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Hello, James. I just invited you to the stage. Would you be able? Have you accepted the invitation? Yeah. Hello, everybody. And welcome to our first ent event. We're going to give it a few minutes before we start just to allow more people to join. So congratulations for being early. Yeah, I got Brailer. Is James. Hello? Let me know when there's enough people around them. Well, get started. Yeah. There's about 12 people on so far. I'll give it a couple of minutes to just after seven. PM I imagine what? We'll get a few stragglers after that, but it's just about everybody possible to join. No, just a check or you able to share your slides on to the screen? If not, I've got access to the slides and I could put them up. Well, I'm pretty sure I could share them on there. Yeah, thanks to be working. Also, just to say if there's anybody that you know of who wants to come to this talk but can't come live? We will have recordings posted on both YouTube. I'm medal, um, for future reference, so yeah, you can share it with your friends. It's fine. So I'll just give a brief introduction and then James, if you want to start afterwards, go for it s o hi and welcome. Everybody who's joined so far I'm hosting or helping to host this event on behalf of mind the sleep, um, which I'm sure you guys are all familiar with, which is basically a Norgle is a shin dedicated to trying to help foundation doctors and medical students kind of get through on DNO. How best to prepare. Uh, we've got tips on pretty much every specialty that you can think off as well as general staff about how to be enough one portfolios. A R C E p is things like that. Um, I'm always open to people joining us on. We're always open to people wanting to do things. So if you're interested, give us feel free to send us an email. This is set up to basically given introduction to people who were doing ah foundation job in ent. But it's open to anybody interested. Eso again feel free to share with your friends and stuff if you know that they're keen. Um, but yeah, it's open to everybody and should hopefully provide a really good overview. Um, so we've got I think six talks lined up you so far, uh, trying to basically cover every area of ent that would be most valuable to a foundation doctor trying to give it to you in kind of a condensed hour long slots. Yeah. To help keep people engaged. If you've got any questions, it'll we've got a live chat. A z. Well, so feel free to, uh, put post your questions in there. I'll be checking it throughout. Um, on again. Yeah, if you have anything to add. Um, you got any feedback? We also have a feedback section on. It's also a good way to get your certificates to add to your portfolio to get your teaching hours up. So yeah, again. Thank you, everybody for joining us so far. Uh, yeah, that James way. Thanks very much. Get really, um, on a personal note your mind believe is great. It's certainly got me through a lot of situations in their phone. Enough to a lot of stuff they publish is very useful when you're starting out. Hi, everyone. I'm, um James. I've been any anti clinical fellow, but my just roll infirmary, the last two years. Now, on day before that, I did any any GI job enough to a few years ago and appointment. This talk isn't to give you so often exhaustive list of everything that you should possibly know about ent because that's pretty hard to do in an hour. It's just to cover some basic common presentations and where your mind should be going in terms of treatment on many red flags to look at about four. Um so without further day, um, if you've got any questions as we go talk them in the chat box, um would be easy to go about it or just leave it to the end in the morning at the end. Hopefully, you know, we'll see. Um, discreet. Um, I'm sure every other will tell me if you can't see it any point or for having issues. Um, as it says, we're going to be going through just a couple of case scenarios. What the likely don't know cysts would be. And then what's, um, Red flags are to look out for in the ears, nose and throats. Really? Um, so, first one, a very common aunty thing. Somebody comes in with otalgia a painful A. This particular instance, you have an 82 year old male who's had left side of the pain for the last four weeks. He's seen his GP a couple of times during that period, and it's given some oral antibiotics for presumed ear infection of some kind of Jeep. You thinks it's the tightest external, so infection of the canal, but it's not getting any better. In fact, is is pain. Um, it's generally getting worse. Um, he feels a bit run down on himself, but it doesn't have any obvious systemic symptoms. Just this pounding painful here that's been going on for months now. Um, a bit of background about him in himself, for a man in his eighties is pretty well, he's Ah, he's only on one drug, really is only on metformin for his Type two diabetes over the past month. He's noticed now and again. Some nasty gonna come out is there is. You can see in that photo he had doesn't really know what this is all about. It hasn't bothered in much is the pain has, um, more recently, though, the pain has got to a point where when is This is a sleep at night. You can't lie on that side of his face. That hurts too much. Um, Andi. He's getting headaches alongside just his ear pain as well. So everything's just gradually deteriorating for the sports. Yeah. Um, so first thing you're going to do is if you're referred this or if this person comes into a near into clinic, this is quite common thing for people to walk. It is a walk in center or anything. Or maybe they're just off on a impatient board under a different specialty, and it's referred. This something dodgy with an A. Um, this is what a normal rotoscoping should look like. Um, so because we need it established what a normal one is before we can carry five. What is abnormal? So normal findings on oscopy