MODULE 1 · GDFM PROGRAMME

M12.1: Ear Conditions

Dr Paul Ang | Updated June 2024 | Evidence Review March 2026

📅 2026-03-01 🏛 College of Family Physicians Singapore

Learning Objectives

Recognise and differentiate common causes of ear discharge (otorrhoea)
Diagnose and manage acute otitis externa and otitis media in adults and children
Apply a structured approach to otalgia, tinnitus, vertigo, and hearing loss
Interpret a basic pure-tone audiogram and identify key patterns
Identify red flags requiring urgent ENT referral (SSNHL, cholesteatoma, central vertigo, unilateral OME in adults)
Perform or supervise common ear procedures: aural toileting, syringing, microsuction, foreign body removal

Normal Tympanic Membrane — The Baseline

Landmark: cone of light (anterior-inferior), handle of malleus, pars tensa and pars flaccida
Normal TM: pearlescent/grey, intact, mobile on pneumatoscopy
Any deviation from this baseline is clinically significant
Always examine both ears; compare sides
A confident normal finding is as important as detecting pathology

Normal tympanic membrane with visible light reflex and handle of malleus

Ear Discharge (Otorrhoea) — Overview

Otorrhoea has many causes; history and otoscopy are essential to differentiate
Key question: Did pain precede the discharge? (AOM) or is pain constant? (OE)
Character: watery (CSF?), purulent (bacterial), cheesy/black (fungal), foul-smelling (cholesteatoma)
Always perform aural toileting — diagnostic and therapeutic
Red flag: persistent foul discharge + marginal/attic perforation → cholesteatoma (mandatory ENT referral)

Otitis Externa — Clinical Features

Pain constant, worsened by tragal pressure or pinna traction
Creamy/white discharge; canal erythematous, oedematous, with debris
TM usually intact and normal
Risk factors: water exposure, instrumentation, skin conditions
Chronic OE: thick, malodorous discharge with desquamated skin

External ear showing erythema, scaling, and moist debris — otitis externa

Otitis Externa — Management

Aural toileting first — clear the canal to allow drops to penetrate
Antibiotic/steroid eardrops (fluoroquinolone-based) × 5–10 days; massage tragus after instillation
If canal oedema >50%: insert Pope Wick, change every 2–3 days
Oral antibiotics only for severe infection, immunocompromised, or diabetic patients
No improvement after 1 week → suspect otomycosis; start clotrimazole drops
Refer if no improvement after 1 week of appropriate treatment

Dermatitis of the Ear Canal

Consider when OE does not respond after 1 week of treatment
Causes: otic medications, cosmetics, earplugs, shampoos, hearing aid moulds
Classic: shiny, erythematous canal extending to the conchal bowl
Manage by identifying and removing the irritant
Topical steroid cream may help; avoid prolonged use

External ear showing mild erythema and scaling of conchal bowl — early otitis externa or eczema

Otomycosis — Fungal Otitis Externa

~9% of otitis externa cases; more common after antibiotic eardrops
Predominant symptom: intense itch (more than in bacterial OE)
Candida spp.: white fungal ball in canal
Aspergillus spp.: black spore heads on canal wall or TM

Otoscopic view showing white fungal mass consistent with otomycosis (Aspergillus or Candida)

💎 Aspergillus Niger Otomycosis — Classic Appearance

Black spore heads on tympanic membrane or canal wall — pathognomonic
Do NOT confuse with a foreign body
Treatment: thorough aural toileting + clotrimazole 1% drops or solution
Avoid prolonged antibiotic drops — predisposes to fungal superinfection
Local Singapore study: 38% of community OE patients had positive fungal culture

Otoscopic view of Aspergillus niger otomycosis with characteristic black spore heads on tympanic membrane

Acute Suppurative Otitis Media — Recognition

Classic history: severe otalgia → sudden painless yellowish discharge (perforation)
Otoscopy before perforation: red, bulging, opaque TM — loss of light reflex
After perforation: pulsatile discharge; pain relieves
Central/tubo-tympanic perforations = 'safe'; marginal/attic = 'unsafe' (cholesteatoma risk)
Most perforations heal within weeks; refer to ENT if persists >3 months

Otoscopic view showing bulging, opaque tympanic membrane with middle ear effusion — acute otitis media

AOM Management — Children (Updated 2022)

Pain management is always the first priority: paracetamol or ibuprofen
Immediate antibiotics for: age <2 years, bilateral AOM, otorrhoea, or severe symptoms (T ≥39°C, severe otalgia)
Watchful waiting 48–72h: children ≥2 years, mild-moderate, unilateral AOM — arrange reliable follow-up
First-line: amoxicillin 80–90 mg/kg/day; switch to amoxicillin-clavulanate if no improvement at 48–72h
Duration: 10 days for <2 years or severe; 5–7 days may suffice for older children with mild disease
Penicillin allergy: cephalosporin (non-anaphylactic), macrolide, or clindamycin

AOM Management — Adults & Travel Advice

Adults: amoxicillin-clavulanate 875/125 mg BD × 5–10 days; alternatives: high-dose amoxicillin, cephalosporins, fluoroquinolones
🚨 Red flag: recurrent unilateral AOM >2 episodes in 6 months → urgent ENT referral to exclude NPC
If perforated: keep ear dry (no swimming, use petrolatum-covered cotton during bathing)
Refer to ENT if perforation persists >3 months
Travel advice: avoid air travel; infants: pacifier/bottle; older children: chew gum or Otovent device

Cholesteatoma — Do Not Miss

Keratinized squamous epithelium in middle ear/mastoid — erodes bone
Key features: persistent foul-smelling otorrhoea, marginal or attic perforation
May cause: facial nerve palsy, SNHL, intracranial complications
Can be congenital or acquired (secondary to retraction pocket)
🚨 Mandatory ENT referral — surgical treatment required

Otoscopic view showing cholesteatoma with keratin debris and retraction pocket in the tympanic membrane

OME and Tympanosclerosis — Differentiating TM Appearances

OME: dull, retracted TM; bluish hue, air-fluid level, or bubbles visible
OME does NOT cause discharge unless it evolves into AOM
🚨 Unilateral OME in adults → urgent ENT referral to exclude NPC
Tympanosclerosis: chalky white plaques on TM; does NOT cause discharge
Tympanosclerosis: history of grommet insertion; rarely causes conductive hearing loss

Otitis media with effusion — bluish tympanic membrane with air-fluid level

Tympanosclerosis

Chalky white calcified plaques on the tympanic membrane
Result of prior inflammation — common after grommet insertion
Does NOT cause ear discharge
Usually clinically insignificant; rarely involves ossicles causing conductive HL
Reassure the patient — no treatment required unless symptomatic

Tympanosclerosis — white calcified plaques on tympanic membrane

Otalgia — Differential Diagnosis

Primary otalgia: ear itself is the source (OE, AOM, furunculosis, Ramsay Hunt)
Referred otalgia: pain from a distant site via shared nerve supply — normal ear exam
Common referred sources: dental (impacted wisdom teeth, caries), TMJ dysfunction, tonsillitis/pharynx, base of tongue, pyriform sinus
Normal ear canal + mobile TM on Valsalva → strongly suggests referred pain
Always consider pharyngeal pathology — base of tongue or pyriform sinus cancer may present with otalgia
If workup negative: consider depression or cervical spine dysfunction

Tinnitus — Classification

Subjective tinnitus: only heard by patient — far more common
Objective tinnitus: audible to examiner — suggests vascular or mechanical cause
Pulsatile tinnitus: synchronous with heartbeat — red flag (AV fistula, glomus tumour)
Main risk factor for subjective tinnitus: sensorineural hearing loss
Bilateral non-pulsatile tinnitus in an older adult → most likely presbycusis

Tinnitus classification flowchart: subjective (hearing loss pattern, somatic, typewriter) vs objective (pulsatile vs non-pulsatile)

Objective Tinnitus — Differential Diagnoses

Pulsatile: arterial (carotid stenosis, AV fistula, glomus tumour) or venous (sigmoid sinus dehiscence, benign intracranial hypertension)
Non-pulsatile objective: palatal myoclonus, tensor tympani spasm, patulous Eustachian tube
Investigation: MRI/MRA of head and neck; Doppler studies
Urgent referral if objective pulsatile tinnitus confirmed

Objective tinnitus etiologies: pulsatile (arterial/venous) and non-pulsatile causes

Tinnitus Red Flags

🚨 Emergency — Act Now

🚨

🚨 Unilateral tinnitus → MRI of internal auditory meatus (IAM) to exclude vestibular schwannoma
🚨 Pulsatile tinnitus → urgent vascular imaging (MRI/MRA)
🚨 Tinnitus with asymmetric SNHL → MRI IAM mandatory
💎 All chronic (>6 months) or bothersome tinnitus → pure tone audiometry (PTA) first
Management of chronic subjective tinnitus: counselling, CBT, sound therapy, hearing aids if HL present

