formation and that needs to be drained and or if there's something a bit more boring touches, Um, a a cranial nerve palsy, um, severe Deepa Talaja. And if symptoms are still there despite adequate adequate treatment, so you've given them 1 to 2 weeks of the topical antibiotics and steroids. If that persists, uh, get a senior, um, breast factors for complications include immuno compromise or immuno suppression, and it's classically. This is why diabetes is a risk factor if they're older than 65 or if there's recurrent infection and the risk factors that we're worried about. This right? The complications that were particularly worried about our next arising tie. Six Turner, which I think used to be called malignant otitis external er. And this is osteomyelitis of the mastoid and temporal bone. Um, so similar to and in otitis media, where you get that the infection spreads through the soft tissue. And then you get this sort of boggy swelling of the mastoid process, and you can even see sometimes evidence of graduation, necrotic tissue in the ear canal and cranial nerve pauses as well. Um, other complications include abscess and cellulitis. Other examples of external ear infections. We've got Ramsay Hunt, which is, as we all know, herpes zoster affecting the facial nerve, Um, and classically with with herpes zoster, you get those vehicles in the canal and side of the face. Um, those blisters that sort of crossed over after. And if the nerve supplying supes ius is paralyzed because of this, you can get hyperacusis, so they're very, very sensitive to noise. Everything is a lot loud with them, and they can also suffer from tinnitus. Furunculosis ISS is just an infection of the hair follicles within the air. And you can also get a preauricular Sinus, which is just a congenital, um, Sinus that's in the front of the air. And sometimes you can get sort of discharge and passed coming out of that as well. So answer the question. The answer was otitis external, well done of those well done to those of you put it in the chat and other features on examination, as we said, narrow an inflamed ear canal discharge. And then we can sometimes see cellulitis abscess mastoiditis in the process, um, as complications. Okay, next question. Uh, if again we cannon mute or if you're if you can just let me know what people are saying In the chat, Uh, an 18 month old first born infant is brought to a and E by her anxious parents. The report. Their daughter has been unsettled of her food and has a mild temperature. For the last three days, she's been pulling on her ear as well. And what do we think the most likely diagnosis is? What otitis media? Good. So we'll we'll get onto glue are actually That's interesting that some of you have put that in the chat, Um, and the next thing in E. D. She suddenly cries loud and then stops discharges seen coming from the air. What we think has happened causes change in her symptoms while she's been in the E. D. Really well done. Caris. Yeah, So her tympanic membrane has indeed perforated. Let's continue, so I keep otitis media. This is just inflammation of the middle ear. If discharges seen, then you can assume there's been eardrum, perforation, symptoms and science, gradually increasing ear pain in Children who can't really communicate. They're they're in pain or tell us where their pain is. They might just be pulling up there here intermittently throughout the day. Um, there's fever. There might be a history of a recent upper respiratory tract infection, and there may also be a tinnitus and hearing loss. Most commonly, this is viral, and it's most associated with influenza and bacterial causes are less common, but they are. They are significant. Him, a Phyllis and Streptococcus are the most common causative organism, and we can look at the image from not oscopy as well. Um, the signs are an opaque, bulging erythematosus, eardrum and vessels tend to be a bit more obvious as well when looking at it so we can sort of see, um, these lines. I'm not sure if you can see my mouse, but where all these lines are on the ear drum, they're a bit red. Those are the vessels that just a bit more obvious during infection. Um, so rest factors. It's more common in boys. Um, and most common in Children under the age of um seven. Recent upper respiratory tract infection is a risk factor being bottle bottle fed as if you're a child and you have otitis media. Um, is rest factor passive smoking and also clef pallets and other craniofacial abnormalities. Cystic fibrosis is also an important risk factor as well, and complications again. Try and classify everything so extracranial cause extracranial complications. Arm Assad itis um, which is the most important one to know of a rare of complications that you don't really need to necessarily go into too much detail, either something called Petra Petros itis, which will go into a little bit just if you're interested. It's, uh uh not. It's just another part of the the bone and the another part of the temporal bone, and that can become infected as well and facial palsy. And that's a facial. If the infection sort of goes down to the facial nerve intracranial. We've got meningitis, sigmoid Sinus thrombosis and brain abscesses. But these are particularly rare. Um, these days, and just to show you, um, mastoid ice, I've got an image there as well. You've got this swelling at the back of the air and the there's usually what we call it might be here, actually, yes. So this dip that you normally have behind your ear, um, separating the skull and the ear that's called the auricular mastoid sulcus. That's because of the swelling that's lost. And that is just how we can identify quite easily. A mastoid itis being a complication, Um, that we're most frequently see, it's an infection within the mastoid air spaces of the temporal bone. If we leave it long enough, it can result in a subperiosteal abscess as well, um, as well as the sulcus being lost, you can see that the pin is pushed down downwards and forwards that those bogginess on palpitation and as the abscess forms that swelling that's behind the ear can become, um, fluctuance as well. And as we said earlier, and they're spread to the Petrous apex of the temporal bone that can lead to petrositis. But that is for finals. A bit too much knowledge. Really. You don't need to worry about festival, Okay? And a couple of you mentioned gluey. Same acute otitis media with a fusion, uh, is what we call a glue it And that is this. This is this sort of clear, thick, sticky, glue like substance, that source of fills between behind the tympanic membrane. Um, science and symptoms of this increasing pressure sensation in the ear popping. Um, and that's often because of all these bubbles that form. And as those sort of pop, you can sort of hear this popping sensation your ear as well. Conductive hearing loss, um, loss of balance. And if this is chronic, um, particularly at a critical period of time in your development, it can need to developmental delay with speech as well. This is a particular red flag. If you see this image