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OK, good afternoon everyone and welcome to our session uh on Ent Oh, hello to speaker. Oh, thank you. Um Hello everyone. My name is V VT Revello. I work as an ent consultant in Sherwood Forest Hospitals and this is a, I've tried to capture everything that you need regarding Ent. So hopefully, um you'll find it useful. Um So I'm gonna start with the TTI externa, which is one of the commonest things that you were gonna see as an foundation ear doctor or as a GP. Um It has got, there are three main types of, of otitis externa. Um diffuse ait externa Ronal and malignant or necrotizing otitis externa, diffuse ait externa is a generalized inflammation of ex of the external auditory canal and it may be part of a generalized condition uh such as eczema or psoriasis or it can be localized due to trauma from cotton buds, um scratching with dirty fingernails, et cetera. There are uh causes can be infective and non infective. Um infected causes include bacterial um with main pathogen, pseudomonas and staph Oros uh fungal um with candidia Aspergillus and viral. Uh such as herzo. Um noninfected causes include um an allergy or irritation to uh shampoos or met ear drops and a condition called neurodermatitis as part of an anxiety disorder. The symptoms include itchiness, irritation, pain, and swelling, aoria and deafness due to occlusion of the um outer ear canal. Um there is pain when you try to examine the um the ear canal and you try to move the pen, insert, the oral speculum um and oor can vary from debris to pass. It can leak out to um involve the skin to, to irritate rather the skin of the conchal b um or of the penis and I in um Aspergillus and Candida, it looks like a white patch or white and uh black um um spots. Um It can be associated with enlarged pre and post ire and upper deep cervical lymph nodes. The treatment includes um painkillers, oral toilet and topical medication. I have um I'm going to share this presentation so you can have um um this table ii, it shows all the topical medication that we use in otitis external. So quite useful to have it in hand. Um If the ear canal is closed, none of this is going to work. So you will probably have to think um of inserting an auto week, a pop auto week, which will help with the drops to go to the right place to work. Um Please note that systemic antibiotics um given without oral toilet and and or topical medication can lead to recurrence as infected debris may remain in the external ear canal when skin inflammation has um settled, moving on to the second type of uh otitis externa. That's fungal, which basically is a painful infection of one of the hair follicles of the outer one third of the ear canal, usually due to um staphylococcus. Um it arises after one of the hairs has been plucked or the ear canal has been scratched. Main sign is that of red swelling arising from one aspect of the external ear canal bulging into the meatus. And treatment includes analgesia and astringent, such as glycerin and uh eyal antibiotics can be given in more severe um infection uh associated with lymphadenitis moving on to the third type of Otitis externa. That's malignant or necrotizing otitis externa. It's an aggressive form of otitis externa. It's not a cancerous condition though. However, it can be lethal. Um main um causative pathogen is pseudomonas, aeroginosa, aeroginosa. And it's more common in elderly people, diabetics and immunocompromised patients. It spreads from the external ear canal to the bone, causing osteitis, severe pain and um paralysis of various uh nerves including um the seventh facial uh fa facial nerve. Um the pain uh in the ear canal is out of proportion to clinical findings. And clinically, you may see uh some granulation at the floor of the uh external ear canal with discharge or not imaging. Cross sectional imaging is very important because it will show the um defect of the um skull base and treatment is with high dose of antibiotics, intravenous uh for several weeks. Um Another common condition is acute TTI media which is basically an infection of the middle ear. 50% of the cases is viral in origin, but um can be bacterial as well. And main symptoms include hearing loss, pain, aoria when the the the the eardrum burst and uh high fever and uh systemic upset. Um Main treatment is with amoxicillin, myringotomy, which is an incision um at the um eardrum um is indicated uh when only if the condition does not, I'm sorry, does not resolve um or if there are complications such as facial nerve palsy or intracranial complications. Um acute mastoiditis is a complication of acute itis media. It's a serious condition with significant long term morbidity and mortality. Um What happens is that the infection from the middle ear spreads uh into the mastoid s uh along with a pass, the patient is systemically unwell. Um And if the pass spreads out through the bone, so, periosteally can form an abscess, sole abscess. Um The treatment is with intravenous uh broad spectrum antibiotics. Uh and if there is a an abscess formed incision and drainage and of course analgesia, hm, facial nerve palsy. Um So when you, when a patient presents to you with a facial nerve palsy, I think the first question you need to ask yourself is is it an upper or a lower motor neurone lesion because in, in the lower motor lesion, uh lower motor uh neuron uh lesions, the forehead is also affected, which means that patients will not be able to raise their eyebrows. However, in the upper motor neuron um lesions, the lower face is involved with preservation of bilateral eyebrow rays. And that's because as you all know, forehead muscles receive innervation from both motor cortices, causes of facial nerve palsy, uh can be congenital um trauma, head trauma, uh with uh fracture of the temporal bone, iatrogenic um during various surgical