const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Chronic Suppurative Otitis Media";
pres.author = "ENT Department";

// ── Color Palette ──────────────────────────────────────────────
// Dominant: Deep Navy #0B1F4B  |  Mid: Steel Blue #1B5E8E
// Accent: Gold #E8A820          |  Light BG: #EEF4FB
// Text on dark: #F0F6FF         |  Text on light: #0B1F4B
const C = {
  navy:    "0B1F4B",
  blue:    "1B5E8E",
  gold:    "E8A820",
  ltbg:    "EEF4FB",
  white:   "F0F6FF",
  dktext:  "0B1F4B",
  gray:    "4A6080",
  lgray:   "C5D6EC",
  red:     "C0392B",
  green:   "1A7A4A",
};

// ── Reusable helpers ───────────────────────────────────────────
function titleSlide(slide) {
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.navy } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 4.2, w: "100%", h: 1.4, fill: { color: C.blue } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: "100%", fill: { color: C.gold } });
}

function contentSlide(slide, withAccent) {
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.ltbg } });
  if (withAccent !== false) {
    slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.85, fill: { color: C.navy } });
    slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: "100%", fill: { color: C.gold } });
  }
}

function addHeading(slide, text) {
  slide.addText(text.toUpperCase(), {
    x: 0.36, y: 0.12, w: 9.3, h: 0.62,
    fontSize: 18, bold: true, color: C.white,
    fontFace: "Calibri", charSpacing: 1.5, valign: "middle", margin: 0,
  });
}

function addBullets(slide, items, opts = {}) {
  const { x = 0.45, y = 1.05, w = 9.2, h = 4.2, size = 15, color = C.dktext, indentLevel = 0 } = opts;
  const textArr = items.map((item, i) => ({
    text: item.text || item,
    options: {
      bullet: item.sub ? { indent: 36 } : { indent: 18 },
      fontSize: item.sub ? size - 1 : size,
      color: item.sub ? C.gray : color,
      bold: item.bold || false,
      breakLine: i < items.length - 1,
      paraSpaceAfter: item.sub ? 0 : 4,
    },
  }));
  slide.addText(textArr, { x, y, w, h, fontFace: "Calibri", valign: "top" });
}

function addDivider(slide, y) {
  slide.addShape(pres.ShapeType.line, {
    x: 0.36, y, w: 9.28, h: 0, line: { color: C.gold, width: 1.5 },
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 1 — Title
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleSlide(s);

  s.addText("CHRONIC SUPPURATIVE\nOTITIS MEDIA", {
    x: 0.5, y: 0.6, w: 9, h: 2.4,
    fontSize: 38, bold: true, color: C.white, fontFace: "Calibri",
    align: "center", valign: "middle", charSpacing: 2,
  });

  s.addText("CSOM", {
    x: 0.5, y: 3.1, w: 9, h: 0.7,
    fontSize: 22, color: C.gold, fontFace: "Calibri", align: "center", bold: true, charSpacing: 8,
  });

  s.addText("Based on: Shambaugh Surgery of the Ear  |  Cummings Otolaryngology  |  Scott-Brown's ORL HNS", {
    x: 0.5, y: 4.25, w: 9, h: 0.8,
    fontSize: 10.5, color: C.lgray, fontFace: "Calibri", align: "center", italic: true,
  });

  s.addText("ENT Department  ·  2026", {
    x: 0.5, y: 5.1, w: 9, h: 0.35,
    fontSize: 10, color: C.lgray, fontFace: "Calibri", align: "center",
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 2 — Outline
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Outline");

  const topics = [
    "Definition & Introduction",
    "Epidemiology",
    "Etiopathogenesis",
    "Classification",
    "Clinical Features",
    "Audiological & Radiological Evaluation",
    "Medical Management",
    "Surgical Management",
    "Complications",
    "Key Points & Take-Away",
  ];

  // Two-column layout
  const col1 = topics.slice(0, 5);
  const col2 = topics.slice(5);

  const makeCol = (items, x) =>
    items.map((t, i) => ({
      text: `${["01","02","03","04","05","06","07","08","09","10"][items === col1 ? i : i + 5]}  ${t}`,
      options: { bullet: false, fontSize: 14, color: C.dktext, bold: false, breakLine: i < items.length - 1, paraSpaceAfter: 6 },
    }));

  s.addText(makeCol(col1, 0.4), { x: 0.36, y: 1.05, w: 4.5, h: 4.3, fontFace: "Calibri", valign: "top" });
  s.addText(makeCol(col2, 5.0), { x: 5.0, y: 1.05, w: 4.5, h: 4.3, fontFace: "Calibri", valign: "top" });

  // vertical divider
  s.addShape(pres.ShapeType.line, {
    x: 4.92, y: 1.1, w: 0, h: 4.1, line: { color: C.lgray, width: 1 },
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 3 — Definition
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Definition & Introduction");
  addDivider(s, 0.88);

  s.addText([
    { text: "CSOM is defined as ", options: { fontSize: 15, color: C.dktext } },
    { text: "chronic inflammation of the mucoperiosteum of the middle ear cleft", options: { fontSize: 15, color: C.blue, bold: true } },
    { text: " — characterized by a persistent tympanic membrane perforation with intermittent or continuous otorrhea, lasting more than ", options: { fontSize: 15, color: C.dktext } },
    { text: "6–12 weeks.", options: { fontSize: 15, color: C.blue, bold: true } },
  ], { x: 0.36, y: 0.95, w: 9.28, h: 0.85, fontFace: "Calibri", valign: "top" });

  addBullets(s, [
    { text: "The middle ear cleft includes the Eustachian tube, middle ear, mastoid antrum, and mastoid air cell system", bold: false },
    { text: "Eustachian tube dysfunction is the central driver: persistent effusion → mucosal oedema → granulation tissue → TM perforation", bold: false },
    { text: "Bacterial toxins and inflammatory mediators → basement membrane rupture → lamina propria extrusion → polyp formation", bold: false },
    { text: "Chronic inflammation → submucosal gland metaplasia → secretory mucosa → perpetuates effusion", bold: false },
    { text: "One of the leading causes of preventable hearing loss worldwide — particularly in developing nations", bold: true },
  ], { x: 0.45, y: 1.9, w: 9.1, h: 3.5, size: 14 });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 4 — Epidemiology
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Epidemiology");
  addDivider(s, 0.88);

  addBullets(s, [
    { text: "Prevalence: ~1–2% of the general population; higher in low-income countries and indigenous populations", bold: false },
    { text: "Peak incidence: early childhood (6 months – 2 years); correlates with Eustachian tube immaturity", bold: false },
    { text: "Risk factors:", bold: true },
    { text: "Overcrowding, poverty, malnutrition, poor hygiene", sub: true },
    { text: "Recurrent acute otitis media", sub: true },
    { text: "Cleft palate, Down syndrome — associated with ET dysfunction", sub: true },
    { text: "Allergic rhinitis and adenoid hypertrophy", sub: true },
    { text: "Immunodeficiency states (HIV, primary immunodeficiencies)", sub: true },
    { text: "WHO classifies bilateral CSOM discharging for ≥2 weeks as a 'massive' public health problem", bold: true },
  ], { x: 0.45, y: 1.0, w: 9.1, h: 4.4, size: 14 });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 5 — Etiopathogenesis
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Etiopathogenesis");
  addDivider(s, 0.88);

  // Pathway boxes
  const steps = [
    { label: "ET Dysfunction", detail: "Negative middle\near pressure" },
    { label: "Effusion", detail: "Serous / purulent\nmiddle ear fluid" },
    { label: "Mucosal Oedema &\nGranulation Tissue", detail: "BM rupture,\nfibroblast recruitment" },
    { label: "TM Weakening", detail: "Enzyme degradation\nof collagen skeleton" },
    { label: "Perforation /\nRetraction Pocket", detail: "Anchoring by fibrous\nbands → CSOM" },
  ];

  const boxW = 1.6, boxH = 1.1, startX = 0.38, y = 1.3, gap = 0.38;
  steps.forEach((st, i) => {
    const x = startX + i * (boxW + gap);
    s.addShape(pres.ShapeType.roundRect, {
      x, y, w: boxW, h: boxH,
      fill: { color: i === 4 ? C.red : C.blue },
      line: { color: C.navy, width: 0 },
      rectRadius: 0.08,
    });
    s.addText(st.label, { x, y: y + 0.05, w: boxW, h: 0.5, fontSize: 10.5, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle", margin: 2 });
    s.addText(st.detail, { x, y: y + 0.55, w: boxW, h: 0.5, fontSize: 9, color: C.lgray, fontFace: "Calibri", align: "center", valign: "middle", margin: 2 });
    if (i < steps.length - 1) {
      s.addShape(pres.ShapeType.line, { x: x + boxW + 0.03, y: y + boxH / 2, w: gap - 0.06, h: 0, line: { color: C.gold, width: 2 } });
    }
  });

  addBullets(s, [
    { text: "Microbiology: Most common organisms — Pseudomonas aeruginosa, Staphylococcus aureus, Proteus mirabilis, Klebsiella", bold: false },
    { text: "Biofilm formation: Bacterial biofilms demonstrated in 2006 in chronic OM; found in infected CI explants — increases treatment resistance", bold: false },
    { text: "Fungal infection: Candida spp. in 10% of purulent ears; rises to 35% after 3-week topical ciprofloxacin course (Cummings)", bold: false },
    { text: "Cholesteatoma genesis: Deep retraction pockets or perforations → keratinising squamous epithelium in middle ear cleft", bold: false },
  ], { x: 0.45, y: 2.6, w: 9.1, h: 3.0, size: 13.5 });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 6 — Classification
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Classification");
  addDivider(s, 0.88);

  // Two columns
  // Left: Tubo-tympanic
  s.addShape(pres.ShapeType.roundRect, { x: 0.36, y: 1.0, w: 4.3, h: 4.4, fill: { color: "D6EAF8" }, line: { color: C.blue, width: 1.5 }, rectRadius: 0.1 });
  s.addText("TUBO-TYMPANIC TYPE", { x: 0.36, y: 1.0, w: 4.3, h: 0.55, fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle", fill: { color: C.blue } });
  s.addText([
    { text: "("Safe" / Benign)", options: { italic: true, fontSize: 12, color: C.blue, breakLine: true, bold: true } },
    { text: "\n", options: { fontSize: 6, breakLine: true } },
    { text: "• Central TM perforation (pars tensa)", options: { fontSize: 12, color: C.dktext, breakLine: true } },
    { text: "• No cholesteatoma", options: { fontSize: 12, color: C.dktext, breakLine: true } },
    { text: "• Mucoid or mucopurulent discharge, usually odourless", options: { fontSize: 12, color: C.dktext, breakLine: true } },
    { text: "• Conductive hearing loss", options: { fontSize: 12, color: C.dktext, breakLine: true } },
    { text: "• Responds to medical treatment", options: { fontSize: 12, color: C.dktext, breakLine: true } },
    { text: "• Surgery: Myringoplasty / Tympanoplasty", options: { fontSize: 12, color: C.dktext, breakLine: true } },
  ], { x: 0.5, y: 1.6, w: 4.0, h: 3.7, fontFace: "Calibri", valign: "top" });

  // Right: Attico-antral
  s.addShape(pres.ShapeType.roundRect, { x: 5.0, y: 1.0, w: 4.3, h: 4.4, fill: { color: "FDECEA" }, line: { color: C.red, width: 1.5 }, rectRadius: 0.1 });
  s.addText("ATTICO-ANTRAL TYPE", { x: 5.0, y: 1.0, w: 4.3, h: 0.55, fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle", fill: { color: C.red } });
  s.addText([
    { text: "("Unsafe" / Dangerous)", options: { italic: true, fontSize: 12, color: C.red, breakLine: true, bold: true } },
    { text: "\n", options: { fontSize: 6, breakLine: true } },
    { text: "• Attic (marginal) perforation — pars flaccida", options: { fontSize: 12, color: C.dktext, breakLine: true } },
    { text: "• Cholesteatoma PRESENT", options: { fontSize: 12, color: C.red, bold: true, breakLine: true } },
    { text: "• Scanty, foul-smelling (fetid) discharge", options: { fontSize: 12, color: C.dktext, breakLine: true } },
    { text: "• Scutal / ossicular erosion on examination", options: { fontSize: 12, color: C.dktext, breakLine: true } },
    { text: "• Risk of intracranial complications", options: { fontSize: 12, color: C.red, bold: true, breakLine: true } },
    { text: "• Surgery: Mastoidectomy (CWU or CWD)", options: { fontSize: 12, color: C.dktext, breakLine: true } },
  ], { x: 5.14, y: 1.6, w: 4.0, h: 3.7, fontFace: "Calibri", valign: "top" });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 7 — Clinical Features
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Clinical Features");
  addDivider(s, 0.88);

