12: Ear, nose and oropharynx



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12: Ear, nose and oropharynx

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12.1 Drugs acting on the ear

12.2 Drugs acting on the nose

12.3 Drugs acting on the oropharynx

Changes to the Formulary since previous version

(1.8.2013)


Section

Change

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12.1 Drugs acting on the ear



Anti-inflammatory preparations

  • Betamethasone 0.1% ear/eye/nose drops

  • Betamethasone 0.1% ointment

  • Gentamicin 0.3% ear/eye drops

  • Gentisone HC® - Hydrocortisone with gentamicin ear drops

  • Locorten-Vioform® - Flumetasone with clioquinol ear drops

  • Otomize® - Dexamethasone with neomycin ear spray

  • Otosporin® - Hydrocortisone with neomycin and polymixim ear drops

  • Prednisolone 0.5% ear/eye drops

  • Sofradex® - Dexamethasone with framycetin ear/eye drops

Dose

- Betamethasone ear/eye/nose drops 0.1%: for eczematous inflammation in otitis externa, apply 2-3 drops every 2-3 hours.

- Gentamicin ear/eye drops 0.3%: apply 2-3 drops into the ear 3-4 times a day and at night.

- Gentisone HC® ear drops: apply 2-4 drops into the ear 3-4 times a day and at night.

- Locorten-Vioform® ear drops: apply 2-3 drops into the ear twice daily for up to 7-10 days.

- Otomize® ear spray: 1 metred spray into the ear each day.

- Otosporin® ear drop: apply 3 drops into the ear 3-4 times daily.

- Prednisolone ear/eye drops 0.5%: apply 2-3 drops every 2-3 hours.

- Sofradex® ear/eye drops: apply 2-3 drops 3-4 times a day into the affected ear(s).

Prescribing notes


  • Many cases of otitis externa recover after thorough cleansing of the external ear canal by suction and dry mopping.

  • It is often difficult to differentiate between infection on its own and inflammation, therefore a combined preparation is suitable first choice.

  • Otomize® spray is first choice because the delivery system is more effective in getting the drug to the infected site.

  • Locorten-Vioform® should not be used for longer than 10 days to prevent fungal overgrowth.

  • Recurrent or persistent cases should be swabbed and treated according to sensitivities.

  • Otomize® and other products containing aminoglycosides, polymyxin or chlorhexidine should not be used routinely if the eardrum is perforated.

  • Eczema of the outer canal and pinna may need treatment with a steroid cream.


Anti-infective preparations


  • Acetic acid 2% spray (EarCalm®)

  • Clotrimazole 1% solution

  • Ciprofloxacin 0.3% eye drops (unlicensed)

Dose

- Canesten® Clotrimazole 1% solution: for fungal infection in otitis externa, apply 2-3 times daily continuing for at least 14 days after disappearance of infection.

- Ciloxan® Ciprofloxacin 0.3% eye drops: unlicensed for use in otitis media.

- Ear Calm® Acetic acid 2% spray: one metered dose (60 milligrams) to be administered directly into each effected ear at least three times daily (morning, evening and after swimming, showering or bathing). Maximum dosage frequency one spray every 2-3 hours. Treatment should be continued until two days after symptoms have disappeared but no longer than 7 days.



Removal of ear wax

Dose

- Olive oil ear drops: for hard, impacted wax apply twice daily for a few days before syringing, otherwise soften the wax on the day of syringing.
- Sodium bicarbonate ear drops 5%: for hard, impacted wax apply twice daily for a few days before syringing, otherwise soften the wax on the day of syringing.

Prescribing notes


  • To soften ear wax the oil should be warmed and a generous amount introduced into the affected ear. The patient should lie with the affected ear uppermost for 5-10 minutes. The treatment should preferably be given for 3-4 days before syringing to ensure maximum softening of the wax.

  • Olive oil is a suitable alternative to almond oil.

  • Some proprietary preparations contain organic solvents that cause irritation of the meatal skin. In most cases, simple almond or olive oil is just as effective, less likely to cause irritation of the skin and less expensive.

12.2 Drugs acting on the nose


Drugs used in nasal allergy

  • Azelastine aqueous nasal spray (Rhinolast)

  • Beclometasone dipropionate nasal spray (Beconase)

  • Betamethasone sodium phosphate ear/eye/nose drops (Betnesol)

  • Fluticasone propionate aqueous nasal spray (Flixonase)

  • Fluticasone furoate nasal spray (Avamys)

  • Mometasone furoate 50mcg nasal spray (Nasonex) ENT clinic only

  • Fluticasone nasal drops (Flixonase nasules)

Dose

- Rhinolast® aqueous nasal spray(azelastine hydrochloride), 140micrograms/puff: 140 micrograms (1 spray) into each nostril twice daily.

