Wax should only be removed if it causes deafness or interferes with examination of the eardrum.
Syringing should be avoided where there is a perforated eardrum, previous ear surgery or deafness in the other ear.
Sodium bicarbonate drops may be used 2 or 3 times daily for 1-2 weeks before syringing if the wax is impacted. The patient should be advised to lie with the affected ear uppermost for 5-10 minutes after use of the ear drops. Use of sodium bicarbonate drops for up to a month may alleviate the need for syringing altogether.
Seek specialist advice for difficult cases.
Warm before use.
Sodium Bicarbonate ear drops BP
Ear drops Prison use only
Drugs acting on the nose
Drugs used in nasal allergy
Corticosteroid nasal sprays are appropriate as first-line treatment. They are more effective than oral antihistamines in reducing nasal blockage, postnasal drip and providing overall relief of symptoms. Additional benefit may be obtained by combining with an antihistamine.
All corticosteroid nasal sprays are equally effective.
Regular use is essential to ensure maximum benefit and non-compliance is a common cause of treatment failure.
Antihistamine nasal sprays tend to be less effective than topical steroids. They offer an alternative for a small number of patients (or parents) that express concern about the long-term safety of corticosteroids. Local infection should be treated.
Local advice on technique for using steroid nasal sprays / Dymista is as follows: It is best to use the nasal spray when the nose is clearest, not when blocked. Point the spray slightly away from the midline to reduce the risk of nosebleeds. Don't sniff when taking the spray (keeping the mouth open will facilitate this) This prevents the majority of the spray ending up in the throat and improves compliance as patients complain of the bitter taste of some sprays. For patients who do experience nosebleeds use Vaseline to both sides of the nose twice a day ideally before using the spray.
For patients not responding to treatment check technique before considering alternative therapy.
Mometasone nasal spray may be used in children aged 3-6 years of age as it is the only licensed product for this age group.
Beclometasone Nasal Spray
Fluticasone Furoate Nasal Spray (Avamys®)
More costly choice than beclometasone.
Fluticasone + Azelastine (Dymista®)
For use in line with allergic rhinitis guideline.
For patients who have not responded to other therapies and who would otherwise be considered for Sub Lingual Immunotherapy (SLIT) or a referral to secondary care
They can cause rebound congestion leading to habituation and overuse (rhinitis medicamentosa).
Inhalation of steam is an inexpensive alternative that may be beneficial. Addition of an aromatic product e.g. compound benzoin tincture may make this a more attractive therapy to use.
Topical nasal decongestants
Drugs acting on the oropharynx
Drugs for oral ulceration and inflammation
Mouthwashes A large number of pathological processes may cause ulceration of the oral mucosa. The cause should be established in each case, as specific therapy may be required.
Mouthwash solution tablets may help relieve traumatic ulceration. One tablet dissolved in a tumblerful of warm water produces a solution that can be used to rinse the mouth at frequent intervals.
Benzydamine oral rinse (‘Difflam’) is useful where there is painful inflammation of the mouth and throat. The recommended dose is 10-15mL used every 1.5-3 hours. Dilute with an equal volume of water if stinging or numbness occurs.
Chlorhexidine gluconate 0.2% mouthwash ('Corsodyl') is recommended for oral hygiene in patients that are particularly at risk of infection (e.g. neutropenia). 10mL should be used to rinse the mouth twice daily (for about 1 minute). Patients should be advised that it might cause reversible brown staining of teeth.
Betamethasone soluble tablets dissolved in water can be used as a mouthwash to treat oral ulceration (unlicensed use).
Throat lozenges Antiseptic throat lozenges are not recommended for routine use as most infections are viral and there is little evidence of benefit. Lozenges with local anaesthetics such as benzocaine may be appropriate for some painful conditions but may reduce swallowing sensation in the short-term and cause sensitisation with prolonged use.
Gelclair sachets supported as a mouthwash for mucositis
Drugs for oral ulceration and inflammation
Treatment of dry mouth
Biotene is available in small tubes for hospital use and this will be kept for LOROS use only.
Product of choice to replace Glandosane and Biotene (with the exception stated above)
Drugs not recommended for use in the Leicestershire Health Community because of lack of evidence of clinical effectiveness, cost prioritization or concerns over safety.
All new drugs will be black until they have been through the appropriate approval process - then they will appear as a specific entry
Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).
Drugs which would initially be prescribed by a hospital specialist and then by a GP where full agreement to share the care of each specific patient has been reached under a LMSG Shared Care Agreement (SCA). Specific patient monitoring or intervention required.
Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.
Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.
Drugs not yet reviewed
Drugs for which GPs are able to take full responsibility for prescribing and monitoring subject to specified conditions e.g. prescribing in line with agreed LMSG guidance or able to demonstrate suitable competence. See comments under individual entries