Work Instruction for Management of Ear, Nose, Throat, Problems

Document No: COP/ HWC-SC I...

Date of Issue:
I...

Version/Issue No: 01 Effective Date:

Work Instruction
For

Management of Common Ear, Nose and Throat Problems

ABHWC-HSCs
DABLI

Sabina esmi
Page 1 of 19
Officer
Comnmuity !lcalth
i/e Dabli HWC
MornoiBPHC, Goalpara
The signatures below certify that this procedure has been reviewed and approved, and

demonstrate that the Signatories are aware of all the requirements contained herein and are

committed to ensuring their provision.

Name Position Signature

Page 2 of 19 Saloine Yasm

Commnity Health Officer
ieDabli HWC
MornoiBPHC,
Goalpara
 Prepared By

Approved By

Amendment Note:

Page No Context Revision Date

Note: Prior to use, ensure thís document is the most recent issued

This procedure is reviewed to ensure its continuing relevance to the systems and process

that it describes. A record of contextual additions or omissions is given below:

Sabim Yami
Page 3 of 19
Communiy Healih Oflicer
cDabli
i/c) HWC
MornoiBPHC,
Goalpara
S.No. Content

Purpose and Scope

2 Service Delivery Frame Work

3 Role & Responsibilities
ASHA
b. ANM/MPW
C
CHO
4 Common Condition, their Management and referral

5 Commonly used ENT Medicines at HWC-SHC

6 References

Sabina Yasmi
Community Health Oflicer
Page 4 of 19 iVe Dabli HWC
Mormoi BPHC, Goalpara
 ensure patients with Ear, Nose and
Overall purpose of this work instruction is to
Purpose:
and timely referred.
Throat problems are screened, managed

who are involved to provide ENT services in the HWC. It

Scope: lt applies to all the staffs

two areas availability of ENT services at HWCs and

covers broadly covers
activities.
preventive and promotive

Service Delivery Framework

activities will be
management of common ear, nose and throat problems, following
For effective

ensured at HWCSCs
Individual/Family/Community level

effective Information Education &

Health promotion through appropriate and

with special emphasis on prevention of Ear, Nose and

Communication (IEC) strategies

Throat related problems.

Educating community about healthy Ear, Nose and Throat habits.

excessive noise, safe listening and improving the acoustic

Awareness on protection against

environment.

workers, ASHA, Multiple Purpose WorkerlAuxiliary Nurse Midwife (MPWIANM)

Frontline

and community level preventive care for ENT

to be skilled for Primary, basic diagnostic

related problems.
(ENT) related problems, signs of
Early identification of Ear, Nose and Throat including

hearing loss in infants, children and adults.

home MPWs for new-borns six weeks

Community based New
till
born screening at through

which are approved for the

of age,during home visits/immunization sessions using devices,

Public Health interventions.

For children from six weeks to 18 years, - Anganwadi Centre (AWC)/ school-based

screening will be undertaken through the Rashtriya Bal Swasthya Karyakram (RBSK).

Informing children and adults with Ear, Nose and Throat problems, family members and the

general public about available options for their inclusion and integration in the community.

Counselling and appropriate referral of patients requiring medical/ surgical interventions.

Health and Wellness Centre-Sub Health Centre level (HWC-SHC)

Sabiny Yasmi

Page 5 of 19 Comnunity Health Oflicer

i/eDabli HWC
Momoi BPHC,Goalpara
 Public health Actions through promotion and implementation of immunization, maternal and

perinatal health care and child health care.

to Ear, Nose and Throat, including hearing

Early detection of common problems related

impairment and deafness.

and referral of thyroid swelling, discharge from ear (Wet ear), blocked nose,
ldentification

hoarseness and dysphagia.

for ear discharge after Community Health Officers (CHO) are trained
Undertake Otoscopy
on its use.
otomycosis, otitis externa, ear
management for common diseases like
Diagnosis and

discharge, etc.

laryngitis, rhinitis, Upper Respiratory

Management of common cold, injury, pharyngitis,

Infections (URI), sinusitis, epistaxis.

laryngitis, sinusitis.
tonsillitis, pharyngitis,
Management of common throat complaints like

First aid for injuries/ stabilization and referral.

the anterior part of the nasal cavity) and

Removal of Foreign body nose (if it can be seen in

foreign body ear (if it is superficial).

for nasal bleeds.