in adults, um, this is very unusual in adults, and you want to rule out cancer as soon as possible, Um, or at least investigate for any other causes of postnasal space occlusion and treatments. Normally, it's conservative treatment. Antibiotics don't really do anything to shorten, uh, the duration of illness, and most cases are viral anyway. Medical treatment. We can consider a museum antibiotics in, um, patient's who are under two with bilateral infection or, if they've noticed discharge coming out of the air so we can assume there's been It's impoundment membrane perforation there. If there's no tympanic membrane perforation or if they're under two years old with just one sided disease, then you can consider delayed antibiotics so you can give a prescription to the parents and say, If you know this doesn't improve within 3 to 5 days, you can go and pick up some antibiotics from the pharmacy. Um, if they're systemically unwell, uh, presenting with signs of sepsis, then admit, and they required immediate antibiotics. Usually we give oral and to amoxicillin for 3 to 7 days. If they're penicillin allergic, you can give clarithromycin and the case of glue were surgical intervention is, um, an option if the if it doesn't resolve within 3 to 6 months. Most commonly, we wait until six months before trying to insert this grommet. And this the grommet is just this little plastic ring that we, uh, insert through a nick that we make in the eardrum, that sort of larger on one side, Um, and that large edges sort of as person on the outside of the eardrum so that as the ear drum closes where we've made that small neck, the tube that we've put in sort of pushes out outwards and being bigger on this side means that it won't fall in and behind the ear drum fab. And we've gone through the answers to that as well a cholesteatoma. And this is a This is quite a rare, um, growth that we have in here. It's a mass of stratified characterizing squamous epithelium, and it's a benign mask. Um, most commonly, this is a quiet and and it's due to chronic inflammation. Um, this results and eardrum retraction, and it's usually the, um, parts faster. So it's the superior part of the eardrum, and that retraction results in a pocket forming behind the ear drum. As a result, you get this waxy parasinus, um, tissue and also granulation tissue that grows behind the eardrum, and it can cause local destruction of surrounding structures, particularly the bones of the air and temporal bone. There are some cases of congenital cholesteatomas, um, which occur? I think they occur within the second trimester of pregnancy. Um, but this there's a Maura treatments, usually surgical, so we can start with suction to try and get rid of this debris and granulation tissue. But ultimately, they will need, um, surgery to remove either the mastoid or just the top part of their ear canal. Which schools in the US It cost me brilliant. Am I moving too quickly? By the way, let me just let me know in the the chat how you're finding the speed of. If you want me to slow down, speed up. Can you repeat what an atticotomy is? Yes. So it's removal of the top parts of the, um, Air Canal just by where they're, um, where the tympanic membrane is. So it's that very, very top part, which is usually affected. So as we said, let's go back to the slide. It's the past placid er or the this sort of top parts of the ear drum. That's usually retracted back. Um, and that's the part that will usually be affected in cholesteatoma, particularly acquired ones. Um, and atticotomy Let me get the full definition for you. It's a limited mastoidectomy. So it's just that very, very top part of the of the bone that's above the tympanic membrane there. Is that clear Red hands? Yeah, I'll continue. Okay. Next question. Just looking at time show. Um, well, put your answers in the chest as we go, Um, and we can come back and I can see how you've done after we've done the topic. If that's where it with you guys, I'm just conscious of time. Um, but yeah, it's a question. 5 27 year old cage fighter, his softer blow to the side of his head during a match an hour ago. And he lost consciousness during this match. He opens his eyes, uh, to voice is speaking, but he seems confused and disoriented and disobeying commands. And just to keep you on your toes. What's his G. C s? And it's an ent talk. But have a think about this. Questions like this do come up in finals. They're quite nice. Easy ones. So it's definitely worth knowing question. Six. Why does his ear look like this? Questions? Seven. How should this have been treated initially? So write your answers down, put them in the chart, and you can put them in the notes function on your phone. Uh, we'll come back to okay, yeah, pen a hematoma. So this is as it sounds. It's just a bleeding that occurs within a track space, um, between the cartilage and the perichondrium, which is just a layer that's tightly overlying the cartilage. And it can become complicated by avascular necrosis or abscess if it's left untreated. This, as the question stem suggested before the suit usually draw due to a head trauma or direct trauma of the year. Management can be medical or surgical. Medical treatment includes analgesia, and if there's evidence that it's contaminated, um, for example, if there's damage the skin and you can see that there's there's some luck in there or if it's older than 24 hours or if it just feels quite red hot to touch more than you would expect, Um, then you would give antibiotics in that instance as well and surgical treatment you want to try and aspirate, ordering these as soon as possible. And if it re accumulates or serum reforms, drain it again. If it keeps, uh, re accumulating, it may need to wash out if this treatment is delayed. Um, then in July, as a vassal in the process of the air, uh, we can consider kassid grafting or remodeling of the air as well. But this is not commonly done, to be honest with you, Um, at least for this indication. So it answers. Well, let's see if any of you put it in the chat. Yes, his GCS is 13 out of five. He scores three out of four for Responsive Eyes Voices four out of five and M six up. Six. He's got cauliflower, so cauliflower isn't just he's that he's got a hematoma with. It's untreated Pinna hematoma, which has led to, uh, avascular necrosis of the underlying cartilage. And it should have been treated with aspiration or an incision and drainage of the hematoma. That's good to the next. Okay, okay, so the next topic will be dizziness. Okay. So 38 32 year old man stumbles into your urgent care clinic holding a vomit bowl, and he heaves as he leans forward, stand up from his chair in the waiting room. He's attending with his wife, who explains that her husband has been complaining of dizziness and severe vomiting, which then gradually worsening over the last 24 hours. Once slightly settled, the patient managed to tell you he's had a cold for the last few days, and he's also noticed a ringing noise in his ears. What do you think the most likely diagnosis is? Again? Put your answers