ENT procedures are focused examination, sampling and treatment actions involving the ear, nose, throat and related structures. Safe practice depends on choosing the right instrument for the site, seeing what you are doing, explaining the procedure, preventing infection and knowing when to stop or refer. This guide follows the DCM 2203 ENT Care topic on basic instrumentation, diagnostic swabs, nasal patency and allergy testing, ear irrigation, aural toilet and foreign-body removal.
1. Principles before any ENT procedure
A procedure should answer a clinical question or achieve a clear treatment goal. Before opening an instrument pack, confirm the patient, the reason for the procedure, the exact site and side, relevant allergies, previous ENT surgery or complications, and any factor that may change the risk. Explain what will happen in language the patient understands, discuss likely discomfort and alternatives, invite questions, and obtain consent. For children or patients who cannot consent independently, follow local consent and safeguarding policy and involve an appropriate caregiver while still explaining the procedure to the patient.
- Prepare the environment. Ensure good lighting, a clean surface, the correct instrument size and a safe position. Have the specimen container, waste bin, suction or emergency support that the procedure requires within reach before beginning.
- Use infection-prevention precautions. Perform hand hygiene, select gloves and other personal protective equipment according to anticipated exposure and local IPC guidance, and use sterile single-use items or properly reprocessed equipment as required. Keep clean and contaminated items separate.
- Work under direct vision. Do not insert instruments deeply or blindly into the ear, nose or throat. Use an appropriate light and view. Do not force an examination or continue when the patient moves unpredictably, becomes distressed, or reports significant pain.
- Pause when the view or diagnosis is uncertain. A limited view is a reason to stop, reassess, seek help or refer. Repeated attempts can push an object deeper, injure delicate tissue, cause bleeding, or turn a manageable situation into an emergency.
- Finish the loop. Check the patient after the procedure, label specimens at the bedside, document what was done and what was found, communicate results that need follow-up, and give clear return precautions.
Always verify cleaning, disinfection or sterilisation requirements against the facility policy and the instrument manufacturer. Do not reuse a device labelled single-use. Reprocessing must be appropriate to the device and its intended use; simply wiping an instrument is not equivalent to validated reprocessing.
2. Basic instruments in ENT
Basic ENT equipment improves visibility and allows a specific task to be performed with control. The instrument should match the body site and the patient’s age and anatomy. A tool being available does not mean that every operator is trained to use it.
| Instrument or equipment | Main use | Practical safety point |
|---|---|---|
| Otoscope with ear specula | Illuminates and magnifies the external auditory canal and tympanic membrane. | Choose a speculum that fits without force, use a clean disposable or correctly reprocessed speculum, and stabilise the hand holding the otoscope. Avoid advancing if the canal is painful or the view is inadequate. |
| Headlight or examination lamp | Provides hands-free illumination for the nose, mouth and throat, and for instrument work. | Direct the beam to the target without shining into the patient’s eyes. Check the light before starting. |
| Nasal speculum | Gently separates the nostril to assist anterior rhinoscopy. | Insert only into the nasal vestibule and open gently under direct vision. The nasal mucosa bleeds easily; avoid levering against the septum or using force. |
| Tongue depressor | Helps inspect the oral cavity, tonsils and visible oropharynx. | Use a clean single-use depressor when indicated. Do not press on the tongue in a patient with airway distress, severe trismus or poor cooperation. |
| Tilley or dressing forceps | Handles small dressings or accessible material in selected ENT procedures. | Use only where the target can be seen. The forceps can traumatise mucosa or push material deeper if used blindly. |
| Jobson–Horne probe or cerumen curette | May assist a trained clinician with selected ear-canal debris or wax under magnified/direct view. | Not a home tool. Never pass beyond what can be seen or direct it toward the tympanic membrane. Stop if the patient moves, pain occurs or the view is lost. |
| Suction with an appropriate tip | Removes fluid or debris under direct visualisation; selected ENT clinicians use fine suction for aural toilet. | Use the correct tip and suction setting, maintain visibility, and avoid injuring canal skin or mucosa. It requires training and appropriate equipment. |
