Cases/Ear, Nose and Throat

Man Who Woke Up Deaf in One Ear — Free SCA Practice Case

Man who woke up deaf in one ear

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Try 5 free cases

Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Hamish Calder

Age

50 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. He rang asking for ear syringing and reception booked a GP call first.

Reason for Encounter

"Left ear blocked for a couple of days. Using olive oil drops from the chemist. Asking for a nurse appointment for ear syringing."

Medical Records

●PMH: Hypercholesterolaemia. Impacted earwax, right ear, four years ago, cleared by irrigation.
●Medications: Atorvastatin 20 mg at night.
●Allergies: NKDA.
●Social: Funeral director. Ex smoker.

Patient Script

For the friend playing the patient role

Character Overview: You are Hamish Calder, a 50 year old funeral director. You run the family funeral business with your sister and you are taking this call in the office at the funeral home between appointments. You are courteous, calm and measured, because staying composed is part of your job, and you apologise for taking up the doctor's time. Underneath the calm you are more rattled than you let on. You hold the phone to your right ear, because the left one is no good at the moment.

On Monday morning, two days ago, you woke up and your left ear was muffled, with a high whistling noise in it. It was fine when you went to bed on Sunday night and it has not changed since. You assumed it was wax, because four years ago your right ear got bunged up and the nurse washed it out. You have used olive oil drops from the chemist since Monday evening and nothing has changed. You have paid for a wax suction appointment at a hearing shop in town on Saturday morning, but you rang the surgery hoping the nurse could do it sooner.

You have two worries you keep to yourself. The whistling kept you awake last night and, lying in the dark, you wondered whether something is going on in your head. You are also conducting a funeral at two o'clock this afternoon for a woman who was your headteacher at primary school, and her family asked for you personally. You mention neither unless the doctor asks how you are feeling about it, what is worrying you, or about work.

Opening Sentence: "Hello, Doctor, thank you for calling, and sorry to bother you with something so small. It's my left ear. It's been blocked for a couple of days and the drops aren't shifting it, so I was hoping the nurse could wash it out. The receptionist said I needed to speak to you first."

History if Asked (Data Gathering Phase)

●How it started: "I woke up with it on Monday morning. It was perfectly fine when I went to bed on Sunday night, and when I got up it was as if that side had been switched off." If asked whether it came on over hours or days: "No, it was just there when I woke up. It hasn't got better or worse since."
●How much he can hear: "I can tell someone's speaking on that side, but I can't make out the words. My daughter rang on Monday night and I put the phone to my left ear out of habit and couldn't follow a thing she said. I've used the right one since."
●The noise and the feeling: "There's a high whistle in that ear all the time, worse at night when everything's quiet. I've never had that before. That side feels heavy and dull, as if I'm wearing a tight hat over it."
●The drops: "Olive oil, two or three drops, morning and night since Monday evening. Nothing's come out and it's no different at all."
●The other ear: "The right one's fine. I can hear you perfectly on that side."
●The wax four years ago: "That was my right ear. It came on gradually over a couple of weeks, muffled, no whistling. The nurse washed it out and it was like someone had turned the volume back up. This feels muffled like that did, which is why I assumed it was wax again."
●The Saturday booking: "I've paid sixty pounds for suction at the hearing place in town on Saturday morning. But I wondered whether the nurse could do it sooner."

Ideas, Concerns, Expectations

Gating note: Hamish does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

●Ideas: He is fairly sure it is wax, because the muffled feeling reminds him of last time. "It's wax, isn't it? Same as last time, just the other side. I imagine it just needs longer with the drops."
●Concerns: Two worries. The first is the whistling, and his voice drops when he admits it. "Honestly? That whistling. It kept me awake half the night, and when you're lying there in the dark you start to wonder whether something's going on in your head." The second is work: "And I'm taking a funeral at two o'clock today. She was my headteacher when I was a boy, and the family asked for me. I'm not letting them down."
●Expectations: He wants the nurse to wash it out this week, or to be told to carry on with the drops until Saturday. "I'd just like it cleared so I can get on. If the nurse can't do it, I'll keep going with the drops and have it sucked out on Saturday."