procedures, um superficial protid omy, um mili er or mastoid um uh or pits bone um surgical procedures. Um uh various tumors along the course of the facial nerve from its exit from the skull base to its entry in uh in the parotid gland uh can uh cause uh facial nerve palsy inflammatory causes such as part acuity, media and cholestatoma or vascular um A stroke, uh neurological uh uh multiple sclerosis and unknown. Um We use the House Brackmann Scale. You must have heard of it uh to grade the the severity of the uh facial nerve palsy. Um grade one in grade one, the the the the function of the nerve is normal. In grade two, there is um slight weakness, noticeable only on close inspection. Um In grade three, there is obvious weakness but not disfiguring. Uh the face of the patient in grade four, there is severe reduction in movement and incomplete eye closure. And in grade five and six, there is asymmetry at rest with um barely perceptible motion in grade five and no facial movement at all. In grade grade six, investigations include um a hearing assessment with a put on audiogram, um stapedial reflexes, electroneurography which will uh most likely give you the prognosis and uh imaging uh such as MRI and CT um scans. Um Bell's palsy is first described by Sir Charles Bell in 1829. Basically, it's an idiopathic lower motor neurone palsy of the seventh nerve. Um and it's a diagnosis of exclusion um with an incidence rate of 20 in 100,000 and and a largely unknown cause. It could be viral or immunological. Um signs of recovery begin in two months. Um oral steroids may help recovery if given early 90% of patients have satisfactory to fal function and poor prognosis is associated with increasing age associated pain, complete palsy and increased latency to onset of reca recovery Ramsay. Uh Ramsay hansom um is a is a viral um condition um that can present with a facial nerve palsy. Um uh it's, it's caused by herpes uh zoster virus which may attack spiral or vesulia ganglion in the inner ear. Um There is intense pain um which is followed a few days later by a vesicular eruption on penna and external ear which you can see on the third uh picture. Um uh These are photos of a of a patient in day three, day seven and day 10. Um It can be associated with sensorineural hearing loss, vertigo, and facial paralysis. Um and early treatment with Acyclovir improves prognosis and risk of post herpetic neuralgia. Um facial nerve palsy treatment includes eye because if, if with with incomplete eye closure, there, there is a risk of um dryness um and abrasion which can result in uh blindness. Um so artificial tears are recommended or um ointments um to moisturize the eye um and an eye patch at night. Of course, you can always uh seek an ophthalmology opinion. Um If, if there are concerns, um general treatment includes oral steroids with a typical dose in an adult of 80 mg um which is reduced gradually uh to zero over two weeks. Um um Acyclovir if started within first few days of onset and facial weakness is severe. And if impermanent facial weakness, uh facial slings and um Botox injections could be an option. Um Next, we're going to look into various causes of conductive hearing loss. Um with um uh the most commonest one which is a TTI media with a fusion or um blue ear. Um This is simply a sterile collection of fluid in the middle ear anti, resulting in a conductive loss of 10 to 40 B and a flat tympanogram. On the photo. You can see actually the level of the liquid of the fluid behind the eardrum. Um It usually it follows a uti and results spontaneously in a few weeks. Um, uh, it's most common in Children once it's glue year is confirmed in the first ent attendance. We need to see the Children, the child again to evaluate in three months. Um, 50% of patients will improve. Um, but if, if glue year still persists, um, gromes would be an option. Please note that tonsillectomy, decongestants and antihistamines have no beneficial effect. We don't use them, we don't give them and we don't do tonsillectomy to treat per year. Um Grommets are small ventilation tubes that are inserted after we have made a small incision to the anterior and inferior part of the um eardrum just here where the reflex is. Um this is called myringotomy. Um um complications. Post grommets include tympanosclerosis, scarring of the eardrum and eardrum perforation. The, the, the, the, the, the the grommets are used to improve the ventilation of the middle ear and not to drain the uh the glue ear. Uh another cause for conductive hearing loss is acute super otitis media, um which is a bacterial infection of the middle ear. Um pass forms um within the middle ear and inflamed, uh eardrum bulges outward uh as you can see in uh in in, in the picture. Uh this phase is quite painful for the patient when the eardrum ruptures and the pass um drains in the outer ear canal, the pain uh becomes less um improves the eardrum. Uh once it has burst, it, it heals up in 4 to 5 days and the first line of treatment is uh called molo. Um Again, myotomy is uh an option if uh uh if the condition fails to resolve or uh if there are uh other neurotological complications, uh and or uh facial nerve palsy, another cause for conductive hearing loss, um um would be cholestatoma which is basically accumulation of benign keratinizing squamous cells. Skin um um most commonly involves the middle ear. It's just skin in the wrong place. It can erode through ossicles causing conductive loss of 50 degree or more or into the lateral semicircular canal causing vertigo. It can cause facial nerve palsy. It can erode into the cochlea and cause sensorineural hearing loss or through the roof of the middle ear, uh which is called teg into the brain and cause intracranial abscess or um thrombosis of the uh sigmoid sinus. Um The treat treatment is surgical with surgical excision. Um just briefly, uh retraction