Nasal packing, blood pressure measurement and investigation

Detecting voice problems in the absence of common cold or throat infections.

treatment compliance.
Follow up for cases referred to higher centre to ensure

2. Key roles and responsibilities in ENT care

a. ASHA
the village area and prepare a line list of
To identify people with hearing impairment in

and adults living in your service

those with hearing loss or reduced hearing including children

area.

the community and undertake the exercise of filling

Screening for hearing impairment in

Checklist (CBAC) for all individuals aged 30 years and above.

Community Based Assessment

found at risk (complaint of reduced hearing) for further screening at

Mobilise individuals

SHCHWC by the CHO/MPVWIANM.

preterm and low birth weight
Mobilise the motherlcaregivers of all children (including

and Anganwadi
children) and adolescents for screening for hearing examination at school

levels through RBSK (0-18 years of age).

Create awareness in the communities regarding maintenance of personal hygiene and

environmental and lifestyle modifications, including maintaining ear and nose hygiene and

avoiding use of any form of tobacco.

Create awareness on protection against excessive noise, safe listening and improving the

acoustic environment.

preventionand treatment of common diseases and infections of

Educate communities about
the ear, nose and throat.

Monitor and encourage patients with infections and other conditions of the ear, nose and

throat to complete their treatment and coordinate with the Health and Wellness Centre.

Sabim Yasm
Page 6 of 19 Community Health Oflicer
ilc Dabli HWC
Momoi BPHC, Goalpara
 Assist in organising community outreach activities such as hearing camps through HWC.
Provide support in mobilising community members for attending screening camps organised
in the community.
Utilise community-based platforms like VHSNC/MAS, VHSND/UHSND and other

community level meetings for health talk fixed for care of ear, nose and throat; impart
information about healthy habits of the ear, nose and throat.

ldentify individuals in community for common conditions such as allergic rhinitis, sinusitis,

pharyngitis, infections of the ear or foreign body in the ear, nose or throat and refer identified

cases to the SHC-HWC for a proper check up by CHO/MPWIANM.

Ensure follow-up of patients requiring long term medication and post-operative patients

through home visits.

Offering support services to hearing aid users e.g. day-to-day care such as change of batteries,

Do's & Don't while handling the aid, etc.

Rehabilitation by counselling people about role of family in supporting hearing impaired and
deaf individual.

b. ANM/MPW:

As we are committed to provide quality comprehensive health care at HWCs, ANM/MPW

play a crucial role in providing basic ENT services at SHC-HWC and in the community. They
will support the ASHA in carrying out screening and awareness-generation activities in the
community. They will continue to 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. Using these platforms, they would undertake activities of health
promotion related to care of ear, nose and throat,early identification and referral and ensuring
adherence to treatment. They will also assist the CHO inthe SHC-HWC to undertake the

following activities:

Screening for common disorders of the ear, nose and throat in patients attending SHC
HWC
Early identification of cases at the SHC-HWC
Distributing medicines to patients with ENT disorders at the SHC-HWC
Refer cases that cannot be managed at the primary level

Follow up of referred case when they return from the referral facility to ensure
compliance with treatment and re-referral if necessary

Diagnose, treat, or refer cases of ENT disorders during home visits

C. CHO
CHO will support the ASHA and MPW in carrying out screening and awareness
generation activities in the community.

Screen,detect and provide primary management to patients coming to the SHC-HWC

with conditions of ear, nose and throat.

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.

Page 7 of 19
Sobina Yam
Community Health
Oficer
Ve Dabli
HWC
Mornoi
 and any side of
referred cases for treatment adherence, recovery
effect
Follow up all

necessary.
medications, as well as re-referral if

ENT Conditions and

screen for hearing loss and other
Organise screening camps to
for these camps.
coordinate with Medical Officer/specialist
and Nutrition Day
Support ASHA and MPW in Home Visits, Village Health Sanitation

and Nutrition Day (UHSND), meetings of Village

(VHSND), Urban Health Sanitation
(MAS) and
Health Sanitation and Nutrition Committee (VHSNC), Mahila Arogya Samiti

health promotion campaigns.

of drugs
records at the SHC-HWC and maintain inventory control
Maintain relevant

and equipment related to ENT care.

