CHAPTER 12 EAR, NOSE AND THROAT (ENT)

12.01 DRUGS FOR EAR INFECTION, OTITIS EXTERNA

 

CLOTRIMAZOLE (EAR)

Mode of action
Impair biosynthesis of ergosterol for cytoplasmic membrane, inhibiting fungal growth; fungistatic.
Indications
Dermatophytoses; Mucocutaneous candidiasis, including paronychia; Pityriasis versicolor; Dermatophytoses; Pityriasis versicolor; Seborrhoeic dermatitis.
Specific considerations
Pregnancy: safe to use; ADEC category A.
Lactation: safe to use.
Adverse effects
Topical imidazoles are generally well tolerated.
Infrequent: burning, stinging, itch, erythema.
Rare: allergic reactions.
Dosage
Apply sparingly twice a day.
Patient counselling
Regular application is essential for successful treatment.
Complete the full treatment course even if signs of infection have sisappeared.
Attention to hygiene is important in the management of fungal disease of the feet; after washing, dry feet thoroughly, especially between toes.
Practice points

·         continue treatment for 2–4 weeks in dermatophytoses

·         use sparingly, especially in intertriginous areas, to avoid maceration

·         creams are preferred; powders may be used on feet, moist lesions of the groin and intertriginous areas with creams or to prevent reinfection

·         intractable candidiasis may be the presenting symptom of undiagnosed diabetes; appropriate urine and blood tests may be indicated in patients not responding to treatment

·         topical imidazoles are not usually successful in treating infections of the nails or hair

Products

CLOTRIMAZOLE EAR DROPS 1 %   10-20 ML BOTTLE (CLOTREX OTIC®, OTOZOL®)


POLYMYXIN B+NEOMYCIN+HYDROCORTISON (EAR)
   
HYDROCORTISONE ACETATE
NEOMYCIN SULFATe

Neomycin is an aminoglycoside antibiotic used topically in the treatment of infections of the skin, ear, and eye due to susceptible staphylococci and other organisms

Polymyxin B Sulfate

Polymyxin B sulfate is used topically, often with other drugs, in the treatment of skin, ear, and eye infections due to susceptible organisms.

Hydrocortisone possesses anti-inflammatory, anti-allergic and anti-pruritic activity

For topical application polymyxin B is usually available as a 0.1% solution or ointment, in combination with other drugs

Lidocaine Hydrochloride

Products

POLYMYXIN B SULFATE 10,000 IU/ML+NEOMYCIN SULFATE 3.400 IU/ML+ HYDROCORTISON 1 %  EAR DROPS   5 ML BOTTLE  (OTOSPORIN®)

 

12.03 DRUGS FOR VESTIBULAR DISORDERS

Tinnitus
Tinnitus may be idiopathic or associated with hearing loss; it can be a prominent feature of Ménière's disease, see Vertigo.
Before starting treatment
It may be associated with common and treatable conditions, eg ear wax or otitis media.
If tinnitus is unilateral refer to an ENT specialist to exclude retrocochlear pathology, eg acoustic neuroma.
Consider drug associations, eg salicylates, NSAIDs, aminoglycosides, loop diuretics, aspartame.
Drug choice
Many different approaches to drug treatment have been tried. There is little evidence of benefit for most interventions.
Tricyclic antidepressants may be of some benefit but their adverse effects may limit use (especially in older patients).
Practice points

·         hearing aids may help by increasing awareness of surrounding ambient noise

·         there is insufficient evidence to support the use of masking devices (they produce sound to cover tinnitus symptoms)

Vertigo
It is important to distinguish peripheral pathology (nystagmus and hearing loss usually present) from CNS or inner ear pathology (nystagmus usually absent, hearing loss rare).
In many cases vertigo is mild and self-limiting and a cause will not be found.
There is little evidence of benefit for most drugs used for vertigo.
Special cases
Benign paroxysmal positional vertigo
Severe, short-lasting vertigo induced by certain head positions.
Postural retraining using a sequence of movements called the Epley manoeuvre is useful.
Medication is usually ineffective.
Severe persistent symptoms may require surgery.
Vestibular neuronitis (labyrinthitis)
Inflammation of the vestibular nerve, frequently caused by a virus. It is usually self-limiting and may cause severe vertigo associated with nausea, vomiting and nystagmus.
Acute attacks may be treated as for
Ménière's disease. Continual vomiting may require IV fluids.
Ménière's disease
Ménière's disease involves recurrent attacks of vertigo, tinnitus and hearing loss. Restrict salt intake and avoid cigarettes, alcohol, caffeine and CNS stimulants.
Prochlorperazine or antihistamines are used for symptomatic relief of acute attacks; avoid long term use. See
Antihistamines (antiemetic).
Betahistine, with or without diuretics, may be effective for long term control of vertigo, dizziness or imbalance, but does not improve hearing.
Surgery is an option if medical treatment fails.

