Management of Common Eye & ENT Conditions

Posted on by Soumya Ranjan Parida
Community Screening & Management of Common Eye & ENT Conditions | Nursing Notes

Management of Common Eye & ENT Conditions

A Comprehensive Guide for Community Health Nursing

This guide provides essential information for community health nurses on screening, diagnosing, managing, and referring common eye and ENT conditions.

Table of Contents

  1. Introduction to Community Screening for Eye & ENT Conditions
  2. Standing Orders: Definition and Uses
  3. Screening and Identification Methods
  4. Common Eye Conditions
  5. Common ENT Conditions
  6. First Aid and Emergency Management
  7. Primary Care and Referral Guidelines
  8. Best Practices in Community Screening

Introduction to Community Screening for Eye & ENT Conditions

Eye and Ear, Nose, and Throat (ENT) conditions represent some of the most common health issues encountered in community settings. These conditions can significantly impact quality of life and, if left untreated, may lead to serious complications including permanent vision or hearing loss. Community health nurses play a pivotal role in early detection, management, and referral of these conditions.

Effective community screening programs for eye and ENT conditions help identify health issues at early stages when interventions are most effective. These programs are particularly important in underserved areas where access to specialized healthcare may be limited. By implementing standardized screening protocols, community health nurses can significantly improve health outcomes for their populations.

This guide provides comprehensive information on common eye and ENT conditions, including their identification, primary care management, and appropriate referral pathways. It also outlines standing orders and first aid measures that community health nurses can implement in various settings.

A detailed anatomical illustration showing the eye and ear structure, with labeled parts highlighting common conditions. The image includes a cross-section of the eye showing conjunctiva, cornea, and lens, and a cross-section of ear showing middle ear where otitis media occurs.

Anatomical illustration of eye and ear structures, highlighting areas commonly affected by conditions discussed in this guide.

Standing Orders: Definition and Uses

Definition

Standing orders are written protocols approved by a qualified healthcare provider that authorize nurses and other appropriate healthcare staff to provide specific services or interventions without direct physician supervision at the time of service.

Key Components of Standing Orders

Effective standing orders should include:

  • Specific conditions or symptoms that trigger the order
  • Detailed protocols for assessment
  • Clear intervention guidelines
  • Medication administration protocols (if applicable)
  • Documentation requirements
  • Criteria for physician notification or patient referral

Uses in Community Health Nursing

Standing orders for eye and ENT conditions serve several important purposes in community health settings:

Purpose Application in Community Screening
Standardization of Care Ensures consistent assessment and treatment approaches across different community health workers
Timely Intervention Allows immediate initiation of appropriate treatment for common conditions
Resource Optimization Maximizes the scope of practice for community health nurses while preserving physician time for complex cases
Care Accessibility Expands healthcare access in underserved areas where physician availability may be limited
Quality Control Provides a framework for maintaining consistent quality standards in community health services

Standing orders particularly enhance community screening programs by allowing community health nurses to independently assess, provide initial treatment, and make appropriate referral decisions for common eye and ENT conditions.

Screening and Identification Methods

Effective community screening relies on systematic approaches to identify eye and ENT conditions at early stages. The following tools and techniques are essential components of a comprehensive screening program:

Vision Screening Tools

Screening Tool Application Procedure Interpretation
Snellen Chart Distance vision assessment Patient stands 20 feet (6 meters) from chart and reads smallest visible line Normal vision: 20/20 (6/6); Values like 20/40 indicate individual can see at 20 feet what a person with normal vision sees at 40 feet
Near Vision Chart Reading and close-work vision assessment Patient holds chart at 14-16 inches (35-40 cm) and reads smallest visible text Normal near vision correlates with age; presbyopia common after age 40
Ishihara Plates Color vision testing Patient identifies numbers or patterns within colored dots Inability to identify patterns suggests color vision deficiency
Penlight Examination Basic eye structure assessment External examination of eye structures and pupillary response Abnormalities in external structures or pupillary response require further evaluation

ENT Screening Tools

Screening Tool Application Procedure Interpretation
Otoscope Ear canal and tympanic membrane examination Visualize ear canal and tympanic membrane with otoscope Normal TM: pearly gray, transparent, intact; Abnormalities include redness, bulging, retraction, or perforation
Whispered Voice Test Basic hearing assessment Examiner whispers words at arm’s length behind patient; patient repeats words Inability to repeat correctly suggests hearing impairment
Tuning Fork Tests (Rinne and Weber) Differentiation between conductive and sensorineural hearing loss Rinne: Compare air and bone conduction
Weber: Tuning fork placed on midline of forehead 		Rinne: Normal = air conduction > bone conduction
Weber: Normal = sound heard equally in both ears
Throat Examination Assessment of oropharynx Visual inspection with penlight and tongue depressor Observe for redness, swelling, exudates, or structural abnormalities

Comprehensive Screening Approach

An effective community screening program integrates multiple assessment components:

1. History Taking

  • Chief complaint and duration
  • Associated symptoms
  • Previous episodes and treatments
  • Family history
  • Environmental and occupational factors

2. Physical Examination

  • Systematic assessment using appropriate tools
  • Documentation of findings
  • Comparison with normal parameters
  • Assessment of impact on daily functioning

3. Risk Factor Assessment

  • Age-related factors
  • Comorbid conditions
  • Lifestyle factors
  • Environmental exposures

4. Documentation and Referral

  • Standardized recording of findings
  • Decision-making based on protocols
  • Clear communication of findings
  • Appropriate follow-up planning

Mnemonic: “SCREEN” for Community Screening Process

  • S – Systematic assessment using standardized tools
  • C – Collect comprehensive history
  • R – Record findings accurately
  • E – Evaluate against normal parameters
  • E – Educate patient about findings
  • N – Navigate to appropriate care level (treat or refer)

Common Eye Conditions

Community health nurses frequently encounter various eye conditions during community screening activities. Understanding their presentation, management, and referral criteria is essential for effective primary care.

