OBAT PADA KELAINAN THT

OTITIS EXTERNA

1. Acute edematous otitis externa (Swimmer’s Ear)

2. Eczematoid dermatitis with secondary infections

3. True otomycosis

(Swimmer’s Ear) * Inflammations edema and pain.

1. Acute edematous otitis externa

* Cleansing the ear canal with a suction apparatus. (acetic acid – corticosteroids – antibacterial

solutions irigations or topical ear drop 4 times a day).

* Neomycin, framycetin, polymixin-B, gentamycin or
ciprofloxacin.

2. Infected eczematoid dermatitis

inflammations edema, itching and pain. *

* cleansing the ear canal with a suction apparatus (ethanol 75 –

90%), Burow’s solution (saturated -alumonium acetat) 3 times a day

for 3 days.

- corticosteroids – antibacterial solutions (7 days)

3. Otomycosis

Ear canal cleansing with antifungal solutions * (tolnaftate 1%, cresylate solutions : merthiolate, m-cresyl acetate, propylane glycol, boric acid, ethanol) Gentian violet 10%, antifungal powder : nystatin or * clioquinol (iodochlorhydroxyquinoline). Tolnaftate 1% ear drop twice a day * Clotrimazole 1% topically for Aspergillus or Candida *

4. Acute Furunculosis

Analgesic opiate may be needed at first 24 hours and to be continued with NSAIDs, * Cleansing of the ear canal (70% alcohol).
Gentamycin or solution of Burrow may be applied.

5. Malignant otitis externa * Rapidly progressive disorders.

(associated with DM, malnutritions or anemia).

Parenteral gentamycin.

OTITIS MEDIA

1. Acute Otitis Media a. Common in infants.

b Suppurative or effusion (serous or catarrhal).

c. Perforate or nonperforate.

d. Purulent otitis media (suppurative)

TO TREAT OR NOT TO TREAT?

Assess severity of infection
May not to treat the older children who are afebrile
Ensure you have adequate follow up if patient is not treated
Treat children < 2 years, with increased risk of otitis media

THE THERAPY OF

Amoxicillin remains frst line antibiotic Standard versus high doses
Follow up in 48 - 72 days
Treatment failures should be treated with
amoxicillin-clavulinic, cefuroxime axetil or ceftriaxone
Tympanocentesis is indicated for treatment failures
Children > 2 years
symptomatic therapy for 3 days

re-evaluate if symptoms persist
antibiotics for 7 >Children < 2 years
symptomatic treatment for 1 day
re-evaluate if symptoms persist, give antibio
Continued observation in all cases

TREATMENT FAILURES

Lack of clinical improvement in signs and symptoms such as ear pain, fever and tympanic membrane fndings of redness, bulging or otorrhea after 3 days of therapy Due to inefective drug or viral infection
Not every failure is due to a resistant bug

DURATION OF THERAPY

1 dose versus 5 days versus 10 days
27 clinical trials show no diference in outcome
Shorter duration will improve compliance and increase likelihood the course will be completed

ANTIMICROBIAL RESISTANCE

S. pneumoniae 30-40% penicillin

resistant

H. infuenzae 30-40% -lactamase

positive M. catarrhalis 80-90% -lactamase

positive

REASONS FOR INCREASING RESISTANCE

Inappropriate drugs: resistant organism, wrong or unusual pathogen
Appropriate drug but inadequate dose
Poor compliance
Subinhibitory concentrations with inadequate levels

WAYS TO REDUCE RESISTANCE

Increase accuracy of diagnosis
New antimicrobials
Avoid chemoprophylaxis
New vaccines
Educate parents, ensure they complete a course of antibiotic
Investigate other types of therapy

ACUTE OTITIS MEDIA: ANTIBIOTIC SELECTION Accurate diagnosis

Local resistance patterns Assess for risk factors for resistance

ANTIMICROBIAL SELECTION

Antibiotics Convenien ce Cost Efficacy Safety

ANTIBIOTICS FOR ACUTE OTITIS MEDIA:

Amoxicillin
Ceftibuten
Amoxicillin-clavulinic
Cefuroxime axetil
Azithromycin
Ceftriaxone
Cefaclor
Clarithromycin
Cefdinir
Clindamycin
Cefxime
Erythro/sulfa
Cefpodoxime
TMP/SMX
Cefprozil

AMOXICILLIN

Still drug of choice
Safe, well tolerated and inexpensive
Usually efective against S. pneumoniae
and H. infuenzae
• Higher doses have greater efcacy against
more strains of S. pneumoniae
Studies show comparative clinical efcacy

PENICILLINS S. pneumoniae H. infuenzae

Amoxicillin
Amoxicillin (80-100 mg/kg/d)

Amoxicillin/

Clinical efcacy varies
Cefprozil, cefuroxime, cefpodoxime and ceftriaxone IM have greater efcacy against pneumococci Cefuroxime, cefpodoxime and ceftriaxone IM efective
against both S. pneumoniae and H. infuenzae

CEPHALOSPORINS S.pnuemoniae H. infuenzae

Cefaclor

Cefxime
Cefuroxime ++++ Cefprozil

Ceftibuten

Ceftriaxone
Cefpodoxime

OTHER ANTIBIOTICS

Macrolides, TMP/SMX and clindamycin are not as good as the cephalosporins • TMP/SMX has good efcacy against H.

infuenzae but not S. pneumoniae Clindamycin efective against many

penicillin resistant pneumococci but is inefective against H. infuenzae

MACROLIDES/OTHER ANTIBIOTICS

S. pneumoniae H. infuenzae

Clarithromycin
Azithromycin +++ +++ Erythro/sulfa

Trimeth/sulfa

Clindamycin

Advantages
short duration 3 days
compliance better
efcacious against all 3 organisms
alteration of gut fora is less
Disadvantages
painful injections multiple
expensive

ACUTE OTITIS MEDIA: FOLLOW UP

Follow up in 3 days if still symptomatic
3-6 weeks of asymptomatic

OTITIS MEDIA: RECURRENT

Defned as 3 or more episodes/6 months or 4 or more episodes/12 months
• Reappearance of signs and symptoms 5-
14 days after completing treatment
failure so may be treated with the same antibiotics

Due to new infection, not treatment

Prophylaxis 44% reduction of AOM

OTOTOXICITY

Defnition
Damage to the cochlea or vestibular apparatus from exposure to a chemical source
Many sources
Mercury
Herbs
Streptomycin
Dihydrostreptomycin

Some drugs have been associated with impaired auditory or vestibular function. The risk of ototoxicity is greatly increased in
patients with impaired renal function

elderly patients
follo>a high dose
or a large total dose of an ototoxic drug over a prolonged period of
if there has been a previous course or concurrent administration of another ototoxic drug.

adjust the dose of an ototoxic drug on

AMINOGLYCOSIDES

Streptomycin
Kanamycin
Neomycin
Amikacin
Gentamicin
Tobramycin
Sisomycin
Netilmicin Enter into inner ear by unknown mechanism

Diferential ototoxicity of aminoglycosides Drug Vestibular Auditory Early symptoms toxicity toxicity Tinnitus Vertigo

Streptomycin
Gentam
Tobramycin

?+ ?+

Amikacin

?+ ? ? ++ +++ + Kanamycin

Neomycin

? ++++

Netilmicin

?+ ?+

Sisomicin

MACROLIDES

Discovered erythromycin 1952 (McGuire)
Mintz (1972) frst report of ototoxicity
Reversible 50-55 dB losses in two cases
Clinically
Hearing loss with/without tinnitus– 2 days
All frequencies, recovery after stopping
Rarely permanent (hepatic)
Incidence unknown

MACROLIDES

Mechanism unknown
Azithromycin and clarithromycin can cause similar fndings in animals

OTHER ANTIBIOTICS

Vancomycin
Believed to be ototoxic
Penicillin, sulfonamides, cephalosporins
May have topical toxicity in middle ear
Nucleoside analog reverse transcriptase inhibitors
Poor study

