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Detailed History Taking in ENT OPD

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1. BIODATA (Patient Identification)

Name

• Establishes patient identity and builds rapport.
• Helps avoid confusion with other patients.
• Cultural/regional names can give clues to ethnic susceptibility (e.g., certain hereditary hearing disorders in specific populations).

Age

• One of the most discriminating data points in ENT.
• Children: Adenoid hypertrophy, recurrent otitis media, foreign bodies in ear/nose, choanal atresia, laryngomalacia.
• Young adults: Acute tonsillitis, allergic rhinitis, vocal cord nodules (singers), otosclerosis (20-40 years).
• Middle age: Presbycusis begins, chronic sinusitis, laryngeal carcinoma, thyroid swellings.
• Elderly: Carcinoma of larynx/hypopharynx, age-related hearing loss, dysphagia due to malignancy.

Sex

• Males: Higher incidence of laryngeal carcinoma, head and neck cancers (smoking-related), noise-induced hearing loss (occupational).
• Females: Otosclerosis is more common and progresses faster. Thyroid swellings are 8x more common. Vocal cord nodules in female professional singers.
• Hormonal factors influence nasal congestion (pregnancy rhinitis, menstrual-cycle related changes).

Occupation

• Extremely important in ENT.
• Noise exposure: Factory workers, musicians, military personnel → noise-induced sensorineural hearing loss (NIHL).
• Dust/chemical exposure: Carpenters, nickel/chromate workers → sinonasal adenocarcinoma, perforation of nasal septum.
• Voice professionals: Singers, teachers, call center agents → vocal cord nodules, vocal fatigue, chronic laryngitis.
• Agriculture: Farmers → fungal sinusitis (aspergillosis), leech in throat (endemic areas).
• Referred to in Scott-Brown's Otorhinolaryngology as essential for diagnosing occupational rhinitis - symptoms worsen during the working week and improve on weekends/holidays.

Address / Residence

• Geographical/endemic patterns: Rhinosporidiosis in South India and Sri Lanka, Wegener's granulomatosis, nasopharyngeal carcinoma (Southern China, Southeast Asia).
• Rural vs. urban: allergic rhinitis higher in urban (pollution), tuberculosis higher in rural/overcrowded areas.
• Helps with follow-up and contact tracing (e.g., active TB of larynx).

Socioeconomic Status

• Poverty → malnutrition → poor immune function → recurrent tonsillitis, otitis media, TB.
• Overcrowded living → easy spread of upper respiratory infections among children.
• Impacts access to healthcare and treatment compliance.

Marital Status

• Relevant for sexually transmitted causes: syphilis (saddle nose, palatal perforation, sensorineural hearing loss), HPV-related laryngeal papillomatosis (vertical transmission from mother during delivery).
• Impacts patient stress levels (voice disorders can be stress-related).

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2. PRESENTING COMPLAINT (PC)

• Recorded in the patient's own words, not medical terminology.
• Note the number of complaints and arrange in order of duration (longest first) or severity.
• Common ENT complaints: ear pain (otalgia), ear discharge (otorrhoea), hearing loss (hypoacusis), ringing in ears (tinnitus), vertigo/dizziness, nasal obstruction, nasal discharge (rhinorrhoea), sneezing, loss of smell (anosmia), nose bleed (epistaxis), sore throat, difficulty swallowing (dysphagia), change in voice (dysphonia), neck swelling, snoring, facial pain/pressure.

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3. HISTORY OF PRESENTING ILLNESS (HPI)

Key symptom-specific questions:

• Unilateral vs. bilateral; sudden vs. gradual
• Fluctuating? (Meniere's disease)
• Associated tinnitus, vertigo?
• Better in noisy environment? (paracusis Willisii = otosclerosis)
• Preceded by URTI? (sudden SNHL)
• Drug intake (aminoglycosides, quinine, aspirin, furosemide = ototoxic drugs)

• Continuous vs. intermittent; unilateral vs. bilateral
• Color: yellow/green (infected), blood-stained (cholesteatoma, malignancy), watery (CSF otorrhoea)
• Odour: foul-smelling (cholesteatoma, malignancy)
• Associated hearing loss

• True rotatory vertigo vs. giddiness/unsteadiness
• Duration: seconds (BPPV), minutes-hours (Meniere's), days (vestibular neuritis)
• Positional? (BPPV)
• Associated nausea/vomiting
• Hearing loss/tinnitus with vertigo = labyrinthine cause

• Unilateral (septal deviation, polyp, foreign body, angiofibroma, malignancy) vs. bilateral (allergic rhinitis, vasomotor rhinitis)
• Constant vs. alternate (alternating nasal obstruction = vasomotor rhinitis)
• Since childhood? (choanal atresia, DNS)

• Which nostril? Quantity (trickle vs. torrential)? Anterior vs. posterior bleeding?
• Spontaneous vs. post-traumatic
• Anticoagulant/aspirin use? (as noted in K.J. Lee's Essential Otolaryngology - bleeding history is more reliable than lab tests)
• Hypertension? Blood disorders?

