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Have you tried recording again? Yeah, Very cool. Okay. All right. Um, if you feel happy for me to crack on on all that, So, um, very fantastic. So sorry for the delay start guys leaving work and trying to get this, uh, sort of. But money is my card. One of the, uh, here in ST one training at West Midlands. Um, firstly, thanks, BSO Junior, for hosting this event on that deal. Um, you know, I had the other night. I go way back in medical school, and, you know, I think she always wanted to be a surgeon. I think, you know, definitely picked up my specialty. Um, as much as I hate talking about myself, have you asked me to do this? So I went to the Hamptons University. Um, I can see some familiar names on the screen. Uh, hi, everyone. Um, I spent one you're doing on integrated, agree? And then, um, most recently, I've been a PT certain medical education and medical education. Something that I'm really passionate about. Something that I want to take him board. Um, I did my foundation training and master. Um, and you don't know where Lester is? It's basically in the middle of nowhere between London and Birmingham. Um, it's a great little city. Um, really underrated. Had some good training there, but it's not to take a year out. Uh, to be honest, because I didn't get into court surgical training the first time around. Um, but afterwards I somehow moved into urology. So, um, I might not be the most credible person to take the session from because I'm dealing with, um, male genitalia now, but I guess the pipe is a pipe. Um, so, yeah, that's that's about me. Uh, so, you know, like the full surprises isn't. I thought I wanted to the ent in the first place. They decided to do a year of the anti teaching, Um, and then I'll under urology. I'm perfectly happy on, but hopefully us will learn. Ah, few things. Basically anti things that you guys might be asked in your exams. Or when you guys go into your foundation program or when you're doing your core training program, Um, especially in the ent. So let's just talk about some learning objective today, So we want to cover some common nose dermatology on this is very, very Common and GP, uh, so we'll briefly touched on that. But most importantly, I want you guys to, uh, understand. Keep finally, biology conditions and emergencies avoid falls and patient management, especially with patients with run a lot of conditions on Also, understand the triage of patients, especially when you're that half one of the S h o admitting these patients into the surgical unit. Okay, so we'll send a procession quiz. Okay, so hopefully you guys, uh, enjoyed that, but let's just go through. The nose is the nose. It's not going in the middle of your face. Okay? For most people, it looks symmetrical. But when you look inside, it might not be symmetrical. Okay, um, but the nose function is various. You know that we need to smell. And I know that everyone steps The first part of the Creon the exam where you're supposed to get the swelling potter until cold it it on north. There's a big thing now, um, but most importantly, it also says the drainage point for the Sinuses. So we've got several Sinuses in our body, especially in the head, and they open up at different parts off the areas just below determinant on. It also is responsible for equal equilibrating the pressure between your inner and the middle ear to the outside environment. So, you know, for example, if you're going a tunnel or if you're going, ah, long haul flight, you might feel that you're getting a book book up. And that's basically the nose and the station to doing its job. Try to, uh, quit liberate the pressure, that aspect. Now, I think the key thing about the NT is that you need to examine the notes when you examine the notes. You really, really need to make sure that you not only examine the notes from the outside because I think to be honest, anyone can tell us the nose is bruised or swollen or if it's deviated, but you need to have a look inside. Okay. So question number one here. Okay, So you've got, um, this patient on if you if you look very, very close up, what you can see is actually a septal perforation. Perforation can be due to many things. Okay, so, uh, you know, it can be the fact that they, uh, might take some sympathomimetic drugs here with a recreational aor prescribe the things side cocaine. Okay, Or it could be due to malignancy. Or it can be a vascular condition where there's inflammation, the blood vessels lining the nasal septum on that becomes the crows on. That basically dies out on another thing to keep in mind that if there's a septal perforation that is not treated or not addressed in the first instance, that it's almost like having a house with a very, very poor foundation. The house itself, especially the roof, is going to collapse. So you can get something. Put a step nose for me, Okay, uh, or sat on those deformity. Um, question number two year or image number two. You can quite clearly see that the nasal septum is deviated, Okay? And I think you know, if these deviations are that extent to this extent, you know, you're definitely gonna have some symptoms. And it's mostly union, actually, is a blockage with these patients will have a very hard time sleeping at night. Number three is something called a separation Mottola or an abscess on cephalhematoma is basically a swelling in the midline of the nose. Okay. And people always confused between the nails after he got over as well as the neighbor contra. Okay, so nasal turbinates are coming from lateral wall to the media walk Waas nasal swelling the cold from medio to lateral is definitely abnormal. Okay. And this is because you have a collection of blood in the mucus perichondrium layer on the cartilage yourself, which increases the distance for OCS and effusion on also nutrition. So that happen? It's going to die on number three. Photographs here can lead on to photograph number one here. Okay, Number four. Something that you might you might sometimes see when you examine the nose, especially with ah, right rhinoscope or sexual days on the scope on did a very, very prominent blood vessels in the nose. And these will be very prone to bleeding in an area called a little area. And number five are nasal polyps on. Once again, there's a polyp arrived from the lateral wall to the media wall. Okay, now, looking at some of the skin conditions. Okay, Number one. Okay. You might, for example, concept medicine question or your medical final question is, you know, ah, postmenopausal or perimenopausal lady comes in to your clinic, get with some, um, a reddening around the mid face. Okay, Uh, and it comes and goes, but it's been getting worse every day because it started. What could this be? This is basically, uh, immunization. All right. On number two, um, anyone know what number two might be? Yeah. I'm not sure People are writing down in the function. Yes. I didn't think you could say so. I can see that. I could read about it if you want. Someone said Obsessed almost of basket a malformation. Someone said no idea. Okay, so this I think they're very, very good. Yeah, I think certainly better getting. Then I would have taken before that. Just let me to fly to another. This is basically facial use, in effect. Granuloma. Yeah. So this is your initial mediated? The idea mediated. Okay. On it. Basically, information of granuloma on the tip of the nose. Okay. And then number three. Anyone know what number three? You might be back