CASE INFORMATION

Case ID: ENT-2025-003
Case Name: Emily Johnson
Age: 4 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: H71 (Acute Otitis Media), H72 (Myringitis)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and communicates effectively with caregivers 1.2 Elicits parental concerns and expectations 1.5 Provides clear and appropriate health education
2. Clinical Information Gathering and Interpretation	2.1 Obtains a thorough history including symptom onset and severity 2.3 Performs an appropriate otoscopic examination 2.4 Identifies red flag symptoms requiring escalation of care
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between viral and bacterial otitis media 3.4 Recognises complications requiring referral (e.g., mastoiditis)
4. Clinical Management and Therapeutic Reasoning	4.1 Provides evidence-based treatment and follow-up plan 4.3 Prescribes appropriate antibiotic therapy when indicated 4.6 Advises on symptomatic relief measures
5. Preventive and Population Health	5.1 Discusses strategies to reduce recurrent otitis media
6. Professionalism	6.2 Demonstrates patient-centred care and shared decision-making with parents
7. General Practice Systems and Regulatory Requirements	7.1 Documents findings and management appropriately
9. Managing Uncertainty	9.1 Recognises when observation is appropriate vs. immediate antibiotic use
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies features of severe or complicated acute otitis media

CASE FEATURES

Young child presenting with ear pain and fever for the past 48 hours.
History of recent upper respiratory tract infection (URTI).
Parents are concerned about hearing loss and whether antibiotics are needed.
Otoscopic findings suggest bulging, erythematous tympanic membrane with purulent effusion.
Decision-making around watchful waiting vs. immediate antibiotic therapy.
Parental education on symptomatic management and prevention strategies.

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Emily Johnson
Age: 4 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Paracetamol 250 mg PRN for fever and pain

Past History

No prior ear infections
Up to date with childhood immunisations

Social History

Attends daycare, parents report frequent colds
Non-smoker household

Family History

No family history of chronic ear disease or hearing loss

Vaccination and Preventative Activities

Received pneumococcal and influenza vaccines

SCENARIO

Emily, a 4-year-old girl, presents with right ear pain and fever (38.5°C) for two days. Her parents report increased irritability, poor sleep, and reduced appetite. She had a runny nose and cough last week, but these symptoms are improving.

Her parents are concerned about possible hearing loss and whether she requires antibiotics. They have been giving paracetamol for pain relief, with some improvement.

EXAMINATION FINDINGS

General Appearance: Mildly irritable but consolable. No signs of toxicity.
Vitals:

Temperature: 38.5°C
Heart Rate: 110 bpm
Respiratory Rate: 22 breaths/min
Oxygen Saturation: 99% on room air

Ear Examination:

Right tympanic membrane (TM): Bulging, erythematous, and opacified with a purulent effusion.
Left TM: Normal.
No postauricular swelling, tenderness, or erythema (rules out mastoiditis).
No facial asymmetry (rules out facial nerve involvement).

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What key aspects of history would you explore further to refine your diagnosis?

Prompt: Ask about duration of symptoms, associated respiratory symptoms, and pain severity.
Prompt: Assess hearing changes, balance issues, or signs of systemic illness.

Q2. What are the most likely diagnoses, and what features support your conclusion?

Prompt: Differentiate acute otitis media (AOM) from otitis media with effusion (OME).
Prompt: Justify why this is likely bacterial rather than viral.

Q3. What are your initial management steps for Emily?

Prompt: Discuss pain relief measures (paracetamol/ibuprofen) and watchful waiting criteria.
Prompt: Indicate when antibiotics (e.g., amoxicillin) are warranted.

Q4. When would you consider referral to an ENT specialist?

Prompt: Explain referral indications for recurrent otitis media (>3 episodes in 6 months).
Prompt: Consider complications such as mastoiditis, perforation, or hearing concerns.

Q5. How would you counsel Emily’s parents on prognosis and prevention strategies?

Prompt: Reassure about high likelihood of resolution within 48–72 hours.
Prompt: Discuss preventive strategies (vaccination, daycare hygiene, avoiding second-hand smoke).

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What key aspects of history would you explore further to refine your diagnosis?

A thorough history is essential to distinguish acute otitis media (AOM) from other ear conditions and to assess for potential complications. Key aspects include:

1. Symptom Duration and Progression

When did symptoms start? Sudden vs gradual onset.
Has the pain worsened or improved over time?
Any prior similar episodes? First-time vs recurrent infection.

