l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Benzalkonium chloride
▶ Gentamicin (Non-proprietary)
Gentamicin (as Gentamicin sulfate) 3 mg per 1 ml Gentamicin
0.3% ear/eye drops | 10 ml P £2.63 DT = £2.47
Gentamicin with hydrocortisone
Eczematous inflammation in otitis externa
▶ Child: Apply 2–4 drops 4–5 times a day, (including a
▶ Adult: Apply 2–4 drops 4–5 times a day, (including a
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL
SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC
See Corticosteroids, general use p. 670.
l CONTRA-INDICATIONS Patent grommet (although may be
used by specialists, see Ear p. 1194). perforated tympanic
membrane (although may be used by specialists, see Ear
l CAUTIONS Avoid prolonged use
Medicines for Children leaflet: Gentamicin and hydrocortisone ear
drops for inflammatory ear infections
www.medicinesforchildren.org.uk/gentamicin-andhydrocortisone-ear-drops-inflammatory-ear-infections
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Benzalkonium chloride, disodium edetate
▶ Gentamicin with hydrocortisone (Non-proprietary)
Gentamicin (as Gentamicin sulfate) 3 mg per 1 ml,
Hydrocortisone acetate 10 mg per 1 ml Gentamicin 0.3% /
Hydrocortisone acetate 1% ear drops | 10 ml P £29.86 DT =
Bacterial infection in otitis externa
▶ Child: (consult product literature)
▶ Adult: (consult product literature)
l CONTRA-INDICATIONS Patent grommet (although may be
used by specialists, see Ear p. 1194). perforated tympanic
membrane (although may be used by specialists, see Ear
l CAUTIONS Avoid prolonged use
l INTERACTIONS → Appendix 1: neomycin
l MEDICINAL FORMS No licensed medicines listed.
Combinations available: Betamethasone with neomycin,
p. 1164 . Dexamethasone with glacial acetic acid and
neomycin sulfate, p. 1199 . Hydrocortisone with neomycin and
ANTIBACTERIALS › QUINOLONES eiiiF 557i
▶ Child 1–17 years: Apply 0.25 mL twice daily for 7 days,
each 0.25 mL dose contains 0.5 mg ciprofloxacin
▶ Adult: Apply 0.25 mL twice daily for 7 days, each
0.25 mL dose contains 0.5 mg ciprofloxacin
l CAUTIONS Known (or at risk of) perforated tympanic
l INTERACTIONS → Appendix 1: quinolones
l HANDLING AND STORAGE Manufacturer advises discard
any ampoules remaining 8 days after opening the pouch.
Medicines for Children leaflet: Ciprofloxacin drops for infection
www.medicinesforchildren.org.uk/ciprofloxacin-drops-infection
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (April 2018)
that ciprofloxacin ear drops (Cetraxal ®) are recommended
for use within NHS Scotland for treatment of acute otitis
externa in adults and children over 1 year with an intact
tympanic membrane, caused by ciprofloxacin susceptible
microorganisms when off-label or unlicensed ciprofloxacin
formulations would otherwise be used.
All Wales Medicines Strategy Group (AWMSG) decisions
The All Wales Medicines Strategy Group has advised (July
2018) that ciprofloxacin (Cetraxal ®) is recommended as an
option for use within NHS Wales for the treatment of acute
otitis externa in adults and children older than 1 year with
an intact tympanic membrane, caused by ciprofloxacin
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: ear drops
▶ Cetraxal (Aspire Pharma Ltd)
Ciprofloxacin (as Ciprofloxacin hydrochloride) 2 mg per
1 ml Cetraxal 2mg/ml ear drops 0.25ml unit dose | 15 unit
Combinations available: Ciprofloxacin with dexamethasone,
p. 1198 . Ciprofloxacin with fluocinolone acetonide, p. 1198
l DRUG ACTION Chloramphenicol is a potent broadspectrum antibiotic.
