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spit. So everything in the ear canal until the ear drum is the ultra here. And then we have the middle ear. And from the purple bit is the semicircular canals in the cochlea number. Fibers will be the inner ear, and there are different pathology is that can happen to each site? Yeah, so first in taking a beer history so we can think of it as what can have what can go wrong with the ear. So if you think of the anatomy before and, for example, the external ear, the back, the external ear, that could be inflammation around the area so it can cause discharge and pain is always a symptom as well. So so you have been some ear pain. Some, um, discharged. These are defying six mean cardinal symptoms like ear pain discharge, hearing loss and then, if if it gets to like the sensory nerve fibers normally cost tinnitus business and also, if in the middle ear, if there's fluid in the middle ear with cost fullness. So if you think about the anatomy, sometimes it can help to think about the symptoms to Austrian that your exact, um, your history taking a swell and in any kind of Yeah, and he history taking. It's always good to take the other things as well. So if you ask if you're currently getting with an air history, always ask about the nose and throat as well. And just generally, I think Socrates all complaints. This is in the site on sad character radiation associated symptoms of the timeline is a cup. When does it start it come and go has it progressively worsen and exacerbating factors and also severity. Uh, just as a general rule. And so that's the history taking and when we come on to the examination, So with the ears, there are probably just three examinations available, um, birds and to run a PSA, the weather's and run a test of the problems and can do an auto scope to directly visualized the ear drum and also an audiogram to test your hearing. And this is the picture on the left. Just shows, uh, how how did you do another scope to look visualized the ear drum and on the right, This is the picture that you see with it after, uh, during a not a scope exam so you can see, there's the ear drum and a good trick to tell whether it's the left ear drum order. Right, your drum normal. You can tell from this handle of the malleus. If it's pointing to the left off the screen, it's the left ear. And if the handle of the bone under manubrium of malleus this this way to the right of the screen, it is the right here. But this is a healthy looking ear drum, and so next. So that's the author scope. You can also do a little bit Webber's and run a PSA test. So this is the test was. Sometimes you have to do a bit of thinking in terms off, Um, what is the result? What is the outcome off the each test that tells us the diagnoses, whether it is a conductive hearing loss or a sensory neural hearing loss. So if just so got a bit of question here, So what would be what would be someone's results for a conductive hearing problem in the left ear? So if you can chapped in the bottom in the check box to say, what will the weather's results be and what will be there Renee. So results be in terms off. But when Webber's, where does it naturalized two and INR a nasal. What would a D each year would have, like the results of each year, with its airconditioning more than bone conduction or bone conduction? More than airconditioning, Maybe Just check the check months. I'll give you about a minute or so, Yeah, so we've got a few answers. Connection that I left you Very good. Get a couple of answers. So weather is today perfect, so I'll just go through it. They we got a good couple of answers is, Well, so um, our troops, me, you hide this. So in any kind of scenario, First of all, I would think in terms off the weather's test is when you put it in the middle. So it's like a double you. So you put it in the middle of the patients head and in conduct him here conductive hearing loss. It's always you actualizes to the pathologist call here or the ear that has the problem. I would and easy way for me to think about. Why is that? Is that, for example, in conducting hearing loss, it's as if you're closing, using your finger to close the pathology call here and that way, the sound reverberates more in that ear, and it allows the patient to hear a lot louder in that problematic ear. Basically, eso the weather will in a conductive hearing loss, the weather will naturalized to the problematic ear. And so in this case, the Webber's will electrolyes to the left. And when we do the run a PSA test, the air condition will be less than the bone conduction because, obviously the one with the test we have to allow the sound to go through the external ear. And if the external ear is blocked, which is the case in a conductive hearing, loss will be less than the bone when you just stick the promise threat to our bones. Okay, that's good. And in ah Webber's So those sound so in the second is a second case. It's well, this time you have to work out What is the pathology? Or which is the pope problematic ear. So in the second question is when you do the weather's test on the patient, that sound after arises to the right and in the run, a test airconditioning louder and bone conduction the left ear and in the right ear. Air condition is last also louder than the bone conduction. So if you and just chat into the chat bucks for me, you have a look. All right. Think those people got it right. So it is the left sensory neural hearing loss. It's because if the sound matter ises to the right. But if he bought the run, a PSA test is positive or normal for both years. That, it means, is the other ear. That is pathological. Yeah. Okay. Does anyone have any questions? Or if not, I will move on Okay. Of false. When would you get a false? Renee says, Do you mean, like, a negative negative run a test? Because, um in run a PSA test, it is the only. It's only when it's so a positive for Nasonex is air condition louder and bone conduction, which is how is it normally so if they're conduction is bigger than bone is louder and bone conduction, which is normal run. A PSA test is one of the few tests that means if it's positive, it is normal, So air condition, lot of bone conduction is positive. But if it's bone conduction louder than airconditioning, it's negative. Is the statics that this that explain that Let me just bring my check box up again like a false negative. That is when, um when you do the run a test. But you don't moss The other ear is because a false negative means that even though you are testing the right here in the bone conduction, sometimes they're the vibration goes all the way to the other air, and then it makes it see your brain things that you're also hearing that However, actually you're not on the pathology call here. I hope that answers the question. But that is why in a Nodia gram and you test a hearing, they have a They have one part where the mosque, the other ear. So that you are sure that your only testing the pathology clear. Okay, so which brings us next cycle back brings us next two d. Next examination is our next investigation. So you've done the auto scope the, um, urination members tests and now the old Ingraham. So the audiogram is a test where patients put on a here, uh, head falls and then they will test on different frequencies and the different, uh, decibels, Audie loudness off the noise or this on the left. Here down is the decibel level, which is the hearing level. The lower you go, the louder it gets and two on the X access is the frequency and this thirsty levels. The different categories that can get normal is between nine is 10 to 20. But so bit into audiogram interpretation. So see if this is a audiogram on, I think, Let's just concentrate on the right side. It's both the same, just the rights that have more information. So on the left, on the right side, it shows the red is the right year and the blue is the left ear and as you can see, so the blue, the blue line and the blue lights are all in the same level and they're all above 20. So the blue means the left ear. So they're all they're all normal. The left ear is normal. We can say that however, on the red line on the red circles and and also this red brackets, there is a gap between them. So that means there is something going on. And we call this the air bone gap because the circles means that there's the air condition is actually lower than the brackets, which is the bone conduction. And when there's an air airborne gap, this means that there is a conductive hearing loss indi right here. So we'll go to a bit of cases as well. So this is a case one off the pathologies. So this is a picture of a 54 year old male with two day history off left ear pain, bit of tenderness and itching and feeling fullness with some hearing loss as well. And he is a swimmer and enjoy swimming. He has a past medical history of type two diabetes. Um, and we do. We did an extra examination, and this looks of it, What it looks like in the picture. What do we think that the, um that knows this is Mm, Yeah, yeah, I got a cup of answers, Correct. So it's tightest external, and it says, careful of malignant otitis, external malignant ascites external just basically means when the infection erodes into the temporal bones and through, and that is very common in patients with type two diabetes and normally do you mean symptom is that the pain is out of level, out off, out of the level in terms off it's just more severe Pain, rather than a normal appetite, is external. And normally we have a warrant like a C T and otitis external. How we treat them is giving them some antibiotic drops, some gentamicin drops and also symptom control with paracetamol or other types of energy. Asia. So always remember otitis external A and the malignant Titus external in type two that in diabetic patients. And is this case too? So, uh, patient came in with some, um complaining off your discharge and has an unpleasant order and tends to be resistant to antibiotics. There is also hearing loss and in tennis and some of your pain and also altered taste and dizziness. And this is the picture that is showing the ear drum. When we do the other scope, you can see that on the top, off the manubrium off the malleus or the Actiq, or we call it there is some redness and it doesn't look great. Basically, Does anyone know what diagnosis? What