should be able to see the tympanic membrane. There shouldn't be any debris or gunk in the way. If there's a bit of wax in the way, that's fine. A little bit of wax is normal, but as long as you can see some part that dependent membrane, it should be flat. It should be reflective and shiny. It shouldn't have any holes in it on the procedure of just looking in the air itself shouldn't be a painful one if they say our there's probably something going wrong. But this picture here is perfectly representative off a normal one. It looks like stretched clean film is the best way to describe it. That is a normal a drum, um, some other options that you may come across in ears if you look in the canal walls itself are red and instant nosed, and it's full of salt college cheese nastiness. This is pretty typical off the tightest external. Otherwise, no swimmer's its own infection off the canal itself. It will hurt. There will be occasional discharge coming out of it. At times, they tend to settle by themselves in 7 to 10 days in most people, if they don't or if they're particularly painful than the treatment is topical antibiotics. Um, for most of these slides have put the treatment in blue at the bottom. Um, so all right, antibiotics doesn't really do anything at all for a tightest Xterra, but topical drop treatment on it depends on local guidelines wherever you're going to work. But most places ciprofloxacin or gentamicin drops for 7 to 10 days tends to do the job. Um, but the time you can also take a swab and send it off to see what the sensitivities are, but still start them on one of those to drop regimes on. Hopefully that'll clear up. Pretty commonly, Um, this kind of your infection is far more common in adults. The nasal kids thea other major type of their infection is an attack. This media, which is an infection of the middle ear. So behind the ear drum, you get a red bulging eardrum, as you can see in this picture, which sometimes you can see sort of a yellowy Hugh behind it, which is a buildup of Purell in discharge, waiting to pop them come out. This is far more common in kids than it is in adults because they're eustation. Tubes are a lot smaller, and infection can get up from from the nasopharynx. Far more readily, I almost always comes after some sort of upper respiratory tract infection. Eso attorneys, external adults discharge red painful canal attacks, media, usually kids. The canal is fine, but the year from his bulgy in bed, both they're going to be sore. But the soreness in the titers media tends to be more of a deep seated pain, and it feels like pressure on the inside of the head. The treatment for this would be more often than not to do nothing. They tend to resolve. Either they just go away or the eardrum perforates. The pressure comes out, and then the symptoms are largely resolved. But now you've got perfected eardrum, which takes a few weeks to heal up. Okay, Um, so off those two options, it's probably attacks is external because he's got discharge coming. I was there. He is an older guy. Oh, he is far more common in adults compared to our. So you give him some topical antibiotic drops. As I discussed, however, it's been taking them for a week on his. His symptoms are really getting worse. He now comes back to you or tense back up to GPR idea wherever with a good going facial nerve palsy. He's got raising temperature, and the pain is now a full blown 10 hour 10. Um, do some blood on is inflammatory markers are pretty high. Um, so something has taken a turn for the worst in this job, I should say that this is uncommon. Usually, you know, it's straightforward. Ear infection give drops goes away. But if you ever see a picture like VESIcare should be running alarm bells is too warm about to reveal a minute. But if you've got signs that are causing a cranial nerve palsy secondary to an infection, we tend to have a fairly low threshold to get a CT. At this point, you'd like you'd lucky be discussing with one of you seen these anyway. But the end result is probably going to be a CT on what that CT is going to show is. So if we start on the normal side of his head first, he's got a nice, normal Payton ear canal on this side. It's black. It's full of air, as it should be on his mastoid bone. On that side is again a rated as it should be. On the other side. He doesn't have a nice airfield. Air Canal, it is full of gunk is swollen, and it's the noticed. There has been destruction of some aspect of his temporal bone. There is a little gap there where the arrows pointing to where they shouldn't be. A gap on his mastoid instead of being a rated is full of stuff. What has happened in this instance is the infection has spread from just being contained within his ear canal to the surrounding boat. It has munched its way through on He's now got osteomyelitis off his temple boat, which we call necrotizing. Attack is external is relatively rare on the grand scheme things, but if you're going to have, if you're going to look out for anything when it comes to air infections in a pain, this is the thing that you need to have the back of your head. Um, it's it's almost always you to pseudomonas infection, and I don't think I've ever seen a patient have it. Who hasn't been severely immunodepressed slash Very old slash diabetic, usually all three. Um, so if you see an elderly patient who's diabetic, who has a pain that's not going away and it is very severe, you've got to think right has this spread to the bone on the treatment, for this will be. Usually he's off a couple of months of IV antibiotics on occasionally surgical Diprivan of the bone, if necessary. um, if left untreated, um, it kind of wrote through into the cranial cavity. And you can get meningitis and careful itis, brain obsesses, seizures and death. Um, early on in the in the scheme of necrotizing attacks. Externally, it's quite common to get cranial nerve palsy because if they're the level of inflammation and pressure