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Yeah. So, for you to continue cool. Sounds good. And then that's your MD spiel. Thanks for sponsoring us. Uh, okay, so let's start with case one. So the pinna say that's the outer part of the year that you can see it's main function. Is Teo direct sound towards weeks? Don't know. Water drinking. Now say, basically your the opening to your after it, um, basically just put out a few labels. So if using that poor function that we can and start writing down what you think a B c D E f g is, and then we'll start talking about different parts of the year. I'll give you a couple of minutes. That's just going to the pool. Uh, I haven't seen no one's applied or the pole of the working really gone away Where you got something. It's the way you don't know. Just educate on to the bed and nothing. I'll give you 10 more seconds on the and the whole Well oh, only end up. Oh, um all right. Um, okay, So work for it then, because smoking important just to know what the structure of the outer ear it's that by clicking the next slide or basically show you what each one is. Um, okay, so a a sense of the hell. It's That's kind of like the the Carby part that you can see and then when you need to be is the anti healing. So that's pretty much the oxygen. So it's a second curb they can see on your ear. Um, as we, uh, what's called as we a So what? What time? What down the air on the seas? Obviously, lobules. That's where people that can't be stopped like cartilaginous. So that's where people can't get air piercings and so on. Then purpose of the traders in the antitragus of this sort of and compasses the opening towards the extent it'll examinal auditory meatus, which is basically opening to your ear canal. Say moving on. So this is the structure of the air, so I can see it's split free parts. Really? So you got your ultra, which is basically anything from the pinner moving up to tympanic membrane. You got your middle ear, which encompasses the space from the medial part, the companion membrane to the to the right window around and over windows. And then you got your inner ear, which involves, like, the new oral side to hearing and balance. So two cochlearia the best day Buell's on basically order. Nerve said vestibular, testicular, cocky and basically runs from here and get it up to the brain. That's part of the auditory pathway. So in this, um, in this teaching session will be talking about the outer ear. So looking at a bit up, some it membrane Well, we talked about the middle ears. Where else? That stuff that really caused issues and people in weather, the pediatric or adults? Um, moving on. So I've got another image here. So this is the inside about in a dusty inside the ear. So you're looking at the tympanic membrane? A. But when you look for the tympanic membrane, you can see certain structures. Um, let Lily start the pole. Just say that we can basically, we can label a B c d e f g be really useful to see we're good. Uh, yeah. There's a poll. You can only choose an option from a T e. You'd be better off just letting them answer in the child. Fine. Fine. Yeah. You want to answer the chaplain So what's a on a child? Poles, Like a call. It's here. What's a guy's just writing Chop? Uh, yeah, which pause? Uh, Okay. How about you guys, right? What a is B A, C and D is he And then we'll come. We can get free. Doctor. Must be CD. Actually, guys, that's the one. That is a malleus the procedure attic. Okay, good suggestion. We'll give you a couple more minutes. Yeah, D is the, um big. Yeah. So what's that make g? Yeah. Handle malleus. Yeah. Good. Good On What's f this thought ring like structure? Yeah. I mean, that's good. Um, perfect cell of me, Bond. And I just got the full women for you guys to look at. So, um as continue. So whoever pass Blaster a year. Well done. Yeah. So that's the sort of blocking part of the compounding membrane. And that's usually where stuff like last detainments and stuff like teo like originate from on B is the long process. The anchor. So in case is happily fine. So that's another one. The little bones that basically connects the stapes and the malleus to each other. And it's really important in allowing to conducted side of hearing. Um, c is, uh, see, seeing was a quarter tympanic. So, essentially, if one the branches, the patient in some people will get really clear drums, you can actually see the branch of the facial nerve. You can't see this branch the base from the next bunch of patients. Basically, supply supplies Taste sensation to the Ampyra two thirds of your tongue. So it's really important to see how, like if you're getting some pathology in your middle there, there's a high risk off sensation to have a party. Oh, are possible had neck being effective as well. Um, he's the past, tenser and f. It's basically the annual is which, basically a, uh, what's it called? A Strengthening that part's tensor and G is the minimum would handle of the malleus. Um, just a curiosity. What? Um, Airway looking into we're looking to left ear with right to put it on chart. Yeah. Why is that left there? Yeah, Any other things that could on go, uh, heavy to being elected X and some people that have, like boating to panic membranes like that blue here. That kind of like will be distorted because of the way, the yes of the Malleus appointment well, and then the last thing is, Well, it's it's anterior recess. So until really you'd be trying to figure out where, Anterior, they'll be wanting to know any points to the side of the road, it's on. So if the Antara recess on the left, then it's usually that it's on a diet, not be the right here. If it on by meeting on, we got a something the polls should work for. This one's essentially got your in your in GP land on being asked to see a free or boy then brought in by its mother. She reports that the kids had a recent cold like symptoms for a while and start in the last four days, she reports, charging more irritable than