 

BETAHISTINE

Mode of action
Vasodilator, thought to improve blood flow to labyrinth and brain stem.
Indications
Ménière's disease.
Contraindications
Phaeochromocytoma; History of peptic ulcer; Asthma (Use with caution); Porphyria.
Specific considerations
Urticaria: may be exacerbated.
Children: avoid use in children <12 years.
Pregnancy: limited data; ADEC category B2.
Lactation: unlikely to be of concern.
Adverse effects
Rare: GI disturbances, headache, fatigue, dizziness, vasodilation, hypotension, bronchospasm, rash, angioedema.
Dosage
8–16 mg 3 times a day.
Patient counselling
Response may be rapid or take several weeks.

Products

BETAHISTINE TABS  8 MG (BETASERC®, BETASTIN®)

BETAHISTINE TABS 16 MG (BETASERC®, BETASTIN®)

 

CINNARIZINE

Mode of action
Cinnarizine is a piperazine derivative with antihistamine, sedative, and calcium-channel blocking activity.
It acts by interfering with the signal transmission between vestibular apparatus of the inner ear and the vomiting centre of the hypothalamus. The disparity of signal processing between inner ear motion receptors and the visual senses is abolished, so that the confusion of brain whether the individual is moving or standing is reduced.

Indications
Symptomatic treatment of nausea and vertigo caused by Ménière's disease and other vestibular disorders and for the prevention and treatment of motion sickness.
Contraindications
See under antihimines.
Specific considerations
See under antihimines.
Adverse effects
Rare: As for the sedating antihistamines in general . Adverse effects also include: GI disturbances, fatigue, drowsiness, blurred vision, wight gain, sweating, lichen planus, and lupus-like reactions,  extrapyramidal symptoms associated with depressive feelings.

Dosage
Vertigo and vestibular disorders: 30 mg three times daily by mouth.

Motion sickness a dose of 30 mg is taken 2 hours before the start of the journey and 15 mg every 8 hours during the journey if necessary.

Children aged 5 to 12 years are given half the adult dose for both indications.

Products

CINNARIZINE TABS 25 MG (CINAR®, STUGERON®, VERTIZIN®)

CINNARIZINE TABS/CAPS 75 MG (CEREPAR®, CINAR®, STUGERON FORTE®, VERTIZIN ®)

 

FLUNARIZINE

Mode of action
Flunarizine is the difluorinated derivative of cinnarizine. It has antihistamine, sedative, and calcium-channel blocking activity.

Indications
Migraine prophylaxis; Vertigo and vestibular disorders; Peripheral and cerebral vascular disorders; As adjunctive antiepileptic therapy in patients refractory to standard regimens.
Contraindications
Hypersensitivity to flunarizine; Patients with a history of depressive illness, or with pre-existing symptoms of Parkinson's disease or other extrapyramidal disorders..
Adverse effects
Common: Drowsiness, fatigue, weight gain, increased appetite.
Infrequent: depression, extrapyramidal symptoms (such as bradykinesia, rigidity, akathisia, orofacial dyskinesia, tremor).
Rare: heartburn, nausea, gastralgia, insomnia, anxiety, galactorrhoea, dry mouth, muscle ache, skin rash.

Dosage
Migraine Prophylaxis
Starting Dose:
10 mg at night in patients less than 65 years of age and 5 mg daily in patients older than 65 years.

Maintenance Treatment:
If a patient is responding satisfactorily and if a maintenance treatment is needed, the dose should be decreased to 5 days treatment at the same daily dose with two successive medicine free days every week.
Even if the prophylactic maintenance treatment is successful and well tolerated, it should be interrupted after 6 months and it should be re-initiated only if the patient relapses.
Vertigo
The same dosage should be used as for migraine, but the starting treatment should not be given longer than needed for symptom control, which generally takes less than two months.

