ENT: #1 Common Ear disorders

• Basics: How the Ear Works | Examining the Ear | Hearing Tests
• Hearing loss: Approach to Hearing Loss | Age-related and Noise-induced Hearing Loss | Earwax | Otosclerosis | Ototoxic Drugs | Hearing Aids and Implants
• Ear infections: Otitis Externa | Acute Otitis Media | Glue Ear (Otitis Media with Effusion) | Chronic Suppurative Otitis Media | Cholesteatoma
• Dizziness and tinnitus: Approach to Vertigo | BPPV | Vestibular Neuritis and Labyrinthitis | Ménière's Disease | Vestibular Migraine and Other Causes | Vestibular Schwannoma | Tinnitus | Ear Pain With a Normal Ear
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

👂 The ear does two jobs — hearing and balance. Hearing loss affects about 1 in 5 adults in the UK and is the biggest modifiable risk factor for dementia, yet it is often missed. Dizziness is one of the commonest reasons older people see a doctor; most is benign (BPPV, vestibular neuritis), but you need to recognise stroke. Ear infections are mostly managed without antibiotics.
Your four questions for every patient: Is the hearing loss conductive or sensorineural (tuning forks, otoscopy)? Is it one-sided (needs investigation) or both? Is the dizziness true vertigo — and is it episodic, positional or continuous? Are there red flags (sudden deafness, neurological signs, facial palsy, chronic smelly discharge)?

How the Ear Works

• Outer ear — pinna and ear canal; funnels sound to the ear drum (tympanic membrane).
• Middle ear — an air-filled space with three tiny bones (malleus, incus, stapes) that carry vibration from the drum to the inner ear. Air pressure is balanced through the Eustachian tube to the back of the nose.
• Inner ear:
  • Cochlea — hair cells turn vibration into nerve signals (hearing). High pitches are detected at the base, low pitches at the tip.
  • Vestibular system — three semicircular canals (detect rotation) and the utricle and saccule (detect gravity and linear movement).
• Vestibulocochlear nerve (VIII) carries both signals to the brainstem, passing with the facial nerve (VII) through the internal auditory meatus.
• Two types of hearing loss:
  • Conductive — sound can't get to the inner ear (wax, fluid, perforation, bone problems).
  • Sensorineural — the cochlea or nerve is damaged (age, noise, drugs, schwannoma).

↑ Back to index

Examining the Ear

• Inspect the pinna and behind the ear (scars, swelling, mastoid tenderness).
• Otoscopy — pull the pinna up and back in adults (down and back in young children):
  • Ear canal — wax, discharge, swelling, foreign body, vesicles, granulation tissue.
  • Ear drum — normally pearly grey with a light reflex:
    • Red, bulging — acute otitis media.
    • Dull, retracted, fluid level or bubbles — glue ear.
    • Perforation.
    • White mass or retraction pocket with debris in the upper drum (attic) — cholesteatoma.
    • Blue drum — blood behind it (haemotympanum).
• Hearing — whispered voice test; tuning forks.
• Facial nerve function.
• In dizziness — eye movements and nystagmus, HINTS, Dix–Hallpike, Romberg, gait, cerebellar signs, BP lying and standing.

↑ Back to index

Hearing Tests

• Pure tone audiometry — hearing thresholds at each frequency, air and bone conduction:
  • Normal is 20 dB or better.
  • An air–bone gap means conductive loss.
  • Patterns: high-frequency loss (age), a notch at 4 kHz (noise), low-frequency loss (Ménière's), Carhart notch at 2 kHz (otosclerosis).
• Tympanometry — measures ear drum movement: a flat trace suggests fluid (glue ear) or perforation.
• Newborn hearing screening (otoacoustic emissions, auditory brainstem response) — all babies in the UK.
• Speech audiometry; MRI of the internal auditory meatus for asymmetric loss.

