ENT history taking

Rule of 5 for EAR

The 5 key symptoms to remember when asking about the ear are:
Earache (Also called otalgia)
Ear discharge (Also called otorrhoea)
Hearing loss
Tinnitus
Dizziness
Other symptoms can occur and include:
Aural blockage
Itching

Nose
Nasal obstruction
Runny nose (Also called anterior rhinorrhoea)
Loss of sense of smell (Also called hyposmia)
Nose bleeds (Also called epistaxis)
Facial pain
Other symptoms include:
Post nasal drip
Nasal itch
Sneezing
Ocular itching

Throat
Sore throat
Difficulty swallowing (Also called dysphagia)
Pain on swallowing (Also called odynophagia)
Hoarse voice (Also called dysphonia)
Regurgitation
Other symptoms include:
A feeling of a lump in the throat
Burning in the throat
Weight loss

Systemic conditions rel to ENT

30% of patients with chronic rhinosinusitis also have asthma
The nasal cavity and lungs are lined by the same type of epithelium, respiratory
epithelium. They should be regarded as all part of the same airway and as such
diseases of one can affect the other and vice versa. Always ask patients with chronic
rhinosinusitis about their chest and if necessary refer them to a chest physician for
an opinion. Some patients with chronic rhinosinusitis and asthma are also sensitive
to aspirin. People with this triad can be very difficult to treat.
Diabetes mellitus
Hypertension
Sarcoidosis
Tuberculosis
Wegener's granulomatosis
Neurofibromatosis type 2

Otorrhoea
PC
The duration of the discharge?
Is it painful?
Is it itchy?
Is there any associated hearing loss?
Has he got water into the ear (particularly if he has been on holiday - pool and sea
water contain numerous bacteria that can cause infection of the skin of the ear)?
Has he used any cotton buds or other foreign bodies to clean the ear or relieve
itching - this can damage the delicate skin of the ear canal allowing bacteria to cause
infection?
PMH
What medication if any has been used so far to treat the ear?
Has he had any problems with his ear in the past (previous ear infections requiring
medical or surgical treatment)
Other relevant medical history particularly if he is diabetic, has any skin complaints
for example eczema or any other conditions that may affect his immune system?

Otitis externa
RF: foreign body, swimming, skin conditions (eczema, psoriasis)
Causative organisms:
Aspergillus niger - commonest fungal organism to cause otitis
externa; typical white fluffy fungal hyphae and black spores that
are seen in the ear canal (cotton wool)
Staphylococcus aureus - also causes more localized infection
such as furuncles. Less common: Escherichia coli and proteus
species
Pseudomonas aeriguinosa - 50% of the cases
Malignant OE = when skull base is involved (e.g. diabetic
patients)
Mx: Gentle microsuction + 1/52 of topical Abx&steroid drops

Acute otitis media

Most common organisms: H. influenza, M. catarrhalis, S.
pneumoniae

Management of AOM
For children over the age of 2 years: Treat expectantly with analgesia and if there is no
response after 5 days, the child should be commenced on amoxicillin 50mg/kg/day
divided into three doses for 5 days
For children uner 2 years, amoxicillin should be started immediately. If there is no
response in 72 hours or the child is a neonate or immunosuppressed or there is a high
risk of B-lactamase producing organisims, use Co-amoxiclav (45mg/kg/day in three
divided doses).
If they are allegic to penicillin, use clarithromycin (15mg/kg/day in two divided doses)
Management of recurrent AOM
If the child has recurrent episodes of acute otitis media, a 6 week course of low dose
trimethroprim (1-2mg/kg/day) or amoxicillin 20mg/kg/day can be used.
It may also be important to check their immunological status including levels of
functional antibodies to streptococcus and haemophilus
If medical management fails, grommet insertion can be used to improve the
ventilation of the middle ear. This often resolves the recurrent infections.
On going problems with discharge despite the above measures raises the possibility of
rare underlying mucociliary conditions such as primary ciliary dyskinesia.

Complications of untreated AOM

include
Intratemporal
Acute otitis externa
Perforated tympanic membrane
Conductive hearing loss due to damage and adhessions around the ossicles
Sensorineural hearing loss due to toxins from bacteria entering the inner ear
Facial nerve weakness (temporary)
Vertigo
Mastoiditis
Extratemporal
Subdural/extradural abscess
Meningitis
Lateral and sigmoid sinus thrombosis
Intracranial abscess
Otic hydrocephalus

Otalgia
The duration of symptoms?
Is there associated otalgia (ear pain)?
Type of pain - dull, sharp, throbbing?
Does the pain radiate anywhere?
Is there associated otorrhoea (discharge) and is this thick or watery?
Is there hearing loss?
Is there any tinnitus?
Is there any imbalance or vertigo?
Is there any facial weakness?
What treatment have they used?
Have they been sticking foreign bodies or getting water in the ear?
Have they had any surgery to the ear?
What significant medical conditions are there eg. diabetes, eczema?
Are there any problems with their jaw, teeth, throat (referred pain)

Inflammation, debris

Otalgia - exam
External auditory canal and tympanic membrane
Insertion of trapezius and SCM muscles - spasm or myofacial
tenderness-> referred pain to the ear (ear may look normal)
TMJ - inflammatory process/mal-occlusion of TMJ pain
radiation to the ear and muscles of mastication; palpate TMJ
if the ear appears normal to assess for tenderness and
crepitation when opening and closing the jaw and moving it
from side-to-side
Throat and oropharynx - CN9 supplies sensation to post 1/3
tongue, mucosa of the oropharynx - check to ensure no lesion
in the oral cavity or pharynx causing referred pain; incl acute
pharyngitis, acute tonsillitis, dental disease, SCC, etc

Referred otalgia
The glossopharyngeal nerve supplies the posterior 1/3 of the tongue and
oropharyngeal wall as well as the medial surface of the tympanic membrane.
The trigeminal nerve supplies sensation to the oral cavity via the maxillary and
mandibular branch and the auriculotemporal branch supplies the jaw joint and the
surface of the ear.
The posterior cervical cutaneous nerves arising from the neck supply the posterior
aspect of the ear.
As a result any pathological processes in these areas can result in referred pain to the
ear:
Dental pathology
Oral and oropharyngeal carcinoma
Cervical vertabra pathology
TMJ dysfunction
Neuralgic pain

These need to be excluded if a patient presents with otalgia without any identifiable
cause within the outer, middle and inner ear
Unilateral referred otalgia - think SCC, lymphoma