Patient counselling
Flunarizine may lead to drowsiness which is aggravated by the simultaneous intake of alcohol or other central nervous system depressants.
Patients should be cautioned against driving motor vehicles or performing other potentially hazardous tasks where a loss of mental alertness may lead to accidents.
Flunarizine
is not suited for aborting a migraine attack. The possible occurrence of an attack is therefore no reason to increase the dose.

This treatment may give rise to extrapyramidal and depressive symptoms and reveal Parkinsonism, especially in predisposed patients such as the elderly. Flunarizine should therefore be used with caution in such patients.

Products

FLUNARIZINE CAPS 5 MG (SIBELIUM®)

 

12.04 DRUGS FOR RHINITIS AND SINUSITIS

Rhinitis
Rhinitis is an inflammation of the lining of the nose causing congestion, rhinorrhoea, sneezing and itching; classified as acute (infectious), allergic (hay fever) or other (including drug-induced, irritant, occupational).
Acute rhinitis
Usually viral (common cold); no specific treatment has been found to be effective.
Steam inhalations and sodium chloride 0.9% nose drops or spray may help to thin nasal secretions and decrease nasal congestion and irritation.
Oral decongestants may help; intranasal decongestants should be used only for a limited time (eg 4–5 days) due to risk of rebound mucosal congestion, which may take several weeks to resolve.
Use of antihistamines or corticosteroids is not indicated.
Allergic rhinitis
Seasonal or perennial symptoms, eg sneezing and rhinorrhoea, are due to a type 1 hypersensitivity reaction.
Where possible, identify and avoid allergen.
Usually a combination of drugs is required to relieve symptoms.
Drug choice
See
Table 12 -03 Symptomatic treatment of allergic rhinitis in adults( If this table is to be added, then it should be renamed eg 12.1)
Intranasal corticosteroids are first line treatment in moderate to severe cases; a combination of an intranasal antihistamine with an intranasal decongestant (if needed) is an effective alternative.
Intranasal corticosteroids reduce inflammation and decrease mucus production. Although maximum effect is achieved after several days of regular use, they have an effect on symptoms such as blocked nose and rhinorrhoea within 3–7 hours of starting treatment. They are still effective if used on an as-needed basis.
Intranasal antihistamines are less effective than intranasal corticosteroids; treatment with an intranasal decongestant (4–5 days) may also be needed to control symptoms.
Oral antihistamines,
sedating antihistamines and less sedating antihistamines appear to be equally effective, but are less effective than other treatments.
Intranasal mast cell stabilisers, eg cromoglycate, may be preferred to corticosteroids in children.
Intranasal anticholinergics, eg ipratropium, may be useful when rhinorrhoea is the dominant problem.
Oral corticosteroids (short course) are used rarely for disabling symptoms or if polyps are present (see
Prednisone/prednisolone).
Decongestants reduce nasal congestion but have no effect on other symptoms. Oral decongestants commonly cause symptoms of CNS stimulation, eg insomnia, irritability. Prolonged use of intranasal agents causes rebound congestion. However, short term treatment (4–5 days) may be useful (with other treatments) if congestion is a problem.
Desensitization may be tried if an allergen is identified and other treatments have failed.
Other causes of rhinitis
Include environmental irritants (eg heat, cold, smoke, dust); hormonal causes (no treatment advised during pregnancy); drug-induced rhinitis (eg beta-blockers, oral contraceptives, aspirin, NSAIDs, ACE inhibitors); diet (eg alcohol, spicy foods); and emotional factors.
Response to drug treatment is variable. Management involves identifying and avoiding precipitating factors.
Ensure symptoms are not due to excessive use of intranasal decongestants, causing rebound congestion.
Oral decongestants, intranasal corticosteroids and, in some cases, ipratropium nasal spray, may be useful if non-drug measures fail.

Sinusitis
Acute sinusitis
Acute sinusitis is often viral or allergic and may be managed symptomatically.
Analgesics, eg paracetamol or NSAIDs, relieve pain and fever. Steam inhalations, intranasal or oral decongestants, or sodium chloride 0.9% nasal drops and sprays may increase drainage of exudate and improve symptoms.
Consider antibacterials if there is: poor response to decongestants, maxillary toothache, tenderness over the sinuses, headache, mucopurulent discharge for >1 week or prolonged fever. Amoxycillin is preferred in uncomplicated cases.
Seek ENT specialist advice if:

·         there is poor response after 5–7 days of antibacterial treatment

·         signs of abscess formation or infection spread beyond sinuses

·         frequent acute attacks, eg 3–6 per year (depending on severity), or persistent (chronic) symptoms.

