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  • 1. Dr. Yasser A. Nour M.D, FRCSEd Fellow of the Royal College of Surgeons of Edinburgh. Lecturer of Otolaryngology – Head & Neck Surgery. PHARMACOTHERAPY FOR DISEASES OF THE NOSE
  • 2.  
  • 3. Common Cold Rhinovirus Coronavirus The commenst viral infection in human
  • 4. Mode of Transmission
  • 5. Clinical Picture
    • Clinical picture:
    • Fever, headache,
    • malaise.
    • Dryness of nose.
    • Sore throat.
    • Sneezing.
    • Nasal obstruction.
    • Watery rhinorrhea.
    • Mucopurulent
    • Rhinorrhea.
    • Resolution within
    • 5-10 days.
  • 6.
    • Complications:
    • Sinusitis.
    • Pharyngitis.
    • Adenoiditis.
    • Tonsillitis.
    • Otitis media.
    • Laryngotrachitis.
    • Bronchitis.
    • Pneumonia.
    • Nephritis.
    • Rheumatic fever.
  • 7.
    • Treatment:
    • Bed rest.
    • Vitamins.
    • Fluids.
    • Analgesic.
    • Antipyretics.
    • Antihistaminics.
    • Anticholenergic.
    • Decongestant.
    • Antibiotics.
  • 8.  
  • 9. Influenza One of the most common infectious diseases in human. It is caused by influenza virus that is classified as type A, B & C.
  • 10. Influenza It may occur in epidemics. Spanish flu epidemic 1918 killed 20 millions all over the world.
  • 11.
    • People were struck with illness on the street and died rapid deaths. Four women were playing bridge together late into the night. Overnight, three of the women died from influenza.
    • One physician writes that patients with seemingly ordinary influenza would rapidly "develop the most viscous type of pneumonia that has ever been seen" and later when cyanosis appeared in the patients, "it is simply a struggle for air until they suffocate,“.
    Spanish Flu Epidemic
  • 12. Influenza Two types of influenza virus. Human influenza Avian influenza
  • 13. Influenza Two types of influenza virus. Human influenza A person infected with a particular flu virus strain develops antibody against that virus. As newer virus strains appear through antigenic shift and drift , the antibodies against the older strains no longer recognize the "newer" virus, and infection with a new strain can occur.
  • 14. Common Occasional Sore throat Common Occasional Sneezing Common Occasional Stuffy nose Mild to moderate Common, severe Chest discomfort Very mild, short lasting More common Fatigue, weakness Mild Severe Malaise Mild to moderate Common, severe Cough (dry) Severe, common Severe, common Headache Uncommon Common Anorexia Uncommon Severe, common Arthralgia Uncommon Severe, common Myalgia Uncommon only 0.5°C Common up to 40.0°C Fever More gradual Abrupt Onset Common cold Influenza Features
  • 15. Complications
    • Healthy children six to 23 months of age.
    • Adults 65 years and older.
    • Persons six months to 64 years with cardiopulmonary, respiratory, renal, metabolic, or immunodeficient conditions.
    • Pregnant women
    Reye's syndrome Pericarditis Myositis Myoglobinuria Encephalitis Transverse myelitis Guillain-Barré syndrome Rhabdomyolysis Pneumonia Otitis media Tracheobronchitis Acute sinusitis Uncommon Common
  • 16.
    • Children aged 6–23 months.
    • Adults aged ≥50 years.
    • Persons aged 2–64 years with underlying chronic medical conditions.
    • Women who will be pregnant during the influenza season.
    • Residents of nursing homes and long-term care facilities.
    • Children aged 2–18 years on chronic aspirin therapy.
    • Health-care workers involved in direct patient care; and
    • Out-of-home caregivers and household contacts of children aged <6 months.
