CCE-CE-045

CASE INFORMATION

Case ID: CCE-EW01
Case Name: John Carmichael
Age: 48 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: H84 – Impacted cerumen (excessive ear wax)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages with the patient
1.2 Uses active listening and questioning techniques
1.5 Provides clear and patient-centred education on ear hygiene and management
2. Clinical Information Gathering and Interpretation2.1 Gathers relevant history, including symptoms and risk factors
2.2 Performs appropriate examination and interpretation of findings
3. Diagnosis, Decision-Making and Reasoning3.1 Forms a structured differential diagnosis
3.2 Recognises red flags for serious conditions such as cholesteatoma or otitis externa
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based management plan
4.2 Safely performs or refers for ear wax removal if indicated
5. Preventive and Population Health5.1 Provides education on safe ear hygiene practices and risk factors for excessive ear wax
6. Professionalism6.2 Ensures patient-centred care and shared decision-making
7. General Practice Systems and Regulatory Requirements7.2 Understands and follows procedural guidelines for ear irrigation and wax removal
8. Procedural Skills8.1 Demonstrates appropriate technique for ear wax removal, including irrigation and manual extraction
9. Managing Uncertainty9.1 Recognises when referral to an ENT specialist is required (e.g., recurrent impactions, suspected pathology)
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies and escalates care for complications such as otitis externa or tympanic membrane perforation

CASE FEATURES

Recognising red flags: Pain, otorrhoea, tinnitus, vertigo, or previous ear surgery requiring further assessment.

  • Common general practice presentation: Impacted ear wax causing discomfort, hearing loss, and irritation.
  • Opportunity for education: Correct ear hygiene practices, risks of overuse of cotton buds, and proper wax removal techniques.
  • Procedural skill component: Ear syringing, manual wax removal, or cerumenolytics.
  • Managing patient concerns: Fear of hearing loss, discomfort, and misconceptions about ear hygiene.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

John Carmichael, a 48-year-old man, presents to your clinic complaining of blocked ears and reduced hearing over the past two weeks. He states that it feels like “there’s something stuck inside,” and that his hearing is muffled in his right ear. He denies pain or dizziness but feels frustrated that it is interfering with his work as a sales consultant.

He has tried using cotton buds to clear his ears but feels that this has made things worse. He has also tried over-the-counter ear drops without significant improvement. He is concerned that he is losing his hearing permanently.

PATIENT RECORD SUMMARY

Patient Details

Name: John Carmichael
Age: 48 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Nil regular medications

Past History

  • Seasonal allergic rhinitis

Social History

  • Works as a sales consultant

Family History

  • No known hearing loss or ear disease in family

Smoking & Alcohol

  • Non-smoker
  • Drinks alcohol socially (1-2 standard drinks per week)

Vaccination and Preventative Activities

  • Routine immunisations up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

Opening Line

“Doctor, my ear feels completely blocked, and I think I’m losing my hearing.”

General Information

John Carmichael is a 48-year-old sales consultant who has been experiencing progressive hearing loss in his right ear over the last two weeks. He first noticed that sounds started to feel slightly muffled but assumed it would clear up on its own. Instead, it has worsened, and now he feels like he is hearing everything through a tunnel.

Specific Information

(Only reveal when asked)

Background Information

He describes the sensation as if there’s cotton stuffed in his ear or water trapped inside. There’s no pain, but it’s becoming very annoying. He has noticed that conversations feel harder to follow, especially at work, where he takes a lot of phone calls.

About a week ago, he tried using cotton buds to “fix the problem,” but this seemed to make things worse. Since then, he has tried over-the-counter ear drops from the pharmacy but hasn’t noticed much improvement.

He is worried that this could be permanent hearing loss and wants to know what’s wrong. He’s never had issues with his hearing before, so he is quite concerned.

Symptoms

  • The right ear has been blocked for two weeks, with worsening muffled hearing.
  • Feels pressure in the ear but no pain, fever, dizziness, or ringing (tinnitus).
  • No ear discharge.
  • No recent colds, sinus infections, or flu-like symptoms.

