chronic rhinosinusitis CT scan coronal view medical image free

mkdir -p /home/daytona/workspace/crs-presentation

~/crs-presentation/build.js

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

// ─── color palette ────────────────────────────────────────────────────────────
const NAVY   = "1A2B5F";   // dominant dark
const TEAL   = "0E7C7B";   // accent / header bar
const CREAM  = "F5F0E8";   // slide backgrounds
const WHITE  = "FFFFFF";
const ORANGE = "E07B39";   // highlight accent
const LIGHT  = "D6EAF8";   // pale blue for boxes
const GREY   = "6B7280";   // body text
const DARK   = "1E293B";   // main body text

// ─── helpers ─────────────────────────────────────────────────────────────────
function titleSlide(pres, title, subtitle) {
  const s = pres.addSlide();
  // Full-bleed dark background
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: NAVY } });
  // accent bar
  s.addShape(pres.ShapeType.rect, { x: 0, y: 3.8, w: "100%", h: 0.08, fill: { color: ORANGE } });
  s.addText(title, { x: 0.6, y: 1.2, w: 8.8, h: 1.8, fontSize: 38, bold: true, color: WHITE, fontFace: "Calibri", align: "center", valign: "middle" });
  if (subtitle) s.addText(subtitle, { x: 0.6, y: 3.0, w: 8.8, h: 0.7, fontSize: 18, color: "B0C4DE", fontFace: "Calibri", align: "center" });
  s.addText("Cummings Otolaryngology | Scott-Brown's ENT | Goldman-Cecil Medicine", { x: 0, y: 5.1, w: "100%", h: 0.35, fontSize: 10, color: "7F8C8D", align: "center" });
  return s;
}

function sectionHeader(pres, title, icon) {
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 4.8, w: "100%", h: 0.825, fill: { color: NAVY } });
  s.addText((icon || "") + "  " + title, { x: 0.5, y: 1.8, w: 9, h: 1.5, fontSize: 36, bold: true, color: WHITE, fontFace: "Calibri", align: "center", valign: "middle" });
  return s;
}

function contentSlide(pres, heading, bullets, opts = {}) {
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: CREAM } });
  // header bar
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: NAVY } });
  s.addText(heading, { x: 0.25, y: 0, w: 9.5, h: 0.75, fontSize: 20, bold: true, color: WHITE, fontFace: "Calibri", valign: "middle", margin: 0 });

  const items = bullets.map((b, i) => {
    const isNested = b.startsWith("  ");
    return {
      text: b.replace(/^  /, ""),
      options: {
        bullet: { indent: isNested ? 30 : 0, characterCode: isNested ? "2013" : "2022" },
        fontSize: isNested ? 14 : 16,
        color: isNested ? GREY : DARK,
        bold: b.startsWith("**"),
        breakLine: i < bullets.length - 1
      }
    };
  });
  s.addText(items, { x: 0.35, y: 0.88, w: opts.narrow ? 5.2 : 9.3, h: 4.55, fontFace: "Calibri", valign: "top" });
  return s;
}

function twoColSlide(pres, heading, leftBullets, rightBullets, leftTitle, rightTitle) {
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: CREAM } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: NAVY } });
  s.addText(heading, { x: 0.25, y: 0, w: 9.5, h: 0.75, fontSize: 20, bold: true, color: WHITE, fontFace: "Calibri", valign: "middle", margin: 0 });
  // left column label
  s.addShape(pres.ShapeType.rect, { x: 0.2, y: 0.85, w: 4.5, h: 0.38, fill: { color: TEAL }, line: { color: TEAL } });
  s.addText(leftTitle, { x: 0.2, y: 0.85, w: 4.5, h: 0.38, fontSize: 13, bold: true, color: WHITE, align: "center", fontFace: "Calibri" });
  // right column label
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  // bullets
  const makeItems = (arr) => arr.map((b, i) => ({
    text: b.replace(/^  /, ""),
    options: { bullet: { indent: b.startsWith("  ") ? 20 : 0 }, fontSize: b.startsWith("  ") ? 13 : 15, color: DARK, breakLine: i < arr.length - 1 }
  }));
  s.addText(makeItems(leftBullets),  { x: 0.2, y: 1.3, w: 4.5, h: 3.9, fontFace: "Calibri", valign: "top" });
  s.addText(makeItems(rightBullets), { x: 5.2, y: 1.3, w: 4.5, h: 3.9, fontFace: "Calibri", valign: "top" });
  return s;
}

