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Um, I can see Izzy and D miming to me in the background. So that's good. Um Right. So we'll get started. Um, because I can't hear if there's any questions as we go along, feel free to drop things off in the chat. Um Today, we're gonna keep it relatively simple. I haven't planned something that will extend for the full hour. So there's loads of space or questions if you have. Um, we can go over some things, essentially, the aim is to go over some of the basics, some of the things that you'd be expected to assess and grapple with on call. Um, and sort of some of the practicalities around that. Um I think to start off, I'll also drop a pull off, um, in the chat which you can have a look at, uh, just to see which departments you're in, what sort of level you're at at. So we all have a sort of fair idea. So there's a couple of you who will be going into ent, um, looks like a few of you in Ed and some in another surgical specialty. Ok. And predominantly F one sh O level. Um And some people, it's the, so the first ent job. Great. So we'll keep an eye on that as we go along and I'll try and keep an eye on uh, the chat as well. I do apologize for my lack of multitasking ability so you can harass Dean and Izzy as well. Right. So in terms of overview, like I said, I've kept it relatively simple. So we're gonna look at very basic sort of nasal anatomy just to facilitate us, um approaching these rhinology emergencies and conditions. Um We'll have a bit of a chat around some of the equipment that we use. Um, ent notoriously has loads of gadgets and sort of equipment that we all travel along with. Uh And then in terms of the things we'll be talking about predominantly will be epistaxis and then we'll have a chat about nasal trauma and a little bit about foreign bodies as well. Ok. So we'll start off with the nasal anatomy, like I said, I've decided to keep it relatively simple. Um Firstly because no one loves logging on on a Thursday evening to have a lecture about nasal anatomy. Um, but it is obviously important when we're looking at trying to do certain procedures or certain interventions that we have an understanding um of what anatomy we're sort of playing with. Um And it also helps to facilitate some of the care that we deliver. So it's quite useful sometimes to think of the no as a little bit like an iceberg where you only really see the tip sticking out at the front and actually a lot of the nose goes into the face. Um, so instead of sort of this escalator going up the face that, er, lay people tend to imagine the nose actually goes backwards into the face along the top of the pellet. Um And so actually the space is quite large if you sort of think about how far back the pallet reaches. Um And this is something that's useful to try and imagine, especially if we are thinking about what can be going on within the space or how we facilitate procedures within that space. It's quite useful to understand um where there's empty space where we'll be encountering some bones and also remembering um that it's actually a 3d space and not two dimensional. Um And so the most important thing, the nose is essentially like a big long corridor that runs above the top of the palate and goes back towards the throat. The sinuses are like little rooms that come off of that long corridor. Um And so you get sort of the frontal and maxillary sinuses opening up into that middle meatus between the inferior and the middle turbinates. And then you've got ethmoid sinuses opening up into the same space a bit further back and the sphenoid right at the back. And so that's how you can sort of imagine it. It's also quite important to remember that the turbinates are not just sort of spikes that come out as you sort of imagine in that uh Coronal cut picture, but actually that they sort of extend along all the way, sort of where the hard palate would be. Um And so it's useful to remember that for things like foreign bodies or for when we're trying to insert things into the nose, um, to sort of be aware of that. Um, I'm not sure where everyone is based. Um, but if any of you are, uh based in the Imperial Circuit or if you're nearby, for example, at Chelsea or Westminster, feel free to come across to any of our clinics or theaters. Er, we're more than happy to show you and it's quite useful to get a, a, a look on scope, whether it's in theater or whether it's in one of our clinics. Um, at what that 3D anatomy actually looks like and you often find yourself a lot more sort of comfortable and competent when it comes to your own skills and navigating the nose. Um, once you've seen it sort of up on the big screen, so we're gonna play a very lame little game. There's only six of them. Um, so we're gonna be talking about equipment. So, who's that Pokemon we're gonna be doing? Who is that piece of equipment? Um, so the first one we have kept nice and easy. I, as I said, I can't hear anything coming through the speakers, feel free to shout out to each other or scribble into the chat. Um, but what is this very important piece of equipment? Yeah, I'm gonna pretend that you're all screaming out the right answer. And so, yeah, so head torch, head light, head lamp, um, really, really important piece of kit. Um, often that picture on the side with a man with a big bag is kind of what the ent on call kind of looks like with the big door of the explorer bag of equipment and a headlight on. Um, but basically it's an important thing, sort of, regardless of whether we're talking about the nose or whether we're sort of in the talks later on looking at things like the airway or the throat, um, to be able to see what you're doing and sort of the other perk of the headlight compared to something like your cell phone torch or pen torch. Is that when you put it on, you have two hands free. So it facilitates a lot of your, uh, procedures a lot more comfortably. Um, I also mention it because it's quite a useful thing if you're gonna be working as an Entsho and it depends on sort of the department that you're in and what sort of equipments available. Um, but if there isn't a headlight all the time available or if you have to sort of go hunt a gathering to get your headlight um, it's probably a useful idea to just get a cheap one off of Amazon. Um, in my case, get two or three because you'll inevitably lose it in a, at some point. Um, but it's a cheap piece of equipment and it really goes a long way in terms of facilitating the job. Ok. Next piece of equipment. What is this? Ok. So nothing coming through yet on the chart. Yeah, there we go. So we've got a couple coming through now. So just keeps suggesting nasal speculum and that's spot on. So it's TTIC which is a nasal speculum. Um We get different types of nasal specula, some of them we use in theater and are slightly different in shape. Some, you can sort of lock in place. This is sort of the general one that we use, you get the sort of standard size one and you get the smaller one that we use for pediatrics. Um They're a little bit of a mind bender the first time you see them because it's a bit counterintuitive um as to how you actually use it. So that's why I've put these images. Um So essentially the little feets stick forward because that's what you're sticking into the nose, you hook it over your index finger and the aim essentially is to use your ring and in and middle finger to sort of squeeze it to open and close. Um Like I said, it's a bit of a strange thing the first time round, but once you, um, sort of get used to using it, it's, it's really useful. Uh, and gives you a really great view into the nasal cavity primarily for sort of the anterior aspect of the nose. Um, sometimes if the patient's decongested or there's not much sort of going on, you can sort of see all the way to the back. Um, but really, really important for, um, a lot of the skills that we do. Um The other sort of thing you have to get used to besides using the thu is sort of aligning using the th um having a look in the nose and making sure that your headlight is pointing at the right place. Um So there's no point, sort of blinding the patient with your lights, but actually you can't see what you're