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Hi, everyone. Um, my name is Maya. I'm one of the, um, junior doctor representatives at Incision today. I'll be giving a talk on common ent conditions that you might face as an ent doctor or as like a junior doctor. Um, so I think we've got quite a lot of people and I'll, oh, yeah, we've got quite a lot of people. So I'll start off now. Oh, sorry. Just fing a few things out. So, yeah. So, um I'll, I'll just be talking about a few common ent conditions that you might encounter when you start working in ent as a sh or as a junior doctor. Um, the main aim of this talk is basically for you to be able to recognize and identify common ent emergencies and formulate an initial management plan. Um, and also appropriately escalating to your seniors. We won't be able to cover everything um, because there is so much ent is so vast. Um, y you'd require like two full days to talk about everything. But um I'll just give you an overview of some common things that you might come across, so we'll start off with ears. Um So this is a very common, um, referral that you'll get from GPS or, you know, from other, um, specialties in the hospital. So, it's very important to, um, triage probably and ask important questions. So when, when someone's calling you, it's very important to ask about things like what, which ear is involved, um, is, is it painful, is the patient having Atalia and how, uh, uh, and to also, uh, um, understand the severity of the pain. So, does the pa pain keep the patient up at night? Um Another important thing is to determine how old the patient is because that can give you a clue as to the diagnosis of, um, you know, uh it can give you a clue to the diagnosis. So, for example, if the patient is having uh a painful ear and they're an adult, it's most likely to be a acute Otitis externa. Whereas if there's um, i, if it's, if it's a child and they're having a painful ear, then it's most likely to be an acute Otitis media. Um And if they're having lots of copious discharge, but there's not that much pain and it's, um, you know, it's painless, it's most likely to be chronic Otitis media. So it's very important to ask these questions. Other questions that are important is for example, what is the discharge like? Um what color is it? How much are they, uh how much discharge are they having? If it's green and custard and foul smelling or odorous. It's most likely to be infectious. If it's watery and clear, it's, it, it, it sounds like some chronic inflammation that's been going on. Um something long standing. So, something like chronic Otitis media or c um or something like uh cholester tumor as well or if it's thick and white discharge, it's, it's likely to be a fungal infection. It's also important to ask um to uh to ask about red flags. So, for example, um is the infection spreading um outside of the external ear canal into the pinna? Is there a pin cellulitis? Is there periauricular cellulitis? Is the patient having any systemic symptoms? Um Is there stenosis of the ear canal? Um And on examination, can uh the the referring clinician, can they see the tympanic membrane or not? Um Is there, is there cranial nerve involvement? So, um cranial nerve seven, it passes through the ear and uh through the parotid and it can often get involved in infection. So it's important to ask if there's any um signs of cranial nerve palsy, specifically the seventh cranial nerve, always very, very important to examine and always ask the referring clinician if they've examined the patient. Um because that can uh ca that can um influence your decision if the patient needs to come into ent and for them, if they need to be assessed uh by the ent department. Um Also, it's, it's another um it's also very, you also need to ask about if the patients received any treatment and if they have received treatment, how long have they received the treatment for? What sort of treatment ha what sort of treatment have they received? So, these are very, very important questions that you need to ask when triaging um and determining if a patient needs to come into the hospital to be treated by the ent team or if they can be managed as an outpatient by um the GP there, I found this really uh great flow chart on EN TSH O. So it's a, it's a really good website for anyone who's starting off in ENT um and provides lots of clues and tips as to how to manage conditions and how to assess patients. So it provides a really good flow chart about um a discharging ear. So you guys can refer to that later in your free time. Um If you're interested, we'll start off with a few cases and then we can discuss them in a bit more depth. So basically, you've uh a 45 year old lady presents to the GP with a three day history of Atalia associated with um associated with custard like discharge from her right ear. She also mentioned some hearing loss on the right side and she's never experienced this before. Um She also mentions that she recently um came back from a holiday in Greece and was swimming quite a lot. So, what would your most likely diagnosis be, I'll give you guys a couple of seconds to think about this and then we'll discuss the answer or actually we'll discuss the next, uh, question