  // Symptoms column
  s.addText("SYMPTOMS", { x: 0.36, y: 0.97, w: 4.3, h: 0.38, fontSize: 12.5, bold: true, color: C.blue, fontFace: "Calibri", align: "left", charSpacing: 1 });
  addBullets(s, [
    { text: "Otorrhoea: intermittent or continuous; mucoid/mucopurulent (safe) vs. scanty fetid (unsafe)", bold: false },
    { text: "Hearing loss: conductive (most common); SNHL if labyrinthitis or cochlear involvement", bold: false },
    { text: "Otalgia / headache: UNCOMMON — if present, suspect intracranial complication or malignancy", bold: true },
    { text: "Vertigo: suggests labyrinthitis or labyrinthine fistula", bold: false },
    { text: "Tinnitus: may accompany hearing loss", bold: false },
    { text: "Facial weakness: rare — suggests facial nerve involvement", bold: false },
  ], { x: 0.36, y: 1.38, w: 4.5, h: 3.9, size: 13 });

  // Signs column
  s.addShape(pres.ShapeType.line, { x: 4.92, y: 1.0, w: 0, h: 4.4, line: { color: C.lgray, width: 1 } });
  s.addText("SIGNS (on otoscopy / otomicroscopy)", { x: 5.04, y: 0.97, w: 4.5, h: 0.38, fontSize: 12.5, bold: true, color: C.blue, fontFace: "Calibri", align: "left", charSpacing: 1 });
  addBullets(s, [
    { text: "TM perforation: central (pars tensa) or attic/marginal (pars flaccida)", bold: false },
    { text: "Discharge in EAC; granulation tissue or polyps may obscure TM", bold: false },
    { text: "Scutal erosion (bony EAC erosion): hallmark of cholesteatoma", bold: true },
    { text: "Retraction pocket filled with squamous debris — pathognomonic of cholesteatoma", bold: false },
    { text: "CHL on tuning fork (Rinne negative, Weber lateralised to affected side)", bold: false },
    { text: "Post-auricular fistula / mastoid tenderness: suggests acute mastoiditis", bold: false },
  ], { x: 5.04, y: 1.38, w: 4.5, h: 3.9, size: 13 });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 8 — Audiological & Radiological Evaluation
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Audiological & Radiological Evaluation");
  addDivider(s, 0.88);

  s.addText("AUDIOLOGICAL", { x: 0.36, y: 0.96, w: 4.5, h: 0.38, fontSize: 12.5, bold: true, color: C.blue, fontFace: "Calibri", charSpacing: 1 });
  addBullets(s, [
    { text: "Pure tone audiogram (PTA): mandatory preoperative — documents type and degree of HL", bold: false },
    { text: "Conductive loss most common; CHL >30 dB suggests ossicular chain erosion", bold: false },
    { text: "Sound may still be conducted directly to oval window via cholesteatoma mass, preserving hearing despite ossicular erosion", bold: false },
    { text: "SNHL: 5–33 dB range documented in CSOM studies — indicates cochlear involvement (Shambaugh)", bold: false },
    { text: "Tympanometry: type B (flat) curve — confirms TM perforation or middle ear effusion", bold: false },
  ], { x: 0.36, y: 1.38, w: 4.5, h: 3.9, size: 13 });

  s.addShape(pres.ShapeType.line, { x: 4.92, y: 1.0, w: 0, h: 4.4, line: { color: C.lgray, width: 1 } });
  s.addText("RADIOLOGY", { x: 5.04, y: 0.96, w: 4.5, h: 0.38, fontSize: 12.5, bold: true, color: C.blue, fontFace: "Calibri", charSpacing: 1 });
  addBullets(s, [
    { text: "HRCT temporal bone (non-contrast): gold standard — assess bony erosion, ossicular chain, tegmen, sigmoid sinus, facial canal", bold: true },
    { text: "CT findings: soft tissue density in middle ear/mastoid, scutal erosion, ossicular erosion, labyrinthine fistula", bold: false },
    { text: "MRI temporal bone: evaluates intracranial extension, dural involvement, and cholesteatoma on DW-MRI (non-EPI DWI)", bold: false },
    { text: "DW-MRI: cholesteatoma shows restricted diffusion (bright on DWI, dark ADC) — useful for detecting residual/recurrent disease", bold: false },
    { text: "Complementary HRCT + MRI recommended when cochlear nerve hypoplasia suspected (Cummings)", bold: false },
  ], { x: 5.04, y: 1.38, w: 4.5, h: 3.9, size: 13 });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 9 — Medical Management
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Medical Management");
  addDivider(s, 0.88);

  addBullets(s, [
    { text: "Goal: dry the ear, limit inflammation, prevent progression to complications", bold: true },
    { text: "Aural toilet (ear syringing / microsuction): removes debris, discharge, and granulation tissue — essential first step", bold: false },
    { text: "Topical ototopical antibiotics:", bold: true },
    { text: "Quinolone drops (ciprofloxacin/ofloxacin): first-line — broad spectrum, not ototoxic at clinical doses", sub: true },
    { text: "Aminoglycoside drops (framycetin, gentamicin): use with caution — potential ototoxicity with TM perforation", sub: true },
    { text: "Note: 35% of ears treated with topical ciprofloxacin ≥3 weeks develop Candida overgrowth (Cummings)", sub: true },
    { text: "Systemic antibiotics: indicated for acute exacerbations, resistant infections, or when topical therapy fails", bold: false },
    { text: "Treat underlying causes: allergic rhinitis, adenoid hypertrophy, nasal polyposis", bold: false },
    { text: "Indications to proceed to surgery:", bold: true },
    { text: "Failure of multiple courses of medical treatment", sub: true },
    { text: "Presence of cholesteatoma (near-absolute indication)", sub: true },
    { text: "Complications: vertigo, facial weakness, headache (suspect intracranial spread)", sub: true },
    { text: "Atelectatic ears with significant CHL", sub: true },
  ], { x: 0.45, y: 0.95, w: 9.1, h: 4.5, size: 13.5 });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 10 — Surgical Management
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Surgical Management");
  addDivider(s, 0.88);

  s.addText("THREE PRIORITIES (Shambaugh)", { x: 0.36, y: 0.96, w: 9.28, h: 0.36, fontSize: 12, bold: true, color: C.blue, fontFace: "Calibri", align: "left", charSpacing: 1 });

  const priorities = [
    { num: "1", label: "Eradication\nof Disease", color: C.red },
    { num: "2", label: "Prevention of\nRecurrence", color: C.blue },
    { num: "3", label: "Preservation /\nRestoration of Hearing", color: C.green },
  ];
  priorities.forEach((p, i) => {
    const x = 0.36 + i * 3.15;
    s.addShape(pres.ShapeType.roundRect, { x, y: 1.38, w: 2.8, h: 0.85, fill: { color: p.color }, line: { color: p.color, width: 0 }, rectRadius: 0.08 });
    s.addText(`${p.num}. ${p.label}`, { x, y: 1.38, w: 2.8, h: 0.85, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  });

  addBullets(s, [
    { text: "Tympanoplasty / Myringoplasty: TM repair for tubo-tympanic type without cholesteatoma; fascia graft (underlay/overlay technique)", bold: false },
    { text: "Canal Wall Up (CWU) Mastoidectomy: posterior EAC preserved; preferred approach — fewer cavity problems; higher cholesteatoma recidivism (5–71% in children)", bold: false },
    { text: "Canal Wall Down (CWD) Mastoidectomy: posterior canal wall removed → open cavity; better access, lower recurrence; requires lifelong cavity maintenance", bold: false },
    { text: "Ossiculoplasty: reconstruction of eroded ossicular chain (TORP / PORP / autologous incus interposition)", bold: false },
    { text: "CWD indications: labyrinthine fistula, unresectable disease on facial nerve or stapes footplate, low-lying tegmen, sinus tympani disease, unreconstructable posterior wall defect (Shambaugh)", bold: false },
    { text: "Second-look surgery: planned at 12–18 months for CWU to check for residual cholesteatoma", bold: false },
  ], { x: 0.45, y: 2.35, w: 9.1, h: 3.0, size: 13 });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 11 — Complications
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Complications");
  addDivider(s, 0.88);

  // Extracranial
  s.addShape(pres.ShapeType.roundRect, { x: 0.36, y: 1.0, w: 4.3, h: 4.35, fill: { color: "EAF4FB" }, line: { color: C.blue, width: 1.5 }, rectRadius: 0.1 });
  s.addText("EXTRACRANIAL", { x: 0.36, y: 1.0, w: 4.3, h: 0.5, fontSize: 12.5, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle", fill: { color: C.blue } });
  s.addText([
    { text: "• Hearing loss (CHL / SNHL)", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "• Labyrinthitis (suppurative / serous)", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "• Labyrinthine fistula (most common: lateral SCC)", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "• Facial nerve palsy (Fallopian canal erosion)", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "• Acute mastoiditis / subperiosteal abscess", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "• Petrous apicitis (Gradenigo's syndrome)", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "• Bezold's abscess (pus tracks under SCM)", options: { fontSize: 13, color: C.dktext, breakLine: true } },
  ], { x: 0.5, y: 1.56, w: 4.0, h: 3.7, fontFace: "Calibri", valign: "top" });

  // Intracranial
  s.addShape(pres.ShapeType.roundRect, { x: 5.0, y: 1.0, w: 4.3, h: 4.35, fill: { color: "FDECEA" }, line: { color: C.red, width: 1.5 }, rectRadius: 0.1 });
  s.addText("INTRACRANIAL", { x: 5.0, y: 1.0, w: 4.3, h: 0.5, fontSize: 12.5, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle", fill: { color: C.red } });
  s.addText([
    { text: "• Meningitis (most common intracranial)", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "• Extradural abscess", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "• Subdural empyema", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "• Brain abscess (temporal lobe / cerebellum)", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "• Sigmoid / lateral sinus thrombophlebitis", options: { fontSize: 13, color: C.red, bold: true, breakLine: true } },
    { text: "• Otitic hydrocephalus", options: { fontSize: 13, color: C.dktext, breakLine: true } },
    { text: "⚠ Otalgia + headache + CSOM = suspect intracranial complication until proved otherwise", options: { fontSize: 12, color: C.red, bold: true, breakLine: true } },
  ], { x: 5.14, y: 1.56, w: 4.0, h: 3.7, fontFace: "Calibri", valign: "top" });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 12 — Cholesteatoma Close-Up
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Cholesteatoma — Key Concepts");
  addDivider(s, 0.88);

  addBullets(s, [
    { text: "Definition: keratinising squamous epithelium within the middle ear cleft — NOT a true tumour", bold: true },
    { text: "Types:", bold: true },
    { text: "Congenital: behind intact TM, typically antero-superior quadrant; no prior OM / surgery", sub: true },
    { text: "Acquired primary: migration from attic retraction pocket (pars flaccida)", sub: true },
    { text: "Acquired secondary: ingrowth of squamous epithelium through TM perforation", sub: true },
    { text: "Mechanism of bone erosion: osteoclast activation by prostaglandins, TNF-α, IL-1, collagenases produced by keratinocytes", bold: false },
    { text: "Paediatric cholesteatoma: considered more aggressive — faster keratinocyte replication (Bujia et al.); recidivism 5–71% post-CWU surgery", bold: false },
    { text: "Imaging: DW-MRI (non-EPI) — diffusion restriction identifies residual or recurrent cholesteatoma non-invasively", bold: true },
    { text: "Surgery is the only definitive treatment; combined approach tympanoplasty (CAT) allows staged disease removal with hearing reconstruction", bold: false },
  ], { x: 0.45, y: 0.95, w: 9.1, h: 4.5, size: 13.5 });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 13 — Key Take-Away Points
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s);
  addHeading(s, "Key Points & Take-Away");
  addDivider(s, 0.88);

  const points = [
    { icon: "01", text: "CSOM = persistent TM perforation + otorrhoea >6–12 weeks; central pathology is ET dysfunction" },
    { icon: "02", text: "Safe (tubo-tympanic) vs. Unsafe (attico-antral/cholesteatoma) — a critical clinical distinction governing management" },
    { icon: "03", text: "Otalgia or headache in CSOM = red flag — rule out intracranial complication urgently" },
    { icon: "04", text: "Full audiogram preoperatively is mandatory; CHL >30 dB suggests ossicular erosion" },
    { icon: "05", text: "HRCT temporal bone is the imaging gold standard; DW-MRI detects residual/recurrent cholesteatoma" },
    { icon: "06", text: "Medical Rx: aural toilet + ototopical quinolones; monitor for fungal superinfection with prolonged use" },
    { icon: "07", text: "Surgery goals: 1. Eradicate disease  2. Prevent recurrence  3. Restore hearing (Shambaugh)" },
    { icon: "08", text: "Cholesteatoma combined with medically refractory CSOM = near-absolute indication for mastoidectomy" },
  ];

  const rows = 4, cols = 2;
  const bW = 4.4, bH = 0.78, gapX = 0.5, gapY = 0.15;
  const startX = 0.38, startY = 0.97;
  points.forEach((p, i) => {
    const col = i % cols;
    const row = Math.floor(i / cols);
    const x = startX + col * (bW + gapX);
    const y = startY + row * (bH + gapY);
    s.addShape(pres.ShapeType.roundRect, { x, y, w: bW, h: bH, fill: { color: row % 2 === 0 ? "E8F4FD" : "EDF7EE" }, line: { color: C.lgray, width: 0 }, rectRadius: 0.07 });
    s.addText(p.icon, { x: x + 0.05, y, w: 0.55, h: bH, fontSize: 18, bold: true, color: C.gold, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addText(p.text, { x: x + 0.6, y: y + 0.06, w: bW - 0.68, h: bH - 0.12, fontSize: 11.5, color: C.dktext, fontFace: "Calibri", valign: "middle" });
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 14 — References
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleSlide(s);
  addHeading(s, "References");

