ENT Pharm

Question 1

Sinus infection is likely to be caused by bacteria rather than virus if any of what the three conditions are present?

Answer 1

1. sx last for 10days w/o evidence of clinical improvement
2. severe sx, fever 102 or greater, nasal discharge and facial pain for at least 3-4days, maxillary tooth pain, unilateral maxillary sinus tenderness.
3. sx or signs worsen as characterized by new fever or HA developing or nasal discharge increasing, typically after a viral upper resp infection taht lasted 5-6 days and initially seemed to improve.

Question 2

What are the three hallmark sx of sinusitis?

Do you need to be stronger/more aggressive when treating children w/ abx?

Answer 2

HA, fever, sinus pain

YES!!! b/c they have less of an immune system.

Question 3

Symptomatic tx of viral sinusitis?

Answer 3

• analgesics (ibuprofen)
• saline irrigation
• topical steroids
• topical decongestants
• oral decongestants.

Question 4

Tx of bacterial sinusitis?

What are the common bacteria causing sinusitis?

Answer 4

-abx!!!!, tx initiated empirically & cultures only for complicated cases.

• if absolute dx of strep pneumo sinusitis give Pen VK, otherwise first line is AMOXACILLIN 500mg PO TID x 7days.
• if bacteria is beta lactam resistant you give them AUGMENTING.
• DOXYCYCLINE; dont use this though its recommended next.
• AZITHROMYCIN: indicated for pregnant pt who are pcn allergic.
• LEVOFLOXACIN
• BACTRIM

Bugs:

• strep pneumo
• h flu
• pseudomonas
• staph aureus
• m. cat
• anaerobic

Question 5

Adverse Rxn of:

• Amoxicillin
• Augmentin
• doxycycline
• azithromycin

Answer 5

Amoxicillin-GI upset, rash, SJS

Augmentin: diarrhea, rash, and n/v
*CI in severe renal impairment

Doxycycline: hepatotoxicity, rash, cant use in kids or pregnancy!!

Azithromycin:
-GI upset, acute renal failure. QT prolongation

Question 6

Tx of acute sinusitis if uncomplicated with mild sx?

Answer 6

• pseudoephedrine (Sudafed)
• afrin (oxymetazoline)
• normal saline nasal spray

Question 7

Acute sinusitis duration of tx?

Answer 7

-abx should be prescribed for 5-7days

Question 8

Chronic Sinusitis

• tx
• reasons for tx failure
• what is empiric 2nd line after tx failure?

Answer 8

Tx: abx usually not effective, consult ENT MDD

Tx failure: resistant pathogen, inadequate dosing, structural abnormalitis, noninfectious etiology

2nd line:
-amoxicilling-clavulanate, levofloxacin, or moxifloxacin

Question 9

When to refer chronic sinusitis to ENT?

Answer 9

• multiple episodes of acute bacterial rhinosinusitis.
• pts with allergic rhinitis who may be candidates for immunotherapy
• urgent referral: severe infection( high persistent fever, orbital edema, HA, visual disturbance, altered mental status)

Question 10

what is the key to dx of otitis media?

Answer 10

pneumoscopy, the TM will not move.

Question 11

AOM

• most frequent dx in what age?
• sx treatment
• tx
• recommnded duration of tx

Answer 11

-kids ages 1-3

• sx tx:
• -ibuprofen/motrin
• -auralgan (benzocaine & glycerin), never use in children under 2. reduces pain and swelling
• topical aqueous lidocaine

Tx:

• amoxicillin is 1st line
• augmentin
• kids allergic to PCN get azithromycin
• clarithromycin
• erythromycin
• alternatives:
• cefdinir (omnicef)
• cefuoxime (ceftin)

Duration of tx:

• 10day course in those younger than 2 years
• 5-7day course for children 6yrs and older
• single dose azithromax has FDA approval.

Question 12

AAP/AAFP guidline committee recommends abx when?

Answer 12

-any child younger than 6mo

• ages 6mo - 2 years when dx is certain or the dz is uncertain but illness is severe.
• observation is an option for children in whom the dz is not certain and illness is not severe.
• abx recommended fro children older than 2 yeaers if the dx is certain and illness is severe.
• observation is an option when the dx is certain but illness is not severe and in pts with uncertain dx.

