Child with Ear Symptoms

Patient record — as seen by the candidate

Patient

Lily Marsden · 3 years, 7 months – Female

Past medical history

Eczema – managed with emollients and intermittent mild topical steroid

One previous episode of acute otitis media aged 18 months (resolved without antibiotics)

Born at term via normal vaginal delivery, no neonatal complications

Medication

Cetraben emollient cream PRN

Hydrocortisone 1% ointment PRN (eczema flares)

Allergy

Penicillin (documented rash as an infant)

Recent notes

1. DNA – Missed scheduled flu nasal spray (Fluenz) vaccination at the practice flu clinic, 5 months ago. Practice sent one reminder letter; no response received.

2. Seen by HCA (Amina Patel)

   6 weeks ago

   Height and weight measured for routine growth monitoring. Weight 15.1 kg, height 97 cm – both plotted on 50th centile. Parents advised to book outstanding immunisations.

3. Letter from community paediatrics

   2 days ago

   Speech and language therapy (SALT) review appointment not attended. Patient discharged back to GP with recommendation to re-refer if concerns persist.

Background

Reason for consultation

Father, Craig Marsden, has telephoned requesting a same-day call back from the GP regarding his daughter’s ear symptoms.

Social history

You live with your wife and two children in a rented terraced house. Your wife, Emma, usually handles medical appointments but she flew to Spain four days ago because her father has been admitted to hospital following a heart attack. She is likely to be away for at least another three weeks. You have taken leave from your job as a warehouse operative to look after Lily and her older brother, Alfie (aged 7, Year 2). Alfie is off school this week (half-term). You have a sister locally who works full-time and cannot help during the day.

Says freely

You are Craig Marsden, Lily’s father. You are phoning the surgery from home.

Your wife, Emma, usually handles medical appointments but she flew to Spain four days ago because her father has been admitted to hospital following a heart attack. She is likely to be away for at least another three weeks. You have taken leave from your job as a warehouse operative to look after Lily and her older brother, Alfie (aged 7, Year 2).

Lily has been unwell for three days. It started with a runny nose and mild temperature. Yesterday she began pulling at her left ear and crying, especially at bedtime. This morning you noticed a damp, greenish-yellow stain on her pillowcase and some discharge crusted around her left ear. Her temperature measured 38.4°C with an ear thermometer (taken in the right ear). She ate about half her breakfast and has been drinking water and diluted squash.

You have been giving children’s ibuprofen (Nurofen) since yesterday. You also tried Calpol, but Lily spat most of it out. The fever came down slightly after the ibuprofen but returned by evening.

Ideas, concerns & expectations

Ideas

You think it could be an ear infection. Your sister, who is a pharmacist, mentioned she might need antibiotic drops.

Concerns

You are worried because the discharge looks “unusual” and you have never seen anything come out of her ear before. You are also anxious about managing on your own without Emma.

Expectations

You are hoping the GP can prescribe something today that you can collect from the pharmacy, as you don’t think you can get to the surgery easily.

Data gathering & diagnosis

1. 1 Establish which ear is affected and whether symptoms are unilateral or bilateral.
2. 2 Clarify the timeline: when did the coryzal symptoms begin, when did the ear pain start, and when did the discharge appear.
3. 3 Ask about the character and colour of the discharge.
4. 4 Enquire about fever – how high, how long, response to antipyretics.
5. 5 Ask whether Lily is pulling or tugging at the ear, and whether pain worsens with pressure on the tragus (to differentiate otitis externa from otitis media).
6. 6 Ask about fluid intake, how often she is going to the toilet (or whether she is still having wet nappies if not yet fully toilet-trained), and appetite.
7. 7 Ask about associated upper respiratory symptoms: cough, nasal congestion, sore throat.
8. 8 Ask about red flag features: redness or swelling behind the ear, protruding pinna, neck stiffness, severe drowsiness, non-blanching rash, persistent vomiting.
9. 9 Ask about recent water exposure (swimming, prolonged bathing) as a risk factor for otitis externa.
10. 10 Ask about history of recurrent ear infections.
11. 11 Ask about any change in hearing: does she turn when her name is called, is she asking for things to be repeated, has the TV volume been turned up? These proxy observations are particularly important in a telephone consultation where direct assessment is not possible.
12. 12 Consider and ask about the possibility of a foreign body in the ear canal – insertion of small objects is common at this age and can present with unilateral discharge and pain.
13. 13 Explore the penicillin allergy: nature, severity, documented or parental report.
14. 14 Address the missed SALT appointment and missed flu vaccination – explore reasons sensitively.
15. 15 Ask about siblings – is Alfie well? Any similar symptoms?
16. 16 Explore how Craig is coping as sole carer: practical support, emotional wellbeing, any concerns about his ability to manage.
17. 17 Elicit ICE: what does Craig think is going on, what worries him most, what does he hope will happen today.
18. 18 Reach a working diagnosis of acute otitis media with spontaneous tympanic membrane perforation, evidenced by preceding otalgia followed by purulent discharge and partial symptom relief.
19. 19 Demonstrate awareness that recurrent middle ear disease can cause conductive hearing loss, which may be contributing to Lily’s existing speech delay and is directly relevant to the outstanding SALT referral (NICE NG233).