we call this is Yes, a few answers. Already called lists, they're Toma and Cholesteatoma is basically an abnormal accumulation off us, like the squamous epithelium in the middle ear, when it it can't when it comparable, or come basically slide off to accumulate in the attic, um, region and cost the space to become infected. And it also might erode the neighboring structures. That's why in the middle here we have the facial nerve that that if that is eroded, it can cost the sent the altered taste sensation as well. And the investigations that we do is an auto scope audiogram. That's the standard is always a the Webber's Renee about a scope in audiogram and plus minus and the CT temporal bones. And the management will be some topical antibiotics as well and urgent ENT referral, especially if it's associated with the facial nerve policy, because it means it has eroded destructors. And normally they would go into surgery to remove the attic and reconstruct it basically. And yeah, um, case Tree is a one year old child with, um, irritability and keeps pulling his right ear and with associated with vomiting but no discharge, and he frequently gets this kind of symptoms the mother says. And this is the on examination we can after in the otoscope. Um, if we put the most likely diagnosis in the check again. Perfect. Yeah, so it's It is otitis media, so otitis. It's on a tight fist media with effusion, and is you can see there is some ball holding and readiness of the ear drums that which means there is fluid inside. And the reason there's no discharges, because off this bulging and Children get really irritated. And actually, when it acts on the drum actually pops, or when it actually breaks the Children get a lot more comfortable is because the pressure in the ear has been released, and that is when this church occurs. But in this case, since the eardrum still intact, it's just a test medium perfusion, and how we treat that is also with energy easier and sometimes with the delayed antibiotic prescription because, um, because at times it can resolve on its own. So so the complications of acute otitis media is actually the perforation of Simponi man. Brain mastered itis because remembered it in the middle area. It's party temporal bones and specifically the mastoid and cause facial nerve policy. As I explained before, and it erodes and sigmoid Sinus Trumbo cysts, which is three Trumbo's, is off the vent in the brains in the head intracranially. So another symptom that we should be aware of an ent where common is what we call dizziness. And there are two main causes off dizziness, common causes of dizziness that we should know anti. One is benign positional vertigo, and the other one is in years and the two different. The main difference in both is that Meniere's has progressive hearing loss, and normally it's unilateral. And when we do the run A Z and remembers tests it, no, it is normally pointing towards sensorineural, and they normally also have. It starts off like patients also experienced some tinnitus and some fullness in the ear, sometimes just unilaterally, whereas a big TV like classically, it's when patients moved your head when they turn our look left and right when across the roads or when they when they get up from their bed in the morning. That's when to get attacks of the dizziness and with BPPV how we there, how we diagnose them is by a maneuver. Addicts Hallpike maneuvers for how remember it is that Dex Hole starts with D. So it's to diagnose BPPV. And it's positive is when we make you do the maneuver with their heads with the patient's head. And then there is the status, and that shows that it's positive. And that is how we diagnose because he and the how we treat them is also with another maneuver. Call up the maneuver. It's, um it's a bear, very quick maneuver and patients Mommy takes about two or three times to finally resolved. They're PV symptoms, but it can come back. And with many years it is, um, normally more like symptom. Control of how you manage them is lifestyle factors like no salt diet and some medication, like as a tell it's all the might and the cause of the PVM in years. It's also thought to be different. So in BPPV is thought to be caused by some loose like debris or like calcium carbonate debris inside the on know them. So the semi circular canals that causes some like destruction into the motion of the fluid in the inner ear. That's why it's only when patients move their head that that that removes, and it causes them to feel dizzy with mean yes. And the theory is that the lining in the semi circular canal cause is like an abnormal production off the endo limbs or the fluid is extra in the semi circular canals, and that causes type of like a fullness and pressure, which causes them to have the vertigo or dizziness. Uh huh hurts. So with the ear pathologies a swell in the external air, the A common thala gee, is perichondritis, or sometimes what people call, um, cauliflower ear just because it's considered the right side. It looks very good, Emmett. It's a very like chunky, beastly, and normally it it's caused by a recent ear piercing or surgery, and that caused, like the bacteria on the skin