usual and constantly talking. They're right here clinically, he appears to stressing, like saying, Oh, my heart, my ear hurts Mommy and month saying, actually had a kid in office foods been having on not fevers. Now these are the observations, and this is what you can see on the otoscope E. What you think is your primary diagnosis is I'll give you a couple minutes. Okay. Say the majority of you for a lady. Guys don't answer. I'll give you 10 more seconds. So I lost my second when the pool. Ah, five or three. T one. Right. So the majority of you put a c k otitis media, and that is correct. But some of you also particular sinusitis in Kyoto, right? External. But we'll talk through, uh, we'll talk to you by. That isn't the case. Um, so I It's pretty much the reason it's a key. Otitis media is pretty much one the keeps your presentation a child symptom. So the fact that it still happened, we've been the last three or four days alongside of fact, that kid kind of recent borrow illness, which tends to be a pre disposing factor for Children, the developing cute otitis media of the clinical features of air pay, as well as the fact they got very informative, quite red Compatic membrane and bulging to panic memory kind of points towards an infected cords in the middle Here, Some of you did put acute otitis external and I degree like it doesn't bother here. Pay on Theo. Only thing is, they usually involves the Ear canal and the Pinner. So the external part of the year on it also tends to be associated with your discharges. Well, I'm good, Um, so just bit more on the otitis media. So it's pretty much the second most common pediatric ent presentation. That thought is working GP on DNA. Any will see on. Like I said earlier, it can be a complication or having upper respiratory tract infection, which kind of predisposes you to developing a secondary bacterial infection on G otitis media essentially is a key information the middle ear and it can be caused by bacteria viruses. So these are some of this or common bacterias that can cause it. So haemophilus influenza. The predominance of this bacteria decrease in between the hip vaccine the kids are getting now when they're younger. Strepnenmonia. You seem to be driving terms of the incidence well and other stuff, but it's also more Xeloda, Qatar less and strep pilot needs, and then the company viruses that can call this RSP and rhinovirus meeting on. So about the same child you've diagnosed this kid with the key otitis media, and it's still Carney now, been moved pizza. You need mom wasn't happy. Happy with the with the plan that we gave you so needy, they got given some analgesia on, but they're not able to eat and drink. And now your seniors come up to you asking you for a mansion pan. So what would you do for this patient? Um on this is like it said. This is the same sort of. So this is the observations and stuff that you go on. This is what you still see on your task? A B and it still date for, uh, no, but the best, most common is and salt for a food tonsil, tonsillitis and stuff. But not for the ent. Yeah, pull it open. Maybe 20 more seconds. Cool. We'll stop the end pole. They're cooked. Right? So it seems like if I should have thought to go there let's lie. Um, 50 50 basically between Ruben on TV and sitting home. No antibiotics on the allergy and antibiotics and home. So actually, in this case, given the fact that the child's had it about four days, that's no resolution of symptoms. You would probably actually going final give you antibiotics and George um, home. So given the fact that so the rationale for sending him home is about that. You know, you can send it. The child's now able to eat and drink, and I've got normalized observations for their age on the pain is not controlled Some panel duties that can actually deem safe for discharge. But generally speaking on departing use in key otitis media car is quite controversial on D for those that answered a I totally agree. So actually antepartum use in the vast majority of people with the otitis media on do tend to be called their viral course it tends, have a viral cause to it and actually use antibiotics, doesn't improve pay, nor does only reduces the length of the disease by just under 24 hours. So, in a normal case, yeah, I do agree. Um oh, I want your question bread in a bit. Let me just finish speaking my wife on the antibiotics for this patient in particular that generally speaking, the course of a key otitis media should resolve by three days. And what normally happens is, you know the job. You know, the compact member and bulges and then you get resolution either by the fluid going out through the eustation tube or the eardrum perforates on that provides that release in the pain caused by the bulging Compatic membrane is gone. Um, however, in this case, it's been talked about four days. The kid came in not eating and drinking and having a lot of pain as well as that, despite being four days in based on the pictures from before the tympanic membranes quite red and quite a parameters so it doesn't look like resolution. It's gonna come any time soon. Some patients like this. You would want to give him antibiotics a Z, a precaution on. Yet it does reduce the risk of developing master a diet. It's I degree on such a kids where the stool was infused yet, but you happy? Careful. You get antibiotics, too, especially in community, because this's a really common on pediatric presentation, and we start giving antibiotics and okie otitis media, especially they're short lived and a viral virgin. We're gonna start developing resistance toe bacteria on. That's probably a bigger risk, then the chance of charge for mastoiditis, which is actually quite small. What a serious risk nonetheless, on back, I said at the bottom. Most patient, the key otitis media don't actually need admitting unless they're really young, unable to tolerate anything or early. Or they have complications of acute otitis media. Onda leaving on maybe on um