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Rick. All right, guys. Um, we will start our last webinar today. Thank you so much for all of you guys are joining us today. And thank you so much for all of you guys who are being giving us support and sending us, uh, positive feedback and messages over the last 12 weeks. Um, we are having our last webinar today on E N t with our guest speaker. Mr. Walker, Uh, we will be recording, um, the video for all of those that have to live earlier or kind, um, make it for today. Um, first of all, we would like to thank you all. And we would like to thanks asset for helping us developing discourse. And, uh, the end you as well for sponsoring a zoo and, uh, no. Lastly, um, to medal for providing us a platform to, um um allow you guys with certificates. Um, the video for today will be on sebaceous cyst removal. So we'll be playing that naturally. And then I will let Mister Walker carry on with the e n t session. So let me just share my screen sebaceous cyst excision. Excision of the sebaceous cyst requires some care as we ideally want to remove the cyst without damaging or breaking the integrity of its capsule starts. By identifying the margins of your cyst, you should plan to make a slim elliptical incision to include the punked. Um, if this is visible, there should be no more than a few millimeters in where it's make your incision over the top of the cyst, being careful not to go so deep as to puncture the capsule. Once in the subcutaneous tissue, it's preferable to use blunt dissection to gently dissect down to the capsule. I don't know what's happening. Guys dissect down to the capsule before working your way around the margins of the cyst. You risk puncturing your capsule, and you will leave yourself with more work to do. Once you have freed your cyst from the surrounding subcutaneous tissue, you can gently work the cyst within its capsule out of your incision. Occasionally, there may be a stalk at the base of your cyst, where infection may have caused the capsule to adhere to the surrounding tissue, which may require cutting. Be sure what you're cutting before you cut to avoid inadvertent damage to other structures. Once you've delivered your cyst. You can close the wound as demonstrated previously with either an interrupted suture or sub you particular common pitfalls carelessness. When cutting and dissecting or grasping the cyst capsule with tooth forceps, it can lead to rupture of the cyst. In this instance, the sebum or infected material must be evacuated and then the capsule broken up before cleaning as leaving behind the capsule will see a recurrence. Use some gauze to sweep the inside of the wound to break up the capsule. Once cleaned, the wound should be left open and loosely packed with gauze or ribbon to allow the wound to drain. Yeah, all right, guys, I hope that was useful. Sorry about the technical issues. As you know, you can find that video in our metal platform and we will be unloading the videos from next week onwards onto our instagram page. So I would like to introduce and thank Mr Walker, who is an ent consultant on the right Sorry Cantel Hospital for giving this great talk and participating with us. Um, just like we're reminded guys, if you go any questions along the session, just please type then on the shock box and we will answer. And then as we go through, So thank you for having, um, us here, Mr Wilkin today. That's a play there. So I'll share my screen and okay, we'll get talking, watching the sebaceous cyst. Um, video. You know, it does remind me of many times training Teflon's up to doing these procedures, and, you know, whilst you you know, you're desperate to get that cyst out. You know, too much pressure around it will definitely cause a rupture. And definitely one side remembered, uh, telling my trainee don't push so hard, and, uh, he managed to evacuate the entire thing over his watch. We're wearing watches for some reason those days and over his leg. So, um, so be careful not to try and push you hard, but, uh, it's a great it's a great way to start surgery. Something simple, like a sebaceous cyst, simple skin excisions, suturing closed wounds. You know, this is the way to start, because a lot of surgery is these basic surgical skills, which once you start to develop, you can you can take on to do almost anything. And, uh, some of my trainees last week, we we did a huge case, uh, pharyngolaryngectomy a free flat to reconstruct throat. And, um, it's a huge case, but actually, when you drink break it down into its component parts, it really is only extension of the surgical skills that you guys will learn from now into your consultants. So, um, so surgery, Uh, as I say, Well, you know, from these basic steps in these early days, well, that will carry you through consultant level. So I work at Royal Surrey and, uh, in Guilford and, uh, thank you very much for inviting me to speak about E n t. I mean, it's your it's your last webinar. I'm definitely hopefully not the last, but the least or or whatever the expression is. But the reality is that, uh, it is a small specialty, and, uh, and we like to keep We like to think it's probably the best kept secret within surgery because actually, it's got fantastic range of surgical procedures, range of patient age. Uh, and, uh and it's extra, incredibly intricate and interesting area of of surgery and generally ent surgeons are all pretty nice. So, uh, so you work with a good team and good people. Uh, so I'm going to talk about in tears, especially specialty. Uh, the organizers wanted me to have a chat about two areas of, uh, the ent that you might find useful in terms of your early years learning. So I've gone for tonsils because the ent surgeons love the tonsils. Uh, and I'm going to stride or because stridor is a worrisome symptom for someone who encounters it, be it an A and e you're on the woods and then I'm just going to not sell ent. Just talk about cutting edge ent because, you know, we've got a lot of exciting directions forward, so we do a lot in the mt. And, um, it's not often well taught medical school. So you probably haven't seen a lot of this, uh, this stuff going through in your training, Uh, and in your early years of of learning, But actually, e n t