pockets are in drawings of the eardrum um as it shows here uh mostly in the attic area which is the upper part of the eardrum, the self cleansing, but when the debris starts to accumulate, then uh artem uh cholestatoma and tympanosclerosis is this white patch on the eardrum. It's just a calcification of collagenous scar tissue originating from previous infection or trauma. Um Otosclerosis is another cause for conductive hearing loss. Um It's basically a familial condition and it's Mendelian dominant with incomplete penetration. It is characterized by a spongy bone formation around our window which um fuses with sta um causing conductive loss. And the treatment is hearing aid or um a surgical procedure to remove the stapes and replace it with a prosthesis called stapedectomy. Um Chronic supportive otitis media is another disease of the middle ear mucosa which gets repeatedly infected. Uh It can be associated with a perforation. Patients usually complain of an odorless chronic discharge. Uh if there is a perforation, um and treatment is a uh myringoplasty to graft the uh hole or if it's affecting uh the mastoid cells, uh cortical mastoidectomy and the graft, a conductive hearing loss could be uh chronic dry perforations, which are usually the result of a viral infection in childhood and can be left uh uh can be left alone unless they're causing significant deafness or they are preventing someone's admission to some profession or uh sports such as swimming. Um myringoplasty uh is successful in 80% of those cases. Tumors are rare. Um uh uh uh you should suspect a tumor if a patient with a previous stable mastoid cavity complains of discharge, which may be blood stained and is usually associated with pain. Um Other causes of conductive loss could be trauma, um skull base fractures as it shows here on the CT scan, um could be associated with hemotympanum hemotympanum which is just blood uh accumulation uh in the middle ear behind the eardrum. Uh you can see the, the color uh on the photo um conductive loss is of uh 30 DB. Um blood will be reabsorbed spontaneously. So you don't need to do anything about it. Um uh Trauma can result in Icar fracture or disruption um which however, it does not resolve and an exploration is required once the blood has been uh reabsorbed. Um If the if the exploration is delay, delayed, displaced ossicle may be uh resorbed. Um congenital causes of conductive loss are very rare. Um, sensorineural hearing loss um is another um common condition and Presbycusis is the first is the most commonest thing uh sorry cause uh for sensor neural loss. It's um common in elderly. It's due to aging. Uh and it's always bilateral and symmetrical, affecting usually high frequencies. Mm Acoustic neuroma is a benign tumor arising from the auditory nerve. It's clearly shown here on the photos. Its earliest symptom is unilateral loss or tinnitus and early diagnosis is crucial because mortality and motility, morbidity from surgery is directly related to tumor size. And investigations include a hearing assessment with put on audiogram and an MRI um treatment is radiotherapy with the socalled GMA Gamma knife and surgery. Sudden sensorineural hearing loss is emergency. It is defined as 30 degree or more of sensorineural hearing loss over at least three adjacent frequencies occurring within a period of three days or less. The etiologies are known. Um hearing uh recovery rates range from between 30% to 68% without treatment and uh typically within two weeks of onset. Um unfortunately, low frequency loss is recover, sorry. Uh fortunately low, uh frequency losses, recover better than high frequency deficits. And severe vertigo is an unfavorable factor. Treatment is with oral steroids. Um And I have uh put a table to show the uh start dose of tapering um or with intratympanic steroid injections, noise induced loss. Um um happens due to uh sudden acoustic trauma or prolonged exposure to excessive noise. With prolonged exposure, hearing loss may be reversible within two hours of exposure due to cochlear fatigue. Temporary threshold shift is called um after two hours. If the uh exposure still happens, uh we have a condition which is called a permanent threshold shift and the the loss is irreversible. Um Typical presentation or hearing test is the notch at uh uh for uh kilohertz. Um uh But it can gradually involve lower frequencies as well if uh the exposure continues. Um Other causes include nonorganic loss which occurs in pursuit of a compensation following head injury or alleged injuries, exposure to noise or in teenage girls. Um um electrical response. A geometry will confirm diagnosis um and last but not least um baro trauma and perilymph fistula that happens when um sudden pressure during sudden pressure changes such as uh flying or diving or even sneezing or um straining, which can rupture the membranes of the inner ear and cause leakage of perilymph into the middle ear cavity or mixing of biochemically different fluids in the inner ear. Um It can be associated not only with uh sensorineural loss, but with thus and vertigo um trauma to the skull base um with fractures of the temporal bone. Um these are uh can be longitudinal or transverse. Um total facial paralysis is imme immediately following head injury suggests major injury to the nerve and delayed paralysis usually recovers spontaneously. Aids can affect the ear as well. Um um with uh uh fungal externa or eno en composes sarcoma. When it's affecting external ear. In the middle ear. You can um these patients uh can develop acute or um and er oitis media or mastoiditis and in the inner ear can cause sensor neural loss due to neuropathy of the auditory nerve or iatrogenic. Uh due to the uh um agents that uh are used to treat the condition. Um, autotoxicity is another cause for sensorineural loss. Um The, the, the, the, the, the commonest group of