ENT History Taking: Approach to an Ear Case
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๐ ENT History Taking: Approach to an Ear Case
Today, we're going to discuss a fundamental skill in clinical practice, especially in ENT: how to take a history in an ear case.
This guide is designed to be helpful for both undergraduate and postgraduate students.
Taking a detailed history is crucial. Every piece of information a patient provides gives us valuable clues, helping us identify potential causes and reach a provisional diagnosis.
Let's break down the key areas to cover:
โจ Patient Identification and Demographics
Gathering these basic details provides context and can offer initial diagnostic hints.
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Name: For identification, building rapport, maintaining records, and can sometimes hint at cultural/religious background relevant to consanguinity.
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Age: Certain ear conditions are more prevalent in specific age groups.
What are some disease of ear commmonly seen in children and adult age groups?
- Sex: Some conditions show gender predisposition.
What are some diseases common in men and women?
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Address: Can provide clues if there are endemic issues in a particular geographical area.
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Occupation: Exposure to specific environmental factors is key.
- Noise-induced hearing loss: Boilermakers, blacksmiths, riveters (constant loud noise/vibration).
- Pressure changes: Divers, mountaineers (barotrauma, blocked sensation).
๐ฃ๏ธ Chief Complaints
Note down the patient's main complaints in their own words and in chronological order of onset. Common ear-related chief complaints include:
- Discharge from ear (Otorya)
- Decreased hearing / Hearing loss (Deafness)
- Pain in the ear (Otalgia)
- Giddiness / Vertigo
- Ringing sensation / Noise in the ear (Tinnitus)
- Facial asymmetry / Facial palsy
- Swelling or deformity of the ear
- Associated symptoms (itching, blocked sensation, fullness, autophony, etc.)
๐ History of Present Illness (HPI)
Elaborate on each chief complaint in detail, using specific questions to uncover characteristics and associated features.
1. Discharge from Ear (Otorrhoea)
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Onset: Sudden (ASOM) vs Insidious (CSOM)
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Duration: Short (ASOM) vs Long (CSOM)
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Progression: Constant, increasing, or intermittent?
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Side: Unilateral vs Bilateral
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Continuity: Continuous (atticoantral disease) vs Intermittent (tubotympanic type)
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Quantity:
- Scanty (stains swab tip - atticoantral CSOM)
- Moderate (remains in EAC - tubotympanic CSOM)
- Profuse (spills out - tubotympanic CSOM)
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Type / Character:
- Serous: Serum-like
- Serosanguinous: Blood-tinged serum
- Mucoid: White, acellular, contains mucin threads
- Mucopurulent: Mucoid mixed with pus
- Purulent: Pus-like, yellowish
- Watery: Clear, water-like
- Bloody: Frank blood (trauma) vs Blood-stained (atticoantral CSOM)
- Smell: Foul, fishy odor
Name diseases for the different types of ear discharge.
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Color:
- Whitish (mucoid)
- Whitish-yellow (mucopurulent)
- Yellowish (purulent)
- Greenish (Pseudomonas infection)
Name diseases for the different colors of ear discharge.
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Aggravating/Relieving Factors:
- Aggravated by cold/URTIs?
- Relieved by medication?
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Associated Symptoms: Pain, decreased hearing, URTI symptoms.
2. Decreased Hearing / Hearing Loss
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Onset: Sudden (viral) vs Insidious (CSOM)
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Duration: How long has the hearing loss been present?
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Side: Unilateral (CSOM) vs Bilateral (Meniere's disease)
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Progression: Rapidly progressive vs Slowly progressive
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Degree: Subjective estimate (whispers, spoken speech, doorbell, loud sounds)
How to assess degree hearing loss based on History?
- Fluctuation: Constant vs Fluctuating
Name a disease where you see fluctuating Hearing Loss.
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Specific Phenomena:
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Autophony: Hearing one's own voice louder in the affected ear.
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Diplacusis: Apparent difference in pitch of the same tone between the two ears.
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Paracusis Willisii: Hearing better in a noisy environment.
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Hearing with Discharge:
Hearing loss usually increases during active discharge (flare-up). Hearing may improve with discharge in cases of ossicular disruption (discharge acts as better sound transmission medium). This is an important clue for ossicular discontinuity.
- Recruitment: Small increase in stimulus intensity causes discomfort.
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Associated Features: Discharge, pain, tinnitus, aural fullness.
3. Pain in the Ear (Otalgia)
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Onset: Sudden (furunculosis) vs Insidious (CSOM)
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Duration: Short vs Long
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Progression: Rapidly progressive vs Slowly progressive
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Side: Unilateral vs. Bilateral
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Intensity:
- Mild, moderate, severe
- Affects work/sleep?
- Requires medication?
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Nature:
- Continuous dull throbbing (furunculosis)
- Dull (Impacted Wax)
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Location within Ear:
- In front of ear/at tragus (furunculosis)
- Deep inside ear (middle ear problem)
- Behind ear/at mastoid tip (mastoiditis)
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Referred Pain (Otalgia):
Crucial when ear examination is normal. Due to shared nerve supply (CN V, IX, X, C2, C3).