just to invade the the the lining or the cartilage off the ears, causing pericarditis. And the symptoms include in duration, pure itis of itching, swelling and some. Sometimes it's a crusting and pass with reaping out as well. And the man, the management of these, um, pericarditis ears are like a long time, like quite a next ensign. Time a week. Sometimes off ciprofloxacin are antibiotics or really, and they do come back. And but sometimes complication is that they can a devil of abscess collection in the ear. And if that's the case, then you have to drain it. Okay, so the red flags for your pathologies include any or any rapport and any rapidly progressing hearing loss. And the unilateral symptoms, in any case, normally is always a bad sign. Media and tea. Any young or middle age patients who has any, uh, typical episodes of vertigo that points towards more off a central cause like a mess. Multiple sclerosis and or any pain or bleeding from the ear. That is to exclude any trauma. Because the ear is basically the the middle ears pop off the intracranial content. That's why people are very cautious when there's a middle ear infection is, well, they're worried about spreading into the winter cream or contents. Mm, so that is with the ear. So we move on to the nose pathologies. So but But most off the ent pathologies is a lot of it is in the ears. So some history taking do it for, like, nasal symptoms as mentioned before, always if you want. If you get lost dream all skis or always fall back to the sake structure when taking a history like where? Which side is it? Is it unilateral bilateral? Um, and how long has the symptoms lasted for or when did it start? Is a constant intermittent like Think off that that timeline has it gotten worse or has it gotten better? Any associated symptoms with it, like blockages, any faith, official pain, a rhinorrhea or any post nasal drip that points towards like sinusitis. Um, any bleeding and history of trauma and and also after that, osteopenic patients thesis and er positive history of drug history, history and social history. Now remember it as a PdF past medical history of drug history from history of social history. Okay, so very common presentation to ent is epistaxis. Um it is normally quite mild, but when it when you can't stop the bleeding, that is when things go wrong. So in terms of taking a history, you asked. But it's unilateral bilateral. Normally, if it's bilateral, it's likely something systemic rather than like a polyp or or any any structural cause. And how long has it been going on for any family history of bleeding disorders, any past medical history or the card medication on the on any anticoagulants. And the treatment examination is quite simple, really. It's just a wreck. Visualization using A um they're a crucial ization to identify if you can see any bleeding point where the, um and the anterior or posteriors portion off the off the nostril. So if it is anterior and we're able to visualize the source off the bleeding, normally it is indeed what we call the exact box plexus, where there was a rich network off arteries near the front of the nose on extra septum. And if we can see a leading point, normally we just go on to a culture I submitting porn using like a silver nitrate stick, and it will nicely stop the bleeding. Um, however, if me can't see the building point s, so it means it's something more deep or posterior, and then we can use a posterior nasal pack, too, basically tried to tumble, not the whole nose to stop the bleeding and believe it about 48 hours and then remove it afterwards. That works very well. A swell for patients with more off a risk for risk factors like any beating his orders or if they're on warfarin. So these are the main causes off his Taxus. Um, can he have a really? Later on when you guys get the slide? Swell. But the main, um, cause is normally it you, Patrick So or or so are the ones highlighted or know highlighted. But underlying out of Maine Common What? Swell. Like any trauma, um, hypertension, Or if there any, um, and on any anticoagulants. Yeah. So if they asked if any, uh, skin situation, they ask for any management off a pissed axis or either management of most conditions, Really, you can always fall back on to, um, do A to assessment, so just make sure they're stable and also do some investigations. And how I think off investigations dream. Ask if I do get a bit of a like a brain freezes. I think off BBI. I saw any bedside tests like any BP and BP measurements. Obs you're in the but not in this case, but just any blood blood bedside test. And then I'll be going to Bloods. So Fpc's group and say for clotting studies and LFTs as well just in case, if, if any, um, liver dysfunction, causing them to have bleeding disorder and be be and then the eyes for any imaging. In this case, we wouldn't do look and epistaxis. We don't really do imaging. But we could do like a effort because directly visualize with a nasal endoscope is, well, so like a little camera through the nose. If we can't see any obvious bleeding point from the outside and also the other the last one or miss invasive, and that would mean any so surgical management. So just specific to Epistaxis is, um, we've we've done a to eat and remix your Have I Be access if for patients who are having major hemorrhage and take bloods to for group and safe and make sure the position themselves forward, so to avoid swallowing or aspirating any blood. And most importantly, as any bleeding situation always to tumble, not the vessel with pressure. And this is just a nice flow chart to give an overview what to do. So so if patient coming with nosebleed, ask them to try to do a 10 minute kind of using their finger to put pressure on the nose and if the bid it bleeding stops good. But if not, Nancy's continue to examine the, um using a speculum to see if they can see any bleeding point in because that backpacks is. And if we can, we cauterize it. So the nitrate and if not, we do anterior packing. And if that fails as well, then when we want to surgery. So, um, after bleeding inflammation around the nose area and then the nasal compartments also can happen, especially in the Sinuses. And two main common confusion that people get is that right? Night is the difference with the rhinitis and sinusitis. So with the rhinitis, it is mainly the inflammation in the mucous membranes off the nose rather than the actual Sinuses, which is on the different compartment. So with the rhinitis, their their symptoms are quite similar. So some nasal congestion friend Arria post nasal drip, um, sneezing. And it's normally divided into allergic and non allergy causes. The treatment we use is either a steroid nasal spray. Some auntie estimates well for people with allergies and nasal irrigation with salt water. Uh, whereas acute right? No sinusitis is the as mentioned acute is the inflammation of the mucus membranes in the nose and also paradise and Sinuses. It could include the frontal Sinus, the mix it with a maxillary Sinus. Those are the main are common places, and we call it chronic when it goes about above 12 weeks and also with with chronic sinusitis, it often comes with patients often comes with polyps well in their nose. Good, so rhinosinusitis are also known as just sinusitis. It could be the fat into acute and chronic, and also went over that polyps, and mainly the causes are either for patients with acute is not a bacterial but for longer of chronic ones is normally patients with allergies and how to diagnose them or the main cardinals side. Your symptoms are having two of the symptoms listed below us also one of the signs, either in the public. It's probably more that we visualized them directly that we can see a polyp or any discharge to the patient has, and the main symptoms are official paid and, um, reduction in the sense of smell and in discharge. And if you like feeling congested, it's basically like feeling when you have a flu. Yeah, so management of sinusitis. I think this is helpful if those people would ask is with any prescribing stations. So with symptoms off less than 10 days. So the discharge of the congestion and the facial pain off less than 10 days, we normally can manage it conservatively. No antibiotics. Advice the patients that's normally caused by a virus and just treat symptomatically. Drink lots of water, paracetamol for the fever and the pain. But if the symptoms is more than 10 days, um, patients normally get a high dose nasals cortical steroid spray for about 14 days. And, um, we can also give patients, especially if their symptoms of discharge and green discharge more signs of like a bacterial kind of infection. You do, uh, prescribe patients. Antibiotics and self care advice is well with. If it's chronic sinusitis, it's a mainly trying to get hold off the root cause off the side of scientists. Normally, it's the allergies or the asthma and then advise on any exacerbating factors to the patients. And amazing irrigation with saline is always good indicator case acute or chronic, and the same goes with the intranasal cortical steroids and the antibiotics. So, um, this is more off a, um, prescribing exercise. If, for example, a 30 year old off patient came in two weeks, two weeks or 14 day history off nasal blockage, discharge and pain across the forehead. What would you prescribe? Um, so there are different types off nasal cortico steroids, but the ones that, if you look it up on the benefit, continues any of them. But the ones that I stick to normally is moment. The sewn 50 micrograms per dose nasal spray. So I used the one that starts with M mometasone More Bets Zone and, um, first in down the answers in the notes section in the PowerPoint presentation. So when you get them, you were able to check it as well. And I'll just write mometasone 50 micrograms per dose nasal spray and to take 200 micrograms twice a day, you can check the under be an F, and because of the discharge, you would also give the patient some antibiotic cover so normally they would give Pook oh amoxiclav 625 mg three times a day for five days. Some. Normally you can follow your local guidelines as well regards to the antibiotics prescription so hopefully drink the osteo. They would give you like a sheet on the side, showing the lyrical guidelines on what antibiotics they normally use in the area. Um, so bad flags for nose