EAR NOSE THROAT (ENT) OPD RX GUIDE
%20OPD%20RX%20GUIDE.jpg "EAR NOSE THROAT (ENT) OPD RX GUIDE")
INTRODUCTION
ENT OPD RX GUIDE" serves as a comprehensive handbook for medical professionals, particularly those specializing in Ear, Nose, and Throat (ENT) care. This guide offers concise yet thorough recommendations for treatment strategies commonly encountered in outpatient settings. From common ailments like sinusitis and otitis media to more complex conditions, this book provides practical insights, evidence-based approaches, and medication dosages tailored to ENT care. Whether for seasoned practitioners seeking quick reference or trainees navigating their early clinical experiences, this guide aims to streamline decision-making and enhance patient care in the dynamic field of ENT medicine
ACUTE TONSILLITIS /ACUTE PHARYNGITIS Rx
ACUTE SINUSITIS (ACUTE SINUS INFECTION) Rx
CHRONIC SINUSITIS Rx
ACUTE RHINITIS Rx
CHRONIC SIMPLE RHINITIS Rx
HYPERTROPHIC RHINITIS (CHRONIC) Rx
ALLERGIC RHINITIS Rx DEVIATED NASAL SEPTUM (DNS) Rx
SEPTAL HAEMATOMA Rx
SEPTAL ABSCESS Rx
ADULT/CHILDERN WITH EAR DISCHARGE/INFECTION Rx
ACUTE SUPPURATIVE OTITIS MEDIA (ASOM)Rx
CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM) Rx
TINNITUS Rx
VERTIGO Rx
BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)Rx
1 ACUTE TONSILLITIS /ACUTE PHARYNGITIS Rx
C/C:
The leading symptoms tend to be mild and non-specific, and include:
Fever, malaise, headache
Sore throat (acute phase)
Runny nose, Dry Cough in 1/3
Nasal obstruction Headache
Low-grade fever
Cough (dry) in 1/3
Signs
inflamed tonsils, pillars, soft palate, uvula
Bilateral jugulodigastric lymph nodes are enlarged and tender,
Most of the infections are due to Streptococcus and penicillin is the DOC.
Patients allergic to penicillin can be treated with Macrolides: Erythromycin OR • Clarithromycin.
>> Other: Cephalexin, Cefadroxil
>> Improvement can be expected within 3-4 days.
>> Antibiotics should be continued for 5-7 days (10 days)
>> Azithromycin only for 5 days
Rx
1. Tab. Co-Amoxiclav 375mg, 625mg, 1g (Augmentin, Amclave) Or Cap. Cephalexin 250mg, 500mg (Ceporex, Keflex)
Or Cap. Cefadroxil 250mg, 500mg (Cedrox, Duricef)
1-1-1 (TDS), 1-0-1(BD)
2. Tab. Paracetamol 500mg (Panadol, Calpol, Febrol) 1-1-1 (TDS)
If symptoms of allergy, hay fever, cough and common cold.
3. Syp. Dextromethorphan + Chlorpheniramine + Ephedrine (Corex-D)
1-2 teaspoonful TDS
4. Gargle with salt water/medicated gargle (Benzarin, Listerine) Gargle 2/3 Times a day
2nd Alternative Rx
1. Cap. Azithromycin 250mg OR Tab. Azithromycin 500mg 1-0-1 (BD), 0-0-1(OD)(Azomax, Zetro, Azitma)
Or Tab. Clarithromycin 250mg, 500mg (Claritek, Klaricid)
1-1-1(TDS), 1-0-1(BD) 250mg (Ponstan, Mefnac)
2. Tab. Mefenamic Acid 500mg (Ponstan forte, Mefnac DS)
Or Tab. Ibuprofen 200mg, 400mg (Brufen)
1-1-1 (TDS)
If symptoms of allergy, hay fever, cough and common cold.
3. Syp. Dextromethorphan+Chlorpheniramine+Ephedrine (Reltus DM) 1-2 teaspoonful TDS
4. Gargle with salt water/medicated gargle (Benzarin, Listerine) Gargle 2/3 Times a day
3rd Alternative Rx
1. Tab. Moxifloxacin 400mg (Moxiget, Avelox, Xefecta) 0-0-1(OD) OR Levofloxacin 250mg x BD, 500mg OD (Leflox, Cravit)
2. Tab. Paracetamol 500mg (Panadol, Calpol, Febrol) 1-1-1 (TDS)
If Pt. present with sneezing, itchy throat, flu add on 3. Tab Fexet 60mg, 120mg, 180mg (Fexet, Telfast) 0-0-1(OD)
2 ACUTE SINUSITIS (ACUTE SINUS INFECTION) Rx
C/C:
Anosmia: Loss of smell
Blockage/obstruction of Nasal
Congestion/Cough
Discharge: Purulent
discolored nasal discharge
Ear pressure/fullness
Facial pain, Fever
Generalized malaise/Fatigue
Headache/Halitosis
Investigation:
CBC
X-Ray PNS
CT scan PNS
Surgery: It is not done in acute sinusitis except in case of impending complications like orbital cellulitis.
