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Otalgia, or ear pain, is a very common presentation in general practice. Test yourself on a range of causes with this quiz!

 

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Approach to the Patient with Otalgia

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Question 1

Stem 1, question 1 of 4

Ophelia, a 13 month old female, is brought to GP by her Father with ear pain, fever, decreased appetite and a cough. She attends nursery 3 days a week and is meeting all developmental milestones.
What is the most likely diagnosis?
A
Otitis externa
B
Otitis media
C
Mastoiditis
D
Tonsilitis
E
Simple cold
Question 1 Explanation: 
This case is illustrating a classical presentation of otitis media. Otitis media (OM) is an infection involving the middle ear space with over 80% of children having at least one episode before age of 2. OM presents with ear pain, often preceded by upper respiratory symptoms, fever, decreased appetite and sleep disturbance. Otitis externa is a form of cellulitis that develops rapidly. Mastoiditis is a rare but serious complication of of otitis media with infection spreading to the mastoid air cells. Tonsillitis does not present with a cough. A simple cold is reasonable but given her age and attendance at nursery, otitis media is more likely.
Question 2

Stem 1, question 2 of 4

Which of the following are common bacterial cause of otitis media? Select all that apply
A
Streptococcus pneumoniae
B
Pseudomonas aeruginosa
C
Moraxella catarrhalis
D
Haemophilus influenzae
E
Staphylococcus aureus
Question 2 Explanation: 
The majority of cases of otitis media are caused by respiratory viruses but it is important to have an awareness of bacterial causes too. Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are three common causes of bacterial otitis media. Pseudomonas aeruginosa and Staphylococcus aureus are common causes of Otitis Externa. (BMJ Best Practice 2020)
Question 3

Stem 1, question 3 of 4

The GP takes Ophelia's observations with the following results: No cyanosis or pallor, respiratory rate of 35, heart rate of 128 bpm, CRT of 2 seconds. Ophelia is slightly grumpy but still smiles at her Father and is drinking well
How should the GP manage Ophelia?
A
Immediate attendance at Paediatric Emergency Department
B
Same day attendance at paediatric ward
C
Repeat GP appointment tomorrow
D
Appointment with practice nurse in 2 days
E
Worsening advice and reassurance to Father
Question 3 Explanation: 
NICE (2019) published a traffic light system for assessing fever in under 5s and the associated management. Using this table, Ophelia does not show any amber or red features and so can be safely managed at home. It is very important to give specific worsening advice to carers of children. This should include what the carer is to look out for and what they should do e.g phone 111, phone GP surgery, attend A&E, call 999 immediately".
Question 4

Stem 1, question 4 of 4

3 weeks later, Ophelia presents to A&E with her worried parents. She has a fever, swelling, pain and tenderness to the posterior of the ear with otorrhoea.
What is the likely diagnosis?
A
Chronic otitis media
B
Ramsay Hunt Syndrome
C
Dental abscess
D
Mastoiditis
E
Tonsilitis
Question 4 Explanation: 
Mastoiditis is a rare but serious infection fo the mastoid air cells posterior to the ear which can occur following persistent otitis media. Mastoiditis presents with erythema, tenderness and pain posterior to the ear with fever, discharge from the ear, irritability, tiredness and hearing loss in affected ear. This requires intravenous antibiotics and may require surgery.
Question 5

Stem 2, question 1 of 3

Leon, a 27 year old male, presents with 1 day history of ear pain, itching, hearing loss and otorrhoea. His right ear appears swollen, red and inflamed. Leon has type 1 diabetes and eczema but is normally fit and healthy, swimming 5 times a week.
What is the most likely diagnosis?  
A
Otitis media
B
Erysipelas
C
Otitis externa
D
Cholesteatoma
E
Dental abscess
Question 5 Explanation: 
Otitis externa is a form of cellulitis that involves the skin and sub dermis of the external auditory canal and is most commonly bacterial in nature. Risk factors include high environmental humidity, swimming, allergy, skin disease and diabetes. Otitis media is often preceded by upper respiratory tract infections. Erysipelas is a type of cellulitis with notable lymphatic involvement. Cholesteatoma is a destructive growth of skin cells within the external auditory meatus. Dental abscesses can cause referred pain to the ear.
Question 6

Stem 2, question 2 of 3

The GP examines Leon's ear.
What is the likely examination finding?
A
Inflamed tympanic membrane
B
Normal tympanic membrane
C
Abnormal pneumatic otoscopy
D
Extra oral oedema
E
Mastication muscle tenderness
Question 6 Explanation: 
Tympanometry should be normal in acute otitis externa as the underlying pathology affects the external ear canal including the pinna. An inflamed tympanic membrane is likely in otitis media, pneumatic otoscopy is usually normal in acute otitis externa. Extra oral oedema occurs in dental abscesses. Mastication muscle tenderness occurs temporo-mandibular arthritis.
Question 7

Stem 2, question 3 of 3

What is the treatment of otitis externa? Select all that apply
A
Ciprofloxacin
B
Acyclovir
C
Dexamethasone
D
Analgesia
E
Clindamycin
Question 7 Explanation: 
Otitis externa is treated with ciprofloxacin and dexamethasone with pain management and debridement. Acyclovir is an antiviral used for Ramsay Hunt syndrome which can refer pain to the ear. Clindamycin is used in dental abscesses . (BMJ best practice 2020)
Question 8
Jacob is found to have a dental abscess and is experiencing ear pain
How is pain from a dental abscess referred to the ear?
A
Via the tympanic branch of the glossopharyngeal nerve
B
Via the auriculo-temporal branch of the trigeminal nerve
C
Via the facial nerve
D
Via the vagus nerve
E
Via C2 nerve
Question 8 Explanation: 
The ear can be a large site of referred pain with Cranial nerves V, VII, X and C2 and 3 all referring pain to the ear. Dental abscesses can be a cause of referred pain to the ear via the auriculo-temporal branch fo the trigeminal nerve. Tonsillitis refers via the glossopharyngeal nerve to the ear. Ramsay Hunt syndrome refers to the ear via the facial nerve.
Question 9
Cancer of the base of the tongue can refer pain to the ear
What is the the predominant type of base of tongue cancers?
A
Squamous cell carcinoma
B
Adenoma
C
Sarcoma
D
Lymphoma
E
Basal cell carcinoma
Question 9 Explanation: 
Carcinoma of the base of the tongue can refer pain to the ear via the glossopharyngeal nerve. Squamous cell carcinoma is the predominant type of base of tongue cancers. Risk factors include tobacco use, alcohol abuse and HPV exposure.
Question 10
What causes Ramsay Hunt Syndrome?
A
Herpes simplex virus
B
Cytomegalovirus
C
Respiratory Synticial virus
D
Zaricella zoster virus
E
Human papilloma virus
Question 10 Explanation: 
Ramsay Hunt syndrome is a peripheral facial nerve palsy accompanied by an erythematous vesicular rash on the ear or mouth with ear pain occurring via the facial nerve. It is caused by previously inactive varicella zoster virus becoming reactivated and spreading to the facial nerve.
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