is is a broad church of, uh, of procedures of sub specialty areas, my bit his head and neck, which is probably the most dangerous bit, if you like the most most difficult in some respects, and it contains a lot of difficult patient in terms of cancer but also benign disease as well. Ideal with cancers. The throat of the oropharynx, which is kind of your tonsils in your tongue base. I deal with laryngeal or voice box cancers, thyroid cancers, saliva re and skin cancers. And, um, that's a huge range of, uh, of work, but actually benign head neck surgery can include again thyroid disease but airway work. When you get Married Airways, I deal with a lot of voice pathology, which is a really interesting area. I used to do a lot of singing before I got too busy. And so I hear the, uh, the reality is, if you if you sing, you actually like to meet singers because you've got you've got a lot, a lot in common lot to talk about. Um, and we do with lots of swallowing disorders, including Found your pouch. But that's my bit. But there's a lot of a lot of my colleagues who are doing some fantastic work in ear surgery mending uh operated gear drums, dealing with a disease called cholesteatoma, which is a really odd condition of the inner ear. Which of the middle ear story, which destroys the bones of hearing, uh, and and works its way through the mastoid bones. You would have heard these expressions or maybe even seen some of this stuff. Um, and they'll also be dealing with patient's with hearing loss. Can restore hearing in patient's, uh, with fantastically intricate operations and deal with balance disturbance. Extension of electrology into the skull base is through mainly acoustic neuroma surgery, and that can be paired with surgeons, particularly in tertiary hospitals. Uh, Rhinology is is also in tertiary in, in in some hospitals, going through the anterior skull base, dealing with pituitary tumor, uh, dealing with complex frontal Sinus disease. So there's a lot of cross specialty cover, but the day to day rhinology those procedures are polyps and rhino sinusitis, from which we all suffer occasionally, um, nasal blockage and deformity, and you can branch off into cosmetic surgery if you like. It's not for me. I can't deal with patient's with this all sort of tiny imbalance of their upper lateral cart. Cartilage is it's not, it's not. It takes a particular type of surgeon, I think, but you know, there is plenty of scope cosmetic, practicing mine ology, and this is the point I was making earlier about pediatrics. There's a lot. There's a whole realm of pediatric surgery with the ENT dealing on a basic level with tonsils, adenoids and hearing with with fluid and fluid but also difficult, complex congenital work and airway disorders. Uh, and it is thought that the number of ent presentations in primary care is something like 40% of their work. So a lot of this is dealt in the community. But we we've seen the niggly end of a lot of, uh, conditions from from young. Well, from from Cradle Parade. The training pathway is like a lot of surgical training in the UK, and I'm aware we've got potential international crowd. But, you know, if you're if you're going through your your standard u K training out of medical school, you'll get through F one, uh, and then in F two, you might be trying to to never get your way into some surgical specialties. And I do have, um two or three fy two or fy three equivalent trust grade jobs. Uh, in fact, I have three FY two s and three fy three or trust grade jobs. So you know, it's a lot. A lot of trainees coming through the ENT department every four months. Um, I have one c t. Two and I have one G p. Trainee. So you there's plenty scope to get into jobs like this within the U. K training environment. Taste D and T as a specialty to really understand what it all means. And and the trainees love it. And they love it because in those early years you're giving lots of responsibility for patient's your own clinic, often as an emergency clinic dealing with ear infections and those bleeds and, uh, and and nasal fractures. Uh, and you know, from a very early stage you take referrals from GPS and an external hospital. So it really is a good way to get into any surgical job, because actually, you're given that responsibility early. We do have court trainees in E N T training pathways, and they often come to us as a CT, too. But, you know, our CT one jobs throughout the region there were there was, over the last couple of years, a vogue for employing run three trainees from ST one and two. But the reality is that I'm not sure that particular experiment has worked, and it looks like they're going to be pulling those opportunities. I think it's difficult to know exactly what you want to do by ST one. Uh, some people know, but you know, the vast majority of people need a little bit more time, a little bit more experience within other specialties to allow them to choose correctly for them. And the ENT won't be for everyone. But I have to say, once people start experiencing it within their early years training, they start to realize. Actually, it's a really good opportunity to operate to see lots of different age groups, as I say. And, uh, the out of hours commitment, particularly a consultant, starts to be quite appealing because actually, don't get called that often. Whereas, you know, if you're doing laparotomy is in the middle of the night, it's not very fun. Um, so, uh, so really, the main hurdle in the training pathway is the F T three applications. Uh, and it's by national selection. Uh, and you need to do a lot of portfolio buffing to get to you get your S d three number, and it's competitive. I mean, I I got onto national selection, Uh, 10 years ago, something like that. And there were any 30 jobs in the country. And that includes Scotland. 