So, Like I said, 10 to result in three days, could tell when we do them so on. But it's kind of guide, but typical picture of the patient. So some of the complications you can get from untreated or complicated at acute otitis media is like a friend said. Muscle dies. You can also get sepsis because your sigmoid Sinuses very runs very close to the middle part of the ear. That's just a big pain that's in your brain. On Onda course. Get meningitis because of the positioning off the middle ear. Next, them in in Geez, get brain abscesses and you can also get chronic perforation. Special. The child's having recurrent acute otitis media media, which is it's all being by the perforation of panic membranes. Um, so generally speaking antibiotics. It's a difficult one in the community. Um, ideally, this less than three days, you should just let it ride, and then you can always give mom or dad a can always give the mother or father a delayed antibiotic prescription to take if they look like they're getting worse, despite the three days passing. Or there's just no no solution of symptoms after about a week, that's usually what happens out in the community. Um, hold on to your question. And how is Tympanic membrane here off the preparation? So that's really variable. So in some people, it might take up to about three months, and some people might take up to a year, and some people never healed. So it's really Barry Ble. The tympanic membrane were healing on Have it moving on. So you got case The next case, you you asked to see a day five year old man who presents with the three day history off left ear. Okay, He states that paying is really unbearable and reports persistent yellow discharge. And he's been trying to stem this this type by using cotton wool. But And he was. The report is hearing being slightly muffled in that left is well. And then he also mentioned that the blue that you know, he was swimming in the C a few days ago. The world prior prior toward the symptoms starting. So here is observations again one last time. And then this is what is a real It's like from the outside. What do you guys think is going on and pull out that really? You want to the polls? Should I? Well, since they almost always be there on said, we'll give you 10 more seconds. Okay, get I'll stop the pool there. And so the vast majority of you actually could be. Keep tight extent, Um, which is good, Which is good. So that's the correct answer. Ah, let's talk about why so basically sort of acute nature of the presentation alongside of fact that this patient's got, um, some risk factors, but the Kyoto extent. So you know, recent history of swimming and untreated water is one of the fact that they you they're putting stuff in their ears, such as corn birds that kind of increase your risk of developing cure otitis external, and so that's a very really severe acute. So keep it tight. Extended, Remember, includes not just the air canal that can also about the pinots well, and we get really severe Cute. It's a severe otitis external that can also cause perichondritis. They get cellulitis. So bacon infection of the skin, which can go deeper on, in fact, the cartilage below it. And now the cartilage in your artery and your pin A doesn't really have a very good blood supply. So once that blood supply is damaged, it can cause stuff like cauliflower is so it's really it's really a n'importe know. We kind of like get on top recognized key, otitis external and treat it aggressively when we can. Um, yeah, so cholesteatoma something called put class. You taper down, but that tends to cause pain in this area. It's a painless here. Discharge, in this case is patients got quite a lot of pain. So which, and it's quite sure history. Which is why we're going towards a key otitis external on. So you see more things is also no swimmer's ears. And that's due to the fact that one the risk factors of swimming and untreated water on defense affect. Like I said, the now on the Pinner, and it tends to affect people in the middle age directly between 14 and sixties on something main symptoms really is otologist AARP a day oh, to really just here Discharge. Sometimes if it's cause of your of your we have, like tiny breaks in your skin, and you have the X amounts that what controlled get itchiness in the air Canal, which, um, predispose you to developing acute otitis extender on depends on how much discharge you get. You get a temporary conducted hearing loss that's really important that in diabetics and also immunosuppressive people, there are really high risk of developing become malignant or next time thing. Otitis external. That's basically when you otitis external in Beijing to temporal bone, and it causes facial nerve palsy. Which one's really close to the middle ear on D and the Air Canal so that that's a That's probably the biggest risk from acute otitis external on tandem managing as well. So it's usually a course of topical air job. So in GPT tend to use it. Um, I've, um, in our ent emergency clinic. We can attend to you saw for dexa Lidex or Generous own the dexa the end of those two things, basically the dexamethasone. It's a bit of steroids trying Giusti Deemer that you get with the key otitis external on the cellar and the software is based on the different variable antibiotics we've been jobs on that we use Okie otitis external air jobs, Temple best in the oral tablets because they tend to penetrate the area. Well, where's all the tablets? Don't on day if you look inside a patient with the key otitis external and you notice that I've got quite a lot of discharge coming out. And actually the Air Canal is quite a dermatitis, since dinner used to quite small. And they actually do need a referral to the ENT Emergency Clinic for my exception, which essentially just suctioning out any discharge on putting in a little, uh, little cotton, but then called ApoE quick. And that's actually that's stents. The mouth open allows the drops to diffuse fruit, which allowed