Chronic sinusitis
Continued symptoms require further investigation. Anaerobic bacteria and/or chronic allergic rhinitis may be involved. Management may include local or systemic corticosteroids, decongestants, antihistamines, nasal lavage, antibacterials, and/or surgery.

 

12.04.01 Nasal Sympathomimetic Decosgestants

XYLOMETAZOLINE

Mode of action
Produce vasoconstriction in nasal mucosa; decrease nasal blood flow and congestion.
Indications
Relief of nasal congestion associated with acute and chronic rhinitis, common cold, sinusitis; Facilitate intranasal examination.
Contraindications
MAOI treatment.
Specific considerations
Children: Avoid use in infants <6 months as rebound congestion may cause breathing difficulty. CNS effects are more common in children.
Adverse effects
Rarely associated with systemic effects.
Common: transient burning, stinging, increased nasal discharge, rebound congestion with prolonged use (4–5 days)
Rare: hypertension, nausea, nervousness, dizziness, drowsiness, insomnia, headache
Dosage
Adult, child >12 years: Nasal drop 0.1%, 2–3 drops into each nostril up to 3 times daily.
Child >6 years: Nasal drop 0.05%, 2–3 drops into each nostril up to 3 times daily.
Child 6 months – 6 years: Nasal drop 0.05%, 1 drop into each nostril up to 3 times daily.
Practice points

·         encourage use of sodium chloride 0.9% solution (nasal drops, irrigation or spray) in preference to a topical sympathomimetic, especially for children

·         do not use in infants <6 months of age; if nasal congestion impairs feeding, use sodium chloride 0.9% nose drops (a few drops in each nostril just before feed) to loosen and liquefy mucus secretions

·         keep dose and length of treatment to a minimum (maximum duration of treatment 5 days) to reduce risk of rebound congestion (may take several weeks to reverse)

·         oral products, eg pseudoephedrine, are preferred for prolonged use

Products

XYLOMETAZOLINE NASAL DROPS 0.05 % (AS HCL)   10 ML BOTTLE (DECOZAL®, DECOZOLINE®, OTRIVIN®)

XYLOMETAZOLINE NASAL DROPS 0.1 % (AS HCL)   10 ML BOTTLE (DECOZAL®, DECOZOLINE®)

 

12.04.02 Corticostereoids (Nasal)

BECLOMETHASONE (NASAL)
Mode of action
Produce local anti-inflammatory effects, decrease capillary permeability and mucus production, and produce vasoconstriction in the nasal mucosa.
Indications
Allergic rhinitis.

Contraindications
Severe nasal infection; Allergy to particular corticosteroid.
Specific considerations
Bleeding disorders: may cause nose bleeding.
Recent nasal surgery or trauma: may delay healing.
Pregnancy: safe to use.
Lactation: safe to use.
Adverse effects
Systemic adverse effects are rare with nasal preparations used at recommended doses.
Common: nasal stinging, itching, sneezing, sore throat, dry mouth, cough.
Infrequent: nose bleed.
Rare: nasal septal perforation, glaucoma, cataract, allergic reactions (urticaria, angioedema, bronchospasm, rash).
Dosage
Adult, 2 sprays into each nostril twice daily. Dose may be reduced to 1 spray into each nostril twice daily when symptoms controlled.
Child 3–12 years, initially 1 spray into each nostril twice daily; reduce to 1 spray into each nostril once daily when symptoms controlled.
Practice points

·         nasal corticosteroids are similarly effective

·         onset of action within 3–7 hours; effective on an as-needed basis; optimum effect after several days of regular use

·         patients transferred from oral to nasal corticosteroids may have impaired adrenal function; nasal corticosteroids have little systemic effect

Products

BECLOMETHASONE DIPROPIONATE NASAL SPRAY 50 MCG/DOSE (BECLOMETHASONE DIPRO®, BECONASE®, RINO CLENIL®)

 

