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All right. Is that Us live? Can't quite tell that should be Us live. Hi, everyone. Um, if you can hear us slash see Us live, you can pop something in the chat just to let us know. And good evening to everyone who's joined already, we're gonna give it just a couple of minutes to let everyone join and make sure everyone's ready. Perfect. Thank you, Sophie. And then it'll be ready to start. Uh, probably aim for maybe three minutes past. So, thank you very much for your patience. Ok. So we've got 30 people in. So that's probably a good time to start. So, hello, everyone who's just joined. Welcome to the first of the year five s this evening, we'll be covering Ent and Sophia will be delivering a wonderful presentation. So I hope everyone enjoys and I'll hand over to Sophia. Hello. Um, I hope it's wonderful. Um, I'm Sophia finally a med student. Um, and I've been asked to teach Ent in 45 minutes, which really isn't that much time considering, like people spend eight years becoming masters at Ent. Um, but yeah, probably reflective of the amount of time the uni gives us to learn ent. So I'm gonna try and focus on the stuff in the MLA. Um So you should be familiar with the MLA content map because this is what you're gonna be examined on in final year and they've got a bunch of presentations which are really good to revise for Aussies especially. Um and some of the key conditions um interestingly though they don't include head and neck cancers on this list of conditions. So just make sure you revise that as well because that could come up in ent acies. Um So the way this session will work is we'll do a bunch of questions, it'll be really interactive. Um And shout out to Joseph for helping me make the quiz, but I'll just put in the link to the quiz now and you can join on your phone or on your laptop, whichever works. Um And we'll do a bunch of questions. Um And you can think through the questions yourself and we'll just talk through it afterwards as well. When we put um some summary slides in here as well, the slides will be sent out to you after the session. So you don't have to worry about taking notes. Um So we'll give her another 10 seconds if you're not joined by them, then t, well, so you don't have to put your actual name in if you don't want to as long as it's not like um you the 3000 or something and we got 16 people in just now. Hm. Nice med student. So no. Ok. Five more seconds. 4321. Ok. Cool. So we'll start off with the first question. Sign up pretty easy. Mm. Mhm. Ok. Ok. Ok. Three seconds 21 sound. So the answer for this one acute otitis media. Um let me try and see. Yeah. So most of you got it right. Um And some of you put otitis media with effusion as well and I can see why there's some confusion. So let's talk through it. So, acute otitis media is infection of your middle ear. Um and it's characterized by the bulging tympanic membrane. Um and you can get some discharge and it typically like they're pulling the ear, it's a very acute onset. So 12 hours is very acute. Um And in this case, she's had this discharge that's come from the ear and since then the pain has gone. So that tells you that the fluid was like building up causing pain in her middle ear and then something happened. Tympanic membrane burst, the fluid came out and now she's feeling a bit better. Um So that's what makes acute otitis media the most likely diagnosis here. The titus media with effusion is blue ear. Um So that's similar. So it's a collection of fluid in the ear um with or without signs of acute acute inflammation. Um and these tend to present over a longer period of time. So 12 hours is quite acute here. Um The way we manage a glue ear is we observe for three months. Um And if there's still some symptoms after those three months, then you can refer them on for Gromes. Um And the only um indications when you'd refer them immediately is if they have something like Down syndrome or cleft palate. Um And I think 1000 on discharge as well that is looking a bit dodgy. Um But yeah, so the glue ear would present a bit more insidiously. Cholesteatoma is an abnormal growth of your epi like squamous epithelium in your ear. Um And that tends to present over time as well. It's characterized by an attic crust. Hi, Sophia, sorry to interrupt this from meadow. We've noticed that your slide seem to have swapped with your presenter camera. Do you mind turning off your camera and just seeing if this changes things back to normal now, never mind, never mind. All good. Well, I can, I can turn off my camera as well if that would help. Is that better? I think so. Thanks Jingjing. Ok. Um Well, you don't get to see my beautiful face. That's ok. Concentrate on the knowledge. Um So yeah, so cholesteatoma um can present with an attic crust, um and a foul smelling discharge as well, but it can cause um local invasion into the cranial nerves seven and eight. So you can also get symptoms of like cranial nerve, seven palsies or facial palsies and a bit of vertigo as well and it tends to present in teenagers. So a bit unusual in a three year old girl. Um, otitis externa infection of an outer ear. I don't think many people put that. Um, it's not malignant eis externa either because that's a condition of elderly diabetics. Nice. So this is just a recap of the anatomy. So just if you just remember the outer ears, like the canal, bit in the middle ear is behind the tympanic membrane and that's the bit that's affected by um otitis media. So we'll do the next question. OK. I'll give you a bit more time for this one. Couple more seconds. Nice. I'll stop it right there. Nice. So, um let's see what everyone put for this one. So, yeah, so this one is a refer to ent specialist for further management. So if you're thinking about what, what's the most likely diagnosis