Cases/Ear, Nose and Throat

Painful, Itchy, Discharging Ear — Free SCA Practice Case

Swimmer with a painful, itchy, discharging ear

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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

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Materials for Candidate

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Patient Profile

Full Name

Ravi Menon

Age

38 years

Consultation Type

Video

Age

Situation

Video Consultation. Booked by the patient through the practice online form.

Reason for Encounter

"Right ear itchy, painful and leaking for a few days. I swim every morning. Could I get some drops please so I can keep training?"

Medical Records

●PMH: Type 2 diabetes, diagnosed 3 years ago.
●Medications: Metformin 1 g twice daily.
●Allergies: NKDA.
●Social: Estate agency branch manager. Non smoker.

Recent Notes

●Diabetes review, 4 months ago: HbA1c 51 mmol/mol (54 a year earlier). BP 124/78. BMI 26. eGFR above 90. Foot check normal.

Patient Script

For the friend playing the patient role

Character Overview: You are Ravi Menon, a 38 year old branch manager at an estate agency in the town centre, where you run a team of four. You are taking this video call from the small back office at the branch with the door shut. You live with your wife Anjali, a primary school teacher, and your daughter Mira, who is six. Three years ago a work health check found type 2 diabetes. Your dad has it too, and is on insulin now. After your diagnosis you joined the masters swimming club and you now swim at six every morning before work, plus Saturdays. You have lost about seven kilos and your sugar tests have improved, and you are proud of that. In four weeks you swim the breaststroke leg of the club's medley relay at the regional masters gala.

Your right ear started itching a week ago, became painful four days ago and started leaking two days ago. You want drops sent to the chemist today so you can swim tomorrow morning. You are upbeat, quick and practical, used to solving problems at work, and a bit impatient with anything that sounds like time out of the pool. You do not volunteer how you have been drying your ears, that you swam this morning, or what really worries you, until the doctor asks.

Opening Sentence: "Hello, thanks for fitting me in. My right ear's been itchy for about a week, and now it's sore and leaking a bit. I swim every morning, so I was hoping you could send some drops to the chemist and I can keep training."

History if Asked (Data Gathering Phase)

●How it started: "It started itching about a week ago, right down inside. Then about four days ago it started to hurt, and it's got worse each day since."
●The pain: "It's a constant throbbing ache, about six out of ten. It's worse when I chew on that side, and it hurts if I touch the outside of the ear or tug on it. I can't lie on that side, but it's not keeping me up."
●The leaking: "Two days ago some stuff started coming out. It's thin, a pale yellow colour, and it smells a bit. There's a crust round the opening when I wake up." The pain has not eased since the leaking started: "If anything it's been more sore."
●Hearing: "It's muffled on that side, like there's water stuck in it that won't come out. The left ear's fine."
●A cold beforehand: "No, I've been fine apart from the ear."
●How he dries his ears: "I use cotton buds after every swim to get the water out. And when it started itching I was going at it with them, to be honest, quite a lot."
●What he has tried: "I put some olive oil drops in on Friday because I thought it might be wax, but they stung like mad, so I stopped. I've been taking ibuprofen, two in the morning and two at night, and that takes the edge off."
●Swimming since it started: "I've not missed a session. I bought some foam earplugs from the pool shop on Saturday and I've worn them since, including this morning. They hurt a bit going in, if I'm honest."
●Previous ear problems: "I had grommets in both ears when I was about five. The hospital signed me off at about eight when the holes in my eardrums had closed up. Nothing since, no burst eardrum and no ear infections."
●Skin: "No eczema or dandruff or anything like that."

Ideas, Concerns, Expectations

Gating note: Ravi 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 thinks the chlorine has irritated his ear, or that he has scratched it with a cotton bud and it has got a bit infected. "I reckon it's the chlorine, or I've scratched it digging around with cotton buds. Bit of infection. I figured some drops and the earplugs and I'm sorted."
●Concerns: His first worry is the gala. "The regional gala's in four weeks and I'm in the relay. If I miss more than a week of sessions, Bev, our coach, will put the reserve in, and I've worked really hard for that spot." If the doctor explores further, a deeper worry comes out and his voice loses its brightness: "Honestly, it's the swimming that's got my sugars down. When I hurt my shoulder last year and stopped for three weeks, my test went up straight away. My dad's on injections now. The pool is how I'm staying off that road."
●Expectations: He wants drops sent to the chemist today, with no need to come in, and to swim tomorrow with his earplugs. "I'll pick them up on the way home and be back in the pool tomorrow."

