History Taking of an ENT Patient

How Should You Begin?

First, explain the process of history taking and examination to the patient. Gain their confidence before you commence. For a small child, the mother serves as the ideal informant. Examine the child while seated in the mother’s lap, or at least keep one parent close to the patient. A female patient should always have her attendant present. Furthermore, a female staff member should remain in the room when a male doctor examines a female patient. Note the patient’s name, sex, age, occupation, and other demographic details at the outset.

History Taking for Ear Complaints

What Questions Should You Ask About Ear Discharge?

1. Duration of ear discharge: A discharge lasting less than three months indicates an acute or subacute ear infection. However, a discharge persisting for more than three months suggests chronic otitis media (COM) or a malignancy.
2. Nature of discharge: Mucoid, mucopurulent, or purulent discharge points to otitis media. Serous discharge suggests otitis media with effusion. Watery discharge may indicate a cerebrospinal fluid (CSF) leak or otitis externa. Blood‑stained (serosanguinous) discharge occurs in squamous COM, acute otitis media (AOM), malignancy, malignant otitis externa, or trauma. Brown discharge is simply wax. Black discharge indicates otomycosis (fungal infection).
3. Amount of discharge: Scanty discharge, which does not come out of the external auditory canal (EAC), typically occurs in squamous COM. Profuse discharge, which wets the pillow at night, points to mucosal COM.
4. Continuous or intermittent: Continuous discharge means the ear never becomes dry; this occurs in squamous COM. Intermittent discharge has periods of no discharge in between; this characterises mucosal COM.
5. Smell of discharge: A foul smell, resembling rotten fish, suggests squamous COM or malignancy. A musty odour indicates otomycosis.
6. Relief with medication: Discharge that relieves with medication points to mucosal COM. Discharge that does not relieve suggests squamous COM.
7. Aggravating factors: Discharge that increases with upper respiratory tract infections (URI) or water entry into the ear suggests mucosal COM.
8. Frank bleeding from the ear: This indicates trauma, glomus tumour, or vascular anomalies of the middle ear and EAC.

What Questions Should You Ask About Hearing Loss?

Ask about the duration of hearing loss. Assess the severity as mild, moderate, or severe. Furthermore, ask about specific problems resulting from the loss, such as inability to hear the doorbell, difficulty in telephonic conversation, or difficulty in normal conversation. Loss of speech discrimination suggests sensorineural hearing loss (SNHL).

1. Paracusis Willisii: All patients with conductive hearing loss hear better in noisy surroundings. Therefore, ask whether the patient hears better in a crowd or a noisy room. This happens because people speak louder in noisy environments, which overcomes the conductive deafness.
2. Fluctuating hearing loss: Ask whether the hearing loss worsens during episodes of vertigo. This fluctuation occurs in Meniere’s disease.
3. Autophony: Ask whether the patient hears their own voice as abnormally loud or echoing. Autophony indicates eustachian tube dysfunction.
4. Diplacusis: Ask whether the patient perceives a single sound as having different pitches in the two ears. Diplacusis occurs in endolymphatic hydrops (Meniere’s disease).
5. Other important questions: Ask about a history of ototoxic drug intake, occupational noise trauma, or noise exposure. Enquire about a family history of hearing loss. Finally, ask about any history of head or ear trauma.

What Questions Should You Ask About Earache?

Ask about a history of trauma. Determine the site and distribution of pain. Ask about diurnal variation: pain due to eustachian tube dysfunction and acute mastoiditis is more severe at night. This occurs because of increased venous congestion and decreased frequency of swallowing. Ask whether the pain started suddenly or insidiously. A sudden decrease in pain in a patient with AOM suggests perforation of the tympanic membrane. Pain developing in a known case of COM suggests a complication. Enquire about dental complaints because dental pathology can cause referred ear pain. Similarly, ask about difficulty in swallowing because oropharyngeal lesions can also refer pain to the ear.

What Questions Should You Ask About Vertigo and Dizziness?

