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Of a delay. Um But we're, we're all ready to go now. Um Welcome to our final week of our two N series. I'm here with Doctor Williams, um who's also helped um create this course for the last four weeks. And this week, we're going to be talking about pediatric ent um its own unique kind of area um that you don't really get taught much of in medical school. So I think it'll be very interesting talk and essential to anyone that's doing an ent job that might come into contact with pediatric patients. Um As always, please just post questions in the chart and we'll send out the feedback link at the end. So if you could all fill that in at the end, that'd be great, appreciated. Um So I'll hand over to Doctor Williams. Thank you very much. Great. Hi, guys. Um I'm Izzy, I'm currently working at the um on P TNT um as a junior clinical fellow. And you're gonna have to bear with me because I've only been able to share a version of my slide. So the animations won't work and there's some kind of overlapping diagram. So I've got my powerpoint next to me, if you just bear with me and I know that you guys can't come on the microphone but do feel free to pop questions in the chat and, and I will try and make things as interactive as possible. Um I think the first thing to say is pediatric ent, you will see it in GP in A&E um or ENT if you choose to do that, but it is quite a specialist area. Um And today I'm gonna be talking about some common presentations that you'll see in kids, but also some more uh more rare areas and just for your information because I think it's something that we don't get any exposure to at all. Um And even though I've only been at the Elina for about a week and it's been a steep learning curve and so hopefully this will be interesting and useful for you all. Um So the first thing to say are kids just little adults. No, they're not. That is the myth. Um Children have completely different anatomy and physiology um compared to adults. Um And that's very important when considering how we diagnose, investigate and manage uh ent problems in Children. So to start with, I'm just going to talk about some key differences between the pediatric and the adult airway. Um The head is relatively large compared to the adult head, the head compared to the body is relatively large. Um And that's really important because in Children, they adopt a naturally flexed position when they're lying, steep time, which has important implications for when you're resuscitating a child. Um and trying to optimize their airway, we'll show you a diagram in the minute um of the kind of optimal position to have a child when you're doing a BLS or a resuscitation kind of scenario. The nose, the difference compared to an adult is that Children or infants up until the age of six months are obligate nasal breathers. So they only primarily breathe through their nose. Um and that has implications for conditions like perianal atresia where you're born with kind of a nonperforated posterior nasal aperture. Um they present with cyanosis unless they're crying because they can't breathe through their nose. The tongue is large relative to the size of the head and the oropharynx um in any child, but also particularly in Children who are syndromic um to Children who have Down Syndrome or a more rare syndrome like Pierre Robin or Reer Collins where there's underdevelopment of the jaw, their tongues are relatively more large. And so if I just flick quickly onto this picture. So on the left, does anyone know what syndrome this child has based on those facial features? It's difficult because they all look quite similar or they, they have similar um underdevelopment of the jaw, but anyone know it kind of spot diagnosis. It's not very easy. I've not given you any other clinical signs essentially that that child has to reach a Collins. Uh Oh yeah, good. Tanya micrognathia. So on the right, the child on the right has downs injury. So you can see she's, this little girl has quite a flat nasal bridge. She's got epic folds, she's got down slanting palpable fissures and you can see her tongue which looks relatively large. Um So if I just flip back, so yeah, the ta the larynx in a child is higher and more anterior. So it sits around the level of C 2 to 3. Whereas in an adult, the larynx sits around C six to C seven, the epiglottis. So on the right, I've got two pictures of epiglottis. Which one do you think is the child? And which one is the adults? So this one can you see my arrow? But is this an adult or a child? No one, any ideas? So this one at the top is an adult's epiglottis and this one at the bottom is a child. So the epiglottis in a child is a mega shaped and it's much stiffer because there's not been development of the elastic um tissues which has implications when you're doing direct laryngoscopy. Um because normally in an adult, we used the curved blade, which is called a macintosh up here to the left. Um But because the epiglottis is much stiffer in a child, it's actually very difficult to use a curved blades. We tend to use a straight blade which is called a Miller blade. The vocal cords in a child's airway are slanted rather than say they're kind of slanted like this anteriorly. Whereas in an adult, they perpendicular. And that means that if you think about, if you've got a child lying supine and their vocal cords are slanted, you want to do a Jew lift to bring them vertical and that will give you a better