3. Common ENT problems and how to approachthem

Name of common ENT problem

Name of common ENT problem SI.

Otitis Media (Middle Ear Infection)

A. Epistaxis (Nosebleeds)]
B. Tract Infections J. Vertigo
Upper Respiratory

K. Hearing Loss/Reduced Hearing

C Acute Tonsilitis

D Acute Epiglottits
L. Foreign Body in Ear

E M. Foreign body in nasal cavity

Earache (Otalgia)

F. Otitis Externa (External Ear

Infection)

Management of Epistaxis (Nose bleeds)

Referral Pathway for Epistaxis

ASHA/ANM identifies the patient/patient directly comes tothe

HWC with hlo bleedina from noce

Reassure the patient

Check BP

Ask to sit in upright position,slightly bending forward

i/c Dabli HWC

Ask:
Meteirt,Gipan
Check for:
Duration of current episode
Site of bleeding
Previous hlo of similar episodes
Blood pressure
H/O trauma, bleeding tendencies, chronic liver
 Posterior Bleeds

Anterior Bleeds

further
Refer to DH/Specialist for
the
Apply pressure on nasal
evaluation and management
septum for 10mins

not
Relief
Relief obtained obrained

Apply a combination of lignocaine and topical

vasoconstrictor such as oxymetazoline 0.05%
and nress it for l0 mins

Relief obtained not

Relief
obrained

Flucare by CHO @SHC-HWC (I)Ensure compliance to the Flu visits Ax advised; (2)
Counsel about avoid pricking of nose, maintaining moist nasal mucosa (especially during
dry seasons) by applying vaseline/sniffing water with little salt and importance of
maintaining BP (3) Encourage people to eat oranges, tomatoes etc. (Vitamin C rich
the
foods) to strengthen the small blood vessels so that nose bleeds decrease; (4)Advise
patient to re-visit the Specialist in case of relapse

Flu care by ASHA/ANM @Community (1) Encourage known HTN cases to undergone

regular check ups; (2) Promote consumption of Vitamin C rich foods (3)Counsel for

Management of Upper Respiratory Tract Infections

Referral Pathway for Upper Respiratory Tract Infection

Patients present with fever,cough and cold, sore throat,running

noce etr

Ask for:

Onset and progression of symptoms (2) previous h/o

similar episodes (3) use of OTCmedicines/self Chmmunity Health Oflicer
medication (4)relevant risk factors such as smoking (5) ile Dabli HWC
Co morbid conditions such as HTN/DM/Cirhosis, etc.
omoi BPHC,Goalpara
Asses

Vitals (remperature/pulse/BP/RR) (2) Cervical

 Patient appears
Patient appears
stable
unstable

Refer to PHC-HWC for

Advise and initiate the patient on the further evaluation and Mn

nonpharmacological treatment options

Give symptomatic Rx in the form of

TCPM/TPM/Nasal decongestants

Counsel the patient to avoid sleeping

in congested rooms and cover his mouth
with handkerchiefwhile coughing

Relief obtained not

Relief
obtained

Flucare @SHC_HWC through CHO

Ask if the patient has any issues in being compliant to the treatment advised

Advise the patient to refer similar cases,especially children in the family to the
SHC-HWC
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

anagement of Acute Tonsillitis:

Referral Pathway for Acute Tonsilitis

Patient presents himself/herself at the facility complaining of

fever core throat diffirulru in cwallowinalnainfiul cwallowina etr

Page 10of 19 Sabine Yesm

Community Health Oficer
ile Dabli HWC
MormoiBPHC, Goalpara
 Ask: Check for:

Onset and progression of current episode Presence of High grade fever

Previous h/o of similar episodes (patient looks toxic)

tonsils
H/O recurrent URTI Enlarged swollen
inflamed

First episode and patient is stable Recurrent episodes/patient

pain in
appears toxic/severe
covered with
swallowing/tonsils

Initiate treatment with

in 3 divided doses
Paracetamol 25-30 mg/kg/day
Give a dose of
PCM and
3-4
Warm saline water/ Betadine drop gargles
and refer
amoxcilin
times a day
in three divided
Amoxycilin 25-30 mg/kg/day
doses