Local Infections

Local eye infections involve inflammation of various external eye structures and are commonly encountered during community screening.

Type Clinical Features Primary Care Management Referral Criteria
Blepharitis (eyelid infection)
  • Redness along eyelid margins
  • Crusty or greasy eyelashes
  • Burning sensation
  • Foreign body sensation
  • Warm compresses 2-4 times daily
  • Eyelid hygiene with diluted baby shampoo
  • Artificial tears for dryness
  • Severe or persistent symptoms
  • Secondary complications
  • Vision changes
Hordeolum (external stye)
  • Painful red bump on eyelid margin
  • Localized swelling
  • Tenderness on palpation
  • Warm compresses 4-6 times daily
  • No squeezing or puncturing
  • Pain control as needed
  • No improvement after 48 hours
  • Spreading redness or cellulitis
  • Visual disturbances
Dacryocystitis (lacrimal sac infection)
  • Pain and swelling near nasal corner of eye
  • Excessive tearing
  • Discharge
  • Possible fever
  • Warm compresses
  • Gentle massage over lacrimal sac
  • Immediate referral if acute
  • All cases should be referred
  • Urgent referral if acute with fever

Important Note:

Local eye infections may be contagious. Educate patients about proper hand hygiene, avoiding sharing of towels and makeup, and refraining from touching or rubbing eyes.

Redness of Eye

Red eye is a common presentation in community screening settings and can indicate various underlying conditions from minor irritation to serious ocular emergencies.

Differential Diagnosis of Red Eye

Condition Pattern of Redness Associated Symptoms Primary Care Management Urgency Level
Conjunctivitis Diffuse, more pronounced in fornices Discharge, grittiness, mild discomfort See conjunctivitis section Non-urgent
Subconjunctival Hemorrhage Bright red, well-demarcated patch Usually asymptomatic, no pain or vision changes Reassurance, check BP, investigate if recurrent Non-urgent
Acute Glaucoma Ciliary flush (redness around iris) Severe pain, blurred vision, halos around lights, nausea Immediate referral Emergency
Iritis/Uveitis Ciliary flush Photophobia, pain, small pupil, blurred vision Urgent referral Urgent
Foreign Body Localized redness Pain, foreign body sensation, tearing Irrigation if visible and loosely adhering; otherwise refer Semi-urgent
Corneal Abrasion Localized or diffuse Pain, photophobia, foreign body sensation Referral for fluorescein staining and treatment Semi-urgent

Mnemonic: “REDNESS” for Assessing Red Eye

  • R – Redness pattern (diffuse or localized)
  • E – Exudate or discharge (type and amount)
  • D – Discomfort level (mild to severe)
  • N – Neurological symptoms (headache, nausea)
  • E – Eye structures involved (conjunctiva, cornea, etc.)
  • S – Systemic symptoms (fever, malaise)
  • S – Sight affected (visual acuity changes)

Warning Signs Requiring Immediate Referral:

  • Severe pain
  • Vision loss or significant blurring
  • Halos around lights
  • Associated nausea/vomiting
  • Pupil abnormalities
  • History of trauma or chemical exposure

Conjunctivitis

Conjunctivitis (pink eye) is a common eye condition frequently identified during community screening. It involves inflammation of the conjunctiva, the thin transparent layer covering the white of the eye and inner eyelid.

Types of Conjunctivitis

Type Causes Clinical Features Management
Bacterial Conjunctivitis
  • Staphylococcus aureus
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Purulent discharge (yellow-green)
  • Crusting of eyelids, especially upon waking
  • Bilateral or unilateral
  • Mild to moderate redness
  • Antibiotic eye drops/ointment (according to standing orders)
  • Gentle cleaning of eyelids with warm water
  • Isolation precautions for 24 hours after starting antibiotics
Viral Conjunctivitis
  • Adenovirus (most common)
  • Herpes simplex virus
  • Enterovirus
  • Watery discharge
  • Often starts in one eye, may spread to both
  • Associated with URI symptoms
  • Preauricular lymphadenopathy
  • Symptomatic relief (cool compresses)
  • Artificial tears for comfort
  • Isolation precautions (highly contagious)
  • Referral if severe or no improvement within 7 days
Allergic Conjunctivitis
  • Seasonal allergens (pollen)
  • Perennial allergens (dust mites, pet dander)
  • Contact allergens (makeup, eye drops)
  • Bilateral itching (hallmark symptom)
  • Watery discharge
  • Mild redness
  • Often seasonal or related to exposure
  • Allergen avoidance
  • Cold compresses
  • Antihistamine eye drops (per standing orders)
  • Artificial tears

Prevention and Education

Community health nurses should educate patients on:

  • Proper hand hygiene
  • Avoiding eye touching and sharing of personal items
  • Proper application of eye medications
  • Isolation measures for infectious conjunctivitis
  • When to seek further medical attention

Conjunctivitis in Schools and Community Settings

Conjunctivitis can spread rapidly in community settings. Community screening programs should include protocols for identifying potential outbreaks and implementing control measures. Children with bacterial or viral conjunctivitis should avoid school until 24 hours after beginning treatment or until no longer contagious.