- Betamethasone sodium phosphate 0.1% ear/eye/nose drops: apply 2-3 drops into each nostril 2-3 times a day.

- Mometasone furoate nasal spray 50micrograms/puff: apply 50micrograms (1 spray) to max 200micrograms (4 sprays) into each nostril once daily.

- Flixonase nasules® nasal drops 400micrograms: Apply 200micrograms (approx. 6 drops) into each nostril once or twice daily; consider alternative treatment if no improvement after 4-6 weeks.

- Beclometasone dipropionate nasal spray, 50micrograms/puff: 100 micrograms (2 sprays) into each nostril twice daily or 50 micrograms (1 spray) into each nostril 3-4 times daily; max total 400 micrograms (8 sprays) daily; when symptoms controlled, reduce dose to 50 micrograms (1 spray) into each nostril twice daily.
- Fluticasone propionate aqueous nasal spray 50micrograms/metered spray: 100micrograms (2 sprays) into each nostril once daily, preferably in the morning, increased to max twice daily if required; when control achieved reduce to 50micrograms (1 spray) into each nostril once daily.

- Fluticasone furoate nasal spray 27.5micrograms/metered spray: 55micrograms (2 sprays) into each nostril once daily, preferably in the morning, increased to max twice daily if required; when control achieved reduce to 27.5micrograms (1 spray) into each nostril once daily.


Prescribing notes


  • For seasonal allergic rhinitis, prophylaxis should begin 2-3 weeks before the start of the pollen season and continue throughout.

  • If symptoms due to nasal polyps are severe, consider a course of oral prednisolone (25mg daily for 2 weeks) followed by topical nasal steroid spray. Steroid drops (Betnesol® drops, Flixonase Nasules®) should be prescribed on specialist advice only.

MHRA Drug Safety Update

Inhaled and intranasal corticosteroids: risk of psychological and behavioural side effects
Article date: September 2010

Summary

Psychological and behavioural side effects may occur in association with use of inhaled and intranasal formulations of corticosteroids.


Link: http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON093853
Topical nasal decongestants

  • Ephedrine 0.5% nasal drops

  • Xylometazoline 0.05% and 0.1% nasal drops

  • Ipratropium bromide 0.03% nasal spray (Rinatec)

  • Sodium chloride 0.9% minims

Dose

- Sodium chloride 0.9% nasal drops: instil 1-2 drops into each nostril when necessary.


- Ephedrine nasal drops 0.5%, 1%: instil 1-2 drops into each nostril up to 3 or 4 times daily when required.

- Xylometazoline nasal drops 0.05% and 0.1%: instil 2-3 drops into each nostril when required for 7 days.

- Rinatec® nasal spray 0.03%: apply 42micrograms (2 sprays) into each nostril 2-3 times a day.

Prescribing notes


  • Inhalation of warm moist air is useful in the treatment of symptoms of acute infective conditions.

  • Sodium chloride 0.9% nasal drops may relieve nasal congestion by helping to liquefy mucous secretions.

  • Topical nasal decongestants are of limited value because they can give rise to rebound congestion on withdrawal. These products should not be used for more than 7 days.

  • Ephedrine nasal drops are the safest sympathomimetic preparation.

Nasal preparations for infection and epistaxis

  • Chlorhexidine and neomycin cream (Naseptin)

  • Mupirocin 2% nasal ointment (Bactroban)

Dose

- Naseptin® cream (chlorhexidine hydrochloride 0.1%, neomycin sulphate 3250units/g): for eradication of nasal carriage of staphylococci, apply to nostrils 4 times daily for 10 days; for preventing nasal carriage of staphylococci apply to nostrils twice daily.

- Bactroban® nasal ointment (mupirocin 2%): for eradication of nasal carriage of staphylococci, apply 2-3 times daily to the inner surface of each nostril.

Prescribing notes


  • Elimination of organisms such as staphylococci from the nasal vestibule can be achieved by the use of Naseptin® cream.

  • Mupirocin 2% nasal ointment (Bactroban Nasal®) is also available for eradication of staphylococci from the nose but should be reserved for resistant cases only and used for no longer than 10 days to avoid resistance. In hospital, it should be reserved for eradication of methicillin-resistant Staphylococcus aureus (MRSA).