Refer to DH/Specialist for

further evaluation and
Follow up after 5 management
days

not
Relief
Relief obtained ohraind

Flu care @SHC-HWC through MLHP

to avoid oily/spicy food for few days

Counsel the patient

Assess the compliance and response to

Rx advised

Flu care @Community through ASHAIANM

Assess if the patient is having any difficulty in taking medicines

Counsel for warm saline water gargling,soft diet and avoid crowded places for few

days

Page 11 of 19 Sabin Yasni

Community Health Oicer
ile Dabli HWC
Management of EARACHE (OTALGIA)

Referral pathway for Otitis Media

the with complaints of:ear

ASHA identifies a case/patient presents to facility

discharge, reduced hearing, irritability, fever

Look for signs of severe infection:

Ask about:

High-grade fever, prostration, neck

h/o recurrent /past URTI
rigidity, pus discharge from ears,

h/o severe headache, facial deviation.

allergies

h/o travel to high altitude

Signs of severe infection

present
Signs of severe infection

absent

Refer to DH/ENT Sspecialist for

Initiate treatment with:

further evaluation and Mn

PCM: 10-15 mg/kg/day 3 divided doses

in

Chloramphenicol/ciplox ear 2 drops twice a day

Amoxycillin 25-30 mg/kg/d in 3 divided doses

Xylometazoline 0.I%2 drops thrice a day

Relief not obtained

VC through CHO:
Relief Obtained
ance to treatment

Ajvise the patient regarding personal hygiene, ear care including avoiding inserting

medicines in the ear.

foreign objects/indigenous

Counsel them to watch out for signs such as diminishing heating. facial deviarion ConmunityHealth Ofie
Socain Ysi HWC
PHC. Goalps
Management of OTITIS MEDIA (MIDDLE EAR INFECTION)

Sabina Yasmen
Page 13 of 19 Community IHealth
Oicer
i/e Dabli
HWC
MamoiBPHC,
Goalpara
 Referral pathway for Otitis Media
ASHA identifies a case/patient presents
tothe facility with complaints oT: ear
discharge, reduced hearing,
irritability, fever

Ask about: Look for signs of severe infection:

h/o recurrent /past

URTI High-grade fever, prostration,

hlo neck rigidity, pus discharge from

allergies

ears, severe headache, facial

hlo travel to high deviation.

altitude

Signs of severe infection

Signs of severe infection
absent
present

Initiate treatment with:

PCM:
Refer to DH/ENT specialist for
10-15 mg/kgday in 3 divided doses
further evaluation and Mn
Chloramphenicol/ciplox ear 2 drops twice
a day

Amoxycillin 25-30mg/kg/d in 3 divided

doses

Xylometazoline 0. 1% 2 drops thrice a day

Relief Obtained Relief not obtained

Flu care @SHC-HWC through CHO:

Ensuring compliance to treatment

Advise the patient regarding personal hygiene, ear care

including avoiding inserting forejgn
objects/indigenous medicines in the ear.

Counsel them to watch out for signs such as diminishing hearing. facial deviation pe

Sabl
naYaseicer
HWC
ilcDabli

MomoiBPHC.
 Referral
pathway for ver tigo

Patient
presents with
dizziness

Ak about
Detailed desc Check for Feeling that himself or his
iptionof dizziness
h/o of any drug SUrr oundings ar e moving aw
alcohol intake
h/o trauma to tinnitusea ing loss
head

Disturbed balanoe pr edominntly on

wailing relieved on sitting

Feeling of losing consiousness of blacking

ou or h/o dizziness tauma
Refee to DHÆNT after

special ist for fur ther

evaluation nd treatment
Robble case of Ver tigp

Counsel the patient about reduced intake of caffeine/

aloohol

Avoid per for minghaza dous task

Consult the
Antihistaminics
O for
and initiate

15 days
Rx with Cinnar izine 15mg'

Relief O btained
Relief not obtained

Fu care thr ough HWC SHC

i) bisu ingonpilalie io u eauleil aiv isH in ouji

ASHAs
2) Counsel reçar dingreduced cafience/alcohol intake,

avoidance of haza dous tasks, per sonal car e

3) Warning sgs needingrepeat tu visit to HWC-HC

Sooinm Yasmen
Page 15 of 19 Comnunity Health Oficer
ic Dabli HWC
Mornoi BPHC, Goalpara
 of Hearing loss/Reduced
Management Hearing