doing inside the nose. Um So that's just another useful piece of kit. Um It's worthwhile having a load of these inside your backpack on call right next piece of kits, if anyone knows what this is. Ok. So I'll put this one in because it's quite a useful piece of kit. We use it predominantly in the nose. We use it a lot in Rhinology theater. Um We can also use it for some things uh in the throat or sort of digging around inside of a tray. Um But it's called the chili dressing forceps essentially as you can see in the picture with the little zoomed in circle bit. Um, it's got sort of a blunt but that you can pick up er, things with. So whether that's dressings as the name suggests. So if you're using things like ribbon gauze or putting in some dissolvable packing um or sort of gliding in some, some suction with it. Um, but you can also use it to grab things so pulling sort of blood clots out um to sort of blunt dissect in spaces in the throat. So it's a useful piece of kit, the other thing to sort of appreciate. And this is common with a lot of the airway equipment that we use is it's got this angulation. Um So that it's angled out of the way of your line of sight. So you can be operating the tiles, um opening and closing them without your hand being in the way of your line of sight. So again, just a useful piece of kit. Um Again, something useful to just have in the on call bag, you can almost never find them in, um A&E uh and very useful to have. Right. So last few, what is this? It's not spaghetti. I've also done that sort of terrible half job of covering up the labeling at the top there. If anyone has Hawk like vision. Yeah. So we've got a couple of answers coming through. So there are s the nitrate Ry sticks. Again, super useful. We use them a lot in rhinology, really, really useful to get comfortable with, um, and really useful for A&E uh as you get sort of familiar with the equipment and with other aspects of ent, we sometimes use them for other sort of bits and pieces. So skin edges on a tray or um granulation, tissue and things like that. Um But by and large, we use them for cauterizing in the nose. Um So they're really easy to use. You don't need to connect it up to any electricity. It's just a chemical reaction. Uh, and we'll chat a little bit about them in a little bit, but just so that everyone knows what they look like. Ok, I think this is the second last one. Cool. So, any ideas, it's a bit of a strange picture. Um, and again, it's something that we'll be chatting a lot about. But yeah, we've got some answers coming through now and correctly. It is a Rapid Rhino. This is what it looks like in the packaging. Um, you get different types, you get ones that are a little bit smaller, which is like the one that's outside of its packaging, um, which is sort of more for anterior packing, although they're actually quite large in any case. So it may reach the, the back of the nose and then you can see the one that's sealed inside the packet. It's got the double balloon. Uh, it's a little bit longer. It's about 7.5 centimeters long. And so the idea is that it packs all the way through to the posterior nose. Um, so you get good posterior packing as well. Um So it essentially, it has that tampering effect along the entire passage of the nose. Um, really, really useful piece of kit. If it's something that you have in your department and is running low, it's something to escalate early to whoever does stock take in ordering. Um because it's um quite devastating when they run out and you have to go with plan B. Um patients hate them, but they are much nicer than the alternatives, right? I think this is the last one and then we'll climb into the next bit. Um This image is not fantastic. But does anyone have any idea what this is? Ok. So this is something we tend to use a lot more in otology, um especially in sort of the emergency clinics or when we're using the microscope. Um But as Raven has pointed out, it is a hook. So it's got a couple of different names. There's a couple of different um configurations. Um So can be called Jobson Horn or Wax hook or Jobson Hook or whatever you wish to call it. Um The sort of useful one particularly in the Rhinology setting is the one with the little hook with the little sort of probe at the end. Um But you do get ones that have sort of a little spatula ending, there's some with a little, um, sort of probe, circular end. Um, and so it will come in handy um, for different scenarios. Um, but another nice little piece of kit to have with you, er, that you may not find in Amy, right? So we're gonna chat just quickly a little bit about, um, nasal examination and a couple of tips, um, that I found obviously there's the standard approach, which is sort of the OSI type approach where you go in, um, introduce yourself, uh et cetera. Um I find especially with uh a lot of the ent procedures, particularly procedures in the nose and sort of in the mouth and throat. Um It's really helpful if you explain what you're doing. Um This sounds like it's something that sort of goes without saying. Um but being sort of in the patient's position, having sort of a needle waved in your face and going through your throat can be quite unnerving. So patients like to have a bit of an outline of what's going to be happening. Um And if you can sort of narrate along the way, tell them what you're doing, why you're doing it, uh it makes it a lot easier. Um And especially for these procedures in the nose because they're quite intrusive, but you sort of often dealing with things like foreign bodies or bleeding. It's really, really helpful if the patient sort of buys into the examination and helps facilitate it the other thing goes back to, uh, what we were just talking about in terms of equipment. So we've got lots of little strange bits of equipment, um, that we use all the time in ent that you won't necessarily find, um, in A&E. And so it's quite useful to anticipate what you're gonna be needing for a particular patient. Um, you inevitably aren't going to be able to carry everything with you unless you feel like carrying the huge backpack with you all the time. Um It's quite useful to be able to anticipate a little bit uh in terms of what you're gonna be needing before you start. Um, it just makes it a lot easier. So whether you're gonna need extra gauze, whether you're gonna need a little sort of vomit bucket, um What kind of suction you'd like, et cetera? Um Usually at the end of the day, particularly in this sort of A&E scenario ent basically boils down to you being the person in A&E with the right equipment for the job. The next thing for nasal examination, it makes it a lot easier if the patient is positioned correctly and this goes sort of hand in hand with general examinations or procedures. So for a nasal examination, your life will be a lot easier if the patient can sit upright or if they are on a bed with the sort of back tilted up. Um if they can tilt their head slightly upwards, um it makes it a lot easier for you to then sort of look down the, the tunnel towards the, the nasopharynx and the biggest tip that I can give you. And this goes for both the nose and for throat type procedures and examinations, it's a lot easier if the patient is able to rest their head against something. So if they are sitting in a chair, try to get that chair up against a wall and let them have their head against the wall, um, it's always a little bit awkward when you're trying to sort of tunnel down the nose and the patient's trying to back away from you. So it makes it a lot easier if you're stuck with a stretcher or a bed scenario, tilt the bed up, you can have them sort of slide down a little bit so that their head is resting on the bed and it just makes things a whole lot easier. And when you have the talks later, er, in the next couple of weeks and they discuss things like, um, Quinsy and tonsillitis procedures in the throat, the same thing applies. You don't wanna be sort of chasing a patient who's squirming across the bed with a blade in your hand. Um, so things like this just help to facilitate the, the procedure. And then the other thing is to check the patient's allergy status and sort of make it a habit. There