drugs that cause uh that are autotoxic are that are well known that is well known that are autotoxic is aminoglycosides, uh followed by diuretic salicylates and hemo therapeutic agents. Unfortunately, the damage is irreversible. However, serial audiometry can be helpful um to monitor the levels of um the hearing. Um and of course, use of nontoxic non on drugs should be considered. Um Ramsay Hunt syndrome is another cause we've seen it before um moving on to glomus tumors. These are benign tumors that arise from nonchromogen, paraganglionic tissue. Um The symptoms include tinnitus synchroma with pulse bit pulsatile, tinnitus, hearing loss, facial paralysis and paralysis of other cranial nerves as well. And on examination, you might be able to see the mm pulsatile red mass behind the eardrum, which is called setting sun. Uh The U usually there is audible bruit uh over temporal bone and uh paralysis of the facial nerve or of the cranial nerves. 9 to 10 to 12. Treatment is surgery, radiotherapy or combination of both um tinnitus. In another is another condition that is uh quite common in people. Um It can be subjective or objective uh in uh subjective tinnitus is basically a hallucination of noises in the head and ears and can be associated with hearing loss and vertigo. Um in uh uh objective t the noise in the head and ears is heard by another individual such as the clicking noise of soft palate in palatal uh myoclonus or vascular bruits. Um Treatment uh requires a careful neurotological assessment uh to rule out other conditions. Uh counseling a hearing aid if it is associated with hearing loss and tinnitus musculus. Um the uh vestibular system has evolved to, to uh provide two main functions um to give us a right and to avoid injury despite movement of the individual or the um surroundings to maintain visual fixation, despite movement of the head body or surroundings and it receives uh sensory inputs. Sorry brain receives sensory inputs from three major sites, proper receptors, vision and labyrinth. One can still maintain balance if any two of these systems are intact. Nystagmus is an in a voluntary conjugated rhythmic to and from movement of the eyes. Uh It's a clinical sign of vestibular abnormality and it's called a fast and slow component with a fast component. Um uh oh my brain stopped the, the direction of the nystagmus is taken by the um the fast component. Um Sorry about this. Um Sagm can be horizontal or rotatory which we see in peripheral causes of dizziness and vertigo or uh it can change uh direction which is uh more common in central uh causes of dizziness. Um You will see a normal uh nystagmus when irises of the eyes are deviated horizontally further than, than the punctum of the lacrimal sac, that's a normal nystagmus. Um moving on to uh vertigo. What is vertigo? Vertigo is a hallucination of movement. Um It's spinning uh of the individual uh in, in relation to the surroundings or of the surroundings um in relation to the individual. Uh um and often it is associated with nausea, vomiting, paler and diarrhea. There are various causes. Um There are various conditions that cause dizziness, central causes. Uh I'm not going to go into details. Um It's uh the, the presentation usually includes ataxia, unsteadiness on one's feet, a feeling of imbalance gradually in onsets. Um, central vertigo which is mild and not associated with nausea or vomiting, um, as well as hearing loss. And tinnitus Presby. Presby, similarly to Presbycusis is a condition which is common in elderly, is age related. Um, and basically, it, it, it involves an episode of unsteadiness lasting a few seconds were worse on movement. Um, cardiovascular causes such as hypertension, hypotension, um present with a syncope, lightheadedness, vague unsteadiness and veins in peripheral causes vertigo. Um is the the the the the most uh the predominant symptom. Um and they can present with sudden episodes of vertigo. Um, vertigo is almost always associated with nausea or vomiting. Um And if there is hearing loss and tinnitus, uh uh they, they point to the cochlear involvement. BP benign paroxysmal position. Uh uh the cause is usually spontaneous um or occasionally after head injury. Um Typical histories is that of a uh middle aged or older patient presenting with sudden onset recurrent episodes of vertigo associated with nausea and often vomiting on head movement to a particular side, especially when turning over in bed, turning head, when driving and on bending down usually lasts 1 to 2 minutes. It's typical examination includes dick Hallpike test which is uh almost always positive uh with rotatory nystagmus stimulated by turning the head to the affected side a lot as well as vertigo. Uh the nystagmus disappear and the vertigo disappear after 30 to 40 seconds. Treatment is reassurance. Uh with reassurance and um at least uh positioning maneuver. Um and usually it improves spontaneously over 12 to 18 months. Meniere's disease um is over diagnosed. It's not as often as you think it is. Um attacks are often preceded by a feeling of fullness in affected ear, followed by a sudden onset of vertigo associated with nausea and vomiting, sudden loss of hearing and an increase in the loudness of tinnitus in the affected ear at the end of the attack. Uh the hearing recovers but rarely to preattack levels in leading to progressive sensorineural hearing loss after many attacks. So you can see that there is fullness, vertigo, loss of hearing loss. Um tinnitus which gets louder. Um The cause is unknown but it is thought to be due to an excessive accumulation of fluid. He drops eye drops in the endolymphatic fluid compartment and the treatment is medical with uh bed rest vestibular sedatives antiemetics during acute phase and scenario. And betahistine sought restriction during prophylaxis surgery is reserved for cases that do not respond to uh