Prior Interventions

  • Uses cotton buds weekly to clean his ears.
  • A week ago, he tried ear drops (carbamide peroxide) from the pharmacy for five days but didn’t notice much change.
  • Has never had ear syringing or professional ear cleaning before.

Medical History

  • Generally healthy, with only seasonal allergies (allergic rhinitis).
  • No history of ear infections, eczema, or dermatitis affecting the ears.
  • No history of hearing loss in the family.

Social and Lifestyle Factors

  • Works in sales and is on the phone a lot.
  • Does not swim or dive.
  • No recent exposure to loud noise, concerts, or air travel.
  • Has never had ear problems before.

Patient Concerns and Expectations

  • He is worried about permanent hearing loss and wants to know if this will be a long-term problem.
  • He hopes for a quick fix so he can get back to work without struggling to hear.
  • He does not want a painful procedure and is hesitant about having water flushed into his ear (ear irrigation).
  • He is a bit defensive about his cotton bud use because he has been cleaning his ears this way for years and thinks it’s necessary.
  • He wants to know how to prevent this from happening again.

Questions for the Candidate

  • “Is this going to cause permanent hearing loss?”
  • “Is it safe to clean my ears with cotton buds? I’ve always done it this way.”
  • “What’s the quickest and safest way to fix this?”
  • “Will this keep happening to me?”
  • “Do I need to see a specialist?”

Emotional and Non-Verbal Cues

John presents as frustrated but not overly anxious. He is feeling annoyed that his ear is blocked, especially because it is interfering with his job.

  • He leans slightly to his left side when listening, showing difficulty hearing from his right ear.
  • When the candidate mentions that cotton buds can make things worse, he may defend the habit at first, saying, “But I’ve been doing this for years.” However, he will become more accepting if the candidate explains clearly why it’s harmful.
  • If the candidate is confident and reassuring, he will relax slightly and be more willing to proceed with treatment.
  • If the candidate seems uncertain or vague, John may become more anxious and repeatedly ask if he will lose his hearing permanently.

Possible Reactions Based on the Candidate’s Approach

If the Candidate Communicates Clearly and Reassures Well

  • John will become more cooperative and accept professional wax removal as the best option.
  • He will express relief when told that the problem is temporary and fixable.
  • He will listen carefully when given advice on ear hygiene and prevention.

If the Candidate Fails to Address Concerns

  • John will become more anxious, asking repeatedly if his hearing will come back.
  • He may express doubt about the treatment, especially if the candidate does not explain it well.
  • He may say, “So what if this happens again? Am I just going to keep losing my hearing?”

If the Candidate Dismisses His Concerns

  • John may get irritated, saying: “So you’re telling me I just have to wait it out?”
  • He may question whether he should see an ENT specialist instead.

Patient’s Final Decision Based on Consultation

John is open to having his ear professionally cleaned but wants to be reassured that it’s safe and effective. If the candidate explains the procedure well and addresses his concerns about pain, he will agree to ear irrigation or manual removal.

If the candidate fails to explain treatment clearly or doesn’t reassure him properly, John may refuse treatment and insist on seeing a specialist instead.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering symptoms, risk factors, and any prior interventions.

The competent candidate should:

  • Elicit a thorough history of the patient’s symptoms, including onset, duration, progression, and associated symptoms such as pain, tinnitus, dizziness, or discharge.
  • Assess functional impact, including difficulties at work or in daily life.
  • Explore previous interventions, including the use of cotton buds, over-the-counter ear drops, and any prior ear syringing.
  • Identify risk factors such as a history of allergies, eczema, recurrent ear infections, hearing loss, or recent colds/sinus infections.
  • Address the patient’s concerns, including fears about hearing loss, misconceptions about ear hygiene, and expectations regarding treatment.
  • Screen for red flags, such as sudden sensorineural hearing loss, persistent pain, recurrent infections, or previous ear surgery.

Task 2: Explain your differential diagnosis and outline key features of examination and investigations.

