Examination | Ear Wax | First Presentation

Plabforum · November 6, 2024, 6:56am

Where you are:
You are an FY2 Doctor in GP surgery

Who the patient is:
Theresa Scott is a 45-year-old lady who has presented with some complaints

Other information you have about the patient:
None

What you must do:
Assess the patient and discuss management

Patient information:

You are a 45 Theresa Scott, a 45-year-old lady who has presented with ear pain
Opening sentence: “Doctor, I have earache and I think I have earwax” OR “ Doctor I think I need something for my earwax”?
You have had this pain for 3 days
Recently you have been well.
One of your friends had earwax before, so you also think you have got wax as well.
You clean your ears everyday with an earbud.
2 weeks ago you travelled to Spain/Caribbean and you went swimming in the sea.
You got a lot of water entering your ear.
No fever/No chest pain/No Shortness of breath.
You have reduced hearing in the last few days.

Examiner’s prompt

Examiner should say ear examination is normal
Examiner should give a picture of wax in the ear
Aurioscopy
BNF

Questions:

Why do I have wax?
How do I prevent earwax in the future?
How often should I clean my ears?
How should I clean the ear?

Approach:

GRIPS
How can I help you?
History of ear pain and wax
Differential Diagnosis
- AOM
- Otitis externa
- Trauma
- URTI
PMAFTOSA
ICE
Effects of symptoms on patient life
Examinations
- Observations: All are normal
- Ear examinations
  - Inspection
  - Temperature
  - Tenderness
- Otoscope (Auriscopy): The examiner will give you a picture.
- Tunning fork test.
Explain your examinations findings to the patient.
Diagnosis
- Wax: Ear wax is formed from sweat and dead cells which are produced in the ear
- Earwax protects the ear canal, it usually falls off on its own, however if it doesn’t fall off it can Block the ear canal.
- Blockage of the ear usually occurs if one uses cotton ear buds, this ends up pushing the wax inwards.
- Swimming can also cause blockage of the ear from ear wax, this happens when water causes the wax to expand and block the ear canal.
- Some people are just physiologically more prone to produce more earwax.
- The hearing loss will improve once the wax is removed
Management
- Ear drops of olive oil for 3 – 5 days, it will dissolve the wax
- If it does not improve then we can do irrigation
- Advice about hygiene
- Cover the ear during swimming
- Avoid using cotton ear buds
- Use olive oil or almond oil once a week or every 2 weeks.
- If the earwax doesn’t come off after ear drops we will try something known as irrigation, we can use eardrops for that
Safety netting
- High temperature and worsening pain
- Worsens hearing problem
Concerns:
1. How can I stop this from happening? You cannot stop earwax from happening. It is a normal process that prevents the ear.
2. How often do I have to clean the ear? You do not have to do it often, but you can try and put eardrops over a week if you notice that you develop earwax too frequently.

Plabforum · November 6, 2024, 10:13am

	Earwax Initial	Earwax Follow up	Earwax Follow up
Symptoms	Hearing Loss	Hearing Loss	Hearing Loss
	Hearing Loss	Hearing Loss	Hearing Loss
	Discomfort/pain	Discomfort/pain	Discomfort/pain
	Fullness	Fullness	Fullness
Explore	Previous earwax? removal?	What has been done so far?	What has been done so far?
	Chronic disease?	Symptoms improved?	Symptoms improved?
Rule Out	Foreign body	Foreign body	Foreign body
	Otitis externa	Otitis externa	Otitis externa
Examination	Otoscopy	Otoscopy	Otoscopy
	Hearing test	Hearing test	Hearing test
Finding	Wax	Wax	Nothing
Diagnoses	Earwax, it’s produced by the ear as part of it’s natural process of cleaning and protection, that can build up and block the ear.	Earwax, it’s produced by the ear as part of it’s natural process of cleaning and protection, that can build up and block the ear.	Sensorineural hearing loss
Treatment	Initial- medical grade olive/almond oil drops 3-4 times daily, 3-5 days initially Might cause discomfort/dizziness	Irrigation	Immediate referral to ENT Audiometry/ more tests and scans based on that they will offer u T/t or procedure Rn im not sure what’s going on
	Second line- irrigation

Ear questions:

since when?
which ear?
what about the other ear?
is it all time or comes and goes?
is it getting worse?
anything makes it better/worse?
ear pain?discharge?trauma?

Plabforum · November 7, 2024, 3:45am

Risk factors for earwax problems:
- Water entering the ear
- Using earbuds
Presenting complaint: Hearing problem after swimming
Patient background: Works in a bank
History-taking:
- Ask about swimming or recent water exposure
- Inquire about earbud use
Examination:
- Use otoscope
- Technique:
  - Hold otoscope with three fingers
  - Use two fingers to stabilize on patient’s face
  - Pull ear upwards and backwards
  - Rest two fingers on cheek while examining
If earwax is found:
- Explain to patient:
  - “I can see some earwax in your ear canal”
  - “Earwax is a natural substance made of dead cells, salt, and oily secretions”
  - “It’s actually a natural cleaning and protective mechanism for your ear”
  - “Sometimes it can build up and cause hearing problems”
Treatment plan:
- Prescribe medicated ear drops (almond oil-based or olive oil-based)
- Instructions: “Use 3 drops, 2 times a day, for 3 weeks” (3-2-3 rule)
If patient asks about immediate irrigation:
- Response: “Irrigation is not recommended as a first-line treatment”
- Explanation:
  - “It can sometimes cause complications like perforation or irritation of the ear canal”
  - “It’s better to try the ear drops first, which are safer and often effective”
If patient insists due to work:
- “I understand your concern about work, but irrigation is now done privately and you’d need to pay for it”
- “It’s best to try the ear drops first, as they’re often effective and much safer”

Plabforum · November 7, 2024, 4:28am

Scenario: Ear Wax-First presentation

CANDIDATES INSTRUCTION

A 35-year-old man presented with hearing problem.

Background Information

3 weeks ago he went to spain and was swimming when water entered in his ear.
It is affecting his work. Works in a bank. Can’t hear his customer clearly.

Approach

GRIPS
History: hearing loss
Differential diagnosis
- Acoustic neuroma
- Trauma
- Tumour
- Ear wax
- AOM
- Noise induced hearing loss
- Meniere’s disease
Family hx of hearing loss (otosclerosis)?

Examination

Otoscopy manikin of ear wax

Diagnosis

In my examination I saw a ear was in your ear canal, because of this you’re having hearing problem.

Management

First line: Ear drops (olive oil, Almond oil, Sodium bicarbonate).
Apply 3-4 times a day for a period of 5 days at least.
If no improvement, then refer him to the ENT specialist and the specialist may try irrigation.
Offer leaflets about ear wax.
Safety netting: any signs of ear infection, pain in the ear, fever, needs to come back

Concern

Can you do an irrigation for me? The recommended first line treatment is ear drop and most people experience improvemnt with it.

Plabforum · November 7, 2024, 5:16am

Problem with hearing

PC Ear Pain started after swimming in spain
Swim after work (bank) everyday
Examination finding: Otoscopy Ear wax very dark

Management

Ear wax is a collection of oily secretions and dead cells in your ears, and it’s a cleaning and protective system for your ears.
Cotton buds and water exposure can affect this system. Water causes the wax to expand and cotton buds pushes the wax inside and cause them to collect together.
Ear softeners: Medicated olive or almond oil based ear drops (3-2-3) 3 times a day, 2 drops for 3 weeks
If no improvement then we do irrigation
Can you do the irrigation today? I work in a bank and I can’t take calls.
- Irrigation is not the first line of treatment because most people respond very well with the ear softeners and irrigation has complication like perforation and damage ear drum. If someone is not responding to ear drops then we do irrigation.
- It requires booking of an appointment and arrange a treatment room.
- This is not funded under NHS, therefore to be done at private clinic.
Can GP do the irrigation?
- Some GP may do and some don’t as it requires additional training and certification.

NOte: Hearing loss rule out acoustic neuroma

Plabforum · November 7, 2024, 6:24am