Ask about the frequency of attacks. Determine the duration of each vertigo episode. Ask whether the vertigo relates to postural changes (suggesting benign paroxysmal positional vertigo). Enquire about a history of head or ear trauma. Finally, ask about associated hearing loss because this helps differentiate peripheral from central causes.

What Questions Should You Ask About Tinnitus?

Ask whether the tinnitus is continuous or intermittent. Determine the type of sound: ringing, roaring, or musical. Ask whether the tinnitus relates to the pulse (pulsatile tinnitus). Pulsatile tinnitus suggests glomus tumour, arteriovenous malformation, or sigmoid sinus diverticulum. Fluctuating tinnitus occurs with Meniere’s disease.

What Questions Should You Ask About Swelling in and Around the Ear?

Ask specifically about a postauricular abscess (behind the ear), a neck swelling (which may indicate Bezold’s abscess), a temporal swelling (Luc’s abscess), or swelling of the pinna itself (perichondritis, pseudocyst, or haematoma).

What Questions Should You Ask About Itching in the Ear?

Fungal infections usually cause constant itching. Nevertheless, remember that any ear discharge can also cause itching.

History Taking for Nose and Paranasal Sinuses

What Questions Should You Ask About Nasal Obstruction?

1. Unilateral or bilateral: Unilateral nasal obstruction occurs with a foreign body in the nose, a deviated nasal septum, a small antrochoanal polyp, a malignancy, sinusitis, or congenital unilateral choanal atresia. Bilateral nasal obstruction can result from allergic polyposis, sinusitis, deviated nasal septum, tumours, bilateral choanal atresia, enlarged adenoids, angiofibroma, a large antrochoanal polyp, or nasopharyngeal malignancy.
2. Persistent or intermittent: Determine whether the obstruction is always present or comes and goes.
3. Partial or complete: Assess the severity of obstruction.
4. History of trauma: Always ask about any previous nasal trauma.

What Questions Should You Ask About Nasal Discharge?

1. Nature of discharge: Mucoid discharge suggests allergy. Mucopurulent discharge points to sinusitis. Purulent discharge indicates bacterial infection. Watery discharge raises suspicion of CSF rhinorrhoea. Blood‑stained discharge suggests malignancy, tumours, angiofibroma, or adenoids.
2. Quantity of discharge: Assess whether the discharge is scanty or profuse.
3. Unilateral or bilateral: Unilateral nasal discharge occurs with unilateral sinusitis, a nasal mass, CSF rhinorrhoea, or a foreign body. Bilateral discharge occurs with allergic rhinitis, bilateral sinusitis, or nasopharyngeal tumours.
4. Foul‑smelling discharge: This suggests sinusitis or a neglected foreign body.
5. Postnasal discharge: Ask whether the patient feels discharge dripping from the back of the nose into the throat. This occurs in sinusitis and nasopharyngitis.

What Questions Should You Ask About Sneezing?

Ask about the frequency, timing, and triggers of sneezing. Paroxysmal sneezing suggests allergic rhinitis.

What Questions Should You Ask About Epistaxis (Nasal Bleeding)?

Ask whether the bleeding is unilateral or bilateral. Determine the amount of blood loss. Ask about a history of nasal trauma. Finally, ask about a history of hypertension.

What Questions Should You Ask About Facial Pain and Headache?

Ask about the site and character of facial pain. Frontal headache suggests frontal sinusitis. Temporal or occipital headache suggests sphenoiditis.

What Questions Should You Ask About Smell Disturbances?

Ask about loss of smell (anosmia) or alteration of smell (parosmia).

What Questions Should You Ask About Snoring and Daytime Sleepiness?

Snoring with daytime sleepiness suggests obstructive sleep apnoea, often due to nasal obstruction or enlarged adenoids.

What Questions Should You Ask About Change in Voice?

