ENT Conditions

Facial Paralysis

• Wear an eye pad over the affected eye or use lubricant eye drops to avoid exposure keratitis.
• Facial exercises to be done.

Facial Nerve and it’s Disorders. In: Diseases of the Ear, Nose and Throat. PL Dhingra (ed), 2nd Edition, 1998, pp 95-105.

Acute Parotitis

It is an acute bacterial infection of the parotid gland.

1. Cap. Cloxacillin 20-40 mg/kg in 3 divided doses for 7 days.
   Or
   Tab. Ciprofloxacin 500 mg twice daily for 7 days in adults.
2. Tab. Paracetamol 8-10 mg/kg thrice daily for 3 days & then SOS, if pain and fever persists.
   Or
   Tab. Nimesulide 1.5-2 mg/kg twice daily for 3 days & then SOS, if pain and fever persists.
3. Antiseptic mouthwash containing (Povidone Iodine 1% or Chloroxylenol 1.02%, Menthol 0.12%, Absolute Alcohol 60.8%) to be used 3 times a day.
   In case parotitis is not responding, and there is increasing swelling over the parotid region or development of induration over the gland, it may require incision and drainage. This should be done by a Otolaryngologist in a direction parallel to the direction of the facial nerve.

• To maintain good oral hygiene.

Non Neoplastic Diseases of Salivary Glands. In: Diseases of Ear Nose and Throat Dhingra PL (ed) 2nd Edition, 1998.

Acute Tonsillitis

1. Cap. Amoxycillin 500 mg 3 times a day.
   In Children 50 mg/kg/day in 3 divided doses for 7 days.
   Or
   Cap. Erythromycin 500 mg four times a day.
   In Children 50 mg/kg/day in three divided doses for 7 days.
2. Tab. Paracetamol 8-10 mg/kg 6-8 hourly and SOS for pain and fever, till fever subsides.
   Or
   Tab. Nimesulide 1.5-2 mg/kg/day and SOS for pain and fever, till fever subsides.

• In case of development of any complication such as peritonsillar abscess or peritonsillitis, the patient should be admitted for intravenous antibiotic treatment and/or surgical drainage, if required, under the supervision of an ENT surgeon.
• In case of recurrent episodes of acute tonsillitis, more than 4-5 annually, the patient must be referred for surgical modality of treatment.

Acute and Chronic Tonsillitis. In: Diseases of Ear Nose and Throat, Dhingra PL (ed), 2nd edition 1998.

Acute Rhinosinusitis

1. Tab. Paracetamol 500 mg 3-4 times a day for 5 days.
   In Children 10 mg/kg/dose.
   Or
   Tab. Ibuprofen 400 mg – 600 mg 3 times a day for 5 days.
   In Children 10 mg/kg/dose.
2. Cap. Amoxycillin 500 mg 8 hourly for 5-7 days.
   In Children 50 mg/kg/day in 3 divided doses.
   Or
   Tab. Ciprofloxacin 250-500 mg twice a day for 5-7 days.
   (not recommended in children)

1. Cap. Amoxycillin 500 mg 3 times a day for 5-7 days.
2. Tab. Metronidazole 400 mg 3 times a day for 5-7 days.Or

1. Tab. Ciprofloxacin 500 mg 3 times a day for 5-7 days.
2. Tab. Tinidazole 600 mg 3 times a day for 5-7 days.
3. Tab. Bromhexine 8 mg 3 times a day for 7 days.
4. If nasal obstruction or rhinorrhoea,
   Normal saline nasal 1-2 drops in each nostril 2-3 times a day.
   Or
   Ephedrine 0.75% nasal drops in isotonic saline 1-2 drops in each
   nostril 2 times a day.
   In Children 0.5% 1-2 drops in each nostril 2 times daily.
   Or
   Oxymetazoline HCl 0.05% nasal drops. 1-2 drops in each nostril 2 times a day.
   In Children 0.025% 1-2 drops in each nostril 2 times daily.
   Or
   Xylometazoline 0.1% nasal drops 2-3 drops in each nostril 2-3 times a day.
   In Children 0.05% 1-2 drops in each nostril 2 times daily.
   (CAUTION: Medicated nasal drops should not be used for more than 7 days).

Improvement is seen in symptoms viz. pain tenderness, nasal obstruction and discharge within 48-72 hours after initiation of therapy. If there is no desirable response patient should be referred to a Otolaryngologist.

• To take full course of systemic antibiotics to avoid the risk of developing antimicrobial resistance.
• Prolonged use of topical decongestants more than a week to be avoided as it can cause atrophic rhinitis, anosmia and rhinitis medicamentosa.

