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Trouble shooting. We are hopefully ready to go. Can you all see that now? Yes. Great. Perfect. So, like I said, we're just going to apply airway procedures to a few cases which I've seen during, um, my Ent and my time in Ent as a core surgical trainee and how I dealt with them and what you should do. Um, and we'll go through some procedure as well. So, so first case you are the sho on call at a tertiary ENT unit, it's a Saturday afternoon. So there's no one else really around. You have a consultant and a registrar available by phone, but they aren't on site. You're called by an A&E sho who wants you to come and see a 38 year old man who doesn't have any relevant past medical history, um, doesn't have any allergies but smokes quite a lot, smokes 2025 cigarettes a day. Um, and he's presented with a 48 hour history of an increasing sore throat and voice change. Um, he's not been eating and drinking over the past couple of days either and today he can't swallow his own saliva. And the a nesho says, oh, Yeah, he's, he's gone through three or four sick bowls and he's just filled them up. Um, so he's spitting up all of his saliva. Um, he also tells you over the phone that, um, this gentleman's had sudden difficulty breathing throughout the day and quite a lot of difficulty breathing overnight. And the sho on the phone says he, his breathing sounds really noisy, like, like he's gasping for air and he also gives you some observations and these are them. So heart rate, 100 and 10 BP 11 5/75 Respi rate 24 sats 89% on room air and a temperature of 38.3 degrees. Now, there's multiple things here that you should be concerned about in this history and I've highlighted them all. I'm sure that you're all aware. But nonetheless, this is a gentleman who's young and fit and well, who has got an increasing sore throat over a fairly short history, only 48 hours with a voice change, who can no longer swallow his own saliva in his drooling and has noisy breathing. In addition, he seems to be hemodynamically compromised. He's tachycardic, he's tachypneic, he's got low sats and he's febrile. Um whi all of which is quite unusual for a 38 year old because th um fit and well young patient has decent compensatory mechanisms and really what a lot of these things are pointing to is an impending airway disaster. I I can appreciate that sounds a bit dramatic, but really what this means is um there are certain signs which are pointing to a potential airway compromise, namely rapid onset aphagia or dysphagia. Um frequently associated with odynophagia, which is painful, swallowing. So a severe sore throat, a rapid onset voice change and it's often quite hoarse or husky or the patient can't speak at all, they can't phonate at all. Um And often these patients are incredibly unwell. So tachycardic, tachypneic, agitated, pyrexic things like that. So what does this mean? You need to review this patient as soon as possible. You may be wondering why I haven't touched on noisy breathing and that's because noisy breathing is a sign that airway compromise is actively happening. So it's not a sign of an impending airway compromise. It is a sign of airway compromise. And I just wanted to talk you through the difference between Stridor and stir because a lot of the calls that you'll get where you know your referral will be saying, I'm really worried about this patient because they're Stridor or we think we can hear some soft Stridor. Um You'll go and you'll realize that it's not Stridor at all. Um So while Stridor is very noisy, harsh, high pitched breathing, um Sturr is much lower pitched and sounds a bit more like snoring. Um So Stridor is the direct result of airway compromise and the, the quality of the Stridor varies a bit with the location of the, of the airway obstruction or the airway problem. Um And you can see that on, on this diagram here. So further up, you just have inspiratory around the glottis and the subglottis, it's biphasic and further down it's expiratory. Um Whereas certa isn't necessarily an acutely concerning sign, it can be, it can be a concerning sign and it, it, it does point to some degree of upper airway obstruction. However, we routinely see it in, for instance, perfect example, is a young child with adenotonsillar hypertrophy who has obstructed breathing, um in particular at night. Um and just to illustrate what these sound like at the risk of making myself sound a bit a bit. Um Ridiculous, Stridor is a bit more like and stir is a bit more like a so quite a stark difference between pitch and quality. Um So what are the possible causes here generally when we speak of airway obstruction and when we speak of airway compromise, which leads to things like Stridor. Um We're talking about things like infections and malignancies which are obstructing the airway. But it can also be as a result of severe airway swelling, for instance, in anaphylaxis um or a foreign body, which we won't touch on too much today. But I'm happy to talk about in the Q and A um and potentially trauma which can be blunt or penetrating into the neck. Again, we won't try to touch on that uh Today So you go down and assess the patient and the patient's in the majors area of A&E, um, he's not in a monitored bed. Um, he's on a stretcher and he sat upright and he looks visibly distressed. He looks like he's in quite a lot of pain. And you're a new e, you're a new Entsho, you don't really know where to start. So you figure I may as well do an, a two week. He's unwell, I'll do an A swing. So you start with a and you notice this very, very noisy, acute, high pitched, coarse sounding inspirations, um possibly Stridor. Um He is able to talk, however, his voice is very, very hoarse. Um Moving on to b his saturations are now 92% because the A nesho has put on an oxygen mask, he's put on a non rebreathe mask, supplying 15 liters of oxygen. He listens to his chest and he's got transmitted air, upper airway sounds, but that's good air entry. Um The BP cycles again and it's a bit lower this time. It's 100 and 5/70. His heart rate is still 100 and 10, his cap refill times, ok? And he does have access. He's got a single can in the right hand. He hasn't had a blood gas sent, but he's had some bloods since um his gcs is OK. Um And you use D to um as a prompt to check his drug chart and you notice that he's not really had any analgesic, he's had a single dose of IV paracetamol on uh admissions to A&E but nothing since he also hasn't had any antibiotics or any adjuncts apart from oxygen. And then you get to e and what does e mean here? E means when you, when you work in any specialist environment in medicine, E means your specialist examination a trauma E or uh an uh an AC LSE or an A PLS. Um exposure is, is a bit different. But when we're talking about a specialist assessment, E should stand for your specialist examination. And what I mean by that in this case is an examination of the neck, the oral cavity and flexible nasopharyngoscopy or as, as it's commonly called flexible nasal endoscopy, I'm gonna go through each of these in turn. So your neck examination, all this sounds quite daunting, but I promise you it's, it's if you take a systematic approach, it's fine. Um So have a look, look for, look how, look how the neck looks, see if it's inflamed, see if there's any massive swellings. You, you will rarely see this. This, this is horrible. Um And looks like the gentleman has possibly a lot like angina or a deep neck space infection, but we won't talk too much more about that. Um Is the neck large, are there any obvious lumps? Is there any erythema or cellulitis? And is there any torticollis? Torticollis is a skew of the head to one side or the other and it's caused by tetany. So, spasms of the sternocleidomastoid muscle, um the causes for that are various but often in, in, in this context, it's um caused by irritation, usually inflammatory or infectious irritation of of the sternocleidal mastoid muscle, check the patient's neck movements. A normal patient with a normal neck should have a full range of motion of the neck. So they should be able to look to both sides, look all the way up to the sky and put their chin down to their chest. I quite like to ask patients um who have some kind of pathology in the neck just to do these neck movements with me. Um So the way that I'll, I'll, I'll ask them to do it is look all the way up to the sky, put your chin down to your chest and then I'll hold my hand out to out to their periphery and say, look all the way to, to your right