vision. If you're doing direct laryngoscopy, the trachea overall is shorter and it's much more compliant and therefore, the trachea is more compressible if you've got any external um mass. So a cystic IMA or a branchial cyst or something like that, you're more likely to get an airway obstruction, the overall diameter of the pediatric airway is narrower. Um And the airway is narrowest at the level of the cricoid ring in the pediatric airway, whereas it's narrowest at the uh entrance to the glottis. So at the level of the vocal cords in the adult, and then obviously, the child has an overall smaller lung capacity than an adult, which means that they have a smaller reserve. So for all of these reasons, a child, an infant is more prone to airway obstruction um than adults. So it's important to know about. And this just shows you the position that you want to put a child in, in order to optimize their air base, it's the classic sniffing the morning air. Um and in order to achieve that position you need to obey kind of three planes. So you want the plane between the glabellar. So the kind of tip of the forehead and the chin to be horizontally aligned, the plane between the external auditory meatus and the suprasternal notch. Again to be horizontally aligned. And then you want the anterior neck base to be nice and wide. So a nice kind of uh yeah, wide angle, Obus angle, yeah, fine. Um and then we've done this slide and then just quickly uh bit of physiology, Children overall have an underdeveloped physiology and anatomy when it comes to breathing, um particularly premature babies, their airways overall are more compliant to have a tendency to collapse. And because of this, they adopt this thing called laryngeal breaking, which is essentially grunting. So if a child has any signs of airway obstruction, one of the clinical signs you look for is grunting. But what is grunting? Well, they're essentially doing laryngeal braking and that's squeezing their supraglottic region in order to create peep. So they're essentially giving themselves positive end expiratory pressure in order to stent to open their airways. Yeah, that is what grunting is. Um And then does anyone know what this formula? I've hidden something with a red box. Can anybody in the chat tell me what this formula is and what? So you've got airway resistance is proportional to one over the what to the powerful. Yes, well done Mohammed. Um And what is under this red box, anyone get the radius. Um and this formula is very kind of informative because it essentially tells you that in a child, you've already got a relatively small airway. And so anything which decreases the size of that airway, whether it's inflammation, a mass stenosis, anything had a significant, sorry, had a significant effect on airway resistance and as in it increased it by a significant factor for. Um no. So just a quick word on subglottic stenosis seems a bit rogue. But actually, when you're doing pediatric ent that is the bread and butter. So we see lots of babies and who are typically premature, they've gone to NICU and they've been intubated for days, weeks, months and pretty much all of them have subglottic stenosis, which is a form of laryngeal steno stenosis. You can obviously get stenosis at the level of the glottis. You can get it supraglottic or subglottic. They're quickly to go through some simple anatomy. You've got your vestibular folds which are your fourth vocal cords and then you've got your vocal folds, which are your true chords. The area in between that region is your glottis. Above the vestibular folds is the supraglottic region and then below the vocal folds is your subglottic region. You can get laryngeal stenosis. It can be congenital, which is quite rare or it can be acquired. The most common causes of acquired uh laryngeal stenosis are trauma. So, either blunt or penetrating, which is more common in adults or adolescents and then internal laryngeal trauma, which the most common of which is iatrogenic, who's secondary to intubation. You can also get stenosis secondary to chronic infection, which is less common in kind of the developing western world. Um and more common in areas where kind of diphtheria and other infectious diseases are a rife um or chronic inflammation. So, autoimmune diseases, um gaud. So reflux disease, you can also get uh laryngeal stenosis. And the reason why you get stenosis is I'm not gonna kind of, I don't know that I've got it on this. Hang on, let me, I got it. No, I'm good on that. Oh I do have on there. So, the reason why you're prone to getting laryngeal stenosis after intubation is it's es essentially all to do with anatomy. So it because of pressure necrosis which causes edema and ulceration. Um But there's very poor blood flow to the cartilages of the larynx. Um And I, I'm not gonna kind of go through all of this, but essentially you, you don't get very good healing and until you get lots of scar tissue and granulation tissue forming um over time and that results in stenosis essentially um and results in airway collapse. So I'm going to, this is a slide I was meant to take out. Um But I've got it here. It, it ignore these pictures. Um It was on my powerpoint, but essentially, I'm just going to go through a quick case. So this is a case we've got on the wall at the moment. So it's a 38 week old baby, um, who was diagnosed antenatal with an interrupted aortic heart. So it was delivered by emergency C section. The little boy had cardiac surgery at birth. And then following his surgery, mom noted that his cry was quieter and she felt like he had something stuck in his throat. So key things in the history when somebody is reporting a change in voice or any sign of age obstruction is you want to ask in a child about feeding and voice change. Um So this child wasn't coughing, um s were fine, there were no desaturations um while the baby was feeding. Um and this baby was being breast bottle and NG fed. So I was gonna ask you how you would, would you assess this child? But I can't really do that on here because there's no animation. But essentially this child had no signs of upper airway obstruction. So there was no Stridor or ST um I think Dave went through with you guys last week. The difference between Stridor and stur um the baby had no increased work of breathing at rest. And as I said, SATS were fine on room air. So you then went on to do a flexible nas endoscopy on this baby, which showed that he had a normal post nasal space. So there was no mass or any signs of big tonsils or adenoids. But going further down, the baby had a left vocal cord, dy, seemingly the right cord looked normal, the subglottic space, there was no evidence of any stenosis and there was no laryngo malacia. So essentially, that's a floppy larynx, which is very common in premature babies. You would then in a child or a baby with subglottic stenosis, you would want to do a MLB, which is a micro laryngo bronchoscopy. And the reason why you want to do that is because it's very, this is all quite complex stuff. It's the key diagno, the key differential diagnosis for subglottic stenosis is vocal cord paralysis, most likely secondary to damage to your recurrent laryngeal nerve, which is common post cardiac surgery. It's very difficult to tell whether you've got a subglottic stenosis because the cords are so fibrosed by scar tissue that they're not moving properly. Very difficult to differentiate that between paralysis secondary to nerve damage. When the patient is awake, you need them to sleep because you need to actually assess the mobility of the cord when the muscles are relaxed, which is why you need to put them under G A to do an MLB because during an MLB, the child or the baby is relaxed and then you actually try and move the vocal cords and if they're mobile, then you know that they've got a paralysis secondary to a nerve damage. Whereas if they're immobile, then you know that they've got a stenosis secondary to the fact that you've got just a load of scar tissue um forming. And that's your optic stenosis. You can also do an EMG and look for actual muscle stimulation. Um Yeah. Um And then, so how would you manage a baby with subglottic stenosis? Well, first of all, you want to make sure that the airway is secure. So, in this case, this baby wasn't showing any signs of acute airway obstruction, but you'd obviously want to secure the airway doing an A two E and give them oxygen support if they need it and optimize that positioning. So they're sniffing the morning air. Do you need any airway, adjunct, et cetera, et cetera. You don't want to reduce any inflammation if there is any. So, dexamethasone can be really useful um because it dampens down any inflammation and it can have a, a negative effect. So it can stop proliferation of fibroblasts. Um and therefore laying down of scar tissue. If there's any signs of edema, secondary to chronic inflammation, you can give nebulized adrenalin. Um Adrenaline is an alpha one agonist which causes vasoconstriction which stops ate or uh stops extra radiation of inflammatory cells from arterials and arteries into the space. However, you've got to be careful when giving nebulizer adrenaline um because you can get rebound. Um bronch construction, you can reduce the work of breathing by trying to improve the flow um through the airways and you can give something called heliox, which is a mix of helium and oxygen. For those of you who did physics at a level, um you have lamina flow and turbulent flow. The R number can be really low in lamina flow and it can be super high in turbulent flow helium for reasons that I do not know decreases our number. So it essentially helps to improve uh flow by making it more lamina, You can then stent the area of any obstruction. So, like I was talking about the laryngeal braking that uh infants do, you can actually give noninvasive ventilation using CPAP or bipap and that will help stent open the airways. Um You can also reduce the work of breathing by decreasing oxygen requirements by giving a child or a baby sedation. Um And then you can bypass any area of obstruction using airway adjuncts or ultimately intubation if you need to get past the subglottic stenosis. Fine. So that was quite a rogue first case, um which I appreciate may be a bit beyond F one S level. So here's some more simple stuff. So this may have been covered in some of the other talks. Um But it is very relevant to PT and T. So I've kind of put it in again. So, sore throats you have. Here's a case you've got a 10 year old child who presents with enlarged tonsils that meet in the middle line. Oops, sorry. Uh oropharyngeal examination confirms this finding. And you also notice some petechial hemorrhages affecting the oropharynx on systemic examination. The child is noted to have splenomegaly. So what investigation is most likely to be diagnostic? Is it a throat swab, bone marrow aspirate and trapping a full blood count, serum trophy antibody test or