  • 17. Allergic Rhinitis Dr. Yasser A. Nour, M.D., FRCSEd Lecturer of Otolaryngology – Head & Neck Surgery. Alexandria University Fellow of the Royal College of Surgeons of Edinburgh
  • 18. Allergic rhinitis is an IgE mediated hypersensitivity of nasal mucous membrane characterized by sneezing, itching, watery rhinorrhea and a sensation of nasal obstruction . It may also involve the lining of paranasal sinuses . Allergic rhinitis occurs in atopic individuals who are exposed to common aeroallergens
  • 19. Allergens:
    • Seasonal rhinitis
    • Perennial allergic rhinitis
    • Occupational allergens
    • Food and drug induced rhinitis
    • Role of pollution
    Grass Pollen
  • 20. Allergens:
    • Seasonal rhinitis
    • Perennial allergic rhinitis
    • Occupational allergens
    • Food and drug induced rhinitis
    • Role of pollution
    House dust mites
  • 21. Allergens:
    • Seasonal rhinitis
    • Perennial allergic rhinitis
    • Occupational allergens
    • Food and drug induced rhinitis
    • Role of pollution
    Domestic animals
  • 22. Allergens:
    • Seasonal rhinitis
    • Perennial allergic rhinitis
    • Occupational allergens
    • Food and drug induced rhinitis
    • Role of pollution
  • 23. Allergens:
    • Seasonal rhinitis
    • Perennial allergic rhinitis
    • Occupational allergens
    • Food and drug induced rhinitis
    • Role of pollution
  • 24. Allergens:
    • Seasonal rhinitis
    • Perennial allergic rhinitis
    • Occupational allergens
    • Food and drug induced rhinitis
    • Role of pollution
  • 25. Pathogenesis
  • 26. Pathogenesis Early, or immediate, phase of the reaction
  • 27. Pathogenesis Late-phase response
  • 28.
    • Vasodilatation.
    • Increase vascular permeability.
    • Increase plasma exudation.
    • Chemoattractants for eosinophils and neutrophils.
    • Potent mucus secretogogue.
    • Histamine also increases the release of acetylcholine. This may account more for increased mucus production in allergic rhinitis than do mast cell-derived mediators.
    The biological properties of these mediators include:
  • 29.
    • Sneezing & Itching
    • Rhinorrhea
    • Loss of taste and smell
    • Associated sinusitis and Eustachian Dysfunction
    Positive personal and family history of other atopic diseases + Mucoid + PND +++ +++ ++++ Watery + + Perennial allergic rhinitis Seasonal allergic rhinitis Clinical Picture
  • 30. External signs
    • Allergic salute.
    • Mouth breathing.
    • Allergic shiners.
  • 31. Allergen Avoidance Mites control Mattress covers
  • 32. Allergen Avoidance Mites control Mattress covers Air conditioner Dehumidifier
  • 33. Allergen Avoidance Mites control Mattress covers Dust & Pollen mask Food avoidance Pets control
  • 34. Antihistamines Driving Using machines Glaucoma Prostatic hypertrophy Blurred vision Dry mouth Urinary retention Constipation GI upset Drowsiness Cognitive impairment Impaired reflexes Gastrointestinal Anticholinergic effects Central nervous system Intra-Nasal Antihistamine (Azelastine nasal spray) Side effects Fexofenadine Cetirizine Loratadine Diphenhydramine Brompheniramine Hydroxyzine Second generation First generation
  • 35. Decongestants Care should be taken in those with: Heart disease Hypertension Glaucoma Prostatic hypertrophy Diabetes mellitus Local Systemic Drowsiness Insomnia Dizziness Weakness Acute glucoma Tachycardia Palpitations Nervousness Headache Urine retention Burning Sneezing Increased discharge Rebound congestion Side effects Pseudoephedrine Oxymetazoline Systemic Intranasal
  • 36. Steroids Local Systemic
    • Bone and muscle problems
    • Growth problems in children
    • Increased sugar in the blood
    • Upset stomach
    • Skin rash
    • Swollen face
    • Muscle weakness
    • Increased appetite
    Epistaxis Burning sensation Crusting, dryness Pharyngitis Septal perforation Side effects Prednisone (oral) Trimacinolone (injection) Fluticasone Beclomethasone Budesonide Systemic Intranasal
  • 37. Others IMMUNOTHERAPY Epistaxis Nasal irritation: burning, sneezing Intra-Nasal Anticholinergic Ipratropium bromide Intra-Nasal Mast Cell Stabilizers Cromolyn sodium
  • 38. Others SINGULAIR is indicated for relief of symptoms of allergic rhinitis (seasonal allergic rhinitis in adults and children aged 2 years and older and perennial allergic rhinitis in adults and children aged 6 months and older).