If Asked: Medical History and Medications

Gating note: Hamish answers each of these plainly when the doctor asks about it.

●Cholesterol and other medicines: "I take a cholesterol tablet at night, a couple of years now, no trouble with it. Nothing else. No painkillers, no antibiotics, nothing new, just the drops."
●Previous ear problems: "Only the wax four years ago. No ear infections, no operations. My hearing has never gone like this before, and it's never come and gone."
●Other conditions (diabetes, stomach ulcers, mood problems): No to all. His sugar was checked at the cholesterol review and was fine.
●Allergies: "None that I know of."
●Family history: "My mother has had hearing aids since her seventies, but that crept up on her slowly. Nobody has had anything like this."

Social History and Lifestyle Impact

Gating note: Hamish shares this naturally as the conversation goes on, not as a speech.

●Work: He has worked in the family funeral business for over twenty years. He conducts services and drives the hearse. He has a funeral at two o'clock today and two more this week. He is free until about one, and again from about four once the funeral is over. His sister could cover in an emergency.
●Home: He lives with his wife and has two grown up children. He drives a car, and the hearse for work.
●Smoking and alcohol: Gave up smoking eight years ago. Drinks modestly.
●Impact: "Families talk quietly when they're grieving. Yesterday I had to ask a widow to repeat herself twice. That's not how I want to be with people. And the whistling at night is wearing me down."

If Asked: Associated Symptoms

Gating note: Hamish answers these briefly, in a sentence or two, only when asked.

●All negative: ear pain, discharge or bleeding, itching, a recent cold, blocked nose or sore throat, fever, headache, feeling sick, a knock to the head, loud noise (his is a quiet job), flying, diving or swimming, cotton buds ("Never. My mother drummed that into me."), and any rash or blisters in or around the ear or mouth.
●Balance and nerves: No dizziness, spinning or unsteadiness ("I was one of the bearers on Monday afternoon and I was perfectly steady"). No drooping or numbness of the face, no weakness in his arms or legs, and no problem with speech, vision, double vision or swallowing.
●Sleep and mood: "My sleep's been poor because of the whistling. Otherwise I'm alright."

Responses to Management (The Negotiation Phase)

●
If the doctor says it might not be wax and could be a problem with the nerve or inner ear:
- ●Reaction: Thrown. "The nerve? But it feels just like last time. How can you tell that over the phone?" If asked to do a test on himself, such as humming, rubbing his fingers by his ear or holding the phone against his head, he declines politely: "I'd rather not, I've a family due in any minute. Couldn't someone just have a proper look at it?"
●
If the doctor says he needs to be seen today or within 24 hours:
- ●Reaction: Reluctant. "Today? I've a funeral at two. Can it not wait until Saturday, when I've got the suction booked anyway?" If told that treatment works best when started early, and that waiting could cost him his hearing, he goes quiet, then: "I see. Then I'd better not wait. What do I need to do?" If the doctor suggests his sister takes the funeral: "The family asked for me." He agrees if the doctor acknowledges what it means to him, or suggests going straight afterwards, after four.
●
If the doctor mentions the hospital ear team, the emergency department, a hearing test, steroids or a scan:
- ●Reaction: Worried about practicalities. "Will I be sat in A&E all evening? Where do I actually go?" On steroids: "Tablets? What do they do to you? Couldn't you just give me them now and save me the trip?" On a scan: "A scan of my head? So you do think there's something in there?" He settles when the doctor explains honestly why each step is done and roughly when and where it will happen.
●
If driving, the drops or the Saturday booking come up:
- ●Reaction: "Am I alright to drive myself? I'm meant to be driving the hearse this afternoon. And do I keep putting the drops in? Should I cancel Saturday? I've paid for it."
●
When the plan is clear, or the doctor says they will speak to the hospital and ring him back:
- ●Reaction: "Be honest with me, Doctor. Will my hearing come back?" Then: "Of course. I'll keep my phone with me until two. How long will you be?" If offered the details by text: "Yes, please. That would be easier, I might miss something on the phone."
●
If the doctor gives vague safety netting, such as "ring back if it gets worse":
- ●Reaction: "Worse in what way? It's already gone on that side. What exactly am I looking out for, and what do I do if it happens?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Hamish asks for ear syringing for what he is sure is wax. The history says otherwise: a left ear that was normal at bedtime and muffled on waking, a new constant whistle, no pain, discharge or cold, and two days of olive oil drops that changed nothing. The task is to recognise a possible sudden sensorineural hearing loss (SSNHL), accept that it cannot be confirmed or excluded by phone, and get him assessed within 24 hours, while bringing along a funeral director with a funeral this afternoon and a wax appointment already booked.
●The cost of error is lopsided. If it is wax, an urgent assessment costs him an afternoon. If it is SSNHL and he waits for Saturday, he loses days from the period in which treatment is most likely to help.
●Model answer: contact the on call ear, nose and throat (ENT) team now and arrange for him to be seen within 24 hours, ideally today, in the ENT emergency clinic or emergency department as the local pathway directs. Going straight after the funeral, or first thing tomorrow if ENT offers it, is acceptable because both fall within 24 hours.
●Also acceptable: a face to face GP appointment today for otoscopy, with immediate ENT referral if there is no outer or middle ear cause; or examining him today and, if the canal and drum look normal, starting oral prednisolone 1 mg/kg (maximum 60 mg once daily, so 60 mg for him) after discussing risks and benefits, with the ENT call made the same day, as some UK ENT pathways ask of GPs.

