Summary

Minor office procedures form an important part in the management of patients with ear, nose and throat disorders. Office procedures can be performed by a wide range of health-care practitioners who are suitably trained and have an interest in ENT diseases, allowing the patient to be treated definitively. A certain understanding of local anatomy and the specialised equipment used is needed as is an understanding of the potential pitfalls and complications. Once the anatomy of the ear canal is familiarised, removing wax and foreign bodies can be undertaken; as well as cleaning and packing of the canal, in otitis externa. Active and recurrent epistaxis can be managed once the nasal cavity has been anaesthetised. These office-based procedures are described.

摘要

簡單的門診操作是治療耳鼻喉疾病重要組成部分。受過適當訓練並對耳鼻喉疾病有興趣的各種醫生都可以進行這些門診操作，使病人得到徹底的治療。醫生需要對局部解剖、專科設備、可能出現的錯誤和合併症有一定的瞭解。在熟悉了耳道解剖之後，就可以進行耵聹和異物的清除，在外耳道炎時進行耳道的清潔和處理。鼻腔局部麻醉之後，就可以治療對活動性和復發性鼻衄。本文對這些門診操作進行了詳細的解釋。

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Introduction

The specialist field of ear, nose and throat surgery is heavily outpatient based. As a result, minor office procedures form an important part in the management of patients with ear, nose and throat disorders. While many office procedures can be suitably performed by a wide spectrum of health-care practitioners, others demand a high level of specialist skills and are therefore not suitable for generalists. This is because the air-containing cavities of the head and neck are adjacent to vital structures such as the eye and brain. The cavities themselves are often difficult to visualise making procedures hazardous. A certain understanding of local anatomy and specialised equipment is needed in order to perform routine ENT office procedures safely. However, there are a number of ENT office procedures that a suitably trained health-care practitioner with an interest in ENT can competently perform, allowing the patient to be treated completely.

The ear canal

Anatomy

The external ear consists of the pinna and the ear canal. The ear canal is about 25mm long and 7mm wide in adults. The outer half of the ear canal is cartilaginous and the inner half, bony. The ear canal narrows slightly at the cartilage-bony junction before widening out again at the eardrum. The first part of the ear canal can be straightened by gently pulling the pinna upwards and backwards. Cerumen or wax is produced in the outer half of the ear canal where the fine hairs of the ear canal grow, and keeps the canal moist while inhibiting the growth of bacteria.

Wax removal from the ear canal

The indications for removal of wax from the external ear canal include hard wax causing ear discomfort, wax affecting hearing, wax causing infection and when the eardrum needs to be visualised.

The simplest method to remove wax is to irrigate it out of the ear canal with a syringe. If there is a history of a perforated eardrum, chronic middle ear disease, mastoid surgery or if the patient is deaf in the other ear, the ear should not be syringed. To facilitate syringing, the wax can be softened by instilling olive oil or 5% sodium bicarbonate eardrops into the ear canal four times a day for five days prior to syringing.¹ Alternatively, proprietary products like Waxsol and Cerumol can be used.

To syringe the ear, it is best to use a specifically designed metal ear syringe available on the market, but a disposable 50ml plastic syringe fitted with a suitable wide nozzle or cannula will suffice. The length of the nozzle or cannula should be shorter than that of the ear canal, so that damage to the eardrum will not occur. In practice, the nozzle or cannula should not be inserted into the ear canal. A stream of water at body temperature is gently aimed at the roof of the ear canal while the pinna is pulled upwards and backwards to straighten the ear canal in the adult² (see Figures 1a and 1b). In children, it may not be necessary to pull the pinna backwards and upwards as the ear canal is relatively straight. The patient should be in a sitting position and a kidney dish or an ear syringe cup is placed below the ear to receive the water and prevent soiling of the patient's clothing. Remember that the eardrum is very delicate and is at the medial end of the ear canal, therefore the force of water should never be enough to damage the eardrum. The main risk of ear syringing is to the eardrum, and so care must be taken not to insert the nozzle or cannula of the syringe into the ear canal, and not to irrigate with too much force. Wax is removed by the volume of water used, and not by the pressure of the water stream.³ Ear syringing systems are also available on the market e.g., the Earwash System by Welch Allyn - this system requires the preliminary use of wax softeners before syringing to be most effective.