Miscellaneous

  • Lidocaine 5% and phenylephidrine 0.5% nasal spray

  • Boric acid & Povidone Iodine Insufflation (unlicensed)


12.3 Drugs acting on the oropharynx



Drugs for oral ulceration and inflammation

  • Benzydamine oral rinse (Difflam)

  • Benzydamine oral spray (Difflam)

  • Calgel (Lidocaine Hydrochloride 0.33%, Cetylpyridinium Chloride 0.10%)

  • Gelclair sachets

Dose

- Benzydamine hydrochloride 0.15% oral rinse: rinse or gargle with 15mL (diluted with water if stinging occurs) every 1½ - 3 hours as required, usually for not more than 7 days.

- Benzydamine hydrochloride 0.15% spray: 4-8 sprays onto affected area every 2-3 hours as required.

- Calgel®: apply up to 6 times per day.


- Gelclair® sachets: use up to 3 times a day as required.

Prescribing notes

  • It is important to consider any possible underlying diagnosis.

  • There is some evidence that chlorhexidine gluconate may reduce the duration and severity of each episode of ulceration. Benzydamine mouthwash can be used 10 minutes before meals to relieve pain in patients suffering from aphthous ulcers.

Oropharyngeal anti-infective drugs

  • Miconazole 24mg/ml oral gel

  • Nystatin 100 000 units/ml oral suspension

Dose

- Nystatin oral suspension 100,000 units/mL: 100,000 units 4 times daily after food, usually for 7 days (continued for 48 hours after lesions have resolved); higher doses may be needed for immunosuppressed patients. (e.g. 500,000 units 4 times daily).

- Miconazole oral gel 24mg/ml: 5-10ml in the mouth after food and retain near lesions 4 times a day; localised lesions, smear a small amount on the affected area with clean finger 4 times daily.

Prescribing notes


  • Nystatin is not absorbed from the gastro-intestinal tract.

  • Good denture care is important. Nystatin may be used as a denture soak for the duration of treatment.

Lozenges and sprays

  • Dequacaine lozenges (benzocaine 10mg, dequalinium chloride 250microgram)


Mouthwashes, gargles and dentifrices

  • Chlorhexidine 0.2% mouthwash

  • Chlorhexidine 1% dental gel

  • Chlorhexidine 0.2% oral spray

  • Hexetidine 0.1% mouthwash

Dose

- Chlorhexidine gluconate 0.2% mouthwash: rinse mouth with 10mL for about 1 minute twice daily.


- Chlorhexidine gluconate 0.2% oral spray: apply as required to tooth and gingival surfaces using up to a maximum of 12 actuations (approximately 0.14mL/actuation) twice daily.

- Chlorhexidine gluconate 1% dental gel: apply as required once or twice a day.

- Hexetidine 0.1% mouthwash:use 15ml undiluted 2-3 times daily


Prescribing notes


  • There is evidence that chlorhexidine has a specific effect in inhibiting the formation of plaque on teeth. A chlorhexideine mouthwash may be useful as an adjunct to other oral hygiene measures for oral infection or when toothbrushing is not possible.



Treatment of dry mouth

  • AS Saliva Orthana® Spray

  • Salivix pastilles

  • Biotine oral balance gel

Dose

- Biotene Oralbalance® saliva replacement gel: apply to gums and under tongue as required.

- AS Saliva Orthana® spray: spray onto oral and pharyngeal mucosa as required.

- Salivix pastilles: suck one pastille when required.


Prescribing notes


  • Dry mouth can be relieved in many patients by simple measures such as frequent sips of cool drinks or sucking pieces of ice or sugar-free fruit pastilles.

  • Biotene Oralbalance® and AS Saliva Orthana® have ACBS approval for dry mouth due to having (or having undergone) radiotherapy, or sicca syndrome. Prescriptions should be marked ACBS.

  • If Biotene Oralbalance® gel is unsuccessful when used in combination with a normal toothpaste then one which does not contain sodium lauryl sulphate (e.g. Biotene toothpaste (non-prescribable)) may be tried instead.

  • Glandosane® spray available on a non-formulary basis as AS Saliva Orthana® not Kosher/Halal.




Red = Hospital use only

Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as Green by default

Amber 1 = Drugs with shared care agreement

Green + = Initiated by Hospital specialist only


Gateshead Health NHS Foundation Trust Page of Date: 22.8.2013

Drug Formulary





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