Page 3 of 44
EN2.1 | ENT History Taking and Case Presentation — SDL Guide (Part 3)
Self-Assessment: ENT History Competency Check
Test your readiness for the ENT history OSCE by working through these self-check scenarios before your clinical posting. For each scenario, identify the most likely diagnosis and the key red-flag features you would NOT want to miss.
Self-check scenario 1: A 28-year-old female teacher presents with bilateral gradually progressive hearing loss over 5 years, worse in noisy environments. She denies ear discharge, vertigo, or tinnitus. Her mother also had hearing loss. She takes no regular medications. — Most likely diagnosis? (Bilateral progressive SNHL in a young adult with positive family history — suspect otosclerosis or hereditary SNHL.) Key question you must ask? (Any history of congenital rubella, aminoglycoside use in infancy, or consanguineous parents.)
Self-check scenario 2: A 55-year-old male smoker and daily drinker presents with a neck swelling for 6 weeks. It is firm, non-tender, 3 × 4 cm, located at level II of the right neck. He has no pain. He noticed mild hoarseness 2 months ago. — Red flag count? (Four: smoker + alcohol + painless cervical lymphadenopathy >3 weeks + hoarseness. This is head-and-neck SCC until proven otherwise.) What must you examine? (Oral cavity, oropharynx, larynx — to find the primary tumour.)
Self-check scenario 3: A 12-year-old girl is brought with a 2-day history of left otalgia and fever after an upper respiratory tract infection. The ear drum is red and bulging. She has no discharge. — Stage of ASOM? (Suppuration — the ear drum is bulging with pus, prior to spontaneous perforation. This is the stage at which myringotomy in the antero-inferior quadrant may be indicated.)
Reflect on this question before your posting: Which ENT symptom are you most likely to fail to ask about in an OSCE, and how will you make sure you don't forget it?
| Symptom | Key characterising question | Most dangerous missed diagnosis |
|---|---|---|
| Hearing loss | Unilateral or bilateral? Sudden or gradual? | SSHL; CSOM with complications |
| Otorrhoea | Foul-smelling? When did it stop? | Cholesteatoma; intracranial complication |
| Hoarseness | Duration? > 3 weeks? | Laryngeal carcinoma |
| Epistaxis | Anterior or posterior? Anticoagulants? | Posterior bleed; JNA; nasopharyngeal carcinoma |
| Neck swelling | Duration? Constitutional symptoms? | Metastatic SCC; lymphoma |
| Vertigo | Positional? Duration of episodes? Hearing change? | Meniere's disease; central vertigo |
SELF-CHECK
A 50-year-old male presents with left otalgia for 3 months. Otoscopy shows a completely normal left tympanic membrane with a normal external canal. The most important next step is:
A. Prescribe ear drops and review in 2 weeks
B. Examine the oral cavity, oropharynx, and larynx for a referred pain source
C. Arrange an audiogram
D. Refer for MRI of the ear
Reveal Answer
Answer: B. Examine the oral cavity, oropharynx, and larynx for a referred pain source
A normal otoscopic examination in a patient with otalgia means the pain is referred otalgia until proven otherwise. The ear shares sensory innervation with the teeth and jaw (CN V), tonsils and tongue base (CN IX), larynx and hypopharynx (CN X), and the neck (C2/C3). In a 50-year-old male, a carcinoma of the tonsil, tongue base, or hypopharynx presenting as referred otalgia is a well-recognised scenario. The mandatory next step is a thorough examination of the oral cavity, oropharynx, and larynx to exclude a mucosal malignancy. Prescribing ear drops without this examination is a medicolegal hazard.