Practical 1 Dry mopping of
ear
(equipment: matches and cotton wool)
Indications
Otitis externa and media
What you need
Cotton wool and wooden stick
How to do it
Wrap cotton wool around stick and twist.
Make the end fluffy
When placing the fluffy end into the ear canal ensure
some of the cotton wool is under your finger to ensure
the cotton wool is not lost
Change the cotton wool a few times
Check the ear canal afterwards with otoscope
Possible complications
Very unlikely
Scratch to ear canal if to rough
Cotton wool may come off if not held properly
Practical 2 Removal of foreign
body with syringing
(equipment: 20 ml syringe, brown venflon)
Indications
Inorganic foreign body
What you need
20 ml syringe
Brown venflon (metal needle removed)
Bowel to collect saline
Warm saline or water (37o C)
How to do it
Hold pinna back and up to straighten ear canal
Flush ear canal initially gently aiming at the posterior
superior of canal.
Once foreign body removed check no other foreign
bodies and state of tympanic membrane (also check
other side)
Possible complications
Otitis externa: treat with antibiotic ear drops.
Perforation of tympanic membrane: treat conservatively
as most will heal spontaneously, keep ears dry.
Practical 3 Ear syringing
(equipment: 20 ml syringe, brown venflon)
Indications
Hearing loss due to wax (generally rare).
What you need
Automated syringing machine
Or
20ml/50 ml syringe
Brown venflon with metal needle removed
Warm saline or water (37o C)
How to do it
Soften wax with Sodium Bicarbonate ear drops (3 drops
tds for 3 days prior to syringing). Wax is more soluble in
water than oil. Olive oil will also help but will not disperse
ear wax.
Hold pinna back and up to straighten ear canal
Flush ear canal initially gently aiming at the posterior
superior of canal.
Once wax removed check no more wax. If there is more
hard wax further softening with Sodium Bicarbonate
ear drop for 3 days and repeat. Check state of tympanic
membrane once wax cleared.
Possible complications
Otitis externa: treat with antibiotic ear drops.
Perforation of tympanic membrane: treat conservatively
as most will heal spontaneously, keep ears dry.
Practical 4 How to make an
ear wick
(equipment: matches, cotton wool)
Indications
Acute otitis externa with a narrow ear canal.
What you need
1.25 cm ribbon gauze or gauze cut to this width.
How to do it
Fold over the gauze so that there are four layers and the
wick is 2 cm long.
One end is introduced into the ear canal for 1.5 cm
using forceps.
To the external end can now be applied antibiotic ear
drops.
Possible complications
Rarely damage to ear canal.
Practical 5 Hearing Aid
(equipment: a hearing aid, mould and tubing)
What are the different part of the hearing
aid?
Mould
Tubing
Hearing aid body
How to switch hearing aid on.
How to check if hearing aid is working.
How to change battery.
How to put a hearing aid in.
Practical 6 How to hold child
for ear exam or syringing
(equipment: an unruly child!)
Indications
 If child uncooperative
 Generally avoid restraint if practical, consider
alternatives such as GA.
 Do a exam on parent to calm child down.
 Consent from parent.
 Parent to hold child
Syringing of ear in child
What you need
Chair
Nurse & parent to help
How to do it
Possible complications
None
Practical 7 Ear Anatomy
Model of ear
Poster of ear
Putt the arrow on the right bit!
Attic
Handle of malleus
Eustachian tube shadow
Chorda tympani
Long process of incus
Light reflex
Round window shadow
Annulus of tympanic membrane
Left ear
Right ear
Attic
Handle of malleus
Eustachian tube shadow
Chorda tympani
Long process of incus
Light reflex
Round window shadow
Annulus of tympanic membrane
Left ear
Right ear
Practical 8 Ear pathology with
printed pictures or diagnostic
trainer/ ear simulator
Answers:
1.
Normal tympanic
membrane.
2.
Acute otitis media
3.
Cholesteatoma and
perforation of tympanic membrane.
(Active squamous chronic otits media.)
4.
Nasal Polyps
5. Ethmoiditis with peri-orbital cellulitis
6. Thyroid enlargement
Practical 9 Examination ear
(equipment: otoscope with various specula (20))
1.
Wash hands
2.
Introduce yourself to
patient
3.
Ask about tenderness
4.
Which is better ear
5.
Start with better ear
6.
Inspect pinna, mastoid
area
7.
Otoscopy:
a.
External auditory
canal
b.
Tympanic membrane
8.
Hearing tests (Practical
10)
9.
