Chapter 12 page number 1 Produced: May 2009 Review due: May 2012

Chapter 12 Ear, Nose and Oropharynx

First line drugs Second line drugs Specialist initiated drugs Secondary care only drugs Drugs recommended in Alternatives (often in Secondary care, GP with Drugs only suitable for both primary and specific conditions) in both special interest initiation or secondary care use and secondary care primary and secondary care authorised independent initiated by appropriate prescribers. Suitable for team, authorised continuation by primary care. independent prescribers or Shared care agreements may be specialist. Primary care applicable. prescribers should not be asked to prescribe.

Primary & Secondary Notes Secondary Care 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 if no evidence of infection, as follows: sodium phosphate 0.1% drops

Betnovate scalp application Unlicensed use - useful in chronic otitis externa (1) . If infection is suspected use the following: Drops 0.02% & 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 0.1%, Unlicensed use of eye ointment in the ear. Bipp paste 1.25cm x 200cm & neomycin 0.35% (Maxitrol ointment) 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).

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Chapter 12 page number 2 Produced: May 2009 Review due: May 2012

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

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Chapter 12 page number 3 Produced: May 2009 Review due: May 2012

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) 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 ‘. diproprionate 50mcg/metered spray (Beconase nasal spray)

Betamethasone sodium For non-infected inflammation of the nose. phosphate 0.1% drops Please note: If manufacturers are unable to supply betamethasone sodium phosphate 0.1% drops and a 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.

Budesonide 64 For adult use. mcg/metered spray (Rhinocort Aqua nasal spray)

Fluticasone furoate For paediatric use. 27.5mcg/metered spray (Avamys nasal spray)

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 For paediatrics use Xylometazoline hydrochloride Ephedrine nasal drops – initiation hydrochloride 0.1% 0.05% nasal drops. by ENT consultant only. nasal drops

Antimuscarinic Ipratropium bromide 21mcg/metered spray (Rinatec nasal spray)

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Chapter 12 page number 4 Produced: May 2009 Review due: May 2012

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 Sinusitis- see Swindon Primary Care antibiotic In chronic rhinosinusitis: (Erythromycin if guidelines, for details. Azithromycin penicillin allergic) 500mg od for 7 days. Repeat monthly for three months (1). Co-amoxiclav

Miscellaneous Sodium chloride nasal douche (Sterimar) available over the counter. Sodium Chloride 0.9 % Used post-op within the Acute Trust. sachets

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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% More extensive ulceration: (Adcortyl in Orabase sol tablets 5mg – oral paste) 10mg dissolved in 10ml of water and used as a mouthwash up to 5 Lidocaine ointment 5% times a day.

Choline Salicylate Betamethasone tablets 8.7% oral gel 500mcg dissolved in 10mls of water and used as a mouthbath up Benzydamine to 5 times a day. Hydrochloride Oral Rinse and Oral Spray Siopel cream –For preventing angular chelitis. Beclometasone Applied topically orally to smaller areas of oral diproprionate ulceration up to 5 times daily (normally not less than 4 (Beconase nasal times daily). Unlicensed use – GWH consultant (1) spray) recommendation .

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 Hydrogen Peroxide Solution gluconate 0.2%. 10vols (3%)

Hexetidine Recommended for Geographic Tongue. A benign Caphosol mouthwash – (Oraldene ) condition of unknown aetiology caused by loss of Restricted for use in patients tongue papillae over patches of the tongue. undergoing autologous stem cell transplant ONLY. Haematologist Hydrogen Peroxide prescription ONLY. Solution 20vols (6%). 12.3.5 Treatment of dry mouth Local treatment BioXtra® oral gel Gelclair

Biotene Saliva replacement gel (Oralbalance )

Glandosane® Systemic treatment Pilocarpine hydrochloride 5mg tablets

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Chapter 12 page number 6 Produced: May 2009 Review due: May 2012

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/

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