1. Derby GP Specialty Training Programme
EARS

2. Ear Anatomy 2

3. Practical exercise Get into pairs Look in each others ears
Draw and label what you see! 3

4. Normal eardrum Right or left?
The normal tympanic membrane should appear
Pearly grey
With a light reflex
Concave
Should be able to make out malleus – looks like an arm 4

5. 1 = pars flaccida (=attic) 2 = lat process of malleus
3 = handle of malleus
4 = end of malleus
5 = light reflex
6 = eardrum margin
7 = pars tensa 6 7 5

6. Anterior, posterior, inferior regions
Attic – this area is located above the elbow.
Anterior – this is the area the elbow is point towards
(Face end of patient)
Posterior – this is the area opposite the elbow.
Inferior – this is the area below the hand. 6

7. Malleus 7

8. What are you looking for?
Shape of the eardrum – bulging or retracted
Colour of the eardrum – red (infection), yellow (glue ear), brown (blood), presence of blood vessels (injected?)
Light reflex present or not? (usually absent in bulging ear drums)
Things that should not be there… 8

9. Case Studies 9

10. Case Study 1 2 ½ year old ♂
History Presents with a 2 day history of irritability, runny nose and fever. He’s not been playing as much as usual and today his Mum noticed that he’s been pulling his left ear. He had an ear infection last year and was given some antibiotics, Mum would like the same again please. Examination Irritable. HR 100, RR 22, Temp 37.4ºC HS I+II+0, cap refil <2sec. Chest clear, no signs of respiratory distress Abdo SNT ENT – throat red, right ear nad, left ear – see picture...

12. What further information would you like to know?
What are your differential diagnoses?
How would you manage him? Who would you see again?
When would you consider referral?
Any advice to prevent further episodes?

13. What else would you like to know?
More common:
In winter
Have older siblings
At nursery
Uses a dummy
Parents smoke
Symptoms
Earache or pulling/tugging ear
URTI
Pain
Malaise
Fever
Irritability
Vomiting
Signs
Pyrexia
Red, bulging tympanic membrane
May be air-fluid level behind TM
Perforated TM +/or discharge in canal
Possibly hearing loss

14. What are your differential diagnoses?
Otitis Externa
URTI – TM a little red
Acute mastoiditis – swelling, erythema & tenderness over mastoid bone; displacement (downwards & outwards) of pinna
Post auricular adenitis
Referred pain from teeth

15. How would you manage him?
Pain relief & antipyretic – regular paracetamol, ibuprofen
Antibiotics
For most people no or delayed Abx with appropriate explanation or risk vs benefit
Consider if
<2yrs
Systemic Sx inc temp >38ºC or vomiting
Bilateral AOM
Perforated TM with discharge
Amoxicillin (Erythromycin)
Co-amoxiclav (Azithromycin) if Rx failure
Consider admission – systemically unwell
Safety netting – “Needs review if...”
Review at 2-3 weeks if perforated TM

16. When would you consider referral?
3+ episodes in 6 months or 4+ episodes in 1 year with the absence of disease between episodes
Adults with >2 episodes in a year with suspicion of nasopharyngeal cancer – persistent Sx & signs, cervical lymphadenopathy, unilateral epistaxis

17. Any advice to prevent further episodes?
Eliminate passive smoking
Avoid dummies
Avoid supine feeding
?pneumococcal vaccinations 17

18. Case study 2 Red itchy ear 40 year old female
1 week history of an “Itchy Ear”, getting worse
Keen Swimmer
Type 2 Diabetic – on Metformin
No other medical history of note

19. Red, Itchy Ear On Examination BMI 35 Swollen Ear Canal with erythema
No discharge, some debris
Pain on moving pinna
Nil else of note

20. Red, Itchy Ear

21. Otitis Externa Often occurs after trauma Symptoms Signs
e.g. Scratching, ear cleaning, swimming
Symptoms
Pain (Severe, also on pinna movement),
Discharge (May be offensive)
Signs
Swollen ear Canal +/- Discharge / Debris
May have swollen pre/post auricular lymph glands

22. Otitis Externa Management Aural Toilet (unless mild case)
ABX Ear Drops (Gentamicin 0.3%)
+/- steroid if eczematous (Gentisone HC)
May need strong analgesia, and wick
If refractory , need to swab - may be candida or aspergillus (Clotrimazole)

23. Otitis Externa Prevention If mild itchiness / eczema No cotton buds!
Keep ears dry
If mild itchiness / eczema
Short course steroid drops (Prednisolone 0.5% TDS)

24. Case Study 3
History: 28 year old woman with known anxiety problems presented with ear popping and occasional pain for the past 3 weeks following a cold. She has no history of ear problems and recently had a relaxing holiday in Turkey. She is very concerned and thinks she is becoming deaf. She is otherwise well and apyrexial.

26. What further information would you like to know as the GP?
What do you think is going on? Can you formulate a differential list?
Can you think of a simple test to aid diagnosis?
How are you going to manage this patient?
When will you think about referring for ENT opinion?