The competent candidate should:

  • Discuss the most likely diagnosis, which is impacted ear wax (cerumen impaction).
  • Consider other differential diagnoses, including:
    • Otitis externa (if pain or discharge were present).
    • Eustachian tube dysfunction (if associated with recent upper respiratory infection).
    • Sudden sensorineural hearing loss (SSNHL) (if hearing loss was sudden and unexplained).
    • Cholesteatoma (if recurrent ear infections and foul-smelling discharge were present).
  • Describe key examination findings, including otoscopy findings (e.g., impacted wax, intact tympanic membrane).
  • Explain indications for further investigations, including:
    • Formal audiometry if hearing loss persists after wax removal.
    • ENT referral if red flags are present (e.g., unilateral persistent hearing loss, perforation, recurrent infections).

Task 3: Provide appropriate management advice, including options for ear wax removal and prevention strategies.

The competent candidate should:

  • Discuss treatment options, including:
    • Cerumenolytic drops (e.g., sodium bicarbonate, olive oil, or carbamide peroxide).
    • Ear syringing/irrigation, provided there are no contraindications (e.g., tympanic membrane perforation).
    • Manual removal with curette or microsuction, especially in resistant cases.
  • Explain proper ear hygiene, including:
    • Avoidance of cotton buds to prevent further impaction.
    • Regular use of ear drops if prone to excessive wax build-up.
  • Outline follow-up care, including when to return for review if symptoms persist.

Task 4: Address any patient concerns, including safety and risks of various management approaches.

The competent candidate should:

  • Reassure the patient that hearing loss due to impacted wax is reversible once the blockage is cleared.
  • Explain the risks and benefits of treatment options, including the potential for discomfort, mild dizziness, or rare complications like infection or perforation with ear syringing.
  • Correct misconceptions about cotton bud use, explaining that they often push wax further into the canal.
  • Offer strategies to prevent recurrence, such as using cerumenolytic drops periodically.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured history, identifying symptom onset, progression, and prior interventions.
  • Forms a clear differential diagnosis, considering other potential causes of hearing loss.
  • Explains examination findings and rationale for investigations in an understandable manner.
  • Provides evidence-based management, including safe and appropriate wax removal methods.
  • Addresses patient concerns, offering reassurance and practical advice on ear hygiene and prevention.

PITFALLS

  • Failing to rule out red flags, such as sudden sensorineural hearing loss or chronic ear disease.
  • Overlooking patient concerns, particularly fears about hearing loss or discomfort during treatment.
  • Not explaining proper ear hygiene, including avoiding cotton bud use.
  • Recommending ear syringing without checking for contraindications, such as a history of ear surgery or perforation.
  • Neglecting follow-up or safety netting, particularly if symptoms persist or worsen.

REFERENCES

MARKING

Each competency area is assessed on the following scale:

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

Competency Areas Assessed in This Case:

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about symptoms, concerns, and expectations.
1.5 Provides clear and patient-centred education on ear hygiene and management.

2. Clinical Information Gathering and Interpretation

2.1 Gathers a thorough history, considering symptoms, risk factors, and lifestyle.
2.2 Performs appropriate examination and interpretation of findings.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a structured differential diagnosis.
3.2 Recognises red flags for serious conditions such as cholesteatoma or otitis externa.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.2 Safely performs or refers for ear wax removal if indicated.

5. Preventive and Population Health

5.1 Provides education on safe ear hygiene practices and risk factors for excessive ear wax.

6. Professionalism

6.2 Ensures patient-centred care and shared decision-making.

7. General Practice Systems and Regulatory Requirements

7.2 Understands and follows procedural guidelines for ear irrigation and wax removal.

8. Procedural Skills

8.1 Demonstrates appropriate technique for ear wax removal, including irrigation and manual extraction.

9. Managing Uncertainty

9.1 Recognises when referral to an ENT specialist is required (e.g., recurrent impactions, suspected pathology).

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and escalates care for complications such as otitis externa or tympanic membrane perforation.

Competency at Fellowship Level

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