medical treatment. Um um Other causes of dizziness, uh peripheral dizziness include benign vestibulopathy. The um the cause uh for this condition is unknown and the typical history is that of a middle aged person with clusters of attacks of vertigo without autolog symptoms. Treatment is with reassure and the uh cough and cookie exercises. It gets better spontaneously over 12 to 14 to 24 months, acute labyrinthine failure or labyrinthitis, acute labyrinthitis, uh could be idiopathic after viral or uh due to local uh vascular occlusion, autoimmune fracture of temporal bone. Um The a typical presentation is that of a person of any age presenting with sudden attack of hearing loss and severe vertigo, nausea and vomiting. Uh The attack lasts for 10 to 10 days to three weeks. And the treatment is symptomatic antiemetics, vestibular sedatives and fluids. Um vestibular neuronitis uh is probably viral. Um and it, it, it involves a sudden onset of vertigo with nausea, vomiting and antag, but without hearing loss and tinnitus, it lasts several hours to a few days. And again, treatment is symptomatic drug induced vertigo. Uh uh can be associated with use of aminoglycosides, chemotherapy, uh antidepressants and sedatives in elderly, um often it's not recognized um until patient recovers from the illness that require the antibiotics or the uh chemotherapeutic agents. And uh we now moving you uh some rhinology topics, acute rhinosis, acute rhinosinusitis is one of them, which is uh basically an acute inflammation of one, some or all of the sinuses. Um usually follows a viral URTI, only up to 2% of viral tis are complicated with bacterial rhinosinusitis. Um It presents with a severe unilateral pain over the infected sinus and uh nasal obstruction and mucopurulent rhinorrhea. We should, you should be able to see uh on anterior rhinoscopy or on flexible nasal endoscopy. Um which is available in the secondary care. You will be able to see uh the discharge within the millimeters which is the area where most of the sinuses drain treatment is uh with er, analgesia decongestants, intranasal steroids and broad spectrum antibiotics. Um chronic rhinosinusitis is a chronic inflammation of the sinuses. It may follow an acute rhinosinusitis or have a more insidious onset. It's over diagnosed uh as the facial pain is incorrectly thought to be sinogenic. Um it presents with nasal obstruction and disc discharge for over 12 years. Um smell disturbance um and on nas endoscopy or you will be able to see a nasal polyp within the metus or this uh mucopus. Um um Treatment is uh with saline irrigation, intranasal steroids, antibiotics and surgery in the form of uh functional endoscopic sinus surgery, which is not to treat the infection per sorry, the chronic inflammation per se. Um It it may not be a permanent fix but it will help for the topical medication to work better. Um complications of an in of the infective sinusitis include a periorbital cellulitis and periorbital. Uh an orbital abscess. It's the most common serious complication and it's treated with high dose antibiotics. It's important to monitor the um color vision and the visual acuity as well as the eye movements. And uh if in doubt to perform a CT scan of the sinuses, um facial cellulitis and pos puffy tumor which is uh shown here. Uh That's basically a a forehead edema resulting from osteomyelitis of the frontal bone with associated superior cell abscess, it's a very serious complication. Um Other complications include mucoceles um which are late complication of A S uh they're basically collection of sterile mucus occupying an obstructed sinus. Usually it's the frontal sinus that is affected as you can see on imaging and it can uh uh present with facial swelling and visual disturbances. Uh proptosis of the eye, et cetera treatment is surgical only mm in interlining complications uh can be associated with the previous um acute rhinosinusitis. And these include meningitis, govern sinus, thrombosis, brain abscesses, extra abscesses and suture, abscesses. I'm not gonna go into detail but the information will be there for you um to uh revise um moving on to um head and neck tonsillitis is an inflammation of palatine tonsils. It presents with sore throat and painful, swallowing. Um systemic upset. Um viral tonsillitis may present with uh milder symptoms. Um typically uh tonsils are swollen. As you can see on the photo, they may have white exudates, white spots. Um and patients can present with a thick or hot potato voice. Uh If the tonsils are very big, the treatment is with antibiotics, penicillin, v fluids, analgesia difflam spray, um peritonsillar abscess is a complication of tonsillitis. It's called as well. Um Quinsy um and it's basically a pass collection in the uh peritonsillar area in the area around the tonsil. Um It presents with a sore throat and odynophagia, trismus inability to open the mouth widely. Um When you examine the patient, you should be able to see a swelling of one tonsil only with a displaced uvula to the unaffected side. I've never seen bilateral queens. Um Treatment includes um caloxylon, uh intravenously, analgesia fluids and of course incision and drainage or aspiration or both. Um, glandular fever is a viral condition that affects the um tonsils. Uh It's usually caused by the Epstein Barr virus EBV and it's also called infectious mononucleosis. Um, symptoms are similar to uh tonsil. Um However, um the systemic upset is a lot worse and there is neck lymphadenopathy, um fatigue, nausea and possibly a rash and treatment is symptomatic. We don't routinely give antibiotics um as it's a viral infection. However, if there is a clinical suspicion of a bacterial infection on top of the viral, then uh um should be given um uh analgesia fluids, uh rest, um alcohol, avoidance and avoidance of contact sports for eight weeks. Um um are uh advice that we