Explaining glue ear and the watchful-waiting plan — OSCE

Candidate instructions (8-minute station)

You are the paediatric registrar in the general practice clinic. A 2-year-old boy is brought in two weeks after a cold because he has been turning the television up loud. He is well and afebrile. Otoscopy shows a dull, retracted right tympanic membrane with a faint fluid level; the left ear is normal. The parent is anxious and wants to know whether the ear is infected, whether he needs antibiotics, and whether he will need an operation. [2]

Your tasks are: [3]

1. Explain the diagnosis of glue ear (otitis media with effusion) in plain language and reassure the parent that this is not an acute ear infection. [2]
2. Explain why no antibiotics or surgery are needed right now, and outline the watchful-waiting plan with the three-month reassessment. [7]
3. Give clear, specific advice on supporting his hearing and speech at home during the waiting period. [3]
4. Give a clear safety-net for the features that would mean an earlier return, including the signs of an acute ear infection. [3]

You are not expected to arrange grommets or imaging for this child today, because the effusion has been present for only two weeks and does not meet the three-month threshold. [3]

Examiner prompt to the actor (parent)

"He keeps turning the telly right up and half the time he ignores me when I call him. After that cold last week I thought it was just blocked ears, but is the ear actually infected? My nephew had grommets — will he need an operation? I do not want his hearing to be damaged." [2]

Marking domains

• Frame and reassurance (3): explains glue ear as fluid behind the eardrum after a cold, not an acute infection — no pain, no fever, no infected bulging drum — and reassures that the child is well, his hearing is muffled by the fluid rather than permanently damaged, and most cases clear on their own within three months. [2]
• Why no antibiotics or surgery, and the watchful-waiting plan (3): explains that antibiotics do not clear glue ear and can cause side effects and resistance, so they are not needed; that an operation is only considered if the fluid persists for three months or longer with a confirmed hearing problem; and that the plan is to wait and reassess at three months with a hearing test, so no grommets are needed today. [7] [3]
• Supporting hearing and speech at home (2): advises getting the child's attention before speaking, facing him, speaking clearly without shouting, reducing background noise such as the television, and reading together — measures that help him hear and develop speech while the fluid settles. [3]
• Safety-net for an earlier return (2): tells the parent to return sooner if the child develops acute ear pain, fever or becomes unwell with a bulging red ear (a superimposed acute ear infection), or if the hearing does not improve or he falls behind with speech over the coming weeks. [3]

Model answer — the explanatory script

"Thank you for bringing him in. You have noticed exactly the right thing — he is turning the television up and not always responding, and that is because he has a little fluid sitting behind his eardrum after that cold he had. I have had a good look, and I can reassure you: his ear is not infected. He has no pain, no fever, and the eardrum itself is healthy — it is just a bit dull and pulled in because of the fluid behind it. We call this glue ear, and it is very common in little children after a cold." [2]

"The reason his hearing is a bit muffled is that the fluid stops the eardrum moving freely, a bit like listening with water in your ears. The good news is that in most children this fluid clears on its own within about three months as he gets over the cold and the little tube that drains the ear starts working properly again. His hearing will come back to normal as the fluid goes." [2]

"So he does not need antibiotics — they do not clear this kind of fluid, and they can cause side effects and resistance, so we do not use them for glue ear. And he does not need an operation today. An operation to put a tiny ventilation tube, a grommet, into the eardrum is something we only think about if the fluid is still there after three months and a hearing test shows it is causing a real problem. He has only had this for two weeks, so the right thing to do now is to wait and let nature take its course." [7]

"While we are waiting, there are some simple things that really help. Get his attention and make sure he can see your face before you speak to him, because he lip-reads more than we realise. Speak clearly and normally — please do not shout, as that distorts the sound. Turn the television down or off when you are talking to him, so there is less background noise. And read with him and talk with him as much as you can, because that helps his speech develop even while his hearing is a little down." [3]

"I would like to see him again in about three months to check the fluid has gone and to do a proper hearing test if it has not. In the meantime, please bring him back sooner if he gets a high fever, or ear pain, or becomes unwell with a red, bulging ear — that would be a separate acute ear infection on top of the fluid, and we would treat that differently. And if his hearing does not improve over the next few weeks, or you feel he is falling behind with his speech, please come back so we can check him sooner. His hearing is not permanently damaged, and the vast majority of children his age get completely back to normal." [3]