1. Rhinolalia clausa (hyponasality): This muffled, “blocked‑nose” voice occurs with nasal polyps, trauma, or a deviated nasal septum.
2. Rhinolalia aperta (hypernasality): This excessively nasal voice occurs with cleft palate, palatal paralysis, or palatal surgeries.

What Questions Should You Ask About Deformity of the Nose?

Ask about any visible or felt deformity, whether congenital or acquired.

History Taking for Nasopharynx

What Specific Questions Should You Ask?

1. Nasal obstruction: This is mostly bilateral in nasopharyngeal conditions.
2. Nasal discharge: The discharge may be mucoid, mucopurulent, purulent, or blood‑tinged.
3. Epistaxis: Ask about recurrent nasal bleeding, which occurs in angiofibroma and nasopharyngeal malignancy.
4. Hearing loss: Eustachian tube obstruction from adenoids or malignancy causes conductive hearing loss.
5. Postnasal discharge: This occurs in nasopharyngitis.
6. Change in voice: Tenth cranial nerve involvement causes hoarseness or nasal regurgitation.
7. Headache: Ask about occipital or temporal headache.
8. Neck swelling: Bilateral cervical lymphadenopathy is a common presenting symptom in nasopharyngeal malignancy. Therefore, always ask about any lump in the neck.
9. Halitosis (bad breath): This occurs in chronic nasopharyngitis and Thornwaldt’s cyst.
10. Eye symptoms: Ask about proptosis (bulging eyes) or restricted eye movements.

History Taking for Oral Cavity

What Questions Should You Ask?

1. Odynophagia (painful swallowing): This occurs in aphthous ulcers, stomatitis, and malignancy.
2. Burning sensation in the mouth: This occurs in lichen planus and glossitis.
3. Salivary disorders: Xerostomia (decreased saliva production) commonly results from post‑irradiation changes, mouth breathing, or certain drugs. Excessive saliva production may result from poor orodental hygiene, ill‑fitting dentures, or oral malignancy. However, mental retardation leads to poor swallowing of saliva, not excessive production.
4. Halitosis: This is a common complaint with poor orodental hygiene, abscesses, or tumours of the oral cavity.
5. Taste alterations: These occur in cases of coated tongue, injury to the facial nerve (chorda tympani), or due to certain drugs.
6. Earache (referred): Referred ear pain can occur in malignancies of the tongue and retromolar trigone.
7. Oral mass: Patients may present with an oral mass that they can easily see themselves, especially when located on the lips, tongue, or cheek. The cheek is slightly insensitive to pain; therefore, patients tend to ignore obvious growths there and consequently present late.
8. Neck swelling: Metastasis to lymph nodes is common with oral malignancies. Patients with tongue and floor‑of‑mouth malignancies may present with bilateral metastatic neck nodes.

History Taking for Oropharynx

What Questions Should You Ask?

1. Irritation in the throat: This occurs in tonsillitis and pharyngitis.
2. Dysphagia (difficulty swallowing): This results from bilateral tonsillar enlargement, tongue abscess, quinsy (peritonsillar abscess), malignancy of the base of the tongue, tonsil, or posterior pharyngeal wall, or parapharyngeal tumours.
3. Odynophagia (painful swallowing): This occurs in aphthous ulcers, peritonsillar abscess, and tonsillitis.
4. Hot potato voice: This muffled voice results from a large growth, especially of the tongue.
5. Foreign body sensation: Ask whether the patient feels something stuck in the throat.
6. Otalgia (referred ear pain): Referred otalgia can result from oropharyngeal malignancy.
7. Hypernasality of speech: This indicates palatal dysfunction.
8. Trismus (difficulty opening the mouth): This suggests deep infiltration or peritonsillar abscess.
9. Oral bleeding: Large ulceroproliferative malignancies or tongue bite may cause oral bleeding.
10. Halitosis: This occurs with abscesses or malignancy.
11. Nasal regurgitation: This indicates palatal palsy, where food or liquid comes out through the nose during swallowing.
12. Hearing loss: Eustachian tube dysfunction from oropharyngeal pathology can cause hearing loss.
13. Neck swelling: Metastasis to lymph nodes is common with oropharyngeal malignancies. Patients with base‑of‑tongue malignancy may present with bilateral metastatic neck nodes.

