Hearing loss

• Conductive: bone > air conduction (Rinne's negative)

• Sensorineural: Air > bone conduction (Rinne's positive). Hearing loss in adults: assessment and management (NICE), Hearing loss (NHS Choices), Deafness in adults (patient.info)

Ear wax

• Conductive hearing loss across all frequencies. Ear wax (CKS)

Cholesteatoma

• Usually unilateral (? due to squamous epithelium trapped in middle ear during embryogenesis which proliferates & expands). Typically present with chronic, suppurative otitis media and a progressive unilateral conductive deafness. Congenital cholesteatoma mean age of presentation 4.5 years. Pearly white mass behind TM. Cholesteatoma (CKS)

Otosclerosis

• typically middle-aged women with FH. Abnormal deposition of bone at the base of the stapes resulting a conductive deafness across all frequencies.

Sudden sensorineural hearing loss

• Otological emergency. Usually unilateral. Cause found after investigation (audiology, MRI and blood studies for systemic disease) in 15% cases. Some patients recover completely without medical intervention, often within the first 3 days. Others get better slowly over a 1–2 week period. Although a good to excellent recovery is likely, 15% of those with sudden sensorineural hearing loss experience a worsening over time. Stop ototoxic drugs (e.g. aminogylcosides, diuretics, NSAIDS, antineoplastic agents, streptomycin/kanomycin). Some evidence for oral steroids.

Acoustic neuroma

• Unilateral sensorineural hearing loss. Acoustic Neuroma (patient.info)

Noise-induced hearing loss (NIHL)

• Often with tinnitus. Usually bilateral & symmetrical. Normal examination. Audiogram: high-frequency (4,000 Hz/4kHz) dip. Refer if occupational as possible employment/legal implications.

Presbyacusis

• Progressive, bilateral sensorineural hearing loss in older people – usually <50Y. Most common cause of sensorineural hearing loss in the UK. Audiogram shows a much broader high frequency hearing loss (difficult to understand speech)

Meniere's disease

• Intermittent acute deafness, tinnitus, vertigo, nausea. Inform DVLA and cease driving till symptoms controlled: Meniere's disease (CKS)

Otitis externa

• Presence of white, cotton-like strands of candida, or small, black or white dots of aspergillus is suggestive of fungal colonisation: clotrimazole 1% solution. Otitis externa (CKS), Management of patients presenting with otorrhoea: diagnostic and treatment factors (BJGP)

• acetic acid 2% spray (Earcalm), (neomycin sulphate, + corticosteroid), flucloxacillin

• Necrotising or malignant OE: OE which has spread to cause osteomyelitis of the skull base. Due to Pseudomonas aeruginosa and anaerobes causing a mound of tissue in the external canal. A facial nerve palsy occurs in 50% of patients with this condition, and nerves IX to XII may also be involved. It affects immunocompromised patients, especially elderly diabetics. It may be life threatening and is worth considering in diabetic patients presenting with ear pain.

Otitis media

• Acute otitis media (AOM): antibiotics most beneficial in children <2Y with bilateral infection or otorrhoea. Otitis media - acute (CKS), Antibiotics for AOM in children (Cochrane)

• Otitis media - chronic suppurative (CKS)

• Amoxicillin (erythro)

• Otitis media with effusion 'glue ear'. Usually self-limiting. Observe for 3M. No benefit of antihistamines, decongestant, nasal steroids, antibiotics. Refer to ENT (from grommets) if hearing loss has significant impact on the child's developmental, social, or educational status, hearing loss is severe (≥61 dB), significant hearing loss persists x2 (usually following repeat testing after 6–12 weeks), TM is structurally abnormal (or other features suggesting an alternative diagnosis), persistent, foul-smelling discharge suggestive of cholesteatoma, Down's syndrome or cleft palate. Hearing aids alternative to surgery. Otitis media with effusion (CKS), Antibiotics for otitis media with effusion in children (Cochrane)

Perforated eardrum

• Perforated eardrum (NHS Choices), Perforated eardrum (patient.info)

Eustachian tube dysfunction

• Connects middle ear to back of nose (3-4cm). Usually full of air. ETD: eustaciahn tube blocked or doesn't open properly and decreased pressure in middle ear, TM tense and hearing muffled/dull +/- pain, tinnitus, dizziness, popping.clicking. URTI, glue ear, allergies, smoking, nasopharynx tumour. Chronic sx: chronic sinusitis, rhinitis, smoking. >6.52: audiogram, tympanogram, nasopharynoscopy, CT, ENT? Rx: increase air flow: valsalva, decongestants, antihistamine, steroid nasal spray.drops, refer (?grommet). Eustachian tube dysfunction (Patient.info)

Chondrodermatitis nodularis

You see a 69-year-old man who has noticed a painful lump on his right ear pinna that has been present for the past five months.

What is the SINGLE MOST likely diagnosis in this patient?

1. Keratoacanthoma

2. Chondrodermatitis nodularis

3. Basal cell carcinoma

4. Actinic keratosis

5. Perichondrial hematoma

Chondrodermatitis nodularis is a painful inflammatory condition affecting the helix or antihelix of the ear. It is most often seen in middle-aged or elderly men and is characterised by an exquisitely tender small papule that may ulcerate. Consequently it may be confused with a skin cancer, and basal cell carcinoma is an important differential diagnosis.

Chondrodermatitis nodularis can persist for several months or years. Treatment is usually conservative with advice to avoid sleeping on that side and wear a warm hat over the ears when outside in the cold. Intra-lesional steroid injections, cryotherapy or surgery with curettage may benefit some but are not usually needed.

Reference

• Chondrodermatitis nodularis helicis (PCDS); Image courtesy of the Primary Care Dermatology Society