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Medicine finals Prithvi > ENT > Flashcards

ENT Flashcards

1
Q

two parts of the external ear

A
  1. auricle/pinna

2. external auditory canal

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2
Q

what causes cauliflower ear deformity?

A

Accumulation of blood between cartilage and overlying perichondrium can disrupt the blood supply to the cartilage. If untreated can result in avascular necrosis of the cartilage, resulting in a ‘cauliflower ear’ deformity

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3
Q

significance of external auditory canal being S-shaped

A

This means you will have to pull back the auricle when examining the canal to attempt to straighten this

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4
Q

what is the light reflex when using an otoscope and what is its significance?

A

Light shining from the otoscope on the tympanic membrane is known as the ‘light reflex’ - use this to tell which ear we are looking at:
A light reflex at 5 o’clock is a RIGHT SIDED EAR
A light reflex at 7 o’clock is a LEFT SIDED EAR

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5
Q

imp structures of tympanic membrane

A

The pars flaccida is the weakest part of the tympanic membrane and is flaccid
Pars tensa forms the rest of the membrane

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6
Q

the middle ear contains?…

A 
1 nerve (facial nerve)
2 muscles (stapedius and tensor tympani, both useful to protect the ears from loud noise to avoid damage)
3 bones (the ossicles - malleus, incus and stapes. These attach in a chain from the tympanic membrane to the oval window)
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7
Q

what is the mastoid process and significance of being close to the middle ear?

A

The mastoid process is the area of the temporal bone located behind the ear and contains air cells that both protect the ear and can equalise ear pressure
These mastoid air cells sit posterior to the middle ear and are therefore vulnerable to infection from the middle ear

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8
Q

purpose of eustachian tube

A

When atmospheric pressures changes, pressure differences can develop between the outer and middle ear. The eustachian tube opens allowing pressure to equalise. this can happen when swallowing, performing the valsalva manoeuvre

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9
Q

contents of the vestibular system and importance

A

3 semicircular canals and utricle and saccule.The semicircular canals are in three different positions; horizontal, superior and posterior. Each contain endolymph and sensory hair cells
The vestibular system detects balance and positioning

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10
Q

what ducts make up the cochlea?

A

Vibrations received from the ossicles via the oval window continue via this system to be translated as sound by the brain
The cochlea is made up of three ducts; scala media, scala tympani and scala vestibuli. Vibrations work across the membranes between these ducts to transmit this into an electrical signal via the Organ of Corti

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11
Q

which part of the nasal cavity can the olfactory nerve be found?

A

The olfactory nerve sits at the superior aspect of the nasal cavity

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12
Q

what are the lateral walls of the nasal cavity covered by and what purpose does this serve?

A

The lateral walls of the nasal cavity are covered by a superior, middle and inferior turbinate or concha
These are projections that increase the surface area within the nasal cavity
This allows for improved humidification, temperature change and filtration of inspired air

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13
Q

what are the clinically important plexuses in the nose?

A

anterior and posterior,
Anterior is known as Little’s area or Kiesselbach’s plexus (arterial) and has a rich blood supply that is the frequent source of epistaxis (nose bleeds)
Posterior is Woodruff’s plexus (venous) and is the site of posterior nose bleeds

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14
Q

bleeding from little’s area

A

more common
occurs in children/young adults
usually due to mucosal dryness
less severe

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15
Q

bleeding from woodruff’s area

A 
less common
older population
hypertension/atherosclerotic disease
more severe
use of aspirin and warfarin
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16
Q

what are the 2 triangles of the neck and what are they divided by

A

anterior and posterior traingle of the neck. divided by the sternocleidomastoid

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17
Q

boundaries of the anterior triangle of the neck

A

superior: mandible
medial: midline of the neck
lateral: sternocleidomastoid

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18
Q

key structures in the anterior triangle of the neck

A

Thyroid and parathyroid glands
Cranial Nerve IX, X and XII
Carotid artery and internal jugular
Salivary glands

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19
Q

boundaries of the posterior triangle of the neck

A

Anterior - Sternocleidomastoid
Inferior- Clavicle
Posterior- Trapezius

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20
Q

key structures in the psoterior triangle of the neck

A

Subclavian artery and vein
External jugular vein
Cranial Nerve XI
Brachial Plexus

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21
Q

cystic hygroma vs branchial cyst

A

Both are benign, malformations that result in a neck lump however branchial cysts are found in the anterior triangle and cystic hygromas in the posterior triangle

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22
Q

what is the most common site of salivary gland tumours?