to dye her access to where the infection is. That's what it is that it's also really, really painful. So it's important to make sure that we're quite get analgesia as well. When we do this on getting the air stopped. Also useful for this later. Different Michael that can cause it, But, uh, main thing, but otitis external is prevention to cure. So are they gonna got a neighbor that come current on down infection. It's important that you kind of pull can feel a risk. Factors that I think, you know, kinds extent that's premeditated. Manage acute otitis external. Um, so it's not That's not how long do they avoid water for it? It's a sensor. So she made up. It'll clear it's It's a sense of making sure that water doesn't go inside the ear. So if that's swimmers telling you, use our air plugged and stuff like that to keep the drive in Central, What happens is what people are swimming, untreated water, a lot of water. Some of it doesn't come out. It stays there. It's a nice breeding ground for bacteria, So it's just making sure that it's just making sure that they're not sore by festering a breeding ground for these bacteria to grow in court. Kind six. Downer. Make sense. Um, maybe on, um, you won't say anything about this or no, no, I'm good. If everyone else got to continue, just got Yeah. Oh, cocoa. Uh, it's just one of our cattle adverts. It seemed, uh, leaving on. Um okay, cool. Right. Say you're in your ent clinic and you've been on See a four year old? There's two that we're hearing loss, and we've done all the ground. What type of hearing loss it president quite buried on since first one. Interesting. I'll give you 10 more seconds. Wasn't all right. I'll stop the pole there, so I think the vast majority of you to still put a by that that appear in August. But there have been then why it sort of mixed. Wanted to go and be a boat as well. It's quite interesting, but yeah, it's correct it by natural conducting, hearing loss on I'm I thought talking for on here and then we'll talk about what's going on. So the reason this is bilateral conducted hearing loss and I think before we even talk about why it's hearing loss and best place is sort to understand what it's a lack of what it's right on a on an audiogram. So if you can see here on to the right hand side of the screen, got the, uh, these plots Martin X. So in the British Society of all the allergy, this basically the universal sign for left ear hearing. The left airconditioning hearing is the eggs, and then the circles are the right pick. A conduction hearing. So that's essentially when I got on the head bone on you and then they basically play a sound. Martha cover one on the cover, one a row going to play a sound that is based on what you can hear through the head bone when they're playing that sound. And then this thing here, the top. So you see the kind of like square brackets so the square brackets are the way. Imagine it's and you imagine the meds like the air piece of the head pieces for the head phones say, um, the one, the one that far right. It's the electro own conduction on the one that are left is the right bone conduction so essentially in conducted hearing. Also, remember what? Like what you deep Renee's the weapons test saying conducted hearing loss bone conduction. It's better than airconditioning on. The reason for that is remember it with the M out area in the middle ear, there's a there's a pathology. Was something going on in that part of the year, which doesn't allow sound be transmitted from the outside world to your inner ear, which is what recognizes the sound and transmit them electrical signals. So when you have a discrepancy or more than 10 said, you look intellect. You see the best ball level if you have a discrepancy of more than 10 decibels on between airconditioning in on bone conduction. The implying on dairy is a hearing loss in the air conduction level, which are going to get a bit. It basically means that you got conducting here. Not so in this case. This patient's got bilateral hearing loss conducted hearing loss because they're the air condition. It's a lot worse than the bone conduction on normal hearing I should mention is also is basically anything between zero and 20 decibels. So anything below 20 decibels is hearing loss. And then depending on how bad that that the hearing loss is because, like French, eight into my or moderate or severe profound hearing months. So in this case, this patient's got bilateral conductive here in March. So yeah, this basically shows an art soap of biologic conduct hear us a big gap between airconditioning bone production space. What I mean by airbag up. It's more than 10 on the hearing is also worse than 20 decibels hearing loss across all spectrums. Want to go through the notation again? So I just got a message. Ah. Okay. We'll get that. Okay. So Okay. So do you see this image in the far right? Can go see my mouth. Uh, yeah. Can you see a mouse? You can call. Okay. Uh, yes. Exactly. Yeah. Perfect. Yeah. The X is lap circles, right? Had bones, bone conduction. And then for conducting here. A second hearing loss. It has to be worse than 20 decibels. February on the Y axis is usually 20 decibels. Anything worse than that? Less more than so. Anything greater than that is hearing loss. Anything between zero and 20 is normal. And then, if you wanted to differentiate between the fact that it's conducted or sensory neuro conductive is basically when you have a gap between a round bone off more than 10 best bowls on, it's less than 20 decibels here. Does that make sense? Okay, cool. Half it. So this is really important because learning how to read audiogram also help it. So you just kind of just explain the same thing again. So as I mentioned as you progress down the spectrum, you can kind of see kind of see what's going on in terms of hearing loss for people so that between 20 and 40 decibels mild hearing loss between 40 and 70. Moderate. Hearing us between 17 19, severe and more than 90 desk