Clinical management

1. 1 Attempt to arrange a face-to-face review to examine Lily’s ears, assess her general condition, and check observations. Explore practical solutions: a later appointment so Craig can arrange travel, permission for Alfie to attend the surgery too, or a home visit if appropriate.
2. 2 If face-to-face assessment cannot be arranged today, provide telephone management and ensure a review within 24–48 hours.
3. 3 Lily has ear discharge (otorrhoea) and a fever. NICE CKS advises considering no antibiotic, a back-up prescription or an immediate antibiotic when there is otorrhoea, and an immediate antibiotic if the child is systemically unwell or at high risk of complications; here, prescribe an immediate antibiotic. In view of the documented penicillin allergy, prescribe clarithromycin oral suspension (NICE CKS: AOM – first-line alternative if penicillin-allergic). BNFc weight-band dosing: Lily’s recorded weight of 15.1 kg falls in the 12–19 kg band — 125 mg twice daily (5 ml of 125 mg/5 ml suspension) for 5 days.
4. 4 Advise continuing regular ibuprofen for pain and comfort, not to bring the temperature down. Explore why paracetamol administration has been difficult and offer practical tips (e.g. mixing with a small amount of juice, using a syringe, trying melt-in-the-mouth formulation if available).
5. 5 Encourage adequate fluid intake and rest.
6. 6 Advise that the ear discharge is expected and will likely settle; the ear should be kept dry but not plugged with cotton wool.
7. 7 Arrange re-referral to SALT now that the reason for the missed appointment is understood. Offer to have the practice coordinate this.
8. 8 Address the missed flu vaccination: explain its importance and offer to book it alongside Lily’s next appointment.
9. 9 Acknowledge Craig’s situation with empathy. Explain that the practice understands his family circumstances but emphasise that missed appointments can affect continuity of Lily’s care. Offer practical support: text reminders, flexible booking, or signposting to local family/carer support services.
10. 10 Sensitively explain that if appointments continue to be missed despite support being offered, the practice may have a duty to make a safeguarding referral – not as a punitive measure, but to ensure Lily’s health needs are met.
11. 11 Return urgently or call 999 if Lily develops swelling, redness, or tenderness behind the ear (possible mastoiditis).
12. 12 Seek immediate help if she becomes unusually drowsy, difficult to rouse, or develops a non-blanching rash.
13. 13 Contact the surgery if she stops drinking, is going to the toilet much less often than usual (or has significantly fewer wet nappies if still in pull-ups), or if the fever does not begin to settle within 48 hours of starting antibiotics.
14. 14 Seek medical review if the discharge has not resolved or has worsened after completing the antibiotic course.
15. 15 Follow-up telephone review in 2–3 days to assess progress.

