Hearing loss
ENT
Introduction
As with any history taking it is important to initially exclude any emergency conditions. For ENT histories relating to hearing loss this may relate to sudden sensorineural hearing loss.
WIPER
Wash hands:
Introduction: Introduce yourself by your full name and your role
Patient details: Gather the patient’s full name and DOB
Explain/Establish: Explain what you are going to do and Establish consent
ExPose: Expose & Position the patient if necessary.
Presenting Complaint
Main symptom: Hearing loss
History of Presenting complaint:
Use the acronym SOCRATES where applicable
Site- Is the left or right ear affected or both?
Onset- When did you first notice this? Did it start suddenly or gradually?
Character- Is it difficult to hear higher or lower pitched noises?
Radiation
Associated features –Ear discharge, muffled sounds, otalgia, tinnitus
Timing – Has hearing changed overtime?
Exacerbating & relieving factors: Loud places, distant noises, watching TV
Severity – Is this impacting your day-to-day life?
- Don’t neglect asking in-depth questions about associated features, eg: regarding the pain, since when have you had ear pain? You can again use SOCRATES if applicable. This may help separate acute issues from non-acute ones
Systems review:
- A systems review may help identify risk factors which will help to narrow down differentials
- For ENT histories ask about: Balance, headaches, foreign bodies, vertigo, infection, motor (feelings of weakness), sensory (numbness or tingling), high/low altitude exposure
Always do a constitutional systems review asking about: Unintentional weight loss, SOB, fevers, fatigue, loss of appetite, pain
Elicit ideas, concerns and expectations using the acronym ICE
Ideas- Do you have any ideas what might be causing this?
Concerns- Is there anything you’re worried about?
Expectations- What are you most hoping for from me today?
Summarise everything the patient has told you to ensure you have correct information or in case anything was missed
Past Medical History
Wash hands:
Introduction: Introduce yourself by your full name and your role
Patient details: Gather the patient’s full name and DOB
Explain/Establish: Explain what you are going to do and Establish consent
ExPose: Expose & Position the patient if necessary.
Medications
Are there any medical conditions that run in the family?
Family History
Ask about allergies and OTC, herbal or prescribed medications
For hearing loss specify antibiotic use and chemotherapy
Social History
Social history refers to a patient’s sexual activity, smoking, alcohol and drug use, as well as housing, dietary, hobbies and occupational status
Tailor these towards whichever history you are undertaking. For ENT histories important factors include: smoking (how many a day and for how long), hobbies, occupation and alcohol use
Differential Diagnosis
Separate differentials into most likely, less likely and can’t miss.
Each section will differ based on results from the history and examination
Examples of differentials for hearing loss include: cerumen impaction, presbycusis, malignancy, Ménieres disease, TM perforation, barotrauma, OM +/- effusion.
Further investigations to consider:
- Remember: Bedside --> Laboratory --> Imaging
Bedside examination includes:
Otoscopy, ear exam, UMN/LMN exam, cranial nerve exam, cerebellar exam
Laboratory investigations include:
Blood tests including ESR, CRP, FBC, U&Es, LFTs, gentamicin level (if relevant)
Imaging includes:
CT/ MRI
Pure tone audiometry
Summarise and present findings from history, exam and lab results
Management
Tailor the management based on diagnoses