first? So you've got a five year old boy with persistent hearing loss, um left eardrum is retracted and they already presented 12 weeks ago. So three months ago with similar symptoms and they had some hearing loss. So this is most likely going to be a glue ear. Um And we know this because it's happening over quite a long, a long time and it's persistent hearing loss. Um And if you're confused about audiometry, GKI Medics has a really good page on how to interpret common audiometry findings and you might get asked to interpret Amery in your OS as well. Well, I'm not sure if anyone's had that before. Um, so they've already had their 12 weeks. So the next step is referral for gro me. So that's why you need to refer to ent um, some people put, reassure that it resolves spontaneously, but again, they've already had their three weeks. So delaying any longer might lead to secondary speech problems or language delay or behavioral problems. So three month, three months is considered a cut off for when you want to refer. Um Giving antibiotics is if you're considering an acute otitis media decongestants, if you're considering a non allergic sinusitis type of picture and a hearing aid is a bit excessive for a child. Um You want to do everything else first before you give a hearing aid. Um and they're mostly given for elderly patients with sensorineural hearing loss. Cool. Next question, few more seconds. Nice. So most likely diagnosis here, we've got an avid swimmer who has a painful ear that's come on relatively acutely over the past two days and may have some creamy discharge in the ear canal. Um And the canal itself is red and inflamed, but the tympanic membrane is intact. So if we go back to um the anatomy, so we can tell the in the canal itself is inflamed. So that's pointing at the fact that it's an a uh acute ati externa. Um, and what do we do for Otitis Externa? We advise them not to go swimming for now and then we give them topical antibiotics. Nice. So most people got that one. Right. Um, some people put acetic acid drops so you can give, um, 2% acetic acid drops if it's a mild Otitis Externa. Um, how the most appropriate management here, if you remember, like giving osk advice, you'd want to do like your conservative in lifestyle, then your medical, then you're surgical. So your conservative and lifestyle would be things like don't swim for. Now, um Medical would be giving you topical antibiotics and steroid drops which would reduce the inflammation and then that should be sufficient for an Otitis externa. Um Other sort of risk factors for anti externa include like being in a tropical climate. So, like I did my elective in Mauritius which is very, very tropical and a lot of people had a tti externa there. Um but it was mainly due to like a fungal cause rather than a a bacterial cause. So, different hospitals across the world have different um approaches to otitis externa, but it's just a nice little tidbit. Um And if you're doing MC QS as well, um And the picture shows an Otitis externa with a blepharitis and the patient also has some dandruff and they're kind of like in the seventies eighties, you're thinking Seborrhoic dermatitis. Um and that has its own management path. So, next question. Nice. So this question, it's trying to test whether you can differentiate the different causes of vertigo. So this 33 year old woman, she has an episode of vertigo that's made her vomit. Um And she's had similar episodes previously. So, you know, they're recurrent and they're associated with difficulty hearing and tinnitus. So whenever you see recurring episodes of vertigo, think Meniere's disease or BPPV, um and in this case, it's associated with difficulty hearing and ringing in the ears. So that points more towards Meniere's disease. Um It's also typically characterized by an oral fullness. So the pathophysiology of men years diseases, there's just too much endolymph fluid in the ear and that causes the cochlea and the semicircular canals to become really swollen. So that's why you get a sensation of oral fullness and it kind of, it affects your hearing and your vestibular function. Um But I can see why some people put the other options. So these are all quarters of vertigo. If you've got in the question, stem someone who's had an infection previously, then you're thinking it's either a viral labyrinthitis or vestibular neuro neuritis. Um If they have just vertigo and an infection, think viral, um no vestibular neuronitis because that is, that affects the vestibular function alone. But if you've got an infection with hearing loss and the vertigo think viral labyrinthitis because that affects um both of those functions of the ear. Um vestibular migraine, it's like a regular migraine but with ear symptoms. Um and in the question stem, you might see particular risk factors in an osk scenario. Um You'll get like really high marks if you ask specifically about triggers for migraine, um not necessarily just a vestibular migraine but any sort of migraine. So the way I try to remember the triggers is basically like things around Valentine's day. So you're gonna be stressed. So stress can cause migraine. You could have a box of chocolates cheese board, glass of wine, maybe go out to see a show and that's where the like bright lights can precipitate in migraine as well. And if, if everything goes well, then you might find you don't sleep too well that night you might be physically exerted and then you might need um a cup of coffee in the morning to get you through work the next day. So those triggers, if you think about like Valentine's Day, you can think about the triggers of migraine. And if you ask that at the ay, you'll get high marks. Um And then acoustic neuroma is also known as vestibular Schwannoma. It's a benign tumor of the nerve tissue. Um And that's a really