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Aggravating Factors:
- Increases on swallowing (ASOM)
- Increases on yawning/chewing (furunculosis - anterior canal wall)
- Increases on pulling pinna/pressing tragus (Otitis Externa)
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Relieving Factors:
Pain relieves with discharge (ASOM - ruptured TM relieves pressure)
4. Giddiness / Vertigo
- Type:
- Rotational vs. Unsteadiness
- Episodic vs. Prolonged
- Central vs. Peripheral
Central Vertigo: Gradual onset, less intense, increased gait disturbance, not affected by positional changes, swaying/tilting to one side. Lesion in brain/central connections.
Peripheral Vertigo: Sudden onset, very intense, significantly affected by head movements/positional changes (BPPV), often rotatory. Lesion in the inner ear.
What is Central and Peripheral Vertigo?
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Association with other features:
- Vertigo with Deafness
- Vertigo without Deafness
- Vertigo with Neck Movement
- Vertigo with/without Loss of Consciousness
Name some diseases for the above.
- Associated Symptoms: Vomiting, sweating, hearing loss, tinnitus, blackouts, Tullio phenomenon (vertigo/nystagmus induced by loud sound), Nystagmus.
5. Ringing Sensation / Noise in the Ear (Tinnitus)
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Onset & Duration:
- Sudden/Insidious
- Short (middle ear pathology) vs Long (Meniere's)
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Type:
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Subjective: Only heard by the patient (most common)
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Objective: Can be heard by the examiner (rare)
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Continuous vs. Intermittent
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Pitch: Low pitched vs High pitched (ASOM)
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Pulsatile: Synchronous with pulse
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What are some causes of Pulsatile Tinnitus?
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Trigger Factors: Stress, pregnancy, menstruation, alcohol, noise exposure, trauma
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Aggravating Factors: Smoking (cochlear pathology), Yawning/blowing (Eustachian tube dysfunction)
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Relieving Factors: Pressure on the side of the neck (vascular causes)
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Side: Unilateral (acoustic neuroma) vs Bilateral (otosclerosis)
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Associated Features:
- Vertigo (increases before vertigo in Meniere's)
- Deafness (seen together in Meniere's and otosclerosis)
6. Facial Asymmetry / Facial Palsy
- Complaints:
Change in facial contour, inability to close eye, dribbling saliva, difficulty glowing cheeks/chewing, inability to whistle, decreased/blurred vision, eye redness/itching/watering, loss of forehead wrinkling.
- Characteristics:
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Onset: Slow vs Sudden (Bell's palsy)
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Degree: Incomplete vs. Complete paralysis
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History:
- Concurrent/preceding URTI (Bell's palsy)
- Pain/numbness around ear (Ramsay-Hunt syndrome)
- Surgical intervention or trauma (iatrogenic, traumatic facial palsy)
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Association with Ear Symptoms:
- Facial palsy with ear discharge: Suggests CSOM (atticoantral type).
- Facial palsy with deafness: Seen in Acoustic Neuroma.
- Facial palsy with intact TM and no discharge: More indicative of Bell's palsy.
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7. Swelling or Deformity of the Ear
- Describe location, size, shape, consistency, tenderness, associated pain or discharge.
8. Associated Symptoms
- Itching, blocked sensation, feeling of fullness, autophony.
๐ Relevant History Points
Beyond the chief complaints, ask about factors that could relate to the ear condition.
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Positive/Negative History:
- Postural swelling, fever, headache (rule out mastoid abscess).
- Fever, vomiting, unconsciousness, headache, visual disturbances, speech problems (rule out intracranial complications of CSOM).
- History of trauma (ear, head, neck).
- Exposure to excess noise.
- Use of ototoxic drugs (e.g., aminoglycosides, loop diuretics, cisplatin).
- History of URTI.
- History of other nose or throat complaints.
- History of TB, Allergy, past Otological surgery, or Meningitis.
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Past Medical History (Systemic Illnesses):
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Diabetes Mellitus: Malignant Otitis Externa
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Allergy / Bronchial Asthma: Secretory Otitis Media
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Hypertension: Sensorineural Hearing Loss
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Tuberculosis: Tuberculous Otitis Media (painless discharge). Anti-TB drugs can be ototoxic
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Syphilis: Syphilitic Otomastoiditis and Labyrinthitis.
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Childhood Diseases: Mumps, Measles, Rubella (can cause deaf-mutism, unilateral SNHL)
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Radiation: Malignancies
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Bleeding Conditions (Polycythemia, Leukemia, Purpura): Unexplained ear bleeding, Hemotympanum.
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Connective Tissue Disorders (SLE, Costan's Syndrome): Middle ear involvement.
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Thyroid Disorders (Anti-thyroid drugs, Hypothyroidism): Vertigo.
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Family History:
- Consanguineous marriage (increased congenital SNHL/deaf-mutism).
- History of Otosclerosis in the family.
- History of similar ear complaints in family members.
- History of TB, Diabetes, Hypertension in the family.
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Past Treatment History:
- Any previous treatments or surgeries for similar complaints or other ear problems.
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Personal History:
- Diet/Nutrition: Poor nutrition can contribute to CSOM.
- Hygiene: Bad hygiene can lead to Myiasis (maggots in ear canal).
- Addictions: Smoking, Alcohol (risk factors for carcinomas).
- Weight Loss: May be relevant if malignancy is suspected.
- Bladder and Bowel habits, Sleep patterns (general health indicators).
- For females: Detailed Menstrual history, Pregnancy history.
๐ All the topics and questions mentioned in this post are explained in detail in my ENT notes - built for exam success and clinical understanding. Get full access by purchasing the notes.
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๐ฎ๐ณ For Indian Students
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