are a lot of procedures that we do in Ent where we will use topical agents. Um, some of those things might not be charted on the medical charts in A&E and so you might not get the usual sort of allergy reminders and things that you would have. Um, and so it's just useful to get into the habit of asking if they've got any allergies to anything in particular. And one peculiarity to just remember is one of the creams we often use in the nose, especially for nose bleeds called NAIN. Um, has a peanut oil inside. I think they're phasing that out at the moment. Um, but I'm not entirely sure when that will be the case entirely. Um, and so it's quite important to remember not to give someone with a peanut allergy, the CEPTA ointment. So, just as something to keep in the back of your mind. Ok. So the, in terms of, er, nas endoscopy, I'm not gonna go too much into it. I think you're gonna have, um, talks with regards to tracks and with regards to sort of laryngology that will sort of walk you through, um, flexible nas endoscopy. Um, it's a really, really useful skill. Um, it's a skill that if you're working in ent as a junior, you sort of expect it to pick up. But actually, um, it's something that you can become really good at really quickly often what I tend to find is people, um, especially because from a no's point of view. There's very little that we use the, um, flexible NAS endoscope for in A&E. So most of the time, if you're using it an A&E, it's because you're sort of interested in the airway. Um And so there's a tendency to sort of rocket the scope through the nose harpoon it all the way through lots of blurry images and then you see vocal cords and everyone's satisfied. Um So it's sort of a good idea to get into the habit of understanding the anatomy, knowing where your scope is going. Um And it's why I say if you're able to pop into one of the rhinology theaters on days that they're doing sinus surgery, um or into any of the clinics, there's loads of opportunity to do scoping and to get really, really good at it. Um But essentially, it's a two handed technique and I've got another image coming up in a sec that will sort of explain things a little bit easier. But essentially, you've got one hand holding the controller of the scope, the other hand holds the tip of the scope that's gonna be inserted into the nose. So you probably hold it sort of two or three centimeters away from the end and the job of that hand is to brace against the nose. Um So I'll pop the next image up just so it makes a bit more sense. So you can see in this image you've got the person who's using the scope has got the one hand with the scope going miraculously through a mask, this must have been in COVID. Um So sort of bracing it against the nose, the job of that hand is just to feed the scope through all of the direction control comes from the hand that's at the controller. So in this case, the doctors got their, their thumb on the controller. Some people prefer to use their index finger, essentially the finger on that controller will control up and down. And then by you swinging in an arc, sort of in the direction of the red arrows, you'll be able to see left and right. So, um it's basically just a, a bit of a tip. It's like I said, really useful in terms of improving your uh scoping um to go to sign a surgery theater, um get them to let you scrub in, use the rigid scope, it's slightly different, but you get a real sort of good appreciation of the anatomy and it makes your scoping a lot uh better. And basically the goal much like the image we saw earlier is to go along the bottom of um the nose. So just along the top of the palate, and that'll be sort of your easiest way in. Um it's a useful skill to remember for ent but also for anesthetics for sort of awake fiber optic intubations. Um And even though sort of the medics tend to go through the mouth with their bronchoscopes. Still sort of the same handling in terms of the controls. Right. So, we're gonna jump onto Epistaxis, which is what I've, um, spent most of the time on this presentation on, um, just because it's something that's really, really common. Um, please excuse the cheesy image. I was post call when I started making this and I thought I was hilarious. So, in terms of, um, if he sucks this, it's really important as a junior, it's a common presentation to the emergency department. Um It doesn't necessarily need specialist referral. It certainly doesn't necessarily need admission. Inevitably if you're working in sort of a tertiary center where they know ent is available, um you will often be called to see epistaxis. Um And, you know, we sort of, everyone has their uh opinions on whether that's always appropriate or not, but there are so if you have different pressures when you're in a busy Ed versus when you are the Entsho on call. And so for better or worse, it's a really useful um skill to have. It's something that's good to be comfortable with. Um We don't only see epistaxis within Ent or A&E we often deal with it on the wards. Um And if you go into things like uh trauma or anesthetics, it's something that they see commonly as well. Um And of course, all of the medical patients on their whopping doses of Apixaban or Warfarin um love to present with epistaxis. And so the majority of cases that we tend to see are anterior epistaxis, meaning it's coming from the front of the nose, um from an arterial plexus called kissel wax plexus, um which we commonly call li's area. So it's right in the front on the sort of anterior septum. Um This is usually quite helpful because it's something that's quite amenable to even first aid measures. Um You can tamper it, it quite effectively just by squeezing sort of the, the nostrils and the fleshy part of the nose and basically squeezing that down against the septum. Um Anterior epistaxis, they say is usually about 85% of cases in the literature, they sometimes mention up to 95% of cases. Um It's not always super evident on initial referral whether someone has anterior posterior epistaxis. Uh especially because the first aid is usually quite poor. Um And they're sort of left in a corner to bleed an ed. Um So by the time you get there, they sort of pouring out the mouth and both, both nostrils. Um and it's almost never posterior epistaxis. Um having said that it's a useful differentiator to have. Um And obviously, then for epistaxis, a focused history is gonna be really important. Um So things like whether they're on anticoagulants, if they're on antihypertensives, if they're sort of undiagnosed, um hypertensive and have a so systolic BP of 2 20. Um if they've got a history of trauma if they are um bleeding disorders on board, um the bleeding disorders tend to be something rarer. Um However, we've got a lot of patients, particularly within the Imperial Circuit who are sort of specifically referred to our Rhinology department who have um HHT um which is a hemorrhagic hereditary telangiectasia. Um And so even though you sometimes get these obscure diagnoses, they're really relevant because they sometimes change the way you would sort of want to manage the patient. So we're gonna discuss just the initial bits of management and then we'll sort of get into the stepwise specific treatment. Um I apologize that this sounds like a really long monologue uh because I can't hear anyone, but if there's any questions, please feel free to shoot them through at any time. Um So there's a bit of a diagram here which describes the, the plexus that we discussed earlier. Um which sort of ends in Li's area, which is why you often get anterior bleeds. Um The cause for these bleeds can be a myriad of things. So whether it's um trauma, so blunt trauma to the nose, whether it's trauma from sort of picking and scratching, whether it's because of crusting in the nose, which tends to happen in Children. So often there's sort of staph aureus in the nose, lots of crusting and when that picks off, there's loads of bleeding. Um So anterior is the most common when we get bleeds posteriorly, the sphenopalatine artery is often the sort of implicated um artery. Um but we sometimes have to go in and dis ligate the ethmoids as well. So in terms of initial management, it's the same