Acute sinusitis
Symptoms for < 4 weeks
Subacute sinusitis
Symptoms for 4-12 weeks
Chronic sinusitis
Symptoms for > 12 weeks Recurrent sinusitis = 4 or more episodes of sinusitis each year, lasting for more than 7-10 days
Rx
1. Tab Fexofenadine 60mg + Pseudoephedrine 120mg (Fexet-D) +-+-1(OD)
2. Tab Co-Amoxiclave 375mg, 625mg, 1g (Augmentin, Amoxiclave) 1-1-1 (TDS), 1--+--1 (BD)
3. Tab Mefenamic acid (Ponstan, Ponstan Forte) 1--1--1 (BD)
4. Vaporization 2-3 time/day
2nd Alternative Rx
1. Tab Fexofenadine 120mg (Fexet, Telfast) +--+-1 (OD)
2. Tab Clarithromycin 250mg/500mg (Klaricid/Claritek) 1--+--1 (BD)
3. Tab Aceclofenac 100mg (Acenac, Acelo) 1--+--1 (BD)
4. Vaporization 2-3 time/day
3rd Alternative Rx
1. Tab Loratidine 10mg (Fexet, Telfast) +--+--I (OD), I--+--1 (BD)
2. Tab Moxifloxacin 400mg (moxiget, maxlox) +-+-1 (OD)
3. Tab Diclofenac potassium 50mg (Caflam, Cataflam) 1--+--1 (BD)
4. Vaporization 2-3 time/d
3 CHRONIC SINUSITIS Rx
Definition: When symptoms of sinusitis persist for more than 3 months (> 12 weeks) chronic state develops. Most important cause of chronic sinusitis is failure of acute infection to resolve
Clinical features are often vague and similar to those of acute sinusitis but of lesser severity.
Anosmia: Loss of smell
Blockage/obstruction of Nasal
Congestion/Cough
Discharge: Purulent discolored nasal discharge
Ear pressure/Ear fullness
Facial pain, Fever
Generalized malaise/Fatigue
Headache/Halitosis
Investigation:
> X-Ray PNS: The involved sinus may show mucosal thickening or opacity.
> X-rays after injection of contrast material may show soft tissue changes in the sinus mucosa.
> CT scan PNS: Particularly useful in ethmoid and sphenoid sinus infections and has replaced studies with contrast materials.
> Aspiration and irrigation: Finding of pus in the sinus is confirmatory
Rx
It is essential to search for underlying aetiological factors which obstruct sinus drainage and ventilation.
A work-up for nasal allergy may be required.
Culture and sensitivity of sinus discharge helps in the proper selection of an antibiotic.
Initial treatment of chronic sinusitis is conservative, including antibiotics, decongestants, antihistamines and sinus irrigations.
Surgical: Indication: If medical treatment given for a period of 3-4 weeks fails.
1. Tab. Fexofenadine 60 mg, 120mg, 180mg (Fexet, Telfast) 0-0-1(OD)
Or Tab. Loratidine 10mg (Softin, Loril, Lorin-NSA)
0-0-1(OD), 1-0-1(BD)
2. Tab. Co-Amoxiclav 375mg, 625mg, 1g (Augmentin)
1-1-1 (TDS), 1-0-1 (BD)
Or Cap. Cefixime 400mg (Cefspan, Cefim)
Or Tab. Moxifloxacin 400mg (Moxiget, Avelox, Maxlox)
0-0-1(OD) 250mg (Ponstan, Mefnac)
3. Tab. Mefenamic Acid 500mg (Ponstan forte, Mefnac DS)
Or Tab. Paracetamol 500mg (Panadol, Calpol, Febrol) 1-1-1 (TDS)
Or Tab. Aceclofenac 100mg (Acenac, Acelo)
Or Tab. Flurbiprofen 50mg, 100mg (Tab Froben) 1-0-1(BD)
4. Steam inhalation - Vicks balm (Vaporization) at night
SURGERIES FOR CHRONIC SINUSITIS
For Chronic Maxillary Sinusitis:
1. Antral lavage: Done by performing antral puncture in inferior meatus with the help of Tilley Lichtwitz trocar and cannula.
2. Intranasal Antrostomy: Done by making a window in inferior meatus to facilitate drainage through gravity.
3. Caldwell-Luc operation: Discussed later.
4. FESS: These days all sinus surgeries have been replaced by FESS-discussed later
Chronic Frontal Sinusitis:
1. Trephination of frontal sinus:
Done in acute frontal sinusitis if pain persists or exacerbates or there is fever in spite of antibiotic treatment for 48 hrs.
Also done in chronic frontal sinusitis.
A 2 cm long horizontal incision is made in the superomedial part of the eye to expose the frontal sinus.
» A hole is made and PUS is drained.
2. External frontal ethmoidectomy (Howarth's or Lynch operation): Frontal sinus is entered via inner margin of the orbit.
3. Other surgeries: Paterson operation, osteoplastic flap operation.
These surgeries are seldom done now and are replaced by FESS.
4 ACUTE RHINITIS Rx
C/C:
Etiology: It is caused by a virus.
The infection is usually contracted through airborne droplets. Several viruses (adenovirus, picornavirus and its subgroups such as rhinovirus, coxsackie virus and enteric cytopathic human orphan virus) are responsible.
Incubation period is 1-4 days and illness lasts for 2-3 weeks.
Clinical features:
> To begin with, there is a burning sensation at the back of the nose soon followed by nasal stuffiness, rhinorrhoea and sneezing.
> Patient feels chilly and there is a low-grade fever.
> Initially, nasal discharge is watery and profuse but may become mucopurulent due to secondary bacterial invasion.
Secondary invaders include Streptococcus haemolyticus, pneumococcus, Staphylococcus, Haemophilus influenzae, Klebsiella pneumoniae and Moraxella Catarrhalis
Rx
Bed rest is essential to cut down the course of illness Plenty of fluids are encouraged
Symptoms can be easily controlled with antihistamines and nasal decongestants.
Analgesics are useful to relieve headache, fever and myalgia.
Non-aspirin containing analgesics are preferable as aspirin causes increased shedding of virus.
