5/28/2026, 7:30 AM PDT TO: +160452272G6 FROM: 16045219323 PAGE 1/2

DR. IDRIS SAMAD, MD, FRCSG
Otolaryngology - Head and Neck Sumery
MSP: 44406

Basement 48-625 Filth Ava

New Westminster, 3C. V3M-1X4

P; 604-524-4931

F: 604-521-9923
Dr. Gbogboade Adeboyega Ademiluyi Mr. HOLAND, Mark
311-318 anges street
New Westminster, BC, CAN
MSP: 68199
420 Columbia St
New Westminster, BC, V3L-181 :
= ¥ + 604.809. date of birth : Septomber 04; 1978 age: 47
P: (604) 522-2206 F: 604-522-7206 home phone: (236) 994-3376 sex: Male
work phone :
other phone : PHN: 9128 549 736
May 27, 2026

Dear Dr Ademiiuyi,

Thank you for referring this 47-year-old gentleman who is here today for ears. He has provided some
reference materials to review prior to consultation.

Subjective:

~ Reports left ear pain since 01/23/2026, following exposure to Industria! server noise at work. The pain was
initially severe (9-10/10) and is now rated 2-5/10. The tight ear pain has resolved.

- Associated symptoms include pulsatile tinnilus in both ears, worse on the right, and a history of migraines,
which are typically well-managed but were exacerbated by the ear pain.

- Past medical history includes chronic spontaneous urticaria, managed with bilastine, and a concussion 20
years ago.

~ Medications: bilastine daily, trazodone, quetiapine, risperidone, sertraline, coenzyme Q for migraines.

- Allergies: No known allergies.

- Social history: Quit smoking and drinking. Works for SkyTrain.

~ Reports significant sleep disruption, with body twitching every 30 seconds, requiring trazodone and
quetiapine for sleep. Has not seen a sleep medicine specialist.

- Hearing testing performed elsewhere was normal.

Head and Neck Examination:

- Inspection of the head.and neck reveals no significant abnormalities. Voice is normal; Speech is normal.

- Palpation of the neck is soft and non-tender, without adenopathy. Mild tenderness noted on palpation of th
left temporomandibular joinmasseter muscle. A click was noted on wide opening of the jaw.

~ Ears were microscopically normal bilaterally.

- Oral cavity examination reveals signs of bruxism. Tongue movement is full in all directions,

~ Anterior rhinoscopy demonstrates a midline nasal septum with normal nasal mucosa bilaterally.

o

Audiometry and case files reviewed.

Impression:

- Left ear pain, likely secondary to masseter muscle inflammation and temporomandibular joint dysfunction.
- Laud noise exposure from work may have been an exacerbating factor causing muscle tension related
Issues.

- No-apparent otologic pathology.

~ Normal hearing without significant concern.

Pian:
- The patient is quite distressed by his symptoms and continues to be bothered by left sided otalgia.

Consultation Report PLEXIA Electronic Medical Systems irc.
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