at my hand and look all the way to the, to, to your left at my hand. If there's any, what I mean by restriction or pain is. So a normal examination would, would result in, you know, free movements of the neck. Um restriction would be. So for instance, the patient looks all the way to the left and they're wincing a bit and then they start to look to the right and they're like So it's stiff, it's painful. It could be limited by pain rather than, you know, stiffness. But it's important to check this. Um and palpate the neck. So stand behind the patient, you, you're all doctors, you all know how to palpate the neck. Stand behind the patient systematically palpate the neck feeling for any masses. Um seeing whether they're fluctuant, fixed mobile, feel for any lymph nodes, um lymphadenopathy in the um in the anterior chain for instance. Um So that's your neck examination and short um and your oral cavity examination. So you'll need some equipment for this. I've put 1 to 2 lax tongue depressors by which I mean, these things here um because I personally prefer them and a lot of a lot of people in more emergent scenarios, more acute scenarios prefer them just because they have a little handle and they allow you a bit better control over the buccal mucosa and the mouth. So you can really get a good view in addition, a headlight. So I've put this on because this is what's available in the majority of the nt departments in the country. However, I'll be honest, the headlight that I use day to day on call is a, is a 10 lb trail running headlight that I bought from Amazon. And honestly, that's just as good. If you, if it's bright and if you can angle it properly, it's fine. Just keep your just something to keep your hands free and provide you with a light sources is the important thing. First things, first check what the patient's mouth opening is like and see whether or not that's restricted. So, a normal mouth opening is around 3.5 centimeters or approximately three fingerbreadths. Um, mine is slightly, is slightly larger than 3.5 centimeters. But you get the point, it's a good, it's a good measure and you'll notice that if the patient has restricted mouth opening or, or Trismus, um they can't open their mouth very wide and they'll go and they, they'll be trying, but they can't open it any further. And it's not so much that they feel pain, which, which restricts them. It just feels very tight. Trismus is essentially tetany of the muscles of mastication. And again, what causes that most likely in this context, some kind of inflammatory process which is causing some irritation. Um And it's a good sign that there's some kind of inflammatory or infectious process happening in the, in the mouth or in the oropharynx, you then need to have a look inside the mouth system and systematically examine all of the buccal lighting. So two tongue presses is very useful, but you can put them inside, inside the cheeks and use them to avert the lips. Have a look at the back of mucosa, have a look at the openings of the stents and ducts in the cheek. Have a look at the floor of the mouth and the tongue in its underside, the floor of the mouth. Um, if it's edematous that can point to a possible dental or sliver gland pathology. So it's important to bear that in mind. Have a look at the teeth as well. We're not dentists. Well, I speak for myself, maybe there are some dual trained people in the audience, but majority of us aren't dentists. However, we can tell when there is gum swelling, um when there's an abscess and when there's broken teeth, I think if you do a good examination, you'll be able to see that and it should help you tailor your, your differential down. Um Also have a look at the retro mo trigo tonsils for pillars and the posterior oropharyngeal wall. And I'm not just throwing anatomy terms at you. There is a diagram here. So um this is what you see inside this gentleman's mouth. When you look his mouth opening, isn't this good? Um It's a bit more restricted, but you see that initially, you think that he might have a peritonsillar abscess because you can see that his uvula, which is this dangly thing here is pushed to one side and usually it should be central. However, you notice that there's no, there's no, this is not the best image, but there's no swelling of the, of the soft palate. And actually, there's quite a lot of erythema around the anterior pillar on the left hand side. In addition, you notice that the tonsil, which is this thing here is the thing which is pushing the uvula out OD. But we'll, we'll touch on that in a second. I'm just going to go over the rest of the, the rest of the examination. Oral cavity examination is, is imperative is, is what I'm trying to strike out finally, nasal endoscopy. So I know that Tiago went through nasal endoscopy with you guys, um a couple of weeks ago. However, I'm going to touch on it again and this, this time I'm going to focus on more of an uh airway context. So you will need some equipment. Um depending on the unit that you work at, you'll have access to various different scopes. So you may have a reusable, a flexible scope and a big old school light source which you have to lug around or you might have a reasonable scope with a built in light source or a screw on a light source which can act as a handle. And you know, you can, you can balance, um you can balance on your hands to provide you a bit more extra stability. You'll need some lubricating jelly, um some local anesthetic spray. I've put both Xylocaine and phenol canine here. I've never really used Xylocaine in the, in the nose, but it is useful for using it in the mouth if, if um if you want to suppress the gag reflex. Um Phenol canine, I don't always use it in an emergency environment. You, you wouldn't necessarily use it. However, it does make your examination a little easier. It makes it a lot more comfortable for the patients and it decongests the nose because it contains phenylephrine. So it opens up the nose and allows for easier passage of your camera, finding an alcohol wipe. Um, before you scope touch the alcohol wipe on the tip of the scope. So this bit here, um, and uh, just, just clean it with the alcohol wipe. Um, even if it's a sterile scope, even if it's a single use scope, like an AMBI scope which I've put here. Um, this will prevent it from fogging. It's not so much for sterility, it's, it's prevent the, the, uh, the view from fogging. Um There's various different indications which I won't go too much into. Um, as you can see, this gentleman hits, um, a few, quite a few of them. So sore throat, voice changes, potentially a suspected deep neck space infection. Um, and I'll briefly touch on the procedure. I've got a video as well, which I'll show you, which is, which I think demonstrates it quite well. Um So ensure the scopes clean, tell the patient you what you're about to do. So the way that I phrase it is, um I'd now like to use a thin camera to have a look at your, have a look at your nose, your, um, your nose, the back of your mouth, the back of your nose and the structures in, um, the structures beyond the back of your mouth above the level of the voice box. Um, I'll tell them that it's going to be slightly uncomfortable and it feels a bit like a COVID swab, which goes a bit too far back. If I'm going to give them local anesthetic, I'll then ask, and they'll then ask them if they, they have any allergies, I'll give them a couple of pumps of local anesthetic into both their nostrils and ask them to take a deep sniff. Um And then ask the patient to look straight ahead if you've scoped someone before you know that patients intuitively cock their head back and that complicates your, your technique and your, your, your view. So ask them to sit up straight and just look straight ahead. Pass a scope through the easy nostril. What I mean by easy and nostril is the nostril with the least resistance. So before you pass your scope, have a quick look up, just put your camera at the opening of the nostril and just see whether or not there's any obstruction. So for instance, a big septal big septal deviation, which is going to make your view harder to get, try not to touch the septum and skate along the floor of the nose. You'll see what I mean when I show you the video. Um But that will prevent unnecessary trauma. Um Let me show you on, on your, on your scope, you'll have these little handles and that will allow you to control the tip of the scope. So this part here, as you can see this, this tips already um angled slightly slightly up here. Um And moving