around both, the extra one in the middle of the facial nerve is quite commonly compressed, giving you a palsy. It needs to be recognized semi early. Um, really the back to really most. As I said, most ear infections are not a necrotizing attacks external, even if they're painful. But if they're resistant to treatment, if they already had a course of antibiotic drops and it's done nothing. If the pain is way out of character, by which I mean, you know, normal air infections shouldn't be keeping you up at night. It should be annoying. It shouldn't be absolutely, you know, pounding painful if they're immunocompromised relatively on. If if it's going on for a prolonged time frame, you've got to think isn't necrotizing away? Do we need to get a scan? Worse comes to worse to get a scan, and it's not bad, but we see ruled out of that point and he we can start IV therapy as needed. Um, so quick. Recap on is most infections are fine. If it's a toxic sterner drops will go away. It's the Times media tend to leave it and will go away. But next time ago, we need to be taking quite seriously, um, the second case. So we've got a 24 year old male female even who has had a few weeks off period and nasal discharge with a nasty cough headache. Right, The front of the head, Onda general Cold like symptoms. Um, just from that alone, um, we're going to think long has this Newell upper respiratory tract infection, whatever it started out, as has it spread into a Sinus is, um all of the paranasal Sinuses off the face, you know, drain into the nose. So any infection that could that can exist within the upper respiratory tract can work its way into the Sinuses. If you're unlucky enough, some people are more prone for it to get into the Sinuses than others. Just because of anatomical variations of how white the Sinus openings are. And if it does. And I'm sure a couple of people listening now that sinusitis I've heard it's far from pleasant. You will get the classic symptoms of a bad frontal headache. Tenderness over your forehead or cheeks hurts more if you lean forward. Really sort sort of sneeze and out of your nose will be coming. Greeny yellow, Nasty discharge. Um, it tends to settle after it 7 to 10 days. You just feel miserable for that time areas. Um, but it doesn't go away. Have to copious amounts of over the counter. I don't use you a bit better. Rest. Um, so this is what she's presented with. Sounds like pretty classic sinusitis, but she's feeling pretty well with it. So we want to take a slightly closer look. Um, used initially have a quick look up the nose, um, to see if it was really inflamed and red and lows of gunk coming out. You could if you're feeling fancy, do a fiber optic nerves endoscope, uh, which, if you're due to work any anti in the coming weeks or months, you'll be taught how to to scoop patients pretty early on. It's quite fundamental scale in the ent but that's where the camera would be pointing. You put that the nose have a good look at the turpidence to see what was going on. What a normal inside of the nose is gonna look like. It's something like this. You're going to have various ridges is you got to know it was coming off the the septum. Those those ridges planes are turbanance. They should be. They should be fair enough gap between them, as there are on that picture on there shouldn't be much in the way of any gunk. A little bit of mucus it's not. It's fine, but it's no completely rampant in that photo. Where is this one that the turbinates are really swollen, touching each other? There's not a lot of room for maneuver around. And there's a lot this nasty yellow keep your and discharged dripping off everywhere. So this is pretty classic off sinusitis most of the time. 7 to 10 days. They feel a bit rubbish, but it goes away. If it doesn't, we can give it. That came something that could be slightly systemically. I'm okay with it. I could have a mild fever. Perhaps you can give some oral antibiotics. But the best thing for is gonna be nasal treatment. So direct nasal treatment in the form of decongestion and steroid sprays and drops just to really open up the nose to allow all the drug to come out along sides off nasal douche in salt water, dosing up the nose to again please everything out. Wash everything away and to allow the the Sinuses and the nose to just hell of it. However, she's had all of this, so that's not to go. Six. She's had good going nasal treatment. She comes back afterwards, and she's not looking brilliant. You don't I know all of these scenarios are look, the worst case scenarios, so don't think he and he's a lot, you know, scary. Most sinusitis is 99% will respond to this treatment. 99% of the time. It's external, is work. Turn into necrotizing attack six tennis. But the point of this talk is to just give you a little bit of context of when you shouldn't shouldn't be worried, Um, so she comes back in to clinic and she's looking somewhat like this. She has a red puffy prop toes Chemo's I which wasn't there before. It all the eyes very sore. It hurts to move it. Um, she may even be saying that the vision out of that side is a little bit blurry. She the eyelid itself may be completely swollen over, and she can't opener island. It'll be any way she could do is buy prising open with the fingers. Um, this is pretty bad on if there's any hint that no, there's compromise to vision or you can't see the eye because the amount of swelling before you're gonna have a low threshold to get a CT to see what's going on behind the eye. So we get a CT. This as I said, the threshold to get a CT if the eyes very painful, that can't move it or you can't see the eye. What this CT shows is significantly Proctozone left. I have compared to the right, you can see it bulging out. Teo. Pretty significant degree there, um, within the the ethmoids final Sinuses, it should be black. The Sinuses should be full of air on a run. A CT comes up is black, as it does on the contractor side