SOME PRACTICAL ENT SKILLS
Dry mopping of ears

The most commonly used method of cleaning ears that are discharging is by dry
mopping. To do this you first have to prepare the mop. Take an orange stick
and some cotton wool. Tease out a small piece of cotton wool and place the tip of the orange
stick halfway onto it. By twisting the orange stick around and around, wrap the piece of
cotton wool onto the end of the stick so that about half of the cotton wool sticks out from the
end as a fluffy tip. The size of the fluffy tip is determined by the size of the ear canal into
which you are going to insert it. It needs to be thin for a child's ear but can be larger for a
wide adult ear canal.

You need to do the actual mopping in good light so that you can see what you are
doing. Adults can be mopped while they are sitting sideways-on in front of you with their ear
pointing towards the source of light. Children need to be wrapped up and held firmly in a
sitting position on an adult's lap with one of the adult's hands holding the child's head steady
agaist her body and the other hand holding the child's body so that he can't wriggle; see
If this is unsatisfactory, the child needs to be laid down on his side on a bew
with the ear to be cleaned facing upwards and an adult holding both the child's head and body
steady.

With one hand, gently pull the pinna of the external ear away from the head to
straighten up the ear canal. Hold the mop between the thumb and first finger of the other
hand. While rotating the mop between the fingers, work the fluffy tip into the ear canal as
far as it will go. The fluffy tip prevents the tip of the orange stick from damaging the
eardrum, but be very careful not to push it into the ear canal too hard, and be prepared to let
go of the mop if the patient jerks his head as you work it into the ear canal.

Work the mop out of the ear canal and inspect the fluffy tip to see what kind of
discharge you have been able to clean out - usually purulent but sometimes discoloured by
wax. Occasionally there will be some blood-staining. As long as you are not hurting the
patient, there is no reason to stop mopping if there is blood-staining, but you should not
continue to mop if there is blood-staining and mopping is painful. In this circumstance,




consider syringing to clean the ear canal

Take off the cotton wool, make another mop, and clean the ear canal again. Repeat
this until no more discharge is being mopped out.

When the ear canal is dry, examine the ear with an otoscope. You want to check that
you have managed to get all the discharge and debris cleaned out. If not, you can either
continue mopping or resort to syringing - see Syringing of ears below. Once the canal is
clean, examine both the ear canal and the eardrum to make a diagnosis.

If you lose the cotton wool part of the mop in the ear canal, you will have to get it
out again. Try and catch it with a pair of fine-toothed forceps and remove it. If this is
unsuccessful, you will have to try and syringe it out.

Once you are experienced with making mops and mopping patients' ears you can teach
your patients, or the attending adult in the case of children, how to make up mops and how
to clean their own ears.

Syringing of ears

Syringing is a way of cleaning out ear canals by flushing them with a gentle jet of
water. The most important point to remember about syringing is that the temperature of the
syringing water has to be exactly the same as body temperature. If it is either too hot or too
cold, syringing is going to induce vertigo (remember the caloric test for vestibular function!),
a sensation described as 'being drunk in the head'. This occurs because the balance organ in
the inner ear is close to the ear canal and is easily upset by changes in temperature. Syringing
is a safe technique to use, provided it is done gently and only for ears with either a foreign
body, wax, purulent discharge, or infected debris in the ear canal. After syringing it is
essential that you examine the ear canal to check that you have indeed cleaned it out and that
you are now able to examine the eardrum.

To syringe ears you will need a suitable syringe. The usual one is large and made of
metal with loops for your fingers.One problem with this type of syringe is
that the plunger is often tight and does not move up and down easily inside the barrel of the
syringe. If this is the case, take the syringe apart and clean the plunger and the inside of the
barrel. You may need to use wire wool, an abrasive scourer, or scouring powder to get the
metal surfaces clean and shiny. Apply a coating of Vaseline or something simuilarly greasy
to both the plunger and the inside of the barrel and then try it again.