LOOP DIURETICS

Ethacrinic acid, furosemide, bumetaside
Clinically (6-7%)
Usually tinnitus, temporary and reversible SNHL (sensory neural hearing loss), rare vertigo within minutes High doses can cause permanent SNHL

LOOP DIURETICS

Pathologically

Edema of stria vascularis Ionic gradient changes

Inhibition of adenylate cyclase and G-
proteins

SALICYLATES AND NSAIDS

Most common OTC
Mechanism
Normal histology (no hair cell loss)
Decreased blood fow, decreased enzymes
Clinically
Tonal, high frequency tinnitus (7-9 kHz)
Reversible mild to moderate SNHL (usually high frequency)– rarely permanent

QUININE

Similar clinical fndings with aspirin
Usage up for leg cramps
Clinically
High-pitched tinnitus
Reversible, symmetric SNHL
Occasional vertigo
Mechanism
Decreased perfusion, direct damage to outer

ANTINEOPLASTIC AGENTS

Cisplatin Incidence is high (62%-81%)

Pathologically

Outer hair cell degeneration Clinically
Bilateral symmetric SNHL, usually high frequency– not
reversible, cumulative Risks factors– age extremes, cranial irradiation, high dose
therapy, high cumulative dose

TOPICAL ANTIMICROBIALS

Commonly prescribed for otorrhea after tubes and CSOM
Controversial subject Agents may enter middle ear and gain access to membranous

TOPICAL ANTIMICROBIALS

Polymixin B
Chloramphenicol
Neomycin
Gentamicin
Ticarcillin
Vasocidin
Ciprofoxacin

TOPICAL ANTIMICROBIALS

Remains a possibility in humans
Patient education important
Prescribe for only necessary duration
Avoid in healthy ear
Caution with prexisting vestibular defects

NOSE DISORDERS

* A condition characterized by :

excessive watery secretions of nasal mucosa infection discharge (become purulent)

RHINORRHEA

manifestation of nasal irritation caused by :

chemical inhalants
allergic reaction in the nasal mucosa
infection (viral or baterial)

involves some chemical mediators (histamine, PGs,

ect.)

COMMON COLD

Symptoms – signs

Fever - Headache / muscleache
Nasal congestion rhinorrhea
Cough / sore throat
Malaise

DRUGS FOR NASAL DISCHARGE

1. Irritative infamation

antiinfamatory drugs (short term corticosteroids if really necessary)

2. Allergic infammation

anti-allergic – anti-infammatory drugs (H -blockers, ₁ short term corticosteroids)

3. Infectious infammation

systemic anti-infective (antibiotics / chemotherapy - antiviral)

- Analgesics – antipyretics - Antihistamines (H

₁

-blockers)
- Antitusive (dextrometorphan) or

expectorants (bromhexin)

DRUGS FOR COMMON

COLD
- Sympatomimetics
DRUGS FOR RHINORRHEA
(COMMON COLD)
- (local – systemics, selectives – nonselecti
stimulants)
Sympathomimetics ( ₁
- Antihistamines (H -blockers)
_{1<- Antiinfamatory drugs
corticosteroids
ketotifen, chromolyn}
SYMPATHOMIMETIC DRUGS
To treat Inflamed nasal, sinus, and eustachian tube mucosa -adrenoceptor agonists pseudoephedrine phenilephrine, oxymetazoline, and phenylpropanolamine xylometazoline produce a smooth muscle contraction & an open nasal
ANTIHISTAMINES Second-generation
First generation (nonsedating):
(sedating) Acrivastine Astemizole
Chlorpheniramine Azelastine Cetirizine
Diphenhydramine Levocabastine Loratadine
Diphenylpyraline RATIONAL DRUG USE OF ANTIBIOTICS
May be / have to be based on :
Suspect microorganism (scientifc guessing)
Evidence based – clinical - trial
Efective and safe
minimal risk of side efects or toxic efects
Pharingitis & Tonsilitis Upper respiratory tract infection

Caused by viruses (90%) Do not respond to antibacterial drugs
Begin an antypiretic/analgesic drugs for symptomatic treatment
Visible pus on the Throat swab, await the results tonsil or elsewhere

OBAT PADA KELAINAN THT