Bacterial infection in otitis externa
▶ Child: Apply 2–3 drops 2–3 times a day
▶ Adult: Apply 2–3 drops 2–3 times a day
l CAUTIONS Avoid prolonged use
l INTERACTIONS → Appendix 1: chloramphenicol
l SIDE-EFFECTS Blood disorder. bone marrow depression
Medicines for Children leaflet: Chloramphenicol ear drops for ear
infections (otitis externa) www.medicinesforchildren.org.uk/
chloramphenicol-ear-drops-ear-infections-otitis-externa-0
l LESS SUITABLE FOR PRESCRIBING Chloramphenicol ear
drops are less suitable for prescribing.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Propylene glycol
▶ Chloramphenicol (Non-proprietary)
Chloramphenicol 50 mg per 1 ml Chloramphenicol 5% ear drops |
Chloramphenicol 100 mg per 1 ml Chloramphenicol 10% ear drops
ANTIFUNGALS › IMIDAZOLE ANTIFUNGALS
Fungal infection in otitis externa
▶ Child: Apply 2–3 times a day continue for at least
14 days after disappearance of infection
▶ Adult: Apply 2–3 times a day continue for at least
14 days after disappearance of infection
l INTERACTIONS → Appendix 1: antifungals, azoles
Medicines for Children leaflet: Clotrimazole for fungal infections
www.medicinesforchildren.org.uk/clotrimazole-fungalinfections
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Canesten (clotrimazole) (Bayer Plc)
Clotrimazole 10 mg per 1 ml Canesten 1% solution | 20 ml p
l DRUG ACTION Betamethasone has very high glucocorticoid
activity and insignificant mineralocorticoid activity.
Eczematous inflammation in otitis externa
▶ Adult: Apply 2–3 drops every 2–3 hours, reduce
frequency when relief obtained
Eczematous inflammation in otitis externa
▶ Adult: Apply 2–3 drops every 3–4 hours, reduce
frequency when relief obtained
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL
SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC
See Corticosteroids, general use p. 670.
l CONTRA-INDICATIONS Avoid alone in the presence of
untreated infection (combine with suitable anti-infective)
l CAUTIONS Avoid prolonged use
l INTERACTIONS → Appendix 1: corticosteroids
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Benzalkonium chloride, disodium edetate
▶ Betnesol (RPH Pharmaceuticals AB)
Betamethasone sodium phosphate 1 mg per 1 ml Betnesol 0.1%
eye/ear/nose drops | 10 ml P £2.32 DT = £2.32
▶ Vistamethasone (Martindale Pharmaceuticals Ltd)
Betamethasone sodium phosphate 1 mg per 1 ml Vistamethasone
0.1% ear/eye/nose drops | 5 ml P £1.02 | 10 ml P £1.16 DT =
Combinations available: Betamethasone with neomycin,
Flumetasone pivalate with clioquinol
Eczematous inflammation in otitis externa | Mild bacterial
or fungal infections in otitis externa
▶ Child 2–17 years: 2–3 drops twice daily for 7–10 days, to
▶ Adult: 2–3 drops twice daily for 7–10 days, to be
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL
SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC
See Corticosteroids, general use p. 670.