pills. Hearing. That's basically what called that here on your question about whether they should be straight line to normal hitting the normal, healthy person. When you're young, they should stay between zero and 20. But as you get older, you can't. Your your copier becomes less sensitive to higher frequency pictures, which is why I remember the kid like when you're like less than 10. Oh, ever You know those dog whistles you can hear them, but you can't hear them when you get older. This space because your copy it's lost ability to hear those high transmitted sounds high pitched transmitted sounds Does that make sense? And then, as a Zantac, just summarize again. Sometimes all you guys can get really complicated, but basically a conduction is normally has be greater than bone conduction normal hero for you to have conducted hearing loss, so you basically need a 20 decibels or greater hearing loss across and where it says no 0.51 and two kilohertz. That's basically 500 heart's here, 1000 and 2000 hertz. So if those three averages of below 20 as in so somewhere around here that I've got hearing loss on the air bone gaps of the gap between the air condition of bone conduction has been more than 10 desk called, which we can not. A clear in sensory neuro hearing loss is basically what is conducted in sensory neuro. So conducted hearing loss essentially is so it's the process of getting sound a Z molecules. They're getting that transmitted through your ear. So from the outer ear into your middle ear and then getting that sound, um, wavelength basically vibrate on the full window, which is where your stapes, which one the little bone to New York in your ear, collects onto. And that's connected onto the cochlea, which is what transmits those sound vibrations into electrical signals. So that's a sensory neuro part that goes to your brain. Electrical signals, so conductive is dealing with the like the transmission of air air molecules to create sound from the outside world into your, um over window. And then sensory neuro is the bit which cock it involved in. And that's involved with transmitting nerve signals out Teo up to your brain so that you can I should understand the sound, the Air Monica that you've heard of that Kiko leaving on, right? So you're saying the kid so four year old has been brought in by their mother? I should be concerned about his development. So the teachers in school basically report that they have to raise it. But ray, that boy's name to hear his speech and language skills seem to be affected. It's got a past medical history of recurrent tonsillitis and months also worried that the breathing is not that great because they're at night. He seemed to snore quite a lot on then. The order ground they did for him is the one that you saw just now, but the bilateral conducted hearing loss on When you look inside, it's really that's what you see. You see this? Look, it's idea. It's it's kind of tied 50 50 between Still on SIDS. Um, maybe No, no, I'll give you two walks. Give me five more seconds in the place of all. Okay, Interesting. So you're going to have them up graceful, But, um, so you guys are basically you're kind of tied between type of media effusion or chronic separative a types media. Um interesting. Okay, cool. So that if the answer is actually okay for me, dear infusion, say clear. But we'll talk about why that is the case. So basically the history of the fact that he's got, you know, poor speech and language development, which compound by the fact that, like he's got hearing lots of, well, kind of points towards the diagnosis type of media effusion. So Children this age is low. The readings why they can develop it. But Children's in the in these ages. They tend to have a smaller mouth, but large adenoids and that can obstruct the adenoides can lie. Just posterior teo What called the eustation tube, which fits tube that drains the middle ear to the kidneys on basic Because the adenoids are so big, they basically kind of create a little spincter. Kind of makes it very difficult for fluid from the middle ear to drain out into your nose. And so you get a backlog of fluid, which then solidified and can distort blue like structure. That's what you call a type of media infusion. Now you guys put chronic separative otitis media, so that tends to be sort of social. So chronic discharge from the ear as well as that tend to have a sort of chronic bacterial presence as well. Being this kid, it sounds like the likely by you tend to get chronic subdiv otitis media as well, from having some recurrent keep retires media or having like really like being syndrome or having sold poor anatomy as well. Which Concordes am a backlog bacteria abuse station tube into the middle ear. So that's the reason why is it chronic supper? Two types, media and the answers otitis media future over those. A little doctor statement. Yeah, I degree probably is suffering from this doctor sleep apnea. But you remember that that condition is part of a spectrum of diseases they can get from happening large adenoids and tonsils, which this kid has probably got. I mean, the reason why I just This patient has poor speech. Development is probably due to the fact that as they are really young speech and language. It's heavily influenced by good hearing. So we have poor hearing or speech. Your ability to create good speech language skills are affected, which is why I feel it's it's tight. Meet with fusion, um, moving on. So it's also called Blue and the most common court hearing impairment in childhood on more than 50% of cases following episode. Acute otitis media, especially in Children, the free of the age. They tend to get it. But a lot of, um pentacel self self insult after and after it developed after an episode. Acute otitis media on. So the reason you might get persistence of otitis media that doesn't self resolved doesn't go away, and it's usually caused by one arm or the following. So basically, um, kids are really small