Vertigo — Structured Approach

Step 1 — Timing: single episode vs recurrent? Duration: seconds-to-minutes (BPPV) or hours (Ménière's) or days (vestibular neuritis)?
Step 2 — Trigger: positional (BPPV) vs spontaneous?
Step 3 — Associated symptoms: hearing loss, tinnitus, aural fullness (Ménière's)?
Step 4 — Neurological symptoms? (5 D's) → suspect central cause → A&E
Step 5 — Examine: Dix-Hallpike, HINTS exam, cerebellar signs, gait

BPPV — Diagnosis with the Dix-Hallpike Manoeuvre

BPPV: most common peripheral vertigo — canalith(s) displaced in semicircular canals
Triggered by head movements (rolling over, looking up); comfortable at rest
Dix-Hallpike: patient seated, head rotated 45° to affected side, then rapidly supine with head hanging 20°
Positive test: vertigo + geotropic nystagmus (up-beating torsional) after a latency of 1–5 seconds
Nystagmus fatigues on repeated testing — distinguishes from central nystagmus

Dix-Hallpike manoeuvre — (A) head turned 45° seated, (B) rapid supine positioning with head hanging for BPPV diagnosis

Dizziness Assessment Algorithm

Episodic + positional → BPPV (Dix-Hallpike, Epley)
Episodic + spontaneous → Ménière's disease (triad) or vestibular migraine
Continuous → vestibular neuritis (viral), stroke (central)
HINTS exam differentiates peripheral from central in continuous vertigo
🚨 Any neurological sign → A&E; do not perform Epley if central cause suspected

Dizziness and vertigo assessment algorithm: episodic vs continuous, triggered vs spontaneous, HINTS exam, differential diagnoses

Hearing Loss — Types and Causes

Conductive (CHL): problem in outer or middle ear; BC normal, AC reduced — air-bone gap ≥15 dB
CHL causes: impacted wax, OE, AOM, OME, perforation, tympanosclerosis, otosclerosis
Sensorineural (SNHL): cochlear or retrocochlear; both AC and BC reduced — no air-bone gap
SNHL causes: presbycusis, NIHL, ototoxicity, SSNHL, Ménière's, vestibular schwannoma
Mixed: both components present — depressed BC with further AC reduction

SNHL Aetiology — Cochlear vs Retrocochlear

Cochlear (sensory): presbycusis, NIHL, Ménière's, ototoxicity, viral/autoimmune
Retrocochlear (neural): vestibular schwannoma, meningioma, MS
Key discriminator: word recognition disproportionately poor → suspect retrocochlear
Asymmetric SNHL (>15 dB at 3 kHz or any frequency) → MRI IAM mandatory
Ototoxic drugs to monitor: aminoglycosides, loop diuretics, cisplatin/carboplatin

Causes of sensorineural hearing loss: cochlear (sensory) vs retrocochlear (neural) — includes presbycusis, NIHL, vestibular schwannoma, ototoxicity

Conductive Hearing Loss — Aetiology by Site

Outer ear: cerumen impaction, OE, foreign body, exostoses
Tympanic membrane: perforation, tympanosclerosis, retraction
Middle ear: otosclerosis, ossicular disruption (trauma), cholesteatoma, OME
Key clinical test: Rinne negative (BC > AC on affected side), Weber lateralises to affected ear
Most causes of CHL in primary care are treatable

Causes of conductive hearing loss by site: outer ear (OE, cerumen), tympanic membrane (perforation), middle ear (otosclerosis, cholesteatoma)

Audiogram Interpretation — Symbols Key

Air conduction (AC): right ear — O (unmasked), Δ (masked); left ear — X (unmasked), ☐ (masked)
Bone conduction (BC): right ear — < (unmasked), [ (masked); left ear — > (unmasked), ] (masked)
Normal hearing: ≤25 dB HL in adults; ≤20 dB in children
X-axis: frequency (Hz, 250–8000); Y-axis: intensity (dB HL, 0 at top)
Air-bone gap ≥15 dB → conductive component present

Audiogram symbol key: air and bone conduction symbols for right/left ears, masked/unmasked, sound field and aided testing