| Sterile swab and transport system | Collects a specimen from the specific site requested by the clinician or laboratory. | Check the correct swab and medium for the requested test. Do not touch the collection tip or contaminate it on surrounding surfaces. |
| Irrigation device and receiver | Selected trained providers use controlled irrigation to remove suitable cerumen. | Screen carefully first; use fluid close to body temperature, low controlled flow and direct visualisation. Irrigation is not a general method for extracting foreign bodies. |
| Tuning fork and basic diagnostic aids | A tuning fork can support bedside hearing assessment; a nasal flow meter can quantify inspiratory airflow where available. | These aids answer limited questions. Interpret them alongside history and examination; do not treat a screening result as a complete diagnosis. |
3. Taking and handling ENT swabs
A swab is useful when microbiology or another laboratory result is likely to guide care. A poorly selected or contaminated sample can mislead: it may grow normal surface flora, miss the relevant organism, or be rejected by the laboratory. Use the laboratory’s current test directory and collection instructions because swabs, transport media, storage and accepted sites vary between tests.
When should a swab be considered?
- A throat swab may be indicated when a locally approved clinical pathway recommends microbiological testing and the result will affect management.
- An ear-discharge swab may be helpful in selected severe, recurrent, atypical or treatment-resistant infection, or when the clinician needs a culture to guide treatment. Routine swabbing of every uncomplicated case is not automatically helpful.
- Nasal or sinus sampling should answer a specific question. An anterior nasal swab does not necessarily represent what is occurring within a sinus; specialist-directed sampling may be required in selected complicated or refractory cases.
- Use fungal, mycobacterial or other specialised studies only when the history and examination make them plausible, and alert the laboratory so the correct collection and processing pathway is used.
General collection sequence
- Check the request. Confirm the suspected condition, exact anatomical site, test required, correct swab or container, and laboratory instructions. If the requested test and sample do not match, clarify before collecting.
- Identify and explain. Use the facility’s required patient identifiers; explain the collection and obtain cooperation or consent. Position the patient safely and use PPE based on exposure risk and facility IPC policy.
- Collect from the target. Use a sterile swab and sample the relevant lesion or surface without touching unrelated areas. For respiratory pathogens, follow the manufacturer and laboratory instructions for that specific assay.
- Protect the sample. Place the swab in the specified transport medium or container, secure it, and label it at the bedside with patient identifiers, site, date and time. Include relevant clinical details and prior antimicrobial treatment on the request.
- Transport and document. Send the specimen promptly using the facility’s transport rules. Record the site, test, collection time, patient tolerance and any difficulty or contamination.
Throat swab: the sampling target matters
When an oropharyngeal swab is indicated, the intended area is the tonsillar pillars and posterior oropharynx. The collector should avoid touching the tongue, teeth and gums because this can contaminate the sample. A trained collector should follow the exact test instructions; for a patient who gags, cannot cooperate, or has airway warning signs, do not force the procedure.
Ear swab: sample what is actually infected
Collect visible canal discharge only when the clinical indication supports it and the correct sampling method is known. Do not push a swab blindly into the canal or toward the eardrum. State whether the material came from the external canal and note any visible perforation, ventilation tube or other relevant finding. A swab from the canal is not automatically a specimen from the middle ear.
Common sampling errors
Wrong site
A sample from an easy-to-reach surface may not represent the clinical focus. Confirm the site and test before collection.
Contamination
Touching the swab tip on the tongue, teeth, fingers, bed linen or container exterior can alter the result.
Wrong container or delay
Incorrect transport medium, missing identifiers, a leaking pot or avoidable transport delay may invalidate a specimen.
Unhelpful testing
A positive result must fit the clinical picture. Colonisation or surface flora can be mistaken for the cause of symptoms.