  s.addText([
    { text: "1. ", options: { bold: true, color: C.gold } },
    { text: "Shambaugh GE, Glasscock ME. ", options: { italic: true, color: C.white } },
    { text: "Surgery of the Ear", options: { italic: true, bold: true, color: C.lgray } },
    { text: ", 6th ed. PMPH-USA; 2010. Chapter 30 — Mastoiditis and Chronic Suppurative Otitis Media.", options: { italic: false, color: C.lgray } },
    { text: "\n", options: { breakLine: true, fontSize: 8, color: C.navy } },
    { text: "2. ", options: { bold: true, color: C.gold } },
    { text: "Flint PW, et al. ", options: { italic: true, color: C.white } },
    { text: "Cummings Otolaryngology Head and Neck Surgery", options: { italic: true, bold: true, color: C.lgray } },
    { text: ", 7th ed. Elsevier; 2021. Cochlear Implantation in CSOM.", options: { italic: false, color: C.lgray } },
    { text: "\n", options: { breakLine: true, fontSize: 8, color: C.navy } },
    { text: "3. ", options: { bold: true, color: C.gold } },
    { text: "Gleeson MJ, et al. ", options: { italic: true, color: C.white } },
    { text: "Scott-Brown's Otorhinolaryngology Head & Neck Surgery", options: { italic: true, bold: true, color: C.lgray } },
    { text: ", 8th ed. CRC Press; 2019. Chronic Otitis Media and Cholesteatoma.", options: { italic: false, color: C.lgray } },
    { text: "\n", options: { breakLine: true, fontSize: 8, color: C.navy } },
    { text: "4. ", options: { bold: true, color: C.gold } },
    { text: "Lee KJ. ", options: { italic: true, color: C.white } },
    { text: "K.J. Lee's Essential Otolaryngology", options: { italic: true, bold: true, color: C.lgray } },
    { text: ", 11th ed. McGraw-Hill; 2019.", options: { italic: false, color: C.lgray } },
  ], { x: 0.5, y: 1.0, w: 9.1, h: 4.0, fontFace: "Calibri", fontSize: 13, valign: "top" });

  s.addText("Thank You", { x: 0.5, y: 4.6, w: 9, h: 0.7, fontSize: 22, bold: true, color: C.gold, fontFace: "Calibri", align: "center", charSpacing: 6 });
}

// ── Write file ─────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/csom-ppt/CSOM_Presentation.pptx" })
  .then(() => console.log("SUCCESS: /home/daytona/workspace/csom-ppt/CSOM_Presentation.pptx"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/csom-ppt/csom.js'

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/csom-ppt/csom.js'

const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// ─── Fetch images as base64 ────────────────────────────────────
const IMG_URLS = [
  "https://cdn.orris.care/cdss_images/aaee9da2a72b7ca8b88ad6b3528b9f5190f0404ce8eb5c5c06f321d3c509aeaa.png", // mastoid abscess ear A
  "https://cdn.orris.care/cdss_images/714765bc5fb265cf5b0caef47a53948f22aeac9d3aefcc7652d1ed7c0f02bc17.png", // cholesteatoma otoscopy
  "https://cdn.orris.care/cdss_images/aa2041c7dd351612453d54f0591d6a35e36fc6744f94e5948e3d51e0ea04af25.png", // temporal bone histo
  "https://cdn.orris.care/cdss_images/c0bf0d337eab6e7ae3de5732b271dd4d2d5da7dcc9df9edc92515fc34f1f9079.png", // COM without cholesteatoma histo
];
console.log("Fetching images...");
let imgs = [];
try {
  const raw = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${IMG_URLS.map(u => `"${u}"`).join(" ")}`,
    { maxBuffer: 50 * 1024 * 1024 }
  ).toString();
  imgs = JSON.parse(raw);
  console.log("Images fetched:", imgs.map(i => i.error ? "FAIL" : "OK"));
} catch(e) {
  console.error("Image fetch error:", e.message);
  imgs = IMG_URLS.map(() => ({ base64: null, error: "failed" }));
}

function imgData(idx) {
  return imgs[idx] && !imgs[idx].error ? imgs[idx].base64 : null;
}

// ─── Palette ───────────────────────────────────────────────────
const C = {
  // Per-slide accent colors (vibrant)
  c1: "E74C3C",  // red
  c2: "E67E22",  // orange
  c3: "F1C40F",  // yellow
  c4: "27AE60",  // green
  c5: "1ABC9C",  // teal
  c6: "2980B9",  // blue
  c7: "8E44AD",  // purple
  c8: "D35400",  // dark orange
  c9: "16A085",  // dark teal
  c10:"C0392B",  // dark red
  white: "FFFFFF",
  dktext: "1A1A2E",
  ltgray: "ECF0F1",
  midgray:"95A5A6",
};

const SLIDE_COLORS = [C.c1, C.c2, C.c4, C.c6, C.c7, C.c5, C.c8, C.c3, C.c9, C.c10];

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Chronic Suppurative Otitis Media";

// ─── Helpers ──────────────────────────────────────────────────
function darkBg(slide, accent) {
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{ color:"1A1A2E" } });
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:0.2, h:"100%", fill:{ color: accent } });
}

function contentBg(slide, accent) {
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{ color:"F8F9FA" } });
  // top bar
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:0.75, fill:{ color: accent } });
  // left accent strip
  slide.addShape(pres.ShapeType.rect, { x:0, y:0.75, w:0.06, h:"100%", fill:{ color: accent } });
}

function heading(slide, text, accent) {
  slide.addText(text, {
    x:0.25, y:0.08, w:9.5, h:0.6,
    fontSize:20, bold:true, color:C.white,
    fontFace:"Calibri", valign:"middle", align:"left",
  });
  // small decorative line at bottom of header
  slide.addShape(pres.ShapeType.rect, { x:0.25, y:0.69, w:9.5, h:0.04, fill:{ color:"FFFFFF" }, line:{ type:"none" } });
}

function crisp(items) {
  // takes array of strings and returns pptxgen rich text array
  return items.map((txt, i) => ({
    text: txt,
    options: {
      bullet: { code: "25B6", fontSize: 8 }, // filled triangle bullet
      fontSize: 13.5,
      color: C.dktext,
      bold: false,
      breakLine: i < items.length - 1,
      paraSpaceAfter: 5,
    }
  }));
}

// ══════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  // gradient-ish with dark navy + teal accent
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{ color:"0D1B2A" } });
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:0.18, fill:{ color:"1ABC9C" } });
  s.addShape(pres.ShapeType.rect, { x:0, y:5.46, w:"100%", h:0.18, fill:{ color:"1ABC9C" } });
  // big vertical colour splash
  s.addShape(pres.ShapeType.rect, { x:7.2, y:0, w:2.8, h:"100%", fill:{ color:"1ABC9C" }, transparency:75 });

  s.addText("CHRONIC\nSUPPURATIVE\nOTITIS MEDIA", {
    x:0.4, y:0.5, w:6.5, h:3.4,
    fontSize:42, bold:true, color:C.white, fontFace:"Calibri",
    align:"left", valign:"middle", lineSpacingMultiple:1.1,
  });
  s.addText("CSOM", {
    x:0.4, y:3.9, w:3, h:0.65,
    fontSize:28, bold:true, color:"1ABC9C", fontFace:"Calibri", charSpacing:10,
  });
  s.addText("ENT Department  ·  2026", {
    x:0.4, y:4.7, w:6, h:0.45,
    fontSize:13, color:"95A5A6", fontFace:"Calibri", italic:true,
  });
  s.addText("Source: Shambaugh Surgery of the Ear | Cummings Otolaryngology | Scott-Brown's ORL", {
    x:0.4, y:5.1, w:9, h:0.3,
    fontSize:9, color:"607080", fontFace:"Calibri", italic:true,
  });
  // decorative ear icon text
  s.addText("👂", { x:7.5, y:1.2, w:2, h:2, fontSize:80, align:"center" });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 2 — DEFINITION & EPIDEMIOLOGY  (accent: red)
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[0];
  contentBg(s, acc);
  heading(s, "Definition & Epidemiology", acc);

  // Definition box (left)
  s.addShape(pres.ShapeType.roundRect, {
    x:0.2, y:0.82, w:5.8, h:2.0,
    fill:{ color: acc }, line:{ type:"none" }, rectRadius:0.1,
  });
  s.addText("DEFINITION", { x:0.3, y:0.84, w:5.6, h:0.4, fontSize:11, bold:true, color:C.white, fontFace:"Calibri", charSpacing:2 });
  s.addText(
    "Chronic inflammation of the mucoperiosteum of the middle ear cleft — persistent TM perforation + otorrhoea > 6–12 weeks",
    { x:0.3, y:1.2, w:5.6, h:1.5, fontSize:13.5, color:C.white, fontFace:"Calibri", valign:"top" }
  );

  // Stats boxes (right column)
  const stats = [
    { val:"1–2%", lbl:"global prevalence" },
    { val:"<2 yrs", lbl:"peak incidence" },
    { val:"WHO", lbl:"massive public\nhealth problem" },
  ];
  stats.forEach((st, i) => {
    const y = 0.82 + i * 0.75;
    s.addShape(pres.ShapeType.roundRect, { x:6.2, y, w:3.5, h:0.65, fill:{ color:"FDECEA" }, line:{ color: acc, width:1.5 }, rectRadius:0.08 });
    s.addText(st.val, { x:6.3, y: y+0.04, w:1.0, h:0.55, fontSize:16, bold:true, color: acc, fontFace:"Calibri", align:"center", valign:"middle" });
    s.addText(st.lbl, { x:7.35, y: y+0.08, w:2.2, h:0.5, fontSize:11, color: C.dktext, fontFace:"Calibri", valign:"middle" });
  });

  // Risk factors
  s.addText("RISK FACTORS", { x:0.25, y:2.9, w:9.5, h:0.35, fontSize:11, bold:true, color: acc, fontFace:"Calibri", charSpacing:2 });
  const risks = ["Eustachian tube dysfunction", "Recurrent acute otitis media", "Overcrowding & malnutrition", "Cleft palate / Down syndrome", "Allergic rhinitis / adenoid hypertrophy", "Immunodeficiency (HIV, primary)"];
  risks.forEach((r, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.2 + col * 3.25;
    const y = 3.3 + row * 0.58;
    s.addShape(pres.ShapeType.roundRect, { x, y, w:3.1, h:0.5, fill:{ color:"FDECEA" }, line:{ color: acc, width:1 }, rectRadius:0.07 });
    s.addText("• " + r, { x: x+0.1, y, w:2.95, h:0.5, fontSize:12, color:C.dktext, fontFace:"Calibri", valign:"middle" });
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 3 — ETIOPATHOGENESIS FLOWCHART  (accent: orange)
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[1];
  contentBg(s, acc);
  heading(s, "Etiopathogenesis", acc);

  // Vertical flowchart with 5 nodes
  const nodes = [
    { label:"Eustachian Tube\nDysfunction", sub:"Negative middle ear\npressure", color: acc },
    { label:"Middle Ear\nEffusion", sub:"Serous / purulent\nfluid accumulates", color:"E67E22" },
    { label:"Mucosal Oedema &\nGranulation Tissue", sub:"BM rupture → fibroblast\nrecruitment, polyp formation", color:"D35400" },
    { label:"TM Weakening", sub:"Enzymes degrade\ncollagen skeleton", color:"C0392B" },
    { label:"Perforation /\nRetraction Pocket", sub:"→ CSOM / Cholesteatoma", color:"8B0000" },
  ];

  const nodeW = 1.7, nodeH = 0.98, startX = 0.25, arrowGap = 0.2;
  const totalW = nodes.length * nodeW + (nodes.length - 1) * arrowGap;
  nodes.forEach((n, i) => {
    const x = startX + i * (nodeW + arrowGap);
    const y = 0.88;
    s.addShape(pres.ShapeType.roundRect, { x, y, w:nodeW, h:nodeH, fill:{ color: n.color }, line:{ type:"none" }, rectRadius:0.1 });
    s.addText(n.label, { x, y: y+0.05, w:nodeW, h:0.5, fontSize:11, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
    s.addText(n.sub, { x, y: y+0.53, w:nodeW, h:0.42, fontSize:9, color:"FFD5C8", fontFace:"Calibri", align:"center", valign:"top" });
    if (i < nodes.length - 1) {
      const ax = x + nodeW + 0.02;
      s.addShape(pres.ShapeType.line, { x: ax, y: y + nodeH/2, w: arrowGap - 0.04, h:0, line:{ color:"FFFFFF", width:2.5 } });
      s.addText("▶", { x: ax + arrowGap - 0.2, y: y + nodeH/2 - 0.15, w:0.25, h:0.3, fontSize:12, color:C.white, fontFace:"Calibri" });
    }
  });

  // Microbiology strip
  s.addShape(pres.ShapeType.rect, { x:0.1, y:2.0, w:9.8, h:0.38, fill:{ color:"FEF9E7" }, line:{ color: acc, width:1 } });
  s.addText("🦠  KEY ORGANISMS: Pseudomonas aeruginosa  ·  Staph. aureus  ·  Proteus mirabilis  ·  Klebsiella  ·  Candida (after prolonged topical Abx)", {
    x:0.2, y:2.0, w:9.6, h:0.38, fontSize:11, color:"7D6608", fontFace:"Calibri", valign:"middle", bold:true,
  });