in the chat. So a as many as disease be is Wallenberg syndrome. C is BPPV. D is lab bronchitis and e is acoustic neuroma. Fine. Okay. And again, try and classify as many conditions as you can so we can think of vertigo as being peripheral in origin or central in origin. Peripheral is the most common, so examples of peripheral cause of vertigo are benign. Paroxysmal, postural vertigo, uh, many as labyrinth Isis vestibular neurosis. Acoustic neuroma, which is also known as a vestibular schwannoma and Ramsay hunt syndrome and central um, causes are are much more uncommon, and these can be a bit more serious as well. So we want to rule out a stroke such as cerebella stroke or Wannenburg syndrome. Vestibular, migraines and multiple sclerosis are also causes. And the reason I put vestibular neuritis in central, um, some people because it's affecting the nerve. Do think of it as a central cause. I personally, because it's extracranial. I would put it down, um, in peripheral personally, but it's up to you, is how you think of it and just to go through. Some of them are more common cause of peripheral vertigo, Um, many as it's classic tried or vertigo hearing loss and tinnitus. And there's oral fullness or a sensation of fullness within the air, and the patient's tend to complain of as well. And it's an episodic, so it's not there all the time. But when it does come on, it can last minutes to hours. Labyrinth itis Um, sorry, BP B V Um, let's move on to the next one. Is, um, Also there's also the classic triad of Vertigo, hearing loss and tinnitus. But it's difference with many years is that the episodes are much shorter. So where many years? Last minutes to hours BPPV, uh, last seconds. Two minutes, and it's also brought on by head turning, which is, um, the most common cause, Uh, the most common exacerbating symptom. Um, if the lateral, uh, semilunar canals are affected, it may also be exacerbated by lifting the head up labyrinth itis. There's also the triad of vertigo, uh, hearing loss and tinnitus. Um, but the way we can distinguish it is that the all three of their constantly and that it's gradually worsening. And there's also most commonly am an upper respiratory tract infection that's proceeding. This, uh, with the hearing loss, we can identify that there are higher frequencies that are lost first. And it's unilateral, uh, and with labyrinth itis, um, it's standing, uh, from lying that tends to exacerbate it rather than head turning festively enteritis. This causes vertigo, and some people like to equate labyrinth itis and festival enteritis with each other. The way we can tell the difference between them is that although vertigo is present in both, there is no hearing loss or tinnitus. If only the vestibular nerve is affected. Um, so again, um, there may be a recent er c as well. With acoustic neuroma. Vertigo is present and and then they also be a crown nerve. seven or facial nerve palsy, headache and diplopia. So the answer to the question was, Let's see if any of you got it, right? Yes. Labyrinthitis. So we finished otology. Those were the most common conditions that I thought we should cover within otology and audiology or just very, very quickly Go through what normal hearing is. So sound waves enter the air and they go through the air canal. That Pinner is shaped specifically like a cone to allow as much sound as possible to enter the air. Um, once the sounds travel down the air canal 10 panic membrane vibrates. Um, the tympanic membrane, uh, is, um, directly connected to the obstacles. So the malleus is the bone that we see. Um, very clearly on ought oscopy malleus vibrates, which causes the anvil to vibrate and stapedius is attached anvil the anvil which um which is directly connected to the oval window. And as the over window vibrates, there's a change in pressure in the fluid in the cochlea. The pressure is changed by these hair cells in the organ of corti with within the cochlea, and these hair cells produce electoral signals. Um, the cochlear ganglion. Um is, then then picks up these electrical signals and impulses sent to the auditory pathway, elderly nerve pathways and the auditory cortex. And that's how you perceive sound. So just to show you an image of the hair cells within the cochlea, um, you've got the tectal. Remember, rain fluid is sort of overlying that in the tectal membrane, uh, Texas changed in the pressure of the fluid. And then you've got the outer hair cells attaching to the technical Remember, rain. These are then changed into electrical signals, which moved down, um, to the artery nerve and the artery nerve takes to way down, um, into the brain into the primary auditory cortex. We've got several ways of testing. Hearing gold standard is pure tone audiometry. And these results can be plotted on an audiogram, um, across all the frequencies that we test on pure 10 or or audiometry, it should be heard at 25 decibels. Other tests, um, that we particularly used in pediatrics. Um, ordinary brainstem response, which we use in newborn screening. Acoustic reflex response, um, play or geometry is also used a lot in pediatrics as well. Bone conduction testing and Tim pornography. Um sort of tests. Tympanic membrane. Um, reaction to air pressure changes in air pressure in the ear canal. And we have Plus is, um, the results from pure Tane audiometry onto this graph. What would your top differential be in the following patient's with these results? It's a question nine. Um, that's sorry. The resort The answer already there. Um, the question nine, uh, and otherwise relatively healthy 85 year old man Um Presbycusis. Um, it's going to be the most likely and cause of his hearing loss there. So just old age with as we age, we lose the hair cells that detect high pitched frequencies first, Um, and that's why, uh, you get this hearing loss, particularly with hearing a chirping of birds in the morning babies crying These the ability here, those that we tend to use those first and a 32 year old women complaining of recurrent episodes of dizziness, tinnitus and hearing loss as well as fullness within the ear, many as disease. So we lose, um, high pitch frequency, hearing first with many years disease and then you've got conductive versus sensorineural hearing loss. Conductive hearing loss is always an issue with the outer ear or the middle ear. For example, you've got a wax and foreign body ear infections, and it's usually temporary. The exception to this, uh, would be of auto sclerosis. So although most causes a temporary Otis, sclerosis is progressively worse. Um, and ultimately you will need surgery. Um, for that sensorineural hearing loss is much more common than conductive hearing loss, and it's an hearing. It's an inner ear issue. There's damage to the hair cells or the auditory nerve or both. Um, and it's due to age trauma. A tumor that's sim filtrating thoughts, tree nerve head trauma or some drugs. For example. Some antibiotics, like, um gentamicin, can cause sensorineural hearing loss, and this is permanent. Mixed hearing loss is a combination of conductive