4. Nasal patency tests
Nasal patency means how freely air passes through each nasal passage. Ask about the patient’s sense of blockage and compare sides, then examine the nose. Patency varies with posture, the normal nasal cycle, congestion, recent medication and the environment, so a simple bedside test is a screening observation rather than a definitive diagnosis.
Simple bedside comparison
- Explain the test and have the patient sit comfortably and breathe normally.
- Ask the patient to close one nostril gently while breathing in through the other, then compare the opposite side. The patient can describe which side feels more open; the clinician may also observe airflow at the nostril.
- Record whether airflow seems equal, reduced on one side or difficult on both sides, and relate this to symptoms and anterior nasal examination.
Do not interpret a single subjective comparison as proof of a structural obstruction, allergy or sinus disease. A recent cold, secretions, nasal cycle, poor effort or anxiety can change the result. Do not repeatedly provoke symptoms or manipulate a recently injured or bleeding nose; escalate if trauma, severe pain or other red flags are present.
Objective tests and specialist assessment
| Method | What it contributes | Important limit |
|---|---|---|
| Peak nasal inspiratory flow (PNIF) | A nasal inspiratory flow meter gives a simple, repeatable airflow measure where available. | Effort, technique, congestion and patient ability affect the result; it does not show the cause of obstruction. |
| Rhinomanometry | Measures airflow and pressure to estimate nasal airway resistance. | Requires equipment and a consistent method; it is not a routine bedside test in every clinic. |
| Acoustic rhinometry | Uses reflected sound to estimate dimensions of the nasal cavity. | Measures anatomical dimensions rather than directly explaining symptoms; specialist interpretation is needed. |
| Anterior rhinoscopy or nasal endoscopy | Directly examines visible nasal structures; endoscopy may extend the view when routine examination is insufficient. | Use appropriate training, consent, light and equipment. A limited view should be documented; concerning unilateral obstruction, recurrent bleeding or a mass needs clinical review. |
Objective measurement may be useful for selected patients or specialist assessment, but the test should answer a defined question. A patient with new unilateral obstruction, recurrent unilateral epistaxis, suspected foreign body, a visible mass, trauma or severe infection needs examination and an appropriate referral pathway rather than reassurance from a simple airflow comparison alone.
5. Allergen testing in ENT practice
Allergy testing is most useful when the history suggests allergic rhinitis and identifying a relevant allergen could change advice or management. Ask about the timing and pattern of sneezing, nasal or eye itching, watery rhinorrhoea, congestion, likely exposures, seasonality, home or occupational triggers, asthma symptoms, medicines and impact on sleep or study. Also consider non-allergic rhinitis, infection, medication-related symptoms, structural obstruction and other diagnoses.
Testing options include a skin-prick test and a blood test for allergen-specific IgE. Selection depends on the clinical question, availability, patient factors and specialist or local pathway. Skin-prick testing should be performed and interpreted by trained staff using appropriate positive and negative controls, standardised extracts where available, and a setting prepared to recognise and manage a significant allergic reaction. Follow local instructions about medicines that can interfere with testing; do not apply a blanket antihistamine-withholding rule without checking the relevant protocol and the patient’s safety.
| Test | What it can show | How to interpret it |
|---|---|---|
| Skin-prick test | Immediate skin response to selected allergen extracts under controlled clinical conditions. | A positive result shows sensitisation, not automatically symptomatic allergy. Relate the allergen to the patient’s exposure and symptom history. |
| Serum allergen-specific IgE | Detects IgE directed against selected allergens from a blood sample. | Interpret with the assay, threshold, symptoms and exposure. A detectable result by itself does not establish that the allergen causes the patient’s symptoms. |
| Total IgE | May be considered in selected contexts as a general laboratory measure. | Total IgE alone does not identify the cause of rhinitis and should not be used as a stand-alone allergy diagnosis. |
6. Ear syringing and ear irrigation
Ear syringing, commonly performed with a controlled electronic irrigator in settings that offer the service, is a method for removing suitable earwax. It is not an appropriate default for every blocked ear and it is not a method for removing foreign bodies. Before recommending irrigation, confirm that wax is the likely problem, assess the ear and ask specifically about perforation, grommets, previous surgery, discharge, infection and complications from earlier procedures.
