ENT Care Training Manual For CHO

2 TRAINING MANUAL ON EAR, NOSE AND THROAT (ENT) CARE FOR COMMUNITY HEALTH FOR OFFICER AT AYUSHMAN BHARAT
AT – HEALTH AND WELLNESS CENTRES

Training Manual on Ear, Nose and Throat (ENT) Care
for Community Health Officer
at Ayushman Bharat – Health and Wellness Centres
2021
TRAINING MANUAL ON EAR, NOSE AND THROAT (ENT) CARE FOR COMMUNITY HEALTH FOR OFFICER AT AYUSHMAN BHARAT – HEALTH AND WELLNESS CENTRES 1
ENT
2 TRAINING MANUAL ON EAR, NOSE AND THROAT (ENT) CARE FOR COMMUNITY HEALTH FOR OFFICER AT AYUSHMAN BHARAT – HEALTH AND WELLNESS CENTRES
CONTENTS
3
Chapter 1: Introduction
Chapter 2: Understanding the Ear, Nose and Throat 8

Chapter 3: Examination of ear, nose and throat 9
13
Chapter 4: Common ENT
Complaints and How to Approach Them
44
Chapter 5: Essential skills needed
for providing primary ENT services
48
Chapter 6: Health promotion
and prevention of ENT problems
53
Chapter 7: Service delivery framework:
Providing ENT care as a team and Key tasks of CHO
ANNEXURES
Annexure 1: Commonly-used ENT medicines in SHC-HWC 54

55
Annexure 2: How to communicate
with people with reduced hearing/hearing loss
Annexure 3: Screening for common ENT conditions 56
Annexure 4: Community-Based Assessment Checklist 57

01 INTRODUCTION
CHAPTER
A
yushman Bharat initiative was launched as recommended by the National Health Policy 2017
to move from sectoral and segmented approach to a comprehensive need-based health
care delivery to achieve the vision of Universal Health Coverage (UHC). Under this scheme
1,50,000 Health and Wellness Centres (HWCs) were proposed to be operationalised by transforming
existing Sub Centres and Primary Health Centres which would deliver Comprehensive Primary Health
Care (CPHC) covering maternal and child health services communicable and noncommunicable
diseases, including free essential drugs and diagnostic services.
Problems related to the Ear, Nose and Throat (ENT) constitute the bulk of the patients visiting the
Out-patient Department. Owing to availability of large number of home-based remedies, patients
suffering from the common ENT problems seek medical care less frequently. This, along with limited
access to health care professionals trained in proper ENT care, often delays the initiation of correct
diagnosis and treatment.
From the data available from various community-level surveys in India, the burden of ENT-related
illnesses range from 4.3% to 11%. Out of these, Ear, Nose and Throat related disorders are 60%, 27%
and 13% respectively, thus making disorders leading to hearing loss a major public health concern.
The common ear problems include ear wax (18.7%), Chronic Suppurative Otitis media (5.4%), dry
perforation of Tympanic Membrane (0.6%), Congenital deafness (0.2%) and age-related hearing loss
i.e., presbycusis (10.5%)
Adult-onset hearing loss ranks 15th amongst the leading causes of the Global Burden of Disease
(GBD), and second in the leading causes of Years Lived with a Disability (YLD). In developing countries,
children with hearing loss and deafness rarely receive any schooling. The adults with hearing loss
are usually paid lower and have a much higher unemployment rate.
The National Programme for Prevention and Control of Deafness (NPPCD) was launched in 2006
with a purpose of early identification, diagnosis and treatment of ear problems responsible for
hearing loss and deafness. Under the programme, training of health personnel, screening camps
for deafness, provision of hearing aids, screening at schools, etc. were undertaken to reduce the
burden of hearing loss. However, basic ENT services were not available at health care facilities at the
grassroot level, thus increasing patient load in tertiary health care facilities.
Under the Ayushman Bharat Scheme, delivery of basic ENT services has been included in the
package in HWCs, thus bringing comprehensive care closer to the community. Focus is on training
ASHA, ANM and CHO in providing ENT services at the SHC-HWCs and the community.
This module will guide you and provide you with new information and skills related to ENT care.
This module has four parts:
1. Understanding the anatomy, physiology, and procedure for examination of the ear, nose and
throat.
2. Protocols for detection and management for common problems of the ear, nose and throat at
the SHC-HWC.
3. Health promotion activities for health of ear, nose and throat.
4. Service delivery framework and roles and responsibilities of the SHC-HWC team in ENT services.
02 UNDERSTANDING THE EAR,
CHAPTER NOSE AND THROAT
Structure of ear
The ear is made up of 3 parts:
Outer ear – This consists of the pinna (earlobe)

and the external auditory meatus (ear canal). The
ear canal ends with a cover called the tympanic
membrane (ear drum).
Middle ear – It is a closed box like structure which

starts from the ear drum and contains three small
bones – Auditory Ossicle attached to each other
known as malleus, incus, and stapes.
Inner ear – The inside most part of the ear which

has the hearing centre called the cochlea and the balance canals called the semi-circular canals.
How does the ear function?

Sound waves enter the ear through the pinna and ear canal and hit the ear drum. These cause the
ear drum to vibrate. The vibrations cause the small bones to carry the sound to the cochlea in the
inner ear. These send electrical signals through auditory nerves to the brain and sound is perceived.
Structure of nose and throat
External nose – It is a triangular projection
made up of nasal bone and cartilage
Nasal cavity – There are two nasal cavities/

passages separated by a nasal septum.
Pharynx – The nasal passages end in

the nasopharynx which further continues
downward as the oropharynx (back of the oral
cavity) and ends in the epiglottis (a cartilage
separating the entry to the air passage from
the food passage).
How does the nose function?

The nose helps in the sense of smell as well
as filtering dust particles from entering the airway. There are nerve endings in the roof of the nose
called the olfactory bulb which carry the smell signals to the brain and smell is perceived.
03 EXAMINATION OF EAR,
CHAPTER NOSE AND THROAT
To undertake and record an ENT examination, you will need
yy A torch or LED head lamp
yy Ear speculum
yy Nasal speculum
yy Tongue depressor
yy Pen and record card
Preparation
yy Find a space which has enough light.
yy Make the person sit comfortably.
yy Explain to the person what you are going to do.
yy Record the name, age, sex, address, and date.
Method
yy Greet the patient and find out their main complaint, duration of symptoms, and any other
associated predisposing factors.
yy Record if they say they have any symptoms of the ear, nose or throat – pain, loss of hearing,
injury, difficulty in swallowing, difficulty in breathing, bleeding from nasal cavity, or anything else
indicating disease.
yy Examine the person’s ears. The pinna should be normal in shape and size and there should be no
visible discharge (watery, purulent or blood-stained) coming out from the ear. Now pull the pinna
outwards and upwards to view the ear canal with a torch. There should be no discharge, pus,
blood, boil or swelling. You can use an ear speculum to view the ear canal more clearly.
yy Examine the person’s nose. Lift the tip of the nose to view
Normal Abnormal
the nasal cavity. Use a nasal speculum to view each nasal
cavity separately. There should be no swelling, blood, pus,
or discharge.
Uvula Throat redness
Pharynx Whitish spots
Soft palate Swollen tonsil
yy Examine the person’s throat. Ask the person to open his/

Normal tonsil
her mouth wide and say “Aah”. Place the tongue depressor
over the centre of the patient’s tongue and pull down. This
will open up the throat and you will be able to see the tonsils, soft palate, uvula and pharynx.
There should be no swelling, redness, or pus.
yy In all the three examinations, look for the following:
o Any kind of discharge - pus, clear fluid, blood etc.
o Any kind of foreign body - visible as it is or with help of torch.
o Any sign of inflammation i.e., redness, warmth, swelling, pain.
yy Record what you see under examination of ear, nose and throat separately.
Hearing assessment
For this you will require a tuning fork (512 Hz).
Initial assessment
Sit about one metre from the child/adult with one ear towards you. The other ear should be blocked.
Cover your lips while speaking (to prevent lip reading).
First, whisper:
Correct response = normal hearing
Incorrect response: Repeat in conversational voice
yy Correct response = slight hearing loss
yy Incorrect response: Repeat in loud voice
o Correct response = moderate hearing loss
o Incorrect response: Repeat by shouting
⁃ Correct response = Severe hearing loss
⁃ Incorrect response: Deafness
Tuning fork tests
Tuning fork tests are examinations that test for hearing loss and differentiate the types of hearing
loss. There are three types of hearing loss:
1. Conductive hearing loss – due to problems in the ear canal, ear drum or middle ear, like ear
infection, blockage due to ear wax, punctured ear drum, fluid in the middle ear, damage to the
bones of middle ear.
2. Sensorineural hearing loss – damage to cochlea or auditory nerve
3. Mixed type
A) Rinne’s test
a. Strike the tuning fork and place it on the mastoid bone behind one ear of the patient. Instruct the
patient to tell you exactly when the sound stops.
b. When the patient can no longer hear the sound, move the tuning fork to 1-2 cm beside the
patient’s ear canal and instruct to tell you when the sound stops again.
c. Record the length of time the patient hears each sound..
Normal hearing – The sound next to the ear (air conduction) will be twice as long as the
sound behind the ear on mastoid bone (bone conduction).
Conductive hearing loss – Bone conduction is heard longer than the air conduction sound.
Sensorineural hearing loss – Air conduction is heard longer than bone conduction but may
not be twice as long.
B) Weber’s test
a. Strike the tuning fork and place it on the middle of the patient’s head or on the bone in between
patient’s eyebrows.
b. Instruct the patient to tell you where the sound is better heard: the left ear, the right ear, or both
ears equally.
Normal hearing will produce equal sound in both ears.
Conductive loss will cause the sound to be heard better in the abnormal ear.
Sensorineural loss will cause the sound to be heard better in the normal ear.
04 COMMON ENT
COMPLAINTS AND HOW
CHAPTER
TO APPROACH THEM
1. EPISTAXIS (NOSE BLEEDS)
Epistaxis, or bleeding from the nose, is a common complaint, especially during winters. In
majority of cases, nosebleeds are self-limiting and spontaneous, but it may be of significant
concern if it is recurrent, massive or occurring in children.
Based on the site of bleeding, it is classified as:
a) Anterior bleeds: Most common and relatively easier to control. Occurs as bleeding from the
nose.
b) Posterior bleeds: Less common. May cause profuse bleeding. More difficult to control.
Usually occurs as bleeding from mouth.
Pathophysiology Anterior ethmoidal artery
Posterior ethmoidal artery

The nose has a rich vascular supply (as depicted in the figure).
Sphenopalatine artery
There is one part in the anterior cartilaginous septum where a Kiesselbach’s
number of blood vessel connections exists. This is the most plexus
common site for epistaxis.

