ENT History Taking: Approach to an Ear Case

📝 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:

✨ Patient Identification and Demographics

Gathering these basic details provides context and can offer initial diagnostic hints.

• Name: For identification, building rapport, maintaining records, and can sometimes hint at cultural/religious background relevant to consanguinity.

• 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?

• Address: Can provide clues if there are endemic issues in a particular geographical area.

• 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).

🗣️ 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:

1. Discharge from ear (Otorya)
2. Decreased hearing / Hearing loss (Deafness)
3. Pain in the ear (Otalgia)
4. Giddiness / Vertigo
5. Ringing sensation / Noise in the ear (Tinnitus)
6. Facial asymmetry / Facial palsy
7. Swelling or deformity of the ear
8. Associated symptoms (itching, blocked sensation, fullness, autophony, etc.)

📚 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)

• Onset: Sudden (ASOM) vs Insidious (CSOM)

• Duration: Short (ASOM) vs Long (CSOM)

• Progression: Constant, increasing, or intermittent?

• Side: Unilateral vs Bilateral

• Continuity: Continuous (atticoantral disease) vs Intermittent (tubotympanic type)

• Quantity:

  • Scanty (stains swab tip - atticoantral CSOM)
  • Moderate (remains in EAC - tubotympanic CSOM)
  • Profuse (spills out - tubotympanic CSOM)

• 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.

• Color:

  • Whitish (mucoid)
  • Whitish-yellow (mucopurulent)
  • Yellowish (purulent)
  • Greenish (Pseudomonas infection)

Name diseases for the different colors of ear discharge.

• Aggravating/Relieving Factors:

  • Aggravated by cold/URTIs?
  • Relieved by medication?

• Associated Symptoms: Pain, decreased hearing, URTI symptoms.

2. Decreased Hearing / Hearing Loss

• Onset: Sudden (viral) vs Insidious (CSOM)

• Duration: How long has the hearing loss been present?

• Side: Unilateral (CSOM) vs Bilateral (Meniere's disease)

• Progression: Rapidly progressive vs Slowly progressive

• 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.

• Specific Phenomena:

  • Autophony: Hearing one's own voice louder in the affected ear.

  • Diplacusis: Apparent difference in pitch of the same tone between the two ears.

  • Paracusis Willisii: Hearing better in a noisy environment.

  • 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.

• Associated Features: Discharge, pain, tinnitus, aural fullness.

3. Pain in the Ear (Otalgia)

• Onset: Sudden (furunculosis) vs Insidious (CSOM)

• Duration: Short vs Long

• Progression: Rapidly progressive vs Slowly progressive

• Side: Unilateral vs. Bilateral

• Intensity:

  • Mild, moderate, severe
  • Affects work/sleep?
  • Requires medication?

• Nature:

  • Continuous dull throbbing (furunculosis)
  • Dull (Impacted Wax)

• Location within Ear:

  • In front of ear/at tragus (furunculosis)
  • Deep inside ear (middle ear problem)
  • Behind ear/at mastoid tip (mastoiditis)

• Referred Pain (Otalgia):

Crucial when ear examination is normal. Due to shared nerve supply (CN V, IX, X, C2, C3).

• Aggravating Factors:

  • Increases on swallowing (ASOM)
  • Increases on yawning/chewing (furunculosis - anterior canal wall)
  • Increases on pulling pinna/pressing tragus (Otitis Externa)

• 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?

• 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)

• Onset & Duration:

  • Sudden/Insidious
  • Short (middle ear pathology) vs Long (Meniere's)

• Type:

  • Subjective: Only heard by the patient (most common)

  • Objective: Can be heard by the examiner (rare)

  • Continuous vs. Intermittent

  • Pitch: Low pitched vs High pitched (ASOM)

  • Pulsatile: Synchronous with pulse

What are some causes of Pulsatile Tinnitus?

• Trigger Factors: Stress, pregnancy, menstruation, alcohol, noise exposure, trauma

• Aggravating Factors: Smoking (cochlear pathology), Yawning/blowing (Eustachian tube dysfunction)

• Relieving Factors: Pressure on the side of the neck (vascular causes)

• Side: Unilateral (acoustic neuroma) vs Bilateral (otosclerosis)

• 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:

  • Onset: Slow vs Sudden (Bell's palsy)

  • Degree: Incomplete vs. Complete paralysis

  • History:

    • Concurrent/preceding URTI (Bell's palsy)
    • Pain/numbness around ear (Ramsay-Hunt syndrome)
    • Surgical intervention or trauma (iatrogenic, traumatic facial palsy)

  • 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.

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.

📋 Relevant History Points

Beyond the chief complaints, ask about factors that could relate to the ear condition.

• 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.

• Past Medical History (Systemic Illnesses):

  • Diabetes Mellitus: Malignant Otitis Externa

  • Allergy / Bronchial Asthma: Secretory Otitis Media

  • Hypertension: Sensorineural Hearing Loss

  • Tuberculosis: Tuberculous Otitis Media (painless discharge). Anti-TB drugs can be ototoxic

  • Syphilis: Syphilitic Otomastoiditis and Labyrinthitis.

  • Childhood Diseases: Mumps, Measles, Rubella (can cause deaf-mutism, unilateral SNHL)

  • Radiation: Malignancies

  • Bleeding Conditions (Polycythemia, Leukemia, Purpura): Unexplained ear bleeding, Hemotympanum.

  • Connective Tissue Disorders (SLE, Costan's Syndrome): Middle ear involvement.

  • Thyroid Disorders (Anti-thyroid drugs, Hypothyroidism): Vertigo.

• 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.

• Past Treatment History:

  • Any previous treatments or surgeries for similar complaints or other ear problems.

• 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.