Pharm HEENT summarized

+ lyd

abbreviations for left ear, right ear, both ears *

left ear: as

right ear: ad

both ears: au

tx otitis externa (general)

ABX/corticosteroid drops

-Polymyxin B/neomycin/hydrocortisone (Cortisporin) drops

Ciprofloxacin/dexamethasone (Ciprodex)

ear wick, lie w ear up x5min

oral quinolones for severe

tx mild OE w intact TM

acidifying solution + glucocorticoid

tx moderate OE intact TM

ABX + glucocorticoid

tx severe OE intact TM

abx + glucocorticoid w wick and/or systemic abx (quinolones)

what pathogens should be covered for OE

staph aureus

pseudomonas (mc)

tx OE w perforated TM *

topical fluoroquinolones x7days

no aminoglycosides, acidic preps, alcohol (ototoxic)

why do you add an acidifying solution to OE tx

dry out fluid in ear, bacteria can't grow in acidic environment

acidifying agent used in OE tx

acetic acid 2% otic solution

Daprano's "go to" for OE tx*

ciprofloxacin 0.3% and dexamethasone 0.1% otic suspension (Ciprodex)

what can be used to tx OE if otic product not available

ophthalmic solutions

4 groups of drugs to tx OE (general)

1. acidifying agent (acetic acid)

2. glucocorticoids

3. fluoroquinolones

4. aminoglycosides (not if TM perforated)

T/F you can use acetic acid to tx OE if TM is perforated

F

"go to" OE tx if perforated TM

ciprofloxacin 0.2% otic solution (Cetraxal otic)

or

Ofloxacin otic (Floxin)

both fluoroquinolonesx7days

interactions w ciprofloxacin

antacids

iron

sucralfate

steroids

calcium

SE ciprofloxacin

tendon rupture

QT prolongation

who is fluoroquinolones contraindicated in

pregnancy and kids

other tx for OE besides prescriptions

ear canal cleaning under direct visualization

ear hygiene

analgesia

malignant (necrotizing OE) organism and tx

pseudomonas

mild: oral ciprofloxacin

mod-severe: admission + IV antipseudomonal abx (zosyn, ceftazadime, cefepime)

pathogens AOM

strep pneumo

H. flu

moraxella catarrhalis

1st line tx AOM

high dose amoxicillin (wt based dose)

2nd line tx AOM

augmentin

cefuroxime (2nd gen)

cefdinir (3rd gen)

cefpodoxime (3rd gen)

cefixime (3rd gen)

can use all 3rd gens if non-life threatening PCN allergy too

tx AOM if PCN allergy

macrolides (azithromycin, clarithromycin, erythromycin)

TMP-SMZ

main SE macrolides

GI

tx of otalgia from AOM in kids

oral acetaminophen or ibuprofen

1st line tx chronic OM

topical ABX (ofloxacin or ciprofloxacin)

avoid when TM not intact: water, moisture, topical aminoglycosides

T/F OM w effusion typically resolves spontaneously

T

complication of OM

mastoiditis

tx mastoiditis no PCN allergy *

IV ABX x4wks

vancomycin PLUS

-ceftazidime

-cefepime

-piperacillin-tazobactam

tx mastoiditis true PCN allergy

vancomycin PLUS aztreonam IV x4wks

what drug class is aztreonam

carbapenem

tx cerumen impaction

cerumenolytic agents (only if TM intact)

-carbamide peroxide 6.5% (Debrox)

-hydrogen peroxide 3%

effervescent activity in ear

bubbling/crackling (softening of ear wax)

tx eustachian tube dysfunction

decongestants (decrease ET edema) (psuedophederine, Afrin)

auto-insufflation (swallowing, yawning)

intranasal corticosteroids (triamcinolone, budesonide, fluticasone, mometasone)

MOA decongestants for ET dysfunction

sympathomimetics

constricts blood vessels in nasal passages

why should you not use oxymetazoline (Afrin) for >3days

rebound s/sx

tx vertigo

antihistamine - meclizine (antivert)

tx BPPV

antihistamine-meclizine (Antivert)

what generation antihistamine is meclizine

1st

SE meclizine

anticholinergic

tx Meniere's disease

antihistamines (meclizine or dimenhydrinate)

antiemetic (prochlorperazine)

benzodiasepines (diazepam)

anticholinergices (scopolamine)

triggers for meniere's disease that increase endolymphatic pressure

high salt intake

caffeine

alcohol

nicotine

stress

MSG

allergens

tx motion sickness (physiologic vertigo)

scopolamine

diphenhydramine (dramamine)

meclizine

causes of ototoxicity

aminoglycosides

erythromycin and tetracycline

chemotherapy

loop diuretics

ED drugs (PDE5 inhibitors)

cocaine

heavy metals

pharm cause of reversible ototoxicity

high dose ASA 6-8g/day and other salicylates (tinnitus and hearing loss)

also antimalarials and high dose NSAIDs

tx epistaxis

1. direct pressure

2. topical decongestants/vasoconstrictors

-oxymetazoline

-phenylephrine

other: cauterization, nasal packing, avoid exercise, spicy foods, humidifier

MOA oxymetazoline nasal spray (Afrin)

sympathomimetic - vasoconstriction

pt education for use of oxymetazoline nasal spray (Afrin)

limit use NMT 3 days - will get rebound s/sx

SE oxymetazoline (Afrin)

elevated BP

population you should not use oxymetazoline nasal spray (Afrin)