Stye (Hordeolum)

A stye is an acute infection of the oil glands of the eyelid that presents as a painful, localized swelling. During community screening, styes are commonly identified conditions that can typically be managed with primary care interventions.

Types of Styes

  • External Hordeolum: Infection of the sebaceous (Zeis) glands or sweat (Moll) glands at the eyelid margin
  • Internal Hordeolum: Infection of the meibomian glands within the tarsal plate of the eyelid

Causes

  • Bacterial infection (usually Staphylococcus aureus)
  • Blocked oil glands
  • Poor eyelid hygiene
  • Underlying blepharitis
  • Use of contaminated cosmetics

Clinical Features

  • Painful, red, localized swelling on eyelid margin or within eyelid
  • Tenderness to touch
  • May develop a yellowish spot at the center (pointing)
  • Tearing and mild photophobia
  • Foreign body sensation
  • Usually unilateral

Management

Primary Care
  • Warm compresses for 10-15 minutes, 4-6 times daily
  • Gentle massage to promote drainage (once pointing appears)
  • Analgesics for pain relief
  • Proper eyelid hygiene instruction
Medication (per standing orders)
  • Topical antibiotic ointment (erythromycin or bacitracin) for external styes
  • Oral antibiotics rarely needed unless cellulitis develops
  • Avoid eye makeup until resolved
Referral Criteria
  • No improvement after 48 hours of treatment
  • Spreading redness or cellulitis
  • Recurrent styes
  • Internal hordeolum not responding to treatment
  • Visual changes

Important:

Patients should be advised never to squeeze or attempt to drain a stye manually, as this can spread the infection and potentially cause serious complications.

Prevention

During community screening, educate patients on preventive measures:

  • Good hand hygiene before touching eyes
  • Proper eyelid cleansing for those with oily skin or blepharitis
  • Regular replacement of eye makeup (every 3-6 months)
  • Never sharing eye makeup
  • Removing eye makeup before sleeping

Trachoma

Trachoma is a chronic contagious eye infection caused by Chlamydia trachomatis. It remains the leading infectious cause of blindness worldwide and is a critical target for community screening programs in endemic areas.

Public Health Significance

Trachoma is prevalent in areas with poor sanitation, limited access to clean water, and overcrowded living conditions. Effective community screening and early intervention can significantly reduce the burden of trachoma-related blindness.

Etiology and Transmission

  • Causative agent: Chlamydia trachomatis (serotypes A, B, Ba, and C)
  • Transmission: Direct contact with eye and nose discharges of infected persons
  • Indirect transmission: Via contaminated towels, clothing, or flies
  • Risk factors: Poor personal hygiene, limited water access, overcrowding

Clinical Stages (WHO Simplified Grading System)

Stage Description Clinical Features Management
Trachomatous Inflammation – Follicular (TF) Early active infection
  • Five or more follicles (≥0.5mm) on upper tarsal conjunctiva
  • Redness and irritation
  • Discharge
  • Antibiotic treatment (azithromycin or tetracycline eye ointment)
  • Face washing education
  • Environmental improvements
Trachomatous Inflammation – Intense (TI) More severe inflammation
  • Pronounced inflammatory thickening of upper tarsal conjunctiva
  • Papillary hypertrophy
  • Obscuring of normal tarsal vessels
  • Antibiotic treatment as above
  • More aggressive follow-up
  • Consider community-wide treatment
Trachomatous Scarring (TS) Cicatricial stage
  • White scarring of tarsal conjunctiva
  • Fibrosis
  • Monitor for progression
  • Referral for ophthalmology assessment
Trachomatous Trichiasis (TT) Inturned eyelashes
  • At least one eyelash rubs on eyeball
  • Evidence of recent epilation
  • Urgent referral for surgery
  • Epilation as temporary measure
Corneal Opacity (CO) End-stage disease
  • Easily visible corneal opacity over pupil
  • Visual impairment or blindness
  • Referral for specialist care
  • Vision rehabilitation

Community Screening and Management Strategy: SAFE

S – Surgery

For advanced cases with trichiasis to prevent corneal damage and blindness

A – Antibiotics

Mass treatment in endemic communities or individual treatment for active cases

F – Facial cleanliness

Promotion of face washing to reduce transmission

E – Environmental improvements

Access to clean water, sanitation, and reducing fly breeding sites

Role of Community Health Nurses

  • Conduct regular community screening in endemic areas using simplified grading system
  • Identify and treat active cases according to standing orders
  • Refer advanced cases for surgical management
  • Implement health education regarding facial hygiene and environmental factors
  • Coordinate with public health authorities for community-wide interventions
  • Follow up treated cases to assess response and prevent recurrence

Refractive Errors

Refractive errors are common vision problems that occur when the shape of the eye prevents light from focusing correctly on the retina. Community screening for refractive errors is essential for early detection and intervention, particularly in school-aged children and older adults.