Nosebleeds occur more frequently in the drier, colder months,
and in less humid environments. This is because dry air
facilitates drying and cracking of the nasal mucosa, vessel
trauma, and subsequent epistaxis.
Causes
a) Local causes: finger-nail trauma, mucosal irritation,
inflammation, tumours
b) Systemic causes: hypertension, liver disease, kidney disease, blood thinning drugs like aspirin,
warfarin, etc.
c) Idiopathic or reason unknown
Management at SHC-HWC
History taking Examination
Duration of current episode Site of bleeding
Previous h/o of similar episodes Blood pressure check
H/o trauma Nasal septum deviation
H/o bleeding tendencies elsewhere
H/o chronic liver disease
H/o any drug intake
Family history
H/o Chronic alcohol intake
If the bleeding is mild and from the anterior part of the nose, it can be managed easily at the
SHCHWC. If it is moderate to massive anterior bleeding as well as from the posterior part of the
nose, it will need specialised care, and hence, must be referred to a facility with ENT specialist for
further management after giving first aid.
yy For mild bleed: Immediate relief can be obtained by tilting the head forward and pinching the
nostrils together for 10 minutes. If it continues bleeding, pinch nostrils together for 10 more
minutes.
yy For moderate bleed:
⁃ Make sure the person is relaxed. Check whether the bleeding is anterior (bleeding from
nose) or posterior (bleeding from mouth).
⁃ Make him/her sit upright with head slight bent forward.
⁃ Ask the patient not to blow through his nose.
⁃ In case of anterior bleeds, apply pressure on the bleeding side of the nose for 10 mins.
⁃ If bleeding does not stop, apply a combination of topical anaesthetic, such as 2% lidocaine
and vasoconstrictor and wait for 10 mins. Soak cotton balls in a mix of 2% lidocaine and
1:1000 epinephrine. Put 1-2 cotton balls into the bleeding nostril. (If bleeding is not clearly
unilateral, put cotton balls into both nostrils.) Place a dry cotton ball at the nostril opening
to prevent leakage and dripping. Leave the cotton balls in place for 10 minutes.
⁃ If the bleeding still does not stop, or in case of posterior bleeds, pack the nose and refer to
higher centre for appropriate care.
⁃ Antibiotics may be given to prevent infection (sinusitis) if pack is to be kept beyond 24 hours.
(can only be prescribed by a doctor; the CHO will consult the MO-PHC for antibiotics)
⁃ If bleeding is severe or the person is unconscious, call an ambulance and refer immediately
to the District Hospital where ENT surgeon is available.
Indications for referral
i. High BP at presentation
ii. Epistaxis not controlled with local pressure for over 20 min
iii. Massive blood loss
iv. Bleeding following trauma to the face, with suspected facial fractures
v. Other co morbidities requiring appropriate cross consultations
vi. For posterior nasal packing in case of posterior epistaxis
Follow up of cases
After an episode of nosebleed, it is important to follow up with the client. If the case has been treated
at the SHC-HWC, follow up after a week to see that the person has recovered. If the client has high
blood pressure, then this also needs to be followed up. All the cases that are referred to higher
facilities must be followed up after treatment.
Prevention of epistaxis
Some advice that can be given during health promotion activities to prevent nose bleeds include:
yy Keep fingernails short to prevent injuring the nostril
yy Blow nose gently and without too much force
yy In winter, can use a vaporiser in the room of the person prone to nose bleeds
yy Apply a thin coating of petroleum jelly inside each nostril daily in the dry season. The inner lining
will then be moist
ANTERIOR PACKING OF THE BLEEDING NOSE

Indication: Controlling nose bleeds which are not controlled by pressure or lignocaine.
Tools needed: Gloves, 2% lignocaine jelly, lubricants such as petroleum jelly, gauze ribbon, forceps,
etc.
Procedure:
Make the patient sit up with a back rest.
Apply local anaesthetic such as lignocaine 2% to the nasal mucosa
Prepare a long ribbon gauze piece and smear it with abundant lubricant such as petroleum jelly
Using the help of a scalpel, the gauze pieces have to be layered one upon each other, packing it from
anterior to posterior, as depicted in the diagram below.
The gauze should be pushed in back as far as possible. Packing is continued until the anterior nasal
cavity is filled.
©2005 CHRISTY KRAMES
A B C
RESPONSIBILTIES OF CHO IN MANAGING EPISTAXIS

Administer first aid for any case of nose bleeds brought to the centre.
Check for high blood pressure or any other injury.
If nose bleed does not stop after 15 minutes, refer to higher centre.
Follow up all cases that are referred or treated.
During health education, focus on awareness of how to prevent nose bleeds by avoiding picking of
the nose and to use vaseline during summer and dry season.
Keep records of all cases and report on a monthly basis to the PHC.
Referral pathway for epistaxis
ASHA/ANM identifies a patient/patient directly comes to the
HWC with h/o bleeding from nose
Reassure the patient

Check BP
Ask to sit in upright position, slightly bending forward
Ask: Check for:

Duration of current episode Site of bleeding
Previous h/o of similar episodes Blood pressure
H/O trauma, bleeding tendencies, chronic liver Nasal septum deviation
disease, any drug intake, chronic alcohol intake
Anterior Bleeds Posterior Bleeds
Apply pressure on the nasal

septum for 10 mins Refer to DH/Specialist for further
evaluatioin and management
Relief obtained Relief not obtained
Apply a combination of Lignocaine

and topical vasocontrictor
such as oxymetazoline 0.05% and
press for 10 mins
A) F/u care by CHO @SHC-HWC:(1) Ensure compliance to the f/u visits and Rx advised; (2)
Counsel about avoiding picking of nose, maintaining moist nasal mucosa (especially during
dry seasons) by applying vaseline/sniffing water with little salt in it and importance of
maintaining BP (3) Encourage people to eat oranges, tomatoes, etc. (Vitamin C rich foods)
to strengthen the small blood vessels so that nose bleeds decrease; (4) Advise the patient to
revisit the Specialist in case of relapse.
B) F/u care by ASHA/ ANM @Community: (1) Encourage known HTN cases to undergo regular
check-up; (2) Promote consumption of Vitamin C rich foods; (3) Counsel for care of nasal
mucosa, especially during the drier, winter seasons.
2. UPPER RESPIRATORY TRACT INFECTIONS
Most people develop an acute respiratory tract infection (RTI) every year. Upper respiratory
tract infections (URTIs) are one of the most common reasons for seeking Out-patient medical
care, especially amongst children. Since the vast majority of these are viral infections, the use
of antibiotics to treat URIs is usually not recommended, and symptom-based treatment is
practised. However, certain conditions which need antibiotics include:
- If the patient has symptoms and signs suggestive of serious illness and/or complications
(particularly pneumonia, throat abscess, etc.).
- All cases of bacterial infection like acute tonsillitis, sinusitis.
- If the patient is at high risk of serious complications because of pre-existing conditions like
heart, lung, kidney, liver disease.
- Young children who were born prematurely or patients older than 65 years with severe
disease..
Types of URIs
1. Sinusitis
2. Rhinitis – may be viral (common cold), allergic or atrophic rhinitis
3. Pharyngitis
4. Tonsillitis (discussed in the next section)
Clinical features
SINUSITIS PHARYNGITIS
Facial pain or sinus pain; Sudden onset of sore throat;
Purulent nasal drainage; Pain in throat;
Fever, malaise.
Fever;
Stuffy/blocked nose.
RHINITIS
Simple viral rhinitis: Watery nasal discharge; Watering from eyes; Nasal stuffiness; Malaise, fever
and headache.
Allergic rhinitis: Frequent bouts of sneezing, about 10 to 20 sneezes at a time; Itching of nose, eyes,
ears, palate; Watery nasal discharge; Blockage of nose; Watering from eyes with redness & itching.
Atrophic rhinitis: Greenish crusts present in nasal cavity; Foul smell from nose and patient unaware
of it; Nasal blockage, roomy nasal cavity, nasal deformity, history of maggots.
Most cases of rhinitis and pharyngitis are viral, and will need only symptomatic treatment, if any.
You should counsel the patient about the following for treatment and prevention of these diseases.
1. Drink plenty of water and get enough rest.
2. Sniff a little salt water into the nose or inhale steam from hot water to clear the nose.
3. No special diet is needed. However, eating oranges, tomatoes, and other fruit containing vitamin
C may help.
4. Do not take antibiotics if not prescribed.
5. Contrary to popular belief, colds do not occur from getting cold or wet (although getting very
cold, wet, or tired can make a cold worse). A cold is ‘caught’ from others who have the infection
and sneeze the virus into the air.
6. To prevent infecting others with cold, the sick person should eat and sleep separately and take
special care to stay far away from small babies. He/she should cover his/her nose and mouth
when coughing or sneezing, and wash hands as often as possible.
7. Simple medicine such as Paracetamol helps lower temperature and relieves body aches and
headaches. The expensive ‘cold tablets’ are not necessarily better.
8. Wipe a runny or stuffy nose but try not to blow it. Blowing the nose may lead to earache and
sinus infections.
Note: If the facial pain/sinus pain is continuing for more than 3 months than it is known as
chronic sinusitis, for which you must refer the patient to a higher centre for further management
and treatment. Follow-up is the key here.
Some medicines which are commonly used for the treatment of URTIs include:
- T. Paracetamol 500 mg TDS (Adult) OR Syrup Paracetamol 10-15mg/kg bodyweight in 3
divided doses (Paediatric)
- Nasal drops containing nasal decongestants such as 1% Ephedrine, 0.1% Xylometazoline
- Antibiotics such as Amoxicillin 500mg TDS/Azithromycin 500mg OD, when indicated OR
Syrup Amoxicillin 40mg/kg/day in 3 divided doses for Paediatric age group. (can only be
prescribed by a doctor; the CHO will consult the MO-PHC for antibiotics)
RESPONSIBILTIES OF CHO IN MANAGING URIs

Identify the type of URTI when the patient comes to the clinic or you see a case in the field.
Provide general symptomatic treatment for the fever, runny nose and headache.
Advise rest, steam inhalation, drinking warm fluids and good nutrition.
If suspecting a bacterial infection, refer to the MO to initiate antibiotics. Once prescribed, you can
ensure that the patient gets and takes the antibiotics correctly and completes the course.
Follow up all cases treated with antibiotics and all chronic cases.
Conduct health education session to prevent colds and raise immunity through good nutrition and
regular health checkups.
Keep records updated.
Referral pathway for Upper Respiratory Tract Infection
Patient presents with ever, cough & cold, sore throat, running nose, etc.
Ask for:
(1) onset and progression of symptoms (2) previous h/of similar episode (3) use of OTC
medicines/ self-medication (4) relevant risk factors such as smoking (5) Co-mordid
conditions such as HTN/DM/Cirrhosis, etc.
Assess:
(1) vitals (temperature/pulse/BP/RR) (2) Cervical lymphadenopathy (3) tonsillar exudates
Patient appears unstable Patient appears stable
- Advise and Initiate the patient on the nonpharmacological Refer to PHC-HWC for
treatment options further evaluation and Mn
- Give symptomatic Rx in the form of
T.PCM/T.CPM/ Nasal decongestants
- Counsel the patient to avoid sleeping in
congested rooms and cover his mouth with
handkerchief while coughing
- F/u the patient after a period of 5 days
F/u care @ SHC_HWC through CHO:

(1) Ask if the patient has any issues in being compliant to the treatment advised
(2) Advise the patient to refer similar cases, especially children in the family to the SHC-HWC
(3) Counsel the patient to avoid OTC medications and home-based, non-pharmacological
remedies which can be started by the patient in case of future episodes
(4) Advise the patient to report back to the Centre if: (i) there is no response to the treatment
advised within in 5 days, patient experiences new symptoms such as high-grade fever,
breathlessness, purulent ear/throat discharge, etc.
3. ACUTE TONSILLITIS
Tonsils are a pair of special tissues situated at the back of the throat. Often, especially in children,
they get infected and inflamed leading to a condition known as Tonsillitis.
Clinical features
Symptoms:
yy Sore throat
yy Difficult or painful swallowing
yy Fever
yy Earache
yy Change in voice
yy General symptoms like headache, body ache etc.
Signs:
yy Red and swollen tonsils. May be studded with follicles
or membrane. (White or yellow coating or patches on
the tonsils)
yy Enlarged, tender glands (lymph nodes) in the neck
Most of the cases with tonsillitis can be managed by medicines alone. The usual line of treatment in
uncomplicated cases includes:
1. T. Paracetamol (500 mg) 3 times a day OR Syrup Paracetamol 10-15mg/kg bodyweight in 3
divided doses (Paediatric)
2. T. Amoxicillin (500 mg) 3 times a day OR Syrup Amoxicillin 40mg/kg/day in 3 divided doses for
Paediatric age group (can only be prescribed by a doctor; the CHO will consult the MO-PHC for
antibiotics)
3. Warm saline gargles/betadine gargles 3-4 times a day
4. If the symptoms persist, then the person must be referred to an ENT specialist or to the DH for
investigations (blood counts, throat swab, chest x-ray)
Some patients may need to undergo surgery for cure. Indications for surgery are as follows:
yy Recurrent infection of throat (7 or more episodes in 1 year or 5 episodes per year for 2 years
or 3 episodes per year for 3 years)
yy Association with febrile seizures
yy Tonsillar swelling causing airway obstruction
yy Difficulty in swallowing/speaking, suspicion of cancer
yy Cases who do not respond to antibiotics.
RESPONSIBILTIES OF CHO IN MANAGING ACUTE TONSILLITIS
Check the throat of all those who complain of sore throat or difficulty in swallowing.
Advise hot saline water gargles and to avoid cold, oily, or spicy food.
If tonsils are inflamed or there is an exudate, the patient will require antibiotics, refer the patient
to the MO-PHC to initiate antibiotics. Ensure that the patient is taking the full course of antibiotics
and other medicines prescribed.
Follow up all cases. If there is no improvement in a week, refer the case back to a higher centre
where there is an ENT specialist.
During health education sessions, emphasise on importance of avoiding dust, keeping the throat
moist by sipping water often and maintaining good personal hygiene.
Keep records of all cases updated.
Referral pathway for Acute tonsillitis
Patient presents himself/herself at the facility complaining of fever,
sore throat, difficulty in swallowing, painful swallowing, etc.
Ask for: Check for:

Onset and progression of current episode Presence of high grade fever
Previous h/o of similar episodes (patient looks toxic)
H/O recurrent URTI Enlarged swollen inflamed tonsils
Tender cervical lymph nodes
First episode and patient Recurrent episodes/patient

is stable appears toxic/severe pain in
swallowing/tonsils covered
with exudate
Initiate treatment with:
- Paracetamol 25-30 mg/kg/day in 3 divided doses
- Warm saline water/Betadine drop gargles 3-4 times a Give a dose of PCM and
day Amoxcillin and refer
- Amoxycillin 25-30 mg /kg/day in three divided doses
Counsel about:
Diet - Soft, bland diet for few days. Avoid oily/spicy food Refer to DH/Specialist
for further evaluation &
management
Follow-up after 5 days
F/u care @ SHC-HWC through MLHP:

(1) Counsel the patient to avoid oily/spicy food for few days
(2) Assess the compliance and response to Rx advised
(3) Ask the patient to refer cases with similar complaints in the family, especially children
F/u care @ Community through ASHA/ANM:

(1) Assess if the patient is having any difficulty in taking medicines
(2) Counsel for warm saline water gargling, soft diet and to avoid crowded places for few days
(3) Check if there are others in the family/neighbourhood with similar complaints, especially
children
4. ACUTE EPIGLOTTITIS
It is a very serious/dangerous condition which mostly affects children between 2 to 7 years of
age. It is caused by bacterial infection of the lower airway (larynx), which causes the airway to
swell up and leads to obstruction and difficulty in breathing.
Clinical features
yy Sudden onset of symptoms
yy Difficulty in breathing
yy Noisy breathing
yy Very high fever
yy Sore throat and difficulty in eating (in adults)
Children with this infection must be hospitalised because there is danger of respiratory obstruction
and death. The child might be unable to swallow, therefore, intravenous fluids and antibiotics have
to be started urgently. Immediately refer the child to a higher centre where an ENT specialist or
paediatrician is available.
RESPONSIBILTIES OF CHO IN MANAGING ACUTE EPIGLOTTITIS

If you see a child with breathlessness, noisy breathing and fever, immediately refer the patient to
an ENT specialist to initiate treatment.
Follow up with the child once he/she returns from the facility to ensure that he/she is taking the full
course of antibiotics and other medicines prescribed.
Follow up all cases. If there is no improvement in a week, refer the case back to a higher centre
where there is an ENT specialist.
During health education sessions, emphasise on maintaining good personal hygiene.
Pentavalent vaccine (given at 6, 10 and 14 weeks of age) is protective against this disease. Ensure
that all children are fully immunised.
Keep records of all cases updated.
5. EARACHE (OTALGIA)
Pain in the ear is known as Otalgia. It is a
symptom caused by several conditions. It is
essential to find its cause before a specific Three ear bones:
1. Malleus
treatment can be started. Most commonly 2. Incus
3. Stapes
occurs during childhood, although it may
Semicircular canals
occur in adults too. Nerves
Cochlea
Causes of otalgia Ear Drum
a) Primary otalgia (most common): Eustachian tube
Ear canal
The cause of the pain exists within the ear itself. E.g., external otitis, otitis media, mastoiditis,
impacted wax etc..
b) Secondary (referred) otalgia:
The ear is innervated by many nerves, namely the cranial nerves number V, VII, IX and X.
Any abnormal stimulation of any branch of the above-mentioned nerves leads to pain in ear
(known a ‘referred pain’). E.g., problems in the teeth, jaw, trigeminal neuralgia, intracranial
lesions, etc.
yy Carry out a thorough general and systemic examination, including ear, oral and throat
examination.
yy It is important to find out the underlying cause before starting any specific treatment.
yy Look for signs of infection/trauma around the ear.
yy If there are secretions in the ear canal, mop them clean with a sterile gauze piece.
yy Instil antibiotic ear drops such as Ciprofloxacin ear drops, 2 drops at a time, 2-3 times a day only
when no discharge is coming out from ear. In case of active discharge, the possibility of ear
perforation may be there, so keep the ear dry.
yy For reducing pain, start Paracetamol 25-30 mg/kg/d in three divided doses.
yy Follow up after 5 days to assess response to treatment.
Indications for referral to ENT specialist
yy Any severe acute pain needs referral after giving painkillers.
yy Chronic pain (i.e., pain lasting >2 weeks), especially if associated with other head/neck
symptoms.
yy Swelling/other signs of inflammation at external auditory canal.
yy Patient having high grade fever/appearing toxic.
yy Earache following trauma.
yy When no apparent reason for earache can be found even after thorough history taking and
examination.
Referral pathway for Earache
Patient presents with c/o pain in ears
Ask for: Check for:

- the duratrion and progression - Presence of high grade fever
- h/o trauma to the ear / travel to high - Wax in the ear
altitudes - Signs of inflammation around
- h/o recurrent URTI the ear
- nature of ear discharge, if any
Patient is stable/ earache - patient appears toxic/ ear ache

of recent onset/ mild following trauma/ earache of very
grade fever/ ear wax in long duration/ high grade fever/
auditort canal/ presence signs of inflammation around the
of URTI ear/ blood stained ear discharge/
diagnosis not clear
- Ask the patient to sit still

- Instill soda bicarb/ paradichlorobenze ear
drops and mop the Ext. Aduitory Canal
with sterile cotton
- Counsel the patient for steam inhalation Refer to DH/ ENT specialist
- Give PCM 25-30 mg/kg/day in 3 divided for further evaluation and
doses
management
- Antibiotic ear drops (ciproflox/
chloramphenicol) 3-4 times a day for 5
days
F/u after 5 days
F/u care through HWC-SHC:

(1) Ensuring compliance to treatment advised through ASHAs.
(2) Counsel regarding personal hygiene, ear care including avoiding inserting foreign objects/
indigenous medicines in the ear.
(3) Warning signs needing repeat f/u visit to HWC-SHC
6. OTITIS EXTERNA (EXTERNAL EAR INFECTION)
Otitis externa is an inflammatory process of the external ear canal. It is most commonly caused
by infection (usually bacterial, although occasionally fungal), but it may also be associated with
a variety of non-infectious systemic or local dermatologic processes.
Risk factors
i. The ear canal is warm, dark, and prone to becoming moist, making it an excellent
environment for bacterial and fungal growth.
ii. The canal is easily traumatised in injuries.
iii. Because there is a curve in the canal, anything that goes inside is difficult to come out.
iv. The presence of hair, especially the thicker hair common in older men can lead to infected
boils.
Clinical features
i. Severe pain in ear on movement of pinna.
ii. Jaw movements can also be painful.
iii. Swelling of lymph nodes around the neck can also be present.
iv. Diffuse inflammation of ear canal with crusts and discharge from ear.
i. Clean ear with a dry cotton wick.
ii. An ear pack of 10% ichthammol glycerine provides relief and reduces pain. (Hygroscopic
action of glycerine reduces oedema, while ichthammol is mildly antiseptic).
iii. Cap Amoxicillin for 5 days in age-appropriate dosage (can only be prescribed by a doctor;
the CHO will consult the MO-PHC for antibiotics)
iv. Tab Paracetamol 500 mg twice daily for 5 days.
7. OTITIS MEDIA (MIDDLE EAR INFECTION)
An inflammatory condition of the middle ear space is known as Otitis Media. It is common in
infants and children but may also occur in adults. It is commonly associated with poor hygiene.
There are two types of otitis media:
1. Acute Suppurative Otitis Media which is an acute bacterial infection of the middle ear
2. Chronic Suppurative Otitis Media which is a result of long-standing infection of the middle ear
Risk factors Symptoms Signs
Recurrent attacks of Earache – which even Signs of Upper Respiratory
common cold and upper disturbs sleep; Tract Infection;
respiratory tract infections; Reduced hearing; Tenderness can be present
Diseases like measles, Very high fever; over mastoid region (bony
diphtheria, whooping cough; part behind the ear lobe);
Infections of tonsils; If the ear drum is perforated:
External auditory canal
Bleeding/pus ear discharge,
Chronic rhinitis and sinusitis; may contain blood-tinged
Tinnitus (ringing sound in the discharge which may also
Nasal allergy; ear) in some cases; have pus.
Cleft palate (congenital Additional symptoms in
disorder) children – fever/vomiting/
loose motion/sleeplessness/
incessant crying/irritability.
Note: There is a condition known as Serous Otitis Media which has watery discharge from
the middle ear. The condition is commonin school-going children. Mostly, viral infection and
seasonal allergies are its causes. It is also associated with hearing loss, mild earaches but the
symptoms are less severe than Suppurative Otitis Media. This condition can be treated only
with nasal decongestants and antiallergic medicines and does not require antibiotics.
yy Counsel the patient to:
o Keep the ear dry (prevent water from getting into the ear).
o In case of discharge – dry mopping of the ear with a clean cotton wick.
o No putting of any ear drops or oil into the ear.
yy Dry mopping of the of the ear canal with sterile cotton wick.
yy Tab Paracetamol (500 mg) 3 times a day OR Syrup Paracetamol 10-15mg/kg bodyweight in 3
divided doses (Paediatric).
yy Antibiotics like Amoxicillin or Azithromycin for 5-7 days (can only be prescribed by a doctor; the
CHO will consult the MO-PHC for antibiotics)
yy Nose drops (1% in adults and 0.5% in children or Xylometazoline or oxymetazoline can be used
2-3 drops thrice a day) to reduce nasal blockage. This can improve symptoms.
yy Ear toilet: If discharge is present, then a sterile cotton can be used to mopped it but care to be
taken not to put cotton roll inside, only discharging pus needs to be cleaned.
yy Dry local heat: it also helps to relieve pain. Take a small hand towel, dip in hot water, and place
over the ear lobe.
When to refer to a specialist
yy No improvement or symptoms worsen even after 48 hours of medical treatment
yy Patient develops features like vomiting with headache/facial palsy/dizziness/mastoid

