Exostoses: overgrowths of bone in the external ear canal; they present as whitish lumps narrowing the canal. They are particularly common in people who spend a lot of time swimming in cold water. They can obstruct wax or cause hearing loss, and can be surgically removed if they become a problem, which is the exception rather than the rule. They can be distinguished from aural polyps (red and fleshy) and osteomata (benign bone tumours of skull sutures within inner ear – usually pedunculated and single).
Foreign bodies in ear: Referral for removal at some point in next seven days is fine, unless it’s a button battery, in which case the FB needs removing urgently.
Cholesteatoma: Presents with scanty recurrent or persistent offensive cream-coloured discharge and progressive hearing loss. Examination typically shows pearly-white mass (usually in pars tensa) and/or crust. May look similar to OM. Note that a crust adherent to the tympanic membrane is cholesteatoma till proved otherwise (though it may be possible to try a short course of steroid drops or drops for wax first, then review).
While waiting for ENT appointment for cholesteatoma, keep the ear dry and, if signs of infection, try 2/52 antibiotic drops, with or without steroids.
Cholesteatoma surgery leaves a mastoid cavity. This can be prone to discharge/wax buildup; if it becomes problematic, further surgery can be done to obliterate it.
Retraction pockets vs. perforations: They look similar, but the edge of a perforation will be more clearly delineated and the membrane will be visible over the structures behind (‘shrink-wrapped’ look).
Neither needs referral unless causing problems. With perforations, the ear must be kept dry. Note that clean traumatic perforations will mostly heal within 6 – 8 weeks.
Otitis media with effusion: In >90% of cases will resolve spontaneously within three months, so hold off on ENT referral until then if symptoms not a big problem. However, in the case of children, do refer to paediatric audiology in meantime to assess hearing, and do advise parents about possibility of hearing loss and about managing this by speaking clearly, having time to talk to child with no competing sounds, letting child sit at front of groups to see the speaker, etc.
Blocked grommet: Prescribe sodium bicarbonate ear drops, review, normally arrange hearing test to see how much of a problem there is.
Fungal otitis externa: Causes itching, otorrhoea, greyish-white creamy mucopurulent exudate, disproportionate pain. On examination, the exudate is visible plus a localised white fluffy patch of fungal mycelia. Can often be triggered by moisture or by topical antibiotic drops (especially neomycin).
Bullous myringitis: Blisters on the inside of the tympanic membrane, caused by viral or bacterial infections. Can cause serosanguinous discharge. Easily confused with Ramsay-Hunt syndrome, but in the latter the blisters are multiple and smaller.
Treat with antibiotics (ideally Amoxicillin) and review in a week – refer to ENT if not resolving.
(BMJ Learning: Tympanic membrane diagnostic picture tests and more tympanic membrane diagnostic picture tests.)