EXAMINER ONLY INFORMATION

QUESTIONS

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

• Prompt: What is the most likely diagnosis and why?
• Prompt: What other conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What features suggest serious pathology or complications?
• Prompt: What initial investigations would you consider if symptoms persist?

Q3. How would you manage Daniel’s Eustachian salpingitis?

• Prompt: What pharmacological and non-pharmacological treatments would you recommend?
• Prompt: When would you consider ENT referral?

Q4. Daniel is concerned about permanent hearing loss. How would you counsel him?

• Prompt: How do you explain his symptoms and likely prognosis?
• Prompt: What advice would you provide about when to seek further medical review?

Q5. What preventive strategies can Daniel implement to reduce recurrence?

• Prompt: How can he modify his environment and habits to prevent future episodes?
• Prompt: What role do allergy management and nasal care play?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

Daniel’s most likely diagnosis is Eustachian tube dysfunction (ETD) due to Eustachian salpingitis, given the ear fullness, recent URTI, mild hearing reduction, and retracted tympanic membrane on otoscopy.

Key Differential Diagnoses:

1. Eustachian Tube Dysfunction (ETD) due to Eustachian Salpingitis (Most Likely) – Ear fullness, mild hearing loss, nasal congestion, history of allergic rhinitis, and recent URTI.
2. Acute Otitis Media (AOM) – Consider if fever, otalgia, bulging TM, or purulent discharge.
3. Otitis Media with Effusion (OME) – If chronic ear fullness, no infection signs, fluid behind TM.
4. Barotrauma – If symptoms started after flying, diving, or altitude change.
5. Sensorineural Hearing Loss (e.g., Sudden Sensorineural Hearing Loss, Ménière’s Disease) – If unilateral sensorineural loss, tinnitus, vertigo.

Further history, including onset, severity, and associated symptoms, will help refine the diagnosis.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent referral:

• Persistent unilateral symptoms (>3 months) – Rule out nasopharyngeal carcinoma.
• Severe ear pain, fever, or purulent discharge – Suggests AOM or mastoiditis.
• Sudden sensorineural hearing loss – Requires urgent audiology and ENT referral.
• Vertigo or neurological symptoms – Consider vestibular pathology, stroke, or brainstem lesion.
• Visible middle ear mass or effusion in an adult without recent infection – Rule out middle ear tumour or chronic effusion.

Recommended Investigations (if red flags present):

• Tympanometry – To assess middle ear pressure and TM mobility.
• Audiometry – If symptoms persist or hearing loss is suspected.
• Nasopharyngeal Examination (ENT referral) – If concern for tumour or persistent effusion.

Daniel has no immediate red flags, so symptomatic management and follow-up are appropriate.

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Q3: How would you manage Daniel’s Eustachian salpingitis?

1. Pharmacological Management:

• Intranasal corticosteroids (e.g., mometasone 50 mcg BD) – If allergic rhinitis contributes.
• Oral decongestants (e.g., pseudoephedrine 60mg PRN) – Short-term for symptom relief.
• Analgesia (paracetamol or ibuprofen PRN) – For mild ear discomfort.

2. Non-Pharmacological Management:

• Nasal saline irrigation – Helps clear congestion.
• Autoinflation techniques (Valsalva, Toynbee manoeuvre) – To improve middle ear ventilation.
• Steam inhalation or humidifier – To ease nasal congestion.

3. When to Refer to ENT:

• Persistent symptoms >3 months.
• Unilateral effusion without infection history (concern for malignancy).
• Hearing loss not improving after resolution of infection.

4. Follow-Up:

• Review in 4–6 weeks – Ensure resolution of symptoms.
• Refer for audiometry if hearing concerns persist.

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Q4: Daniel is concerned about permanent hearing loss. How would you counsel him?

1. Acknowledge Concerns & Provide Reassurance
   • “It’s understandable to be worried, but Eustachian tube dysfunction is common and usually temporary.”
   • “Your hearing should return to normal once the inflammation resolves.”
2. Explain the Condition Clearly
   • “The Eustachian tubes help equalise pressure in the middle ear, but they can become blocked after infections or allergies.”
   • “This causes fullness and mild hearing reduction, but it’s not permanent.”
3. Discuss Expected Recovery Timeline
   • “Most cases resolve within a few weeks as inflammation subsides.”
   • “Using nasal sprays, decongestants, and autoinflation can speed up recovery.”
4. When to Seek Further Review
   • “If your symptoms persist beyond 3 months or worsen, let’s re-evaluate for further testing.”

Providing clear, structured reassurance helps reduce anxiety about hearing loss.

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Q5: What preventive strategies can Daniel implement to reduce recurrence?

1. Allergy Management:
   • Intranasal steroids (mometasone, fluticasone) during allergy season.
   • Antihistamines (loratadine, fexofenadine) if allergic rhinitis is a trigger.
2. Nasal and Sinus Care:
   • Saline nasal irrigation – Clears mucus and prevents blockage.
   • Avoid nasal irritants (dust, smoke, pollution).
3. Preventing URTI-Related Eustachian Tube Dysfunction:
   • Practice good hand hygiene to reduce viral infections.
   • Stay hydrated to maintain mucosal health.
4. Barotrauma Prevention:
   • Use autoinflation techniques before flying or diving.
   • Chew gum or sip water during altitude changes.
5. Regular GP Reviews:
   • Monitor for persistent symptoms needing specialist referral.

Preventing recurrence focuses on allergy control, nasal care, and avoiding pressure-related ear dysfunction.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing ETD from AOM, OME, and other causes of ear fullness.
• Identification of red flags, ensuring urgent ENT referral if needed.
• Structured, evidence-based management plan, including intranasal corticosteroids, autoinflation, and symptomatic relief.
• Clear patient-centred counselling, addressing concerns about hearing loss and expected recovery timeline.
• Preventive strategies, including allergy management, nasal hygiene, and barotrauma prevention.

PITFALLS

• Failing to assess for red flags, missing serious conditions like nasopharyngeal carcinoma.
• Overprescribing antibiotics unnecessarily, when most cases are viral or inflammatory.
• Not addressing lifestyle factors, such as allergic rhinitis and nasal hygiene.
• Dismissing patient concerns about hearing loss, rather than providing structured reassurance.
• Lack of follow-up planning, missing progression to chronic ETD or hearing impairment.

REFERENCES

• 
  RACGP Guidelines for Acute Otitis Media and Ear Disorders
• National Institutes of Health on Otolaryngology
• Australian Prescriber on Eustachian Tube Dysfunction Management
• GP Exams – Eustachian salpingitis

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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 Takes a structured otological history, including symptom onset, duration, and triggers.
1.2 Provides clear explanations about the diagnosis, management, and when to seek further care.

2. Clinical Information Gathering and Interpretation

2.1 Conducts an ear, nose, and throat (ENT) examination, including otoscopy and nasal assessment.
2.2 Differentiates between ETD and other causes of ear pain and fullness.

3. Diagnosis, Decision-Making and Reasoning

3.1 Diagnoses Eustachian salpingitis based on clinical features.
3.2 Determines when further investigations or specialist ENT referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate treatment plan, including symptomatic relief and infection management.
4.2 Provides education on self-care techniques to reduce symptoms and prevent recurrence.

Competency at Fellowship Level

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