Antibiotics are required when secondary infection supervenes.
(Fexet, Telfast, Fexo)
1. Tab Fexofenadine 60 mg, 120mg, 180mg OR Tab Fexofenadine 60mg + Pseudoephedrine 120mg 0-0-1(OD) (Fexet-D, Telfast-D, Fexo-D)
250mg (Ponstan, Mefnac)
2. Tab. Mefenamic Acid 500mg (Ponstan forte, Mefnac DS) OR Tab Paracetamol 500mg (Panadol, Calpol, Febrol)
1-1-1 (TDS)
3. Sodium chloride 0.9% nasal spray (Normal saline, Norsaline-P) Intranasal sprays - 3 nostril 2-3 times a day
4. Tab. Co-Amoxiclav 375mg, 625mg, 1g (Augmentin, Amoxiclave) Or Cap. Cephalexin 250mg, 500mg (Ceporex, Keflex) Or Cap. Cefadroxil 250mg, 500mg (Cedrox, Duricef)
1-1-1 (TDS), 1-0-1 (BD)
Rx
1. Tab. Cetirizine 10mg (T-day, Zyrtec, Rigix) Or Tab. Loratidine 10mg (Softin, Loril, Lorin-NSA) 0-0-1(OD), 1-0-1 (BD)
2. Tab. Aceclofenac 100mg (Acenac, Acelo) Or Tab. Flurbiprofen 50mg, 100mg (Froben, Ansaid)
1-0-1 (BD)
(Azomax, Zetro, Azitma)
3. Cap. Azithromycin 250 mg, Tab. Azithromycin 500mg 1-0-1(BD), 0-0-1(OD)
Or Tab. Clarithromycin 250mg, 500mg (Claritek, Klaricid) 1-1-1(TDS), 1-0-1(BD)
4. Rhinosone nasal spray OR Xynosine nasal spray (Intranasal sprays) 2-3 nostril 2-3 times a day Note: Nasal decongestants- They should not be given for longer period else patient may develop Rhinitis medicamentosa
5 CHRONIC SIMPLE RHINITIS Rx
C/C:
>>> Nasal obstruction: Usually worse on lying and affects the dependent side of nose.
>>>> Nasal discharge: It may be mucoid or mucopurulent, thick and viscid and often trickles into the throat as postnasal drip.
>>> Patient has a constant desire to blow the nose or clear the throat.
>>> Headache: It is due to swollen turbinates impinging on the nasal septum.
>>> Swollen turbinates: Nasal mucosa is dull red in color. Turbinates are swollen; they pit on pressure and shrink with application of vasoconstrictor drops (this differentiates the condition from hypertrophic rhinitis). Middle turbinate may also be swollen and impinge on the septum.
>>> Postnasal discharge: Mucoid or mucopurulent
discharge is seen on the posterior pharyngeal wall.
Rx
1. Treat the cause with particular attention to sinuses, tonsils, adenoids, allergy, personal habits (smoking or alcohol indulgence), environment or work situation (smoky or dusty surroundings).
2. Nasal irrigations with alkaline solution help to keep the nose free from viscid secretions and also remove superficial infection.
3. Nasal decongestants help to relieve nasal obstruction and improve sinus ventilation. Excessive use of nasal drops and sprays should be avoided because it may lead to rhinitis medicamentosa. A short course of systemic steroids helps to wean the patients already addicted to excessive use of decongestant drops or sprays.
4. Antibiotics help to clear nasal infection and concomitant sinusitis.
5. Symptomatic Rx are same as Acute Rhinitis
6 HYPERTROPHIC RHINITIS (CHRONIC) Rx
It is characterized by thickening of mucosa, submucosa, Seromucinous glands, periosteum and bone. Changes are more marked on the turbinates.
C/C:
ETIOLOGY
Common causes are recurrent nasal infections, chronic sinusitis, chronic irritation of nasal mucosa due to smoking, industrial irritants, prolonged use of nasal drops and vasomotor and allergic rhinitis.
SYMPTOMS
Nasal obstruction is the predominant symptom. Nasal discharge is thick and sticky. Some complain of headache, heaviness of head or transient anosmia.
SIGNS
Examination shows hypertrophy of turbinates. Turbinal mucosa is thick and does not pit on pressure. It shows little shrinkage with vasoconstrictor drugs due to presence of underlying fibrosis. Maximum changes are seen in the inferior turbinate. It may be hypertrophied in its entirety or only at the anterior end, posterior end or along the inferior border giving it a mulberry appearance.
Rx
Attempts should be made to discover the cause and remove it.
Nasal obstruction can be relieved by reduction in size of turbinates.
The various methods are:
1. Linear cauterization.
2. Submucosal diathermy.
3. Cryosurgery of turbinates.
4. Partial or total turbinectomy. Hypertrophied
inferior turbinate can be partially removed at
its anterior end, inferior border or posterior
end. Middle turbinate, if hypertrophied, can
also be removed partially or totally. Excessive
removal of turbinates should be avoided as it
leads to persistent crusting.
5. Submucous resection of turbinate bone. This removes bony obstruction but preserves turbinal mucosa for its function.
6. Lasers have also been used to reduce the size of turbinates.
7 ALLERGIC RHINITIS Rx
C/C:
Recurrent episodes of:
Sneezing
Nasal congestion
Rhinorrhea
Post-nasal drip
* Itchy nose and throat
Pale, boggy nasal mucosa with hypertrophic turbinates, and/or nasal polyps may be seen in long-standing cases of allergic rhinitis.
