Chapter 12 page number 1 Chapter 12 Ear, Nose and Oropharynx First line drugs Drugs recommended in both primary and secondary care Second line drugs Alternatives (often in specific conditions) in both primary and secondary care Specialist initiated drugs Secondary care, GP with special interest initiation or authorised independent prescribers. Suitable for continuation by primary care. Shared care agreements may be applicable. Secondary care only drugs Drugs only suitable for secondary care use and initiated by appropriate team, authorised independent prescribers or specialist. Primary care prescribers should not be asked to prescribe. Primary & Secondary Care Notes Secondary Care 12.1 Drugs acting on the ear Treatment of otitis externa Otis externa often responds to over the counter preparations. A proprietary preparation containing Acetic acid 2% (EarCalm spray) is available. Ensure the correct administration of drops to the ear. Ear drops should be administered with the patient s head to one side. The top of the ear should then be pulled up (for an adult) or down (for a child) and the tragus (flap of skin and cartilage immediately in front of the ear canal) pushed in and out to force the drops down to the ear drum. If possible patients should lie with the affected ear uppermost for ten minutes after the canal has been filled. Use a simple steroid if no evidence of infection, as follows: Betamethasone sodium phosphate 0.1% drops Betnovate scalp application Unlicensed use - useful in chronic otitis externa (1). If infection is suspected use the following: Drops Flumetasone pivalate 0.02% & clioquinol 1% (Locorten-Vioform drops) Hydrocortisone 1% & gentamicin 0.3% (Gentisone HC drops) Dexamethasone 0.05% & framycetin 0.5% & gramicidin 0.005% (Sofradex drops) Cream preparation Trimovate Ointment preparation Dexamethasone 0.1%, & neomycin 0.35% (Maxitrol ointment) Unlicensed use of eye ointment in the ear. Bipp paste 1.25cm x 200cm Glycerin and Icthammol solution 500ml. Recurrent episodes with discharge are best managed with surgery. Consider referral. If ear discharge in presence of long standing perforation use the following: Ciprofloxacin 0.3% Unlicensed use of eye drops in the ear - preferred when Gentamicin injection (Ciloxan ) eye drops use is frequent and prolonged (1).
Chapter 12 page number 2 Dexamethasone 0.05% & framycetin 0.5% & gramicidin 0.005% (Sofradex drops) Dexamethasone 0.1% & neomycin 3250 units/ml & glacial acetic acid 2% (Otomize spray) Clotrimazole 1% Antifungal (Canesten ) 12.1.2 Otitis media Acute Otitis media - Many infections are caused by viruses, most uncomplicated cases resolve without antibacterial treatment, a simple analgesic may be sufficient. (See BNF for further information). 12.1.3 Removal of ear wax Use of over the counter products is encouraged. Olive oil drops Sodium bicarbonate 5% drops
Chapter 12 page number 3 12.2 Drugs acting on the nose 12.2.1 Drugs used in nasal allergy Antihistamines Cetirizine Oral - Non-sedating hydrochloride Azelastine hydrochloride 140mcg/metered spray (Rhinolast spray) Corticosteroids There is no difference in efficacy between products (sprays and drops) (2). In the event of incomplete symptom control, add a non sedating oral antihistamine (3). Some preparations are available over the counter. Beclometasone diproprionate 50mcg/metered spray (Beconase nasal spray) Betamethasone sodium phosphate 0.1% drops Budesonide 64 mcg/metered spray (Rhinocort Aqua nasal spray) For non-infected inflammation of the nose. Please note: If manufacturers are unable to supply betamethasone sodium phosphate 0.1% drops and a corticosteroid nasal spray is clinically inappropriate (e.g. after nasal surgery), Flixonase nasules may be prescribed on a short-term basis as a temporary alternative BUT these are expensive. For adult use. Fluticasone furoate 27.5mcg/metered spray (Avamys nasal spray) For paediatric use. Cromoglicate Sodium cromoglicate 4% (Rynacrom aqueous nasal spray) 12.2.2 Topical nasal decongestants Use only for self-limiting conditions. Short-term use only, maximum 7 days. Sympathomimetics Xylometazoline hydrochloride 0.1% nasal drops For paediatrics use Xylometazoline hydrochloride 0.05% nasal drops. Ephedrine nasal drops initiation by ENT consultant only. Antimuscarinic Ipratropium bromide 21mcg/metered spray (Rinatec nasal spray)