BUDESONIDE (NASAL)
Mode of action
Produce local anti-inflammatory effects, decrease capillary permeability and mucus production, and produce vasoconstriction in the nasal mucosa.
Indications
Rhinitis (allergic and non-allergic); Nasal polyposis; Nasal polyposis (beclomethasone, budesonide, fluticasone).
Contraindications
Severe nasal infection; Allergy to particular corticosteroid.
Specific considerations
Bleeding disorders: may cause nose bleeding.
Recent nasal surgery or trauma: may delay healing.
Pregnancy: safe to use.
Lactation: safe to use.
Adverse effects
Systemic adverse effects are rare with nasal preparations used at recommended doses.
Common: nasal stinging, itching, sneezing, sore throat, dry mouth, cough.
Infrequent: nose bleed.
Rare: nasal septal perforation, glaucoma, cataract, allergic reactions (urticaria, angioedema, bronchospasm, rash).
Dosage
Rhinitis: Adult, child >6 years, initially 128 micrograms into each nostril once daily or 64 micrograms into each nostril twice daily; maintenance 32–64 micrograms into each nostril once daily.
Nasal polyps: Adult, 64 micrograms into each nostril twice daily.
Practice points

·         nasal corticosteroids are similarly effective

·         onset of action within 3–7 hours; effective on an as-needed basis; optimum effect after several days of regular use

·         patients transferred from oral to nasal corticosteroids may have impaired adrenal function; nasal corticosteroids have little systemic effect

Products

BUDESONIDE NASAL SPRAY 100 MCG/DOSE (AQUA) 200 DOSE (ESONIDE®)

 

FLUTICASONE (NASAL)

Mode of action
Produce local anti-inflammatory effects, decrease capillary permeability and mucus production, and produce vasoconstriction in the nasal mucosa.
Indications
Allergic rhinitis (spray); Nasal polyposis (drops); Rhinitis (allergic and non-allergic); Nasal polyposis.
Contraindications
Severe nasal infection; Allergy to particular corticosteroid.
Specific considerations
Bleeding disorders: may cause nose bleeding.
Recent nasal surgery or trauma: may delay healing.
Pregnancy: safe to use.
Lactation: safe to use.
Adverse effects
Systemic adverse effects are rare with nasal preparations used at recommended doses.
Common: nasal stinging, itching, sneezing, sore throat, dry mouth, cough.
Infrequent: nose bleed.
Rare: nasal septal perforation, glaucoma, cataract, allergic reactions (urticaria, angioedema, bronchospasm, rash).
Dosage
Allergic rhinitis: Adult, child >12 years, initially 2 sprays into each nostril once daily, then 1 spray into each nostril once daily.
Nasal polyposis: >16 years, instil drops from 1 container into both nostrils, once or twice daily.
Practice points

·         nasal corticosteroids are similarly effective

·         onset of action within 3–7 hours; effective on an as-needed basis; optimum effect after several days of regular use

·         patients transferred from oral to nasal corticosteroids may have impaired adrenal function; nasal corticosteroids have little systemic effect,

Products

FLUTICASONE NASAL SPRAY 50 MCG/DOSE (AS PROPIONATE)   120 DOSE BOTTLE (FLIXONASE®)

 

12.04.03 Other Drugs (Nasal)

DIMETINDENE+ PHENYLEPHRINE

Mode of action
Dimetindene maleate, an alkylamine derivative, is a sedating antihistamine; it is mildly sedative and is reported to have mast-cell stabilising properties. Phenylephrine is a sympthomimetic amine. Due to its selective action on Ü1-adrenergic receptors of the cavernous venous tissue of the nasal mucosa, phenylephrine is a gentle vasoconstrictor, which allows rapid and durable decongestion of the nasal fossae.
Indications
Common colds; Acute and chronic rhinitis; Seasonal (hay fever) and non-seasonal allergic rhinitis; Acute and chronic sinusitis; Pre- and postoperative care; adjuvant in cases of acute otitis media.
Contraindications

Hypersensitivity to any of the active principles; Atrophic rhinitis; Patients taking MAO inhibitors.

Specific considerations
Pregnancy: no data available.
Lactation: no data available.
Adverse effects.
Infrequent: local and transient sensation of smarting dryness of the nose.
Rare: allergic reactions.
Dosage
Apply sparingly 3 to 4 times a day.
Practice points

·         don’t  use continuously for more than 2 weeks. If the symptoms persist, consult a doctor.

·         prolonged or excessive use may lead to tachyphylaxis, rebound congestion or drug-induced rhinitis.