normally give. Um if uh LFT S are deranged, uh then uh should be repeated in four week time. Um moving on to salivary glands. Um I'd like to talk to you about the um dry mouth and what are the most common causes? Um um These include depression, anxiety and various drugs such as um atropine, antidepressants, antihistamines, antiparkinson drugs, um decongestants. Uh Bronchodilators. Mm Sjogren's syndrome uh is another cause for dry mouth um as well as radiotherapy to had a neck region, um swellings in the area of the salivary glands. The major salivary glands uh can be nonsalivary related. Um A and I mean, uh with this, I mean that a hypertrophy, for example of the master muscle can um present with the swelling in the area of the parotid gland. Um with aging, there is absorption of adipose tissue, uh which leaves the glands more conspicuous skin structures such as uh sebaceous cysts um are not really are swellings are not related to the underneath uh salivary gland. Um Other other causes would be uh neuromas and cysts within the protein gland. Uh lymphadenopathy secondary to otitis, externa or skin and scalp infections, dental infections and mastoiditis causing a subperiosteal lases and drainage into the upper neck behind the tail of the carotid. Benign tumors are usually slow growing painless masses. Um The most common is pleomorphic adenoma which with which uh comes with a malignant transformation rate of 2 to 5%. Um The most common tumor of the malignant tumors is mucoepidermoid uh or metastasis from skin primaries. Um red flags in um s um tumors of the salivary glands, uh include hardness, rapid growth tenderness, infiltration of the surrounding structures, overlying skin ulceration and facial weakness in the photo. The photo shows a pleomorphic adenoma of the left parotid gland, a little bit of on. Uh uh some information uh let's put it that way on um voice disorders and um laryngeal um conditions. Um so voice disorder. So, so the causes for voice diso disorders can be um divided into two major groups, structural and functional amongst the structural. Number one would be neoplastic and malignant such as low gel car carcinoma. Um It, it you should always consider if there is hoarseness, persisting for more than six weeks. Um It is caused by smoking but it could be genetic as well. And uh symptoms include progressive hoarseness, stridor, referred aia, difficulty swallowing and lymphadenopathy. And the treatment is with radiotherapy and surgery. Um, nodules are benign, um little uh swellings of the vocal folds. Um They, they affect usually the anterior part of the vocal folds um and they are caused by voice abuse, shouting, talking about background noise and reflux. Um The treatment is uh with voice therapy. Uh surgical excision is very, very rare and is indicated only if they don't respond to voice therapy. Um, polyps is another uh type of um benign swellings of the, the, the vocal vocal folds. Um again, they, they, they are caused by uh voice abuse um especially when there is an underlying cold. So shouting when suffering with a cold or er Lango reflux. Um the voice is husky worsens with views may be deeper cuts out during speaking and they may have shocking episodes as well. And um usually they on a direct view on flexible laryngoscopy, they present either as a hemorrhagic swelling um arising from the mid uh membraneous portion of the vocal fold or um uh like a smooth um swelling. Um sometimes can be a gray color. Uh Treatment is surgical with or without voice therapy afterwards. Rian edema is directly um uh linked to smoking. Um Basically, it's um edema of um of both vocal folds, uh which can um be hemorrhagic as well. Um And uh it, it causes a deep uh gravely, deep pitched, gravely voice, um and sometimes jogging episodes and it can compromise the airway. Of course. Um Treatment is includes smoking, cessation and surgical reduction of the polypoidal uh swelling. Cysts are another um cause for voice disorders. Um The cause is unknown. The etiologies unknown, there are two types of cysts in the, in the larynx, mucus retention cysts, um and epidermoid cysts. The top photo um shows a mucus retention cyst and the, the lower photo, uh the bottom photo shows um epidermoid cyst. Um uh they, they, they, they on a flexible laryngoscopy, they, they show like um uh nodular swelling or uh a localized bulge or stiffness of the vocal fold, which is um w which can be shown on stroboscopy. Um The treatment includes surgical, surgical excision and uh voice therapy. Um infectious laryngitis could be viral, bacteria or fungal um in viral um laryngitis. There is uh usually on examination, there is a hypervascularity of the vocal folds. Um if it cause if it is caused by human papilloma virus six or 11 which can result in a condition called uh recurrent respiratory uh papilloma. Um then you can see a growth, papillomatous growth uh which can be anywhere uh in the larynx. Um uh infectious laryngitis can also be bacterial um and a fungal um in, in the fungal laryngitis, there is a slough um in the vocal cords and around the, the vocal folds. Um and there is a, of course a um a white patch which is called eucopia and, and it's a, a risk factor for laryngeal carcinoma. Um Treatment is with voice rest analgesia, surgical excision with laser or microdebrider. Um noninfectious laryngitis is uh caused usually by um extra esophageal reflux uh or allergies. Um The huskiness is um variable and the voice may, may worsen with use. Uh There's a lot of higher range uh of voice, uh chronic throat clearing, um excessive mucus in the throat, choking glos um symptoms. Um And on, on, on examination, there is uh edema and uh eryth of the vocal folds. Uh but it can affect the interarytenoid area or the post cricoid area. Um Treatment is with vocal hygiene, dietary vs PPIs and CS advance. Um paralysis of the recurrent laryngeal nerve um