History Taking for Larynx and Hypopharynx

What Questions Should You Ask?

Generally, early symptoms help distinguish between laryngeal and hypopharyngeal diseases.

1. Voice complaints: Ask about the age of onset and progression of the voice change. Determine the character of the voice change: hoarseness, voice fatigue, aphonia (complete loss of voice), or low‑pitch voice. Ask about puberphonia (persistent high‑pitched voice after puberty). Enquire about the professional use of voice (teachers, singers, etc.). Finally, ask about any history of associated injury.
2. Respiratory obstruction: Laryngeal pathologies produce inspiratory stridor or obstruction. This occurs in subglottic malignancy and large supraglottic malignancy.
3. Foreign body sensation: This occurs in laryngitis and laryngeal tumours.
4. Cough: Ask about the duration and character of any cough.
5. Dysphagia: Difficulty swallowing can result from laryngeal or hypopharyngeal pathology.
6. Pain in the throat: Perichondritis of the laryngeal cartilages causes throat pain. Pain on deglutition can occur with arthritis of the laryngeal joints.
7. Neck nodes: Metastatic neck nodes are more common in hypopharyngeal malignancies than in laryngeal malignancies.

Past History

Ask the patient about any history of trauma, previous surgeries, long‑term medication use, tuberculosis, asthma, diabetes mellitus, hypertension, or allergies.

Socioeconomic History

Ask about the number of family members, type of house, family income, overcrowding, and education status.

Personal History

Ask about habits of addiction, alcohol intake, smoking, chewing tobacco, and the patient’s occupation.

Family History

Ask about a family history of allergy, diabetes mellitus, tuberculosis, malignancy, and bleeding disorders.

—-End of the chapter—-

High‑Yield Points for NEET PG and University Exams

1. Paracusis Willisii (better hearing in noisy surroundings) is characteristic of conductive hearing loss.
2. Autophony (hearing one’s own voice as abnormally loud) indicates eustachian tube dysfunction.
3. Diplacusis (different pitch perception in the two ears) occurs in endolymphatic hydrops (Meniere’s disease).
4. Continuous ear discharge suggests squamous COM; intermittent discharge suggests mucosal COM.
5. Foul‑smelling (rotten fish) discharge indicates squamous COM or malignancy.
6. Black discharge indicates otomycosis; watery discharge raises suspicion of CSF leak.
7. Unilateral nasal obstruction in a child suggests a foreign body until proven otherwise.
8. Bilateral cervical lymphadenopathy is a common presenting symptom of nasopharyngeal carcinoma.
9. Hot potato voice suggests a large tongue or oropharyngeal growth.
10. Nasal regurgitation indicates palatal palsy (IXth or Xth cranial nerve involvement).
11. Trismus suggests deep infiltration or peritonsillar abscess.
12. Paroxysmal sneezing with watery discharge suggests allergic rhinitis.
13. Fluctuating hearing loss with vertigo and tinnitus suggests Meniere’s disease.
14. Pulsatile tinnitus suggests glomus tumour, AV malformation, or sigmoid sinus diverticulum.
15. Referred otalgia can originate from the tongue, tonsil, or larynx because of shared nerve supply (CN IX and X).

Clinical Case Scenarios for Viva and Practical Exams

Case 1. A 35‑year‑old patient presents with a 2‑year history of intermittent, scanty, foul‑smelling discharge from the right ear. The ear becomes dry for weeks at a time. On further questioning, the patient reports no significant pain. Most likely diagnosis: Squamous chronic otitis media with cholesteatoma. What key feature in the history supports this? The discharge is scanty, foul‑smelling, and intermittent (squamous COM), whereas mucosal COM would give profuse, non‑foul, continuous discharge.