tenderness.
yy Any other condition is also present, such as tonsillitis, rhinosinusitis.
yy If foul smelling discharge is present.
RESPONSIBILTIES OF CHO IN MANAGING MIDDLE EAR INFECTION

Diagnose all cases of ear pain and fever confirm infection of the middle ear.
Clean ear with a dry cotton wick.
Give symptomatic treatment for pain.
Consult with the MO-PHC or ENT specialist for confirming diagnosis and initiating treatment.
Follow up all cases to ensure that they complete the antibiotic treatment. In case there is no
improvement after one week, refer the case back to the ENT specialist.
Maintain updated records.
Advise the community about maintaining personal hygiene and how to clean the ear regularly.
Also advise to avoid putting sharp objects in the ear. Clean and dry the ears after swimming.
Ensure that all children in your area are fully immunised.
Referral pathway for Otitis Media
ASHA identifies a case/ patient presents to the facility with complaints of : ear
discharge, reduced hearing, irritability, fever
Ask for: Look for signs of severe infection:

h/o recurrent / past URTI High grade fever, prostration, neck
h/o allergies rigidity, pus discharge from ears,
h/o travel to high altitude severe headache, facial deviation.
h/o cleft lip/ palate, bottle feeding
Signs of severe infection absent Signs of severe infection present
Initiate treatment with:

PCM: 10-15 mg/kg/day in 3 divided doses
chloramphenicol/ ciplox ear 2drops twice Refer to DH/ENT specialist for
a day further evaluation and Mn
Amoxycillin 25-30 mg/kg/d in 3 divided
doses
Xylometazoline 0.1% 2 drops thrice a day
F/u after 5 days
relief obtained relief not obtained
F/u care @ SHC-HWC through CHO:

(1) Ensuring compliance to treatment
(2) Advise the patient regarding personal hygiene, ear care including avoiding inserting foreign
objects/ indigenous medicines in the ear.
(3) Counsel them to watch out for signs such as diminishing hearing, facial deviation, neck
stiffness, vertigo, high grade fever, etc. needing repeat f/u visit to HWC-SHC
8. VERTIGO
Vertigo is a subjective feeling of movement, either of self or the objects around in the
environment. Various terms are used by patients to describe this feeling. For e.g., bouncing,
oscillating, twisting, rolling, spinning, light-headedness, imbalance, floating, fainting, etc.
It is different from dizziness which occurs due to low blood pressure or weakness. The inner
ear is responsible for carrying sound and for maintaining balance. Any disease of the inner ear,
therefore, causes a feeling of imbalance. Most of these conditions are treated with specific
medicines, but sometimes the underlying cause can also be a tumour (benign or malignant) in
the inner ear or in the brain.
Clinical features
The patient complains of:
yy Dizziness
yy Feeling of rotation or spinning
yy Light headedness, faintness, weakness
yy May be associated with blurring of vision, syncope or ‘blacking out’ and imbalance/unsteadiness
Causes Symptoms Signs
Ear related causes: ⁃ Dizziness ⁃ Detailed general and
Meniere’s disease, Benign ⁃ Feeling of rotation or systemic examination
paroxysmal positional spinning (especially CVS and CNS
vertigo (BPPV), labyrinthitis, examination) may show
⁃ Light headedness, abnormalities
vestibule-toxic drugs, faintness, weakness
otosclerosis, etc. ⁃ BP and RBS may be
⁃ May be associated raised
with blurring of vision,
syncope or ‘blacking ⁃ Tuning fork tests may
out’ and imbalance/ show reduced hearing
unsteadiness
Neurological causes: Multiple Romberg’s test:
sclerosis, transient ischemic Ask the patient to stand with their feet together (touching
attacks, intra-cranial tumours, each other). Then ask the patient to close their eyes. Remain
seizures, etc close at hand in case the patient begins to sway or fall.
Systemic causes: Interpretation:
Hypotension, certain viral
infections, hypothyroidism, If the patient does not sway at all: Normal
DM, head injury Patient sways after closure of eyes: Also known as Romberg
Certain drugs such as Positive.
anticonvulsants (phenytoin, Occurs due to diseases in the vestibular system (ear
pregabalin, gabapentin), problem) or sensory nervous system
anti-hypertensive If the patient sways even with eyes open: Disease in the
(propranolol, furosemide), cerebellar functions of the patient
anti-depressants (fluoxetine),
analgesics (codeine), alcohol,
etc.
• Reassurance regarding the nature of the disease, avoiding the posture that triggers the
symptoms.
yy Certain drugs like Prochlorperazine 5mg BD OR Cinnarizine 25 mg BD OR Betahistine 16 mg BD
for 5 days may be started in consultation with the Medical Officer.
yy Multi-vitamin supplements may also be added.
yy Counsel the patient about:
o Reducing intake of caffeine/alcohol
o Avoiding performing tasks which may cause harm, such as working on heavy machines,
driving, etc.
o Keeping a note of the medicines being taken and emergency contact numbers in pocket
whenever going out of house alone
yy Exercises are helpful in regaining the balance and confidence of the patient: The manoeuvre
consists of five positions.
Position 1- Ask the person to sit on the bed. Turn the head
45 degrees towards the affected ear.
Position 2 - With the head turned 45 degrees, the patient
is made to lie down in head hanging position. It will cause
vertigo and nystagmus (sudden jerky movements of the
eyes). Wait till vertigo and nystagmus subside.
Position 3 - Head is now turned so that the affected ear
is up.
Position 4 - The whole body and head are now rotated
away from the affected ear to a lateral recumbent position
in a facedown position.
Position 5 - Patient is now brought in a sitting position
with head still turned to the unaffected side by 45 degrees.
Position 6 - The head is now turned forward and chin brought down 20 degrees.
There should be a pause at each position till there is no nystagmus or there is slowing of nystagmus,
before changing to the next position. After the manoeuvre is complete, the patient should maintain
an upright position for 4 to 6 hours. 80% of the patients will benefit from this exercise. If the patient
remains symptomatic, the manoeuvre can be repeated..
When to refer to a specialist
yy No improvement after 2 days of starting treatment
yy Sudden fainting
yy History of injury to the head or ear
yy Known case of Epilepsy (fits)
Known case of any inner ear problems, tumours
RESPONSIBILTIES OF CHO IN MANAGING VERTIGO

Consult with the MO-PHC and refer the patient to an ENT specialist for confirming diagnosis and
initiating treatment.
Follow up all cases to ensure that they complete the prescribed treatment. In case there is no
improvement after one week, refer the case back to the ENT specialist.
Support the patient for any lifestyle modification or exercise that may have been prescribed by the
Specialist.
Referral pathway for Vertigo
Patient presents with dizziness
Ask about:
- Detailed description of dizziness Check for Feeling that himself or his surroundings
- h/o of any drug, alcohol intake are moving. a.w tinitus/ hearing loss
- h/o trauma to head Disturbed balance predominantly on waling.
relieved on sitting
Feeling of loosing consciouness of ‘blacking out’
or h/o dizziness after trauma
Refer to DH/ENT
specialist for further
evaluation and
treatment
Probable case of
Vertigo
- Counsel the patient about reduced intake of caffine/

alcohol
- Avoid performing hazardous taks
- Consult the MO and initate Rx with Cinnarizine 15 mg/
Antihistaminics for 5 days
Relief Obtained Relief not obtained
F/u care through HWC-SHC:

1) Ensuring compliance to treatment advised through ASHAs.
2) Counsel regarding reduced caffeine/ alcohol intake, avoidance of hazardous tasks,
personal care.
3) Warning signs needing repeat f/u visit to HWC-SHC
9. HEARING LOSS/ REDUCED HEARING
Reduced hearing or loss
of hearing (deafness) is
a condition where the
person is not able to hear
anything or can hear only
loud sounds. Hearing
loss may affect people of
any age group. Children
and adults may also lose
their hearing completely
or partially due to various
reasons, like an injury
causing rupture of the
eardrum, severe infection
of the ear, tumour in the
ear, sudden exposure to
very loud sounds (like
explosions) or prolonged
exposure to loud sounds (like people working in factories with noise from heavy machinery).
Sometimes, babies are born with deafness (known as congenital deafness) which happens
when the mother is exposed to certain infections, medicines, or radiation during pregnancy. As
people become older, they slowly lose their hearing (known as presbycusis), usually after 65
years of age, due to physiological ageing process.
Hearing loss can be of three types – conductive hearing loss, sensorineural hearing loss and
mixed type of hearing loss (refer to the chapter on ENT examination).
Untreated hearing loss affects communication and thus may also contribute to social isolation
and loss of autonomy. Not being able to hear properly is often associated with anxiety, and
depression. Hearing loss in children can affect their growing-up years, education, interaction
with others and personality development. Hearing loss in old age can impair the quality of life..
ASHA/MPW will identify the people with hearing loss in the community and refer them to you at the
SHC-HWC.
At the sub centre HWC level, it is important to get the history of hearing loss. Some of the questions
that should be asked and answered are:
a) Onset of hearing loss – from birth or later
b) Hearing loss happened suddenly or gradually
c) Hearing loss is stationary or progressive
d) Any family history of hearing loss
e) Any other ear symptoms
f) Any test or treatment done earlier
Since most of the diagnosis and treatment requires a specialist, you should confirm the presence of
hearing loss and refer the patient to the centre where there is an ENT specialist.
Before referring the person, you can check for the following:
1) Any obstruction in the ear canal – foreign body, wax, etc.
2) Any discharge from the ear or recent history of injury to the ear.
3) Whether speech is affected or not.
4) If the hearing is lost for low frequency sounds or high frequency sounds.
5) Any history of taking certain drugs recently.
6) Exposure to very loud sounds – explosion, gun fire..
Disability certificate and entitlements: WHO classifies hearing loss as a disability depending
on the percentage of hearing loss (determined by audiometric tests). The people with hearing
loss are issued a disability certificate by a Medical Officer. These people are eligible for social
security schemes and benefits. You must be aware of the social benefits in your State and
inform the client regarding the benefits that he/she is eligible for.
RESPONSIBILTIES OF CHO IN HEARING LOSS