in there. Settle. Nosy. Yeah. Yeah. So it's It's pretty much like that bag nurse, but this is Simon nasal sarcoidosis. The sarcoid conditions and other vascular condition. What? What? You will find that these patients are this really deformed tip of the nose. But also, you can see that the nose itself has completely classed. And this is due to a vascular vasculitis and a vascular necrosis of the septum. Pretty much okay. And they've got a very flat face colon quote. Okay? And we mean this in a very medical term. Okay? And not be mean or anything. Number four common cause of concerns from patients and their, uh, especially parents of the faces. What could this be? So the tip of the nose looks a bedspread. This is quite a tricky one, Michael. Yeah, Someone said, uh, yes, that could be tried on you today because I kept doing this like I do. Okay, but, um, this let's say that, you know, it's a four year old child coming into the pediatric, uh, department or GP. And the mom's really concerned that she's got this red spot on her nose and she thinks it might be cancer. Yeah, basically, what this is is the vascular malformation. Again, this is something called cherry hemangioma. Very, very common in Children. It's usually located the midline of the face. Yeah, So these patients will come in mom's very, very worried child, Probably worried at the same time, depending on how old they are. House naive they are. But basically this is completely benign condition completely benign when you give them is basically a course of propranolol, which is a beat, a blocker. And over time, this is going to be very, very effective that if it's shrinking down these vascular malformations, um and this goes away after a few months of taking propranolol. Okay, So very, very effective on parents will thank you forever moving onto number five number five. If anyone's happy to take a stab, I'll give you guys, you know, a few seconds. But I didn't know this, Um, but I've read up on it very, very interesting. This is like a distinction level medical questions. Although having said that, there's someone in this child who has received medical distinctions, and I'm not sure if they would get it. Um, this is something called J A N A A J. And J. And A is a very, very rare but the nine aggressive fibrous growth and almost exclusively occurred in young male, and it can spread into Sinuses in the cranial vault. So if something special for the Sinuses or the cranial vault, what do you think it happened to people? What do you think is the thing that people worry about the most? There's a straight highway from the nose to the back of the head. What do you think it up in there so said Maybe 2 to 3 involvement. Yes, it can. It can lead to pituitary involvement. It can lead to infection. Yes, that's the biggest thing there. So you can basically get cranial actresses considerable advance if you get meningitis, okay. And these people can die. So this is usually manage surgically, usually in a very, very specialized tertiary center. The Birmingham's one of them on what you need to do it. A few suspects, which is basically a very and large nostril over on one side, basically discharge coming out. Then you would definitely need to involved in a neurosurgeon a lot of the, um azelastine, the, uh, ent surgeon. But this would be done in a tertiary setting, and this would be a good admission just to make sure that they get an initial scan and nothing is actually happening at that particular point in time. Okay. Number six Very, very common in elderly patients. Very good. Rhinophyma. Yes, the right time. A guy call it the Cialis Ferguson note because he's the only guy that I could really think of. Fame of them has. It's basically, um you know, the cause is awfully well understood. What happened? More, More so on occasion, especially during the winter. You get this really bulbous appearance of the nose. Okay. And it can occur. Been conduction with Revatio. Okay, but it's not mutually exclusive to one another. Okay, I think we're just gonna crack on with the rest of the park. So let's talk about nasal laceration. Okay, So you're the ent. Shh. Uncle. Okay. Um um And, you know, you're you're very keen to start, and then suddenly you get a patient with, uh, perspective. Nasal laceration. The laceration, by any definition, is basically putting those involving the skin on quite possibly, the cartilage in the bone itself. Patients will come in usually after a fall or trauma. Okay. Usually Saturday night or early Sunday morning. Just a bless you for under shift. Okay. On, uh, what, you need to do it need to examine them and look at the extent of the damage and this Can you manage the needy can result in the ent referral ongoing patient going to be a teacher. And there's a practical advice. I mean, everyone caused by the appearance of the no. Okay, um, on what you really need to do is you need to repair on opposing skin. I just Well, okay, so if you don't feel comfortable in your suitcase skills, you know, if you've done the only surgery that you've done is very, very dodgy. You know, intraabdominal future when you're 30 and medical student, then definitely is doing attempted are probably escalate your registrar or if you have a friendly max accessory to run. Um, they are very good at, uh, the tremor. Facial lacerations on it requires something like a five or a six or nylon or pearl in, which is a very thin monofilament nonabsorbable futures that you can barely just above she with normal vision. Okay. And you might need a pair of Lupus with surgical glasses. So what you can do in the meantime, it's just clean the wound, make sure that's not contaminated, and that can be infection, and you can oppose it by using Steri strips there just to keep it intact. You know, if there's any concerns about, you know, getting cut was very dodgy looking blades or especially animal bite. You might want to think about tetanus prophylaxis as well attended politics. Okay, now something that we see very, very commonly, Okay. Especially living in Birmingham. I quickly realized that, you know, there are a lot of trauma patients come in. Okay? Usually Sunday morning, Um, from Monday morning, usually after, you know, a heavy, nice hot or something on patients coming in like this. Okay, so this is what a nasal fracture looks like. Okay. The nasal fracture basically means a bone break. Isn't that okay? Remember that the nose is made up of a third bone and two thirds cartilage, most commonly after trauma. So you want to do an internal external examination of the note from the outside? You might not be able to see much because I know they're so swollen. Okay, Um, on DMTs they chose might be expected to minutes with a nasal fractures under local anesthetic, but but But we'll talk about the caveats of that in a second. Okay. On the treatment of this really depends on the time period. Now, how the actual faithless that needs a fracture. Because that's what we the bread and butter of what we'll be doing. You basically want to rule out, um, both worrying signs when I had the most worrying size, I mean, the ones that could potentially suspicion that okay. And these are things like the skull injuries or pan face of factors. Okay, so if you see a patient, okay, and they've got a nasal major fracture or a lot of nasal swelling. But if you look at the back of the ear at the master region and it looks very, very, uh, bruised, uh, do you know what? The Sinus cold, The bruising of the mastoid. Let's say that the patient