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But like I said, so we supposed to cover ENT today and II mean, can you hear me again? Just I want to before. Um Yeah, we can hear you can see your screen. Perfect. So, yeah, we're going to come an ent today and the main purpose of the, the teaching series is not to make it too complex and overwhelm everybody, but just to sort of give people a bit more confidence and sort of maybe, maybe, you know, the, the aim would be to, for people to come away with, be able to manage some of the common sort of complications or presentations, er for the different specialties that we covered. Um And today we'll discuss the NT um so sponsored by the MDU and they've asked us to put this in. Um So, yeah, thank thanks to them, our aims and objectives of today. Uh Like all the series, all the um sessions so far is to get an understanding of the basic anatomy, um discuss about acute presentations for ent um and then how to manage them and how to make, how to be safe essentially in, in an ENT as a doctor on call. Um And then we'll sort of talk about the operative principles, but there aren't, there are actually too many that's a giveaway, but there aren't any, too many operative sort of surgical interventions uh for the, the sort of presentations we have to discuss if you have any questions, just pop them in the chat. Um And then hand there maybe give, if you flag them to me at some point. Um So I can try to answer them. So if we want, we can try and do a cahoot. Um just share the code and see if we, we do it. It's quite a short one. So, so don't worry too much. Um Just get your brains warm. If we don't get anyone, then we just sort of move on. But so if we get two people to use my tabs, I've got quite a few of and if I think we can, you can join as the game's going on. So um just, just that pin is, is there, I think. So we'll just start. So which of the following is the most common cause of epistaxis? Yeah. So no picking is actually is, is maybe the second most common but actually sort of idiopathic. So look, epistaxis often just occurs completely randomly without any obvious sort of cause. Um But nose picking is definitely a, a close second, I think. Yeah, that's true. So one of the guys is it falls um 95% of all nose bleeds are actually anterior and we can t we'll talk about that in a bit just whiz through this. What is the name of the vascular plexus at the anterior nasal septum? Yeah, Castle Backs Plexus. Um I should mention that we did that. We, we actually ran this um this session on Monday and there was some issues with, with presenting it online. So that's why we're doing it again. But, but they, um, they got this one right as well. It's Castle Backs Plexus or also known as Little's area and an A and Z. So let's see if this is Quins or tonsillitis. So, so 5050 I'll show you the me again. So, can you see my mouse? Yeah, we can. So if you see both of these tonsils are, they're swollen. There's, it's not as unilateral and it, it's the tonsils themselves which gives it away in a Quinsy, which we'll talk about. It's usually just anterior along this sort of, uh, I think it's a palatopharyngeal arch. It just is more anterior and you'll get uvular deviation. It's not always the easiest to see, but, but this is uh tonsillitis for this one. So, I've done a quiz or tonsillitis. That's right. So it's not the, sorry, not the best image I couldn't find much online. But if you could, you could just appreciate that, that this is a unilateral swelling of the left sort of peri tonsillar. So just anterior to the tonsil, there's the swelling area, um, and the uvula is just deviated to the right as well. Um It's the picture in, in the context of the history and things like that that help guide us. So more than a last one, hopefully warming up. Ok. Aspiration. Um IV, antibiotics are really important and sort of uh supportive management as well includes including fluids and rehydration and analgesia. But, but the main, main sort of treatment is aspiration. So we'll, we'll talk about it a bit more but well done. Um, my third, the second, I think it was a speed round, wasn't it the difference? You, you got a five, you got one more. Uh, and a so well done. Um, cool. So these are the sort of three main topics we're going to talk about and have a think about. Um, ent covers sort of lots of different presentations and pathologies. Um, but I, we want to focus specifically more on what might come through ed and be called to the junior doctor about and, um, what the junior doctors expected to sort of be able to manage and make safe, um, ent sort of covers a lot of, sort of the cancer, um, pathologies. Uh, and also there's a lot of sort of clinical, um, er, sort of, er, pathology that path pathologies that can be managed sort of clinically and sort of rather in the, the outpatient setting. Um, but these sort of are three common things that, that might come through Ed essentially. So we'll talk about Epistaxis and I'm Welsh. So this, I chose a Welsh rugby player, but, um, epistaxis is a nose is supposedly a fancy term for a nose bleed. Um, so that's one of the props obviously being bashed on the nose, er, for an, and so it's a rupture of a blood vessel within the nasal mucosa. So you, you, the sort of nasal mucosa is, has a really rich blood supply. As you can see, there's lots of these blood vessels. Um and the reason for that is to warm air and sort of to, to allow the air to be moistened and, and warmed as it goes down, sort of to the to the sort of more um distal airway. Um But as a consequence of that, with this thin sort of mucosal lining, there's a, there's a risk that these, these blood vessels can rupture and, and they can be quite friable um causing bleeding. Um As you can see in this image is you, you, you both knew that sort of the anterior sections is sort of the most common area and it, and it's where little, little area, um the plexus of blood vessels where all these sort of blood vessels sort of um merge is where the most common site of bleeding is. And, and they sort of talk about the, the vast vascular supply. So you've got two big branches that sort of the external carotid and the internal carotid and they sort of provide the branches that supply the nasal septum and the mucosa. And the internal carotid artery branches to the ophthalmic, which then provides these two anterior and posterior ethmoidal arteries and they travel inferiorly um and join the er sort of sphenopalatine artery um to, to form this castle backs plexus. The posterior, as mentioned in the quiz is called woodruff. So that's actually a venous plexus. We'll talk about that in a second. Um Yeah, 95% of, of nose bleeds come from the anterior part of the, of the nasal cavity, 5% from the posterior. Um So sort of the main differentiators between anterior and posterior, obviously one being it's so much more common. Um but the anterior sort of maybe think about what, what when we think about