Types of Refractive Errors

Type Description Clinical Features Screening Methods Management
Myopia (Nearsightedness) Distant objects appear blurry while near objects remain clear
  • Difficulty seeing distant objects
  • Squinting
  • Eye strain
  • Headaches
  • Snellen chart testing
  • Pinhole testing
  • Concave (minus) lenses
  • Referral to optometrist/ophthalmologist
Hyperopia (Farsightedness) Near objects appear blurry while distant objects may be clearer
  • Difficulty with near tasks
  • Eye strain
  • Headaches after reading
  • Crossed eyes in children (accommodative esotropia)
  • Near vision chart
  • Snellen chart for distance
  • Convex (plus) lenses
  • Referral to optometrist/ophthalmologist
Astigmatism Irregular curvature of cornea or lens causing distorted vision
  • Blurred or distorted vision at all distances
  • Squinting
  • Eye strain
  • Headaches
  • Snellen chart
  • Astigmatism charts
  • Cylindrical lenses or toric lenses
  • Referral to specialist
Presbyopia Age-related loss of near focusing ability
  • Difficulty reading small print
  • Holding reading material at arm’s length
  • Eye fatigue with near work
  • Headaches
  • Near vision chart
  • Reading tests
  • Reading glasses
  • Bifocals or progressive lenses
  • Referral for assessment

Community Screening Approaches

School-Based Screening
  • Annual visual acuity testing using age-appropriate charts
  • Assessment of eye alignment and movement
  • Screening for color vision deficiencies (usually grades 1-2)
  • Documentation and referral system for failed screenings
  • Follow-up mechanism to ensure compliance with referrals
Adult Screening (40+ years)
  • Distance visual acuity testing
  • Near vision assessment for presbyopia
  • Basic ocular health screening
  • Glaucoma risk assessment
  • Education about age-related vision changes
  • Referral protocols for comprehensive eye examinations

Mnemonic: “VISION” for Refractive Error Screening

  • V – Visual acuity measurement (distance and near)
  • I – Identify risk factors (family history, age, symptoms)
  • S – Screen using appropriate tools (Snellen, near cards)
  • I – Interview for symptoms (headaches, eye strain, squinting)
  • O – Observe behavior (reading distance, head tilting)
  • N – Note findings and make appropriate referrals

Importance in Community Health

Uncorrected refractive errors can have significant impacts on:

  • Educational achievement in children
  • Occupational performance in adults
  • Quality of life in older adults
  • Safety (e.g., driving, preventing falls)
  • Psychosocial well-being

Community Health Nurse’s Role

Community health nurses should advocate for regular vision screening across the lifespan, educate communities about the importance of eye care, and facilitate access to vision correction resources, especially for underserved populations.

Common ENT Conditions

Ear, Nose, and Throat (ENT) conditions are frequently encountered during community screening activities. Community health nurses must be proficient in assessing, managing, and making appropriate referrals for these conditions.

Epistaxis (Nosebleed)

Epistaxis refers to acute hemorrhage from the nostril, nasal cavity, or nasopharynx. It is a common emergency encountered during community screening and requires prompt assessment and management.

Classification

  • Anterior Epistaxis (90-95%): Bleeding from Kiesselbach’s plexus in the anterior nasal septum
  • Posterior Epistaxis (5-10%): Bleeding from posterior nasal cavity, often from branches of sphenopalatine artery

Etiology

  • Local Causes: Trauma, foreign body, nose picking, digital trauma, mucosal dryness, septal deviation
  • Systemic Causes: Hypertension, anticoagulant therapy, coagulopathies, liver disease, alcohol use
  • Other Factors: Environmental (dry climate, high altitude), allergic rhinitis, upper respiratory infections

Assessment

Parameter Assessment Focus Significance
Bleeding Source Anterior vs. posterior Determines management approach and urgency
Bleeding Severity Volume, duration, recurrence Indicates need for emergency referral
Vital Signs BP, pulse, respiratory rate Assesses hemodynamic stability
Medical History Hypertension, bleeding disorders, medications Identifies contributing factors
Examination Nasal cavity, throat for posterior bleeding Localizes bleeding source

Management of Anterior Epistaxis

First Aid Measures
  1. Position patient upright with head tilted slightly forward
  2. Apply firm pressure to the fleshy part of the nose for 10-15 minutes continuously
  3. Use ice pack or cold compress on the bridge of the nose
  4. Instruct patient to breathe through mouth and avoid swallowing blood
Advanced Measures (per standing orders)
  1. Inspect nasal cavity with good light source
  2. Apply cotton with vasoconstrictor agent (e.g., oxymetazoline)
  3. Consider chemical cautery with silver nitrate if bleeding point visible
  4. Anterior nasal packing if bleeding continues
Referral Criteria
  • Bleeding not controlled with first aid measures
  • Suspected posterior bleeding
  • Significant blood loss or hemodynamic instability
  • Patient on anticoagulants
  • Recurrent epistaxis

Warning Signs Requiring Immediate Referral:

  • Bleeding not controlled after 20 minutes of pressure
  • Blood flowing down throat (posterior bleeding)
  • Signs of significant blood loss (pallor, dizziness, tachycardia)
  • Respiratory distress
  • Known bleeding disorder or anticoagulant therapy

Patient Education

During community screening and after epistaxis management, education should include:

  • Avoiding nose picking, forceful nose blowing, and strenuous activity for 24 hours
  • Keeping head elevated when resting
  • Using saline nasal spray or water-soluble lubricant to prevent nasal dryness
  • Humidifying the home environment
  • When to seek medical attention for recurrent episodes
  • Importance of blood pressure monitoring for hypertensive patients

Acute Suppurative Otitis Media (ASOM)

Acute Suppurative Otitis Media (ASOM) is an infection of the middle ear characterized by rapid onset of signs and symptoms of infection with middle ear effusion. It is commonly identified during community screening, especially in pediatric populations.

