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Awesome. Alright. I think, I think we're live now. Uh, good evening, everyone hope everyone's doing well and had a fantastic week. My name is James, uh, one of the co chairs of soup to and uh, we're very glad to have Damilola Matthew here from Aston Medical School to give her presentation on the second session of E N T and Max Facts surgery. We're very excited to learn about the specialty and we're really looking for presentation. Thanks again, Damilola for your time today. And uh, yeah, all the best. Take it away. No worries. So today we're gonna be talking about A N T and maxillofacial surgery like he said, and I'm damn e these are the sponsors for Super as usual and these are the learning outcomes for today. So we're gonna basically talk about the bony anatomy, sort of visa cranium and the TMJ. Then we're gonna talk a bit about the neuro vascular structures in the face and the head and neck. And then we're gonna talk about the condition of tonsilitis and some red flags that present in E N T. So the main thing is talking about anatomy just a bit of a recap, not really learning the whole thing. So talking about the visa cranium, the visa cranium is the whole of the brain is um is just the face of the brain of the bones, sorry, of the face and the of the head. What am I doing it? Sorry guys. Um So the neurocranium is the one that protects the brain. So the skull and then the visa cranium is the bit of your face and both of them together make up the cranium. What we're talking about is the visa cranium, like I said, and these are the bones here. So there's certain text that, that include the mandible and some don't include the mandible, but this is from Grey's Anatomy for students and they don't include Amanda. Most part of the visa cranium were talking about it. You can see here, you can see the frontal bone, you can see the vomer, you can see the Zygomatic bone E T C, the maxilla and this is just another structure, another view of the same structure. Then talking about the TMJ, the TMJ is a temporal mandibular joint. That is this over here, this joint capsule over here. The main importance is talking about how it attaches onto from the man, how the mandible attaches onto the temporal bone just behind the zygomatic process and then we will move on. So this is just kind of a recap not necessarily the lecture about that. Now, we're talking about the muscles of facial expression, the muscle of facial expression are the executor executor. The frontal is the orbicularis oculi optical area or is box box innate a muscle. The mentalist and the platysma. And they're very important because they help with regulating how you speak and how you talk, you're the fluidity of your speech as well. One thing I learned about the occipitofrontal. So this has to Belize there's a frontal belly and the occipet, the belly at the back on the occipet, the teacher when he taught us about head and neck, he was like, if you had a lacerations, for example, in the middle. So this is the upon you upon neurosis that connects the both of them. If you had a lacerations here, both sides would pull in opposite directions. So that's one way I've always been able to remember it since you said that. Like, I just imagine if you cut someone's head, like both parts of just pull like that. So then the, the hole in the middle just gets bigger and bigger and bigger. But yeah, it's not that deep, but I just thought was quite interesting. The, the nerve that innovates, the muscles of facial expression is cranial nerve seven. Does anyone know what nerve that is? In terms of the name of the nerve? I can't really see the chat say, I'll tell you if someone uh put something in the chest. Oh, thank you. Okay. Okay. So the cranial know seven is the facial. No, I'm just gonna move on because we've got a bit to do. And there's a key fact about the box in Ator that I'm not sure if anyone um is aware of, but if you are any key facts that you guys know about the box in nature muscle. Okay. So the key fact I was getting that is that it's pierced by the doctor, the parotid gland, which is important when it comes to things about for things like surgery E T C and then we'll continue on to the muscles of mastication. So the muscles of mastication, there's four of them and they're innovated, bike, raining of five. See. So the third branch of the trigeminal nerve, which is the mandibular nerve, that is the mass eater. The temporal is the medial part pterygoid and the lateral part pterygoid, the main function of the muscles of mastication is for chewing and for speech as well, just to make that your speech clearer like we're speaking about. Um So if you wanted to test out your muscle mastication, I'm not sure if you guys have done your examination, but you can get yourself to like clench your jaw. You can fill the muscles here and you can feel your temporal Asus well, here at the top clenching at the same time. So that just helps you to visualize where these muscles are on your face itself. The muscle that's important for a tympanoplasty does anyone, is anyone aware of this a tympanoplasty is when you um change the tympanic membrane in the? Okay, it's gonna leave for a bit. Is anyone aware of it or not? Really? Okay. I'm gonna take that as no one's really sure. So the temporalis fascia can be used to repair a perforated tympanic membrane is why I was getting out. So the muscle, the temporalis muscle is important in the tympanic plasty. The main reason why it's important to learn about these things is to learn about what can go wrong essentially. So the main thing we're worried about is for the facial expression of the muscle, facial expression is the risk of paralysis when there's damage to the facial nerve. So blame it to the feitian of can be idiopathic. So that's called Bell's palsy where someone just hasn't, has