Screen before irrigation
Do not proceed with irrigation when the tympanic membrane is known or suspected to be perforated, a ventilation tube is present, there is a history of relevant ear surgery, active discharge or infection, canal injury, significant canal abnormality, or previous serious complications from irrigation. Do not irrigate a foreign body, particularly a seed or other organic object that may swell. If the ear cannot be assessed adequately, or the patient cannot cooperate safely, stop and seek advice or refer.
People with diabetes, immunocompromise, recurrent ear disease, a single serviceable hearing ear, a very narrow canal, significant pain, or uncertainty about the tympanic membrane may need an alternative technique or a more experienced clinician. Follow local Uganda and facility protocols for eligibility. A history that raises doubt is a reason to choose a safer assessment pathway, not to test the ear by irrigating it.
Safe outline for a trained provider
- Confirm indication and consent. Explain that the aim is to clear suitable wax and that the procedure may need to stop or be changed if the ear is not safe to irrigate.
- Inspect first. Perform otoscopy, note the canal and tympanic membrane findings, and check the patient’s relevant ear history. If the membrane is not visible and history raises a concern, do not assume it is intact.
- Prepare correctly. Use a controlled irrigation system approved by the facility. The irrigating fluid should be close to body temperature; fluid that is too cold or too warm can provoke caloric dizziness. Position the patient and receiver so the return flow can be observed.
- Irrigate gently under visual control. Direct low-pressure flow along the canal wall rather than straight at the tympanic membrane. Do not force the nozzle into the ear canal. Follow the device and facility procedure; students should practise only under direct supervision.
- Stop promptly if symptoms occur. Stop for pain, marked discomfort, vertigo, nausea, bleeding, sudden hearing change, distress or poor return flow. Reassess rather than repeating forceful attempts.
- Re-examine after the procedure. Check the canal and tympanic membrane, document what is visible, and arrange follow-up or an alternative removal method if wax remains or the ear is not normal.
Where irrigation is not suitable or unsuccessful, a trained clinician may consider another method such as microsuction or careful manual removal, according to skill, equipment and local referral pathways. Patients should not put cotton buds, sharp objects or improvised syringes into the ear. Avoid presenting clinic irrigation as a self-care procedure.
7. Aural toilet
Aural toilet is the careful clearing of discharge, debris or wax from the external auditory canal so the clinician can examine the ear or allow prescribed topical treatment to reach the canal skin. Depending on the setting and the material, a trained practitioner may use dry mopping, suction or another method under direct visualisation. The purpose is to clear what is safely accessible; it is not blind probing or forceful cleaning.
Core steps and limits
- Explain the purpose, obtain consent and assess pain, discharge, canal swelling, previous ear surgery, perforation or tubes.
- Position the patient so the ear and clinician’s hand are stable; use an otoscope, microscope or other suitable magnification and light.
- Use the method for which the practitioner is trained. Remove accessible debris in small controlled steps and keep the instrument tip visible.
- Stop if pain, bleeding, loss of view, unexpected anatomy or patient movement makes the next step unsafe. Do not dig deeply or use irrigation when perforation, active infection or another contraindication is suspected.
- Reassess the canal and tympanic membrane as far as possible, then document the degree of clearance and any remaining limitation.
Aural toilet can support assessment and topical treatment in selected cases of otitis externa when debris or discharge blocks the canal. It does not replace the rest of the assessment or the prescribed treatment plan. Swab only when the clinical indication supports it. Severe pain, canal granulation, persistent discharge, suspected middle-ear disease, a mass, diabetes or immunocompromise, or failure to improve should prompt senior review or ENT referral according to local pathways. Cotton buds may irritate the canal and push material inward, so they should not be used for deep cleaning.
