ENT Therapeutics

ì
ENT THERAPEUTICS
KR BALMORES, MD, FPSOHNS
References
ì  Caparas MB et al. Basic Otolaryngology, 3rd ed.
ì  KJ Lee. Essential Otolaryngology: Head and Neck

Surgery, 9th ed.
PENICILLINS
ì  Penicillin G
ì  Penicillin V
ì  Penicillinase-Resistant Penicillins
ì  Extended-Spectrum Penicillins
Penicillin G
ì  Aerobic Gram (+) organisms
ì  Corynebacterium diphtheriae
ì  Clostridium tetani
ì  High doses (12-24 million units)

ì  Bacteroides
ì  Gram (-) strains
ì  T. pallidum
ì  Leptospira monocytogenes
ì  Usual dose:100,000u/kg/day (4-6 divided doses)

Penicillin V
ì  Acid stable
ì  Better absorbed orally
ì  500mg-1g 3-4x/day
Penicillinase-Resistant Penicillins
ì  Nafcillin, Oxacillin, Cloxacillin
ì  S. aureus
Extended Spectrum Penicillins
ì  Ampicillin
ì  Amoxicillin
ì  G(-): H. influenzae, E. coli, P.mirabilis

Oxacillin and Cloxacillin
ì  Good oral aborsption
ì  Better on empty stomach
ì  Staphylococci
ì  2-4g/day in 4 divided doses (adults)
ì  50-100mg/kg/day in 3-4 divided doses (child)

Amoxicillin
ì  More rapid and complete absorption than

ampicillin
ì  Less incidence of diarrhea
ì  W/O regard to meals
ì  250-500mg TID
Co-Amoxiclav
ì  Amoxicillin + clavulanic acid
ì  Inhibitor of beta lactamase

CEPHALOSPORINS
ì  Inhibit bacterial wall synthesis
ì  G(+) and G(-)
ì  S. aureus, N.gonorrhea, C.diphtheria, Klebsiella
ì  Not: Pseudomonas, Bacteroides, Proteus,

Acinetobacter
First Generation Cephalosporins
ì  Cephalexin
ì  G(+) species
ì  Some G(-) E.coli, Proteus, Klebsiella

Second Generation Cephalosporins
ì  Cefuroxime
ì  Good G(+) coverage
ì  Increased coverage for H. influenzae and

M.catarrhalis
Third Generation Cephalosporins
ì  Ceftriaxone, Ceftazidime
ì  G(-): H. influenzae, M. catarrhalis, N.gonorrhea,

N.meningitidis
ì  Less active against G(+) and anaerobes
ì  Good CNS penetration

Fourth Generation Cephalosporins
ì  Cefepime
ì  +Ceftazidime: best coverage against Pseudomonas

ERYTHROMYCIN
ì  Macrolide
ì  Bacteriostatic/bactericidal
ì  Inhibits protein synthesis by binding to 50s ribosomal subunit
ì  S. pyogenes, S.pneumoniae, C. perfringens, C. diphtheriae, L.

monocytogenes
ì  G(-) bacteria: mostly not active
ì  1/2g/day in 4 divided doses
ì  30-50mg/kg/day in 4 divided doses

CHLORAMPHENICOL
ì  Nitrobenzene moiety and a derivation of dichloroacetic

acid
ì  Inhibit protein synthesis in bacteria and some eukaryotic

cells by reversibly binding to the 50s ribosomal subunit
ì  Inhibit mitochondrial protein synthesis in mammals
ì  Rapidly absorbed from GIT
ì  High absolute bioavailability in body (even CSF), crosses

placental barrier
CHLORAMPHENICOL
ì  Bacteriostatic
ì  Bactericidal to H. influenzae
ì  H. influenzae, N. meningitides, N. gonorrhea, S. typhi, Bordatella

pertussis, anaerobic bacteria, G(+) cocci, Clostridium, G(-) rods
ì  Pseudomonas is resistant
ì  Most important adverse effect – bone marrow suppression –

pancytopenia
ì  PO, IV
ì  1-4g/day in 3-4 divided doses
ì  Intracranial infections: large doses

