An 18-month-old toddler presents with ACUTE OTITIS MEDIA
1 week of rhinorrhoea, cough, and EPIDEMIOLOGY: commonly in young children (0-4
years peak), <6 weeks, often settles in 48 hours
congestion. Her parents report she is PATHOPHYSIOLOGY: pathogen transmission via
irritable, sleeping restlessly, and not eustachian tube -> middle ear. In young children,
eating well. Overnight she developed a less acute angle of the eustachian tube within the
wall of the pharynx -> increased transmission of
fever. She attends daycare and both pathogens. Most infections are secondary to
parents’ smoke. On examination, signs bacteria, particularly strep. Pneumonia, H.
are consistent with a viral respiratory influenzae, Moraxella. Viral URTIs disturb normal
microbiome, allowing bacteria to infect
infection including rhinorrhoea and
CLINICAL FEATURES: rapid onset pain, fever +/-
congestion. irritability, loss of appetite, N&V, difficulty feeding,
The toddler tugging ear, hearing loss
appears INVESTIGATIONS: otoscopy (bulging tympanic
membrane -> loss of light reflex, opacification or
irritable erythema, perforation with purulent otorrhoea,
and decreased mobility if using pneumatic otoscope)
MANAGEMENT: generally self-limiting (3 days-
1week), seek medical help if worsen, analgesia, for
most, abx not indicated, if needed, use amoxicillin
5-7 days
apprehensive and has a fever. What is COMPLICATIONS: perforation, hearing loss,
labyrinthitis, mastoiditis, meningitis, brain abscess,
the likely diagnosis? facial palsy
A 2-year-old patient comes in with his OTITIS MEDIA WITH EFFUSION/ GLUE EAR
parents who noticed that their son has RISK FACTORS: male, siblings with glue ear,
Winter and Spring, bottle feeding, day-care
poor listening, he does not complain of
attendance, parental smoking, atopy, primary
pain but has also noticed problems with ciliary dyskinesia
his speech. Both parents’ smoke. PATHOPHYSIOLOGY: peaks 3-6 years, eustachian
Otoscopy tube dysfunction associated with URTI,
shows…What oversized adenoids and narrow nasopharyngeal
dimensions
is the likely
CLINICAL FEATURES: may cause no pain, hearing
diagnosis? loss, poor listening/speech, inattention, poor
behaviour, balance problems.
INVESTIGATIONS: otoscopy (retracted or bulging
eardrum or a fluid level), audiogram (conductive
hearing loss)
MANAGEMENT: resolves over time, surgery if
persists (grommets, suction of fluid +/-
adenoidectomy)
COMPLICATIONS: mastoiditis, labyrinthitis, facial
palsy, meningitis, brain abscess
A 6-year-old patient was brought to CHRONIC OTITIS MEDIA
the GP by their parents due to 7 weeks PATHOPHYSIOLOGY: due to chronic inflammation
of discharging ear. She had an episode secondary to perforation in tympanic
membrane, can be due to infection, iatrogenic
of acute otitis media a few weeks ago. (grommets) or trauma. Associated discharge
On examination, the patient was from perforation is termed an active mucosal
apyrexial and no otalgia. Otoscopy COM/ chronic suppurative OM. Mastoid air cells
shows… What is the diagnosis? may also be affected
CLINICAL FEATURES: chronically discharging ear
(>6wks), absence of fever or otalgia, reduced
hearing
INVESTIGATIONS: otoscopy (perforation of
tympanic membrane, otorrhoea, mucosa), facial
nerve function, audiometry (conductive hearing
loss) and tympanometry- may not be
appropriate in heavily discharging ear.
Microbiological swabs
MANAGEMENT: aural toilet, topical abx or steroid
treatments until symptoms reduce or resolve.
Take swab. Symptoms >6 weeks or large
amounts of debris, ENT referral for surgery
,A 65-year-old woman presents with a BENIGN PAROXYSMAL POSITIONAL
chief complaint of dizziness. She VERTIGO
describes it as a sudden and severe PATHOPHYSIOLOGY: caused by otoconia (loose
debris composed of calcium carbonate) within
spinning sensation precipitated by
semi-circular canals. Attacks triggered by head
rolling over in bed onto her right side. movements that result in movement of the
Symptoms typically last <30 seconds. otoconia, abnormal motion of endolymph and
They have occurred nightly over the vertigo
last month and occasionally during the CLINICAL FEATURES: ~10-20 sec vertigo, episodic,
triggered by change in head position, nausea
day when she tilts her head back to
INVESTIGATIONS: Dix-Hallpike (vertigo, rotatory
look upwards. She describes no nystagmus)
precipitating event prior to onset and MANAGEMENT: reduce alcohol, self-limiting in
no associated hearing loss, tinnitus, or months, Epley manoeuvre, vestibular rehab at
other neurological symptoms. What is home for pt, medication (betahistine,
prochlorperazine, antidepressants), inform DVLA
the likely diagnosis? DIFFERENTIALS: vestibular neuritis, labyrinthitis,
Meniere’s, migraine, stroke/TIA
A 40-year-old woman presents with a 1- MENIERE’S DISEASE
year history of recurrent episodes of PATHOPHYSIOLOGY: endolymphatic hydrops. From
vertigo. The vertigo spells are described as abnormal fluctuations in endolymph ->
a sensation of the room spinning that lasts distention of membranous endolymph system
from 20 minutes to a few hours and may be RISK FACTORS: genetic susceptibility,
autoimmune, viral infections, migraines,
associated with nausea and vomiting. The
trauma, syphilis
spells are incapacitating and are
CLINICAL FEATURES: vertigo for around 12h with
accompanied by disequilibrium, which may prostration, N&V, aural fullness +/- tinnitus +/-
last for days. No loss of consciousness is sensorineural deafness, attacks in clusters
reported. The patient also reports aural (<20/month), nystagmus, positive Romberg’s
fullness, tinnitus, and hearing loss in the INVESTIGATIONS: audiogram,
right ear that is more pronounced around electrocochleography, MRI to exclude alternative
the time of her vertigo spells. Physical diagnosis, bloods
examination of the head and neck is MANAGEMENT: acute attacks (buccal or IM
prochlorperazine if vomiting), prevention
normal. A horizontal nystagmus is noted.
