Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

To chat about the text. Thank you. Sorry. No worries. Hi guys. Um I think we finally fixed things, apologies and thank you for bearing with us. Er, Kara. I won't waste any more time talking. That's all right. Um The only thing I will say is that I can't see you guys. So um you'll have to bear with me if er, how well this is gonna work because I'm try, I'm gonna try and be interactive but I'd quite like to, um, well, I'd quite like to be interactive but if it doesn't work out being interactive, I apologize in advance because I'm not, I'm not used to this medal, er, platform so well, so as, as I think as you said, I, I'm currently cause surgical trainee working in London at the moment. Um And today we're going to talk a bit about ears. I was going to try and make it interactive, but we'll see how that goes. Um So without much further ado hopefully we're going to do some revision of some bits of anatomy for you guys, then we'll go through some case presentations of common referrals that you might see and in there we'll get some practical tips that will be of interest. So, some anatomy. Now, I was hoping to make this fairly interactive. Um, but I don't, I saw something in the chat saying that you guys can't unmute. Is that correct? If they can't, then, then, yeah, I think they can type. So I'll just manage. So you're gonna get really bored of this. But my, one of the things I quite like to do for you guys is try and put boxes that will disappear if you click on them. So if people want to put some answers in the chat of what they think behind the different letters might be for the anatomy of the part of the year, then izz. You can let me know what they say. Don't be too shy. Go and glide with a come on A is an easy one. Don't make me click it for you. Uh A we've got auricle, external auditory meatus, not quite external auditory meatus. That's gonna be uh your ear canal as part of K A is just the outer ear. Uh sometimes referred to as the pinner, which is J. What about eye guys? What's that bit tympanic membrane? Is that I is the membrane? Yes or tympanum. I managed to get a chat up on another computer so I can see what you guys are typing. What about? So then we've got some little bits in here. So B CBC and F all go together So we have got an Incus. Which one's the Incus BC RF Incus or Anvil is, is, is c there, if you think about Malleus, it means hammer in Latin. So that's gonna be b your hammer has to hit against your anvil. So your Incus. So hammer was the one that comes first and you have your anvil. Anyone know what the F one is? It looks like what it's called. Yeah, it's called stirrups or stapes. Then you get into your middle part of your ear. So this is our, so we've got, so that's in the mid middle ear. Then you've got your inner ear, which is where your cochlear sits. You've got your anyone balanced organs, semicircular canals, you've got the nerves that go off to do your, so you, you've got vestibular cochlear nerve. So your vestibular, which is your balance nerve and your cochlear nerve, which is your hearing nerve. And then you've got h and you know what H is, it's the one you go when you're going up and down in planes or diving or anything like that. So your Eustachian tube, OK. So the outer ear is generally defined as your pinner to your tympanic membrane. Uh Your middle ear is your tympanic membrane to the lateral wall of the inner part of the ear. And your inner ear is your middle ear to your inter internal acoustic meatus. The middle ear itself is quite a complex bit of anatomy and quite difficult to get your head around when you first start thinking about it because it's a box and it's got a lot in it. Um, it's split up into two different parts known as the Epitympanic recess, which is that part at the top and at the bottom you've got the Tympanic cavity itself. It should be nice and wey, er, well, aerated and if it isn't aerated, that's when you start having problems, which we'll come to a bit later on. This is quite a nice diagram which sort of shows you exactly how this box works. So if you imagine this is your lateral wall, so that's been reflected off and you're looking into the middle ear at the moment. So you've got your stapes sitting at the back there on top of the, um, on the top of the oval window, the Eustachian tube going off down the side and then you've got the round window at the bottom down there. And these are all the different nerves and how they travel through that box. The inner ear is your cochlear and your, your semicircular canals. So they allow you to do your, your balance, but also your hearing. Ok. And again, that's comes, comes into play later when we start talking about some of the pathology. So anatomy guys, it's important because one, if you know your anatomy, then when you see something that's gone wrong, you can work out why or what might be the cause. But based on the anatomy that you've got and the problems. Ok. So when you're examining an ear, it is not just about looking in the ear canal. The biggest thing is looking at the ear itself and that's preauricular. So in front of the ear, behind the ear and the pinner and feeling for any swellings, any temperatures, but your, your, your mainstay of your examination in the ear exam is gonna be the looking part rather than actually the oscopy or the use of the microscope. Remember when you're examining ears, you need to check the facial nerve because as we look back in this, so you can see how it runs through the middle part of the ear and can be affected in any ear pathology. And also remember to look at some of the other cranial nerves as well. Uh Most, most ear issues, if they're infections and things like that, you can do your standard baseline tests. But then you might need to include some special tests, listening for hearing, et cetera. Um One thing I will say, which is a cheat that I learnt quite early on is when you're using these otoscope down in D or in in the clinic, these back parts often come off. So it means that it's much easier to then direct uh tools down the Osco or swabs down the Osco. So you can swab what you want to do. Obviously, it's easier to do that with a microscope, but sometimes you don't have one. Ok. So first case presentation you have been called, you are the sho on call and you have been called from the emergency department. They've got a 19 year old male who has been playing rugby earlier today. He plays in the scrum. He's normally fit and well, but he's turned up today, so he's now got a swollen ear. What things do you think you need to consider in this history? What more, what other questions are you gonna want to