this, the subtle control, you can angle the tip further around that way or that way. Um And that allows that facilitates you getting a better view, systematically examine everything. Um There are certain maneuvers that you can do in order to um facilitate your examination, which I'll show you in the video and then withdraw it carefully. And as you withdraw the scope carefully, re-examine everything again because you may have missed something and then document your findings clearly. Um I document it systematically so knows whether there's any findings, postnasal space and nasopharynx, oropharynx, base of tongue and vallecula. And I'll show you what that is. Hypopharynx and larynx. So I've got a video here. I'm not going to play the whole thing. I've got a, I've put a QR code up here if you want to watch it in full. Um Bear with me, we'll just show about three minutes of it. Can you guys hear that? Uh No, not very well. Um Maybe if I put up the volume, tell me if you can hear the, hear what they're saying. No, no, maybe that's fine. That's fine. I'll talk through it. So, um so equipment we've already been through. So some coe Alcaine is useful to have lubricating jelly and an alcohol swab um to prevent your the tip of your scope from fogging. Explain to the patient, ask the patient if they've got any allergies and explain to the patient that you're going to give them a couple of pumps of local anesthetic spray into their nose in order to facilitate the examination, um speed forward. There we go. So put the applicator just inside the nostril couple of pumps on both sides um and ask them to take a deep inhalation through their nose and that ensures local anesthetic gets to gets to where it needs to be. So obviously, wash your hands, aseptic technique and all that um prepare your nas endoscope. This is a reusable scope with an eye piece. Um Often you will have stats or some kind of screen which you can connect the scope to which you can then view your examination on um the way that I know that thi has been through all of this with you before. But um things that you can do in order to facilitate the examination is hold the scope, buy the handle with one hand and use the other hand to and put the, put your other hand and and stabilize it on the patient's nose and use that to pass the scope into the nose. Um And that just ensures that you get a better overall view. This has a light source connected by a lead and you can see that the light is coming through. Um, lubricate the tip. Try not to get any, um, that's probably gone a bit too far forward. Actually, try not to get any lubrication jelly on, on the top, um, on the, on the actual camera on the lens because that can obscure your view. Have a look through and make sure that it looks. Ok, some reusable scopes. Um, I'll just pause it for a second, some reasonable scopes which get sent off to sterily, uh get sterilized, often get damaged. So it's better to realize that you, you've got a dud scope before you start examining. Um Now the actual examination, explain what you're about to do, explain that you are going to ask them at certain points during the examination to do certain things, have a look at the opening of both nostrils and see which one is easier and pass it through. So that's the inferior turbinate and that's the septum. You can see the middle tur not up here, but you'll see a be better as we come back out. Um That is the back of the nose, that's the nasopharynx. And we see the opening of the Eustachian tube uh here and you can swing the camera to the other side to have a look around the postnasal space. That's the foss of Rose and Mueller, um which is a common site for nasopharyngeal tumors and to facilitate your passage from the nasopharynx through cio pharynx, ask the patient to inhale deeply through their nose. That's that will bring the pallet forward and allow you to move, move your camera further down. So we're going further down and that's the base of the tongue. And you can see a little bit of the vallecula here, which is just between the base of the tongue and the epiglottis, which is this curved structure here. So you ask the patient to pro protrude their, I'll just pause it here. They, they should protrude their tongue. So um stick your tongue out in order to see the vallecula. Well, um I think the video shows a bit better in a couple of a couple of seconds um and have a look at the other structures. So these are the a ero cartilages, false cords and the true vocal cords which you can see are coming together. The way that you can ask the patient to the best way to evaluate the vocal cords is to see them moving. So ask the patient to say e and that should bring the vocal cords together. You can also see part of the, you can also see a little bit of a subglottic view. So you can see a bit of the trachea beyond the vocal cords, try not to get too close to the vocal cords if you touch the vocal cords, that can cause laryngospasm and respiratory arrest. However, you can, you can go a little beyond, sometimes go just beyond epiglottic and now bear with me, he's about to puff out his cheeks and that will allow you to see the piriform SSI. That's not a great view. There we go. That's a bit better. Um And the uh opening of the esophagus. These are also a common site of, of origin of laryngeal uh cancers. So re-examine as you're coming out, we're going to have another look at the base of the tongue here, he's sticking his tongue out and you can see that a lot better. Um Just a quick mention if you have foreign bodies in the mouth, in particular fish bones. Um The vallecular is a common site where they get large. So if you ask to examine someone who's got a possible um impacted fish bone, just have a good look at the vallecula. Um And as you come out, examine everything again, so have a look around, that's where the adenoid pad is and kids, some adults have it too. Um but it shrinks down naturally over, over time, inferior turbinate, septum, middle turbinate and gradually withdraw from the nose. Perfect. So um a couple of uh pictures which illustrate the anatomy quite well. So that's the inferior turbinate. We're talking lateral. So this is the right nostril that's lateral, that's medial. Um that's a septal spa middle term. It, we'll just go a little beyond keen to show you the airway. So this is the nasopharynx that's the opening of the Eustachian tube and here we go. Let me just uh here we go. Perfect. So that's the subglottic view of the trachea, true vocal cords, false vocal cords and often in airway insult, you'll see that these are quite edematous and they will obscure the airway. Um make your view of the true vocal cords a lot harder. Um These are the erno cartilages and the aryepiglottic folds. Um and 56, that's the piriform fossa and you can't really see the left, that's the epiglottis and that's not the best view but the vallecular um we've seen quite well on the video, like I said, if you want to watch the whole video, I've got a link at the end and there's a QR code here which you can scan, leave it up for a second and we'll move on. So you do the examination and your findings are, there's some erythema on the anterior neck and there's some restrictive range of motion, motion in particular to the left, um particularly limited by pain. It's not mentioned here, but there's also some anterior cervical chain retinopathy. You examine his oral cavity and you see what I showed you before, um which is the tonsils a bit pushed out. There's no evidence of a peritonsillar abscess. Um He's got decent oral hygiene, normal floor of the mouth. Everything else looks OK. But he's pulling secretions by which I mean, there's quite a lot of saliva at the back of his mouth, which he's not able to swallow. He's got this big pushed out tonsil and you scoped him and you see this. So what is this is? So we are in the oropharynx just beyond the oropharynx and the tonsils would usually be a little further up. And normally the lateral and postero parapharyngeal wall is nice and flat and uninflamed and doesn't obscure the airway. So you've seen what a normal I scope looks like in that video. However, you can see that the lateral postero pharyngeal wall here is completely eff face on the left hand side. Um And that could be a number of things. However, in this context, it's most likely to represent a deep neck space infection in particular, a parapharyngeal abscess and I'll explain what that is in a second. Um in reality, so you can see some pooling of secretions here. And in reality, in the actual patient, it's