Supervision of ASHA/MPW in screening of individuals for hearing loss in the community.
Assist RBSK teams to screen children up to18 years of age for hearing loss through Anganwadi
centres, schools, etc.
Identify hearing loss in patients and refer to an ENT specialist for confirming diagnosis and initiating
treatment.
Follow up and support individuals who have been prescribed hearing aid and post-operative
individuals in the community.
Arrange for assistive devices (hearing aids, etc.) as per the requirement from the PHC.
Inform people with deafness about financial schemes and benefits for their uptake, if found to be
eligible.
Referral pathway for Hearing loss
Patient presents to the facility with complains reduced hearing
Ask for:
Onset and progression of Clinical evaluation for:
current episode Obvious causes of reduced
Previous h/o of similar episodes hearing such as congenital
Is hearing loss uni/bi-lateral malformations / ear wax /
Painless/ painful hearing loss infections / trauma, etc
Family history Perform rinne’s/ weber’s tests
H/O trauma, tinitus, chronic ear using tunning forks
discharge, fullness in the ear,
chronic drug intake
Pt. appears stable & Probable 1. Pt. appears unstable

cause for the hearing loss 2. H/o sudden/ painful loss of hearing
found 3. h/o HL following trauma
4. a/w features such as high grade
fever/ purulent discharge/ facial
deviation, etc.
5. Probable underlying cause not found
Manage as per the

underlying condition
Refer to DH/ Specialist

Follow-up after 3-5 days for further evaluation
and treatment
Relief obtained No Relief
10. FOREIGN BODY IN EAR
Foreign bodies of the ear are relatively common. Usually, children insert small objects such as
small toys, beads, stones, folded paper, and biologic materials such as insects or seeds into
their ear, but even adults may also be affected by a foreign body in the ear canal, such as cotton
swabs/first-aid products, etc.
Classification of foreign bodies
(a) Living: e.g., Insect, Flies, Maggots
(b) Non - living:
i. Hygroscopic (can expand in moisture): e.g., vegetable, beans, and seeds
ii. Non-hygroscopic: e.g., beads, stones, pebbles, rubber, metallic object
Clinical Features
yy History of foreign body entering the ear
yy Ear Pain
yy Tinnitus (ringing sound in the ear)
yy Discomfort and complaint of nausea or vomiting if a live insect is in the ear canal
yy Bleeding may occur in case of sharp objects
yy Hearing loss
yy With delayed presentation, erythema and swelling of the canal, and a foul-smelling discharge
may be present
Inspect the ear canal using a torch to confirm the presence of foreign body. Method of removing
foreign body depends on its type.
Type of foreign body What to use to remove

Soft and irregular like a piece of paper, Fine alligator forceps
swab, or a piece of sponge
Smooth objects like seed grains, Syringing
metallic objects
Insect First step is to kill the insect with mineral oil or lidocaine
Then remove dead insect with forceps
Sharp object Refer to the ENT specialist for removal
When to refer to an ENT specialist

yy Small child who cannot stay in one position to attempt removal
yy Sharp objects
yy Objects appear deep in ear canal
yy Object appears to be tightly impacted
yy Any kind of discharge from the ear
yy Previous removal attempt was unsuccessful
RESPONSIBILTIES OF CHO IN CASE OF FOREIGN BODY IN EAR
First find out the type of foreign body and where exactly it is.
If possible, try and remove.
If person is restless, then do not try to remove the object; refer to an ENT specialist or the DH.
Ensure that there is no other injury to the head or neighbouring area.
Follow up all the cases that are referred
Advise the community about keeping children safe and away from small seeds, stones etc. that
can go into their ear.
Keep records and registers updated.
Referral pathway for Foreign Body in ear
Patient presents with a foreign body in the ear
Ask for: Look for:

- Nature of the object - Site of FB lodging
- Symptoms suggesting perforation - Bloody discharge indicating
such as acute ear pain, hearing trauma to TM
loss, tinitus, vertigo, etc - Margins of the object
- Object is clearly visible / appears Object not clearly visible /

graspable ungraspable friable
- position: not deep in canal - position: deep inside canal
- margins: blunt - sharp / pointed margins
- no signs/symptoms s/o TM - signs /symptoms s/o TM
perforation perforation
- Relax the patient

- Pull the pinna upwards and backwards
to straighten the canal
- Visualize under good illumination
Non-hygroscopic objects
live FB such as
such as pebbles, stone,
insects, flies
plastic beads, etc
-gently flood the ear with attempt manual removal Refer to DH/ENT
warm water/ mineral oil using forceps specialist for further
or 4% xyloocaine evaluation and Mgt
Attempt fails
11. FOREIGN BODY IN NASAL CAVITY
Sometimes, some foreign object may enter the nose either accidentally, or children may insert
objects into their nose. If the object is hygroscopic (e.g., vegetable or seed), it can absorb
moisture and swell up and cause difficulty in breathing. The foreign body may even be aspirated
into the airway.
Clinical Features
yy History of foreign body entering the nose
yy Pain in nose
yy Difficulty in breathing
yy Discomfort and watering of nose and eyes
yy If the foreign body is superficial, visible, and not a sharp object, you may attempt to remove
it. Otherwise refer the person to the Specialist at the DH.
yy Forceps may be used to remove the foreign body at the SHC-HWC.
yy If the patient is breathless and gasping, call an ambulance and urgently refer to an ENT
specialist.
yy Small child who cannot stay in one position to attempt removal
yy Sharp objects
yy Objects appear deep in nasal cavity
yy Object appears to be tightly impacted
yy Any kind of discharge from the nose
yy Previous removal attempt was unsuccessful
12. FOREIGN BODY IN AIR PASSAGE
Foreign body aspirated into air passage is yet another emergency which may happen in the
community or at the HWC. The object can lodge in the back of the throat, voice box or upper
lung tubes called bronchi. It depends on the size of the foreign body. This condition is more
common in children (50% of them are below 4 years) but can also occur in adults.
Clinical features:
yy Foreign body in the back of the throat: there will be an initial period of choking, gagging and
wheezing. Then it may be coughed out or it may lodge in the larynx.
yy Foreign body in voice box (larynx) – will have discomfort, pain in throat, hoarseness of voice,
cough, and difficulty in breathing, wheezing and coughing blood.
yy Foreign body in upper tube (Tracheal) – a sharp object will produce cough and hemoptysis
(blood in sputum).
A person can suspect there is a foreign body if there is a sudden choking after eating food, or sudden
bout of cough, discomfort and difficulty in breathing.
Steps to perform in case of choking:
i. If the person is able to cough forcefully, the person should keep coughing.
ii. If the person is choking and can’t talk, cry or laugh forcefully, the American Red Cross
recommends a ‘five-and-five’ approach to delivering first aid:
Figure: Showing ‘five-and-five’ approach in case of choking
a) Give 5 back blows (as shown in the image above). Stand to the side and just behind a choking
adult. For a child, kneel behind. Place one arm across the person’s chest for support. Bend the
person over at the waist so that the upper body is parallel with the ground. Deliver five separate
back blows between the person’s shoulder blades with the heel of your hand.
b) Give 5 abdominal thrusts. Perform five abdominal thrusts (also known as the Heimlich
manoeuvre).
c) Alternate between 5 blows and 5 thrusts until the blockage is dislodged.
The Heimlich maneuver
Do not perform the Heimlich maneuver if the
victim is coughing, speaking or breathing. If
the person cannot cough, speak or breathe,
proceed as follows :
1. Stand behind the victim, wrap your arms

around his or her waist.
2. Clasp your hands together in a double fist

and place the fist - thumb side in - just
below the victim’s rib cage and above the
navel*
3. Press into the victim’s abdomen (not the

rib cage) with a quick, upward thrust.
4. Repeat thrusts until object is dislodged.
yy If all the above methods fail
yy If patient is turning blue (facial skin colour turning blue – cyanosis)
yy If patient become unconscious
yy If suspected foreign body is poisonous
yy If patient requires immediate investigation (like X-ray) to locate the position of the object
RESPONSIBILTIES OF CHO IN CASE OF FOREIGN BODY IN AIRWAY

First find out the type of foreign body and where exactly it is.
If possible, try and remove by asking the patient to cough it out.
Try the Heimlich manoeuvre if the person is choking.
If person is restless, then do not try and remove object – refer to an ENT specialist or the DH.
Ensure that there is no other injury to the head or neighbouring area.
Follow up all cases that are referred.
Advise the community about keeping children safe and away from small seeds, toys, stones etc
that can go into the throat or be swallowed.
Referral pathway for Foreign Body in throat/airway
Patient presents with foriegn body ingestion
Ask for:
- Nature of the suspected object
- difficulty in breathing Look for:
- blood stained discharge from mouth - signs s/o chocking
- h/o alcohol/ substance abuse - unstable/ uncoperative
patient
- Smooth, small objects - Large / sharp objects

- patient stable i.e no - difficulty in breathing
sign of choking - unstable patient
Attempt insertion of - ask the patient to bend forwards

ryle’s tube if trained for it and give blows at back
or - attempt Helmich’s maneouver
Ask the patient to drink
3-4 glasses of water
Obstruction Obstruction not