l CONTRA-INDICATIONS Iodine sensitivity
l CAUTIONS Avoid prolonged use . manufacturer advises
avoid in perforated tympanic membrane (but used by
specialists for short periods)
l SIDE-EFFECTS Paraesthesia . skin reactions
l PATIENT AND CARER ADVICE Clioquinol stains skin and
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Flumetasone pivalate with clioquinol (Non-proprietary)
Flumetasone pivalate 200 microgram per 1 ml, Clioquinol 10 mg
per 1 ml Flumetasone 0.02% / Clioquinol 1% ear drops |
7.5 ml P £11.34 DT = £11.34 | 10 ml P £15.13 DT = £15.13
l DRUG ACTION Prednisolone exerts predominantly
glucocorticoid effects with minimal mineralocorticoid
Eczematous inflammation in otitis externa
▶ Child: Apply 2–3 drops every 2–3 hours, frequency to
be reduced when relief obtained
▶ Adult: Apply 2–3 drops every 2–3 hours, frequency to
be reduced when relief obtained
l CONTRA-INDICATIONS Avoid alone in the presence of
untreated infection (combine with suitable anti-infective)
l CAUTIONS Avoid prolonged use
l INTERACTIONS → Appendix 1: corticosteroids
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: ear drops
EXCIPIENTS: May contain Benzalkonium chloride, disodium edetate
▶ Predsol (RPH Pharmaceuticals AB)
Prednisolone sodium phosphate 5 mg per 1 ml Predsol 0.5%
ear/eye drops | 10 ml P £2.00 DT = £2.00
CORTICOSTEROIDS › CORTICOSTEROID
COMBINATIONS WITH ANTI-INFECTIVES
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, betamethasone p. 1197, neomycin sulfate
Eczematous inflammation in otitis externa
▶ Child: Apply 2–3 drops 3–4 times a day
▶ Adult: Apply 2–3 drops 3–4 times a day
l CONTRA-INDICATIONS Patent grommet (although may be
used by specialists, see Ear p. 1194). perforated tympanic
membrane (although may be used by specialists, see Ear
l CAUTIONS Avoid prolonged use
l INTERACTIONS → Appendix 1: corticosteroids . neomycin
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Benzalkonium chloride, disodium edetate
▶ Betnesol-N (RPH Pharmaceuticals AB)
Betamethasone (as Betamethasone sodium phosphate) 1 mg per
1 ml, Neomycin sulfate 5 mg per 1 ml Betnesol-N ear/eye/nose
drops | 10 ml P £2.39 DT = £2.39
Ciprofloxacin with dexamethasone
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, dexamethasone p. 675, ciprofloxacin
Acute otitis media in patients with tympanostomy tubes
▶ Adult: Apply 4 drops twice daily for 7 days
▶ Adult: Apply 4 drops twice daily for 7 days
l CONTRA-INDICATIONS Fungal ear infections . viral ear
l CAUTIONS Avoid prolonged use
l INTERACTIONS → Appendix 1: corticosteroids . quinolones
▶ Common or very common Ear discomfort
▶ Rare or very rare Dizziness . headache . hearing loss . tinnitus
SIDE-EFFECTS, FURTHER INFORMATION Manufacturer
advises further evaluation of underlying conditions if
otorrhoea persists after a full course, or if at least two
episodes of otorrhoea occur within 6 months.
l PREGNANCY Manufacturer advises use only if potential
benefit outweighs risk—no information available.
l BREAST FEEDING Manufacturer advises caution—no
l PATIENT AND CARER ADVICE Manufacturer advises
counselling on administration.
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (July 2017)
that dexamethasone with ciprofloxacin (Cilodex ®) is
accepted for restricted use within NHS Scotland for the
treatment of acute otitis media in patients with
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Benzalkonium chloride, disodium edetate
▶ Cilodex (Novartis Pharmaceuticals UK Ltd)
Dexamethasone 1 mg per 1 ml, Ciprofloxacin (as Ciprofloxacin
hydrochloride) 3 mg per 1 ml Cilodex ear drops | 5 ml P £6.12
Ciprofloxacin with fluocinolone
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, ciprofloxacin p. 1196.
Acute otitis externa | Acute otitis media in patients with
▶ Adult: Apply 0.25 mL twice daily for 7 days
DOSE EQUIVALENCE AND CONVERSION
▶ Each 0.25 mL dose contains 0.75 mg ciprofloxacin and
0.0625 mg of fluocinolone acetonide.
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL
SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC
See Corticosteroids, general use p. 670.
l CONTRA-INDICATIONS Fungal ear infections . viral ear
l INTERACTIONS → Appendix 1: fluocinolone . quinolones
▶ Common or very common Ear discomfort.taste altered
SIDE-EFFECTS, FURTHER INFORMATION Manufacturer
advises further evaluation of underlying conditions if
otorrhoea persists after a full course, or if at least two
episodes of otorrhoea occur within 6 months.
l PREGNANCY Manufacturer advises use only if potential
benefit outweighs risk—limited information available.
l BREAST FEEDING Manufacturer advises caution.