complaints and Sinus complaints. So, as I mentioned before, any unilateral symptoms, not only here tea and it's always a red flag. Any persistence is also a red flag. And, um, polyps is polyps and also unexplained expert Texas. So any bleeding so lastly, remove onto our growth ology ease. So mainly for rheumatology is we're thinking off more like neck alums. Um, so with any tropocollagen is, always ask for any pain and the so troll and hoarseness. And the boys and dysphagia ordered aphasia pain on swallowing and in the clumps that the patient can feel or any persistent cough and with any any off the symptoms. Also, us always remember to ask the most history a swell just in case they have any sinusitis of symptoms. So one of the one of the very common presentations off throat pathologies are in Children, especially is tonsillitis or sore throat. And there's the pictures on the middle is showing some past in the tonsils that is one of the cardinal symptoms or signs off tonsillitis and how we We also have a score called the fever Pains. For that, uh oh that doctors used to decide what to decide what. It's appropriate to prescribe patients with antibiotics or not, and normally, of the pains. The fever paid score consists off whether defeat the patient has a fever if there is an absence of cough, and if the symptom onset is less than three days, so more like acute presentation and the Purell in Tom cells, which we can see on the pick middle picture here and also an inflammation of the thoughts cells. And normally. So the higher dose for is the more likely that the patient is having a structure cockle infection, a bacterial infection rather than a upper respiratory track and a viral infection that what? That is why I hired the score, The more likely you are to give antibiotic prescription and with the man with the management off on slightest, is a simple energy Z A, and especially if the patient can't swallow or can't tolerate anything to swallow down, needs to be admitted for it. Some IV fluids at least and the antibiotic that we use is for not seen without insulin for about 7 to 10 days. Uh, so this is the picture off the on the throat examination, and the tonsils normally lies in between the anterior arch and a posterior arch here, Yes, so Quincy is is it is a complication off kid tonsillitis and the main symptoms are often read a unilateral pain Christmas so they aren't able to open their mouth fully, which makes it hard to examine them on like a true examination. And there's also referred pain to the ear, so otalgia and during your throat examination, normally you can see the uvula, which is deviated because basically Quincy is an abscess or collection forming around the tonsils, which we can see here where my mouth is and it pushes the uvula to the other side. And and this is this case to the left and do one with the abscess, the right tonsils and how we treat Quincy is normally by drainage, So we osteopenic patient to say God, and we just take a needle and aspirated for any puss. That is the quickest way for relief, and we also sometimes give him IV. Antibiotics for cover Um, laryngitis is also a cause of one of the common throat presentation. So, like so throat. So it's more for inflammation off the voice box itself, and it's usually viral cause, and it's self limiting. So the symptoms include the same hoarseness, difficulty speaking. So troll fever of the dry cough and also feeling like constantly need to clear your throat. Or there is something stuck in there. It can be chronicles as well do two other secondary to any gastroesophageal reflux disease, excessive alcohol or smoking ISS. So in neck examination is a main thing that you should do when someone comes in with the throat with ology, and mainly it's to assess for any lymph nodes. So with tonsillitis or my mean people are more concerned of had a neck malignancies when with the, um, metastases to the lymph nodes so we normally start on the picture. Here. There are levels, often neck, so normally people start at the some mental and what are we back to the stuff mentals mandibular it and go up really regular and then go down the neck, which is level 234 and then, um, basically down the neck and reach the super political ER and then go back a Xarelto, the posterior triangle and then roof your way up. That's normally how I do my neck examination. So that's just more off, like a smoother transition from the chain to the along, majora up the ear down the neck and then behind the neck as well. And then, lastly, the midline. And that is basically just to be sure that we don't miss any, um, lymph node stations. And with any examination always the same. We inspect the outside, and we palpate for the size position. If their mobile the consistency, whether it's hard, firm or soft, any, uh, hospitality. So it it's a typo of any positivity, which means it's more of a T o like an arterial malformation. And, um, if there's any tenderness and with the investigations of any like lump, it would be so any bloods. The imaging imaging would include ultrasound, the best modality to assess lymph nodes, and also you can do like after knees, which the five middle aspiration off the lymph node