 

Products

DIMETINDENE 0.025 GM+PHENYLEPHRINE 0.25 GM NASAL GEL (VIBROCIL®)

DIMETINDENE 0.025 GM+PHENYLEPHRINE 0.25 GM NASAL SPRAY (VIBROCIL®)

 

IPRATROPIUM (NASAL)
Mode of action
Dries nasal secretions and may reduce rhinorrhoea associated with non-allergic rhinitis.
Indications
Rhinorrhoea associated with allergic and non-allergic rhinitis, and common cold.
Contraindications
Allergy to ipratropium.
Specific considerations
Narrow angle glaucoma: may exacerbate.
Pregnancy: safe to use; ADEC category B1.
Lactation: safe to use.
Adverse effects
Common: nasal dryness, nosebleed, dry mouth, altered taste.
Rare: visual accommodation disturbance, urinary retention, allergic reactions (urticaria, angioedema, rash, bronchospasm).
Dosage
Rhinorrhoea (allergic or non-allergic rhinitis)
For adults and children >12 years.

Initially 42-84 micrograms into each nostril 2–3 times daily, then reduce dose as rhinorrhoea improves.
Rhinorrhoea (common cold)
Initially 84 micrograms into each nostril 3–4 times daily, then reduce dose as rhinorrhoea improves; use for up to 4 days.

Products

IPRATROPIUM NASAL SPRAY 0.03 %(21 MCG/DOSE)   180 DOSE BOTTLE (ATROVENT®)

 

12.05 DRUGS ACTING ON THE OROPHARYNX

CHLORHEXIDINE MOUTH WASH 

Adverse Effects and Treatment

Skin sensitivity to chlorhexidine has occasionally been reported. Strong solutions may cause irritation of the conjunctiva and other sensitive tissues. The use of chlorhexidine dental gel and mouthwash has been associated with reversible discoloration of the tongue, teeth, and silicate or composite dental restorations. Transient taste disturbances and a burning sensation of the tongue may occur on initial use.

The main consequence of ingestion is mucosal irritation and systemic toxicity is rare.

Precautions

Oral hygiene.

As toothpastes may contain anionic surfactants such as sodium laurilsulfate, which are incompatible with chlorhexidine, it has been recommended that at least 30 minutes should be allowed to elapse between the use of toothpaste and oral chlorhexidine preparations.  

Uses and Administration

Chlorhexidine is a bisbiguanide antiseptic and disinfectant that is bactericidal or bacteriostatic against a wide range of Gram-positive and Gram-negative bacteria. It is more effective against Gram-positive than Gram-negative bacteria, and some species of Pseudomonas and Proteus have low susceptibility. It is relatively ineffective against mycobacteria. Chlorhexidine inhibits some viruses and is active against some fungi. It is inactive against bacterial spores at room temperature. Chlorhexidine is most active at a neutral or slightly acid pH.

Chlorhexidine is formulated as lotions, washes, and creams for disinfection and cleansing of skin and wounds, and as oral gels, sprays, and mouthwashes for mouth infections including candidiasis and to reduce dental plaque accumulation..

Mouth disorders.

Chlorhexidine mouthwashes, sprays, and gels are used to prevent accumulation of dental plaque (see Mouth Infections. Studies have generally shown chlorhexidine mouthwash 0.1 to 0.2% used 2 or 3 times daily to be effective in reducing plaque accumulation and gingivitis,1-4 and to be superior to other disinfectant mouthwashes.5 Its effect against subgingival plaque bacteria is enhanced by phenoxyethanol.6 However, a 1% gel used nightly as a toothpaste was not more effective than placebo in reducing gingivitis in children.7 Other studies have shown that chlorhexidine reduces gingivitis by 60 to 90% but its use is limited by its unpleasant taste and staining properties; special circumstances in which chlorhexidine is helpful include management of acute gingivitis, control of periodontal involvement in immunocompromised patients, and promotion of healing after periodontal treatment.  

Chlorhexidine gluconate may be useful in controlling secondary bacterial infections of aphthous ulcers (see Mouth

Chlorhexidine may be a useful adjunct to antifungal treatment of oral candidiasis.

