Otitis externa — formative SAQs

SAQ 1 — The swimmer with a painful discharging ear (10 marks, 15 minutes)

An eight-year-old girl who has been at swimming lessons all week presents with two days of worsening right ear pain, a mucky discharge, and itching. She cries when the ear is touched. On examination, pressing the tragus and gently pulling the pinna backwards reproduces her pain, the canal is swollen and red with yellowish debris, and once a small amount is cleared the eardrum looks normal. She is afebrile and well. [1]

a) What is the diagnosis, and which two bedside signs localise it to the external canal rather than the middle ear? (2 marks) [1]

b) Outline your stepwise management, including analgesia, the topical agent and duration, and the ear-care advice. (3 marks) [5]

c) The canal is now so swollen that drops will not pass into the canal. What device do you place, for how long, and why? (2 marks) [1]

d) Give two circumstances in which you would add an oral antibiotic, and name an appropriate first-line oral agent with its paediatric dose. (3 marks) [3]

SAQ 2 — The immunocompromised child with severe ear pain and a facial palsy (10 marks, 15 minutes)

A six-year-old boy on chemotherapy for leukaemia, now neutropenic, presents with five days of severe, unremitting right ear pain that keeps him awake at night, a purulent discharge, and on the morning of presentation a right-sided facial droop. Otoscopy shows granulation tissue at the deep bony-cartilaginous junction of the canal. He is febrile and unwell. [7]

a) What is the diagnosis, and which three clinical features make it a skull-base emergency? (2 marks) [7]

b) List the laboratory investigations you would send, identifying the two inflammatory markers that are both diagnostic and used to monitor treatment response. (3 marks) [11]

c) Outline your imaging strategy, naming the first-line modality for bony erosion and the nuclear-medicine scans used to diagnose osteomyelitis and to monitor treatment response. (3 marks) [10]

d) Give the definitive systemic antimicrobial, including drug, dose, route and intended duration, and state how the decision to stop therapy is guided. (2 marks) [9]