  // Two-column key concepts
  const cols = [
    ["Biofilm formation — major driver of treatment resistance (demonstrated 2006)", "Bacterial toxins → BM rupture → lamina propria extrusion", "Fibroblast + neovascularization → granulation polyps"],
    ["Candida overgrowth: 10% at baseline, rises to 35% after 3-week topical ciprofloxacin (Cummings)", "Submucosal gland metaplasia → secretory mucosa → perpetuates effusion", "Retraction pocket → trapped keratin → cholesteatoma"],
  ];
  cols.forEach((col, ci) => {
    const x = 0.2 + ci * 4.9;
    col.forEach((txt, ti) => {
      s.addText("▸  " + txt, {
        x, y: 2.5 + ti * 0.82, w: 4.7, h: 0.75,
        fontSize:12, color:C.dktext, fontFace:"Calibri", valign:"top",
      });
      if (ti < col.length-1) {
        s.addShape(pres.ShapeType.line, { x, y: 2.5 + (ti+1)*0.82 - 0.05, w:4.7, h:0, line:{ color:"D5D8DC", width:0.5 } });
      }
    });
  });
  s.addShape(pres.ShapeType.line, { x:5.0, y:2.5, w:0, h:2.55, line:{ color:"D5D8DC", width:1 } });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 4 — CLASSIFICATION (Safe vs Unsafe)  (accent: green)
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[2];
  contentBg(s, acc);
  heading(s, "Classification", acc);

  // VS badge centre
  s.addShape(pres.ShapeType.ellipse, { x:4.6, y:1.5, w:0.8, h:0.8, fill:{ color:"1A1A2E" }, line:{ type:"none" } });
  s.addText("VS", { x:4.6, y:1.5, w:0.8, h:0.8, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });

  // Left (Safe / Tubo-tympanic)
  const ltCol = [
    "Central TM perforation (pars tensa)",
    "No cholesteatoma",
    "Mucoid, odourless discharge",
    "Responds to medical Rx",
    "Surgery: Myringoplasty / Tympanoplasty",
    "Lower risk of complications",
  ];
  s.addShape(pres.ShapeType.roundRect, { x:0.15, y:0.82, w:4.3, h:4.5, fill:{ color:"E9F7EF" }, line:{ color: acc, width:2 }, rectRadius:0.12 });
  s.addShape(pres.ShapeType.roundRect, { x:0.15, y:0.82, w:4.3, h:0.7, fill:{ color: acc }, line:{ type:"none" }, rectRadius:0.12 });
  s.addText("TUBO-TYMPANIC\n(SAFE / BENIGN)", { x:0.2, y:0.84, w:4.2, h:0.65, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  ltCol.forEach((t, i) => {
    s.addText("✔  " + t, { x:0.3, y:1.6 + i*0.54, w:4.0, h:0.5, fontSize:12.5, color:C.dktext, fontFace:"Calibri", valign:"top" });
  });

  // Right (Unsafe / Attico-antral)
  const unsafeCol = [
    "Attic / marginal perforation (pars flaccida)",
    "CHOLESTEATOMA present",
    "Scanty, FETID (foul-smelling) discharge",
    "Scutal & ossicular erosion on examination",
    "Risk of intracranial complications ⚠",
    "Surgery: Mastoidectomy (CWU or CWD)",
  ];
  const urgRed = "C0392B";
  s.addShape(pres.ShapeType.roundRect, { x:5.55, y:0.82, w:4.3, h:4.5, fill:{ color:"FDEDEC" }, line:{ color: urgRed, width:2 }, rectRadius:0.12 });
  s.addShape(pres.ShapeType.roundRect, { x:5.55, y:0.82, w:4.3, h:0.7, fill:{ color: urgRed }, line:{ type:"none" }, rectRadius:0.12 });
  s.addText("ATTICO-ANTRAL\n(UNSAFE / DANGEROUS)", { x:5.6, y:0.84, w:4.2, h:0.65, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  unsafeCol.forEach((t, i) => {
    const isRed = t.includes("CHOLESTEATOMA") || t.includes("intracranial");
    s.addText((isRed ? "⚠  " : "✖  ") + t, { x:5.65, y:1.6 + i*0.54, w:4.1, h:0.5, fontSize:12.5, color: isRed ? urgRed : C.dktext, bold: isRed, fontFace:"Calibri", valign:"top" });
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 5 — CLINICAL FEATURES  (accent: blue)
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[3];
  contentBg(s, acc);
  heading(s, "Clinical Features", acc);

  // Two columns: Symptoms | Signs
  const symptoms = [
    "Otorrhoea — intermittent/continuous",
    "CHL — most common hearing complaint",
    "Otalgia / headache ⚠ = red flag (suspect complication)",
    "Vertigo → labyrinthitis / fistula",
    "Tinnitus",
    "Facial weakness — rare (CN VII involvement)",
  ];
  const signs = [
    "TM perforation (central vs. attic/marginal)",
    "Discharge / granulation tissue in EAC",
    "Scutal erosion — hallmark of cholesteatoma",
    "Retraction pocket with squamous debris",
    "Tuning fork: Rinne −ve, Weber lateralised",
    "Post-auricular swelling / fistula (mastoiditis)",
  ];

  s.addShape(pres.ShapeType.rect, { x:0.12, y:0.82, w:4.75, h:0.42, fill:{ color: acc }, line:{ type:"none" } });
  s.addText("SYMPTOMS", { x:0.2, y:0.82, w:4.6, h:0.42, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", charSpacing:2 });
  symptoms.forEach((t, i) => {
    const isRed = t.includes("red flag");
    s.addShape(pres.ShapeType.rect, { x:0.12, y:1.3+i*0.63, w:4.75, h:0.56, fill:{ color: i%2===0 ? "EBF5FB" : "D6EAF8" }, line:{ type:"none" } });
    s.addText((isRed ? "⚠ " : "► ") + t, { x:0.22, y:1.33+i*0.63, w:4.5, h:0.5, fontSize:12, color: isRed ? "C0392B" : C.dktext, bold: isRed, fontFace:"Calibri", valign:"middle" });
  });

  s.addShape(pres.ShapeType.rect, { x:5.13, y:0.82, w:4.75, h:0.42, fill:{ color:"1A5276" }, line:{ type:"none" } });
  s.addText("SIGNS (Otomicroscopy)", { x:5.21, y:0.82, w:4.6, h:0.42, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", charSpacing:2 });
  signs.forEach((t, i) => {
    const isRed = t.includes("Scutal") || t.includes("hallmark");
    s.addShape(pres.ShapeType.rect, { x:5.13, y:1.3+i*0.63, w:4.75, h:0.56, fill:{ color: i%2===0 ? "EBF5FB" : "D6EAF8" }, line:{ type:"none" } });
    s.addText((isRed ? "★ " : "► ") + t, { x:5.23, y:1.33+i*0.63, w:4.5, h:0.5, fontSize:12, color: isRed ? "8E44AD" : C.dktext, bold: isRed, fontFace:"Calibri", valign:"middle" });
  });

  // vertical divider
  s.addShape(pres.ShapeType.line, { x:4.97, y:0.82, w:0, h:4.1, line:{ color:"BDC3C7", width:1.5 } });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 6 — OTOSCOPIC IMAGES + HISTOLOGY (Image slide)  (accent: purple)
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[4];
  contentBg(s, acc);
  heading(s, "Otoscopic & Histological Findings", acc);

  // Image 1 (cholesteatoma otoscopy)
  const img1 = imgData(1);
  const img2 = imgData(2);
  const img3 = imgData(3);

  if (img1) {
    s.addImage({ data: img1, x:0.15, y:0.85, w:3.1, h:2.3 });
  } else {
    s.addShape(pres.ShapeType.rect, { x:0.15, y:0.85, w:3.1, h:2.3, fill:{ color:"D5D8DC" } });
  }
  s.addText("Cholesteatoma — otoscopy\n(attic retraction with keratin debris)", {
    x:0.15, y:3.2, w:3.1, h:0.65, fontSize:10.5, color:"4A235A", fontFace:"Calibri", align:"center", italic:true,
  });

  if (img2) {
    s.addImage({ data: img2, x:3.45, y:0.85, w:3.1, h:2.3 });
  } else {
    s.addShape(pres.ShapeType.rect, { x:3.45, y:0.85, w:3.1, h:2.3, fill:{ color:"D5D8DC" } });
  }
  s.addText("Cholesteatoma — H&E temporal bone\n(keratin sac eroding stapes suprastructure)", {
    x:3.45, y:3.2, w:3.1, h:0.65, fontSize:10.5, color:"4A235A", fontFace:"Calibri", align:"center", italic:true,
  });

  if (img3) {
    s.addImage({ data: img3, x:6.75, y:0.85, w:3.1, h:2.3 });
  } else {
    s.addShape(pres.ShapeType.rect, { x:6.75, y:0.85, w:3.1, h:2.3, fill:{ color:"D5D8DC" } });
  }
  s.addText("COM without cholesteatoma — H&E\n(TM perforation + inflammatory exudate)", {
    x:6.75, y:3.2, w:3.1, h:0.65, fontSize:10.5, color:"4A235A", fontFace:"Calibri", align:"center", italic:true,
  });

  // Key diagnostic points strip
  s.addShape(pres.ShapeType.rect, { x:0.1, y:4.0, w:9.8, h:1.48, fill:{ color:"F4ECF7" }, line:{ color: acc, width:1 } });
  const diagPts = [
    "Scutal erosion on CT = cholesteatoma until proved otherwise",
    "Pars flaccida retraction most common cholesteatoma origin",
    "DW-MRI (non-EPI) — restricted diffusion = cholesteatoma",
    "HRCT temporal bone = gold standard pre-op imaging",
  ];
  diagPts.forEach((d, i) => {
    const col = i % 2, row = Math.floor(i / 2);
    s.addText("◆  " + d, { x:0.25 + col*4.9, y:4.1 + row*0.65, w:4.7, h:0.6, fontSize:12, color:"6C3483", bold: i===0||i===2, fontFace:"Calibri", valign:"middle" });
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 7 — INVESTIGATIONS (Audiology + Radiology)  (accent: teal)
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[5];
  contentBg(s, acc);
  heading(s, "Investigations", acc);

  // Audiology column
  s.addShape(pres.ShapeType.roundRect, { x:0.15, y:0.82, w:4.6, h:4.6, fill:{ color:"E8F8F5" }, line:{ color: acc, width:1.5 }, rectRadius:0.1 });
  s.addShape(pres.ShapeType.rect, { x:0.15, y:0.82, w:4.6, h:0.55, fill:{ color: acc }, line:{ type:"none" } });
  s.addText("🎧  AUDIOLOGICAL", { x:0.25, y:0.84, w:4.4, h:0.5, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", valign:"middle" });
  const audPts = [
    "Pure Tone Audiogram (PTA) — mandatory pre-op",
    "CHL most common; SNHL if cochlear involvement",
    "CHL >30 dB → suspect ossicular erosion",
    "Sound via cholesteatoma mass can preserve hearing despite ossicular erosion",
    "Tympanometry: Type B (flat) = TM perf / MEE",
    "SNHL range documented: 5–33 dB (Shambaugh)",
  ];
  audPts.forEach((t, i) => {
    s.addText("▸  " + t, { x:0.25, y:1.45 + i*0.58, w:4.4, h:0.54, fontSize:12, color:C.dktext, fontFace:"Calibri", valign:"top" });
    if (i < audPts.length-1) s.addShape(pres.ShapeType.line, { x:0.25, y:1.45+(i+1)*0.58-0.04, w:4.4, h:0, line:{ color:"A9DFBF", width:0.5 } });
  });

  // Radiology column
  s.addShape(pres.ShapeType.roundRect, { x:5.15, y:0.82, w:4.6, h:4.6, fill:{ color:"EBF5FB" }, line:{ color:"1A5276", width:1.5 }, rectRadius:0.1 });
  s.addShape(pres.ShapeType.rect, { x:5.15, y:0.82, w:4.6, h:0.55, fill:{ color:"1A5276" }, line:{ type:"none" } });
  s.addText("🔬  RADIOLOGY", { x:5.25, y:0.84, w:4.4, h:0.5, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", valign:"middle" });
  const radPts = [
    "HRCT temporal bone — GOLD STANDARD ★",
    "CT shows: soft tissue density, scutal/ossicular erosion, labyrinthine fistula",
    "DW-MRI — bright on DWI = cholesteatoma; detects residual/recurrent disease",
    "MRI for intracranial extension, dural involvement",
    "Complementary HRCT + MRI if cochlear nerve hypoplasia suspected",
    "Plain X-rays (Schuller's view): mastoid haziness — now largely obsolete",
  ];
  radPts.forEach((t, i) => {
    const bold = t.includes("GOLD STANDARD") || t.includes("DW-MRI");
    s.addText("▸  " + t, { x:5.25, y:1.45 + i*0.58, w:4.4, h:0.54, fontSize:12, color: bold ? "1A5276" : C.dktext, bold, fontFace:"Calibri", valign:"top" });
    if (i < radPts.length-1) s.addShape(pres.ShapeType.line, { x:5.25, y:1.45+(i+1)*0.58-0.04, w:4.4, h:0, line:{ color:"AED6F1", width:0.5 } });
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 8 — MEDICAL MANAGEMENT  (accent: dark orange)
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[6];
  contentBg(s, acc);
  heading(s, "Medical Management", acc);