Oral ulceration
Identify cause (trauma, nutritional deficiency, immunosuppression, dermatological disease, drugs, infection, eg herpes simplex, coxsackie viruses, Candida, syphilis) and treat cause when possible; however, cause is often unknown and in many cases healing occurs spontaneously (usually within 10–14 days).
Therapeutic agents may reduce inflammation (local corticosteroids, eg triamcinolone paste); reduce pain at the site (local anaesthetics, eg lignocaine, benzocaine; anti-inflammatory, eg benzydamine), or protect the ulcerated area. There are a number of OTC combination products available.
Consider neoplasia in non-healing ulcers (present for >3 weeks).
Sore throat
Commonly caused by a virus; occasionally the cause is bacterial (typically streptococcal). Preparations for symptomatic relief often combine anaesthetic and antiseptic agents in a lozenge, gargle or spray. There is little evidence of benefit.
Group A beta-haemolytic streptococci are a more common cause of sore throat in children than in adults.
If group A streptococcal pharyngitis (fever, tonsillar exudate, cervical lymphadenopathy, absence of cough) is considered likely, then it is reasonable to start antibiotics (phenoxymethylpenicillin is first choice) as symptom duration and complications may be reduced.
( If this table is to be added, then it should be renamed eg 12.2). I prefer not to have it.
Recurrent tonsillitis in children
Recurrent sore throat is common in childhood and usually has a viral cause.
Recurrent tonsillitis is often over-diagnosed. Throat swab during an acute episode can help to guide diagnosis and management.
Although a number of approaches have been used to treat true recurrent tonsillitis, including long term low dose penicillin or other antibiotic (eg a cephalosporin or macrolide), there is no good evidence of benefit for these.
Tooth decay (caries)
Regular brushing and flossing and avoiding sugary foods and smoking (reduces saliva) are important in preventing tooth decay.
Fluoride encourages tooth enamel to repair itself. Fluoride mouth rinses may reduce tooth decay in children even when fluoridated water and toothpaste are used.

Products

CHLOROHEXIDINE MOUTH WASH SOLUTION 0.2 (AS GLUCONATE) (TRACHISAN)

 

MICONAZOL (Oral gel) 

See also Miconazole Skin preparations

Products

MICONAZOLE ORAL GEL 2 % (AS NITRATE) 40 GM TUBE (CANDIZOL®, DAKTARIN®, MECONAZOL®, MICOVER®, MYCOHEAL®)

 

NYSTATIN (ORAL) 

Mode of action
Polyene antifungals bind to ergosterol in fungal cell membranes altering their permeability and allowing leakage of intracellular components.
Indications
Marketed: Treatment of mucocutaneous candidiasis, Treatment and suppression of intestinal candidiasis.
Accepted: Prophylaxis against candidiasis in immunocompromised people.
Specific considerations
Pregnancy: safe to use; GI absorption negligible; ADEC category A.
Breastfeeding: safe to use.
Adverse effects
Common: nausea, vomiting, diarrhoea (mild with usual doses but more severe with high doses, e.g. 5 million units daily).
Dosage
Intestinal candidiasis: Adult, child, oral, 500 000–1 000 000 units 3 times daily (tablet/capsule).
Treatment and prophylaxis of oral candidiasis: Adult, child, oral, 100 000 units 4 times daily (oral liquid/lozenge).
Patient Counselling
It is best to use the oral liquid or lozenge after (rather than before) a meal or drink. Swish the liquid around the mouth for as long as comfortable before swallowing.
Continue to use for about 2 days after your symptoms disappear.
Practice points

·         nystatin suspension is effective treatment for minor oral fungal infections

·         treatment with oral itraconazole or fluconazole is often required in immunocompromised people (especially with HIV)

Products

NYSTATIN SUSP. 100,000 IU/ML   60 ML BOTTLE (MYCOSTAT®, MYCOSTATIN®, MYCOPHIL®)

 

TRIMCINOLONE (ORAL) 

Mode of action

Triamcinolone Acetonide is a synthetic corticosteroid which possesses anti-inflammatory, antipruritic, and antiallergic action. The emollient dental paste acts as an adhesive vehicle for applying the active medication to the oral tissues. The vehicle provides a protective covering which may serve to temporarily reduce the pain associated with oral irritation.

Indications
adjunctive treatment and for the temporary relief of symptoms associated with oral inflammatory lesions and ulcerative lesions resulting from trauma.

Contraindications
hypersensitivity to any of its components; In the presence of fungal, viral, or bacterial infections of the mouth or throat.
Adverse effects
Prolonged administration may elicit the adverse reactions known to occur with systemic steroid preparations; for example, adrenal suppression, alteration of glucose metabolism, protein catabolism, peptic ulcer activations.

Dosage
Apply sparingly 2 to 3 times a day.

Products

TRIAMCINOLONE ACETONIDE ORAL PASTE 0.1 % (KENALOG®)