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Yeah. So, um my name's Prudence. I'll be the one presenting today or are you going to introduce? It's just so good afternoon, everyone. Thank you so much for joining the third session of subcultures um teaching series this year, this session is on his nose and throat and um max back surgery with the first part of it. Kind of focusing more on the ent aspect. Your teacher for today is prudent who is a budding E N T plastics or all of those sergeant. And you're in the very capable hands of her for this session. She has a beautiful presentation lined up. So I'm sure you're in for a treat. Um, over to you, Prudent. Great, thanks Hannah. Um So yes, my name's Prudence. I'll be doing part with part one of the presentation today. Um So it's more ent focused and um now I'm just going to share my screen and if there are any questions, um I think Hannah can um, can answer them in the chat box or I can try to answer them at the end of the session. Um There should be a relatively short talk. I'm just going to share my screen. Yeah. So, um I hope everyone can see that if um you can't, please just shout out so I can know. Um So yes, this is part one and thanks to our sponsors, I mean, partners. Um Yep. So these are, are learning outcomes. I have highlighted the conditions in red. So we're gonna talk about a few years, a few nose and a few um parroted conditions today. So just starting off with the ears, um just going to quickly talk about the anatomy of the ear. So we've got three parts, we've got the external air, which is the pinner. So this is our cartilage that leads us into the ear canal, which then leads us to, to the tympanic membrane. So the eardrum and this is the any air, sorry, the middle ear. So we've got three um bones and these are the smallest bones in our body. We've got the malleus incus stapes and then this leads us into the oval window and this leads us also into the any air. So we've got the cochlear for hearing and uh we've also got these semicircular canals for um uh balance and equilibrium. So I'm just going to talk about the tympanic membrane. So, um this is just um what you, you should be able to see when you're doing an um auto scope. So you've got the lateral process of the malleus that leads you into the handle of the malleus, which is usually quite visible um when doing an auto scope and then you've got um past placid er and also passed tensor. So this is the more tense bit of the eardrum. And um an important landmark of um the tympanic membrane is the cone of light. And this is used to orientate whether you're looking into the right or into the left ear. So with the left ear, you should see it in seven o'clock and with the right way, you should see it in a five o'clock position. So as you can see for this particular image, um it would be the just give you three seconds to think 3 to 1, there should be the right ear. Okay. So moving on to our first condition, this is gonna be a titus media with effusion. Um So this is the infection of the middle ear is also known as glue ear and this is caused by a build up of um inflammatory fluid in the middle ear. And this um as a lot of air conditions commonly affects Children because of the anatomy of the your station tube. So we can see that on the picture um in the right top hand corner, um in Children, the station to be a short it and more horizontal. So then any infection in their nose can easily travel to the ear. Whereas in adults it's more um becomes more tilted. So then um infection in the nose won't travel as easily as Children into the ears. And um this condition is also the most common cause of hearing loss in Children. So just some risk factors. Um young age. So Children, younger than the age of six are more commonly affected um smoking or passive smoking. Um if the infants or Children has got any um cranial facial abnormalities like cleft, lip or cleft palate. Um The use of a dummy bottle feeding in supine position also recurrent um upper respiratory tract infections, um, some signs and symptoms. So, um, you can get difficulty hearing and this is a bit more difficult to tell in um, Children who can't talk. So, so, um, in younger Children, they could percent us ear tugging and also having difficulty in school. And um, can anyone guess if this sort of hearing would be conduct, conductive or neurosensory hearing loss? Um I can't see the chat. So if Hana can um, see if anyone's gonna comment in the chat box, it's not all just inductive. Yes, that's conductive. Yes, because um, you're just blocking the um, canal. So that's more external. That's right. Thanks, Hannah. Um So you also get a sensation of pressure. Um, and less commonly, people can experience vertical and also balance problems. Okay. So some investigations. So first thing, if someone presents other G P, they'll most likely um perform, going to perform autostrada P. So when you look at the tympanic membrane, um they can look retracted or bulging, they can be um scarring in the tympanic membrane, it can appear dull, so like a yellowish or blue color and you, because it might be bulging, um you might not be able to see the code of light reflex and there you might be able to see bubbles behind the your drum as well. So just got a picture here and as you can see the, you can still sort of see the cone of light reflex and there's some bubbles behind the ear drum. So this would be a left, yes, left um Glue ear and some other investigation, you can, you can do this um the rainy and we're best test and also um in a secondary care setting, you can also do audio audiometry or Simpanan Aama tree. Um So if a case scenario, if a male child presents with the right glue ear, um what will his Riney tests