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EN2.1 | ENT History Taking and Case Presentation — SDL Guide (Part 2)

Nose, Sinus, and Throat/Larynx Symptoms in Depth

The nasal and throat sections of the ENT history contain several high-stakes clinical patterns that are easily missed if questions are not asked systematically. This section covers how to elicit and characterise each major symptom in these regions.

Nasal obstruction is the commonest nasal symptom. Establish laterality: unilateral obstruction, especially in an adult, raises concern for a unilateral pathology — deviated nasal septum (DNS), unilateral nasal polyp (antrochoanal polyp — Killian's polyp — single, unilateral, from the maxillary antrum, more common in children and young adults), foreign body, benign or malignant tumour, or juvenile nasopharyngeal angiofibroma (JNA) in adolescent males (recurrent epistaxis + unilateral obstruction). Bilateral obstruction with sneezing and watery rhinorrhoea suggests allergic rhinitis or bilateral ethmoidal polyps (multiple, bilateral, in adults, associated with allergy). Ask about timing: worsening at night or in supine position suggests nasal oedema due to allergy or vasomotor rhinitis.

Rhinorrhoea — Characterise: watery/clear (allergic rhinitis, CSF rhinorrhoea after head trauma), mucoid/thick (chronic sinusitis, upper respiratory infection), purulent yellow-green (bacterial sinusitis), blood-tinged (malignancy, granulomatous disease, trauma). Ask about post-nasal drip — the symptom of mucus trickling down the back of the throat, causing throat-clearing, cough, and hoarseness, particularly at night.

Epistaxis — Quantify frequency, volume (tablespoons vs cupfuls), and laterality. The vast majority of nosebleeds are anterior, arising from Little's area (Kiesselbach's plexus) on the anterior nasal septum — particularly in children, young adults, and dry-weather conditions. Posterior bleeds arise from the sphenopalatine or Woodruff's plexus in the posterior nasal cavity and are more common in elderly, hypertensive patients; they are harder to control and may present as bleeding from both nostrils simultaneously or blood trickling down the throat. Always ask about anticoagulant medications (warfarin, DOACs), antiplatelet agents, NSAIDs, and intranasal cocaine use (septal perforation + epistaxis).

Sore throat and dysphagia — Distinguish acute (viral/bacterial tonsillopharyngitis) from chronic/recurrent (recurrent tonsillitis, defined as ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years, per Paradise criteria as cited by Scott-Brown's). Odynophagia (painful swallowing) suggests active infection or ulceration; progressive painless dysphagia (difficulty swallowing) in an older smoker/drinker strongly suggests a hypopharyngeal or oesophageal malignancy.

Hoarseness — Duration is the single most important parameter. Hoarseness or voice change persisting for more than 3 weeks in an adult is a red flag requiring laryngoscopy to exclude laryngeal carcinoma. Elicit smoking and alcohol history (strong synergistic carcinogens for laryngeal/hypopharyngeal cancer). Ask about voice use (professional voice users: singers, teachers) for benign vocal cord lesions. Sudden onset of hoarseness with a history of thyroid surgery, chest surgery, aortic aneurysm, or mediastinal mass suggests recurrent laryngeal nerve palsy.

Neck swelling — Duration and rate of growth are key. Rapid growth over days suggests infective lymphadenopathy (dental, tonsillar, upper respiratory tract infection); slow, painless, progressive enlargement over weeks–months suggests malignancy (lymphoma, metastatic disease) or thyroid pathology. The presence of constitutional B-symptoms (fever, night sweats, weight loss) with neck swelling suggests lymphoma. In an adult smoker or drinker, a painless neck node without apparent infective cause requires urgent investigation for head-and-neck squamous cell carcinoma with an unknown or occult primary.

Interpreting the ENT History: Diagnostic Clues and Red Flags

The ENT history is not merely a data-collection exercise — it is the primary source of the differential diagnosis. Pattern recognition is the intellectual core of clinical medicine, and in ENT that recognition begins during the history, long before a single instrument is picked up. Certain symptom combinations are so characteristic of specific conditions that a confident working diagnosis is available before examination — and more importantly, certain symptoms function as red flags that change the urgency of management from 'routine clinic' to 'emergency admission' within seconds of being elicited. The ability to move between data-collection and real-time interpretation while continuing to ask questions is the distinguishing mark of a competent ENT clinician, and it is what this section practises.

It is also worth noting that the most consequential errors in ENT practice are not usually wrong treatments — they are missed or delayed diagnoses, and these originate almost always in history taking: a hoarseness that was not asked about for long enough, a neck mass duration that was not clarified, or a cessation of ear discharge that was reassured rather than alarmed about. The red-flag patterns below are the factual antidote to those errors.