30 jobs and 100 and 20 people applying. You know, it's it's it. It's not great. It's not great odds, but it fluctuates. A year after year and something. A few years ago, there was 80 jobs and 100 applicants, you know. So so the jobs will fluctuate the competition radio. It will fluctuate at the moment last year. Two years it's been more difficult to get the Dean ary rotations will go s Q 32 s t 8 to 6 years of training. Uh, and you're generally within a region such as cancerous last six, and that's quite a big area. London Dina is also big, but, um, you need to get experience in different hospitals. Different people do things different ways. So, actually, I really encourage you during your training to really experience different departments, whatever especially you're going to do, because actually, that ability to see what else do well or you know you need will will develop your own, um, skills for the future. Uh, any anti you probably don't need a post CCT fellowship most of the time. So CCT is something I never quite understood when I was training. It's completely certificate of completion of training. So that's the Golden Ticket. Once you've finished your rotations, you've been signed off and it's a golden ticket to go and get a consultant job. Um, you get your C C t by doing S t 32 s, t eight if you like. Um, but you can get non CCT completion of training if you're from overseas and something apart Way called Cesar, which is probably more difficult. You have to prove lots of different. Um uh, competencies and C C T or trainees through the S T three and ST eight to ST eight Root really get given their rotations on a plate, whereas if you're going to come from overseas and, uh, you know, bespoke if you like, it's much more difficult to get all those competencies, but it is possible. But if you're gonna see CT and you want to go into head and neck or you want to do something a little bit more punchy, little bit super specialist, then you might need a special uh, post CCT fellowship. And you can do that in the UK or overseas. And this is recognized roots for For training. Yeah. So if you're going to be an ent surgeon, it's not all about the tonsils, but there's a lot of tonsils involved, And, uh, if you if you don't know about your tonsils, you're gonna be in trouble. So I wanted to talk a little bit about tonsils first, Uh, and, uh, you pretty much hopefully all know you've got some tonsils, a pair of tonsils, but actually, the reality is you've got a bit more than just palatine tonsils in the bag, which I'll show you. Here. You've got lingual tonsils at the base of your tongue and you've also got the adenoid tissue top behind the soft palate. So you got your tonsils and Palatine to cancels the lingual tonsils over the back of the tongue and the adenoid tissue, which is also part of this area of ring like or lymphoid tissue called wall days ring, and that forms a really good barrier. Really good immune system barrier to to bugs entering your body. You probably forget to look at the back of your throat on a regular basis. But if you, if you do like me, look at throats on a regular basis, is worth knowing what you're looking at, the youth, you know in the center, the tonsil sit within the tonsil foster and founded by muscles, political classes and the plate of pharyngitis and this patient saying, uh at the time, allowing their muscles to constrict. And you can see how the muscles are quite quite well developed in this area. Um, anterior part tonsil pillar is all about squamous mucosal. Covering the posterior tonsil pillar is all about the squamous epithelial covering, and that's important in terms of the pathologies we see. But the tonsil sits in the middle, and it's it's it's a walnut size, um, situation. These are small ones. I mean, you can get enormous ones whole covering the whole, uh, tonsil foster or into the midline, Um, and the aggregates of lymphoid tissue. Uh, you can you don't need them. But, uh, and the problem is that they do swell with the confection, uh, as you know, with tonsillitis. So I think it's pretty obvious what's going on here. Hopefully, to most of you, I mean These are hot red and swollen, aren't they? If you're looking for your inflammatory, uh, signs rubor dollar color, et cetera. You know, this is a hot, red swollen tonsils. They're enormous kissing in the midline you could just midline excavate around with with erythema. This is tonsillitis, no doubt about it. And this patient will present with difficult throat when they'll be extremely sore in the throat. It would have come on over a few days. Maybe with the prodrome or illness, it will become more and more difficult for them to swallow to keep their fluids down. And they're they're, uh they're effective. Symptoms will predominate with high temperature sweats, etcetera. It would be very difficult for them to swallow. And patient's often come to hospital because they can't drink. Uh, and you might see them in in all walks of the hospital, difficulty swallowing pain in the throat. Um, even if they're in for something else and it's worth having a good look at their throat, you know what? What does it all look like? That there occasionally a big set of tonsils might cause you breathing difficulty. You can imagine a big couple of walnuts sitting back there hitting the midline. It's been quite difficult to breathe, passed them. And it's particularly in Children a good reason why Children have sleep at me if they've got enormous tonsils. Uh, so not only tonsils, but admit as well restricting their airflow, giving them the difficulty getting that airflow in and giving them sleep happy. Yeah, you can even make you diss phonic. You can imagine a lot of a lot of swelling back there, Uh, and a dean that can affect your vocal chords. But often patient's with really big tonsils will will sound very full in the back of this, right? Um referred Italgas. A bit of a is an important symptom. Any anti referred pain to the years. If you have a really nasty tonsilitis, you can get ear pain, and you might have all experienced a bit of that. If you have a lab sets around your consulate and we'll get to that in a second, that can give you're one sided, uh, earache. And if you've got a cancer of your tonsil your tongue base of your throat, your larynx that a cardinal sign of that is referred otalgia and that's that is basically referred pain up the glossopharyngeal meth and patient's really, you know, really complain of that in order to get trismus if you've got bad tonsillitis or and even even an abscess. And that's because, uh, in the back of the throat, it's very well closely aligned with the pterygoid muscles, which open your jaw and, uh, and that can give