Alternatively, an examination microscope and ear speculum will allow for excellent visualisation of the ear canal and wax, which can then be removed with a cerumen curette, loop, hook or by ear suction. A less expensive magnification system such as a self-illuminating binocular loupe system e.g., the Welch Allyn Lumiview, offers a good view of the ear canal. If magnification is unavailable, a headlight will give illumination to the ear canal but not magnification. While it may be possible to roll out a hard bead of wax, working deeper in the ear canal is dangerous and should not be attempted. A headlight has an added advantage of allowing both hands to be free to work.

Foreign body

Children especially tend to put small objects into their ear canals, but this does not mean that adults never present with tissue paper, cotton wool, or the occasional insect that has crawled into the ear canal.⁴ The diagnosis of a foreign body is usually straightforward and is made on otoscopy. Good magnification and illumination is essential, using either an examination microscope or binocular loupes. It may often be possible to remove a foreign body in the ear canal by irrigation, but other methods can be employed. If the foreign body, e.g. a piece of paper, can be grasped, then an alligator type ear forceps is used to remove it. If the foreign body has a smooth surface, like a metal or a plastic bead or ball, then an instrument, such as a hook, may be placed behind the object, and the object rolled out, in order to extract it.⁵ But, the ear canal is very sensitive and getting an instrument between the object and the canal wall can be very painful. Be careful not to push the object deeper into the ear canal while attempting to grasp or remove it, as you may push it through the ear drum and leave the patient with a permanent hearing loss and damaged ear. Never perform this procedure on a patient who is not 100% co-operative, especially a child. If there is any doubt about performing the procedure or failure after a single attempt, it would be more reasonable to refer the patient to an ENT surgeon. Indeed sometimes general anaesthesia is warranted to facilitate an atraumatic and painless removal of a foreign body.

Otitis externa - cleaning the ear canal

Infection of the ear canal, or otitis externa, presents as otalgia and is frequently accompanied by a discharge. The calibre of the canal is often reduced due to the inflamed swollen ear canal skin and accumulated debris. This makes inspection of the eardrum difficult. Once the diagnosis of otitis externa has been made, the ear canal needs to be cleaned meticulously to remove infected material and to allow for a more accurate diagnosis of the underlying cause to be made. Cleaning is achieved either by careful ear mopping or by gentle suction. To mop the ear canal, cotton wool is twisted onto an applicator with the ends left frayed so that it remains absorbent (see Figure 2). It is used to remove moist pus and to dry the ear canal. The tip of the applicator must not project further than the midpoint of the cotton wool, so that the tip of the applicator will never come in contact with the eardrum and damage it. While the pinna is pulled upwards and backwards, the cotton wool is inserted into the ear canal, twisted and then removed. The soiled cotton wool mop is removed and fresh cotton wool applied. The procedure is repeated until the ear canal is clean and dry. Alternatively, the ear canal can be cleaned and dried with ear suction through a small ear speculum and under illuminating magnification. Once the ear canal is clean, the full length of the canal and ear drum needs to be inspected to gain an accurate clinical impression of the underlying cause of the otitis externa.

Otitis externa - packing the ear canal

Ear pain accompanying otitis externa is due in part to the inflammation and swelling of the canal skin. Reducing the inflammation and swelling of the canal skin leads to a dramatic relief of symptoms, and is best achieved by using a topical steroid ear drop.⁶ In order to keep the steroid in contact with the canal skin, a pack can be placed into the ear canal. This can be in the form of a Merocel ear wick or ribbon gauze onto which steroid-containing eardrops can be instilled.⁷ There are several eardrop preparations available on the market which are suitable as they are compound preparations of steroids and antibiotics e.g., Sofradex Otosporin and Garasone etc. Packing the ear canal means that both the pack and an instrument must be inserted blindly into the ear canal. As a real danger of permanently damaging the eardrum exists, the procedure must be done carefully with a three-dimensional concept of the ear canal, especially its length. Packs should be changed every one or two days until the calibre of the ear canal approaches normal, at which stage the packs are no longer needed. The clinical practitioner must ensure that ear packs are never left in the ear canal without close supervision and follow-up as they can behave like a foreign body themselves and over time can cause otitis externa per se.

