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A long-lasting earache

01 September 2009

Mr Y was a 25-year-old engineer with Type 1 diabetes. He attended his GP, Dr T, regularly for check-ups and on one occasion complained of pain in his left ear. He could not be sure how long it had been there, but thought the pain had come on about three months earlier, following a visit to the swimming pool with his children.

He had attributed it to water getting trapped inside his ear. Dr T examined him and found the external auditory meatus to be extremely tender, but did not record any exudate or erythema. He noted that Mr Y’s pharynx was normal, but there was mild cervical lymphadenopathy and accepted Mr Y’s assertion that the swimming may have been responsible. Dr T diagnosed otitis externa and prescribed topical antibiotic ear drops.

Over the next six weeks, Mr Y visited the surgery and was seen by both Dr T and his partner, Dr L. Mr Y’s complaints ranged from vague flu-like symptoms and tiredness to neck pain, continuing discomfort in his left ear and a sore throat. Mr Y told the doctors that his wife thought he had lost weight. The doctors noted the continuing tenderness in the EAM, but little sign of infection and checked his weight, which appeared stable. They did not arrange any further investigations.

The diagnosis remained that of otitis externa, and Dr T made a note that Mr Y’s diabetes may have been responsible for the poor clinical improvement. Swabs were taken, which did not show any bacterial growth, and he was prescribed a combination of different topical and oral antibiotics.

A month later Mr Y lost his sense of smell and became aware of hearing loss on the left side. He presented at his local A&E department and an urgent ENT opinion was arranged. After ENT assessment and investigations, the final diagnosis was that of a low-grade sinonasal adenocarcinoma in the left nasopharynx and skull base. The tumour was inoperable and the patient received palliative radiotherapy, which gave substantial symptomatic relief, but he died.

Expert opinion

Expert opinion agreed that although the final prognosis may have been the same, the patient could have had a superior quality of life in the period before palliative treatment commenced. They found that an early referral for investigation of recurrent otitis externa would have been standard practice. A claim was settled for a moderate sum.

Learning points

  • Once a diagnosis is made, either by you or your colleagues, it is not set in stone. It can always be challenged and alternatives should be considered.
  • Keep clear, accurate and legible records. This is particularly important where, over a period of time, several different doctors may be involved in a patient’s treatment. 
  • It is important to listen to patients actively, but be wary of false clues the patient can give you. What a patient thinks might be responsible for their problem can be helpful, but can also be misleading and lead to blinkered clinical judgment. In the example above, the patient believed the visit to the swimming pool was responsible for his symptoms, and to most of us this would have made sense. In this case, however, although the symptoms began afterwards, they were unfortunately coincidental and unrelated.
  • When faced with vague information or recollections it is important to further question the patient to try to pin down the patient’s history.
  • Remember to be wary of multiple pathologies.
  • It is important to review a patient’s previous medical notes as they will often present with symptoms which can be relevant, but may be spread out over a number of visits and be easily missed.
  • Recurrent and persistent symptoms that are resistant to treatment should always stimulate a review of the diagnosis and the need for further investigation.
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