-not relieved relieved
relieved
relieved
- Reassure the patient

- f/u the patient for any complains of blood-tinged
discharge from mouth / nose or change in colour or
stools
if yes
Referral to DH/Specialist of further evaluation and management
05 ESSENTIAL SKILLS NEEDED
FOR PROVIDING PRIMARY
CHAPTER ENT SERVICES
A) How to use Nasal Drops:
i. Ask the patient to blow nose gently
ii. Wash the hands thoroughly with soap and water
iii. Check if the dropper tip is chipped or cracked
iv. Avoid touching the dropper tip against the nasal mucosa
v. Tilt your head as far back as possible, or lie down on your

back on a flat surface (such as a bed) and hang your head
over the edge (as shown in the figure above)
vi. Put the correct number of drops into your nose
vii. Bend your head forward towards your knees and gently move
it left and right (as shown in the figure above)
viii. Remain in this position for a few minutes
ix. Clean the dropper tip with warm water. Cap the bottle right
away
x. Wash your hands to remove any medicationn
B) How to put ear drops:
i. Make the patient lie down or tilt the head, with the affected ear facing upwards.
ii. Open the ear canal by gently pulling the ear upwards and backwards. This straightens the
ear canal.
iii. Clear any visible superficial discharge.
iv. Hold the dropper of the medicine upside down over the ear and put the recommended
number of drops into the ear.
v. Avoid touching the dropper tip inside the ear, as it may get contaminated.
vi. After use, wipe the tip with a clean tissue. Do not wash with water or soap.
vii. Advise the patient to stay in the position for at least 15 minutes. A small piece of cotton
may be used to plug the ear.
C) How to check for patency of the nasal passage:
Two clinical procedures can be carried out for assessing the patency of the nose:
a) Spatula Test:
⁃ Place a tongue depressor/spatula below the nostrils of the
patient (as shown in the figure).
⁃ Ask the patient to blow through his nose and compare the area
of mist formation from both the sides.
⁃ In normal cases, the areas of mist formation under both the
nostrils are equal.
b) Cotton-wool test:
⁃ Hold a fluff of cotton against each nostril and observe its movements when the patient
inhales/exhales.
⁃ In case of nasal obstruction due to polyp/septum deviation, the movement of the cotton
fluff on that side would be reduced.
D) How to remove ear wax:
Various techniques are used for the removal of ear wax from the ear canal. Steps to be followed
for removal of ear wax using syringing are as follows:
i. Make the patient sit on a chair, such that the affected ear is towards you.
ii. Pull the ear lobe upwards and backwards gently to straighten the external ear canal and
enable better visualisation (in younger children, pull the pinna downwards and backwards
gently).
iii. Place a kidney-shaped dish under the ear to collect the water overflow.
iv. Fill a large (e.g., 20ml) syringe with a firmly attached metal or plastic cannula with lukewarm
water.
Manual Syringing Equipment Direction of water jet while syringing
v. Direct the jet of water backwards and upwards and not directly at the tympanic membrane.
Several syringefuls may be required before the wax is cleared.
vi. Intermittently inspect the canal.
vii. Inspect the expelled water for evidence of wax.
It is important to ensure that the water is at body temperature (37 °C); otherwise discomfort
and vertigo may be induced by stimulation of the labyrinth (caloric effect)..
E) How to do dry mopping of the ear:
yy Clean the ear with a dry mop only when the ear is discharging.
yy When the ear is dry it must not be cleaned with a dry mop.
yy A dry mop is not the same as a ‘cotton bud’.
yy ‘Cotton buds’ must never be used to clean ear canals as they are too big and the cotton
wool is wound onto the stick too tightly.
yy How to make a dry mop:
⁃ Wash your hands with soap and water – air dry.
⁃ Pull off a small piece of cotton wool.
⁃ Gently pull it out into an oval shape.
⁃ Put the tip of the stick into the centre of the cotton wool.
⁃ Twist the stick round and round with one hand whilst holding half of the cotton wool
tightly against the stick with the thumb and index finger of your other hand.
⁃ Half of the cotton wool should extend from the end of the stick and form a fluffy, soft
⁃ tip.
⁃ The rolled-up piece of cotton wool should be long enough so that when the soft tip is
deep in the ear canal and next to the eardrum there is still some cotton wool sticking
out of the ear canal.
⁃ This is so that you can hold the cotton wool and ensure that the cotton wool comes
out of the ear canal.
⁃ After completing dry mopping, wash your hands again.
How to make a wick:
⁃ Make a wick by rolling a cloth or a tissue paper into a pointed shape.
⁃ Gently pull the ear lobe away from the head. This helps straighten the ear canal.
⁃ Place the wick into the ear canal. It will absorb any discharge or blood in the ear
canal.
⁃ Leave it in place until it is wet.
⁃ Remove the wet wick and inspect it. Is there pus on the wick?
⁃ Replace with a clean wick.
⁃ Repeat until the wick comes out dry.
Dry mop Wick
F) How to perform tuning fork tests:

Described in Chapter 3
G) How to perform Heimlich’s manoeuvre
Described in Chapter 4
06 HEALTH PROMOTION
AND PREVENTION OF ENT
CHAPTER PROBLEMS
M
ost of the conditions of the ear, nose and throat are preventable. It is important to create
awareness among the community members regarding harmful practices which can
predispose one to diseases of the ear, nose and throat. Here are some common risk factors
of these diseases:
Risk factors for diseases of the ear:
1. Cleaning ear canal with sharp objects like hairpins, toothpicks, etc.
2. Applying oil or any liquid inside the ear.
3. Putting unprescribed medication inside the ear.
4. Using dirty cloth or towel to clean the ears.
5. Swimming in dirty water.
6. Leaving cotton wool or other material inside the ear for prolonged period.
7. Getting exposed to very loud noise regularly or for prolonged period.
8. Untreated infection of the ear for a prolonged period.
9. Injury to the ear leading to rupture of eardrum..
Risk factors for diseases of the nose:
1. Inserting sharp objects inside nasal cavity for cleaning.
2. Using dirty cloth or towel to clean the nose.
3. Picking of nose.
4. Injury to the nose might predispose one to infections.
Risk factors for diseases of throat:
1. Exposure to cold climate.
2. Exposure to allergens like pollen, cotton dust, wood shavings, etc.
3. Chewing tobacco/paan/gutka, smoking.
Below are some messages that can be given to patients/community members:
HOW TO MAINTAIN EAR HYGIENE
Personal Hygiene
DO NOT put dirty fingers in ears, wash
hands before working with food and do
not eat with dirty hand ALWAYS wash
your hands after going the toilet DO NOT swim or wash in dirty water
DO NOT put anything in you ears:

yy hot or cold oil NOTE : Teach children NOT to put
yy herbal remedies anything in their ears - seeds, beads,
stones, sticks.
yy liquids such as kerosene
NOTE:
 ONLY use medicine given by the nurse or doctor at the clinic/hospital and take the correct
dosage.
 If the ears are painful or have pus coming out of them, send the person to the clinic or hospital.
This means the ears are infected and need to be treated by the nurse or other health worker or
doctor.
HOW TO MAINTAIN NASAL HYGIENE
General point for advice during community visit:
1. Always use a handkerchief/clean cloth for cleaning nasal secretion.
2. Cover your mouth and nose with a tissue when you cough or sneeze, remember to wash your
hands with soap and water after coughing or sneezing.
3. Maintain a little distance (one arm distance), while sneezing, cleaning nose in public or around
people.
4. Never put finger in your nostril, it might cause bleeding from nose (epistaxis), as nose is a very
vascular organ.
5. Always consult a doctor during the time of illness as it may rapidly infect other family members
and might be serious for small children.
STEAM INHALATION
Steam inhalation is beneficial and one of the common home remedies used in our country. But
there is some caution to be taken:
1. Never leave children alone for it, they might get burns.
2. Never come too close to hot water bowl.
3. Take vapours both from nose and mouth.
HOW TO MAINTAIN THROAT HYGIENE
Many people complain that they have an irritation in the throat. It feels like something is scratching
the throat. Cough is rare and dry. They don’t have pain, but their voice can get hoarse.
There are many causes of irritation – it can be due
to bacteria or viral germs. It could also be because
of allergies to dust. Many times, it is due to gastric
acidity which causes reflux into the throat.
How to Reduce Irritation That Triggers Coughing:
1. Drink lots of fluids: The most important thing
you can do is to drink plenty of water to reduce
dryness of your throat. Drink at least one and
a half litre of water each day, that is about 6-8
glasses. Avoid tea, coffee, or soft drinks as they
usually contain caffeine.
2. Breathing:
a. Sit and stand with good posture – that is, neck and back straight and your chin gently tucked
in. This opens your airway, makes breathing easier and allows you to relax the throat.
b. Avoid bad posture. When you sit or stand in a lazy posture your shoulders tilt forwards and
your head tilts backwards and your chin lifts slightly. This puts pressure on your throat,
vocal cords, and your neck. It can increase irritation and put strain on your voice.
c. Breathe through your nose. Mouth breathing dries your throat. Breathing through your nose
cleans, warms, and moistens the air before it reaches your throat and vocal cords..
3. Talking:
a. Limit harmful voice use, such as shouting, grunting, or screaming. Talking, laughing, or
singing too loudly can also damage your vocal cords.
b. Try not to speak over other noise such as television or music or around machinery such as
a lawnmower.
c. Do not whisper, as whispering increases air pressure in your vocal cords and may irritate
your throat.
d. Use your natural voice, not too high, not too low, and not too loud.
e. Limit coughing and clearing your throat. Sometimes, coughing can be excessive and
clearing the throat can become a habit. When you cough and clear your throat it puts too
much force on your throat and vocal cords.
4. Everyday:
a. Avoid chewing tobacco/paan/gutka, smoking cigarette, bidi, etc.
b. Limit intake of caffeine-containing drinks as caffeine can increase dryness and irritation in
the throat.
c. Do not smoke, avoid smoky environment and avoid alcohol. It also increases the likelihood
of heartburn, which can also damage the throat and vocal cords.
d. Do not use mouthwash that contains alcohol as this will dry your throat.
e. Remember to drink plenty of water every day.
RAISING AWARENESS IN COMMUNITY
REGARDING DEAFNESS
People with hearing loss are often left out in the community. It is necessary to make the community
aware of how to help people with hearing loss. You must encourage them to take the persons with
hearing loss to have their ears examined and tested.
Public awareness campaigns could create a better understanding of hearing loss and the disability
that it causes::
 Local clinics could display posters/pictures about hearing loss and ear care to raise awareness
amongst patients.
 Communities should be encouraged to have a ‘Healthy Ear Day’ to raise awareness in the
community.
 Visit schools and talk to teachers and learners about hearing loss and its causes and effects.
They should encourage activities such as designing posters to raise awareness and playing
“What can you hear?” games to find out if any of the children may have a hearing loss.
 Tell teachers about hearing loss and encourage them to include this in their teaching programme.
 Explain to teachers what to look for in children with hearing loss and refer the children with
possible hearing loss for treatment.
 Encourage people with hearing loss to have their ears checked and their hearing tested.
 Raise awareness in the community by speaking to social, religious, and other groups about
hearing loss.
 Encourage parents and teachers to use sign language with deaf and hard of hearing children.
 Encourage the inclusion of hearing-impaired people in the workplace, in education and in society.
 Encourage and support hearing-impaired people to form support groups for themselves and
their families.
SERVICE DELIVERY
07 FRAMEWORK: PROVIDING
CHAPTER ENT CARE AS A TEAM AND
KEY TASKS OF CHO
I
n earlier chapters, you have learnt about your specific role related to several conditions of theear,
nose and throat. In this chapter, you will learn what tasks are expected of you in primary ENT
care services. You will now learn about services available at referral facilities and role of different
service providers. You will find that many points that have been highlighted are repeated here, but
this will help you to understand and plan your day-to-day work.
Service delivery framework for providing care for ENT related disorders.
As you know, delivery of health care services to the community is a teamwork. You would need to
know about the roles of other team members – ASHA, MPW, PHC team and service providers at
secondary care facility in order to effectively provide Continuum of Care in ENT care services.
What are the roles of other members of Primary Health Care Team at SHC-HWC?
1. ASHA : She will identify and list the individuals in the community having complaints related to the
ear, nose and throat. She will identify individuals with hearing loss while filling up the CBAC form.
She will mobilise people for screening camps, mobilise mothers/caregivers for getting their children
screened through RBSK. She will create awareness in the community regarding healthy habits of
the ear, nose and throat and prevention of diseases. Along with the ASHA Facilitator, she will help in
providing community-based rehabilitation, social acceptance and vocational training and inclusive
education for hearing-impaired patients.
2. MPW : MPW will support the ASHA in carrying out screening and awareness generation activities in
the community. She will use home visits, Village Health Sanitation and Nutrition Day (VHSND), Urban
Health Sanitation and Nutrition Day (UHSND), meetings of Village Health Sanitation and Nutrition
Committee (VHSNC), Mahila Arogya Samiti (MAS) and health promotion campaigns to disseminate
health promotion messages related to health of the ear, nose and throat, early identification and
referral and ensuring treatment adherence. She will also assist you in primary management of ENT
conditions in patients coming to the SHC-HWC, including screening and referral of complicated
cases to higher centres. She will also assist you in maintaining relevant records at the SHC-HWC.
3. PHC team : You will refer the individuals with any signs and symptoms of loss of hearing and
other complicated cases of ENT to Medical Officer at PHC for diagnosis. PHC-MO will confirm the
diagnosis and provide treatment of common ENT conditions/infections, primary care for trauma,
refer cases with hearing impairment to ENT surgeon for further assessment and confirmation,
disability certification, and outreach activities (planning, monitor wellness clinics/community
workers and co-ordination with district hospitals).
The specialists at higher health facilities would prescribe a treatment, which would be continued at
SHC-HWC level. The patient would need to visit the specialist or MO as per the instructions provided.
4. Key roles and responsibilities of CHO in providing ENT care services
As we are committed to provide quality comprehensive health care at HWCs, you play a crucial role
in providing basic ENT services at SHC-HWC and in the community.
 You will support the ASHA and MPW in carrying out screening and awareness generation
activities in the community.
 You will screen, detect, and provide primary management to patients coming to the SHC-HWC
with conditions of ear, nose and throat.
 You will refer complicated cases, cases of hearing loss and any other case requiring specialised
care to the PHC Medical Officer or ENT specialist at the DH.
 You will follow up all referred cases for treatment adherence, recovery, and any side effect of
medications, as well as re-referral if necessary.
 You will organise screening camps to screen for hearing loss and other ENT conditions and
coordinate with Medical Officer/specialist for these camps.
 You will support ASHA and MPW in Home Visits, Village Health Sanitation and Nutrition Day
(VHSND), Urban Health Sanitation and Nutrition Day (UHSND), meetings of Village Health
Sanitation and Nutrition Committee (VHSNC), Mahila Arogya Samiti (MAS) and health promotion
campaigns.
 You will maintain relevant records at the SHC-HWC and maintain inventory control of drugs and
equipment related to ENT care..
List of services to be provided at Community and SHC-HWC level