CLINDAMYCIN
ì  Suppress protein synthesis by binding to 50s subunit of

bacterial ribosomes
ì  Pneumococci, S. pyogenes, S. viridans, S. aureus,
anaerobes
ì  Resistant: Aerobic G(-), enterococci, N. meningitides
ì  150-450mg/kg/day in 3-4 doses
ì  Children: 8-25mg/kg/day in 3 divided doses
ì  IV 600-1200mg/day in 2-4 divided doses

AMINOGLYCOSIDES
ì  Gentamicin, Tobramycin, Amikacin, Netilmicin
ì  Highly effective against Pseudomonas
ì  Ototoxic
ANTIBIOTICS CHOICES
Otology
ì  AOE: Neomycin, polymyxin, ciprofloxacin
compounds +/- steroids
ì  AOM: Amoxicillin 60-80mg/kg/day
ì  Acute coalescent mastoiditis: vancomycin and

ceftriaxone
ì  CSOM: quinolones, antipseudomonal penicillin or
cephalosporin
ANTIBIOTICS CHOICES
Rhinology
ì  Acute sinusitis: Amoxicillin
ì  Orbital extension of acute sinusitis: Ceftriaxone/

Quinolone
ì  Chronic bacterial sinusitis: Co-amoxiclav, Quinolone

ANTIBIOTICS CHOICES
Pharynx, Head and Neck
ì  Thrush: Nystatin or topical azole
ì  Tonsillitis: Clindamycin, Metronidazole, Cephalexin, Co-

amoxiclav
ì  Pharyngitis: Erythromycin, Amoxicillin
ì  Sialadenitis: Co-amoxiclav, Clindamycin
ì  Tracheobronchitis: erythromycin, quinolone
ì  Croup, Epiglottitis: Sultamicillin, Ceftriaxone
ì  Neck abscess: Sultamicillin, Clindamycin
ì  Necrotizing fasciitis: broad spectrum antibiotics with

anaerobic/aerobic. Pen G
DECONGESTANTS
ì  Sympathetic agonists
ì  Vasoconstriction à reduce amount of congestion in tissues
ì  Rhinitis
ì  ET dysfunction
ì  Ear infections with mucosal congestion
ì  Post-mastoidectomy + tympanoplasty patients
ì  Preparation for nasal surgery
ì  Chronic sinusitis
ì  Orally/topically
Ephedrine Sulfate
ì  Topical solution in nasal surgery
ì  Decongestant for better visualization
ì  1-4% solution
ì  Toxic effects: cardiovascular
ì  Bronchial smooth muscle relaxant and tocolytic
ì  Anti-asthmatic preparations
Epinephrine
ì  Topical decongestant
ì  With local anesthetic to prolong duration of action

of infiltrative anesthesia
ì  Topical hemostatic
Pseudoephedrine
ì  60mg tablet 3-4x/day
ì  Yellow prescription
Phenylephrine
ì  Orally effective sympathetic agonist
ì  In combination with cough and cold remedies
ì  Topical nasal decongestants
ì  SE: Cardiovascular stimulation

Phenylpropanolamine
ì  Most widely-marketed decongestant found

combined with antihistamines in cough/cold
preparations
ì  Less CNS stimulation

Oxymetazoline
ì  Nasal spray/pediatric drops for topical

decongestion
ANTIHISTAMINES
ì  Allergic rhinitis/pharyngitis
ì  Vasomotor rhinitis
ì  Motion sickness
Diphenhydramine
ì  Ethanolamine
ì  Urticaria
ì  Sedations (sleep-stimulant in pediatric patients)
ì  Labyrinthine sedative
ì  PO/IV
STEROIDS
ì  Phospholipase inhibitors
ì  Prevent formation of inflammatory autacoids from

arachidonic acid
ì  Prednisone
ì  Hydrocortisone
ì  Triamcinolone
ì  Beclomethasone
ì  Budesonide
Prednisone
ì  Post-surgical trauma
ì  Bell’s palsy
ì  Grade I nasal polyps
ì  Laryngitis
ì  Allergic rhinitis
ì  Acute adrenal insufficiency with prolonged use
ì  1mg/kg/day in 3 divided doses

