ENT History Taking: Approach to a Nose Case

ENT History Taking: Approach to a Nose Case

Today, we'll be learning about history taking in a nose case.

Taking a thorough history in a nose case is vital. Every detail helps us understand the patient's condition and guides us towards a diagnosis.

✨ Patient Particulars

Beginning with the patient's basic information:

• Name: For identification, building rapport, maintaining records, and sometimes indicates cultural background (relevant for certain conditions).

• Age: Different nasal conditions are more common in specific age groups.

What are some diseases of nose seen in children, adults and elderly?

• Gender: Some conditions show gender preference.

What are some diseases of nose seen in males and females?

• Address/Location: Geographical prevalence of certain diseases.

  • Coastal/Tropical Areas (India, Bangladesh, Sri Lanka): Rhinosporidiosis.
  • North India, South Africa, Europe: Rhinoscleroma.

• Occupation: Environmental exposures can be relevant.

  • Farmers: Rhinosporidiosis
  • Dusty Environment: Vasomotor Rhinitis
  • Smoke/Air Pollution Exposure: Asthma

🗣️ Chief Complaints

Note down the main reasons the patient is seeking consultation, in chronological order.

Common nose-related chief complaints:

1. Rhinorrhea / Nasal Discharge
2. Nasal Obstruction
3. Headache or Facial Pain
4. Bleeding from the Nose (Epistaxis)
5. Change in Smell
6. Swelling or Deformity
7. Change in Voice (Hyponasality or Hypernasality)
8. Associated Factors: Sneezing, Post Nasal Drip, Snoring, Dryness of nose/throat.

📚 History of Present Illness (HPI)

Delve into the details of each chief complaint.

1. Nasal Discharge (Rhinorrhea)

• Onset: Sudden vs Gradual

• Progress: Rapidly progressive vs Slowly progressive

• Type:

  • Watery
  • Purulent
  • Blood-Stained
  • Mucoid

Can you name causes of each type?

• Quantity: Profuse, Moderate, Small

• Smell: Foul smelling (Foreign Body, Atrophic Rhinitis).

  Clinical Pearl: Unilateral foul-smelling nasal discharge in a child: Always suspect a Foreign Body!

• Side:

  • Unilateral: Foreign Body

  • Bilateral: Ethmoidal Polyp

2. Nasal Obstruction

• Onset: Sudden vs Gradual

• Progress: Rapidly progressive vs Slowly progressive

• Side:

  • Unilateral: DNS (most common cause)
  • Bilateral: Ethmoidal Polyp

• Continuity: Continuous (Mechanical/Structural cause like DNS) vs Intermittent (Mucosal cause like Allergic Rhinitis).

3. Headache or Facial Pain

• Onset & Progress: Sudden/Gradual onset, Rapid/Slow progress.

• Site: Often related to the affected sinus.

What is the site of pain in different sinuses?

What is Sluder's Neuralgia?

• Radiation: Pain radiating to teeth (Acute Maxillary Sinusitis)

• Character: Dull aching, throbbing, constant

• Aggravating/Relieving Factors: Bending forward (Frontal Sinusitis)

• Associated Symptoms

4. Epistaxis (Bleeding from the Nose)

• Common Sites/Causes:

What is the Most Common Site of Bleeding?

What is the Most Common Site of Bleeding in Children?

What is the Most Common Site of Bleeding in Adults?

What is the Most Common cause of Bleeding in Children?

What is the Most Common cause of Bleeding in Adults?

• Types:

  • Anterior Epistaxis

  • Posterior Epistaxis

• History Points to Ask:

Onset, Quantity, Frequency, Duration, Previous episodes, Unilateral/Bilateral, Frank blood/clots, Anterior/Posterior type, Spontaneous/Provoked (fingernail trauma?), History of trauma, Exanthematous fever, Foreign body, Bleeding disorders, Hypertension, Drug intake, Family history of hypertension/blood disorders.

Clinical Pearl: Recurrent, unprovoked, painless, profuse nasal bleed in an adolescent male: Highly suspicious of Juvenile Nasopharyngeal Angiofibroma.