↑ Back to index

Approach to Hearing Loss

• Conductive causes:
  • Wax (commonest).
  • Otitis externa; foreign body.
  • Glue ear; acute otitis media.
  • Perforation.
  • Otosclerosis.
  • Cholesteatoma.
• Sensorineural causes:
  • Age (presbycusis).
  • Noise.
  • Ototoxic drugs.
  • Sudden SNHL (see the ENT Emergencies chapter).
  • Ménière's disease.
  • Vestibular schwannoma.
  • Infection — meningitis, mumps, measles, CMV (congenital), syphilis.
  • Genetic (GJB2 — connexin 26); syndromes (Alport, Usher, Pendred).
  • Head injury; MS; stroke.
• NICE NG98 — when to refer:
  • Immediate (within 24 hours) — sudden loss within 30 days; rapidly worsening; with new neurological signs; after head injury with hearing loss.
  • Urgent (within 2 weeks) — one-sided loss worsening over 4–90 days; sudden loss more than 30 days ago; loss with pain or discharge not responding to treatment.
  • Routine ENT — persistent unilateral or asymmetric loss (needs MRI); loss with chronic discharge, abnormal drum; fluctuating loss.
  • Audiology — gradual age-related loss affecting daily life (direct referral for hearing aids).
• Dementia — hearing loss is a major modifiable risk factor (Lancet Commission). Ask about hearing in memory assessments; hearing aids may help.
• Communication tips — face the person, good light, speak clearly (not loudly), reduce background noise, check hearing aids are in and working.

↑ Back to index

Age-related and Noise-induced Hearing Loss

• Presbycusis (age-related):
  • Gradual, both ears, symmetrical, high-frequency loss from the 50s–60s.
  • Difficulty following speech in background noise (restaurants), on the phone, or with high voices; others notice the TV is loud.
  • Often with tinnitus.
  • Management — audiology for hearing aids; assistive devices.
• Noise-induced hearing loss:
  • Occupation (construction, factories, military, music), shooting, loud music.
  • Characteristic notch at 4 kHz on the audiogram.
  • Prevention — ear protection; Control of Noise at Work Regulations.
  • Sudden loud noise (explosion) — acoustic trauma.

↑ Back to index

Earwax

• Wax is normal and self-cleaning — only a problem if it blocks the canal and causes hearing loss, fullness, tinnitus, or prevents examination.
• Advice: Don't use cotton buds (they push wax deeper and can perforate the drum).
• Treatment:
  • Ear drops for 3–5 days — olive oil, almond oil (not in nut allergy), sodium bicarbonate.
  • Irrigation (electronic, not metal syringe) or microsuction if drops don't work.
  • Don't irrigate if: perforation (now or past), grommets, previous ear surgery, recent ear infection, only-hearing ear, or cleft palate — use microsuction.
• Hearing aid users get more wax — regular checks.

↑ Back to index

Otosclerosis

• What it is: Abnormal bone growth fixes the stapes so it can't vibrate — a conductive hearing loss.
• Who: Young adults (20s–40s), women; family history (autosomal dominant with variable penetrance); often worse in pregnancy.
• Features:
  • Gradual conductive hearing loss, often both ears.
  • Tinnitus.
  • Normal ear drum (sometimes a pink tinge — Schwartze sign).
  • Some patients hear better in noisy places (paracusis of Willis).
  • Audiogram: conductive loss with a Carhart notch at 2 kHz.
• Treatment: Hearing aids, or stapedotomy (replacing the stapes with a prosthesis).

↑ Back to index

Ototoxic Drugs

↑ Back to index

Hearing Aids and Implants

• Hearing aids — free on the NHS through audiology. Behind-the-ear or in-the-ear; digital. Most benefit for mild to moderate loss; take time to adjust.
• Bone conduction devices — for conductive loss when ordinary aids can't be used (chronic discharge, no ear canal) or single-sided deafness.
• Cochlear implants — electrodes in the cochlea stimulate the nerve directly:
  • For severe to profound sensorineural loss not helped enough by hearing aids (NICE TA566).
  • Children born deaf — best results when implanted early (before 3–4 years).
  • Adults who have lost hearing — good results.
• Middle ear implants and assistive devices (loop systems, captioning, phone amplifiers, flashing doorbells).
• MRI — cochlear implants contain magnets: check compatibility before scanning.