as any other emergency that you get call to you want. If it's not sort of a life and death scenario, go gather your equipment, come prepared with all of your stuff because once you've arrived and everyone deserts you, you kind of are stuck on your own. Um And that includes suction. So if you can, if you get called to A&E, if you can request to be in a room or in a bay that has suction available, it's hugely advantageous for dealing with epistaxis, obviously relevant P pe. Uh So make sure you've got gloves, make sure there's loads of calls around that. You've got the little vomit buckets for them to lean their head into, make sure you've got an apron on eye protection is really important. Um And then as I mentioned, the location is important. So where, where you're sighted. So if you're in A&E and you have the option and you're in a dark corner with no suction and no one can see you move if it's a frail, elderly patient on Apixaban and they are pouring from their nose, you might want to manage this Epistaxis in a recess area where you've got sort of more equipment and more staff around. Um So things like that are quite helpful to think of upfront. Um And then as always, it's the ABC de approach and focused history is really important position, the patient upright, you don't need them to be swinging their head forward with their head between their legs. That's just gonna make the blood pour out of their face. Um But equally, you don't want them leaning backwards and gulping all the blood either. Um, especially because they have a propensity for then vomiting all of that blood onto you further down the line. So think of yourself, have them upright, you can lean them slightly forward. Um, and if they are, if you can keep them sort of calm and cooperative, that's really helpful, um, and encourage the patient not to swallow their blood. Um, while you're sort of getting your things together, get the patients to pinch their nose, tell them not to let go until you sort of remove their hands. Um, and often when I'm seeing an Epistaxis patient, if they're able to sort of pinch their nose, I get them to pinch their nose, I'll release their fingers when I'm busy doing something and then get them to clamp it again in between while I'm changing gas or getting different equipment. Um, and that's something that's quite simple, but often quite effective just on its own without any of the other interventions that we do. Um, if they're going to struggle, um, get someone to try and help you. So whether that's, um, someone else in the Ed, if you've got a member of staff with you, um, or if they've got a family member that's able to help, then that's quite helpful. Um If you are exceptionally organized and you by some miracle have ice, um, then ice can be helpful as well. Um It's sort of the old teaching about popping ice onto the back of the neck and on the forehead. Um And I don't know if it makes an enormous difference, but they have shown that someone sucking on an ice cube um does make some difference. So if you're at Charing Cross Hospital and swinging by Costa on your way to Ed and manage to grab a cup of ice, um then that's great. You can get them to suck on a bit of ice. Um You can also put some ice just directly on the nose as well. Um But there's obviously sort of practicalities about how you then get around all of that. Uh And so when we're actually dealing with the Epistaxis itself, we wanna do things one step at a time. You wanna examine the nose, examine the oropharynx and try and identify where the bleeding is coming from if it's possible. Um when it's sort of looking like a waterfall coming out of their nose, it's sometimes not so straight forward um to pick out the bleeding point. Um But as you sort of go along, try and see if you can figure out a, if you know which side, often it's quite helpful on history if they say, oh, it started with a bit of a bleed on the left side and then went to the right and then through their mouth. Um If you find a point that you think is bleeding, especially if it's in the anterior nose, if it's amenable to cautery, then cauterize it. Um Again, this is something that's not always easy if it's jetting out at you. But when you are treating epistaxis, sort of pop your things down and um come to terms with the fact that you're kind of in this for the long haul. Um So once the bleeding settles, if you've identified something, cauterize it, if there is still bleeding or you can't identify, then you want to pack the nose and we'll talk a, a little bit about what the different sort of strategies are for packing. If you've packed the side that was bleeding and there's still bleeding either from that side or down the throat or out the other side, then go and pack the other side as well. Uh And we do that because of the pressure that it then applies through the septum towards the other side. So if you've packed, for example, with the rapid Rhino on the left, because it was started off as a left sided bleed and they're still bleeding, go ahead and pop one in the right as well just for that extra pressure. Um Like I said, patients don't particularly enjoy having the rapid Rhinos in, but they do work fantastically well. Um if there's still ongoing bleeding or sort of along the way during those steps, think about things like Tranexamic acid. Um It's something that's in most cases quite safe to give. Um So you can just give a gram, I'd probably avoid giving them a gram orally just because um they may be vomiting or you may be wanting to keep them little by mouth. So IV would be ideal, it works quite quickly. Um You can also use it topically which we'll discuss in a sec. Um Think about things like BP. If they're a patient on Warfarin, you might want to get an idea of what the inr is. Uh and see if you need to be intervening from that point of view. Um If at this point, they're still bleeding if you haven't already keep them no by mouth. And at this point, you're sort of working them up for theater. Um And then sort of down the line when you are thinking about taking the packs out. So sort of 24 to 48 hours later. Um Remember to have a look in the nose again. Is there anything to cauterize and then discharge them with some nasal ointments? It'll either be the nein ointment that I mentioned earlier or something like Bactroban, uh which is Mupirocin. Um They are antibiotic ointments. Um and they work for a couple of reasons. So it helps prevent any crusting. Uh the nose and the mouth is full of bacteria. So it helps keep that area clean, forms a bit of a barrier. Um keeps it nice and moisturized. So it basically just supports the healing. It's often quite useful to tell the patient that the highest risk for bleeding again is in the first two weeks and that the cream that you're giving them is not something that's going to cause clotting. So often patients come back with a nose bleed. Uh And they're sort of upset that they've been using the cream and that hasn't made a difference. The, the cream, if they're gonna bleed, they'll bleed through the cream. Um But it does decrease the chance. Uh So there's a question. Can you soak rapid Rhinos with TX A or adrenaline? So we'll chat a little bit in a second. Um I'll, we'll talk about the different packing. Uh The short answer is rapid Rhinos. You can't really soak um in anything so you can sort of pretreat the nose. Um We often use Phenol canine spray which has phenylephrine and some lidocaine. So it's quite good um in terms of the decongestant effect, but also provide some analgesia, um which is quite useful when you're then sort of poking around in the nose. Um And so if you at that point, add some Tranexamic acid into the nose uh or something like atropine or adrenaline. That, that's great. Um, a bit of adrenaline soaked gauze with your A tiles forceps sort of shoved in there and getting them to squeeze that while you fiddle around with your equipment is a great idea. Um The Rapid Rhinos are essentially balloons with a bit of a, um, like a gelatine matrix on the sides. Um And so they don't really absorb much um fluid wise, Um, if you're using something like a rac. So the traditional nasal trap uh tampons, uh those are great, those you can soak tranexamic