Etiology and Risk Factors

Common Pathogens
  • Streptococcus pneumoniae (30-40%)
  • Haemophilus influenzae (20-30%)
  • Moraxella catarrhalis (10-15%)
  • Group A Streptococcus (5%)
  • Viruses (Respiratory Syncytial Virus, Rhinovirus)
Risk Factors
  • Young age (peak incidence 6-18 months)
  • Eustachian tube dysfunction
  • Upper respiratory infections
  • Daycare attendance
  • Passive smoke exposure
  • Bottle feeding while lying down
  • Craniofacial abnormalities
  • Immunodeficiency

Clinical Stages of ASOM

Stage Pathophysiology Clinical Features Otoscopic Findings
Stage 1: Tubal Occlusion Eustachian tube dysfunction with negative middle ear pressure Ear fullness, popping, mild discomfort, mild hearing loss Retracted tympanic membrane (TM), prominent landmarks, amber color
Stage 2: Hydrops Sterile effusion in middle ear Increased pressure sensation, increased hearing loss Retracted TM, fluid level or bubbles visible, decreased mobility
Stage 3: Suppuration Bacterial infection of middle ear fluid Ear pain, fever, irritability, hearing loss, possible systemic symptoms Bulging, erythematous TM, obscured landmarks, decreased mobility
Stage 4: Resolution or Complications Spontaneous resolution or progression to complications Pain reduction or worsening with complications TM perforation with discharge or progression of inflammatory signs

Mnemonic: “ASOM” for ASOM Assessment

  • A – Appearance of tympanic membrane (color, position, landmarks)
  • S – Symptoms (pain, fever, hearing loss, irritability)
  • O – Otorrhea (presence and characteristics if present)
  • M – Mobility of tympanic membrane (using pneumatic otoscopy)

Management

Primary Care (per standing orders)
  • Pain Management:
    • Acetaminophen or ibuprofen for pain and fever
    • Topical analgesics (if TM intact)
  • Antibiotics:
    • First-line: Amoxicillin (80-90 mg/kg/day in divided doses)
    • Alternative: Amoxicillin-clavulanate for treatment failure or high-risk
  • Supportive Care:
    • Adequate hydration
    • Elevated head position
Referral Criteria
  • Age less than 3 months
  • Severe symptoms or toxic appearance
  • Immunocompromised status
  • Complications suspected:
    • Mastoiditis (swelling/tenderness behind ear)
    • Facial nerve paralysis
    • Meningeal signs
    • Labyrinthitis (vertigo, nystagmus)
  • Recurrent ASOM (3+ episodes in 6 months)
  • Persistent effusion > 3 months

Watchful Waiting vs. Immediate Antibiotics

Current guidelines allow for observation without antibiotics in select cases:

Age Group Severity Recommendation
6 months to 2 years Unilateral, mild-moderate symptoms Observation option if reliable follow-up
6 months to 2 years Bilateral or severe symptoms Immediate antibiotics
≥ 2 years Mild to moderate symptoms Observation option with adequate follow-up
≥ 2 years Severe symptoms Immediate antibiotics

Follow-up for ASOM

During community screening programs, establish follow-up protocols:

  • For observation approach: Follow-up in 48-72 hours
  • For antibiotic treatment: Follow-up if no improvement in 48-72 hours
  • Routine follow-up in 4-6 weeks to ensure resolution of effusion
  • Hearing assessment for children with persistent effusion

Prevention Strategies

  • Pneumococcal vaccination
  • Annual influenza vaccination
  • Breastfeeding for at least 6 months
  • Avoiding bottle-feeding in supine position
  • Eliminating passive smoke exposure
  • Proper hand hygiene to reduce URI transmission

Sore Throat

Sore throat (pharyngitis) is a common complaint encountered during community screening activities. Accurate assessment and differentiation between viral and bacterial causes are essential for appropriate management.