  // Step flowchart (horizontal 4 steps)
  const steps = [
    { icon:"🧹", num:"01", lbl:"Aural Toilet", detail:"Micro-suction / syringing\nRemoves debris & discharge\nEssential FIRST step" },
    { icon:"💊", num:"02", lbl:"Topical Abx", detail:"Quinolone drops (1st line)\nOfloxacin / Ciprofloxacin\nNot ototoxic at clinical doses" },
    { icon:"💉", num:"03", lbl:"Systemic Abx", detail:"For acute exacerbations\nResistant infection\nTopical therapy failure" },
    { icon:"🩺", num:"04", lbl:"Treat Cause", detail:"Allergic rhinitis Rx\nAdenoidectomy if needed\nNasal polyposis management" },
  ];

  const sw = 2.2, sh = 2.35, sy = 0.88, gap = 0.12;
  steps.forEach((st, i) => {
    const x = 0.15 + i*(sw+gap);
    s.addShape(pres.ShapeType.roundRect, { x, y:sy, w:sw, h:sh, fill:{ color: acc }, line:{ type:"none" }, rectRadius:0.12 });
    s.addText(st.icon, { x, y:sy+0.1, w:sw, h:0.55, fontSize:26, align:"center" });
    s.addText(st.num, { x, y:sy+0.62, w:sw, h:0.35, fontSize:10, bold:true, color:"FEF9E7", fontFace:"Calibri", align:"center", charSpacing:3 });
    s.addText(st.lbl, { x, y:sy+0.93, w:sw, h:0.42, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center" });
    s.addText(st.detail, { x, y:sy+1.35, w:sw, h:0.94, fontSize:10.5, color:"FEF9E7", fontFace:"Calibri", align:"center", valign:"top" });
    if (i < steps.length-1) {
      s.addText("▶", { x: x+sw+0.01, y: sy+sh/2-0.15, w:0.14, h:0.3, fontSize:13, color:C.white });
    }
  });

  // Indications for surgery
  s.addShape(pres.ShapeType.rect, { x:0.1, y:3.38, w:9.8, h:0.38, fill:{ color:"1A1A2E" }, line:{ type:"none" } });
  s.addText("⚡  INDICATIONS TO ESCALATE TO SURGERY", {
    x:0.2, y:3.38, w:9.6, h:0.38, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", charSpacing:1,
  });
  const surgInd = [
    "Failed multiple courses of medical Rx",
    "Cholesteatoma present (near-absolute indication)",
    "Vertigo → suspect labyrinthine fistula",
    "Facial weakness",
    "Headache / signs of intracranial spread",
    "Atelectatic ear with significant CHL",
  ];
  surgInd.forEach((t, i) => {
    const col = i % 3, row = Math.floor(i/3);
    s.addShape(pres.ShapeType.roundRect, {
      x:0.15 + col*3.25, y:3.85 + row*0.68, w:3.1, h:0.6,
      fill:{ color:"FEF9E7" }, line:{ color: acc, width:1 }, rectRadius:0.07,
    });
    s.addText("⚠  " + t, { x:0.25+col*3.25, y:3.88+row*0.68, w:2.95, h:0.54, fontSize:11.5, color:"7E5109", fontFace:"Calibri", valign:"middle" });
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 9 — SURGICAL MANAGEMENT  (accent: dark teal)
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[8];
  contentBg(s, acc);
  heading(s, "Surgical Management", acc);

  // 3 priorities badges
  const prios = [
    { n:"1", lbl:"ERADICATE\nDISEASE", col:"C0392B" },
    { n:"2", lbl:"PREVENT\nRECURRENCE", col:"1A5276" },
    { n:"3", lbl:"RESTORE\nHEARING", col:"1E8449" },
  ];
  prios.forEach((p, i) => {
    const x = 0.2 + i*3.25;
    s.addShape(pres.ShapeType.roundRect, { x, y:0.84, w:3.1, h:0.78, fill:{ color: p.col }, line:{ type:"none" }, rectRadius:0.1 });
    s.addText(`${p.n}. ${p.lbl}`, { x, y:0.84, w:3.1, h:0.78, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  });

  // CWU vs CWD comparison
  const surgeries = [
    {
      name:"TYMPANOPLASTY\n/ MYRINGOPLASTY",
      color: acc,
      pts:["TM repair for safe CSOM", "Temporalis fascia graft (underlay/overlay)", "Pre-op: ear dry ≥3–4 weeks", "Hearing restoration primary goal"],
    },
    {
      name:"CANAL WALL UP\n(CWU) MASTOIDECTOMY",
      color:"1A5276",
      pts:["Posterior EAC wall preserved", "Combined approach tympanoplasty (CAT)", "Preferred — no cavity problems", "Recidivism: 5–71% paediatric"],
    },
    {
      name:"CANAL WALL DOWN\n(CWD) MASTOIDECTOMY",
      color:"C0392B",
      pts:["Posterior wall removed (open cavity)", "Better access to disease", "Requires lifelong cavity maintenance", "2nd-look at 12–18 months in CWU"],
    },
  ];

  surgeries.forEach((sg, i) => {
    const x = 0.2 + i*3.25;
    s.addShape(pres.ShapeType.roundRect, { x, y:1.75, w:3.1, h:3.65, fill:{ color:"F2F3F4" }, line:{ color: sg.color, width:1.5 }, rectRadius:0.1 });
    s.addShape(pres.ShapeType.roundRect, { x, y:1.75, w:3.1, h:0.65, fill:{ color: sg.color }, line:{ type:"none" }, rectRadius:0.1 });
    s.addText(sg.name, { x: x+0.05, y:1.77, w:3.0, h:0.63, fontSize:11.5, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
    sg.pts.forEach((pt, pi) => {
      s.addText("▸  " + pt, { x: x+0.1, y:2.5 + pi*0.68, w:2.95, h:0.62, fontSize:12, color:C.dktext, fontFace:"Calibri", valign:"top" });
      if (pi < sg.pts.length-1) s.addShape(pres.ShapeType.line, { x: x+0.1, y:2.5+(pi+1)*0.68-0.04, w:2.95, h:0, line:{ color:"D5D8DC", width:0.5 } });
    });
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 10 — COMPLICATIONS  (accent: dark red)
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[9];
  contentBg(s, acc);
  heading(s, "Complications", acc);

  // Extracranial cluster
  s.addShape(pres.ShapeType.roundRect, { x:0.12, y:0.82, w:4.55, h:4.55, fill:{ color:"EBF5FB" }, line:{ color:"1A5276", width:2 }, rectRadius:0.12 });
  s.addShape(pres.ShapeType.roundRect, { x:0.12, y:0.82, w:4.55, h:0.55, fill:{ color:"1A5276" }, line:{ type:"none" }, rectRadius:0.12 });
  s.addText("🦻 EXTRACRANIAL", { x:0.22, y:0.84, w:4.35, h:0.5, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", valign:"middle" });
  const exCC = [
    { t:"Conductive / Sensorineural Hearing Loss", c:C.dktext },
    { t:"Labyrinthitis (suppurative / serous)", c:C.dktext },
    { t:"Labyrinthine fistula — lateral SCC (most common)", c:C.dktext },
    { t:"Facial nerve palsy — Fallopian canal erosion", c:"8E44AD" },
    { t:"Acute mastoiditis / Subperiosteal abscess", c:C.dktext },
    { t:"Petrous apicitis — Gradenigo's syndrome", c:C.dktext },
    { t:"Bezold's abscess (pus under SCM)", c:C.dktext },
  ];
  exCC.forEach((item, i) => {
    s.addShape(pres.ShapeType.rect, { x:0.17, y:1.44+i*0.55, w:4.45, h:0.5, fill:{ color: i%2===0?"D6EAF8":"EBF5FB" }, line:{ type:"none" } });
    s.addText("• " + item.t, { x:0.27, y:1.47+i*0.55, w:4.25, h:0.46, fontSize:11.5, color:item.c, fontFace:"Calibri", valign:"middle" });
  });

  // Intracranial cluster
  s.addShape(pres.ShapeType.roundRect, { x:5.23, y:0.82, w:4.55, h:4.55, fill:{ color:"FDEDEC" }, line:{ color: acc, width:2 }, rectRadius:0.12 });
  s.addShape(pres.ShapeType.roundRect, { x:5.23, y:0.82, w:4.55, h:0.55, fill:{ color: acc }, line:{ type:"none" }, rectRadius:0.12 });
  s.addText("🧠 INTRACRANIAL", { x:5.33, y:0.84, w:4.35, h:0.5, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", valign:"middle" });
  const intCC = [
    { t:"Meningitis — most common intracranial complication", c:acc },
    { t:"Extradural abscess", c:C.dktext },
    { t:"Subdural empyema", c:C.dktext },
    { t:"Brain abscess — temporal lobe / cerebellum", c: acc },
    { t:"Sigmoid / lateral sinus thrombophlebitis", c: acc },
    { t:"Otitic hydrocephalus", c:C.dktext },
    { t:"⚠ Otalgia + headache = intracranial complication until proved otherwise!", c: acc },
  ];
  intCC.forEach((item, i) => {
    const isBold = item.t.startsWith("⚠");
    s.addShape(pres.ShapeType.rect, { x:5.28, y:1.44+i*0.55, w:4.45, h:0.5, fill:{ color: i%2===0?"FADBD8":"FDEDEC" }, line:{ type:"none" } });
    s.addText("• " + item.t, { x:5.38, y:1.47+i*0.55, w:4.25, h:0.46, fontSize:11.5, color:item.c, bold: isBold, fontFace:"Calibri", valign:"middle" });
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 11 — MASTOID ABSCESS IMAGE + KEY SURGICAL POINTS
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = "E74C3C";
  contentBg(s, acc);
  heading(s, "Mastoiditis — Clinical Correlation", acc);

  const img0 = imgData(0);
  if (img0) {
    s.addImage({ data: img0, x:0.15, y:0.85, w:3.8, h:3.0 });
  } else {
    s.addShape(pres.ShapeType.roundRect, { x:0.15, y:0.85, w:3.8, h:3.0, fill:{ color:"D5D8DC" }, rectRadius:0.1 });
    s.addText("Image: Mastoid Subperiosteal Abscess", { x:0.2, y:1.6, w:3.7, h:1.2, fontSize:11, color:"555", fontFace:"Calibri", align:"center" });
  }
  s.addText("Mastoid subperiosteal abscess\n(Shambaugh Surgery of the Ear, Fig. 30–1)", {
    x:0.15, y:3.88, w:3.8, h:0.6, fontSize:10, italic:true, color:"7B241C", fontFace:"Calibri", align:"center",
  });

  // Key points on the right
  const kpts = [
    { icon:"🔴", txt:"Acute-on-chronic — most common complication of CSOM" },
    { icon:"🌡️", txt:"Fever + pinna displacement + post-auricular tenderness + swelling" },
    { icon:"⚕️", txt:"HRCT: bony erosion of mastoid cortex + rim-enhancing collection" },
    { icon:"💊", txt:"IV antibiotics (anti-pseudomonal) + urgent cortical mastoidectomy" },
    { icon:"⚠", txt:"Bezold's abscess: pus perforates mastoid tip → tracks under SCM" },
    { icon:"⚡", txt:"Intracranial extension must always be excluded with MRI" },
  ];
  kpts.forEach((k, i) => {
    s.addShape(pres.ShapeType.roundRect, { x:4.2, y:0.88+i*0.75, w:5.65, h:0.67, fill:{ color: i%2===0?"FDEDEC":"FEF9E7" }, line:{ color: acc, width:0.5 }, rectRadius:0.07 });
    s.addText(k.icon + "  " + k.txt, { x:4.3, y:0.92+i*0.75, w:5.45, h:0.58, fontSize:12, color:C.dktext, fontFace:"Calibri", valign:"middle" });
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 12 — KEY TAKE-AWAYS / SUMMARY  (dark bg with vivid cards)
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{ color:"0D1B2A" } });
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:0.72, fill:{ color:"1ABC9C" } });
  s.addText("KEY TAKE-AWAYS", {
    x:0.3, y:0.1, w:9.4, h:0.55, fontSize:20, bold:true, color:"0D1B2A", fontFace:"Calibri", align:"left", charSpacing:2,
  });

  const cards = [
    { acc:"E74C3C", txt:"CSOM = TM perforation + otorrhoea >6–12 wks | Central cause: ET dysfunction" },
    { acc:"E67E22", txt:"SAFE (tubo-tympanic) vs. UNSAFE (attico-antral / cholesteatoma) — critical distinction" },
    { acc:"F1C40F", txt:"Otalgia + headache = RED FLAG → rule out intracranial complication urgently" },
    { acc:"27AE60", txt:"Full PTA mandatory pre-op; CHL >30 dB = ossicular erosion; document SNHL" },
    { acc:"1ABC9C", txt:"HRCT temporal bone = gold standard; DW-MRI detects residual / recurrent cholesteatoma" },
    { acc:"2980B9", txt:"Medical Rx: aural toilet + ototopical quinolones; watch for Candida with prolonged use" },
    { acc:"8E44AD", txt:"Surgery: (1) Eradicate disease  (2) Prevent recurrence  (3) Restore hearing (Shambaugh)" },
    { acc:"E8A820", txt:"Cholesteatoma + medically refractory CSOM = near-absolute indication for mastoidectomy" },
  ];

  const cw = 4.7, ch = 0.72, gap = 0.12;
  cards.forEach((c, i) => {
    const col = i % 2, row = Math.floor(i / 2);
    const x = 0.15 + col * (cw + gap);
    const y = 0.86 + row * (ch + gap);
    s.addShape(pres.ShapeType.roundRect, { x, y, w:cw, h:ch, fill:{ color:"132236" }, line:{ color: c.acc, width:2 }, rectRadius:0.08 });
    s.addShape(pres.ShapeType.roundRect, { x, y, w:0.35, h:ch, fill:{ color: c.acc }, line:{ type:"none" }, rectRadius:0.08 });
    s.addText(String(i+1).padStart(2,"0"), { x, y, w:0.35, h:ch, fontSize:13, bold:true, color:"0D1B2A", fontFace:"Calibri", align:"center", valign:"middle" });
    s.addText(c.txt, { x: x+0.42, y: y+0.04, w: cw-0.5, h: ch-0.08, fontSize:11.5, color:"ECF0F1", fontFace:"Calibri", valign:"middle" });
  });
}