on basically eustation tubes in adults intend to be quite a long, and it also tends to be a more bleak angle, whereas in Children, because they've got smaller heads, what happened to the eustation tubes Really small And it's also a really flat and goes well. And so what happens is basically we get any infection. My sinusitis, when you don't know that any bacteria knows it's really easy for them to go. Reach, parade up the eustation tube on down on cause a chronic infection off the Aafia middle ear. Which convention? A juice later. Fluid. Um, you can also get some persistent local inflammatory reactions well, but the main reasons, really are this impaired eustation tube function. And all that is that you can also get adenoids, adenoids or hypertrophy hypertrophy, which is what you get. Kids, that the percent of us and poor hearing, um, in terms of managing, there's no evidence that the use of antibiotics in this patient comb or they come to GP, if normally case watching, waiting every three months that you referred to ent you, then watch and wait for three months. You know, audiogram, wait another three months of this memory improvement. Was it back in their speech and language? Because roughly between the ages, about 2 to 5, that's when it's really important that they should have good hearing with their speech now, was he expected then? Then you get referred to ent look good. The insertion of grommets, which kind of tiny little plastic bench elation tube which helped ventilate the middle ear and so prevents that fluid that stuck in the air getting really, really sticky. Does that make sense of bone? Okay, next case. So you're asked to see a 50 year old woman? He reports a you natural deafness with tinnitus in her right here. Gotten a best case in turns you condone order Ground predominantly. What type of hearing loss is present? Yeah. So triangles is basically a number for my brain conduction some some of the It's a really old school way of using it, but it can mean bone conduction, but it isn't used in the UK system, but brought it so it just imagine trying with bone conduction it. We might have you on spring. Nice will stop it there, then say the majority of that, right, Since we're in your hearing us and that's correct in the chat. Do any of you know what can cause thought give you natural sensory neuro hearing loss? Just right out on the onset? Uh, yeah. Houston aroma. Yeah, that's also that's just kind of like a a general name for this stipulation. Namer. Yeah, correct. Um, question tamers. It was really bad. Can cause a sensor in a really neuro hearing loss. But what tends to happen is attention ruin the panic membrane. First you get conductive loss, and then once it invades the nerves and stuff, then it can cause that's entering your hearing loss. So you basically what we call mixed picture with Crestor 10. But that's kind of like a bit messy, but can happen many years yet Greed, Yes. So many years. You could get sensor in your him last Randy Hunt. Yeah, I can get censoring your hearing loss around, hon. So break down the bone to remember that airborne's our we've been the women, the middle ear. So if you get breakdown here bones, that tends to cause conducted hearing loss because basically, there's no the bones are taped vibrate along each other and so you can't transmit the sound wanted planet memory to the able window. So you got conducting hearing loss with the breakdown here, Bones? Um, yeah. Those toxic medications. Yeah, really good. But, uh, but, uh, eso examples of toxic medications? Yeah, gentle with the the classic. Yeah, Yeah. Gen Gen. It's pretty much the one that you're using using that daily life in on the hospital. So it's always good to be careful. And, yeah, there's some samples of chemo. Well, it's a cisplatin, which the platinum based chemotherapy can cause hearing loss. So it's always useful of your bill in the situation that you're consenting someone for chemo that under using cisplatin, then you mention it to them. That's a real risk in here. And I said, Well, good, um, and sides 10 year That's like that. There are some, like a supports. That and said's can cause a hearing loss, but it's quite rare, but it is a big queen. I don't think queens that's high up on my list of the friend showed Uh, uh, talk to medications. But yeah, if, if possible, it's possible. I'm going back to the white center in your hearing loss. So, as I mentioned earlier on, So hearing loss is when you got a hearing impairment worse than 20 decibels, which she doesn't have to be found. Both is, but it's a lot more profound right here, which, by what she's coming reporting okay on as you can see. So if you follow the circles, that's airconditioning. Generally speaking, the air condition drops off off the around the 2000 hertz mark and it gets really bad around 4000 Heart smart heart, Your heart smart and as you can see, what a triangle. So the trial of the bone conduction start. They're fairly following the same pattern as the air condition circles. So that basically implies that it's not conducted in nature. It's actually the sensory neuro on. Get worried with people with the union actual center in your hearing loss and you want one right in the AM. Did they know when ah, was it good? Right In the AM chats the y you know, actual very nice needs to be worked up Unilateral sensor in your hearing loss gets worked up. Yeah, yeah, plus d anti on. So in this case, it's just because the the hearing also report on one side and actually the hearing loss more than two. So in the left ear, what you can do if it drops at the end at really high frequencies, you can get what we call Prince Recuse is, which is basically when you get older, your copier basically doesn't tolerate large sounds very well, so you get a mild hearing impairment, which is what she has now, So between 20 and 40 killer hurts. So you have 20 and 40 kilohertz. So that's really why I bang conduction more than done was in the right ear is a very significant