27. Eustachian tube dysfunction
Symptoms: Muffled hearing, dull hearing, ear popping, ear pain, ringing, dizziness.
Causes: Blocked Eustachian tube – ENT infections, glue ear, allergies, blockages, air travel.
Test: Look at the ear drum whilst asking the patient to perform valsalva manoeuvre, if Eustachian tube dysfunction, the ear drum moves very little.
Treatment: Often no treatement is needed.
Antihistamine tablets, decongestant nasal sprays
or drops may help.
Referral: When symptoms persist despite treatment.

28. Case Study 4
History: 57 year old man who works as a football manager came to see you because he thinks he needs a hearing aid. He has noticed whistling and ringing noise in his right ear for the past 8 months, he put this down to occupational related hearing changes. More recently, he has noticed some headache on the right hand side of the head with occasional tingling sensations. He has been to see the football club doctor, who thought he had tinnitus and advised him to come and see you to arrange assessment for a hearing aid. On examination, you cannot appreciate any obvious abnormality.

30. What are you going to do next?
Can you think of the possible differentials?
What are you worried about?
How will you manage this patient?
When will you think about referring him for ENT opinion?

31. Acoustic neuroma (Schwannoma)
Symptoms: Unilateral hearing loss over months, unilateral ringing/buzzing. Occipital pain. Possible facial numbness.
Pathology: Slow growing neurofibroma arising from the acoustic nerve, associated with type II neurofibromatosis (especially bilateral cases).
Investigations: Audiometry to demonstrate unilateral sensorineural hearing loss. Contrast CT scan. MRI sometimes needed to identify small lesions.
Treatment: Conservative – elderly patients or high risk patients due to tumour location.
Sterostatic radiosurgery – small/medium tumours
Microsurgery – large tumours
Referral: Unilateral sensorineural deafness – 2WW referral criteria

32. Case Study 5
65 year old man, presented to you with hearing loss on one side. Gradual onset, wife has been telling him that the wax coming out from his ear has been very smelly. He wants some olive oil on prescription because he does not pay for his medications anymore.

33. How will you manage this patient if you see this during the examination?

34. Cholesteatoma
9/100,000
Offensive discharge
Retracted eardrum
Crusty lesion, typically attic
Enzymatic destruction of ossicles or temporal
Urgent referral for surgery

36. Conductive hearing loss
Sensorineural hearing loss

37. Presbyacusis
Greek: old, hearing

38. Whisper (letters, numbers)
Weber, Rinnes

39. Pure tone audiometry
250, 500, 1000, 2000, 4000kHz
“Mosquito” kHz

40. Mild dB
Moderate dB
Severe dB
Profound >95dB

41. Case study 6
52 year old lady presents with 1 week history of dizziness and feels like the room keeps spinning. She feels sick with it and has vomited several times. She also complains of reduced hearing in her left ear.

42. This is what you see on examining her left ear…

43. What else do you want to know?
What are your differentials?
What investigations do you want to do?
What would your management be?

44. Viral labyrinthitis/ vestibular neuronitis
Vertigo
BPPV
Menieres
Viral labyrinthitis/ vestibular neuronitis
Duration
seconds/mins
Minutes to hours
>24hrs
Assc. Hearing loss N Y
Assc tinnitus
Related to position
Diagnosis
History & + Hallpikes
History and assc Sx
History and duration
Refer
If not settling for Epleys
All cases to confirm Dx
If persists>6wk 44

45. Examination Ears Cerebellar signs Cranial nerve exam Romberg’s sign
Hearing – Webers + Rinnes
Nystagmus
Hallpike manoeuvre and Epleys 45

46. Management BPPV Viral labyrinthitis / vestibular neuronitis
Self limiting
Reassure
Physio, reduce alcohol
Prochlorperazine/ betahistine
Viral labyrinthitis / vestibular neuronitis
Follows viral URTI
Prochlorperazine/ cyclizine 46

47. Menieres
Clusters of attacks of vertigo, nausea, tinnitus, SNHL and fullness in ear.
Give info and support groups
Treat acutely with labyrinthine sedatives- prochlorperazine /cyclizine
Mobilize
Consider: Betahistine, low salt diet, vestibular rehab, tinnitus masker, HA
Look out for and treat depression/anxiety 47

48. Hallpike and Epley manoeuvre48

49. Picture Quiz

65. Answers…

66. Bubbles

67. Glomus tumour

68. Acute Otitis Media

69. Otitis Media with retraction

70. Eustachian Tube dysfunction

71. Cholesteatoma

72. Tympanic sclerosis

73. Normal tympanic membrane

74. Safe Anterior Perforation

75. Inferior Perforation

76. Unsafe Posterior Perforation

77. Unsafe Attic Perforation

78. Grommet

79. Otitis Externa

80. This is a Monkey…
This is a Bat…
This is a Tiger…
This plant is called Elephant Ears…

81. Thank you for listening, and now it’s time to go home!