can be caused by uh surgical trauma. Um uh malignant disease, uh neurological disorders or it can be idiopathic of unknown cause. Um patients develop a present, sorry with a weak voice which tires and talking perilaryngeal discomfort, choking with fluids, higher pitched voice diplophonia, which is basically two tone voice and a weak cough. Um um obviously on examination, uh only one vocal chord is moving. Uh on this occasion, it's the right vocal fold, left vocal chord is fixed. Um And investigations incl include a CT from the skull base to mid forex and treatment. Um If it's idiopathic a wait for spontaneous recovery up to, I would say two years, um voice therapy, um and uh vocal cord medialization um with uh injections or uh thyroplasty muscle tension, dysphonia is a functional disorder of the larynx. It is caused by stress, anxiety, depression, neck and back problems, poor vocal hygiene, um working in dusty smoky, noisy environments with excessive tension to overcome a deficiency in the voice production. Um The voice is croaky husky Brey, bizarre or aphonic. Um The cough is normal um and vocal cords are normal. There are no structural lesions with good movement, but there is constriction and it can vary from mild up to uh quite severe where you are not able to see the vocal folds at all on examination. Um Treatment is um um conservative with vocal hygiene, uh advice on vocal hygiene and uh voice therapy. Um Stridor is an emergency. Stridor is noisy breathing. Um It can be inspiratory when the obstruction is at the laryngeal level, expiratory when the obstruction is at the level uh uh of the lower airways or mixed uh uh uh when the obstruction, obstruction is at the level of the trach laryngeal or lower airways. Um It can be causes, can be uh congenital such as laryngomalacia, vocal cord palsy or web subglottic stenosis or acquired uh such as in uh uh following trauma. Um for embodies, angioedema, Pittis, croup, vocal cords, palsy, laryngeal, carcinoma, subglottic stenosis, et cetera. Um When you're assessing the severity of the stridor, you want to know um whether it's present on exertion only whether it's present on deep aspiration. Is it audible all the time? Um And patient is unable to and patient is unable to hold normal conversation. Um Does the patient talk in short phrase, phrases? Um Are they only able to get old words out? Are they unable to talk? Um Do they use their accessory muscles? Are they sinus? Um Are they in respiratory arrest? Um Management is um the same. Uh general management is the same um up up until to the point that you know, a specific underlying condition um cause is identified. So you need to make sure that the, the mouth and the uro pharynx are clear. You give heliox if it's uh available uh where you work oxygen, um nebulized adrenaline steroids, uh nebulized or intravenous. And then you need to consider uh to involve anesthetist and ent surgeons if despite the above management um options, uh it's getting the stridor persist or it's getting worse. In which case, um endotracheal intubation would be an option or a front of the neck access with a cricotomy or a tracheostomy. Um ter is different as stridor. I just wanted to um make a little note of it. It's just a noise produced at the level of the oral or nasopharynx. For example, snoring, snoring is a type of ST um I'd like to touch or a pork masses. Um Just generally to tell you that, you know, in um we use a AAA nodal level system um to simplify the discussion of lymph nodes and to ensure that we are all talking the same language and hence, we divide the nodes in, in six groups. Um I'm not gonna go into details. You're gonna forget about it uh in two minutes. Um I just want to, to, to tell you that when a patient comes to you with a, with a neck mass, um you can uh sort of um start to think what this could be um based on their age. So in, in people with less than 20 years of age, the, the, the the cause of the neck neck mass would be more likely to be inflammatory congenital or a lymphoma in uh in ages between 2040 years old. Um salivary gland disease and thyroid disease are uh uh more likely to be uh uh the reason for the neck mass and then over forties, malignancy. Um when I was 20 I found this as a junior um um registrar, I found this very helpful because it's a diagram of all the neck lumps that could possibly see in the neck um and the very likely diagnosis. So, if we see a lump in, in in the submental area, for example, this could be represent a segmental node or it could be a um a metastatic node with a primary in the oral cavity or teeth. Um Similarly, if it's in the upper neck, uh uh side of the neck, um could be a bronchial cyst. Uh If it's in the, the angle of the Mandle ball, it could be related to the protid gland or if it's in the upper digastric, sorry in the upper cervical um nodes, it could be a uh the primary could be in the oropharynx, larynx or hypopharynx um in the posterior triangle, think primary in the skin scalp or postnasal space um in, in, in, in the middle of the neck. Um higher up closer to the hyoid bone could represent the thyroglossal cyst uh in the lower neck, thyroid, supraclavicular uh node could uh be metastatic from um gut, chest, breast or lung. Um urgent referral on two week, wait require any lymph nodes, any neck masses that are rapidly growing, they're firm heart and over three centimeter in diameter, they are associated with other unexplained signs of ill health, night sweats, weight loss, persistent fever, um and any enlarged supraclavicular nodes in the absence of local infection. Um just a AAA little bit about head and neck cancer. Uh We, we, we give this um term to a variety of malignant tumors that develop in the oral cavity, pharynx, paranasal sinuses, nasal cavity, larynx, salivary glands, and thyroid gland. It's the sixth most common cancer worldwide. It's more