Etiology

Viral (70-85%)
  • Rhinovirus
  • Coronavirus
  • Adenovirus
  • Epstein-Barr virus (mononucleosis)
  • Influenza virus
  • Parainfluenza virus
Bacterial (15-30%)
  • Group A Streptococcus (most common)
  • Group C and G Streptococcus
  • Neisseria gonorrhoeae
  • Mycoplasma pneumoniae
  • Chlamydia pneumoniae
  • Corynebacterium diphtheriae (rare)
Non-Infectious
  • Allergic rhinitis with post-nasal drip
  • Gastroesophageal reflux disease
  • Environmental irritants
  • Trauma
  • Excessive voice use
  • Dry air

Clinical Assessment

Feature Viral Pharyngitis Streptococcal Pharyngitis
Onset Gradual Sudden
Age Group Any age Primarily 5-15 years
Season Year-round, peaks in winter Winter and early spring
Throat Appearance Mild to moderate erythema, patchy exudates possible Intense erythema, tonsillar exudates, petechiae on palate
Lymph Nodes Variable, usually minimal enlargement Tender anterior cervical lymphadenopathy
Temperature Low-grade fever or none Fever >38°C (100.4°F)
Cough Common Uncommon
Rhinorrhea Common Uncommon
Headache Variable Common
Abdominal Pain Uncommon Common in children
Rash Variable (depends on virus) Scarlatiniform rash (scarlet fever) in some cases

Diagnostic Tools for Community Screening

Clinical Decision Rules: Centor/McIsaac Criteria

One point each for:

  • Tonsillar exudates
  • Tender anterior cervical lymphadenopathy
  • Absence of cough
  • History of fever (>38°C/100.4°F)
  • Age 3-14 years (+1 point) or Age 15-44 years (0 points) or Age ≥45 years (-1 point)

Score Interpretation:

  • 0-1: No testing or antibiotics
  • 2-3: Test and treat if positive
  • 4-5: Consider empiric treatment or test and treat
Rapid Strep Test (RST)

Procedure:

  1. Visualize posterior pharynx with adequate light
  2. Swab both tonsillar pillars and posterior pharynx
  3. Avoid touching tongue, uvula, or buccal mucosa
  4. Process according to test kit instructions

Interpretation:

  • Sensitivity: 70-90%
  • Specificity: 95-100%
  • Positive result: Treat with antibiotics
  • Negative result: Consider throat culture in high-risk patients

Management

Viral Pharyngitis
  • Symptomatic Treatment:
    • Adequate hydration
    • Acetaminophen or ibuprofen for pain and fever
    • Warm salt water gargles
    • Throat lozenges (for ages >4 years)
    • Cool mist humidifier
  • Education:
    • Expected course (5-7 days)
    • No antibiotics needed
    • Return if worsening symptoms
Streptococcal Pharyngitis (per standing orders)
  • Antibiotic Options:
    • First-line: Penicillin V (children: 250mg BID-TID; adults: 500mg BID) for 10 days
    • Alternative: Amoxicillin (50mg/kg/day, max 1000mg) once daily for 10 days
    • Penicillin-allergic: Cephalexin (non-anaphylactic) or clindamycin/macrolide (anaphylactic)
  • Symptomatic treatment as for viral pharyngitis
  • Follow-up:
    • If symptoms persist >48 hours after antibiotics
    • For recurrent streptococcal infections

Warning Signs Requiring Immediate Referral:

  • Difficulty breathing or swallowing
  • Drooling or inability to handle secretions
  • Stridor or voice changes
  • Severe throat pain with minimal visible inflammation
  • Unilateral peritonsillar swelling (possible abscess)
  • Trismus (difficulty opening mouth)
  • Toxic appearance
  • Immunocompromised status

Prevention in Community Settings

  • Hand hygiene education
  • Respiratory etiquette (covering coughs and sneezes)
  • Avoiding sharing of utensils and drinks
  • Proper disposal of tissues
  • Staying home when ill with fever and sore throat
  • Completing full course of antibiotics if prescribed

Deafness

Hearing loss or deafness is a significant health concern that affects individuals across the lifespan. Community screening for hearing impairment is essential for early identification and intervention, especially in vulnerable populations.

Classification of Hearing Loss

Type Mechanism Common Causes Characteristics Screening Identification
Conductive Hearing Loss Disruption in transmission of sound through outer or middle ear
  • Cerumen impaction
  • Otitis media with effusion
  • Otosclerosis
  • Foreign body
  • Perforated tympanic membrane
  • Voice sounds muffled but clear
  • Better hearing in noisy environments
  • Often reversible
  • Weber test lateralizes to affected ear
  • Rinne test: BC > AC on affected side
  • Abnormal otoscopic findings
Sensorineural Hearing Loss Damage to inner ear (cochlea) or auditory nerve pathways
  • Age-related (presbycusis)
  • Noise exposure
  • Ototoxic medications
  • Genetic factors
  • Viral infections
  • Ménière’s disease
  • Difficulty understanding speech
  • Worse hearing in noisy environments
  • Usually permanent
  • May have tinnitus
  • Weber test lateralizes to unaffected ear
  • Rinne test: AC > BC bilaterally
  • Normal otoscopic examination
Mixed Hearing Loss Combination of conductive and sensorineural components
  • Chronic otitis media with cochlear damage
  • Head trauma
  • Otosclerosis with cochlear involvement
  • Features of both types
  • Varying degrees of reversibility
  • Complex pattern on tuning fork tests
  • Requires comprehensive audiological evaluation

Degrees of Hearing Loss

Degree Hearing Level (dB HL) Functional Impact
Normal -10 to 15 dB No significant difficulty
Slight 16 to 25 dB Difficulty with faint speech, subtle communication issues
Mild 26 to 40 dB Difficulty with soft speech, especially in noise
Moderate 41 to 55 dB Difficulty with conversation speech; benefits from hearing aids
Moderately Severe 56 to 70 dB Misses most conversational speech without amplification
Severe 71 to 90 dB Cannot hear conversational speech; requires powerful amplification
Profound 91+ dB Cannot rely on hearing as primary modality; may use sign language

