This page reveals the answer
Want to test yourself first? Play the original case before reading the clues and explanation below.
Five progressive clues
These are the case findings in their original reveal order, moving from the broader presentation to the most discriminating evidence.
Clue 1
A 58-year-old retired carpenter comes to the audiology clinic because the world sounds muffled in his right ear. He first noticed it last week when he couldn't make out his granddaughter's voice on the phone and kept switching the handset to his left ear.
Clue 2
He describes a gradual sense of blockage and fullness on the right over about two weeks, with no pain and no discharge. It seems to worsen abruptly after a shower, then eases slightly. He admits he routinely cleans both ears with cotton buds and has noticed occasional mild itching, but denies vertigo, fever, or a preceding cold.
Clue 3
Gently tugging on the right pinna and pressing the tragus cause no tenderness. On tuning-fork testing, the Weber lateralizes to the right ear and the Rinne is negative on the right (bone conduction louder than air), while the left ear is normal.
Clue 4
Otoscopy of the right canal reveals a firm, brownish-yellow obstruction filling the canal so the eardrum cannot be seen; the left canal and drum are normal. Pure-tone audiometry shows a flat right-sided air-bone gap of about 30 dB with normal bone-conduction thresholds; tympanometry of the right ear returns a flat trace with a notably reduced ear-canal volume.
Diagnosis
Cerumen Impaction
Why the diagnosis fits
A unilateral, painless conductive loss with a Weber lateralizing to the affected ear and a negative Rinne places the lesion in the outer or middle ear; direct otoscopy showing the canal fully occluded by a firm brownish mass, with an intact mobile drum behind it once cleared, localizes it to the external canal. The single key discriminator from otitis media with effusion — the closest mimic, which also gives a flat tympanogram and a conductive gap — is the tympanometric ear-canal volume: it is REDUCED here because the probe abuts an occluding canal mass, whereas OME shows a NORMAL canal volume with fluid behind an intact drum. The immediate, complete closure of the air-bone gap the moment the plug is removed confirms a purely obstructive external-canal cause with no true middle-ear pathology, and the absence of pinna/tragal tenderness argues against otitis externa.
Educational reference
The explanation and decisive case findings were checked against the source below.
Open the clinical referenceFor education and entertainment only. This fictional case is not medical advice and does not replace supervised clinical training, diagnosis, or treatment.