Ear, nose and throat for AMC MCQ

A 24 year old regular swimmer has three days of an itchy, painful right ear with a feeling of fullness and some discharge. The tragus is tender to press, the canal is red, swollen and moist with debris, and the drum is hard to see but looks normal where visible. He is otherwise well and afebrile. What is the most likely diagnosis?

1. Cholesteatoma Foul discharge with a retraction pocket. A swollen tender discharging canal with tragal tenderness in a swimmer suggests it.
2. Contact dermatitis of the canal Itch from an allergen or drops. A swollen tender discharging canal with tragal tenderness in a swimmer makes it a consideration.
3. Otitis externa correct Correct. A swollen, tender, discharging canal with tragal tenderness in a swimmer is otitis externa.
4. Referred pain Ear pain from the throat or teeth. A swollen tender discharging canal with tragal tenderness in a swimmer makes it worth considering.
5. Furuncle of the canal A localised painful boil. A swollen tender discharging canal with tragal tenderness in a swimmer raises it.

The point: Otitis externa is inflammation of the external ear canal, and it is largely a local problem treated with local measures, but it carries one dangerous variant to keep in mind. It presents with ear pain, itch, a feeling of fullness, discharge and sometimes hearing loss, and examination shows a red, swollen, often moist canal, tenderness on moving the tragus or pinna, and debris obscuring the drum. It is commoner in swimmers, in hot humid weather and with eczema or trauma from cotton buds, and it is usually bacterial, sometimes fungal. The mainstay of treatment is aural toilet to clean the canal, followed by topical treatment with antibiotic or antifungal drops with or without a steroid, keeping the ear dry, and analgesia. Systemic antibiotics are not usually needed unless infection spreads beyond the canal. The important distinction is from acute otitis media, where the drum is inflamed and there is no canal tenderness, and the emergency to recognise is malignant, or necrotising, otitis externa, a spreading osteomyelitis of the skull base seen in older diabetic or immunocompromised patients, with severe unremitting pain, granulation tissue in the canal and sometimes cranial nerve palsies, which needs urgent imaging, admission and prolonged intravenous antibiotics.

Source: Therapeutic Guidelines (Australia) — Otolaryngology: otitis externa Therapeutic Guidelines (Australia) · tier 3, national formulary

A 24 year old regular swimmer has three days of an itchy, painful right ear with a feeling of fullness and some discharge. The tragus is tender to press, the canal is red, swollen and moist with debris, and the drum is hard to see but looks normal where visible. He is otherwise well and afebrile. What is the most appropriate initial investigation?

1. Assessment of tragal and pinna tenderness correct Correct. Tragal tenderness with canal swelling identifies otitis externa rather than otitis media.
2. Cranial nerve examination where severe pain For skull base involvement. A swollen tender discharging canal with tragal tenderness in a swimmer indicates it.
3. Blood glucose and immune status where severe Risk for the malignant form. A swollen tender discharging canal with tragal tenderness in a swimmer makes it important.
4. Assessment for spread beyond the canal For malignant otitis externa. A swollen tender discharging canal with tragal tenderness in a swimmer makes it necessary.
5. Swab of discharge for persistent or severe cases For the organism. A swollen tender discharging canal with tragal tenderness in a swimmer makes it useful.

The point: Otitis externa is inflammation of the external ear canal, and it is largely a local problem treated with local measures, but it carries one dangerous variant to keep in mind. It presents with ear pain, itch, a feeling of fullness, discharge and sometimes hearing loss, and examination shows a red, swollen, often moist canal, tenderness on moving the tragus or pinna, and debris obscuring the drum. It is commoner in swimmers, in hot humid weather and with eczema or trauma from cotton buds, and it is usually bacterial, sometimes fungal. The mainstay of treatment is aural toilet to clean the canal, followed by topical treatment with antibiotic or antifungal drops with or without a steroid, keeping the ear dry, and analgesia. Systemic antibiotics are not usually needed unless infection spreads beyond the canal. The important distinction is from acute otitis media, where the drum is inflamed and there is no canal tenderness, and the emergency to recognise is malignant, or necrotising, otitis externa, a spreading osteomyelitis of the skull base seen in older diabetic or immunocompromised patients, with severe unremitting pain, granulation tissue in the canal and sometimes cranial nerve palsies, which needs urgent imaging, admission and prolonged intravenous antibiotics.

Source: Therapeutic Guidelines (Australia) — Otolaryngology: otitis externa Therapeutic Guidelines (Australia) · tier 3, national formulary

A 24 year old regular swimmer has three days of an itchy, painful right ear with a feeling of fullness and some discharge. The tragus is tender to press, the canal is red, swollen and moist with debris, and the drum is hard to see but looks normal where visible. He is otherwise well and afebrile. What is the most appropriate next step in management?

1. Aural toilet to clean the canal Aural toilet to clear the debris is the key first step so drops can work, and a swollen tender discharging canal with tragal tenderness in a swimmer here points elsewhere.
2. Keep the ear dry and analgesia For healing and comfort. A swollen tender discharging canal with tragal tenderness in a swimmer makes it supportive.
3. Systemic antibiotics only if infection spreads Not for simple disease. A swollen tender discharging canal with tragal tenderness in a swimmer makes it selective.
4. Topical antibiotic or antifungal drops with a steroid correct Correct. Topical drops are the mainstay of treatment after cleaning the canal.
5. Treat underlying eczema or avoid trauma For prevention. A swollen tender discharging canal with tragal tenderness in a swimmer makes it preventive.

The point: Otitis externa is inflammation of the external ear canal, and it is largely a local problem treated with local measures, but it carries one dangerous variant to keep in mind. It presents with ear pain, itch, a feeling of fullness, discharge and sometimes hearing loss, and examination shows a red, swollen, often moist canal, tenderness on moving the tragus or pinna, and debris obscuring the drum. It is commoner in swimmers, in hot humid weather and with eczema or trauma from cotton buds, and it is usually bacterial, sometimes fungal. The mainstay of treatment is aural toilet to clean the canal, followed by topical treatment with antibiotic or antifungal drops with or without a steroid, keeping the ear dry, and analgesia. Systemic antibiotics are not usually needed unless infection spreads beyond the canal. The important distinction is from acute otitis media, where the drum is inflamed and there is no canal tenderness, and the emergency to recognise is malignant, or necrotising, otitis externa, a spreading osteomyelitis of the skull base seen in older diabetic or immunocompromised patients, with severe unremitting pain, granulation tissue in the canal and sometimes cranial nerve palsies, which needs urgent imaging, admission and prolonged intravenous antibiotics.

Source: Therapeutic Guidelines (Australia) — Otolaryngology: otitis externa Therapeutic Guidelines (Australia) · tier 3, national formulary