an aot titer. What do we think this is kind of a trick question? Oh, not a trick question. But you guys may all know the answer, but it's named slightly good Mohammed. It is the he bar antibody test and that test is called the mono spot test. But lots of people don't realize that the mono spot test is testing for the he antibody. And can anybody tell me what the mono spot test is testing for? Thank you, Dean infectious mono, which is EBV get glandular fever. So we'll talk a bit about glandular fever in a minute. Sorry, I've given you the answer to the question. I was gonna ask you because this is on powerpoint. But um sore throats, the main cause of sore throats in a child is either acute pharyngitis or tonsillitis or you can get to, what is it pharyngotonsillitis. Um So you can get both essentially most sore throats in Children in contrast to adults are viral in nature. So they're caused by respiratory viruses like Rhinovirus, Coronavirus, par Pluda virus. I've literally seen so many kids here already who have cough corisa even post-operatively and we do respiratory vi virus panels and they all have Rhinovirus. Um So it really is very, very common. You can use the center criteria to help diagnose or determine the likelihood that a sore throat is bacterial in origin. The most likelihood of which is caused by group A beta hemolytic strep. So, strep A which is very um topical at the moment because everybody knows that there'd been big outbreaks of group A strep. So it's not everybody's agenda not to miss. Um And essentially, if a child has any uh one of the following, so very high grade fevers. So above 38 degrees passed on the tonsils, no cough or tender cervical lymphadenopathy, then they're more likely to have a bacterial throat infection. When you're managing a sore throat, you don't necessarily need to take throat swabs. Um And the aso titer has no role in diagnosis because it's not necessarily very specific, but it can, if the child goes on to have complications of group A strep, then it can help confirm the presence of it. And if they have say kind of my, you know, nephritis or rheumatic fever as a consequence of more invasive infection, the way you manage um, a bacterial throat infection is you want to give them pen v um or Erythromycin. If they're allergic to penicillin for 7 to 10 days, you want to avoid giving amoxicillin because you can get a rash. Um if they have EBV and it's not group A strep. Um, another thing just to be aware of is in your history, you want to ask about whether or not the child's on any immunosuppressants, um, or any biologics or, uh, yeah, anything else. Um, because if they're presenting with high fevers and a sore throat and they're want to say carbimazole or methotrexate for gi A, then you need to be querying neutropenic sepsis and if you're in an ent role, then you want to be getting the medics involved. Um, essentially. Oh, uh, can you see that de No, uh, no, it says, sorry, technical error as a kid. Um, see if we can reshape it perhaps. I don't know. Uh, hang on, stop that. Hm. Sorry guys, I'm not quite sure I would say bizarre. Mhm. Yeah, I've never seen that before right here. Uh, is it your computer? Is it, do you think, or do you think it's the, the metal? Uh, I don't know. I mean, nothing's changed. I've got good signal. Yeah, cause we can hear, hear you and see you. Well, yeah, very random. Hang on. Just bear with me. Hang on. I'm, I'm trying to load it again. Hang on. Ok. Let's see. Ok, back again. Bye. And he's still loading the slots. Uh Right. OK. Um Right. And a quick note on scarlet fever, I put this in, it's more P really than EPD and T. Um, but it is very prominent at the moment. So when you're thinking about group. A strep. You want to be screening for whether or not the child has any sign of scarlet fever, which is essentially a reaction to the toxins produced by the group. A streptococcus. Um So scarlet fever is droplet spread. Um And you want to be looking for a strawberry tongue. Does a child have any sand paper like rash which classically spares the palms and the soles of the feet. You get what this picture shows you can get circumoral palate and disc um which is the classic textbook sign happened a few days after the rash develops. Um And as I said in the previous slide, you treat it again with pen B for 10 days. Um And after 24 hours of being on antibiotics, the child can go back to school. So some of the complications of uh rep pain strep are uh the more rarer thing. So rheumatic fever, glomerular nephritis, you can obviously get invasive infections, say meningitis, bacteremia, sepsis, neck fas, but acute otitis media is actually the most common um complication of it. Ok. And then we kind of went through some of this um in one of the previous sessions, but just as a quick revision, the bottom photo to the left um shows classic tonsillitis. So big plasty tonsils, the difference between that and A quin D is midline shift, deviated bula. Remember that a quin D is not an abscess of the tonsils. It's of the parapharyngeal space just to revise your anatomy. I'm not gonna go ask you to do the boxes, but you've got your two arches. So your uh here and then you've got your pala palatine tonsil, which lies in the middle, your glossopharyngeal nerve runs in between the two arches underneath the tonsils, which is why you get referred pain to the ear because your glossopharyngeal nerve supplies part of your middle ear. Um And then you've obviously got your glottis, uh