World Health Organization · 1st edition, 2023 · 135 pages
A comprehensive training resource for health workers and primary-level doctors on prevention, identification, and management of hearing loss and common ear diseases.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2023
- Audience
- Health workers and doctors working at primary care level in health facilities or communities
- Evidence
- Based on WHO guidelines, published clinical guidelines, systematic reviews, Cochrane reviews, textbooks, peer-reviewed publications, expert discussions, stakeholder consultations, and Delphi surveys
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This 10-module training manual equips health workers and primary care doctors to prevent, identify, and manage hearing loss and ear diseases at the community and primary health facility levels. Developed through an evidence-based consultative process by WHO, it covers ear anatomy, examination techniques using otoscopy, common conditions (otitis media, otitis externa, cholesteatoma, glue ear), hearing assessment methods for all ages, and rehabilitation including hearing aids and cochlear implants.
The manual emphasizes that 60% of childhood hearing loss is preventable through vaccination, treatment of ear infections, safe listening practices, and avoiding ototoxic medicines. It provides practical skills including dry mopping, ear washout, distraction testing in infants (6 months–3 years), voice tests in children (3–7 years), whispered voice tests (>7 years and adults), and use of the hearWHOpro smartphone app. Every module includes examination protocols, referral criteria, and community resources.
Central to the manual is early identification: babies with hearing loss diagnosed within 3 months of birth and receiving intervention by 6 months can develop language at near-normal rates. The manual stresses that health workers are often the first point of contact and can diagnose and manage many common ear problems, while recognizing when specialist referral is essential (e.g., cholesteatoma, mastoiditis, foul-smelling discharge).
Key points
For clinicians — doses and thresholds as stated in the guideline
- Examine both ears with otoscopy even if complaint is unilateral; pull pinna upwards and backwards in adults (straight back in young children) to straighten the ear canal; use largest comfortable speculum.
- Acute otitis media: treat with oral antibiotics for 5–7 days if ear drum is bulging/perforated, discharge present, high fever, or no improvement after 2 days; add antibiotic ear drops only if discharge and perforation present; review after 2 days then 1 week.
- Chronic suppurative otitis media (CSOM): discharge >2 weeks with perforation; clean by dry mopping, then antibiotic or antiseptic ear drops 2–3 times daily for 1 week; teach patient to dry mop before each drop instillation; refer if foul smell, persistent discharge, or hearing loss.
- Refer urgently for suspected mastoiditis (swelling, redness, pain behind pinna), cholesteatoma (white/yellow mass on/through ear drum, foul discharge, polyp), facial palsy, severe headache, neck stiffness, vomiting, or drowsiness (signs of intracranial spread).
- Remove ear wax by washout using 20 mL syringe with water at body temperature (37°C); avoid washout if acute pain, recent surgery, known perforation, or acute otitis; always dry ear thoroughly after washout using tissue wick or dry mop.
- Hearing assessment: distraction test with rattle at 1 metre for 6 months–3 years; voice test (simple commands) for 3–7 years; whispered voice test (number-letter-number at arm's length behind patient, after full exhalation) for >7 years and adults; hearWHOpro app (digits-in-noise, score <50 indicates likely hearing loss) for adults.
- Every baby should have hearing tested, especially if risk factors (birth weight <1.5 kg, birth asphyxia, jaundice requiring exchange transfusion, family history of deafness, maternal infection/ototoxic drugs during pregnancy, prolonged ICU stay, or visible head/neck abnormality).
- Babies with hearing loss identified within 3 months and receiving rehabilitation by 6 months can develop language at rates similar to hearing peers; refer for OAE or AABR testing if any suspicion of hearing loss or delayed speech/hearing milestones.
Hearing and language milestones in children
Table extracted from the guideline
| Age | Hearing and responding | Talking |
|---|---|---|
| Birth–3 months | Startles at loud sounds; becomes quiet or smiles when parent speaks | Makes cooing sounds |
| 4–6 months | Moves eyes toward sound; responds to changes in tone; notices toys that make sounds | Coos and babbles when playing; makes speech-like sounds ('pa', 'ba', 'mi') |
| 7 months–1 year | Turns and looks toward sound; turns when name called; understands common words ('water', 'dog'); responds to simple phrases ('No', 'Come here') | Babbles long strings ('mimi', 'babababa'); imitates speech sounds; says 1–2 words ('hi', 'dada', 'mama') around first birthday |
| 1–2 years | Points to body parts when asked; follows one-part directions ('Roll the ball'); responds to simple questions; listens to stories/songs | Uses many new words; asks questions ('What's that?'); puts 2 words together ('more apple', 'no bed') |
| 2–3 years | Understands opposites (go-stop, big-little); follows two-part directions ('Get the spoon and put on the table'); understands new words quickly | Has word for almost everything; talks about things not in room; puts 3 words together; may repeat some words/sounds |
| 3–4 years | Responds when called from another room; understands colour/shape words; understands words for family members | Answers 'who', 'what', 'where' questions; says rhyming words; most people understand speech; asks 'when' and 'how'; puts 4 words together |
| 4–5 years | Follows longer directions ('Put pyjamas on, brush teeth, choose a book'); hears and understands most at home and school | Talks without repeating sounds/words most of time; names letters and numbers; tells short story; keeps conversation going |
Source: World Health Organization, Primary Ear and Hearing Care: Training Manual. Reproduced in summary form.