<6yrs old

MOA Phenylephrine nasal spray (Neo-synephrine)

sympathomimetic - vasoconstriction

pt education for phenylephrine nasal spray (Neo-synephrine)

limit use to NMT 3 days - will get rebound s/sx

SE Phenylephrine Nasal spray (Neo-synephrine)

elevated BP

duration acute rhinosinusitis

1-4wks

T/F most cases of acute rhinosinusitis are viral

T

tx viral sinusitis

no ABX

pain relief

saline irrigation

decongestion

-topical corticosteroids (mometasone)

-topical decongestants (oxymetazoline)

-oral decongestants (pseudoephedrine)

anticholinergics (ipratropium)

APA or Ibuprofen for pain relief

topical corticosteroids for viral sinusitis

mometasone

fluticasone

topical decongestants

oxymetazoline

oral decongestants

pseudoephedrine

anticholinergic used to tx viral sinusitis

ipratropium

fluticasone administration instructions

prime before using for first time

-shake and release 6 sprays into air away from the face

-shake gently before each use

Sudafed PE vs Sudafed

Sudafed PE: phenylephedrine

Sudafed: pseudoephedrine

MOA Pseudoephedrine (Sudafed)

stimulates alpha adrenergic receptors in upper respiratory tract = vasoconstriction

SE pseudoephedrine (Sudafed)

increased BP

when to tx sinusitis as bacterial

after 7 days

first line tx bacterial sinusitis

Augmentin x10-14 days

tx bacterial sinusitis if PCN allergy

cefpodoxime

can do erythromycin if severe allergy but consider resistance

tx of bacterial sinusitis if recent ABX use or refractory cases

fluoroquinolones

timeline chronic rhinosinusitis

>/12wks

medical management for chronic rhinosinusitis is focused on controlling the _____ and ______

obstruction and inflammation

tx for chronic rhinosinusitis

nasal glucocorticoids

oral glucocorticoids (esp. polyps)

Leukotriene inhibitors (montelukast-singulair)

BBW about Montelukast

neuropsychiatric effects

don't give to elderly or mentally unstable

tx chronic sinusitis (ABXs)

Augmentin

Clindamycin

Moxifloxacin (adults only)

SE Moxifloxacin

tendon rupture

prolonged QT

don't give to kids

interactions Moxifloxacin

metal cations

-give 4hrs before or 8hrs after iron salts d/t chelation

pharmacotherapy for allergic rhinitis

intranasal corticosteroids

(triamcinolone, budesonide, fluticasone, mometasone)

oral and nasal antihistamines

(diphenhydramine, loratadine, cetirizine, fexofenadine)

antihistamine/decongestant combos

(loratadine/pseudoephedrine)

Cromolyn nasal spray MOA

mast cell stabilizer

tx for allergic rhinitis

T/F montelukast is a first line tx for allergic rhinitis

false

-except in pts w concurrent asthma

tx of choice for nasal polyps

intranasal corticosteroids (fluticasone)

ABX for strep pharyngitis

1st line PCN (use amoxicillin)

if PCN allergy: macrolides

supportive: NSAIDs or APAP

1st thing to do if you suspect epiglottitis

secure the airway

Empiric ABX therapy for acute epiglottitis ***

cefotaxime or ceftriaxone

PLUS

clindamycin or vancomycin

IV ABX management for epiglottitis

ceftriaxone or cefotaxime

PLUS

vancomycin or clindamycin or oxacillin or nafcillin or cefazolin

oral candidiasis (thrush) tx

Nystatin oral suspension

swish and swallow

systemic: fluconazole (do not use in 1st trimester of pregnancy)

medication that most commonly causes thrush

ICS inhaler if you don't rinse mouth

T/F you can use fluconazole as a systemic tx for oral candidiasis (thrush) in the first trimester of pregnancy

F

most ophthalmic drugs exhibit ___________ *

first order kinetics

-half life is constant regardless of amount of drug present

pharm causes of contact blepharitis

retinoids

chemotherapy

inflammatory skin conditions causing blepharitis

atopic dermatitis

psoriasis

seborrheic dermatitis

rosacea

tx mild-mod blepharitis

warm compress BID 15-20min

eyelid massage

eyelid wash w baby shampoo

artificial tear eye drops

tx severe or refractory blepharitis

topical ABX (bacitracin, erythromycin, azithromycin ointments)

oral ABX (doxycycline)

topical glucocorticoids (rimexolone, loteprednol, fluoromethalone)

topical cyclosporine (restasis, cequa)

topical ABX for blepharitis

bacitraicin

erythromycin

azithromycin

ointments x7-10days

SE: blurred vision

doxycycline SE

Photosensitivity (sunburn)

GI distress Hepatotoxicity

Deposition in bones and teeth (discoloration); limited use in pediatric pts

hypersensitivity

administration of doxycycline

best on an empty stomach

topical glucocorticoids for blepharitis (names, potency, duration of tx)

rimexolone (vexol)

loteprednol (Lotemax, Eysuvis)

both low potency

x2wks

drug that is FDA approved for dry eyes but is used "off label" for blepharitis *

topical cyclosporine (restasis or cequa)

when to use topical cyclosporine (restasis or cequa) for blepharitis

pts who don't respond to standard tx (also shoudl be prescribed by an ophthalmologist)

tx Hordeolum and Chalazion

warm compress BID x2wks

bactracin or erythromycin ointment HS for hordeolum (tx staph)

tx recurrent chalazia

systemic tetracycline

T/F chalazia usually require ABX

false

they are non infections, but if they are recurrent you can give oral tetracycline