DR MANPREET SINGH NANDA PROFESSOR ENT

2.  Otorhinolaryngology
 Oto – Ear
 Rhino – Nose
 Laryngo – Larynx (Throat)
 Otolaryngology – Head and Neck Surgery
 Both Medical and Surgical field (10%)
 All age groups
 Patience and practice – narrow dark cavities

3.  Listen – Heart of good history taking
 Patience with open mind
 Observe/vigilant
 Relatives
 Opening greetings – Patient at ease
 Good eye contact
 Patient’s own language
 Remember – patient too assesses you

4.  Name
 Age
 Sex
 Religion
 Social status
 Occupation
 Residential address
 Chief Complaints
 History of presenting illness
 Past History; Drug History, Treatment History, Allergy
History
 Personal History
 Family History
 Immunisation History

5.  NAME psychological benefit
 Mr, Mrs , Miss, Shri , Smt
 AGE Nasopharyngeal angiofibroma
 Cancers, Presbycusis
 SEX Thyroid – F,Larynx ca –M,cracked
voice-M
 RELIGION Ca Penis – X Jews, Muslims-
circumcision
 Social Status high, low - CSOM
 Occupation Allergies, Ca,voice disorders-
singers, NIHL
 Address nasopharynx ca,
rhinoscleroma,Peptic ulcers

6.  In patient’s own words
 2-3 chief complaints
 Chronological order as they occur
 according to severity
 Duration Short with pain - acute inflammatory
 Long without pain – neoplastic
 Long with slight pain – chronic inflamm
 Long with severe pain – malignant


7.  Mode of onset – sudden, gradual
 U/L or B/L. U/L – side, B/L – worse side
 Duration
 Progress – slow , rapid, increasing, declining or
CONSTANT
 Continous or intermittent/fluctuating (duration)
 Factors aggravating or relieving/preceding
events
 Treatment since when and where
 How it has impacted life style
 LOOK FOR NEGATIVE ANSWERS

8.  Otorrhoea (Ear discharge)
 Otalgia (Ear ache)
 Hearing Loss/impairment
 Vertigo
 Tinnitus
 Ear fullness/blockage
 Aural polyp
 Itching in ear
 Swelling and Deformity
 Foreign body/ injury

9.  Discharge from the ear
 Etiology
 Infection – EAC - otitis externa, parotitis,
otomycosis, furunculosis, acute dermatitis,
neoplasm, TM joint disease
 Middle ear – ASOM, CSOM, Mastoiditis,
cholesteatoma
 CSF leak
 Side – B/L, Right , left
 Onset – sudden – ASOM, gradual/insidious –
CSOM, malignancy
 Amount – scanty –CSOM -AAD, Otitis externa,
profuse – CSOM –TTD

10.  Duration –long – CSOM-AAD, Otitis externa
intermediate – CSOM-TTD short – ASOM, Furuncle
 Progress – intermittent – CSOM-TTD, continous –
CSOM-AAD, granulations, malignancy
 Nature – purulent – furuncle, mastoiditis,
malignant otitis externa, CSOM-AAD
 Mucoid/mucopurulent – granular myringitis,
CSOM-TTD, ASOM (late stage)
 Watery – CSF leak, eczematous/viral otitis
externa
 Bloody – ASOM (initial stage), trauma,
granulations, malignancy
 Pulsatile – ASOM with pin point perforation,
glomus tumour, ICA aneurysm

11.  Colour – green – pseudomonas infection, yellow
black – otomycosis, yellow
 Smell – odourless – allergic otitis externa, CSOM-
TTD foul smell – CSOM-AAD, cholesteatoma
 Aggravating factors – cold, head bath,
pharyngitis, tonsillitis – CSOM-TTD
 Preceding history – trauma – CSF leak, ear
surgery, skin disease
 Associated complaints
 Ear ache – Acute otitis externa, pruritus –
chronic otitis externa, otomycosis, eczema of
skin – recurrent otitis externa, retro orbital pain
– abscess, hearing loss, vertigo

12.  Pain in and around the ear
 Etiology
 Primary otalgia – local causes – inflammation,
trauma, neoplasm affecting external and middle
ear, inner ear – no pain
 Auricle – perichondritis, trauma
 EAC – furuncle, impacted wax, acute otitis
externa, FB, otomycosis, neoplasm, myringitis
 Middle ear – ASOM, cholesteatoma, mastoiditis,
ET obstruction, malignancy, CSOM- no pain
unless otitis externa, intra cranial complications
of CSOM
 Barotrauma- due to flying or scuba diving

13.  Secondary otalgia
 Referred pain to ear from other regions of head
and neck – common nerve supply
 V CN – Auriculo temporal branch of mandibular
nerve – anterior part of pinna, TM, EAC –
referred from dental, oral cavity, salivary glands,
nose, PNS, TM joint, face, parotid
 VII CN – branch of facial nerve –skin of concha,
anti helix, lobule, post EAC – referred in bell’s
palsy, herpes zoster infection
 IX CN – Jacobson’s nerve – tympanic branch to
middle ear, tympanic plexus, medial part of TM –
referred from nasopharynx, oropharynx, tonsil,
soft palate, styloid process, ET, mastoid