Hearing Loss Severity Classification

Normal: −10 to 25 dB HL
Mild: 26–40 dB; Moderate: 41–55 dB; Moderately severe: 56–70 dB
Severe: 71–90 dB; Profound: >90 dB
Classify by the average of 500, 1000, 2000, and 4000 Hz (PTA4)
Practical screen: patient cannot hear hair rubbed near ear → likely >40 dB loss

Hearing loss classification chart: normal (−10 to 15 dB) through profound (>90 dB) across 125–8000 Hz

Normal Audiogram

All thresholds within normal limits: ≤25 dB HL across all frequencies
AC and BC symbols track closely — no air-bone gap
Symmetric between both ears
Use this as your baseline for comparison when reviewing patient audiograms

Normal audiogram: bilateral air and bone conduction thresholds at ~10 dB HL across all frequencies

Presbycusis — Bilateral Sloping SNHL

Most common cause of hearing loss in older adults
Bilateral, symmetrical, progressive high-frequency SNHL
No air-bone gap — both AC and BC equally depressed
Associated with increased risk of dementia — hearing aids mitigate this risk
Management: counselling, hearing aids (SMF subsidy available for ≥60 years), assistive devices

Bilateral sloping high-frequency sensorineural hearing loss — classic presbycusis or noise-induced pattern

Noise-Induced Hearing Loss — The 4kHz Notch

Most preventable cause of SNHL
Characteristic: bilateral SNHL with a notch at 4000 Hz (sometimes 6000 Hz)
Followed by partial recovery at 8000 Hz — the 'notch' pattern
Singapore study: 1 in 6 young people at risk from personal music players
Prevention: ear protection in noisy environments; safe listening levels (<85 dB for <8 hrs/day)

Audiogram with mid-frequency dip (Carhart notch pattern) — bilateral SNHL worse at 2000–4000 Hz

Conductive Hearing Loss Audiogram

BC thresholds normal (0–20 dB); AC thresholds depressed — creates air-bone gap
Flat pattern across frequencies typical of middle ear effusion or ossicular fixation
Bilateral flat CHL in a child → think OME (glue ear)
Unilateral flat CHL in adult → otosclerosis, ossicular disruption, cholesteatoma
Referral for audiological and ENT assessment if confirmed

Bilateral conductive hearing loss — bone conduction normal (0–5 dB), air conduction at ~40 dB flat across frequencies

Mixed Hearing Loss

Both sensorineural and conductive components present
BC thresholds elevated (SNHL component) + AC further depressed (additional conductive loss)
Air-bone gap present despite depressed BC
Common scenario: presbycusis + wax impaction or otosclerosis + SNHL
Refer to ENT and audiology for comprehensive assessment and management planning

Bilateral mixed hearing loss — air-bone gap present with depressed bone conduction at some frequencies

Severe Mixed Hearing Loss

Large air-bone gap at low frequencies narrowing at high frequencies
Significant SNHL and conductive components both present
May represent advanced otosclerosis with superimposed SNHL
Management: address conductive component surgically if feasible; hearing aid for SNHL remainder
Patient counselling about realistic expectations is essential

Severe-to-profound mixed hearing loss — large air-bone gap at low frequencies narrowing at high frequencies

Unilateral Conductive Hearing Loss

Right ear normal; left ear with significant air-bone gap (25–55 dB)
Consider: unilateral wax, perforation, OME, cholesteatoma, otosclerosis
🚨 Unilateral OME in adult — always exclude NPC
Weber: lateralises to the affected (worse) ear in pure CHL
Refer for ENT assessment to identify and treat the underlying cause

Unilateral left conductive hearing loss — right ear normal, left ear with significant air-bone gap (25–55 dB)

Cookie-Bite SNHL Pattern

U-shaped (mid-frequency) dip: better at 250 Hz and 8000 Hz, worst at 500–2000 Hz
Classic association: genetic/congenital SNHL (autosomal dominant mutations)
Differs from presbycusis (high-frequency) and NIHL (notch at 4kHz)
Family history important — genetic counselling may be indicated
Refer to ENT and genetics if young patient with bilateral symmetric mid-frequency SNHL

Cookie-bite (U-shaped) sensorineural hearing loss — better at 250 Hz and 8000 Hz, worst at 500–2000 Hz

