OTORHINOLARYNGOLOGY 5.

3
ENT THERAPEUTICS by Dr. Fita P. Guzman February 8, 2018

❖ Cinnarizine (Stugeron) 25 mg tab TID or 75 mg cap

HS
INTRODUCTION ❖ Diazepam 5 mg IV or 5 mg tab HS
• Derived from the Greek word, therapeia (curing and healing) ❖ B complex vitamins
• Pharmacology – definition: the use of drugs and the method of their ❖ Piracetam 800 mg to 2400 mg /day
administration in disease
• Treatment and care of patients for the purpose of preventing and TREATMENT OF ALLERGIC RHINITIS (AR)
combating disease or alleviating pain or injury • Environmental Control
• Minimize exposure to pollens, molds and dust
VERTIGO • Pharmacotherapy
Dizziness is an ambiguous term and can range from feeling queasy to blacking • Antihistamines, topical nasal steroids, Leukotriene inhibitors, Cromones and
out due to circulatory problem decongestants
Vertigo defined as illusion or hallucination of movement • Immunotherapy
Fear of heights,” height vertigo” occurs when perception of depth is impaired • Desensitisation: 70-80% effective in AR, for 3-5 years, for production of blocking
feeling of instability and fear of falling IgG

A. Treatment of Vertigo Type of Drug Action

Causes of Antihistamines Block histamines, first line treatment

Primary Evaluation Referral to ENT-HNS
Dizziness Topical steroids Local anti- inflammatory
Leukotriene inhibitors Blocks the inflammatory mediator:
Severe Dizziness refractory to
Systemic Medical/Cardiologic leukotriene
medical treatment
Cromolyn sodium sodium Stabilize mast cells
Persistence of symptoms, if Decongestants Vasoconstriction, treats nasal
Central Neurologic/Eye congestion
associated with deafness and tinnitus
Vertigo is fatigable patients referred A. Antihistamines
Peripheral ENT-HNS to ENT, also if with symptoms of • 1st,2nd,3rd Generation
deafness and tinnitus • 1st generation: frequently used in over-the-counter colds-sinusitis and
AR formulations, may cause drowsiness, dry mouth and urinary
B. Dizziness and Vertigo Peripheral and Central Origin retention
Peripheral Causes • 2nd generation: “nonsedating”, formulation intended so as not to
o Benign Paroxysmal/Positional Vertigo cross the blood-brain barrier
o Meniere’s Disease • 3rd generation: Improvement of 2nd gen because these lacks the
o Syphilis cardiotoxicity and retain nonsedating properties
o Delayed Endolymphatic Hydrops
o Recurrent Vestibulopathy B. Antihistamines in AR
o Vestibular Neuronitis • Decrease symptoms of sneezing, itching and rhinorrhea but not nasal
o Inner Ear Fistula congestion
o Collagen deposition • 1st generation, frequently combined with decongestants =
Central Causes of Vertigo chlorphenamine, carbinoxamine and brompheniramine
o Headache: Migraine, Increased CNS pressure • 2nd generation = loratadine (Claritin) 10 mg OD,Cetirizine (Virlix
o Vascular Disorders: Infarction, embolism, TIA, ,Alnix or Zyrtec) 10 mg HS Bilastine
Vertebrobasilar insufficiency • 3rd Generation= Levocetirizine (Xyzal,Allerzet) 5 mg 1 tab OD,
o Compression: Neoplasm (Schwannoma), Arnold- Fexofenadine (Telfast)120 mg OD, Desloratadine (Aerius) 5 mg OD
Chiari malformation
o Arnold Chiari malformation (both cerebellum and C. Oral Decongestants
brainstem extended into foramen magnum) • Act on alpha adrenergic receptors (agonist) in the nose
o Craniovertebral junction disorders – acquired or vasoconstriction diminish swelling of the turbinates and increase
congenital leading to vertebral artery, CN nasal patency
compression, obstructive hydrocephalus • Do no relieve rhinorrhea, nasal and eye pruritus and sneezing
o Multiple sclerosis • Examples: pseudoephedrine, phenylephrine, phenylpropanolamine
o Vertigous epilepsy (PPA)
o Ataxis disorders
o Intracranial Tumors D. Combination Antihistamine+Decongestants
o Presbystasis (disequilibrium of aging)
o Temporal bone fracture • Brompheniramine + Phenylephrine (Dimetapp) syrup BID
o Seizure disorders • Chlorphenamine + PPA (Nafarin) tablet BID
o Cerebellar abnormalities • Cetirizine+Phenylephrine (Alnix Plus)
• Loratadine + Pseudoephedrine (Clarinase) or (Rhinase) BID
C. Pharmacologic Treatment Options for Vertigo • Antihistamine + leukotriene inhibitor
• Levocetirizine + Montelukast(Co-Altria)
Peripheral Causes
o Benign Paroxysmal/Positional Vertigo E. Topical Nasal Steroids for AR
o Meniere’s Disease
o Antihistamines • Drug of choice for AR
o Meclizine 25 mg (Bonamine or Postadoxine) 1-tab HS or 1- • Topically effective in relieving sneezing, nasal pruritus, rhinorrhea and
tab TID mucosal edema
o Diphenhydramine (Benadryl) 50 mg IV or 25 to 50 mg caps • With minimal systemic absorption because of hepatic 1st pass
o Anticholinergic -Promethazine metabolism
o Miscellaneous Drugs • Examples of nasal sprays: Budesonide, Fluticasone propionate and
❖ Betahistine (Serc) 8, 16 and 24mg, (Merislon) 6 mg furoate, Mometasone, Ciclesonide,Triamcinolone
tab • All equipotent, given 2 puffs per nostril HS
• However, Triamcinolone can affect the HPA
• Can cause irritation and occasional epistaxis