Hearing screening

Occasionally the general practitioner may be asked to see a patient who has a suspected hearing loss. This may pose a problem for the general practitioner as a full assessment is time-consuming. Time is better spent screening patients and determining whether a hearing loss exists, in which case referral to an ENT Specialist is required. In an adult, a hearing loss may be volunteered by the patient and easily confirmed by examining the patient. Difficulties in hearing and especially hearing in noisy environments like restaurants, tinnitus, discharging ears and noise-exposed occupations like construction site workers are signposts in the history of a potential underlying hearing disorder. The ear may indicate signs of a conductive loss e.g., perforated eardrum, middle ear effusion or cholesteatoma. Cochlea hearing loss, whether pure or coexisting with a conductive loss, cannot be adequately determined by inspection alone and will require formal audiometric testing. Tuning fork testing with a 512 Hz tuning fork, including the Rinne and Weber tests can be done but, in the authors' opinion, remains too non-specific to be of practical use for the average general practitioner.

If a hearing problem is suspected, the simplest and most effective diagnostic test is an audiogram. This will usually require a referral to an audiological centre or an ENT Specialist for further evaluation. General practitioners with an interest in more accurate hearing screening tools can explore the use of the Welch Allyn Audiometer, which allows for a simple hearing test to be performed across several pure tone frequencies at different sound level intensities whilst also doubling up as an otoscope.

The screening of hearing loss in children is even more difficult as the problem needs to be elucidated by the clinician. Establishing that there may be a hearing problem lies in the history. The parents may have noticed that the child watches the television with the volume turned up very loud or that the child does not respond to the parents' commands when the child's back is turned to the parents. Parents are usually correct and care is required in taking the history. Signposts of hearing problems in the child are delayed speech development, poor school performance, a positive family history of a hearing disorder that emerges before middle age, a shy and introverted child or recurrent ear pain and ear discharge. The ears should be inspected to exclude wax, perforated eardrums and middle ear effusions. Any child with a suspected hearing loss due to any condition other than an acute otitis media, should be referred to an ENT specialist. The only practical office-based procedure for hearing screening of a child by a general practitioner would be the use of a tympanometer which measures the ear canal volume and middle ear compliance to diagnose normal and negative middle ear pressures, middle ear effusions and perforated eardrums. The test is simple and quick to perform but the cost of the equipment may not be a viable option for all clinical practices.

In general, office-based procedures for hearing screening by the general practitioner are few. A positive screening history and an otoscopic examination is all that can be practically done before referral to a hearing specialist.

Anterior nasal septum

Anatomy

The mucosa overlying the cartilage of the anterior nasal septum, known as Little's area (named after Dr James Little who first described it), is supplied by a plexus of terminal branches of the external and internal carotid arteries known as Kiesselbach's plexus. This area of mucosa is just posterior to the skin lined nasal vestibule and is easily inspected with a Thudicum nasal speculum (see Figure 3) using a headlight. In children who have no nasal vestibule hairs, the anterior nasal cavity is easily inspected even without a speculum by turning up the tip of the nose with the examiners finger.

Anaesthetising the nasal mucosa

If the nasal mucosa is going to be cauterised or the nasal cavity be packed, the nasal mucosa should be prepared by a topical anaesthetic and vasoconstrictor. This will not only make the two procedures more comfortable for the patient, but will also reduce bleeding and vasoconstrict the vascular mucosa, especially the turbinates and allow better visualisation and inspection of the nasal cavity. Anaesthesia and vasoconstriction can be achieved by applying up to 4mls of 4% cocaine solution or 4% aqueous lidocaine with 0.05% oxymetazoline in the form of a spray or soaked cotton pledgets. If cocaine is used, clinicians must take care to avoid the patient ingesting the cocaine or of overdosing the patient (maximum dose: 3mg/kg body weight) as cardiac arrhythmias and complications are well recognised.

Epistaxis - active

A patient with active epistaxis, which cannot be controlled by compression of the external cartilaginous nose (lower one-third), can be managed in the office before referral for further management. The basic technique is to apply pressure to the mucosa of the nasal cavity with a nasal pack and in so doing, stem the flow of blood to the bleeding point. Any pre-existing packs and clots should be removed from the nasal cavity with nasal forceps and gentle nasal suction. Large clots can be self-evacuated by the patient by asking them to sniff, causing the clot to be sucked backwards through the nasopharynx and oropharynx and then spontaneously spat out by the patient through the mouth.

Spraying 4% xylocaine into the nose before inserting the epistaxis packs facilitates a more comfortable insertion procedure for the patient, but absolute anaesthesia is never and need not be achieved. Once anaesthetised, the nasal cavity should be packed with a proprietary epistaxis nasal pack, like Merocel, Brighton balloon or Simpson's balloon.

Epistaxis - recurrent

There is a step-wise protocol for the management of recurrent epistaxis, beginning with simple manoeuvres that the patient can do at home, to more invasive office based procedures. Most epistaxis will be due to bleeding from the anterior nasal septum, which is easily managed by external compression of the cartilaginous portion of the external nose. Recurrent epistaxis from this area can be managed by a physician who has the equipment and knowledge to do so. The anterior portion of the nasal septum is an area that is subject to the drying effects of inhaled air and digital trauma. It is an area that can easily be inspected with a headlight and a Thudicum nasal speculum. Once the offending superficial or dilated blood vessels or bleeding point has been identified, the overlying mucosa can be anaesthetised. It is important to dry the area of the mucosa to be cauterised. The mucosa overlying and surrounding the superficial vessels is then cauterised with silver nitrate.⁸ Silver nitrate is available as a solid coating covering the tip of an applicator stick. When the hard solid silver nitrate comes into contact with water, a chemical reaction occurs with the release of nitric acid (which causes the chemical acid coagulation) and silver hydroxide (which is seen as a white precipitate). The stick should be applied to the mucosa with some pressure and only for a few seconds until chemical cauterisation of the mucosa has occurred, and this is seen as a whitening of the mucosa.⁹ Cautery should never be undertaken on the contralateral adjacent septal mucosal lining of the nose at the same consultation, as septal perforations have been reported to occur. Another complication may arise from the moist silver nitrate as the applicator is withdrawn from the nose. Inadvertent touching of the skin of the vestibule or the nose can result in an unsightly burn with potential scarring and disfigurement, so that extreme caution is necessary. Similarly, mucus with silver nitrate running onto the upper lip may also result in disfigurement and scarring of the skin.

Conclusion

Office based procedures for the ear, nose and throat are many and varied, and some can easily be undertaken by the health-care practitioner in general practice. The above mentioned procedures are relatively simple procedures that can certainly be performed in a general practice setting. Several other procedures can be undertaken but, in the authors' opinion, will require further supervised training which is beyond the current scope of this article.

Key messages

1. Ear wax that causes discomfort, affects hearing, aggravates infection or obscures inspection of the ear drum should be removed.
2. Wax should be softened with eardrops before syringing.
3. To remove wax, gently syringe the ear canal with water at body temperature.
4. Remove foreign bodies in the ear canal with good illumination, magnification and correct instruments.
5. Understand the anatomy of the external ear to avoid damaging the eardrum.
6. Otitis externa requires the ear canal to be cleaned by careful ear mopping or gentle suction.
7. A swollen ear canal due to otitis externa may need packing with an ear pack and a topical steroid preparation.
8. Hearing loss in children may present as behavioural problems or poor school performance. Referral is indicated.
9. Epistaxis can be managed by external compression of the soft lower part of the nose. If this fails to control the bleeding after 15 minutes the nose should be packed.
10. An identified source of bleeding in recurrent epistaxis can be cauterised with silver nitrate.

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References