Community Level
Services Preventive and Curative care activities Responsibilities
Community based  Awareness generation on common disorders ASHA with support/
services for ENT of the ear, nose and throat, and the need for guidance of the ASHA
care seeking early care through VHSNC/MAS, Facilitator (AF)
VHSND/UHSND and other community level
and Counselling
meetings.
and support for
 Providing information about availability
care
of services related to ear, nose and throat
seeking for disorders at different levels of health care.
disorders of ear,
 Identification/Mobilisation of patients with
nose and throat
disease of the ear, nose and throat to attend
the SHC-HWC.
 Follow-up with patients to ensure compliance
to treatment.
Screening for  By ASHA: Screening for hearing impairment Primary Health
hearing impairment and Presbycusis while filling Community Care team (in
Based Assessment Checklist for all individuals coordination with
above 30 years of age. RBSK team, wherever
 Follow up of hearing-impaired patients who needed)
have been prescribed hearing aid.
 Under the RBSK, all children are screened for
visual acuity at school and Anganwadi levels.
 To inform people with deafness about financial
schemes and benefits for their uptake, if found
eligible.
 Record keeping: maintaining a list of individuals
with hearing impairment in the community.
 Undertake rehabilitation and counselling of
hearing-impaired individuals.
Community  Encourage hearing examination for all children Facilitated by ASHA/AF
screening within 30 days of their birth through RBSK.
for congenital
disorders
referral
SHC-HWC level
Services Preventive and Curative care activities Responsibilities
Care for common  Primary management of common conditions CHO/ANM
ENT problems of the ear nose and throat – Common colds,
Acute Suppurative Otitis Media (ASOM),
pharyngitis, tonsillitis, epistaxis, foreign body
removal.
 Referral of complicated cases to the MO-PHC
or ENT specialist as required.
 Early detection of hearing impairment and
deafness with referral to ENT specialist.
 First aid for injuries/stabilisation and then
 Referral to the MO-PHC or ENT specialist.
Where Referral is a must:

Refer immediately to ENT Surgeon District Hospital/Medical College Hospital:
 History of foreign body ingestion/inhalation followed by respiratory distress/dysphagia/
vomiting.
 History of foreign body in ear or nose.
 Ear discharge with fever/giddiness/headache/vomiting/blurring of vision/loss of consciousness.
 Watery discharge from nose following trauma which increases on bending down or coughing.
 Inability to open mouth.
 Severe trauma to ear or nose, resulting in uncontrolled bleeding.
ANNEXURE - 1
COMMONLY USED ENT MEDICINES IN SHC-HWC
1. Normal Saline nasal drops – Sodium chloride (0.5% w/v):
Use: It is used in cases of rhino-sinusitis, rhinitis co-existing with nasal polyps, post nasal
surgeries. It helps in ridding the nose of allergens, mucus and crusting Dose: 2 drops in each
nostril, 2-3 times a day
2. Xylometazoline 0.1% nasal drops:
Use: For relief from nasal congestion caused by conditions such as common cold, sinusitis
and allergies. It works by narrowing the blood vessels in the nose area, reducing swelling and
congestion. Dose: 2-3 drops in each nostril 2 times a day.
Side effects: Temporary burning, stinging, dryness in the nose, runny nose, and sneezing may
occur. Rare side effect: Allergic reactions
3. Wax solvent ear drops:
Use: To treat ear wax build-up in the ear. It helps to soften, loosen, and remove the ear wax.
This medication releases oxygen and starts to foam when it comes in contact with skin. The
foaming helps break and remove the ear wax.
Dose: 4-5 drops in each ear, once a day. The patient has to lie down for at least 15-30 minutes.
It may be repeated after a week if no relief.
Side effects: A foaming or crackling sound in the ear after using the ear drops, temporary
decrease in hearing after using the drops, mild feeling of fullness in the ear, mild itching inside
the ear.
4. Cetirizine syrup/tablets
Use: Cetirizine belongs to the Antihistamines class of medicines. They are used to relieve the
symptoms of allergic inflammation of the nasal airways due to allergens. This medicine works
by blocking the action of an allergic substance in the body known as histamine.
Dose: The usual adult dose is 5-10 mg once a day.
Side effects: Common side effects of cetirizine include dizziness, drowsiness, feeling tired, dry
mouth, etc.
5. Boro spirit ear drops
Use: Boro spirit ear drops contain Alcohol and Boric Acid as active ingredients. They possess
an antiseptic, antifungal, and antibacterial action, and hence, used for ear infections such as
otitis externa or in cases with trauma/boil in the ear canal causing pain. It works by stopping the
growth of bacteria and fungus.
Dose: 2 drops in the affected ear 2 times a day.
Side effects: Side effects are not so common. Some of the side effects include headache,
drowsiness, fainting, vomiting, etc.
6. Amoxicillin – Syrup/tablets
Use: Amoxicillin belongs to a class of drugs called penicillin. It works by killing bacteria and
stopping its growth in your body. As this antibiotic treats only bacterial infections, it is ineffective
for viral infections (such as common cold, flu). This drug may be used alone or in combination
with Clavulanic Acid, which increases its efficacy, for common ENT indications such as Acute
Otitis Media, acute mastoiditis, acute bacterial rhinosinusitis, tonsillitis, peri- tonsillar abscess,
etc.
Adult Dose: 500mg 3 times a day (when used in combination with clavulanic acid dose is 625
mg, 2 times a day).
Side effects: Nausea, vomiting, diarrhoea, and rash.
7. Combo ear drops (Chloramphenicol + Clotrimazole + Lignocaine hydrochloride)
Use: These ear drops having a combination of a broad-spectrum Antibiotic, Antifungal and
local anaesthetic, can be used to treat a variety of ear infections such as otitis media/externa,
otomycosis, etc.
Dose: 4-5 drops in the affected ear, 3-4 times a day.
Side effects: Itching in the ear, mild stinging/burning sensation, dermatitis, etc.
8. Liquid paraffin – menthol drops
Use: It is used as a nasal decongestant.
ANNEXURE - 2
HOW TO COMMUNICATE WITH PEOPLE WITH REDUCED HEARING/HEARING LOSS
Some ways people can help the children or adults who cannot hear well are:
1. Let the person see your face when you speak to him/her.
2. Make sure there is good light for the person to see your face.
3. Get the person’s attention before you speak to him/her.
4. Try to make sure there are no distractions – especially loud noises.
5. Speak clearly and slowly.
6. Don’t shout and make exaggerated movements.
7. Repeat (say again and again) things many times slowly.
8. Use gestures, drawings, pictures – point at things.
9. Do not over protect the person – he/she should be encouraged to mix with other people.
10. Point to your lips so that they learn to watch how the words are formed – this encourages
lipreading.
11. Stand close to the person when you speak.
12. If the person has a hearing aid, he/she should learn to use it.
ANNEXURE - 3
SCREENING FOR COMMON ENT CONDITIONS
The most important ENT condition which is widely screened for is deafness or hearing loss. Hearing
loss is a condition which is prevalent in all age groups. Hearing loss may be congenital (present at
birth) or acquired later in life. Both the types of hearing loss are preventable.
- Congenital hearing loss occurs mainly due to infections in a pregnant woman in early pregnancy
or consumption of certain drugs by a pregnant woman which are harmful for the fetus (ototoxic
drugs).
- Acquired hearing loss can occur due to injury to tympanic membrane, infection of nose or ear,
intake of ototoxic drugs, chronic infections like diabetes and exposure to loud noise.
- Hearing loss also occurs with age in elderly due to degenerative process (presbycusis).
Various National Programmes have aimed at screening the population regularly for hearing loss.
Early diagnosis of deafness by means of screening can find out its cause and provide treatment at
the earliest.
 National Programme for Prevention and Control of Deafness (NPPCD) – Screening for deafness
in hospitals and health camps.
 National Programme for Health Care of the Elderly (NPHCE) – Screening of geriatric population
for deafness in primary health care facilities as well as specialised geriatric clinics.
 Rashtriya Bal Suraksha Karyakram (RBSK) – Screening of children and adolescents using
platforms like anganwadi centres and schools.
ANNEXURE - 4
COMMUNITY BASED ASSESSMENT CHECKLIST
COMMUNITY BASED ASSESSMENT CHECKLIST (CBAC)
revised draft 6 October 2020 V.5
Date: DD/MM/YYYY
General Information
Name of ASHA: Village/Ward:
Name of MPW/ANM: Sub Centre:
PHC/UPHC:
Personal Details
Name: Any Identifier (Aadhar Card/ any other UID – Voter ID etc.):
State Health Insurance Schemes: Yes/No