14.  X CN – arnold nerve- auricular branch of vagus
nerve – inferior part of TM, EAC, external ear,
concha – referred from vallecula, larynx,
laryngopharynx, oesophagus, thyroid, CAD, GERD
 C2, C3 (cervical plexus) – greater auricular and
lesser occipital nerve- post auricular region –
cervical arthritis, spondylosis, injury to cervical
spine, TB spine
 RT, LT, B/L
 Onset – sudden – furuncle, ASOM, trauma,
gradual- otitis externa due to CSOM, malignant
otitis externa, malignancy

15.  Duration – short – ASOM, perichondritis long –
malignancy
 Nature – dull – impacted wax, secretory otitis
media, eczematous otitis externa, sharp –
furuncle throbbing – ASOM
 Location – front of ear – furuncle, deep in ear –
middle ear pathology, behind ear – mastoiditis,
lymphadenitis, below ear – ET pathology
 Aggravating and relieving factors
 Relieved on discharge from ear – ASOM, increase
on swallowing – ASOM, increase on yawning,
chewing – furuncle, increase on pulling pinna
and pressing tragus – acute otitis externa

16.  Associated factors
 Tinnitus present – acoustic neuroma
 Itching present – otomycosis
 Association with ear discharge, hearing loss
 Past history – trauma, ear surgery
 Psychogenic
 More on exertion and left side pain – CAD
 Pain is always more on lying down – increased
blood supply- primary otalgia
 Costen’s syndrome – pain due to TM joint
abnormality – defective bite – associated with
tinnitus, vertigo, blocked sensation

17.  Hard of hearing – if hearing loss can improve on
treatment
 Deaf – very severe or profound with little or no
residual hearing
 Rt/Lt/bilateral
 Unilateral – CSOM, Acoustic neuroma, mumps
 Bilateral – presbycusis, meniere’s disease,
otosclerosis, noise induced
 Onset – sudden – wax, viral deafness, ASOM,
traumatic perforation, head injury, blast injury,
vascular causes, acoustic trauma, labyrinthitis
 Gradual/insidious – CSOM, OME, otosclerosis,
NIHL, presbycusis, acoustic neuroma

18.  Type – conductive – defect in external and
middle ear, SNHL – defect in inner ear or VIII CN,
mixed
 Progress – stable – CSOM TTD (non discharging),
perforated TM
 Progressive – CSOM AAD,CSOM TTD discharging,
otosclerosis, meniere’s disease, acoustic
neuroma, presbycusis
 Fluctuating – meniere’s disease, secretory otitis
media
 Degree – mild – diseases of EAC like wax, FB,
mild to moderate – diseases of middle ear, mild
to profound – inner ear diseases

19.  Duration – since birth – genetic, prenatal drugs,
maternal infections, prolonged labour, infancy
infections like mumps, measles, meningitis
 Recent – trauma, inflammation, neoplasm,
vascular
 Childhood – ASOM, OME, young adults –
otosclerosis, old age – presbycusis
 Family history – otosclerosis, meniere’s disease
 Drug history – ototoxic drugs like
aminoglycoside, quinine, salicylates, cytotoxic
drugs
 Occupational history – noisy enviroment
 Trauma, viral fever, psychogenic

20.  Diplacusis – different pitch in both ears –
meniere’s disease
 Paracusis Willisi – hears better in noisy
surroundings – otosclerosis
 Hears better in quiet place – SNHL
 Autophony – hears own voice louder – serous
otitis media, patulous ET
 Hyperacusis/ phonophobia – increased or painful
sensitivity to everyday sound that wont trouble
normal person – stapedius muscle paralysis,
congenital syphilis
 Recruitment – cant hear at normal intensity but
slight increase in intensity leads to discomfort –
cochlear pathology

21.  Perception of auditory sensation/sound ringing
or noise with no external stimuli
 33% population
 Classification
 Subjective tinnitus – only perceived by patient,
Mainly psychogenic/functional, more common
 Objective tinnitus – perceived by patient as well
as examiner. Seen in chronic contractions of
palatal or tympanic muscles, live insects in ear,
intracranial vascular tumours, patulous ET, AV
malformations, clicking TM joint

22.  Pulsatile tinnitus – non continous –
idiopathic, non vascular causes like
myoclonus, neoplasm, TM joint disease,
vascular causes like HTN, atherosclerosis,
otosclerosis, glomus tumour, anaemia,
pregnancy, exercise
 Non pulsatile tinnitus – continous – with
hearing loss seen in wax, FB, otitis media,
otosclerosis, noise exposure, presbycusis,
meniere’s disease, acoustic neuroma
 Without hearing loss – psychogenic,
idiopathic, migraine

