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. 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: Earcalm Spray Available over the counter (Acetic acid 2%) For use first line in primary care as per guidelines Betamethasone sodium phosphate 0.1% drops Vistamethasone is the most cost effective brand in primary care Betnovate scalp application Unlicensed use - useful in chronic otitis externa (1). See ENT antibiotic guidelines for acute trust and primary care If infection is suspected use the following: Drops Flumetasone pivalate 0.02% & clioquinol 1% drops Hydrocortisone 1% & gentamicin 0.3% (Gentisone HC drops) Hydrocortisone 1% & Neomycin (Otosporin drops) Dexamethasone 0.05% & framycetin 0.5% & gramicidin 0.005% (Sofradex drops) 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. Please note Trimovate cream has been removed from formulary as it is unlicensed and prohibitively expensive (Mar 18).
Chapter 12 page number 2 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% (Ciloxan ) eye drops Unlicensed use of eye drops in the ear - preferred when use is frequent and prolonged (1). Gentamicin injection Dexamethasone 0.1% & neomycin 3250 units/ml & glacial acetic acid 2% (Otomize spray) Second line in primary care for use where Earcalm has not been effective or is not suitable for an individual patient Dexamethasone 0.05% & framycetin 0.5% & gramicidin 0.005% (Sofradex drops) Clotrimazole 1% (Canesten ) Antifungal 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). Please refer to primary care antibiotic guidelines. 12.1.3 Removal of ear wax Use of over the counter products is encouraged. Olive oil drops Sodium bicarbonate 5% drops 12.2 Drugs acting on the nose 12.2.1 Drugs used in nasal allergy Antihistamines see alsoantihistamines Chapter 3.4.1 Cetirizine Oral - Non-sedating hydrochloride Azelastine hydrochloride 140mcg/metered spray (Rhinolast spray) For use in children between 5 and 12 years of age.
Chapter 12 page number 3 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 For prophylaxis & treatment of allergic & vasomoror diproprionate rhinitis. 50mcg/metered spray Most cost-effective choice. (Beconase nasal spray) Betamethasone sodium phosphate 0.1% drops Budesonide 64 mcg/metered spray (Rhinocort Aqua nasal spray) Fluticasone furoate 27.5mcg/metered spray (Avamys nasal spray) For non-infected inflammation of the nose. Vistamethasone is the most cost effective brand in primary care For treatment of allergic rhinitis & polyps in adults. For treatment of allergic rhinitis in adults & children over 6 years of age. Cromoglicate Sodium cromoglicate 4% (Rynacrom 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 Xylometazoline hydrochloride 0.05% nasal drops Xylometazoline 0.1% Nasal Spray Antimuscarinic Ipratropium bromide 21mcg/metered spray (Rinatec nasal spray) For adult use. For paediatrics use For adult use. Ephedrine nasal drops initiation by ENT consultant only. 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 Refer to GWH ENT Antibiotic Guidelines and primary care antibiotic guidelines 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 4 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) Lidocaine ointment 5% More extensive ulceration: Choline Salicylate 8.7% oral gel Benzydamine 0.15% 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). Hydrocortisone 2.5mg buccal tablets Prednisolone sol tablets Unlicensed use - 5mg 10mg dissolved in 10ml of water and used as a mouthwash up to 5 times a day. Betamethasone tablets Unlicensed use - 500mcg dissolved in 10mls of water and used as a mouthbath up to 5 times a day. 12.3.2 Oropharyngeal anti-infective drugs See antibiotic guidelines for acute trust and primary care Oropharyngeal fungal infections Nystatin oral suspension Always prescribe as Nystan in primary care as most cost-effective preparation. Miconazole oral gel See MHRA Drug Safety Update June 2016 for further information and advice on the potential for topical miconazole, including oral gel, to seriously interact with warfarin. See MHRA Drug Safety Update Sept 17 for information on the contraindication of over-the-counter miconazole oral gel in patients taking wafarin, and advice to healthcare professionals wishing to prescribe this combination. 12.3.3 Lozenges and sprays There is no convincing evidence that antiseptic lozenges and sprays have a beneficial action. Refer to BNF.
Chapter 12 page number 5 12.3.4 Mouthwashes, gargles and dentifrices Do not prescribe sodium chloride mouthwash as this is a special order preparation which may be prohibitively expensive. Superficial infections of the mouth are often helped by the use of warm mouthwashes, a warm saline mouthwash is ideal and can be prepared by dissolving half a teaspoonful of salt in a glassful of warm water. See BNF for further information. Chlorhexidine gluconate 0.2%. Chlorhexidine gluconate 1% gel Prescribe generically as Chlorhexidine gluconate 0.2% mouthwash Hydrogen Peroxide Solution 10vols (3%) Hexetidine (Oraldene ) Hydrogen Peroxide Solution 20vols (6%). 12.3.5 Treatment of dry mouth Local treatment BioXtra Gel Saliveze Spray Recommended for Geographic Tongue. A benign condition of unknown aetiology caused by loss of tongue papillae over patches of the tongue. Salivix pastilles Systemic treatment Pilocarpine hydrochloride 5mg tablets Topical anaesthetics see Anaesthesia chapter 15.2 Caphosol mouthwash Restricted for use in patients undergoing autologous stem cell transplant ONLY. Haematologist prescription ONLY. Gelclair 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% SwindonCCG, Wiltshire CCG and Great Western Hospitals NHS Foundation Trust in collaboration with Avon & Wiltshire Mental Health Partnership NHS 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 66, September 2013 March 2014