The ear, nose, and throat have been particularly neglected in primary care, both by community health workers and in health centres. Most of the workers who provide it don't even possess an otoscope, let alone any batteries for one, and very few can even see the ear-drum. So do what you can to improve their standards. Here we are concerned with the patients they refer to you. A third of these may need a foreign body removed. You can also treat otitis media (25.3), and open the mastoid cortex to allow pus to drain, or perhaps do a cortical mastoidectomy (25.4). Unfortunately, a radical mastoidectomy for the many serious complications of acute-on-chronic mastoiditis is an expert's task.

You can treat a patient's bleeding nose (25.6), remove foreign bodies from it (25.5), treat frontal and maxillary sinusitis (25.7), and remove nasal polypi (25.10). About the only surgery you can do on the throat is to remove foreign bodies and drain pus (5.6, 5.7). Don't try to remove tonsils and adenoids; this is seldom justified, unless you are able to give plenty of blood if necessary. If you are skilled, and have a bronchoscope, you may be able to remove foreign bodies from his bronchi (25.13) and oesophagus (25.14).

Here are some of the common mistakes to avoid: (1) Don't use penicillin powder or drops in the ear: they cause sensitivity too easily. (2) Be very careful in using streptomycin or gentamicin parenterally; both are ototoxic, and may cause deafness and giddiness.

This is the equipment you will need:

HEADLIGHT, with forehead band and cords, 6 volt 3 watt bulb, and pin terminals to use with battery, one only. ALSO, 25 spare bulbs. This is less effective than the ENT surgeon's traditional type of head mirror, but is easier to use.

HEAD MIRROR, with webbing or fibre headband, one only.

EXAMINATION LAMP, Chiron, on base with castors, with Bedford Russell extending arm, one only (optional). Ideally, you need this special spotlight with a head mirror, but you can use an ordinary 100 watt light bulb.

ANGLEPOISE LAMP, preferably with internally reflecting bulb giving a parallel beam, one only.

OTOSCOPE, Keeler, new standard halogen type, with rechargeable handle, with: (a) 5 nylon specula, (b) mini-charger, state voltage (normally 240 volts), (c) adaptor for disposable specula, (d) box of disposable (but reusable) 3 mm specula, one outfit only. This is the new Keeler standard otoscope with a rechargeable handle, a charger, and some disposable specula which you can reuse.

TUNING FORK, Hartmann's, with foot, 512 Hz, one only.

PROBE, Jobson Horne, 178 mm, with one serrated and one ring end, one only. Remove wax with the ring end, and wrap cotton wool round the serrated one.

HOOK, wax, St. Bartholomew's pattern, one only. Remove wax and foreign bodies with this.

HOOK, Quire's, one only. This marvellous instrument is sadly neglected, because it is so little known. You can use it in the nose, and sometimes in the ear, where it works better than an ordinary hook, because it does not have to be rotated to be inserted.

SYRINGE, aural, Bacon's, for one-hand use, one only. This has a rubber bulb, a tube, and a valve. It delivers a steadier stream of fluid than a metal syringe, and can be used with one hand. If you don't have an ear syringe, use an ordinary 20 ml syringe with an eccentric nozzle. If you wish, you can fix a small plastic cannula to its tip, and cut it short to prevent it being pushed in too far.

FORCEPS, aural, alligator, Hartmann's, one pair only.

FORCEPS, aural, Wilde, one only. These are standard ear dressing forceps.

FORCEPS, aural, Omerod, elongated cup, crocodile action jaws, one only.

FORCEPS, nasal, dressing, Tilley, one only. You will need long narrow forceps to reach into the ear.

SPECULUM, nasal Thudichum, Mark Hovell modification, size 7, five only Use these for examining the nose. Dangle one on the distal IP joint of your index finger, and control it between the sides of your middle and ring fingers.

SUCTION TUBE, Lempert, one only.

TROCAR, antral, stainless steel with metal handle, Luer fitting, size 7, Tilley Lichwitz, one only. ALSO, rubber syringe with male mount for use with the antral trochar, one only. Use this for washing out a patient's antrum. If the rubber bulb perishes, use a 20 ml syringe and attach this to the trocar with a piece of catheter.

MIRROR, laryngeal, with metal stem, boilable, 24 mm, one only. You will need these to look at the larynx.

MIRROR, rhinoscopic, with metal stem, St Clair Thompson boilable, 14 mm, one only. Use this for examining the nasopharynx.

LAMP, spirit, one only. This is to warm a laryngeal mirror.

SNARE, polypectomy, nasal, Glegg's, (a) one snare only. (b) Five spare wires for the snare. Using topical anaesthesia, pass the wire loop of this snare round the base of a polyp, gently pull it out and cut it off. If you don't have one, you can use Luc's forceps (see below).

FORCEPS, nasal turbinate, Luc's, one only. If you fail to remove a polyp with a snare (unusual), you may need these.

TONGUE DEPRESSOR, Lack, adult, one only.

DRESSINGS AND DRUGS. (1) 5 mm selvage ribbon gauze, 50 metres only. (2) Magnesium Sulphate Paste BPC (magnesium sulphate 38% in phenol 0.5% in anhydrous glycerol), 1 kg only. The gauze is for packing the ear, impregnated with magnesium sulphate for boils.

For nausea and vertigo: (1) Tab prochlorperazine (''Stemetil') 5 mg. Give 5 to 10 mg three times daily. Ampoules 12.5 mg in 2 ml. Give 12.5 mg intramuscularly 6-hourly. (2) Tab. Cinnarizine (''Sturgeron') 15 mg, one or two tablets three times daily.

Silver nitrate applicator stick, for epistaxis (AVO), packet of 50 applicators, one packet only.

Drugs acting on the nose: (1) Ephedrine nasal drops BPC (ephedrine hydrochloride 1%). Put a half-full dropper into each nostril. (2) Beclomethasone dipropionate (a steroid) in metered 50 [gm]g dose aerosol; 200 dose applicator. Three puffs into each nostril three times daily.

Bull TR, ''A Colour Atlas of ENT Diagnosis', Wolfe Medical.[-3] Ludman H, ''ABC of ENT', British Medical Association 1971.[-3] Bull PD, ''Lecture notes on Diseases of the Ear, Nose and Throat', (6th edn), Blackwell Scientific Publications. 25-1 TESTING FOR DEAFNESS. Sit the child on his mother's knee facing your assistant. Meanwhile remain out of sight behind his mother.