Community Screening Approaches

Infants and Young Children
  • Newborn Screening: Otoacoustic emissions (OAE) or Automated Auditory Brainstem Response (AABR)
  • Risk Assessment: History of risk factors
  • Developmental Milestones: Speech and language monitoring
  • Symptom Surveillance: Parent/caregiver concerns
  • Visual Reinforcement Audiometry: For children 6 months to 2 years
School-Age Children
  • Pure Tone Audiometry: At 1000, 2000, and 4000 Hz
  • Tympanometry: To assess middle ear function
  • Otoscopic Examination: For structural abnormalities
  • Academic Performance: Assessment for potential relation to hearing
  • High-Risk Screening: Children with recurrent ear infections, learning difficulties, or speech delays
Adults and Elderly
  • Whispered Voice Test: Simple screening in primary care
  • Questionnaires: Hearing Handicap Inventory for Adults/Elderly
  • Pure Tone Audiometry: For quantitative assessment
  • Risk Factor Assessment: Occupational noise, family history, medications
  • Targeted Screening: For those with diabetes, cardiovascular disease, or cognitive concerns

Basic Hearing Assessment Techniques for Community Screening

Whispered Voice Test
  1. Stand arm’s length (0.6 m) behind the patient, out of view
  2. Mask the non-test ear by gently occluding the canal and rubbing the tragus
  3. Exhale fully before whispering to ensure consistent soft volume
  4. Whisper a combination of numbers and letters (e.g., “4-K-2”)
  5. Ask patient to repeat what they heard
  6. Test is passed if patient correctly repeats at least 50% of items
  7. Repeat with other ear
Tuning Fork Tests

Weber Test:

  1. Strike tuning fork (512 Hz) gently and place on midline of forehead
  2. Ask patient where sound is heard (midline, left, or right)
  3. Normal: Sound heard equally in both ears
  4. Conductive loss: Sound lateralizes to affected ear
  5. Sensorineural loss: Sound lateralizes to unaffected ear

Rinne Test:

  1. Strike tuning fork and place on mastoid process (bone conduction)
  2. When patient no longer hears, move to in front of ear canal (air conduction)
  3. Ask if patient can still hear the sound
  4. Normal or sensorineural loss: Air conduction > bone conduction
  5. Conductive loss: Bone conduction > air conduction

Management and Referral

Condition Primary Care Management Referral Criteria
Cerumen Impaction
  • Cerumenolytic drops
  • Gentle irrigation (if no contraindications)
  • Manual removal with curette (by trained personnel)
  • Failed attempts at removal
  • Tympanic membrane perforation
  • Ear canal abnormalities
  • History of ear surgery
Otitis Media with Effusion
  • Observation for 3 months if no risk factors
  • Monitor hearing and language development
  • Autoinflation techniques (age-appropriate)
  • Persistent beyond 3 months
  • Significant hearing loss
  • Speech/language delays
  • Structural abnormalities
Sensorineural Hearing Loss
  • Education about hearing protection
  • Communication strategies
  • Environmental modifications
  • All cases for audiological evaluation
  • Sudden onset (urgent referral)
  • Progressive hearing loss
  • Unilateral hearing loss
  • Associated symptoms (vertigo, tinnitus)
Age-Related Hearing Loss
  • Education about hearing aids and assistive devices
  • Communication strategies
  • Addressing social isolation
  • For audiological assessment
  • For hearing aid evaluation
  • If affecting quality of life
  • If associated with cognitive decline

Mnemonic: “HEARING” for Community Screening

  • H – History of risk factors and symptoms
  • E – Examine ear structures with otoscope
  • A – Assess hearing with appropriate screening tools
  • R – Recognize early signs of hearing loss
  • I – Intervene with primary care measures when appropriate
  • N – Navigate patient to appropriate specialists when needed
  • G – Guide patients on communication strategies and prevention

Prevention and Education

During community screening activities, provide education on:

  • Noise protection in occupational and recreational settings
  • Signs and symptoms requiring medical attention
  • Avoidance of inserting objects into ears
  • Appropriate use and care of hearing aids
  • Communication strategies for those with hearing loss
  • Available community resources for hearing-impaired individuals
  • Importance of regular hearing screening across the lifespan

First Aid and Emergency Management

Community health nurses must be prepared to provide first aid for eye and ENT emergencies during community screening activities or in other community settings. Prompt and appropriate first aid can prevent complications and preserve function.