↑ Back to index

Otitis Externa

• What it is: Inflammation of the ear canal skin — "swimmer's ear".
• Causes:
  • Bacteria — Pseudomonas, Staphylococcus aureus.
  • Fungi — Aspergillus (black or white spores), Candida — often after antibiotic drops.
  • Skin conditions — eczema, psoriasis, seborrhoeic dermatitis; allergy (to drops or hearing aid moulds).
  • Triggers — swimming, humidity, cotton buds, hearing aids, earphones.
• Features:
  • Ear pain, worse on moving the pinna or pressing the tragus.
  • Itch; discharge; muffled hearing.
  • Red, swollen canal with debris; drum may be hard to see.
• Treatment (NICE CKS):
  • Mild — acetic acid 2% spray (EarCalm).
  • Moderate — topical antibiotic with steroid drops for 7 days (e.g. Otomize spray, Sofradex, Locorten-Vioform; ciprofloxacin drops if a perforation can't be excluded).
  • Very swollen canal — an ear wick (ENT or nurse) so drops can reach.
  • Clear debris — microsuction (ENT or aural care clinic).
  • Keep the ear dry; avoid cotton buds; analgesia.
  • Fungal — clotrimazole solution.
  • Oral antibiotics (flucloxacillin) only if spreading cellulitis or systemic illness.
• Furunculosis — a boil in the outer canal (Staph aureus); very painful; warm compresses, flucloxacillin.
• Necrotising otitis externa — older diabetics with severe pain and granulation tissue (see the ENT Emergencies chapter).

↑ Back to index

Acute Otitis Media

• Who: Mainly young children (6–18 months peak); often after a cold.
• Organisms: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis; viruses.
• Features:
  • Ear pain (young children rub or pull the ear), fever, irritability, poor feeding.
  • Red, bulging ear drum, loss of light reflex.
  • Discharge if the drum perforates (pain often eases).
• Management (NICE NG91):
  • Most settle in about 3 days (up to a week) without antibiotics.
  • Paracetamol or ibuprofen for pain and fever.
  • No antibiotic or a back-up prescription for most.
  • Phenazone and lidocaine ear drops for pain (if no perforation).
  • Immediate antibiotic if:
    • Systemically very unwell.
    • High risk of complications (immunosuppression, Down syndrome, cochlear implant).
    • Under 2 years with infection in both ears.
    • Discharge (perforation).
    • Not improving after 3 days.
  • Amoxicillin for 5–7 days first line; clarithromycin (or erythromycin in pregnancy) if allergic; co-amoxiclav second line.
• Complications: Perforation (usually heals), mastoiditis, facial palsy, labyrinthitis, meningitis, brain abscess; glue ear afterwards.
• Recurrent AOM — ENT referral; grommets in some.

↑ Back to index

Glue Ear (Otitis Media with Effusion)

• What it is: Sticky fluid behind the ear drum without signs of acute infection. The commonest cause of hearing loss in children.
• Who: Children aged 2–5; more common in winter, with Down syndrome, cleft palate, passive smoking, nursery attendance, bottle feeding.
• Features:
  • Hearing loss — not responding, TV loud, poor speech development, behaviour or school problems.
  • Dull, retracted drum, fluid level or bubbles; flat tympanogram.
  • Usually painless.
• Management (NICE NG233):
  • Watchful waiting for 3 months — most clear on their own.
  • Hearing test (audiology).
  • Autoinflation (blowing up a balloon through the nose) can help in children who can do it.
  • No antibiotics, antihistamines, decongestants or steroids.
  • Persistent (over 3 months) with hearing loss affecting development — grommets (ventilation tubes), or hearing aids; adenoidectomy in some.
• Glue ear in an adult — especially one-sided — must be investigated to exclude nasopharyngeal carcinoma (blocking the Eustachian tube): refer for nasendoscopy.