function imageSlide(pres, heading, imgBase64, caption, bullets) {
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: CREAM } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: NAVY } });
  s.addText(heading, { x: 0.25, y: 0, w: 9.5, h: 0.75, fontSize: 20, bold: true, color: WHITE, fontFace: "Calibri", valign: "middle", margin: 0 });
  // image on left
  s.addImage({ data: imgBase64, x: 0.2, y: 0.88, w: 4.6, h: 3.6 });
  s.addText(caption, { x: 0.2, y: 4.5, w: 4.6, h: 0.8, fontSize: 11, color: GREY, italic: true, align: "center", fontFace: "Calibri" });
  // bullets right
  if (bullets && bullets.length) {
    const items = bullets.map((b, i) => ({
      text: b,
      options: { bullet: true, fontSize: 14, color: DARK, breakLine: i < bullets.length - 1 }
    }));
    s.addText(items, { x: 5.1, y: 0.95, w: 4.7, h: 4.4, fontFace: "Calibri", valign: "top" });
  }
  return s;
}

// ─── fetch images ─────────────────────────────────────────────────────────────
const imgUrls = [
  "https://cdn.orris.care/cdss_images/c3cf7f2385121f2b50bf9ec956afabefe2637ce1f876a08ede4a4b4090d81a64.png",   // 0 aetiology diagram
  "https://cdn.orris.care/cdss_images/0265946a95a4d68de5bc4588cd7727821b4ba0f3489ea8ed0ef6a118a1d5c9d8.png",   // 1 OMU CT coronal
  "https://www.researchgate.net/publication/309606463/figure/fig3/AS:560746891313154@1510703885852/Chronic-rhinosinusitis-without-nasal-polyps-CRSsNP-Coronal-CT-scan-of-CRSsNP-limited.png", // 2 CRS CT coronal
  "https://prod-images-static.radiopaedia.org/images/45051961/6353623a2ecf01d0c5913dd20756d978a7f0db348eb60708e6eaea261fe73d71_gallery.jpeg",  // 3 radiopaedia CRS
  "https://cdn.orris.care/cdss_images/9c2e0cd5a07615c44bd81f318a32e56d76a5633fe91f08f8e27eb247d4d4dd0e.png",  // 4 ESS indications box
];

console.log("Fetching images...");
let imgs;
try {
  const raw = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${imgUrls.map(u => `"${u}"`).join(" ")}`,
    { timeout: 60000 }
  ).toString();
  imgs = JSON.parse(raw);
} catch(e) {
  console.error("Image fetch error:", e.message);
  imgs = imgUrls.map(() => ({ base64: null, error: "fetch failed" }));
}

imgs.forEach((img, i) => {
  if (img.error) console.warn(`Image ${i} failed: ${img.error}`);
  else console.log(`Image ${i} OK`);
});

// ─── build presentation ───────────────────────────────────────────────────────
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Chronic Rhinosinusitis";
pres.author = "Medical Education";

// ── Slide 1: Title ────────────────────────────────────────────────────────────
titleSlide(pres,
  "Chronic Rhinosinusitis",
  "Definition  •  Aetiology  •  Pathogenesis  •  Investigations  •  Radiology  •  Management  •  Complications"
);

// ── Slide 2: Outline ──────────────────────────────────────────────────────────
contentSlide(pres, "Contents", [
  "1.  Definition & Diagnostic Criteria",
  "2.  Epidemiology",
  "3.  Aetiology & Risk Factors",
  "4.  Pathogenesis",
  "5.  Clinical Features",
  "6.  Investigations",
  "7.  Radiology",
  "8.  Management — Medical",
  "9.  Management — Surgical",
  "10. Complications",
]);

// ── Slide 3: SECTION ─────────────────────────────────────────────────────────
sectionHeader(pres, "Definition & Epidemiology", "📖");