Age:
If yes, specify:
Sex: Telephone No. (self/family member /other - specify details):
Address:
Does this person have any of the
following:
visible defect/known disability/bed If yes, Please specify

ridden/require support for Activities
of Daily Living
Part A: Risk Assessment

Question Range Circle Any Write Score
1.What is your age? 0 – 29 years 0
(in complete years) 30 – 39 years 1
40 – 49 years 2
50 – 59 years 3
≥ 60 years 4
2. Do you smoke or consume Never 0
smokeless products such Used to consume in the past/ 1
as gutka or khaini?
Sometimes now
Daily 2
3. Do you consume alcohol No 0
daily? Yes 1
4. Measurement of waist (in Female Male
cm) 80 cm or less 90 cm or less 0
81-90 cm 91-100 cm 1
More than 90 cm More than 100 cm 2
5. Do you undertake any At least 150 minutes in a week 0
physical activitie for mini-
mum of 150 minutes in a
Less than 150 minutes in a week 1
week?
(Daily minimum 30 minutes

per day – Five days a week)
6. Do you have a family his- No 0
tory (any one of your par-
ents or siblings) of high
Yes 2
blood pressure, diabetes
and heart disease?
Total Score
Every individual needs to be screened irrespective of their scores.
A score above 4 indicates that the person may be at higher risk of NCDs and needs to be prioritised for
attending the weekly screening day.
Part B: Early Detection: Ask if Patient has any of these Symptoms

B1: Women and Men Y/N Y/N
Shortness of breath (difficulty in History of fits
breathing)
Coughing more than 2 weeks* Difficulty in opening mouth
Blood in sputum* Any ulcers in mouth that has not healed in
two weeks
Fever for > 2 weeks* Any growth in mouth that has not healed in
two weeks
Loss of weight* Any white or red patch in mouth that has
not healed in two weeks
Night Sweats* Pain while chewing
Are you currently taking anti-TB drugs** Any change in the tone of your voice
Anyone in family currently suffering from Any hypopigmented patch(es) or
TB** discoloured lesion(s) with loss of sensation
History of TB * Any thickened skin
Recurrent ulceration on palm or sole Any nodules on skin
Recurrent tingling on palm(s) or sole(s) Recurrent numbness on palm(s) or sole(s)
Cloudy or blurred vision Clawing of fingers in hands and/or feet
Difficulty in reading Tingling and numbness in hands and/or
feet
Pain in eyes lasting for more than a week Inability to close eyelid
Redness in eyes lasting for more than a Difficulty in holding objects with hands/
week fingers
Difficulty in hearing Weakness in feet that causes difficulty in
walking
B2: Women only Y/N Y/N
Lump in the breast Bleeding after menopause
Blood-stained discharge from the nipple Bleeding after intercourse
Change in shape and size of breast Foul smelling vaginal discharge
Bleeding between periods
B3: Elderly Specific (60 years and above) Y/N Y/N
Feeling unsteady while standing or Needing help from others to perform
walking everyday activities such as eating, getting
dressed, grooming, bathing, walking, or
using the toilet
Suffering from any physical disability that Forgetting names of your near ones or your
restricts movement own home address
In case an individual answers ‘Yes’ to any one of the above-mentioned symptoms, refer the patient imme-
diately to the nearest facility where a Medical Officer is available
*If the response is Yes - action suggested: Sputum sample collection and transport to nearest TB testing
centre
** If the answer is Yes, tracing of all family members to be done by ANM/MPW
Part C: Risk factors for COPD

Circle all that Apply
Type of Fuel used for cooking – Firewood/Crop Residue/Cow dung cake/Coal/Kerosene/LPG
Occupational exposure – Crop residue burning/burning of garbage, leaves/working in industries with
smoke, gas and dust exposure such as brick kilns and glass factories etc.
Part D: PHQ 2
Over the last 2 weeks, how often have you been Not at Several More than half Nearly every
bothered by the following problems? all days the days day
1. Little interest or pleasure in doing things? 0 +1 +2 +3
2. Feeling down, depressed or hopeless? 0 +1 +2 +3
Total Score
Anyone with total score greater than 3 should be referred to CHO/MO (PHC/UPHC)
REFERENCES:
1. Srinivasan K, Prabhu GR. A study of the morbidity status of children in social welfare hostels in
Tirupati town. Indian J Community Med. 2006;31:170–2
2. Indian Public Health Standards for Sub-centres, Primary Health Centres, Community Health
Centres, Government of India, Ministry of Health and Family Welfare. Available from: http://
www.nhm.gov.in/nhm/nrhm/guidelines/indian-public-health-standards.html
3. National Programme for Prevention and Control of Deafness (NPPCD). Operational

Guidelines for 12th Five Year Plan. Available at https://mohfw.gov.in/sites/default/
files/51892751619025258383.pdf
4. Dhingra PL, Dhingra S, editors. In: Diseases of ear, nose and throat & head and neck surgery. 6th
ed. New Delhi: Elsevier; 2014.
5. Bhargava KB, Bhargava SK, Shah TM. A Short Textbook of E.N.T. Diseases. 10th ed. Mumbai:
Usha Publications; 2014..
LIST OF CONTRIBUTORS
Dr. Kanwar Sen Addl. DG, Dte. GHS, MoHFW
Dr. Sudhir Gupta Sr. CMO, Dte. GHS, MoHFW
Dr. Sunny Swarnkar DADG, Dte. GHS, MoHFW
Executive Director, National Health Systems Resource Centre

Maj. Gen. (Prof.) Atul Kotwal
(NHSRC), New Delhi
Advisor, Community Processes and Comprehensive Primary Health

Dr. (Flt Lt) M A Balasubramanya
Care, National Health Systems Resource Centre (NHSRC)
External Consultant, National Health Systems Resource Centre

Dr. Maya Mascarenhas
(NHSRC), New Delhi
Dr. Vineet Kumar Pathak
Senior Resident, Department of Community and Family Medicine, All
India Institute of Medical Sciences, Raipur
Lead Consultant, Knowledge Management Division, National Health

Dr. Neha Dumka
Systems Resource Centre (NHSRC)
Senior Consultant, Community Processes and Comprehensive
Dr. Suman Bhardwaj Primary Health Care, National Health Systems Resource Centre
(NHSRC)
Senior Consultant, Community, Processes and Comprehensive

Dr. Anantha Kumar SR Primary Health Care, National Health Systems Resource Centre
(NHSRC)
Senior Consultant, Community, Processes and Comprehensive

Dr Neha Singhal Primary Health Care, National Health Systems Resource Centre
(NHSRC)
Former Senior Consultant, Community Processes and

Dr. Shalini Singh Comprehensive Primary Health Care, National Health Systems
Resource Centre (NHSRC)

Dr. Har Ashish Jindal Comprehensive Primary Health Care, National Health Systems

Dr. Rupsa Banerjee Comprehensive Primary Health Care, National Health Systems
Consultant, Community Processes and Comprehensive Primary

Dr Anusha Sharma
Health Care, National Health Systems Resource Centre (NHSRC)
External Consultant, Community Processes and Comprehensive
Dr. Amit Dhage Primary, Health Care, National Health Systems Resource Centre
(NHSRC)
Junior Consultant, Community Processes and Comprehensive
Dr Vijaya Shekhar Salkar Primary Health Care, National Health Systems Resource Centre
(NHSRC)
NOTES
NOTES

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ENT Care Training Manual For CHO

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2 TRAINING MANUAL ON EAR, NOSE AND THROAT (ENT) CARE FOR COMMUNITY HEALTH FOR OFFICER AT AYUSHMAN BHARAT

AT – HEALTH AND WELLNESS CENTRES

Chapter 2: Understanding the Ear, Nose and Throat 8

Annexure 1: Commonly-used ENT medicines in SHC-HWC 54

Annexure 3: Screening for common ENT conditions 56

Annexure 4: Community-Based Assessment Checklist 57

This module has four parts:

3. Health promotion activities for health of ear, nose and throat.

Outer ear – This consists of the pinna (earlobe)

Middle ear – It is a closed box like structure which

Inner ear – The inside most part of the ear which

How does the ear function?

Nasal cavity – There are two nasal cavities/

Pharynx – The nasal passages end in

How does the nose function?

To undertake and record an ENT examination, you will need

yy A torch or LED head lamp

yy Pen and record card

yy Find a space which has enough light.

yy Make the person sit comfortably.

yy Explain to the person what you are going to do.

yy Record the name, age, sex, address, and date.

Pharynx Whitish spots

Soft palate Swollen tonsil

yy Examine the person’s throat. Ask the person to open his/

o Incorrect response: Repeat by shouting

⁃ Correct response = Severe hearing loss

⁃ Incorrect response: Deafness

Tuning fork tests

2. Sensorineural hearing loss – damage to cochlea or auditory nerve

c. Record the length of time the patient hears each sound..

Normal hearing will produce equal sound in both ears.

Posterior ethmoidal artery

common site for epistaxis.

yy For moderate bleed:

⁃ Make him/her sit upright with head slight bent forward.

⁃ Ask the patient not to blow through his nose.

Indications for referral

iii. Massive blood loss

v. Other co morbidities requiring appropriate cross consultations

vi. For posterior nasal packing in case of posterior epistaxis

yy Keep fingernails short to prevent injuring the nostril

yy Blow nose gently and without too much force

ANTERIOR PACKING OF THE BLEEDING NOSE

Make the patient sit up with a back rest.

Apply local anaesthetic such as lignocaine 2% to the nasal mucosa

©2005 CHRISTY KRAMES

RESPONSIBILTIES OF CHO IN MANAGING EPISTAXIS

Reassure the patient

Ask: Check for:

Anterior Bleeds Posterior Bleeds

Apply pressure on the nasal

Relief obtained Relief not obtained

Apply a combination of Lignocaine

Relief obtained Relief not obtained

RESPONSIBILTIES OF CHO IN MANAGING URIs

Patient appears unstable Patient appears stable

Relief obtained Relief not obtained