posteriors, when they're older patients, um when we've had difficulty managing nose bleeds, um a lot of our management is focused at anterior nosebleeds and with failure of management, you, you'd need to maybe start thinking about a posterior posterior bleed. Um There are obviously different sort of plexuses that cause this so littles versus woodruff's. Um and then it's part of your history or sort of examination, identifying if, if the blood is coming from one nostril that makes it more likely to be an anterior bleed. Uh but versus a posterior where you, you're more likely to have both nostrils and sort of you'll be able to see more blood at the back of the throat when you examine the oral cavity as well. So, and this is what it should look like um on your examination. So a thud come, which is basically a nasal speculum. You need to use one of those to sort of widen and like open the nostrils to allow you to get a good visualization and, and you should be wearing like a head torch as well. Uh And this is what you'd see in a typical anterior epistaxis. So sorry, we still side. But the question is, I guess, what do we do if we do nothing? Um The majority of, of, of patients presenting with epistaxis or not even presenting just having epistaxis that they will self resolve and they will stop spontaneously. Um The reason why you're involved as a, as a ent doctor on call maybe or a G doctor um is because they've not been, they've not resolved and there's still ongoing bleeding. So that's a risk and, and obviously with any bleeding, um like anywhere in the body, you're at risk of uh becoming hemodynamically unstable and that, that sort of might be life threatening. So it's obviously very uncommon that it gets to that point, but it's something that we need to be aware of and sort of need to need to be sort of keeping our, keeping our toes about sort of our, our management and sort of also thinking about resuscitation if needed. Yeah. So it may most results spontaneously. But if we've got continuous bleeding, that isn't being managed by our sort of steps that we'll talk about, you can get hemodynamically compromised patients. So axis we can divide into two sort of areas. So local and more general causes. Um I'll give you a second just to think about what um local causes could be. So local causes are sort of things around the nose. So you've got um idiopa idiopathic, as you mentioned, which is sort of 85% or 90%. Um You've got iatrogenic, which can be sort of uh nasal sprays or it can be surgery to the nose, um where just tissue is injured, you can have trauma. Um and you can have an inflammatory pathology such as rhino sinusitis, um which is inflammation causing the, the blood vessels and mucosa to be more uh sort of um friable and that causes the bleed, obviously, like, like we mentioned in the cahoot, there's nose picking a common cause, but, you know, assault and as we saw in the first slide or second side contact sport, um so often rugby players, what you'll see with lead all down their face from A n from a sort of big hit to the, the nose causing a nose bleed. Um And then thinking about more general causes. I wouldn't give you time to just sort of think about what, what they might be so more sort of systemic things. So that'll be platelet disorders. Um, so you can have primary platelet disorders or you can have secondary, which is caused by drugs and that could be like warfarin. Aspirin. Um Any sort of, well, warfarin obviously isn't, wouldn't reduce your platelets but aspirin and sort of tol things like that. Um, and then you've got hereditary con conditions like a hereditary, uh, t lect Taia, um, or any sort of coagulopathies essentially. Um, yeah. So it's not too many, it's usually sort of more, um, local is sort of the primary causes, but it's important to think about, you know, medications and any sort of, um, past medical histories or any family histories. So, like, like every sort of, um, session, we sort of want to divide our, our presentations into three main things. So you want to review the patient, you want to be able to make them safe and then you want to know when to escalate and how to escalate. Um, and we'll talk or talk about these. So, um, in axis, I guess their history is sort of self presents really but important features. I mean, if you have to think about what you might be asking and what, you know, someone, if maybe an, an ed doctor calls you, asking you to review this patient with Epistaxis, what sort of questions you'd want to ask and then also what you'd like to ask the patient. Um, it's important to know. What sort of time frame, how long have they been bleeding for? Um Is it in one nostril or the other? Um uh also, are they hemodynamically stable, you know, are they clammy cold? Are they sort of dizzy? Um Have they had this before? Have they had any recent surgical surgical procedures? Any trauma? Um And then obviously your, your past medical medication history is important and then fa family history thinking about uh coagulopathies. Um and have they been sick as well? So, so blood is often sort of a um when it, when it goes into the stomach, it can cause sickness, nausea and vomiting. So it sort of indicators but, but usually you'll be able to see it and it's sort of managing it quickly is the key. Um and then examining the patient. So I think it's important thing to sort of, obviously, you know, you've got the sight of the call that is just in your face. It's, it's hard not to see it, but at the same time, you do have to think about, you know, like any patient that you'll, you'll come with. So an A to e so airway breathing, circulation, disability, and exposure. So making sure the patient is hemodynamically stable, um you know, making sure you, you stabilize a patient uh before intervening. So, you know, they may need fluids or they may need blood products and they will need sort of bloods and things like that. But yeah, so your first protocol should be uh A to E and then you can, once you, you're happier patient stabilize, you can then uh go to examine sort of the nose. And that would be with a, with a th which is a nasal speculum looking in the nose and trying to identify any bleeding points. Um, you may need to clean the area up first or, or looking as well in the oral cavity and seeing if there's any blood at the, the back of. Um, so the oropharynx, um and then we'll talk about the different management options. So initial initial management is our first aid. So this is a question that you, you know, will be able to ask your ed doctor referring you or the GP whoever's asking you is you sort of need to emphasize the point of good first aid. So 20 minutes of this, um and have a think what, what that might be. Um and I'll start talking about it. So it's 20 minutes of pinching your, the soft part of your, of your nose. So the soft part there is and pinching hard, leaning your head forward. Um and then spitting any blood out, as I mentioned, the, the, the