to be. It's all them hearing loss found in the AM for moderate severe hearing loss. Found it on the 4 to 6 kilohertz, which then implies that it's on the right, wise on the right on because, as it was the hearing loss in the right. Is that what you're asking? Yeah, yeah. And also her symptoms are more on the right side rather than the left hand's. Why did order? And they did. The bone conduction right could been conducting. Take the wild to do is well, so your best game one year that probably do on the right. Wise on the right. It's basically because remember, I said about the diagram said the X is on the lab. The implied select a conduction and then circled Imply right here. They're conduction that exempts, Say the drop in I'm hearing loss is on order, right? No extent. Yeah, on correct. Yes. Tumor. Yeah. You can get a stroke that causes union actual hearing loss was actually quite low down on your pretty unlucky to get a hearing loss from a straight because basically, the way the Auditory Parkway works, it actually connects to both sides. So if you get impairment one side, the other side should be able to pick up the hearing that make sense. But yeah, tumor is basically your main reason on, but most common this basically just me on two ways. Be a hearing last night, long and right side. No airplane gaps doesn't play in the sensory right. Sensory neuro hearing loss. The most common reason for why people present is basically with accusing neuroma, which is also called vestibular. Your name said, except for his arrow, this white sort of enhanced collection, Um, right, by where the vestibular nerve is, is basically a vestibule issue on Oma on accusing neuroma on basically essentially benign, really slow growing tumors that arrived from the eighth cranial nerve. And they represent roughly around but 80% of the server cerebellopontine angle masses. So it's basically this this area here, it's roughly represents about 80% of massive rise from here. Normally, when patients present you presented quite late because they're so slow growing. That's not quite insecurities. I don't know. It's in their head on. Only realize it's in the head when I'm presented, like hearing loss, tinnitus or it's really, really unlucky. They can get facial paralysis because how close the patient runs to the eighth grade if they have this on both sides and the really young, then the sort of the classic med school finals question is what's called what what's called what syndrome associated bit. And it'll be neurofibromatosis type two. So they're the ones that tend to get the Cafe Ole plus D. A bilateral establish your name is, and then I like. It's a method of like investigating. It would be using a gadolinium enhancing memory on that. Basically, the Thebes tablets for Neymar saw them picks up, and it comes out really enhanced on this guy that you can see here, and there's many ways of dealing with it. So it's really barrel on how sick patients for surgery on down much it's affecting their hearing and stuff. There's many things you can be so obviously festival we always like conservatively. Just watch and wait and see what happens on. There are some like radiate what called radio surgery. So it's called stereotatic Stereotactic Gamma Knife from irritable. It's basically using regular chop it off on does also where you can go get in your circumstance bulb on. But you could bathe the parade and try and remove it. But any type of surgery has really serious risks on even their hearing isn't too badly infected. It can be made worse by trying to remove one news tumors. But if it's completely exciting, recurrence rates I should quite small. It's cool, like less than 1% but one of these things. But it's quite a life changing diagnosis. Uh, okay, I'm just so I'm just going back through the questions that people ask in a chat. As a result, the Cymbalta, um hum, yeah, it's just the really the symbol that it's basically like the British, citing, audiology wanted a universal system, so that basically said exit left ear. So, like I said, next day of samples by and I try and go on like the square brackets for bone conduction, it was strange cause hearing loss. You take natural innovation, wanted to say no, apply to do more for it because the tumor is actually on the actual vestibular nerve itself. On go tumor kind of destroys the pathways. So you basically, uh, what's it called? Contrave eating, or was it called off nerve signals? The tumor when it gets really bad, basically destroys that contributing. So that's basically reason why why tumor is more likely to call in the union actual hair loss. Ah, yeah, yeah, yeah. More international using English words. Yeah. Yeah. Great. Agreed? Yeah. Does anyone have any question about the kids in your meds before I move on? I'm assuming Nice army bone. Cool. Then I think this is the last one, Right? Cool. So you've got a seven year olds, but painless, destroyed from the left ear. They also report hearing loss in that left ear, which is confirmed in your diagram to let conducted hearing loss. The patient doesn't report any fevers on this. What the air looks like on a on a eight escape. What's going on here? Nice. The rest of your bone wants it. I'll give you 10 more seconds and then stop it. Cool. I'll stop 11. So it looks like maybe put class you're taking, which is correct. Um, I think The main thing is like a lot of people mistake there, still bit whacked. I think that's why sometimes it gets like so it kind of just passes through a notice until it starts school. Then we later problems. But you can see here is kind of sort of like carrot in crusted material in the attic. So off the temperament brains in the very top of the tympanic membrane on. That tends to be like the normal place where classy time that centigrade rob. But we'll talk about more somewhat. It's a class get home. So if it's a history of pain, this discharge with hearing last, you should always think that classic attainments. Okay, so that's