If Asked: Medical History and Medications

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

●Diabetes: "Type 2, found at a work health check three years ago. Metformin, one gram twice a day. I never miss it. The nurse did my three month sugar test four months ago and said fifty one, and she was happy with that."
●Home monitoring: "I haven't got a meter now. The nurse said I didn't need to keep checking."
●High sugar symptoms and other infections: No thirst, no passing more urine, no feeling run down. No skin infections, foot sores or slow healing: "My feet were checked at the review and they were fine."
●Other health, allergies and medicines: Nothing else. "No allergies that I know of. I've had penicillin before with no problem." Only the ibuprofen and olive oil already mentioned.
●Family: "Dad's got type 2 as well and he's on insulin now. Mum's well."

Social History and Lifestyle Impact

●Work: Manages the town centre branch of an estate agency: valuations, viewings and a lot of phone calls. The branch opens at nine.
●Swimming: Masters club, six until seven every weekday morning plus Saturdays, with a dry land session in the gym on Thursday evenings run by Bev.
●Lifestyle impact: "It's driving me mad, to be honest. I'm chewing on one side, I can't hear properly on the phone on that side, and the leaking's a bit embarrassing when I'm showing people round houses. I keep checking it with a tissue."
●Alcohol, smoking and diet: A couple of beers at the weekend. Never smoked. Careful with diet since the diagnosis.

If Asked: Associated Symptoms

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

●All negative: fever, shivers or feeling unwell ("I feel fine apart from the ear"), headache, weakness or drooping of the face, trouble closing his eye, dizziness or spinning, ringing in the ear, blood in the discharge, toothache or jaw clicking, blisters or a rash on or around the ear, sore throat, blocked nose, trouble swallowing, and any problem with the left ear.
●Redness or swelling: "Not that I know of. Anjali had a look and said the hole looks red and a bit puffy, but the ear itself and behind it look normal to her."

Responses to Management (The Negotiation Phase)

●
If the doctor says he needs to be seen in person so that someone can look in the ear:
- ●Reaction: Relieved. "Actually, that's a relief. I'd rather someone had a proper look in it. I can get one of the team to cover any time after three today, or I could come first thing tomorrow before the branch opens." If asked to show the ear on camera or press on it himself, he declines politely: "I can't see inside my own ear, and my phone camera won't show you anything useful." If drops are prescribed with no one looking in the ear: "Great. Can you send them to the chemist?"
●
If the doctor explains the drops, the eardrum or how to clean the ear:
- ●Reaction: Curious and practical. "Would I know if I had a hole in my eardrum? How do you tell?" On technique: "I'll get Anjali to do it. How long do I keep them going?" On stopping cotton buds: "How else am I meant to get the water out?" On cleaning: "Could I not just get it syringed? My mate has his done at the chemist."
●
If the doctor advises no swimming for a week or more, or explains why earplugs are not safe:
- ●Reaction: Deflated, then bargaining. "A week and a half? The gala's in four weeks. Can't I just wear the earplugs and a cap and carry on?" Then grudging: "So the earplugs are part of the problem? What am I supposed to do instead, sit on the sofa?" If the doctor suggests the gym, the bike or the dry land session, he engages: "I could do the bike and the gym. I'd have to tell Bev, though."
●
If the doctor links time out of the pool to his diabetes, or asks how he feels about stopping:
- ●Reaction: Quieter. "That's what bothers me, honestly. Last time I stopped, my sugars went up. Is a week or so going to undo all of it?" Later: "So when exactly can I get back in? And will I still make the gala?" If asked about checking his sugar at home: "Can you check it when I come in?"
●
If the doctor says his diabetes makes a difference, offers tablets, or mentions a hospital ear specialist:
- ●Reaction: Concerned. "Should I be worried, then? Is it going to spread?" He settles if the answer is honest, proportionate and gives clear things to watch for. On tablets: "I'd rather not take them if I don't have to, but I'll do what you think." On a specialist: "Is it that serious?" He accepts any choice once it is explained.
●
If the doctor gives vague safety netting, or asks what happens if the drops do not work:
- ●Reaction: "Worse how, though? It already hurts. Give me something specific to look out for." And: "So if it's no better in a couple of days, I ring you? Or do I just keep going with them?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