you trismus. So, of course, with an examination of the back of the throat, you're gonna do what that doc is doing sticking in a tongue depressor. Go slowly, though, because actually, patient's hated. And then I always remember that as a kid having a wooden tons of pressure in my mouth, it's actually disgusting, isn't it? Um, so I go slowly with that. Don't get them to stick their tongue out too far, because that really does make them gag. If you stick it on the back of their tongue, uh, get a good light on your forehead and have a really good gentle look and put your tongue of pressure in the mouth and allow them some time to relax again because that will drop the tongue and allow you to the time to have a look at the the tonsils themselves. You're gonna have a feel of the neck for lymphadenopathy and masses, and you're going to have a really good look around in the throat. The extra thing that ENT do is basically use a nasal endoscope bit like the sarcophagus cape. Just stick a camera in the nose to have a good look at the back of the throat, beyond the tonsils to the larynx. And, um, it's not a difficult skill, but it's so useful to know what's going on and get a diagnosis. So you know, tonsilitis is a prodrome of illness, be to hemolytic. Streptococcus is often called strep throat. So if a patient comes in and says they've got odd or strep throat doctor, you know it is. Actually it is actually quite correct. It's usually streptococcus. It can be bacterial or viral, and it will depend on the, uh, the kind of symptomology and signs these seen. And I've shown you some bacteria, tonsils, tonsils there, uh, and they were hyperemic and enlarged with extra date. But this patient will also have lands lymph nodes up in the neck with their pain. Uh, and the natural course is a couple of weeks and you don't really want to throw its for them. Not really worth it. You're going to work out whether you're gonna give them antibiotics, and you can do that on the score ing system called a center score if they haven't got a cough. Um, that that that's a good sign. Because actually, if you've got a cough, you more likely to have a viral on this. You got extra date. You You're more likely to have bacteria tonsillitis. You've got lymph nodes up in a temperature and you're very young or over 40 for that will affect the way we we we think about your your threat in terms of requiring, uh, antibiotics. So for you guys, in the early years training, you can admit a patient who septic unable to swallow and dehydrate it. They could just have a shot of I D and A and E and then go home. But the vast majority of this patient's come in pretty dry, and they're going to need quite a lot of, uh, fluid resuscitation and the antibiotics into the vein because you can't they can't swallow effectively. The antibiotic of choices bent Alpena. So then and then clerical I Smith are allergic. We tend to dish out quite a lot of dexamethasone and the MP and, uh, we were ahead of the covid curve with that, uh, that understanding, I think. But, you know, we've dished out dexamethasone for years for tonsillitis rate infections. It's fantastic for edema. It's really good as a as a pain relief medication, really in these sorts of patient's and an antiemetics so really fantastic drug, uh, and and we use a lot of it and we'll discharge these patient's once they're tolerating the oral intake to go home. There's another subset of patients who have got bad tonsils, and, uh, this is a different picture, isn't it that than the last one? In terms of the way these look, there's a greyish X a date here. It's a medial grayish exudate. They're quite big tonsils, not as big as some with this condition that we see but the biggest tonsils. But this horrible grayish X today and this is going to the fever. This is infection of swan and nucleocytoplasmic, and we see a lot of teenagers and young adults. And now that the university is back, I suspect. We'll see it a little bit more because we've had a bit of a break during Covid while everyone's been self isolating, but they're all going to go out and swap there. Epstein Barr virus now come back in with tonsilitis and the history is similar, but it's a longer duration. And, uh, they are Pyrex it with lots of lymphadenopathy and often with axillary or growing and lymphadenopathy, and may even have her patterns. Splenomegaly. Uh, it's a it's a it's a it's a It's a very common condition to be honest and and and definitely should be tested for, particularly under patient's coming to a any with tonsilitis and, uh, and lymphadenopathy. Um, it's a whole system disorder, really infectious mononucleosis. And then, apart from the throat symptoms, they said it's the lymphadenopathy. Um they can have visual or central disturbance, uh, and hepatosplenomegaly. But the treatment really is supportive. And, uh, you know, need to be admitting the patient for IV fluids and and algesia. We often give them antibiotics because there is pretty frequently a superimposed bacterial infection, and again there's a forensics and methisazone, and we'll give plenty of dexamethasone to these patient's because they need it. And to be honest, I'll discharge them on some oral prednisolone for a few days because these get very, very swollen and eventually do benefit from from from the some oral predn as well. The test for that is, uh, for the Epstein Barr virus is to do a test called a mono spot test or something called a pool Burnell test, which is like a spot test for for for the virus itself, it's pretty sensitive, but not not. Not fantastic, something like 70 to 80% sensitive. And you can do that through and even before blood count if you send off them on a spot. That might tell you, um, But if that's negative and the patient's got all these grayish excavates, they've got a good history for, uh, the tonsilitis, Uh, and and and all the signs that we've shown then probably, uh, doing a a serology. For Epstein Barr, virus is useful. This is the interesting. What an interesting segue on on infectious mononucleosis. Because if you give someone with Epstein Barr virus and ampicillin antibiotic, they get this maculopapular rash, and it's absolutely pathognomonic really of seemingly of, uh, EBV. It's really ampicillin rather and amoxicillin