🚨 Asymmetric SNHL — Red Flag for Vestibular Schwannoma

Definition: inter-ear difference >15 dB at 3 consecutive frequencies
🚨 Red flag: retrocochlear pathology until proven otherwise
Investigation: MRI with gadolinium of internal auditory canals — gold standard
Vestibular schwannoma: slow-growing; management: active surveillance, stereotactic radiosurgery, or surgery
Associated symptoms: unilateral tinnitus, imbalance — may be absent early
💎 Do not dismiss mild asymmetric loss in a young patient as 'insignificant'

Asymmetric SNHL — right ear normal-to-mild, left ear steeply sloping severe high-frequency loss (warrants retrocochlear workup)

Sudden Sensorineural Hearing Loss — Otologic Emergency

🚨 Emergency — Act Now

🚨

Definition: ≥30 dB hearing loss across 3 contiguous frequencies within 72 hours
Often idiopathic (~71–90%); possibly viral or vascular
🚨 Must be distinguished from simple ear blockage — use Weber/Rinne tuning fork
Weber lateralises to GOOD ear (SNHL); do not reassure as 'blocked ear'
Urgent ENT referral and audiogram — same day/next day if possible

SSNHL — Treatment Protocol (AAO-HNS 2021)

🚨 Emergency — Act Now

🚨

Oral corticosteroids: prednisolone 1 mg/kg/day (max 60 mg) × 10–14 days with taper — start immediately if no contraindications
Treatment window: up to 4 weeks from onset (extended from prior guidance)
Intratympanic (IT) steroids: now offered as PRIMARY therapy when oral steroids contraindicated (diabetes, immunosuppression)
Salvage IT steroids: for patients who do not improve with oral therapy — refer to ENT
Imaging: MRI with gadolinium of IAC — NOT CT scan — to exclude retrocochlear cause
Do NOT delay treatment while awaiting imaging; start steroids and arrange urgent ENT

Cerumen Impaction — Recognition and Softening

Remove wax if symptomatic (hearing loss, otalgia, tinnitus) or obscuring TM view
Banji's test: sudden increase in sound after pulling pinna = positive for impaction (Sn 91.7%, Sp 87.1%)
First step for hard/impacted wax: cerumenolytic for 5–7 days (olive oil, sodium bicarbonate 5%, docusate sodium)
Do not attempt removal without softening hard impacted wax
Always examine TM after wax removal and document findings

Cerumen impaction partially obscuring the tympanic membrane

Types of Cerumen

Dark impacted cerumen: completely occludes canal — common presentation
Golden-brown moist cerumen: partially occluding — responds well to syringing
Dry flaky cerumen: white/grey, friable — often amenable to microsuction or curette
Cerumen type influences removal technique choice
Always examine both ears — bilateral impaction is common

Otoscopic image of dark impacted cerumen completely occluding the external auditory canal

Cerumen Types — Moist and Dry

Moist (golden-brown): common in most ethnic groups; amenable to syringing after softening
Dry (flaky, grey): more common in East Asian populations due to ABCC11 gene variant
Dry cerumen less likely to cause impaction but can accumulate in hearing aid users
Contrast the two types to choose appropriate removal technique
Flaky dry cerumen: prefer microsuction or instrumentation over syringing

Otoscopic image of golden-brown cerumen partially occluding the external auditory canal

Dry Flaky Cerumen

White/grey, flaky, friable cerumen within the ear canal
More common in East Asian populations (ABCC11 gene variant)
Preferred removal: microsuction or gentle instrumentation — NOT syringing
Less likely to cause complete impaction compared to moist cerumen
Common in hearing aid users — recommend regular ENT or primary care follow-up for wax checks

Dry flaky cerumen within the external auditory canal (otoscopic view)

Ear Syringing — Technique and Contraindications

Contraindications: TM perforation (current or past), prior ear surgery, active infection, cholesteatoma, organic FB, button battery, single hearing ear
Technique: body-temperature water; pull pinna up-and-back (adults) or down (children)
Direct water jet along postero-superior canal wall — NOT at TM directly
Stop immediately if patient reports pain
Post-procedure: examine TM and document; if fails, re-soften and retry or refer

Cerumen Removal Instruments

Wire loop curette: used under direct vision for hard wax pieces
Works best for wax adjacent to, but not touching, the TM
Brace hand against patient's head to prevent sudden movement injury
May cause epithelial tears — consider prophylactic antibiotic drops after instrumentation
Do not use blindly — requires good illumination (headlight or microscope)

