Even in this era of sophisticated investigations, good history taking remains as an essential skill and need for an accurate diagnosis.
Name: Most beautiful word to ones ear is his own name. Try to call your patient by his/her name.
Age: Congenital anomalies commonly seen in early childhood. Tonsil and adenoid hypertrophy is seen in children. Nasopharyngeal angiofibroma is seen in puberty. Presbycusis happen in old age. Malignancies seen in older age group, though no age is immune to it.
Sex: Nasopharyngeal angiofibroma seen in males. Malignancies of head and neck except postcricoid malignancy is common in males. Atrophic rhinitis and otosclerosis is common in females.
Occupation: Occupation helps to know the socioeconomic status, in reaching a diagnosis and in planning treatment. Voice disorders due to chronic laryngitis, vocal nodule, vocal polyp, gastroesophageal reflex disease, etc. are mostly seen in school teachers, lawyers, singers or preachers. Sinonasal malignancies are more in woodworkers and those in metal and petroleum refineries.
Residence: Documentation of residence helps in research purpose and follow-up of patient. Rhinosporidiosis is common along coastal areas.2
PRESENTING COMPLAINTS
Common presenting complaints are as follows:
- Ear: Earache (otalgia), ear discharge (otorrhea), hearing loss (deafness), headache, fever, swelling in and around ear, itching, giddiness, ringing in ear (tinnitus), deviation of angle of mouth, inability to close the eyes.
- Nose: Nasal discharge (rhinorrhea), nasal block, facial pain and headache, bleeding from within the nose (epistaxis), smell disturbances, postnasal drip, speech defect, sneezing, cresting, itching nose, epiphora, snoring, deformity of nose.
- Larynx and pharynx: Change in voice, difficulty in breathing, noisy breathing (stridor), cough, sorethroat, foreign body sensation in the throat, mouth breathing, dysphagia (difficulty in swallowing), odynophagia (painful swallowing), swelling neck.
All these should be written in chronological order. If multiple complaints of same duration, write according to severity.
HISTORY OF PRESENTING COMPLAINTS
Narrate this in patient's own language. Avoid medical terms as far as possible. Negative history may be helpful at times.
Details of each presenting complaint should be asked.
Earache (Otalgia)
Pain in the ear may be due to lesions in the ear itself or due to diseases in areas having same dermatomal innervation (Referred Otalgia).
- Duration
- Character—whether it is dull aching, stabbing, pricking type
- Severity—pain is very severe in furuncle ear, acute otitis media and perichondritis of pinna. Mild in uncomplicated chronic suppurative otitis media, wax, etc.
- Whether unilateral or bilateral.
Otorrhea
- Duration: Acute, chronic or acute exacerbation of chronic disease.
- Scanty/Profuse: Discharge is usually scanty in dermatitis of external canal and chronic suppurative otitis media atticoantral disease (CSOM-AAD). In tubotympanic disease (CSOM-TTD) discharge is profuse.
- Constant/Intermittent: If intermittent, relation with upper respiratory infection or water entry to ear should be asked. Such a history is usually associated with CSOM-TTD.
- Character of discharge:
- Watery (serous): CSF otorrhea, diffuse otitis externa, early stage of acute otitis media.
- Mucoid: Discharge is sticky in nature. Produced by mucus glands present in middle ear. Seen in ASOM/CSOM. It shows that discharge is coming from middle ear through a perforation of tympanic membrane.
- Mucopurulent: Colored tenacious ear discharge. Seen in ASOM/CSOM (active).
- Purulent: Thick tenacious discharge. Common in external otitis with furuncle, otomycosis, cholesteatoma, etc. This purulent discharge usually signifies an underlying bone eroding process in middle ear.
- Bloodstained (serosanguinous): Seen in ear trauma, malignancy, barotrauma, hemangioma, glomus jugulare tumor, granulation ear, etc.
Hearing Loss
Ask about:
- Onset: Whether onset is sudden or gradual.
- Duration: Congenital deafness may be due to genetic causes or prenatal/perinatal maternal factors like intake of drugs or infections. Deafness of recent onset is due to trauma, infections, vascular, metabolic, etc.
- Severity
- Laterality: Whether bilateral/unilateral.
- Nature of deafness: Improvement during periods of discharge seen in active stage of CSOM. Paracusis Willisii (improvement of hearing in noisy surroundings) seen in otosclerosis. Recruitment present in cochlear lesions. Fluctuating deafness seen in secretory otitis media and Meniere's disease.
Giddiness
This symptom should be asked in detail as this term is most often interpreted wrongly by the patient. Sense of unsteadiness is termed as giddiness, but vertigo is a hallucination of movement of body or surrounding. It is a subjective feeling of imbalance. This sensation is very unpleasant and patient may vomit during attacks of vertigo. Try to know the exact feeling the patient is having. Find out whether it is true vertigo or a syncopial attack in which patient gets a black out or just a giddiness. Note any history of preceding upper respiratory infection. Ask how and when it started, duration of each attack, frequency of each attack, association with other complaints like nausea, vomiting, tinnitus, hearing loss, visual problems, seizures, history of migrainous attacks, any drug intake, trauma and thyroid medication.
Tinnitus
Ringing sensation in the ear. It can be subjective (heard only by the patient) or objective (heard by other persons also). 5Here also enquire about mode of onset, duration, whether unilateral/bilateral, severity, periodicity and associated symptoms.
Nasal Block
- Duration: Helps to say whether disease is acute/chronic.