Case 2. A 50‑year‑old patient complains of hearing loss. Interestingly, the patient volunteers that he hears better in a crowded restaurant than in a quiet room. Most likely diagnosis: Conductive hearing loss. What is this phenomenon called? Paracusis Willisii. Why does it happen? People speak louder in noisy environments, which overcomes the conductive deafness.

Case 3. A 45‑year‑old male presents with a 3‑month history of unilateral nasal obstruction and blood‑stained nasal discharge. He also reports a painless lump in the left side of the neck for 2 months. On further questioning, he admits to occasional double vision. Most likely diagnosis: Nasopharyngeal carcinoma. What is the most common presenting symptom? Cervical lymphadenopathy (60–90% of patients). Why should you ask about double vision? Because cranial nerve VI is the most commonly involved nerve in NPC.

Case 4. A 60‑year‑old smoker presents with progressive difficulty swallowing solids for 4 months. He also reports a change in voice and unintentional weight loss. He denies any nasal symptoms. Most likely diagnosis: Hypopharyngeal or oesophageal malignancy. What other symptom should you specifically ask about? Referred otalgia (ear pain) because malignancies of the hypopharynx and larynx can refer pain to the ear via the vagus nerve.

Case 5. A 25‑year‑old patient presents with episodes of sudden spinning sensation lasting 20–30 minutes, accompanied by right‑sided hearing loss and a roaring tinnitus. The attacks occur 2–3 times per month. Most likely diagnosis: Meniere’s disease. What key historical features support this? Episodic vertigo (20 minutes to several hours), fluctuating hearing loss, and tinnitus. What is diplacusis? A single sound perceived as different pitches in the two ears; it occurs in endolymphatic hydrops.

Case 6. A mother brings her 4‑year‑old child with a 1‑day history of right‑sided foul‑smelling nasal discharge. The child had been playing with small beads yesterday. Most likely diagnosis: Foreign body in the right nasal cavity. What is the most important question to ask? Ask about the possibility of a foreign body and any history of putting objects into the nose. What is the typical discharge? Unilateral, foul‑smelling, purulent discharge.

NEET PG‑Style MCQs

1. A patient reports better hearing in a noisy environment. This phenomenon is called: A. Autophony B. Paracusis Willisii C. Diplacusis D. Recruitment.
2. A 50‑year‑old patient presents with intermittent, scanty, foul‑smelling ear discharge. The most likely diagnosis is: A. Mucosal chronic otitis media B. Squamous chronic otitis media C. Acute otitis media D. Otitis externa.
3. A patient complains of hearing his own voice as abnormally loud. This indicates: A. Conductive hearing loss B. Sensorineural hearing loss C. Eustachian tube dysfunction D. Meniere’s disease.
4. Blackish ear discharge most likely indicates: A. CSF leak B. Otomycosis C. Cholesteatoma D. Trauma.
5. A 6‑year‑old child presents with unilateral, foul‑smelling, purulent nasal discharge. The most likely diagnosis is: A. Allergic rhinitis B. Deviated nasal septum C. Foreign body nose D. Nasal polyp.
6. Bilateral cervical lymphadenopathy as a presenting symptom most strongly suggests: A. Tonsillitis B. Nasopharyngeal carcinoma C. Tuberculosis D. Lymphoma.
7. A patient with a known case of chronic otitis media suddenly develops severe pain. This suggests: A. Resolution of infection B. Development of a complication C. Tympanic membrane perforation D. Spontaneous healing.
8. A single auditory stimulus perceived as different pitches in the two ears is called: A. Paracusis Willisii B. Autophony C. Diplacusis D. Tinnitus.
9. A patient with oropharyngeal malignancy complains of ear pain. This is an example of: A. Direct extension B. Referred otalgia C. Metastasis D. Concurrent infection.
10. Nasal regurgitation of liquids indicates palsy of which cranial nerve(s)? A. III and IV B. V and VII C. IX and X D. XI and XII.

