• Ear symptoms need to be elicited, as this is often concurrent; unilateral serous otitis media can be a sign of a nasal or nasopharyngeal tumor.
• Throat symptoms are common due to post-nasal drip; always ask about reflux as this is thought to possibly be a factor in nasopharyngitis, and possibly rhinosinusitis, in some patients.
• Orbital symptoms such as restriction of gaze and epiphora can be a sign of a nasal tumor; numbness, particularly in the distribution of the second branch of the trigeminal nerve, can similarly be a sign of malignancy.
• Ask about prior imaging including sinus CTs, plain films, head CTs, and MRIs.
• Discuss any history of nasal trauma, although patients often claim they broke their nose at one point without actual evidence of a previous fracture.
• Smoking and drug use, particularly intranasal drug use, is relevant; smoking decreases mucus transit and increases viscosity of the mucus; intranasal drug use can destroy the nasal cavity—specifically cocaine and crushed pain killers such as oxycodone can cause extensive necrosis.
• Inquire about prior efforts the patient has made to treat this problem:
1. Topical nasal sprays: decongestants, nasal corticosteroids, nasal antihistamines and saline
2. Previous courses of antibiotics, including type of antibiotic and length of treatment and degree of improvement; documentation here is important, especially if imaging is to be obtained; often insurance companies will look for duration of antibiotic treatment for preauthorization for imaging
3. Previous courses of systemic steroids and degree of improvement
• The Unified Airway Theory stresses the concept that both the upper and lower respiratory tract act as one functional unit; conditions that impact one may impact the other; questioning regarding respiratory disease is thus of paramount importance; asthmatics with sinus disease often note a correlation between the severity of their sinonasal symptoms and the severity of their asthma.
• Allergic disorders can similarly have both upper and lower airway manifestations; a full allergic history including reaction to seasonal allergens as well as flare-ups with certain foods is important; Samter’s patients often react to certain foods and beverages, particularly alcohol.
• Several rheumatologic diseases can manifest in the nasal cavity including sarcoidosis, Wegener’s granulomatosis (granulomatosis with polyangiitis GPA), Churg-Strauss syndrome, and relapsing polychondritis.
• Particularly for epistaxis, knowledge of hypertension as well as an existing bleeding diathesis is important.
• Certain disorders can have an impact on methods of treatment, particularly diabetes mellitus, which will limit the ability to use oral steroids, and glaucoma that might limit nasal steroid usage.
• A full surgical history should be elicited.
• Focus on ENT surgeries including adenoidectomy, myringotomy tube placement, and any previous nasal surgery.
• Patients often leave out cosmetic surgeries and knowledge of a previous rhinoplasty is critical.
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