ask over the phone? Do you need to go see this patient? Is this a referral? You would accept blood? Yeah. Good. Where, what do you mean by blood? It's Yeah, ear trauma. Where, where are you worried about blood tympanic membrane rupture, possibly pinar hematoma is more I think what I would consider if I had this referral. So when you are describing the external ear to somebody, you need to be able to tell them which bit of the ear you're talking about. There is nothing worse than when you're on the phone to somebody and they say they've got a problem with their ear and you say which bit and they say the ear and you think right? Because it doesn't tell you anything. So being able to describe your ear and your auricular pinner anatomy is really helpful. So we've got another one of kra really dumb. Click the box games to go. So any letters from any one of different bits of the year? Yeah. Which one's Helix? Yeah, I agree with you. That's Helix. Which one is therefore the Antihelix. We're going e for Antihelix yet again. I agree with you. It's the, it's opposite. The Helix. Very good. Pinna is kind of the whole thing. Gs Tragus. G, I agree is Tragus. And if you go to Tragus, what else have you got an antitragus? Which one's your antitragus? I, I don't know. Mm Not quite, I it's h but in between. So it's opposite, the tragus and in between them. What's that? It's between the tragus and the antitragus. I'll, I'll tell you what guys anatomy is. Oh, pouch is close is the in tragic notch. Anatomy is actually very simple. We call things what they are. Yeah. Very good runner. He got it. What about, what about Jay? Jay is a simple one. Come on, lots of people get it pierced. Yeah, that's a lobe or a lobule. And then KNL are two things. I think somebody's mentioned something or someone's mentioned a scaphoid. Which one's the scaphoid? Can you remember? Conscious? So K and L together make up the conch bowl. Do you know which? So B is the triangular fossa, it's actually D which is the scaphoid fossa. So L and K you might not necessarily know um Donia, what are you saying? Is C mm no sees. So L and K both make up the, the contra together and they're known as the symbol and the caver. Now, people will have slightly varied anatomy here. So that's why we often talk about the contra rather than specifically the symbol. The caver C and F are both similar in what they are. They are actually the crooks of the Helix and the Antihelix, they're where they join on. OK. So quite some complicated words, but once you get your head around them, they all do make sense. And it will help you really describe, especially if you're the one taking the phone calls overnight and you're trying to talk to your reg over the phone, you'll be able to tell them exactly where things are when you have a problem. Ok? So back to our referral, this is what we go when we go and see him. So what is this? Anybody? I think some people had already mentioned that they were worried about it when they were referred it down the phone. If you poked it, it would be squishy. I think we had lots of, we had lots of correct answers. Yeah, exactly. This is a Pinner hematoma. So the reason we get worried about it is similar to the septal hematomas that may have been mentioned in last week's teaching the cartilage of the pinner relies on the overlying skin. So if you get blood collecting between these two places, you get disruption in the blood supply to the cartilage and then you can get um necrosis effectively. So, the principle for this is that we need to drain it and then we need to stop it from reaccumulating. And normally we would cover this with antibiotics. So, what we would do is is I would usually uh numb the ear with a bit of local anesthetic. Then I would introduce a needle into the most fluctuant part. Suck away any blood. If it had been there for a while, I might send it off to the microbiologist, but most likely it's sterile. Um, and then you need to put some compression on there. Does anyone know how you might compress this? Any guesses? So, there's two different schools of thought. Yeah, dental rolls. Some people use a dental roll and some people use a type of button. So one way of doing it is these are little blue Silastic splints that sometimes you put to keep the septum in place after you've done a septoplasty. But once you've drained it and the ear looks normal again, you can cut these down to size and then you do a through and through stitch with some sort of big non-absorbable suture, usually like a silk or whatever you can find in, in d, to be honest, and you, you, you're sewing it so that those two places stick together and then you're gonna bring them back to your emergency clinic, uh, to have those sutures taken out and hopefully it won't reaccumulate the other way. You can do it is with a dental roll, which is very, very similar. So the, the arrow is showing you where this cross section is taken through. And again, what you're trying to do is you're trying to put pressure on both sides and you're doing a through and through stitch to keep that in place. If you don't, what can happen is you can get scarring and collapsing of the ear, which is what's happening in that second picture that I have done there. Uh Antibiotics wise, you'd normally give them something that would just cover the normal sort of skin flora. So most places would just give you Carlo. Um, unless there's a penicillin allergy, in which case, it would be a case of exactly Donno, it's a cauliflower ear. So if you, if you leave this untreated, it will become a cauliflower ear and you should warn these patients that if they do get repeated trauma, each time you drain it, you do run the risk of introducing infection. So it's a purely cosmetic thing. If they're not that bothered about it, you can just leave them, but they will end up with a deformed ear. Cool cara just quickly, um, in case this is relevant for anybody. Um But how long would you leave that in? Like what would your follow up plan be? So, is a general rule. Anything you stitch in the head and neck? I wouldn't want to leave those sued in for more than five. Well, it's 5 to 7 days. So I probably want to see this back in a maximum of five days time. If you were worried about any kind of infection, you'd want to see them back sooner. Ok. And the choice of suture size is in, in most cases because you're trying to put compression on the bigger the suture size, the better. So I would probably use something like AAA 30 or a 20 for this. OK. So referral number two, this time you've got a 28 year old man who's been involved in an altercation where he's been smacked over the head with a glass bottle and he's cut his ear. Do