Something I think many school nurses struggle with – myself included – is looking in ears. What are we looking at in there and why does it matter when RNs can’t diagnose or prescribe anyway?
Well we can certainly look and assess and determine if the student needs to have further evaluation at the doctor or not but no, we can’t diagnose the ear infection or prescribe antibiotics; nor can we clean out the wax in a school health room setting.
Good otoscopy requires lots of practice to know what you’re looking at. My first piece of advice is to look in every student’s ears that it is convenient to so you can get a good handle on what it might look like in different ages and sizes and different states of health.
Some reasons we might need to check a students ears might include: ear pain, difficulty hearing, failure of audiogram hearing screen, sensation of foreign body, noted drainage or bleeding from ear, or injury to ear.
Equipment needed for examination
- Otoscope: The Welch-Allyn is your best bet for a solid otoscope. You can find many styles of Welch-Allyn to meet your needs. I also have a digital otoscope with a screen that I’m still learning to use so the jury is still out on whether it is a good investment or not. Make sure that whatever scope you get that you have extra batteries and bulbs for it.
- Otoscope speculae: You should have a supply of disposable speculae for your scope in multiple sizes depending on the size of the patient. They are mostly universal but make sure they fit your scope before buying.
- Ear-ease or rice pack for heat therapy: This is a cool little tool that helps put moist heat on an earache. People swear by it. If you don’t have an ear-ease you can just make a rice pack with a baby sock and some rice – sprinkle a little water on it and microwave it to make it warm (not hot!).
- Audiometer: If the student’s issue is hearing loss then you may want to check their hearing as part of the ear exam. Audiometers can be purchased through school nurse supply companies such as schoolhealth.com or schoolnursesupplyinc.com.
Steps to performing an ear exam
- Examine the outside of the ear first. Do you note any drainage, bleeding, redness, lesions, or swelling? Is there a piercing that needs attention? Bug bites, scratches, etc?
- Observe the face around the ear noting if there is any swelling, lesions, redness or drainage to the corresponding eye, jaw, cheek, neck and mastoid area. This can be an indicator of mastoiditis, a progression of inner ear infection.
- For a child you will want to pull the pinna (outside part of the ear) straight back. For an adult or teen you will want to pull the pinna up and back to straighten the ear canal. In children the ear canal curves inward but as a person grows the ear canal begins to curve more upward.
- Insert your otoscope speculum with the light turned on.
- You may have to move around a bit to get a good look at the inside of the ear. Reposition the pinna if needed by moving it up, back and down until you can see in the ear canal.
- Observe the ear canal for excessive wax (some wax will be normal). Do not attempt to remove wax if it is occluding.
- Observe the ear canal for redness, bleeding or discharge, or foreign objects.
- Observe the tympanic membrane (TM) for redness, inflammation, leaking of fluid, bulging, myringotomy tubes, or perforations. Typically the TM should be mostly flat, gray, kind of shiny, and somewhat translucent.
- Document what is observed and call parent with any concerning findings.
Things you may see on exam and what to do about them
- Earwax occlusion: earwax blocking the ear canal. Do not attempt to remove the earwax, removal should be performed by the physician or under a physician’s supervision. If the student has ear pain but you can’t see enough to determine if there is anything wrong you are safest to just call the parent and let them know and they can have the doctor manage it.
- Fluid in ear: this can be difficult to see at times but you might see a few bubbles behind the TM. Sometimes if there is a lot of fluid it can cause the TM to bulge out and you can see the line of fluid behind the TM. Fluid in the ear can be caused by allergies, a cold virus or an ear infection.
- Possible infection aka acute otitis media or AOM: possible/probable ear infection can cause the TM to appear red, inflamed, and possibly have fluid or pus behind it. Since we can not diagnose or treat this we must refer the student to the doctor to be examined and treated.
- Swimmers ear aka otitis externa: Inflammation/infection in the ear canal outside of the TM. Usually it will hurt when you attempt to move the pinna to look in the ear. It will appear red or inflamed to the walls of the ear canal. Ask the student if they have been swimming or submerging their ears in water any time recently or if they have suffered any foreign bodies recently. Again, if noted, this needs to be further evaluated by a physician and treated as they wish.
- Ruptured or perforated eardrum: a hole in the TM usually from a buildup of fluid and pressure. You may see the tear or hole or you may see leakage of fluids. This often is accompanied by intense pain and then sudden relief when the pressure has subsided. This requires a phone call home and a trip to the doctor for further evaluation.