High-yield diagnostic patterns from the history alone:

• Unilateral foul-smelling otorrhoea + hearing loss + vertigo/facial weakness → CSOM atticoantral type with cholesteatoma, possibly with complications. This is the 'unsafe ear' pattern — surgery is needed regardless of the presence or absence of acute infection.
• Episodic vertigo (minutes to hours) + fluctuating low-frequency hearing loss + tinnitus + aural fullness → Meniere's disease (endolymphatic hydrops). All four components of the tetrad may not be present in early disease, but the triad of episodic vertigo + SNHL + tinnitus is required for diagnosis.
• Brief positional vertigo (<1 minute) triggered by head movement (rolling over in bed, looking up) + Dix-Hallpike positive + no hearing loss → BPPV (benign paroxysmal positional vertigo, due to otolith displacement into the posterior semicircular canal). Most common cause of vertigo in adults.
• Bilateral nasal obstruction + watery rhinorrhoea + sneezing + anosmia → bilateral ethmoidal polyps (multiple, allergic, in adults). Associated with allergy and aspirin sensitivity (Samter's triad: asthma + aspirin sensitivity + nasal polyps).
• Unilateral nasal obstruction + unilateral epistaxis in adolescent male → suspect JNA (do NOT biopsy).
• Painless, progressive unilateral cervical lymphadenopathy in a smoker >40 years → metastatic squamous cell carcinoma until proven otherwise.

Red-flag symptoms requiring urgent action:

Red flag symptom	Significance	Action
Sudden hearing loss (≥30 dB over ≤72 h)	SSHL — cochlear ischaemia or viral	Same-day ENT referral; systemic corticosteroids
Hoarseness >3 weeks	Laryngeal carcinoma	Urgent laryngoscopy
Otalgia + facial nerve palsy	Malignant otitis externa or skull base erosion	Urgent imaging + ENT
Cessation of chronic otorrhoea + headache	Intracranial complication of CSOM	Emergency admission
Pulsatile tinnitus	Vascular lesion (glomus, AVM, carotid stenosis)	Vascular imaging
Progressive dysphagia + weight loss	Hypopharyngeal/oesophageal malignancy	Urgent panendoscopy
Unilateral cervical mass >3 weeks in adult smoker	SCC of H&N with unknown primary	Pan-endoscopy + biopsy
JNA pattern in adolescent male	JNA (extremely vascular)	CT/MRI; do NOT biopsy

Note the cessation-of-discharge sign from the hook scenario: in CSOM, the ear discharges because the middle ear has a route of drainage through the perforation. When that discharge suddenly stops in a patient with long-standing CSOM and new-onset headache, it can mean the infection has spread — possibly into the mastoid (mastoiditis) or intracranially (meningitis, extradural/subdural abscess, brain abscess). The 'drying up' is not improvement; it is blockage of the drainage route.

Structuring the ENT Case Presentation

The ability to present an ENT case concisely and logically is a clinical skill in its own right, assessed at bedside rounds, in OSCEs, and in the final MBBS examination. A case presentation is not a recitation of everything the patient said — it is a structured synthesis that communicates three things simultaneously: what the patient's problem is, why you think so, and what the clinical urgency requires. When an examiner or senior clinician hears a well-presented ENT case, they should be able to form the differential diagnosis before you state it, because the structure and emphasis of your presentation has already guided them there. Conversely, a disorganised or symptom-list presentation obscures the diagnosis and signals to the examiner that the student does not yet think clinically.

The six-part structure below is the standard for ENT case presentations in clinical postings and OSCEs. Practise it until it is automatic: the structure should feel like scaffolding, not a constraint — once internalised, it frees you to focus on the clinical content rather than deciding what to say next. Each part has a specific purpose that contributes to the overall diagnostic narrative, and leaving any part out weakens the presentation in a specific and predictable way.

Standard structure for an ENT case presentation (3–5 minutes):

1. Demography and chief complaint: 'This is a 35-year-old male farmer who presents with a 10-year history of right ear discharge and gradual hearing loss in the same ear, with a recent episode of dizziness and facial twitching.'

1. HPI (focused, problem-oriented): Describe the primary symptom using SOCRATES/OLDCARTS parameters. State the key characterisation features: 'The discharge is foul-smelling and thick; it had been continuous for 10 years until 3 days ago when it stopped abruptly. He has had two previous hospitalisations for the same ear.' Note the red-flag elements explicitly: 'The recent vertigo and ipsilateral facial weakness are new symptoms and were not present previously.'

1. Relevant positive and negative history (systematic review): 'He has no tinnitus, no contralateral ear symptoms, no nasal or throat complaints. There is no fever.'

1. Background history: Drug, surgical, family, and social history — condensed to what is relevant: 'He has not used any ototoxic medications. He is a non-smoker. No family history of ear disease.'

1. Examination findings (if asked to present): At this point, state the key positive findings concisely: 'On examination, the right tympanic membrane showed a posterior superior (attic) perforation with visible cholesteatoma flakes. Facial nerve examination showed House-Brackmann grade II right facial paresis.'

1. Summary and differential: 'In summary, this is a 35-year-old male with long-standing right CSOM of the atticoantral (unsafe) type, now presenting with complications — probable right labyrinthitis and facial nerve involvement. The differential includes subdural or extradural abscess given the sudden cessation of discharge and new symptoms. He requires emergency imaging and ENT consultation.'

Common presentation errors to avoid:
- Beginning with investigation results before completing the clinical picture.
- Omitting laterality of ear, nose, or throat symptoms.
- Presenting symptoms as a list without characterising them.
- Not stating the duration of the chief complaint at the outset.
- Forgetting to present the relevant negative findings (e.g. no contralateral symptoms in unilateral ear disease).
- Presenting hoarseness without stating its duration (the single most important parameter).

Documentation: In written records, use the same five-domain structure. Document laterality explicitly. For ENT clinical notes, draw a tympanic membrane diagram showing the location of any perforation or landmark abnormality — this is a standard ENT documentation skill.