think that he's fine from every other perspective. They've even done a CT head which was normal. What else do you need to think about for this patient? Yeah. So that's gonna definitely change slightly what you do if there's cartilage involvement? Four contamination. Yeah. So it's not going to be a clean wound, is it? So you're probably gonna want to give him, he's gonna need antibiotic cover. You also want to check his tetanus status because again, it's not, it's not going to be a clean wound. Um and also make sure he's not going to any other injuries. I know Ed have said that they've cleared him but you know, you always got to be a bit careful with these things. Ok. So suture choice if there is cartilage involvement. You want to approximate that first with something absorbable like a vil or a monocryl preferably undyed because obviously it's a thin area and you don't want that blue to be showing through. So an undyed absorbable suture for the cartilage for the skin, you can use a five or a 60 nonabsorbable. So I would probably pick um like a proline or an Elon. And again, because of the trauma you need to think about it might get a hematoma like we saw in the case before. So you might need to put a couple of quilting stitches to stick everything down. OK. So just a quick note about the innovation. So because you're gonna need to anesthetize this ear, it's gonna hurt otherwise, um the it gets supply from a few different nerves. It's a bit of greater auricular nerve, it's a bit of lesser occipital, a bit of auricular temporal and you can get some branches of the face and the vagus in there. So when you're doing a block, you do need to think about which of these you're trying to block or what I actually tend to do. If it's a big laceration is I will just infiltrate locally to do a field block around the things that you're trying to anesthetize funnily enough, the deeper part of the external auditory canal um actually has some stimulation from the vagus nerve, which is why some people might cough when you're suctioning their ears. That's just a fun fact feel. So, you go down to Ed and this is what you see. What are you gonna do? Panic? What's the first thing you're going to do? Cool plastics. Oh, sorry. Yeah, this is plastics. No, we don't deal with this. That's ent wash and clean the wound. Yeah, you're gonna clean it. Are you gonna anesthetize it before you clean it? Yeah, you are gonna anesthetize it before you clean it because if you anesthetize it before you clean it, they'll tolerate it much, much better. So you clean it and now it looks like this. Now, what more panic? Cool plastics again. They tilt to piss off. Yeah, you suture it and actually actually rana the um the done. Yeah, the um, the bleeding will stop once you start suturing it. So you can use a little bit of lidocaine with adrenaline in it if it's bleeding a lot, a lot and that'll help you when you're stitching. But once you stitch it, it will actually stop bleeding quite nicely. So this is actually an ear that I saw in, in a few months ago now and it came together very nicely in the end. So actually for this gentleman, I ended up using a vil repeat, which is an absorbable suture because I knew he was not going to attend his follow up appointment. And unsurprisingly he did not turn up to his follow up appointment. So by putting absorbable stitches in. I did that because I didn't think that he'd ever go and get them out. So that was why I picked that. But normally, yes, I would use, as I said in the previous slide. Ok. But yeah, the I'll put this in here just to show you that no matter what an ear looks like, you can often make it look quite nice at the end. Ok. So, don't panic, right? Any referral number 3, 28 year old female this time she's decided to go and get her ear cartilage pierced up here and now she's got a swollen and sore ear. What do you need to think about in this one? Thank you, Dona. Yeah. Sounds like she's got infection, doesn't she infected piercing site? Uh Dona? Where when you say requested imaging, what do you mean for the ear? For the ear laceration? No, no. Yeah. So I'm worried about infection in this patient. So you want your baseline infection investigations? You want Ed to put a cannula in? So you don't have to. Um, and you go down and this is what you see. What does everyone think that looks like anyone know what this is? It's a fairly classical picture. It's not a hematoma. It's in the same place that you might get a hematoma. And actually, if you leave a hematoma untreated, if there's a breach in the skin, you can end up with an abscess that might look like this Yeah, this is exactly right. This is perichondritis, everyone. So, very, very classical history, someone who's got ear piercing that's got infected. You want baseline infection bloods, you're probably going to admit them for IV antibiotics, particularly if it looks like this. This looks like it probably has some pus in there. So I think you want to drain that pus and you really need to take that earring out. So it's going to be a case of at local anesthetic, potentially cutting down onto that earring and removing, removing it because that earring needs to come out. Normally these patients will be admitted for, as I said, IV antibiotics as per your local guidelines. Um, most places use something like a tazo. Um, you want something that's going to get good, good penetration down into that cartilage. The, the reason you know, this is perichondritis is because you can see classically that ear lobe is spared. So it's only the um, ear that has um cartilage in it that seems to be affected. Ok. Good. Right. Ed referral number 4, 68 year old male, sudden onset dizziness. He's got past medical history. That's type two diabetes, high BP and he's had a recent heart attack. What do you need to think about with this one? You can, sorry for the last one. Yeah, you can still do oral antibiotics. Gordon, um you with the perichondritis if it looks as bad as that and their bloods are awful. You would probably admit them for ivs. In the first instance, if it's very mild, you take the earring out, you can probably give them oral antibiotics. I'd probably give them ciprofloxacin and you might want to give them a topical antibiotic, like a chloramphenicol ointment. And then you bring them back to your clinic early for, for a wound review to make sure they're not getting worse. But yeah, if it's not too bad about perichondritis, you, you can give them oral antibiotics and I would pick ciprofloxacin in that case. M yes, stroke generally ent do not see dizzy patients acutely, it's really important to rule out a cerebellar stroke. So these patients should be referred to