l PATIENT AND CARER ADVICE Manufacturer advises
counselling on administration.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Polysorbates
▶ Cetraxal Plus (Aspire Pharma Ltd)
Fluocinolone acetonide.25 mg per 1 ml, Ciprofloxacin (as
Ciprofloxacin hydrochloride) 3 mg per 1 ml Cetraxal Plus 3mg/ml +
0.25mg/ml ear drops 0.25ml unit dose | 15 unit dose P £6.01
sulfate and gramicidin 21-Dec-2017
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, dexamethasone p. 675, framycetin sulfate
Eczematous inflammation in otitis externa
▶ Child: 2–3 drops 3–4 times a day
▶ Adult: 2–3 drops 3–4 times a day
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL
SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC
See Corticosteroids, general use p. 670.
l CAUTIONS Avoid prolonged use
l INTERACTIONS → Appendix 1: corticosteroids
l LESS SUITABLE FOR PRESCRIBING Sofradex ® is less
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Polysorbates
Gramicidin 50 microgram per 1 ml, Framycetin sulfate 5 mg per
1 ml, Dexamethasone 500 microgram per 1 ml Sofradex ear/eye
Dexamethasone with glacial acetic
acid and neomycin sulfate 21-Dec-2017
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, dexamethasone p. 675, neomycin sulfate
Eczematous inflammation in otitis externa
▶ Child 2–17 years: Apply 1 spray 3 times a day
▶ Adult: Apply 1 spray 3 times a day
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL
SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC
See Corticosteroids, general use p. 670.
l CONTRA-INDICATIONS Patent grommet (although may be
used by specialists, see Ear p. 1194). perforated tympanic
membrane (although may be used by specialists, see Ear
l CAUTIONS Avoid prolonged use
l INTERACTIONS → Appendix 1: corticosteroids . neomycin
l SIDE-EFFECTS Paraesthesia . skin reactions . vision blurred
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Hydroxybenzoates (parabens)
Dexamethasone 1 mg per 1 gram, Neomycin sulfate 5 mg per
1 gram, Acetic acid glacial 20 mg per 1 gram Otomize ear spray |
Hydrocortisone with neomycin and
polymyxin B sulfate 21-Dec-2017
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, hydrocortisone p. 676, neomycin sulfate
Bacterial infection in otitis externa
▶ Child 3–17 years: Apply 3 drops 3–4 times a day for
7 days (review treatment if there is no clinical
▶ Adult: Apply 3 drops 3–4 times a day for 7 days (review
treatment if there is no clinical improvement)
MHRA/CHM ADVICE: CORTICOSTEROIDS: RARE RISK OF CENTRAL
SEROUS CHORIORETINOPATHY WITH LOCAL AS WELL AS SYSTEMIC
See Corticosteroids, general use p. 670.
l INTERACTIONS → Appendix 1: corticosteroids . neomycin . polymyxins
l RENAL IMPAIRMENT Manufacturer advises avoid
Dose adjustments Manufacturer advises reduce dose.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Cetostearyl alcohol (including cetyl and
stearyl alcohol), hydroxybenzoates (parabens), polysorbates
▶ Otosporin (Phoenix Labs Ltd)
Hydrocortisone 10 mg per 1 ml, Neomycin sulfate 3400 unit per
1 ml, Polymyxin B sulfate 10000 unit per 1 ml Otosporin ear drops
DERMATOLOGICAL DRUGS › ASTRINGENTS
Inflammation in otitis externa
▶ Adult: To be inserted into meatus or apply on a ribbon
gauze dressing or sponge wick which should be kept
l DIRECTIONS FOR ADMINISTRATION For ear drops 8%—
dilute 8 parts aluminium acetate ear drops (13%) with
5 parts purified water. Must be freshly prepared.
