The ENT History
Mr T Rockley (consultant ENT surgeon)
As with most branches of medicine, the diagnosis is suggested in the
majority of cases by the history alone. There are five symptoms of ear
disease, five symptoms of nasal / sinus disease,
and five
symptoms of throat disease.
1. Deafness
Used to describe any degree of hearing loss. It
is the single most common symptom in ENT. The hearing loss may
be mild, moderate, severe or profound in degree and may be conductive,
sensorineural or mixed in nature.
Conductive losses may be due to middle ear fluid, eardrum perforation
or ossicular defects.
Sensorineural losses may be due to presbyascusis (old age), excessive
noise damage, Meniere's disease, trauma or VIII nerve tumour.
2. Tinnitus
Definition: a sensation of sound for which there is no external
stimulus.
Clinically, you need to distinguish auditory hallucinations (the sound
is organised into voices), objective tinnitus (the noise is coming from
inside the head eg vascular pulsatile tinnitus or myoclonic clicking of
palatal muscles) and subjective tinnitus (usually a hissing, buzzing or
ringing). Tinnitus may accompany any ear disease, or occur in
the absence of any other ear symptoms.
3. Vertigo
Definition: an abnormal sensation of movement.
Either the subject feels they are moving in relation to their
surroundings, or vice versa. May be rotatory or
non-rotatory. Terms such as ìdizzinessî or
"giddiness" lack precision and should always be clarified to find out
exactly what the patient is experiencing.
Ideally call your senior before admitting a patient with 'dizziness' as
the complaint - these are almost always medical rather than ENT. They
are usually best seen by the medics first.
4. Discharge
Aural discharge always indicates infection, either of the external ear,
when it is often itchy, or the middle ear. (Note- a mucoid discharge
always indicates that the infection must be coming from the middle ear).
5. Pain
Earache can be due to local disease in the ear, or referred from other
distant structures in the head and neck. Local diseases
which cause pain are inflammation in the external or middle
ear. Causes of referred earache are diseases of the
temporomandibular joint and muscles of mastication (the commonest cause
of earache in adults), tonsils, pharynx, cervical spine, or molar teeth.
Symptoms of nasal disease
1. Obstruction
Blockage to the air passage is very common, may be partial or complete.
Typical causes in children are rhinitis or adenoid
enlargement. In adults, common causes are septal
deformity, polyps, or mucosal inflammation.
2. Discharge
Nasal discharge is either clear (non-infected vasomotor mucosal
disease), yellow (might be infected, might be allergic) or
greeny-yellow (definitely infected). Unilateral foul-smelling
discharge in childhood is pathognomic of a foreign body in the nose.
3. Pain
Pain actually in the nose is a rare symptom. Usually,
pain from nasal / sinus disease is felt in the sinuses: frontal,
maxillary or ethmoid.
Sinusitis pain is characteristically described as "pressure" or
"fulness", aggravated by leaning forwards and provoked by URTI.
4. Disturbed sense of smell (dysosmia)
Anosmia is total loss of sense of smell. Other
disturbances are reduced sense of smell (hyposmia), sensing the
wrong smell (parosmia), or nasty smell in the nose (cacosmia).
The cause can be either nasal obstruction (conductive loss) or more
central (sensorineural). Common causes are post-influenza, nasal
polyps, or head injury.
5. Bleeding (epistaxis)
Several clinical types.
Juvenile type is recurrent short-lived minor bleeds from an abnormal
vein on the nasal septum.
Senile type is a single severe bleed requiring hospital admission,
often from an artery further back on the septum.
Haematological type is due to known blood clotting disorder eg liver
failure, thrombocytopenia, anticoagulation etc.
Postoperative bleeds, following septal or turbinate surgery.
Tumours in the nose don't usually cause frank bleeding, more like a
bloodstained nasal discharge.
Symptoms of throat disease
1. Pain
Pain can be localised or may be referred to one or both ears.
Usual causes are inflammation, ulceration, foreign body, or tumour.
2. Difficulty swallowing (dysphagia)
If worse for solids, think of a mechanical cause eg tumour, web,
pharyngeal pouch, peptic stricture.
If worse for liquids, think of a neuromuscular cause eg stroke, motor
neurone disease, myaesthenia gravis, lower cranial nerve palsy.
Inability to control a liquid bolus of food also causes nasal
regurgitation of liquid, or aspiration into the trachea which results
in coughing and recurrent chest infections. In
children, cerebral palsy is the main cause.
3. Stridor
Implies noisy breathing due to obstruction of the airflow in larynx and
trachea.
Noisy breathing from the pharynx is snoring or stertor; noisy breathing
from the bronchi is wheezing.
Stridor may be inspiratory, implying a supraglottic cause; expiratory,
implying a subglottic cause; or biphasic, implying intrinsic
laryngeal obstruction.
4. Globus sensation
A sensation of "lump in the throat" without actual dysphagia.
Typically fluctuates in severity and actually gets better during
mealtimes.
Usually, no underlying cause is apparent and it gets better on its own.
It is sometimes secondary to laryngeal cysts or acid reflux disease.
5. Dysphonia (altered voice)
To be distinguished from dysphasia (difficulty naming words) or
dysarthria (slurred speech, difficulty in articulation of words).
Altered voice can either be hoarse, due to intrinsic laryngeal disease,
or weak and breathy due to a paralysed vocal cord.