of the CT. But this is full off material. You it will be inflamed me a code because that plus nasty infected mucus. But if it isn't black, it means it's almost certainly a seven scientists within that Sinus alongside that, we've got this dome like protrusion from the edge of the Sphenoid Sinus. On that is a formation of a subperiosteal abscess. As a result, off this really nasty sinusitis, it is eroded through the the paper thin Sinus bone into the retro a little space and on abscesses now sat there on this abscess is pushing everything forward. So that's why the eyes being push toward and it is straining. The optic nerve optic nerve doesn't like to be strained, so that's why her eye is having some blurry vision on it. That strained optic nerve is strange. For too long, Um, she may well have her been in sight loss in that side. If we look at it from another angle from head on again, you can see this protrusion of this. This just bulging out sets that's coming off the Sinus on. We could see the Sinuses are again, not black as they should be on the inside. They're full of gunk on the side. We get a few of the maxillary Sinuses well, which is also full of good. So the Sinus scientists fairly well spread. It's in, well, at least story. After four Sinuses, we have not gotten a view of the frontal Sinus, but the sphenoid, ethmoidal and maxillary oral full of rubbish. She's that her face is gonna be very sore, but more importantly than that, her eyesight and that helps of her eyes, are imminent risk. What this demonstrates is Harry orbital cellulitis. Most peri orbital cellulitis starts out. Life is sinusitis. No, all but most, um, if it's gets a little out of hand, the infection within the Sinus can spread to the tissues around the eye on threatened the I house, um, it can result in a process. Sometimes it's just inflammation of the tissues is not discrete abscess. But if that strain upon the optic nerve is there too long, it can be irretrievable, like side loss. There are different types of sinusitis. Is I loaded to can. If it's the if the infection around the I just involves the eye lid itself, then the eye isn't really a threat because you're not paying any strain on the optic nerve that could be treated with antibiotics. And if the tissues behind the eye are infected and inflamed. But there's no discrete abscess to drain, then you can't operatively manage it. You just have to give him IV antibiotics and closely monitor the eye and hope for the best. If there is an abscess on the CT, then that's when the surgical management will get involved on the's kind of surgeries have done this part. The ent, um, all families. You won't do this because the eye the globe of the eye itself isn't requiring any operative management. It's all of the tissues around it on the way that you could. They'll access those tissues, is through the nose and discover Klay. Hence, of being in the anti procedure. If left long enough, it contract backwards and former governor a Sinus thrombosis on. But then patient come pick, Um, profoundly. Septic unwell, have strokes and the mortality rates quite high. Obviously, no know what you want to happen in terms of nose is I'd say it's off. The two main things that you get called to go wrong with them are maybe some sort of sinusitis. As I said, 90% of them are self limiting. If they're really bad or have been dragging on a bit too long, you can give nasal treatment in the form of drops or the congestion or steroid sprays. But if it's starting in any way to affect the eye health, so they're I hurts or their eyelids and swollen or the vision is in any way compromised or they can't move their eyes they want could have done. Then you need to get a CT pronto to see if want to see what's going on behind the eye, because that sinusitis may have spread. Yeah, the other main thing that goes wrong with noses is epistaxis. I'm not going to talk about that in the store because there's an entire the talk in the serious dedicated to Epistaxis because it will be a major feature of your own calls in your ward work. If you're working in the ENT, you get called to a lot of it. Um, I recommend, you know, pretending that talk because you learn a lot of useful practical procedural skills on how to manage epistaxis. But this far as I'm concerned, just sinusitis. Fine. If it's affecting the eyes, no little, um, right now, going to throats most off ent in terms of the work clothes in an emergency department, the workload in clinics and the workload from water barrels, our throat based not so much is in those. Um, The reason for that is because you can become farm or unwell far more quickly from a throat issue, obviously, because you you can compromise your airway compared to any air or any nose problems. So I still about first, um, this job we've got a, ah, 16 year old male with a four day history off a sore throat in the painful swallowing for the last day. You can't even tell her water it has. That was just follow. He's systemically no feeling brilliant. His voice is a bit muffled and Cokie no, and it hurts to fully open his mouth. However, he's breathing. Okay, saturation is 95%. He's breathing for, uh, the most common type of sore throat at, um, at least in adults that presents in this sort of fashion is gonna be tonsillitis. Um, sounds like it's by far no excuse towards younger people. So teenagers, people in the twenties, people in the thirties. By the time you get two forties, fifties sixties, it should drop off. If you see someone with really big good going to, um, slightest in there in there, I say my cough tends to be about 40. It might just be tonsillitis, but there is a higher likelihood that that tonsillitis is there because of the underlying process. It may be because they're immunosuppressive forever. Reason it may be because they have some sinister malignant process going on elsewhere on their throat. That's causing their tonsils to get repeatedly infected. So anybody