History taking and careful clinical examination is very much essential to establish a proper diagnosis. No amount of present day sophisticated investigations can replace thorough history taking and careful clinical examination.
History taking for ear diseases can be described under the following headings:
• Chief complaints
• History of presenting symptoms
• Past history
• Family history
• Personal history
• Treatment history
• General examination
• Local examination
• Systemic examination
• Provisional diagnosis
• Differential diagnosis.
Common Symptoms of Ear Diseases
• Hearing impairment
• Otalgia (pain in the ear)
• Blocked sensation
• Feeling of fullness
• Neuro-otological symptoms like:
(c) Stiffness of neck (d) Facial nerve palsy (e) Vomiting
(g) Cervicofacial pain
• Swelling and deformity.
HISTORY OF PRESENTING ILLNESS
All the above mentioned symptoms have to be analyzed under the following heading. Pertinent questions have to be asked, to know how did the disease start and what is the duration? How has it progressed up to this moment? Whether onset is sudden or gradual? All these questions should be asked strictly and impartially, without the influence of a preconceived idea which may tend to mislead the patient from the beginning. These questions lead to a thorough investigation of the patient’s hereditary and medical history.
Discharge from the Ear
Sudden: ASOM Gradual: CSOM
Type of Discharge Watery discharge
Chronic suppurative otitis media, Eczematous otitis extema
Acute suppurative otitis media, Ruptured furuncu losis
Tubotympanic type of chronic suppurative otitis media
CSF otorrhea, otitis extema (eczematous)
Fungal infection, diffuse otitis extema
CSOM tubotympanic type, fungal infection, granular myringitis
CSOM (tubotympanic), secondary infection in CSOM, tuberculous otitis media (painless otorrhea) Furunculosis, mastoiditis, Malignant otitis externa, Atticoantral type of CSOM.
Consistency of the Discharge
Viscid and tenacious discharge in tubotympanic disease.
Odorless: Allergic otitis extema, CSOM (tubo tympanic).
Foul smelling (Fishy smell): Atticoantral disease.
History Taking and Clinical Examination Associated Conditions
• Discharge increases with cold, head bath, pharyngitis and tonsillitis, enlarged adenoids seen in tubotympanic type of CSOM.
Hearing Impairment (Deafness) Onset
• Sudden: Impacted wax, vascular or viral deafness, acoustic trauma
• Gradual: Presbyacusis, acoustic neuroma, otosclerosis, noise induced hearing loss
• Unilateral: CSOM, mumps, Herpes Zoster oticus, acoustic neuroma, etc.
• Bilateral: Presbyacusis, Meniere’s disease, otosclerosis, noise induced hearing loss
• Progressive: Meniere’s disease, presbyacusis, otosclerosis, acoustic neuroma, tympano sclerosis
• Fluctuating: Meniere’s disease, perilymph leak.
Autophony (Hearing his own voice louder in the ear) Secretory otitis media.
• Hearing better in noisy place-otosclerosis, whereas hearing better in a quiet place – suffering from SN loss.
• Differences in the pitch of the tone in different ear is found in Meniere’s disease.
• A relativel y small increase in intensity of the auditory stimulus may cause frank discomfort to the listener as seen in cochlear pathology.
Otalgia (Pain in the Ear)
Pain in the ear may be because of the local and referred causes. Whenever the patient complains of pain the following questions should be asked in the history of presenting symptoms.
• Sudden: e.g. furunculosis, acute otitis media, trauma like otitic barotraumas
• Gradual: otitis extema secondary to CSOM, malignancy, malignant otitis externa
• Short duration: ASOM, perichondritis of ear pmna
• Long duration: Malignancy
Nature of the Pain
• Dull: eczematous otitis externa, secretory otitis media, impacted wax
• Sharp: furunculosis, otitic barotrauma
• Throbbing pain: ASOM
• Pain relieves with discharge from the ear acute suppurative otitis media (ASOM)
• Pain increasing on swallowing-ASOM.
• Pain increasing on yawning and chewing furunculosis arising from anterior canal wall
• Pain increasing on pulling the pinna and pressing the tragus-otitis externa.
Furuncle arising from anterior wall, pain radiates to preauricular region and posterior wall to the mastoid region.
Referred Pain (Otalgia)
• Referred pain to the ear is because of nerve supply from 5th, 9th and 10th cranial nerves and C2,3 to the ear.
Referred pain via 5th nerve
• Dental: Caries tooth, impacted molar, malocclusion
• Oral cavity: Benign or malignant ulcerative lesion
• Temporomandibular joint disorders like Costen syndrome, T.M joint arthritis.
Referred pain via 9th nerve
• Base of tongue malignancy
• Oropharynx-Acute tonsillitis, peritonsillar abscess, benign or malignant ulcers of the soft palate or tonsils.
• Elongated styloid process also known as Eagles syndrome.
Referred pain via 10th nerve
• Ulcerative lesions of vallecula, epiglottis, larynx or laryngopharynx.
Referred pain via C2, C3
• Cervical spondylosis, caries spine.
Symptoms associated with Otalgia
• Tinnitus-Acoustic neuroma
It is the name given to the symptom of noises in the head or ear. It is very common and sometimes may be the only symptom. It may be regarded as a sign of irritation to the cochlea or central auditory pathway. Tinnitus should be clinically evaluated as follows:
Duration of Tinnitus
• Short: Middle ear pathology.
• Long: Meniere’s disease, acoustic neuroma, palatal myoclonus, glomus jugulare, patent cochlear duct, ototoxicity.
Types of Tinnitus
• Subjective type
• Objective type
Subjective type: Sounds like ringing, whistling or roaring is heard by the patient without the presence of such a sound. This can also be psychogenic and functional in origin, apart from diseases like Meniere’s, ototoxicity, etc.
Objective type: This is heard not only by the patient but also by the examiner, e.g. palatal myoclonus, patulous eustachian tube, vascular bruit, arteriovenous malformation, etc.
• Continuous: Otosclerosis, acoustic neuroma, acute noise trauma.
• Intermittent and fluctuant: Meniere’s disease.
• Pulsatile: Glomus tumors, strychnine poisoning.
• Relieving factors: By putting pressure at the side of the neck in vascular causes.
• Aggravating factors: By smoking cochlear pathology, ototoxicity. Yawning and blowing-eustachian dysfunction.
Sensation of rotation of surrounding environment with respect to person. Vertigo without loss of consciousness is mainly of peripheral origin-BPPV, labrynthitis. Vertigo with loss of hearing is seen in Meniere’s disease, acoustic neuroma, bacterial labrynthitis. Vertigo with loss of consciousness is mainly because of central pathology.
History of similar illness in the past.
Past history of drug intake, especially in sensorineural hearing loss and bronchial asthma. Following are the commonly associated past illnesses that can cause ear diseases.
• Diabetes mellitus
• Allergy and bronchial asthma
• Childhood diseases
• Bleeding condition
• Connective tissue disorder
History of consanguineous marriage causes high incidence of deaf-mutism and other congenital disorders. Otosclerosis runs in the family.
• Personal hygiene
• Smoking and alcohol
• Loss of weight
• Pan chewing Treatment History
Any past medication and surgery should be inquired for better planning of the treatment.