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 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Ravi, a 38 year old swimmer with type 2 diabetes, wants drops sent to the chemist so he can swim tomorrow. The history points to acute otitis externa, but a video call cannot show the canal or the drum, and diabetes raises the stakes. The task is to reach a working diagnosis, get the ear examined, choose a safe treatment, and negotiate time out of the pool with a man whose swimming is how he controls his diabetes.
●Model answer: explain that this is most likely an infection of the ear canal, arrange a face to face examination today or tomorrow, start or choose topical treatment safely, stop cotton buds and earplugs, advise no swimming while it is treated with a route back for the gala, explain how to use the drops, give pain relief, review in two to three days if no better, and safety net for spreading and deep infection.
●Also acceptable: a non ototoxic drop today with a face to face review within 48 to 72 hours; choosing the drops at the examination; adding an oral antibiotic. Not acceptable: managing him entirely by video, or tablets instead of drops.

Acute Otitis Externa and Why Swimmers Get It

●Otitis externa is inflammation of the skin of the external ear canal; NICE Clinical Knowledge Summaries (CKS, revised September 2026) define acute disease as lasting less than 6 weeks.
●Earwax keeps the canal slightly acidic, which inhibits infection. Repeated water exposure undermines that acidity, and cotton buds, scratching and earplugs damage the lining and remove the wax. That is the setting for bacterial infection, most often Pseudomonas aeruginosa or Staphylococcus aureus.
●CKS suggests the diagnosis when there is at least one typical symptom, usually coming on within 48 hours (itch, ear pain with tenderness of the tragus or pinna and possible jaw pain, discharge, or muffled hearing), together with at least two typical signs on examination, such as tenderness, a red, swollen canal with debris, or cellulitis of the pinna.
●Ravi's itch, then pain worse on chewing and touching the ear, then smelly discharge, after daily swimming and cotton buds, is the typical story.

Outer Ear or Burst Drum: Using the History

●Acute otitis media with perforation usually follows a cold, causes deep ear pain often with fever, and the pain characteristically eases when the drum bursts and discharge appears. Otitis externa causes itch, pain on moving the outer ear or jaw, and pain that continues as the discharge appears.
●Ask about previous perforation, ear surgery and grommets. CKS asks specifically about grommets inserted within the previous year, because most extrude and the drum closes within that time, although closure cannot be assumed. Ravi had grommets at about five with healed drums.
●Other causes include a foreign body, impacted wax, dermatitis, cholesteatoma, mastoiditis and Ramsay Hunt syndrome. The history makes otitis externa very likely, but only examination shows whether the drum is intact.

Why This Ear Needs to Be Seen

●CKS recommends examining both ears, the canal, the drum, the pinna and the regional lymph nodes, looking for canal swelling and debris, discharge, fungal infection, cellulitis beyond the ear, and perforation or a grommet. A video call shows none of this, and the diagnosis depends on signs.
●With diabetes the threshold for prompt face to face assessment is lower. CKS sets no timeframe: same day or next day is proportionate with no red flags, and if a non ototoxic drop is started today, a booked review within 48 to 72 hours is reasonable.
●At the visit, check temperature and a finger prick glucose. A canal too swollen to see into or to take drops may need dry mopping, ENT microsuction or a wick.

Choosing the Topical Treatment

●Topical treatment is first line. CKS suggests considering a topical antibiotic, with or without a corticosteroid, for 7 to 14 days, guided by ototoxicity, cost, dosing frequency and whether the drum is intact. The British National Formulary (BNF) advises at least one week and a maximum of two. Outcomes do not differ clearly between drop types, so safety drives the choice.
●Topical aminoglycosides (neomycin, gentamicin, framycetin) are contraindicated with a perforated drum or patent grommet because of ototoxicity. CKS advises a non ototoxic preparation whenever perforation is known or suspected. It does not say to treat every unseen drum as perforated, so an aminoglycoside is reasonable once the history (perforation, surgery, grommets, a preceding middle ear infection) gives no reason to suspect one; some formularies prefer a quinolone whenever the drum is unseen.
●Non ototoxic options: ciprofloxacin with dexamethasone, 4 drops twice daily for 7 days, or ciprofloxacin with fluocinolone, 0.25 mL twice daily for 7 days, both licensed for otitis externa and for middle ear infection with grommets in place. Aminoglycoside and steroid combinations are reasonable once the drum is seen intact; ask about a family history of aminoglycoside deafness.
●Acetic acid 2% spray suits mild disease for up to 7 days; Ravi is beyond mild. If the ear worsens on an aminoglycoside, consider contact sensitivity and switch class.