over the age of 40 45 ish that comes in with going tonsillitis, you should, you know, think about a little bit as to what's going on in May. Require slightly more thought an investigation, but anybody saw, You know, teenagers 20 stays that tent that's par for the course. You look in the throat on. You see two big, juicy tonsils, Um, in this instance, they've got a nice big bowls of Passy X. A date on them of the uvula is in the midline. It's going to hurt a fair amount, but they'll be breathing fine. That swallow might be somewhat impaired. I'm sure a fair amount of you in the audience have had tonsillitis. I know it was a teenager. I have it on awful lot. I haven't had it since I was maybe 17 or 18. Intensity. One of those things that a certain age, you just grow out of it. If they can swallow tablets and they're systemically not to, um well, they can go home with the oral antibiotics. Usually these people presented GP on. There is a primary care issue. Um, however, if they can't get a GP appointment for every sin and you know it, we'll know that it is difficult time of writing to get a GP appointment. It's been some parts of the country, but in the a lot of them end up turning up to an urgent treatment center or two a day instead. Um, because if they really can't swallow anything than fair enough, But if if they could just about get a tablet down them and that systemically not horrific, accept it, then all relative all sixes 1st 10 days should solve them right out. If they cannot swallow it all, or if they're really quite unwell. Then they may need to come in for maybe a day or so for some treatment to really knock on the head. The best way to know go on the head fairly quickly is a shot of IV dexamethasone. To get the swelling down. Assume is the swelling's down. They can drink and get pain relief and get antibiotics in, and they feel a lot better in themselves and give them an IV course of benzol penicillin onda crucially fluids as well. These patients have almost always fairly dehydrated because they've not been able to drink properly for the last, however many days you give him a big old bag of fluids. They feel better almost immediately, Um, a lot of the time if they turn into any after short Dex and a bag of fluids, they look like a different person. And then, more than happy to go home with a course of oral antibiotics. But occasionally if they haven't quite, you know, turned around yet, and you can admit them for a continuous treatment. But that would be my advice and tonsillitis. The other thing that it may be is a Quincy um, a Quincy is not just severe tonsillitis. There are two succinct conditions. Um, Quincy's will always start out with tonsillitis, and then an abscess will form in the soft tissues anterior to one of the tonsils They appear and presents similar to tonsillitis, but just slightly worse in most regards. Really so, whereas sometime till Isis is have a really difficult swallow but can actually swallow a bit, a lot of Quincy's can't swallow it all. Some of them come in with a bucket or something use, and they're just spitting into them because they can't even tolerate their own saliva. They have a quite profound vocal changes. This classic hot potato voice sounds like that they burn their tongue on something, have trismus. Trismus is a painful opening of the jaw so that they're only able to open that door a couple of centimeters and then more likely to be a little bit more systemically unwell than just the slightest um, and the picture. It's not that best picture off Quincy, but it does illustrate the point. It is a one sided swelling that's pushing everything over, so the uvula is no longer in the midline. It's been shifted off to the patient's left in this instance on there is this area feminist bulge. Where the arrow is pointing to behind that bulge is a probably an infected tonsil. That's not the issue at hand of the moment is the bulge itself is a big bowl of puss that needs to be aspirated once that's aspirated. Then they have reverted from a Quincy back into a normal tonsillitis again, and you can treat them as an auto slightest is described on the previous slide. But that big collection of Puss needs needs to be aspirated. The way to do that is to numb the area with a local anesthetic spray and to stab it with the needle on, Try and draw some puss out is a commonly performed procedure within Ent, and you'll be doing a lot of residual urine. The ent in the emergency department. I would strongly advise you to watch someone do one first and be taught how to do them because, although is an easy enough procedure, it can go wrong if you don't know what doing if you if you drift a bit too much laterally on, you go too deep with your needle. We're not going to be a million miles away from their internal carotid, which is the last thing you want to be shoving a needle. So the key is is to essentially where the tip of the arrow is. That's where you want to be stopping. And you're never gonna hit carotid. Then on the needle should only really be going in about a centimeter, max. Once you popped it in, you draw back on the syringe on dope. Fully, you get a big load of pass out. Once you've done that, the patient feels usually ah, lot better very quickly because this swelling that's been taking a huge amount of space in their throats gone, they can. That's still gonna have tonsillitis behind this Quincy. So it's still not gonna be back to normal completely. But they were very much thank you. Well, after they've may be sworn, you a bit for sharing a needle. The back of the throat. The lidocaine is breaking out to do so much bucks. Months they've got over that, um, they bounce back pretty quickly. If you have a seat up Quincy and you're happy and draining one, I'd recommend trying to get sooner rather than later, because those things only tend to grow and the patients only tend to get more of comfortable is they go and then this off to outcomes one. You stab it on aspect it the second one. If you leave it long enough, they tend to pop. And that is really unpleasant for the patient is that they just end up with a mouth full of puss and blood in the middle of the night or, whenever that least expecting it. So it's easier to just go in and aspirate it off cleanly with a needle on after numbing first. Um, anyway, so back to the patient hand who are remind you it's a 16 year old with a few days, a story of a really sore throat. You look in his throat and his throat looks absolutely fine. There is no evidence of tonsillitis or Quincy in this throat. The uvula is in the midline. His tonsils are, you know, not inflamed in the scientists. We can see them on the left and right. The picture there they are just existing. No erythema to them, no pass. But he still has an extremely sore throat. Um, only after you sat in the department for a little bit. Do you notice his breathing is started to sound a bit strange on DNA now, whereas before he could swallow. But it was difficult. Now he can't swallow a tool. Um, on also, this is more of a pediatric sign than a CBC in teenagers. But I thought I mentioned anyway, in case any of you covered easy and two, he's he may be sort of leaning forward and tilting his head back slightly in order to get more breath sounds in. No, it was always getting more breath in. Sorry. And these are all fundamentally, um, very worrying signs and should be ringing alarm bells, especially in the context of a normal examination of the throat. What you'd see if you looked in this chaps throat with a fibrotic nose and the scope is while show in a second. But this is what you use a normal view of a fiber optic nerves endoscope. So you stick a camera into the nose down in through the nasal pharynx into the oropharynx, and you're now we're looking in the larynx itself. This is a nice, thin, pale epiglottis of the bottom it should look vaguely like a critical. Okay. Importantly, you can see beyond it you can see the vocal chords that, like just beyond it on beyond them, you can see trickier the vocal cords, A nice open, which means, yeah, they can get good air flow now on when they talk, those local course should open and shuts accordingly. This is a completely normal love. Leave you off the larynx. If you were to scope somebody with epiglottis Actis, you would see this. You would see a very red swollen sore looking at big artists that looks a bit like an angry jelly bean compared to the nice Pringle looking shape on the left. You can't see the vocal cords anymore because the epiglottis is so swollen. But it's in the way. And, um, it is very bad in the acute setting. I would not Scott scope a person who I thought had a big clot itis I would just treat them and then scoop them when they're stable. I'm just showing you this here through the illustrative purposes, because if somebody has an impending our issue, the last thing you want to do is waste time, you know, looking into their airway. You just want to treat them first and then look afterwards. Okay, but if you're suspecting it because I just which this kid is taking all the boxes for, you know he's young, he's got extremely sore. Throat is breathing, is sounding little bit off. He's only to swallow anything, and yet the back of throat that's absolutely fine. Then you need to antsy rather than later, because it's often impending airway disease. Astor factors they present with the worst sore throats in the world. Really, their voice may be completely gone. If they can talk, it will be very horse and very cranky on. They will be systemically very unwell if they are stretch Elice, which I mean they have strider that is a late side of the clots itis and shows that the degree to which the epiglottis is obstructing the airway is quite severe. If you've never heard Strider, um, it sounds sort of like that, Um, it is an obvious sign. You can't have a subtle strider. You will walk into you know the room in any or recess or wherever they are on. You'll hear it before anything else. It's loud um it sounds very distressing, and the patients are distressed with it. Um, it's very different to a weeks. Where is the weeds? Can be subtle. Strider can never be subtle. Always is a lower airway problem. A strider is an upper where a problem. So I've just got clarifying question a risperidone, every distress. So what a patient like this commonly present in risperidone. Every distress, Yes, they're respiratory would be significantly raised. They may well have low sats on. They won't be able to fully complete sentences without having to her. So we'll do that between every word or any of them. Every other word. So they tickled the boxes for some classical respiratory distress, even though their lungs are fine. But the gateway to their loans, which is the rep got is intolerance is far from fine, but yeah, they'll be tack up near campus tension desaturating. Um, if you see something like this, um then, well, it's not just gonna be your problem. You need to keep a LaRouche, and it's more than appropriate. If you see someone like this on their award and there's no one else around to put our crash, that's absolutely fine. um, any anything tests would be fully on board with attending a crash like this that's very much within their warehouse. If you see a patient at this in any, you don't want to be handling it by yourself unless you're very, very confident in doing any of managed lots of epic lot actresses. Previously, um, the people who you want there are. If you're just working in any you want a senior, any person with you, you want to make a call two anesthetics and you'll want to make a call to a party and tea whilst they're on their way, though there are some things that you can do in the meantime to help but do not delay calling. Um, the initial steps. Well, you're gonna do in a two way. You'll get to a and then immediately realize that you've got airway problem, so B C d. Any ready? Don't really