rather than benzylpenicillin that we predominantly used. But it was. It was first prescribed in about 1960 and you give ampicillin was much more commonly used back Then you give them ampicillin. Suddenly, these patient's you have this fluorid rat. You can get it in about 40% of patient's with the amoxicillin. Uh, it's more common in Children. Have to say, you know, a lot of patients with Epstein Barr virus will have a rash anyway. But but, uh, But if you wanted to test whether someone's got Epstein Barr virus, you give a man Priscilla, and then you see what happens. Uh, the final bit on tonsils really is thinking about Quincy. You know, it's the It's the progression of the tonsilitis into something that's more unilateral. It's often misdiagnosed. I have to say, I've got a you know, as S h. O. Uh, as a registrar. Sometimes hopefully not as a consultant, always a call about you know, this is a Quincy doctor, but actually, you know, it really is the Quincy is Is this Perry tonsil er abscesses, the fullness in the peri consular region, not the tonsil itself. So you can see the tonsil here. You're going to draw a line around this tonsil and hope you can see my mouse moving. But you know, if you're going to draw a line around this tonsil, that would be the size of the tonsil. It's the it's the abscess within the peri times of the region. That's much more, uh, indicative of the tonsil of the Quincy. The user is deviated to the lateral nasal to the lateral, uh, contralateral or a cavity, Or or referring this the either here and, um, the fullness in this peri tonsil of space, mainly young adults. And if if if they're older, you could be a little bit concerned that, you know, is that a tonsil cancer because you know they can present can represent it more acutely. And this patient as I told you before, we probably have, um, the referred otalgia really bad ear pain from the compression in that space, the referral pain up the glass. If, uh, they'll also have that prodrome all illness, but they tend to get worse and worse and worse. It doesn't fluctuate, it gets worse and worse and worse, and they present at that day 2 to 3 with really, really nasty, uh, really nasty throat. They also have this hot potato voice with this fullness in the in the mouth. Uh, got goof. And, uh, they have trismus as well because of the involvement pterygoid. And what does that mean? Well, it needs aspirating and you get this horrible goo out of the greatest smelly pus. But as immediately do that, you stick and stick a needle in that immediately Do the ear pain goes, they are absolutely delighted. And this is a good thing about E n t as a junior, because you get to do stuff like this and you see a patient, you make them better. And it's your job. You've done it. And, you know, I I never have to get involved in this sort of thing because actually, the the S H. O. S are doing this this work, you know, they're seeing a patient that's sticking a needle in it, and if they get really excitable, they might put a knife in it. But you may have heard why Shh, particularly a little worried about putting a knife, and that's because the internal carotid artery is back here. It's not so far from the tonsil, but the reality is that taking, taking what we know the abscess is around. The tonsil is Perry tonsil. Uh, so actually, you have to go pretty long way back to to get your needle in a internal carotid artery. It's possible, but, um, but I think you know, you're you're a good sent me 2.5 away, maybe two. I put this slide in because it's worth having a look at the back of the throat, the aura pharynx When we've taken out tonsils, taking out tonsils is absolutely miserable for a patient. We take out about 40,000 tonsils in the sets of tonsils in the UK every year. We do do a lot of tonsil surgery because it's the right thing to do for patient's with recurrent tonsil itis, recurrent Quincy or sleep apnea. But you can imagine the way that these tonsil Fosse look and this is the normal postoperative cause is pretty nasty. And if you've had your tonsils out, you know, so I always tell a patient this is a miserable operation for two weeks after that. You better because you start off with a charge surface. The chart gets, uh, way lays to actually this fiber informing on the tonsil fossil, and it gets more and more. It gets smelly breath smells. Um and you know, I'd rather not see them at this stage. I'll see them at three weeks when they're much better, but it really does take a couple of weeks, and, uh, it reminds me just to talk about post tonsillectomy bleed because it is quite a scary thing to see someone bleeding through their mouth. The risk is probably around 10%. It used to be created as 4% after having your tonsils now, and most people bleed 5 to 7 days down the line. So somewhere around the end of these photographs, uh, and you can imagine it's quite a raw surface. It's quite sort of seemingly, uh, necrotic surface. It's not infected, but you can imagine as though it's big trust and fiber and form off sort of slough off. Then you get bleeding underneath and again, it's an emergency sort of situation. If a patient presents to a and e to you guys with post on selecting, you bleed. They need to come into hospital for observation, even if they stop. Because actually, that might be a herald bleed for something bigger. So we tend to be written it them for 24 hours. So as tonsils, we love tonsils. We do a lot of times I do a lot of tonsil cancer work. But, uh, the the other area that genius worry about is stride all this, this horrible Darth Vader sound that you're here emanating from Patient's airways and your basic skillful at the moment of a few cracking examples of that on the ward. But there is this very sort of very high pitched off in The sound of the airway, often inspiratory and suggests a narrow, so it depends what the narrowing is. There's 22 words to be used here. Stride or stirred, it'll start. It'll is this noisy, breathing, snoring sound. Where stride or is this higher pitched sound often inspiratory, and these are the patient's that it happens often around the larynx or just below. That's my best best impression for Strider for you, and it's different from wheezing, and it's different from snoring. Uh, it implies airway