important one to look out for, but they tend to be more progressive vertigo. So we'll move on to the next question. Also, Jing Jing, can you like, tell me if I'm being too slow or if I need to hurry up just like jump in whenever t so this is a question on acoustic neuroma. Um So it's a 72 year old woman and she's had progressive hearing problems over the past three months. She doesn't have any vertigo, but you're already thinking, OK, this is a progressive thing. Um We want to rule it out. So, um the most appropriate investigation here is an MRI head to look at the cerebellopontine angle to see if there's any lesions there or anything that they can detect. Um you can you. So most of these patients will also get an audiometry as well. Um And it may show some element of sensorineural hearing loss, but the single most appropriate investigation is an MRI head and the, the MLA questions are your end of your exams will ask questions like this, like what is the most appropriate? And it's always gonna be the one that like is the definitive investigation that can give you the answer all the, so the thing that can rule out the most important things or the most dangerous things. Yep. So here, MRI head, um acoustic neuroma is not a clinical diagnosis and the auto atic emission testing is part of the newborn hearing screening program if you've done peds, um you might remember that and it just tell tests how well your cochlear still works. Um And if that's abnormal, then they do the auditory brainstem response test, we'll go into the next question. Oops. OK. Think to note here as well. So it might help to know that there's no corrective circa that might help if you're struggling. Nice. Ok, so this one kind of test your ability to understand the results of a hint exam. I don't think you'll be asked to perform a hints exam in the OS scenario. I don't know anyone who has been asked to do that, but it's always good to be aware of it. Geeky medics again has a really good page on it. Um So whenever you have someone with vertigo, um and the nystagmus, you're thinking, OK, it could be a central cause or peripheral cause. Um central causes can be things like a posterior circulation stroke and a peripheral cause like vestibular problems, um like men or labyrinthitis and things like that. So, in this scenario, you want to try and rule out the most dangerous causes of vertigo and this is particularly relevant because her head impulse test is normal. And this is one of the weird ones where if you have a normal test, it's actually more worrying. The reason for this is because the head impulse test tests your vestibular ocular reflex and your vestibular ocular reflex um is sort of associated with your vestibular function in your and your peripheral sort of function in your ear. So, if the head impulse test is normal, that means that your vestibular ocular reflex is also normal, which means that your peripheral vestibular function is normal, which means that the most likely cause in that scenario would be a central cause. Um and obviously strict are pretty, pretty dangerous. So you need to refer to A&E to this one for this patient. Um It's, it's a pretty tricky question to be fair. Um If you remember the causes of nystagmus, well, there are quite a few causes of nystagmus. Um, gaze, nystagmus is where you get nystagmus on extremes of gaze or like when you're not looking centrally, um it can be normal. Um But one of the causes is a central um essential cause. Um you could perform a dix Hallpike maneuver if you're suspecting BPPV. And again, BPPV is one of the most common causes of vertigo um in adults. However, you still want to rule out the most important things. Um And I remember there was a question in passed, I think, and in one of the comments, it was like you would never perform a dix Hallpike maneuver and a head impulse test together. And the reason for that is because if you perform a dix Hallpike maneuver, that means you're suspecting BPPV. And that means that the vertigo is lasting like less than a minute if you're performing a head impulse test, that means you're not suspecting a BPPV. That's because the vertigo lasts for more than a minute. So depending on how long the vertigo lasts, you'll be performing either test. So it's probably not good practice to perform both the head impulse test and the dix Hallpike maneuver plus the dix Hallpike maneuver can be misleading if they already have nystagmus. So it could be a bit tricky to interpret. Um The other options are give prochlorperazine and review in for six weeks, which would be an option if she just had persistent vertigo alone. Um And everything else has been ruled out. Um And the EU and exercises are treatments for BPPV. But yeah, that's a tricky question. If you want me to go over that again, I can talk through it again at the end if you have time. So next question, nice people are seeming pretty confident with this one. So we, we literally just talked about it. Um So this is most likely gonna be a BPPV. So you've got a 75 year old gentleman, sudden attack of dizziness. Um And they last 30 seconds sound um and the diagnostic. So D for diagnosis, Dix Hallpike maneuver. Um Yeah, pretty much everyone got that one right. Um Again, Epley maneuver and brand are for treating. Um These are the most common ones mainly because there are a bunch of different types of maneuvers you can do for BPPV. The main, one of the most common causes of BPPV is otoliths which are like crystals in your semicircular canals. You've got three semicircular canals in your ear, if you remember, and they all face different directions. You've got an anterior, a posterior and a horizontal canal um and the most common canal to be affected is the posterior canal, which is kind of why you have to like throw the patient's head backwards. So you can dislodge