came in after a high velocity injury. Usually after, like, a road traffic after that or something. What do you think this would be? Fantastic. You're so smart. Uh, I was when I started. Christ. Okay, so, battle sign? Yeah. So it's apparently not from going to a bottle. Apparently. The guys turning on doctor bottle. What? What a culture name. But yeah, that's battle sign. So that is usually indicative of a lateral skull. Base fracture. Once again. Break it. Get in the skull base. You basically got naked of the CSF on blood into the middle, your cavity. And that's why you see the color hemotympanum as well, which is blood behind the panic membrane. You can also get panfish a factor so these patients might come in their eyes might be very, very swollen and very, very bruised. And we call that a panda I sign, which is indicative of panfish. A fracture from the cold, the 43 fracture on. In that case, the patient area will not be safe for you to do anything yourself. So you need to bring the whole tablet in, which should be there by that point. Now, the past called vice art of use, you know, should I repair patient? Okay, well, if you feel patient and if they got, you know, swelling up the nose, then you really need to know what we need to do from your side. So if that is making due from your side or the no. No, because you don't really notice. The nose is broken a lot. It's very swollen. What? You really need to do is for the nose to swell the swelling to come down over a period of days of 5 to 7 days, and you ask him to return to the S H O clinic, where they might undergo a digital manipulation under local anesthetic. Okay, try the block, and then you basically using both hands. It was from an insulation of the second. Back in place on that is probably the most satisfying thing next to cracking and knuckles probably. Okay, but the problem is, some of the patients don't attend those appointments. Then there's less of a severely deviated nasal septum. Then they need a definitive surgical management, which is, uh, uh, doctor rhinoplasty. Okay, now, another thing that I want you to be aware of it. If you have a patient looking like this, we've already spoke to us. That's a hemotomas. Okay, so nasal fracture. Send the patient home, Okay? Couple days down the line, they say that you know when When I when I breathe I/O through the nose, I can feel the air travel between left on the right side, or they come into e d. Get with, you know, high CRP high temperature getting really, really body is falling off nose because basically they've got infected nasal septal A hematoma on that can be a compromise of supply in the nasal septum and that can die. Basically, I think I've already briefly touched on that. What you can do okay from your side, if you're the and yes, if you're interested you in confidence to do so, you can have a look inside of those come from. The diagnosis I would just need to do is to incise it inside it. You evacuate the blood. Okay, on what sometimes needs to happen is for you to put some dressing lighter side and then put a suture running future one running future just so they can hold itself in place. Now, that's probably a very, very technical move to do on a bed broke. If you're an f Y one on E. D or something just escalated ent. And they're more than happy to do that. And then you can just maybe done in theaters if the patient is not, um, um happy to do so. In a way. Little abscesses or abscess is a question of a collection of uh, line by inflammatory of psyllium. Okay. And it's between the naval cartilage and a perichondrium. And once again, it's normally after troller was not being managed properly, especially after hemotomas. And that can lead to an infection. Okay, so in that case, what you need to do is to you can try to initially lance it. But if there's a body swelling and if you need to evacuate it in theaters, you can do both at the same time. When when you take the patient better. Okay. Yeah. So you basically look at the most fortunate part landmark, and you just basically lancer. Okay, So when I when I feel and if you grab a scalpel, can you do have a vertical last? Okay. Through the mucus perichondrium not too deep, shallow enough so that the blood can come out. Okay. But, you know, to be honest with you, if you see a patient like that, um, you probably want to speak some of more senior, especially if you're out in the early stage of retraining on for me personally, If I saw a patient with nasal septal hematuria, I still speak to my registrars so that they can come and have a look at the patient before I do anything right, That's crap. Come in a video. So I've turned on the sound like computers, so hopefully this will work. Welcome to our instructional video Performing flexible nasal endoscopy. You'll need the following pieces of equipment. First position the patient upright and spray the decongestant into their nose. Asked them to gently inhale. Next. Wipe the end of the endoscope with an alcohol wipe. This will prevent it from misting and lubricate the tip of the scope gently past the endoscope into the lows. Unusual need hand to stabilize the scope against the patient's nose. This image demonstrates the eventual depth toe with the endoscope should reach. Here's a video of what you will see. First you see the inferior turbinates Middle seven in September aimed towards the floor of the nose and advance forward. You look to see the septum immediately in the tablet. Naturally, as you pass further forward, your head towards the postnasal space and the nasopharynx aimed the endoscope. Inferior leads down towards the high preparing Senderens. Now all the structures will come into you. First, you'll see the base of the tongue epiglottis in the air. It annoys as you go further forwards. Well, see the true courts. False cords. Pyriform fossa in the airway, you can ask the patient to make a sound to check vocal cord adduction on abduction. Then carefully look around the remaining erotism track tongue protrusion cheek insulation on DTaP thing the head left and right arm moving the endoscope can help visualize all of the parts of the upper airway gets attract when finished with. Draw the endoscope gently. Thank you for watching. Right. Lay down for instructional. So sexual name of doctor is, uh, uh, skilled. That, um all new starting ntl a chose are taught. Um and I think to be honest with you, almost like cannulation where you feel very, very gratified when you do the task on do you can actually get a lot of clinical information out of it. Conservative diagnosed as well, but they're pewter mean of investigation. So, for example, if a child comes in and they got a foreign body, they've had a bit of fish and they said something stuck in their throat. You can report a Flexeril need endoscope. Okay. If the patient is having, um, upper airway signs and your called trauma call or peri arrest school. Okay, you can think about putting it on. FND on trying to see what's going on. Now, for the next couple of minutes, I like to talk about a topic that very, very commonly presented CT. And I can tell you on my last one called where my current job requires me to cover E N T A Swell. Um, we've had about six of these patients coming in with, um epistaxis your nose, please. Okay. So when you look at patients with nosebleed, you think about the causes, right? But you need to know what what is the story? And when you then try to establish the story, you want to make sure, um that, um you want to make sure that you