// ── Slide 4: Definition ───────────────────────────────────────────────────────
contentSlide(pres, "Definition of Chronic Rhinosinusitis (CRS)", [
  "Inflammation of the nose and paranasal sinuses characterised by ≥ 2 symptoms:",
  "  • Nasal blockage / obstruction / congestion",
  "  • Nasal discharge (anterior or posterior)",
  "  • Facial pain / pressure",
  "  • Reduction or loss of smell",
  "Duration: symptoms persist for > 12 consecutive weeks",
  "Objective confirmation required: positive CT or endoscopy showing mucosal inflammation",
  "Two main phenotypes:",
  "  • CRSsNP — CRS without nasal polyps (TH1-skewed, fibrosis, mononuclear infiltration)",
  "  • CRSwNP — CRS with nasal polyps (TH2-skewed, eosinophilic, oedematous stroma)",
  "Symptom-based diagnosis alone is unreliable: >40% of symptom-positive patients have normal CT and endoscopy",
]);

// ── Slide 5: Epidemiology ─────────────────────────────────────────────────────
contentSlide(pres, "Epidemiology", [
  "Prevalence: ~10–12% of the general adult population in Western countries",
  "One of the most common chronic conditions seen by ENT surgeons",
  "Significant economic burden: billions of dollars annually in healthcare costs",
  "Affects quality of life comparably to congestive heart failure or COPD",
  "CRSsNP is more common than CRSwNP",
  "CRSwNP often associated with:",
  "  • Asthma (25–70% of patients)",
  "  • Aspirin-exacerbated respiratory disease (Samter's triad)",
  "  • Allergic fungal rhinosinusitis (AFRS)",
  "Peak age: 45–65 years; male predominance in CRSwNP",
]);

// ── Slide 6: SECTION ──────────────────────────────────────────────────────────
sectionHeader(pres, "Aetiology & Pathogenesis", "🔬");

// ── Slide 7: Aetiology ────────────────────────────────────────────────────────
let s7 = pres.addSlide();
s7.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: CREAM } });
s7.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: NAVY } });
s7.addText("Aetiology — Multifactorial Disease", { x: 0.25, y: 0, w: 9.5, h: 0.75, fontSize: 20, bold: true, color: WHITE, fontFace: "Calibri", valign: "middle", margin: 0 });

const aetiologyData = [
  { label: "Microbial Factors", items: ["Bacterial biofilms (S. aureus, P. aeruginosa)", "Staphylococcal superantigens (IgE sensitisation)", "Fungal colonisation", "Viral triggers (rhinovirus, influenza)"] },
  { label: "Host Immune Factors", items: ["Impaired mucociliary clearance", "Epithelial barrier dysfunction", "Eosinophil activation (CRSwNP)", "TH2 / TH1 immune skewing"] },
  { label: "Anatomical Factors", items: ["Ostiomeatal unit obstruction", "Septal deviation, concha bullosa", "Nasal polyps obstructing drainage", "Adenoid hypertrophy (children)"] },
  { label: "Systemic Conditions", items: ["Asthma / atopy", "Cystic fibrosis, PCD", "Immunodeficiency (CVID, IgA def)", "Granulomatous disease (GPA, sarcoid)"] },
];
const boxW = 2.25, boxH = 1.8, gap = 0.08;
const startX = 0.2, startY = 0.88;
aetiologyData.forEach((box, i) => {
  const col = i % 4;
  const x = startX + col * (boxW + gap);
  const y = startY;
  s7.addShape(pres.ShapeType.rect, { x, y, w: boxW, h: boxH, fill: { color: LIGHT }, line: { color: TEAL, pt: 1.5 } });
  s7.addShape(pres.ShapeType.rect, { x, y, w: boxW, h: 0.35, fill: { color: TEAL }, line: { color: TEAL } });
  s7.addText(box.label, { x, y, w: boxW, h: 0.35, fontSize: 12, bold: true, color: WHITE, align: "center", fontFace: "Calibri" });
  const bItems = box.items.map((b, j) => ({
    text: b, options: { bullet: true, fontSize: 11, color: DARK, breakLine: j < box.items.length - 1 }
  }));
  s7.addText(bItems, { x: x + 0.05, y: y + 0.38, w: boxW - 0.1, h: boxH - 0.4, fontFace: "Calibri", valign: "top" });
});

// Row 2: additional aetiology factors
const extra = [
  { label: "Environmental", items: ["Air pollution, smoking", "Occupational allergens", "Damp indoor environments"] },
  { label: "Dental / Odontogenic", items: ["Odontogenic sinusitis: maxillary teeth infections", "Root apex near sinus floor", "Often unilateral maxillary sinus disease"] },
  { label: "Unified Airway", items: ["Nasal polyps linked with lower airway disease", "United airway disease concept", "CRS treatment improves asthma control"] },
  { label: "Osteitis", items: ["Bone remodelling in CRS", "Thickened sclerotic bone", "Indicates chronicity & severity"] },
];
const startY2 = startY + boxH + 0.15;
extra.forEach((box, i) => {
  const col = i % 4;
  const x = startX + col * (boxW + gap);
  const y = startY2;
  s7.addShape(pres.ShapeType.rect, { x, y, w: boxW, h: 1.6, fill: { color: "FFF3E0" }, line: { color: ORANGE, pt: 1.5 } });
  s7.addShape(pres.ShapeType.rect, { x, y, w: boxW, h: 0.35, fill: { color: ORANGE }, line: { color: ORANGE } });
  s7.addText(box.label, { x, y, w: boxW, h: 0.35, fontSize: 12, bold: true, color: WHITE, align: "center", fontFace: "Calibri" });
  const bItems = box.items.map((b, j) => ({
    text: b, options: { bullet: true, fontSize: 11, color: DARK, breakLine: j < box.items.length - 1 }
  }));
  s7.addText(bItems, { x: x + 0.05, y: y + 0.38, w: boxW - 0.1, h: 1.2, fontFace: "Calibri", valign: "top" });
});

// ── Slide 8: Aetiology diagram image ──────────────────────────────────────────
if (imgs[0] && !imgs[0].error) {
  imageSlide(pres,
    "Aetiological Mechanisms in CRS (Scott-Brown's)",
    imgs[0].base64,
    "Figure 94.2 — Aetiological mechanisms proposed for CRS\n(Scott-Brown's Otorhinolaryngology)",
    [
      "Staphylococcal superantigens drive IgE production",
      "Unified airway disease links sinus and lower airway inflammation",
      "Osteitic bone acts as a reservoir for chronic infection",
      "Biofilm formation perpetuates mucosal inflammation",
      "Epithelial barrier dysfunction allows allergen/pathogen entry",
    ]
  );
}

// ── Slide 9: Pathogenesis ─────────────────────────────────────────────────────
twoColSlide(pres,
  "Pathogenesis — CRSsNP vs CRSwNP",
  [
    "CRSsNP (without polyps)",
    "TH1-dominated inflammation",
    "IFN-γ elevation, low ECP/MPO",
    "Fibrosis, basement membrane thickening",
    "Goblet cell hyperplasia",
    "Mononuclear cell infiltration",
    "Associated with neutrophilic pattern",
    "Driven by bacterial colonisation",
    "Less responsive to steroids",
  ],
  [
    "CRSwNP (with polyps)",
    "TH2-dominated inflammation",
    "High IL-5 and eosinophil cationic protein",
    "Oedematous stroma in sinonasal epithelium",
    "Albumin deposition & pseudocyst formation",
    "Subepithelial/perivascular eosinophil infiltration",
    "IgE-mediated local reactions (superantigens)",
    "Strong association with asthma & NSAID sensitivity",
    "More responsive to intranasal/systemic steroids",
  ],
  "CRSsNP",
  "CRSwNP"
);

// ── Slide 10: SECTION ─────────────────────────────────────────────────────────
sectionHeader(pres, "Clinical Features & Investigations", "🔍");

// ── Slide 11: Clinical Features ───────────────────────────────────────────────
twoColSlide(pres,
  "Clinical Features",
  [
    "Cardinal Symptoms:",
    "Nasal obstruction / congestion",
    "Nasal discharge (mucopurulent)",
    "Facial pain, pressure or fullness",
    "Reduced / absent sense of smell",
    "",
    "Additional Symptoms:",
    "Post-nasal drip / throat clearing",
    "Cough (especially nocturnal)",
    "Headache (frontal, periorbital)",
    "Dental pain, ear pressure",
    "Fatigue, sleep disturbance",
  ],
  [
    "Physical Examination:",
    "Anterior rhinoscopy: mucosal erythema, discharge",
    "Nasal endoscopy (gold standard exam):",
    "  - Middle meatal polyps / purulent discharge",
    "  - Oedematous mucosa, crusting",
    "Facial tenderness on palpation",
    "Post-nasal drip on oropharyngeal exam",
    "",
    "EPOS Criteria (Adults):",
    "≥ 2 symptoms for > 12 weeks",
    "One symptom must be nasal obstruction OR discharge",
    "Objective evidence (CT / endoscopy)",
  ],
  "Symptoms",
  "Examination & Criteria"
);

// ── Slide 12: Investigations ──────────────────────────────────────────────────
contentSlide(pres, "Investigations", [
  "Nasal Endoscopy (Rigid / Flexible):",
  "  • Visualises middle meatus, ethmoid bulla, sphenoethmoidal recess",
  "  • Identifies polyps, purulent discharge, mucosal oedema",
  "  • Gold standard for direct mucosal assessment",
  "",
  "Laboratory Tests:",
  "  • FBC: eosinophilia (CRSwNP / AFRS / eosinophilic CRS)",
  "  • Serum IgE: elevated in allergic / AFRS subtypes",
  "  • Sweat chloride / CFTR gene analysis (exclude cystic fibrosis)",
  "  • Serum immunoglobulins (CVID, selective IgA deficiency)",
  "  • ANCA, ACE level (Granulomatosis with polyangiitis / sarcoid)",
  "",
  "Allergy Testing: skin-prick tests or specific IgE for aeroallergens",
  "Mucociliary Function: saccharin test, ciliary beat frequency, electron microscopy for PCD",
  "Microbiology: nasal culture / middle meatal swab for refractory / post-surgical cases",
  "Histopathology: biopsy of any unilateral polyp / suspicious lesion",
]);

// ── Slide 13: SECTION ─────────────────────────────────────────────────────────
sectionHeader(pres, "Radiology", "🖥️");

// ── Slide 14: CT imaging ──────────────────────────────────────────────────────
let s14 = pres.addSlide();
s14.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: CREAM } });
s14.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: NAVY } });
s14.addText("CT of Paranasal Sinuses — Gold Standard", { x: 0.25, y: 0, w: 9.5, h: 0.75, fontSize: 20, bold: true, color: WHITE, fontFace: "Calibri", valign: "middle", margin: 0 });

if (imgs[1] && !imgs[1].error) {
  s14.addImage({ data: imgs[1].base64, x: 0.2, y: 0.88, w: 4.2, h: 3.5 });
  s14.addText("OMU pattern sinusitis: left middle meatal opacification with maxillary, frontal and ethmoid sinus disease\n(Cummings Otolaryngology Fig 38.17)", { x: 0.2, y: 4.4, w: 4.2, h: 0.9, fontSize: 10, italic: true, color: GREY, align: "center", fontFace: "Calibri" });
}
const ctBullets = [
  "Indications for CT:",
  "  - Diagnosis confirmation in CRS",
  "  - Pre-operative surgical planning (FESS)",
  "  - Failed medical therapy / recurrent disease",
  "  - Suspected complications",
  "CT Findings in CRS:",
  "  - Mucosal thickening (diffuse or polypoid)",
  "  - Partial / complete sinus opacification",
  "  - Air-fluid levels",
  "  - Osteitis: bone thickening & sclerosis",
  "  - OMU obstruction (72% of CRS patients)",
  "  - Intrasinus calcifications (fungal)",
  "CT Attenuation:",
  "  - Acute: 10–25 HU (watery secretions)",
  "  - Chronic: 30–60 HU (thickened secretions)",
];
const ctItems = ctBullets.map((b, i) => ({
  text: b.replace(/^  /, ""),
  options: { bullet: b.startsWith("  ") ? { indent: 20 } : false, fontSize: b.startsWith("  ") ? 13 : 14, bold: !b.startsWith("  ") && b.endsWith(":"), color: b.startsWith("  ") ? GREY : DARK, breakLine: i < ctBullets.length - 1 }
}));
s14.addText(ctItems, { x: 4.65, y: 0.92, w: 5.15, h: 4.55, fontFace: "Calibri", valign: "top" });

// ── Slide 15: Lund-Mackay + CT patterns ──────────────────────────────────────
let s15 = pres.addSlide();
s15.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: CREAM } });
s15.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: NAVY } });
s15.addText("CT Staging: Lund-Mackay Score & Patterns", { x: 0.25, y: 0, w: 9.5, h: 0.75, fontSize: 20, bold: true, color: WHITE, fontFace: "Calibri", valign: "middle", margin: 0 });
// table
const lmData = [
  ["Subsite", "Score"],
  ["Anterior ethmoid (each side)", "0 / 1 / 2"],
  ["Posterior ethmoid (each side)", "0 / 1 / 2"],
  ["Frontal sinus (each side)", "0 / 1 / 2"],
  ["Maxillary sinus (each side)", "0 / 1 / 2"],
  ["Sphenoid sinus (each side)", "0 / 1 / 2"],
  ["Ostiomeatal complex (each side)", "0 or 2"],
  ["Maximum total score", "24"],
];
s15.addTable(lmData, {
  x: 0.2, y: 0.88, w: 4.5, colW: [3, 1.5],
  fill: { color: WHITE }, border: { pt: 1, color: TEAL },
  fontFace: "Calibri", fontSize: 13, color: DARK,
  firstRowFillColor: TEAL, firstRowFontColor: WHITE, firstRowBold: true,
});
s15.addText("Score: 0 = clear, 1 = partial, 2 = total opacification", { x: 0.2, y: 3.45, w: 4.5, h: 0.4, fontSize: 11, italic: true, color: GREY, fontFace: "Calibri" });

const patternBullets = [
  "Babbel's Patterns of Sinusitis:",
  "1. Infundibular (26%): focal maxillary & infundibulum obstruction",
  "2. Ostiomeatal unit (25%): ipsilateral maxillary + frontal + anterior ethmoid",
  "3. Sphenoethmoidal recess (6%): sphenoid ± posterior ethmoid",
  "4. Sinonasal polyposis: diffuse pansinusitis with polyps",
  "5. Sporadic / unclassified: isolated or patchy disease",
  "",
  "MRI Indications:",
  "Suspected intracranial / orbital complication",
  "Soft tissue characterisation (tumour vs polyp)",
  "Fungal sinusitis (hypointense on T2 = thick/desiccated secretions)",
  "Signal on T1/T2 varies with protein concentration of secretions",
];
const pItems = patternBullets.map((b, i) => ({
  text: b,
  options: { bullet: !b.endsWith(":") && b.length > 0, fontSize: b.endsWith(":") ? 15 : 13, bold: b.endsWith(":"), color: b.endsWith(":") ? TEAL : DARK, breakLine: i < patternBullets.length - 1 }
}));
s15.addText(pItems, { x: 4.9, y: 0.9, w: 4.9, h: 4.5, fontFace: "Calibri", valign: "top" });

// ── Slide 16: Radiology image ─────────────────────────────────────────────────
if (imgs[2] && !imgs[2].error) {
  imageSlide(pres,
    "CT Findings — CRS without Nasal Polyps",
    imgs[2].base64,
    "Coronal CT showing bilateral maxillary mucosal thickening with OMT obstruction (ResearchGate)",
    [
      "Mucosal thickening in both maxillary sinuses",
      "Bilateral ostiomeatal complex obstruction",
      "Classic CRSsNP pattern",
      "Bone remodelling absent in mild disease",
      "Pre-operative assessment for FESS",
      "Lund-Mackay score guides surgical extent",
    ]
  );
} else if (imgs[3] && !imgs[3].error) {
  imageSlide(pres,
    "CT Findings — Chronic Rhinosinusitis (Radiopaedia)",
    imgs[3].base64,
    "Coronal CT — mucosal thickening and sinus opacification in CRS (Radiopaedia)",
    [
      "Diffuse mucosal thickening",
      "Sinus opacification",
      "OMU obstruction pattern",
      "Findings guide surgical planning",
    ]
  );
}

// ── Slide 17: SECTION ─────────────────────────────────────────────────────────
sectionHeader(pres, "Management", "💊");

// ── Slide 18: Medical Management ─────────────────────────────────────────────
contentSlide(pres, "Medical Management — Step-Up Approach", [
  "1. Saline Nasal Irrigation (High-Volume / Low-Pressure):",
  "  • First-line for all CRS — promotes mucociliary clearance",
  "  • Large-volume isotonic or hypertonic saline irrigations",
  "",
  "2. Intranasal Corticosteroids (INCS):",
  "  • Cornerstone of medical therapy (Mometasone, Fluticasone, Budesonide)",
  "  • Reduces mucosal oedema and polyp size",
  "  • High-dose INCS or budesonide rinses in refractory CRSwNP",
  "",
  "3. Systemic Corticosteroids:",
  "  • Short oral prednisolone courses for CRSwNP (polyp debulking)",
  "  • Not recommended long-term due to systemic side effects",
  "",
  "4. Antibiotics:",
  "  • Acute exacerbations: amoxicillin-clavulanate or doxycycline (2–4 weeks)",
  "  • Long-term low-dose macrolides (azithromycin / clarithromycin): anti-inflammatory properties, 3–6 months",
  "  • Not for routine CRS; reserved for culture-guided or macrolide protocols",
  "",
  "5. Antifungals: topical amphotericin — evidence limited; systemic for AFRS or invasive fungal",
]);

// ── Slide 19: Biologics & Adjuncts ───────────────────────────────────────────
contentSlide(pres, "Biologics & Adjunct Therapies", [
  "Biological (Monoclonal Antibody) Therapies — CRSwNP:",
  "  • Dupilumab (anti-IL-4Rα): approved for severe CRSwNP; reduces polyp size, improves smell",
  "  • Mepolizumab (anti-IL-5): reduces eosinophilic polyps",
  "  • Omalizumab (anti-IgE): effective in comorbid asthma + CRSwNP",
  "  • Benralizumab (anti-IL-5Rα): under evaluation",
  "",
  "Adjunct Treatments:",
  "  • Aspirin desensitisation (Aspirin-exacerbated respiratory disease / Samter's triad)",
  "  • Allergen immunotherapy (atopic CRS with allergy)",
  "  • Anti-leukotrienes (Montelukast) — modest evidence",
  "  • Mucolytics: limited role",
  "",
  "Patient Education:",
  "  • Smoking cessation (smoking worsens mucociliary function and outcomes)",
  "  • Allergen avoidance",
  "  • Adherence to nasal irrigation + INCS — daily long-term therapy required",
]);

// ── Slide 20: Surgical Management ────────────────────────────────────────────
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  "Indications for FESS:",
  "  - CRS recalcitrant to maximal medical therapy",
  "  - CRSwNP with functional impairment despite steroids",
  "  - Complications (mucocele, orbital, intracranial)",
  "  - Recurrent acute rhinosinusitis",
  "Principles of FESS:",
  "  - Mucosal preservation (Messerklinger technique)",
  "  - Open OMU and sinus ostia for drainage / ventilation",
  "  - Complete ethmoidectomy especially for CRSwNP",
  "  - Wide cavities for topical drug delivery post-operatively",
  "Outcomes:",
  "  - 80–90% report symptom improvement",
  "  - Reduces healthcare utilisation",
  "  - CRSwNP: surgery facilitates steroid delivery; polyps may recur",
  "  - CRSsNP: can be curative (especially odontogenic sinusitis)",
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// ── Slide 21: SECTION ─────────────────────────────────────────────────────────
sectionHeader(pres, "Complications", "⚠️");

// ── Slide 22: Complications overview ─────────────────────────────────────────
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  { label: "Intracranial (Less Common)", color: "C0392B", items: ["Meningitis", "Epidural abscess", "Subdural empyema", "Intracerebral abscess", "Superior sagittal sinus thrombosis"] },
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// ── Slide 23: Chandler Classification ────────────────────────────────────────
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  ["II",  "Orbital (postseptal) cellulitis",   "Diffuse oedema of orbital fat behind septum; no abscess", "IV antibiotics; CT scan; ophthalmology review"],
  ["III", "Subperiosteal abscess",             "Pus between periorbita and bony orbital wall (usually medial)", "IV antibiotics + surgical drainage (endoscopic)"],
  ["IV",  "Orbital abscess",                  "Pus within orbital fat; proptosis, ophthalmoplegia, pain", "Urgent surgical drainage; optic nerve at risk"],
  ["V",   "Cavernous sinus thrombosis",        "Infection extends to cavernous sinus via ophthalmic veins", "IV antibiotics, anticoagulation; high mortality"],
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// ── Slide 24: Complications management summary ────────────────────────────────
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  "General Principles:",
  "  • Urgent imaging: CT (first line) — bony anatomy + orbital detail; MRI for intracranial extent",
  "  • Multidisciplinary team: ENT + Ophthalmology + Neurosurgery as needed",
  "  • Repeated clinical monitoring (4–6 hourly for orbital complications)",
  "",
  "Medical Management:",
  "  • Broad-spectrum IV antibiotics with streptococcal AND anaerobic cover (e.g. co-amoxiclav + metronidazole)",
  "  • Antifungals: IV voriconazole / amphotericin for invasive fungal complications",
  "  • IV steroids considered for CRSwNP exacerbations",
  "",
  "Surgical Management:",
  "  • Abscess formation = surgical indication (endoscopic or external drainage)",
  "  • Joint ENT + neurosurgery for intracranial complications",
  "  • FESS to address underlying sinusitis",
  "",
  "Chronic Complications:",
  "  • Mucocele: marsupialisation endoscopically",
  "  • Osteomyelitis: long-course IV antibiotics + surgical debridement",
]);

// ── Slide 25: Key Points / Summary ────────────────────────────────────────────
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  "CRS = ≥ 2 symptoms for > 12 weeks with objective confirmation (CT or endoscopy)",
  "Two key phenotypes: CRSsNP (TH1, fibrosis) and CRSwNP (TH2, eosinophilic, polyps)",
  "Multifactorial: biofilms, mucociliary dysfunction, anatomical obstruction, immune dysregulation",
  "CT is the gold standard imaging; Lund-Mackay score used for staging",
  "Step-up therapy: saline → INCS → oral steroids → long-term macrolides → biologics",
  "FESS is effective for medically recalcitrant CRS; wide cavities enhance topical delivery",
  "Orbital complications (Chandler staging) are more common than intracranial",
  "Multidisciplinary management is essential for complicated disease",
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// ── Slide 26: References ──────────────────────────────────────────────────────
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const refs = [
  "1. Flint PW et al. Cummings Otolaryngology Head and Neck Surgery, 7th ed. Philadelphia: Elsevier; 2021.",
  "2. Gleeson M, Clarke R. Scott-Brown's Otorhinolaryngology Head & Neck Surgery, 8th ed. CRC Press; 2018.",
  "3. Murray JF, Nadel JA. Murray & Nadel's Textbook of Respiratory Medicine, 7th ed. Elsevier; 2022.",
  "4. Goldman L, Schafer AI. Goldman-Cecil Medicine, 26th ed. Philadelphia: Elsevier; 2020.",
  "5. Lee KJ. Essential Otolaryngology: Head and Neck Surgery, 11th ed. New York: McGraw-Hill; 2019.",
  "6. EPOS 2020: European Position Paper on Rhinosinusitis and Nasal Polyps. Rhinology 2020;58(Suppl S29):1–464.",
  "7. Fokkens WJ et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology 2020.",
  "8. Babbel RW et al. Recurring patterns of inflammatory sinonasal disease on CT. AJNR 1992;13:903–12.",
  "9. Chandler JR et al. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970.",
  "10. Lund VJ, Mackay IS. Staging in rhinosinusitis. Rhinology 1993;31:183–4.",
];
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// ── Save ──────────────────────────────────────────────────────────────────────
const outPath = "/home/daytona/workspace/crs-presentation/Chronic_Rhinosinusitis.pptx";
pres.writeFile({ fileName: outPath }).then(() => {
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cd /home/daytona/workspace/crs-presentation && node build.js 2>&1

cd /home/daytona/workspace/crs-presentation && node -e " const {execSync} = requ…

mkdir -p /home/daytona/workspace/crs-ppt && node -e " const {execSync} = require…