2. Associated Symptoms

Fever: Severity and duration.
Irritability: Signs of discomfort in a young child.
Ear discharge: Suggests tympanic membrane perforation.
Hearing loss: Temporary conductive hearing loss due to effusion.
Balance disturbance: Assess for inner ear involvement.

3. Recent Infections and Exposure

Recent upper respiratory tract infection (URTI): Viral aetiology is common.
Daycare attendance: Increased exposure to infections.
Household smoking: Passive smoking increases AOM risk.

4. Parental Concerns and Expectations

Parental perception of severity.
Any concerns about hearing loss or complications?
Previous experiences with antibiotics and treatment preferences.

5. Red Flags for Complications

Persistent high fever >39°C despite antipyretics.
Severe pain unrelieved by analgesia.
Postauricular swelling or erythema (concern for mastoiditis).
Facial asymmetry or weakness (suggests facial nerve involvement).

By gathering this information, a more precise diagnosis and management plan can be developed.

Q2: What are the most likely diagnoses, and what features support your conclusion?

1. Acute Otitis Media (AOM) – Most Likely

Bulging, erythematous tympanic membrane with purulent effusion.
Recent URTI, fever, and ear pain.
Irritability and reduced appetite.
No signs of perforation or chronic otitis media.

2. Differential Diagnoses

Otitis Media with Effusion (OME): More common after AOM but lacks acute signs (fever, erythema, pain).
Otitis Externa: Pain worsened by ear manipulation, external canal erythema, but normal tympanic membrane.
Mastoiditis: Requires urgent referral due to postauricular swelling and systemic symptoms.

The findings strongly support bacterial AOM, requiring appropriate management.

Q3: What are your initial management steps for Emily?

1. Pain and Symptom Control

Paracetamol or ibuprofen for pain and fever.
Adequate hydration and rest.

2. Antibiotic Therapy

Watchful waiting for 48 hours if mild symptoms (age >2 years, non-severe infection).
Immediate antibiotics if:
- Age <2 years with bilateral AOM.
- Severe pain, fever >39°C.
- Indigenous child or recurrent AOM.

3. Choice of Antibiotic

First-line: Amoxicillin 15 mg/kg TDS for 5 days.
Penicillin allergy: Cefuroxime or macrolides.
Treatment failure after 48 hours: Consider amoxicillin-clavulanate.

4. Parental Education

Reassure that most AOM cases resolve within 48–72 hours.
Explain the role of antibiotics and when to seek review.

Proper management focuses on symptomatic relief, monitoring, and judicious antibiotic use.

Q4: When would you consider referral to an ENT specialist?

1. Recurrent Otitis Media

≥3 episodes in 6 months or ≥4 episodes in 12 months.
Consider grommet (tympanostomy tube) placement.

2. Persistent Effusion

Persistent OME >3 months with hearing loss or speech delay.

3. Complications

Mastoiditis: Postauricular swelling, tenderness, fever.
Tympanic membrane perforation: Persistent discharge.
Suspected cholesteatoma: Foul-smelling discharge, hearing loss.

Timely ENT referral prevents long-term complications.

Q5: How would you counsel Emily’s parents on prognosis and prevention strategies?

1. Prognosis

Most AOM cases resolve within 48–72 hours.
Hearing usually returns to normal after effusion clears (weeks to months).

2. Prevention Strategies

Routine Vaccinations: Ensure pneumococcal and influenza vaccines are up to date.
Reduce daycare exposure where possible.
Avoid passive smoking.
Breastfeeding for at least 6 months (protective effect).

3. When to Seek Medical Attention

High fever (>39°C) or worsening symptoms after 48 hours.
Ear discharge lasting >2 days.
Speech delay or persistent hearing concerns.

Providing clear parental guidance ensures better understanding and compliance.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, covering symptom progression, risk factors, and red flags.
Accurate diagnosis of AOM, distinguishing from OME, otitis externa, and mastoiditis.
Evidence-based management, including pain relief, watchful waiting, and antibiotic indications.
Appropriate use of ENT referral for persistent or complicated cases.
Effective parental education on prognosis and prevention strategies.

PITFALLS

Overprescribing antibiotics without considering watchful waiting criteria.
Failing to assess for complications (mastoiditis, perforation, facial nerve palsy).
Not addressing parental concerns adequately, leading to misuse of antibiotics.
Missing hearing loss or speech delay, delaying ENT referral.
Neglecting preventive strategies (vaccination, smoking exposure).

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD