History and ExaminationChapter 1
OTORHINOLARYNGOLOGY
Otorhinolaryngology (oto: ear; rhino: nose; laryngo: larynx-throat), which is also called otolaryngology, is the specialty that deals with diseases of ear, nose, throat, head and neck region. Originally, the specialty was commonly called as EENT (eyes, ear, nose and throat) and included ophthalmology as well. But the two disciplines split many years ago because of the explosion of medical knowledge. In recent times, the specialty is usually called “otolaryngology–head and neck surgery”. The doctor who deals with the specialty is called otolaryngologist/ear, nose, throat, head and neck surgeon.
Otolaryngology is both medical as well as surgical specialty. Approximately, only 10% of ENT patients require surgical interference. The otolaryngologist cares for all the age groups of patients such as children, adults and old.
The subdivisions which exist within the specialty are—otology, laryngology, rhinology and bronchoesophagology. The other subspecialties recognized in recent times because of information explosion are: pediatric otolaryngology, otolaryngologic allergy, rhinology and sinus surgery, facial plastic and reconstructive surgery and head and neck (oncology) surgery. Otology includes not only ear and temporal bone but also neurotology and skull base surgery. The recent developments have made some ENT surgeons to specialize in neurolaryngology, microvascular surgery, chemosensation (taste and smell disorders), audiology and speech disorders.
Evaluation of the patient with diseases of ENT requires patience and practice because the examiner will have to deal with the narrow and darker cavities of the ear, nose, pharynx and larynx, which have relatively complex anatomy and physiology.
HISTORY TAKING
On the basis of adequate history, many conditions can be accurately diagnosed. Table 1.1 shows the general scheme of case taking.
- Personal particulars: The name, age, sex, religion, social status, occupation and residential address of the patient are noted, as many a times they are quite relevant and associated with certain diseases.
- Chief complaints: The complaints, side of affection and their duration are recorded in a chronological order of their appearance. Table 1.2 shows the list of common complaints of ENT patients. It is very important to ask patient, “What made you to consult doctor?” The details of ear, nose and throat diseases are covered in the sections of ear, nose and paranasal sinuses, oral cavity and salivary glands, pharynx and esophagus, larynx, trachea and bronchus, and neck.
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- History of present illness: It includes the details of all the complaints mentioned in the chief complaints that begin with the appearance of first symptom and extend up to the time of consultation. It usually consists of the mode of onset (sudden/gradual), preceding events causing onset, course of symptoms (progressive/constant/fluctuant; and continuous/intermittent), factors aggravating/relieving, other accompanying complaints, and the treatment taken. The common causes of headache in women are migraine, tension and trigeminal. Diurnal headache is a feature of acute frontal sinusitis. Vacuum headache is also associated with frontal sinus. In cases of unilateral disorder, note the side and site of affliction. If both ears and/or both sides of nose are affected then it should be mentioned which is more affected. Many a times negative answers are equally important in arriving at a diagnosis. Inquiries are done for any systemic diseases, which a patient might be suffering from such as diabetes, hypertension, coronary artery disease, liver or kidney disease, tuberculosis, HIV/AIDS and any bleeding disorder.
- History of past illness: It includes history of similar complaints in the past and the treatment taken and history of surgeries, accidents, radiation exposure and any complications. All the diseases with which the patient has suffered in the past should be recorded in a chronological order, whether seemingly relevant or irrelevant.
- Drug history: All the drugs which patient was/is taking such as steroids, chemotherapy, insulin, antihypertensives, diuretics, monoamine oxidase (MAO) inhibitors, contraceptives and hormone replacement therapy should be recorded.
- History of allergy: It must not be missed as the consequences can be life-threatening. Patients can be allergic to certain drugs, diets, pollens, fungi, animals and dusts.
- Personal history: Patient's occupation, personal habits (smoking, alcohol and chewing of paan, sopari and tobacco), food habits (vegetarian/nonvegetarian, regular/irregular, spicy food), lifestyle (exercise or sedentary), and marital status are included in this. In women, menstrual history and number of pregnancies and miscarriages should be recorded.
- Family history: It is important as many ENT diseases run in families and have genetic basis such as otospongiosis, certain types of sensorineural hearing loss, malignancies and autoimmune disorders. Infectious diseases such as sexually transmitted diseases (STDs), tuberculosis, mumps, pediculosis, scabies and diphtheria can affect other family members.
- History of immunization: It should be asked in children.
PHYSICAL EXAMINATION
It consists of general survey, local examination and general examination.
General Survey
The general survey includes general assessment of illness, mental state, intelligence, build, nutrition, attitude, decubitus (patient's position in bed), skin color and eruptions, and vital parameters like pulse, blood pressure, respiration and temperature.
Local Examination
It includes inspection and palpation of the affected region. Percussion and auscultation are important in a few ENT conditions.
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Examination of the draining lymph nodes is the essential component of local examination. Detailed description of ENT examination is covered in the sections of ear, nose and paranasal sinuses, oral cavity and salivary glands, pharynx and esophagus, larynx, trachea and bronchus, and neck. The general set up of otorhinolaryngological head and neck examination will be discussed in this chapter. ENT head and neck examination also includes eyes and cranial nerves.
The comprehensive examination of ear, nose, throat, head and neck include following components.
- Ears: See Chapter ‘Otologic Symptoms and Examination’.
- Nose: See Chapter ‘Nasal Symptoms and Examination’.
- Oral cavity: See Chapter ‘Oral Symptoms and Examination’.
- Pharynx: For the details of oropharynx, nasopharynx, and laryngopharynx, see Chapter ‘Pharyngeal Symptoms and Examination’.
- Larynx: See Chapter ‘Laryngeal Symptoms and Examination’.
- Head: The examination of head includes face and scalp.
- Neck: Note movements, neck veins, lymph nodes, carotid pulsation and thyroid glands. For details, see Chapter ‘Cervical Symptoms and Examination’.
Systemic Examination
It is especially required in chronic or systemic diseases, indoor patients and before surgery.
It consists of examination of all the systems such as gastrointestinal, respiratory, cardiovascular and neurological.
GENERAL SET-UP
Bull's Eye Lamp
The lamp house can be tilted and rotated and raised or lowered on the floor stand according to the need. It is a powerful source of light and provides an illumination of about 200 candlepower without any image of the filament. The patient is examined in a semi-dark room. The patient is seated erect on a stool or in a chair opposite the examiner. The head of the patient leans slightly forward towards the examiner. The child feels comfortable in mother's lap but should be held properly. Bull's eye lamp is placed on the left (some prefer right side) of the patient at the level of his shoulder. The examiner adjusts a head mirror on his/her right eye (some prefer left eye), which reflects light from the Bull's eye lamp onto the area of interest.
Head Mirror
It is a concave mirror with a central hole of 19 mm diameter. The mirror has a focal length of about 25 cm and a diameter of 89 mm (3.5 inch). It provides not only good illumination but also permits freedom to use both hands for other activities.
The perfect and comfortable use of Bull's lamp and head mirror needs some coordination, which requires practice and patience. However, some doctors prefer headlights. Both the electric bulb and fiber optic headlight of various types are available. Section ‘Operative Procedures and Instruments’ discusses some of the routinely used out patient department (OPD) instruments that are used for examining ENT patients.