itself can also be ultrasound guided and always remember if someone presents with a neck Lomb. It's important to check the other day and the and as well, so here of the nose. And, um so yeah, so, as I said before, he and he's always related to each other. Okay, And so the examination findings. Um, I don't know about other medical school, but where I treat normally to have, like a model that have different, um, live notes that they can put in. And they asked in the station They can put in different lymph nodes could be the harder one of fluctuating one. And then they can, uh, so the candidate for the student. What is it likely if it's rubbery? Normally, if the findings like when you palpate, it's robbery and fluctuance is always a good sign. Means it's reactive could be just you to some ongoing infection somewhere. And it may be sometimes in the ears, or whether it's painful is normal, so reactive. But in the more alerting signs are. But when it's hard and irregular, and also if it's increasing in size, that means that is possibly more like I had a neck malignancy and also any soup. A click click regular note is a bridge house note or Corey for gastric cancer and improvement. Otherwise so, um, but there are still benign, benign causes off the neck lump. So always go through your surgical, see? So the vitamin C D E f. So so, which includes any infection and then if in in ah pretty have been a benign tumor and also a any congenital or development of lumps like a parabasal cyst. Um, I used to always be confused. Paragraph. So cyst is because the only reason it forms is because when thyroid's form, when you, uh, in babies or when you're on it, it forms from the base of the tongue and then it travels down into the, um, that down to the thyroid cartilage. That's why along that track, sometimes it doesn't close completely, and that is when that forms that they're a glass assist. So where a sinister causes off neck Lem's is not, is normally for lumps that has not gone always persistent for three weeks, and that would warrant for, like a two week wait to investigate for any malignancy and the most common cause off any neck sinister cause of my glands are lymphoma, So any lymph node a malignancy around. So remember instructors again. So in the neck will be the notes. There be the thyroid or any other soft tissue, like a soft tissue sarcoma. So this is just different shows, if the neck logistic to have thyroid nodules. It could be a list of the French ALS, but you just probably have to remember the first two or three and then during Muskie's. If they ask you what to do, just remember to do a good ways to do the B B I get like bed bedside bloods. Invest in a, um, an imaging in this case, ultrasound today and, um, invasive. It's more for management, for surgical management later on. And, um, and the most common type off air a cancer is the papillary thyroid carcinoma. I think that would be good for, like, progress, test and and and always be suspicious of a parent lump in any child. Oh, it's rapidly enlarging, and it's associated with any cervical lymphadenopathy. Oh, and the stride. Ah, horseless. That means that it's quite invaded a recipe. So, um, lymphoma. One of the causes of the common causes of neck lumps, or what people moves worry about is lymphocytic kind of problem, which usually have diffused lymphadenopathy no only in the neck, but also in the hilar in the lungs. And it could also be in vinyl that lymph nodes or just generalized. It's not the maxillaries a swell and and it's normally EBV associate it. So it's people with post it be the infection have it that they are prone or they have a high your risk of developing lymphoma. And if they're immunosuppressive, is well, and they divide it into the Hodgkin's and non Hodgkin lymphoma and, um, Hodgkin's. A small be lymphocytes are affected, and it's classical. When you look under the mice for spoke, you can see the reads time, but cells and there is lymphoma is a lymphocytic problem. It it will cause other problems in the bone marrow because it can infiltrate the bone marrow cause anemia, order it so they can reduce the production of red blood cells, are produced platelets and also reduce. Otherwise, that sounds like me like the neutrophils are causing neutropenia. Mm. And with open and mid lymphoma, always us about the the symptoms. So with, if they come in with the neck, lump us about the Roman systemic symptoms like fever, night sweats, fatigue and weight loss is the red flag symptoms for malignancy and the normal. Those are the main ones. So so that's the end of my presentation. So, in summary, you've talked about a bit of the ear pathologies and how to take the history, remember? And the treatment examination, the scope there in the knees and members, tests and audiogram. It also talked about the pathologies nor, most commonly, any neck plums. So, uh, so how you investigated, how you, um, answer, um, questions about management or investigation and asking a good way of structure is to use a baby. I I and only time you use that. Normally, if I get lost or sometimes run blank drink, all skinny streets do happen on yeah, if anyone has any questions. Oh, thank you for listening.