(betahistine and vestibular rehab, avoid
She is unable to maintain her position
triggers), ENT assessment requirement to
during Romberg's testing or the Fukuda confirm diagnosis, inform DVLA (cease driving
stepping test. What is the likely diagnosis? until satisfactory control of symptoms),
additional (medical ablation, surgery)
A 40-year-old woman presents with a ACOUSTIC NEUROMA
history of progressively decreased PATHOPHYSIOLOGY: benign nerve sheath
Schwann cell tumour in internal auditory
hearing in her left ear over the past
meatus, usually unilateral unless associated
few years. She noticed the hearing with neurofibromatosis type II (bilateral
deficit when trying to use the phone schwannomas)
with the left ear. She has recently CLINICAL FEATURES: CN VIII involvement
complained of (cochlear-> hearing loss, tinnitus, vestibular->
vertigo), CN VII involvement (facial palsy,
intermittent
gustatory disturbances, xerostomia), CN V
dizziness, (facial paraesthesia, hypoesthesia, pain, absent
tinnitus in the corneal reflex)
left ear, and INVESTIGATIONS: pt with suspected vestibular
vague left- schwannoma referred urgently to ENT. MRI
cerebellopontine angle, audiometry
sided (sensorineural hearing loss), CN deficit in CN
headaches. exam
What is the MANAGEMENT: surgery (excision), radiotherapy,
likely observation
diagnosis?
, A 35-year-old man presents with a 2-day history ACUTE OTITIS EXTERNA
of rapid-onset severe ear pain and fullness. The AETIOLOGY: infection (staph. A, pseudomonas,
patient complains of otorrhoea and mild candida, aspergillus), seborrheic dermatitis,
decreased hearing. He reports that his symptoms contact dermatitis,
started after swimming. No fever is reported. On RISK FACTORS: swimming, humidity, young age,
physical examination the external ear canal is diabetes, trauma, narrow external auditory
diffusely swollen and erythematous. He has meatus, atopy, radiotherapy
tenderness of the tragus and pain with CLINICAL FEATURES: ear pain, itch, discharge,
movement of the auricle. The tympanic tenderness, hearing loss
membrane was INVESTIGATIONS: examination (inflamed external
partially visualised auditory canal, erythema, scaly skin, pre-
due to the swelling. auricular lymphadenopathy), otoscopy (red,
The concha and the swollen, eczematous canal)
pinna look normal. MANAGEMENT: initial (topical abx +/- steroid,
Neck examination aural toilet, analgesia, if systematically unwell,
fails to reveal any refer to ENT, if canal extensively swollen, ear
lymphadenopathy. wick), prevention (avoid swimming for 7-10
What is the likely days, ears kept clean and dry, avoid
diagnosis? precipitating factors), second line (oral abx if
spreading, swab, empirical antifungal)
A 45-year-old man presents with a MALIGNANT OTITIS EXTERNA
week history of unrelenting, deep ear PATHOGENESIS: severe, bacterial (pseudomonas)
pain with headaches. He has a current infection of external ear, causing skull base
osteitis. Found in immunocompromised
medical history of T2DM. On individuals, 90% in diabetics, infection
examination, a commence in the soft tissues of external
purulent discharge auditory meatus, then progress to bony ear
is seen with canal -> temporal bone osteomyelitis
CLINICAL FEATURES: diabetes/
erythematous and
immunosuppression, severe, deep-seated otalgia,
inflamed pinna. temporal headaches, purulent otorrhoea,
What is the likely possibly dysphagia, hoarseness and/or facial
diagnosis? nerve dysfunction, jaw pain
INVESTIGATIONS: CT head, blood glucose, bloods,
cultures
MANAGEMENT: non-resolving cases with
worsening pain should be referred to ENT,
surgical debridement, IV abx for pseudomonas
(usually ciprofloxacin)
A 12-year-old girl presents with a CHOLESTEATOMA
history of a recurrently discharging left CHARACTERISTICS: non-cancerous
ear for several months. She complains growth of keratinizing squamous
of an offensive discharge and hearing epithelium in the middle ear and/or
loss. She reports a previous history of mastoid process, often infected and
grommet result in chronically draining ears. 100x
insertion. increased risk with cleft palate
Otoscopy CLINICAL FEATURES: foul-smelling, non-
reveals a resolving discharge, hearing loss
posterosuperior (conductive), pain, facial paralysis and
perforation of vertigo. CN VII palsy is a red flag
the tympanic INVESTIGATIONS: otoscopy (attic crust-
membrane with in the uppermost part of the eardrum)
a white MANAGEMENT: pt referred to ENT for
keratin-like consideration of surgical removal
discharge. She (mastoidectomy)
has conductive hearing loss on
audiometry. What is the likely
diagnosis?
