History Taking in ENT

1. General Framework

• Site, Onset, Character, Radiation, Associations, Timing/course, Exacerbating/relieving factors, Severity

2. Ear (Otological History)

Common presenting symptoms

• Onset: sudden vs. gradual
• Unilateral or bilateral
• Fluctuating or progressive
• Associated tinnitus, vertigo, aural fullness
• History of noise exposure, ototoxic medications, head trauma, ear infections or surgery
• Family history of deafness

• Site: inside the ear or periauricular
• Primary vs. referred otalgia (common referral sources: dental disease, TMJ, tonsils, larynx, cervical spine - via CN V, IX, X, and C2-C3)
• Associated discharge, hearing loss, fever

• Character: watery, mucoid, mucopurulent, bloody, cheesy/foul (suggests cholesteatoma)
• Duration and frequency
• Relation to upper respiratory infection
• Painless chronic discharge - consider chronic suppurative otitis media

• Subjective (most common) or objective (pulsatile - vascular cause)
• Unilateral or bilateral
• Pitch and character (ringing, buzzing, roaring)
• Associated hearing loss or vertigo
• Effect on sleep and quality of life

Flowchart for approaching dizziness history - K.J. Lee's Essential Otolaryngology

3. Nose and Sinuses (Rhinological History)

Common presenting symptoms

• Unilateral or bilateral; constant or intermittent
• Worse at certain times (day/night, season) - suggests allergy or structural cause
• Associated mouth breathing, snoring, sleep apnoea

• Character: clear/watery (allergy, CSF leak), mucoid, mucopurulent, bloody
• Unilateral bloodstained discharge in an adult - consider malignancy

• Site: anterior (Little's area, most common) vs. posterior
• Frequency, duration, volume
• Precipitating factors (trauma, nose-picking, anticoagulants, hypertension)
• Family history (hereditary haemorrhagic telangiectasia)

• Sudden onset (post-URI, post-traumatic) vs. gradual/fluctuating (sinusitis, allergic rhinitis, neurodegenerative disease)
• Congenital anosmia (Kallmann syndrome)
• Clarify the taste-smell distinction: flavor complaints are largely smell-dependent, while basic taste perception (sweet, sour, salty, bitter, umami) is separate

• Location: forehead (frontal), cheeks (maxillary), between eyes (ethmoidal), top of head (sphenoidal)
• Relation to posture (worse bending forward - sinusitis)
• Associated with nasal discharge or blockage

• Suggests allergic rhinitis; ask about allergen exposure (dust, pollen, animals, occupational allergens)

4. Throat and Larynx (Laryngopharyngeal History)

Common presenting symptoms

• Level: oral, pharyngeal (nasal regurgitation, coughing on swallowing), oesophageal
• Solids only (mechanical obstruction - stricture, carcinoma) vs. solids and liquids (motility disorder)
• Progressive (sinister - carcinoma) or intermittent (web, dysmotility)
• Associated odynophagia (painful swallowing), weight loss, hoarseness, regurgitation

• Duration: >3 weeks is a red flag requiring laryngoscopy to exclude malignancy
• Character: breathy (vocal cord palsy), rough/harsh (nodules, laryngitis), strained (spasmodic dysphonia)
• Associated with voice use (singers, teachers - vocal abuse), reflux, smoking

• Acute vs. chronic
• Associated fever, trismus (peritonsillar abscess), difficulty breathing (epiglottitis - emergency)
• Recurrent tonsillitis: number of episodes per year, school/work days lost

• Inspiratory (supraglottic/glottic), expiratory (subglottic/tracheal), or biphasic
• Onset: acute (foreign body, epiglottitis, angioedema) or chronic (subglottic stenosis, papillomatosis)
• This is always a potential airway emergency

• Location, onset, duration, growth rate
• Associated symptoms: dysphagia, voice change, pain, constitutional symptoms (fever, night sweats, weight loss - lymphoma)
• Skin changes, fixation to underlying structures
• Exposure history: TB contact, cat scratch, EBV

