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Probability diagnosis

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Impacted cerumen

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Serous otitis media (glue ear)

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Otitis externa

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Otitis media

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Congenital (children)

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Presbyacusis

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Serious disorders not to be missed

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Neoplasia:

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  • acoustic neuroma

  • temporal lobe tumours (bilateral)

  • otic tumours

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Infection:

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  • generalised infections (e.g. mumps, measles)

  • meningitis

  • syphilis

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Other:

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  • perforated tympanic membrane

  • cholesteatoma

  • perilymphatic fistula (post-stapedectomy)

  • Meniere syndrome

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Pitfalls (often missed)

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Foreign body

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Temporal bone fracture

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Otosclerosis

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Head injury

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Barotrauma

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Noise-induced deafness

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Rarities:

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  • Paget disease of bone

  • multiple sclerosis

  • osteogenesis imperfecta

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Masquerades checklist

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Diabetes

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Drugs (see list)

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Thyroid disorder (hypothyroidism)

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Is the patient trying to tell me something?

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Unlikely.

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Key history

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Onset and progression of any deafness, noise exposure, drug history, swimming or diving, air travel, head injury and family history. A recent or past episode of a generalised infection would be relevant and the presence of associated aural symptoms such as ear pain, discharge, tinnitus and vertigo. Enquire about the effect of noise.

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Key examination

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  • Inspect the facial structures, skull and ears and the ear with an otoscope. Ensure that the external auditory canal is clean

  • Perform simple office hearing tests including tuning fork tests

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Key investigations

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  • Audiometry and tympanometry

  • Swab of any ear discharge for M&C

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Diagnostic tips

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  • People with conductive deafness tend to speak softly, hear better in a noisy environment and hear well on the telephone. The opposite applies for sensorineural deafness.

  • Ototoxic drugs: alcohol, aminoglycosides e.g. streptomycin, neomycin, gentamicin, tobramycin, chemotherapeutic agents, quinine, salicylates/aspirin excess, diuretics e.g. ethacrynic acid, frusemide.

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