me the medics or the neurologists and they should have a A CT and probably an MRI because it's a posterior circulation stroke. So that normally gets picked up on an MRI following this. They can normally be seen in our outpatient otology clinic. Ok. So generally ent do not tend to see dizzy patients acutely from the front door, just a bit of a sort of touch on the sort of things that do come under ent, but again, this will normally be in your outpatient clinics rather than from the emergency department. What you want to find out is how often, how long the dizzy episodes last, whether they have any auditory symptoms. So we're talking about um tinnitus or ringing sensation in the ear or hearing loss and that will sort of help you delineate. What sort of, uh, dizziness that is, um, is the cause? Ok. But that will be, that'll be done in clinic. It's not usually done through the emergency department. Ok. Right. The other thing you get called as a, as a, an ENT H is you'll get called incessantly by GPS. So, uh, you've got a GP calling you, he's got a four year old kid with a two day history of ear pain and fevers. They're normally fit and well, and they're up to date with your immunizations. So, anything you want to ask over the phone when they're calling you, you're just gonna tell them, I'm sure the kid will be fine. They'll get better. Um, without us doing anything. Yeah. You wanna know about discharge? What, what might discharge indicate in this situation? Yeah. Recent coral symptoms. Always good to know. You are worried. So, Otitis Media is probably our diagnosis here. Very good Dean. But if you got discharged from the air, what do you think's happened? They're perfect. Exactly. You can ask about a rash. Yeah. So, sort of other systemic symptoms you can ask about hearing in a four year old might not be able to get much of a history of, to whether they're hearing or not. But if they have things like speech delay as an older child or they're having issues with hearing, you might think that actually they're having and they're having recurrent episodes of ear pain, then that'll lead you down a slightly different pathway. What advice are you gonna give them over the phone? Are you gonna say they need to come to E A A&E M urgently for me to see them or are you gonna give them some other sort of advice tender mastoid process? Always good to find out. Yes. History of swimming. Swimming is more important for the otitis exna patients, but always good to know. Also anyone for some advice you're gonna give this, this GP over the phone. They're panicking because they've got a four year old with a temperature of 39. Yeah, it could. Yeah. In fact, that's, that's right. Izzy is a lot of, a lot of otitis media is a viral infection. So, exactly, you need to safety net them. So, if there's no red flags, most Otitis acute otitis medias can be managed conservatively with analgesia. You get them in warm, humidified rooms and if they're old enough, you can give them a nasal decongestant because a lot of these are viral, upper respiratory tract infections and in kids they've got a much narrower Eustachian tube. So they can't clear any fluid that's going to collect up there and it's going to cause pressure and pain sensations and it's going to really hurt. And if, if, uh, they get discharged and you find that you had the history, but you've got a four year old that's screaming, screaming, screaming, screaming screaming and suddenly there's pop and there's discharge from the ear and they feel a lot better. And that's because the infections taken the path of these, for instance, and popped out through the eardrum. And most perforations will then heal by themselves if they are small enough. Ok. Just on a note for oscopy because I've been talking for a little while. Anyone want to give me some answers for what's behind the boxes for this. First of all, anyone know right or left ear. So red flags would be if the child is becoming drowsy sick, off their food. Um, anything that would make you think that they are becoming more unwell. Er, any, um, yeah. So signs of sepsis, obviously any signs of sort of intracranial complications. So, drowsiness, um, any cranial nerve deficits, any neurology, anything like that, that would make you more worried this, correct. This is the left. How do you know it's the left? Was that just a lucky guess how you know the left everyone? Oh, yeah. But guys, what happens if you've got a dull eardrum or a perforated eardrum that hasn't got a cone of light. How did you know, then, I mean, you could say it's attached to a patient and therefore, you know, but yeah, so the, the, the, the, so the lateral process points forward. So this is a left eardrum. So that's the lateral process there. Ok. Split into A and G what are A and G anyone anyone with for A oh GG is actually the pars tense. I think it's pointing to this whole area, I think. Sorry, that was. So you did say G Yeah, G is just the incus visible through the drum. A is the Pas Cida and one for D D is the umbo Yeah, that's where it attaches. So that's where the, the, the ossicle attaches to the eardrum there. Let's see. See is the handle of the malleus. I know we've said malleus, we've got the lateral process and the handle of the malleus F we've already talked about F is that cone of light or the light reflex E is this ring like structure and you want to know what a Latin for ring is. Yeah, it's annulus. OK. So now you can describe the eardrum when you're looking at it down the down the, the, the otoscope or the microscope, which you know, if you're then documenting it in the notes, it will really help the next person if they're trying to look at it and going, what on earth are they looking at? OK. So this is just another schematic. So this is actually your right ear, a schematic diagram. Now as Izzy mentioned the lining of the middle ear, so behind the eardrum is made up of respiratory epithelium. So the bugs and the bacteria that you get on the otitis media is gonna be different to the external auditory canal, which is epidermis So you're going to more likely get some of the staph infections and the pseudomonal infections there, skin floor infections and otitis exna because it's skin, whereas the middle ear infections or titus media, you're more likely to get the of the upper respiratory tract pathogens. So, like strep pneumonia, for example. Ok. So this GP has called you back again. Their kid did not settle with conservative management. They've given them a week's worth of amoxicillin and they've still not got any better. Now, they're not eating and drinking. They're not really passing urine very much and they're swollen behind the ear and the GP is now really worried. What are you going to do next? Give another round of antibiotics. Yeah, I mean, you're right. This kid needs to come to be seen in Ed. They need to be reviewed urgently and they may well need to be admitted. Um When would you do AC T scan? Do you think what would a CT scan be looking for? Yeah, exactly. We are looking at, we're worried about mastoiditis in this kid, aren't we? So you come to Edie and this is what you see. Oh dear. What does everyone think that might be? Yeah, this is mastoiditis. So there is a difference between fluid in the mastoid air cells on a CT scan and mastoiditis, mastoiditis is, is infection and pus in the mastoid bone. Now, you don't really get that in adults if you scan most adults who've got an upper respiratory tract infection. They will have some fluid in their mastoid that is not mastoiditis. It may be reported as mastoiditis by the, the radiographer or the radiologist. But a mastoiditis, what you're actually talking about is an abscess forming within the mastoid bone. No, this kid needs to be treated like they're septic. You need the pediatric team involved because they're gonna be a joint admission under pediatrics and ent you are if you have any red flags that we talked about before. So any drowsiness, any neurology or you're feeling like this feels boggy. You probably wanna wanna do a CT scan, but you're gonna need to speak to your reg about this because this kid might well need an operation. Ok? So you've done your CT scan and this is what you find. So which side is abnormal? The left or the right? Yeah. So you can see here on this scan you've got, you've got, it's not the best I'm afraid, but you've got fluid within those mastoid air cells there and you've got a great big abscess starting to form here. Ok. So this kid probably does need an operation. Um You're going to treat them with IV antibiotics. Does anyone know what operation you might do for this kid? You are? Yeah. So you're going to do, it's not called a basic, it's called a cortical mastoidectomy. So the cortical mastoidectomy is clearing out the infection in the mastoid bone if you haven't got such a bad mastoiditis and you don't think you need to drill out their mastoid bone, which is actually, you know, fairly drastic. Do you know what else you might do for this kid? And in fact, if you're doing a mastoidectomy, you would also do this, but you might do just this. So, where's the infection originated? Yeah, exactly. Dean, you put a Grumet in. So this kid's got an acute otitis media, right? And the reason it's become more complicated is because they haven't popped their eardrum. Probably. So because that nasty bacteria is all sitting within that middle ear. It's then sort of seeped through the mastoid wall and gone into the mastoid bone. So by putting a Grumet in, you can actually let a lot of that nastiness out which will improve probably their, their, their infection. So that's definitely something you would do. So you do a cortical mastoidectomy and a grom. Ok? Anyone know what some of the complications of mastoiditis are? You might not know this. It's fine if you don't, meningitis is one. Yeah, facial palsy brain abscesses. Yeah. So generally I would break these into intracranial and extra cranial. So the extra cranial ones, you're going to get your be old cli and luck abscesses, that's abscesses, sort of in and around the ear and you can get cranial nerve involvement and then the intracranial one is, as you said, you get temporal lobe abscesses, you can get epidural subdural abscesses and you can actually get venous sinus thrombosis and of course meningitis. Ok. Sorry, this should say GP referral number three because I think I moved them around. So now you've got an 82 year old male with a two week history of a pain and discharge. He's got a past medical history of diabetes, high BP and COPD. What advice are you gonna give to the GP over the phone? So it could be malignant Otitis Exter. It's probably a bit early for that given. It's only a two week history, but it's good that you guys have got that in the back of your mind. Yeah, exactly. So, a lot of GPS seem to like to try and treat a titus external with oral antibiotics. That's not going to work. These guys need to have topical antibiotic drops. They need to keep the ear really dry. So, um, I normally say to people obviously, no swimming, no putting your head under water when you're having a shower, get a, a cotton ball with some Vaseline on it, just pop it in the outside of the ear to keep the water from getting in. And then you can actually, if you've got a hair dryer with a cold setting, you can dry that off with that or just make sure you're toweling it off afterwards. So that's going to be your sort of over the phone advice and then swab any discharge, topical antibiotic therapy. If there's significant discharge, you might wanna bring them to your emergency clinic to have a review. Ok. So it's been going on for a little bit longer. The G P's called you back. He's had rounds and rounds of topical antibiotics. And so you've decided, let's bring them into our emergency clinic. So, actually, this ear infection has now been going on for over three months. He's had lots of oral antibiotics from the GP. He's also now had some topical antibiotics because they spoke to you on the phone and you sensibly told them to put some topical ones on, but the pain is really bad and it's keeping up at night. What are you thinking? Now? I think some, some people have already mentioned it because they had it in the back of their minds already. Now we're talking about malignant or necrotizing Otitis Extender, which is a bit of a misnomer because actually what, what you're talking about there is you're talking about an Osteomyelitis of the temporal bone or skull base. So that is managed slightly differently to just to just an Otitis Ex Terna because you can get really bad Otitis Terna and they can keep you up at night. But in somebody who's got a reason to have immunocompromised, so he's old and he's a type two diabetic. It's important to make sure that we rule out a malignant, a malignant or necrotizing otitis ex terna. So we're gonna make sure we've swabbed our, it, this is what we're seeing. Anyone. Know what that is, spot diagnosis. Yes, obviously it's an entire six standard. Does anyone know what bug that is? That is exactly Izzy. This is pseudomonas. You can tell it looks, it just looks like pseudomonas. It probably smell like pseudomonas. Um And pseudomonas is the most commonly implicated bacteria in this situation. So, depending slightly on where you are, some people will have very well defined pathways for their malignant otitis