Hydrocortisone
ì  Intravenous
ì  Acute inflammatory cases
ì  Acute Epiglottitis
Triamcinolone
ì  Reduce hypertrophic scar formation and scar

contractures
ì  Hypertrophied nasal turbinates

Beclomethasone
ì  Intransal spray
ì  Maximum: 400mcg (50mcg per puff)
ì  6 weeks minimum
ì  Improvement in 2 weeks
Budesonide
ì  Intranasal spray
ì  Allergic rhinitis, nasal polyps

ì  Video presentation – maximum ì  Examination of the oral cavity
5 minutes (no cut and paste)
ì  Examination of the neck
ì  Proper positioning of patient
ì  Physical examination for
ì  Examination of the ear evaluation of maxillofacial
trauma
ì  Tuning Fork Test
ì  3-4 groups per topic, all will
ì  Vestibular tests submit but the best video will
be shown
ì  Anterior rhinoscopy
ì  Deadline: July 8, 2019 (12pm
Monday)

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ì

ì Caparas MB et al. Basic Otolaryngology, 3rd ed.

ì KJ Lee. Essential Otolaryngology: Head and Neck

ì High doses (12-24 million units)

ì Usual dose:100,000u/kg/day (4-6 divided doses)

ì Better absorbed orally

ì Nafcillin, Oxacillin, Cloxacillin

ì G(-): H. influenzae, E. coli, P.mirabilis

ì Good oral aborsption

ì Better on empty stomach

ì 2-4g/day in 4 divided doses (adults)

ì 50-100mg/kg/day in 3-4 divided doses (child)

ì More rapid and complete absorption than

ì Less incidence of diarrhea

ì W/O regard to meals

ì Amoxicillin + clavulanic acid

ì Inhibitor of beta lactamase

ì Inhibit bacterial wall synthesis

ì G(+) and G(-)

ì S. aureus, N.gonorrhea, C.diphtheria, Klebsiella

ì Not: Pseudomonas, Bacteroides, Proteus,

ì Some G(-) E.coli, Proteus, Klebsiella

ì Good G(+) coverage

ì Increased coverage for H. influenzae and

ì G(-): H. influenzae, M. catarrhalis, N.gonorrhea,

ì Less active against G(+) and anaerobes

ì Good CNS penetration

ì +Ceftazidime: best coverage against Pseudomonas

ì Inhibits protein synthesis by binding to 50s ribosomal subunit

ì S. pyogenes, S.pneumoniae, C. perfringens, C. diphtheriae, L.

ì G(-) bacteria: mostly not active

ì 1/2g/day in 4 divided doses

ì 30-50mg/kg/day in 4 divided doses

ì Nitrobenzene moiety and a derivation of dichloroacetic

ì Inhibit protein synthesis in bacteria and some eukaryotic

ì Inhibit mitochondrial protein synthesis in mammals

ì Rapidly absorbed from GIT

ì High absolute bioavailability in body (even CSF), crosses

ì H. influenzae, N. meningitides, N. gonorrhea, S. typhi, Bordatella

ì Most important adverse effect – bone marrow suppression –

ì 1-4g/day in 3-4 divided doses

ì Intracranial infections: large doses

ì Suppress protein synthesis by binding to 50s subunit of

ì Resistant: Aerobic G(-), enterococci, N. meningitides

ì 150-450mg/kg/day in 3-4 doses

ì Children: 8-25mg/kg/day in 3 divided doses

ì IV 600-1200mg/day in 2-4 divided doses

ì Gentamicin, Tobramycin, Amikacin, Netilmicin

ì Highly effective against Pseudomonas

ì Acute coalescent mastoiditis: vancomycin and

ì Acute sinusitis: Amoxicillin

ì Orbital extension of acute sinusitis: Ceftriaxone/

ì Chronic bacterial sinusitis: Co-amoxiclav, Quinolone

ì Tonsillitis: Clindamycin, Metronidazole, Cephalexin, Co-

ì Sialadenitis: Co-amoxiclav, Clindamycin

ì Tracheobronchitis: erythromycin, quinolone

ì Croup, Epiglottitis: Sultamicillin, Ceftriaxone

ì Neck abscess: Sultamicillin, Clindamycin

ì Necrotizing fasciitis: broad spectrum antibiotics with

ì Vasoconstriction à reduce amount of congestion in tissues

ì  Caparas MB et al. Basic Otolaryngology, 3rd ed.