* Cobblestone appearance of the posterior pharyngeal wall
* Associated allergic conditions Allergic conjunctivitis
Atopic dermatitis and/or bronchial asthma
* Long-standing allergic rhinitis can predispose the patient to recurrent sinusitis and/or otitis media.
* Excessive use of nasal drops and sprays should be avoided because it may lead to rhinitis medicamentosa
Rx
1. Avoid exposure to the putative allergen (e.g., Allergen, dust)
2. Tab Cetirizine 10mg (T-day, Zyrtec, Rigix) Or Tab Loratidine 10mg (Softin, Loril, Lorin-NSA) 0-0-1(OD), 1-0-1 (BD)
250mg (Ponstan, Mefnac)
3. Tab. Mefenamic Acid 500mg (Ponstan forte, Mefnac DS) Or Tab Paracetamol 500mg (Panadol, Calpol, Febrol) 1-1-1(TDS)
4. Rhinosone nasal spray OR Xynosine nasal spray (Intranasal sprays) 2-3 nostril 2-3 times a day
2nd ALTERNATIVE Rx
1. Avoid exposure to the putative allergen (e.g., allergen, dust)
(Fexet, Telfast, Fexo)
2. Tab Fexofenadine 60 mg, 120mg, 180mg Or Tab Fexofenadine 60mg + Pseudoephedrine 120mg 0-0-1(OD) (Fexet-D, Telfast-D, Fexo-D)
3. Tab Aceclofenac 100mg (Acenac, Acelo) Or Tab Flurbiprofen 50mg, 100mg (Froben, Ansaid) 1+0+1(BD)
4. Rhinosone nasal spray Or Xynosine nasal spray (Intranasal sprays) 2-3 nostril 2-3 times a day
If Severe Or Hx of allergy, asthma then add 5. Fluticasone propionate 0.05% (Flixonase, Flexosone) (Intranasal sprays) 3 nostril 2/3 times a day
ALTERNATIVE DRUGS
ANTIALLERGIC DRUGS
Fexofenadine + Pseudoephedrine (FEXET-D, TELFAST-D)
Fexofenadine 60, 120, 180mg (FEXET, TELFAST)
Loratadine 10mg (LORIN NSA, SOFTIN)
Desloratadine 5mg (DESLORA)
Cetirizin: Tab Rigix 3mg
ANALGESIC/ANTIPYRETIC
Aceclofenac: Tab Acenac 100mg
Diclofenac potassium: Tab Caflam 50mg
Flurbiprofen: Froben 50mg, 100mg, Cap Froben 200mg (SR)
Mefenamic acid (ponstan/ponstan forte)
Nimesulide: Tab Nims 100mg
Nasal spray
1. Fluticasone propionate 0.05%: (Flixonase/Flexosone)
2. Fluticasone Furoate 27.5 Mcg: Avamys Nasal Spray
3. Ephedrine 5 mg/ml + Fluprednisolone 0.025mg/ml + Naphazoline 1.25mg/ml: Rhinosone nasal spray
4. Xylometazoline HCL 0.1%: Xynosine / Xolisan nasal spray
5. Azelastine Hydrochloride 0.1%: Azosin
6. Flunisolide 0.025%: Tarisin nasal spray
7. Mometasone Furoate 50 mcg: Hivate
8. Sodium Cromoglycate 4%: Oxycrom-P
9. Na Cromoglycate 2% + Xylometazoline HCI 0.025%: Oxycrom
8 DEVIATED NASAL SEPTUM (DNS) Rx
C/C:
* Difficulty breathing (typically in only one nostril)
Nasal congestion/obstruction
Snoring or noisy breathing during sleep
Headaches or facial pain
* Sinusitis: Deviated septum may obstruct sinus ostia resulting in poor ventilation of the sinuses.
* Epistaxis (nosebleeds)
Anosmia: Failure of the inspired air to reach the olfactory region may result in total or partial loss of sense of smell.
* External deformity
Middle ear infection: DNS also predisposes to middle ear infection.
Diagnostics
Anterior rhinoscopy: A nasal speculum and external light source are used to visualize the septum.
CT scan: for more detailed evaluation of the nasal septum (and adjacent structures)
TYPES OF DNS
Deviation may involve only the cartilage, bone or both the cartilage and bone.
1. Anterior dislocation: Septal cartilage may be dislocated into one of the nasal chambers. This is better appreciated by looking at the base of nose
when patient's head is tilted backwards
2. C-shaped deformity: Septum is deviated in a simple curve to one side. Nasal chamber on the concave side of the nasal septum will be wider and may show compensatory hypertrophy of turbinates.
3. S-shaped deformity: Either in vertical or anteroposterior plane. Such a deformity may cause bilateral nasal obstruction.
4. Spurs: A spur is a shelf-like projection often found at the junction of bone and cartilage. A spur may press on the lateral wall and give rise to headache. It may also predispose to repeated epistaxis from the vessels stretched on its convex surface
5. Thickening: It may be due to organized haematoma or overriding of dislocated septal fragments.
Rx
No treatment is required, if it is not causing any symptoms.
Give symptomatic or correct underlying cause
Nasal congestion/Obstruction
1. Tab Cetirizine 10mg (T-day, Zyrtec, Rigix) Or Tab Loratidine 10mg (Softin, Loril, Lorin-NSA) 0-0-1(OD), 1-0-1(BD) Or Tab Fexofenadine 60 mg, 120mg, 180mg x OD
Plus/minus add
2. Rhinosone nasal spray OR Xynosine nasal spray (Intranasal sprays) 2-3 nostril 2-3 times a day
Headache/Facial pain
3. Tab Aceclofenac 100mg (Acenac, Acelo) Or Tab Flurbiprofen 50mg, 100mg (Froben, Ansaid) 1+0+1 (BD)
Sinus infection/ear infection
4. Cap Amoxicillin 250mg, 500mg (Zeemox, Amoxil) Or Tab Co-Amoxiclave 375, 625, 1g (Augmentin) Or Cap Cefadroxil 250mg, 500mg (Duricef, Cedrox) 1-1-1 (TDS), 1-0-1 (BD)
Surgical management is the treatment of choice.