ex terna patients. But the general rule of thumb is is that you need to treat these very aggressively. So it's going to be a case of CT scan picc line and IV antibiotics for at least six weeks, you need to check baseline bloods, including things like renal function because you can be prescribing antibiotics. You want to know what their HBA one C is if they're diabetic and you're going to monitor their CRP because their white cell counts probably not going to be that raised. It's CRP and ESR that tend to be the ones that you use for monitoring in this. Ok. Now, the external acoustic meter is a bit more anatomy. Me for you, it's a sigmoid shape, it's not straight. So when you're actually doing your oscopy, one of the things that you can do is you can actually manipulate the pinner slightly to help you get into those nooks and crannies, the external part is formed by cartilage and then the inner two thirds is more in the temporal bone and it travels as an s shaped curve. So at first it goes Suro anterior, then Suro posterior and then infra anterior. So you can kind of see that I think on this scan. Now, why is that important if this was much more narrow and there was so much gunk in there that you thought, oh my goodness, like we can't even get eardrops in there. You can put in something called a Pope wick. Now, I haven't put a picture on here. Sorry about that, but it's effectively like a little sponge and you insert that either, you can either take the back of the otoscope off if you're on an Ed and you push it through that or with a microscope and you need to make sure that you're pushing it slightly forward in the same way. Like when you're putting your, your ear buds or your uh your stethoscope in, you wanna make sure that it's pointing slightly forward. That's the direction that you're gonna put your, your, um your pope wick in as well. Ok. So remember angle it slightly forward when you're inserting a Pope wick. OK. So what does everybody think of this? This is that same gentleman when he comes to you in clinic, you notice this. What's he got? Yeah, he's got, he's not Bell's palsy. It is not Bell's palsy. So what is Bell's palsy? So Bell's palsy is an idiopathic facial nerve palsy. So you can only call it a Bell's palsy if you've got no underlying cause. Ok. In his case, he's got an underlying cause. He's got necrotizing otitis exna, which has given him a facial nerve palsy. Um, so don't say Bell's palsy. Ok, if somebody has, um, you know, Ramsay hunt or any of these other, you know, if they've got a reason to have a facial nerve weakness, do not call it Bell's palsy. Yeah, exactly. Don you have Bells is Bells is without a cause. So this man's got a facial nerve palsy. He's got necrotizing otitis exter. You can tell that even without a ct scan, anyone know how you would describe a facial palsy. I can see someone said a grade five, grade five. What grading system are you using? Gordon? Not viral? Yeah, Ramsay Hunt is a vi is a viral infection. So usually caused by the her uh, shingles basically. Um So again, that wouldn't be Bell's palsy. This guy's got necrotizing cos we've seen his ear, we know he's got, he's got an ear infection. It looks pseudomonas, we think. Exactly right. He's got a house. So House Brackman, he's the House Brackman Scale. Now, a lot of people will say that House Brackman is, is good as a rudimentary way of s scoring it. But actually you kind of wanna be describing exactly which branches of the facial nerve are being affected. But in this case, the House Brackman is probably reasonable. So is 11 to 6. And the turning point that most people expect you to know the difference between is the difference between a three and a four because in a three, you can just about protect your eye in a four, you cannot. So why do you need, why, why does that worry you, why do you need to worry about whether he can shut his eye or not? Exactly. So you need to, yeah, we worry about corneal abra. So he'll need to be reviewed by the ophthalmologist. So if his facial nerve doesn't improve, his facial function doesn't improve, he may well need ophthalmology involvement as well. So he needs to be taping his eye at night. He needs to be using eye drops. He needs to be very careful with his eye because he needs because he's not going to be able to shut it fully. Ok. GP referral number for this actually is sudden hearing loss. 54 old female suddenly lost hearing in her right ear this morning. She was sitting having her breakfast and suddenly thought, oh, I can't hear out of my right ear. What do you need to think about in this case? Are you bothered? Try to get over it? Yes, I think recent trauma is good to know could be a stroke. So we need to delineate what sort of hearing loss it is, don't we? So she's suddenly lost hearing. Is it conductive or is it sensorineural hearing loss? So, you kind of wanna know what the difference between their Ringnes and their Weber test is. And you do that with a 5 12 tuning fork or as a lot of GPS will tell you, I don't have a tuning fork. You can get them to do the hum test. So you, if you've ever heard your own voice on a recording, you're like, I don't sound like that. That's because you hear your voice through bone conduction more than you do through air conduction. So when you get a patient to hum, you're doing a rudimentary test of their bone conduction. So it's a rudimentary version of Weber's test, which you can do. So you'll get some naturalization. If you get later with the hum test, there's a rudimentary version of Weber. OK? So if it's a sudden sensorineural hearing loss, you're gonna tell them over the phone to start steroids, a milligram per kilogram up to a maximum of 60 with covering with PPI and you're gonna bring them in to your emergency clinic for an urgent audiogram. If you think it's a conductive hearing loss, you need to assess for red flags. And what I mean by this is that the reason you have a conductive hearing loss is because something is blocking the sound conduction. So this could be wax or infection. That's not that exciting. But if they've also got symptoms, sort of like of neck lumps or unilateral nasal blockage. What you're worried about then is you're worried about something sitting at the bottom of the, the Eustachian tube where it enters into the back of the nose. So you need to make sure that you're not missing some sort of um, uh rhinology, sort of a nasopharyngeal carcinoma or cancer, which may have been covered last week. I'm not sure what uh Thiago was covering in his session, I'm afraid. Ok, so a little bit of a Chis chatter about how hearing works. So tell me um this may be a bit too rudimentary, but this is how I explain