compromise, and it is an emergency. Some patient's can a bit like I've just done, uh, imitated. And and And there are a group of particularly anxious patients' that come in with inducible laryngeal obstruction. Have normal saturations that are making a noise, and they're probably just a bit mad. But there is most the most of the time. Stridor is an emergency, and it will imply some some narrow. This causes a strider that you probably don't need to get involved in too much and particularly the pediatric ones. And worrisome because there are lots of congenital abnormalities. The pediatric airway. Of course, there's infection. Of course. There's, um, foreign bodies and trauma, the pediatric airway. But there's some rare causes on the slide here in the adult. It's much simpler, you know, General Eights infection. It can be foreign body trauma or cancer. You know, really, there's not much else that's going to go on there. This is the classics. Tridgell, Iss child. I mean, if you google epiglottitis, you always get this child there probably 50 60 years old now, because this is an old photo and it's trotted out in every talk. But it does show the absolutely panic on the chance place. They're sitting up they probably got some trickier tub their their mouth is open. Uh, they're They're in what we call a tripod position with their hands on their knees, and they are struggling to breathe. Epic otitis is pretty rare now, thankfully, and particularly pediatric patient, but it's pretty worrying. Uh, they've often started with an upper respiratory tract infection or severe throat pain developed noisy breathing, and they become toxic, pale and shot with this drooling and muffled speech. Um, and you would have done moulage is of pediat Patrick resuscitation or difficult, difficult medical problems and ethical Titus might have been one, but you know, once they get quiet and floppy with the reduce the spiritually rate, that's a bad thing. So I'm happier with the noisy child in this situation. The incidents in Children has decreased because of vaccination, and we're all a bit bit more okay within vaccination after the last couple of years. But, uh, the the Haemophilus Influenza B vaccination from 1992. That's basically completely stopped it in Children, but it used to be a real problem at 3 to 6 years old, but it's on the rise in adults because of strep steps in the throat. So we do see ethical titers, But I think you know broadly, particularly that the child you do not want to look in their mouth or throat to examine you gonna inform your seniors and get the anesthetist in. This patient's going to need to be transferred to theater wafting lots of oxygen you can use something called heliox. Heliox is basically helium plus oxygen. The helium allows it to drop through because it's heavier. Drop through the larynx much easier. Adrenaline nebulizers A really useful adjunct to air wake. They reduce the, uh, reduced, uh uh, whether it's, uh, adrenaline. There is another thing, um, and you're going to need a really good and needed to just maybe, P I t u support to help you with management. This patient, that's an effective problem. You know, if they're going to need steroids and antibiotics and occasionally they need a tracheostomy on. I do just talk about the stridor and a super goddess a little bit because these are terms that we use a lot in ent but perhaps are not well, well known. The vocal cords, if you feel down your own neck and feel the thyroid notch. The vocal cords are just below that. This this shield like card least, the thyroid cartilage and that protects the vocal chords beneath the super goddesses. Anything from the vocal cords and up to the epiglottis. And in adults, if you're going to get an infection, it's more like, well, term. It's super glossitis inflammation of that whole area rather than epic aeltus on its own. So that's a cherry red epic Lotus with an ulceration on the top, and that's epic otitis. But we did a lot more with super glue otitis, this inflammation infection of the airway. And if you see a patient with a sword road, uh, difficulty breathing some stridor and you look in their mouth and their tonsils are normal, Uh, and their voice is changed. This is super otitis. Someone needs to have a look down the back because actually, the infection is lower than you that you would expect. And it's best to wait for someone who knows what they're looking at and, uh, seniors to arrive, thinking about involving intensive care. And again, it's this triad of, uh, IV antibiotics IV steroids and adrenaline names, and that will buy you at least some time or even turn around the situation. I can't leave a short talk on stride or without talking about foreign bodies because we do see a number of, uh, ingested inhaled foreign bodies in the ent. And that's fun. You know, this is this is this is quite a fun bit of the ent because actually, you've got something we can go and retrieve it. Hopefully, it's not someone that's obstructed their airway, but but sometimes it can be. And this this is this is real emergency stuff when it happens. So we do think see things in the esophagus, This lateral soft tissue neck X ray sees a patient with, uh, fluid level, and they've swallowed a big bit of roast beef and it's got stuck in their upper esophagus and they filled up and they can't swallow. They've got dysphagia upper upper esophageal, uh, obstruction dysphagia and that can give someone stride or or at least these really nasty throat symptoms. They're drooling, uh, and we can go and fish that out through the mouth under general anesthetic. Not infrequently. Well, I have to fish out a set of dentures from the upper esophagus and So that's a nice set of Nash is that you can see there. Um, it's always a partial denture, so it's always about three or 40. Uh, so this is a very common situation in Surrey, where patient's are very well to do and must have a good set of teeth, uh, to function socially. Uh, so So they'll have a partial set of dentures and the problem with this. It's got little metal looks. And when I go and grab that through the mouth with them asleep under general anesthetic, I can tear their esophagus over. So I have to be very careful. Sometimes I need to get in there with a big pair of pliers and