tested patient and take a history So you run for your a b c d e. On. Then you take the history. So you start with When did that start? How did it start? And then since it started, you know what happened is getting better. Is it getting any worse? And then at the end, what brings you to the hospital down? If the patient is in those six hours ago and you're coming in now. You need to try to work out what made them stay in their house or elsewhere. We're such a long period of time before the current The hospital local causes obvious cause, obvious things, like, you know, local trauma. So if you're six year old kid picking their nose probably explains it. Okay? You have inflammations that they might have had an upper respiratory tract infection. Did they Might have had some sneezing, and then they have a bit of bleeding trauma. Okay. Mean, I same. Or and another one is a topical nasal spray. So if you use no nose sprays very excessively, you can have nasal bleeding from those please. And that's because the what the name of the congestions are, um sympathomimetic. So once you withdraw using an after recommended period of time, your nasal mucosa bit that's very addicted to it, get pretty much on you could have some bleeding afterwards due to increase vascular congestion there. And also, some people just shove it in a bit too far. Okay, now, so what? The rare but important causes to be aware are tumors and That's where your history taking comes into play. So very common questions are efficient. Your exams, you know, patient coming from apparently Far East people from the Far East they're more likely to get asking bar virus infection and that increase your risk of having a needle syringe of carcinoma. Um, you also would like to know if they smoke or if they work with wood dust or if they work with heavy metal fumes that increase your risk of certain types of nasal cancer. Systemic. Called us if you have old doors here, 80 year old looking coming in after starting, um, Anticoagulation. Because the Casodex for was four or something and then you took the iron on eight, you could probably know why. Probably the most serious patient will affect it that I've ever seen with the patients who came in with basically malignant hypertension. Ah, systolic off 242 150 uh, but that, in combination with the start of the patient, was taking warfarin just exacerbated there in those. And also don't forget the stuffy bleeding disorders that you might want to ask the patient about now, in terms of treating, uh, epistaxis We always start from the first eight pins of bread and butter basics. Now, when I was a kid, I was taught to lean backwards and pinched the hard part of my nose. Now what That leads to waas my complete this pace of blood because it tastes pretty nasty. But also, it doesn't really do anything because President does hard part of the nose. You're not really compressing the blood vessel. And the whole point of pinching the nose is to provide a temple, not to the vessels that what you actually meant to do is to lean forward it in the tip of the nose on hold a position to about 10 to 20 minutes. Okay, on that has to be continuous pressure. So, um, if I was to give this advice for patients leaving on the ward, for example, I'll ask one of the A ch or one of the nurses to pinch the nose because it's difficult for someone having the nose to pinch it continuously for 20 minutes. Okay, if the bleeding continues, Okay? That's what we might do. Our something mawr sort of upwards into the stepwise progression, and I'll talk about that nature on now. Just awarding the next video is, ah, depiction of a Nimer ginseng tea of epistaxis scenario. So if your ms squeamish if you're scared of blood, then I would suggest you take the port of break or something on come back in about five. So here's the video. Is Andrew the only armored who does the ent as well with the so called SWAT began? Well, it's for you, then, I'm afraid. Nasal efforts taxes in seven. I don't know. Bugger worley anti. Besides, I'm busy enough with my own patients. See if there's any anti registrar. Cool the results of Justin. She's going to lie to you now. I know your people. I am concerned about his nose bleeds. Where's the anti Roach is? Well, he's in transit between here and the general. Patrick says, I'm really sorry to keep you waiting. It's a madhouse in here, Like under Maitland. Let me take a wild guess. No sleep moment. Is that ever going to stop bleeding? Yes, it that he's going to stop bleeding very soon. Indeed. I'm a human failure, right? Well, then let's get you into the recess. Julie, get the blood banks a factor. Eight, please. You haven't. Okay. Well, we're gonna tell you. Hold some factor. Eight black person factors. You back starts. Sorry to bother you. To blood, Mr Cullen. Recess to worry about. Back to those in my life is theanti richest Rosten Little dessert switchboard stays at the general. I think it's getting worse. Um, I have a go there, You know, What about just called? Know Stocks of Baxter. Date that haven't send out way. Try a small balloon into your nights together. It's coming, Losing out. You do test compression. So what? How's the neck? Okay, right. So who isn't Trauma patient of a A cranky, Um So firstly, we know that that video's very, very old everything like a, um number two. Um, yeah. So, like, that's written there in the tax epistaxis 10 b series on. You know, it's a bit of a dramatization. I mean, I'll get you the patient, that doubling over and things, but it can happen without warning. Okay, So, um, Epistaxis is what a patient come in. You need to know how to manage them. It's not an official level skill to put a neighbor packet. Yeah, and north is an essential levels built escalate. So a couple things from the video is that you know, if you're going to wait for the anti registrar to come in packs of those when the register 30 minutes, 40 minutes out Yeah, You know, you're gonna have a pretty tough time like this. This scenario, okay? Because we always talk about 80. He's in the airway. Bring a circulation and epistaxis can effect on impact all three of them. So if there's a lot of blood Okay, then your airway king a compromise, and you can go into the area. Rest breathing. So if you start swelling blood and she's aspirating, that's an issue. Circulation is the biggie. Okay, people think, knows how much can you lose blood in the note? I mean, trust you can do a lot. Um, there are stories of 80 year old patients coming into the hospital with on warfarin, but they've been bleeding for 12 hours. Tickle the blood, they come in and they go into cardio cardiac arrest because they've gone into basically a half a pill in shock. Okay, so what you can do is to recognize that this patient is bleeding. Try first date and birthday isn't working. You can always escalate. Okay, So what do we have in our stepson's Cialis? But this is something that will be probably in my back after a long cold. Okay, uh, you might have some forceps get you Might happen. Nasal violators. You might have, um, a nasal pack get very sort, which we'll talk about in a second. Um, on in that video that that doctor, what's her name? I can't remember her name, but she put the Foley catheters in. Okay. And that's usually a late maneuver that you need to do. Can you know? I think why would you put a Foley cut it up? The patient knows. I mean, is this guy just having a lot of rubbish? We'll get to that in a second. Okay? No, what you will see sometimes when you're on call, if you