Question 13

Prophylactic tx for otitis media in children who have had 3 infections in 3 months or 4 episodes in 6mo or 6 episodes in 12mo?

Answer 13

amoxicillin 20mg/kg/d for 3-6mo

Question 14

Malignant otitis externa

• aka
• what is this?
• MC bug?
• PE findings
• tx

Answer 14

aka: necrotizing external otitis
what: invasive infection of the canal and skull base

Most common bug: pseudomonas!

PE: mastoid and tragus tenderness.

Tx: antipseudomonal antimicrobials!

• ciprofloxacin
• levofloxacin

Question 15

otic drops are acidic or basic?

Answer 15

-slightly acidic because the external auditory canal is acidic.

Question 16

Otitis Externa

• infection where?
• aka
• cause of infection
• signs and sx

Answer 16

infection of the skin or the ear canal.

aka: swimmers ear

Cause:

• moisture trapped in the ear canal
• hot humid weather
• trauma (cotton swab)
• pseudomonas
• staph
• proteus mirabilis
• fungi

Signs and Sx:

• ear pain with movement of the pinna
• erythematous auditory canal.

Question 17

Otitis Externa

-tx

Answer 17

-remove cerumen, desquamated skin, and purulent material from ear canal (facilitates healing & enhances penetration of ear drops)

• Cortisporin Otic Suspension
• -polymyxin
• -neomycin
• -hydrocortisone
• Cipro HC otic suspension, Ciloxan (ciprofloxacin/hydrocortisone)
• FQ w/ acitivity against pseudomonasm strep, MRSA, staph
• Ciprodex Otic suspension (Cirpo/dexamethasone)
• ofloxin* SAFE in cases of perforated tympanic membrane! this is DOC when perforated TM cannot be ruled out!
• tobradex (tobramycin & dexamethasone); used off label as an otic preparation
• Burows solution (5% aluminum acetate); effective against both bacterial and fungal external otitis
• alcohol vinegar otic mix
• -rubbing alcohol, white vinegar, distill water

Question 18

Auralgan

• indications
• SE

Answer 18

analgesic anesthetic: relieve pain, swelling, and congestion of some ear infections.

-cerumen removal adjunct (softens earwax so it can be washed away more easily)

SE:

• itching
• burning
• redness

Question 19

Debrox

-uses

Answer 19

use: cerumen removal

Question 20

Pt education while using OTICS

Answer 20

wash hands first

avoid contamination and do not touch the dropper or let it touch the ear

if drops are in suspension shake well for 10seconds before using

if edema is evident and prevents application use cotton gauze saturated with abx drops and place in ear. after 24-48hrs the cotton can be removed and the medication applied directly into the canal.

-keep water away from the ear until infection clears and for 4-6wks afterwards

Question 21

Ear Wick

-use

Answer 21

use of ear wick helps topical medication penetrate a severely swollen ear canal (like a sponge)

the ear wick is placed in the ear canal an moistened with topical abx eardrops andd removed after 2-3days

Question 22

summary for OE TX

• mild
• moderate/severe

Answer 22

1. CLEAN
2. mild: non abx topical prep containing acidifying agent and glucocorticoid (acetic acid/hydrocortisone)
3. Moderate/severe: need a prep that contains an abx, an antiseptic, and glucocorticoid (Cipro HC, Cortisporin)
4. wick, protect from water, and NSAIDS

Question 23

Labrynthisis

-tx

Answer 23

Tx: compazine (prochlorperazine) 5-10mg po TID-QID PRN nausea

meclizine (antivert)

Adverse rxns ^^^ drowsiness, sedation, dry mouth, blurred vision

diazepam; supress the vestibular system
Adverse Rxn: cns depression, memory impairment, ataxia

Question 24

Menieres

-tx

Answer 24

diuretics (HCTZ)
antiemetics (compazine, meclizine)
anxiolytics (valium/diazepam) 
antihistamines 
scopolamine

Question 25

Allergic Rhinitis - tx - adverse rxn of meds

Answer 25

intranasal glucocorticoids; beclomethasone, flunisolide, budesonide (rhinocort) Adverse rxn: - HA, pharyngitis, epistaxis * warning: adrenal suppression, delayed wound healing, immunosuppression)