  • 39. Sinusitis Sinusitis is the inflammation/infection of 1 or more paranasal sinuses and occurs with obstruction of the normal drainage mechanism. It is traditionally subdivided into acute (symptoms lasting <3 wk), subacute (symptoms lasting 3 wk to 3 mo), and chronic (symptoms lasting > 3 mo).
  • 40. Several factors may contribute to obstruction: mucosal swelling, abnormalities of the cilia, structural abnormalities and overproduction of secretions. Preceding viral infection or epithelial damage weakens mucosal defenses and facilitates penetration of bacteria into the sinus mucosa. Although nasal allergies also contribute to edema and swelling of the nasal mucosa.
  • 41. A diagnosis of ABS can be made when a viral upper respiratory tract infection (URI) fails to improve after 10 days or worsens after 5–7 days and is accompanied by symptoms of persistent anterior and posterior rhinorrhea, nasal congestion, facial pressure/pain, post-nasal drainage, reduced sense of smell, fever, cough, fatigue, dental pain in the jaw, or ear pressure/fullness.
  • 42. Symptoms associated with acute bacterial rhinosinusitis Nonspecific/infrequent symptoms Malaise/fatigue Purulent anterior nasal or postnasal discharge Cough Fever Hyposmia/anosmia “ Double-sickening” history † Nasal congestion        Maxillary tooth or facial pain (especially when unilateral) Halitosis Unilateral maxillary sinus tenderness Key diagnostic symptoms
  • 43. The most common bacterial pathogens in acute sinusitis are Streptococcus pneumoniae (30-40%), Haemophilus influenzae (20-30%) Moraxella catarrhalis (12-20%). Anaerobic organisms have been found in fewer than 10% of patients with acute bacterial sinusitis, despite the ample environment available for their growth.
  • 44. First-line therapy at most centers is usually amoxicillin or a macrolide antibiotic in patients allergic to penicillin because of the low cost, ease of administration, and low toxicity of these agents. * 500 mg PO first day, then 250 mg/d PO for 4 days Azithromycin 250-500 mg PO bid Clarithromycin 500 mg PO tid Amoxicillin Dosage Antibiotic
  • 45. Patients who live in communities with a high incidence of resistant organisms , those who fail to respond within 48-72 hours of commencement of therapy, and those with persistence of symptoms beyond 10-14 days should be considered for second-line antibiotic therapy. 300 mg PO tid Clindamycin 200 mg/d PO Trovafloxacin 500 mg/d PO Levofloxacin 500-750 mg PO bid Ciprofloxacin 200 mg PO bid 400 mg/d PO Cefpodoxime + cefixime 250-500 mg PO bid Cefuroxime 500 mg PO tid Amoxicillin/clavulanate Dosage Antibiotic
  • 47. External Ear
  • 48. Otitis Externa
    • Otitis externa is a spectrum of infection of the external auditory canal. Although commonly called swimmer’s ear, it may be caused by anything that results in the removal of the protective lipid film from the canal, allowing bacteria to enter the apopilosebaceous unit.
  • 49. Otitis Externa
    • Itching
    • Itch/scratch cycle
    • Pain
    • Purulent discharge
    • Hearing loss
    • Pain on palpation of the tragus
    • Edema and redness of the ear canal
    • Cellulitis of the face or neck or lymphadenopathy of the unilateral neck
  • 50. The most common pathogen is Pseudomonas aeruginosa , followed by Staphylococcus aureus , then other gram-negative organisms.
  • 51.
    • There are four fundamental principles in the treatment of external otitis
    • Frequent and thorough cleaning
    • Judicious use of appropriate antibiotics
    • Treatment of associated inflammation and pain
    • Recommendations regarding the prevention of future infections
    Treatment In the absence of purulence, a brief course of an acidifying drop such as Acetic acid in aluminium acetate is efficacious in discouraging bacterial or fungal growth
  • 52.
    • Mild Stage
    • An antibiotic otic drop
    • Neomycin, polymyxin, dexamethasone (Isoptomaxitrol)
    • Neomycin, polymyxin B, dexamethasone (Dexapolyspectran Otic)
    • Tobramycin and dexamethasone ( Tobradex)
    • Ciprofloxacin (Ciloxan, Cipro HC Otic)
    • Ofloxacin (Floxin otic)
  • 53.
    • Moderate Stage
    • In the moderate stage of inflammation, edema of the canal may interfere with the instillation of drops. The physician should then insert a gauze strip or wick into the canal with antibiotic ointment and instill drops on it.