not very good for you beyond. But um there, there was quite a lot of airway edema and he did have a patent airway, however, it was restricted by, by the swelling. So how do you manage these patients? Get help if you are new to ent or fairly inexperienced or if you're just not happy, I would recommend getting help. I in this situation will get some help. Um Reason being that you will likely need some hands. So call your registrar or your consultant, whoever your immediate available senior is and that should be immediately if there's signs of severe obstruction, um, an anesthetic or an air kind of senior airway trained person is, is the best person to have there as well. So they will help you formulate an airway plan and especially if the patient is, is desaturating and tiring quickly. Um, it may very well be that you'll need to secure an airway and an anesthetist will be able to help you with that nursing staff to administer medications and just help you get a adjuncts and equip equipment. And if this is a situation which happens on a ward, um it get get ICU there or your it outreach team um environment. I mentioned that this chap was in the Mangers area in a non monitored bed. He's got signs of airway compromise and he's hemodynamically unstable, move him to somewhere where he can be monitored. So a resuscitation bay, anesthetic room may be an airway bed, a hu bed somewhere where he will have close monitoring, get the emergency trolley ready and um make sure it's nearby and uh start giving him or her high flow oxygen. So 50 m through a non rebreathe mask, rebreathe mask is a good start. So, immediate medical treatment. So when you see them sit the patient upright, that will provide less restriction to their airway, give them oxygen, adrenaline nebulizers, especially if there's signs of airway compromise. So if they're stridor, give them back to back adrenaline nebulizers give them a high single dose of steroid dexamethasone is a great IV steroid which you can give at. So the dose varies from trust to trust. 6.6 mgs, eight mgs something high dose which will bring down the inflammation and a high single initial dose of a broad spectrum antibiotic, which you can then prescribe as regular a bit later on. Um So something broad spectrum something with anaerobic cover Um My trust at the moment that I work in. So as cefTRIAXone and metroNIDAZOLE trust will differ on this. So check your local policy and then just a a brief chat about deep deep neck space infections. So um what we mean by deep neck space infections is the spread of I've put oropharyngeal infections. But in reality, it's this is the most common cause, but there are other causes spread of oropharyngeal infections to the fascial planes of the neck. And the most common types are parapharyngeal, which is the most common subtype, which is where the infection spreads to the potential space, posterolateral to the nasopharynx and retropharyngeal abscesses, which are where infection spreads to the posterior to the potential space, anterior sub vers fascia. Um And you'll see retropharyngeal abscesses, for instance, more commonly in Children with infected um cervical lymph nodes. Um So I've put some symptoms and signs and as you can see, there's, there's a lot which this gentleman displayed um basically all of them um investigations which you need to do apart from the examination, which we've detailed already a, a full set of blood. So including things like a full blood counts, renal profile, crp or inflammatory markers. Um liver function tests depending on the potential cause, uh coagulation screen and group and stages just in case you need to um prepare them for theater. Um imaging isn't always necessary if you get a very good view with your scope and you see that there is something obvious which is causing airway obstruction and the patient has uh the patient is actively deteriorating. Don't dilly deli don't wait around for a CT, don't wait around for a definitely. Don't wait around for a lateral neck x-ray. Um A CT neck with contrast will give you the best visualization of the location of the infection or the presence of infection, whether or not there's an abscess and whereabouts it is a lateral neck x-ray will sometimes be done prior to referral to you and you might see a couple of signs. So widening of the prevertebral space and loss of the natural cervical lordosis, the loss of the natural curvature of the cervical spine, which is called the straight neck sign that should make you think about something like this management. We've discussed medical management. However, what should you do if medical management doesn't, doesn't work if the patient continues to deteriorate. Um But you manage to stabilize the airway, then what you're talking about is, is surgical drainage. Even if, even if the airway is not stable, you should, you should be preparing the patient for the surgery. And there's various different approaches. It depends on the location and type of abscess. Um You can do a transoral approach or an open approach and this gentleman didn't improve with initial medical management. So we took him to theater and did a transoral incision and drainage of the abscess. He subsequently recovered very well. He stayed in hospice for 48 hours, had some IV antibiotics and decks, um, and then was sent home on a 10 day course of oral antibiotics. So I just want to go through a very similar scenario. Um, so you're the nice shh on call and you meet up with your colleague for handover, er, and your day colleague says that he's had a horrible day, a mental day, um, seems a bit fragile, hasn't stopped to eat or drink. Um, and he mentions in passing that he's admitted um, the following patient during the day. So a 24 year old female, no past medical history, no allergies, nonsmoker fully vaccinated, no issues. Um, who has had a sore throat and some voice change for the past three days and has been drooling since the morning. However, he says that he looked inside the mouth, there wasn't any evidence of tonsillitis or a perons abscess or a Quincy. And he was like, you know, ma I'm just gonna keep her in overnight, you know, treat her as pharyngitis, send her home in the morning when she can eat and drink. What's wrong with that? Well, what's wrong with that is that there are multiple signs of an impending airway disaster. So, sore throat and voice change with a fairly rapid onset drooling and not eating and drinking. So, odynophagia and dysphasia and something odd, no evidence of tonsillitis or a peritonsillar abscess. What should you do? Go and see them if in doubt, just go and see them, you go and see the patient and they're in the waiting area of A&E, they're sat up, they look uncomfortable and they're spitting up, saliva into a sick mob. What they've received is IV, Benzyl penicillin, IV, paracetamol and IV fluids. Are there any other medications that you'd want them to receive the answer to? That should be yes. If you are concerned about the airway, if you're concerned that they're drooling, just give them AAA single dose of high dose uh of, of a high dose steroid like dexamethasone, obviously, if they can, if they can take steroid. Um, but in the majority of circumstances, you should do that. Her observations show that she's that she's got high temperature. She's been febrile since she came in to Ailey. She's tachycardic, however, she's got normal sat. So SATS are 96% on air. She does have a mildly raised, raised respiratory rate though. And objectively she doesn't have any stridor, she's spitting up saliva. She has a sick bo in front of her. She does have a very hoarse voice. However, and she says that her neck feels a bit stiff. So you examine her and her neck doesn't have any skin changes. However, her range of motion is severely limited in all directions by pain. She has marked lymphadenopathy in the anterior cervical chain. Oral cavity examination is actually completely normal. You don't see anything at all. Um You maybe think that you can see some erythema at the back of the mouth. So in the posterior oropharyngeal wall, which you can see UA is midline, there's no evidence of tonsillitis, there's no evidence of abscess and you scope her because you're not happy and you see this. Now, what are we looking at? We're looking at the epiglottis here and you've seen what a normal epiglottis looks like. This is not a normal epiglottis. This is a severely inflamed epiglottis. And you can see from the left lingual page of the epiglottis, there's a small amount of pus discharging not showing on this is that the