a damage to the facial nerve. So they can't move their face as much. And then of this price of of one half of the facial um most of facial expression and there's other areas where the facial nerve itself can be harmed. So if you had damage to your temporal bone, so trauma to your temporal bone that can cause your facial nerve to be at risk and porotic surgeries as well. Because the facial nerve also um merges from the behind the parotid gland as well. It pierces the parotid gland. And then we have the Ramsay Hunt syndrome. This is the one that I'm, I believe Justin Bieber had. Um and it's where it's a cause of Bell's palsy as well, where there's a varicella zoster virus that affects the nerve and then it causes the patient's to have a vesicular rash around the ear. And they also present with a facial palsy as well. This is a facial palsy. And so we're looking here to see and we're looking here and we see that this patient does not have forward sparing. So the next question goes on to talking about foreheads, parent. Is anyone aware about when we have a foreheads parent? Is it that it's an upper motor loo a lesion or lower motor neuron lesion? Is anyone aware of this or the answer for this? Okay. No worries. So the main thing here is that if it was if the forehead was spared, so it wouldn't look like this, whether this food will actually be able to move on both sides. That would be a upper motor neuron lesion because the forehead is special because it gets bilateral input from the upper, from the upper motor Lourens. However, it was a lower motor neuron input. It was a lower motor neuron lesion. It would affect just one side of the brain of the face, the whole half, it wouldn't spare the forehead cause it's lower motor. Okay. Now we're going on to talk about the facial nerve still and the course that it takes. So I was saying about how it's important for the portal gland if you had, if you had any surgery to political and that your facial nerve can be damaged. That's because the fashion of exits the school as a at the style of mastered fossa and it actually passes through the poetic gland and then it goes into its five terminal branches which are the temporal zygomatic bickel marginal mandibular and cervical branches. And then these all go off to supply the muscles of facial expression that we were speaking about previously. Now, we're gonna talk a bit about the trigeminal nerve. The trigeminal nerve is, is interesting cause it splits off into three. You have the Islamic nerve. Um you have the maxillary nerve and you have the, the mandibular nerve. These are the three and it comes out 123. the places where they leave the skull are the ophthalmic nerve which leaves at the superior orbital fissure which is just above the eye. The maxillary nerve which leaves at the form and rotund um and the mandibular love which leaves the cranium at the firm in a valley, those structures dimension previous and just the last two are mainly from the neurocranium. But then they're also interesting to note as well. Now we're gonna talk a bit about the external carotid artery. So normally, you know, as the heart as the delta pumps blood and the leaves, it splits off as well into the carotid arteries which then predicate into the internal and external carotid artery. The internal carotid artery travels along into the brain and it supplies the structures deep was inside the brain to the actual cerebrum and the cerebellum. However, the external carotid artery, they supply superficial structures around your face and your neck and things like that. The main ones that we're going to talk about is the two terminal roots, which are the maxillary and superficial temporal branches of the external carotid artery. And the maxillary artery supplies the tissues which are deep within your face. Whereas a superficial temporal artery, which is this one over here that supplies the structures which are more superficial and so it is the facial nerve as well. So this is just important to note as well. And we'll talk about the retro mandibular a vein and the retro mandibular vein, which is this one over here is made up of the maxillary and the super the superficial temporal vein kind of similar to what we just learned, but the opposite. So it's taken blood away on the head and neck. And the the retro mandibular vein vein, essentially, it descends, crossing the sternocleidomastoid and then it terminates by draining into the subclavian vein which and then go all the way down back into the to the superior vena cava, which is quite cool. This is the oral cavity. So the oral cavity has um a roof, it has a lateral wall, it has the floor of the wall and it also has the posterior part of the wall as well. So if you have a look here in the mouth, this is like a, a schemer of the oral cavity at the top. Here we see the roof of the oral cavity, which is the hard and the soft palate. Then we have the floor of the um oral cavity, which is the muscular diaphragm and the tongue. You have the posterior wall as well, which is the oral pharyngeal Christmas. And then you can further divide the oral cavity into 22 things into two separate parts. If it's divided by here, can you see this the um upper and lower dental arches? So if you have your teeth closed, you can divide the oral cavity into the oral cavity proper, which is behind the um upper and lower dental arches and the oral vegetable, which is a, this is a space which is just here. Okay. The oral cavity has three basic functions. It helps in digestion, communication and breathing digestion in the sense that it helps to um process food initially and also releases saliva as well in your mouth, which can help to start the process of digestion. You have communication, it helps to manipulate sounds are made by the larynx. And lastly, it helps with breathing as well. It can also act as a passage of a passageway for air as well. In terms of innovation for the oral cavity, the trigeminal nerve is the one that supplies main most of this century innovation. However, there's a special century fibers as well which comes from the anterior two thirds of the tongue. So that's um taste is a special sensory, is a special sense sense, sorry. And that is carried by the facial nerve which is cranial nerve seven. Then you have the muscles of the tongue as well, which are innovated by the hypoglossal nerve, which is cranial nerve 12. And then the potato glossal, which is innovated by the vagus nerve. I find it easier to learn these nerves in clusters. And then you can have um you can have the special ones, the ones that are like except this, which is innovative by something else, which is what I tend to learn like as a whole. I'm just talking about when I was studying for head and neck, for example. And all the muscles of the soft palate are innovated by the vagus nerve except the tensor palatine, which is innovated by the mandibular nerve. So for example, these two but bits, you learn the bits that involved are all supplied by the same thing. Then just really remember the bits are special talking about the soft palate as well. If you remember if, if you go back to your um cranial nerve examination, when your occupation to open their mouth and say, ah and you're looking for that evil a deviation as well. It comes into play here. If the soft palate is if the soft palate is getting innovation from both sides, okay, then it should elevate fine. However, if there's some problems with elevation, um so sorry from problems of innovation, then it will deviate towards the side of the lead to away from the sides of the lesion. So towards the normal side, um that is the main thing for the innovation of the oral cavity moving on. We're talking about the tonsils. So the tonsils are essentially a collection of lymphoid tissue. So they're very involved in infection control and they're very involved in T cells B B cells and macrophage formation. There's five of them in total, the pharyngeal tonsils, um which you can see over here just at the top there, then you have the tubal tonsils. You can't really see those here, but they found that the opening of their station tube from the ear. Um So that's here over here. Can you see that their tubal tonsils? So they're station tube that opens, opens down there, the palatine tonsils which are down here and the lingual tonsils as well, which are just behind the tongue. And the main function, like I said is to, is to um act against um any pathogens that want to trying to enter that through the nasal Frank's and oropharynx as well. Now, talking about condition, we have tonsillitis. I have a few questions here, but I'm not really getting any responses. However, I'll just get you to think about it on your own. I guess. So, what do you guys think about, what do you think is tonsilitis? What do you think patient's with tonsilitis present as and how would you distinguish between viral and bacterial tonsillitis based on their symptoms and signs? Thinking about these questions, I'm hoping to answer some of those as we go along. So, tonsillitis is just an inflammation of the tonsils as the word suggest itis, meaning inflammation, patient's typically present with a combination of acute onset of a sore throat. Almost every patient that presents the tonsilitis will have a sore throat. If it's more acute, they could have a fever, dysphasia. So, problems or painful, swallowing, nasal congestion, headache, eric, and cough depending on how far it's spread. Now, talking about the symptoms in that sense, if it was a viral etiology or a viral cause, most of these four symptoms will be present. However, if there's no cough present, that sometimes suggest that it would be more likely a bacterial cause for the tonsilitis, therefore, they will be needing things like antibiotics to keep it under control. Then you have in terms of the signs. So what you see as a doctor, you would see farengitis, fever, malaise and lymphadenopathy as well. So when a patient presents a tonsillitis, it's important to do a lymph node examination as well. The tonsils would you would then check it like you open the mouth, you know, with the light and the tongue depressor to look at the 10 tonsils. If they looked like this with the white bits and the yellow bits inside of it, that's more likely to be a bacterial course for your tonsilitis. However, if they just add immitis and a bit red and inflamed, then most likely just a viral inflammation. Um these are just things that you could use to aid your diagnosis, of course, but everything should be made according to what you see in front of you from the patient and your own clinical judgment, mainly you treat them with analgesia and hydration. However, like I said, if it was a bacterial cause, you'd want to give them some antibiotics as well according to your local guidelines. One thing to note here is that tonsillitis doesn't pose to be a problem most of the time. However, it can end up being a significant problem for some patient's. So there was one patient I was speaking to. So I'm in pediatrics at the moment and the patient literally gets about 7 to 8 um episodes of tonsillitis every single year and she was like, yeah, it's fine. My mom has to get to as well. So for these patient's, it doesn't seem to have much of a problem for them. But there's some people that having that constant, you know, infection and soy leanness with your tonsils doesn't, it just doesn't fit, it doesn't feel and it's not nice to keep having you know, recurrent tonsilitis like that because of the pain that you can get from it and the difficulties with swallowing E T C. So it's when it's really affecting a patient or there's just so many episodes happening every year that you then start considering taking out the tonsils, which