⚠️ Safety Pearl: One-sided glue ear in an adult (particularly of Southern Chinese or North African origin) may be the first sign of nasopharyngeal cancer — examine the postnasal space.

↑ Back to index

Chronic Suppurative Otitis Media

• What it is: A persistent perforation of the ear drum with recurrent or ongoing discharge (over 2 weeks).
• Features:
  • Painless discharge; conductive hearing loss.
  • A central perforation (cholesteatoma is more likely with an upper (attic) or marginal defect).
• Management:
  • Refer to ENT.
  • Aural toilet (microsuction).
  • Topical antibiotic drops — e.g. ciprofloxacin (safe with perforation), with or without steroid.
  • Keep the ear dry (cotton wool with petroleum jelly when showering; ear plugs for swimming).
  • Myringoplasty (repairing the drum) once dry; hearing aids.

↑ Back to index

Cholesteatoma

• What it is: A growth of skin (keratinising squamous epithelium) in the middle ear, usually from a retraction pocket in the upper ear drum. It's not a cancer, but it slowly destroys bone.
• Features:
  • Foul-smelling, persistent discharge that doesn't clear with treatment.
  • Hearing loss (conductive; sensorineural if the inner ear is involved).
  • White, pearly mass or crusting and debris in the attic (top of the drum).
• Complications (bone erosion):
  • Ossicle destruction (hearing loss).
  • Facial nerve palsy.
  • Vertigo (erosion into the lateral semicircular canal — fistula).
  • Intracranial infection — meningitis, brain abscess, sigmoid sinus thrombosis.
  • Mastoiditis.
• Management: ENT referral; CT temporal bones; surgery (mastoidectomy) to remove it; long-term follow-up (recurrence). Urgent if vertigo, facial palsy, headache or neurological signs.

↑ Back to index

Approach to Vertigo

• "Dizziness" can mean:
  • Vertigo — a false sense of movement (spinning, tilting).
  • Presyncope — feeling faint (cardiovascular, postural hypotension).
  • Unsteadiness — balance or gait problems (neuropathy, cerebellar, Parkinson's, frailty).
  • Vague light-headedness — anxiety, drugs, hypoglycaemia.
• Timing and triggers are more useful than the description:

• Acute continuous vertigo — is it a stroke?
  • HINTS exam (only in patients with ongoing vertigo and nystagmus, done by a trained clinician):
    • Head Impulse — abnormal (corrective saccade) suggests a peripheral cause; normal is worrying.
    • Nystagmus — horizontal, one direction = peripheral; direction-changing or vertical = central.
    • Test of Skew — vertical eye realignment on cover test = central.
  • Red flags for stroke — can't walk or sit unaided, new headache or neck pain, any other neurological sign (double vision, slurred speech, numbness, weakness, ataxia), vascular risk factors, sudden hearing loss with vertigo.
  • MRI with diffusion is more sensitive than CT; early MRI can miss small strokes.
  • See the Stroke Emergencies chapter.

↑ Back to index

BPPV

• Benign paroxysmal positional vertigo — the commonest cause of vertigo. Loose crystals (otoconia) drift into a semicircular canal (usually the posterior canal).
• Who: Older adults; after head injury; after vestibular neuritis; often no cause.
• Features:
  • Brief spinning (under 1 minute) triggered by head movement — rolling over in bed, getting up, looking up, bending.
  • Nausea; no hearing loss or tinnitus.
  • Often recurs over weeks to months.
• Diagnosis — Dix–Hallpike test:
  • Patient sits, head turned 45° to one side, then is lowered quickly to lie with the head hanging about 20° below the couch.
  • Positive — after a few seconds' delay, rotatory (torsional) upbeating nystagmus towards the lower ear with vertigo, lasting under a minute and fading with repeats.
  • Caution with neck problems, carotid disease, recent stroke.
• Treatment:
  • Epley manoeuvre — a sequence of head positions that moves the crystals out of the canal; cures most patients in 1–3 treatments.
  • Brandt–Daroff exercises at home.
  • Don't use vestibular suppressants (prochlorperazine, betahistine) — they don't help and slow compensation.
  • Falls risk — advice and physiotherapy.

