EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Daniel’s ear pain?

• Prompt: How would you differentiate otitis externa from other ear conditions?
• Prompt: What red flags would prompt urgent referral?

Q2. What further history would you elicit to confirm the diagnosis?

• Prompt: What risk factors predispose to otitis externa?
• Prompt: How would you assess for complications?

Q3. What treatment options would you offer Daniel?

• Prompt: What is the first-line treatment?
• Prompt: When would oral antibiotics be required?

Q4. What preventive advice would you provide regarding otitis externa?

• Prompt: What hygiene measures should he follow?
• Prompt: What lifestyle modifications would reduce recurrence?

Q5. What are the follow-up and safety-netting considerations?

• Prompt: When should he return for review?
• Prompt: What complications should he be aware of?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are your differential diagnoses for Daniel’s ear pain?

A competent candidate should consider a structured differential diagnosis, including:

• Otitis externa (most likely): External ear canal erythema, swelling, tragal tenderness, and recent swimming history suggest bacterial otitis externa.
• Otitis media: Less likely as there are no systemic symptoms or middle ear effusion, but should be considered if the tympanic membrane can be visualised.
• Foreign body in ear canal: Common in children but can occur in adults using earphones frequently.
• Eczema or contact dermatitis: Chronic itching and scaling without discharge may indicate dermatological involvement.
• Mastoiditis (red flag): Severe pain, post-auricular swelling, fever, and systemic symptoms require urgent referral.
• Malignant otitis externa (red flag): Consider in immunocompromised patients or those with persistent pain not responding to treatment.

Red flags requiring urgent referral:

• Fever, severe pain, cranial nerve deficits, spreading infection, immunosuppression, or lack of response to treatment.

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Q2: What further history would you elicit to confirm the diagnosis?

• Onset and progression: Duration, severity, previous episodes, worsening symptoms.
• Symptoms: Itching, pain, discharge, hearing loss, tinnitus, vertigo.
• Precipitating factors: Recent swimming, earphone use, cotton bud use, trauma.
• Medical history: Diabetes, immunosuppression, atopic dermatitis (predisposing factors).
• Response to treatment: Any self-treatment, effectiveness of over-the-counter drops.

Complications to assess for:

• Malignant otitis externa: Persistent pain, granulation tissue in the canal, facial nerve involvement.
• Mastoiditis: Post-auricular pain and swelling, systemic illness.

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Q3: What treatment options would you offer Daniel?

First-line treatment:

• Topical antibiotic/steroid eardrops (e.g., ciprofloxacin with hydrocortisone): Reduces inflammation and eradicates infection.
• Ear wick placement: If the canal is significantly swollen, to facilitate drug delivery.

Oral antibiotics:

• Indicated only if: Extensive infection, cellulitis beyond the ear, or immunocompromised patient.
• Choice: Flucloxacillin or cephalexin for suspected Staphylococcus aureus involvement.

Pain relief:

• Paracetamol or NSAIDs as required.

Avoid:

• Cotton buds, water exposure, and self-cleaning.

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Q4: What preventive advice would you provide regarding otitis externa?

• Ear hygiene: Avoid inserting objects (cotton buds, earphones) into the canal.
• Water precautions: Use earplugs when swimming and dry ears thoroughly.
• Modify earphone use: Limit prolonged use, especially after swimming.
• Avoid irritants: Avoid frequent ear cleaning, which removes protective cerumen.

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Q5: What are the follow-up and safety-netting considerations?

• Review in 5-7 days: If symptoms persist, re-evaluate for complications.
• Monitor for worsening symptoms: Increased pain, systemic signs, persistent discharge.
• Referral indications:
  • No improvement with standard treatment.
  • Suspected malignant otitis externa or mastoiditis.
  • Recurrent infections requiring ENT assessment.

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SUMMARY OF A COMPETENT ANSWER

• Uses a structured approach to differential diagnoses, identifying common and serious causes of ear pain.
• Conducts a thorough history, including risk factors, symptom evolution, and red flags.
• Prescribes appropriate first-line treatments, including topical antibiotics and pain relief.
• Provides clear prevention strategies, including ear hygiene and water precautions.
• Implements a structured follow-up plan, ensuring early recognition of complications.

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PITFALLS

• Failing to consider serious differentials, such as malignant otitis externa in high-risk patients.
• Overprescribing oral antibiotics, which are unnecessary in most cases.
• Neglecting to educate on prevention, increasing recurrence risk.
• Not assessing for immunosuppression, a key risk factor for complications.
• Inadequate follow-up, potentially missing deterioration or treatment failure.

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REFERENCES

• RACGP – RACGP Clinical Guidelines – Ear Conditions
• GP Exams – Otitis externa

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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 Establishes rapport and gathers relevant history, including symptom onset and risk factors.
1.2 Provides patient-centred education on treatment and prevention.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a focused ENT history and physical examination.
2.2 Differentiates otitis externa from other causes of ear pain.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises otitis externa as the most likely diagnosis while considering differentials.
3.2 Identifies red flags requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an individualised management plan, including first-line and alternative treatments.
4.2 Discusses indications for oral antibiotics and escalation of care.

5. Preventive and Population Health

5.1 Provides education on ear hygiene, risk factors, and preventive measures.

6. Professionalism

6.1 Demonstrates empathy, addressing concerns about pain and recurrence.

7. General Practice Systems and Regulatory Requirements

7.1 Documents findings, treatment plan, and follow-up clearly.

8. Procedural Skills

8.1 Demonstrates safe and effective ear examination, including otoscopy.

9. Managing Uncertainty

9.1 Provides safety-netting and follow-up plans for non-resolving symptoms.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises complications such as malignant otitis externa requiring urgent referral.

Competency at Fellowship Level

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