History Taking
A thorough but focused patient history is essential in guiding diagnosis and determining the approach to further evaluation. While it is not possible to cover the pertinent elements of a patient history for every otolaryngologic complaint, the following are some relevant questions for commonly encountered pathologies.
General:
- Where are the symptoms located?
- How long have the symptoms been present?
- Was the onset of symptoms sudden or gradual?
- Have the symptoms been getting progressively worse?
- Is there pain? If so, describe the location, quality and degree.
- What factors alleviate or exacerbate the symptoms?
- Were there any associated events, conditions, or symptoms?
- Have similar symptoms occurred in the past? If so, what was the diagnosis and treatment?
Otologic Complaint:
- Which is the better hearing ear?
- Have there been changes in hearing? If so, was it sudden or gradual? Is one or both ears affected?
- Is there a history of occupational or other noise exposure?
- Is there tinnitus? If so, describe the character and intensity of the sound. Is it constantly present? Is it pulsatile in nature?
- Have there been problems with dizziness, vertigo, or balance? If so, was it episodic or continuous? Was it provoked by motion/position? Was it associated with hearing loss?
- Is there any history of trauma?
- Is there any facial paralysis? If so, was it sudden or gradual?
- Is there discharge from the ear? If so, is it watery or purulent?
- Was there a history of frequent ear infections as a child?
- Is there a family history of hearing loss? If so, was it congenital or acquired?
- Is there a history of ear surgery?
Nasal/Sinus Complaint:
- Is there nasal obstruction? If so, is it unilateral or bilateral?
- Is there nasal discharge or post-nasal drip? If so, is it clear or purulent?
- Has there been epistaxis? If so, how many episodes and how were they controlled? Was the bleeding anterior or posterior?
- Has there been any change in sense of smell or taste?
- Is there facial pain/pressure or headaches?
- Is there any history of nasal trauma?
- Is there any history of nasal or sinus surgery?
- Is there any personal or family history of allergy or atopy?
- Is there any history of occupational or other inhalant irritant exposure?
- Is there any history of immunocompromise, such as diabetes mellitus or human immunodeficiency virus infection?
- Is there any visual impairment or other symptoms suggestive of orbital involvement?
- Are there any neurologic symptoms suggestive of intracranial disease?
Oral/Pharyngeal Complaint:
- Are there any masses in the oral cavity/pharynx?
- Is there any dysphagia or odynophagia?
- Is there any history of dental disease or procedures?
- Is there any change in sensation or taste?
- Is there any numbness or weakness of the lips, cheeks, chin, or tongue?
- Is there any history of adenotonsillar disease? Have the tonsils been previously removed?
- Is there a history of tobacco use or betel nut chewing?
- Is there any referred otalgia?
Laryngeal Complaint:
- Has there been a change in voice quality? If so, was it sudden or gradual? Describe the nature of the change.
- Describe typical voice use patterns. Is the voice used in an occupational capacity (e.g., singer)?
- Is there dysphagia or odynophagia?
- Is there any history of airway obstruction?
- Are there symptoms of reflux?
- Is there a history of tobacco or alcohol use?
- Is there a history of laryngeal trauma or cervical/cardiac surgery during which vagus or recurrent laryngeal nerve injury may have occurred?
- Is there a history of prolonged intubation or intubation trauma?
- Is there any history of aspiration or recurrent respiratory infection?
Neck Mass:
- Where is the neck mass?
- Is it painful?
- Has it changed in size?
- Is there associated otalgia, change in voice, dysphagia or weight loss?
- Is there a history of head and neck cancer, skin cancer, or other cancer?
- Are there any symptoms of hypo- or hyperthyroidism?
- Is there any history of irradiation of the head and neck?