and sensorineural hearing loss, and it's usually a sensorineural issue that occurs first and then it's super. I did buy a conductive issue, and then just something for paces. Um, you've got your turning fork test as well, so we can tell the difference with renews and weavers. Weavers. Um, I'm sure you know you're paying your tunings fork you placed in the middle of the head. Normally, you hear the sound equally on both sides and conductive hearing loss. The sound is louder in the affected ear and sensorineural hearing loss. The sound is louder in the in the in the good ear, the unaffected ear with Rainey's, um paying the turning fork placed on the mastoid process. Ask the patient to let you know when they can stop hearing the buzzing. You place the turning fork in front of their ear and ask them if they can hear it. Um, if air conduction is lower than bone conduction, and that's really is positive, which is a normal test, Um, to avoid confusion in the exam, especially under stress, I would say that Renee's test was normal. Um, because positive negative, it's It's quite easy to forget which way around is which, with Rainy is in the exam. Um, so really is positive is a normal exam, but I would just go with, um, Britney's test was normal as a finding. If bone conduction, um, is loud than air conduction on Rainey's test, then you have conductive hearing loss. And if you have sensorineural loss, air conduction is louder, then bone, which is the same as, um in Renee's. But you would do weavers to differentiate that as well. So you you can't really tell with just Renee's test for sensory here in sensorineural hearing loss. You want to do both tests well, quickly go through um, Rhinology. And then we can have a bit of a break so very, very quickly, just to just as a reminder of nasal and asked me, Um, nasal canal is much, much bigger than just what you can see from the outside. It's It goes all the way back down to the pharynx, and there's also connections to the air through the you take a new station tube as well, and it's quite a large part of anatomy. Uh, and with the parasite, uh, paranasal Sinuses. There's four pairs of Sinuses. Got the sphenoid maxillary and frontal Sinuses, and you've also got the ethmoid air cells, which are also known as the ethmoid Sinuses. Question 11. Let's go to the chat. 55 year old woman presents too easy with the nose lead. She's given herself good first aid and has been leaning forward and has been pinching her nose. However, it's been more than 20 minutes, and the bleeding hasn't stopped the blood is coming out of the right nostril only. And, uh, the question is, what's the most likely sites of bleeding? So it's a bit of an an ask me question for you guys. Is it a the pterygoid plexus? Be the middle capillary plexus. See the old factory plexus? Do Woodruff Plexus or E Kissel Plaques Plexus. This is quite a difficult one, but if you've done your password early, you might know the answer. Good. Well done. Both of you. Brilliant. So epistaxis or nosebleeds just go over a bit of the anatomy. Most commonly, it's from an anterior site of bleeding, and it's known as Littles Area, also known as Kissel Box plexus. It's usually results in unilateral bleeding, at least initially, as it's, um, as it's, uh, most anterior. If the patient tilt their head back, you can get bleeding from both sides of the nose. Or if there is torrential bleeding and the blood can't escape the nose fast enough, then you can get bilateral bleeding as well. But that's less common. And with posterior sites of bleeding, the most common site is Woodruff plexus, and this results in by actual bleeding because the bleeding starts further back, and it can run down both sides. Breast fact is breathing in dryer if there's any trauma to the nose. Uh, if there's coagulopathy or any other bleeding diagnosis and sign in Azor neoplasms or another rare cause as hereditary hemorrhagic telangiectasia and often any departments will know entire families who have this and they're they they're well known to the department. They come in with frequent nosebleeds. Brilliant. OK, so the management of, uh, nose, please. If there's torrential bleeding, Um, and you're considering massive hemorrhage, then go through your A. T E. Put out your major hemorrhage. Cool. Um, but in most cases, you want to start with your first aid. And this, um, is either trotters or the Hippocratic method, and it's what we all know. Lean forward. Pinch your nose. Don't let go for 20 seconds. You can help calm down the patient as well, with some ice packs on the name of the neck or the forehead. Um, and you want to encourage the patient to spit out any blood that they might have coming down the back because it can make them feel quite sick. Then if after 20 minutes first day. It doesn't work. We can move onto packing. And this is quite a simple procedure, actually. So we have, um, rapid rhinos, and we can just put them into the patient's nose, the inflates, and that just applies direct pressure to, um, size of bleeding. You can have anterior packs and posterior packs, so normally you would start with your anterior packs. Is that's the most common? If that doesn't help the bleeding, then you can move onto your posterior packs. Yeah, with each intervention that you do want to wait about 10 to 15 minutes and recheck if there's any further bleeding. So if after 10 to 15 minutes you have a quick look, you pull out the packs and just see if there's still a bleeding going on. Uh, you want to think about direct therapies so we can use, um, Quarter three in E. D. And that's just still the nitrate sticks. If you're more junior, you haven't done that before. You can't visualize directly where the bleeding is coming from. You can contact ent, just bleep them and they can do a rigid endoscopy, and they can apply this, um, substance called Floseal, which is just gelatin and human thrombin, and that can be applied directly with direct visualization with the endoscopy as well. And that helps to stop the bleeding. So, as we said, if the check every 10 to 15 minutes, if the bleeding settles with packing and you can visualize the the the point of bleeding, uh, you can cauterize with silver nitrate and you can discharge them with an antiseptic cream. Normally, we give no septum, Uh, but if the patient is peanut allergic, we give Bactroban. And that's because no septum contains peanut oil. If there's still bleeding after 10 to 15 minutes with anterior and posterior packing, or if there is torrential bleeding. If the patient is known to have hair it, terry him a Tanja elect, Asia or if the patient is anticoagulated, escalate straight to the ent registrar. Um, and finally, if there is bleeding despite effect of packing, or if there's further bleeding on removal of the packs after 24 hours, if they've been admitted and they can go to theater, surgical options include electric, watery and then ligation of arteries. Um, if these larger arteries are responsible for the source of bleeding and well done to the interview, he said. Kissel back plexus as the source