A 5-year-old is described by his teacher as inattentive and dreamy. He is not unwell and has no earache. His speech is behind that of his classmates. What must be excluded? ANSWER: HEARING LOSS — most likely OTITIS MEDIA WITH EFFUSION. WHY IT IS MISSED: effusion is PAINLESS. There is no fever and no complaint. The child simply does not hear well, so nobody thinks of the ear. WHY IT MATTERS: the hearing loss occurs during the years when language is acquired, producing delayed speech, difficulty at school, and behaviour read as inattention or defiance. ACTION: assess hearing BEFORE the child acquires a behavioural label that follows him for years. NOTE: antibiotics do not help an effusion — there is no acute infection to treat.

A 40-year-old notices hearing loss in one ear developing over two days, with no pain and no discharge. What is the correct action? A. Reassure; arrange routine audiometry in a few months B. Prescribe antibiotics for presumed infection C. Same-day specialist referral D. Syringe the ear for wax ANSWER: C — same-day referral. WHY: this is SUDDEN SENSORINEURAL HEARING LOSS, and it is an emergency. The window in which treatment may help is SHORT and it closes. TWO ADDITIONAL POINTS: - A UNILATERAL loss in an adult is never simply ageing. Age-related loss is SYMMETRICAL, so one-sided loss demands an explanation. - Absence of pain is not reassuring here; it is typical.

A patient has had a foul-smelling ear discharge for several months. He now has a headache and mild facial weakness on the same side. What does this suggest? ANSWER: chronic ear disease — likely CHOLESTEATOMA — with COMPLICATIONS. This is an emergency. MECHANISM: cholesteatoma is not a tumour but behaves destructively. It expands and ERODES the bone it grows into. Sitting in the temporal bone, what it erodes into includes the facial nerve, the inner ear, and ultimately the cranial cavity. THE COMPLICATIONS TO KNOW: facial palsy, vertigo, meningitis, brain abscess, lateral sinus thrombosis. FACIAL WEAKNESS PLUS HEADACHE means the disease has already left the middle ear. WHAT NOT TO DO: another course of drops. The question is what is CAUSING the discharge, not how to dry it.

A young man with a severe sore throat is drooling, cannot swallow his saliva and has a muffled voice. What does this indicate? ANSWER: an AIRWAY problem requiring urgent assessment — not a simple pharyngitis. The danger signs in a sore throat are about the AIRWAY and DEEP INFECTION, not about the severity of the pain: - DROOLING or inability to swallow saliva - MUFFLED "hot potato" voice - TRISMUS (cannot open the mouth) — infection beyond the tonsil - STRIDOR or difficulty breathing - neck swelling, or a very unwell patient A PATIENT WHO CANNOT SWALLOW THEIR OWN SALIVA HAS AN AIRWAY PROBLEM. Do not examine the throat in a way that risks precipitating obstruction, and get senior help.

Most sore throats are viral. Why is streptococcal throat infection nevertheless treated in settings like Nepal? ANSWER: because of its LATE complications. RHEUMATIC FEVER — and rheumatic heart disease remains a leading cause of cardiac disease in young adults in South Asia. POST-STREPTOCOCCAL GLOMERULONEPHRITIS. Both follow the throat infection after a LATENT INTERVAL, by which time the original sore throat has resolved and the connection is not obvious. CONTRAST WITH THE GENERAL RULE: antibiotics shorten the symptoms of a sore throat very little and select resistance, so the consultation is mostly explanation. The justification for treating streptococcal infection is not symptom relief — it is preventing the sequelae.

A 58-year-old smoker has been hoarse for two months. He has no pain and feels otherwise well. What is required? ANSWER: EXAMINATION OF THE VOCAL CORDS. WHY: laryngeal cancer is CURABLE WHEN SMALL, and a changed voice is frequently its ONLY early symptom. Risk rises with smoking and alcohol, and disproportionately when combined. THE FAILURE MODE is not ignorance but REPETITION — "it is probably laryngitis" is a reasonable first thought and a dangerous fourth one. Give it a defined period; if the voice has not recovered, examine rather than repeat the reassurance. FEATURES THAT RAISE CONCERN FURTHER: neck lump, referred ear pain, difficulty swallowing, weight loss.

A 3-year-old has a foul-smelling discharge from ONE nostril, with obstruction on that side only. She is otherwise well. What is the most likely cause? ANSWER: a retained NASAL FOREIGN BODY. THE DISCRIMINATOR IS LATERALITY: BILATERAL obstruction with sneezing and clear discharge is usually allergic or infective. UNILATERAL obstruction, bleeding or foul discharge is a different problem entirely. IN A CHILD: most often a foreign body, which may have been present for weeks — children do not reliably report putting it there. IN AN ADULT: unilateral symptoms require examination to exclude a tumour.