it to patients is sound happens over here. It gets picked up by the, the ear. The pinner which pushes that sound down through the canal, vibrates the eardrum which vibrates the ossicles, the ossicles stamp up and down on the cochlea, which creates a, a wave through the fluid in the cochlea which tickles the little air cells that creates an electrical impulse which goes off to the nerve to the brain. Ok. A problem anywhere conducting the sound from over here to the hearing apparatus is a conductive loss. So anything that blocks it be that infection, blood wax, whatever or if this area is not aerated enough because the Eustachian tube isn't functioning and these things can't vibrate properly or if the eardrum is torn, for example, that will give you a conductive hearing loss. A problem conducting the sound through a problem with the cochlear or the nerve of hearing is gonna give you your sensory neural losses. Ok. So that's how I explain it to patients. And that's how I sort of think of it myself because I'm a bit of a simple person and I'm not clever enough to understand more than that. So that being said, what is the cause of these hearing losses? So which one is this when you do a conductive, if you, so a conductive loss when your sound goes to the impaired ear? Which test is this? Do you think is this ring or Webbers any ideas? Ah, yeah, 50 50 shot. And it's the other one? Ok. Why is that? So this is Ronnie's and then the hum test is, is, as I said, it's rudimentary Webers. So in Ren's Test, what you'll, you expect you expect if Rynn is normal, then you expect a normal test when you're doing your your air com when you're comparing air to bone. Whereas in a Weber's test. Yeah, I know it. I always have to sit and think about it as well. It's not, it's not, it's not straightforward. Just remember that Ringnes is testing the difference between conductive between air and bone. So Ringnes will give you the what will tell you will tell you whether the ear is normal on that side. Ok. So some types of hearing loss that you might get. So things that will give you a conductive loss What's this one? Do you think? Wax or fluid? Yeah, that'll do it. Actually. I think this one was supposed to be wax. It's meant to be a candle. Uh, yeah. Fluid. So blood will do it. Yeah. Go on. What's that one? That's a foreign body. What's that one? My allergy. Uh, yeah. What's that one? What's this v to look like? Noise? Um, yeah. What's making the noise? A drum? So, it's a ruptured eardrum. So if your eardrum can't vibrate, it can't conduct the sound either, can it? Uh So that's this one that's aging. So aging will give you a uh sensorineural hearing loss, something, you know, as Presbycusis noise damage will give you a sensor renewal, hearing loss, certain medications will do it. The classic one being um chemotherapy agents or gentamicin. This one is auditory tumors. So one of the things that you need to worry about when someone comes in with sensorineural hearing loss is you want to scan them to look for an acoustic neuroma. Um And then this one is blas or explosion. I think someone said noise there as well. These three mixed picture which give you a bit of both. What's this one? Genetics, genetics. This one's infections can give you both because if you've got a gunk in your ear canal, but also it's causing problems and yeah, and then this one's hereditary. So head trauma. So if you have um trauma to your ear canal and you rupture your eardrum, but it's also full of blood. That'll give you a mixed picture. And also if you have a fracture of the temporal bone, that can also give you a sensory neural loss if it's damaged the cochlea itself. OK. This is so I realize we're running over time, but I think that's, we did start a bit late. So I'll try and whistle through some last bits. So this is a normal audiogram down the side. You've got decibels, how loud something is across the top. You've got frequency. So the high pitch of it, women's voices tend to be around about here, men's voices, sorry, men's voices tend to be around about here. Women's voices tend to be around about here. So, um which is why you'll find old people will struggle to hear women but will hear your big baritone, um male friends with deep voices because in Presbycusis, you use the higher frequencies first, this would be normal hearing anything up sort of 20 decibels. Then you've got slight, mild hearing loss, moderate, moderately severe, severe and profound and profound hearing loss is actually def defined as loss of 80 decibels or more. OK. So these are some different ones. I I apologize. These haven't come out very well, but this one, so red is right and blue is left. I remember that as rough for red and rough for red and right and then blue must be the other one. So this one you've lost both bone and air conduction. There is no gap. This is therefore sensory neural hearing loss. This one, you've got a gap, it's quite difficult to appreciate. I'm sorry that you haven't come out better. Um So that is there's a gap between air conduction and bone conduction. So, yeah, X left, X left and oh right. I like that as well. Um So here you've got a gap. So if there's an air bone gap, that's a conductive loss. And on this one, it's trying to show you that you've got a gap. So you've got a conductive loss, but actually the whole baseline is down as well. So this one is a mixed picture. OK? So to round off very quickly, we'll do some spot diagnoses. OK? Right or left ear. And what's the diagnosis? Yeah, it's a right ear. The normal, we have got ATM rupture. So I would say that this is a, if I was talking to somebody over the phone or writing the notes, I would say that this is a right ear perforation in the pa tensor, you tend to talk about sort of sort of the inferior in sort of the inferior part. I'd say that's the inferior posterior quadrant and I'd say that's maybe 25% of the eardrum. OK. This will probably if it's not infected and it's dry, heal by itself, it will take about six weeks or so, but it should heal by itself if it doesn't while it's healing you again, you need to keep it dry because it's not protected. How do you know it's the right ear because the the handle is pointing towards says the right ear. So the handle points towards your nose, I always think it looks a bit like a nose. So it points towards your nose. Ok. This will probably heal by itself, keep it dry whilst it's healing. If it doesn't, they may need a tympanoplasty compared to this one. So this is also a tympanic membrane perforation. But you can see here, this is looking more like 50% and it takes up both the posterior, superior and posterior inferior quadrants through that. You can