Referral pathway for Hearingloss

Patient prese nts to the facility with complaints reduced hearing

Ask for:

Clinical evaluation for:

Onset and progression of
reduced
ObviouS causes of
current episode Previous
hearing such as conge ntial
h/o of sinmilar episodes is
malformations/ ear wax/
hearing loss uni/bi-lateral
infections/trauma,etc
Painless/painful hearing
Perform rinne's/we ber's
loss family history
tests using turning frocks

H/O trauma, tinitus, chronic

ear discharge fullness in the

ear chro nic drug intake

1/Pt. appe ars unstable

Pt. appears stable & probable
2/H/o sudden/painful loss of hearing
causesfor the hearing loss
3/H/o HL followingtrauma
4/a/w features such as high-grade
fever/purule nt discharge/facial
deviation. etc

5/Probable underlying cause not

Manage as per underlying
found
condition

Refer toDH/Specialist
for furtherevaluation

3-5 days and treatment

Follow-up after

Relief obtained No Relief

Sabim Yasmen
19 Community
Page 16 of Health Oficer
VeDabli
Mormoi BPHC,
HWC
Goalpara
Management of Foreign body in ear

Referral pathwayfor 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
Symptomssuggesting
preformation such as acute Bloody discharge indicating

ear pain, hearing loss, trauma to TM

tin nitus, Vertigo, etc of the object
Margins

Object is clearly
Object not clearly visible/
visible/appears gras pa ble ungraspable friable
Position: not deep in the
canal Position: Deep Inside Canal

Margins: blunt Sharp/pointed margins

Sign/symptoms s/o TM
no sign/symptoms s/o
TM perforation
perforation

Relax the patient

Pull the pinna upwards and

the canal
backwards to straighten
Visua lize under good illumination

objects such as
Non-hygroscopic
Live FB such as plastic, beads etc
pebbles, stone,
Insects files

Refer to DH/ENT
the Attempt manual
gently food in
specialist for further
removal using forceps
air with warm eva luation and Mgt
oil
water/Mineral
or 4% xylocaine

fails
Attempt

Sacim Yasmn
CommunityHealth Oficer
Page 17of 19 ileDabli HWC
MormoiBPHC,Goalpara
Management of FOREIGN BODY IN Throat/Airway

Body in the throatvairway

Reterr al pathway for For eige
body ingoction
Patient procontc with foreign

Look for:
Ask for:
Sign s/o chocking
Nature of the suspected object
Unstable/uncooperative
ditficulty in breat hing
patient
blood stained discharge from mouth

H/o alcohol/substanceabuse

objects
Large/shape
Smooth, small object in the breathing
difficulty
Patient stable i.e. no sign of choking patient
Unstable

to bend forwards
ryle's ask for patient
Atte mpt insertingof
at back
tube if trained for it or ask and give blows
maneouver
drink 3-4 attempt Helmich's
the pat ie nt to

glasses of water

Obstruction not
Obstruction

relieved relie ved

not relieved relieved

nt
Reassure the patie

any complaintsof the

blood-tinged
for
f/u the patient
in colour or stools

discharge from mouth/nose or change

If yes

Referral to DS/S

Sabina Yani
Cormunity Health Oficer
ile Dabli HWC
Page 18of
19 Momoi BPHC, Goalpara
cOMMONLY USED ENT MEDICINES IN SHC-HWC
Normal saline nasal drops - sodium
chloride (0.5% wl)
hXylometazoline 0.1% nasal drops

C. Wax solvent ear drops

d. Cetrizine syrup/tablets

e Boro spirit ear drops

f. Amoxicillin - syrop/tablets

Combo ear drops (Chloramphenicol + Clotrimazole + Lignocaine hydrochloride)

h. Liquid paraffin - menthol drops

REFERENCES

A. Operational Guidelines for Ear. Nose and Throat (ENT) t Health and Wellness Centre, 2020.

(ENT)Care for Community Health Officer, NHSRC

B
Training Manual on Ear, Nose and Throat

202|

Sabina Yamin
CommunityHealth Oficer

Page 19of 19
i/e Dabli HWC
MornoiBPHC,Goalpara