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Turning a deaf ear

01 January 2009

E was a 12-year-old girl who had been complaining of earache for a week after coming back from an activity holiday in Spain. Despite taking paracetamol suspension, the pain persisted and her mother, Mrs K, brought her along to be reviewed by her regular GP, Dr T. E was well known to Dr T as he had seen her on a number of occasions with mild asthma. Dr T documented the history of pain in her right ear. She was noted to be apyrexial and systemically well, with a normal appetite.

The only abnormal examination finding was debris and inflammation in the right external auditory meatus. E was diagnosed with otitis externa and prescribed topical antibiotic drops, as well as regular paracetamol suspension. Mrs K was given advice about helping E to avoid getting water in her ear, and to avoid swimming until the symptoms had cleared up.

Despite the drops the earache continued and Mrs K brought E to the practice again four days later to see another GP, Dr A. The history was recorded as persistent, offensive discharge from the right ear as well as continuing pain. A swab was taken and sent for culture. A course of oral antibiotics was prescribed for what was felt to be persistent otitis externa.

Unfortunately, despite both topical and oral antibiotics E’s symptoms continued over the ensuing weeks. During this time E was brought in by her parents on multiple occasions and she was reviewed by a number of different GPs at the practice. Mr and Mrs K became increasingly concerned regarding their daughter’s ongoing symptoms.

Six weeks after E had seen Dr T for the first time, he reviewed her again. Dr T checked the swab result, which had shown a growth of pseudomonas. It was noted that the pseudomonas was sensitive to the antibiotics that had been given to E at the last consultation. On this occasion Dr T documented that the ear discharge had persisted for several weeks and noted it to be blood-stained on otoscopy. Dr T then prescribed both antibiotic ear spray and drops.

Finally, eight weeks after the first presentation, E saw Dr S who referred her to an ENT consultant. Detailed otoscopy suggested an abnormality in the appearance of the tympanic membrane, and an urgent CT was requested. Sadly this revealed a cholesteatoma and surgical treatment was necessary. E was left with permanent hearing loss in her right ear. A claim was started against several of the doctors involved in this case.

Expert opinion

On reviewing the notes it was found that none of the doctors had documented whether or not the tympanic membrane was visible, and no-one had commented on any associated hearing loss. GP experts were highly critical of the care provided by the GPs involved. It was felt that such a long history of discharge (especially blood-stained) should have raised suspicions of a cholesteatoma. Prompt specialist opinion should have been sought when the symptoms failed to resolve. The case was settled for a moderate sum.

Learning points

  • If the patient is not responding to treatment, then it is good practice to think again, particularly if there are potentially serious alternatives.
  • Do not be afraid to consider an alternative diagnosis that differs from that of a colleague or partner who had seen the patient previously.
  • If the examination findings do not fit with the working diagnosis (eg, the blood staining of the otorrhoea) then alternative causes should be considered.
  • Comprehensive records are vital for continuity of care – and especially so when a patient is being seen by a series of doctors for the same illness.
  • GPs should keep in mind the rare, serious diagnoses associated with any presenting symptoms, and should endeavour to rule these out themselves or seek specialist opinion if they are unable to do so.
  • This case highlights the importance of making comprehensive notes in the patient’s records to enable continuity of care and of taking the time to read through the most recent entries in the notes before a consultation.