come down and see a patient on you've been told by the ent shor a CT or the battery on the EDSS your eighties and they have no no need to worry. And you come down there and you basically does anyone know what this animal is? That is a low risk indeed. Okay, so we called it a walrus sign, because basically people put nasal pox in, but not completely in. Okay, now, let's talk about things step by step before we even got the nasal packing First aid maneuver. Okay, you get the patient the right position, head leaning forward and punching the wall of the nose 10 to 20 minutes and you can even supplemented by grabbing on ice bag and then putting it on the patient. Know the evidence behind this is very poor, but if I have time on also to miracle trying to find a nice pack in the nation hospital. But if you have it available for you now, you want to make sure that the patient is on some for observation and you want to make sure that the patient is not going to believe in shock. But also, what you also want to do at that point in time is to have a look on actually doing examination. You look at the notes from the front and your, um look at the note from from the inside there with your medical speculums or the nasal violator. And if you see a bleeding point, okay? now, some hospitals don't like doing this You can use called by the cane Fenical. Fine. Okay, story. Or you can put the lidocaine or lignocaine difference accountable and try to dab it there. Get the evidence behind. Very, very poor. Okay, if you're bleeding point what you can also do if grab something called silver nitrate stick and it looks basically like a match. Okay? And it's supernatural. The end of the seven nitrate works by basically buzzing, providing a chemical cauterization to the bleeding area and that usually sorts of problems, if you can see of it. Leading point on the bleeding. Uh, being point there are multiple of them, or the building is to copious that you can actually see the bleeding point. They need to think of something more clever. Okay, so what you don't want to do is go in and go on, manage reading, and then you then call try the entire nose, because then you can lead to having a nasal. Uh, that's a perforation. Okay. Do not do that. So, like I said, take it for my stomach, love. Okay. Gloves everywhere. But it isn't Whatever is available for you. Okay, Um Now, what you done by consider doing is to put in a naval pack. Okay, um, nasal passages pending which ever trust you working? There are different types, different kinds. But right now we've got him to court a rocket science, which is very, very popular in the hospital. Previously, you've got to cook with a nasal for you commerical. It would tear a kind of a dissolvable neighbor pack. Okay, but the problem is, as soon as you stop, uh, with the nasal culture is Asian, or think of something else to do, you're at a point in your mind or final, where you need to start thinking Well, I might need to call my registrar, or this patient might need to be admitted for observation at these. Okay, because at that point, too, of your magic kind of failed. Okay, so at the same time, when you do your 80 80 and when you get, see when you cut them. Honesty, the faxes. You want to ask the other members of your medical team, but through the actual ask your friend, the Afghan or the 80 of the pas to do a full set of blood, including cutting and group and safe. But just remind yourself that those results will take a walk. Come back. Okay on. If you are ever end out, the invitation is becoming. He was another person stable can always actually the major hemorrhage protocol. Because I know you come to that area now, once about bones in my eyes from the seven nights a cauterization of the incident in a pack. And there are two types of packs, depending on the anatomical location and your nasal pack, okay, means that maybe three actual pack will reach the anterior Part of those with a poacher part will go all the way back. There are few and far between culture past available especially on your ward, covered okay. And they're usually protected. So on the example of this would be a rapid viral that's longer the longer than 7.5 centimeters. What do you think you want to do? Okay, is to avoid having a lower sign that you want to basically angle three rapid rhinos. So the rapid rhino it's got two components on other layer on an inner layer on inner layer has a sponge that inflates get using this little balloon at the back and you got the other layer, which is a jello gel. That kind of material in a pen. It's derived from series. And if you know anything less period, if you put it in water, re in place What you want to do if you want to put it in water and what would happen is it will determine is that jelly like structures that when you advise the thie nasal pack into the note, you're not going to traumatize amazing or the neighbor because the further okay and you have to put it all the way to the health. You got a 5.5 centimeter neighbor pack. You put the whole 5 5.5 centimeter in okay, And then once you got it to the health, obviously the patient not gonna like that. So you hold your head or if you're very combative, grab some stronger than you. Okay, Oh, outnumber time. Okay. And then you want to grab a pen, most range, and then basically inflate the little a doctor device here with 10 mills of air, and that's going to find the inner portion on that's going to pull it tight seal around. Even coda. Now, when you do this, one of two things will happen. Leading will stop. Your bleeding will continue the bleeding stops. That's fantastic. But the bleeding continues. Either You haven't traded it enough or the readings after post here, please. Which is more serious on at this point, I would definitely call my registrar, because to do post here pack what you need to do is grab a horizontal perfection goal. And you two pack the nose. Always the back, but even the other Corinna get in the horizontal fashion and you do this by baby 1000. This it was a new except in, or mupirocin, which are antibodies. Bacterial cream. Okay. And you based packet horizontally until you can't have any more. At the same time, you want to put your good old urinary Custer. You see, a 14 gauge can do is a note all day to the back of the patients. They are. And you want to see the tip of the cutoff for the most about. I won't help me not have lost, but just the tip. And you want to inflate it as he was born normal catheter with 10 miles of water, and you want to pull it back. And that's going to for my physical temple are on the fortunate of things, and I don't really do this. Okay, So patient was admitted with, uh, the patient came in needed, uh uh, rapid, right. Inserted this perfect thing on the outside. You to take that off, By the way, you get a thing. The plastic thing on the outside. It's plastic. You literally put in a passing. Okay. On what the patient ultimately need. It wasn't a blazing. Yeah, so I could search. Interrupt? Yes. So this patient is actually one that I saw myself picture taken with consent. I've got it on here because I felt it was very important to pass the message on that. It's key to know at least how to use the equipment when it comes to anti. So this patient was on already had classical brain tumor, already had cutting derangement, and then on top of it, obviously had further throwing the course to his nose by the plastic tube, which is essentially, like, not removing the plastic cover of a tampon, for example. So you