5. Disturbance in Smell

• History Points:

Onset, Duration, Perceived by patient or someone else? (Merciful Anosmia), Constant/Intermittent, Unilateral/Bilateral, Foul smell? Loss for particular odors or generalized? Associated symptoms (crusts, discharge, loss of taste, headache).

What are the different types of Smell Disorder?

6. Swelling or Deformity

• History Points:

Onset, Duration, Progress, Side, Site. Describe the swelling (size, shape, consistency, tenderness).

• Associated Symptoms:

  • Loosening of teeth
  • Ill-fitting dentures
  • Visual symptoms (diplopia, blurring)
  • Loss of nasolabial fold, Intranasal mass

• Specific Deformities: Frog Face Deformity, Telecanthus, Saddle Nose Deformity, Crooked Nose.

6. Change in Voice

• History Points:

Onset (congenital or secondary), Associated symptoms (palate).

• Types:

  • Hyponasality (Rhinolalia Clausa)

  • Hypernasality (Rhinolalia Aperta)

What is Hyponasality & Hypernasality?

What are some causes of Hyponasality & Hypernasality?

Other Associated Symptoms

• Sneezing:

  • Allergic symptom.
  • Ask if in paroxysms, persistent, associated with watering eyes, occurs with face washing/waking up, exposure to dust/pollen/animals, associated itching (eyes, nose, throat).

• Post Nasal Drip (PND):

  • Hawking sensation, feeling something stuck at back of throat, sometimes foul smell/taste or sensation of blood.
  • Ask about discharge color.

• Snoring:

  • Rule out nasal pathology (DNS, polyps, turbinate hypertrophy).
  • Ask age, loudness, sleep disturbance (Obstructive Sleep Apnea?), mouth breathing history (especially in children with Adenoid Hypertrophy).

• Dryness of Nose and Throat: Seen in Atrophic Rhinitis, Cocaine abuse, early Acute Rhinitis.

Additional Relevant Histories

When taking a patient's history in ENT, especially for nasal complaints, it's important to consider specific associated symptoms that can help narrow down your diagnosis. These include:

• Fever with swelling/redness – often a clue toward infections like acute rhinitis or vestibulitis.

• History of trauma or habitual nose picking – commonly linked to conditions like epistaxis or nasal fractures.

• Use of nasal packs or instrumentation – which can affect bleeding, drainage, or even vision in rare cases.

• Eye symptoms like watering or vision changes

• Ear symptoms and referred pain

• Recurrent upper respiratory infections

• Sensory loss or numbness on the cheek

👉 These histories can point towards common and serious conditions ranging from chronic sinusitis and nasal polyps to malignancies with orbital invasion.

📘 In my detailed notes, I’ve broken down each of these symptoms and what they typically indicate — with clinical correlations, differentials, and quick-reference tables to help you save time in exams and clinics.

📋 Past History

Systemic diseases and previous conditions can impact nasal health.

• Systemic Diseases

• History of Surgery: Any previous nasal or sinus surgery (can cause synechiae, atrophic rhinitis, septal perforation).

Family History

• Similar complaints in the family.
• Bleeding disorders, Hypertension, Diabetes Mellitus, TB in the family.
• Consanguinity (rarely relevant for nasal conditions, but generally good to ask in ENT history).

Treatment History

• Any treatment for current or past nasal/sinus complaints.
• Medications used (type, duration, relief/aggravation).
  • Beta blockers: Nasal Obstruction.
  • Anticoagulants: Epistaxis.
  • Long-standing nasal decongestants: Rhinitis Medicamentosa.
• Extensive nasal surgeries in the past (predisposition to Atrophic Rhinitis, Septal Perforation).

Personal History

• Diet/Appetite.
• Sleep: Important if snoring/OSA is a complaint.
• Weight Loss: Relevant if malignancy is suspected.
• Bladder and Bowel habits.
• Socioeconomic status.
• Addiction History: Smoking, Alcohol, Drug/Snuff addiction (Cocaine sniffing: Septal perforation).
• Hygiene (Myiasis).
• Occupation (already covered).
• For females: Menstrual history.