factor into it because eighties fixing first, how you gonna fix a. We need to get this epiglottis trick as quickly as we can to maximize the air flow that's going down into here. The way to do that is with high dose IV steroids, dexamethasone tends to be the steroid of choice on adrenaline, given through a nebulizer, works it treats. If you drive adrenaline through a neb, it's it directly targets the back of the throat and the larger structures. The adrenalin will sit on that big artists cause profound vasoconstriction and shrink it. You can. It can shrink drastically very quickly. The nail by mouth point is somewhat redundant because they would have made this some themselves know by mouth cassettes follow hurts too much. You want to give him oxygen because they're already finding it hard to breathe, even if their saturated at 99% but probably working really hard in order to maintain SATs in 99%. So whenever then know having a neb, make sure they got home, float potentially humidified oxygen and give him some fluid as well, because they're gonna be systemically septic. Those Airil very important things to do but you want and having the back of your mind the knowledge that there is someone on their way to help that someone being ent slash anesthetics. Probably both. Um, but if you call me and say what should I do? The first two things I'm probably going to tell you to do our give some steroids and give some adrenaline naps. Those are the two things that will have the greatest chance of saving this airway. Quickest. Always say they need antibiotics as well, but that's what it's aren't going to fix your airway in the next 5 10 minutes. But the Dex and the adrenaline may well do and and that just they can never have too many adrenaline NEBs either. Just keep giving the back to back until senior support arrives. When seeing the support arrives, a couple of things may happen. It may say Congratulations. You saved them, um, through your dex and you're doing the NEBs and everything else. The Lantus is stroke to a degree that they're no longer strange. A list there breathing. Okay, we'll continue medical management. Happy days. You need that. Just may say I'm not happy with the Safeway on tension. Bait them. They're in there, Teo maintain to say that way. If, um, anesthetics aren't able to because the epiglottis is too swollen. Um, that's when an emergency tracking able put it. That's why you also want ent there alongside anesthetics to check a tracking and if necessary, that won't be up to you. That won't be your call as Ernie anti F two or whatever. That will be one of your seniors. All that just know that's why you want them there. Because that may be the direction of travel. Most difficult sciences do know end up with the trach e move. Stepping out of sight epiglottis is don't end up being chewed the that in my experience, most well managed. Okay, with just the medical treatment off the adrenaline, the dex, the antibiotics, etcetera. But the crucial thing is the recognition of that. And do you starting it sooner rather than later? And then these decisions can be made. Um, afterwards, um so some take home messages about all of that Well, in toward the ent. Most air infections are not serious, but if they start to affect the cranial nerves, all the patients had it for a really long time and losing mirror compromise. You gotta have in the back of the mind. Is this necrotizing attacked? It sits there, and if so, have a chapter of senior about it on Do have a low threshold to getting a CT again. That probably comprises less than 1% of the time is is external, but it's something that you will come across now and again. Um, most nasal slash Sinus infections will go away by themselves, with maybe some assistance of some sprays, some drops, but any periorbital slash orbital involvement than the eyes at risk. And it needs to be taken way more seriously. And it's time to escalate And, um, any any hint of strider call anesthetics and ent Um, pretty much before you do anything else on detriment. Wise adrenaline NEBs and I be Dex has got me out of more sticky situations than you could believe. It's not just medical scientists if they've got a massive laryngeal cancer that they presented to any with really late because they haven't been, you know, they've been scared to go to the GP or the hospital for last two years because of Kobe. It on they come in stretch Elice with, you know, a cancer the size of an orange sat in their throat. If you give them Dex and adrenaline NEBs that cancer will transient, we shrink, and it made by some time to the airway. Um, even with trauma if they've been I've seen you before. Someone got kicked in the neck at a rub your a football match on. They had a really profound internal bruising around their larynx, which is really old presentation and again, adrenaline Name's an IV, Dex Just shrunk it down for enough time for their airway to be safe on for senior to support, to arrive for us to make a decision about what to do. There's never you never gonna be chastised, forgiving and drilling. Name's an IV, Dex. If you worry about airway it, sometimes you'll give it and it doesn't wasn't needed. But I'd rather you give it unnecessarily, then under give it to someone that just definitely need it. Um, I know a lot off those things I talked about. They will ended up into off the worst case in our area. I'm sorry about that. Most of the ent is fine. Uh, but these are the things that you should just have the back of your mind. Um, fence off listening, and I will if you got any questions, feel free to shout now or out of the campus. Got one saying, How do you differentiate in acute hepatitis for amount of Relax. A good question. Yeah, epical Scientists will always have the path off. Um, it will initially present. It's just a sore throat. It's never going to suddenly become a massively, grossly a dentist's epiglottis. They will have a sore throat there, feel a bit systemically