Answers: 1: B. 2: B. 3: C. 4: B. 5: C. 6: B. 7: B. 8: C. 9: B. 10: C.

Frequently Asked Questions in Viva

• What is paracusis Willisii and which condition does it suggest? Paracusis Willisii is the phenomenon of hearing better in noisy surroundings; it strongly suggests conductive hearing loss because people speak louder in noise, which overcomes the conductive deficit.
• How do you differentiate between mucosal and squamous chronic otitis media on history? Mucosal COM typically presents with profuse, non‑foul, continuous discharge that increases with upper respiratory infections. Squamous COM, however, presents with scanty, foul‑smelling (rotten fish), intermittent discharge.
• What does unilateral nasal obstruction in a child most likely indicate? Unilateral nasal obstruction in a child most likely indicates a foreign body, especially if associated with foul‑smelling, purulent discharge.
• Why is bilateral cervical lymphadenopathy an important symptom in ENT history? Bilateral cervical lymphadenopathy is a common presenting symptom of nasopharyngeal carcinoma; therefore, any adult with unexplained neck nodes requires nasopharyngeal examination.
• What is the difference between rhinolalia clausa and rhinolalia aperta? Rhinolalia clausa (hyponasality) is a muffled voice due to nasal obstruction. Rhinolalia aperta (hypernasality) is an excessively nasal voice due to palatal dysfunction.
• What is referred otalgia and what are its common causes? Referred otalgia is ear pain arising from a non‑otological source. Common causes include tonsillitis, peritonsillar abscess, tongue base malignancy, and laryngeal or hypopharyngeal malignancy.
• What questions should you ask a patient with vertigo? Ask about the frequency of attacks, duration of each episode, relation to postural change, history of trauma, and associated hearing loss or tinnitus.
• Why is a history of smoking and alcohol intake important in ENT? Smoking and alcohol are major risk factors for squamous cell carcinomas of the oral cavity, oropharynx, larynx, and hypopharynx. Therefore, this history guides the suspicion of malignancy.

Practical Tips for Viva and Clinical Examinations

How to present an ENT history in viva: “This 55‑year‑old male, a chronic smoker for 30 years, presents with a 4‑month history of progressive hoarseness of voice. He denies any ear discharge, hearing loss, or vertigo. He has no history of trauma or neck surgery. There is no history of weight loss or difficulty swallowing. He has no significant past medical history. Therefore, I suspect a laryngeal pathology, most likely a vocal cord lesion, and I plan to perform indirect laryngoscopy followed by direct laryngoscopy if indicated.”

Common examiner questions and how to answer them:

1. Q: How do you differentiate between conductive and sensorineural hearing loss on history alone? A: Conductive loss typically presents with paracusis Willisii (better hearing in noise), a normal ability to hear loud sounds, and often a history of ear discharge or otitis media. Sensorineural loss, however, presents with difficulty understanding speech (poor discrimination), tinnitus, and often a history of noise exposure or ototoxic drugs.
2. Q: What is the significance of asking about the smell of ear discharge? A: A foul, rotten‑fish smell suggests squamous chronic otitis media with cholesteatoma. A musty odour suggests otomycosis. Therefore, the smell helps differentiate the underlying pathology.
3. Q: Why do you ask about the relationship of vertigo with postural change? A: Vertigo that occurs only with specific head movements and lasts less than a minute suggests benign paroxysmal positional vertigo (BPPV). Vertigo that is not postural and lasts hours suggests Meniere’s disease.
4. Q: What questions help differentiate allergic rhinitis from sinusitis? A: Allergic rhinitis typically presents with paroxysmal sneezing, watery nasal discharge, itching, and seasonal variation. Sinusitis, however, presents with mucopurulent discharge, facial pain or pressure, and often fever.
5. Q: Why is a history of occupational noise exposure important? A: Chronic noise exposure causes sensorineural hearing loss, typically affecting high frequencies first. Therefore, this history helps establish the aetiology of hearing loss and guides prevention.

—-End—-

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