Relating to others

1. 1 Acknowledges Craig’s situation with empathy: Emma abroad after her father’s heart attack, two children on his own, doesn’t drive. Recognises the strain he is under.
2. 2 Works with him on the practical barriers to a face-to-face review (40-minute bus journey, Alfie with him) rather than simply asking him to come in, e.g. offering a time that suits.
3. 3 Raises the missed speech and language appointment and flu spray without judgement, leading with support (re-referral, reminders, flexible booking) before any mention of the practice’s duty around missed appointments.
4. 4 Validates his worry about the ear discharge and explains what it most likely means (the eardrum has burst with the infection and usually heals by itself) in plain language.
5. 5 Offers practical help with giving medicines (Lily spat out the Calpol), e.g. an oral syringe into the side of the cheek, explains how to give the antibiotic, then checks he feels confident.
6. 6 Checks his understanding of the plan and the safety-net, gives the safety-net in a form he can use alone at home (e.g. by text), and offers further support (local family support services, practice contact).

Working Diagnosis

Acute otitis media (AOM) with spontaneous tympanic membrane perforation.

The classical sequence of coryzal prodrome, progressive otalgia, followed by purulent aural discharge with partial relief of pain is consistent with middle ear infection complicated by eardrum rupture. This is common in young children and usually heals spontaneously.

Differential diagnoses to consider: otitis externa (particularly given recent swimming), aural foreign body (common at this age), viral upper respiratory tract infection without AOM, and mastoiditis as a complication of AOM.

Key Learning Points from This Station

This station assesses the candidate’s ability to manage a common paediatric infection by telephone when social and logistical barriers limit attendance. Key areas tested include:

1. 1Recognising the clinical pattern of AOM progressing to perforation: upper respiratory prodrome → otalgia → aural discharge with pain relief.
2. 2Applying NICE guidance on antibiotic prescribing in AOM: an immediate antibiotic is indicated if the child is systemically unwell or at high risk of complications; with otorrhoea (ear discharge), consider no antibiotic, a back-up prescription or an immediate antibiotic.
3. 3Adapting the antibiotic choice appropriately for a documented penicillin allergy (clarithromycin as first-line alternative per NICE CKS).
4. 4Delivering robust safety-netting for complications, particularly mastoiditis and systemic sepsis, using language a non-medical parent can act upon.
5. 5Navigating the tension between empathy for a parent managing alone and the professional obligation to address missed healthcare contacts, including vaccination and developmental follow-up.
6. 6Recognising when repeated missed appointments may require a proportionate safeguarding response, framed supportively rather than punitively.

“What If” Variations

Each variation changes a single element from the core scenario. Consider how it would alter your clinical reasoning and management.

High-Yield Exam Takeaways

The triad of coryzal prodrome, otalgia, and subsequent purulent aural discharge is the hallmark presentation of AOM with tympanic membrane perforation. The discharge often brings partial relief of pain as pressure is released from the middle ear.

NICE CKS recommends an immediate antibiotic for AOM when the child is systemically unwell or at high risk of complications. With otorrhoea, it advises considering no antibiotic, a back-up (delayed) prescription or an immediate antibiotic; a back-up prescription is used if symptoms do not start to improve within 3 days, or worsen at any time.

For penicillin-allergic patients, clarithromycin is the first-line alternative for AOM in children. Always clarify the nature and severity of the allergy to guide safe prescribing.

Tragal tenderness points towards otitis externa rather than otitis media. Asking about this on the telephone helps differentiate the two when direct examination is not possible.

Mastoiditis is the most important complication to safety-net for: post-auricular swelling, erythema, tenderness, and a protruding pinna are the key signs to communicate to a parent in plain language.

Remote consultations with young children rely on parental proxy reporting. Validate the parent’s observations, ask structured questions about activity level, fluid intake, and urine output, and lower your threshold for arranging face-to-face review.

Missed appointments for vaccination and developmental follow-up should be explored non-judgementally but documented clearly. A pattern of non-attendance, even when individually explainable, may represent a cumulative risk to the child’s welfare.

When raising safeguarding concerns gently, frame it as a supportive process rather than a punitive one. The purpose is to ensure the child receives the care they need, not to blame the family.

Gold-standard consultation example

Guidelines referenced

• NICE CKS: Otitis Media – Acute
• NICE NG233: Otitis media with effusion in under 12s
• BNFc — Clarithromycin (weight-band dosing)
• NICE CKS: Penicillin allergy
• BSACI guideline on drug allergy investigation
• BMJ Best Practice: Mastoiditis
• NICE CG192: Antenatal and postnatal mental health
• GMC: Protecting children and young people
• GMC: 0–18 years – guidance for doctors
• Children Act 1989