SEPTOPLASTY:
Conservative surgery as most of the septal framework is retained. Only the most deviated parts are removed. Rest of the septal framework is corrected and re-posited by plastic means. It is the preferred operation
SUBMUCOUS RESECTION (SMR) OPERATION
Here apart from a thin dorsal and caudal strip, the rest of the entire septum is removed.
It is generally done in adults under local anesthesia.
It consists of elevating the mucoperichondrial and mucoperiosteal flaps on either side of the septal framework by a single incision made on one side of the septum, removing the deflected parts of the bony and cartilaginous septum, and then repositioning the flaps.
Note: Septal surgery is usually done after the age of 17 so as not to interfere with the growth of the nasal skeleton. Only if a child has severe septal deviation causing marked nasal obstruction, septoplasty should be done.
9 SEPTAL HAEMATOMA Rx
It is a collection of blood under the perichondrium or periosteum of the nasal septum It often results from nasal trauma or septal surgery. In bleeding disorders, it may occur spontaneously.
C/C:
Bilateral nasal obstruction is the commonest presenting symptom.
This may be associated with frontal headache and a sense of pressure over the nasal bridge.
Examination reveals smooth rounded swelling of the septum in both the nasal fossae.
Palpation may show the mass to be soft and fluctuant.
Duration: 5 days
COMPLICATIONS
Septal haematoma, if not drained, may organize into fibrous tissue leading to a permanently thickened septum. If secondary infection supervenes, it results in septal abscess with necrosis of cartilage and depression of nasal dorsum.
Rx
Small haematomas can be aspirated with a wide bore sterile needle.
Larger haematomas are incised and drained by a small anteroposterior incision parallel to the nasal floor.
Excision of a small piece of mucosa from the edge of the incision gives better drainage.
Following drainage, the nose is packed on both sides to prevent re-accumulation.
Systemic antibiotics should be five to prevent septal abscess.
1. Tab. Co-Amoxiclav 375, 625, 1g (Augmentin, Amclav) 1-1-1 (TDS), 1-0-1 (BD)
Or Cap. Cefixime 400mg (Cefspan, Cefim)
0-0-1(OD)
250mg (Ponstan, Mefnac) 2. Tab. Mefenamic acid 500mg (Ponstan forte, Mefnac DS) 1-1-1(TDS)
10 SEPTAL ABSCESS Rx
Septal abscess mostly, it results from secondary infection of septal haematoma. Occasionally, it follows the furuncle of the nose or upper lip. It may also follow acute infection such as typhoid or measles
C/C:
30 Severe B/L nasal obstruction with pain and tenderness over the bridge of the nose.
Patients may also complain of fever with chills and frontal headache. Skin over the nose may be red and swollen.
> Internal examination of nose reveals smooth bilateral swelling of the nasal septum, Fluctuation can be elicited in this swelling.
Septal mucosa is often congested. Submandibular lymph nodes may also be enlarged and tender.
Rx
Abscess should be drained as early as possible. Incision is made in the most dependent part of the abscess and a piece of septal mucosa excised.
Pus and necrosed pieces of cartilage are removed by suction. Incision may require to be reopened daily for 2-3 days to drain any pus or to remove any necrosed pieces of cartilage.
Systemic antibiotics are started as soon as diagnosis has been made and continued at least for a period of 10 days.
11 ADULT/CHILDERN WITH EAR DISCHARGE/INFECTION Rx
C/C:
Ear Pain
Ear Discharge
Fever
Headache
Duration: 5 days
Rx
1. Cap. Amoxicillin 250mg, 500mg (Zeemox, Amoxii) Or Tab. Co-Amoxiclav 375, 625, 1g (Augmentin, Amclave) 1-1-1(TDS), 1-0-1(BD)
250mg (Ponstan, Mefnac)
2. Tab. Mefenamic acid 500mg (Ponstan fort, Mefnac DS) Or Tab. Paracetamol 500mg (Calpol, Panadol) 1-1-1(TDS)
3. Polymyxin + Lidocaine Ear Drop (Otocain, Lidosporin) Or Polymyxin + Neomycin + Hydrocortisone Ear drop (Otosporin)
2-3-drops 3-4 time a day
2nd Alternative Rx
1. Cap. Cefadroxil 250mg, 500mg (Duricef, Cedrox) Or Cap. Cephalexin 250mg, 500mg (Ceporex, Keflex) 1-1-1(TDS), 1-0-1 (BD)
2. Tab. Flurbiprofen 50mg, 100mg (Froben) Or Tab. Aceclofenac 100mg (Acenac)
1-0-1 (BD)
3. Ciprofloxacin + Lidocaine Ear drops (Cipocain, Zeprocaine) Or Ciprofloxacin + Dexamethasone Ear drops (Cipotic-D, Dexcip)
3rd Alternative Rx
1. Cap. Cefixime 400mg (Cefiget, Cefim) Or Tab. Moxifloxacin 400mg (Moxiget, Avelox) 0-0-1(OD)
2. Tab. Diclofenac sodium 50mg, 100mg (Voren, Voltral) Or Tab. Naproxen sodium 250mg, 500mg (Neoprox/Flexin) 1-0-1(BD)
3. Tobramycin + Dexamethasone Ear drops (Dexatob 0.3%, Dexatob 0.6%)
Rx for childern
1. Syp Augmentin/Syp Augmentin DS OR
Syp Cefadroxil 125mg/250mg (Duricef)
1-2 teaspoon BD/TDS
2. Syp Brufen / Brufen DS OR
Syp Dollor / Dollar DS
1-2 teaspoon BD/TDS
3. Cipocain OR Otocain Ear drop 2-3-drops 3-4 time a day
12 ACUTE SUPPURATIVE OTITIS MEDIA (ASOM)Rx
ASOM is an acute inflammation of the middle ear cleft < 3 weeks, infective in origin.