and then we'll discuss the answers at the end is what I meant. I started pulling as well. Just waiting on responses. Oh, amazing. Thank you, Phoebe. Oh, I can't see the Chapman Port if I can. Ok. Oh, everyone's, um, can you see the chart now? So, right. So I've had three responses so far. We'll just wait for a couple more. Yeah, I mean the thing is I'm, you know. Ok, so move on to the OK. Some people are still responding. Oh, wait for a couple of seconds. Sorry guys. So majority have said otitis external and a few people have um put between acute otitis media and chronic otitis media. Fine. Ok. Um We'll move on to the next question and then um I'll discuss the answers afterwards. So, what treatment would you advise for this lady? Would you give the lady IV antibiotics. Would you give her oral antibiotics, um topical antibiotics and steroids or would you give topical antifungal? The next bowl is out as well? Thank you. Faith. Um And do you guys think that this lady needs to be referred to Ent? Like does she, can she be managed at the GP practice or do you think she needs to come into Ent and to be seen by an ENT doctor? So, with the last question, majority said topical antibiotics and steroid and a few people said topical antifungals. They haven't replied to the ent question yet. Thanks for. Ok. So with, with this, um, with this case, the most likely diagnosis is otitis externa. And the reason being so this lady, she's, she's having ear pain, she's having discharge from her ear and like a major clue is that she's been swimming. Uh Otitis Externa is often known as a swimmer's ear as well. So, the major risk factor is that she's uh that's wetness in her ear and that can predispose to infection of the external ear canal. So, otitis externa is essentially um infection of the infection, inflammatory condition of the external ear canal. Um There's lots of risk factors for it, for example, trauma to the external ear canal, which can happen with um cotton bud, use eczema. Um anyone who's immunocompromised diabetic patients are quite susceptible, there's water exposure or dust exposure. And um it often presents with copious discharge from the ear. The external ear can on examination, the external ear canal can often be stenosed and very inflamed. And in adults who have a discharging ear where you ca where you can't see the tympanic membrane because of the external ear canal being so to nose or if the tympanic membrane is intact, then it's most likely to be um Otitis Externa. Um The treatment for that would involve an ear swab for um for NCN S so you can determine what organism is present and give topical antibiotics targeted towards that organism. Um Another thing that's often done is that we clean the ear. So it's, or we, it's called as an oral toilet. So we, uh, have a micro, um, uh, we microsuction, all the debris in the external ear canal. The other thing to keep in mind is that because that because the ear canal is so stenosed in some patients, uh, topical antibiotics aren't enough because the ear drops won't penetrate the external ear canal. So often, uh, often times what um, en doctors will do is we'll insert a po wick, which is basically kind of like a small, um, small, like a, uh, like a small uh gauze kind of thing. Uh We install it with uh a topical antibiotics and put it inside the ear with forceps and then after um, two days it's removed. And the reason we put this inside is because it can, um, release the anti topical antibiotic, ear drops and steroids into the external ear canal. And actually be effective at uh like, um where the site of infection is. Um, the other thing to advise your patients on is how to appropriately instill the ear drops and also to avoid any, um, uh, avoid any trauma to the ears and avoid, um, swimming until it's all healed. So, it's a very common condition that you'll be, um exposed to if you work in Ent the other thing. So I understand that this can be quite confusing just looking at the picture because it looks like uh it could be a fungal infection as in white and creamy. But this lady's only had a three day history with fungal otitis Externa. It's often Otitis Externa, which is, has been present for a very, very long time. So, something like uh three weeks or it's otitis Externa in which you've given multiple courses of um anti topical antibiotics and it has not resolved and then it suggests that it's more likely to be a fungal sort of infection. Furthermore, like with fungal infections, you might see spores and it will be a bit more thick and curdy. Um This is not as thick and curdy as a fungal infection. So it's not likely to be a um uh fungal infection. We'll move on to case two now. So a six year old boy presents to A&E with a discharging left ear. He has a two day history of fever and increasing ear pain which has gradually started to improve on examination. His cranial nerves are grossly intact and no post or swelling is um identified. Um What would what would be your most likely diagnosis? And what treatment would you advise? Just waiting on a few responses? Yeah, that's fine. Thank you for. The majority have said acute otitis media with a few people saying otitis media with effusion, all righty. Give them a couple more seconds and then