structures above this are her vallecular base of her tongue all inflamed. What is this? This is supraglottitis with epiglottis and a small epiglottic abscess. How do you manage this? You need to sit them upright, treat them as an airway, an impending airway, nurse them at L I've put 75 degrees at least 45 degrees. Uh by which I mean incline at the head end of the bed and move them to a monitored area of A&E SOO or HC or an airway bed immediately discuss them with your senior um and discuss them with anesthetics as well if you are not happy with the patient and it's out of hours, for instance, get your senior to come in and have a look at them. Ent is a very nice specialty. No one will refuse to do that. Anesthetics are very, very useful to have around. They will come and review and they will help you formulate an airway plan. So what to do if the airway deteriorates medication? So she's already had a single dose of benzyl penicillin, which has quite good gramm positive cover. However, you need something broader spectrum and add anaerobic cover. Um add a steroid to help with her symptoms and the inflammation and to help stabilize the airway medically adrenaline. Na if there's signs of active airway compromise such as Stridor and give her pain relief, um, pain relief is imperative. Um I imagine that you were in that situation, you'd want to be receiving pain relief. You'd want to be comfortable, keep them if they're fairly stable, keep them nil by mouth and wait for your senior review. Um If they're not stable, get hands there, get as many people there as you can ensure that you have enough equipment, um ensure that you have uh somewhere someone airway trained and there's always an anesthetist on site everywhere. So get, get that into the scene and review them regularly in the interim. You'll be as sho is doing fairly busy on Court enc is, is, is not as chill as everyone makes it out to be. It's in the majority of centers, it's quite busy. Um, so in spite of you being busy, just make sure that you go back and review these potentially un unstable patients regularly. So the outcome here was that on the correct medications and with the correct management, this patient significantly improved. Um the registrar was informed and didn't come in overnight um because the patient was improving, um however, came in in the morning and repeated the nas endoscopy, which showed significant reduction in the supraglottic swelling and that the abscess of the epiglottis had fully self drained. She was kept in hospital for a fair few days for management of her symptoms and further IV antibiotics and she was then discharged home after three days to complete a course of oral antibiotics. So a few very quick learning points, sore throat, drooling, voice change in the absence of signs of tonsillitis or pharyngitis or periton abscess means that you should rule out supraglottitis. Um It's I showed you the epiglottis in, in the previous slide, I'll just go back to that. Um And you can see that that's quite inflamed. It is unusual uh to find isolated epiglottitis in adults unless they are immunocompromised for some reason and unvaccinated. Um so treat them with appropriate IV antibiotics. So something broad spectrum. Again, some IVRIM steroids and manage them as a potential airway. Um escalate early get hands. There involve anesthetics. Consider imaging, especially if your, your diagnosis is in, in doubt and if there's no improvement, then um its source control during the absence. So we're gonna move on from deep neck space infections and um infectious causes of airway compromise And I just want to touch on something a bit more acute. Um So you are the day sh you on call at a tertiary NT unit, let's say it's a Wednesday afternoon. So there's people around um it's in hours and you're called by the A&E registrar about a 64 year old man who's been brought in by ambulance to A&E, he's calling from reo um because this patient has been brought in severely short of breath and they haven't been able to get his saturations above 84% on maximum oxygen on 100% fraction of oxygen. Um The background of this patient is that he is unhoused. He has, he's unable to give you much of a history, but um they've been able to ascertain that he's an intravenous drug user with a long smoking history. And the A&E consultant has managed to access the GP records which show that he recently did not attend a two week wait appointment at a different tertiary center for increasing dysphasia. And voice change objectively, they tell you over the phone that he's agitated, but he's not able to phone, he's not able to speak. And his observations are, as I've detailed here. R 800 he's slightly hypertensive. He's got high Respi rate. His SATS are low on 15 liters of oxygen through a non rebreathe mask and his temperature is normal. I don't need to highlight the, the issues here. Um I think it's clear that this is a, an actively compromised airway which you need to go and review immediately and given the fact that there is active, severe compromise of the airway, get your registrar, get a senior and take them with you and make sure that A&E get anesthetics there, make sure that in the interim while you are on your way, they put out a call if they're concerned. Um So a double two, double two emergency call if they're concerned about impending respiratory arrest. So they sit the patient upright and administer them high flow oxygen and start giving them adrenaline nebulizers back to back and give them a single high dose of an intravenous steroid. What you need to do is make sure that you have adequate equipment. So every resource department in the country will have an airway trolley, a crash trolley with appropriate equipment and I'll show you what this thing, this Gulas Jie thing is um in a few seconds, working suction will be basically every uh well, every A&E in the country. Um make sure that you've got a NAS endoscope and equipment to have a look down a headlight um and make sure that there's some kind of equipment for front and neck access. And I've said this is during the day in hours, get extra hands, even if it's out of hours, get someone else there because you will need extra hands. So you go down and on arrival, everyone's there apart from your seniors. So an Asics are there, the a consultant register on Sh OS are there? The resource nurses are there and they've got the equipment ready. So you start to assess and you know that he's not able to phone ate, he's physically agitated, he's markedly SD. So he's got biphase ex strider, which means both inspiratory and expiratory stridor um assessing his breathing very briefly. You notice that now on the monitor, his saturations have fallen even further and they are now 80% on 100% 100% fraction of oxygen while you're waiting for your registrar and consultant to arrive. You notice that he, you have a very quick look in the oral Caity. You notice that he's edentulous, he has normal. Um He has a normal mucosal lining of the mouth, he doesn't have any tonsils. So he's probably had a previous tonsillectomy. Um And you can see a lot of pulling saliva in the mouth and you do an FN which shows this. Um unfortunately, I didn't take a picture at the time because of the acuteness of the scenario. Um And this is the best thing that I could find. However, just to show just to orientate you, those are the true vocal cords. In reality, the airway was nowhere near this patient. So we couldn't see the true vocal cords. They were obscured by the false vocal cords. Everything was very inflamed and there was this large fung mass coming from the left piriform fossa. What is this likely to be probably a laryngeal SCC? But that's not our main concern here. Our main concern is that this patient is rapidly losing their airway. And as a result of this, as a result of the fact that his saturations are actively falling on max maximum oxygen treatment and this patient has other signs that he is tiring. Um You need to secure the airway, you need to get a definitive airway. Um First line is to do endotracheal intubation. However, often in these scenarios, um an experienced airway professional may not be able to sight an endotracheal tube. And in that case, you need to consider alternatives. And the main alternative here is to go through the front of the neck and do a front of neck access to the airway. What can buy you some, what I will say is as an sh you will not be expected to do this. Even in even in an emergency scenario, you will not be expected to know how to do a tracheostomy. However, you