Organism
Bacterial: Streptococcus pneumoniae (Most common), H. influenzae (2nd most common), Moraxella catarrhalis Viral: Syncytial virus, Influenza virus, Rhino and adenovirus
One of the most common infectious disease seen in children
Peak incidence - first 2 years of life
Stages of ASOM
1. Stage of tubal occlusion
2. Stage of pre-suppuration
3. Stage of suppuration
4. Stage of resolution
5. Stage of complication
C/C:
>>> Ear Pain: Adults most frequently report
General symptoms
Otalgia/Earache, commonly described as throbbing pain.
Hearing loss in the affected ear
Fever
Otorrhea (Ear Discharge) in the case of a ruptured tympanic membrane.
Examination findings
Otoscopy
>> Bulging tympanic membrane (TM) with loss of landmarks
>>> Opacification and loss of light reflex
>> Retracted and hypomobile TM
>> Purulent/serosanguineous discharge in the external auditory canal or visible perforation
>>> Distinct erythema of the TM
>>> Additional findings that may be present:
Yellow spot on the TM
Cartwheel TM
Blisters/bullae on the TM
Tuning fork test
The Weber test and Rinne test can be performed to verify conductive hearing loss secondary to an effusion.
Weber test: Sound localizes to the affected ear.
Rinne test: Air conduction is impaired in the affected ear, while bone conduction remains intact.
CBC: Leukocytosis maybe present Gram stain and culture of middle ear fluid - if patient not responded to Rx
Blood cultures: indicated only in severe infection
Rx
1. Cap. Amoxicillin 250mg, 500mg (Zeemox, Amoxil)
Or Tab Co-Amoxiclave 375, 625, 1g (Augmentin) 1-1-1 (TDS), 1-0-1 (BD)
(Froben 50mg, 100mg, 200mg)
2. Tab. Flurbiprofen 100mg (Froben, Synalgo, Ansaid) Or Tab. Naproxen sodium 500mg (Neoprox, Flexin) 1-0-1(BD)
3. Polymyxin + Lidocaine Ear drops (Otocain) Or Ciprofloxacin + Lidocaine Ear drops (Cipocain)
2-3-drops 3-4 time a day
No sufficient evidence to support the routine use of opioids, decongestants, antihistamines, steroids
2ND ALTERNATIVE Rx
1. Cap. Cefadroxil 250mg, 500mg (Duricef, Cedrox) 1-1-1 (TDS), 1-0-1 (BD) Or Cap. Cefixime 400mg (Cefspan, Cefiget, Cefim) Or Tab. Moxifloxacin 400mg (Maxlox, Moxiget) 0-0-1(BD)
2. Tab. Diclofenac sodium 50mg, 100mg (Voren, Voltral) Or Tab. Naproxen sodium 250mg, 500mg (Neoprox, Flexin) 1-0-1(BD)
3. Tobramycin + Dexamethasone Ear drops (Dexatob) Or Ciprofloxacin + Dexamethasone Ear drops (Cipotic-D) 2-3-drops 3-4 time a day
13 CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM) Rx
CSOM is a chronic infection of the middle ear and mastoid. It is characterized by a permanent perforation in the Tympanic membrane. Generally, a perforation of TM heals by 6-12 weeks. Therefore any perforation which persists for > 12 weeks is considered as permanent and leads to CSOM.
TYPES OF CSOM
Clinically, it is divided into two types:
1. Tubotympanic: Also called the safe or benign type; it involves anteroinferior part of middle ear cleft, i.e. eustachian tube and mesotympanum and is associated with a central perforation. Most common organisms isolated are - P. aeruginosa, S.aureus and proteus species. Here perforation occurs in any part of parstensa except margins. There is no risk of serious complications. Most common in children.
2. Atticoantral: Also called unsafe or dangerous type; it involves postero-superior part of the cleft (i.e. attic, antrum and mastoid) and is associated with an attic or a marginal perforation. The disease is often associated with a bone eroding process such as cholesteatoma, granulations or osteitis. Risk of complications is high in this variety
Complications: In long standing cases of Tubotympanic variety of CSOM, necrosis of ossicles can occur due to repeated infection. The Most common ossicle to necrosis is Incus (long process)
Differences between tubotympanic and atticoantral type of CSOM
Tubotympanic type of CSOM
C/C:
>> Ear discharge: It is non-offensive, mucoid or mucopurulent, constant or intermittent. The discharge appears mostly at time of upper RTI or on accidental entry of water into the ear.
> Conductive type hearing loss
> Perforation: always central, it may
lie anterior, posterior or inferior to the handle of malleus. It may be small, medium or large or extending up to the annulus, i.e. subtotal
Middle ear mucosa: seen when the perforation is large
Rx
Tubotympanic type of CSOM
Medical Treatment (Treatment of Choice)
Aural toilet: It is an important step in treatment and should not be missed.