of bleeding nociception hematoma. This also a result of trauma to the nose or the face. Um, and blood fills the space between the sexual cartridge and the overlying tissue and always always refer these two ent. This is because a vessel in the process can occur very, very quickly within a few hours and 20 even by 24 hours. It can It can be too late, and there may already be a vascular process. Um, so these need to be drained by ent if you suspect an infection or if the drain fluid looks particularly like purulent, um, you can send a swab or just send a sample of aspirin for my cross P culture and sensitivity, um, to the lab. And after you've drained it, you want to pack the news and try and prevent further hematoma swelling human human formation. Next is another emergency. So we've got peri orbital and orbital cellulitis. Peri orbital, um, will be anterior to the orbital septum, and orbital will be post septal on the way. We can tell the difference between these two. Um, it can be quite subtle. But on examination, we knew that iron movements are affected with orbital cellulitis, as opposed to peri orbital cellulitis. With the path of physiology, para little cellulite is likely to be a result of a direct parallel little trauma or insect bites. And also so litis or abscesses, um, will usually be a result of, or a complication of front to ethmoidal sinusitis. So the scientists at the front here and just behind the eyes, um, and management. So you want to admit them as an emergency. Give antibiotics, um, intravenously, according to local guidelines. Give nasal steroids, decongestions and saline drops, and you need to get the ent off foul, um, involved urgently and pediatrics, if appropriate. If there's an obvious abscess, um, if there's a fluctuance swelling or if there's no improvement with treating with the IV antibiotics and steroids, um, then they will need to go to theater. Finally, this is just, um, to help you with your eye and I station, actually, So this came up for me last year. I had a nail speculum in my eye, and I station, um, and it's used to visualize, um, what's, uh, in the nose. So particularly with nasal foreign bodies. Um, Children are very good at sticking things in their noses, particularly things like peanuts and Lego pieces, um, crayons, even like bits of broken crayon. And they perched up their penny putting into their noses. Um, and sometimes it's witnessed, sometimes on witness, Um, but if it's unwitnessed, you can tell there's something there. If there's foul smelling nasal discharge things we worry about. So although it's usually just things like Lego and peanuts, if it was witnessed, and we know that there's a magnet or a button battery, um, that they've pushed into their nose, this is, um, this is an emergency. So for the management, we want to get a collateral history, and we want to examine with these nasal speculum and remove the button Battery and magnets or any isis have been inhaled into the nose as an emergency. Another treatment option is Mother's kiss. I don't know if any of you have heard of this before, but the this is just if you sort of instruct parents to do this to, um, to their Children, if they've gotten a foreign object in their nose, so you want to occlude the unaffected notes like this and place your mouth or parents mouth over the child's mouth and blow. And that forced the, uh, the foreign object out of the nostril that it's stuck in. If, um that fails, or if there's no one there. Still, no one's willing to do it. You can try direct removing under direct vision. So again you can push the tip of the nose up like here is an image. Or you can just get any other speculum to try and visualize gas out with some tweezers if it's easy to do so, um, if it's difficult or if you can't get it out, um, then they need to go to theater, particularly if they're young. And Wrigley, um, they need to go into general anesthetic up. Okay, Should we take a 10 minute break? And then we can very quickly go over firing ology and laryngology and and just some of the head and neck Seems Is that all right, Harry, if Yep. Sounds good. Thank you very much. Are we all back? Yeah. Brilliant. OK, so we're two thirds down. We'll just make a move now with fang ology laryngology. Um So it's going to be covering mostly differentials of sore throat, presenting a plane of sore throat. So next three questions they're just short answer questions. A 19 year old, fresher living in halls, presents too easy with a five day history of sore throats and swollen glands in his neck, his GPS prescribed amoxin. And he's now come up in a maculopapular rash. Um, Question 12 is, What's the diagnosis? Question 13 is. What's the causative organism and question 14. What advice would you give with this diagnosis? Um, particularly, what should the patient be trying to avoid and given this diagnosis for the next few weeks, I have to think about that, right? Either write it in the chat, make a note on paper, try and be active as possible with this will help you remember the answer. If you physically write it down or type just in your notes somewhere fab Here, start with tonsilitis. Um, so going through, um, etiology of it. Most cases are actually viral, so 50 to 80% are viral, and most common culprits are adenovirus, rhinovirus, um, flu parainfluenza and E B V. Bacterial causes are less common, but they can be more severe, so strep pyogenes is the main culprit, and other causes include stuff aureus and mark seller as well. Signs Um, identify Adrian Dysphagia can lead to anorexia in dehydration swollen tonsils, and this can be with or without exudates, although with bacteria it's more common. There is extra date. Uh, you can have swollen lymph nodes, and you can also have referred ear pain as well. Again. Try and classify your management so especially with vial, um, tonsilitis. We try to stick with conservative therapy. Is is just supportive therapy. Analgesia. Try to keep a patient well hydrated if they're unable to eat or drink, really, and then we can, um, give them some IV fluids. IV pain relief. They need it. Medical. We can give oral IV antibiotics, and it's usually amoxicillin, um, and surgical. We do do tonsillectomy. He's, I think, with, um, the vast amount of help just with how common this is. The criteria. Some meat tonsillectomy criteria is quite high. Uh, so we can go through the criteria. So it's the Scottish criteria for tonsillectomy, which is now used within the throughout the UK Um, and it's all of these episodes have to be dramatically recorded So each time that they have this, they have to be presenting, and it has to be clearly documented that they've had these. So if you've had seven or more episodes in one year, you're eligible for a tonsillectomy. If you've had five or more episodes and for two years in a row, you're eligible for a tonsillectomy. Or if you've had three or more episodes each year for three consecutive years, and you're all set with the tonsil it if a tonsillectomy and adults, um, you need two more peri tonsil abscesses or Quincy ease for a tonsillectomy