From the guideline
Verbatim
“Babies whose hearing loss is diagnosed within 3 months after birth, and interventions initiated within 6 months of age, can develop language at a rate similar to babies with normal hearing.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As a WHO consultant on health system strengthening and former adviser to Georgia's primary care reforms, I see this manual as a vital tool for our region, where 70% of the population accesses care through family medicine ambulatories yet specialist ENT services are concentrated in regional centres. The module on dry mopping and topical antibiotic drops without systemic antibiotics for chronic suppurative otitis media addresses one of the most common yet under-documented burdens in rural Georgia and Armenia—chronic 'runny ears' in children that impair school performance and are often treated with inappropriate oral antibiotics or home remedies like hot oil. The distraction test and hearWHOpro app protocols are immediately deployable within Georgia's existing maternal-child health visits and annual check-ups for adults, requiring minimal equipment. However, successful implementation will require that the Ministry of Health procure and distribute otoscopes to all ambulatories (currently sporadic), ensure uninterrupted supply of topical ciprofloxacin ear drops on the essential medicines reimbursement list, and establish clear referral pathways to the few centres offering OAE testing and hearing aids. Without addressing the hearing-device gap—Georgia has no domestic hearing-aid production and import costs remain prohibitive for most families—we risk identifying children with permanent hearing loss but lacking the means to rehabilitate them. The manual's emphasis on early intervention by 6 months is evidence-based, but our health system must be ready to deliver that intervention, not merely diagnose and refer into a void.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
This manual is directly applicable to Georgia and the South Caucasus, where primary health care networks reach remote and mountainous communities often distant from specialist otolaryngology services. Georgia’s 2013 Universal Health Coverage programme covers consultations and many medicines, but specialist audiology and hearing devices remain limited outside Tbilisi. The manual’s emphasis on health-worker-led screening (hearWHOpro app, distraction testing, otoscopy) and management of common infections without referral aligns with Georgia’s task-shifting strategy and the 2019 strengthening of primary care under the state programme. National hearing screening for newborns is not yet universal; this manual’s protocols for identifying at-risk infants and testing by 6 months would support integration into Georgia’s maternal-child health package. The high burden of chronic suppurative otitis media in the region (often linked to overcrowding, smoke exposure, and delayed care-seeking) makes the dry-mopping and topical antibiotic protocols immediately actionable. Armenia and Azerbaijan face similar constraints, and all three countries have low coverage of hearing aids (WHO estimates <10% of need met in lower-middle-income settings); the manual's community counselling resources and hearing-aid care instructions are thus essential until device access improves.
Questions this guideline answers
Quick answers
When should I urgently refer a patient with ear discharge?
Refer urgently if discharge has a foul smell (suggests cholesteatoma), if there is swelling/redness/pain behind the ear (mastoiditis), facial weakness (facial palsy), severe persistent headache, neck stiffness, vomiting, drowsiness (signs of meningitis or brain abscess), or if discharge persists after 1 week of proper antibiotic ear drops and dry mopping.
How do I perform dry mopping of a discharging ear?
Preferred method (tissue wick): twist end of tissue into a wick, pull pinna back, insert 2–3 cm into ear canal, leave 10 seconds, remove and check if wet; repeat with fresh tissue until wick comes out dry. Alternative (cotton mop): twist small piece of cotton wool onto wooden stick leaving fluffy tip, insert gently without forcing, remove and check; repeat until dry. Always dry mop before instilling ear drops.
Which children need urgent hearing testing?
Test hearing urgently if: birth weight <1.5 kg, lack of oxygen at birth (cord around neck, prolonged labour, baby blue at birth), high jaundice requiring light therapy or exchange transfusion, prolonged ICU stay, family history of deafness, visible ear/head/neck abnormality, maternal infection during pregnancy (fever, rashes), mother received TB or malaria medicines during pregnancy, or if parents report delayed speech or the child does not reach age-appropriate hearing milestones.
When can I safely perform an ear washout, and when is it contraindicated?
Safe for wax removal, foreign bodies (except seeds, which swell), and clearing pus before examination. Never perform washout if acute ear pain, known dry perforation, recent ear surgery, or acute otitis media. Use clean water at body temperature (37°C), 20 mL syringe without needle, direct stream toward top/back of canal, and always dry ear thoroughly with tissue wick or dry mop afterwards. Avoid alcohol-based solutions.
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- Issuer
- World Health Organization
- Type
- Training material
- Edition
- 1st edition, 2023
- Status
- Current
- Published
- 2023-03-02
- Languages
- English (additional languages may be available)
- Scope
- Prevention, identification, and management of hearing loss and common ear diseases at primary care level
- Audience
- Health workers and doctors working at primary care level in health facilities or communities
- Pages
- 135
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-006915-2
- Evidence
- Based on WHO guidelines, published clinical guidelines, systematic reviews, Cochrane reviews, textbooks, peer-reviewed publications, expert discussions, stakeholder consultations, and Delphi surveys
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
World Health Organization. Primary ear and hearing care training manual. Geneva: World Health Organization; 2023. 135 p. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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