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 Bad-smelling discharge with a pocket where the eardrum has pulled inward. But the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer does not point to it.
2. Contact dermatitis of the canal Itch from an allergy to a product or the drops themselves. That does not match the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer.
3. Otitis externa correct Correct. A swollen, tender, discharging canal with pain on pressing the tragus in a swimmer is otitis externa.
4. Referred pain Ear pain that is really coming from the throat or teeth. It does not fit the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer.
5. Furuncle of the canal A single painful boil in one spot in the canal. Here, the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer points elsewhere.

The point: Otitis externa is inflammation of the ear canal, the tube that leads to the eardrum. It is mostly a local problem treated with local measures, but one form is dangerous and you must know it. It causes ear pain, itch, a blocked feeling, discharge, and sometimes hearing loss. On examination the canal is red, swollen and often moist. It hurts when you move the tragus (the small flap of cartilage in front of the ear canal) or pull the pinna (the outer ear), and debris blocks the view of the eardrum. It is more common in swimmers, in hot humid weather, and with eczema or damage from cotton buds. Most cases are bacterial, some are fungal. Treatment starts with aural toilet, which means cleaning the canal, then antibiotic or antifungal drops, sometimes with a steroid, plus keeping the ear dry and pain relief. Antibiotic tablets are not usually needed unless the infection spreads past the canal. Tell it apart from otitis media, an infection of the middle ear behind the drum: there the eardrum itself is red and there is no pain on moving the tragus. The emergency to know is malignant, or necrotising, otitis externa. This is a spreading bone infection at the base of the skull, seen in older people with diabetes or a weak immune system. It causes severe pain that will not stop, granulation tissue, which is raw red tissue, in the canal, and sometimes weakness of the face or other nerves. It needs urgent scans, admission to hospital, and antibiotics through a drip for a long course.

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. Pain on pressing the tragus with a swollen canal points to otitis externa rather than otitis media.
2. Cranial nerve examination where severe pain Checks whether the infection has reached the nerves at the base of the skull. It does not fit the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer.
3. Blood glucose and immune status where severe Checks the risk of the dangerous malignant form. But the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer does not point to it.
4. Assessment for spread beyond the canal Checks whether the infection has spread further, which catches malignant otitis externa. That does not match the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer.
5. Swab of discharge for persistent or severe cases A swab identifies the bug when the infection will not settle. Here, the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer points elsewhere.

The point: Otitis externa is inflammation of the ear canal, the tube that leads to the eardrum. It is mostly a local problem treated with local measures, but one form is dangerous and you must know it. It causes ear pain, itch, a blocked feeling, discharge, and sometimes hearing loss. On examination the canal is red, swollen and often moist. It hurts when you move the tragus (the small flap of cartilage in front of the ear canal) or pull the pinna (the outer ear), and debris blocks the view of the eardrum. It is more common in swimmers, in hot humid weather, and with eczema or damage from cotton buds. Most cases are bacterial, some are fungal. Treatment starts with aural toilet, which means cleaning the canal, then antibiotic or antifungal drops, sometimes with a steroid, plus keeping the ear dry and pain relief. Antibiotic tablets are not usually needed unless the infection spreads past the canal. Tell it apart from otitis media, an infection of the middle ear behind the drum: there the eardrum itself is red and there is no pain on moving the tragus. The emergency to know is malignant, or necrotising, otitis externa. This is a spreading bone infection at the base of the skull, seen in older people with diabetes or a weak immune system. It causes severe pain that will not stop, granulation tissue, which is raw red tissue, in the canal, and sometimes weakness of the face or other nerves. It needs urgent scans, admission to hospital, and antibiotics through a drip for a long course.

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. Keep the ear dry and analgesia Keeping the ear dry helps it heal, and pain relief keeps the person comfortable. Here, the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer points elsewhere.
2. Systemic antibiotics only if infection spreads Antibiotic tablets are not needed for simple disease. That does not match the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer.
3. Topical antibiotic or antifungal drops with a steroid correct Correct. Drops in the ear are the main treatment once the canal is clean.
4. Treat underlying eczema or avoid trauma Treating skin conditions and stopping cotton bud use helps prevent it coming back. It does not fit the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer.
5. Urgent admission and intravenous antibiotics for malignant otitis externa The bone infection at the skull base needs hospital admission and antibiotics through a drip. But the picture of a swollen, tender, discharging canal with pain on pressing the tragus in a swimmer does not point to it.

The point: Otitis externa is inflammation of the ear canal, the tube that leads to the eardrum. It is mostly a local problem treated with local measures, but one form is dangerous and you must know it. It causes ear pain, itch, a blocked feeling, discharge, and sometimes hearing loss. On examination the canal is red, swollen and often moist. It hurts when you move the tragus (the small flap of cartilage in front of the ear canal) or pull the pinna (the outer ear), and debris blocks the view of the eardrum. It is more common in swimmers, in hot humid weather, and with eczema or damage from cotton buds. Most cases are bacterial, some are fungal. Treatment starts with aural toilet, which means cleaning the canal, then antibiotic or antifungal drops, sometimes with a steroid, plus keeping the ear dry and pain relief. Antibiotic tablets are not usually needed unless the infection spreads past the canal. Tell it apart from otitis media, an infection of the middle ear behind the drum: there the eardrum itself is red and there is no pain on moving the tragus. The emergency to know is malignant, or necrotising, otitis externa. This is a spreading bone infection at the base of the skull, seen in older people with diabetes or a weak immune system. It causes severe pain that will not stop, granulation tissue, which is raw red tissue, in the canal, and sometimes weakness of the face or other nerves. It needs urgent scans, admission to hospital, and antibiotics through a drip for a long course.

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