the otoliths from the posterior canal. And in most cases, um the maneuver and the brand exercises could be of benefit to some of these patients, but sometimes these maneuvers don't work. So you have to try different maneuvers and that's because it's the other canals that are affected. So say, for example, if they've got an anterior, um the anterior canal is affected, they have to do like a different maneuver that goes forward. And if they have a horizontal canal that's affected, then they do like a barbecue roll maneuver, which is like you go on the, the patient goes on their belly and they kind of roll around on their belly for a little bit. Um But I digress. So it's, you've got different types of maneuvers, but to diagnose D for diagnosis and D for dick's hole pike. So that's the one you need to do. Um OK. Next question, sorry, this question is pretty chunky. I'll give you some more time. OK. Five more seconds. 4321. Nice. So this question is assessing whether you know what to do with a patient who has sudden onset, sensorineural hearing loss. We know it's sensorineural because of whether or not you can interpret the Webers and renee's test. Um so that it can be quite confusing and you might, you might be asked to perform Wes and Renas in your sy as well. So the way I remember it is Weber has like an Ebe. So I remember like the ES or like the ES and the bee is like the forehead with the tuning fork on it. So that's how I remember. Like Webers is the one where you have to put the tuning fork on the forehead and see whether it localizes to either side. So here it localizes to the right side. So that means that he's either got centrine neural hearing loss on his left side or conductive hearing loss on his right side. The reason for that is because sound kind of travels better and solid. And I think of it like if it's conductive hearing loss, then it could be like a lot of ear wax. And so like the sound troubles ba in a wax. Um It's hard to describe it. But yeah, that's how I remember it figure out your own way of trying to remember it. Um And then the RNAs test um it's positive if air con air conduction is better than bone conduction and that's positive on both sides. So that means it's some type of sensorineural hearing loss. So that's why we know it's um left-sided centrone neural hearing loss. Um And yeah, so it's sudden because it happened within two days. So free nice, has a nice definition of sudden onset hearing loss. So it's sudden onset of a over a period of three days or less. Um And in Livingston, they also say sorry that it has to be more than 30 decibels of hearing loss to qualify. Um We probably won't need to know that for a or exams. Um So yeah, so they've had two days of hearing loss. Um and they need either an urgent referral or an immediate referral. And nice says that if the episode occurred more than 30 days ago, then you do an urgent referral. So that means they're seen within two weeks. Whereas if they're seen less than if they had this episode less than 30 days ago or they have um signs of complications such as facial drip or if they're immunocompromised, then they need an immediate referral for sensory neural hearing loss. Um But it's not stipulated in this question. So the most appropriate answer here would be an urgent referral. Um Yeah, nice. Most people got that one right. Uh Ear irrigation is mainly indicated if there's conductive hearing loss, you probably might need to do, you might need to do that if there's like a conductive cause as well as a sensory neural cause. Um But ent will arrange all of that intranasal intranasal steroids if there's eustachian tube dysfunction. Um And that's where they have a feeling of hearing loss that clears upon doing the valsalva maneuver kind of like when you're on an airplane. Um And Yeah, routine referral is not appropriate here and trial prochlorperazine again, if there's vertigo. Nice. So, so those are the ear questions. Um and I'll just run through. So some of the main conditions on the MLA content map again, you'll get these slides. So don't try to memorize all of this right now, I'll just highlight the main thing. So otitis media um typically in Children, it's a middle ear infection and you have a bit of a cough beforehand, some ear pain. The key thing to note is the bul bulging tympanic membrane and the loss of the light reflex. Um and you may get some perforation as well. You might in your sy, you might get a picture of a bulging tympanic membrane and you won't see that light cone. And so you'll think, oh, that's a titus media. Um And in terms of management painkillers and a potential delayed prescription if it lasts for more than three days and you give them immediate antibiotics again, passed has a really good list of like which scenarios you give antibiotics immediately and that's if it lasts more than four days, systemically unwell, immunocompromised or they're pretty young with bilateral um otitis media oritis media with a perforation. Um We got a question on what's the most common or what's the most likely complication of otitis media. And it gave like pretty much all of these options at the bottom like brain abscess or facial nephrolysis. But the, the answer was hearing loss. So think about like the most common complications first before you start thinking about like the more dangerous ones, but they're also a lot rarer. Um at externa key things, risk factors are if you're a swimmer, if you're in a tropical climate or if you're immunocompromised, um and it tends to be a bit more itchy compared to otitis media. Um in terms of management, you go topical first, you know, it's an external infection. So you can give topical antibiotics and steroid drops um and consider micros suctioning as well if there's debris so that the medication can reach the air canal better. Um Pope works