Remove all discharge and debris from the ear.
>> It can be done by dry mopping with absorbent cotton buds, suction clearance under microscope or irrigation (not forceful syringing) with sterile normal saline.
Ear must be dried after irrigation.
Topical ear drops:
Ciprofloxacin + Lidocaine Ear drops (Cipocain, Zeprocaine)
Or Ciprofloxacin + Dexamethasone Ear drops (Cipotic-D, Dexcip) Or Tobramycin + Dexamethasone Ear drops (Dexatob)
2-3-drops 3-4 times a day
Systemic antibiotics: Limited role, can be given in early, acute cases.
Tab Co-Amoxiclave 375, 625, 1g (Augmentin, Amclav) Or Cap Cefadroxil 250mg, 500mg (Duricef, Cedrox)
Or Cap Cephalexin 250mg, 500mg (Ceporex, Keflex) 1-1-1 (TDS), 1-0-1(BD)
#Precautions: Patients are instructed to keep water out of the ear during bathing, swimming and hair wash. Rubber inserts can be used. Hard nose blowing can also push the infection from nasopharynx to middle ear and should be avoided
Treatment of contributory causes: Attention should be paid to treat concomitantly infected tonsils, adenoids, maxillary antra and nasal allergy.
Surgical Treatment
Surgical treatment is done at a later stage to correct the hearing loss
Prerequisites
Ear dry for 6 weeks without antibiotics
Eustachian tube function normal
Normal middle ear mucosa
Procedure of choice:
Myringoplasty - if ossicle chain is intact
Tympanoplasty - if ossicular chain is disrupted
▲ Atticoantral type of CSOM
C/C:
Ear discharge: Usually scanty, but always foul-smelling due to bone destruction.
Hearing loss: Hearing is normal when ossicular chain is intact or when cholesteatoma, having destroyed the ossicles, bridges the gap caused by destroyed ossicles (cholesteatoma hearer). Hearing loss is mostly conductive but sensorineural element may be seen
>> Bleeding: may occur from granulations or the polyp when cleaning the ear.
>> Perforation: Either attic or posterosuperior marginal type
>> Retraction pocket: An invagination of tympanic membrane is seen in the attic or posterosuperior area of pars tensa. Degree of retraction and invagination varies. In early stages, pocket is shallow and self-cleansing but later when pocket is deep, it accumulates keratin mass and gets infected
> Cholesteatoma: Pearly-white flakes of cholesteatoma can be sucked from the retraction pockets
Rx
Atticoantral type of CSOM
Surgical: It is the mainstay of treatment.
Primary aim is removal of disease by mastoidectomy to make ear safe followed by reconstruction of hearing at a later stage.
Two types of surgical procedures are done to deal with cholesteatoma:
Canal wall down procedures.
Canal wall up procedures.
Surgery of choice: Modified Radical mastoidectomy
14 TINNITUS Rx
Tinnitus is a common condition in which sound (whistling, hissing, buzzing, ringing, and pulsating) is perceived in the absence of an external source. It can be unilateral or bilateral, acute or chronic, and intermittent or constant. Tinnitus is not a specific disease but a symptom that can be connected to a wide variety of etiologies, most commonly conditions associated with hearing loss.
Most people will experience tinnitus at some point in their lifetime.
Increases with age, More common in men and smokers
Associations: hearing loss, hyperacusis
Etiology
Tinnitus is a symptom, not a specific disease, and its presence can indicate an underlying abnormality. Objective tinnitus: tinnitus that can perceived by others, which is due to sounds created by the body (e.g., carotid artery stenosis, stapedial myoclonus)
Subjective tinnitus: tinnitus that is only perceived by the affected individual, which can be due to a wide range of etiologies (e.g., otosclerosis, tumor, infections, temporomandibular joint dysfunction)
Tinnitus
C/C:
>> Perceived sound without an external source (whistling, hissing, buzzing, ringing and pulsating)
>> Symptoms of an underlying disease may be present as well (hearing loss)
Diagnosis
History: characterize the tinnitus (e.g., unilateral vs. bilateral, symptom duration, quality) and risk factors (sound exposure, chronic illness, and recent use of ototoxic medication)
Initial exam
>>> Otoscopic examination: exclude infection, impacted cerumen
>> Head and neck auscultation to assess for bruits or hums
>>> Neurologic examination to look for focal deficits
>> Audiological examination for all patients presenting with tinnitus
>> Imaging (CT/MRI) is recommended for patients with one or more of the following: unilateral tinnitus, asymmetric tinnitus, pulsatile tinnitus, and/or focal neurological deficits
>>> Routine blood test if a treatable cause of tinnitus is suspected CBC (Anemia), TSH (hypothyroidism)
>>> Infectious workup (FTA-ABS for syphilis) and autoimmune workup (ANA, ESR, rheumatoid factor) if suspected
Rx
After symptom onset, treatment should be started as early as possible to prevent the condition from becoming chronic.
Treat any underlying conditions.
Supportive treatment: counseling, stress reduction, cognitive behavioral therapy, sound therapy etc...
Stress Reduction: This includes using biofeedback, Deep breathing exercises, Relaxation to music etc...
Cognitive behavioral Therapy: The more the patient understands what tinnitus is and is not the less negative effect. Once the patient fully cognizes - understands that tinnitus is similar to itching, the symptoms are reduced.
Masking: When the body hears the same sound from the cell phone or sound device, this reduces the symptoms. There are various forms of masking. Essentially these masking sounds take the attention away from the internal tinnitus sound and replace it with relaxing sounds.