can read it. It was very traumatic on, then I actually have to do a posterior pack for this patient. So what I did was I inserted Foley catheter. My personal tip would be Don't use water tea inflate the foley catheter just because if it burst. So for whatever reason, you don't. Anyone not going down patients into the patient's lungs, so I in place it it with their on. Then also, person a rapid right, no side by side as a quick fix. I didn't use this long ribbon on then, of course, escalated immediately. It's my register. All the special into theater and had a procedure done. So it interrupts Michael. No, no, no. I completely agree. Okay. So that okay, not running the plastic. It's like going into battle. So then you got a story, and you haven't used your port, and you're trying to fight people with your garden get, and that's definitely not the way to go. Okay? Yeah. You can do a whole lot of trauma to the patient with the rent on. Yeah, no surprise. Patient needs to go into the other regulation, which is the next step in your management. Okay, so, um, that's the escalation pattern that you need to use the first day the 10 to 20 minutes. Continuous pressure. That doesn't work. Okay. You wanna have a look inside the nose? Probably at this point in time. I see if there are any bleeding points, then you try to cauterize it chemically, Electrically. Usually don't do it, Actually, technically using silver nitrate stick. If that doesn't work, they need to enter a pack. Is that fails? We need to put your pack on alarm. Bell should be going. Okay. In your head. Um, Your Majesty, Patients on if surgical masks and failed the patient not suitable for surgery, then your chemicals in the hospital be the interventional radiologist, and they will they will do an ambulance, a shin, But that also carries the tone risk of stroke on the Okay, So I think. Briefly, person, put your taxes. The learning points. In short, please restock. It can be serious. Okay, kids falling over on, then, you know, having a nose bleed, you need to take a justice serious as your elderly patients coming into the hospital on the war, friend and I are all scraped and nine So if the patient has to anterior passengers still bleeding in the patient is a culture pack because obviously the bleeding stuff from the anterior nasal cavity. Okay, I need to make sure that not just focusing on the notes, but you need to take a step back after you look at the patient, the whole if they're crashing and you put the, uh, neighbor packet and you go for our patients of the pressures in the boot, that's that's not a bit approach to take. Okay, so let's we want to the next topic with nasal obstruction. Okay, So patients coming coming into the hospital, he usually in the chief setting, they say, you know, um, I noticed in the block. Now the cars can be benign. Tumor lignin have been completely knock you out completely, completely on life changing. Okay, so, in my I always tell people that unilateral fine, um, are quote unquote better and better localized and bilateral sign that it's bilateral. Then it can be things that because the information if you have a cold, most of the nostrils would be funkier. Okay, if you're violating their bilateral nasal polyps, the new part of the nasal cavity. Okay, uh, but if it's unilateral that it can be due to a physical problems. That constipation, for example, space off a nation serious foreign body has love stuffing things I don't know, but it can also get you to try a lot of inflammation. The other information. Other important information. So you take a company of your nose and throat history. We want to make sure that there's no bleeding in the area. So in my eyes, if the patient tells me that unilateral obstructive symptoms worsening over, you know period longer than two weeks in my in my eyes on, they also see if they have recurrent those beads that needs to set off alarm bell to my head on. The patient needs to be scanned quite urgently or suspected malignant. Be, uh, nowadays, Okay, olfactory disturbances, everyone. So America because of yeah, um, but also another rest like to look at, especially patient's perspective, off having a nasopharyngeal carcinoma. Or basically, they finally, the cancer. If urology and what I mean by neurology, if you want to do a full cleanout, never examination, especially up their facial muscles and the trigeminal nerve, because those can get affected as the nasal last growth in the Sinus cavity and then invading into I've sample on. If it invade into the eyes, not only will you get the cream on their spine, you also get a paraplegia and copia because the extra ocular muscles will be impinged on the growing man. So I think we've talk about the red flags already. So you know, patients often patients very, very important for you to take a good social history. Okay, patients, when they come to your place and 10% of space of pain? Well, not always. And they've got facial droop or facial. Fine. Okay, that's usually a bad sign. Okay, Um and that that warranted to be great or quote unquote cancer is the cancer. If you're on, the patient needs to be scoped now. Foreign body. Very common in the community. Often needy and urgency enter. So any of the ATP hear any of the pa here and you're not here. You will see the time and time again. People put this Put things inside the nasal passage on day, depending on how long it's been there for. You might just have simple nature obstructive symptoms, but you can also have nasal discharge at the taxes following offensive smelling discharge from her nose is especially if it's been there for a while. Okay, so you need to do a good history and a good combination. And also, if it's a child, any unilateral nasal symptoms, the possible in this chart is they created a foreign body and quick motor wise. If you thought the kids would say hello to straight, what have you put it like? You know, um, obviously, with better, I hope, Um, now, in terms of bored money on those especially for Children, okay. Really, really effective thing to do something called a mother and I'll show it to you in the next. Okay, now, you can also try to have a look inside the notes, but I'm in about you. But when I was a kid, I was very, very combative. I was combative pediatric patients, so you might need to actually examine them under anesthesia. And if you are unable to move it and you remove it and you to have bread, um, TNT and a decision made, uh, where, um, they need to do something, was there. And then because there's always a risk that they take a deep different on the foreign body goes down. It's the right lower lobe they launched in the main bronchitis. Now, what were also worried about are intact foreign body that are crosis. So a very innocuous thing that people forget about our button battery, okay? And but in batteries by UK industrial standards, I believe need to see it be able to identify than a radiograph a double halo. Okay, But even if it doesn't have a double header that mean that you can be rest assured, you don't want course of material inside your, um your inside your mucus membrane because that's what the corrode through the mucous membranes and want to leave you a bunch of cold that you need to sort of. Now, let me show you the modern care how they hold the child. So what you need to do to take a four, then you have security before then. So what I would do? Uh what else? Um, pediatrics was two. For the mom or dad or whoever to hold a child can make the cylinder last. Okay. The right