are like tampons for the ear and they're soaked in um antibiotic and they stay in for a bit longer but they're really uncomfortable for patients. Um and just be aware of malignant or necrotizing otitis externa um which can occur in elderly diabetics. And for that, you also need a scan acoustic neuroma. It's actually pretty rare but just try to remember to do an MRI. Um and you could in reality also perform an audio, perform audiometry, but MRI is the gold standard. Um Meniere's disease, recurrent vertigo, just try and remember recurrent. Um And there are different approaches to management um focusing on reducing the vertigo in an acute attack. And as you can see, prevention is focused on sort of reducing the no uh reducing the amount of fluid in like the indoline fluid in the ear. CSO M um It's chronic spur hepatitis. Yeah, nice thanks to. Um, yeah, so it's one of the complications of otitis media. Um BPO BPPV. Key thing to note here is do your, the diagnosis DPI. Um, and then you've got your different uh, maneuvers to help with that. And I've just got a nice handy little table to help you with your differentials for vertigo and you can look at that a bit later. So on to the end questions, uh I have five minutes. Uh, my bowels are these, I'll try and finish the slides. But, um, if you need to head away, I won't be offended. I promise, I might just send the feedback form in like five minutes as well. Cool. So this one is, so you've got an 11 year old boy who comes in with a nose bleed, um, and he's had recurrent nosebleeds, but he's hemo hemodynamically stable. Um, and you can see a bleeding site. So this knowing the answer to this question is basically like there's a step by step that you need to know for exams. Um First of all, you start off with your compression, you do that for approximately 20 minutes, that's considered the threshold. You pinch the nasal Aler. So that's like your actual nostrils and not the bridge of the nose, you try to tilt the patient's head forward, tell them to cough up the blood. Um And if that fails, then you can try and see if you can see if there's a, a bleeding site in the nose. Um, it will look like a swollen blood vessel. Um, and you use a silver nitrate stick to chemically cauterize that blood vessel and it's done in a spiral motion. If you're in Ent and Livingston, that's actually a procedure that students can do and it gets logged in your logbook as a supervised procedure. So, yeah, have a gander if you can. Um But yeah, for that procedure, you put local anesthetic, use a silver ni silver nitrate stick and then they get given an antibiotic, nasal spray after that. Um Some people said nasal packing. So nasal packing is where you get an adrenaline soaked gauze and you stuff it into the nose and it's actually quite uncomfortable for patients as well. Like it, it's a big blob of cotton wool. Um And the adrenaline is meant to vasoconstrict the vessels. It's a, it's not actually cotton wool, it's like a really expensive version of cotton wool. Um But yeah, that's that's done if you can't see a bleeding site and you need some time before you refer on to Ent. Um Yeah, nice and no one else put any of the other answers we'll move swiftly on kill. So for this question, the most likely diagnosis here, we know it's acute sinusitis. So he's got the classical pain in his forehead and cheeks. It's where your frontal and maxillary sinuses are, and he's had this nasal discharge for the past three days. Um That's what we called. So it's like an infective course. Uh So all of the options are pretty similar with different variations. Um And the answer here is paracetamol, nasal saline irrigation and decongestants. And that's the, that's the management of choice for acute sinusitis. If they were really, really unwell or immunocompromised, then you could consider giving antibiotics as well. But um, it's, it can risk something called a double thickening effect, which is where the viral infection gets better. But then the antibiotics kill all the good bugs in your nose. Um And so the bad bugs can cause a secondary bacterial infection. And so the patient may seem to get better for a bit and then they get worse again. Um, for the intranasal steroids, you probably will know this because you've got this question right. But you give it after 10 days of symptoms. Um cefTRIAXone is not a first line option for sinusitis. It's either penicillin B or amoxicillin or coamoxiclav. Um And yeah, subcutaneous sumatriptan is for treatment attacks. Next question. Also, if you have to head, don't worry. Um uh, all the slides will be sent out. I'll just put the feedback form in the chart in case you need to go and you'll get a certificate and the slides after you fill out the feedback form. Oh, gosh, I don't know why that's sent three times. Cool. So you've got a 29 year old gentleman who's been hit in the face kinda painful. And this epistaxis um key thing to hear is that the na key thing to note here is that the nasal septum is swollen, so it's kind of boggy. Um And so what we're concerned about here is a nasal septal hematoma secondary to trauma. Um So yeah, so that requires nasal packing and an urgent ent referral because we know that a septal hematoma can cause permanent damage. Um As you said before, culture is only applicable if there's a clear bleeding site, um leaving it for a few days is not appropriate because again, they can get a septal perforation or a saddle nose deformity if the septal hematoma is not dealt with um urgently. Next question. Oh Will here. Um I will, I'm, I'm kind of running very late but I'll try and hammer through the rest of the slides. Nice. So this is actually pretty, this is a tricky question. Um So you've got a seven year old boy who attends A&E with a leg block in his nose. Um and he's pretty uncomfortable and he can't really