Derby GP Specialty
Training Programme
E
A
R
S
Practical exercise
• Get into pairs
• Look in each others ears
• Draw and label what you see!
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
7
6
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
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.
Malleus
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…
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...
• 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?
What else would you like to
know?
Symptoms
More common:
In winter
Have older siblings
At nursery
Uses a dummy
Parents smoke
•
•
•
•
•
•
•
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
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
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
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
Any advice to prevent further
episodes?
•
•
•
•
Eliminate passive smoking
Avoid dummies
Avoid supine feeding
?pneumococcal vaccinations
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
Red, Itchy Ear
On Examination
• BMI 35
• Swollen Ear Canal with erythema
• No discharge, some debris
• Pain on moving pinna
• Nil else of note
Red, Itchy Ear
Otitis Externa
• Often occurs after trauma
– 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
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)
Otitis Externa
• Prevention
– No cotton buds!
– Keep ears dry
• If mild itchiness / eczema
• Short course steroid drops (Prednisolone 0.5%
TDS)
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.
• 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?
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.
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.
• 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?
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
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.
How will you manage this patient if you
see this during the examination?
• Cholesteatoma
• 9/100,000
• Offensive discharge
• Retracted eardrum
• Crusty lesion, typically attic
• Enzymatic destruction of ossicles or temporal
• Urgent referral for surgery
Conductive hearing loss
Sensorineural hearing loss
• Presbyacusis
• Greek: old, hearing
• Whisper (letters, numbers)
• Weber, Rinnes
• Pure tone audiometry
• 250, 500, 1000, 2000, 4000kHz
• http://www.phys.unsw.edu.au/jw/hearing.ht
ml
• “Mosquito”
17.4kHz
• Mild
20-40dB
• Moderate
41- 70dB
• Severe
71-95dB
• Profound
>95dB
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.
This is what you see on examining her
left ear…
• What else do you want to know?
• What are your differentials?
• What investigations do you want to do?
• What would your management be?
Vertigo
BPPV
Menieres
Viral labyrinthitis/
vestibular neuronitis
Duration
seconds/mins
Minutes to
hours
>24hrs
Assc.
Hearing loss
N
Y
N
Assc tinnitus
N
Y
N
Related to
position
Y
N
N
Diagnosis
History & + Hallpikes
History and
assc Sx
History and duration
Refer
If not settling for
Epleys
All cases to
confirm Dx
If persists>6wk
Examination
•
•
•
•
•
•
•
Ears
Cerebellar signs
Cranial nerve exam
Romberg’s sign
Hearing – Webers + Rinnes
Nystagmus
Hallpike manoeuvre and Epleys
Management
• BPPV
–
–
–
–
Self limiting
Reassure
Physio, reduce alcohol
Prochlorperazine/ betahistine
• Viral labyrinthitis / vestibular neuronitis
– Follows viral URTI
– Prochlorperazine/ cyclizine
• Menieres
– Clusters of attacks of vertigo, nausea, tinnitus, SNHL and
fullness in ear.
– Give info and support groups
– Treat acutely with labyrinthine sedativesprochlorperazine /cyclizine
– Mobilize
– Consider: Betahistine, low salt diet, vestibular rehab,
tinnitus masker, HA
– Look out for and treat depression/anxiety
Hallpike and Epley manoeuvre
Picture Quiz
Answers…
Bubbles
Glomus tumour
Acute Otitis Media
Otitis Media with retraction
Eustachian Tube dysfunction
Cholesteatoma
Tympanic sclerosis
Normal tympanic membrane
Safe Anterior Perforation
Inferior Perforation
Unsafe Posterior Perforation
Unsafe Attic Perforation
Grommet
Otitis Externa
This is a Monkey…
This is a Bat…
This is a Tiger…
This plant is called Elephant Ears…
Thank you for listening,
and now it’s time to go
home!