23.  Site – ear/head
 Unilateral or bilateral
 Duration – short – middle ear disease, long –
inner ear disease like ototoxicity, meniere’s
disease
 Severity
 Fluctuant – meniere’s disease
 Past history – head injury, ear surgery, drug
intake, noise exposure
 Aggravated by smoking – inner ear pathology
 Aggravated by yawning, blowing – ET dysfunction
 Relieved by putting pressure on side of neck –
vascular cause

24.  Associated with hearing loss – ear disease
 Tinnitus is first symptom of salicylate
poisoning
 Auditory hallucination – in psychiatric
patients – hear voices and sounds like music

25.  Sensation of rotation of surrounding enviroment
with respect to person or person with respect to
surrounding. Disturbance of equilibrium or
movements
 Associated with LOC – central cause, not
associated – peripheral cause – inner ear
 Associated with loss of hearing – labyrinthitis,
meniere’s disease, acoustic neuroma (U/L)
 Associated with discharging ear – labyrinthitis
secondary to ASOM, CSOM
 Sudden onset – ear pathology
 Associated with posture – BPPV
 Associated with URTI – viral labyrinthitis

26.  Duration – 6 weeks or longer – labyrinthitis, 24
minutes to 24 hours – meniere’s disease, few
seconds several times a day – BPPV
 Otological causes – furuncle, wax due to
stimulation of vagus nerve, ET catarrh due to
negative pressure in middle ear, surgical trauma
to inner ear due to mastoidectomy,
stapedectomy, labyrinthitis, mumps, measles,
meningitis, ototoxic drugs like streptomycin
 Outside ear causes – cervical pathology,CVS –
HTN, hypotension, CNS – tumours, head injury,
metabolic – DM, Hypothyroidism, anaemia
 Functional or idiopathic

27.  Drugs like sedatives, antibiotics, anti
hypertensives, aspirin
 Tullio’s phenomenon – very loud sound
causes vertigo – seen in patients with
labyrinthine fistula or those underwent
fenestration operation
 Perilymph fistula- coughing and sneezing
causes vertigo – due to rupture of round
window (barotrauma) or at oval window due
to stapedectomy

28.  Fungal infection – otomycosis
 Allergy
 Wax
 Dermatitis
 BLOCKED EAR/ EAR FULLNESS
 Wax/ FB
 ET blockage/dysfunction – due to URTI –
aggravated on lying down
 Patulous ET – disappears on lying down or alters
with position of head
 Meniere’s disease – pressure in ear

29.  Pedunculated mass in EAC arising from EAC
or middle ear, associated with ear discharge,
hearing loss and pain in ear
 Can bleed
 Etiology
 EAC – furuncle, trauma, FB, granuloma
 CSOM TTD/AAD
 Glomus tumour – red polyp which easily
bleeds

30.  COMPLICATIONS OF CSOM
 Fever – high grade
 Headache – severe and deep seated
 Nausea and vomiting – labyrinthitis,
complications of CSOM, Meniere’s disease
 Convulsions
 Diplopia
 Cervico facial pain
 Facial nerve palsy – idiopathic (bell’s palsy),
complications of ASOM/CSOM
 Post aural swelling - mastoiditis

31.  Nasal complaints like nasal obstruction,
discharge, post nasal discharge
 Throat complaints like irritation, dysphagia,
change in voice
 Allergy and bronchial asthma – ET
dysfunction, serous otitis media
 DM – Malignant otitis externa, sudden SNHL
 HTN – Sudden SNHL
 Radiation – SNHL
 Mumps, measles, chicken pox – SNHL
 Anti thyroid drugs - giddiness

32.  Treatment for the same illness in the past or
any other illness
 Diabetes, HTN, TB, Asthma and allergies, HIV,
HBV, syphilis, radiation exposure
 Surgeries - ear, hospital admissions, Trauma
 Deliveries and pregnancies
 Drug history- at present or past- steroids,
insulin, ocp, anti hypertensives, nasal
decongestants, ototoxic drugs
 Allergy history – drugs or diet or allergen
 FOR DRUG ALLERGY – WRITE IN RED

33.  Life style – exercise, sedentary, hygiene
 Food habits – regular-irregular, spicy-non
spicy, nonveg- veg, excess tea or coffee
 Work place – noisy enviroment
 Home – dampness, pets, hobbies
 Alcohol, Tobacco – quantity, quality
 Sexual life
 Bladder & Bowel habits
 Menstrual history

34.  Enquire about parents, siblings and children
 h/o similar illness in family
 Familial diseases like Peptic ulcer, cancers,
allergies, diabetes and HTN, otosclerosis,
deaf mutism, meniere’s disease
 Consanguinous marriage
 Infectious diseases- by contact – TB , acute
infections

35.  Children – immunisation schedule
 OBSTETRIC HISTORY – early deafness
 Ototoxic drugs to mother during 1st trimester
 Infections to mother – rubella, mumps
 Birth trauma
 Post natal jaundice
 CONCLUSION OF HISTORY
 Ask patient about his any other concerns
 Say Thank You
 Explain the examination part and need
 Proceed to examine