History taking in ENT Flashcards
History for Epistaxis
- UNI VS BILAT?***
- Character
- fresh blood vs blood stained discharge
- colour of discharge (sinusitis is green or yellow, normal is clear) - Volume***
- If fresh blood, how much? Number of tissue papers used (dropful), spoonfuls, cupfuls, covering basin?
- >/= 1/2 cup each time: SIGNIFICANT BLEED
(think 5 causes: coagulopathy, HTN, mucosal AVM, carotid blowout syndrome, base of skull #)
- Blood stained secretions: slow bleed - Location
“When you’re standing up, where does the blood come out from first?”
- Anterior bleed: comes out from nose first
- Posterior bleed: comes out from back of throat and mouth - TRO ddx
- Trauma: nose digging, significant head injury
- Tumour: NPC sx, risk factors, constitutional sx
- Mucosal AVM: spontaneous, blocked nose
- Sinusitis: green or yellow discharge
- Coagulopathy: blood in stools/urine/gums - Red flag
- Adult
- Unilateral
- Short history
- Blood stained secretions: likely rhinosinusitis but TRO tumour
- Significant bleeding - Others
- Pmhx (HTN, cancers, coagulopathy issues)
- Drug hx (blood thinners)
- Fam hx (HHT, cancer)
Red flag signs in epistaxis
Signs of malignancy:
- Facial or nasal swelling
- Unilateral polyp (bilateral polyps are more likely to be due to allergic rhinitis)
- Unilateral otitis media effusion
- Eye signs (NPC)
- Cervical lymphadenopathy (NPC)
- Cranial nerve palsies (NPC)
History for nasal obstruction
- Characteristics of obstruction
- Duration (acute vs chronic)
- Progression (getting better or worse)
- Trigger: post URTI
- Intermittent: Inflammatory / mucosal vs persistent: structural
- Unilateral: tumour vs bilateral: inflammation vs alternating: nasal cycle (AR) - Associated nasal symptoms
* Rhinorrhoea
- Anterior or posterior (dripping sensation at back of throat, cough, at night)
- Colour of mucus
- Yellow or green: infection
- Clear: AR, CSF
- Itch, sneezing: AR
- Blood stained mucus: Tumour
- Smell (hyposmia, anosmia): sinusitis
- Facial pain/pressure: sinusitis
Localise which sinus is involved - Frontal sinus: Forehead
- Maxillary sinus: Cheeks, below eyes, upper teeth/jaw (upper toothache)
- Ethmoid sinus: Between eyes
- Sphenoid sinus: Headache, earache
- Facial numbness: tumour in maxillary sinus (compress on infraorbital branch of trigeminal nerve V2) or fracture can cause infraorbital and upper lip numbness
- Eye symptoms: Diplopia, epiphora, decreased vision –> Neoplasm
- Ear symptoms: ear blockage, OME
- Medical conditions
- Asthma
- Eczema
- Past surgeries
- Medications
-> Nasal decongestants
-> Aspirin sensitivity
-> Aspirin-exacerbated respiratory disease’s (AERD) aka Samter triad - Red flags
- Epistaxis or blood-stained mucus
- Ocular symptoms
- Facial numbness, pain or swelling
- Short duration and rapid progression - Peripheries
- SHx: occupation (wood, dust etc)
- Smoking
- Alcohol
Physical Examination for nasal obstruction
- Anterior rhinoscopy (With headlight and speculum) –> Sufficient for visualizing internal nasal valve (Aka narrowest part of nose) which is located at the front of nose
- Septum (Deviation)
- Inferior turbinate (Hypertrophy)
- Mucosa (Erythema, oedema)
- Masses or polyps - Eyes
- Chemosis
- Proptosis
- Ptosis
- Epiphora
- Ocular movements - Oral PE
- Post nasal drainage
- Ulcers
- Neurological dysfunction - Otoscopy
- Middle-ear effusion - Cervical LNs
- Lungs
- Nasoendoscopy
- Nasal cavity, nasopharynx
- Infection (sinusitis confirmed if pus seen coming out from middle meatus)
- Masses
- Polyps - Cottle’s maneuver
Investigations for nasal obstruction
Not often indicated except in specific situations
- Microbiology (Cultures of discharge like mucopus)
- Histopathology (Biopsy of any suspicious mass)
- Any lesions that appears vascular or are suspected to originate from skull base should be biopsied under GA - Allergy testing (For AR)