- Whether unilateral/bilateral: Unilateral nasal block is common in deviated nasal septum, foreign body nose, antrochoanal polyp, etc. Bilateral nasal block seen in ethmoid polyps, allergic rhinitis or septal hematoma.
- Whether constant or intermittent.
- Whether progressive in nature or not.
Nasal Discharge
- Unilateral or bilateral.
- Types of discharge:
- Watery discharge seen in early stages of common cold, vasomotor rhinitis and CSF rhinorrea.
- Mucoid discharge is common in allergic rhinitis.
- Purulent in atrophic rhinitis, FB nose, furunculosis.
- Bloodstained in malignancy, FB, nonhealing granuloma, nasal myiasis, etc.
- Mucopurulent discharge is seen in infective rhinitis, sinusitis, malignancy, etc.
- Amount: Scanty/Moderate/Copious.
Facial Pain and Headache
Ask
- How it started: Spontaneously/induced by something like trauma
- How long the pain last?
- Any aggravating/relieving factors
- Any diurnal variation (change with time of day/night)
- Does associated with restricted/painful neck movements.
Headache of each sinusitis have typical characters:
- Frontal sinusitis: Headache of frontal sinusitis is usually located in frontal and superciliary area. Pain aggravates on looking down. Headache is more when patient wakes up in the morning, lasts for few hours and relieves by evening. This is called office headache as pain present during office hours. This is due the gravity dependent drainage of frontal sinus.
- Maxillary sinusitis: Pain more on upper jaw, teeth and spread over cheek. Usually dull aching type more towards evening. Pain more on stooping or coughing.
- Ethmoid sinusitis: Pain more marked in children. Movement of eye will be painful and associated with lid edema. Pain localized over nasal bridge and inner canthus behind the eye.
- Sphenoid sinusitis: Headache is experienced in the vertex or occiput. Severe cases are associated with visual problems.
Epistaxis
Confirm whether fresh blood, clotted blood or bloodstained discharge.
- Enquire about amount of blood loss
- History of trauma causing epistaxis
- Intake of any drugs like anticoagulants
- Bleeding from any other sites
- History of similar episodes in the past should be asked.
Disturbances of Smell
- Anosmia: Total loss of smell (seen in head injury, intracranial mass lesions or functional)
- Parosmia: Altered sense of smell (allergic rhinitis)
- Cacosmia: Any smell is experienced as fowl (chronic sinusitis).
Postnasal Drip
Defined as waterfall like whitish discharge seen in posterior wall of oropharynx. Patient will tell as excessive discharge coming from behind the nose causing various pharyngeal symptoms. Postnasal drip occurs more in allergic and infective diseases of nose, nasopharynx (adenoids and Thornwald's disease, bursitis) or paranasal sinuses (sinusitis).
Change in Voice
Nose and paranasal sinus give timber to our voice. In nasal mass and in rhinitis, there will be a nasal twang of voice. Mass in the nasopharynx cause rhinolalia clausa. Cleft lip, cleft palate and postadenoidectomy patients speak in rhinolalia aperta.
Sneezing
Occasional sneezing is a normal nasal reflex. Excessive sneezing is seen in allergic rhinitis.
Pain in the Throat (Sore Throat)
Enquire whether pain or discomfort, present at rest or during chewing and swallowing, duration, progressive or not, constant/intermittent, localized/spread to surrounding area, associated symptoms like fever, change in voice, swelling neck, etc.
Difficulty in Swallowing (Dysphagia)
Ask whether swallowing difficulty is due to pain on swallowing (Odynophagia) or food does not pass down below or both.
Neck Swellings
Can be enlargement of thyroid or cervical lymph nodes or salivary gland swellings.
Like this positive and negative history of each presenting complaint should be asked and noted down.
HISTORY OF PAST ILLNESS
Ask about
- Similar complaints in the past
- History of diabetes mellitus, hypertension, bronchial asthma, pulmonary tuberculosis
- History of exanthematous fevers (influenza, scarlet fever, viral pneumonia, measles, etc. can lead to acute necrotizing otitis media)
- History of any surgeries in the past (if present enquire done under general or local anesthesia, duration of hospital stay, any intraoperative/postoperative complications)
- Allergy to drugs (aspirin hypersensitivity seen in ethmoid polyp)
- History of allergic rhinitis.
PERSONAL HISTORY
- Bowel/bladder habits
- Sleep/appetite
- Addictions: Important in malignancies. In smokers, calculate the number of pack years (number of packets per day multiplied by years of use).
FAMILY HISTORY
- History of overcrowding: Overcrowding is defined as “two persons of opposite sex having age above 9 years forced to live in same room, because of a situation in which more people are living within a single dwelling than there is space for, so that movement is restricted, privacy secluded, hygiene impossible, rest and sleep difficult”
- Socioeconomic status (calculate per capita income or ask APL/BPL ration card)
- History of diabetes mellitus, hypertension, bronchial asthma in the family.
MENSTRUAL HISTORY IN FEMALES
Thyroid disorders are usually associated with menstrual distur- bances.
TREATMENT HISTORY
Drugs like salicylates, aminoglycosides, quinine and cytotoxic drugs can cause deafness. Tinnitus is the first important symptom of salicylate poisoning. Patients taking ototoxic drugs may also get vertigo. Glossitis, stomatitis, etc. are seen after chemoradiation. History of treatment for hypo/hyperthyroidism should be asked as it is usually associated with complaints of voice and throat. Drugs like warfarin and anticoagulants can cause epistaxis.