Putting Drops in Properly, and Self Care

●Poor technique is a common reason for treatment failure. Warm the bottle in the hand, lie with the affected ear up, fill the canal, gently move the outer ear to let air out and drops in, and stay still for 3 to 5 minutes, ideally with someone else putting them in.
●No cotton buds or objects in the ear. Keep it dry: cotton wool coated in petroleum jelly in the shower and a hairdryer on its lowest setting afterwards. Stop olive oil and home remedies; the BNF advises against softening drops when the canal is infected.
●Pain can be severe because the canal skin sits on bone. Paracetamol or ibuprofen with food is usually enough, with codeine for severe pain.
●Irrigation is not recommended with a swollen canal and painful pinna, and is linked with necrotising otitis externa in diabetes. Cleaning is by dry mopping or microsuction.

Swimming, Earplugs and Getting Back in the Pool

●CKS advises avoiding swimming and water sports for at least 7 to 10 days during treatment. Earplugs do not make swimming through an infected ear safe: water still gets in and plugs rub an inflamed canal.
●He can return when pain and discharge have settled and the course is complete, then use well fitting swimming earplugs or a tight cap, dry the ears with a hairdryer and avoid cotton buds.
●Staying active on the bike or in the gym supports his glucose control while the ear heals.

When Oral Antibiotics Are Needed

●Oral antibiotics have a limited role in uncomplicated otitis externa. They reach the canal poorly and add adverse effects and resistance (CKS).
●CKS suggests considering one if the person is immunocompromised, the infection is severe or it has spread beyond the canal. The BNF adds that one may be considered in high risk groups including people with diabetes. BNF choices: flucloxacillin; clarithromycin, azithromycin or erythromycin if allergic to penicillin; ciprofloxacin if Pseudomonas is suspected, usually on specialist advice. Oral antibiotics are an addition to topical treatment, never a substitute.

Diabetes and the Ear

●Diabetes, particularly when poorly controlled, raises the risk of fungal infection and of necrotising otitis externa, and makes systemic antibiotics more likely to be needed. Necrotising otitis externa is infection spreading into the skull base. Suspect it with unremitting pain out of proportion, headache, fever, vertigo, marked hearing loss, granulation tissue or facial palsy. It needs emergency admission or urgent ENT referral and prolonged antibiotics.
●CKS advises ENT advice, with urgency by clinical judgement, for people with poorly controlled diabetes. Ravi's HbA1c of 51 mmol/mol is reasonably controlled, so routine ENT referral is not needed, but it is a reason to examine promptly, review early and act quickly on any warning sign.

Follow Up, Safety Netting and Common Mistakes

●Symptoms should improve within 48 to 72 hours of starting topical treatment, although they may take up to 2 weeks to settle. At reassessment check technique, look again at the canal and drum, consider fungal infection or contact sensitivity, and take a swab. Refer to ENT if the canal is too swollen for drops, symptoms persist despite optimal treatment, or cellulitis cannot be managed in primary care.
●Same day help for spreading redness or swelling, fever, severe pain not controlled by painkillers or waking him, headache, facial weakness, dizziness or much worse hearing. 999 if very unwell or for sudden facial droop.
●Common mistakes: sending drops with no one ever looking in the ear of a man with diabetes; prescribing aminoglycoside drops before the drum is seen without asking about perforation, grommets or a preceding middle ear infection; oral antibiotics instead of drops; agreeing earplugs let him swim through it, or banning swimming with no return plan; missing the cotton buds and foam earplugs; not screening for spreading or deep infection; suggesting syringing; missing his fear about his sugars and his father; and safety netting limited to "come back if it gets worse".

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

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