- Skin prick test
- Serum specific IgE - Imaging (XR/CT/MRI paranasal sinuses)
- MRI for assessing how extensive the tumour is
- Coronal cuts are used
- Opacification (does not tell you the cause): Tumour/ Fluid/ inflammation
- XR of paranasal sinuses for fractures
Approach to hearing loss
Duration, onset, progression
- congenital vs acquired
- rapid vs slow progression
Bilateral vs unilateral
Associated symptoms (TRO Ddx)
- Ear discharge (Otorrhea); Itch
- Ear pain (Otalgia)
- Blocked ears sensation
- Tinnitus (pulsatile vs non-pulsatile)
- Vertigo (Inner ear symptoms)
–> If with discharge, be careful as can have infx to inner ear
- Dizziness
–> Meniere’s
- Neurological deficit
TITS
- Trauma
- Infection
- Tumour
Risk factors (PPDFSO)
- Occupation (exposure)
- Recreational noise exposure
- Ototoxic medications (Abx, Streptomycin)
- Previous ear infections/surgery
- Perinatal/childhood infection
- Family history
Impact on life
Smoking/alcohol/drugs
Drug allergies
Clinical examination to do for hearing loss
Otoscopy
- look for visible pathologies
Rinne’s and weber’s test
History taking for hoarseness
- DROPS
- Duration
- Recurrent or persistent
- Onset
- Progression
- Severity - Characteristic
- Rough
- Strained
- Weak
- Fatiguable - Exacerbating vs alleviating factors
- Improved by voice rest - Associated factors (TRO ddx)
- Recent infection
- Iatrogenic
- FB
- Malignancy - Red flag symptoms
- Chronic smoker
- Chronic hoarseness >3months
- Dyspnea
- Dysphagia
- Blood-stained phlegm
- LOW/LOA
- Cervical Las - Voice use history
- Home
- Occupation
- Singing - Pmhx/PSuhx
- Allergic rhinitis
- LPR
- Neurological disease
- Past radiotherapy
- Endocrine (hypothyroidism): vocal cord edema
- Intubation
- Thyroid/C-spine surgery - Drug history
- Steroid use (fungal)
- ACE-i (chronic cough)
- Antihistamine (drying effect)
- Bisphosphonates (chemical laryngitis) - Social history
- Smoking
- Alcohol
- Caffeine - Impact
- Switch job
- Modify behaviour at work
- Function - How are you coping?
- Voice Handicap Inventory (VHI-10)
Physical examination for hoarseness
- GRBAS scale to assess hoarseness
- Neck PE (Masses, surgical incision)
- Oral cavity, oropharynx
- Nasoendoscopy
- Gold standard: Strobovideolaryngoscopy
History taking in Paeds stridor
- Antenatal history
- Delivery mode and perinatal complications
- Prematurity
- Syndromic features
- Voice (hoarseness) and volume of cry
- Feeding (choke, regurgitation)
- Failure to thrive
- Sleep pattern
- Cyanotic episodes / Apnea
- Previous intubation (Indication, size of ETT, traumatic, difficult , duration)
- Previous surgical intervention (cardiac, airway surgery)
- FB history
PE and ix for stable child
- Auscultate lungs
- Nose
- Oropharynx
- Neck
- Awake Flexible Nasolaryngoscopy
- High KV radiograph (lateral and AP view of neck)
- CXR (AP and lat view)
- Direct laryngoscopy, bronchoscopy and esophagoscopy
- CT/MRI reserved for cases when extrinsic vascular compression suspected
History taking in facial nerve palsy
DROPS
TRO UMN first!!!
Facial palsy
- Site
- Complete / Partial
- UMN / LMN
- Recovery (Reversible causes)
Associated symptoms (Confirm LMN + TRO DDX)
- Twitching (Less likely Bell’s palsy)
- Ear pain
- Rash
- Dry eyes
- Taste disturbances (Chorda tympani affected)
- Ear numbness
- Hyperacusis (Stapedius paralysis)
Complications
- EYE
- MOUTH
- FACE
Examination for LMN CN7 palsy
- Cranial nerve PE TRO UMN and neuro PE
INSPECT EAR CLOSELY
- Otoscopy to look at EAC and TM/ middle ear/ vesicular rashes
- Rinne’s and Weber’s tests
CHL –> Middle ear pathology
SNHL –> IAM/CPA/Brain pathology
- Parotid PE for parotid lumps or post-auricular scar suggesting past parotidectomy
- Signs of trauma (temporal bone fracture)
- Grading: House-Brackmann grading