Trans: Lameda
Edited by: Lexi :)
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• Toxicities: allergies (rashes, stevens-Johnson Synfrome, erythema

F. Other Drugs Used in AR multiformae, toxic epidermal necrolysis)
• Mast Cell Stabilizers: Cromolyn sodium spray G. Lincosamides
• Anticholinergics: Ipratropium spray • Clindamycin only member
• Mucolytic agents: saline nasal spray, guaifenesin, ambroxol, • Addition of chlorine atom to lincomycin
erdosteine, steam inhalation • Spectrum:Gram positive bacteria (except Enterococcus and
• Leukotriene inhibitors like montelukast and zafirlukast MRSA),anaerobes and some protozoa
• Topical antihistamines: Azelastine (Azep), Olopatadine • Drawback: N/V, diarrhea, pseudomembranous colitis and resistance
• Combination topical steroid and antihistamine: Olopatadine + by S. pneumoniae
Fluticasone propionate (Olanaze)
H. Fluoroquinolones
ANTIBIOTICS • Only available anti-Pseudomonas for head and neck infections
• Reason for development of bacterial resistance to antibiotics: the use • Potent ototopical and not ototoxic (ciprofloxacin and ofloxacin)
of antibiotic itself • Potential for development of resistance during use and in
• Bacterial resistance a survival technique and result of evolutionary communities where use is common,ex.ciprofloxacin
pressure on bacteria • “Respiratory“ quinolones: levofloxacin, ofloxacin active vs.
• Excessive and unnecessary prescribing by physicians, use of S.pyogenes, S.pneumoniae, Chlamydia, Legionella ,non-MRSA S.
antibiotics in animal feeds and inability of physician to successfully aureus
treat infection resistance • Drawbacks:except for topical, not used in children; antacids and Zinc
impair absorption
A. Microbiologic Studies
I. Metronidazole
• Swab cultures should never be done
• Swab cultures cannot distinguish bacteria that are causing the • Bactericidal against anaerobes
infection from those that are simply on the surface • Maybe combined with any other antibiotics for mixed infections with
• Instead: infected area to be debrided or entered in sterile manner aerobes
• However, invasive techniques like tympanocentesis and sinus • Active vs. anaerobes, B. fragilis, Clostridium difficile (etiol of antibiotic
puncture as routine are unjustified –induced pseudomembranous colitis)
• Clinicians are forced to treat sinusitis and otitis media without direct • High CSF penetration
proof of bacterial cause
RHINOSINUSITIS
B. Empirical Use of Antibiotics • Definition Infectious inflammatory condition caused by various
• Physicians should know susceptibility patterns of common bacteria in bacteria affecting the nasal passages and sinuses
their area of practice empirical choice • Typical Symptoms nasal obstruction, mucopurulent discharge, facial
• Information from Microbiology Section pressure/headache, postnasal drip, cough, halitosis, hyposmia, ear
fullness, pharyngitis, fatigue, malaise, fever
C. Penicillins
• Penicillin G or V A. Antibiotics for Acute Rhinosinusitis and Acute Otitis Media
• Antistaphylococcal: cloxacillin, methicillin, nafcillin • High dose amoxicillin
• Aminopenicillins: ampicillin/amoxicillin • Amoxiclav (Augmentin or Amoclav) 375 mg 1 tab TID or 30 to 50
• Augmented penicillins: Ampicillin + sulbactam/Amoxicillin+clavulanic mg/kg BW for 10 to 14 days;adults 625 mg BID x7 days
acid Active against H. influenzae. M. catarrhalis, Staph aureus, most • Sultamicillin (Unasyn) 375 mg 1-tab TID or 30 to 50 mg /kg BW for 10
S.pneumoniae, anaerobes ,Strept pyogenes to 14 days
• Anti-Pseudomonas penicilin, synergistic with aminoglycosides, • Cefuroxime axetil 250 to 500 mg 1-tab BID
parenteral use only Ex. Ticarcillin,piperacillin • Levofloxacin 500 mg 1-tab BID x 5 days
• Moxifloacin 1 tab BID x 7 days
D. Cephalosporins • Ciprofloxacin 500mg,1-tab BID
• 1st,2nd and 3rd generations • Clindamycin for those who are allergic to B-lactam antibiotics 300 mg
• 1ST: cephalexin, active against S. Aureus, Strept and most 1 cap BID to TID for 7-10 days
Pneumococci,E. coli, Proteus and Klebsiella but not vs. H. Influenzae,
M.catarrhalis, Pseudomonas,Klebsiella B. Management of Chronic Sinusitis, >12 wks
• 2nd: Cefuroxime,cefaclor,cefdinir active vs. H.influenzae,M. • Polymicrobial infection that involve both aerobes and anaerobes
catarrhalis ,most S.pneumoniae,N. gonorrheae • Supportive measures: saline irrigation
• 3rd generation oral: cefixime • Antibiotics: Coamoxiclav, Sultamicillin, Clindamycin and Ciprofloxacin
• 3rd generation parenteral: Ceftriaxone and cefotaxime advantage: • Topical Steroid spray
CSF penetration • Decongestants
• Antihistamines for those with AR
E. Macrolides • US: topical nasal steroids + saline irrigation
• Erythromycin active vs Streptpyogenes, S.pneumoniae, 80% of Staph • EU:Clarithromycin 250 mg 1 tab OD for 3 months +topical nasal
aureus toxicities: nausea, cramps, vomiting, ototoxic, drug steroids+saline irrigation
interactions
• Azithromycin and Clarithromycin longer lasting compared to above, C. Treatment of Acute Tonsillopharyngitis
less nausea and drug interactionsn Clarithromycin is given to those • 40% viral vs 30% bacterial vs. others
with chronic sinusitis 250 mg OD x 3 months • Strept pyogenes (B-hemolytic group A) of concern due to risk of RHD
- features that are highly indicative of Strept infection=severe throat
F. Sulfonamides and Trimethoprim pain for a few days (w/o cough or hoarseness), fever, marked
• Sulfonamide most frequently used is sulfamethoxazole (400mg) erythema, pharyngeal/tonsillar exudates, tender cervical lymph nodes
which is always in fixed combination with trimethoprim (80mg) • Treatment: Penicillin G or V Amoxicillin with or w/o clavulanate 1st or
• Above useful for treatment of sisusitis, otitis media, uninary tract 2nd generation Cephalosporin Clindamycin
infections, and acute exacerbation of bronchitis, etc
• Sulfonamides should not used for the treatment of sore throat D. Stomatitis: Thrush, Moniliasis or Candidiasis
because they do not eradicate Strept. Pyogenes from the tonsils • Etiol. Candida albicans
compared to penicilins • 1st line treatment: Nystatin drops or oral tablets QID
• Bacteria sensitive to sulfas: H.influenzae, M.catarrhalis, some • Alternative: Clotrimazole oral tablet Fluoconazole oral tablet
S.pneumoniae, enteric bacteria like E.coli, klebsiella, Proteus etc