er, the blood, if it goes to the stomach can cause nausea and vomiting. Um, so it's important to ask, make the, make the patient spit any blood that goes to the back of the throat out and then some people can use ice packs on the neck or on the nose or on the forehead. And that often has been thought to help slow down or reduce um prolonged bleeding or help, help stop epistaxis. And so, yeah, and that's it. So to, to reassure the patient is really important. A lot of these patients are quite traumatized and panicky by the time they get to you as an ed doctor, uh Ent Junior, um you know, that it's obviously very visual and, and sort of uh people aren't used to seeing that much blood. So they're usually sort of in a bit of a state by the time you've seen them. So it's just really important to reassure them and, and, you know, a small amount of blood can look like quite a lot. Um So, yeah, it always helps. However, if so, some of the, you know, if you've done, if you know, if you're confident that good first aid management has been undertaken. So that's 20 minutes of that, you need to start thinking about different options and going down the line of your epistaxis management. So, um the first, the first step in that uh oh, sorry, I she mentioned that the, the red flags to think about when, when you start sort of thinking if this, if we'll need to go down further lines of management. But after first aid is, you know, are they on any anticoagulation like your warfarin? And um, have you got sky high? I nr um, have we, are they bleeding despite good treatment, uh, and trauma patients because, you know, their internal anatomy might be deformed. Um, but yeah, so if all first aid fails then you're, you're gonna start getting involved and that's initially with, um, cay essentially. So this is chemical cautery and I'm not sure if any of you have seen them before, but this is what you'd use. It's sort of um, Corry sticks, silver nitrate sticks and this is a silver nitrate covering here. And basically it, it reacts with water in your nasal mucosa um to cause a chemical reaction, an exothermic reaction um to make nitric acid, nitric acid. Er, and that is a heater exotherm reaction that, that sort of, yeah, essentially heats up the blood vessels and causing them to sort of be cauterized. Um What you, what you essentially do is you, you sort of get to make sure you've got a good site. So you're looking for that little area. And so you'll need to clean up, clean up the site first and have good lighting. So with a head torch, um you need to anesthetize slightly the area as well and, and this is often with sprays that contain lidocaine and can contain epinephrine. Um This is sort of has two fold. Um, reasons is be one is because obviously it, it, it um analgesia is the site. So this can be a little bit painful because it's a heat reaction and to it with the, obviously the vaso constrictors, lidocaine and epinephrine. So, um, this might actually help relieve the bleeding. The way we do that is we just get cotton wool and we soak it in a spray. Um, and then we put, put those at the, the patient's nostrils and then pinch the nose, give that 10 minutes that might even do the trick. But you need to sort of be anticipating that that's not going to work and have these sort of plan for a court. What you then need to do is you, you just, I'll go back to the, this. So you then need to sort of basically make a, a cylindrical sort of, um, a spiral sorry pattern of cautery. So you sort of dab here and then you dab here, dab here, dab here, dab here and then until you've made sort of a spiral shape. Um, and, and then sort of give it sort of 10 minutes. I mean, often you keep patients in for about an hour after, after this and, er, to sort of assess the patient and see if that bleeding stopped. The other thing you need to do is like, put some Vaseline on the upper lip and just at the, the sort of, um, sort of, uh, just at the, the base of the nose. That's because this, this reaction can burn the skin and it can leave with like a dark mark as well. So you just need to put sort of Vaseline to protect the area. Um, and yeah, hopefully that should work. The other thing they do is then put NA NAIN in which is, uh, sort of like a, it's got like, um, a coagulating factor in it and that just goes up into the nostrils and, and that can help and it also, um, prevents scabs falling off as well as you've made sort of this scabbing effect, often sort of that can flake off and that can restart bleeding. But this sort of naseptin cream just helps prevent that as well. So hopefully that works. But if not, you need to then know how to manage it further and, and the junior doctor can be doing all of this. So what that would involve. So, ignore this posterior packing first. What, what you'd be doing is anterior nasal packing. So crudely, it's a bit like a tampon. Um and it's effectively you're tampon ing the site. Um So as that, as that sort of tampon or you can fill it also, you have some places have sort of um actual sort of uh they like filled with fluid or, or air that, that could do this as well and you place it along the base of the, the nasal cavity and you inflate the air of water or you, you just put this sort of um tissue in and that, that will swell itself with the blood and that tamponades puts pressure on, on the site and that can often be the trick to stop the bleeding and it supports sort of coagulation. Um So that, that's your sort of next step in the management all the while you should be thinking is this patient stable? Where, where is this going? You know, they have, they got any of these red flags that I need to be thinking about to sort of be wary about escalating patients like this. Um So that sort of is in conjunction with all this. So I forgot to mention um with the court you, if so sometimes people are bleeding with trauma or anything that, you know, they're bleeding in both nostrils and you've got two little black little um sort of chx plexuses that are bleeding. What you want to do is find the worst bleeding side and cauterize that don't cauterize both sides as you, you're at risk of sort of perforating the septum and that can have some severe cosmetic outcomes. Um something you just need to avoid. So cauterize one side. Um and hopefully, you know, the um the lidocaine epinephrine should do the trick on the other or the good first aid management. So if you put that in the bleeding side and that's not worked, the next thing you can do is put one in the other side and that can help sort of provide counter pressure to further aid tampering. Um that's an option and, and you're reassessing this patient sort of half hourly hourly, depending on sort of how concerned you are about them. And then if that hasn't worked, y you're going to start thinking about posterior packing osteopathy is done usually by the registrar. So at this point, you're going to escalate to a senior doctor. Um, and it looks strange