breathe through his nose and he's got an oxygen saturation that shows he's struggling a little bit. Um but not yet requiring oxygen. So you, I don't think you'd be completely penalized in an osk scenario if you said you'd prefer immediately for ent for like immediate removal of the foreign body. Um officially, if you're thinking of an immediate referral, you also have to think is this something I'd want to wake up my ent registrar for? And there are only a few scenarios in which you'd actually want to wake up your ent registrar for. And it would be if there's a battery in the nose, particularly a button battery because this can leak, um, into the nose or cause a corrosive reaction in the nose and erode the mucosa. And the second thing is if there's magnets in the nose, because again, that can cause like a septal perforation. Um So these are the two main ones um where you'd want an immediate removal of the foreign body for this, for this little boy, he's got a Lego block and so he's not in any dire um He's not in need of a dire removal of the Lego block. Um But we still want to try and remove it as soon as we can. So that's why we'd want to book an E OA of the nose right now. Um and schedule in removal by tomorrow morning. So any time before tomorrow. Hello. Hello. I'm not sure if my connections just been cut off or not. Can you hear me now? Sorry. I think my connection just went off for a bit. Sound thanks. Sorry. NHS Wifi being a little bugger today. Um Yeah, so II don't know where I went up to but T LD R is if it's not a button battery or a magnet, then consider like a very, very urgent a nose. But if it is a button battery or magnet, then you'd want immediate removal of the foreign body. Oh, you can see me as well. Oh, interesting. OK. Um So epistaxis. So this just note again, you'll get the slides. So a key thing to know about Epistaxis, it can be anterior or posterior, posterior is the more dangerous one. But it's also a lot rarer anterior is the most common. Um And you've got a bunch of things that can cause it in younger patients. You want to think about um trauma or bleeding disorders. So you'd want to do a full blood count and test for hemophilias. But if they're a bit older, think about hypertension, you'd want to check their BP and see if they are on any BP medications. Um And yeah, you've got your step by step management for epistaxis and just ro learn that if you can, epistaxis is actually quite dangerous if it's not managed correctly. So if you're, if you're in A&E and you've got someone with a nose bleed, don't just brush it off because they can become hemodynamically unstable very quickly. Um This is just a flow trot from Liverpool and again, step by step. Um It's just a top thing. It, it's changed to 20 minutes instead of 10 minutes. Um Rhinosinusitis can be a little bit intimidating because there's so many like subcategories. But if you think of it as allergic or non allergic causes of rhinosinusitis, then it can help frame your management. So if you've got someone with allergic rhinosis, you do all the things you do with a normal allergy. So avoid your allergen, give an antihistamine, give some steroids and consider nasal douching just like cleaning out your nose with a special solution. Um And if it's non allergic, then it can be acute or chronic. If it's chronic, that means it lasts for more than three months. And that pretty much applies to anything that has chronic in the name. Um And again, the way you manage that, um you give analgesia nasal douching decongestants plus or minus steroids if it's more than 10 days. Um and consider a fe if it's due to a nasal polyp, we need to explore a bit more fe stands for functional endoscopic sinus surgery. Um, and you might get to see if you're an ent placement. Um It's pretty cool. It's like a little muncher that eats away at any of the polyps and they try to open up the sinuses as well. So you might see them just like pulling out bits of skull from the nose. Um And that just helps clear everything out and it helps the patient breathe. Uh And that was a video, but you can just youtube the video. Next question. I'm gonna have to rattle through these. Ok. Nice. So this question is asking to see whether you know your differentials of sore throat. And in particular, here, you've got someone with a maculopapular rash that developed quite quickly after they were given antibiotics. So immediately that screams, um, this is a glandular fever because you can get that rash once you've been given antibiotics. Um, it doesn't quite come under ent, but you do get a lot of patients in the ent wards who have glandular fever, get given antibiotics and then they end up with this rash. Um So that's why it's really, really important when you're um suspecting a tonsillitis to also do a monospot test or an iron test uh for infectious mononucleosis. Um just to kind of rule out a glandular fever and also do LFT S. Um So yeah, you'll get top marks if in an osk station, you're suspecting a tonsillitis and you'll say I want to rule out the glandular fever. Um Some people put group a strep. So yeah, it, it could be, again, it could have like a bacterial superimposed on a viral infection. But the key thing here is that they developed a rash after they were given the antibiotics. Um So that rash means that they got an initial wrong diagnosis. Um Next question. Oops, I'm just gonna plug my laptop in as well. No pill. Oh. Um This patient does have a tonsillitis. Um And it's assessing to see whether you know your fever pain score and your central criteria and it, it looks like most of you do. Um First line, yeah, is oral penicillin. B. Um You can give amoxicillin as well. Um But it's not first line. So this is kind of a cheeky question to be honest. Um But yeah, it looks like most of, you know, your uh cent and fever pain