By Marcello Cherchi, MD PhD
For patients
When you visit a health care professional because of problems with hearing or balance, they will usually ask you fairly detailed questions. Many of the questions will focus on the hearing or balance complaint, but the health care professional may also ask you questions that initially do not seem directly relevant to those symptoms.
For clinicians
Practical summary
Taking a good history is important in nearly every medical specialty. We review some points of history-taking that tend to be more relevant for practitioners interviewing a patient with otoneurological symptoms.
Introduction
As in most medical subspecialties, taking a good clinical history provides the first, and probably the most important, set of data on which a practitioner constructs a differential diagnosis in otoneurology. All practitioners develop their own routines and styles for this. What we discuss below is not intended to be proscriptive, but we emphasize some parts of history-taking that may be somewhat distinct from a general medical history. We draw on several sources regarding history-taking in a patient with disequilibrium (Baloh et al. 2011; Edlow 2013; Edlow et al. 2017; Khattar and Hathiram 2012; Perepa 2017).
History of present illness
If a patient does not spontaneously offer information regarding disequilibrium, aural symptoms and headaches, then we will elicit that information.
Disequilibrium
Despite a century of medical education stressing the importance of eliciting symptom qualities, it has been repeatedly demonstrated that as far as disequilibrium is concerned, there is little to no correlation between patients’ descriptors and the ultimate diagnosis (Kerber 2021; Kerber et al. 2017; Kerber and Newman-Toker 2015; Newman-Toker et al. 2007; Newman-Toker and Edlow 2015; Stanton et al. 2007). We strongly agree with Dr. Newman-Toker and Dr. Edlow (Newman-Toker and Edlow 2015) that in determining the etiology of disequilibrium, the historical features most likely to narrow the differential diagnosis are:
- Timing
- When did it first occur, and how old was the patient at that time?
- When did it last occur?
- Is it chronic (present every waking moment) or episodic (starting and stopping)?
- Triggers/exacerbators and ameliorators
- Are there triggers (that bring on the symptom in someone who was previously asymptomatic) or exacerbators (that worsen symptoms which were already present?
- Are there any factors that make the symptoms improve or resolve?
- Associated symptoms
- Are there any symptoms that tend to happen at the same time as the disequilibrium, or fluctuate in intensity with it? (such as aural symptoms; see below)
We also ask whom the patient has previously consulted about this problem, what the results/conclusions of those evaluations were, what (if any) treatments were attempted, and what the outcomes were.
Aural symptoms
In this category we include both auditory symptoms (hearing loss, tinnitus) and non-auditory aural symptoms (fullness, pain, discharge). Similar to the symptom of disequilibrium, we also ask about timing and triggers of the aural symptoms.
Headache
Given the high prevalence of migraine associated vertigo (MAV), we usually specifically ask about headaches and the features that meet criteria for migraine.
Review of systems
In the United States, on January 1 of 2021, the Centers for Medicare and Medicaid Services advised that it was no longer necessary to elicit a complete review of systems (Barry and Tseng 2022). This saves some time, but we continue to ask the following targeted questions within the 14-point review of systems:
- Constitutional
- Weight loss
- Fevers
- Ophthalmological
- Changes in vision
- Xerophthalmia
- Otolaryngological
- Symptoms not already covered in the “aural symptoms” section of the history of present illness, such as xerostomia and aphthous ulcers
- Cardiovascular
- Palpitations
- Respiratory
- Cough
- Dyspnea
- Gastrointestinal
- Dysphagia
- Genitourinary
- Erectile dysfunction
- Musculoskeletal
- Weakness
- Muscle spasms
- Myalgias
- Arthralgias
- Integumentary
- Rashes
- Neurological
- Tremor
- Whether handwriting has become smaller
- Dysarthria
- Psychiatric
- Depressive symptoms
- Anxiety
- Endocrinological
- Unusual temperature intolerance
- Hematological
- Easy bruising
- Unusual bleeding
- Allergic
- Rhinorrhea
Lifestyle
Several specific lifestyle factors may be more relevant in otoneurology.
Diet
If there is clinical suspicion for migraine associated vertigo (MAV), we may ask about relevant dietary factors (e.g., caffeine, alcohol, aged cheeses, monosodium glutamate and nitrites).
If there is clinical suspicion for Ménière’s disease, we will inquire about sodium intake.
Sleep
An irregular sleep schedule may be a risk factor for migraine and migraine associated vertigo (MAV).
A report of acting out one’s dreams may raise suspicion for a REM sleep behavior disorder, such as occurs in several neurodegenerative diseases.
Smoking/nicotine consumption
We routinely try to quantify this, including start date, stop date (if any), and quantity smoked.
