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Probability diagnosis

Impacted cerumen

Serous otitis media (glue ear)

Otitis externa

Otitis media

Congenital (children)


Serious disorders not to be missed


  • acoustic neuroma

  • temporal lobe tumours (bilateral)

  • otic tumours


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

  • meningitis

  • syphilis


  • perforated tympanic membrane

  • cholesteatoma

  • perilymphatic fistula (post-stapedectomy)

  • Meniere syndrome

Pitfalls (often missed)

Foreign body

Temporal bone fracture


Head injury


Noise-induced deafness


  • Paget disease of bone

  • multiple sclerosis

  • osteogenesis imperfecta

Masquerades checklist


Drugs (see list)

Thyroid disorder (hypothyroidism)

Is the patient trying to tell me something?


Key history

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.

Key examination

  • 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

Key investigations

  • Audiometry and tympanometry

  • Swab of any ear discharge for M&C

Diagnostic tips

  • 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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