see you can start to see some of the ossicles coming through. This is most likely going to need go going to need an operation to fix it. Ok. What about this one? Does it look normal? So this isn't a perforation? This Yeah, exactly Gordon, you can s can you can you can you see how it's kind of sucked onto the obstacle and the ossicles are sort of stuck to the tympanic membrane. So this is a retracted tympanic membrane. This might well have some problems with the eustachian tube. And there's different things that you can do that a lot of that sort of like is intranasal treatments trying to sort of get the Eustachian tube working. But again, this might actually need some some interventions surgically So some people will put a G gramme into this in the hope that it will help aerate better. Other people will do um operations on the Eustachian tube where they operate from the bottom end. So they go up the nose and they try and dilate it up with balloons. What about this one? So this patient is slightly different. This patients, I think lying down, which is why their ossicles are pointing at slight. Yeah, exactly. So you've got fluid behind the eardrum here. So if this is an effusion, so if this was that screaming four year old kid, we would say, yeah, this is definitely an acute otitis media. If this kid was fit and well and was having issues with speech delay and um not paying attention to their parents, what would you then think? So it's been going on for months. Not, not got any temperatures otherwise. Well, and this is what you're seeing. So yeah, you, you probably would treat them with a granite. What are you treating with that granite Danya? So you do uh so you do a tympanotomy to put the grommet in? What are you trying to treat? What's the diagnosis? What are you putting a gramme in for? Yeah. So otitis media with a fusion. So because kids have got those narrow eustachian tubes, they can't clear the fluid out of their middle ear. So they're not going to be hearing properly. They'll have a conductive hearing loss. Because of that fluid sitting behind the eardrum, not allowing everything to vibrate properly. And that's why they're not hearing properly. So by putting a Grumet in, you've effectively deliberately perforated their eardrum, you can get all that gunk out and it can start to hear properly. OK? And this is another picture of the same. So again, you can see these bubbles make you think. Oh yes, exactly. Rara, it's known as glue ear and that is a gram. It, so the grum you can see there. So this is a, so this is the left ear and the G gramme has been put in the inferior as far towards the anterior quadrant as you can. And that is because that's a safe place to put it. So you're not near any of the dangerous. So you're not near the facial nerve or the cor Timpani or any of the ossicles, this area is safe. So when you're putting your grommets in, that's where you're aiming for. Yeah, exactly. And you know, this is, yes, tympanosclerosis. Do you need to do anything about? It? Could be an old scar? Yeah, they could have had grams in the past or lots of perforations. Yeah, you don't really need to do anything about it. They may find that um in future they might have issues with their hearing and actually sometimes tympanosclerosis is also linked to ossis. So if they are having hearing issues, they may need something doing. Um but if you just see this isolated, you don't need to worry about it at all. Ok? And final one, anyone know what this is exactly. This is a cholesteatoma. So if you remember back to this one where we have that sucked in ear, what happens is is that normally the skin of your eardrums grows out by itself and it clears all its debris for some reason and we're not sure why retraction is potentially one risk factor for it. Instead of growing the right way out, the ear skin grows inwards and you get these pockets and they effectively act a bit like a tumor. So they will burrow down through the ear and they'll burrow into that. And you usually write, you usually find them in the attic and the pars flaccida that flaccid parts, that's where you're gonna get your retraction. And in fact, they sort of, they can act a bit like a tumor. So they burrow down and they eat away at all of the structures behind. So these need to be removed surgically. Ok. So, um this is when you're going to do your sort of your combined approach. Tymp your uh combined combined approach, um Tymp Tyan um Tympanomastoidectomy. So you're going to remove this surgically. So this needs to be scanned and sent to your um send to your auto consultant for an operation. Ok. Any questions I know that was quite a whistle stop tour and I apologize that we run over a little bit and I apologize for the delays at the start, but hopefully that was at least some useful and interesting otology bits and pieces. Um You will see a lot of ear infections, particularly if you're doing the emergency clinics. Um but you will also get the ear lacerations and things like that. So it's good to be able to know what you're doing when you're dealing with them. The other thing I would say is that um everyone in Ent is always lovely and will never mind you calling them or asking me for help because I mean, I've, I Izzy mentioned at the start, I've been an Ensh for a while now and I've never, I've never come across a registrar or consultant that doesn't, gets upset when you call them. So if, if you are ever anxious about something, there is always someone that you can pick up the phone to and they will always be happy to help. But if you do have any questions or if you, if you want, um I'm happy for Izzy to share my email so you guys can email me if you have any other questions about NT or it doesn't have to be ear. Um I actually probably want to do head and neck. Um If you, no, no, it's fine. Everyone needs to know everything right and I don't mind ears. Um But if, if you do have any questions or if you just want to pick my brains about nt in general. I'm always happy to talk. Right? Clara. Thank you so much. That was amazing. And thank you everybody for coming. Please fill out the feedback because it's really helpful for us because it helps um guide our future sessions so we can improve and otherwise we will see you back next week. Um And the session of next week is all airway. Um So key track Larry Management, um how to do a knee endoscopy, et cetera. The main thing about airways is don't panic. It, it, you always have longer than you think you do and time will slow down when you're dealing with a problem. Amazing. Great. Thanks Kara. I've got a run. No problem. Me too. I gotta get home and have some dinner. Thank you so much. Thanks guys. Bye.