epiglottis here. You've got your bea there, which is between the posterior arch and your epiglottis and you can get like bodies stuck in there. And then you've got your constricted muscles which line the back of your pharynx. Um And this picture on the right just shows a quin D you put your tonsil underneath. So as you can see, this is the bulging of the parapharyngeal space. And then this black line just shows where you would make an incision. Um When you're draining your quin the and the important thing is you want to go posterior rather than laterally because your carotid is somewhere lateral to this space here, running in the carotid sheath. You want to go posteriorly rather than laterally. Ok. Um So how to manage tonsillitis, pharyngotonsillitis? You want to give them analgesia IV, fluids, shot of IV Feen or Pen G and you can also give them a stat of uh DEXAmet IV as well, essentially if they're better and they're able to tolerate oral intake, you can send them home with safety netting advice. If they're not able to swallow or manage eating and drinking, then you need to admit them. Um You can also give them Benzidine spray as well. So, is it mono um just some classic features of infective uh or glandular fever that were in the history that I gave you at the beginning. So they tend to have a more viral prodrome. So malaise arthralgia, myalgia, typically it's a low grade fever rather than a high grade fever. If a child has glandular fever and they've got a high grade uh yeah, glandular fever, but they've got a high grade fever, then you need to be thinking that they have a superimposed strep throat infection and, and just to clarify, you give ent that pen g, if you think they've got tonsillitis, pharyngotonsillitis, you only give pen V if you think they've got group a be hemolytic strep scarlet fever. So I think that was a bit confusing. Um The other thing you want to do with glandular fever is you want to feel that tummy for any hepatis splenomegaly, you'd do your test. Um And then in terms of management, it's pretty conservative with analgesia and then safety netting to avoid contact sports um for about six weeks, post um infection. Next uh presentation. So a blocked nose, the common cold is the other delay term for acute viral Rinus sinusitis, which a which is a common presentation in kids and classically acute viral rhino sinusitis is symptoms lasting for less than 12 weeks. If you have symptoms, more than 12 weeks, then it becomes chronic rhino sinusitis, which can be associated with or without polyps. Most Rhino sinusitis is viral and, but signs of bacterial include any p So do they have actual yellow, greeny puss? Do they have severe facial pain, high grade fevers again, high CRP and then the whole double thickening. So are they kind of unwell, get a bit better and then they get a lot worse? Um And then again, the slide is kind of blocked by this table. Um Let me just get it up. Here we go. So your classic symptoms. So the four most kind of specific signs of rhinosinusitis are nasal blockage, rhin or runny, runny nose, hyposmia. So you decreased sense of smell and then facial pain, you can also ask about symptoms of cough, headache, fever, malaise, um as well as sore throat. Um I did have a nice pitch stool. Um You can't, you can't see this picture, but one of the things you need to be aware of with acute rhino sinusitis is it can progress to involve the orbit. Um So even though it doesn't seem like an ent problem, actually, we do see people with uh orbital or periorbital cellulitis, which are one of the things you need to look for. Um peri cellulitis is anything involving kind of periorbital tissues and it hasn't actually involved the orbit. So that's a lot less concerning um than an orbital cellulitis. The red flags of which you can't see but include any proptosis, any bulging of the eye if there's any chemosis. So you want to look at the sclera and is there any an any kind of injections? Was the eye red? One of the very sensitive signs of an orbital cellulitis is when you're doing your kind of mu testing your eye movement. That is there any pain limited on eye movements? You obviously want to look in the pupils. Do they have any relevant uh relative afro pupillary defect? Um, any altered color vision and then obviously looking systemically um as well. Um But the key key thing is pain on eye movements is a very sensitive to sign for an orbital cellulitis. And if you're suspecting an orbital cellulitis, you need to get, get a CT orbit. Um and sinuses with contrast that is gold standard as well as doing your statistics bundle. Um hang on, bear with me. I need to plug my laptop pen before it dies. Uh Sorry as good. So how do we um classify uh orbital infection? So it's classically it's classified using the Chandlers classification, but just note that this isn't step wise. So it doesn't go up 1234 with severity. It's more for group one and two. So that's your preseptal cellulitis and kind of a AAA mild orbital cellulitis, they're managed medically or conservatively. Whereas anything 3 to 5 so involving pus abscesses requires surgical management. Ok. So for periorbital cellulitis imaging is not normally needed. And yeah, I think this is mainly so this I think I'm talking about for Rhin and sinusitis imaging isn't normally needed and you can manage this conservatively with pain relief and a five day course of nasal decongestant. So that's xylometazoline and Ovine is the kind of brand name. Um And you wanna