um ask the next question as uh what treatment would you advise for this patient? So yeah, everyone settled on oral antibiotics for this one. Ok. Awesome. Yeah. So this is, this is a bit tricky. Um II find ears tricky all the time. Um So it this pa this patient he's got acute otitis media. And what gives it away is that he's had a two day history of P fever um with, with ear pain, which was initially increasing. But now the pa the now the pain has gradually started to improve. Um And on examination, you can clearly see that the tympanic membrane is perforated and there's discharging uh p there's uh you know, pus which is discharging or dis there's discharge. So that gives a very, very clear picture of acute otitis media. It's the most um one of the most common infections that chil ear infections that Children um suffer from. So, um that's quite clear. Another infection that Children often have is otitis media with effusion. And that's, that's uh that's a different presentation. Um It there wouldn't be a perforation in the um tympanic membrane. The tympanic membrane would be intact and you would be able to see a uh fluid level or like um little like bubbles on the tympanic membrane. But this is acute otitis media, the treat. Uh every ii think every oh yeah, there's one person who's got topical antibiotics and steroids or yeah, just a couple. But the answer for this one, the answer for this is oral antibiotics. And the reason for that being is um acute otitis media is infection of the middle ear. And that's if most effectively targeted with oral antibiotics rather than topical antibiotics. So topical antibiotics act on the external ear. A anything externally. But if there's infection in the middle ear, oral antibiotics or IV antibiotics are more uh more effective. So the answer here would be oral antibiotics. Um So as I said, acute otitis media is an infection of the middle ear. Um most commonly affecting Children, most most infections are viral infections that can resolve um by themselves. However, uh bacterial infections, um uh some, they do not resolve by themselves and it's important to give antibiotics to treat that infection. The, the main reason why Children develop this infection is because they have uh there's an anatomical difference in their eustachian tubes. Uh So the eustachian tubes connect, connects the um middle ear to the nasopharynx. And in Children, it's more shorter, narrower and horizontal compared to adults. And this predisposes them to infection. Um It's, it's difficult for fluid from the middle ear to drain into the nasopharynx. And also because it, because it's um horizontal and shorter i infection from the nasopharynx can be transmitted uh to the middle ear and cause infections. So that's one of the major risk factors as to why Children develop this, the uh this ear infection. Um P uh Children who are, who are um bottle fed are more likely to develop uh acute infectious media as well as um boys are more likely. And if there's passive, if they're exposed to, if there's smokers in the house and they're exposed to passive smoking, they're more uh predisposed to developing this infection treatment. Um is with oral antibiotics and um you have to be really vigilant with acute otitis media and treat it appropriately because it can lead to complications. So it can lead to intracranial complications or extracranial complications. Um The infection can travel um and cause uh meningitis. It can cause um sigmoid sinus, thrombosis. It can cause abscesses as well. Uh So these are some intracranial complications. Extracranial complications can in um include mastoiditis. Um there can be petrositis, there can be facial nerve palsy as well and ab um muscle abscesses. So, um it there might be um abscesses which can develop um in the muscles attached to the mastoid. So you may, so whenever you're examining a child with acute fit media, make sure you um ensure that they, they're not ha they, they're not having any complications because if they are, then they need to, to be admitted, you'll need to have imaging done um and be treated with IV antibiotics. So, those are just a few of the ear conditions that you'll be commonly exposed to. There are others how, however, in the interest of time, we don't have time to cover, you know, all of them. So I'll move on to noses now. So, um with regards to noses, the most common um emergency or condition that you'll be exposed to is epistaxis. So, staxis is essentially bleeding from the nose. The most um common type uh that people have is bleeding from the anterior aspect of their nose. Um There can be posterior uh bleeding from the posterior aspect of the nose as well. Um Risk factors include patients who are on blood thinners, um on any sort of anticoagulation if they have high BP, if they've got liver disease. Um the reason uh liver disease is a risk factor is because the liver is important for synthesizing clotting factors like 279, 10 and also protein C and protein S. Um if these aren't produced um appropriately, it can lead to a clotting abnormalities and predispose a patient to um bruising and easily bleeding. Um Alcohol consumption is another risk factor, uh bleeding uh problems such as hemophilia, Von Willebrand's disease, hereditary