  • 54.
    • Severe Stage : Infection often extends beyond the limit of the canal. An oral antibiotic with broad-spectrum coverage is needed.
    Treatment In prolonged therapy, periodically evaluate organ system functions (eg, renal, hepatic, hematopoietic) Precautions <18 years: Not recommended Pediatric Dose 250-500 mg PO bid Adult Dose Ciprofloxacin (Cipro) -- Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms but with no activity against anaerobes. Drug Name
  • 55.
    • Instruct the patient to avoid future infections by not placing any object or instrument into the canal.
    • Patients who have repeated infections are best advised to use an acidifying drop composed of equal measures of vinegar and water , or ethyl alcohol and water , when exposed to high humidity.
    • Custom-made ear molds are useful for these patients.
  • 56. Otomycosis
    • Otomycosis is a fungal infection of the skin of the external canal.
    • All fungi have three basic growth requirements:
    • Moisture
    • Warmth
    • Darkness
  • 57.
    • Aspergillus species are most common, and pruritus is the primary clinical manifestation.
    • Physical examination commonly shows a white, black, or dotted gray membrane.
  • 58.
    • Thorough cleaning with removal of the matted fungal debris is supplemented by the topical application of an acidifying solution
    • 2% Acetic acid in aluminium acetate
    • 3% Boric acid in 70% alcohol.
    • Topical Antifungal:
    • Clotrimazole cream or solution (Canestin or dermatin).
    • Nystatin drops (Mycostatin)
  • 59. Furunculosis Acute localized otitis externa, also known as furunculosis, is associated with infection of a hair follicle.
    • Analgesics, ant-inflammatory
    • Antibiotics
    • Ear wick
  • 60. Wax impaction Cerumen impaction is the most common abnormality found on otoscopic examination. It is the most common cause of hearing loss.
    • Ceruminolytic agents:
    • 3% Hydrogen Peroxide solution
    • Triethanolamine (Ceruminex)
    • Carbamide peroxide in glycerol
    • Olive oil, Mineral oil or Baby oil
  • 61. MIDDLE EAR
  • 62. Acute Otitis Media
            • Otitis media (OM) is the second most common disease of childhood after upper respiratory tract infections and is one of the most common reasons for a child to visit the pediatrician’s office.
    Acute otitis media usually arises as a complication of a preceding viral upper respiratory infection (URI).
  • 63.
    • Risk factors for otitis media:
    • Host risk factors include age, prematurity, race, allergy, craniofacial abnormalities, gastroesophageal reflux, presence of adenoids, and genetic predisposition.
    • Daycare center attendance increases risk of development of AOM.
    • Bottle-feeding increases the incidence compared with breastfeeding.
    • Smoking in the household.
    Acute Otitis Media
  • 64. Pneumococcus species, Haemophilus influenzae, and Moraxella species are the bacteria most commonly involved in otitis media.
  • 65.
    • Earache
    • Fever (not required for the diagnosis)
    • Accompanying or precedent URI symptoms (very common)
    • Decreased hearing
    • Injected tympanic membrane
    Acute Otitis Media
  • 66. Treatment &quot; Wait-and-see prescription “ for antibiotics in AOM The observation option is a 48- to 72-hour period of symptomatic treatment with analgesics and without antibiotics, followed by reexamination.
  • 67. Treatment Adjust dose in renal impairment; use in Ebstein-Barr viral mononucleosis increases risk of severe rash Precautions 80-90 mg/kg/d PO divided q8h for 10 d in younger children and in patients with severe disease Pediatric Dose 250-500 mg PO q8h Adult Dose Amoxicillin (Amoxil, Biomox) Drug Name
  • 68. Treatment Give for minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); after treatment, perform cultures to confirm eradication of streptococci Precautions 90 mg/kg (amoxicillin) with 6.4 mg/kg (clavulanate) divided PO q12h Pediatric Dose 500-875 mg PO q12h PO or 250-500 mg PO q8h Adult Dose Amoxicillin and clavulanate potassium (Augmentin) Drug Name
  • 69. Treatment 30 mg/kg PO q12h Pediatric Dose 125-500 mg PO q12h Adult Dose Second-generation cephalosporin maintains gram-positive activity of first-generation cephalosporins; adds activity against Proteus mirabilis , H influenzae , Escherichia coli , Klebsiella pneumoniae , and M catarrhalis . Condition of patient, severity of infection, and susceptibility of microorganism determines proper dose and route. Description Cefuroxime Drug Name
  • 70. Ceftriaxone 50 mg/kg/d is recommended for children who are unable to take oral antibiotics and for patients with compliance problems. Treatment
  • 71. Bell’s palsy
    • The term Bell’s palsy has been used to describe a facial paralysis of acute onset and limited duration, the etiology of which was deemed idiopathic.