Chapter 12 page number 4 12.2.3 Nasal preparations for infection Nasal staphylococci Naseptin cream Should be avoided in the peanut allergic patient. Bactroban nasal ointment - as per hospital Trust MRSA treatment guidelines. Antibacterials Useful in chronic infective rhinitis in combination with steroid spray. Intermittent use recommended. Refer to GWH ENT Antibiotic Guidelines. Amoxicillin (Erythromycin if penicillin allergic) Co-amoxiclav Sinusitis- see Swindon Primary Care antibiotic guidelines, for details. In chronic rhinosinusitis: Azithromycin 500mg od for 7 days. Repeat monthly for three months (1). Miscellaneous Sodium chloride nasal douche (Sterimar) available over the counter. Sodium Chloride 0.9 % Used post-op within the Acute Trust. sachets
Chapter 12 page number 5 12.3 Drugs acting on the oropharynx 12.3.1 Drugs for oral ulceration and inflammation It is important to establish the diagnosis in each case as it may require specific management in addition to local treatment. (4) Triamcinolone 0.1% (Adcortyl in Orabase oral paste) Lidocaine ointment 5% Choline Salicylate 8.7% oral gel Benzydamine Hydrochloride Oral Rinse and Oral Spray Beclometasone diproprionate (Beconase nasal spray) Applied topically orally to smaller areas of oral ulceration up to 5 times daily (normally not less than 4 times daily). Unlicensed use GWH consultant recommendation (1). More extensive ulceration: Prednisolone sol tablets 5mg 10mg dissolved in 10ml of water and used as a mouthwash up to 5 times a day. Betamethasone tablets 500mcg dissolved in 10mls of water and used as a mouthbath up to 5 times a day. Siopel cream For preventing angular chelitis. 12.3.2 Oropharyngeal anti-infective drugs Oropharyngeal fungal infections Nystatin oral suspension (Nystan ) Miconazole oral gel Amphotericin Lozenges 12.3.4 Mouthwashes, gargles and dentifrices Chlorhexidine gluconate 0.2%. Hexetidine (Oraldene ) Hydrogen Peroxide Solution 20vols (6%). 12.3.5 Treatment of dry mouth Local treatment BioXtra oral gel Recommended for Geographic Tongue. A benign condition of unknown aetiology caused by loss of tongue papillae over patches of the tongue. Hydrogen Peroxide Solution 10vols (3%) Caphosol mouthwash Restricted for use in patients undergoing autologous stem cell transplant ONLY. Haematologist prescription ONLY. Gelclair Biotene Saliva replacement gel (Oralbalance ) Glandosane Systemic treatment Pilocarpine hydrochloride 5mg tablets
Chapter 12 page number 6 Topical anaesthetics see Anaesthesia chapter 15.2 Cocaine solution Can be used to make Moffats Solution. Lidocaine dental cartridges Lignospan Special - lidocaine hydrochloride 2% + adrenaline 1:80000. Lidocaine 5% with Phenylephrine 0.5% NHS Swindon, NHS Wiltshire and Great Western Hospitals NHS Foundation Trust in collaboration with Avon & Wilts Mental Healthcare Partnership Trust. References 1. GWH local consultant recommendation. 2. Waddell A, Patel SK, Toma AG, Maw AR. Intranasal steroid sprays in the treatment of rhinitis & J Laryngol Otol. 2003 Nov;117(11):843-5. 3. Oral antihistamines for the symptom of nasal obstruction in persistent allergic rhinitis--a systematic review of randomized controlled trials. Clin Exp Allergy. 2005 Feb;35(2):207-12 Hore I, Georgalas C, Scadding G 4. BNF 57, March 2009. 12.3.1 Drugs for oral ulceration and inflammation. http://www.bnf.org/bnf/