hemorrhagic tect Taia. Um if patients using intranasal drugs, for example, cocaine use, um if the patient sustained any trauma, for example, if there are a rugby player, a sports player um in kids, a common cause is nose picking if uh and also this is quite common in kids as well if they put some foreign bodies up their nose that can lead to epistaxis as well. Um So the treatment of epistaxis is just like any other medical emergency. You need to follow an A two E approach. Um because with Epistaxis, a major concern is the airway and circulation, you can lose large amounts of blood um in epistaxis. So it's very important to um approach these patients in a very systematic manner. So, first of all, when you're approaching a patient, you need to um ensure that you're um following your A to E um, and once one thing that you'd want to do is to identify the site of bleeding. So if it's, if it's just like a trickle, you can get your um headlight and your knees and your um th fatum, which is basically an instrument used to expose the nostrils and identify the source of bleed. So initially, you could do conser if it's, if it's just like a trickle, you can try conservative measures. Um And what, what this involves is, um, instructing the patient to hold the soft part of their nose or not even hold, pinch the soft part of their nose and slightly lean, lean forwards. Um And they'll, they'll need to pinch the nose for around 20 minutes. If this controls the bleed, then it's fine. You can monitor and observe them and it should, it should be fine. However, if they continue to bleed, you could try some other measures. Um, oftentimes putting ice packs at the nape of the neck or on the forehead or just around the nose. That also helps because it causes the blood vessels to constrict and, um, helps in the management of epistaxis. Other measures include cauterizing the nose. So, um, silver nitrate sticks, the, they look like match sticks and essentially that you can, um, rub it over the mucosa and it causes, um, it's, it's a very good, uh, hemostatic agent. You have to be very careful though because sometimes this silver nitrate can kind of melt and trickle over the skin and leave marks. Um And patients don't like that. Um So you have to be very careful when you're using this. Um other, there are also other um adjuncts that you can use in addition to like nasal Corry and um packing of the nose. One of these is fibrilla, which is essentially like a gauze um which dissolves it's a very good hemostatic agent. Another one is um miro pore. It looks like a, it essentially looks like a nasal tampon and it, you can push it inside the nose and it just dissolves, it's a very good hemostatic agent. Um and there are more out there, but these are a few that I have used um when I was working in ent um if, if the bleeding is not getting controlled um with these measures, you'll probably need, if it's in, if you and you can identify the site of bleed and it's in the anterior aspect of the nerves, you'll need to use a rapid Rhino. Um I think I have a photo in the next uh slide. So it's essentially if, if a patient is bleeding from uh the right nostril, you'd uh put a rapid drain in the right nostril and wait. However, sometimes what can happen is the blood from the right nostril. It can um it can go towards the back and come out through the left nostril that can happen sometimes. Um So you'll need, so in that situation, you need to pack both nostrils. So instead of unilateral packing, you'd have to pack the right nostril and the left nostril. Um And if that doesn't work and or you can't identify the source of bleed, the bleeding might be um uh a posterior bleed in, in that situation, you'll need to insert a fly uh catheter to control um the bleeding. If, if we, if after all these measures, the bleeding is still not getting controlled and the patient is extensively bleeding, um you'll need to um take the patient to surgery for surgical intervention to either ligate the arteries or figure out what else to do essential or call the interventional radiologist to help you out to embolize a vessel. Um One thing to be careful about with nasal cautery, which I forgot to mention earlier with silver nitrate is that you can't cauterize both sides of the septum. So if you do that, you can, there's a risk of causing a perforation. So never cauterize both sides of the septum at the same time or just cauterize one side. And in, um, patients who have hereditary, um, hemorrhagic telangiectasia, uh, don't cauterize them, don't pack them because that can just, that just causes them to bleed even more and it doesn't control the, um, bleeding in situations like that. People like to use um, fibrilla or um, uh flu seal. Sorry, I forgot what it was called for a moment. But yeah, people like to use flu seal that those are some important things to consider. Um Another important thing that I've got to mention is that if a patient is on anticoagulation, you want to consider reversal agents. So for example, if they're on warfarin, you wanna give Vitamin K or prothrombin um complex. Um uh the other thing is uh if, if the patient's uh hypertensive, you wanna give them some fluids, resuscitate them and giving a stat dose of tranexamic acid