An alternative is to use the largest size of syringe that you can find, if at all possible
one with finger loops because these syringes require only one hand for filling each time they
are emptied. Do not use a metal needle but use either a suction catheter, which is then cut
short, or a wide-bore intravenous cannula. It must fit onto the syringe tightly and not come
off when your squirt a jet of water through it as hard as you can. Test it a few times to make
sure of this before you use it but remember that you will only syringe an ear with a gentle
squirt!







You will also need a jug or bowl for the syringing water, a bowl or receiver to catch
the water as it pours out of the ear, and a towel or waterproof to keep the patient dry.

Syringing is done in good light so that you can see where you are placing the tip of
the syringe. The patient should be sitting sideways-on in front of you with the ear to be
syringed pointing towards the source of light. A child should be seated on an adult's lap with
both the head and the body firmly held. Place the towel or the waterproof around the patient
so that he will not get too wet. Older children and adults are shown how to hold the receiving
container so that it catches the water that will come out of the ear. For co-operative younger
children the attending adult should be able to hold the receiving container at the same time
as holding the child but for less co-operative children a second assistant will have to be
enrolled for this task.

Check the water temperature with the back of your hand - it should be exactly body
temperature, no warmer and no colder. Fill and squirt out the syringe a few times to check
that it is working smoothly. Fill the syringe and hold it in one hand. With the other hand
gently pull the pinna of the external ear away from the head - this helps to straighten out the
ear canal - and then place the tip on the syringe just next to or just into the ear canal and
gently empty the syringe, directing the stram of water into the ear canal. Check the water that
has come out into your receiving container to see what you have been able to flush out of the
ear.

Repeat a few times and then examine the ear canal with your otoscope. Repeat the
whole process a few times until the ear canal is clean.

It is sometimes difficult to get hard, impacted wax out of the ear canal. If this is the
case, remember that wax dissolves in water. Lie the patient down with the wax-filled ear
uppermost and fill the ear canal with water. Get the patient to pump it about a bit for ten
minutes - refilling the canal a few times - and then try syringing again. Repeat this again if
necessary. If this doesn't work, ask the patient to fill his ear with water and to pump it about
a few times during the rest of the day and return the next day for another attempt.

When it is clean, examine the ear canal to check that you have not caused any injury
by scratching it with the tip on the syringe. If you have scratched it, explain to the patient
what has happened and put some ear drops in. Explain that he should return if the ear
becomes sore or begins to discharge. If there is no injury, dry the ear canal by dry mopping
(see above), and you will be able to examine the eardrum. If the problem for which you were
syringing the ear was a discharge, you should now be able to see the eardrum well enough
to make a diagnosis. If the problem was wax or a foreign body, you should check that there
is not a perforation in the eardrum because, if there is a perforation, it is a possibility that the
syringing may cause infection to flare up. To prevent this you should instill ear drops and
instruct the patient to do this three times each day for two days and to return if the ear begins
to discharge.

If the patient comes back because the ear is discharging there are two possibilities:

- The eardrum was intact. Syringing has caused an otitis externa.




- There was a perforation in the eadrum. Syringing has caused an inactive chronic
otitis media to flare up and to become an active chronic otitis media. (See Treatmetn of active
chronic otitis media.)

Instilling ear drops

Three different types of ear drops are used for treating ear infections. Ear drops may
be antiseptic - an example is boracic ear drops, a cheal 'all round' preparation to use. They
may be acidification agents - an example is 2 per cent acetic acid drops. These are used
particularly for Pseudomonas infection - very common in active chronic otitis media. Lastly
they may contain specific antibiotics. These latter drops tend to be expensive but are generally
more effective than the others at clearing up infection. It is worth remembering that some ear
drops burn or sting for a short while after they have been instilled and patients need to be
warned about this. If you find that your patient will not use a particular ear drop because of
this then try a different preparation.

When instilling an ear drop it should be obvious that the drop is not going to do any
good unless it penetrates down to the area of infection. This will not be possible if the ear
canal is full of pur or debris, so that cleaning of the ear canal is an essential first step .To successfully instill ear drops, the light needs to be good
enough for you to see where the ear drops are being placed. The patient should lie on her side
or tilt her head so that the ear into which the drop is to be instilled is pointing upwards.
Gently pull the pinna away from the head to straighten the ear canal. Drop two or three drops
directly into the ear canal - if you miss, wiggle the pinna about until the drops run into the
canal. Once the ear drops are in the ear canal, wiggle the pinna about until the drops run all
the way down to the bottom of the canal and drop in a further two or three drops. The place
a finger on the tragus - the small bump just in front of the ear canal - and squash it down so
that it closes off the canal. Repeat this pumping action a few times. This helps to spread the
ear drops around inside the ear canal and also pushes some of the drops through into the
middle ear if there is a perforation in the eardrum. (Sometimes the drops go all the way down
the eustachian tube and the patient can then taste them!) The patient should stay on her side
for a further minute. As she straightens her head, some of the drops may run out and need
to be wiped away.

This technique should be taught to the person who will be going to instill the ear
drops at home. It is difficult for patient to instill ear drops in their own ears but if they do
not have anyone to do it for them they will have to learn how to do it as well as they can.

Removal of a foreign body from the nose

These patients will usually be small, unco-operative children whose parents will either
have noticed or been told about the foreign body or noted a unilateral, often foul-smelling,
discharge from the nose. Parents will often have tried to get the child to blow it out but if
they haven't, and the child will co-operate, this is worth trying initially.

Wrap the child up in a sheet and sit him upright, facing you, on the parent's lap with
the child's legs restrained by the parent's crossed legs, one of the parent's arms holding the
child's body and the other firmly holding the child's head



Confirm the n body, using a head light, if available, a torch, or
an otoscope with a large speculum. You may need to suction away any accumulated
secretions to see it. Is it a solid object or something soft such as sponge or paper? If
something soft it can usually be grasped with a fine-toothed forceps and removed. If it is solid
do not attempt to grasp it as it may slide deeper into the nasal cavity.

For solid objects, take a probe with a curved tip in one hand, steady the nose with the
other hand, and pass the tip of the probe along the floor of the nose until it is past the object.
Elevate the tip, trapping the object between the probe and the dorsum of the nasal cavity.
Keeping the tip elevated, draw the probe out of the nose, bringing the foreign body with it
until it reaches the vestibule when it can be extruded by pinching behind it with the thumb
and first finger of the hand on the nose. The nose may bleed a little, especially if there is an
infection, but this will soon stop.

If unsuccessful, re-examine the nose and if the foreign body is still visible, try again.
If still unsuccessful it is worth a third attempt before resorting to either a general anaesthetic
or, if available, referral to a specialist service.

Cauterizing a nose

Patients suitable for cautery will be those with a bleeding site that is visible and
accessible on the anterior nasal septum.

Active bleeding will need to be controlled before attempting cautery. Soak a piece of
cotton wool in some vasoconstrictor nasal drops, place this into the nostril to rest against the
bleeding site and request the patient to pinch his nose for five to ten minutes. Then gently
remove the cotton wool.

The first step in cautery is to accurately identify the bleeding site. If a headlight is
available, gently insert a nasal speculum into the nostril to open it out and push the hairs out
of the way, then inspect the anterior septum. If not, many otoscopes are supplied with a fat
nasal speculum which is very useful in adults. In children, you will have to use the largest
ear speculum - which is too small to cauterize through, but children don't have hairy noses
and the area can often be seen by just tilting the nasal tip upwards a little with a finger. In
children, the usual bleeding vessel lies at the junction of skin and mucosa, in adults it is often
a little behind this in Little's area.

The next step is to anaesthetize the area and this is done by spraying the septum with
topical local anaesthetic solution. The 10 per cent sprays are the most effective but patients
do not particularly like it when they are sprayed with them and need to be warned that it may
be a little unpleasant. An alternative is to soak a piece of cotton wool with the spray and
place this inthe nostril against the bleeding site. Request the patient to pinch his nose lightly
for a few minutes.

While the anaesthetic is working, prepare for cautery. The most useful device is a
commercially available orange stick tipped with solid silver nitrate. Also prepare two or three
orange stickes with cotton wool tips - these will be used to apply pressure should the bleeding
point start bleeding when the silver nitrate is applied to it. Make two or three small balls of