ì  KJ Lee. Essential Otolaryngology: Head and Neck

ì  High doses (12-24 million units)

ì  Usual dose:100,000u/kg/day (4-6 divided doses)

ì  Better absorbed orally

ì  Nafcillin, Oxacillin, Cloxacillin

ì  G(-): H. influenzae, E. coli, P.mirabilis

ì  Good oral aborsption

ì  Better on empty stomach

ì  2-4g/day in 4 divided doses (adults)

ì  50-100mg/kg/day in 3-4 divided doses (child)

ì  More rapid and complete absorption than

ì  Less incidence of diarrhea

ì  W/O regard to meals

ì  Amoxicillin + clavulanic acid

ì  Inhibitor of beta lactamase

ì  Inhibit bacterial wall synthesis

ì  G(+) and G(-)

ì  S. aureus, N.gonorrhea, C.diphtheria, Klebsiella

ì  Not: Pseudomonas, Bacteroides, Proteus,

ì  Some G(-) E.coli, Proteus, Klebsiella

ì  Good G(+) coverage

ì  Increased coverage for H. influenzae and

ì  G(-): H. influenzae, M. catarrhalis, N.gonorrhea,

ì  Less active against G(+) and anaerobes

ì  Good CNS penetration

ì  +Ceftazidime: best coverage against Pseudomonas

ì  Inhibits protein synthesis by binding to 50s ribosomal subunit

ì  S. pyogenes, S.pneumoniae, C. perfringens, C. diphtheriae, L.

ì  G(-) bacteria: mostly not active

ì  1/2g/day in 4 divided doses

ì  30-50mg/kg/day in 4 divided doses

ì  Nitrobenzene moiety and a derivation of dichloroacetic

ì  Inhibit protein synthesis in bacteria and some eukaryotic

ì  Inhibit mitochondrial protein synthesis in mammals

ì  Rapidly absorbed from GIT

ì  High absolute bioavailability in body (even CSF), crosses

ì  H. influenzae, N. meningitides, N. gonorrhea, S. typhi, Bordatella

ì  Most important adverse effect – bone marrow suppression –

ì  1-4g/day in 3-4 divided doses

ì  Intracranial infections: large doses

ì  Suppress protein synthesis by binding to 50s subunit of

ì  Resistant: Aerobic G(-), enterococci, N. meningitides

ì  150-450mg/kg/day in 3-4 doses

ì  Children: 8-25mg/kg/day in 3 divided doses

ì  IV 600-1200mg/day in 2-4 divided doses

ì  Gentamicin, Tobramycin, Amikacin, Netilmicin

ì  Highly effective against Pseudomonas

ì  Acute coalescent mastoiditis: vancomycin and

ì  Acute sinusitis: Amoxicillin

ì  Orbital extension of acute sinusitis: Ceftriaxone/

ì  Chronic bacterial sinusitis: Co-amoxiclav, Quinolone

ì  Tonsillitis: Clindamycin, Metronidazole, Cephalexin, Co-

ì  Sialadenitis: Co-amoxiclav, Clindamycin

ì  Tracheobronchitis: erythromycin, quinolone

ì  Croup, Epiglottitis: Sultamicillin, Ceftriaxone

ì  Neck abscess: Sultamicillin, Clindamycin

ì  Necrotizing fasciitis: broad spectrum antibiotics with

ì  Vasoconstriction à reduce amount of congestion in tissues

ì  Ear infections with mucosal congestion

ì  Post-mastoidectomy + tympanoplasty patients

ì  Preparation for nasal surgery

ì  Topical solution in nasal surgery

ì  Decongestant for better visualization

ì  Toxic effects: cardiovascular

ì  Bronchial smooth muscle relaxant and tocolytic

ì  With local anesthetic to prolong duration of action

ì  60mg tablet 3-4x/day

ì  Orally effective sympathetic agonist

ì  In combination with cough and cold remedies

ì  Topical nasal decongestants

ì  SE: Cardiovascular stimulation

ì  Most widely-marketed decongestant found

ì  Less CNS stimulation

ì  Nasal spray/pediatric drops for topical

ì  Sedations (sleep-stimulant in pediatric patients)

ì  Prevent formation of inflammatory autacoids from

ì  Grade I nasal polyps

ì  Acute adrenal insufficiency with prolonged use

ì  1mg/kg/day in 3 divided doses