and well on gradually left swallowing, and the breathing will get worse on little be systemically septic. There is an anaphylaxis. There tends to be, you know, I to problem eight a peanut. And then my lips felt tingly. And now they're puffy and my tongue is puffy and I can't breathe properly. Um, so in the absence of a fever or any infective signs, you're gonna hear towards more anaphylaxis on. If things started out sounding like an infection with a sore throat, you can, I think, more difficult itis. However, if you're really stuck, then again I'd be Dex and nebulizer. Jenaline will help with both, um And if you're if you're you can give I am adrenaline as well if you want, because that's more of a first line and anaphylaxis. But again, if you're worried about the airway, can't recommend enough Dex and adrenaline. If you're really stuck, but they do present in in different ways. Um, can you briefly about vertigo, please? On my gosh vertigo. I think there is a talk later in the Siris about balance issues on do all sorts of little logical things. So largely Leave that to them. Um, because, yeah, vertigo in itself is a minefield. There are all right. A lot sale in vertigo is. Be sure to separate out that that there's two main causes of vertigo. Either there is something wrong with your semi circular canals, or it's centrally there something wrong with the processing of your A balance orientation within your brain. That one is far more worrying and couldn't indicate a stroke. If it's something to do with your cochlear and your Senate second canals, it's far less worry, so those you need to rule if it's stroke in around on early stage. But I'll leave that to the other talk. How do you describe nebulizer? Jenaline. I can't find a recommendation or nebulizer using to be enough. So, um, you gave it. Adrenaline comes in different strengths. You want to give one in 1000 is the posted one in 10,000, so that one in 1000 adrenaline. You want to get a five millimeters vial of it? Um, never lost. That's it. You just crack open a five mil vial of off of one in 1000 adrenaline, tip it into a nebulizer, put it on the face. That's have to give nebulized adrenaline. Excellent. Thank you. Do you have any more questions? Any voting? Speak now. I just saw you. No, there's no more questions, but 20 of thank you. Thank you for me to you from We're agreeing to give up your time and giving such a really great informative talk. I particularly enjoyed you using the scans. That was really, really useful. Thank you on. Yeah. Yeah. I hope you enjoyed it. If you've got any other questions I don't know, you can probably email me or access me somehow. My my details are on the UK the ent UK representative website. Any way you could find my email on there? Out of the interest. Where about you a wrap for this year? A z Well, you know, I'm I I'm I think I'm up now. My rep times up. But I think my details are still on there because they haven't found new reps yet. Been a rep for the last 12 months accident. Do you want to tell, uh, use just a little bit about being an SSI wrapping a little bit about that? So because I'm I recently became an SFO rat, and I think it would be useful for you guys here to know, especially if they're interested in two years of Korea. Sure. So SFO, which does feel students and foundation doctors in otolaryngology, is the a branch of the anti U K. Which is the National Ent Organization, which promotes ent as a career to student center people starting out, um, on the role of the rep is to educate a bit but ent to provide, um if, um no lives about how to get into training, Any tips and tricks about order, it's and presentations and things like that on It's a good place to start. If you're thinking about going into is to just email in your local rep and a lot off the, um that there are around the country. There are reps at different levels. Some medical schools have their own rep, and then there tends to be a foundation rep and a core training wrap. I'm the core training rent for the Northwest. I think that might be another one or two of us, But any part of country, there's a few, um, they roll everybody who is a rep. His had to jump through those hoops a some point and are the best people to talk to you about how to take those boxes have to jump through those hoops on. If you've just got any general questions I NT or if you, you know, work for, if you're a member of a unique society that is to do with surgery or is to do the anti there that people get into contact with about delivering a talk I done them for It doesn't even need to be your local wrap. I don't talk. So for some reason, Scottish lows. The Scottish Ent Societies. I don't know why. Maybe I'm listed down. It's the Scottish Ent breath because my surname, Gregor, but they're I know a few of the other reps. They're all very nice and they're good. Poor, of course, for a career advice and any anti advice. Excellent. Thank you very much on just to say we'll be back. Link. I posted it in the chat. Um, hopefully you should all get feedback. Link a zwelling when you signed up. But if not feel free to message on the Facebook group. When you feel in the feedback form, you should get a certificate for attending this event on. We're really keen to hear your feedback because we want to know how to make these events fast for you on Do also. Yes, the most applicable as well. So yeah, we'll free Teo, give the feedback. And again, Thank you so much, James, for giving up your time to do this Talk. Right. Good luck. Everyone in your future careers on If you want to do the ent Good choice. It's quite funny. It's a very welcoming such a three. A swell, Yeah, one of the friendly ones. Thank you so much, everyone. I'm gonna end the talk now, But again, if you thought any questions, be back messages on Facebook awful in the feedback form. But yeah, thank you very much for attending a swell on giving up your evenings. Technolo. So thank you. On by Uh huh