and Children, we tend to do it within a few weeks after, um, Quincy complications of tonsilitis. Um, this is Quincy. We'll talk about that in a moment. Um, in very severe cases, patient can become septic. Don't see it too often. Translate it, um, but it does happen, Um, or you can have complications of the surgery as well, and this involves translates post tonsillectomy bleeding. It's a patient coughs up more than a teaspoon and of blood. It's indicative that there's probably some more bleeding going on, and patient's swallowing quite a large amount of blood, so they will need to be taken it back into theater. Quincy. So this is one of the complications of tonsilitis, and it's a collection of passed in the peri tonsil tonsils space. Um, it's also known as the Peritonsillar abscess. And signs of this is that as we can see an image here, the tonsil that's affected, um, is pushed in for, um, usually so down and towards the middle of the space in the back of the mouth. And we also have the Liverpool Perry tonsil er, um obsessed score. If your score is four or greater, you're more likely to have a Quincy than a tonsil itis. Um, and criteria for this are unilateral pain, which cause you three points. This is defined as having pain. That's within an 80% to 1 side and 20 to the other side, so the minimum is 80% unilateral pain, as described by the patient, um, hot potato voice. Uh, that's cause you two points trismus or difficulty opening the mouth will score you one point. Um, it can happen tonsillitis, but it's much more common in Quincy, and being male, Quincy is more common in males compared to females. Um, management um, start with analgesia I and D or aspiration. Um is, uh, it needs to be done quite early. Um, antibiotics according to local guidelines. And some surgeons also like to use dexamethasone, so 6.6 mg IV, especially if there's difficulty opening the mouth and glandular fever. This is the classical triad of fever farengitis or sore throat and, uh, swollen lymph nodes. You can have patiki eye on the hard palate within the mouth. Um, enlarged Chancellor's role to a future 1950% Patient's, uh, you have, uh, splenomegaly. Um, this is quite important. Um, as with the question with that we had at the beginning, um, with splenomegaly or increased risk of splenic rupture. So you want to be avoiding heavy lifting contact sports, um, to try and minimize that risk as much as possible for at least six weeks after the diagnosis. We do have, uh, instances of of hip acid megaly and drawn decks, but this is, uh, rare. So it is a complication, but it's it's not. We don't see it too often. And the management for this it's mostly supportive therapy. We don't give antibiotics. Um, it's a virus. It won't help them. And with amoxicillin particular, you get maculopapular rash, which is a common question that you get an exams as well. Same diagnosis of the 19 year old fracture that we had earlier. Glandular fever or infectious mononucleosis? Causative organism outside bar virus. And what would you do? What advice would you give you? Try and avoid them and from being involved in any contact sports or doing any heavy lifting to try and reduce the risk of splenic rupture. Next question. Three year old son of anti vax parents is rushed E. D. With difficulty speaking, difficulty eating, respiratory distress and drooling. Uh, he has a temperature and he's leaning forward and he just looks really, really sick. What's the next most appropriate step? A n T. Referral. Be tape, blood and cultures. See examine the patient's mouth and throats D throat swabs e start dose of kept tracks in again. Put yours is in the chat. Good, good to see and more of you get involved. The question is good. Fine. So ethic lot Isis. This is the most likely diagnosis of the patient we had in the question before. Um, it's usually bacterial, uh, most commonly caused by Haemophilus, um, which we vaccinate against that this is actually less written 10 years ago. We didn't see it so much in the last 10 years as the anti vax movement sort of gained a bit more momentum. This is actually becoming a bit more common now, Um, other cause of organisms includes staff and be huma lytic strap and pneumococcus signs. If we look at that obs, they're often hypoxic. Juice, airway, um, airway blockage, Um, and the we've got a quite a high temperature of at least 38 degrees, normally on inspection there in a tripod position. So they're leaning forward, hands on their knees, trying to open up and extend, um, their airway by lifting up their chin as much as possible. They can be drawling, and juice difficulties are swallowing. With epiglottis being so swollen with being in respiratory distress, you can see they're got their accessory muscles being used as well, and their voice will be quite muffled as well. On palpation of the neck, you might notice that there's, um, swollen lymph nodes and tenderness of the neck. Um, but try and avoid, um, sort of agitating this area either. How patient externally or visualization directly. So as soon as you have any suspicion of this call ent and anesthetics as an emergency. Um, what you want to do is try and keep the child and the parents calm. If the child is scared or anxious, they'll start crying, and it just knocks off this horrible cycle of them being distressed. They end up having difficulty breathing, Um, and that makes them more distressed than they have difficulty breathing to try and put them in a side room where it's quiet, if you can at all, um, keep the parents calm as well, because the Children can sense when their parents were upset as well. Um, and once the n T. R. Anesthetics, if they're they'll secure the airway and drop the child would have moved to I t. U. So once they've been intubated and they're stable and observe them in I t u get IV access culture swabs, um, once that once they're intubated and then you want to treat with IV antibiotics and some again, some patient's and some surgeons like to give dexamethasone antibiotics will depend on local guidelines and cause of organism, Um, and after 24 to 48 hours. You can consider extra baiting them once the inflammation is reduced. So the answer to the next question it's good to see that so many of you got it right. Uh, ent referral and try and make it close. And it's an urgent referral. If you say that you suspect epiglottis. Isis Bell? No, thank you, Sub. And then we're moving on to our last topic. Uh, that shouldn't take too long. Um, it's we'll go through some thyroid cancers and, um, some saliva gland. Um, do you miss as well? So next question moving on to a head and neck now an orthopedic scrub. Nurses referred to ent after noticing an enlarging mass on the left side of his neck. Ultrasound of the neck shows single lesion in the left Hemi thyroids, and finally, the aspiration shows follicular cells. What's the best? Next step? A. Repeat, a fine needle aspiration be total thyroidectomy. See hemithyroidectomy, do you watch and wait or e radioiodine Question 16. Which major risk factor is present? Just having a look at this and the