acid or adrenaline into. Um, it's sometimes a little bit fiddly to do. So, people often tend to sort of spray it onto the back. Um And I'm not sure how much of that sort of penetrates its way through the whole um, tampon. Um Some people pop a cannula into the meisel before they put it in, remove the needle and then sort of stick it in. Uh, and then use that as like a port to put the Tranexamic acid sort of more in the middle. Um So you can definitely, my sort of go to is usually to use the Coen Alcaine spray. Um, and then to not chuck it out when you're finished because you can sort of keep topping up ingredients into that little bottle and using that basically just as a vehicle to spray whatever you want. Um So I'll show you some pictures of that in a second. Um But that's a, a good question. Um So the essentially from the stepwise approach, we get what's called the Epistaxis ladder um as a sort of rough guideline, this is what it looks like. It's often slightly different from um facility to facility and depending on whether you have ent on site or not. Um But essentially, it's almost always the same. So it's always your ABC de your history send off bloods, you want to get IV access. Um If you're not getting the bleeding to stop with basic first aid measures, then you want to think about things like cautery. Um They've mentioned the Phenol cane spray, which I'm super in favor of. Um and then stepwise from there going to packing, if you're still bleeding through the packing, then we're thinking about things like theater um for examination and anesthesia, we usually do um ligation of the sphenopalatine artery um or we can sort of buzz a couple of bleeders in the front depending on what we find. Um And if there's still bleeding after that, then it's usually for interventional radiology. Obviously, this is a bit of a guide because um we've had cases, for example, um patients on ECMO that we can't sort of feasibly take to theater, we can't stop the anticoagulation because they connected to the ECMO. Um And so interventional radiology is usually quite a good option. Um I think this algorithm is from Ent UK and sort of, if in doubt, Ent UK has great algorithms for a lot of things. So they've got uh this sort of epistaxis ladder. They've got one for sudden sensorineural hearing loss. Um They've got ones for dizziness. Um So it's a really, really useful resource. Uh And the other thing that's great on their website is they've got patient information sheets as well. So for things like surgeries, um that explain things with pictures and with risks. Um So I definitely recommend um basically you just whatever topic you are looking up, type that into Google and say ENT UK. Um The other really useful um resource is entsho, I think it's entsho dot com. Um But again, um from a junior point of view and actually, even beyond, um they've got sort of really intuitive, really easy to follow little, almost like Wikipedia entries on um sort of anything you need. Um So it's another really useful resource, right? So, before we talk about the packing, let's just talk a little bit about the cay. So we saw the um little Matchstick Silver nitrate Cay a little bit earlier. Um And so that's usually what we use in the Ed setting for cauterizing. Um Often when we cauterizing it's to the anterior septum, sometimes you get little bleeders on sort of the, in the inferior turbinate, it's usually less likely. Um So firstly, you want to counsel the patient, tell them what you're going to be doing, what the risks are, um, of what you're going to be doing. So, remember that something like this, even if you put a bit of anesthesia can sting a little bit so they can expect some pain. Um, it's usually not painful afterwards but it's painful while you're doing it. Um, if you spray them up with the anesthetic, well, often they don't even know, um, sort of that you finished basically. Um, there's a risk of um sort of damage to that mucosa and sort of subsequent septal perforation. So that's something that they need to be counseled for. Um There's a risk that it causes adhesions as that scar is over, you sometimes get scar bands. Um There's a risk that it could fail sort of altogether and the other common thing, especially when you're sort of starting out. Um And you're still trying to juggle aiming your headlamp and using the th and trying to shove the silver nitrate Cay where you want it. Um is that it may sort of tattoo the outside area of the skin. So tell them this before, if they notice a bit of sort of silver gray tattooing on the outside of the nose or if the nose runs while you're doing it and they sort of get some dripping out. Um tell them to expect it, it won't tattoo them permanently. It normally goes away after two weeks if you see it there, try and wipe it away initially. Um And also, I suppose just practice, um, with aim. Um, ideally you wanna try and identify the spot where it's bleeding from. It's sometimes not super obvious, especially if they've had packing and things inside the nose. Um, because it's sometimes a little bit sort of macerated or a little bit squashed. Um, if you can find sort of the, the side that you can see the bleeding is coming from and you see prominent vessels and that's where bleeding is coming from. You can kind of zap the general area without painting the entire nose. Um And ideally you want to go into a circular motion and you kind of spiral around from the outside towards the middle to where the bleeding point is. Um I normally cauterize, put the stick down, wait a second, grab another stick, have a look. Um By the time you go back in, you should be able to see sort of what's in that bottom, right picture with that sort of whitish appearance. Um And usually that's quite useful. So it shows you where you've sort of cauterized before. And if there's a bit of bleeding coming through or around the around the edges, you can sort of top it up as you need um resist the urge to cauterize on both sides. Um because it's more likely that you'll cause a perforation. So essentially a perforation is because that's um that layer of cartilage requires the, the layer above it for its blood supply. And so if you kill off both sides or you're burning both sides, it's a lot, um, higher risk basically. Um So ask them to pick a side if they're coming to you in emergency clinic, pick the most recent side or the most obvious side and they can come back in six weeks time to have the other side done. Ok. In terms of nasal packing, we've spoken a little bit about it. The main options like we've discussed are the Rapid Rhino or the meisel. Um It depends where you work. Um Often the ent departments have rapid Rhinos lying around. They may or may not be available in A&E if they are a ne people may or may not know where to find them. Um Often you can find nasal tampons in A&E or in the UCC. Um The biggest difference in terms of when you're using them, the Rapid Rhino, you want to run under some water basically to get that lubricant gel activated before you slide it in. Um Whereas the Marisol you do not want to wet before you put it in because it's a tampon. So if you wet it, it's gonna inflate and be impossible to insert. Um Some people like to wait just the end so you get sort of like a, a cushiony bit to insert. Um Otherwise just use uh lubricating jelly. Um And the idea like you can see in the picture at the top is you want to be imagining that you're inserting it along the top of the pallet. Um, so you're not going up the nose, you're not trying to go for their pituitary or their brain, you're trying to aim for the throat at the back. Um, and that's the way that you'll get it in. So, if they look like a Walrus at the end, it's probably not going to do very much unless it's an anterior bleed. Um, the other thing to be aware of is people often present to the ed with nose bleeds, but sometimes they have a nose bleed as a result of other injuries. Um, and so in cases where there is a big mechanism of injury where you're worried about sort of a trauma case, if there's a query that there's potentially a base of skull fracture, um, do not insert the nasal packing, um, because you basically can create problems. Um, so we'd want to sort of