EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess David’s condition and confirm the diagnosis?

• Prompt: What history and examination findings support the diagnosis of impacted cerumen?
• Prompt: What alternative causes of hearing loss should be considered?

Q2. What are the management options for David’s impacted cerumen?

• Prompt: What first-line treatments should be considered?
• Prompt: When is ear syringing appropriate, and what precautions should be taken?

Q3. What are the contraindications for ear syringing, and when should an alternative approach be used?

• Prompt: What risks are associated with syringing in certain patients?
• Prompt: What are safer alternatives in these cases?

Q4. What preventive measures would you recommend to David to reduce recurrent cerumen impaction?

• Prompt: How can he safely clean his ears?
• Prompt: What advice is relevant for hearing aid users?

Q5. When would you refer David to an ENT specialist?

• Prompt: What red flag symptoms indicate the need for referral?
• Prompt: What conditions require specialist intervention?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess David’s condition and confirm the diagnosis?

David presents with gradual hearing loss, a sensation of blocked ears, and occasional tinnitus, which are consistent with impacted cerumen. A structured assessment includes history, examination, and differentiation from other causes of hearing loss.

1. History

• Onset and progression – gradual vs sudden hearing loss
• Laterality – bilateral vs unilateral
• Associated symptoms – pain, discharge, dizziness, vertigo (suggesting other pathology)
• Use of cotton buds or hearing aids – risk factors for impaction
• Previous ear infections or ear procedures

2. Otoscopic Examination

• Impacted wax obscuring the tympanic membrane (confirming diagnosis)
• Signs of infection or perforation (red flags)

3. Hearing Assessment

• Weber and Rinne tests
  • Conductive hearing loss (Weber lateralises to affected ear, Rinne negative)
  • Sensorineural loss (e.g., presbycusis) has a different pattern

A diagnosis of cerumen impaction is confirmed, and other causes of hearing loss are ruled out.

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Q2: What are the management options for David’s impacted cerumen?

1. First-Line Treatment

• Cerumenolytics (ear drops such as sodium bicarbonate, olive oil, or docusate sodium)
• Softens wax over several days to facilitate natural expulsion or removal

2. Manual Removal

• Curettage or microsuction
• Preferred in patients with contraindications to irrigation

3. Ear Irrigation (Ear Syringing)

• Indicated if cerumenolytics fail and there are no contraindications
• Use body-temperature water to avoid vertigo
• Monitor for discomfort or signs of infection

4. Follow-Up

• Review in 1-2 weeks if symptoms persist
• Assess hearing once wax is cleared

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Q3: What are the contraindications for ear syringing, and when should an alternative approach be used?

1. Absolute Contraindications

• Perforated tympanic membrane (or history of perforation)
• Recurrent ear infections
• Grommets in situ
• Recent ear surgery

2. Relative Contraindications

• Severe otitis externa
• Diabetes (risk of infection)

3. Alternative Approaches

• Microsuction or manual removal
• Referral to ENT if complex or recurrent cases

Avoiding syringing in high-risk patients prevents complications like infection and perforation.

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Q4: What preventive measures would you recommend to David to reduce recurrent cerumen impaction?

1. Safe Ear Hygiene Practices

• Avoid cotton buds (pushes wax deeper)
• Limit use of hearing aids during active wax build-up
• Regular cerumenolytics if prone to impaction

2. Education on Natural Ear Cleaning

• Wax naturally migrates out of the ear canal
• Tilt head while showering to allow water drainage

3. Regular Monitoring

• Routine ear checks for hearing aid users
• Early intervention if symptoms recur

Preventive care reduces recurrence and maintains optimal hearing health.

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Q5: When would you refer David to an ENT specialist?

1. Red Flags Requiring Urgent Referral

• Unilateral hearing loss without clear cause
• Persistent tinnitus or vertigo
• Suspected tympanic membrane perforation or cholesteatoma

2. When Routine ENT Referral is Needed

• Recurrent or impacted wax despite treatment
• Patients with anatomical abnormalities (e.g., narrow ear canals)
• Persistent conductive hearing loss after wax removal

Timely referral ensures appropriate specialist management for complex cases.

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SUMMARY OF A COMPETENT ANSWER

• Accurately diagnoses cerumen impaction based on history and examination
• Considers alternative causes of hearing loss and performs appropriate assessments
• Provides safe and effective treatment options, including cerumenolytics and irrigation
• Recognises contraindications for ear syringing and recommends alternatives when needed
• Offers preventive strategies to minimise recurrence
• Identifies red flag symptoms that warrant ENT referral

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PITFALLS

• Failing to differentiate conductive from sensorineural hearing loss
• Performing ear syringing in a contraindicated patient (e.g., perforation, infection)
• Not educating on proper ear hygiene, leading to recurrent impaction
• Ignoring red flags such as unilateral hearing loss or persistent tinnitus
• Overlooking referral when specialist intervention is required

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REFERENCES

• RACGP – Ear Wax Management
• GP Exams – Ear Wax

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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

1. Communication and Consultation Skills

1.1 Communicates clearly about ear hygiene and wax removal methods.
1.3 Uses appropriate language to address patient concerns and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a focused otoscopic examination.
2.3 Identifies other possible causes of hearing loss (e.g., sensorineural vs conductive).

3. Diagnosis, Decision-Making and Reasoning

3.1 Accurately diagnoses cerumen impaction and differentiates from other conditions.
3.3 Recognises when further investigation or specialist referral is needed.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate management options, including cerumenolytics and irrigation.
4.4 Recognises contraindications for ear syringing.

5. Preventive and Population Health

5.1 Educates on safe ear hygiene practices to prevent recurrent impaction.

6. Professionalism

6.2 Provides patient-centred care, considering individual risk factors (e.g., hearing aids).

7. General Practice Systems and Regulatory Requirements

7.1 Documents appropriate assessment and management plan.

8. Procedural Skills

8.2 Performs safe and effective ear syringing when indicated.

9. Managing Uncertainty

9.1 Identifies red flags requiring referral to an ENT specialist.

10. Identifying and Managing the Patient with Significant Illness

10.2 Recognises complications such as external ear infection or tympanic membrane perforation.

Competency at Fellowship Level

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