give it for five days, max, you don't wanna give it for longer because you can end up with uh like rebound, congestion or stopping if you give it for any longer. And most of the time you don't need to prescribe antibiotics. However, if their symptoms are lasting beyond 10 days or they have any of those signs of bacterial infection, like high grade fevers, very high crp um or pu purulent d uh discharge from the nose, then you can give them pen b uh 500 mg four times a day for five days, which is first line. If there's any red flag symptoms or signs of orbit involvement, then as I said, you want to be doing sepsis six bundle, putting them on IV Comox broad spectrum and discussing with ent plus minus ophthalmology and doing a CT, you can also, if their symptoms are lasting beyond 10 days, consider giving them nasal steroid drops. Um And if that helps, then they continue, they can continue them for 7 to 14 days as well. Ok. And then the last big topic I'm going to talk about is foreign bodies because that is again, one of the most common things that, uh, pediatric ent surgeons deal with and you can get foreign bodies in the ear, the nose or the throat. And so I'm just gonna essentially go through the ears and nose and the throat and how we manage it. So we had a little boy the other day who came in who had an oat stuck in his ear. I think he was making breakfast bars with his mom and somehow managed to get an oat in his ear. Um, some key things to look for in it or what do you need to be asking about? Um, when a mum brings her three year old boy in saying that he's got something stuck in his it. So you wanna know what the kind of foreign body is? So what is it, is it a bay that you really need to be worried about or is it something that you that can wait and it's less urgent? You want to know when was it inserted? So was it, has it been in there for months, weeks, days hours? Do they have any other ear problems? So, did they have any existing hearing loss? Do they have s inserted? Are they known to have a ruptured tympanic membrane? All of these things will affect how you try and get the object out and how you manage them. So when it comes to examination, um you need light. So either with a head, head torch your phone light, it doesn't really matter. Um Sorry. Yeah, fine, sorry. Um Yeah, you need a light source. You need to be looking for any blood, any pus, any discharge you want to actually be looking for the object. Can you visualize it? And can you see whether or not the tympanic membrane is intact? So, if you were in an Ed setting, you would be using just basic oscopy. Um If you're in an ent job, so whether there is an F one or an F two, then it's a lot easier to use the microscope and it can be quite challenging if the child is young. So if it's a two or a three year old, um and with this little boy, he really wasn't cooperative at all. Um So he ended up needing a G A because he just would not tolerate micros suction. Um And so management really is based on how cooperative the child is positioning is key. If the object in the ear is plastic, then you can syringe it out. So with the MS, you essentially just put saline in the ear and then syringe it out. You shouldn't do that if there's any or organic foreign body in the ear because the water can cause it to swell. So if it was a raisin, for example, and you shoved saline or water in the ear, then that raisin could swell theoretically, if it's an insect in the ear, you want to use oil. So, uh classic olive oil drops which all ent um clinics will have um because that essentially gets the insect out by floating out. Don't ask me how that works, but it does. Um And then, yeah, so microscopy or if, if none of it. So if syringing doesn't work or you can use a little uh hook um as well using a microscope, if, if none of that works, then they'll need to go under A G A essentially um to get it removed. So what happens when the foreign object is in the node? Well, you do the same thing you need to examine them, need anterior rhinoscopy. So you can use uh one of the, what's it called? You do anterior rhinoscopy. You're looking again for the brom body. Is there any discharge bleeding? Is there any signs of a septal perforation? Um And then you can use a variety of techniques to get the object out. So the first thing you should do is try and get the child to blow their nose because it might come shooting out. Um You can also get them to cover the uh contralateral nostril. Um Whilst they're doing that, you may have heard of the mother's kiss um which some people choose to do an ed. So that's where you get the mum or the dad um to essentially kiss their, they blow through the child's mouth and the object can come out of the nose. You can also use a variety of, of tools to help you get the object out. So up at the top, you've got suction, you can use crocodile forceps, you can use tilly forceps or you can use a hook. The thing to note with the hook, particularly with a young child, which I experienced today is if the child is non cooperative and you shove one of these right angled hooks into the nose because they're actually really sharp, it will go in there, they'll turn their head and then you end up stabbing their nose and causing a massive nose bleed. Um which isn't ideal because you then have to start managing that. Epistaxis. Um So it's probably best in a non cooperative trial to use Tilly's forceps because they're blunter um or the crocodile forceps. But if the child's older or an adult, the hip can be really useful. Um Yeah, the red flag with any ingested foreign body or in the ear or the nose is. But, but batteries, the kids love putting things in their mouth. It's most common ingested throm bodies between the ages of six months to three years. There are Children more at risk. So those with developmental or behavioral problems, which obviously makes things even more challenging when you're examining them. Trying to get it out. You've also got to be aware of all the Children with perhaps mental health problems. You may intentionally ingest throm bodies. Um and they also do need psychiatric reviews um as well as ent input factors to consider with any ingested thrombo are the size, the shape and the composition. And as I said, you need to have button batteries um kind of flagged up. It's like a red flag. Um and button batteries are found in a whole host of things that you wouldn't think of. So hearing aid, battery batteries are, but batteries all cheap toys like kiddies toys, uh like yo yos anything uh light up tiaras, they will all have bottom batteries in. So as I said, red flags with any ingested throm bodies are have they injected the bottom battery. It's a particularly large object. So more than six by two centimeters. Um And you're worried about those because they can lodge in the Pylorus, any supra absorbent polymer. So things which will absorb water or interstitial fluid magnets are very worrying, particularly if a child potentially has ingested either two magnets or a magnet and another metal object because that can obviously be catastrophic. Um If you get magnets attracting each other inside the body, anything lead base or multi component object. So an entire toy with a battery inside that could decompose and then you've got your high risk Children to any child with a preexisting uh gut abnormality um or things like eosinophilic esophagitis because they're more reactive um or any child with uh a neuromuscular disability um as well. So lacks tone and therefore has impaired re reflexes or coughing reflex. Um I've kind of been through this all but on assessment, you want to be looking for any signs of as well as asking the type the timing screening for high risk. You want to be asking for signs of any airway obstruction. So, first of all, are they talking to you? Um can they swallow? Do they have any pain on swallowing any voice change? Did they have any abdominal pain? Have they vomited? Um And then you know, asking the symptoms of G I bleeding um as well and then you do a systemic examination. So oro pharynx, is there any obvious foreign body stuck at the back of the throat that you can see um the neck? So you want to feel the neck um do a proper examination uh that we should also scope them, do an f any listen to their chest. Is there any signs of kind of surgical emphysema to suggest an esophageal perforation? You want to feel their tummy, any tenderness? Um And yeah, as I said, you would scope them as well. So sorry, this hasn't been very interactive. Um So we're now gonna have some interaction. Um This is a lateral neck x-ray. Can anybody tell me what these arrays are pointing to you? So what is a, the top of your abbey. Good thanks, Dean. It is the epiglottis. What is B? Hi, all. Welcome you again. It is the hyoid vein. See anybody? Not very clear, actually, quite hard, but it's pointing to if you see that little black strip of air, quite a hard one, that's actually the ventricle. So that's a space between your true and your false vocal cords. D again, quite a hard one. It's one of the laryngeal cartilages if that helps. Um not the glottis. So D is actually a calcified cricoid cartilage again, for reasons. I'm not sure, but the cricoid often becomes calcified and can be confused with a foreign body. So it almost looks like there's a foreign body here. It's like a white dense strip. Uh but it's not a foreign body that is the prio cartilage. Um And then E ed one, the is just your trachea and then f which cervical vertebra is F. So it's basically at the level of the cricoid. So what level is, what level does the cryo set at? Excellent C six. So it kind of actually sits between T five and T six. But yes. Um oh Julian, you are right. Don't delete your comment. Um But yeah, so with, with foreign bodies in the neck, particularly with older Children, um you want to get a lateral neck x-ray um And, but things like fishbone, they not always radiolucent and actually some radiographers uh will ask you to try and specify what fish bone uh the per the patient has ingested because they have a book which tells them which bone is radio mutant or not. Um But you do it anyway to see if you can visualize it. They still need examination. Um But you would do a lateral neck x-ray and you can also look for other things in a lateral neck x-ray. So do they have any widening of their retropharyngeal uh space? Um Is there any loss of the spine, the spi spin lordosis to suggest kind of they're obstructed in the neck and? Yeah, yeah, please do. I'm gonna, there's not that much long left and, but if you guys have to go, then please do fill out the feedback. So investigation. So normally x-ray. So this is in a younger child with most adults or kind of older teenagers, your threshold for doing x-rays is a lot lower. But with a young child, as I'm learning, everything is very conservative. So if you have a young child who's asymptomatic and has no red flag risk factors and the bottom battery