You can thank your stars all you want but I’ll always be the lucky one.
TOPIC: ENT THERAPEUTICS.

E. Stomatitis: Vincent’s Angina (Trench Mouth)

• Seen in debilitated patients with poor oral hygiene
• Microbiol.: Mixed infections of spirochetes, fusiforms and anaerobes
• Treatment: 1st line, Clindamycin Alternative: Sultamicillin or Co-
amoxiclav Pen G + Metronidazole IV

F. Otitis Externa
• Diffuse Otitis Externa Treatment(Tx)=Neomycin+ polymyxin B +
Steroid
• Localized otitis externa (furunculosis) Tx=1st line, Cephalexin;
alt.Clindamycin or cloxacillin
• Otomycosis (Fungual infection of Outer Ear) Tx=Clotrimazle;
alt,Nystatin +Steroid (Kenacomb)
• Necrotizing malignant otitis externa Tx: Imipenem or Meropene Alt.
Ciprofloxacin, Ceftazidime, Ticarcillin + gentamycin

G. Deep Neck Space Abscesses & Acute Suppurative Thyroiditis

• DNSA: most common, mixed infection (Aerobic vs anaerobic ,1:2),
with B-lactamase
• AST, Microbiol. +Strept species and Staph aureus facultative aerobes
and anaerobes
• Tx for both: 1st line, Clindamycin ALT: Sultamicillin or coamoxiclav,
oral Cefuroxime IV + Metronidazole

H. Bacterial Parotitis (BP) Cellulitis (CL) Folliculitis/ Furunculosis/

Carbuncles, FFC
• BP< FFC, and CL Tx: Coamoxiclav or sultamicillin Alt. Clindamycin or
1st and 2nd generation cephalosporin
• CL is subcutaneous infection
• For FFC, mupirocin (Bactroban) ointment can be applied

I. Impacted Cerumen
• Treatment
o Cerumenolytics
❖ Docusate sodium (Otosol)
❖ Antipyrine +benzocaine +oxyquinoline SO4
(Auralgan)
❖ Baby oil or mineral oil
o Aural irrigation, suctioning or manual extraction using
cerumen spoon or curette

END

You can thank your stars all you want but I’ll always be the lucky one.