• For solids only (mechanical/obstructive = malignancy), liquids (neurological), or both
• Progressive (carcinoma) vs. intermittent (pharyngeal pouch, foreign body)
• Level: oropharyngeal (difficulty initiating swallow) vs. esophageal (food sticking)
• Associated weight loss, hoarseness (malignancy red flags)

• Duration: >3 weeks = always investigate to exclude malignancy
• Progressive (malignancy) vs. intermittent (vocal cord nodules, functional)
• Voice overuse? Smoking? GERD? (laryngopharyngeal reflux)
• Preceded by URTI? (acute laryngitis)

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4. PAST HISTORY (PH)

• Previous ENT surgeries: Tonsillectomy, adenoidectomy, myringotomy with tubes, septoplasty, FESS - changes anatomy, modifies presentation of new complaints.
• Previous ENT illnesses: History of chronic otitis media, allergic rhinitis, sinusitis, recurrent tonsillitis.
• Trauma to head/neck/ear: Temporal bone fractures cause SNHL/facial nerve palsy; nasal fractures alter anatomy.
• Radiation therapy to head/neck: Can cause xerostomia, osteoradionecrosis, radiation-induced deafness.
• Hospitalizations: Prior anesthesia (relevance if patient needs surgery - difficult airway in ankylosis, restricted mouth opening).

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5. MEDICAL HISTORY

• Diabetes mellitus: Predisposes to malignant otitis externa, mucormycosis (rhinocerebral), invasive fungal sinusitis - all emergencies.
• Hypertension: Common cause of posterior epistaxis; warrants careful management.
• Hypothyroidism: Can cause hoarseness (myxedematous infiltration of cords), macroglossia, mucosal fullness.
• GERD/LPR: Major cause of chronic laryngitis, throat clearing, subglottic stenosis in children.
• Autoimmune diseases: Wegener's granulomatosis (saddle nose, perforated septum, deafness), Sjogren's (xerostomia), sarcoidosis (nasal polyps, lupus pernio), relapsing polychondritis (auricular chondritis, nasal collapse).
• HIV/immunosuppression: Unusual infections (Pneumocystis, CMV), Kaposi's sarcoma (palate/nasal), lymphoma.

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6. DRUG HISTORY

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7. ALLERGY HISTORY

• Drug allergies (especially antibiotics like penicillin - relevant for ENT infections; sulfa drugs; local anesthetics).
• Allergic rhinitis: What triggers? (seasonal = pollens; perennial = dust mites, animal dander, cockroach).
• Food allergies: Some link with laryngeal edema (angioedema).
• Latex allergy is important pre-operatively.
• Atopy triad (asthma + allergic rhinitis + eczema): high probability of nasal polyps.

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8. FAMILY HISTORY

• Hearing loss: Hereditary hearing loss is the most common sensory deficit at birth; many are autosomal recessive (connexin 26 mutations - GJB2 gene). Ask if parents are consanguineous.
• Otosclerosis: Strong familial tendency (autosomal dominant, 25% penetrance).
• Allergic rhinitis/asthma: Strong genetic component (atopic tendency runs in families).
• Head and neck cancer: HPV-related oropharyngeal cancer can cluster; familial nasopharyngeal carcinoma in Chinese families.
• Von Willebrand disease/hemophilia: Relevant for recurrent epistaxis and pre-operative assessment.
• Neurofibromatosis type 2: Bilateral acoustic neuromas (vestibular schwannomas).

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9. PERSONAL HISTORY (Lifestyle & Habits)

Addiction/Substance Use

Diet

• Vitamin C deficiency → poor wound healing (post-tonsillectomy).
• Iron deficiency anaemia → Plummer-Vinson syndrome (dysphagia, post-cricoid web, koilonychia).
• Spicy/hot food, coffee, chocolate → worsens GERD/LPR → chronic laryngitis.

Sleep

• Snoring, witnessed apneas, waking up unrefreshed → screen for Obstructive Sleep Apnea (OSA).
• Epworth Sleepiness Scale score as a quick screen.

Menstrual/Obstetric History (in females)

• Pregnancy rhinitis (due to elevated estrogen causing nasal congestion).
• Menstrual cycle-related epistaxis (vicarious menstruation).
• Hormonal changes worsen otosclerosis.
• Vocal changes premenstrually (premenstrual vocal syndrome in singers).

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10. TREATMENT HISTORY

• What treatment has already been taken for the current complaint?
• Response to antibiotics (partial response may indicate resistant organism or malignancy masquerading as infection).
• Response to steroids (implies inflammatory/allergic etiology).
• Previous failed surgeries.

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11. REVIEW OF SYSTEMS (Systemic Enquiry)

• General: Weight loss (malignancy), fever (infection, lymphoma), fatigue.
• Eyes: Diplopia/proptosis (orbital extension of sinusitis/malignancy), epiphora (NLD obstruction, nasal pathology).
• Respiratory: Asthma (united airway disease with rhinitis - both share same mucosal lining), cough (postnasal drip, LPR).
• Cardiovascular: Hypertension (epistaxis), atrial fibrillation (anticoagulant use).
• Neurological: Facial pain/numbness (skull base involvement), facial palsy (temporal bone disease, parotid malignancy), headache (sinusitis, intracranial complication).
• Neck: Cervical lymphadenopathy, thyroid swelling (as a neck mass in ENT OPD).

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Summary Table: Why Each Point Matters

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