kind of like what would come up in your medical finals and always be the case. It can be a chronic tympanic membrane preparation and that a cholesteatoma can cause that in this case, and you look back of the picture. Actually, the companion membranes fairly intact there, on a obvious hold on things like that partners tiny hole here and maybe, but the biggest problem here is really the class you're taking and sold character and crust the material that's their on but otitis external things, um, you put that well can cause discharge, but it's so so a kid with an acute presentation and with pain as well. That's why it's a cholesteatoma, right? So just talking a bit more about plastic tape that's essentially an abnormal collection of Claritin. I think it's going to separate. Really, it's, I think it's like a really abnormal bunch of skin cells that grows and just posterior and actually on the medial aspect of the tympanic membrane. It's on the inside of the ear drum on one, the most common symptom that people will cut with persistence or start smelling discharge. With associated hearing loss on, they tend to come to GI. People go like recurrent ear infection until someone clears out and have a look and actually notices So ball of skin cells. Um, like I said earlier, it can also cause perforation tympanic membrane. So that's how you get that conducted hearing loss and then depends on how far I am, baby, that can also road some deep little bones in your ear. I never get to really bad. It can invade into the vestibular now that well, while you get here the mixed hearing loss of bed conducted and a bit since we knew or hearing loss. So, generally speaking, you like Stephen Patient's name. Your on GP just referred to ent, and they're stable on what we do normally into expected CT to pull boned. And it basically inhalants is basically shows us. What's the reading? What's doing tacked on how far the classic treatment of faded. Unfortunately, it's one of these diseases where, actually there's no medical management for it. It's literally a surgery to remove the receive on There is a with a small, small risk of recurrence, and so that coming back well on the reason you're not might be some vitamins in emergency that they start presenting with face from their pools. They will get vertigo with bone. Cholesteatoma is you get worried that my invaded into the picture of that stuff. And so what you do is you want, admit him for some steroids, and I think steroids other stuff is well, because of where that where it grow that can go into the brain that can cause stuff like meningitis and obsesses, and also sepsis as well. So they present with that, then you have to treat them using your except six bundled and I antibiotics and what? No, that's generally what we did last time with, but then you wouldn't have any questions clapping. That is actually last ride. Yeah, okay. Uh huh. Well, no one's got any questions. Thank you guys for cheating in. I mean, listen, I hope that's helped. Um, act on 10 questions. Anyone's going all guys before you go. Please, can you just start fillin the, uh uh, Are you guys? Can you fill out the feedback for my Well, I'll just get one last time here. And also, lab is back tomorrow as well to give the second story a while on business that correct? Yeah. I think you're having inpatient nerve weakness and, well, because I'm wise based on doing a week to work by ent lecture tomorrow to do a dizziness and facial nerve weakness, which is quite important to start, man. On Wednesday, I was thinking of going on, like, had next or pathologies. And then on one Thursday, I was thinking of doing it on nose related stuff. Uh, yeah. So your chin in could be great, but we get stuff. Uh, past. How long into ent training can you stop to refine down? Then how far into you? What subspecialized that were asking about mean? Yeah, I'm not too sure. I think I would just ask Oh, one of the anti e o. T. Normally it's after ST six s t seven kind of rough idea. What you want to go into says laser like different variable subspecialties He he had to go into the cytology, which tends to like, which has a lot of, like microscopic work. Uh, you got a head neck which splits into head neck cancers, which is quite satisfied, but it's also quite hard work. And then you got, like, benign had next Gordon's I Pratibha like start the prostate tumor across masses and syllable like thyroid like Like it's a multi nodular goiter It it's and parathyroid Thyroid's of parents are dead meat. And then you got like, rhinologist PSAs. Well, that made people they don't have a good life on. Then you go on PT and Tedral which week you Yeah, we go, kids coming in, uh, wanting tonsils out on. But usually after that test in 6 67 you start thinking about it. And then I've been in ST a kind of like by burke. Your or so. But last year towards the dispatch do you want to do? And then what most people do? They come to do a fellowship after a year in a specialty, but in their subspecialty. But they want to go into and then they'd come consult in that area. So yeah, uh, or the source, the skull base in law. That's really cool. They do some recourse up with school. They said, with the side removing. I don't need that neighbor found your cancer. Is that right back? But what it did, they kind of, like make a little card that pure to face up. And then they go down, remove the cancer, and then for the face back on time, told him, not cradle. It's quite cool. Yeah. Uh, so yeah. ST xxxxx Been lasting seven. Usually it's a good specialty. Anyone's interested? Yeah. Any other questions going? Thank you for listening. That's, uh that's good. And so you about the other. The whole thing is still I didn't realize they're here. Yeah, I bet you could fill out. The people will be great with it cool. Think we ended here? Think without of her other people signed for junk. How? Yeah. All right. Thanks, everyone for a send you most. You tomorrow at six again. All right, you know. Uh huh.