8. Foreign-body removal in the ear, nose and throat
Foreign-body removal is safest when the clinician identifies the object, its location and the risk before choosing a method. First assess airway, breathing, distress, bleeding, pain and cooperation. Ask when and how the object entered, what it is made of, whether an attempt has already been made, and whether any part may be missing. Do not delay emergency care to obtain a detailed history from a patient who is struggling to breathe or swallow.
| Risk feature | Why it matters | Immediate approach |
|---|---|---|
| Button battery or paired magnets in nose/ear | Can cause rapid local tissue injury or pressure damage. | Urgent emergency/senior ENT pathway. Do not irrigate or wait for spontaneous passage. |
| Possible airway foreign body | Stridor, choking, cyanosis or respiratory distress can progress rapidly. | Emergency airway response and urgent senior help. Do not perform blind finger sweeps. |
| Sharp, deeply impacted or poorly visualised object | Repeated attempts can cause bleeding, perforation or displacement into a less accessible site. | Stop and arrange experienced clinician or ENT assessment. |
| Seed, bean or other organic object in the ear | It may absorb fluid and enlarge, making removal more difficult. | Avoid irrigation; obtain prompt clinical advice for a suitable visualised removal plan. |
| Uncooperative child or prior failed attempt | Movement and swelling/trauma increase the risk of harm. | Do not persist with repeated attempts. Seek senior help and an age-appropriate specialist pathway. |
Ear foreign body
Inspect the canal and object with good light and magnification. Note whether it is mobile or impacted, whether it is against the tympanic membrane, and whether there is bleeding, discharge or a pre-existing canal problem. The selected method depends on the object’s shape and position and the operator’s competence. A visible object that can be safely grasped or approached under direct vision may be suitable for removal by a trained clinician. Do not push it deeper, use an unvisualised instrument, irrigate a battery or organic material, or keep trying after a failed attempt. A button battery, object touching the eardrum, significant pain, bleeding, perforation or failed attempt warrants urgent experienced assessment.
Nasal foreign body
Suspect a nasal foreign body in a child with sudden unilateral blockage, foul-smelling or blood-stained discharge, or a witnessed insertion. Assess distress and airway; examine gently with appropriate light. A button battery or paired magnets require urgent emergency management. Do not probe blindly or use irrigation. If the object is deep, not clearly seen, associated with bleeding or injury, or the child cannot cooperate, stop and arrange experienced care. After removal, the clinician should confirm the nasal passage is clear and give return advice if symptoms persist.
Throat or airway foreign body
Inability to swallow saliva, drooling, choking, stridor, respiratory distress, a sharp object, or suspected airway obstruction is an emergency. Call for senior or emergency support and follow the facility’s airway and foreign-body pathway. Do not make blind sweeps with a finger or instrument, and do not delay escalation by repeatedly examining an unstable patient. Stable patients with a suspected lodged object still need appropriate assessment because an object may be below the area visible on routine mouth examination.
9. Documentation and safety checklist
Good documentation makes the procedure understandable to the next clinician and confirms whether further action is needed. Include:
- Indication: symptom, duration, side/site, examination finding and the question the procedure should answer.
- Consent and preparation: explanation, consent, relevant allergies or history, positioning, PPE and equipment used.
- Technique: instrument or sample type, site sampled, irrigation method or removal approach, and whether the target remained visible.
- Findings: appearance before and after, amount cleared or removed, specimen appearance, tympanic membrane status if seen, and any limitation.
- Tolerance and complications: pain, bleeding, dizziness, gagging, distress or other event; record that the procedure was stopped when appropriate.
- Plan: specimen destination, who will review the result and when, treatment or referral, follow-up, and warning signs explained to the patient or caregiver.