should know who to contact, you should know how to manage these patients in the interim. And what I've, what I've once had to do is something to buy some time, which is a cricothyroidotomy. Um Speaking to my colleagues before doing this presentation today, um Only one other colleague who I know has had to do a cricothyroidotomy during their years. So it's not a common thing. So don't worry too much, but I'll explain what it is. Um And there's a couple of different types of scalpel bougie and needle cricothyroid ostomies. Um Recent guidelines say that you should be doing a scalp or bougie cricothyroidotomy, but whatever you can do in order to ensure ventilation um will buy you some time. So here's a few different things I want to discuss. So for a cricothyroidotomy, let's talk about a needle cricothyroidotomy, you'll need a syringe, you'll need something to clean the neck with and you'll need the widest ball cannula that you can get, have a look at the anatomy of the neck. So here this is a very good diagram, but you can probably see it on me actually. So do what we call a, a laryngeal handshake you. If you've done a TLS, you'll know what I'm talking about. If you haven't, don't worry, you'll cover it. Um So feel down from the chin down the front of the neck and feel for your thyroid cartilage first of all. So you can see, hopefully see that quite clearly. You can definitely see it on him and then keep feeling down the neck and feel for the cricoid cartilage, which you might be able to see on me. Um and feel between there should be a small recess. And that's the si and that's the site of the cricothyroid membrane. That is your site for the introduction of either the blade or the cannula. In the case of the needle cricothyroidotomy wide vol Cannula connected to a, a syringe with saline in and insert angles slightly quarterly by which I mean away from the head into this recess. So where these asterisks are um and that ensures that you get into the airway and as you're angling and inserting aspirate, and you'll start to notice air bubbles forming in the syringe. If you get into the airway scalp of Beijing is a bit better. Um Reason being that uh it's, it's rare that you have a patient who is an extremist who has a, a perfectly normal neck and a nice neck to do something like this in. There's a, a higher chance that you, you don't succeed in getting a Kio in. So scalpel bougie, you'll need a scalpel. These are Ruso Jackson tracheal dilators which have a little hinge here um which will allow you to. So pinching these together, expands these tips and will allow you to dilate your incision. Um And you'll need some gum elastic Boies. So gum las bees are these uh these thin rods, essentially, these thin thin flexible rods which you put into your hole and railroad tubes, either tracheostomy or endotracheal tubes over in order to secure the airway. So um the technique is blade stab incision here, angled very slightly quarterly in this, this, this recess here which we've discussed. Um and then turn your blade 90 degrees to expand your incision. Put in your tracheal dilators to open it up, withdraw the blade, get someone to insert a gum elastic beauty and then get someone to railroad a tube or a tracheostomy tube over the top of that. And that's a good way of, of buying you some time, connect it to the anesthetic shaving either way and see whether or not there is an improvement in, in um in the saturations. Um However, it's not a definitive solution and it's not a tracheostomy. So, whilst the cricothyroid ostomy, this is the thyroid cartilage, cricoid cartilage. And then these are the tracheal rings. 1st, 2nd and 3rd. Once the cricothyroidotomy is up here, a tracheostomy is further down and tracheostomy is typically cited in the second or third tracheal rings and we'll talk about that in a second. So the outcome here was that the anesthetist was unable to s site an E tube. However, what they were able to do was put in an eye gel. And for some reason, some, some magical reason that was able to, they were able to bag mask, ventilate the patient through the eye gel. That is obviously not a solution. And it's not a definitive airway because I gels can slip around the NT registrar and consultant arrive and the patient is taken to theater urgently for a formal local anesthetic tracheostomy and they're admitted to ICU following. However, four days later, you're on call again and it call you about the same man who's now had his tracheostomy in situ for four days, but has increasing ventilatory pressures and an increasing oxygen requirement. They tell you that his chest is apparently completely normal. He doesn't have rising inflammatory markers. There's nothing else concerning which could be causing this. However, they relay that the nurses have been um have been finding it very difficult to pass a flexible suction catheter down the tracheostomy tube. I realize that I've talked a lot about tracheostomy, but I've not told you much about them just yet. So tracheostomy refers not to the tube but rather to the stoma at the surface of the skin leading through to the trachea. It's typically situated, as I said in the second or third tracheal ring. However, percutaneous tracheostomy are typically put in the first tracheal ring and there's various indications for tracheostomy. So, airway obstruction being the acute one, but there are also elective indications for tracheostomy including for long term ventilation. So for instance, as an ent sh you will often get calls from ICU saying we've got a referral for an elective tracheostomy because we've got a patient who's been intubated for 21 days, um who we've failed extubation on twice. Um And that will allow for progression in the clinical progress um and reduction in dead space prevention of sub stenosis and allowing better bronchial wash out of the toilet. So parts of a tracheostomy, there are multiple different types of tracheostomy as and I'll, I'll show you in a second what those can include. But in general, these are the parts of the tracheostomy and I've, I've listed what um what each part functions to do. Um Here. So that part there is the a cannula which sits, which is a soft silicone cannula which sits in the trachea. That's the cough, which is inflated and protects the patient patient's airways from aspiration and allows for better control over the patient's secretions. It's particularly useful in sedation patients or patients who aren't able to manage their own secretions don't have an adequate cough reflex and things like that. Um This is the pilot balloon and a one way inflation a valve through which you inflate the cuff, try not to overinflate the cuff as that can cause damage to the tracheal mucosa, it can cause long term negative outcomes. Um This is the inner cannula and a lot of new. Basically, every new tracheostomy that you will see will have a dual uh dual cannula. So an outset and an inner cannula purely because it's safer. Um The reason being that you can remove it and replace it if it's obstructed. Um This is the plan and that sits against the patient's neck and prevents the tube from migrating. New tracheostomy are sutured in place in order to add extra security. But the majority of tracheostomy that you'll see will be secured with cotton ties, cotton V velcro ties around the neck. Quick word on types of tracheostomy. You this isn't exhaustive. There are multiple different types. I've just listed the most common ones that you will encounter as an sh so new tracheostomy most commonly, you will find dual cannula, non fenestrated cuffed tracheostomy tubes. And often they have an additional port called a suction aid which aids cleaning out the, the tracheostomy and suction, the tracheostomy. This is the most suitable um type of tracheostomy for temporarily controlling the airway during critical illness. And as I've mentioned, the inner cannula provides an extra degree of safety, fenestrated tracheostomy refer to. So fenestrations, all that means is that there are holes in the outer and inner cannula of the Tracheostomy, inner cannula if it's if it's a double movement and that's useful for patients undergoing weaning from ventilation as it facilitates things like speech and reduces the work of breathing. However, you shouldn't use them in new stoma, especially in patients who are having p pressure ventilation as that increases the risk of surgi surgical emphysema significantly. Um just a word on uncuffed and coughed tracheostomy. So, this is an uncuff tracheostomy. This is a cough tracheostomy and the difference