Airplane travel
We inquire about this because of the possibility of aerotitis media.
Employment
We ask about this for potential exposures.
Medico-legal issues
We routinely ask about disability and medico-legal proceedings or intentions.
Traumas and exposures
We specifically ask about physical trauma to the ears, head or neck.
We also ask about unusual noise exposure, exposure to toxins (e.g., organophosphate pesticides) and heavy metals.
Past medical history
We ask about past medical history in general, but add specific questions about ear-related events, such as a history of ear infections, tympanic membrane perforations, and tympanostomy tube placements.
Family history
In addition to a general family history, we specifically inquire about:
- Balance problems
- Otologic problems
- Early hearing loss (before the age of 40 years)
- Otosclerosis
- Ménière’s disease
- Neurologic problems
- Migraines
- Seizures
- Brain aneurysms
- Brain tumors
- Stroke
- Parkinson’s disease or parkinsonian disorders
- Other neurodegenerative disorders (Alzheimer’s disease, other dementias)
- Hereditary ataxias
- Multiple sclerosis
- Autoimmune diseases
- Lupus
- Sarcoid
- Sjogren syndrome
- Rheumatoid arthritis
Allergies
Specific allergies are rarely directly relevant to otoneurological diagnoses, but may influence subsequent medication options.
Current treatments
We ask about current treatments, including:
- Medications (both prescription and over-the-counter)
- Nutritional/herbal supplements
- Physical therapy
- Vestibular rehabilitation therapy
- Vision therapy
- Acupuncture
- Neck physical therapy
- Chiropractic manipulation
Prior treatments
We ask about previous treatments (similar to the items listed under “current treatments”).
Specific medications
We routinely ask about medications with specific ototoxic potential, including:
- Aspirin in large doses
- Cisplatin
- Furosemide
- Gentamicin
- Kanamycin
- Anti-malarial medications
- Nifedipine
- Quinidine
- Streptomycin
- Tamoxifen
- Tobramycin
- Vancomycin
Prior studies
We specifically inquire about auditory evaluations, vestibular testing, and imaging of the brain and cervical spine.
References
Baloh RW, Honrubia V, Kerber KA (2011) The History of the Dizzy Patient. In: Baloh MDFRW, Honrubia MDDV, Kerber MDKA (eds) Baloh and Honrubia’s Clinical Neurophysiology of the Vestibular System. Oxford University Press, pp 0
Barry MJ, Tseng CW (2022) Moving to More Evidence-Based Primary Care Encounters: A Farewell to the Review of Systems. JAMA 328: 1495-1496. doi: 10.1001/jama.2022.18346
Edlow JA (2013) Diagnosing dizziness: we are teaching the wrong paradigm! Acad Emerg Med 20: 1064-6. doi: 10.1111/acem.12234
Edlow JA, Gurley KL, Newman-Toker DE (2017) A New Diagnostic Approach to the Adult Patient with Acute Dizziness. J Emerg Med 54: 469-483. doi: 10.1016/j.jemermed.2017.12.024
Kerber KA (2021) Episodic Positional Dizziness. Continuum (Minneap Minn) 27: 348-368. doi: 10.1212/con.0000000000000909
Kerber KA, Callaghan BC, Telian SA, Meurer WJ, Skolarus LE, Carender W, Burke JF (2017) Dizziness Symptom Type Prevalence and Overlap: A US Nationally Representative Survey. Am J Med 130: 1465 e1-1465 e9. doi: 10.1016/j.amjmed.2017.05.048
Kerber KA, Newman-Toker DE (2015) Misdiagnosing Dizzy Patients: Common Pitfalls in Clinical Practice. Neurol Clin 33: 565-75, viii. doi: 10.1016/j.ncl.2015.04.009
Khattar V, Hathiram B (2012) The Importance of Eliciting a Good History in Patients Suffering from Vertigo. Otorhinolaryngology Clinics – An International Journal 4: 1-4. doi: 10.5005/jp-journals-10003-1082
Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh YH, Zee DS (2007) Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. Mayo Clin Proc 82: 1329-40. doi: 10.4065/82.11.1329
Newman-Toker DE, Edlow JA (2015) TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin 33: 577-99, viii. doi: 10.1016/j.ncl.2015.04.011
Perepa L (2017) History Taking in Vertigo Patients. Global Journal of Otolaryngology 5. doi: 10.19080/GJO.2017.05.555660
Stanton VA, Hsieh YH, Camargo CA, Jr., Edlow JA, Lovett PB, Goldstein JN, Abbuhl S, Lin M, Chanmugam A, Rothman RE, Newman-Toker DE (2007) Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians. Mayo Clin Proc 82: 1319-28. doi: 10.4065/82.11.1319