5. Sleep-Related History (OSA)

• Sleep habits, hygiene, typical sleep/wake times, shift work
• Daytime sleepiness (Epworth Sleepiness Scale - score >10 is significant)
• Observed apnoeic episodes (history from bed partner is invaluable)
• Morning headaches, nocturia, poor concentration
• Comorbidities: hypertension, obesity, metabolic syndrome, cardiovascular disease
• Occupational risk: drivers or heavy machinery operators have legal reporting implications in some jurisdictions

6. Head and Neck / Salivary Gland History

• Which gland(s) are affected: onset, duration, progression
• Pain: character, intensity, duration
• Cranial nerve deficit (facial nerve - parotid; trigeminal)
• Salivary discharge, dry mouth/eyes (Sjogren's)
• Otalgia (referred from parotid)
• Fever, weight loss, neck swelling
• Social history: smoking, alcohol, travel, infections, sexual history
• Family history: autoimmune disorders, head and neck neoplasms, lymphoma, genetic syndromes

7. Red Flag Symptoms in ENT

Section 1: General Framework of ENT History Taking - Expanded

Step 1 - Introduce and Establish Rapport

• Greet the patient, confirm their name and age
• Open with an open-ended question: "What has brought you in today?" or "Tell me what's been bothering you."
• Let the patient speak for 1-2 minutes without interruption - studies show most patients finish their opening statement in under 90 seconds if allowed to continue

Step 2 - Presenting Complaint (PC)

Step 3 - History of Presenting Complaint (HPC)

• Onset: abrupt vs. gradual; progressive, intermittent, or continuous
• Associated symptoms: tinnitus, vertigo, aural fullness, pain, allergy symptoms, distorted auditory perception
• Whether symptoms worsen with pregnancy or oral contraceptive use (relevant for otosclerosis)

Step 4 - Past Medical History (PMH)

• General medical conditions: diabetes (wax buildup, malignant otitis externa), hypertension (epistaxis, pulsatile tinnitus), autoimmune disease (sudden SNHL, Wegener's, Sjogren's), hypothyroidism (hoarseness, goitre)
• Previous ENT conditions: recurrent tonsillitis, otitis media, sinusitis, nasal polyps, previous hearing loss
• Previous ENT surgery: myringotomy and grommets, tonsillectomy, adenoidectomy, septoplasty, FESS, mastoidectomy - ask about outcome and any complications
• Other surgical history that may be relevant (e.g., neck dissection, thyroid surgery affecting the recurrent laryngeal nerve causing hoarseness)
• Significant infections: meningitis (causes SNHL), syphilis (causes SNHL and vestibular problems), mumps (unilateral SNHL)

Step 5 - Drug History

Step 6 - Allergy History

• Drug allergies: ask about the specific reaction (true anaphylaxis vs. intolerance)
• Atopic triad: allergic rhinitis, asthma, eczema - often co-exist; critical for rhinology workup
• Seasonal vs. perennial pattern (perennial suggests house dust mite or pet allergy; seasonal suggests pollen)
• Food allergies (relevant in eosinophilic oesophagitis causing dysphagia; oral allergy syndrome)
• Latex allergy (relevant pre-operatively)

Step 7 - Family History (FH)

Step 8 - Social History (SH)

Step 9 - Systems Review

• Constitutional: fever, night sweats, unintentional weight loss (lymphoma, malignancy)
• Neurological: diplopia, facial weakness/numbness, dysphagia, hoarseness (cranial nerve involvement)
• Respiratory: cough, wheeze, breathlessness (asthma linked to nasal polyps; laryngeal cause of cough)
• Gastrointestinal: heartburn, regurgitation (laryngopharyngeal reflux causing hoarseness, globus, chronic cough)
• Rheumatological: joint pains, dry eyes/mouth (Sjogren's affecting salivary glands)

1. General Framework - Opening the consultation + SOCRATES table
2. Ear (Otological) - Hearing loss, otalgia, otorrhoea, tinnitus, vertigo (with the K.J. Lee vertigo history table)
3. Nose & Sinuses - Obstruction, rhinorrhoea, epistaxis, anosmia, facial pain
4. Throat & Larynx - Dysphagia, hoarseness, sore throat, stridor, neck lump
5. Drug History - ENT-relevant medications table (ototoxics, anticoagulants, etc.)
6. Family & Social History - Genetic conditions + occupational/lifestyle factors
7. OSA History - Sleep-specific questions
8. Red Flags - Highlighted in red for quick reference