  • 72. Bell’s palsy
    • Steroids
    • Antiviral agents
    • Eye care:
      • Artificial tears
      • Lubricants
      • Eye glasses or shields
  • 73. Bell’s palsy Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use Precautions 1 mg/kg/d PO for 7 d Adult Dose Prednisone (Hostacortin) Drug Name
  • 74. Bell’s palsy Caution in renal failure or when using nephrotoxic drugs Precautions <2 years: Not recommended >2 years: 1000 mg PO divided qid for 10 d Pediatric Dose 4000 mg/24 h PO for 7-10 d Adult Dose Acyclovir (Zovirax) -- Has demonstrated inhibitory activity directed against both HSV-1 and HSV-2, and infected cells selectively take it up. Drug Name
  • 75. INNER EAR
  • 76. Vertigo
    • Subjective sensation of disturbed relationship between the individual and his environment in which either the patient or his environment is moving.
    Meniere’s disease Vestibular neuronitis
  • 77. Meniere’s disease Caution in angle-closure glaucoma, prostatic hypertrophy, pyloric or duodenal obstruction, and bladder neck obstruction Precautions 25-50 mg PO q4-6h Adult Dose Decreases the excitability of the middle ear labyrinth and blocks conduction in the middle ear vestibular-cerebellar pathways. These effects are associated with its therapeutic effects in vertigo. Description Meclizine (Antivert) Drug Name
  • 78. Meniere’s disease Neonates: Do not administer 2-6 years: 12.5-25 mg q6-8h; not to exceed 75 mg/d 6-12 years: 25-50 mg PO q6-8h; not to exceed 150 mg/d Pediatric Dose 50 mg PO/IM q4-6h or a 100-mg suppository q8h Adult Dose Used for treatment and prophylaxis of vestibular disorders that may cause nausea and vomiting. Through its central anticholinergic activity, it diminishes vestibular stimulation and depresses labyrinthine function. Description Dimenhydrinate (Dramamine) Drug Name
  • 79. Meniere’s disease 5-10 mg PO/IV/IM q4-6h Adult Dose Depresses all levels of the CNS, including limbic and reticular formation, possibly by increasing GABA activity, which is a major inhibitory neurotransmitter. Description Diazepam (Valium) Drug Name
  • 80. Meniere’s disease Can be associated with CNS depression, dry mouth, extrapyramidal symptoms, hypertension, hypotension, and rash; caution in patients with cardiovascular or hepatic disease Precautions <2 years: Contraindicated >2 years: 0.5 mg/kg q4-6h Pediatric Dose 25-50 mg PO/IM/PR q4-6h Adult Dose Antidopaminergic agent effective in the treatment of emesis. Description Promethazine (Phenergan) Drug Name
  • 81.
    • Low-sodium diet (1–1.5 g Na+/day)
    • Diuretic:-
    • Triamterene and hydrochlorothiazide (Dyazide)
    • Acetazolamide (Diamox)
    • Hydrochlorothiazide
    • Betahistine ( Betaserc)
    Meniere’s disease
    • Betahistine (Betaserc,Microserc 8,16 mg ,Verserc 24 mg)
    • H3 receptor agonist. It dilates blood vessels in the inner ear.
    • Increases serotonin in brain stem leading to decrease in activity of vestibular nuclei.
  • 83.
    • Cinnarizine (Stugeron 25 mg):
    • Calcium channel blocker that decreases contraction of vascular smooth muscles.
    • Vincamine (Oxybral 30 mg):
    • Peripheral vasodilator that increases blood supply to the brain.
  • 84.
    • Almitrine besmesylate (duxil):
    • Acts on chemoreceptors of the carotid bodies leading to increase in the arterial oxygen tension.
    • Piracetam (Nootropil):
    • It increases blood flow and oxygen consumption in the brain
  • 85. Thank you www.yasser-nour .com