manage those ideally with, um, with other things. Um, and once you've inserted it, be sure to check in the next sort of 20 to 30 minutes. So don't just walk away, um, because they may need sort of some air topped up or you may need to pack the other side. Um, but basically they need to be assessed again. Um, when the patient is packed, you most likely will admit them er, in the majority of cases. Um, in some cases, if the patient seems sort of sensible. They're very young. They've got no other comorbidities. You can potentially negotiate, getting them to go home and come back the next day for removal in the clinic. I probably discuss that with, um, with the senior before doing that just so that you have someone that you've discussed it with to write down. Basically. Um, the worst case scenario is basically them going and living their life with their pack inside their nose. Um, they'll probably need analgesia. It's extremely uncomfortable. Um, people tend to get headaches and if it's gonna stay in for longer than 24 hours, so typically your older patients on Warfarin or Rivaroxaban or whatever they're on, um, you need to put them on antibiotics as well if it stays in for longer than 24 hours, the other thing to just be aware of when you are packing the nose, um, and this sort of goes without saying because you'd be examining the nose as you go along, but look before you pack. So make sure you're having a look, patients often don't just bleed and arrive. They often try and er, avoid coming to hospital. They often shove tissues and cotton all up their nose, they wait hours for the ambulance to arrive. And so sometimes if you go in shove packing in without looking, you can sort of shove whatever cotton wool or whatever they've got in their nose just further back into their nose without realizing. Um, and So that's something to be aware of. Um It's a question. Can we send a patient home who's packed with the rapper Rhino? The short answer is yes. Um We don't tend to although in over COVID, uh that was sort of the policy. If someone was young, they fit in well, you can, in theory, um we've done it before with, with patients. So if, like I said, it's someone who's relatively young. Um they're relatively well, otherwise they're happy and they're comfortable, then you can send them home, obviously with some safety netting to come back if there's any issues. Um, but with the plan to come back to clinic the next day for, um, deflation ends plus minus quarter three, um, we tend not to do it if it's someone elderly or with comorbidities. Um, just because it's sort of a recipe for disaster and if there's sort of a feeling that the person's gonna abscond then, um, it's probably not a great idea, but you can, um, as long as there's a established pathway for them to come back, you can send them home. Um, most of the time we just did nothing. All right. So these are some of the adjuncts that we spoke about. The one right at the top is Coe Alcaine, um, which is sometimes just known as blue spray. Um, make sure, you know where blue spray is, um, track it down, make sure you have loads of supplies of it. It's really, really useful. Um, mostly for nose related things. You can use it before scoping to sort of anesthetize the nose. Um, you sort of tend to find that you become maybe less anesthetic as you go along in terms of analgesia. But it's, um, great in terms of its decongestant effect. Um, and if you're gonna be packing the nose, it's great to have the, um, anesthetic on board. Otherwise it's excruciating. Um, It's also useful because you can see at the top you can unscrew the lid. Um And so you can use it sort of initially and then top it up. So the question earlier about the tranexamic acid and adrenaline, you can pop some adrenaline into that, you can pop some tranexamic acid into that. Um You can put a bit of atropine inside as a decongestant and spray that in the nose. It's just a useful um actual tool. Um There's a question about the, the skull base fracture. So essentially, we, we don't want to be packing the nose if there's potentially a skull base fracture just because you might disrupt that area. So you don't want to a for example, push a rapid Rhino through the skull base um intracranially um or things like NG tubes or suction, um things like that so that we avoid, we'd rather do that under vision with a scope um or try and use one of these adjuncts if possible uh to try and stop the bleeding. So, um, something like surgery flow that we have here is really, really useful for, um, things like that. If you've got it, um, if you're at a hospital that has ent or cardiothoracic, uh, or neurosurgery, they'll definitely have surgery flow or flow seal available. It's basically, um, a hemostatic matrix with thrombin, it's really, really useful. Um, and even just sort of old sort of fragile patients whose epistaxis you manage to stop, but they sort of seem a little bit woozy or you feel a little bit iffy. Um It's often quite useful to pop in some surgery flow um into the nose, um just to help prevent rebleeding. So it'll help the the area to clot. Um and it works really, really well. Um It's also quite a little fun sort of science experiment you get to do in front of the patient because you have to sort of put the thrombin in the water and everything together. Um The, in terms of decongestants, we have atropine, that's the one we often have in our clinic. Uh, things like Sudafed are very similar. So Xylem Me, Zo um they're really useful for epistaxis. Um And like I said, you can pop them into the blue spray bottle, um and sort of shoot it into the nose. We also have things like dissolvable packing. Um for example, Nasop PO which you should have if you've got ent available. Um It's also quite useful for those sort of precarious cases where they look, look a little bit crumbly. The bleeding has stopped. You aren't really sure you can pop a bit of the, that dissolvable packing in. Um, it's made out of a sort of like synthetic um dissolvable um matrix. So it's like a sponge basically that you pop in the nose. Um It exerts a little bit of pressure, uh it absorb, absorbs the fluid, it helps with the clotting and then it dissolves usually after about a week or so. So it's also quite useful. Um My biggest tips basically for epistaxis and it's some of the things I would have said um earlier, but the first thing is you're in it for the long haul. Um So stay calm, be patient. It's a little bit like a roller coaster ride. Tell the patient that it's gonna be like that. Um You can tell them that you're there to help but that you helping may cause more bleeding initially and that that's fine. Um You just have to kind of stick it out. Um Often you get there, there's a bit of bleeding. You look in the nose and then it starts torrential bleeding. Don't panic. That's normal. Squeeze the nose, get the patient to squeeze the nose. My biggest biggest advice if you have the blue spray, get that in early. So have a look, pop some spray in, get them to squeeze the nose fa around with your equipment. Have another look get some suction, suction out, blood suction out clots. So you can actually see where you're meant to be looking at. Um, and so that the agents you're spraying are actually spraying where you want them. Um, even if that causes bleeding and dislodges a clot, um, spray some more, give it a squeeze and just go through it sequentially and you'll be fine. Um, have the equipment you want and have assistance available if it's possible. Um If possible, if you're in A&E try to be in an area where there's suction, um things like Yanker suction are useful, but you're not gonna be able to sort of shove that all the way into the nose. So the soft suction that they use, um sort of down et tubes and things is, is also useful because you can pass that in like you would be passing an NG tube, apply suction and sort of suction out all of the clots. Um And that's often quite useful just to clear the nose. So you have sort of a, a good starting place. Um The other thing, look before you pack, we mentioned that earlier and if in doubt or you're not sure or you're struggling, just pack the nose pop in a rapid Rhino on one side, if it's still not working, pop another one on the other side and then you know that you've sort of got bilateral packing in um and sort of worst case scenario, you always can keep them overnight and sort of stepwise deflate it the next day. Um, well, it's a lot easier to sort of work backwards once you're in control. Um, so basically don't panic, um, and have the right equipment with you. Ok. The next couple topics, um, are relatively quick. So they're going to be a lot quicker than the Epistaxis. The Epistaxis is just something that comes up, um, a lot and it's quite useful to basically be comfortable with. Um So this one is nasal trauma. It's a common presentation you get phoned about it loads, especially if you're on weekend nights. Um The most important things related to uh nasal trauma are epistaxis, which we've dealt with uh septal hematoma, nasal fracture and CSF leaks, which is often a lot less common. Um and a lot less likely to present sort of acutely to a so we'll discuss, sorry, I keep hitting my side arrow, which doesn't work. Um So we'll discuss se hematoma first. Um This is something that is relevant. Um It is an emergency. Uh and it's something you should be asking if someone phones you about a nasal fracture. So usually um A&E is very excited to call ent about nasal fractures. We often are not super interested about fractures on the day. Um But cephalhematoma is something that's important to exclude. So, in all nasal or facial trauma because the complications can be quite severe. So basically, it's where you've got bleeding between the cartilage and that perichondrium or pink fleshy layer that you can see in the nose, it disrupts the blood supply um to the septum. And so you can get the, the cartilage degrading and result in perforation. But you can also get um basically something like a an abscess um forming in that area. So infection where that hematoma is. Um and as you would have known from the likes of med school, this is sort of the danger triangle of the face because of the venous drainage. Um and so an infection in that part of the nose, a big abscess in that part of the nose has the potential to extend intracranially. Uh and we're particularly interested in the cavernous sinus. So often severe infections can cause things like cavernous sinus thrombosis. This is obviously extremely rare, but it's also something that you don't want to have missed. So often septal hematoma will be as a result of trauma, it'll present as red, fluctuant, bilateral, usually septal swelling, it's almost always anterior. So it usually looks like that picture where if you look right in the nose, you get bulging where the septum should be. Um, it shouldn't be confused with the turbinates which are coming, which would be coming sort of from the lateral aspect and not from the medial aspect. Er, it shouldn't be confused with polyps which are sort of like a yellowy adipo color. Um, and sometimes it's a bit confusing because patients after having trauma, have a septal deviation. And so your cartilage can be sort of poking to one side. Um, but if you feel that that will be firm, um, and if, if it's sticking out on one side, it should be concave on the other side, if it's a deviation. So if you have a feel, either with your finger or with the Jobson hook with the wax hook and you have a feel of that area, it should feel fluctuant, boggy, soft. Uh And that's something that needs to go to theater. Um As a means to confirm the diagnosis, you can stick a green needle in and see if you can aspirate anything. If you've got blood or pus coming out, then that's a septal hematoma. Uh and that needs admission and it needs theater. Um And you get necrosis essentially to the cartilage within 24 hours. So the sooner you deal with it, um, the better. Um So the management would be escalate to the reg admit under ent nor by mouth for theater, they'll be four incision and drainage. Um And you will almost always have them on antibiotics. Um You can discuss with sort of the reg what the local policy is or if they want to wait for theater to see if they get a pus swab, but more than likely you want to start antibiotics and you'll keep them on it for a week. So that's just one to bear in mind. The other thing is nasal fractures. Um Like I said, this is often something we get called about. So often as the sho you're covering a couple of hospitals. So you might get phone calls from elsewhere. Like I said, septal hematoma is something that you want to actively exclude um a nasal fracture. You are not necessarily especially interested on the day. Um So it is something we address. Usually by the time we get to see them, if it's on the same day, the face is hugely swollen and there's not very much that we can constructively do. So if it's a referral, you're taking over the phone, it does not need to be seen acutely. If it's an isolated nasal injury, it does not require imaging. If they've had a CT head or an x-ray, that's fantastic. It doesn't really change your management and you certainly don't need to be ordering any imaging. Um Usually, if someone has a nasal nasal fracture, the first five days are the worst in terms of the swelling. So we usually bring them back to clinic after the first five days, but within the first two weeks, ideally, so before 14 days, you can theoretically see them up until 21 days after, but it becomes a lot more difficult. So you want to catch them before there's callus formation and while the nasal bones are still sort of mobile for you to manipulate. Um and this is something that you'd bring back to the emergency clinic. Um So, like I said, in the acute setting, you ideally perform manipulation between days, sort of seven and 14. Um It's useful if you have preinjury photographs because you'll get a rugby player or a boxer, come with their twisted nose and you are then sitting in clinic trying to reverse an injury that's 10 years old. Um So it's useful to try and understand a has there actually been a change in shape of the nose? And if so, where has there been a change in terms of the breathing? And that's essentially all we're interested in. It's quite likely that if there's nasal obstruction. So in terms of breathing, that manipulation of the bones may not make a difference. So usually if there's been a fracture and it's accentuated, a septal deviation, it's sort of walked the cartilage. So sometimes correcting the or reducing the bones improves that. Um, but often it doesn't do very much for them at the time. And so it ends up essentially being a um cosmetic procedure. It can be performed under G A, which is how the consultants like to do it. Um The bulk of them that we see, we end up just seeing an emergency clinic and you can just do it under local anesthesia. It's quite useful to get sort of people to show you what they do locally. There's lots of different tips and tricks for how to anesthetize Um, and you get some registrars that prefer not to anesthetize at all. I tend to give some local anesthetic just because it's obviously, um, quite uncomfortable. Um, but giving loads of local anesthetic around the nose where you then want to be assessing the shape, um, can also be quite counterproductive because then you can't see essentially what you're doing. Um And so the patient needs to be counseled that there's a risk of pain of bleeding, bruising and swelling and that you may essentially still be dissatisfied with the cosmetic appearance. And if that's the case, if there's still um sort of unsatisfactory cosmesis or there's nasal obstruction, then they need to follow up with the Rhinology clinic in six months once it's all healed up and we can try and address it um, down the line. Um There's different ways to do the manipulation. Um When you're using sort of instruments inside the nose, that's normally what's done under general anesthetic. It's often extremely uncomfortable to try and do in someone that's awake. Um Unless your block was really good and the patients really cooperative, um, it is useful even in an awake patient for um a fracture that just looks like it's depressed. So if the nose doesn't look twisted, but the one side just feel, looks a bit concave, it feels a bit concave, then sometimes getting achilles underneath to just