- Abrasions: If the student is sticking anything in their ear and scratching the ear canal they may have abrasions or scratches and some minor bleeding present. Just leave it alone and advise the student to refrain from placing anything in ears going forward. Note any signs of infection related to the wound and call home if needed.
- Myringotomy tubes: Often the tubes will remain in place for a few years but on occasion will migrate out and fall out. You may see intact tubes in the TM or you may see a tube embedded in wax or just sitting there in the ear canal. Just leave it alone and document. Let the parent know that you noted the tube has fallen out so they can have it addressed if needed.
- Foreign body: Kids do the darndest things. You might find anything in the ear from wads of tissue, cotton from q-tips, or bugs to pills, beads, berries and tiny legos. If a foreign body is noted call the parent to have them evaluated at the doctor. Do not attempt to remove the foreign body unless it is close to the outside and easy to grasp and remove.
- Infected piercing: If there is a piercing on the ear that shows signs of infection such as acute pain, redness, swelling, or drainage the student needs to be evaluated by the doctor. Do not remove the piercing but clean gently around it if possible. If there is irritation from an earring get a parent’s permission first to remove the earring and clean the piercing. Do not put the earring back in, place it in a small zip lock bag and send it home.
In the health room
- As I mentioned, as RN’s in an autonomous setting such as a school health clinic, we don’t have the ability to diagnose or treat findings on an ear exam. It is important that we call the parent or guardian with any findings and impress on them that the student should see the doctor for further evaluation. You can report to the parent what your observations are but avoid stating things such as “they have an ear infection” because that would be assigning a diagnosis. Instead try letting them know that the student has ear pain and it appears red and inflamed inside so they need to be evaluated further by the doctor to determine treatment.
- Practice makes perfect. Look in as many ears as you can so you can get an idea of how they should look and what is abnormal.
- Never perform any procedures such as earwax removal, ear lavage, or foreign body removal in the health room. Any procedures to the ears aside from general exam should be performed by the doctor or under a doctor’s supervision, NOT at school.
- Google is your friend! There is nothing wrong with pulling up pictures of eardrums on Google so you can compare what you see with some images of various ailments.
- Educate your students when appropriate. Make sure they know that they should never put anything in their ears including q-tips. Make sure they know not to try and dig out wax themselves. Parents should also avoid using q-tips and removing wax and refer to the doctor if there is a concern.
Tips and tricks
- Ear-ease or moist heat: The ear-ease is a cool little tool that uses warm water over the ear to help relieve some ear pain with moist heat. You can get it from Amazon or some of the school nurse supply companies. Alternatively you can make a heat pack using rice and a baby sock: put the rice in the sock and tie it closed. When you need to use it sprinkle some water on it and warm it up in the microwave for a few seconds. Avoid burns by making sure to knead it well and ensure it is not too hot before using it on a student.
- Not all ear infections require antibiotics. Some are viral or allergic in etiology and can be remedied by using decongestants and supportive care.
- Tylenol or Motrin: Tylenol or Motrin can of course help in a pinch to relieve pain but will not get to the root of the problem.
- Decongestants/cold medicine: Decongestants can help relieve fluid and pressure in the ear caused by colds and allergies. This should be reserved for the parents to give at home unless they have appropriate doctor’s orders to be given at school.
- Chewing gum: chewing motion can help relieve pressure in the ears by helping them “pop”.
- People have been known to use warm (not hot) olive oil in the ear to relieve ear pain. This should be reserved for home and not performed by the school nurse.
- Another home remedy for ear pain is to use a few drops of onion juice in the sore ear. Apparently the quercetins in onions have antiinflammatory properties and can help with minor earaches. Alternatively one could use ginger juice, garlic oil, tea tree oil, or oil of oregano for relief of inflammation. Placing anything in the ear should be done at home by the parent or under the doctor’s supervision, not the school nurse. This should be avoided if the person has a perforation or myringotomy tubes. Note: these remedies are not medically proven and may carry risk.
When is ear pain an emergency?
- When it is accompanied by a penetrating injury ie: stuck a pencil in the ear and poked the eardrum. Call the parent to have evaluated ASAP.
- When is is accompanied by a real head injury. Assess the head injury and call the parent to have evaluated. Call 911 if the injury is severe.
- When they do not have tubes but they have fluid or blood leaking out. This can be an indicator of an acute perforation or a head injury and should be evaluated ASAP.
- When there is a foreign body in the ear.
- When it is accompanied by a fever. Call parent to have evaluated.
- When it is accompanied by acute hearing loss, dizziness/vertigo, or extreme sharp or throbbing pain.
If you have anything to add to ear assessments please feel free to follow and comment! I would love some experts to weigh in.