is this balloon here. Um So cough tracheostomy are better for patients who can't protect their own airway. As I've mentioned, uncuffed are when you want to, when the patient can protect their own airway when they have an active um intact cough reflex and things like that. Um And they're quite often used in the community and they're better because they're a bit more comfortable. They aid swallowing, they a communication and what the cuff functions to do is um eliminate the space around the tracheostomy tube. So there's no space for anything to go past. Um However, with an uncuff tube, the patient can't just uh is able, not only to breathe through the tracheostomy tube, they're able to breathe through their nose and mouth as well because there isn't this, there's a bit more space around. And finally, uh just a word on you, you'll often hear um about tracheostomy with adjustable flanges. All this means is that you can um give the tracheostomy tube a bit of extra length for patients who have deeper set trachea. So for instance, really obese patients, patients with neck masses, patients with goiters and things like that and adjustable PHS are two different types. They can either give you extra proximal length. Um So between the stoma and the trachea or extra distal length. So, within the trachea and that's so proximal length is more for people with abnormal neck anatomy or large necks, distal length is more for patients with normal neck anatomy, but tracheal abnormalities. Um brief word on tracheostomy care in a new tracheostomy don't change it for the first week unless there is an emergency. And the reason for this is that you want the stoma to establish if you change the tracheostomy too early, then there is a higher likelihood that you will insert the tracheostomy into a false passage or not insert it into the trachea again. And that can cause respiratory decline and arrest in the patient. So what I mean by a false passage is when you do a tracheostomy, you cut down through the layers um of the neck in order to reach the trachea. And while the sto stoma is healing, those layers are gradually fusing together and scarring down until those layers scar down, they're still open. And you can insert the tracheostomy tube into those layers, which is less than ideal for obvious reasons. Um And ensure that um you only give humidified air or humidified oxygen through the through the tracheostomy tube and that prevents irritation, increased tracheal secretions and things like that. Following this tracheostomy changes typically happen every 7 to 14 days. Um and wherever they are, they should be regularly cleaned and suctioned with the appropriate size, flexible suction catheter for oral secretions, you can just give the patient a Yanker sucker. So a regular ward based uh suction, they can suction out their oral secretions if they, especially if they're ill by mouth. Um And the inner cannula should be removed and cleaned or inspected at least once a day. Um Guidance varies. Most trusts say every eight hours, I just want to briefly talk about tracheostomy weaning. You won't have to do this yourself. It is an MDT decision. It's usually quite senior led and involves speech and language therapists and senior ent colleagues and airway colleagues. However, uh these are the vague steps. So uh you try the patient with cough down, first of all to facilitate breathing through the mouth. Um And that means that the patient is then required to maintain their own secretions and their own swallowing. If they're able to tolerate that, then with physiotherapists and SLT S, you do glove to finger occlusion of the tracheostomy tube and the patient can do this themselves and this is to, for them to try phoning, try breathing through their mouth. Um And if they become stridulous or if you don't hear much in the way of breath sounds, um This indicates that there's not much flow around the tube. Um and you should go back to step one, you can always push up the cuff again. You know, the track is and sit, you, you can always put up the cuff again. Um If they tolerate that, however, you can then put the, put on something called a one way speaking valve and that attaches to the outside this part of the trachea, the tra tracheostomy tube, sorry. Um And that is a one way valve which allows inspiration through the valve, but it closes on expiration and that allows air to flow over the vocal cords and come out of the mouth. And therefore, that facilitates phonation that facilitates production of voice. Um And what you're aiming for is a ultimately for de cannulation, which means removal of the of the trachea. You're aiming for tolerance of the speaking valve for over 12 hours. Um However, um in order to pro progress to capping the trachea, you want to, I want the patient to tolerate it for more than four hours in one block. Um If they do, then you can start trying to cap the trachea. So put this thing which occlude the trich means that they have to use their mouth and nose entirely for inspiration and exploration. Um And if they can manage all of that, then you can consider taking out the tracheostomy cheek. However, this is never a decision that you will have to make. This is senior led and is as a result of MDT discussion, I promise we're almost at the end, I know that I've gone on for a bit too long. Um So this patient has a blocked or partially blocked tracheostomy and this requires immediate assessment, get someone there who's competent with an airway. So, an ent registrar or consultant, an anesthetist, an ICU specialist and make sure that you have appropriate equipment. So one or more spare tubes at the bedside, including a smaller tube. Patients will have something called a blue box, which is a little blue box which contains this equipment just in case of a, of a, of a tracheostomy emergency tracheal dila which we've shown you before, um which can allow you to expand the stoma working suction with a sorted sort of catheters, not only the anchor but flexible suction, catheters oxygen. So make sure that you have a face mask on the face and one around the tracheostomy um which should be given always in an emergency, both er a good light. So a headlight which will, will allow you to keep your hands free and the airway will crash strong you nearby including a gum elastic be, which will allow you to secure an airway in, in extremist. OK. Um So have a look for anything obvious. So this is a very, very brief algorithm on how to approach the block block tracheostomy do an objective examination. So look for anything obvious, blocking the tube and remove it. If you can, um you can attempt to pass a suction catheter or an FN. Um in order to visualize down the Tracheostomy tube to see whether or not there's a blockage. Um If you're not able to pass a suction catheter, then that is a sign that the tracheostomy is blocked. And what you should do in this case, if you're concerned about blockage is remove the ino cannula, removing the in a cannula and seeing if that improves things is what the incan is for. It's a safety measure. So, remove the incan, see if it improves things. If that doesn't improve it, then put the cuff down. If the tracheostomy is cuffed and if that doesn't work, then what we should be considering is, is replacing the tracheostomy tube or railroading an endotracheal tube over a over a ji. Now, all of this sounds quite daunting again. Senior support is key. Don't do anything which you're not confident in doing. I would say anything. I, I would probably be escalating quite early. Um But as a fairly junior sho anything beyond ascertain that the tracheostomy is blocked, you should be getting a senior there. Um I would say anything beyond removing me in a cannula at my stage. If, if, if I'm not happy, I'd, I'd call the senior, I'd probably put the cuff down and probably have a look. But um I'd be involving a senior early and that, that's a good algorithm which is essentially what I, what I've talked about. And something that I should say is you can do oral airway maneuvers. Um If there's respiratory arrest or respiratory compromise and a tracheostomy and you can attempt oral intubation or intubation of the stoma. Um I've got a link to this at the end of the presentation or you can take a picture of this if you want. So the outcome here was that the patient was oxygenated by their face and mouth. Uh The inner cannula was removed and there was dense secretions and crossing and he immediately improved, popped in a new inner cannula and the patient continued to improve. So, just a very quick