// ══════════════════════════════════════════════════════════════
// SLIDE 13 — THANK YOU
// ══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{ color:"0D1B2A" } });
  // colorful diagonal strips
  const strips = ["E74C3C","E67E22","F1C40F","27AE60","1ABC9C","2980B9","8E44AD"];
  strips.forEach((col, i) => {
    s.addShape(pres.ShapeType.rect, { x: i * (10/strips.length), y:0, w: 10/strips.length, h:0.22, fill:{ color: col }, line:{ type:"none" } });
    s.addShape(pres.ShapeType.rect, { x: i * (10/strips.length), y:5.4, w: 10/strips.length, h:0.22, fill:{ color: col }, line:{ type:"none" } });
  });

  s.addText("THANK YOU", {
    x:0.5, y:1.4, w:9, h:1.5, fontSize:52, bold:true, color:"1ABC9C",
    fontFace:"Calibri", align:"center", valign:"middle", charSpacing:8,
  });
  s.addText("Questions & Discussion", {
    x:0.5, y:3.0, w:9, h:0.7, fontSize:22, color:"95A5A6",
    fontFace:"Calibri", align:"center", italic:true,
  });
  s.addText("Sources: Shambaugh Surgery of the Ear  ·  Cummings Otolaryngology  ·  Scott-Brown's ORL HNS  ·  KJ Lee's Essential Otolaryngology", {
    x:0.5, y:4.6, w:9, h:0.5, fontSize:9.5, color:"607080",
    fontFace:"Calibri", align:"center", italic:true,
  });
}

// ─── Write ─────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/csom-ppt/CSOM_v2.pptx" })
  .then(() => console.log("SUCCESS: /home/daytona/workspace/csom-ppt/CSOM_v2.pptx"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

const pptxgen = require("pptxgenjs");
const fs = require("fs");

// ─── Load images ──────────────────────────────────────────────
// images.json has base64 for img0 and img1; img2/3 are local files
const imgs = JSON.parse(fs.readFileSync("/home/daytona/workspace/csom-ppt/images.json"));
// img2 and img3 from local file
try {
  const raw2 = fs.readFileSync("/home/daytona/workspace/csom-ppt/img2.png");
  imgs[2] = "image/png;base64," + raw2.toString("base64");
  console.log("img2 loaded from file, size:", raw2.length);
} catch(e) { console.log("img2 not available:", e.message); }
try {
  const raw3 = fs.readFileSync("/home/daytona/workspace/csom-ppt/img3.png");
  imgs[3] = "image/png;base64," + raw3.toString("base64");
  console.log("img3 loaded from file, size:", raw3.length);
} catch(e) { console.log("img3 not available:", e.message); }

function imgData(idx) { return imgs[idx] || null; }

// ─── Palette ──────────────────────────────────────────────────
const C = {
  c1: "E74C3C", c2: "E67E22", c3: "F39C12", c4: "27AE60",
  c5: "1ABC9C", c6: "2980B9", c7: "8E44AD", c8: "D35400",
  c9: "16A085", c10:"C0392B",
  white: "FFFFFF", dktext: "1A1A2E", ltgray: "ECF0F1",
};
const SLIDE_COLORS = [C.c1,C.c2,C.c4,C.c6,C.c7,C.c5,C.c8,C.c3,C.c9,C.c10];

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Chronic Suppurative Otitis Media";

// ─── Helpers ──────────────────────────────────────────────────
function contentBg(slide, accent) {
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{ color:"F8F9FA" } });
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:0.75, fill:{ color: accent } });
  slide.addShape(pres.ShapeType.rect, { x:0, y:0.75, w:0.06, h:"100%", fill:{ color: accent } });
}
function heading(slide, text) {
  slide.addText(text, {
    x:0.22, y:0.1, w:9.5, h:0.57,
    fontSize:20, bold:true, color:C.white,
    fontFace:"Calibri", valign:"middle", align:"left",
  });
}
function addImg(slide, idx, x, y, w, h, fallbackLabel) {
  const d = imgData(idx);
  if (d) {
    slide.addImage({ data: d, x, y, w, h });
  } else {
    slide.addShape(pres.ShapeType.roundRect, { x, y, w, h, fill:{ color:"D5D8DC" }, line:{ color:"AEB6BF", width:1 }, rectRadius:0.1 });
    slide.addText(fallbackLabel || "Image", { x, y: y+h/2-0.3, w, h:0.6, fontSize:10, color:"666666", fontFace:"Calibri", align:"center" });
  }
}

// ════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{ color:"0D1B2A" } });
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:0.2, fill:{ color:"1ABC9C" } });
  s.addShape(pres.ShapeType.rect, { x:0, y:5.4, w:"100%", h:0.22, fill:{ color:"1ABC9C" } });
  // right splash
  s.addShape(pres.ShapeType.rect, { x:7.5, y:0.2, w:2.5, h:5.2, fill:{ color:"132236" } });
  // coloured vertical bar on right
  const barCols = ["E74C3C","E67E22","F1C40F","27AE60","1ABC9C","2980B9","8E44AD"];
  barCols.forEach((c,i) => s.addShape(pres.ShapeType.rect, { x:9.6, y:0.2+i*(5.2/7), w:0.4, h:5.2/7, fill:{ color:c }, line:{ type:"none" } }));

  s.addText("CHRONIC\nSUPPURATIVE\nOTITIS MEDIA", {
    x:0.4, y:0.45, w:6.8, h:3.2, fontSize:44, bold:true, color:C.white,
    fontFace:"Calibri", align:"left", valign:"middle", lineSpacingMultiple:1.1,
  });
  s.addText("C S O M", { x:0.4, y:3.75, w:3, h:0.65, fontSize:26, bold:true, color:"1ABC9C", fontFace:"Calibri", charSpacing:12 });
  s.addText("ENT Department  ·  2026", { x:0.4, y:4.52, w:6.5, h:0.4, fontSize:13, color:"95A5A6", fontFace:"Calibri", italic:true });
  s.addText("Sources: Shambaugh Surgery of the Ear | Cummings Otolaryngology | Scott-Brown's ORL", {
    x:0.4, y:4.94, w:9, h:0.28, fontSize:9, color:"607080", fontFace:"Calibri", italic:true,
  });
  s.addText("👂", { x:7.6, y:1.0, w:1.8, h:2.5, fontSize:90, align:"center" });
}

// ════════════════════════════════════════════════════════════
// SLIDE 2 — DEFINITION & EPIDEMIOLOGY
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[0];
  contentBg(s, acc);
  heading(s, "Definition & Epidemiology");

  s.addShape(pres.ShapeType.roundRect, { x:0.15, y:0.82, w:5.5, h:1.85, fill:{ color: acc }, line:{ type:"none" }, rectRadius:0.1 });
  s.addText("DEFINITION", { x:0.25, y:0.84, w:5.3, h:0.35, fontSize:10.5, bold:true, color:C.white, fontFace:"Calibri", charSpacing:2 });
  s.addText("Chronic inflammation of the mucoperiosteum of the middle ear cleft — persistent TM perforation + otorrhoea lasting > 6–12 weeks.", {
    x:0.25, y:1.18, w:5.3, h:1.42, fontSize:13.5, color:C.white, fontFace:"Calibri", valign:"top",
  });

  const stats = [
    { val:"1–2%", lbl:"Global prevalence" },
    { val:"<2 yrs", lbl:"Peak incidence" },
    { val:"WHO", lbl:"Massive public health problem" },
  ];
  stats.forEach((st, i) => {
    const y = 0.82 + i*0.65;
    s.addShape(pres.ShapeType.roundRect, { x:5.85, y, w:3.9, h:0.58, fill:{ color:"FDECEA" }, line:{ color: acc, width:1.5 }, rectRadius:0.08 });
    s.addText(st.val, { x:5.95, y: y+0.04, w:1.1, h:0.5, fontSize:16, bold:true, color: acc, fontFace:"Calibri", align:"center", valign:"middle" });
    s.addText(st.lbl, { x:7.12, y: y+0.09, w:2.5, h:0.42, fontSize:11.5, color:C.dktext, fontFace:"Calibri", valign:"middle" });
  });

  s.addText("RISK FACTORS", { x:0.18, y:2.75, w:9.5, h:0.32, fontSize:10.5, bold:true, color: acc, fontFace:"Calibri", charSpacing:2 });
  const risks = ["ET dysfunction","Recurrent AOM","Overcrowding / malnutrition","Cleft palate / Down syndrome","Allergic rhinitis / adenoid hypertrophy","Immunodeficiency (HIV, primary)"];
  risks.forEach((r, i) => {
    const col = i % 3, row = Math.floor(i / 3);
    const x = 0.18 + col * 3.22, y = 3.12 + row * 0.58;
    s.addShape(pres.ShapeType.roundRect, { x, y, w:3.08, h:0.5, fill:{ color:"FDECEA" }, line:{ color: acc, width:1 }, rectRadius:0.07 });
    s.addText("• " + r, { x: x+0.1, y, w:2.94, h:0.5, fontSize:12, color:C.dktext, fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 3 — ETIOPATHOGENESIS FLOWCHART
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[1];
  contentBg(s, acc);
  heading(s, "Etiopathogenesis");

  // Flowchart nodes
  const nodes = [
    { lbl:"ET\nDysfunction", sub:"Negative ME\npressure", color:"E67E22" },
    { lbl:"ME\nEffusion", sub:"Serous /\npurulent fluid", color:"D35400" },
    { lbl:"Mucosal Oedema\n& Granulation", sub:"BM rupture,\npolyps", color:"C0392B" },
    { lbl:"TM\nWeakening", sub:"Enzyme collagen\ndegradation", color:"992D22" },
    { lbl:"Perforation /\nRetraction", sub:"→ CSOM /\nCholesteatoma", color:"7B241C" },
  ];
  const nW=1.78, nH=1.0, sy=0.88, gap=0.23, sx=0.18;
  nodes.forEach((n,i)=>{
    const x = sx + i*(nW+gap);
    s.addShape(pres.ShapeType.roundRect, { x, y:sy, w:nW, h:nH, fill:{ color: n.color }, line:{ type:"none" }, rectRadius:0.1 });
    s.addText(n.lbl, { x, y:sy+0.06, w:nW, h:0.46, fontSize:11, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
    s.addText(n.sub, { x, y:sy+0.54, w:nW, h:0.42, fontSize:9, color:"FFD5C8", fontFace:"Calibri", align:"center", valign:"top" });
    if (i<nodes.length-1) {
      const ax = x+nW+0.04;
      s.addShape(pres.ShapeType.line, { x:ax, y:sy+nH/2, w:gap-0.1, h:0, line:{ color:C.white, width:2 } });
      s.addText("▶", { x:ax+gap-0.22, y:sy+nH/2-0.16, w:0.22, h:0.32, fontSize:12, color:C.white });
    }
  });

  // Microbiology bar
  s.addShape(pres.ShapeType.rect, { x:0.1, y:2.02, w:9.8, h:0.38, fill:{ color:"FEF9E7" }, line:{ color: acc, width:1 } });
  s.addText("🦠  KEY ORGANISMS:  Pseudomonas aeruginosa  ·  Staph. aureus  ·  Proteus mirabilis  ·  Klebsiella  ·  Candida (after prolonged topical Abx)", {
    x:0.2, y:2.02, w:9.6, h:0.38, fontSize:11, bold:true, color:"7D6608", fontFace:"Calibri", valign:"middle",
  });

  // Key concept 6-box grid
  const concepts = [
    "Biofilm formation — key driver of treatment resistance (2006)",
    "Bacterial toxins → BM rupture → lamina propria extrusion → granulation",
    "Submucosal gland metaplasia → secretory mucosa → perpetuates effusion",
    "Candida overgrowth 10% baseline → 35% after 3-wk topical ciprofloxacin (Cummings)",
    "Retraction pocket deepening → contact with mucosa → fibrous band / perforation",
    "Deep retraction pocket or perforation → cholesteatoma genesis",
  ];
  concepts.forEach((c,i) => {
    const col=i%3, row=Math.floor(i/3);
    const x=0.18+col*3.22, y=2.52+row*0.8;
    s.addShape(pres.ShapeType.roundRect, { x, y, w:3.08, h:0.72, fill:{ color: col%2===0?"FFF3E0":"FFF8E1" }, line:{ color: acc, width:0.5 }, rectRadius:0.07 });
    s.addText("▸  "+c, { x:x+0.08, y:y+0.05, w:2.95, h:0.62, fontSize:11, color:C.dktext, fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 4 — CLASSIFICATION (Safe vs Unsafe)
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[2];
  contentBg(s, acc);
  heading(s, "Classification — Safe vs. Unsafe");

  // VS badge
  s.addShape(pres.ShapeType.ellipse, { x:4.62, y:1.6, w:0.76, h:0.76, fill:{ color:"1A1A2E" }, line:{ type:"none" } });
  s.addText("VS", { x:4.62, y:1.6, w:0.76, h:0.76, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });

  // Safe
  s.addShape(pres.ShapeType.roundRect, { x:0.12, y:0.82, w:4.38, h:4.55, fill:{ color:"E9F7EF" }, line:{ color: acc, width:2 }, rectRadius:0.12 });
  s.addShape(pres.ShapeType.roundRect, { x:0.12, y:0.82, w:4.38, h:0.68, fill:{ color: acc }, line:{ type:"none" }, rectRadius:0.12 });
  s.addText("TUBO-TYMPANIC  (SAFE)", { x:0.18, y:0.84, w:4.25, h:0.64, fontSize:12.5, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  const safeItems = ["Central TM perforation (pars tensa)","No cholesteatoma","Mucoid, odourless discharge","Responds to medical treatment","Surgery: Myringoplasty / Tympanoplasty","Lower risk of complications","Conductive hearing loss"];
  safeItems.forEach((t,i) => {
    s.addShape(pres.ShapeType.rect, { x:0.17, y:1.57+i*0.54, w:4.28, h:0.5, fill:{ color: i%2===0?"D5F5E3":"E9F7EF" }, line:{ type:"none" } });
    s.addText("✔  "+t, { x:0.27, y:1.6+i*0.54, w:4.08, h:0.45, fontSize:12, color:"145A32", fontFace:"Calibri", valign:"middle" });
  });

  // Unsafe
  const ured = "C0392B";
  s.addShape(pres.ShapeType.roundRect, { x:5.5, y:0.82, w:4.38, h:4.55, fill:{ color:"FDEDEC" }, line:{ color: ured, width:2 }, rectRadius:0.12 });
  s.addShape(pres.ShapeType.roundRect, { x:5.5, y:0.82, w:4.38, h:0.68, fill:{ color: ured }, line:{ type:"none" }, rectRadius:0.12 });
  s.addText("ATTICO-ANTRAL  (UNSAFE)", { x:5.56, y:0.84, w:4.25, h:0.64, fontSize:12.5, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  const unsafeItems = [
    { t:"Attic / marginal perforation (pars flaccida)", red:false },
    { t:"CHOLESTEATOMA present ⚠", red:true },
    { t:"Scanty, FETID (foul-smelling) discharge", red:false },
    { t:"Scutal & ossicular erosion", red:false },
    { t:"HIGH risk — intracranial complications ⚠", red:true },
    { t:"Surgery: CWU or CWD Mastoidectomy", red:false },
    { t:"Second-look surgery at 12–18 months (CWU)", red:false },
  ];
  unsafeItems.forEach((item,i) => {
    s.addShape(pres.ShapeType.rect, { x:5.55, y:1.57+i*0.54, w:4.28, h:0.5, fill:{ color: i%2===0?"FADBD8":"FDEDEC" }, line:{ type:"none" } });
    s.addText((item.red?"⚠  ":"✖  ")+item.t, { x:5.65, y:1.6+i*0.54, w:4.08, h:0.45, fontSize:12, color: item.red ? ured : "7B241C", bold: item.red, fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 5 — CLINICAL FEATURES
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[3];
  contentBg(s, acc);
  heading(s, "Clinical Features");

  const symptoms = [
    { t:"Otorrhoea — intermittent / continuous", red:false },
    { t:"Conductive hearing loss (most common)", red:false },
    { t:"Otalgia / headache  ⚠ RED FLAG = suspect complication", red:true },
    { t:"Vertigo → labyrinthitis / labyrinthine fistula", red:false },
    { t:"Tinnitus", red:false },
    { t:"Facial weakness — CN VII involvement (rare)", red:false },
  ];
  const signs = [
    { t:"TM perforation — central (safe) vs attic/marginal (unsafe)", red:false },
    { t:"Discharge / granulation tissue / polyp in EAC", red:false },
    { t:"Scutal erosion ★ = hallmark of cholesteatoma", red:true },
    { t:"Retraction pocket with squamous keratin debris", red:false },
    { t:"Tuning fork: Rinne −ve, Weber lateralised to affected ear", red:false },
    { t:"Post-auricular swelling / fistula = mastoiditis", red:false },
  ];

  // Headers
  s.addShape(pres.ShapeType.rect, { x:0.1, y:0.82, w:4.75, h:0.42, fill:{ color: acc }, line:{ type:"none" } });
  s.addText("SYMPTOMS", { x:0.18, y:0.82, w:4.6, h:0.42, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", charSpacing:2 });
  symptoms.forEach((item,i) => {
    s.addShape(pres.ShapeType.rect, { x:0.1, y:1.3+i*0.63, w:4.75, h:0.57, fill:{ color: i%2===0?"EBF5FB":"D6EAF8" }, line:{ type:"none" } });
    s.addText((item.red?"⚠ ":"▶ ")+item.t, { x:0.2, y:1.33+i*0.63, w:4.55, h:0.5, fontSize:12, color: item.red?"C0392B":C.dktext, bold:item.red, fontFace:"Calibri", valign:"middle" });
  });

  s.addShape(pres.ShapeType.line, { x:5.0, y:0.82, w:0, h:4.5, line:{ color:"BDC3C7", width:1.5 } });

  s.addShape(pres.ShapeType.rect, { x:5.15, y:0.82, w:4.75, h:0.42, fill:{ color:"1A5276" }, line:{ type:"none" } });
  s.addText("SIGNS — Otomicroscopy", { x:5.23, y:0.82, w:4.6, h:0.42, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", charSpacing:2 });
  signs.forEach((item,i) => {
    s.addShape(pres.ShapeType.rect, { x:5.15, y:1.3+i*0.63, w:4.75, h:0.57, fill:{ color: i%2===0?"EBF5FB":"D6EAF8" }, line:{ type:"none" } });
    s.addText((item.red?"★ ":"▶ ")+item.t, { x:5.25, y:1.33+i*0.63, w:4.55, h:0.5, fontSize:12, color: item.red?"8E44AD":C.dktext, bold:item.red, fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 6 — OTOSCOPIC & HISTOLOGICAL IMAGES
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[4];
  contentBg(s, acc);
  heading(s, "Otoscopic & Histological Findings");

  // 3 images in a row
  addImg(s, 1, 0.12, 0.82, 3.2, 2.5, "Cholesteatoma — otoscopy");
  s.addShape(pres.ShapeType.rect, { x:0.12, y:3.35, w:3.2, h:0.55, fill:{ color:"F4ECF7" }, line:{ type:"none" } });
  s.addText("Cholesteatoma (otoscopy)\nAttic retraction with keratin debris\n(Shambaugh, Fig. 25–5)", { x:0.14, y:3.36, w:3.16, h:0.52, fontSize:9, color:"6C3483", fontFace:"Calibri", align:"center", italic:true });

  addImg(s, 2, 3.4, 0.82, 3.2, 2.5, "Cholesteatoma — H&E temporal bone");
  s.addShape(pres.ShapeType.rect, { x:3.4, y:3.35, w:3.2, h:0.55, fill:{ color:"F4ECF7" }, line:{ type:"none" } });
  s.addText("COM with cholesteatoma — H&E\nKeratin sac eroding stapes suprastructure\n(Shambaugh, Fig. 25–6)", { x:3.42, y:3.36, w:3.16, h:0.52, fontSize:9, color:"6C3483", fontFace:"Calibri", align:"center", italic:true });

  addImg(s, 3, 6.68, 0.82, 3.2, 2.5, "COM without cholesteatoma — H&E");
  s.addShape(pres.ShapeType.rect, { x:6.68, y:3.35, w:3.2, h:0.55, fill:{ color:"F4ECF7" }, line:{ type:"none" } });
  s.addText("COM without cholesteatoma — H&E\nTM perf + inflammatory exudate\n(Shambaugh, Fig. 25–7)", { x:6.7, y:3.36, w:3.16, h:0.52, fontSize:9, color:"6C3483", fontFace:"Calibri", align:"center", italic:true });

  // Key imaging facts
  const diagPts = [
    "Scutal erosion on CT = cholesteatoma until proved otherwise",
    "DW-MRI (non-EPI) — restricted diffusion = cholesteatoma",
    "HRCT temporal bone = gold standard pre-op imaging",
    "Pars flaccida retraction = most common cholesteatoma site",
  ];
  diagPts.forEach((d,i) => {
    const col=i%2, row=Math.floor(i/2);
    s.addShape(pres.ShapeType.roundRect, { x:0.2+col*4.9, y:4.0+row*0.63, w:4.7, h:0.55, fill:{ color:"F4ECF7" }, line:{ color: acc, width:1 }, rectRadius:0.07 });
    s.addText("◆  "+d, { x:0.3+col*4.9, y:4.03+row*0.63, w:4.5, h:0.5, fontSize:12, color:"6C3483", bold: d.includes("gold standard")||d.includes("DW-MRI"), fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 7 — INVESTIGATIONS
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[5];
  contentBg(s, acc);
  heading(s, "Investigations");

  // Audiology card
  s.addShape(pres.ShapeType.roundRect, { x:0.12, y:0.82, w:4.65, h:4.55, fill:{ color:"E8F8F5" }, line:{ color: acc, width:1.5 }, rectRadius:0.1 });
  s.addShape(pres.ShapeType.rect, { x:0.12, y:0.82, w:4.65, h:0.55, fill:{ color: acc }, line:{ type:"none" } });
  s.addText("🎧  AUDIOLOGICAL", { x:0.2, y:0.84, w:4.5, h:0.5, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", valign:"middle" });
  [
    "Pure Tone Audiogram (PTA) — mandatory pre-op",
    "CHL most common; SNHL if cochlear involvement",
    "CHL >30 dB → suspect ossicular erosion",
    "Hearing preserved by cholesteatoma mass despite ossicular erosion",
    "Tympanometry: Type B (flat) = TM perf or MEE",
    "SNHL range documented: 5–33 dB (Shambaugh)",
  ].forEach((t,i) => {
    const bold = t.includes("30 dB") || t.includes("mandatory");
    s.addShape(pres.ShapeType.rect, { x:0.17, y:1.44+i*0.59, w:4.55, h:0.52, fill:{ color:i%2===0?"D1F2EB":"E8F8F5" }, line:{ type:"none" } });
    s.addText("▸  "+t, { x:0.27, y:1.47+i*0.59, w:4.35, h:0.48, fontSize:12, color: bold?"16A085":C.dktext, bold, fontFace:"Calibri", valign:"middle" });
  });

  // Radiology card
  s.addShape(pres.ShapeType.roundRect, { x:5.23, y:0.82, w:4.65, h:4.55, fill:{ color:"EBF5FB" }, line:{ color:"1A5276", width:1.5 }, rectRadius:0.1 });
  s.addShape(pres.ShapeType.rect, { x:5.23, y:0.82, w:4.65, h:0.55, fill:{ color:"1A5276" }, line:{ type:"none" } });
  s.addText("🔬  RADIOLOGY", { x:5.31, y:0.84, w:4.5, h:0.5, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", valign:"middle" });
  [
    { t:"HRCT temporal bone — GOLD STANDARD ★", bold:true },
    { t:"CT shows: soft tissue, scutal & ossicular erosion, labyrinthine fistula", bold:false },
    { t:"DW-MRI — bright DWI = cholesteatoma; detects residual/recurrent disease", bold:true },
    { t:"MRI for intracranial extension & dural involvement", bold:false },
    { t:"CT + MRI complementary if cochlear nerve hypoplasia suspected", bold:false },
    { t:"Plain X-ray (Schuller's view) — mastoid haziness; largely obsolete", bold:false },
  ].forEach((item,i) => {
    s.addShape(pres.ShapeType.rect, { x:5.28, y:1.44+i*0.59, w:4.55, h:0.52, fill:{ color:i%2===0?"D6EAF8":"EBF5FB" }, line:{ type:"none" } });
    s.addText("▸  "+item.t, { x:5.38, y:1.47+i*0.59, w:4.35, h:0.48, fontSize:12, color: item.bold?"1A5276":C.dktext, bold:item.bold, fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 8 — MEDICAL MANAGEMENT
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[6];
  contentBg(s, acc);
  heading(s, "Medical Management");

  // Step flowchart
  const steps = [
    { icon:"🧹", n:"01", lbl:"Aural Toilet", detail:"Micro-suction / syringing\nRemoves debris & discharge\nESSENTIAL first step" },
    { icon:"💊", n:"02", lbl:"Topical Abx", detail:"Quinolone drops (1st line)\nOfloxacin / Ciprofloxacin\nNot ototoxic at clinical doses" },
    { icon:"💉", n:"03", lbl:"Systemic Abx", detail:"Acute exacerbations\nResistant infections\nTopical therapy failure" },
    { icon:"🩺", n:"04", lbl:"Treat Cause", detail:"Allergic rhinitis Rx\nAdenoidectomy\nNasal polyposis Rx" },
  ];
  const sw=2.25, sh=2.3, sy=0.85, gap=0.12;
  steps.forEach((st,i) => {
    const x=0.15+i*(sw+gap);
    s.addShape(pres.ShapeType.roundRect, { x, y:sy, w:sw, h:sh, fill:{ color: acc }, line:{ type:"none" }, rectRadius:0.12 });
    s.addText(st.icon, { x, y:sy+0.08, w:sw, h:0.55, fontSize:28, align:"center" });
    s.addText(st.n, { x, y:sy+0.6, w:sw, h:0.3, fontSize:9.5, bold:true, color:"FEF9E7", fontFace:"Calibri", align:"center", charSpacing:3 });
    s.addText(st.lbl, { x, y:sy+0.88, w:sw, h:0.4, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center" });
    s.addText(st.detail, { x, y:sy+1.28, w:sw, h:0.96, fontSize:10.5, color:"FEF9E7", fontFace:"Calibri", align:"center", valign:"top" });
    if (i<steps.length-1) s.addText("▶", { x:x+sw+0.02, y:sy+sh/2-0.16, w:0.14, h:0.32, fontSize:14, color:C.white });
  });

  // Warning about Candida
  s.addShape(pres.ShapeType.rect, { x:0.1, y:3.28, w:9.8, h:0.38, fill:{ color:"FEF9E7" }, line:{ color:"F39C12", width:1.5 } });
  s.addText("⚠  NOTE: Candida overgrowth occurs in 35% of ears after 3 weeks of topical ciprofloxacin — monitor for fungal superinfection (Cummings Otolaryngology)", {
    x:0.2, y:3.28, w:9.6, h:0.38, fontSize:11, bold:false, color:"7D6608", fontFace:"Calibri", valign:"middle",
  });

  // Indications for surgery
  s.addShape(pres.ShapeType.rect, { x:0.1, y:3.74, w:9.8, h:0.38, fill:{ color:"1A1A2E" }, line:{ type:"none" } });
  s.addText("⚡  ESCALATE TO SURGERY WHEN:", { x:0.2, y:3.74, w:9.6, h:0.38, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", charSpacing:1 });
  const ind = ["Failed multiple courses of medical Rx","Cholesteatoma present (near-absolute indication)","Vertigo → labyrinthine fistula","Facial weakness — CN VII involvement","Headache → intracranial extension","Atelectatic ear with significant CHL"];
  ind.forEach((t,i) => {
    const col=i%3, row=Math.floor(i/3);
    const x=0.15+col*3.25, y=4.2+row*0.65;
    s.addShape(pres.ShapeType.roundRect, { x, y, w:3.1, h:0.58, fill:{ color:"FEF9E7" }, line:{ color: acc, width:1 }, rectRadius:0.07 });
    s.addText("⚠  "+t, { x:x+0.1, y, w:2.96, h:0.58, fontSize:11.5, color:"7E5109", fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 9 — SURGICAL MANAGEMENT
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[8];
  contentBg(s, acc);
  heading(s, "Surgical Management");

  // Priority badges
  [
    { n:"1", lbl:"ERADICATE DISEASE", col:"C0392B" },
    { n:"2", lbl:"PREVENT RECURRENCE", col:"1A5276" },
    { n:"3", lbl:"RESTORE HEARING", col:"1E8449" },
  ].forEach((p,i) => {
    const x=0.18+i*3.25;
    s.addShape(pres.ShapeType.roundRect, { x, y:0.84, w:3.1, h:0.72, fill:{ color: p.col }, line:{ type:"none" }, rectRadius:0.1 });
    s.addText(`${p.n}. ${p.lbl}`, { x, y:0.84, w:3.1, h:0.72, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  });

  // 3-column surgery type cards
  const surgeries = [
    { name:"TYMPANOPLASTY /\nMYRINGOPLASTY", color: acc,
      pts:["TM repair for safe CSOM (no cholesteatoma)","Temporalis fascia graft — underlay / overlay","Pre-op: ear dry ≥3–4 weeks","Eustachian tube function = key to success","Hearing restoration primary goal"] },
    { name:"CANAL WALL UP\n(CWU) MASTOIDECTOMY", color:"1A5276",
      pts:["Posterior EAC wall preserved","Combined approach tympanoplasty (CAT)","Preferred — avoids chronic cavity problems","Recidivism: 5–71% in paediatric cases","Second-look surgery at 12–18 months"] },
    { name:"CANAL WALL DOWN\n(CWD) MASTOIDECTOMY", color:"C0392B",
      pts:["Posterior canal wall removed (open cavity)","Better surgical access / exposure","Lifelong cavity maintenance required","Indications: labyrinthine fistula, low tegmen, unresectable disease (Shambaugh)","Lower recurrence vs CWU"] },
  ];
  surgeries.forEach((sg,i) => {
    const x=0.18+i*3.25;
    s.addShape(pres.ShapeType.roundRect, { x, y:1.65, w:3.1, h:3.75, fill:{ color:"F2F3F4" }, line:{ color: sg.color, width:1.5 }, rectRadius:0.1 });
    s.addShape(pres.ShapeType.roundRect, { x, y:1.65, w:3.1, h:0.65, fill:{ color: sg.color }, line:{ type:"none" }, rectRadius:0.1 });
    s.addText(sg.name, { x:x+0.05, y:1.67, w:3.0, h:0.63, fontSize:11.5, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
    sg.pts.forEach((pt,pi) => {
      s.addShape(pres.ShapeType.rect, { x:x+0.05, y:2.38+pi*0.59, w:3.0, h:0.54, fill:{ color:pi%2===0?"EAECEE":"F8F9FA" }, line:{ type:"none" } });
      s.addText("▸  "+pt, { x:x+0.1, y:2.4+pi*0.59, w:2.9, h:0.5, fontSize:11.5, color:C.dktext, fontFace:"Calibri", valign:"middle" });
    });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 10 — COMPLICATIONS
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  const acc = SLIDE_COLORS[9];
  contentBg(s, acc);
  heading(s, "Complications");

  // Mastoid abscess image on left
  addImg(s, 0, 0.12, 0.82, 2.5, 2.1, "Mastoid Subperiosteal Abscess");
  s.addText("Mastoid subperiosteal\nabscess (Shambaugh, Fig. 30–1)", { x:0.12, y:2.94, w:2.5, h:0.42, fontSize:9, italic:true, color:"7B241C", fontFace:"Calibri", align:"center" });

  // Extracranial
  s.addShape(pres.ShapeType.roundRect, { x:2.72, y:0.82, w:3.45, h:4.5, fill:{ color:"EBF5FB" }, line:{ color:"1A5276", width:1.5 }, rectRadius:0.1 });
  s.addShape(pres.ShapeType.roundRect, { x:2.72, y:0.82, w:3.45, h:0.52, fill:{ color:"1A5276" }, line:{ type:"none" }, rectRadius:0.1 });
  s.addText("🦻 EXTRACRANIAL", { x:2.8, y:0.84, w:3.3, h:0.48, fontSize:12.5, bold:true, color:C.white, fontFace:"Calibri", valign:"middle" });
  ["Conductive / Sensorineural hearing loss","Labyrinthitis (suppurative / serous)","Labyrinthine fistula — lateral SCC (most common)","Facial nerve palsy — Fallopian canal erosion","Acute mastoiditis / subperiosteal abscess","Petrous apicitis — Gradenigo's syndrome","Bezold's abscess (pus tracks under SCM)"].forEach((t,i) => {
    s.addShape(pres.ShapeType.rect, { x:2.77, y:1.4+i*0.54, w:3.35, h:0.5, fill:{ color:i%2===0?"D6EAF8":"EBF5FB" }, line:{ type:"none" } });
    s.addText("• "+t, { x:2.87, y:1.43+i*0.54, w:3.15, h:0.44, fontSize:11.5, color: t.includes("Facial")?"8E44AD":C.dktext, fontFace:"Calibri", valign:"middle" });
  });

  // Intracranial
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  s.addShape(pres.ShapeType.roundRect, { x:6.3, y:0.82, w:3.58, h:0.52, fill:{ color: acc }, line:{ type:"none" }, rectRadius:0.1 });
  s.addText("🧠 INTRACRANIAL", { x:6.38, y:0.84, w:3.43, h:0.48, fontSize:12.5, bold:true, color:C.white, fontFace:"Calibri", valign:"middle" });
  [
    { t:"Meningitis — MOST COMMON intracranial complication", red:true },
    { t:"Extradural abscess", red:false },
    { t:"Subdural empyema", red:false },
    { t:"Brain abscess — temporal lobe / cerebellum", red:true },
    { t:"Sigmoid / lateral sinus thrombophlebitis", red:true },
    { t:"Otitic hydrocephalus", red:false },
    { t:"⚠ Otalgia + headache = intracranial until proved otherwise!", red:true },
  ].forEach((item,i) => {
    s.addShape(pres.ShapeType.rect, { x:6.35, y:1.4+i*0.54, w:3.48, h:0.5, fill:{ color:i%2===0?"FADBD8":"FDEDEC" }, line:{ type:"none" } });
    s.addText("• "+item.t, { x:6.45, y:1.43+i*0.54, w:3.28, h:0.44, fontSize:11, color: item.red ? acc : C.dktext, bold: item.t.startsWith("⚠"), fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 11 — KEY TAKE-AWAYS
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{ color:"0D1B2A" } });
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:0.72, fill:{ color:"1ABC9C" } });
  s.addText("KEY TAKE-AWAYS", { x:0.3, y:0.1, w:9.4, h:0.55, fontSize:20, bold:true, color:"0D1B2A", fontFace:"Calibri", align:"left", charSpacing:2 });

  const cards = [
    { acc:"E74C3C", txt:"CSOM = TM perforation + otorrhoea >6–12 wks; central cause: Eustachian tube dysfunction" },
    { acc:"E67E22", txt:"SAFE (tubo-tympanic) vs. UNSAFE (attico-antral/cholesteatoma) — critical clinical distinction" },
    { acc:"F1C40F", txt:"Otalgia + headache = RED FLAG → rule out intracranial complication urgently" },
    { acc:"27AE60", txt:"Full PTA mandatory pre-op; CHL >30 dB = ossicular erosion; document any SNHL" },
    { acc:"1ABC9C", txt:"HRCT temporal bone = gold standard; DW-MRI detects residual / recurrent cholesteatoma" },
    { acc:"2980B9", txt:"Medical Rx: aural toilet + ototopical quinolones; watch for Candida with prolonged use" },
    { acc:"8E44AD", txt:"Surgery goals: 1. Eradicate disease  2. Prevent recurrence  3. Restore hearing (Shambaugh)" },
    { acc:"D35400", txt:"Cholesteatoma + medically refractory CSOM = near-absolute indication for mastoidectomy" },
  ];

  const cw=4.75, ch=0.72, gap=0.1;
  cards.forEach((c,i) => {
    const col=i%2, row=Math.floor(i/2);
    const x=0.12+col*(cw+gap), y=0.84+row*(ch+gap);
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    s.addShape(pres.ShapeType.roundRect, { x, y, w:0.34, h:ch, fill:{ color: c.acc }, line:{ type:"none" }, rectRadius:0.08 });
    s.addText(String(i+1).padStart(2,"0"), { x, y, w:0.34, h:ch, fontSize:13, bold:true, color:"0D1B2A", fontFace:"Calibri", align:"center", valign:"middle" });
    s.addText(c.txt, { x:x+0.42, y:y+0.04, w:cw-0.5, h:ch-0.08, fontSize:11.5, color:"ECF0F1", fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════
// SLIDE 12 — THANK YOU
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{ color:"0D1B2A" } });
  const cols = ["E74C3C","E67E22","F1C40F","27AE60","1ABC9C","2980B9","8E44AD"];
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  s.addText("THANK YOU", { x:0.5, y:1.4, w:9, h:1.5, fontSize:52, bold:true, color:"1ABC9C", fontFace:"Calibri", align:"center", valign:"middle", charSpacing:8 });
  s.addText("Questions & Discussion", { x:0.5, y:3.0, w:9, h:0.7, fontSize:22, color:"95A5A6", fontFace:"Calibri", align:"center", italic:true });
  s.addText("Sources: Shambaugh Surgery of the Ear  ·  Cummings Otolaryngology  ·  Scott-Brown's ORL HNS  ·  KJ Lee's Essential Otolaryngology", {
    x:0.5, y:4.6, w:9, h:0.5, fontSize:9.5, color:"607080", fontFace:"Calibri", align:"center", italic:true,
  });
}

// ─── Write ────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/csom-ppt/CSOM_v2.pptx" })
  .then(() => console.log("SUCCESS: /home/daytona/workspace/csom-ppt/CSOM_v2.pptx"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });