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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3998_Библиотеки_им_академика_М_И_Перельмана
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Adult bilateral deafness 107
OSCE Counselling case
OSCE COUNSELLING CASE 2.11 –
A patient wants to use a hearing aid
but feels that it will exacerbate the
condition. What is your advice?
There is no evidence that wearing a hearing aid worsens any sensorineural hearing loss. Stress that the
hearing will change over time and become slightly worse irrespective of whether or not a hearing aid is
used.
REVISION PANEL
Bilateral sensorineural hearing loss is a common nding in the elderly.
Diagnosis of presbycusis requires exclusion of other otological conditions and the audiometric
conrmation of symmetrical sensorineural hearing loss, worse in the high frequencies.
Treatment of presbycusis involves reassurance that there is not a sinister cause and discussions
regarding the patient’s desire to wear a hearing aid.
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108 Ear, nose and throat (ENT)
EARACHE
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What is the important nding on examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.12 –
Child with earache
A child aged 3 years has an acute earache, which has started that day.
CASE 2.13 –
Adult with earache
An adult aged 37 years presents with intermittently painful ears, mostly affecting the right side.
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Earache 109
OSCE Counselling case
OSCE COUNSELLING CASE 2.12 –
A patient wants to swim when you
have diagnosed otitis externa. What is
your advice?
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110 Ear, nose and throat (ENT)
Key concepts
Acute otitis media may be treated conservatively, if mild.
Do not poke the ears in otitis externa.
Pain may be referred to the ears from the jaw or the neck.
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Earache 111
Answers
Clinical cases
CASE 2.12 –
Child with earache
A1: What is the likely differential diagnosis?
The most likely diagnosis is acute otitis media. Other structures may refer pain to the ear and a teething
child may have pain, which can be difcult to distinguish from a middle-ear problem.
A2: What additional features in the history would you like to elicit?
Ask if the child has a respiratory infection. How severe is the pain? This can be gauged by asking
whether the child is kept awake at night, holds his ear and wants to go to bed. Ascertain the
relationship between pain, hearing loss and discharge. Patients with pain, hearing loss and no discharge
have acute otitis media. If discharge starts and the pain and hearing loss resolve, this is due to the
tympanic membrane perforating reducing the pressure in the middle ear.
A3: What is the important nding on examination?
Examine both ears and see whether one sticks out more than the other. In acute mastoiditis, a
complication of acute otitis media, there is often a swelling behind the ear and it is pushed forwards and
slightly downwards. Examine the better ear rst. Children often have a pink eardrum when they have a
cold. If both ears look the same, acute otitis media is unlikely. If there is pus behind the drum (diagnostic
of acute otitis media), it looks yellow and bulging. This is most obvious in the posterosuperior region
and this is the most common site of rupture. If the eardrum has not been examined, the diagnosis of
acute otitis media is presumptive.
A4: What investigations would be most helpful and why?
No investigations are required for simple acute otitis media.
A5: What are the treatment options?
There is much debate about the need for antibiotic chemotherapy in acute otitis media. There have
been many obvious aws in the clinical trials conducted in this area. Basically, if the child is well
and has little in the way of constitutional symptoms, no treatment is required. If the child has mild
discomfort, treat with analgesia, because the condition will settle in the vast majority of cases. If
the child is unwell and the eardrum is bulging dramatically, treat with antibiotics such as amoxicillin
at the appropriate dose for the weight and age of the child. If the child is vomiting, the rst dose
should be given intramuscularly. Erythromycin is a suitable alternative if the child is sensitive to
penicillin. Very occasionally intracranial sepsis follows acute ear infections.
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112 Ear, nose and throat (ENT)
CASE 2.13 –
Adult with earache
A1: What is the likely differential diagnosis?
The most likely causes of earache in the adult are either otitis externa or referred otalgia. Young adults
may have temporomandibular problems and questions about chewing and pain will help to determine if
this is the cause. Elderly people may have problems with the cervical spine, which also causes a referred
otalgia. Otitis externa may go from ear to ear and there is a period of irritation followed by self-inicted
trauma and secondary infection. The cycle repeats itself.
A2: What additional features in the history would you like to elicit?
Ascertain the relationship between pain, discharge and hearing loss. In acute otitis externa, there is
typically scanty discharge, severe pain, but no hearing loss. There is usually a precipitating history of
trauma, cotton buds or water exposure, swimming or syringing. Patients with acute otitis media also
often complain of itching.
A3: What is the important nding on examination?
Examine the better ear rst so that it can be compared with the one causing the problem. If there
is debris, this should be removed. The diagnosis of otitis externa cannot be made until the drum has
been examined and is shown to be intact. Sometimes there is a secondary otitis externa when there
is a perforation, but mucus means that there is middle-ear disease. There are three common types of
otitis externa: a furuncle in the hair-bearing area, and diffuse oedematous and diffuse eczematous otitis
externa. Examine the temporomandibular joint and neck. Some patients poke their ears if there is pain
there and set up secondary otitis externa.
A4: What investigations would be most helpful and why?
No investigations are mandatory, although an ear swab may help with antibiotic sensitivity. The
infecting organism is Pseudomonas aeruginosa in most cases.
A5: What are the treatment options?
Treatment is meticulous aural toilet. Once the debris is removed, treat with antibiotic eardrops. Tell the
patient to keep the ear dry and not to poke it. If the problem does not settle easily, referral to the ENT
department may be required. Patients with diabetes mellitus need careful monitoring because they may
develop a severe otitis externa called malignant otitis externa. The condition may erode into the cranial
cavity and can be fatal.
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Earache 113
OSCE Counselling case
OSCE COUNSELLING CASE 2.12 –
A patient wants to swim when you
have diagnosed otitis externa. What is
your advice?
No. The patient should be symptom free for 3 months before re-commencing swimming.
REVISION PANEL
Acute otitis media is generally a self-limiting infection treated initially with conservative therapy.
If there is no resolution of acute otitis media after 48 hours, antibiotic therapy is commenced.
Mastoiditis and intracranial sepsis are rare complications of acute otitis media.
Acute otitis externa typically presents after trauma, direct or water, to the ear canal.
Treatment of acute otitis externa is with aural toilet and antibiotic drops.
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114 Ear, nose and throat (ENT)
THE DIZZY PATIENT
Questions
Clinical cases
For the clinical case scenario given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What should one look for in the examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.14 –
Dizziness
An adult presents with dizziness when she turns her head and rolls over in bed. She says that it comes
from the left side of the head.
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The dizzy patient 115
OSCE Counselling case
OSCE COUNSELLING CASE 2.13 –
The patient is obviously worried that
there is something sinister going on.
What is your advice?
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116 Ear, nose and throat (ENT)
Key concepts
Dizziness may be unsteadiness or true vertigo.
True vertigo coming from the labyrinth never causes unconsciousness.
Vertigo on head movements for a few seconds is benign positional vertigo.
Episodic vertigo with hearing loss and tinnitus may be Ménière’s disease.
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