Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently a Foundation Year 2 Doctor working in General Practice. Your next patient is called Harry Tiles – a 46-year-old gentleman presenting buzzing in the ear. Please take a history and perform an appropriate examination.
Patient History:
Your name is Harry Tiles – a 46-year-old male – Property Manager.
You noticed since a few days ago that there's this buzzing in the ear, and your hearing has gotten a little more muffled than usual. This is affecting only your left ear, and it is getting gradually worse. You haven't tried to insert foreign bodies into your ears except a cotton bud to clean your left ear and remove any waxes, but it hasn't made any difference.
You went for a swim quite a few times lately when your friend came over to visit you since it has been much warmer and sunnier. You rare get these sort of weather nowadays!
You also noticed an earache rating it 4-5/10 which started around the same time - worsened by moving your left ear or chewing, with some itchiness on the left ear, but this is mild and is not concerning for you – thinking it might just be your eczema. You also noticed some colourless thick discharge from your left ear. You feel there's a sense of fullness in your left ear. You are unsure if you have a fever, but you felt a little cold yesterday night with some shivering and took paracetamol to relieve this.
No headache. No vertigo. No Facial weakness or drop. No rashes or skin changes around the ear. No fever. No recent infection. No sore throat. No running nose.
Ideas, Concerns, Expectations:
You think you have some wax in your left ear, which you have used cotton wool to repeatedly take out the wax in the last few days. You are concerned as you noticed you often have to ask someone to repeat themselves, affecting your social relationship with other people. You would like something to clear the wax if possible.
Past Medical History:
Type 2 diabetes, hirsutism, eczema (usually well controlled)
Drug History:
Doublebase cream, metformin
NKDA
Family History:
Hypertension, Migraines
Social History:
Occupation is property manager
Smoke 5-10 cigarettes a day for 10 years
Occasionally drink 1-2 pints of beer in a pub weekly
Live with partner and has 3 kids
Examination Findings:
Pain with movement of the left tragus/ auricle during otoscope examination.
Hirsute ear canal
Pre-auricular lymphadenopathy left ear.
Left erythema and swelling at the left ear canal with tenderness and exudate discharge
Left ear tympanic membrane – no perforation but may be erythematous if otitis externa extends to the tympanic membrane. Mobile tympanic membrane otherwise.
Conductive hearing loss on the left ear.
Pre-auricular lymphadenopathy left ear.
No granulation tissue can be seen that can suggest malignant otitis externa
No cellulitis/signs of dermatitis can be seen around the ears
No facial weakness or cranial nerve involvement
No tenderness or swelling palpating mastoids
Differentials:
Acute Otitis Externa
Trauma
Otitis media
Cholesteatoma to rule out
Dermatitis e.g. atopic/ contact
To rule out mastoiditis / complications of OE
Investigations:
Bedside:
Consider Ear swab/discharge culture and sensitivity +/- microscopy
Observation (pyrexia)
Pneumatic otoscopy (normal in AOE)
Tympanometry (normal in AOE)
Bloods:
Consider routine bloods e.g. FBC, CRP, U&Es, Bone Profile, LFTs + blood culture (baseline, infection) if patient appears to be systemically unwell.
Imaging:
CT/MRI head to assess the extent of infection in malignant otitis externa if suspected – to look for bone/soft tissue erosion or invasion
Management (Otitis Externa):