ingestion, et cetera, et cetera with no significant past medical history that otherwise, well, then you don't need to do an x-ray and you can kind of watch and wait, approach, um observe them for a while and then send them home otherwise you want um plain A P in actual views. Um And I've already spoken about this here are two cardinal signs but battery ingestion. So unlike a coin, what differentiates a simple coin from a button battery is you get a halo sign. So they like kind of two circles you proposed and then you end up with this step off sign because there's two parts of the bottom battery. Um and I've got that better shown here. Um So the reason why they're so dangerous is they release hydroxide ions and cause liquefaction necrosis essentially. And this side. So the thin and narrower side um is the side which is more dangerous. And so it can be helpful to visualize on an x-ray because you can kind of see if this narrower side is facing the esophageal wall. Then you need to be more worried because you're likely to get a perforation. Um and they cause damage within two hours. Um So, particularly in the developing world where foreign bodies are, you know, detected months or years later. Um esophageal perforations or tracheoesophageal fistulas, aorto esophageal fistulas um are all very common aorto esophageal fistulas, obviously lifethreatening. So that would be something that kids live with. Um Yeah, and then this is a very complicated diagram, but just kind of gives you a stepwise approach for how you'd manage a suspected foreign body ingestion. The gist is when you're assessing the child, you want to assess whether they have any airway obstruction and if they do, then you need to manage the acute airway problem using your, we, you need to screen for any high risk foreign bodies or any other risk factors in terms of their past medical history, et cetera if they're fine. So they're well and there are no high risk factors, then you can discharge them with safety neft advice if they're not. Well or there are risk factors, then they may need imaging. Um And so you do an x-ray if you can't visualize the foreign body. But again, the child's, well, they don't have any distress, they're pain free, able to eat and drink, then you can discharge them home if you can see the. So you're less bothered if the foreign body has made its way into the stomach because once it's in the stomach, it's, it's most likely going to pass into the bowel and then the child will poop it out unless it's very, very big and it could get dislodged in the pylorus. Um, which is why if it's meeting that criteria. So it's high risk, it's that big. Then you then need to discuss with ent general surgery, gastric. If the foreign body is in the esophagus and it's causing. So it's in the upper esophagus, then you would probably discuss with n if it's in the lower esophagus, then you would tend to discuss with gastro general surgery. It can get very contentious and often it, that's between the two. because Ent says it's not our problem. It's gastro and the gastro stay it's too high up. It's the ent problem. Um, but either way, if it's in the esophagus or higher, it needs to be dis or if it's anywhere in the esophagus, it needs to be discussed with his senior. So either Ent or Gastro and then I think that is my last slide. So, I'm sorry, that's been a bit of a whirlwind tour and it's not been very interactive. I apologize. Um, but I hope that was vaguely interesting slash useful. Um And yeah, if anyone had any questions, feel free to post on the chat. Thank you again for joining us. This was our last session um of this four part series. Um We really appreciate all of your feedback. So please do um fill out form. We may look to run this series again and kind of change over time in four months time. So your feedback will be really helpful in guiding how we can make this course better. Um Yeah, I don't think if, unless Dean has anything to add, you guys can go and enjoy your evening. No, I just want to say thank you very much. Um Really interesting to use all about stuff. So, yeah, thank you very much. I will just post the um the guidelines. I think Mohammad mentioned, he wants to know where the algorithm is from. Um I have found it here if I just send you the link. Um And yeah, please fill in the feedback as I said thank you very much. And on that note, um, Mohamed, uh, or anybody pe peds, everybody uses the, um, is that the Royal College one? Yeah, it's from Royal something. Yeah. Yeah. Yeah. Yeah. So that one. But also everybody here uses the Royal Melbourne Hospital, pediatric ent guidelines. So Australian guidelines are used a lot here. Whether it's, um, the Royal Melbourne Children's Hospital or the New Zealand Starship Children's Hospital guidelines. Interesting. I don't know. Maybe they do this better than not. Yeah. Um, and other good are, uh, what's that? Don't forget the bubbles. But, uh, is it specific for pediatrics that my best one I've used is NTO. Yeah, I think there's any specific pediatric stuff on there. Yes. The, yes, the ent sho is amazing. Um, but don't forget the bubbles is also really good for either general peds or they do have good peds. Ent stuff and they've put good videos on foreign body removal. I use it. Yeah. Yeah, I'll just paste it. You. Ok. Oh. Oh, wonderful. Thank you very much. Oh, no worries. Bye. You guys enjoy your Thursday evening. Take care. Thanks everyone for coming, uh, attacks anything. Uh, Dean. I'm, I'm going to go.