A

parotid glands

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23
Q

what can be affected by any pathology of the parotid gland?

A

The motor branch of the facial nerve runs through this structure and is thus affected by any pathology to the parotid gland

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24
Q

which gland produces most of our saliva when not eating?

A

Submandibular gland

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25
Q

which salivary gland which produces the most mucous secretions

A

sublingual. However, this does mean that mucocoele formation is more likely at this gland and these are called ranula

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26
Q

where is the problem in conductive hearing loss?

A

external or middle ear

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27
Q

where is the problem in sensorineural loss?

A

inner ear or cranial nerve VIII.

Most commonly caused by age-related changes

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28
Q

explain rinne’s test

A

In a normal ear, air conduction should be greater than bone conduction. This is a POSITIVE Rinne test
Due to obstruction of the ear canal, bone conduction is better in conductive hearing loss. This is a NEGATIVE Rinne test

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29
Q

explain weber’s test

A

Weber test should be equal in both ears in a normal patient
Again, because bone conduction is greater than air in conductive hearing loss, the sound lateralises to the affected ear
In sensorineural hearing loss, the reverse happens; sound is louder in their normal, unaffected ear

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30
Q

signs and symptoms of acute otitis media

A

otalgia (ear pain), inflammation of the tympanic membrane and malaise

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31
Q

pathophys of AOM

A

Caused by upper respiratory tract infections migrating via the Eustachian tube into the middle ear
Much more common in children as their Eustachian tube is shorter and wider therefore allowing easier transmission
Can be viral or bacterial. Common viruses involved are RSV, rhinovirus, enterovirus. Most common bacteria is s. pneumoniae

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32
Q

management of AOM

A

Mostly self-resolves, support with analgesia such as paracetamol
If worsening or significantly unwell can treat with amoxicillin
Children with recurrent acute otitis media infections are considered for grommets

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33
Q

complications of AOM

A

Tympanic membrane can perforate due to build up of pus
Recurrent infections can cause hearing loss
Severe complications include mastoiditis, facial nerve palsy and intracranial infection

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34
Q

presenting complaint of perforated tympanic membrane as a complication of AOM

A

Patients may complain of otorrhoea (discharge from the ear) and a sudden relief of pain

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35
Q

what is OME (otitis media with effusion) and what is the key presenting complaint?

A

A collection of NON-INFECTIVE fluid in the middle ear
Key presenting symptom will be hearing loss, in very young children this can manifest as delayed speech development
Sometimes known as glue ear and seen almost exclusively in children

Otoscopy - Classical findings are of a dull tympanic membrane with a light reflex reflected upwards or an absent light reflex

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36
Q

pathophys of OME

A

Most common cause is Eustachian tube dysfunction. In childhood, the wider and short eustachian tube is more prone to infection AND also poorer ventilation
Other exacerbating factos include other congenital structural malformations such as cleft palate and allergies
In adults, always consider malignancy causing obstruction of the Eustachian tube

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37
Q

management of OME

A

50% resolve in 3 months
Unresolved cases will be considered for hearing aids or grommet insertion
No indication for antibiotics. Remember this is non-infective

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38
Q

chronic otitis media signs and symptoms

A

Recurrent otitis media infections can cause tympanic membrane perforations
Symptoms are hearing loss and ongoing otorrhoea usually for > 6 weeks
There are usually no infective signs such as fever or otalgia

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39
Q

pathophys of chronic OM

A

Recurrent acute otitis media infections causing perforation of the tympanic membrane
Can also occur due to trauma to the ear resulting in perforation
Iatrogenic from grommet insertion

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40
Q

management of chronic OM

A
  1. Aural toilet - washing out the ear canal
  2. Topical antibiotics/steroids - allow the perforation to heal
  3. If the perforation is not healing/is too large to heal, can surgically repair it. This is called myringoplasty and involves taking cartilage from the tragus and using that to fill the space.
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41
Q

complications of chronic OM

A

Recurrent infections can cause hearing loss

Severe complications include mastoiditis, facial nerve palsy and intracranial infection

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42
Q

what is a cholestatoma?

A

A destructive, hyperproliferating growth of keratinazing squamous epithelial cells of the middle ear
Keratinazed squamous epithelium is essentially skin that has collected within the middle ear. This squamous epithelium is expansile and can erode into surrounding structures.

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43
Q

signs and symptoms of cholesteatoma?

A

Symptoms will vary depending on invasion of the cholesteatoma:
Otorrhoea (most common) - chronic in nature, classically brown in colour without otalgia or fever which differentiates this from infection
Conductive hearing loss - occurs if invasion damages the ossicles
Senosorineural hearing loss - invasion of the cochlea
Dizziness - damage to the semicircular canals
Facial nerve palsy - invasion of cranial nerve VII

Exam questions classicaly describe a ‘pearly white/grey appearance’ on otoscopy with painless, brown discharge.

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44
Q

pathophys of cholestatoma

A

This collection forms due to the presence of a ‘retraction pocket’; a space that forms behind the tympanic membrane that is prone to trapping squamous epithelial cells.
Risk factors for developing this retraction pocket are: recurrent acute otitis media, Eustachian tube dysfunction and previous ear surgery

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45
Q

management of cholestatoma

A

A CT scan of the temporal bone is required to confirm diagnosis and for pre-operative planning
The definitive treatment is complete surgical removal. All of it must be removed otherwise it will recur

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46
Q

complications of cholestatoma

A

Dependent on the site of invasion

Severe cases can result in intracranial invasion leading to infection

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47
Q

otitis externa signs and symptoms

A

Presenting symptoms are otalgia, otorrhoea with a swollen, erythematous ear
Patients are often very tender at the pinna on movement
May also complain of itching of the ear

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48
Q

risk factors for otitis externa

A 
A very common condition sometimes called 'swimmer's ear'. Risk factors include:
Increased water contact
Humid conditions
Excessive use of cotton buds 
Presence of hearing aids
Immunocompromised patients eg. diabetics
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49
Q

pathophys of otitis externa

A

Disruption of the external ear canal’s protective mechanisms (through water, trauma etc) trap bacteria that results in infection of the external auditory canal
The most common bacteria is pseudomonas aeruginosa

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50
Q

management of otitis externa

A

Topical antibiotics and steroids
This may need to be inserted via a Pope Wick to ensure topical anibiotics are delivered effectively
Consider aural toilet and microsuction

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51
Q

complications of otitis externa

A

Necrotising otitis externa is a result of spreading infection into the mastoid and temporal bones which can cause cranial nerve palsies. If left untreated, can result in death
Treatment for this requires a prolonged course of iv antibiotics

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52
Q

what is dizzines/vertigo?

A

True vertigo is the inappropriate sensation of movement of the surroundings - “Like the room is spinning”

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53
Q

name 3 common otological causes and 3 central causes of vertigo

A

otological - BPPV, Meniere’s disease, vestibular neuronitis

central - stroke, MS, migraine

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54
Q

what is BPPV and its pathophys

A

Benign Positional Paroxysmal Vertigo is a condition defined by temporary episodes (paroxysmal) of vertigo brought on by moving the head in certain positions (positional).
It is caused by the presence of crystals called canaliths in the semi-circular canals. These are normally found in the utricle of the inner ear and can dislodge due to age, infection/injury or diabetes
On head movement these crystals cause abnormal movement of the endolymph in the canal thus triggering symptoms of vertigo
This vertigo usually only lasts seconds

55
Q

how to test for BPPV?

A

dix-hallpike mamanouevre

56
Q

management of BPPV?

A

epley monouevre

57
Q

what is meniere’s disease?

A

Meniere’s disease is a triad of vertigo, tinnitus and sensorineural hearing loss.
It is thought to be due to increased endolymphatic pressure within the semicircular canals
An episode usually lasts minutes to hours

58
Q

management of meniere’s disease?

A

It usually self-resolves however if recurrent or severe patients are advised to reduce salt and caffeine intake. If this fails, intratympanic steroid or antibiotic injections may be considered

59
Q

vestibular neuronitis

A

Inflammation of the vestibular nerve can result in vertigo.
This is usually associated with a viral infection and patients may describe typical viral symptoms of the respiratory tract.
This usually lasts for days and is severe; patients are usually bed-bound

60
Q

management of vestibular neuronitis

A

This usually self-resolves and patients can be given anti-emetics and encourage fluids to avoid dehydration due to vomiting
Long-term damage can be managed with rehab exercises

61
Q

what is referred ear pain? and where can the origin be?

A

If there are no clinical symptoms or signs of ear disease other than otalgia it is important to remember that this could be referred pain (pain from somewhere else manifesting as otalgia),

Sensory innervation to the ear is supplied by CN V, VII and IX and the cervical spinal nerves.
CN V
Disease of the teeth
TMJ disease (temporomandibular joint) eg. excessive grinding of the teeth
Parotid gland disease
CN VII
Herpez zoster infection
Bell’s Palsy
CN IX
Disease of the throat such as tonsillitis, pharyngitis
Oropharyngeal malignancy such as cancer of the tongue
Cervical nerves
Cervical arthritis

62
Q

what is rhinosinusitis? symptoms?

A 
Inflammation of the mucosal lining of the nose and paranasal sinuses.
Symptoms can range from:
Rhinorrhoea (runny nose)
Nasal congestion
Reduced sense of smell
Facial pain/headache
63
Q

pathophys of rhinosinusitis

A

Has several potential causes and this should be elicited from the history

Infection - This is most likely viral and common organisms include rhinovirus, RSV, parainfluenza virus. Can also be bacterial; s. pneumoniae and H. influenza
Allergy - This is an IgE mediated Type 1 hypersensitivity reaction. This is one of the symptoms of ‘hayfever’ and is more common in those with asthma and eczema
Other triggers - This can be cigarette smoke, environmental changes (such as cold or dry air), pollution, exercise

64
Q

management of rhinosinusitis

A

depends on cause -
Infection - most viral infections will self-resolve. Can offer nasal decongestants and severe bacterial infections may require antibiotics
Allergy - Avoid known triggers. Nasal decongestants or intranasal steroids may be of benefit
Other triggers - Lifestyle modification where relevant and avoid triggers. Again, intranasal steroids may be helpful

65
Q

complications of rhinosinusitis

A

Spreading infection
Intra-cranial infection
Osteomyelitis
Infections in or around the eye: peri-orbital cellulitis or orbital abscess which can result in loss of vision

66
Q

what is the most common facial bone fracture?

A

nasal fracture

67
Q

what are the 2 things to look out for when suspecting a nasal fracture?

A
  1. Septal haematoma
  2. Nasal deformity
    If neither are present, there is no further management required
68
Q

what is a septal haematoma, what can it lead to and what must be done to manage this?

A

Collection of blood within the septum after a nasal fracture is called a septal haematoma.
Similar to cauliflower ear, this cuts off the blood supply to the cartilage and results in saddle-nose deformity
Therefore this MUST be drained if seen on examination.

69
Q

management of nasal deformity

A

can be manipulated or surgically improved around one week after the break.

70
Q

what is tonsillitis and signs and symptpms

A

Infection of the palatine tonsils caused by viral or bacterial infection
pain, fever, dysphagia and cough

71
Q

complications

A

Severe cases may form abscesses

72
Q

pathophys of tonisillitis

A

70% of infections are viral, the rest bacterial
Adenovirus, influenza, rhinovirus and parainfluenza are the common viruses involved
30% of tonsillitis is bacterial: Group A beta-haemolytic streptococci is the most common

73
Q

management of tonsillitis

A

Most cases self-resolve
If clinical suspicion of bacterial infection, give antibiotics
tonsillectomy if they fit tonsillectomy criteria

74
Q

where is centor criteria used and what is it?

A 
For use in GP. Scores of 2 or more mean antibiotics should be considered as bacterial infection more likely. One point is scored for each of the following criteria:
HEAT - 
History of pyrexia
Exudates on tonsil
Absence of cough
Tender cervical lymphadenopathy
75
Q

what is the tonsillectomy criteria?

A

7 episodes in the last year OR
5 episodes in each of the last two years OR
3 episodes in each of the last three years
Swelling from tonsillitis affecting normal function

76
Q

what is quinsy?

A

A quinsy is a peritonsillar abscess that is a rare but severe complication of bacterial tonsillitis

77
Q

symptoms of quinsy

A

In addition to symptoms of tonsillitis (which will be severe in this case), patients may also experience trismus (difficulty fully opening the jaw), unilateral symptoms and a ‘hot potato’ voice (as though they have a hot potato in their mouth)

78
Q

management of quinsy

A

admission and treatment with iv antibiotics

quinsy must be drained of pus

79
Q

complication of quinsy

A

without drainage of pus, patients can develop deep neck infections or upper airway obstruction

80
Q

what is the most common histological type for cancers of the head and neck

A

90% of these are squamous cell carcinomas

81
Q

late symptoms of cancers of the head and neck

A

invasion into important surrounding structures and affecting ability to breathe, swallow and communicate

82
Q

what are the 2 biggest risk factors relevant for all types of head and neck cancers?

A

smoking and alcohol

83
Q

red flags and risk factors for cancers of the nasopharynx

A

red flags - otalgia, hearing loss, changes to sensation of smell
RFs - asian ethnicity, EBV infection

84
Q

red flags and risk factors for cancers of oral cavity

A

red flags - ulcer for >3 weeks, jaw swelling.

RFs - recurrent dental infections, sun exposure (if on lips)

85
Q

red flags and risk factors for cancers of the pharyns

A

red flags - persistent neck lump, dysphagia, otalgia

RFs - HPV infection

86
Q

red flags and risk factors for cancers of the larynx

A

red flags - persistent neck lump, dysphagia, hoarse voice, stridor
RFs - smoking ++

87
Q

1st line investigation for any neck lump

A

FNA (fine needle aspiration)

88
Q

management options available for head and neck cancers

A

chemotherapy, radiotherapy and surgery

89
Q

raised TSH, raised T4

A

secondary hyperthyroidism (TSH secreting pituitary adenoma)

90
Q

raised TSH, normal T4

A

subclinical hypothyroidism

91
Q

raised TSH, low T4

A

primary hypothyroidism (eg autoimmune thyroiditis)

92
Q

low TSH, raised T4

A

primary hyperthyroidism (eg grave’s disease)

93
Q

low TSH, normal T4

A

subclinical hyperthyroidism or T3 toxicosis

94
Q

low TSH, low T4

A

secondary hypothyroidism (non-secretory pituitary adenoma)

95
Q

normal TSH, raised T4

A

secondary hyperthyroidism (TSH secreting pituitary adenoma)

96
Q

normal TSH, low T4

A

secondary hypothyroidism (non-secretory pituitary adenoma)

97
Q

how does malignant thyroid disease present

A

NOT with symptoms of hyper/hypothyroidism but WITH neck lump

98
Q

management of thyroid cancers

A

surgical removal - thyroidectomy with radioactive iodine for more advanced disease following surgery

99
Q

how can foreign body in the ear present?

A

pain, hearing loss or discharge

100
Q

when is a foreign body in ear an emergency

A

Live insects- their movement and sound can be distressing particularly for young children
Button batteries - can burn the tissue and cause significant damage and complications such as hearing loss

101
Q

what are the options for removal of foreign body in ear?

A

Crocodile forceps

Microsuction

102
Q

can a nose bleed be a potentially life threatening condition?

A

YES. A nose-bleed can appear trivial, however is a potentially life threatening condition

103
Q

location of most nose bleeds?

A

90% are anterior

104
Q

causes of nose bleeds

A

spontaneous, or secondary to trauma, hypertension or blood thinning medication

105
Q

management of epistaxis

A

should be managed in a step-wise approach. If the bleeding fails to stop, move on to the next step

  1. Always start with ABCDE approach
  2. Pinch the cartilage of the nose and get the patient to learn forward for 20 minutes
  3. attempt to cauterise the bleeding point using a silver nitrate stick if it can be visualised
  4. Pack the nose, anterior or posterior depending on where you suspect the bleed is.
  5. At this point, the patient may require surgical ligation of the arteries.
106
Q

what is the ultimate and most severe complication of any ENT condition

A

airway obstruction. This can lead to respiratory arrest and death very quickly

107
Q

some causes of airway obstruction

A

Cancers

  • Oropharyngeal
  • Laryngeal
  • Base of tongue

Infections

  • Epiglottitis
  • Deep neck space infections

Foreign body
-Mostly seen in children

108
Q

Red flag Signs and Symptoms of impending airway obstruction

A 
Stridor/Stertor
Cyanosis
Agitation
Respiratory distress
Wheeze
Decreased breath sounds on auscultation
109
Q

management of suspected airway obstruction

A

Call for help!
Oxygen
Nebulised adrenaline/salbutamol may be useful here
If not improving, will require intubation
If unable to intubate due to obstruction/swelling may need a tracheostomy

110
Q

what is epiglottitis and its cause

A

It is an acute infection of the supraglottic tissue which can result in airway occlusion. This is a true ENT emergency.
Caused by Haemophilus Influenza type B - this has become rare due to HiB vaccine

111
Q

main symptoms of epiglottitis

A

3 D’s are the key symptoms:
Drooling
Distressed
Dysphagia

112
Q

what can an x-ray show in epiglottitis

A

A lateral C-spine X-ray shows a ‘thumb print’ sign

113
Q

management of epiglottitis

A

same as for airway obstruction starting with ABCDE plus -

  • may require intubation
  • IV abx
114
Q

what is leukoplakia

A

white patch adhering to oral mucosa that cannot be removed by rubbing. Biopsy of leukoplakia is necessary as there is a raised risk of malignancy.

115
Q

most likely diagnosis of a neck lump described as: a smooth anterior midline lump that moves upwards on tongue protrusion

A

thyroglossal duct cyst

116
Q

On examination, a large polyp is seen in the left nostril. Examination of the right nostril is unremarkable.

What is the most appropriate next step in management?

A

Unilateral polyps are a red flag symptom. urgent referral to ENT required.

117
Q

imp structures of auricle?

A

helix, tragus, concha and lobule

118
Q

external auditory canal

A

Extends from the concha to the tympanic membrane
Is S-shaped, not straight. This means you will have to pull back the auricle when examining the canal to attempt to straighten this
Outer one third is made of cartilage and produces wax
Inner two thirds are made of bone

119
Q
A

otitis media with inflamed and bulging tympanic membrane. this is another eg

120
Q
A

ranula - collection filled with saliva near sublingual gland

121
Q

lymph nodes of neck and what clinical examinations shd u palpate them in?

A

palpation relevant in thyroid, respiratory and abdominal examination

122
Q
A

perforated tympanic membrane

123
Q
A

large cholesteatoma in dome of middle ear

124
Q
A

sinus tympanic cholesteatoma

125
Q
A

normal healthy tympanic membrane

126
Q
A

septal haematomas

127
Q
A

tonsiliitis with exudates visible bilaterally

128
Q
A

quinsy/peritonsillar abscess on the right side. here the swelling from this is deviating the uvula away

129
Q
A

epiglottitis

130
Q

acute v chronic sinusitis

A

Acute (less than 12 weeks)

Chronic (more than 12 weeks)

131
Q

paranasal sinuses

A

They produce mucous and drain into the nasal cavities via holes called ostia. Blockage of the ostia prevents drainage of the sinuses, resulting in sinusitis.

There are four sets of paranasal sinuses:

    Frontal sinuses (above the eyebrows)
    Maxillary sinuses (either side of the nose below the eyes)
    Ethmoid sinuses (in the ethmoid bone in the middle of the nasal cavity)
    Sphenoid sinuses (in the sphenoid bone at the back of the nasal cavity)
132
Q

ix for sinusitis

A

n most cases, investigations are not necessary. In patients with persistent symptoms despite treatment, investigations include:

Nasal endoscopy 
CT scan
133
Q

sinusitis mx

A

Patients with systemic infection or sepsis require admission to hospital for emergency management.

NICE recommend not offering antibiotics to patients with symptoms for up to 10 days. Most cases are caused by a viral infection and resolve within 2-3 weeks.

NICE recommend for patients with symptoms that are not improving after 10 days, the options of:

High dose steroid nasal spray for 14 days (e.g., mometasone 200 mcg twice daily)
A delayed antibiotic prescription, used if worsening or not improving within 7 days (phenoxymethylpenicillin first-line)

Options for chronic sinusitis are:

Saline nasal irrigation
Steroid nasal sprays or drops (e.g., mometasone or fluticasone)
Functional endoscopic sinus surgery (FESS)
134
Q

Nasal Spray Technique

A

A good question to ask is, “do you taste the spray at the back of your throat after using it?” Tasting the spray means it has gone past the nasal mucosa and will not be as effective.

The technique involves:

Tilting the head slightly forward
Using the left hand to spray into the right nostril, and vice versa (this directs the spray slightly away from the septum)
NOT sniffing hard during the spray
Very gently inhaling through the nose after the spray

Medicine finals Prithvi (22 decks)

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