l MEDICINAL FORMS Forms available from special-order
manufacturers include: ear drops
Removal of earwax (with 5% ear drop solution)
▶ Child: (consult product literature)
▶ Adult: (consult product literature)
l INTERACTIONS → Appendix 1: sodium bicarbonate
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Sodium bicarbonate (Non-proprietary)
Sodium bicarbonate 50 mg per 1 ml Sodium bicarbonate 5% ear
▶ KliarVax Sodium Bicarbonate (Essential-Healthcare Ltd)
Sodium bicarbonate 50 mg per 1 ml KliarVax Sodium Bicarbonate
▶ Child: Allow drops to warm to room temperature before
use (consult product literature)
▶ Adult: Allow drops to warm to room temperature
before use (consult product literature)
l DIRECTIONS FOR ADMINISTRATION The patient should lie
with the affected ear uppermost for 5 to 10 minutes after a
generous amount of the softening remedy has been
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Almond oil (Non-proprietary)
Almond oil 1 ml per 1 ml Almond oil liquid | 50 ml £0.95 DT = £0.95
(Dioctyl sodium sulphosuccinate)
▶ Adult: (consult product literature)
l INTERACTIONS → Appendix 1: docusate sodium
l LESS SUITABLE FOR PRESCRIBING Ear drops less suitable
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Propylene glycol
▶ Molcer (Wallace Manufacturing Chemists Ltd)
Docusate sodium 50 mg per 1 ml Molcer ear drops | 15 ml p
▶ Waxsol (Meda Pharmaceuticals Ltd)
Docusate sodium 5 mg per 1 ml Waxsol ear drops | 10 ml p £1.95
▶ Child: Apply twice daily for several days (if wax is hard
▶ Adult: Apply twice daily for several days (if wax is hard
l DIRECTIONS FOR ADMINISTRATION The patient should lie
with the affected ear uppermost for 5 to 10 minutes after a
generous amount of the softening remedy has been
introduced into the ear. Allow ear drops to warm to room
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Earol olive oil ear spray | 10 ml s
Olive oil ear drops | 10 ml £1.35–£1.42
▶ Cerumol (olive oil) (Thornton & Ross Ltd)
Cerumol olive oil ear drops | 10 ml s
▶ KliarVax (Essential-Healthcare Ltd)
KliarVax Olive Oil ear drops | 10 ml £0.97
▶ Olive oil (Thornton & Ross Ltd)
Care olive oil ear drops | 10 ml £1.42
▶ St George’s (St Georges Medical Ltd)
Olive oil ear drops | 10 ml £1.40 | 20 ml £2.70
Softening and removal of earwax
▶ Adult: (consult product literature)
l PATIENT AND CARER ADVICE The patient should lie with
the affected ear uppermost for 5 to 10 minutes after a
generous amount of the softening remedy has been
l LESS SUITABLE FOR PRESCRIBING Urea-hydrogen peroxide
ear drops are less suitable for prescribing.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Exterol (Dermal Laboratories Ltd)
Urea hydrogen peroxide 50 mg per 1 gram Exterol 5% ear drops | 8 ml p £1.75 DT = £2.89
Urea hydrogen peroxide 50 mg per 1 gram Otex 5% ear drops | 8 ml p £2.89 DT = £2.89
Rhinitis is often self-limiting. There are few indications for
nasal sprays and drops except in allergic rhinitis and
perennial rhinitis. Many nasal preparations contain
sympathomimetic drugs which may damage the nasal cilia.
Sodium chloride 0.9% solution p. 1040 may be used as a
douche or ‘sniff’ following endonasal surgery.
Mild allergic rhinitis is controlled by antihistamines (see
under Antihistamines, allergen immunotherapy and allergic
emergencies p. 277) or topical nasal corticosteroids;
systemic nasal decongestants are of doubtful value. Topical
nasal decongestants can be used for a short period to relieve
congestion and allow penetration of a topical nasal
More persistent symptoms and nasal congestion can be
relieved by topical nasal corticosteroids; sodium
cromoglicate p. 1208 is an alternative, but may be less
effective. The topical antihistamine azelastine hydrochloride
p. 1204 is useful for controlling breakthrough symptoms in
allergic rhinitis. Topical antihistamines are considered less
effective than topical corticosteroids but probably more
effective than cromoglicate. In seasonal allergic rhinitis (e.g.
hay fever), treatment should begin 2 to 3 weeks before the
season commences and may have to be continued for several
months; continuous treatment may be required for years in
Montelukast p. 269 is less effective than topical nasal
corticosteroids; montelukast can be used in patients with
seasonal allergic rhinitis and concomitant asthma.
Sometimes allergic rhinitis is accompanied by vasomotor
rhinitis. In this situation, the addition of topical nasal
ipratropium bromide can reduce watery rhinorrhoea.
