--- title: "ENT History Taking: Approach to an Ear Case" description: "A guide on taking a detailed History for Ear related complaints, covering chief complaints, history of present illness, and relevant past/personal history." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/history-taking-ear" categories: ["History and Clinical Examination"] video: "https://www.youtube.com/watch?v=cCROX5SFo3k" image: "https://media.theentresident.com/og-images/history-taking-ear.png" --- # ENT History Taking: Approach to an Ear Case A guide on taking a detailed History for Ear related complaints, covering chief complaints, history of present illness, and relevant past/personal history. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=cCROX5SFo3k ## 📝 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. --- ## About This Note This free ENT note on ENT History Taking: Approach to an Ear Case was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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