chop it in half and take it out in pieces. And then you get the weird and wonderful and not so recent work. In recent months, we've taken out an iPod shuffle from the throat, and I put shuffles quite quite a retro bit of kit now. So So you know, you can imagine our surprise to to see that it's a good X ray haven't got it on here, but but the iPod shuffle came out interestingly. That's not the only thing she swallowed as her pair of glasses got passed through her whole bow. And she produced that for us the next day. This is the serious foreign body. They and they want to bring this up because it's very important for everyone to recognize well, often do a an X ray in the pediatric patient who has swallowed something drooling, uh, parents have seen swallow something, don't know what it is. And on first glance, this looks like a coin. You always see it. This sort of direction in the in the AP film, you see it as a nice round circle. It's absolute disk supposed coin because this is called the double halo side. So you can see a nice halo around this, uh, this supposed coin. This is not a coin. This is a button battery. And this is an absolute nightmare, really, really important emergency to get hold of to get them straight to theater, to remove it. Because if you don't, what happens is that sets up a local circuit and it burns through and it will burn straight through into the trachea within an hour or two. So that actually has to come out absolutely immediately as an emergency. So real big problem and you'll see this on the news quite frequently. You know, probably every few months will be a button battery that's a child has swallowed or people try to raise awareness about it. So So I think in in any talk about stride or about airway sentence about emergencies, it's always worth just just reminding yourself of that. So after we talked about all of the common stuff, so we know about tonsils, we know about our strider a little bit now, So you've got a bit of education and I don't really want to sell ent. I don't want to sell any specialty to you. You make your own choices and clearly by by joining these sorts of forums by the symposiums by it's fantastic piece of work that you guys have done between this together you will get experience and you'll get experienced through what you do, uh, in your jobs. But I think it's important to know that, you know, all specialties are moving forward, and, uh, they're moving forward through well through robotics. But through better instrumentation, better knowledge about about conditions. But and ent is no is no slouch were on it as well. And so we've We've moved through into robotics. So I'm going to play you a video of, uh, my theater, uh, in Royal. Sorry where? We've been doing robotics two years now. So we were one of the earlier doctors head and neck robotics. And just look at that photograph. It's, uh, Well, this is the start of the video, but it's unbelievable, isn't it? You can get all that bit of kick in one patient's mouth, but what we're doing, we're moving forward in terms of cutting out tonsil and tongue based cancers. Even taking whole larynx is out with the robot through the mouth, minimizing scarring, reducing length of stay, improving patients' long term survival and side effects. And so I will play this video. I may have to drop the sound because otherwise you just hear me talking on it, which is a bit annoying. Um, uh, but then you guess you've done that for the last 40 minutes anyway. But but you're you'll you'll see the see the room. So this is a patient docked with the robot, and we'll pan to the screen where we're operating and you'll see my colleague in the corner doing the operation itself. Uh, maybe if I turn the sound down on the way, he so hopefully you can still hear me. Um and this is a tonsil cancer resection. You can see the instruments in the mouth. You can see the nasal little tube at the back that's parapharyngeal your fat in there. So if we went through, uh, that paraffin into your fat, that's where we'd find internal courted. And there's my colleague in the corner. I mean, you've probably seen robotics. Now it's becoming more old hat, but e N T Robotics is not. And there's me looking at the screen. Make sure he's doing a good job, but, uh, you know, this is two person work, but but, you know, this is really pushing, pushing ent forward and and for the best patient's. So we've got robotic ent Seen that and that's exciting, but e n t is a broad church. As I said, we've got endoscopic ent. So these guys are going into the front frontal. Uh, frontal, uh, skull base taking opportunity. Tumor's helping neurosurgeons to take out, uh, anterior skull base tuners and these guys are dealing with the tiniest bones in the body. The stapes here, the incus malleus replacing them, replacing the drum, allowing for hearing implanting Children with tiny implants to allow them to hear. And I think if you're going to do surgery with this scope with this breadth of interventions, this, you know, this is a fantastic specially for you. Um, but, uh, but I don't need to sell it anymore. We can. We we can. We can go on talking about it all night. Okay? Thanks. Hell, no. Sorry. It's good to get me. Thank you so much, Mr Walker. That was amazing. You know, actually, I'm doing ent. Next is my expectations and looking forward to meeting the guys and meeting you in person. Looking forward for my interpretation. Uh, we've got a couple of questions already. Um, one of them is from Erin Kelly. She's asking Do you have any students for elective or know anyone who does? Thank you. So what we do? And I had I had a student elective, uh, six months ago, who ended up staying with us for a, you know, a good amount of time. And and he was able to get a few projects out of it. But also, he also helped me set up the first Guilford Robotics EMT course. And I did that last Friday with him, so you know, you can get some good stuff out of it. So, yes, you're very welcome to contact me on that. And I got another one, Actually, I think I've got another elective student coming. See, I can't keep up with them Mhm through someone that is. We got a message from Georgia's that is interested in doing a test a week. An ent at the Royal. Sorry. No problem. Yeah, that's