often helps as well. So that's so those are some important things to keep in mind when managing a patient with epistaxis. So this is what a rapid looks like. Uh you there, there are two of them right there. So one of them is an anterior one and the other one is a posterior pack. So you essentially insert it into the nose um and you have to insert it at the uh in, at the, in the floor of the nose. So insert it horizontally rather than like um vertically because the base of your nose runs horizontally. So you need to insert it like in a horizontal fashion. Um So this slide just shows how we insert rapid dry nose once again. So you can soak it in adrenaline or temic acid and then um just uh push it inside essentially and inflate the balloon so that it, it provides a tampon adding effect and controls the bleed. So, uh we'll run through a few cases. So a 19 year old um girl, she suffers a nasal injury when playing rugby. She was admitted to A&E and required bilateral anterior nasal packs to achieve hemostasis. You called to the ward to see the patient patient as she is now continuing to spit out fresh blood. And als also said that some blood is coming out from her eyes. So what would you do in this situation? Ok, I can see the chart. So um 80% of you have said posterior nasal packing and then 20% have said examination under anesthetic. So in this girl, um you'd want to do, you want, you'd want to do posterior nasal packing. Um And the reason for that is she's, she's had bilateral anterior packs, but she's still continuing to spit out fresh blood. So that's suggested that she's bleeding from the posterior aspect of her nose and we haven't packed it packed um the posterior part of her nose. So you'd want to try that out first before taking her to theaters for examination under anesthetic. So the right answer is posterior nasal packing. We'll move on to the next question now. So a 65 year old lady is on Warfarin for atrial fibrillation. She continues to bleed from her nose. Despite both anterior and posterior nasal pap being performed a stat dose of tranexamic acid has been administered. She's slightly tachycardic and her BP is 100 by 60. The inr is 2.02. Sorry. And all her other blood tests are normal. So what would you do in this situation? I'll give you guys a couple more seconds to answer this one. Ok. So e 80% of you guys have said examination of the nose under general anesthetic and 20% have said silver nitrate watery. So, in this lady, because she has had both anterior um bilateral anterior nasal packing and also a posterior nasal pack. And despite all of this, her um epistaxis is not controlled, you'd want to examine her nose under general anesthetic and see which vessel is responsible and you know, appropriately ligate it or involve the interventional radiologist. Silver nitrate quarter would not be appropriate in this situation because it's used um for minor bleeds or bleeds which are kind of oozing or trickling. So silver nitrate quarter wouldn't, wouldn't be appropriate in this situation. But um you'd want to uh optimize this patient and prepare them for theater. If you guys have any questions at any point, feel free to, um, type them in the chat box or, um, ask them at the end. Um, because I know this can be quite tricky to, um, understand. But anyways the next question, so when, when you're walking in the, when you're going for a walk in the countryside, you come across a 10 year old boy who has been hit in the face with a branch when climbing a tree, he has a small ooze from both nostrils and is attempting to stem the flow of blood by dabbing the nose with the sleeve of his t-shirt. Um How would you, how would you manage this condition? And what would be most appropriate? I'll give you guys a couple more seconds to answer this one. Ok. So the majority of people have voted for anterior packing of the nerves and a few have said simple first aid measures. The, uh, so in this situation, you can see that, um, he's this boy, he's just started bleeding from his nerves. There's a bit of a trickle going on in this situation. You want to, first of all try simple first aid measures. So you'd tell him to hold the, uh, uh, pinch the uh soft part of his nose, lean forward and you'd wait for around 20 minutes and then see if the bleeding had resolved. Um, and if it had resolved, you, we don't need to do anything else. However, if it's not resolved, then you need to move on to, you know, the other steps. So you wouldn't straight away, pack the nose um without having tried conservative, you know, simple first aid measures. So, in this situation, you'd want to do simple first aid measures first before trying any other interventions. So, um moving on to the neck and throat, um when you're working in ent, uh you'll be referred lots of weird and wonderful swellings of um the neck. So when you're trying to explain these swellings to your seniors, it's very important to understand the levels of the neck. Um And this is, this is a good classification uh system to learn and it's quite easy to learn actually. So, uh I usually struggled with this. But um I think once you understand the surface landmarks, it's quite uh it's quite um easy to uh lung. So there is uh there are seven levels. So the first level is just underneath the um underneath the chin and it's above the hyoid burn. Levels 23 and four, they're along the sternocleidomastoid. So level two is above the hyoid bone and it's the upper third of the sternocleidomastoid. Level three is between the hyoid bone and the cricoid cartilage. And it's kind of the uh middle third of the sternocleidomastoid muscle. Level four is below the cricoid um cartilage and the lower third I is the lower third of the sternocleidomastoid. Level five is anything behind the stoc sternocleidomastoid muscle and um level six is anything, um you know, below the cricoid um cartilage. So, it's quite an easy way to remember the different levels of the neck. Um And when you're describing swellings to your colleagues or your seniors, um so, with the neck and throat, um it's very important to ask about uh a few questions such as if the, if the patient is having any difficulty breathing, if they're having any dysphasia, if there's any tr if they've noticed any changes to their voice, if they're um having any hemoptysis, any epistaxis, any un unintentional weight loss, night sweats, fevers, lumps or bumps in the body. Uh If they've experienced any symptoms of hyperthyroidism or hyperthyroidism because this can really help you to characterize um the lump and kind of understand if it, is it just an abscess? Is it a lymph node? Is it possibly a lymphoma? Is it um uh cancer somewhere? Is it a laryngeal cancer? Um So these questions are very, very important to kind of guide you as to the diagnosis as to what the swelling could be. It's very important. Um Another, um So when you're, when you, when you'll be examining the um neck and throat region and ent you'll be asked to do a um fine uh fiber optic nase endoscopy, which is basically um putting like it's, it's kind of like a uh a scope which goes through your nose and you can see the top of the um oropharynx and the uh so you can see the nasopharynx oropharynx and the hypopharynx. Um It provides a good uh inside view and it, it can be um tricky to kind of understand the anatomy, but the more you look at it and the more you, the more um FN ES you do, the better you come at it. So this is just kind of um the anatomy of the neck and this is what you'll see if you do AFN E. Um what I put there, the, so with um neck and throat, um ent conditions, there's a wide range of differentials. Um It can be something as trivial as, you know, tonsillitis to something life threatening like a um foreign body stuck in your neck or a deep neck space infection, um which can cause sepsis. Um and things like that. We don't really have that much time to discuss these at the moment. But um I would recommend um that you guys, you know, read about it in your free time. Um because it is quite interesting when you come across these patients. There's also um some useful resources um that you guys can refer to um when you're working in Ent. So Ent UK is a very good website, en TSH O has lots of resources um and teach me surgery, teach me anatomy to kind of understand the um anatomy of the ear, the nose and throat. Um So there's also plenty of youtube videos as well. Um if you have any, um you know, uh any burning questions or any, um anything that you'd like to understand a bit more, so make sure you check them out. Um Thank you for listening to my talk. And if you guys have any um, questions, feel free to pop them in the chat box and I'll try my best to answer them. Thank you, man. Oh, thank you for, um, thank you for organizing everything. Um, the core is used quite often actually. Um I think it's, it's commonly used in uh ent clinics as well. So for example, if a patient is having multiple episodes of epistaxis, but it's not if they're not gushing out um, blood, uh they, and you know, it's controlled with simple conservative measures, but it's happening like three times a week, they'll be seen in e clinic and we can cauterize that area and for some patients that works quite well. Um and helps control the bleeding. Um So if it's like a minor bleed, silver nitrate Corry is um used um quite often actually. Does anyone have any other questions? I don't think anyone does them. Oh, I think that's just one last one. Josh uh was also curious if you need multiple uses within weeks for some patients. Oh, sorry. Yeah, I did scroll down um multiple. Yeah, so sometimes um the they we do reapply um silver nitrate quarter. So uh multiple uses are required for some patients so they may reattend after like three weeks. Um, and we can just cauterize that area once again. Um, so, yeah, that, that does happen, but other times with nosebleeds, they're quite unpredictable. Even if you cauterize that area, sometimes with some people, they just continue to bleed and there's no real treatment apart from, um, conservative measures. So you ensure that they're very well versed with, um, f um, Epistaxis first aid. Um, uh, Yeah, that's essentially it actually. Yep. I think, I think that's it then. Thank you so much, Monia for ending the session with such a great um teaching session. Thank you f for organizing everything and um thank you everyone for attending. Um I hope you learned something new and I hope it was beneficial for you guys. Um Thank you so much.