word on tracheostomy versus laryngectomy. Um So it's common for people to confuse these. And it's because it's often quite difficult to tell the difference, especially in an emergency environment. It's, it's very difficult to tell the difference. People see the hole in the front of the neck and they assume it's a tracheostomy. So whilst the tracheostomy is an opening in the skin through of the trachea. And there is a patent airway, a patent passage from the mouth and nose through to the trachea and the lungs. Um A laryngectomy is essentially an end stoma. So it is an end stoma of the tracheostomy, which means that it is the only connection to the uh trachea and, and lungs. Um So traditional airway manipulation through the mouth, supplying oxygen to the mouth won't work, that won't do anything. And you would be surprised at how often people make this mistake. I once received a call, I was at a DG, I was the sh on call, a DH and got a call from a ne saying we're really worried. We've got a, an elderly gentleman who we know has lots of quite a bad respiratory history and we know probably has quite a large pleural infected pleural effusion, but we're unable to get his oxygen saturation is above 70%. And he's got a long term tracheostomy. Can you come down and have a look and it transpired that this gentleman had a laryngectomy and they were only oxygenating him via the mouth. So it's important to make this distinction. Sometimes there is a connection between the trachea in the esophagus in a laryngectomy. Um And this is called a trachea esophageal puncture. And there will be a valve visible through the stoma. This is put in place to improve phonation, improve production of voice. Um However, again, that's, that's something I won't get too bogged down into. So what about a blocked laryngectomy? The approach is similar. However, you need to consider that you can't oxygenate by the mouth and nose. So use a laryngectomy face mask or if you don't have access to one, a pediatric face mask to the stoma. For oxygenation, you can remove the inner cannulas and clean uh la laryngectomy. You should not be removing the laryngectomy tube by your by yourself. So get early senior support. And here's an algorithm which again, I've linked a bit later for um managing a BP. Hey, Dave, sorry about that. I think the slide's got to talk on the tracheostomy um algorithm. I, you know things. Um but it was only about two minutes ago. It, it, I'm sorry, can you see, bear with me? Can you see my screen at all? Yeah, I can see the emergency Tracheostomy like algorithm page. Um So if I put this up, can you see that? Now? Can you see Tracheostomy versus la laryngectomy? Um No. Oh, maybe I can't, I think. Yes. Don you put in the chat that she can see it. I'll send you the signs a bit later so you can have a look. Um Thank you. I'm just going to uh conclude it there. So, um this has been a lot of information. I can appreciate that. I've gone through quite a lot. Um I would encourage you to go and read by yourself. Have a look at entsho dot com. It's an invaluable resource and I still have the app on my phone. I still sometimes use it to this day. Um The S FA N youtube channel is pretty good. Um It has some good videos on examinations and that Tracheostomy video that you saw earlier is from the channel tracheostomy dot org org dot UK. Um Sorry, the FN video which you saw earlier, it is from that channel Tracheostomy dot org org dot UK is a great site which has a lot of information, lots of guidelines for management of things like Tracheostomy and Laryngectomy. And I'll just mention these two books as well which I found invaluable. Uh Any questions I'm more than happy to answer now. If not send me an email, my email's down there. Perfect. Thank you so much for that. That's very uh does anyone have any questions or anything they want to ask you about what we've been speaking about today? I know, you know, as they mentioned a lot of information. Um Well, you know, questions are always welcome. I am. I've also put the feedback link in the chart if people can complete it. So we can uh get a good idea. You know, I'm just looking, bear with me. I'm just looking through the questions. There's one from just before the talk started um about iatrogenic epistaxis in a patient who's anticoag. I I know it's not airway. I'm more than happy to answer it if you want and it's in a patient who's had anticoagulated. Um So as patient, I, I'm assuming that iatrogenic epistaxis means that rather than intervention to the nose, they, they just, this is a question about um epistaxis which has resulted from um the anticoagulant treatment. Um So the answer to that is uh first of all, um we're talking about what you can do to the nose. You can do if there's active epistaxis, you can do things like I'm sure that went through all this a couple of weeks ago, but you can do things like packing the nose. There's various different things that you can use if you're worried about a patient with, for instance, low platelets or coagulopathy. Um packing the nose might not be the best thing. It might not be the best thing um because it can cause further excoriation of the nasal mucosa and that can cause further bleeding in itself. So what you can do is use things like naso pore, which is a dissolvable sponge. You can use um Sergel which is a, a thin kind of dissolvable hemostatic matrix or you can use, there are various injectable matrixes which you put into the nose, which will, which will help. So, flow seal is quite a good one. It's clotting factors in a matrix and that falls out or dissolves by itself vis a vis the anticoagulation treatment if they are hypercoagulable, if, if they have uh if they're having active treatment for AD VT or A P or if they've got a high risk of developing further clots, then just speak to hematology, speak to hematology and speak to their parent team. Um and clarify what you can do with the anticoagulation more often than not in this situation. Um They will say, well, this patient is very, very high risk. Their chance vask is, is quite high, they're at high risk of developing a further clot. Um Don't touch the anticoagulation and you know, you're, you're stuck. But uh I hope that hope that answers. Uh Yeah. Anything, anything else you want me to answer? Um Mohammed was wondering if you could see the slides from your eight week assessment. I think it was fairly early in the first case. Yeah, I think that's the best case. Bear with me. Uh I'll share my screen again. Yeah. Mhm. So uh sorry, sorry, here we go. This isn't what I will say. I'll caveat this by saying that saying that this isn't exhaustive. Hu So this is a very, very brief bridge to A two E um and actually you should be doing A&E will likely do a full form A&E A A two E before you arrive. But um you should be doing something a bit more in depth if you're, if you're concerned about something else going on somewhere else. Um I can also just show you the examination parts again if you want. So neck uh I'll make the slides available. I'll send them to uh send them out. Thank you. Thank you. Um There's one more question I think from Dona. She, I think you mentioned earlier about um the registrar, I would make airway plans. Um You know, if the patient was to deteriorate from an airway perspective. So, does that kind of include like cricothyroidotomy that you were talking about before? What kind of things would you be thinking of? So, cricothyroidotomy. Um So I've, I've touched on it a a bit already, but I'm happy to go through it again. Um Cricothyroidotomy buys you time when you know that you can't intubate and can't ventilate the patient. So, cricothyroidotomy is a direct form of access again. Now, I can see the, the screen, I can show you exactly where, so you can see the, see my thyroid cartilage. You can see my cricoid cartilage. You can see the recess between them, um, actually marked by where I've cut myself shaving. Um So just so the scalpel or cannula in um, will bit you some time. And oftentimes you'll have while you're waiting for your seniors to get there. If they're not already there, you'll have someone like a very antsy anesthetist being like, um we need to do something we need to do front of neck, we need to do Xy and Z um I've done a, I've done a scalpel cricothyroidotomy once. Um And I can't stress this enough. It was so much more simple than I expected. Um It's really just stab turn dilators in. Um Someone helped me by putting a gum elastic bug in and then we put an endotracheal tube over the top and inflated the cuff that.