happened at least twice already this year. That's fine. Let me know. That's lovely. They're asking if you could provide them with your email. That's all right. Let's stick it in. Um, we got another question from, uh, radiant. Haskin is a biomedical engineer present in the in there or during the robotic surgeries. Biomedical. Yeah, biomedical engineer. No. So I mean so I mean, really, I'm not sure what you exactly mean, biomedical engineer, but but what I would say about robotic surgery is essentially a big tool to do a very specific and delicate job and So once you've had training on the equipment, what What you have is the the whole system whole team train in terms of the theater staff and the scrub assistance and, uh, and the surgeons, And actually, once you have that, you don't need any sort of, uh, other people involved. You know, they intuitive who make da Vinci robots do supply a lot of reps to hospital to troubleshoot. But actually, you don't need them after a while. All right, we've got another question. How do you manage a post or bleeding from the chancellor bed? Yeah. So? So, hopefully conservatively. Because actually, one of the scariest things is to take a bleeding patient to theater. You can't intubate because the anesthetist are going to be worried about this patient trying to get them safely intubated in theater. So ideally, managed them conservatively. A lot of post on Celexa and you bleeds sort themselves out. You give the patient, you sit them forward in the a n e department, you get an IV access, you give them fluid resuscitation. You take a group and say you give them tranexamic acid and, uh, analgesia, and, uh, it depends on the volume of blood there producing. Okay, you very in the tolerant, adult tolerant, tolerant adult patient. You can use cotton wall soap with adrenaline on a sponge and then put it with some forceps and put it in the back of the mouth. You can imagine if you if you're stuffing something in the back of someone's mouth when they're bleeding, they're not really going to tolerate that too long, so hopefully you manage it conservatively. But if you can't, what you're going to need to do is take the theater with a very decent to need. It is because the interpretation is going to be the most difficult part of that procedure. Once the patient is intubated, it becomes extremely easy. It's using swabs like you would with any operation to pack the tonsil fossa to allow the bleeding to to settle down on using suction, to really isolate a bleeding point and using bipolar cautery often to stop the bleeding. Occasionally, you have to use a suture to overrun the tonsil bed to stop the bleeding. But generally that's that's not required in very rare cases, never done it, never seen it, never heard of it done in any local hospitals. But in very rare cases, you might have to tie off the external carotid because the facial artery supplies most of the tonsil bed. Mm. So I saw I saw, um, I saw a question on the memorable case of my career. Well, that's that's a great question, actually. And do you know some of the some of the some of the some of the biggest cases we've done it can be very memorable. I, uh last week we did off the first case in Guilford of a removal of the larynx. As I told you earlier removed the larynx of the throat called a pharyngolaryngectomy using thigh muscle. Uh, sorry to thigh skin called an anterolateral five flat, turning it into a tube and then plumbing it in. That was a great case. Last year. I did even better case, actually, which was a acid ingestion injury patient where what we had to do is again remove the pharynx and larynx with the upper GI surgeons. They mobilized her colon, which they brought it up to her her neck. We took off that lack the medial third of the clavicle and plumbed it all in that that is a once in a five year case and really, really good teamwork. Good cross surgical specialty work. And you know, that's probably the most unforgettable one. Actually, I saw something about robotics, and tactile feedback is a problem. Actually, it's the only. It's the only disadvantage of robotic surgery not having haptic or tactile feedback. But after a while, you you watch on the screen to see how the tissues move and the more you do surgery. The more you understand the tissue planes, the more you understand how tissues to move in response to every movement. Actually, the tactile feedback with haptic feedback becomes less important. Having said that, sometimes you do need to feel a tumor. So in that case, what you do is you take the robot out, you stick your finger in, have a good feel, and you put the robot back in, and that's all possible. All right, I've got one more question. Someone is asking, What do you enjoy the most of our ent? A good night's sleep? You know, you know, the reality for free anti surgeons is they're all quite relaxed, and the reason they're relaxed is because most of the work happens in daylight hours. You do get some juicy good stuff to do. But not a lot is going to keep you up or get you back in overnight. And, you know, whilst that, you know, it doesn't It doesn't feel important at the early stage when you're when you're a consultant or, you know, you got young Children then or into your into your later career. Actually, that's quite important from the quality of life point of view. So I can balance my quality of life with really quality work. That's why I like it. That's brilliant. All right. I don't think we have any more questions. Feel free to pop any question, guys. Um, does it just send the feedback phone right now? So if you just present the link, um, and just give us your feedback, and then you can get the certificate. That way, we got any more questions? No, they can see. So thank you So much for everyone joining us. Thank you so much, Mr Walker, for, um, presenting today on ent. That was amazing. I really enjoyed that. Webinar. Uh, thank you so much for every single of you guys that have been joining us for the last 12 weeks. It's been an amazing journey. We will keep posting on Instagram and sending you emails so we will keep in touch. We are aiming to do another course soon in a couple of months, so definitely keep an eye as on social media. All right. Thank you so much, guys. Very nice. Mhm.