Wire loop ear curette used for cerumen removal

Dry Mopping Technique

Jobson Horne probe with cotton wisp twisted onto tip
Used for aural toileting — removing debris and discharge from the canal
Absorbs moisture; clears canal for better visualisation
Essential first step before applying ear drops in OE
Also used post-irrigation to dry the canal and check TM

Wire loop curette with cotton wisp attached — gentle cerumen removal technique

Post-Procedure: Retrieved Cerumen

Inspect retrieved wax/debris — confirms successful removal
Dark, hard wax: likely longstanding impaction
Document the procedure, technique used, and post-procedure TM appearance
If wax is mixed with blood or tissue — examine TM carefully for injury
Patient education: avoid cotton buds; ear canals are self-cleaning

Cotton wisp on instrument tip after cerumen removal — post-procedure appearance

Seniors' Mobility & Enabling Fund (SMF) — Hearing Aid Subsidy

💎 Clinical Pearl

Administered by Agency for Integrated Care (AIC); up to 90% subsidy on hearing aids
Eligibility: Singapore Citizen or PR aged ≥60; not in nursing/sheltered home; household per-capita monthly income ≤$4,800
Apply through restructured hospitals, polyclinics, or community hospitals
>99% of applicants approved; standard hearing aid costs ~$3,000–$3,200 before subsidy
💎 Always counsel eligible patients — hearing aids reduce dementia risk and improve quality of life [AIC 2025; MOH 2024]

Foreign Body in the Ear — Approach

🚨 Emergency — Act Now

🚨

Attempt removal ONLY if: child is cooperative, object clearly visible and graspable
Live insect: kill first with olive oil or 2% lignocaine, then remove
Small smooth object (bead): irrigation — aim stream past object to flush out
Organic object (peanut, bean): NO irrigation — swells with water; use hook or loop
🚨 Button battery: emergency — DO NOT irrigate; refer immediately for removal (liquefaction necrosis risk)
Cotton wool: crocodile forceps; if in doubt about any FB — refer

Key Summary

Key Point

🔑 Ear discharge: differentiate OE vs AOM perforation by sequence of pain and discharge; cholesteatoma = foul smell + marginal/attic perforation → mandatory ENT referral

Key Point

🔑 AOM in children: stratify by age and severity; watchful waiting 48–72h for ≥2 years, mild-moderate, unilateral AOM [AAP 2022]

Key Point

🔑 SSNHL is an otologic emergency: tuning fork test to distinguish from blocked ear; start prednisolone ≤4 weeks from onset; IT steroids as primary or salvage option [AAO-HNS 2021]

Key Point

🔑 Unilateral OME in adult or unilateral tinnitus/asymmetric SNHL → MRI and ENT referral (NPC / vestibular schwannoma)

Key Point

🔑 Vertigo: positional + fatigable nystagmus = BPPV → Epley; 5 D's or non-fatigable nystagmus = central → A&E

Key Point

🔑 Ear procedures: check contraindications before syringing; button battery = emergency; microsuction preferred in complex cases; counsel all eligible patients about SMF hearing aid subsidy

References

1. American Academy of Pediatrics. Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013;131(3):e964–e999. Reaffirmed 2022.
2. Lieberthal AS, et al. Watchful Waiting for Acute Otitis Media. Pediatrics. 2022;150(1):e2021055613.
3. Stachler RJ, et al. Clinical Practice Guideline: Sudden Hearing Loss (Update). Otolaryngol Head Neck Surg. 2021;166(1_suppl):S1–S55.
4. Agency for Integrated Care (AIC). Seniors' Mobility and Enabling Fund (SMF) — Mobility and Assistive Devices. www.aic.sg. Accessed March 2026.
5. Ministry of Health Singapore. Statistics of Successful Applications by Seniors to AIC for Funding of Hearing Aids. 2024. www.moh.gov.sg.
6. NICE Guideline NG98. Otitis Media with Effusion in Under 12s: Surgery. National Institute for Health and Care Excellence. 2023.
7. Rosenfeld RM, et al. Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngol Head Neck Surg. 2016;154(1_suppl):S1–S41.
8. Bhutta MF. Otomycosis: An Underdiagnosed Condition. J Laryngol Otol. 2022;136(1):1–6.
9. Shargorodsky J, et al. Change in Prevalence of Hearing Loss in US Adolescents. JAMA. 2010;304(7):772–778.
10. Livingston G, et al. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. Lancet. 2024;404(10452):572–628.