Other test: Postnasal
space, cranial nerve (Practical 15) , coordination and Romberg (Practical 15)
Practical 10 Hearing test
(equipment: tuning fork)
Tuning fork
Clinical hearing test
o Use numbers, mask the other ear
using tragal rub
o Whisper at 2’ 30-40dB or better
o Whisper at 6” 40-60dB
o Conversational voice at 2’ 60-70dB
o Conversational voice at 6” 70-80dB
o Shouting 80dB or worse
Weber
o Lateralises to side of conductive
loss and/or away from sensoneural
hearing loss
Rinne
o Air conduction louder than bone
conduction
Practical 11 Examination
of the mouth and
oropharynx
(equipment: torch and 20 wooden tongue
depressor)
1.
Wash hands
2.
Intro
3.
Ask about tenderness
4.
Use wooden tongue
depressor
5.
Inspection
6.
Start from hard palate
and work down
7.
Hard Palate
8.
Sup alveolar ridge
9.
Sup bucco-alveolar
sulcus
10.
Buccal mucosa
11.
Inf bucco-alveolar sulcus
12.
Inferior alveolar ridge
13.
Floor of mouth
14.
Tongue
15.
Palpation of above (esp tonge
and floor of mouth)
16.
Listen to voice
17.
Neck (practical 13)
Practical 12 Examination nose
(equipment: otoscope and specula, metal tongue
depressor)
–
–
–
–
–
–
Wash hands
Intro
Ask about tenderness
Inspect external nose
Palpate external nose
Evaluate nasal airway
•
Steam pattern on metal
tongue depressor
– Inspect nasal mucosa
•
Use otoscope
•
Lateral, medial (look for
septum and inferior turbinate
(concha))
– Inspect palpate over sinuses
– Olfaction (ask patient or if
available scratch and sniff strips)
Practical 13 Examination neck
–
–
–
–
–
–
–
Wash hands
Intro
Ask about pain/tenderness
Exposure above clavicles
Inspect from front and side
Inspect while swallowing
Palpate from behind
– Start from mastoid
– Down posterior triangle
– Up posterior border of
sternocleiodo-mastoid
– Down ant border SCM
– Work up ant triangle including
thyroid (ask patient to swallow
when at thyroid)
– Continue working up anterior
triangle: feel laryngeal cartilage,
hyoid.
– Sumandibular and submental
area.
– Finish with parotid and
preauricular area.
– If you did feel a lesion further
local (percussion of sternum or
auscultation), regional &
systemic examination may be
needed (eg thyroid or other
lymph node groups)
Practical 14 Examination of
cranial nerves
(equipment: cotton wool, tongue depressor, torch)
1.
2.
3.
4.
Wash hands
Introduction
CN 1. Ask about smell
CN 2. Eye (this is covered by
opthalmolgy)
5.
CN 3, 4, 6. Eye movements. Ask
if patient sees double and look for
nystagmus.
6.
CN 5. Facial sensation. Compare
sides
7.
CN 7. Facial muscle function
8.
CN 8. Hearing (Practical 10)
9.
CN 9,10. Listen to patient voice,
look at palatal movements and
compare oroharyngeal sensation on
left and right.
10. CN 11. Movement of
sternocleidomastoid. Head turning
and palpation of muscle.
11. CN 12. Tongue inspection and
movement.
Practical 15 Examination of
vestibular/cerebellar system
(parts relevant ear
examination)
1.
2.
3.
4.
5.
Eye movements looking for
nystagmus in neutral, in abduction
and adduction.
Co-ordination
a.
Looking for
dysdidochokinesis
b.
Finger nose
Romberg
Tandem Romberg
Hall Pike manoeuvre
Equipment needed:
1.
Wooden tongue depressor (x30)
for Practical 11 and 14.
2.
Torch or otoscope (x2) for
practical 11 and 14.
3.
x2 Otoscopes for practical 9 and
12.
4.
Various specula for otoscope
(x20) for practical 9 and 12.
5.
Tuning fork (for practical 10)
6.
Matches for practical 1.
7.
Cotton wool for practical 1 and
14.
8.
x2 Brown venflon for practical 2
and 3.
9.
x2 20 ml syringe practical 2 and
3.
10. Metal /wooden tongue depressor for
practical 12.
11. Hearing aid with mould, tubing for
practical 5.
12 Ear simulator. Go to postgraduate
office in CSB (behind reception) and
ask Rachel Davies or Sandra
Davidson to get the ear simulator
which is in room 48 and is in a large
sky blue case. Practical 8.