show on his right ear? So many, I hope everyone remembers what the rainy test is. So that's when you put the um shooting for behind the ear. So if anyone wants to shout out any answer, no, I'll just refill it. Um So the Riney tests should show that because this is a conductive hearing loss. You should show that bone conduction is um travels faster than air conduction. So um the person would be able to hear the sound louder with when the training focus touching the bone. And so in the weather's test, this is always quite confusing um which sound, so it will the sound lateralized to his right or the left ear. So in a conductive loss setting, um hearing loss setting, um the sound will lateralize to the affected ear. So this will be the right ear. So with management, um the nice guidelines suggest active surveillance for three months because most most cases would resolve on their own. But um they should include to hearing tests um at least three months apart as well as to manometry and um in older Children, they um nice guidelines also recommend them to do also inflation all the false have a movement manoeuvre. So that that is when you press on your nose and you try to blow. Um so that your ear drums would inflict to equalize the pressure in your ears. And if this is not resolved in within three months, um got two different options. So with nonsurgical option, you can use hearing aids, with surgical option. Um that the option is to do myringotomy with the insertion of grommets. So these are more specific, nice guideline details of who are of the eligibility of the grommets. So this is a picture of how a gram it looks like within um the eardrum. So this can drain help, drain the fluid in the air. So that's all for um otitis media within infusion. Um I'm just gonna quickly talk about tympanic membrane membrane perforation. So there are a few courses it could be a complication of otitis media. So glue here or just without infusion, um it could be due to draw trauma. So people using a cotton bed um in in their ears or head injury. And also um our trauma which is when you go scuba diving or if you hear explosive noise that courses trauma to the ears. So some features can include conductive hearing loss, just like um otitis media, you can experience ear pain, um and also you can get a recurrent ear infections because there's a perforation in the A drum. Um, with management, um, small perforations usually resolve on their own, however large perforations, um, usually require surgery and this surgery is usually done by um using a graft to um sort of patch up the hole in the ear drum and then next we're moving to the external air. So a condition called cauliflower air. Um, sorry. Yeah, that's um, so this is a deformity of the pinner as a result of untreated or repeated more regular hematoma us. So you can see on the picture. Um, this is a well known MMA fighter called Cab Bebe Know, mcglone Mendeloff. Sorry, I don't have to pronounce that. Um, so yeah, he is uh M M M fight fight fight, er, and you can see on his right ear, he's got the cauliflower appearance here and just talking more about a regular hematoma, it's usually caused by trauma or direct blow to the ear. So, this is more commonly seen in rugby players boxes, um people who do contact sports. Um so the the mechanism is that's the trauma courses of blood vessels to tear in the perichondrium. So that's the layer overlying the cartilage. So that will result in the hematoma and this will lead to impaired blood supply to the underlying cartilage. So there would be a risk of the vascular necrosis to the pinner and because of the injury, um there would be some repair done and fibrocartilage overgrowth might take place and this will lead to the appearance of the air. So this is quite a, so this is quite a uh emergency. So, so that you don't get cauliflower air, if there's, there's someone who has presented with a regular hematoma. So this is just a quick um anatomy of the penis. I've got the helix antihelix, agonal anti triggers, the lobe got the triggers and the culture. So this is just to show you how the normal anatomy should be okay. Um So if someone presents with a hematoma in the air, it's important to assess it. So, so you start by inspection and also power patient of the external air and also any um bones surrounding it. So like the pope and poorer bone and also um the parietal bonus or perhaps um and you'd like to do an autopsy capi to check if, if there's any um injury into the middle ear. And this is usually a clinical diagnosis, um it's also important to rule out a temporal bone fracture um which will include the um features such as um hearing loss, um facial nerve injury or pulse e and also battle sign. So this is um what that'll sign looks like, which is um leading into the post auricular area. So, if anyone presents with these features, it's more alarming. So management wise because there's a risk of the vascular necrosis and the appearance of the cauliflower, it's important to drain it as soon as possible. So, so this should be done in, in an aseptic field. So um prefer for the in theaters. So just some steps of how this is done. So you apply no local anesthetic to the air and then you make an incision um preferably in the in the room of the Helix. So that aesthetically looks nicer and then the hematoma is evacuated and there will be a tight dressing applied. So that to prevent any more um hem a thomas forming and then your future the attempt to um suture it up. So this is just a quick picture to demonstrate how it's done. So the incision is made here and then you apply a tight um dressing with vertical mattresses. Okay. So now that's all done with here. So we're going to move on to the nose. Um just a quick