The Perils of a Leaky Ear
By Mr Jonathan Hobson, Consultant ENT / Head & Neck Surgeon & Honorary Senior Lecturer
The majority of children will have at least one and often more ear problems during childhood. This may take the form of an ear infection following a poolside holiday, glue ear causing deafness and requiring grommet insertion and in less common cases children may end up having episodes of repeated ear infections or otorrhoea. Most childhood ear infections are due to acute otitis media whereby the bugs that cause general winter-time coughs and colds ‘set up shop’ in the middle ear and cause the typical pain, fever and irritability followed by discharge of pus through a hole in the eardrum and often almost instantaneous relief from the symptoms.
A recent clinical negligence case that I was instructed to provide an expert opinion on involved a 7 year old girl who had been seen by her GP on several occasions with a discharging ear. On each of these occasions, the girl was prescribed antibiotic drops and appeared to make a good recovery. She was, however, referred to the local audiology department due to Mum’s concern about hearing loss. A subsequent examination identified glue ear for which he was referred to the local ear, nose and throat department to discuss further management options. For a variety of reasons, the girl was seen again in the audiology department and GP practice but did not see an ENT doctor until approximately 18 months later. At that time, she was noted to have some wax in her left ear and a moderate hearing loss on that side. She was listed to come in for grommets and adenoidectomy in order to ventilate the middle ear and drain out the offending fluid but at the time of surgery she was noted to have some polypoidal tissue arising from the superior (attic) region of the ear. This was biopsied and the results of the biopsy and a subsequent CT scan led to the diagnosis of cholesteatoma for which she underwent a modified radical mastoidectomy operation which left her with a long term conductive hearing loss in the left ear.
Cholesteatoma is collection of keratinous debris that collects in a retraction pocket of the tympanic membrane. It can be filled with keratin and appear quite dry or can be associated with active bacterial infection leading to profuse malodorous discharge. Cholesteatomas are potentially dangerous because of their potential to incite resorption of bone leading to intra-temporal or intra-cranial complications such as meningitis and brain abscesses in very rare cases. As well as the serious complications, cholesteatomas, when left untreated, can cause persistent, offensive otorrhoea (ear discharge) which most people find troublesome. The aim of surgery is to remove the cholesteatoma disease and render the ear safe, clean and dry.
The NICE guidelines on glue ear outline the presentation of glue ear with a history of repeated ear infections or earache, recurrent upper respiratory tract infections or frequent nasal obstruction and hearing difficulty. The claimant in this case suffered from all of these symptoms and although it may have seemed appropriate that she had been diagnosed with glue ear, there is an overlap in the presentation and symptoms of glue ear and cholesteatoma. The claimant in this case had predominantly unilateral ie left sided ear discharge. Otorrhoea can be seen in glue ear but is less common than the hearing loss that is seen. Persistent and unilateral discharge should have prompted the search for another cause. In addition the hearing loss that was diagnosed was moderate to severe whereas the typical level of hearing loss in glue ear is mild. A misinterpretation of the claimant’s symptoms as being due to glue ear led to a delay in the diagnosis of the underlying cholesteatoma and a delay in the appropriate, curative surgery.
- It is important that practitioners follow published speciality or National guidelines with regards to symptoms and diagnoses. Failure to do so may represent a breach of duty.
- Common things are common. That being said, cases that do not ‘fit the mould’ for example in this case whereby the hearing loss was in one ear rather than both and was more severe than is often seen with common glue ear, need to be considered for early(er) referral
- Beware the patient or claimant who has repeated attendances for the same condition. This may represent an underlying chronic disease, but it may represent the possibility of a missed diagnosis
- In this case the claimant had a several year history of recurrent ear discharge due to a delayed diagnosis. Following the appropriate and successful mastoid surgery she was left with a moderate conductive hearing loss on the operated ear, however, the cholesteatoma disease process may well have caused this by itself and so although a breach of duty was apparent, it was not clear that this led to causation of injury.
Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery. 7th Edition 2008
NICE Clinical Guideline CG60
About the Author:
Mr Jonathan C Hobson MA(Cantab) BM BCh FRCS(ORL-HNS) PGCertMedEd is a consultant ENT, head and neck and thyroid surgeon at Manchester University Foundation Trust.
Mr Hobson, can provide medico-legal opinion in Medical Negligence cases for general elective and emergency ENT where he can provide both screening and court report. He can also assist with Personal Injury claims; ENT problems arising from road traffic accidents as well as tinnitus and Noise Induced Hearing Loss.
To instruct Mr Hobson or for a fee quote and terms, email firstname.lastname@example.org