lift that fragment up and packing some dissolvable, packing like nasal pore underneath just to hold it in place. Um is a really, really useful trick. Um But often patients won't tolerate you sort of moving the nose around with instruments like you would in theater. And so we usually end up doing um what you can see on the right, which is using your thumbs. Um We usually push in the direction of the fracture, so you try and sort of displace it in the direction that it's fractured and then you go across and push the other way to realign it back into the middle. Um Sometimes you get a click, sometimes you don't, it's can be quite brutal, it's quite satisfying when it does click back into place. Um and it sometimes requires a bit more of a sort of twisting motion and sort of, instead of sort of pushing directly across, you want to be pushing across and slightly down to sort of distract it away from the, the forehead. Um Basically, it's something that's worthwhile seeing in person because then you can have a, a good feel of it. The other thing that I said is really, really rare is CS F Leak. Um I just mentioned it because um sometimes you get cases that come sort of rogue lead to A&E er with a CS F leak, it's often following trauma, um but they may not present with this at the time of the trauma. So more than likely they're presenting down the line with this chronic rhinorrhea um If there's no signs of meningitis, if there's no other neurology that you're concerned about, then there's nothing to acutely do. So they don't require admission, they don't require antibiotics. Um It's probably quite a good idea to check with them if they're up to date with the meningococcal vaccines because obviously they've got a breach in the skull base. Um But essentially they need work up. So you need to prove the CS F leak. Um We normally send off fluid for B to two transfer. And um if they're not able to provide a sample, you can give them the little bottle with the label and when they have a sample, they can come drop it off at the lab. Um You can also dip it in sort of a urine dipstick to look for glucose, um which is sort of a, a more crude way of looking at it. Um But either way you'll want a positive beta two transfer. Um They can then be worked up as an outpatient. So you'd get an outpatient ct of the sinuses and the skull base, um an outpatient rhinology follow up um or rhinology or skull base um because they'll need probably endoscopic repair. Um So not something very common, it's something quite obscure, but um if it arrives, there's probably very little for you to do. And then the last thing that we're going to touch on, sorry, this has taken a bit longer than I expected. Is foreign bodies. Um, it's relevant, um, from the point of view of the nose because there's a theoretical risk of aspiration. Er, even though anecdotally it's quite unlikely. So anyone you speak to, um, will tell you that they've sort of never seen it but it's very uncomfortable sending a small child with a bead in their nose home, um, without feeling sort of a little bit weary. Um, it's really important in cases like these to take a careful history because there are things that we are sort of more worried about. So things like button batteries or magnets are big red flags, that button battery has to come out sort of immediately. Um, whereas something like Barbie's shoe or a piece of Lego, you're kind of less in a panic about. Um, it should however, be removed as soon as feasible. So, for example, uh, something like a plastic bead in an ear, if you only have an emergency clinic appointment in a week or in two weeks, it's probably fine. It's not, it's inorganic, it's not going to react. You're not gonna get an infection. Um, but in the nose you probably wanna aim to get it out because of the potential airway risk. Um, and so it's usually something you check, the sort of, your local facility will have its policy on what you do is some pa, some places will let people go home overnight and come back the next morning for theater. Er, some places will admit some places will go straight to surgery. Um, so it depends, um, and obviously there's a variety of methods for getting the foreign body out, depending on what the object is and the age of the patient and sort of how cooperative they are. Um, it's worth bearing in mind that you should have airway equipment available with you, even if it's unlikely that it's sort of going to go that way just so that you don't get caught off guard if they then aspirate the, the item. Um, and so usually as a starting point, especially if it's a child, we get them to do, uh, something called mother's kiss, which you can see on the bottom left. Um, it's totally revolting. Um, but it sometimes works so you get the mom to or the parent or the guardian or whoever's with them to get a seal over the mouth, they block the nostril that doesn't have the foreign body and give it a blow, sort of like a hard jet of air and see if you can get it to shoot out. Um, the nostril. Um, it does sometimes work, usually by the time they're seeing you sort of seven people have had to go in A&E to try and get it out. Um, and so it's probably less likely to work. Um, and also the child is probably by that point quite unimpressed with the entire situation. Um, we've got different, er, things that we can use. So we spoke about the tilly earlier, er, Tilles dressing forceps are great for things like cotton wool or paper or something big and chunky that you can grab. Um You can see in the top image on the left is er, someone using the crocodile forceps which is like little mini mouth at the end, um which is also useful. Sometimes I find that Pat tiles is a little bit easier to get grip versus the crocodile forceps. Um, because sometimes you end up sort of crocodiles things further back. Um, if the object is round and smooth, er, if it's not lodged in place, sometimes suction is really, really useful, er, or otherwise your wax hook is really, really good. So you can sort of slide behind it and then flick the hook around and try and sort of hockey baller towards you. Um, similarly there's a picture below the sort of picture with the hook where there's someone with a sort of syringe and a balloon situation. Um, we often don't have that kit, er, or at least where I've worked. Um, but you almost always have, um, Foley catheters or urinary catheters. Um, so again, if it's something wrong, if it's something that keeps slipping, but you're able to slip a catheter past, you can then inflate the balloon and pull it out. Um, and the last tip is something that, uh, is often quite useful for ears, but you can do in the nose. Um, it can only be in someone who's cooperative. Um, and that's basically to use something like the end of a swab or, um, you know, something like that, you put a bit of, um, glue at the end and then go and touch the object so that the glue sticks to it and then you can pull it out. Um, if it's a toddler at three in the morning with a bead in her nose and it looks like an exorcism. You probably don't want to be going with the glue stick. Um, and so basically for foreign body removal, the idea, especially if it's a child, you want sort of your first go to be the best go. Um, try and have a look first before putting any equipment and then have the equipment that you want and sort of everything in line of sight so that, uh, if you're able to get this thing out without having to take a child to theater, then you can do it. Ok. Um, so that's all I've sort of got prepared. So I thought it was gonna be really quick. Um, but essentially if there's any questions or anything, anyone wants to know, feel free to drop it in the chat if you're speaking out loud, I'm sure Izzy and Dean, um, can catch that as well. Thanks Ted. That was amazing. Um, yeah, guys, if anybody has any questions, just drop them in the chat. Um, otherwise please do fill out the feedback form, um which you guys will have had emailed to you or do you just posted it in the chat? Um And we'll see you next week. Um The theme of next week's session will be on ears. So I'm sure that will be just as informative as tonight's session. Great. Ok. Well, thanks everyone. Have a great evening. Yeah.