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 Formulary Chapter 12: Ear, nose and oropharynx - Full Chapter
12.01  Drugs acting on the ear
12.01.01  Otitis externa
Ciprofloxacin 2mg/ml ear drops (Cetraxal®)
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Green

Use in line with Antimicrobial Guidance for Primary Care

 
Link  Leicestershire Guidance: Antimicrobial Guidance for Primary Care
   
12.01.01  Anti-infective preparations
12.01.03  Removal of ear wax
 note 
  • 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.
Olive Oil
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First Choice
Green
Warm before use. 
Sodium Bicarbonate ear drops BP
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Second Choice
Green
 
   
Exterol®
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Restricted Drug Restricted Ear drops
Prison use only 
   
12.02  Drugs acting on the nose to top
12.02.01  Drugs used in nasal allergy
 note 
  • 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.
12.02.01  Corticosteroids
Beclometasone Nasal Spray
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First Choice
Green
 
Fluticasone Furoate Nasal Spray (Avamys®)
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Second Choice
Green
More costly choice than beclometasone. 
   
Fluticasone + Azelastine  (Dymista®)
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Second Choice
Green
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

 
Link  Leicestershire Evaluation: Dymista® in Allergic Rhinitis
   
12.02.02  Topical nasal decongestants
 note 
  • Considered Drugs of Limited Clinical Value.
  • 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
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12.03  Drugs acting on the oropharynx
12.03.01  Drugs for oral ulceration and inflammation to top
 note 
  • 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
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12.03.05  Treatment of dry mouth
12.03.05  Local Treatment
 note 

Biotene is available in small tubes for hospital use and this will be kept for LOROS use only.

BioXtra®
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First Choice
Green
Product of choice to replace Glandosane and Biotene (with the exception stated above) 
 ....
 Non Formulary Items
Budesonide nasal spray  (Benacort®)

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Non Formulary
Black
 
Fluticasone Propionate (nasules)

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Non Formulary
 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
SMC
Scottish Medicines Consortium
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Black

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   

Red

Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).  

Amber SCA

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.   

Amber Simple

Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.  

Green Conditional

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.   

Green

Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.   

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