What SSNHL Is and How It Differs From Wax

●NICE Clinical Knowledge Summaries (CKS) define SSNHL as loss of 30 dB or more across three consecutive frequencies, developing within 72 hours and not explained by an outer or middle ear condition. It is usually one sided. About 90% of cases are idiopathic; recognised causes include viral, vascular, autoimmune and neoplastic disease. Many people wake with it, as Hamish did.
●Wax and SSNHL overlap more than candidates expect. The NHS website lists hearing loss, blocked feeling, tinnitus and even vertigo as symptoms of wax, so no single symptom settles it. Speed of onset is the most useful pointer. Wax usually builds gradually, as his did four years ago, or blocks suddenly after water gets in. A loss simply present on waking, with no water, cold, pain or discharge, is SSNHL until examination says otherwise.
●Ask about pain, discharge, itch, a recent cold, flying, diving, swimming, cotton buds, head injury, loud noise, rash or blisters, new or ototoxic medicines and any previous or fluctuating loss.

Screening for Features That Change the Pathway

●NICE NG98 recommends that unilateral hearing loss with altered sensation or facial droop on the same side is seen by ENT within 24 hours, or follows the stroke pathway if stroke is suspected. Sudden loss with vertigo can be a posterior circulation stroke, so ask about spinning, unsteadiness, facial weakness or numbness, speech, limb weakness, double vision and headache.
●Hearing loss after head or neck injury needs immediate referral. Painful vesicles in the canal or palate with facial weakness suggest Ramsay Hunt syndrome, which needs same day assessment.
●Hamish has none of these, so his pathway is ENT within 24 hours rather than 999 or the stroke team.

Referral Timescales

●NG98 recommendation 1.1.2, for loss not explained by outer or middle ear causes: sudden loss (3 days or less) within the past 30 days, refer immediately to be seen within 24 hours by an ENT service or emergency department. Sudden loss that developed more than 30 days ago, or loss that worsened rapidly over 4 to 90 days: refer urgently, to be seen within 2 weeks.
●Routine referral applies to gradual, asymmetric or fluctuating loss. NICE quality standard QS185 describes sudden loss not explained by outer or middle ear causes as an emergency.

