Examination | Ear Wax | Follow Up

Casebank Combined
1

Scenario: Ear Wax - Follow up

Candidates instruction

  • 35 years/Male was here 2 weeks ago with hearing problem. (C/o hearing loss)
  • He was prescribed ear drops and advised to come back if no improvement.
  • He has come back because the symptoms did not subside.
  • Previously on examination, the doctor couldn’t visualise the Tympanic membrane.

Approach

  • GRIPS
  • Take a history
  • Differential diagnosis
    • Ear wax
    • AOM
    • Trauma
    • Otitis media
    • Otitis externa
    • Acoustic neuroma

Examination

Set up:

  • Mannikin
  • Otoscope: There could 3 possible findings.
    1. Scenario 1: Ear wax
    2. Scenario 2: Normal ear drum
    3. Scenario 3: Not able to visualise tympanic membrane

Management

  • Emergency/immediate
  • Refer to ENT specialist in all 3 cases
    • P: How will you refer me doctor?
    • D: I’m gonna give a call to a specialist and request them to see you today or tomorrow.
  • Explain what the specialist would do:
    • Ask questions about his symptoms
    • Examine, and asses for other causes of hearing loss INCLUDING performing investigations such audiometry, MRI scan .
  • If there is there is ear wax - ENT will try irrigation if they can see earwax in the ear.
  • ENT specialist may do an Audiometry to assess other causes of hearing loss.
2

Scenario 2: Earwax follow-up

  • Patient background:
    • Previous visit: Doctor couldn’t visualize eardrum
    • Given sodium bicarbonate ear drops
    • History of swimming in Spain, sudden ear block
  • Current presentation:
    • Patient speaks loudly, bends down to hear
    • History-taking (speak loudly and clearly):
    • “When did you first notice the hearing problem?”
    • “What symptoms did you have when you first came in last week?”
    • “What tests did the doctor do last time?”
    • “What treatment were you given?”
    • “Have you been using the ear drops as prescribed?”
    • “Have you noticed any improvement since using the drops?”
  • Examination:
    • Use otoscope as described earlier
  • Two possible outcomes:

Outcome A: Impacted wax still visible

  • Explain to patient:
    • “I can still see some impacted wax in your ear canal”
    • “The ear drops haven’t fully cleared the blockage”
  • Recommend irrigation:
    • “The next step would be to perform ear irrigation to remove the wax”
    • “However, this procedure is now done privately and you’ll need to pay for it”
    • “I can refer you to a nearby clinic that offers this service”
    • “You can choose your preferred clinic and negotiate the price with them”

Outcome B: Clear tympanic membrane

  • Explain to patient:
    • “I’ve examined your ear and I can see your eardrum clearly now”
    • “There’s no visible earwax causing a blockage”
  • Address ongoing hearing loss:
    • “Since you’re still experiencing hearing loss, we need to investigate further”
    • “Sudden hearing loss without a clear cause is a serious condition that we need to address quickly”
  • Action plan:
    • “I’m going to refer you for a hearing test (audiometry) and to see an ENT specialist today”
    • “This is to rule out any underlying conditions causing your hearing loss”
  • Possible diagnoses:
    • Acute idiopathic sensorineural hearing loss
    • Acoustic neuroma
  • Further tests:
    • “The ENT specialist may recommend an MRI scan to check for any abnormalities”
  • Treatment possibilities:
    • “If it’s a condition called acute idiopathic sensorineural hearing loss, it’s usually treated with steroids”
    • “If they find a growth called an acoustic neuroma, surgery might be necessary”
  • Prognosis:
    • “In many cases, more than 50% of people recover their hearing with proper treatment”
    • “For those who don’t fully recover, hearing aids can be very helpful”
3

Candidate Information

  • Came 5 days ago with hearing problems. (CO hearing loss)
  • GP couldn’t visualise tympanic membrane on examination.
  • GP thought it was ear wax and therefore given sodium bicarbonate ear drops (2nd line after ear softeners).
  • He was asked to come back as he has no improvement.
  • Manikin in the room.

Simulator information

  • Simulators shout very loud as they can’t hear
  • Simulator has lean forward with their ear facing you to hear you better
  • IPS: speak louder

Data gathering

  • Acknowledge: I understand you here for a follow up and came earlier.

Previous visit questions:

  • What sort of symptoms you had?
  • What sort of tests did they do?
  • What did they tell you was wrong?
  • What sort of treatment did they offer?
  • Did you improve? P: No

Ask symptoms of Ear wax and other ear disease

Examine

  • Otoscopy: dark substance in the ear canal
  • Tuning fork in the cubicle

Management

  • Dx : Ear wax
  • It seems your ear wax has not come out yet, the concern is that you’re having sudden onset hearing loss, that’s quite severe in nature. We’re not sure at the moment whether it’s due to wax or some other problem.
  • Same day referral to ENT specialist
  • We need to clear this wax and do the hearing test again.
  • If after clearing hearing test if your hearing improves then you don’t need to worry but if it doesn’t improve then you’ll advice to do MRI of ear to rule out any nerve damage.

Concern

  • P: Why did other doctor waste my time and sent me to ENT earlier?
  • D: Intially we thought this could be ear wax, that’s why we gave you ear drops but unfortunately it didn’t work very well. This is what we usually do for a patient with ear wax.