10. Worked examples and quick self-check
Case 1: an adult with a blocked ear and previous perforation
The patient has wax-like blockage but reports a past perforated eardrum. Do not irrigate based only on the symptom. Clarify the ear history, inspect what can safely be seen, and arrange assessment by a clinician who can select an appropriate removal method. Document the history and the reason irrigation was not used.
Case 2: a child with sudden one-sided foul nasal discharge
A nasal foreign body is possible. Assess breathing and distress, look only if the child is stable and the object can be visualised, and urgently escalate if a battery or magnets may be involved. Avoid blind instrumentation and repeated attempts. Ensure the nasal cavity is reassessed after any clinician-led removal.
Case 3: a throat swab is requested
Confirm which test the clinician or local guideline requires and obtain the correct swab kit. Use the instructed sampling site and avoid contaminating the swab on the tongue, teeth or gums. Label it with the patient identifiers, exact site, date/time and relevant clinical details, then transport it as the laboratory directs.
Case 4: seasonal sneezing and itchy eyes
Take a focused exposure and symptom history first. If testing will change advice or management, a trained clinician may select skin-prick testing or serum-specific IgE. Explain that a positive test must fit the patient’s real-world symptom pattern; an isolated positive result does not prove clinically important allergy.
Quick self-check
- Why should the throat-swab collector avoid touching the tongue and teeth?
- What should you do if a patient experiences pain or vertigo during ear irrigation?
- Why is nasal airflow comparison not, by itself, a diagnosis?
- Does a positive skin-prick test automatically mean that an allergen causes symptoms?
- Which foreign-body features require urgent escalation?
Suggested answers: Avoiding the tongue and teeth reduces contamination; stop irrigation and reassess rather than continuing through symptoms; a bedside comparison is subjective and can vary with congestion, position and technique; a positive result indicates sensitisation and requires clinical correlation; button batteries or paired magnets, airway symptoms, sharp or deeply impacted objects, poor visualisation, bleeding, failed attempts or an uncooperative patient need urgent experienced assessment.
Summary
- Choose instruments for the site and task, and use them only within your training.
- Collect swabs from the correct target with the correct kit; label and transport them according to the laboratory protocol.
- Assess nasal patency alongside history and examination; objective tests or endoscopy may be needed for selected questions.
- Allergy tests support, but do not replace, a compatible clinical history.
- Ear irrigation is for selected cerumen cases after careful screening. It is not a foreign-body technique.
- Aural toilet is controlled, visualised canal cleaning by a trained provider; it is not blind probing.
- For foreign bodies, prioritise airway and high-risk objects, avoid blind or repeated attempts, and refer early when visibility, cooperation or competence is inadequate.
Further ENT revision
Continue with our related guides on ENT history taking, physical examination in ENT and ENT investigations. Practise procedures through skills-lab demonstration and supervised clinical teaching.
References and further reading
- Ministry of Health, Uganda. Uganda Clinical Guidelines 2023. Use the current national guideline and facility pathway for local clinical decisions.
- Ministry of Health, Uganda. Uganda National Infection Prevention and Control Guidelines, 2nd edition, January 2025.
- U.S. Centers for Disease Control and Prevention. Interim guidelines for collecting and handling clinical specimens for COVID-19 testing. Collection requirements are test-specific; follow the local laboratory and manufacturer instructions.
- NHS. Earwax build-up. Patient-facing information on wax, clinic removal methods and avoiding objects in the ear.
- American Academy of Otolaryngology–Head and Neck Surgery Foundation. Clinical Practice Guideline: Earwax (Cerumen Impaction).
- British Society for Allergy and Clinical Immunology. Guideline for the diagnosis and management of allergic and non-allergic rhinitis.
- American Academy of Otolaryngology–Head and Neck Surgery. Clinical Indicators: Diagnostic Nasal Endoscopy.
- American Academy of Otolaryngology–Head and Neck Surgery. Clinical Indicators: Laryngoscopy/Nasopharyngoscopy.
Class notes: Coming soon.