Why the Phone Is Not Enough, and the Realistic Options

●The pathway depends on excluding outer and middle ear causes, which needs otoscopy. Weber and Rinne tests help: in sensorineural loss Weber lateralises to the better ear, whereas in conductive loss such as wax it lateralises to the affected ear, and Rinne stays positive. None of this can be done by phone and a patient should not be asked to improvise self tests.
●Nurse syringing, more drops, routine audiology, a two week referral or waiting for a private wax appointment all miss the window.

Specialist Treatment and Why Timing Matters

●NG98 says to consider a steroid for idiopathic SSNHL. The ENT UK pathway suggests oral prednisolone 1 mg/kg a day (maximum 60 mg) for 7 days, then a taper over the following week, after discussing risks and benefits. Intratympanic injection is used when oral steroids are declined or unsuitable, or as salvage.
●Who starts the steroid varies. CKS describes it as specialist treatment, while several UK ENT pathways ask GPs to start it, after the ear has been examined, if ENT cannot see the patient that day, typically 60 mg once daily for 7 days. Follow the local pathway or the on call team's advice.
●A 2020 British Journal of General Practice review describes treatment within 48 hours of onset as ideal and beyond 2 weeks as ineffective. The evidence for benefit is uncertain, but any benefit seems greatest when started early, which is why Saturday is too late.
●Side effects to discuss are stomach upset, mood change, bruising, raised blood glucose and, rarely, avascular necrosis of the hip. Hamish is not diabetic (HbA1c 39 mmol/mol) and has no ulcer or mental health history.

Investigations After the Acute Assessment

●Pure tone audiometry confirms the loss is sensorineural and measures it, and is repeated within 10 to 14 days to follow recovery.
●NG98 says to consider MRI of the internal auditory meati for asymmetry of 15 dB or more at two adjacent frequencies, and to offer it with localising signs such as facial weakness. The purpose is to exclude a vestibular schwannoma or another cerebellopontine angle lesion; most scans find nothing.
●A GP does not need to request an urgent scan, and should explain that the scan is a routine check rather than frighten him with talk of a tumour.

Prognosis and Support if Hearing Does Not Recover

●CKS cites spontaneous recovery in 32% to 65%. Honest counselling is that many people recover some or all of their hearing but some keep a permanent loss in that ear, and that tinnitus often eases as hearing improves.
●If the loss persists, NG98 asks audiology to discuss options for single sided deafness, including hearing aids and implantable devices, alongside tinnitus support.

Practical Advice, Driving and Safety Netting

●No more drops or wax removal are needed before he is seen. NG98 advises against manual syringing and supports electronic irrigation or microsuction by trained staff, but only once SSNHL is no longer the concern.
●Driving: DVLA guidance says even profound deafness does not need notifying for a car licence provided the person can communicate in an emergency. Dizziness is different: a car driver liable to sudden disabling dizziness must not drive and must notify the DVLA, so if he became dizzy he should not drive himself.
●Advise avoiding loud noise, and offer details and warning signs by text.
●Safety net: 999 for facial droop or numbness, limb weakness, slurred speech, double vision, sudden severe headache or severe spinning with inability to stand. Same day contact for new spinning or unsteadiness, hearing loss in the other ear, ear pain, discharge or fever. Agree what he does if ENT have not contacted him by a set time, and arrange practice follow up after the hospital visit.

Common Mistakes in This Station

●Accepting the wax label and booking nurse syringing or advising more drops because he is confident and had wax before.
●Not establishing the onset: "a couple of days" sounds routine until the candidate asks how quickly it came on.
●Using the wrong timescale: routine audiology or a two week referral for a loss that started two days ago.
●Trying to examine over the phone, or prescribing steroids remotely without anyone looking in the ear or arranging specialist assessment.
●Skipping the balance and neurological screen, which decides between ENT and the stroke pathway.
●Overpromising recovery, or frightening him with a brain tumour instead of explaining why a scan is routine.
●Leaving him to choose between hospital and the funeral without solving the practical problem, when going straight afterwards still keeps him within 24 hours, so he quietly waits for Saturday.

Mapped to the RCGP curriculum topic: Ear, Nose and Throat.

← Back to Free SCA Practice Cases