Earache

Question 1

Sequence of events and symptom analysis

Answer 1

OSOCRATES

Open question
Site- which ear, is the other ear a problem
Onset- when did you first notice it, how have things progressed
Radiation- does pain radiate anywhere, how is surrounding area and throat
Associated features- systems review
Timing- is it always there or does it come and go
Exacerbating or reliving factors (better or worse)
Severity- how bad on a scale of 1-10

Question 2

Systems review

Answer 2

Ear- discharge (describe), itchy ears, vertigo (balance issues/room spinning), tinnitus
ENT- throat pain, hoarse voice, neck lumps etc. (nasopharyngeal carcinoma)
Foreign bodies- do you clean your ears with buds
NS- headache, neck stiffness, rashes, photophobia, any numbness or weakness, tingling, muscle weakness
Constitutional- FWARJCNL

Question 3

Patients perspective

Answer 3

Feelings and impact

ICE

Question 4

Background check

Answer 4

PMH- ear surgeries?
DH- OTC or allergies
FH
SH

Question 5

Otitis externa

Answer 5

Itchy painful ear with discharge
Often history of recurrent similar infections, use of cotton buds, skin conditions like eczema
Beware of elderly diabetic patients with ear pain out of proportion to clinical findings- may have necrotising otitis externa, where infection spreads to base of skull (temporal bone)- urgent ENT referral

Question 6

Acute otitis media

Answer 6

Common in children
Hearing loss and severe pain
Pressure in ear
Thick purulent discharge and resolution if pain as ear drum bursts
Typically an URTI beforehand
Infants may be ear tugging and irritable
Can lead to mastoiditis

Question 7

Otitis media with effusion (glue ear)

Answer 7

Longer history
Hearing difficulty is predominant feature
Pain is milder if present at all

Question 8

Chronic suppuration otitis media

Answer 8

Chronic inflammation of middle ear with recurrent discharge through a perforated tympanic membrane
Otorrhoea present for more than 2 weeks without pain or fever

Question 9

Earwax

Answer 9

Decreased hearing and mild pain only occurs if patients have been manipulating the EAC or wax and it gets dislodged or otitis externa occurs
Patient may have used cotton buds

Question 10

Referred pain from oropharynx

Answer 10

Eg, tonsillitis

If no resolution and a cause isn’t identified, may need ENT input

Question 11

Investigations

Answer 11

Otoscopy
If treatment failure, can take an ear swab
Audiometry and tympanometry may be needed with glue ear
MRI head if worried about mastoiditis malignant otitis externa etc.