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 appearPearly greyWith a light reflexConcaveShould be able to make out malleus – looks like an arm4
5 1 = pars flaccida (=attic) 2 = lat process of malleus 3 = handle of malleus4 = end of malleus5 = light reflex6 = eardrum margin7 = pars tensa675
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
8 What are you looking for? Shape of the eardrum – bulging or retractedColour 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
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 winterHave older siblingsAt nurseryUses a dummyParents smokeSymptomsEarache or pulling/tugging earURTIPainMalaiseFeverIrritabilityVomitingSignsPyrexiaRed, bulging tympanic membraneMay be air-fluid level behind TMPerforated TM +/or discharge in canalPossibly hearing loss
14 What are your differential diagnoses? Otitis ExternaURTI – TM a little redAcute mastoiditis – swelling, erythema & tenderness over mastoid bone; displacement (downwards & outwards) of pinnaPost auricular adenitisReferred pain from teeth
15 How would you manage him? Pain relief & antipyretic – regular paracetamol, ibuprofenAntibioticsFor most people no or delayed Abx with appropriate explanation or risk vs benefitConsider if<2yrsSystemic Sx inc temp >38ºC or vomitingBilateral AOMPerforated TM with dischargeAmoxicillin (Erythromycin)Co-amoxiclav (Azithromycin) if Rx failureConsider admission – systemically unwellSafety 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 episodesAdults 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 smokingAvoid dummiesAvoid supine feeding?pneumococcal vaccinations17
18 Case study 2 Red itchy ear 40 year old female 1 week history of an “Itchy Ear”, getting worseKeen SwimmerType 2 Diabetic – on MetforminNo other medical history of note
19 Red, Itchy Ear On Examination BMI 35 Swollen Ear Canal with erythema No discharge, some debrisPain on moving pinnaNil else of note
21 Otitis Externa Often occurs after trauma Symptoms Signs e.g. Scratching, ear cleaning, swimmingSymptomsPain (Severe, also on pinna movement),Discharge (May be offensive)SignsSwollen ear Canal +/- Discharge / DebrisMay 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 wickIf refractory , need to swab - may be candida or aspergillus (Clotrimazole)
24 Case Study 3History: 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 spraysor drops may help.Referral: When symptoms persist despite treatment.
28 Case Study 4History: 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 tumoursMicrosurgery – large tumoursReferral: Unilateral sensorineural deafness – 2WW referral criteria
32 Case Study 565 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 Cholesteatoma9/100,000Offensive dischargeRetracted eardrumCrusty lesion, typically atticEnzymatic destruction of ossicles or temporalUrgent referral for surgery
41 Case study 652 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 VertigoBPPVMenieresViral labyrinthitis/ vestibular neuronitisDurationseconds/minsMinutes to hours>24hrsAssc. Hearing lossNYAssc tinnitusRelated to positionDiagnosisHistory & + HallpikesHistory and assc SxHistory and durationReferIf not settling for EpleysAll cases to confirm DxIf persists>6wk44
47 MenieresClusters of attacks of vertigo, nausea, tinnitus, SNHL and fullness in ear.Give info and support groupsTreat acutely with labyrinthine sedatives- prochlorperazine /cyclizineMobilizeConsider: Betahistine, low salt diet, vestibular rehab, tinnitus masker, HALook out for and treat depression/anxiety47