but posterior pax essentially is using a catheter. So a sort of a, a catheter, a 14 gauge foley catheter. Um Also when, if they're not, if this nasal anti nasal packet isn't, isn't working, you're also thinking about is this a posterior bleed as well? So have you got sort of posterior aspects of the woods plexus, is that causing the bleeding? And is what that why we're not able to manage these patients that should be in the back of your mind? And the posterior packing helps with that. So what you you do is you, what the registrar would do is obviously with appropriate lighting and visualization, you're going to insert a 14 gauge of 12 to 14 gauge catheter all the way back to the back of the throat. So you can see the tip of that in there or a pharynx. So you're gonna open their mouth, shine a light and see that that sort of the tip of the catheter dangling there. What you then need to do is use, um I think air, so use sort of 10 mils of air, not water, 10 mils of air inflate that and then pull back until you just get on to this sort of post nasal space here. Um, and it should trap between sort of your palatine arch. Uh Yeah, and your um sphenoid bone. So it should base there. And that's also, um that's also tamponade, essentially, you can be putting packs here, importantly, what you need to do. So you don't want this to fall backwards and occlude an airway. That's, that would be disastrous. So, depending on your, your hospital, you need to find a umbilical clip. Um, it's a bit like those, those clips that you seal um sort of food that you, you want to keep, you know, food essentially where you like, clip it tight and, and you want to clip this here with having a bit of wool or sort of a, a gauze, sorry against that sort of um sort of nostril. Uh the, the gau that just prevents um, necrosis of the tissue, which obviously is sort of cosmetic effects as well. Um And then the clip prevents it going further backwards and blocking the airway. These can't be in. So both of these anterior and posterior can't be in for more than 24 hours, er, or they shouldn't be in for more than 24 hours. If an anterior nasal packing is in for more than 24 hours, you need to start thinking about giving antibiotics as it sort of says you breeding ground for bacteria. Um So, yeah, that just something to know. Um, but posterior packing, you've, you've already involved the registrar and you've explained to them that your, your management of anterior er, haven't worked and that, you know, you think that they'll need a posterior pack if you're worried about a posterior bleed. And so, yeah, after all that fails you, you, then while the registrar is thinking about surgical options. So these are the different er surgical options increasing er downwards in, in terms of uh how invasive they are so often all is needed is a good examination under anesthetic with electrical cautery. So these two is often all that's needed and A G A. So you, you just get your opportunity to have a really good look with the right equipment to, to sort of um er get a good visual field and then you can use effective electro quarry to prevent that bleed and really coagulate the vessels that are bleeding. Next step would be a vessel ligation, which is usually the sphenopalatine artery, which I showed at the, the initial exam, which er initial um slide, which the artery slide where the uh external carotid and it's got a branch of the sphenopalatine and that sometimes is called uh you know, knees locating and then you've got embolization and ligation of the external carotid. And this. So these two does, this doesn't happen very commonly examination and, and electrical Corry that doesn't happen very commonly at all. This happens even less. So. And then this is incredibly rare, these two options. But I think I saw one person on my ent placement having a vessel ligation and that was a big thing. That was a big deal. So, so they're really rarely done, but there are options if needed um in a sort of step wise manner. So you try this and then you look for vessel ligation and then you go to embolization. An embolization is essentially sort of an interventional radiology effect where they sort of go through the um one of the arteries and sort of embolize the think it be sphenopalatine or, or the artery that's causing the extra. So yeah, that's, that's the management. So just to quickly go over, it is epistaxis. You want to do your a to e you want to um resuscitate if need and make the patient safe by resuscitating and then giving good first aid management. Anterior knowing a history and knowing when to think about anterior and posterior, having a good examination and identify a bleeding source c eyes with lidocaine and epinephrine, and then move on to anterior packing on the side and then you can put another one on the other side. Um and then you move on, start moving on to posterior packing with anterior packing in place as well and then start thinking about surgical management time to escalate is when you're concerned about the patient's safety and if they're stable, you know, or if they're sort of showing signs of, er, hemo becoming hemodynamically unstable. Um, or if, if you're moving on to sort of the posterior packing sort of side of things, that's when you want to be getting your edge involved. Or you see if you have any questions pop in the chat and hanno and er, flag them to me, but we'll move on to tonsillitis next. So think about what tonsillitis is. Um it's essentially an effective process of the tonsillar tissues, uh the sort of lymphatic tissue, one of the lymphatic tissues in the oropharynx. Um it could be bacterial or, or viral and you know, you got good, you got those criterias, essential criteria uh which can help determine if this is viral or bacterial. Um and it, it's infection which causes inflammation of the tonsil the tissues. Um and this is often commonly presented to the one, you know, comes in through Ed or GP referrals to the et doctors because so either you're querying something else which needs drainage and we'll talk about that or, or you're worried or they're worried that the patient isn't eating or drinking and is dehydrated because of the swelling and the pain and they need sort of um me management to help reduce that swelling and also rehydration through IV so doing nothing. So it's always important to think about what, what would happen if you did nothing. Um and it often helps you sort of determine how quickly you need to involve yourself and what sort of management you'll need to do um to prevent the complications. So it can self resolve. Um So I had to put up well in that slice, but it can self resolve. It's like it can get worse. Um And it can cause abscess formation or peritonsillar abscess formations called a quinsy. And also you can, as a patient, you can become septic. And these patients are often young. Sort of the common patient is a, a young child who's who's got tonsillitis and, and sort of sepsis, you know, is obviously a big thing that we want to avoid, especially in a young patient. Um And then, like I said, with unable to, due to pain or difficulty swallowing, um not tolerating, eating and drinking can cause dehydration, which obviously could be very dangerous in itself. Um Sort of been thinking about our presentation. So, um these patients usually complain of a, I think sore throat aphasia, which is pain, pain on swallowing. Um Otalgia, which is a referred pain to the ear um and a a plus or minus the cough. Um and plus or minus subjective fevers with temperatures feeling hot, cold, sweaty, and they might find it painful to open their mouth. Um but they should be able to open it fully and not be restricted. And we'll talk about that when we talk about Quinsy and sort of similar to the history. You were looking at our sides. So the sore throat is coming from these horribly swollen erythema inflamed tonsils that can have tonsillar exudate, which means sort of those white particles that we saw here and that's the tonsil exudate. Uh And then you as sort of part of your ent examination, you need to be feeling the lymph nodes on the neck um because we're thinking about differentials as well and what this could, could might be and what, what sort of other pathologies this could be. So you need to be feeling for cervical lymph nodes. Um and knowing sort of your um sort of having a good structured approach to, to how to fully and competently assess um lymph nodes in, in your sort of neck area. Um And then you can have what we call Strel, which is a clinical sign where it's, it's the sort of noisy breathing, but it's breathing in a, a way that sort of, it's quite particular to tonsillitis or swollen tonsils because it's the airway being disrupted at that oropharynx. So sort of sort of sort of the back of the throat due to the swelling of the tonsils and that causes sort of turbulent airflow, which, which gives you this horribly noisy breathing. Um I won't demonstrate it now, but I'm sure there'll be youtube videos if you want to look at that and maybe objective temperatures or temperatures and sort of signs of sepsis are differentials. What we, what we have to think about. So we al the reason they've come in is either they're dehydrated and they're unable to eat and drink and they need fluid resuscitation, they're septic, er, and they need sort of management from that point of view or they've got a Quinsy and that needs to be managed as well. The o other, more maybe unlikely causes, I mean, are, um, cancers. So you can have tonsillar cancers, you can have tone based cancers which can cause appearing sort of swollen tonsils. Um And you, you can also have what we call epsin barr virus or uh mononucleosis. Um and that can present as a tonsillitis, but in a way, it is because it's a sort of viral tonsillitis um but quite different and, and then um the other common cause can be things like pharyngitis, which is sort of inflammation in the pharynx. So that, that's it. We should sorry, not VV, glandular fever, my my mistake. So glandular fever, infectious mononucleosis. Um and the other thing you need to be concerned about maybe is, is an airway, like we said, there could be Tresus, which is noisy airway, breathing epiglottitis, which is more likely to call stridor, but it's similarly a a noisy airway and it's something which you need to rule out or be concerned about. In which case you then need to be escalating to see doctors and meet very quickly. Um because that can be life threatening. Like I said, neck malignancies can also cause this sort of tonsillar swelling. Um, and then thinking about glandular fever, thinking just quickly how we can, when we may become suspicious of that is when the tonsils are, they call it sort of like a strawberry red, um, appearance of the tonsils. And they're just much brighter and more red than tonsil, typical tonsillitis. And then thinking about exact investigations you can do, um, having deranged LFT S to increased sort of APA LT or bilirubin, maybe. So sort of one usually AP or a LT, um, having raised at AP can be an indicator of glandular fever. You can also do a sort of infectious mononucleosis test. But I think depending on your location that can take a few days or I think you can do rapid tests now. But um, r work before it's, it usually takes a couple of days to process. So the initial management of tonsillitis, uh so like previously, we went to review, make safe and confirm our diagnosis. We're gonna review and take the history and examine as we. So we discussed with the, the symptoms and the examination findings. If we're worried, we're going to escalate early if we're concerned about airway, um or other sort of maybe epiglottitis, but we're going to continue our management and do what we can to make the these people safe while the escalation is sort of uh while the patient's been escalated. Um We need to do initial investigations and treatment and we need to determine our severity and then finally determine the diagnosis. But it's always important before making, you know, getting the diagnosis, we need to make these people safe. So, um specifically for tonsillitis, we may need to um provide IV fluids. Um we'll talk about initial management, but we need to fluid resuscitate and we need to provide prompt treatment um with tonsillitis. So this is our treatment steps. So the key of all of this for tonsillitis is IV antibiotics. And that's as per your guidelines. So everywhere should have guidelines on what to use in different pathologies and presentations. But where I work, it's penicillin four times a day um for sort of more mi mild to moderate or moderate um cases. And then in severe cases, we use Benzyl penicillin and metroNIDAZOLE. Um So IV Ben Pen and then an oral metroNIDAZOLE always important to hydrate these patients. Often they're not able to eat and drink if they've made their way to A&E or sort of through GP and they've not been. So you need to hydrate them or they might be sort of hypertensive and tachycardic or septic and you need to invest, initiate that sepsis six protocol, um including IV fluids and IV antibiotics. Um So the other, the other important part about tonsillitis is um IV corticosteroids and that's oral or IV dexamethasone 6.6 mg. And that can be done every 12 hours, I think, or 24 I think it's 12. Um, but then look in your sort of medication books or discuss with, with people. Um, you're probably not gonna be initiating this unless you're sort of um being in the, for a while. But um, don't be able to tell you the specific guidelines for IV Corsos and this importantly, helps with the inflammation and, and can sort of make a really big difference to the pain and their ability to swallow that will help them eat and drink um alongside good analgesia. So, multimodal analgesia including paracetamol, thinking about codeine, thinking about ibuprofen and you can give morphine as well. There's APR N that's sort of on the side. And then Benz benzoine, which is a sort of dila spray, which you just spray at the back of the throat. Um And that can be sort of your local analgesia as well and then sometimes antiemetics for nausea. But, but it's mainly IV antibiotics, IV corticosteroids and fluids if needed. And then you can often review these patients every sort of 6 to 8 hours. Um And then if they're able to eat and drink and often by the time you've, you know, you've given that the Ivy cor to work, um they're doing much better and that they could be ready to go home with close safety netting. And then what you do is you, it sort of doing it simultaneously, but you need to confirm your diagnosis with bloods. Um FBC, your knees, LFT S, uh you can do a V VG to look at lactate as well. Lactate helps determine severity and dehydration. If it's raised, we're more concerned. If it's lower, then we're sort of slightly more reassured, but it's not a specific, um, but it's not specific to a particular diagnosis, but it's just a good marker of illness. Um and then blood cultures if they're septic or concerned, and then obviously your examination is key and that's the key part to sort of deciding if this is a tonsillitis or your other differentials. And speaking of other differentials, the main, the other reason people are coming in is because we're oh, sorry to, I thought there was, we were talking about Quinsy but just to go over it again, review history and examination and escalate if you're concerned about sepsis or, or sort of airway issues, make safe with antibiotics, corticosteroids, fluids and good analgesia fluids. Sort of if you think they're, they're sort of um hemodynamically unstable. Um and you can initiate your sepsis six here as well. Um When you confirm your diagnosis with bloods, blood cultures, um and then monitoring the response to the IV antibiotics and the text me soon but often the the the diagnosis is confirmed on your examination. So, Quincy, so that's what I was going to talk about. And that's the other differential that is why they've sort of presented to ent and that is sort of cos there's a peritonsillar abscess, er, which is a collection of pus, um, within sort of the, usually the palatopharyngeal arch and that's a complication of usually bacterial tonsillitis or untreated tonsillitis. It's usually unilateral pain and the key distinguishing features about Quinsy or when you start thinking about it is if they, they complain of change in voice. Um, and it's called the hot potato voice. I think it basically is imagine someone's got a hot potato in their mouth and they're trying to talk with. That seems to be, I don't, I don't really understand why they call it hot potato, but that's what it is classically known as and then Trismus, which maybe, you know, but it's um as I alluded to before is tonsillitis, um they'll be able to open their mouth fully or sort of to a good range of movement in, in Quinsy. Typically you have restricted jaw opening. So, um they'll only be able to open it sort of, I don't know half of what they were maybe or may, maybe less. This makes your examination difficult and often sort of um is one of those signs of all sort of reasons why you start thinking about a Quin um or pointing more towards that direction. And then, um and then your, like I said, your differentiation sign. So I mentioned Trismus twice. You got your on examination when you either use a tongue depressor or whatever way and good visualization with a head torch, you'll see this sort of anterior swelling that almost doesn't involve the tonsils. So it sort of this extra swelling part and then your uvula is deviated, deviated to the opposite direction. Um, and then often the, the, the sort of other tonsil looks. Ok. I think you could probably get you quinsy bilaterally, but obviously very uncommon and it's usually unilateral and to manage these. Uh, basically, it's the same as tonsillitis. So you're going to give antibiotics, you're going to give fluids, you're going to make them safe and er, escalate soon you're going to give dexamethasone sometimes. Um, but it needs drainage and it needs so pus, it's a pus filled, it's a collection filled with pus and in any of those circumstances, you usually try, try and take that pus out and a classic UV pus ev evacuol, which means if there's pus, you remove the pus. Um And so you essentially as good. It sounds, you literally get a needle and you, you draw out, pass from there. Um, there's ways of doing that. So, so we'll talk about that quickly. Um, the method to aspirate is you need to make sure you're safe. Obviously, there's a, there's an important artery. I think it's a lingual artery that runs just behind the tonsil. Um, so it's important to get your landmarks correct and also prepare correctly, but you look for the left standing molar. You, you sort of get an imaginary horizontal line and then you sort of draw a vertical line at the sort of um the sort of medial edge of the sort of inferior molars. And then anything sort of just inside of that is usually your safe point and you look for maybe sort of a maximal spot to where you think, you know, the fluid is collected and sometimes you can see, you know, a good area where you think. Yeah, that's where I want to go. Other times it's just not, not so clear and you, you just need to give it, give it a try, but it needs to be safe and you need to avoid these arteries one by doing this and making sure you've got your safe zone, but also making sure that you're not going to go too deep when you aspirate the way we can do this. And it seems quite crude, but the way we were taught is you can get a cannula um like a wide bore cannula. You, you get the needle so you unsheath it all. Sorry if there's, you know, cannons are different in different places. But this, it's what ours looks like. Usually you get this needle here and then you got the sheath here, the protective sheath, you can cut that um leaving sort of about two centimeters at the edge and you literally attach that you sort of pop it back on. So you pop that sheath over here you attach a sort of um a what are these called, what's it called? Um syringe, sorry to it. And then you micropore it and, and you can use that anergies like deflam and you can give paracetamol and morphine and things like that. And then you, you literally just need to sort of inject and this two centimeters, this sheath prevents you going too far and sort of too posterior RP at risk of sort of it nicking one of the big arteries. So hopefully you've got your pus and you can send that for micro um microscopy culture and sensitivities and sort of be more specific with your, your antibiotic therapy. Um but usually patients, you know, feel gr feel much better after this and then range of movement. If you get good aspiration, their jaw movement improves and their pain improves significantly. Um You still need to give them the antibiotics and dexamethasone and be reviewing them every sort of 6 to 8 hours. Um But often these pe people go home the following day um as they just feel so much better. Yeah, that's, that's, that's Quincy's er tonsillitis, but yeah, not, not too complicated. Um So we move on to orbital cellulitis and sort of this classically comes under ent and um although it's not typically sort of ear nose throat, it's something that just happens to come under under us all the time. But um a cellulitis is a vision threatening condition that needs, sort of is an emergency and needs to be ruled out or ruled in. But it's often the reason why sort of um we can't wait too long on these patients. We need to be confident in our review and management and know when to escalate early um to ensure that, you know, we do as much as we can to prevent vision loss, um orbital cellulitis. So I want basically out of this, I want to be able to, I want you to be more competent with distinguishing periorbital versus orbital cellulitis. Um and another sort of differentiating or sort of differentials. So, peri this is orbital periorbital citti is an inflammation, uh sort of an infectious process as a superficial eyelid, orbital citti is er the same but with as orbital soft tissue with associated eye dysfunction, ocular dysfunction. And what differentiates these is the orbital septum. So periorbital citti is an anterior to the orbital septum. Orbital salit is posterior and uh orbital telis is the, the emergency that we need to treat periorbital cells can become orbital if untreated. So it's also very important but is sort of seen as less severe. Um And then this is, this is our sort of orbital septum. So it's an extension of the orbital periosteum. So you, you've got your, your orbit orbit here, you at your base and then your sort of anterior, your, your er superior and inferior aspects of your orbit. And there's a, there's a sort of continuation of the periosteum, um which sort of goes along here and it involves your sort of levator lab labor eyes and things like that. And um, it's sort of like a protective mechanism almost of the orbit. Um, and that helps prevent spread of infections, but obviously not always. And like I said, Perry can become orbital. So if we do nothing, obviously, it's always important to think and, you know, like anything things can get better. But these are, this is an emergency, especially oralis and doing nothing would be the worst thing. Um You're at risk of very severe complications, you get abscess formation, um which typically is called subperiosteal abscess formation, cavernous sinus thrombosis where you have a sort of thrombo thrombotic event from an infection in your cavernous sinus. You can get intracranial abscesses, you can lose your vision and you can get a, a systemic inflammatory response which can sort of lead to sort of vice through sepsis. And you know, you can die from this. But the main, the main issue is vision loss, permanent visual er loss. Our differentials for these are conjunctivitis. So, any sort of inflammation or swelling or erythema around the eye, you know, there's a risk of it could potential to be conjunctivitis, um uh proptosis, which is sort of uh sort of um the eye, the eyeball pushing out. Um That's also a sign of venous sinus thrombosis, which is and also a complication of alt cellulitis but can be standalone. So it's important to do what you need to, to rule that out. And then obviously, trauma can cause swelling of the sort of surrounding eye area and inflammation. Insect bite can lead to cellulitis as well. Um and it can be acute rhinosinusitis, which is, it can cause inflammation, erythema around the eye. But with all of these, you need to any, any of these, you also need to be thinking, oh, is this or, or is this peri peri orbital cellulitis? We've sort of gone over those and sort of feel like I'm labored the point a bit but superficial is very uh it can manage as an outpatient but often sort of requires a few hours of antibiotics and then usually a few complications are treated early orbital. There's a deep infection which is an absolute emergency and there's a risk of severe complications and death and vision loss, of course. Um So the way to distinguish between these two, essentially, if you think about the pathogenesis or the definition of orbital being deeper, then you sort of can probably work out the different symptoms and which one correlates to which, but there's a quick um table. So uh sorry proptosis. So, perioral should be no there. So that's no for perioral Proctosol, you, you might find proptosis. Um you usually have this ocular dysfunction, including pain and restriction on sort of uh sort of lateral and vertical movement uh horizontal. Um, we sorry, and, and they can in or they can sort of have reduced vision at this point. Um And that, and that's usually in severe cases and they can have change in vision as well. Um And that's because your blood supply is being reduced, sort of to your um retina, uh not your retina, sorry, the, the, the poster aspect of your, of your eye. Um And then you sort of a R APD which is a reactive afferent pupillary defect. Um And that's basically when you not, if you might already know, but it's you shine a light, you do AAA swing light eye test. Um And then if you shine a light into the affected eye, you get bilateral dilatation, you get dilatation of the normal eye as well where you usually get obviously constriction if you're shining a light in somebody's eye. Um and that could be a sign of orbital cellulitis in severe cases, usually the distinguishing feature and the one you need, you sort of start pointing you towards orbital if there's ocular pain. So if there's ocular pain on movement, um and if that movement is restricted as well, so usually they're unilateral eye pain with erythema and they've got painful eye movement. If it's also like with, like we said, potentially blurred vision, potentially color changes and potential proptosis on examination and they might be septic. And you also like all of these, you need to make them safe and sort of fluid resuscitate if need and then initiate sepsis. Six if, if, if that's a concern, um which often is in these patients who are unwell as sort of slight crossover from our, of how we'd rule out or sort of differentiate between peri and orbital cellulitis. But red flags um were mostly thinking about sort of um CNS complications. Um, as you mentioned, complications of orbital cellulitis of the intracranial abscesses, uh cavernous sinus thrombosis meningitis as well is, is one of them. So, um any signs suggestive of a sort of um uh central nervous involvement, including drowsiness, mening features like um like pain, stiffness, severe headache, photophobia, vomiting, um new eye pain, as we mentioned before and worsened vision and then limb weakness, sort of suggestive of severe sort of central nervous system involvement, uh and unsteady gait, these red flags sort of, you know, while escalating are important features to think about or ask about when um you're concerned about patients and, and knowing to mention them to your registrar or seeing your doctor. Um So like, like all all our conditions we're reviewing, we're making safe and confirming diagnosis. We're taking a history exam, escalating if early, if we're concerned or, or sort of, if you're thinking ultra haitis, you've already escalated. Um And you're, you're going to continue your care once you've escalated. So continue your management and your, your initial investigations. So like your bloods, your F PC, your blood cultures, you're starting your sepsis, six stabilizing patients from an A to e perspective and then finally confirming a diagnosis which we'll talk about. So, antibiotics are the mainstay, so good, strong antibiotics. In our cases, IV tazocin or can be IV Keone fluid resuscitation, neuro observations are really important and you start doing every four hours and that's because of, as you mentioned, the red flag symptoms and the complications that sort of central nervous involvement. If you think of how close your eye or your eyes are, the extension of your sort of um your sort of intracranial cavity, isn't it? So, so there's a, there's a, a communicating tract there which is just perfect for infection to spread. So it's really important to do your new observations and ask, make stress to the nurses that if there's any change that it needs to be quickly found um is at that high risk of developing intracranial complications, head of the bed elevation, like any infection, any inflammation, any sort of superficial infection or inflammation. So, in your arm, um or your legs that then we, we suggest elevating it and usually your head is elevated, but it's just important to mention in our plan and then good strong analgesia IV um you know, paracetamol, codeine morphine and Ibuprofen. Um this is often very painful uh and then to investigate the main CT scan. So you do a ct of your orbit sinus and brain and that looks for complications and that looks for severity of the orbital cellulitis. Um, so of course you're doing your bloods and you're looking for your inflammatory markers and your lactate and, and with these patients, we're going to do coup and save and that's because of the complications. If there are complications, they'll need surgery or they may need an operation. Sorry. Um, we'll talk a bit about that in a second and doing your blood cultures, doing your sepsis six. And if there is an opportunity to gather the maybe pass, um that's sort of coming out of whatever area of the sort of orbit you can culture that in microscopy and sensory and that's really important um because it can help guide us with our antibiotic therapy. And as part of the complications, I mentioned meningitis or cns involvement. And so a lumbar puncture may be done just um you know, to, to rule out meningitis rule in. Um but CT orbit signs and brain is our main, um main investigations to rule out, you know, read the sort of the complications, the the sort of most common complications. So besides just a quick overview again, uh escalate early i antibiotics, new observations in our CT orbit and initiate sepsis six. But so the most common um complication of oritis is a subperiosteal abscess. And in that case, we need to evacuate so much like our Quinsy. If there's a pus, we need to remove it because you're not going to get effective treatment of the sort of the capsule and the, the abscess because um you know, it's got a reduced blood supply and sort of penetrations are gonna be good. So you need to manually remove that pus. Um And sometimes, you know, I mentioned you've got intracranial abscesses that can form. Um and that may lead neurosurgical involvement for craniotomies and sort of drainage of the abscess. The periosteal abscess is the most common. And what essentially it is is sort of uh sort of in superior anterior, but it's sort of this orbital floor, um, due to sort of the nature of our sort of um orbital septum, you can have infection that sort of gets under the sort of the sort of periosteum and that's sort of a, a clo, you know, fairly closed area where you can get the infection and sort of a large amount of pressure which can push on the optic nerve. Um, and that's where you really start coming into concerns about the sort of um losing, losing vision permanently. The way they usually treat this is with endoscopic sinus surgery. So that's going through the nostril with sort of an endoscope. And then, um, this is sorry, this is actually uh I think this sphenoid sinus. But, um, you'd sort of go in with an endoscope and you'd, you'd have a good ct where, you know, exactly where you need to go and you'd, you'd sort of penetrate into maybe the, er, the middle turbinate and get into sort of the maxi, the, er, axillary sinus and then through the orbital floor and drain it that way. Um, and that will help remove the periosteal abscess. Um, again, you sort of, if there's a intracranial abscess with thinking neurosurgery involvement for craniotomies and things. So sorry that last one was quite quick. I'm just conscious about time and we've run over a little bit, But just to conclude, epistaxis, the, the aim is to sort of do your a to e do your good first aid treatment for 20 minutes quarter with um er lidocaine and epinephrine. And then if that doesn't work packing either anterior or posterior and if that doesn't work, then we start thinking about surgery, usually achieved with um good visualization under an anesthetic and electric artery. Um but can be sort of sphenopalatine artery ligation, tonsillitis. We're going to ensure they're not septic if they are going to initiate as sepsis six and provide fluids, antibiotics. I should have mentioned there's dexamethasone in this one as well is really important. We're going to rule out differentials, sort of specifically um quinsy and treat that if we think concerned about that with aspiration um or epi rule out epiglottitis and we need to escalate earlier if we're concerned about that because that's an airway emergency, orbital cellulitis is the emergency of these three. and it needs urgent quick escalation if concerned about it. And the way to, to sort of, um, think the way to put you in at orbital cellulitis versus periorbital cellulitis or superficial cellulitis of the face. Um, is with that pain on eye movement. If there's any pain on eye movement, that's when you, you sort of start getting a bit jumpy. You need IV antibiotics. You can get a CT scan to sepsis six. and good analgesia and, and CT scan determines the complications are quite scary and you need to do your neuro observations. Yeah, that's it. Um, getting responsible by MDU. And if you just, oh, sorry, I haven't brought in, I need to get the, um, we've got a, a, um, feedback form which I'd be really grateful if you could complete. Um, I'll just get that up quickly for you. Um, but if you have any questions in the meantime, I can try and.