↑ Back to index

Vestibular Neuritis and Labyrinthitis

• Vestibular neuritis — inflammation of the vestibular nerve (probably viral):
  • Sudden, severe, continuous vertigo over hours, lasting days, with nausea and vomiting.
  • Often after a viral illness.
  • No hearing loss.
  • Horizontal nystagmus beating away from the affected side; abnormal head impulse test.
  • Unsteady but can walk.
• Labyrinthitis — the same, but with hearing loss (and tinnitus) — the inner ear itself is affected. Bacterial labyrinthitis (from otitis media or meningitis) is more severe.
• Management:
  • Exclude stroke (HINTS, neurological examination, red flags).
  • Short-term vestibular suppressants for severe nausea and vertigo — prochlorperazine (buccal, oral or IM) or cyclizine, for no more than 3 days (longer use delays recovery).
  • IV fluids if vomiting.
  • Get moving early; vestibular rehabilitation exercises help the brain compensate.
  • Steroids may help within 72 hours (evidence mixed).
  • Labyrinthitis with hearing loss — audiology; ENT if sudden SNHL.
• Recovery — most improve within days to weeks; some have lingering unsteadiness (persistent postural-perceptual dizziness).
• Driving — don't drive while dizzy.

↑ Back to index

Ménière's Disease

• What it is: Excess fluid in the inner ear (endolymphatic hydrops) causing attacks.
• Who: Usually ages 40–60; usually one ear at first.
• Features — attacks of:
  • Vertigo lasting 20 minutes to 12 hours.
  • Fluctuating hearing loss (low frequency at first, becoming permanent over years).
  • Tinnitus (often roaring).
  • Aural fullness (pressure in the ear).
  • Nausea and vomiting.
  • Drop attacks (Tumarkin crises) — sudden falls without loss of consciousness, in later disease.
• Diagnosis: Clinical, plus an audiogram showing low-frequency sensorineural loss; MRI to exclude a schwannoma.
• Management:
  • Acute attacks — prochlorperazine or cyclizine; rest.
  • Prevention:
    • Reduce salt, caffeine and alcohol (limited evidence).
    • Betahistine is widely used, but a large trial (BEMED) showed no benefit over placebo.
    • Diuretics (thiazide).
  • Specialist options — intratympanic steroid injections; intratympanic gentamicin (destroys balance function in that ear — risk to hearing); surgery.
  • Hearing aids; vestibular rehabilitation; tinnitus support.
  • DVLA — must tell the DVLA and stop driving if sudden, disabling attacks without warning.

↑ Back to index

Vestibular Migraine and Other Causes

• Vestibular migraine — the commonest cause of recurrent spontaneous vertigo:
  • Episodes of vertigo lasting 5 minutes to 72 hours.
  • History of migraine; headache, light or sound sensitivity, or aura with some attacks (not all).
  • Triggers — stress, sleep loss, foods, hormones.
  • Normal examination between attacks.
  • Treatment — as for migraine: triggers, acute treatment, preventers (propranolol, amitriptyline, topiramate, candesartan); vestibular rehabilitation.
• Persistent postural-perceptual dizziness (PPPD) — chronic non-spinning dizziness or unsteadiness for 3 months or more, worse when upright, moving, or in busy visual environments (supermarkets). Often after an acute vestibular problem. Treatment: explanation, vestibular rehabilitation, CBT, SSRIs.
• Superior canal dehiscence — vertigo with loud sounds or straining; hearing your own heartbeat or eye movements (autophony).
• Perilymph fistula — after barotrauma or straining.
• Central causes — posterior circulation stroke or TIA, MS, cerebellar tumours, Chiari malformation, drugs (anticonvulsants, alcohol).
• Bilateral vestibular loss — gentamicin toxicity: oscillopsia (the world jumps with head movement) and unsteadiness in the dark.
• Older people — dizziness is often multifactorial (postural hypotension, drugs, vision, neuropathy, BPPV) — a falls assessment helps.

