Nasal preparations for infection 607

12.2.3 Nasal preparations for infection 607

12.3 Drugs acting on the oro- pharynx

12.1.1 Otitis externa

12.3.1 Drugs for oral ulceration and inflammation

Otitis externa is an inflammatory reaction of the meatal skin. It is important to exclude an underlying chronic

12.3.2 Oropharyngeal anti-infective otitis media before treatment is commenced. Many drugs

cases recover after thorough cleansing of the external

12.3.3 Lozenges and sprays

ear canal by suction or dry mopping. A frequent pro-

12.3.4 blem in resistant cases is the difficulty in applying

Mouthwashes, gargles, and lotions and ointments satisfactorily to the relatively dentifrices

inaccessible affected skin. The most effective method

12.3.5 Treatment of dry mouth

is to introduce a ribbon gauze dressing or sponge wick soaked with corticosteroid ear drops or with an astrin-

rynx gent such as aluminium acetate solution. When this is This chapter also includes advice on the drug man- agement of the following:

not practical, the ear should be gently cleansed with a opha probe covered in cotton wool and the patient encour- allergic rhinitis, p. 604

or aged to lie with the affected ear uppermost for ten

nasal polyps, p. 604

oropharyngeal infections, p. 610 minutes after the canal has been filled with a liberal

and

periodontitis, p. 609 quantity of the appropriate solution.

e,

If infection is present, a topical anti-infective which is not used systemically (such as neomycin or clioquinol)

nos ,

may be used, but for only about a week as excessive use

Ear may result in fungal infections; these may be difficult to

treat and require expert advice. Sensitivity to the anti-

12 infective or solvent may occur and resistance to anti-

bacterials is a possibility with prolonged use. Aluminium acetate ear drops are also effective against bacterial infection and inflammation of the ear. Chlorampheni- col may be used but the ear drops contain propylene glycol and cause hypersensitivity reactions in about 10% of patients. Solutions containing an anti-infective

and a corticosteroid (such as Locorten-Vioform c ) are used for treating cases where infection is present with inflammation and eczema.

In view of reports of ototoxicity in patients with a perforated tympanic membrane (eardrum), the CSM has stated that treatment with a topical aminoglycoside antibiotic is contra-indicated in those with a tympanic perforation. However, many specialists do use these drops cautiously in the presence of a perforation in patients with otitis media (section 12.1.2) and where other measures have failed for otitis externa.

A solution of acetic acid 2% acts as an antifungal and antibacterial in the external ear canal. It may be used to treat mild otitis externa but in severe cases an anti- inflammatory preparation with or without an anti-infec- tive drug is required. A proprietary preparation contain-

ing acetic acid 2% (EarCalm c spray) is on sale to the

public.

BNF 57

12.1.1 Otitis externa 601

For severe pain associated with otitis externa, a simple Betnesol c (UCB Pharma) A analgesic, such as paracetamol (section 4.7.1) or ibu-

Drops (for ear, eye, or nose), betamethasone sodium profen (section 10.1.1), can be used. A systemic anti-

phosphate 0.1%. Net price 10 mL = £2.32 bacterial (Table 1, section 5.1) can be used if there is

Excipients include benzalkonium chloride, disodium edetate

spreading cellulitis or if the patient is systemically Dose ear , apply 2–3 drops every 2–3 hours; reduce frequency unwell. When a resistant staphylococcal infection (a

when relief obtained; eye , section 11.4.1; nose , section 12.2.1 boil) is present in the external auditory meatus, fluclox-

Vistamethasone c (Martindale) A acillin is the drug of choice; ciprofloxacin (or an

Drops (for ear, eye, or nose), betamethasone sodium aminoglycoside) may be needed in pseudomonal infec-

phosphate 0.1%. Net price 5 mL = £1.02; 10 mL = tions which may occur if the patient has diabetes or is

immunocompromised.

Excipients include benzalkonium chloride, disodium edetate

The skin of the pinna adjacent to the ear canal is often Dose ear , apply 2–3 drops every 3–4 hours; reduce frequency when relief obtained; eye , section 11.4.1; nose , section 12.2.1

affected by eczema. Topical corticosteroid creams and ointments (section 13.4) are then required, but pro-

With antibacterial longed use should be avoided.

Betnesol-N c (UCB Pharma) A Drops (for ear, eye, or nose), betamethasone sodium phosphate 0.1%, neomycin sulphate 0.5%. Net price

Astringent preparations

10 mL = £2.39

Excipients include benzalkonium chloride, disodium edetate Dose ear , apply 2–3 drops 3–4 times daily; eye , section 11.4.1;

nose ALUMINIUM ACETATE , section 12.2.3

Indications Vistamethasone N (Martindale) A

inflammation in otitis externa (see notes Drops (for ear, eye, or nose), betamethasone sodium above)

phosphate 0.1%, neomycin sulphate 0.5%. Net price Dose

5 mL = £1.09; 10 mL = £1.20 . Insert into meatus or apply on a ribbon gauze dressing

Excipients include thiomersal

or sponge wick which should be kept saturated with Dose ear , apply 2–3 drops every 3–4 hours; reduce frequency when relief obtained; eye , section 11.4.1; nose the ear drops , section 12.2.3

Aluminium Acetate (Non-proprietary) , aluminium sulphate 2.25 g, calcium

DEXAMETHASONE

Ear drops 13% carbonate 1 g, tartaric acid 450 mg, acetic acid (33%)

Indications eczematous inflammation in otitis externa

2.5 mL, purified water 7.5 mL

(see notes above)

Available from manufacturers of ‘special order’ products Cautions see notes above Ear drops 8% , dilute 8 parts aluminium acetate ear

Contra-indications see notes above drops (13%) with 5 parts purified water. Must be

Side-effects see notes above freshly prepared

With antibacterial Otomize c (GSK Consumer Healthcare) A

Ear spray Anti-inflammatory preparations , dexamethasone 0.1%, neomycin sulphate

3250 units/mL, glacial acetic acid 2%. Net price 5-mL

Corticosteroids pump-action aerosol unit = £4.24

Excipients include hydroxybenzoates (parabens) Dose ear , apply 1 metered spray 3 times daily

Topical corticosteroids are used to treat inflammation and eczema in otitis externa.

Sofradex c (Sanofi-Aventis) AU

Cautions Prolonged use of topical corticosteroid ear Drops (for ear or eye), dexamethasone (as sodium preparations should be avoided.

Ear

metasulphobenzoate) 0.05%, framycetin sulphate

nose,

0.5%, gramicidin 0.005%. Net price 10 mL = £5.21

Excipients include polysorbate 80

Contra-indications Corticosteroid ear preparations

Dose ear , apply 2–3 drops 3–4 times daily; eye , section 11.4.1

and

should be avoided in the presence of an untreated ear infection. If infection is present, the corticosteroid

FLUMETASONE PIVALATE

or

should be used in combination with a suitable anti-

(Flumethasone Pivalate)

opharynx

infective (see notes above). Indications eczematous inflammation in otitis externa

(see notes above)

Side-effects Local sensitivity reactions may occur. Cautions see notes above Contra-indications see notes above Side-effects see notes above

BETAMETHASONE SODIUM PHOSPHATE With antibacterial

Locorten-Vioform c (Amdipharm) A Indications eczematous inflammation in otitis externa

Ear drops , flumetasone pivalate 0.02%, clioquinol 1%. (see notes above)

Net price 7.5 mL = £1.47 Cautions see notes above

Contra-indications iodine sensitivity Contra-indications see notes above

Dose ADULT and CHILD over 2 years apply 2–3 drops into the ear twice daily for 7–10 days

Side-effects see notes above Note Clioquinol stains skin and clothing

12.1.1 Otitis externa BNF 57

HYDROCORTISONE Anti-infective preparations

Indications eczematous inflammation in otitis externa (see notes above)

CHLORAMPHENICOL U

Cautions see notes above Indications bacterial infection in otitis externa (but Contra-indications see notes above

see notes above) Side-effects see notes above

Cautions avoid prolonged use (see notes above) Side-effects high incidence of sensitivity reactions to

With antibacterial

vehicle

Chloramphenicol (Non-proprietary) Ear drops

AU 0.3% (as sulphate). Net price 10 mL = £3.69

Gentisone c HC (Amdipharm) A , hydrocortisone acetate 1%, gentamicin

Ear drops , chloramphenicol in propylene glycol, net

Excipients include benzalkonium chloride, disodium edetate

price 5%, 10 mL = £1.83; 10%, 10 mL = £5.62 Dose ear , apply 2–4 drops 3–4 times daily and at night

Dose ear , apply 2–3 drops 2–3 times daily Neo-Cortef c (PLIVA) A

CLIOQUINOL

Ointment (for ear or eye), hydrocortisone acetate

1.5%, neomycin sulphate 0.5%. Net price 3.9 g = £1.53 Indications mild bacterial or fungal infections in otitis

Excipients include wool fat

externa (see notes above) Dose ear , apply 1–2 times daily; eye , see section 11.4.1 Note May be difficult to obtain

Cautions avoid prolonged use (see notes above); manufacturer advises avoid in perforated tympanic Otosporin c (GSK) AU

membrane (but used by specialists for short periods) Ear drops , hydrocortisone 1%, neomycin sulphate

Side-effects local sensitivity; stains skin and clothing 3400 units, polymyxin B sulphate 10 000 units/mL.

Net price 5 mL = £2.00; 10 mL = £4.00 With corticosteroid

Excipients include cetostearyl alcohol, hydroxybenzoates (parabens), polysorbate 20

Locorten-Vioform c see Flumetasone, p. 601 Dose ADULT and CHILD over 3 years, ear , apply 3 drops 3–4 times

daily

CLOTRIMAZOLE

Indications fungal infection in otitis externa (see notes

PREDNISOLONE SODIUM above) Side-effects PHOSPHATE occasional local irritation or sensitivity

rynx

Canesten Indications c (Bayer Consumer Care) eczematous inflammation in otitis externa

Solution , clotrimazole 1% in polyethylene glycol 400

(see notes above) or Cautions

opha

(macrogol 400). Net price 20 mL = £2.43 see notes above

Dose ear , apply 2–3 times daily continuing for at least 14 days Contra-indications see notes above

after disappearance of infection; skin , section 13.10.2

and Side-effects see notes above

e, Predsol c (UCB Pharma) A FRAMYCETIN SULPHATE , nos

Drops (for ear or eye), prednisolone sodium phos- Indications bacterial infection in otitis externa (see phate 0.5%. Net price 10 mL = £2.00

notes above)

Ear

Dose ear avoid prolonged use (see notes above)

Excipients include benzalkonium chloride, disodium edetate

Cautions