arm with a dominant arm over the pictures forehead and the left dominant arm over the patient portal came finding their arms together. And that allows you to have a look in that? No. Okay. Almost like an m m. A movie, I think. But, um, other kids, it's basically next day that the foreign body in there by side of the nose, what you do is you cover the left side of the no. Okay, on the parents is going to, um, basically provide Ah, positive pressure through the mouth very quick through the mouth. They want him in the kitchen. And that on the pressure is going to dislodge the foreign body away from the affected nostril. It's going to come out, and it's oddly satisfying. I seen one done, uh, when I was, uh what? My own calls. Where a child put a Lego head on. I saw a Lego had come out. Um, like a bullet. When the when the mom mother care, it can be quite amusing. Now it can. Some people name some of the instrument. You You might see them on EENT truly when you're in an answer. Okay. So you can feel function and that's right, left hand side. Okay. What are these things here? Luxiq or Chairman Hook. Fantastic on investing. Yeah. You got coconut for that? And then this. Yeah, let's stop the horn. This's Yeah, Yeah, but this is the fire. So, um, and then here, you can get get the suction to turn on your contract. Suctioned out that fails. You might want to try to relax. Okay. Now, be careful with wax in jobs and horn. You need to be able to see beyond the foreign body. That's what I mean by that. If there's a foreign body here in the nostril like this, yeah, you can use the oxycodone corn. Okay, if the nostril, it's tight around the foreign body and there's not a face. And don't try to wiggle the walk for 10. Don't try to put the drops in corn, and okay, what's next? Best to do is to basically the cocaine or four steps. Um, and the cock little forceps don't work. Then you're gonna have to take the Children to be a teacher, and I should talk with Okay, Any questions? And, you know, to be honest, if you 99% of the time, if the child comes in with a foreign body in the note. Um, and if it's significant, they'll need to quit for examination on seizure under general, which my son like an overkill. But, hey, it's best to be based on your today, but she's got she's got a governor on. Be pretty bad if you got it wrong. Yeah, I always put up by much from nurses were getting that could have made for, uh, that's good. The well done now leading on nicely from that. So let's say let me give you a story. Okay? So I had a child in clinic when I was doing my tree job. Um, and she basically came in. Okay, um, after having some foreign body in the nose, she recurrently puts things up or no, I have no idea what she put in. It wasn't specified, but nothing with crows This but she had recurrence of discharge. And actually, a few weeks later, she presented to ET um She printed the e. D. With a very, very swollen Ireland. Okay, um, on, but she was still complaining of that discharge from out of the note. So that history and the contact shit trigger, you know, alarm bells on your head for payroll little or precept life as basically inflammation of the island in the air. It's running on that, um, on, um, there, uh, tennis complication, which basically a justice severity off Harold with colitis. What it is pre or with preseptal or post after is better or alive or a little after. Okay, so, preseptal like the definition you've got swelling of the I live. Okay, you've got some pain. You have a fever, but there's no pain, and I movement. That's an important thing. And the child may be able to open their eyes through the swelling of the island. Okay, so what, you want to do it if your child like this in pediatric TV, if you want to take a good history and you want to try to do some form of a criminal of nerve examination just to make sure that they've got no facial droop or they've got no trains, a little nerve neuralgia. You know, I don't have a look inside and know, if possible, you want to make sure that these these Children are senior reviewed by both the ent and pediatric. Okay, because these patients might deter it very quickly and may need pediatric involvement because they know their stuff about pediatric area. Um, breathing in situations like that pa left, um, the Children may also need to go to the theater. It but their conditions change. And if they start to complain off pain upon moving their eyes Okay, um, then they want your scan, and then when you could be taking in theater, get to try to be 50 compresses area on, indicate CT orbits and Sinuses are the way forward. So attention loss. Okay, Especially consequence of all this. If you have orbital swelling, all the information is loss of vision and also intracranial actresses. So stage for internal classification, if you start to have meningitis durable, okay, because now you've got an open communication from the eye to the, uh, to the school. They and that's not a good sign. So you need to give them intravenous antibiotics and refer them to the the Holy Trinity off Pediatric care with ophthalmology ent on a pediatric. I don't know the pilot to 20% that they liked it, but I'm doing that your car now. If it's preseptal in there, no red flag signs, then you can hear the side of caution on admitted child, but that's needs to be discovered. The seniors on is your confidence that this is not a serious problem that you can give them according, um, for example, and discharged him when you want to admit a patient. I mean, you want to visit patient their clinically septic, and if they've got, you know, hemodynamic instability, uh, they already taken couple confident that that's not getting any better than you. Just kind them you keeping know by mouth, and you could put them for days. Okay, so we're coming up to the last point, and I'll start taking questions afterwards because I'm cautious that I'm running behind them time. So when you're in the community, Okay, so you know a lot of nursing nursing the district nurses. A lot of GI process is with p a, a sippy. Get a lot of a lot of complaints about patients coming in with a seasonal or acute sinusitis eyes. Um, on a very, very common is that she around this time of the year also in the thing of the year, and you can imagine drink over it. It's one absolutely ballistic, basically a patient with acute right outside of sizes. Usually by definition, have the problem for under 12 weeks. So it's an information of mucosal lining on the nasal passage dependent finances. Sometimes I can imagine our neighbor blockage. You can't rhinorrhea or nasal discharge. I mean, which is reduced. No, you can have facial pain or dental pressure as this. Technically, you might have a fever. Fatigue has sore throat cough, depending on the call. Okay, the examination Always full ent time you want to do in your exam It all and they're different types of white of sinusitis. Okay, so let me give you an example. So I get acute sinusitis, probably borderline and chronic sinusitis. Because during the winter time, I I get vasomotor rhinitis. Where if I go outside and especially with cold air, What what happens to my neighbor? Because if that gets very dilated and then I start profound rhinorrhea if you look at me, okay. If you cross streets on you, you know, I think I'm having shared not a good time because my nose is constantly running a constant flow. I know, um, and that can be debilitating for some people. Okay. The treatment you need to target your treatment based on what the