↑ Back to index

Vestibular Schwannoma

• What it is: A benign tumour of the Schwann cells of the vestibular nerve (sometimes called "acoustic neuroma"), at the cerebellopontine angle.
• Features:
  • One-sided, gradual sensorineural hearing loss (the commonest presentation; sometimes sudden).
  • One-sided tinnitus.
  • Imbalance (true vertigo is uncommon because it grows slowly).
  • Large tumours — facial numbness (loss of the corneal reflex — trigeminal nerve), facial weakness (late), cerebellar signs, hydrocephalus.
• Neurofibromatosis type 2 (NF2-related schwannomatosis) — bilateral vestibular schwannomas, often in young people; meningiomas; genetic counselling.
• Diagnosis: MRI internal auditory meatus (with gadolinium) for anyone with asymmetric sensorineural hearing loss or one-sided tinnitus.
• Management:
  • Watch and scan — many small tumours grow slowly or not at all.
  • Stereotactic radiosurgery (Gamma Knife) for small to medium growing tumours.
  • Surgery for large tumours (risk to hearing and facial nerve).
  • Bevacizumab for NF2-related tumours.

↑ Back to index

Tinnitus

• What it is: Hearing a sound (ringing, buzzing, hissing) without an outside source. Very common, especially with hearing loss.
• Causes:
  • Hearing loss of any kind (age, noise) — the commonest.
  • Wax; ear infection; Ménière's disease; otosclerosis.
  • Drugs — aspirin, loop diuretics, aminoglycosides, quinine.
  • Vestibular schwannoma (one-sided).
  • Stress, anxiety, poor sleep (make it worse).
• Pulsatile tinnitus (in time with the heartbeat) — needs investigation:
  • Idiopathic intracranial hypertension (headache, disc swelling).
  • Vascular — carotid stenosis or dissection, dural arteriovenous fistula, venous sinus stenosis, aneurysm.
  • Glomus tumour (paraganglioma) — a red mass behind the drum.
  • High-output states — anaemia, thyrotoxicosis, pregnancy.
• NICE NG155 — refer:
  • Immediately — tinnitus with sudden neurological symptoms or signs, after a head injury, or with sudden hearing loss; or if the person is at risk of suicide because of severe distress (crisis team).
  • Urgently — pulsatile tinnitus (for imaging), one-sided tinnitus with hearing loss (MRI).
  • Audiology — distressing tinnitus, hearing loss.
• Management:
  • Explanation and reassurance; treat hearing loss (hearing aids help many).
  • Sound therapy (background noise at night, sound generators).
  • CBT and tinnitus support (British Tinnitus Association).
  • Manage sleep problems, anxiety and depression.
  • No drug cures tinnitus; avoid betahistine for tinnitus alone.

↑ Back to index

Ear Pain With a Normal Ear

• Referred otalgia — the ear shares nerve supply with the jaw, teeth, throat and larynx (V, VII, IX, X, C2–3).
• Causes:
  • Temporomandibular joint dysfunction (the commonest) — jaw clicking, tenderness, worse chewing; teeth grinding.
  • Dental problems (molars).
  • Tonsillitis, quinsy; after tonsillectomy.
  • Cervical spine disease.
  • Glossopharyngeal neuralgia; trigeminal neuralgia.
  • Giant cell arteritis (over 50).
  • Herpes zoster (before the rash appears).
  • Head and neck cancer — throat, tongue base, larynx, or nasopharynx — especially in older smokers with persistent one-sided ear pain, hoarseness or swallowing problems.

💡 Clinical Pearl: Persistent one-sided ear pain with a normal ear in a smoker over 45 needs the throat examined by ENT — it can be referred pain from a laryngeal or pharyngeal cancer.

↑ Back to index

Drug Reference Table

↑ Back to index

Spot the Diagnosis