is where E N T surgery comes in tonsillectomy is the removal of a palatine tonsils. And that's a definitive prevention for patient's that have recurrent tonsilitis. Like we're speaking about, this is the recommendation and nice gives to when you offer someone a tonsillectomy and there's some other indications as well that you can make. I think, I think this person needs it. So these are the tonsils, they will be very inflamed as well and then you just take them out. It's easy as that for that for emphasis. Um Okay. So moving on, we have complications of tonsillitis and tonsillectomy. One complication and the main complication for tonsillitis that we need to be aware of is peritoneal abscess is that can form and that's mainly from bacteria, tonsilitis, all tightest media, rheumatic fever and glomerulonephritis are very, very rare. But does anyone know what a peritoneal abscess is? I'm not sure I'm physically really fast. Sorry guys. Um So perry Tunsil abscess is essentially a abscess of perry. Meaning next two of the in the inflammation, the sorry, the inflammation spreading beyond just the tonsils and going to the areas around and surrounding the tonsils as well, and obviously, abscess is a collection of infective fluid, you know, in like a little sack in a contained sac um, complications or tonsilitis of tonsillectomy is themselves are prime. The main primary ones is hemorrhage. So, bleeding after a tonsillectomy and you can also have a lot of pain as well, obviously, because you've just had surgery. Um, so that's the main complication from tonsillectomy and tonsilitis. We'll get to a bit a bit more about white contact tonsil abscesses. Um But in particular, quite dangerous or what problems they compose. And that comes in here with the retro fire and your space. So the retro find your space is not very one too. It's not, it's not easy to visualize. But if you could just bear with me, I'll try to use this image to explain it properly to you guys. The retro find your space is a potential space that's within the body and it is, it can go all the way from the base of your skull down to the mediastinum depending on which one. The true true retropharyngeal space is the one that goes from the base of the skull to the mediastinum to the media. Sorry. No, that's the dangerous place. The true retropharyngeal space normally ends at the upper thoracic spine. That's where the ala fascia joins infuses of the visual fascia. So this is the L A fashion over here. If you can have a look, I don't know if you can see my mouth. But the a lot fashion from this picture here, you can see how it divides the retropharyngeal space to from the danger space. Yeah. So the retropharyngeal space, you can see how it kind of just ends up here. Whereas the danger space continues to go all the way down to the to literally to the level of the diaphragm. Now this composes a problem because obviously that allows for communication between the base of the skull and the mediastinum. And in everything in medicine is almost like just save the brain, save the brain. So you would really need to just save the brain in the most common causes of retropharyngeal abscess is our pyogenic lymphadenitis. And consular abscess is that we just spoke about and that's that spread can essentially go all the way up to the brain and cause, you know, things like meningitis and all the neurological complications which are more difficult to fix. And you would like to avoid them as much as possible. The symptoms are very nonspecific. They can't read, they might not even present with anything that you'd be like. Oh my God, that's definitely from the retropharyngeal space. The best way to know is to do a CT CT scan with contrast of the neck and the treatment for it is just surgical drainage. You just need to remove the abscess from the retropharyngeal space. Just anything really can affect this bit here, which is what we're trying to save because we don't want things to go up to the brain. These are the red flags that I was speaking about. So they might, they might come and present with these things, but they might not. So it's very, very good to get the CT scan first. So this is Trismus here. So that's locking of the jaw kind of. And then you have, they might not be able to move their neck as much. Their neck is very see stiff. You're having respiratory compromised, you're having chest pain, E T C, you're thinking that this is just spreading all over the pace. So maybe it's a retro find your space compromise and these are the red flags in general for E N T, I'm not really gonna go too much into it. But if you're thinking about things like the nose, your CSF leak, if you had trauma to your nose, then you'd be like, oh okay, you know, they just hit your nose. So if you're having CSF leak, there might be a basal skull fracture E T C. So you're just looking at things to make sure that there's nothing of higher compromise happening. So those are the main things I wanted to go through in this session. And obviously, like always, you can see the future sessions if you watch the recordings at doctor dot co dot UK. That is it, does anyone have any questions or you know anything like that? I hope I didn't go too quickly. I hope that was okay. Okay. Oh, I saw that. I saw, you know, sorry guys. Bear. That is it for everything? It's a day. No worries. I hope you guys have a great week and I'll see, I won't see you again. But yeah, I hope you guys have a great week. Bye everyone. Thank you so much. Damn e for that love, you know, it was really wonderful. Let me just don't want bombs so everyone can see me. Uh So that concludes this week is there's some throat session. I hope everyone tunes into next week. There is a feedback form that we're just going to attach to the bottom of this chat and would be greatly appreciated if everyone could fill that out. Thank you. Bye everyone.