A 10 year old boy presents to clinic with poor grades in school and difficulty in hearing. There has been recurrent ear infections in the past which was resolved by medication. On examination: bone conduction is normal, air conduction is reduced bilaterally, and there is no lateralization in the Weber’s test. There is no pain. What is the SINGLE most likely diagnosis?
A. Acute otitis media
B. Perforation of tympanic membrane
C. Otitis media with effusion
D. Congenital sensorineural deficit
E. Otosclerosis
In PLAB 1, paediatrics ENT questions would come up occasionally. The ones to focus on would be acute otitis media, otitis media with effusion and cholesteatoma. When PLAB 1 has case scenarios where mothers notice their children “turning up the TV volume” or “doing badly in school”, before thinking of behavioral / developmental problems, go with physical problems (i.e. hearing).
Otitis media with effusion
Also known as glue ear is common with the majority of children having at least one episode during childhood
An important risk factor for otitis media with effusion is parental smoking. This is extremely important to note as PLAB questions sometimes ask which would be the SINGLE best management and then provide an option of “tell parents to stop smoking”. One might not think this is the answer as it sounds silly, but in actual fact this is the correct answer.
Presentation:
• Hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss in childhood). May present as o Listening to the TV at excessively high volumes or needing things to be repeated. o Lack of concentration, withdrawal especially in school • Secondary problems such as speech and language delay, behavioural or balance problems may also be seen • Rarely complains of ear pain • May have prior history of infections (especially upper respiratory tract) or oversized adenoids
Signs:
• Variable, eg retracted or bulging drum. It can look dull, grey, or yellow. There may be bubbles or a fluid level
Diagnosis:
• Audiograms: conductive defects. • Impedance audiometry: flat tympanogram
Treatment:
• Observation first because may resolve, monitor every 3 months. • (thus if a scenario is given with a recent diagnosis of otitis media with effusion, and the question is asking for the SINGLE best management → “Reassure and review in 3 months” would be the best choice. • Surgery: If persistent bilateral OME over 3 months → insert grommets • Hearing aids: Reserve for persistent bilateral OME and hearing loss if surgery is not accepted.