criteria. Just make sure you, you learn those. We'll move on to the next question since you all did so well on that one. Cool. Um So this Vitis would be on your differentials, but I've already given you a question on tonsillitis. Um And in particular, you've got the uvula which is deviated towards the left. So that's telling you that there's something that's pushing it towards the left and that would be a Quincy or a um peritonsillar abscess and that requires immediate um sending to hospital so that they can have it drained or aspirated. Um It's also associated with Christmas and that can be considered sort of like a red flag if they're not able to eat and drink and they might be sent to hospital for IV. Um And yeah, the, this I mentioned level two on the question, that's actually not something you need to know for like osteo exams. It'll be quite mean if they ask you like, oh what level is the lymph nodes in the neck, but just be aware that the neck has seven regions. Um And you can Google it a bit later, but that's a bit more specialist if you're really interested in ent um the first option, treat tonsillitis and request routine referral for, for tonsillectomy would not be indicated in this case because she's had five episodes in the past year. Um And if you remember the sign guidelines for a tonsillectomy, you need seven in one year or five in two years or three in three years. So it's like five, it's 753 and then 123. So it's, yeah, it's got a nice little part to it. Um But yeah, I think most of you got that right next question. Last few questions. Ok. Ok. He's all doing really well. Yeah. No, cool. Um So he's got a 62 year old man with a persistently hoarse voice and a sore throat for three weeks or yeah, so it's been ongoing for those three weeks. Um And so what you're always gonna be concerned about in anything that lasts more than 2 to 3 weeks, whether that be an ulcer in the mouth or as he, he has a um unexplained hoarseness in his voice. Then you're considering a two week cancer pathway. No other way to memorize it other than just go on to the C KS. Nice um web page, head and neck cancers recognition referral. And it just outlines all the scenarios in which you want to refer for head and neck cancer. I'll put the link in the chat just now. Um, but that's fair game for Aussies. So, if someone's got a persistently hoarse voice for 2 to 3 weeks, I think cancer specifically laryngeal cancer for this gentleman. Um, yeah, and some people. So for the ot for vocal rehabilitation exercises, again, you want to rule out the laryngeal cancer. But if, if, if you find that he doesn't have cancer, then you could do the rehab exercises after next question. Second to last question. So you've got a 48 year old gentleman who's really tired. Um And snores really loudly, he's obese. He's got all these risk factors in your thinking. He's probably got some kind of obstructive airway. So he needs a formal diagnosis and to do that, he needs polysomnography assessment. Um All the other options. So, um if you do a pulse oximetry diary for a minimum of two weeks, you could do that alongside the polysomnography. But polysomnography is the gold standard um advising weight loss and you would do that as well. Um Especially if you're doing an s scenario, you're conservative medical and surgical management. But um the question asking for what's the most appropriate next step. So he needs a diagnosis so he can access CPAP, which is the treatment for this. Um So you'd want to get that diagnosis first and then once it's diagnosed, then you can re um refer to ent for an adenoidectomy. Um, evidence for adenoidectomy is a little bit conflicting um for a lot, a lot of the time it can help open up the space. Um but in Children, in particularly um the adenoids kind of enlarge when they're young anyway, or at least they're larger in comparison to the rest of their head and neck anyway. So, um it's quite normal for the adenoids to be, to appear enlarged in Children at least. And so there are a couple of papers being like, oh, we're overdoing adenoidectomies. Um And there's actually a consultant in Livingston who thinks adenoidectomies are a complete fallacy, but for all intents and purposes. Um yeah, they're, they're pretty effective. And then last question, nice. So 50 year old woman, she has diffuse swelling in her right parotid gland with facial pain and it has affected her facial nerve as well. So, you know, this is something dangerous and not benign. So immediately you're thinking, OK, it's probably not benign pleo pleomorphic adenoma even though it is the most common, but these benign things don't tend to invade the nerves. So, OK, so you're ruling that one out sarcoidosis, it can be associated with parotid gland enlargement, but you also tend to get um other symptoms as well. Um And it's none of those are mentioned in here and no calcium is mentioned either. Um Sjogren's syndrome is associated with more systemic dryness. It can be associated with lymphoid malignancies, but it's not as likely in this scenario. Um Warfarin's tumor is also a type of parotid gland tumor, but it's associated with smoking, it tends to be bilateral rather than unilateral. Um And so that means the most likely is the adenoid cystic carcinoma. Um If this question confuses you passed has a really good table on all the different types of tumors. Um In particular, the, the key thing in this question is to note that it's invaded the right, the right facial nerve. And so it's something that's a bit more malignant. Um So I can see why, why most people put the benign preic adenoma, but that one doesn't tend to invade. So just raffling through the the notes. So epiglottitis, I didn't have a question on it in here. But the most important thing to note is if epiglottitis is in your differential, do not examine because that could cause the patient to become anxious and that might close up the airway and that's a apple that you don't want to deal with. Um So immediately just brief anesthetics or ent and they need to be intubated. But that's less common nowadays because people get um vaccinated obstructive sleep apnea, um tends to be associated with obese people and can also be associated with acromegaly and Marfan syndrome, which are um collagen disorders, I think. Um and you do your polysomnography, which is the gold standard and you can ask the patient to keep to do a sleep in a scale as well to assess how severe it is um tonsillitis. You all did really, really well on that. Um It's your bread and butter or B NT. So remember your center and fever pain scores. Um And remember your tonsillectomy criteria don't refer a tonsillectomy. If they're in the acute phase, try to resolve the acute phase first. Um And if you go see a tonsillectomy in theater, I think most of, most of the surgeons here do the hot method, which is using cautery. Um But if you go to different countries, they still use the Cold method, which is where they use a scalpel and they literally just cut out your tonsils. Um And it works because there's an a, a vascular plane. Um So there's not as much bleeding until you reach the inferior pole, which is where all the blood vessels are. Um But you need to be really, really skilled in this and it can be associated with more bleeding. It's also less painful. So it's a bit of a balancing act. Um And to not as well, if there's a hemorrhage after a tonsillectomy, um then that can be also quite life threatening. So you need to do your a to e and your major hemorrhage. I don't know if that will come up in, I don't know, like maybe a POSTOP osk scenario in the final year. Um Don't forget that glandular fever exists. It's um you do your monospot test and your bloods FBC LFT S. Um And it's supportive man management after that and don't forget your neck lumps as well. Um Past me again, has a good list of differentials and don't forget your cancers. Um And this is just a brief, a few slides on ay so ent osteo osteo stations can be a bit intimidating at first. Um But the way I think about it is I always ask about pain infection, swelling and discharge. Um and then depending on what their symptoms are, I focus in on like the ear first and then the nose and then the throat. So the ear, you think about what function the ear has. So it, you use your ear to hear things and for balance. So you ask them, ok, do you have loss of hearing or do you have a gain in hearing which is tinnitus or like extra sounds? Um Do you have any balance problems then for nose, um mainly used for smell, any changes in your smell, any deformities around your nose and then throat. Do you have any problems with breathing, speaking or eating? Those are the three functions roughly of your throat. And if you use, use this in your history for all ent stations, then you'll, you'll fly through. Um and in terms of examinations and you may be presented, you may be asked to do the examination and then be presented with the finding. So it's always worth it to know what you're looking at. Um So on the left, I have a normal um tympanic membrane, but then spot diagnosis. I don't know if anyone wants to shout out. Probably not enough time. But so top left is again normal. Top right. That's your bulging tympanic membranes. If you remember from before, that's gonna be your acute otitis media. And then the bottom left is um the effusion. So that's the, that's retracted and then your bottom right is the grommet and the grommet falls out on its own after a few weeks. Um And they could be asked to interpret a throat. So you've got a normal throat examination on the left, maybe a little bit erythematous, but mostly normal. And then top left, you've got the um the tonsillar exudate. So that's your bacterial tonsillitis. And then top right. Um You can see there's a peritonsillar swelling and valid deviation towards the patient's left. So that's a right quinsy. Um And again, if you look on the normal side, you can see an arch, your palatopharyngeal arch and your palatoglossal arch as well. Um And a peritoneal abscess, you won't see the arches as clearly. So that's how you can tell that's um a quinsy on one side and then the bottom one is a glandular fever and it can be quite tricky to differentiate between glandular fever and bacterial tonsillitis on examination. But I've been told that a glandular fever looks a bit more creamy, a bit thicker, um, a bit more cheese like compared to bacterial, but again, you'll still do your monospot and your LFT S and yeah, this is your investigations. But look at the medics if you're still concerned about this. Yeah, that's, that's it. Thank you very much for listening and thank you very much for engaging as well and answering all the questions. Um, please please fill in the feedback, I'll send it again. Um, if you somehow missed the three links that I sent already. Um If you're really interested in Ent I'd recommend looking at the ENT UK booklet uh and looking at En TSH o.com. Nice also has some really good guidelines but they're pretty hefty. I I'd stick to memorizing the head and neck cancer. Nice guidelines. Um And let me know if you have any questions. Yeah. Thank you very much. I hope it was useful. Yeah, and you're free to go. I don't know if will is still here. But um he might want me to tell you about the future Ess sessions. I'm I'm not sure when they are and I don't know who's doing them, but make sure you go to those. It's always really good practice. Mhm. Um Yeah, and if you uh if you have any questions, just email me, email is at the bottom, but otherwise thank you very much for listening. Um and please fill in the feedback form and come to the future sessions. Thank you very much.