recap with the anatomy of the nasal cavity. So, we've got three images here. So um the nasal cavity can be separated into three parts um are seen on this picture. So we've got the respiratory region. So the the region in red, um olfactory regions, the region and blue responsible for smell and the festival. And then we can also see that um the nasal cavity is made up of a lot of um bones. So we've got the nasal bone, the frontal bone, ethmoid, um the sphenoid foma, maxillary and um palatine bones. And then um these bones also create um pathways called um meatus. And this is done by the different conscious so conscious. So I've got superior, middle and inferior concha and it's a very important for the um your breathing. So some functions, first of all, smell, this is very important, of course, um this warms the inspired air, especially very important for winter nowadays. So you don't feel like your um your breathing in air that's too cold. And there's also um help and also the nasal cavity helps trap particles. So it's, it's important for our immune system as well. And also this um the nasal cavity drains are paranasal sinuses and also are like more ducks. So, just a picture to show our sinuses. So we've got four pairs. Um so the frontal ethmoid like celery and our sphenoid sinuses and just more, more about the functions of our turbinates. So I can't chase um this form for matrices. So, these are the pathways I mentioned um when we breathe. So this helps to increase surface area, slows down the air. Um we breathe in so it's humidified and also some proposed functions of the sinuses because it's not very well understood yet. So, um it helps, they help reduce the weight of our head, helps him who mid if I up the air helps aid voice resonance and also act as an actis airbags in traumatic events and also help support giving system. So, um the nasal cavity is important in a surgical sense for this type of procedure called the transsphenoidal surgery. So I'm sure um some of us might have heard of it. Um This is also called endoscopic endoscopic transsphenoidal surgery. So E T S S, it's a very common surgical management for perpetuity. Tumor's. So just a picture illustrating how it's done. So, an endoscope will be inserted into our nasal cavity and this reaches our sphenoid bone and we can see that the pituitary gland sits on the cell, it urtica of this uh you know, it bone and that will help. That is how the pituitary gland can be removed. Um This is quite minimally minimally and face and face of competitive. We had to make a big incision in into our cranium. So, yes, the this is just the anatomy. So the pituitary pituitary gland sits on top of the Zyrtec Solar Tess ICKA. Um Yeah, and that's the importance of the nasal cavity and it's gonna talk about epis taxes so nosebleeds. Um There are multiple courses such as trauma clotting disorders. Um if anyone's on anti coags or even the change in weather, so if it's too cold or it's too dry, it's too hot that, that can lead to um no split as well. So there are two types. So anterior bleeds. Um There are more common. Um this is due to the rupture of the vessels in the kissel backs, plexus also known as the little area. So this is a highly vascular region because there's um the system anastomosis of five arteries in this area. So this just shows um the anastomosis of the five arteries. So it's yeah, more common. Um and the second type is the posterior bleed and this is usually due to the rupture of this sphenopalatine artery. So it's more um posterior as you can see here or the or the terminal branches of the maxillary artery, which isn't shown on this uh image. And as this small posterior carries the risk of airway compromise. So this is um more alarming. Um So for the management, always in a step wise approach. So first thing to do um would always just to pinch, to be pinching, pinching down on the cartilage. So here um not on the bone because that doesn't do anything. So on the cartilage with the help head tilted forward for at least 15 minutes. And if that doesn't stop the, if that doesn't stop the bleeding, then um by the time they, hopefully the patient's would be in E D or in uh an outpatient setting. And the second thing done should be um nasal cautery. So this is using so finale trait on a like a little stick that helps to quartering eyes, the arteries if you can see the bleeding point. Um And then thirdly if that doesn't help, um you'd have to do uh to do nasal packing. Um I've got some images suddenly if yes. So this is what a pack looks like. It just, it's like a big cotton cotton thingy that goes up your nasal cavity and helps to block the helped absorb and also compress on the bleeding points. And this is an interior one and this would be a posterior one for pasta gary bleeds. And yeah, usually they would by that, by that point and the patient's would require admission because that would be quite serious if they keep bleeding still. And if everything fails to patient's would hopefully need to do surgery. So this is done by ligating the vessels commonly this phon oh Palantine artery. So this is done um Endoscopically just got a picture here. Um So I'm not too, I'm not too sure actually how this I can describe this, but this is a picture I found on the internet. Um So I believe they are, they found this phenotype Allentown artery and they're just um clipping it so that um the bleeding stops So that's it for um know Swedes and a very important um condition to mention in um E N T setting is a septal hematoma. So this is always an emergency um um uh thing to manage. Um So you can see there is um a hematoma in the septal cartilage and this happens um when the blood vessels between the cartilage and the perichondrium tier and accumulate and there would be a vascular compromise to the cartilage which will also again, um lead to the risk of developing avascular necrosis. And because um in fact, um and that will also lead to that may also lead to septal perforation and also the saddlenose and deformity due to the compromise in the vasculature. So this is what a sad a nose looks like. And therefore, this is quite an important um condition to recognize. So anyone who presents with um any trauma to nose should always be checked for sepp talking martoma. And how would we manage this? So, if that's as this is quite urgent, we'll need to do an urgent incision and drainage. And that's um everything done for nose. And lastly, I'm just going to talk about salivary glands. So we've got three pairs of saliva glands. We've got the biggest one which is rotted and then we've got decent mandible a and the sublingual glands as well. So just some um information about them. So, sublingual is the smallest out of three, um contributes to a small volume of our saliva. Um So this is the drainage pathways. So it's quite a complex one. Um It's innovated by the court dart and party. So that's a branch of a cranial nerve. Um seven and then there's some mandibular glands they found below um behind the ramos of the mandibular mandible. Sorry. So it should be around here. Um Drainage is the duct, the water stocked um into the sublingual populate and the neurovascular suppliers same ask you sublingual glands. So also innovated by the um cord a timpani, the porotic glands um life superficially to the mandibular ramus. So just here, um drainage is from the Stenson ducked into the oral cavity um near the second upper molar. So sometimes I can feel it when I'm salivating. I can feel that like where it's coming from as well. The drainage of the porotic glands. Um it's innovated by um this is a more complex um pathway of innovation. So it's the, it's from the cranial nerve nine into the otic gang ganglion and then finally into the irregular temporal enough. So that's the branch of cranial nerve if 55. See. So that's the Oh, sorry. Yep. So that's the yeah queen of five and then the blood supply is from the posterior regular and this superficial temporal arteries. So, facial nerve and the parotid gland important, very important um and side by side and fatima and anatomical structures. So, um the facial nerves give gives are five branches within the parodic land. So that's why um any porotic pathologies can um commonly affect the facial nerve such as tumor's or parodied itis porotic itis. So this is just a picture illustrating the five branches. We've got 12345 and um yep. So temporal zygomatic buckle mandible and suffix call and a pneumonic that I learned in medical school was 10 zombies. Fit my cat. So these are the five branches of the facial nerve. Um Other important structures around the parotid gland is the external carotid artery and also the retro amendable Athene. So this is a picture showing that. So that is the artery just running along the parroted and also the fame just here. So, onto salivary gland tumor's um they are quite rare. Um They can be benign, malignant or mixed, usually mixed is when benign tumor becomes malignant. So, parotid are more porotic tumor's are more commonly benign. While some and some mandibular and sublingual are more commonly malignant. So just like many tumor's, they normally present as a slow growing painless mass. So if it's painful, then it might suggest something else, but usually it's painless. Um And they may also cause facial nerve policy as um they're closely related to the facial nerve. And um the most common type of the night um is called pleomorphic adenoma. So they're pleomorphic is the um there named pleomorphic because they can become malignant and with saliva gland tumor is the most commonly managed surgically. So, um surgical resection is done plus or minus cervical lymph node clearance and also plus or minus a driven radiotherapy and some complications of um parathyroidectomy. So, patient commonly can complain of facial nerve paralysis and this is usually self limiting. So, so it will resolve within 12 weeks. Um Also people can get saliva, the fistula. This is when there's official a between the skin and also um the parotid gland. Um for example, and then some people may have um saliva dripping down their face. And this is also also usually self limiting and the more rare complication is the phrase syndrome. So this is when people um salivate um when they're eating and they get sweating and flushing of their face. Um This is due to the auricular temporal nerve being injured as this nerve innovates the parotid gland and there is um parasympathetic um supply to that. So when it's injured, it can present us um sweating and flushing when people are eating. So, um this is just a surgical incision um for shown in the picture here for parotid glands, humor's and this is also commonly seen in people with face lifts. So, um that's all for my presentation and my colleague will do part two on Friday at 6:30 p.m. So, thank you very much. And um yet future sessions couldn't be seen on sector dot U K. Um Thank you so much prudent to that wonderful session. Um I hope everyone's learned something from that. Uh The feedback form is in the chat. So it'd be greatly appreciated if you could take a few minutes just to fill that up. And I think that's all from us today. If there were no questions from anyone. Great. Um So we'll see you on Friday then. Yeah. Um Someone's asking if they can get this light. I'm not sure. What do you think? China? Yeah. So the slight be uploaded on the metal platform by tomorrow latest. So just keep an eye out for them. Great. Thank you everyone. Bye.