3 Common methods of presentation

All of the below may apply to children, but the majority of neck masses in children are benign and most are reactive lymph nodes. Parotid lumps in children are more frequently malignant than in adults.

Careful examination of the nasal anatomy will reveal what is responsible for nasal obstruction. Always remember that several anatomical problems can coexist. Symptoms can vary, especially for mucosal problems, so ascertain the severity of the problem when you examine the patient’s nose.

The timing of the onset of discharge in relation to any pain often helps with diagnosis. Otitis externa in particular can be secondary to infection spreading from the middle ear. Microsuction, or dry mopping, is often necessary to visualize the tympanic membrane. A final diagnosis is sometimes not possible until the ear has been cleaned and the local infection has been treated. It is important to visualize the eardrum after treatment to exclude serious pathology at the level of the tympanic membrane.

The most important aspect here is the patient’s history. Take great care to elicit the character of the dizziness and its timecourse to establish if this is dizziness or true vertigo.

Patients who present with otalgia can present a challenging problem. A careful history can help distinguish many conditions. Beware the red reflex—a reflex dilatation of the blood vessels on the handle of the malleus caused by the otoscope speculum touching the bony ear canal. This is often misdiagnosed as early acute otitis media, and the true cause of otalgia is missed. Always consider if the otalgia is referred pain.

A diagnosis of hearing loss in children and adults depends on combining the information from the patient’s history, the examination and any special investigations. An audiogram, or a tympanogram with tuning fork tests will help to distinguish conductive from sensorineural hearing loss and will determine if the problem is bilateral or affects only one ear. Sudden hearing loss is an emergency.

It is important to distinguish between objective tinnitus (which the examiner can hear) and subjective tinnitus (which only the patient can hear). The character of the tinnitus is also important. A thorough otoneurological examination—of the ears, cranial nerves, and central nervous system—is essential. Auscultate the ear, eye, and carotids. Remember that tinnitus can be caused by medication or other drugs.

Patients with this problem may present to a variety of specialties for an opinion, e.g. ENT, neurology, or maxillofacial surgery. It is important to have a broad mind to avoid a misdiagnosis. Never be afraid to ask for another specialist’s opinion.