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Endgames Picture Quiz

Hearing impairment in a 5 year old child

BMJ 2014; 348 doi: (Published 03 April 2014) Cite this as: BMJ 2014;348:g2468
  1. Natalie Ronan, ear, nose, and throat specialist trainee year 5,
  2. George Barrett, ear, nose, and throat specialist trainee year 4
  1. 1Ear, Nose, and Throat Department, Royal Cornwall Hospital, Truro TR1 3LJ, UK
  1. Correspondence to: N Ronan natalieronan{at}

A 5 year old boy was referred to the ear, nose, and throat (ENT) outpatients department by his general practitioner after his school had raised concerns about his hearing and attention. His parents had also noted that he tended to have the television on a loud volume, and they thought that he was a “loud child,” often shouting unnecessarily in quiet situations. On further questioning, it was apparent that his speech was delayed and difficult to understand. He had no history of other ENT problems or ear infections, and he had passed his neonatal hearing screening test. He was otherwise fit and well, had reached his milestones appropriately, and had no family history of note.

On examination, he had dull retracted ear drums with loss of the light reflex on both sides, and tympanometry showed flat traces bilaterally, consistent with no movement of the ear drums. The remainder of the examination was normal.

A pure tone audiogram was obtained (figure).

Pure tone audiogram showing air conduction thresholds (“x” for the left ear and “o” for the right) and masked bone conduction thresholds (“]” for the left and “[” for the right)


  • 1. What is the most likely diagnosis?

  • 2. What does the audiogram show?

  • 3. When should patients with this condition be referred to ENT?

  • 4. What are the treatment options for this condition?


1. What is the most likely diagnosis?

Short answer

Consider all possible causes for childhood hearing loss, including impacted wax, cholesteatoma, and …

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