Introduction of the same sound
Introduction of an altered sound
Music with the tinnitus sound removed
White noise or pleasant sounds
Sleep improvement: Tinnitus can affect normal sleep and therapy should be directed to better sleep hygiene.
1. Tab. Alprazolam 0.5mg (Alp, Xanax)
Tab. Diazepam 5mg (Valium) Or Tab. Clonazepam 0.5mg (Revotril, Naze) 0-0-1(HS)
2. Softgel. Cod liver oil (Seven seas, Seamega) 0-0-1(OD)
Antidepressants may be indicated for patients who do not respond to protocol therapy
3. Tab. Amitriptyline 25mg (Sensival) x HS titrated the dose if not responded. (Maximum dose: 25mg-150mg/day) Or Cap. Fluoxetine 20mg (Depex, Flux) x OD after breakfast
15 VERTIGO Rx
Definition: Vertigo is the sensation of spinning or swaying of oneself (internal vertigo) or of one's surroundings (external
vertigo) while stationary.
Vertigo are divided into:
1. Peripheral vertigo: Involve vestibular end organs and their 1st order neurons (i.e. the vestibular nerve).
The cause lies in the internal ear or the 8th nerve.
They are responsible for 85% of all cases of vertigo.
2. Central vertigo: Involve central nervous system after the entrance of vestibular nerve in the brainstem and involve vestibulo-ocular, vestibulospinal and other central nervous system pathways
DIFFERENTIATING PERIPHERAL VERTIGO FROM CENTRAL VERTIGO
▲ Vertigo
C/C: ********
Diagnostics
>> Diagnosis is clinical
>> Dix-Hallpike maneuver
>> supine head roll test
Rx
Vestibular rehabilitation therapy (Brandt-Daroff exercise, Cawthorne-Cooksey exercise), training on maintaining balance based on visual and proprioceptive clues
Lifestyle recommendations: avoiding caffeine, salt and alcohol, avoiding triggers
Canalith repositioning procedure: Epley maneuver
1. Tab. Betahistine 8mg, 16mg or 24mg (Serc, Enier, Setspin) x 8mg to 48mg x TDS/BD Or Tab. Prochlorperazine 5mg (Stemetil) x TDS, increasing up to 30mg if not respond Or Tab. Dimenhydrinate 50mg (Gravinate) x TDS (maximum dose 400 mg/day)
2. Tab. Alprazolam 0.5mg (Alp, Xanax) Or Tab. Diazepam 5mg (Valium) Or Tab. Clonazepam 0.5mg (Revotril, Naze)
0-0-1(HS)
16 BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)Rx
Definition: Episodic vertigo triggered by certain changes in the position of the head
Prevalence
BPPV is the most common type of peripheral vestibular vertigo with a prevalence of ~ 2%.
BPPV is the underlying cause in approx. 40% of geriatric patients presenting with dizziness
.
Sex: female > male
Age: peak incidence between 50-60 years
Clinical features:
" Episodic vertigo (spinning sensation)
Sudden ("paroxysmal") and recurrent episodes
Lasts several seconds (typically ≤1 min)
Triggered by certain head movements (positional vertigo) after a latency of a few seconds.
Associated with: Nystagmus, Risk of falls and subsequent injury, Nausea and vomiting
Triggers: Quick rotation of the head relative to gravity is the main trigger of BPPV
.
Lying down, reclining, or standing up quickly
. Rolling over in bed
Bending forwards
Suddenly jerking the head to look up or down
Diagnostic approach
Dix-Hallpike maneuver
The Dix-Hallpike maneuver should be performed in all patients with suspected BPPV to identify posterior canal BPPV
If the Dix-Hallpike maneuver is negative, the supine head roll test should be performed to assess for lateral canal BPPV
Indication
First-line test for suspected BPPV
Gold standard test to diagnose suspected posterior semicircular canal BPPV
Suspected anterior semicircular canal BPPV
Characteristic findings
Positive Dix-Hallpike test: positional vertigo and nystagmus triggered during the maneuver
Direction of nystagmus
Posterior canal BPPV: upbeat nystagmus with ipsiversive torsional nystagmus component
- Anterior canal BPPV: downbeat nystagmus with ipsiversive torsional nystagmus
BPPV
C/C:******
Diagnostics
>>> Diagnosis is clinical
>> Dix-Hallpike maneuver
>>> supine head roll test
Rx
Vestibular rehabilitation therapy (Brandt-Daroff exercise, Cawthorne-Cooksey exercise), training on maintaining balance based on visual and proprioceptive clues
Lifestyle recommendations: avoiding caffeine, salt and alcohol, avoiding triggers
Canalith repositioning procedure: Epley maneuver
1. Tab. Betahistine 8mg, 16mg or 24mg (Serc, Enier, Setspin) 8mg or 16mg = 1-1-1 (TDS), 24mg = 1-0-1 (BD)
Or Tab. Prochlorperazine 5mg (Stemetil)
1-1-1 (TDS) titrated up to 30mg if not respond.
Or Tab. Cinnarizine (Tab. Stugeron 25mg) or Cap. Stugeron 75mg)
Tablets-1-1-1 (TDS) or Capsules = OD/BD per day
Or Tab. Dimenhydrinate 50mg (Gravinate)
1-1-1 (TDS) Maximum Dose: <400mg/day
2. Tab. Alprazolam 0.5mg (Alp, Xanax, Praz)
Or Tab. Diazepam 5mg (Valium) 0-0-1(HS)
Or Tab. Clonazepam 0.5mg (Revotril, Naze)
Surgical treatment Indication
Intractable BPPV
Severe and frequent recurrences
Options
Singular neurectomy
Posterior semicircular canal occlusion
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