Eye Emergencies

Condition First Aid Measures Do Not Follow-up Requirements
Chemical Exposure
  1. Immediately flush eye with clean water or saline for 15-20 minutes
  2. Hold eyelids open during irrigation
  3. Direct stream from inner to outer corner
  4. Continue irrigation during transport
  • Do not delay irrigation to identify chemical
  • Do not use neutralizing agents
  • Do not apply ointments or drops
 All chemical exposures require immediate medical evaluation after first aid
Foreign Body
  1. Wash hands before examination
  2. Examine under good light
  3. For visible, superficial objects: irrigate with clean water or saline
  4. If easily accessible on conjunctiva, may remove with moistened cotton-tipped applicator
  • Do not rub the eye
  • Do not attempt to remove embedded objects
  • Do not use tweezers or sharp instruments
  • Refer if foreign body not easily removed
  • Refer if embedded, metallic, or central corneal location
  • Refer if pain persists after removal
Eye Trauma/Contusion
  1. Apply cold compress without pressure
  2. Keep patient upright, limit eye movement
  3. Shield eye without applying pressure
  4. Avoid analgesics with bleeding risk (e.g., aspirin, NSAIDs)
  • Do not apply pressure to injured eye
  • Do not remove objects that have penetrated eye
  • Do not wash eye if rupture suspected
 All significant eye trauma requires immediate referral
Penetrating Injury
  1. Do not remove embedded object
  2. Shield eye with paper cup or eye shield without pressure
  3. Cover both eyes to prevent movement
  4. Keep patient calm and upright
  5. Arrange immediate transport
  • Do not remove penetrating objects
  • Do not irrigate or apply drops/ointments
  • Do not allow eye movement
  • Do not apply pressure
 Requires immediate emergency referral
Acute Visual Loss
  1. Take brief history of onset and symptoms
  2. Check vital signs
  3. Check pupils and basic eye movements
  4. Cover eye for comfort if photophobic
  5. Arrange immediate transport
  • Do not delay referral for extended testing
  • Do not provide false reassurance
  • Do not administer medications without protocol
 Requires immediate emergency referral

ENT Emergencies

Condition First Aid Measures Do Not Follow-up Requirements
Epistaxis (Nosebleed)
  1. Have patient sit upright and lean slightly forward
  2. Apply firm pressure to the soft part of the nose for 10-15 minutes continuously
  3. Apply cold compress to bridge of nose
  4. If bleeding continues, reapply pressure for another 10-15 minutes
  • Do not have patient lie flat or tilt head back
  • Do not release pressure repeatedly to check bleeding
  • Do not pack nose without proper training
  • Do not allow nose blowing or strenuous activity
  • Refer if bleeding persists beyond 30 minutes
  • Refer if bleeding is profuse or patient is on anticoagulants
  • Refer for posterior bleeds or signs of significant blood loss
Foreign Body in Ear
  1. If object is visible and graspable, remove gently with tweezers
  2. For insects, instill room-temperature mineral oil, baby oil, or water to immobilize and float out
  3. Do not attempt removal if not easily accessible
  • Do not probe deeply into ear canal
  • Do not use water for removal if object can absorb water
  • Do not use suction without training
  • Do not attempt removal if patient is uncooperative
  • Refer if object cannot be easily removed
  • Refer if pain, bleeding, or hearing loss occur
  • Refer if tympanic membrane not visible
Foreign Body in Nose
  1. Have patient breathe through mouth
  2. If object visible, may have patient blow nose gently while occluding unaffected nostril
  3. If easily visible and retrievable, may remove with tweezers
  • Do not probe deeply into nostril
  • Do not use suction without training
  • Do not push object further into nose
  • Do not induce sneezing
  • Refer if object cannot be easily removed
  • Refer if pain, bleeding, or breathing difficulty occur
  • Refer if object has been present for extended time
Sudden Hearing Loss
  1. Take brief history of onset and associated symptoms
  2. Examine ear with otoscope if available
  3. Document symptoms and timing
  4. Arrange prompt referral
  • Do not delay referral for extended testing
  • Do not irrigate ear
  • Do not insert drops without medical direction
  • Do not dismiss as minor if sudden onset
  • True sudden sensorineural hearing loss is a medical emergency
  • Ideally referred within 24-48 hours
Severe Throat Pain/Difficulty Swallowing
  1. Assess for airway compromise
  2. Position upright
  3. Assess vital signs and oxygen saturation if available
  4. Examine throat if patient can cooperate
  5. Cool liquids if tolerated
  • Do not force examination if patient unable to open mouth
  • Do not force oral intake
  • Do not delay referral if breathing difficulty
  • Do not administer aspirin to children
  • Immediate referral for: drooling, stridor, respiratory distress, trismus, voice changes, inability to swallow secretions
  • Urgent referral for severe pain, asymmetric swelling, hot potato voice

Important First Aid Supplies for Eye and ENT Emergencies

Community health nurses conducting community screening should have access to:

  • Sterile saline solution or eye wash
  • Eye shields or paper cups
  • Gauze pads and medical tape
  • Penlight and magnifying glass
  • Otoscope with various specula sizes
  • Blunt-tipped tweezers
  • Cotton-tipped applicators
  • Ice packs or cold compresses
  • Tuning forks (512 Hz)
  • Basic analgesics (acetaminophen)
  • Epinephrine auto-injector for allergic reactions
  • Referral forms and emergency contact information

Primary Care and Referral Guidelines

A critical component of community screening programs for eye and ENT conditions is establishing clear guidelines for primary care management versus referral to specialized services. Community health nurses must be able to make appropriate decisions based on assessment findings.

General Principles for Referral Decision-Making

Urgency Assessment

  • Emergency: Immediate threat to vision, hearing, or life
  • Urgent: Needs specialist care within 24-48 hours
  • Semi-urgent: Needs specialist care within 1-2 weeks
  • Routine: Can be scheduled at next available appointment

Standing Order Considerations

  • Is condition covered in standing orders?
  • Do assessment findings match criteria for primary care management?
  • Are there any exclusions or special considerations?
  • Is patient in a high-risk category?
  • Is follow-up assured?
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