Makindo Medical Notes

🩺 OSCE Station – Hearing Loss

Candidate Instructions 📋

You are a final-year medical student in the ENT clinic. A 62-year-old patient presents with hearing loss. Take a focused history, screen for red flags, outline the differential diagnosis, and discuss initial investigations and management. You do not need to perform an ear examination. You have 8 minutes.

Key OSCE Learning Points 🔑

• Differentiate between conductive and sensorineural hearing loss. 👂
• Screen for red flags (sudden sensorineural hearing loss, unilateral symptoms, neurological signs, recurrent infections). ⚠️
• Consider age-related (presbycusis), noise-induced, infective, and malignant causes.

History to Cover 📝

• Onset: Sudden vs gradual, unilateral vs bilateral.
• Associated symptoms: tinnitus, vertigo, ear pain, discharge, pressure/fullness, facial weakness.
• Red flags:
  • Sudden sensorineural loss (within 72h).
  • Unilateral tinnitus/vertigo (acoustic neuroma risk).
  • Facial nerve palsy.
  • Recurrent/persistent otorrhoea or bleeding.
• Precipitants: recent URTI, trauma, loud noise exposure, ototoxic medications (e.g., aminoglycosides, chemotherapy).
• Past/family history: childhood ear infections, ear surgery, family deafness syndromes.
• Social history: occupational noise exposure, smoking, alcohol, hearing aids use.

Examiner Prompts 👩‍⚕️

• Progressive hearing loss, worse in noisy environments.
• No pain or discharge.
• Bilateral tinnitus, no vertigo.
• No neurological symptoms.

Differential Diagnosis ⚖️

• Conductive: otitis media with effusion, otosclerosis, chronic otitis externa/media, impacted wax.
• Sensorineural: presbycusis, noise-induced hearing loss, acoustic neuroma, Ménière’s disease, sudden SNHL.
• Mixed: long-standing middle ear disease with cochlear involvement.

Investigations 🔬

• Bedside: Rinne and Weber tuning fork tests.
• Audiometry: Pure-tone audiogram (conductive vs sensorineural pattern).
• Tympanometry: Middle ear pressure and ossicular chain assessment.
• Bloods: FBC, ESR if systemic/infective suspicion.
• Imaging: MRI IAM/cerebellopontine angle for unilateral SNHL (exclude acoustic neuroma).

Management 🚑 (NICE CKS & ENT UK)

• General: Reassure, optimise communication (lip-reading, background noise reduction).
• Conductive:
  • Wax: removal (microsuction, irrigation if safe).
  • Otitis externa/media: topical or systemic antibiotics as indicated.
  • Otosclerosis: stapedectomy or hearing aids.
• Sensorineural:
  • Presbycusis: hearing aids, audiology referral.
  • Sudden SNHL (<72h): urgent ENT referral + high-dose steroids.
  • Acoustic neuroma: MRI + neurosurgical referral.
• Multidisciplinary support: audiology, speech therapy, occupational advice.

Examiner’s Marking Guide 📋

• Introduces self, takes consent.
• Asks about onset, progression, laterality, associated symptoms.
• Screens for red flag features.
• Suggests tuning fork tests, audiometry, MRI for unilateral SNHL.
• Mentions NICE guidance on urgent referral for sudden sensorineural loss.

References 📚

• NICE CKS: Hearing loss in adults
• ENT UK guidelines on sudden sensorineural hearing loss.