stem. Let's have a look and see what you guys say in the chat. Come on. Have a guess. Okay. Uh, okay. Good to see some of you having a guess as well. Okay, first, um, thyroid cancer that we're going to talk about is papillary cast moment. This is the most common one, and it council about 60 to 80%. Depending on which sources you read of all thyroid cancers. Major major restructures radiation, And when it metastasized, it usually metastasizes to lymph nodes. Very rarely does it metastasize through the blood. And although Imperial is moving away from sort of buzz worthy questions, um, it's good to know with them anyway. And what they mean, because they may well give the definition of the buzzwords in the question. Um, being able to recognize both is a good skill to have, especially when it comes to SBS. So they are well differentiated tumor of, um aw, thyroid gland. They are papillary and colloidal filled follicles within, um, the thyroid gland. And they tend to be, And that sorry. They tend to have the pillar progress projections, um, and pale empty nuclei. And these are called orphan Annie Nuclear. I I didn't really know why they were called orphan Annie nuclei during finals and then I googled it. Well, then, making this so paradises comic in like the fifties or sixties wolf nanny, which is absolutely nightmare fuel. Um, And then there's a photo there for you. Um, just yeah, it's just empty, empty eyes. And it's very similar, apparently, or someone thought it was to these cells that are seen in papillary carcinoma, other very clear and other clear and links that that is in histology is the Simona body. And these are just points of calcification within slides as well. Other places that you can see these. Sometimes they're actually in ovarian cancers and and somebody's have seen quite a few cancers. Actually, most mostly endocrine ones, these tumors are seldom encapsulated. So then un encapsulated, well differentiated, um, tumor's of the capillary cells of the thyroid, and you can see often any nuclear and Samoan bodies management of this. So you want to do a total thyroidectomy central compartment compartment and nodal dissection as well. So that's just one of the the nodes, um, that you want to remove better commonly and metastasizes to. If there's spread further throughout, then you want to do a lymph extended lymphadenectomy. These tumors also produce thyroid globulin. So if once you've taken out the whole thyroid and there's still levels of thyroid globulin in the blood, uh, it may well be that you haven't got all of it. There's some thyroid, uh, tissue circulating in other lymph nodes, or that there's recurrence elsewhere in the body. Next, thyroid neoplasm we're going to talk about is follicular carcinoma. Um, this usually presents as a solitary thyroid nodule. Most of them will be benign. However, you can't really tell the difference unless you do formal histology of this nodule. Um, most multifocal disease is very rare, and if it invades, it invades through the blood vessels. And that's why human hematology Ennis metastases is more common and interesting. And this is more of a buzzword. Um, as well, very sign is, um, something that can be seen particularly if the thyroid gland is particularly large with this type of cancer. Um, militant thyromegaly can lead an absolute absent carotid pulse more and buzzwords um, it's microscopically encapsulated and microscopically Differentiation between adenoma and and carcinoma is that there's capsule. It invasion with these fine needle aspiration will not diagnose them accurately. So you need to take out the entire Hemi thyroid, and you need to have a look at it under a microscope and microscopically once, um, you've realized that it is, uh, in fact, costa carcinoma. You need to take out the rest of the thyroid, so it's a total thyroid thyroidectomy, and it's usually, as we said, because the completion thyroidectomy as they've already had half their thyroid removed. These also produced thorough globulin. So once you've taken out the entire thyroid, if they're still thyroglobulin circulating, um, then they will be a recurrence. Anaplastic carcinoma of the thyroid is really, really aggressive, and it's quite rapidly enlarging Net Mass. It usually is a result of anaplastic transformation of, um, already existing thyroid cancers, including papillary or for follicular her Thor cell carcinoma can also become anaplastic carcinoma. I won't go into detail of what her Thor cell carcinoma is. Um, the only context you really need to know about it in finals is that it can undergo anaplastic transformation and with anaplastic carcinoma. As we said, it's very aggressive, and it can undergo, um, local. It can invade local structures leading to hoarseness, dysphasia and dyspnea, particularly if the current laryngeal nerve is infected, most commonly in question stems. Uh, you'll see the elderly females, uh, the ones who have this disease, and it's It's not the most common, but it's relatively common. It counts for about 10% of all thyroid cancers, and it has quite a poor prognosis. Um, looking at buzzwords. It's polymorphic, undifferentiated, follicular cells. There's infiltration into local structures, and there's a necrotic background. So as we can see microscopically on the image on the right here there are patches of yellow, and this yellow and bit of tissue represents necrosis management. For this, um, we'll we'll resect them if we can, Um, if they're not invading any important structures, Um, otherwise, we give palliative radiotherapy, and we can remove the SMS or just the sort of the middle bit connecting the two lobes of the thyro together. Chemotherapy is not going to help these patient's unfortunately, treatment for most patient's will be palliative. It doesn't have a great outcome at all for most patient's, and finally, the last thyroid Council are going to be discussing is medullary carcinoma. Um, it's derived from C cells, which are from neural crest origin. They're not thyroids and sell tumor's um and this is important because it won't be responsive to radioiodine. Most cases are sporadic, but in about 20 to 25 cases, 20 to 25% of cases it's familial. Um, it's particularly associated with multiple endocrine neoplasm syndrome, or M E, and particularly Emmy and to A and B. If it metastasizes, it, metastasizes through the lymph nodes, Uh, and through the blood. If there is no dull disease, unfortunately, does correlate to quite a poor prognosis. Um, with buzzwords for medullary carcinoma. It's mostly going to be, um, about M e n uh, to A or to be, uh, amyloid deposition as well. It's something that we can see histologically so Congo red stain. If we slick at, um under normal light, then we can see if there's red and orange deposits throughout the tissue. If we put it under polarized light and we can see there's Apple Green by reference management of this going to be a total thyroidectomy, Um, and again, no dull dissection and central compartment nodes need to go. Um, it won't be responsive to Radioiodine, as we said are the things that we can do our screen for two other men tumor's and and these won't. As we said, these arise from the neural crest. They're not thyroid cells, so they won't be producing thyroid globulin that they do produce calcitonin and see a. So we can monitor these, um, in the blood and look for occurrence as well. Uh um, So this was a case of papillary carcinoma, um, the most common in, um, pain in patients who work a lot with radiation, actually, So radiology radiographers, um, interventional radiologists, both peed IX. Um, unfortunately, quite higher risk of getting, um, such cancers. And the way we diagnose that, if we see a lesion on ultrasound, um, then we just We do a fine needle aspiration with papillary costumes. You can't actually diagnose them with fine needle aspiration. As we said, um, you have to take out the whole Hemi thyroid and looking at microscopically fab. Does that make sense? Let's see if there's any questions in the chat. No. All good, brilliant. Last year slides, guys, it's I know it's been a bit of a marathon tonight, but we'll go over a couple of salivary gland tumor's, um, the most common being pleomorphic adenoma. This is about 70 to 80% of all um, slavery gland tumor's. Most of them will occur in the parotid saliva gland, and they used to be called benign. Mixed Tumor's. Um, it's a combination of epithelial tissue that's involved mesenchyme all and stromal tissue. Hence the name Pleomorphic. Um, there's lots of different shapes and types of cells seen under the microscope. Rest factors. Most commonly there'll be, um, female patient's um, and neck. A. Radiation is also a risk factor. Uh, they'll present with and smooth, painless swelling on one side of their face. And and if it's very large, and if it's compressing against the facial nerve, it can even cause facial nerve weakness as well. So they'll have difficulty. Um, chewing, swallowing, moving, Um, potentially, uh, the lower part of their face as well on imaging. Usually we go for CT or MRI. Um, get the best image of the size. Um, get an idea of local invasion, um, or local nerve compression. Sorry. Rather invasion. And there's a smooth round mass with defined borders that's seen on CT and MRI. Um, just to be clear. Sorry, there's no invasion. It's a benign, Um, it's a benign tumor. Any side effect of symptoms that we have as a result of this will be a result of, uh, compression on local structures, not invasion management. For this, we can give radiotherapy if it's really large. Um, and this can help to shrink down the tumor before we operate on it, and we do like to operate on them as early as possible. There's a small butts present risk of malignant transformation in these patient's, it's about 5%. Um, if there's any worry of there being any of the tumor left behind, we can, um, do radiotherapy after surgery as well. Um, classically, this even has come up and past paper questions. Um, it's a It's a lady in her sixties who has come in with swelling of her face. What's the most likely, um, swelling and of her saliva gland? What's the most likely diagnosis? Just knowing the the epidemiology of it, knowing nothing else the most likely cause is going to be a pleomorphic adenoma. And then, lastly, war thins tumor. This is second most common slavery gland tumor, and it's about 12% of them tumor's of this library gland, and this is benign. But this, um, is of lymphoid origin. Breast factors are being male. Um, smoking is also a big rest factor. Signs are quite similar. Um, it's a painless swelling and side of the face, usually the angle of the mandible. Um, and on imaging rather than one large swelling, you might see multi centric cystic lesions. Um, the fluid filled and they're usually in the tail of the library gland. Hence the presence at their, um, angle of the mandible and management for this is going to be surgical as well. So local reception. If it's easier if it's sort of widespread and it's too many to get it once, we can just do a superficial and parroted ectomy as well. Oh, and that is the end of the talk. Thanks for staying so long with me. I think I might have gone a bit over my time. Um, does anyone have any questions? If, uh, no one has any questions? Um, at the moment, I have my email address on the slides, which will will get sent out. So you want the feedback is going on? Um, I just also wanted to share with you, um, good resources for finals revision. While I'm here. Um, just for reading a note, I would really highly recommend Scots notes. Um, I printed these out. I got them professionally bound, highlighted, annotated. These, um mine was pretty beat up by the end of final year, but I would not got throughout through final year without this, Um, other resources oxide medical education is really good. Um, radio pedia is excellent. BMJ best practice and for ent in particular e n t s h o has really, really good summaries of all of the conditions that I've just described today and I used it quite a bit. Is that some of the sources of images and things like that for the talk today and questions I'm sure most of you have already started Pass med these I found that these were the most similar to the national question bank imperial questions. And if you have time trying to do these twice, um, if you haven't got around to doing it completely yet, once will be enough. But just try and get it done. Um, as many questions you as you can Medlyn really, really make them most of these questions. I wasn't even aware that these were on Medlen until January, maybe even February. And I wish I had seen them early because these are repeated and Quest Med I did use it for a bit, but I just didn't I Personally, I didn't think they were that good or at least as good as Pass Med. I would rely more heavily on parsnip personally. And the finest revision course that you have at the beginning of next year attend as many of these as possible, especially e N t off foul surgery, the ones that you don't get such heavy teaching on for paces. Um, yeah, Thank you. If any of you have any questions, my email is here and feel free to take the screenshots or which one's on Midland you're talking about on revision resources. They I can't remember exactly where they are, But, um, someone in your year will definitely know, um, where they are on med learn their their for throughout the year and also at towards the end of, um, exam towards the end of revision time just before your exams. All of the marks that you've done will, um, we'll be back on med land for you to redo as Well, so I think you have, like, four marks throughout the year. And those will be back on med land as well. And you can go and do those questions. All right. Thank you so much for giving us to this session. That's all right. I'm sorry I went on for so long, but this is quite comprehensive. This is all you need to know. Really? Uh, plus or minus a few other neck clumps. Um, but I've tried to make the slides as clear as possible just to use them as a comprehensive revision tool as well. Yeah, great. Thanks so much. Thank you, Guys. Have a good rest of your evening, you see?