common in men and older people. Risk factors as you very well know, uh include smoking, both tobacco and marijuana or chewing tobacco, alcohol use and leucoplakia. Um Most of the cancers are squamous cell car, but there are other tumor types such as lymphoma, adenoid cystic mccoy. Um Ain cell which are found in the salivary glands, papillary, follicular medullary, um anaplastic in the gland sarcomas and undifferentiated carcinomas as well. Um The, the presentation includes persistent pain in the throat, odynophagia, dysphagia, persistent hoarseness, referred pain to the ear bleeding in the mouth or throat, enlarging, neck node, persistent ulceration, leukoplakia or erythroplakia, um lump or thickening in the oral soft tissues, soreness or feeling that something is stuck in the throat, difficulty chewing or opening of the mouth, difficulty moving the tongue numbness of the tongue or other parts of the mouth, swelling of the jaw that causes dangerous to feed poorly or become uncomfortable. Um We use various tools to help us with uh to confirm diagnosis. Of course, detailed history and examination is uh number one uh tool. Um We use fine needle aspiration for cytology of any neck masses. Um imaging with CT MRI of the neck, from skull base to thoracic inlet uh sometimes with the chest x rays and ct chest uh blood test, of course, um and panendoscopy with biopsies. And it is uh also another important thing is to assess nutritional status of the patient. Um which is important uh in um uh decision making about treatment. Treatment includes surgery, radiation chemotherapy, either alone or in combination. And it can be curative or palliative. Most suitable treatment plan is discussed at an entity uh meeting. And with regards to staging, staging, as you know, is a process of describing the extent to which cancer has spread from the side of its origin. We use the letter T um for the size of the primary tumor. Um N for the regional lymph node involvement and m for um distant metastasis, um absence or presence. Um and just a few words, starting thyroid cancer, um the incidence um has increased but mortality has remained low. The risk factors include radiation exposure and family history. The staging is a bit different with uh thyroid cancer. We use ultrasound of the neck to look at the size lymph nodes and the presence of metastasis. Um imaging CT in the form of CT or MRI is used in selected cases. Um thyroid nodules undergo further cytological classification um with 51255. and uh uh the entity, the multidisciplinary team um will recommend appropriate combination of surgery plus or minus radiotherapy plus or minus chemotherapy if indicated. Um The order of prevalence is um papillary follicular medullary anaplastic thyroid cancer, as well as lymphoma of the thyroid gland. Any uh uh an urgent referral on the on the two week wait, um is required for any solitary nodule increasing in size, history of neck radiation, um, family history of endocrine tumor, unexplained hoarseness or voice changes when there is cervical lymphadenopathy, very young patients um and patients aged 65 years and older. Hm. Thank you for listening. Thank you for being very patient. And I do apologize if it has felt as if I was rushing, but I was a little bit. I was concerned that I wouldn't be able to go through the whole all the presentation and, um, talk to you about all these things within an hour. Oh, thank you so much doctor. It was a great sessions. Hi, everyone. If you have any questions, please do put it in the chat. I think we have one question here. Are you able to see the chat by any chance? Um, or I'll, I'll read out, read it out. Oh, is it about Ramsey Hunt? Yeah. Yeah. So, uh, yes, for early treatment of, uh, Ramsay Hunt syndrome does early refer to hours or days if there is a delay of few hours from, is that acceptable? Um, it's not hours, it's days within three days, 72 hours. Ideally, um, but if obviously for II understand that, um, delays can happen, uh, it's not the end of the world, we can still give the treatment as long as they, they don't come to us after three months. Ok. Ok. Thank you. I think we have few minutes to spare. I'll just give a few minutes if anybody has any questions. Fantastic. Um Marriott, I'm going to email you this presentation so you can share it with um, everyone. Yeah, I think that would be great and helpful, but thank you, you II think covered most of the ent at this level and that would be great for them. E ND is a very diverse speciality. I wish I had time to speak about it more because we didn't cover allergic rhinitis, non allergic rhinitis. Um, but I think that most people are, you know, know how to treat these conditions more or less. Um, they're not very challenging and, and when to refer, you know, patients. Um Anyway, thank you. Thank you so much. I've tried to keep it simple and I hope it's useful to you all and best of luck with your exams. No, I think, I think it would be definitely helpful to, for them. Most of us we didn't had ENTs or placements during the medical school. I mean, or if even if they were, they were very small, but they do come in exam, especially if they are like looking for surgery ahead like mrcs and stuff. There are lots of questions and this I think will definitely help them a lot in this, uh and hopefully uh in the exam and enter into training as well. Fantastic. Ok. Yeah, I would love to have you in the Sherwood Forest in the NT Department. II think there would be a lot of them who would be aspiring to be NT surgeons. So it would be even better, even better. Yeah, thank you. Fabulous. Thank you so much. Thank you. Thank you, enjoy the rest of the weekend and thank you for doing it. Thank you very much. Bye bye. Ok, so we're now we're approaching the final session of the day. Uh, we'll give it a brief f 4 to 5 minute break and then we'll resume at 5 p.m. Ok?