Very disabling symptoms occasionally justify the use of
systemic corticosteroids for short periods, for example, in
students taking important examinations. They may also be
used at the beginning of a course of treatment with a
corticosteroid spray to relieve severe mucosal oedema and
allow the spray to penetrate the nasal cavity.
Corticosteroid nasal preparations should be avoided in the
presence of untreated nasal infections, after nasal surgery
(until healing has occurred), and in pulmonary tuberculosis.
Patients transferred from systemic corticosteroids may
experience exacerbation of some symptoms. Systemic
absorption may follow nasal administration particularly if
high doses are used or if treatment is prolonged; for cautions
and side-effects of systemic corticosteroids. The risk of
systemic effects may be greater with nasal drops than with
nasal sprays; drops are administered incorrectly more often
than sprays. The height of children receiving prolonged
treatment with nasal corticosteroids should be monitored; if
growth is slowed, referral to a paediatrician should be
Short-term use of corticosteroid nasal drops helps to shrink
nasal polyps; to be effective, the drops must be administered
with the patient in the ‘head down’ position. A short course
of a systemic corticosteroid may be required initially to
shrink large polyps. A corticosteroid nasal spray can be used
to maintain the reduction in swelling and also for the initial
If a pregnant woman cannot tolerate the symptoms of
allergic rhinitis, treatment with nasal beclometasone
dipropionate p. 1205, budesonide p. 1206, fluticasone
p. 1206, or sodium cromoglicate may be considered.
The nasal mucosa is sensitive to changes in atmospheric
temperature and humidity and these alone may cause slight
nasal congestion. The nose and nasal sinuses produce a litre
of mucus in 24 hours and much of this finds its way silently
into the stomach via the nasopharynx. Slight changes in the
nasal airway, accompanied by an awareness of mucus
passing along the nasopharynx causes some patients to be
inaccurately diagnosed as suffering from chronic sinusitis.
These symptoms are particularly noticeable in the later
stages of the common cold. Sodium chloride 0.9% given as
nasal drops or spray may relieve nasal congestion by helping
Inhalation of warm moist air may be useful in the
treatment of symptoms of acute infective conditions. The
addition of volatile substances such as menthol and
eucalyptus may encourage the use of warm moist air (see
under Aromatic inhalations, cough preparations and
systemic nasal decongestants p. 296).
Symptoms of nasal congestion associated with vasomotor
nasal drops and sprays. These all contain sympathomimetic
drugs which exert their effect by vasoconstriction of the
mucosal blood vessels which in turn reduces oedema of the
nasal mucosa. They are of limited value because they can
give rise to a rebound congestion (rhinitis medicamentosa)
on withdrawal, due to a secondary vasodilatation with a
subsequent temporary increase in nasal congestion. This in
turn tempts the further use of the decongestant, leading to a
vicious cycle of events. Ephedrine hydrochloride p. 1202
nasal drops is the safest sympathomimetic preparation and
can give relief for several hours. The more potent
sympathomimetic drugs oxymetazoline and xylometazoline
hydrochloride p. 1203 are more likely to cause a rebound
Non-allergic watery rhinorrhoea often responds well to
treatment with the antimuscarinic ipratropium bromide
Nasal preparations for infection
There is no evidence that topical anti-infective nasal
preparations have any therapeutic value in rhinitis; see
elimination of nasal staphylococci.
Elimination of organisms such as staphylococci from the
nasal vestibule can be achieved by the use of a cream
containing chlorhexidine and neomycin (Naseptin ®), but
re-colonisation frequently occurs. Coagulase-positive
staphylococci are present in the noses of 40% of the
A nasal ointment containing mupirocin p. 1204 is also
available; it should probably be held in reserve for resistant
infections. In hospitals or in care establishments, mupirocin
nasal ointment should be reserved for the eradication (in
taken 2 days after treatment to confirm eradication. The
course may be repeated if the sample is positive (and the
throat is not colonised). To avoid the development of
resistance, the treatment course should not exceed 7 days
and the course should not be repeated on more than one
occasion. If the MRSA strain is mupirocin-resistant or does
not respond after 2 courses, consider alternative products
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