cause is okay. And most of the time, you can imagine community and doesn't need any further escalation. The first line is, you know, give her some pain killers, and you get the nasal decongestants. So, um, the's are things like, um, a puzzle in a But remember that you can only give the congestions when, uh so you can only give the congestion okay for a maximum of 5, 10 days. Okay. If you get any more than that, you can get from the cold rhinitis medicamentos, uh, which is, in a sense, making there may be discharged. Worse. Okay, because your neighbor, because the basic addicted to the decongestion you can have reflux Finally. Okay. And if it's going on for more than 10 days and if it's not worse if you're not getting any better with nasal decongestant and you can give them popcorn, nasal steroid steroids are general anti inflammatory agents. When you give them topical nasal steroid, it's completely different spray. So the way administrative favor important, and I'll use this pen. It's a demonstration. Okay, so when you're using a spray, you need to lean your head forward. And in order to spray the last nostril, I need to hold the notable with my right hand and aimed for the lateral wall, because that's where the, um, well, that's where the heaviness comes. And inflammation and the injection turbinates are the things that are calling with not the MS line common the accident. It doesn't really help, so that means the front okay, left hand right hand for a left nostril, left hand for a right, not draw on a gentle sniff in one or two times. And that should provide local effects if you have to quickly, that's all. What about the back of the throat? Gets work in contract when you give them a nasal steroid? Draw. What need to do if you lie down with your head hanging off the edge of the bed, Okay, and you've basically gently dropped one or two drops in each of the nostrils, and you stay in that position for about five minutes. If that doesn't improve things, you basically maxed out in your community treatment options, and you need to for the community and red black size. As always, our eye problems with pear, a little swelling in there. A FEMA in patients with acute, right? A sinusitis had suggest apparel that they're like, Okay, so most of these cases can be matched the community and do not require a girl. And I mean that for I could run a sinusitis on a lot of these things on the treatment options are available over the counter that well, no complications. We spoke about which appreciate over. Like, it's also osteo my life into the cold base. So puffy tumor is on enemas. Name for osteomyelitis with the front side. Okay, on. I've seen one patient with this. This is a guy that was living along the canal and not again. I notice a little canal. Um, and he took shower, maybe one every week if that very poor personal hygiene. And he was pretty cold. It's January 2020. He came in for a dental extraction. And, as you can imagine, he has the upper set done. The Lord that wasn't taken up, Uh, because she needs some time to recover and then public it between that, he didn't get seen. That whole. He has the infection off the upper gun where he thought caused dentist, dentist prescribed in coma car. Okay, before few days, but a bit better help taking it, and it got worse. Then he called it GP and the GP kind of a course called Take it for a few days. Got a bit better help taking it. You know, the, uh, the, uh this one of work. Two months. And then he came into the ent department in August 2020. Um, well, yes, he came into any because he was very feverish. I had two big swelling on his forehead. Um, and he felt incredibly sick. CRP was in the two hundred's. White cells were through the roof. Okay. And then we did a CT scan basically showed optimize my life at the front, and he told us they have to show the photos of the he thought his head looked. It's getting bigger. Um, and he didn't really think much of it. So because of the protracted course of antibiotics, hey kept having the's interesting. $12. And that's because he had this infection from the upper boulders of the two into the Sinuses and then into the frontal Sinus front of a clearance Sinus into the front. Yeah, we called a puppy tumor. And that is what part party to relook by under that people. Frontal. Uh, you can also also see frontal offices. And then, if not, that's left untreated and that, you know it can lead to over the congestion. I remember. If there's over, the congestion is you've got arteries nerve. Um, veins going there. But you might have a little extra getting the closest you can also have damaged the office nerve. We can go blind, but also the same time you can get venous congestion. Dizziness from both the and that can either occur in the I work in deed to infection tracking to the back of the small. And you can you can get having a kind of from both with something that you want to avoid, what you can see here. But these are cabinet from both. Okay, remember, cabinet Sinus is a wall of Venus blood here, and you've got a lot of important structures going through it. You've got the optic nerve and the third nerve, The fourth nerve. Six nerve on the first one. That there. And you've also got the I see a going around. But if you get from both is there That's going to lead to a lot of good time, and the patient can get very, very sick. Okay, so I have run over time, and I'm really, really sorry about that. Uh um, hopefully you'll find a fashion useful in summary. Okay, if you are working in those healthier I mentioned, but in the GP, in the community or in the acute care turning or if you're working in 80 or even as an ent, pa or effort or a CT, you need to be aware of these conditions where you can do the practical still will come with time and experience on under the guidance of the registrar's the consult. Um, so make sure that the taxes need to be aware that you need to understand that you have a very low threshold for saying that goes the same thing goes for foreign bodies in the note and Children at all. And if you have a patient with nasal fracture, then you can three do much about it initially. Make sure your rule out the red flag on Ask him to come in after 7 10 days in the right. The deal I think I'll stop sharing. And now, um, yeah, that's fine. You know, I just want Teo. Thank you all for coming and sorry that the session run over slightly. Thank you so much for giving up your evening to attend that. I hope that it was useful for you. Um, I'm just going to show my screen again because we have a procession quiz that I would love if you could do because it helps to kind of decide whether their picture the right level on whether you would benefit from any other information. So I'd be delighted if you could fill it in or post a link in the actual chats and also push up my slides. Thank you so much, Michel, for doing the session. Yeah, No worries. It's always a pleasure. Thank you. And we have a few more of the sessions coming up. I really hope that it's useful as before. If you fill in the feet, the feedback form that you automatically gets your certificates and if there's an issue with that, then please let me know and I'll sort out. Um and I will just put up this wide now for the posession quiz so that in case you want to use a cure code to enter, if anyone has any questions specifically for me on my call, then we're happy. If you just put it in the chat, then we're happy to answer them, so we'll stick around for anyone who has any extra questions.