Acute Rhinosinusitis. In: Logan Turner’s Diseases of Nose, Throat and Ear. 10th Edition pp 34-36.

Epistaxis

• Type and severity of bleeding.
• Condition of the patient.
• Identification of a local or systemic cause for the bleeding.

1. In cases with active epistaxis, Check the vitals and pinch the nose (apply firm pressure below the nasal bone) then wait for 15 minutes and again check nose for bleeding. If bleeding does not stop refer to an Otolaryngologist for nasal cautery. Patient should be admitted in the hospital for nasal cautery.
   If nasal cautery is not able to stop bleeding do nasal packing (anterior, posterior, merocel). If bleeding is controlled start antibiotics and remove the pack after 48 hours. If bleeding not controlled arterial ligation, angiography and embolization may be required.
2. Simultaneously treat the underlying cause.

• Patients must be advised against inserting fingers into the nose, especially children.
• As first aid, explain how to pinch the nose tightly and apply ice pack over the nose, hile waiting for proper medical attention.

Epistaxis. In: Scott Brown’s Otolaryngology, IS MacKay & TR Bull (eds) Vd4, 6th Edition, 1997, London: Butterworths, pp 4/18/1-19.

Furunculosis Of Nose (Vestibulitis)

1. Cap. Amoxycillin 500 mg 8 hourly for 5-7 days.
   In Children 25-50 mg/kg/day divided in 3 doses.
   Or
   Cap. Amoxycillin 250 mg + Cloxacillin 250 mg 8 hourly for 5-7 days.
   In Children 25-50 mg/kg/day divided in 3 doses.
   Or
   Cap. Amoxycillin 250/500 mg + Clavulanic acid 125 mg 12 hourly 5- 7 days.
2. Tab. Ibuprofen 400-600 mg 3 times a day for 5 days.
   In Children 10 mg/kg/dose.
   Or
   Tab. Paracetamol 500 mg 6 hourly for 2-3 days then SOS.
   In Children 10 mg/kg 6-8 hourly for 2-3 days and then SOS till pain
   and fever subsides.
   Usually improvement in pain, tenderness and inflammation occurs within 24-48 hours after initiation of treatment. Patient should be monitored regularly. If there is flaring of infection in the form of spreading facial cellulitis then patient should be hospitalized and shifted to systemic intravenous antibiotics.If patient is having recurrent furunculosis, then the patient should be investigated for diabetes mellitus.

• Do not fidget with the furuncle as this lies in the dangerous area of the face and can cause serious complications.
• Complete antibiotic therapy to avoid risk of developing antimicrobial resistance.

1. Diseases of the External Nose & Nasal Vestibule. In: Diseases of Ear, Nose & Throat, PL Dhingra’s (ed), 2nd Edition, pp 144.

Allergic Rhinitis

• Seasonal allergic rhinitis (SAR/Hay fever): sneezing, itching watery rhinorrhoea and conjunctivitis are prominent symptoms.
• Perennial allergic rhinitis (PAR): This differs from SAR as
  this is due to long standing nasal mucosal congestion. In this condition nasal discharge is more viscous or purulent. Usual symptoms are nasal blockage, post nasal discharge and hyposmia. Diagnosis can be made if patient is having two or more symptoms (viz. sneezing/itching, nasal discharge and nasal blockage) occurring for more than one hour on most days.

1. Tab. Cetrizine 10-20 mg in a single daily dose for 7 days
   In Children 5 mg in a single daily dose.
   Or
   Tab. Chlorpheniramine maleate 4 mg 6-8 hourly for 7 days.
   In Children 1-2 years 1 mg twice daily; 2/5 kg 1 mg every 3-6 hours; 6-12 years 2 mg every 4-6 hours.
   (CAUTION: Not recommended for children under 1 year)
   Or
   Tab. Pheniramine maleate 25-50 mg 8 hourly for 7 days.
   In Children 0.5 mg/kg/day divided in 3 doses.
   The duration of treatment may need to be extended depending upon the response of the patient.
2. If nasal obstruction and rhinorrhoea,
   Normal saline nasal drops 1-2 drops in each nostril 2 times daily.
   Or
   Xylometazoline 0.1% nasal drops 1-2 drops 2-3 times daily for 5-7 days.
   In Children 0.05% 1-2 drops 2 times daily.
   Or
   Oxymetazoline 0.5% nasal drops 2-3 drops 2-3 times daily for 5-7 days.
   In Children 0.025% 1-2 drops 2 times in each nostril
3. In case signs and symptoms are persistent
   Betamethasone nasal drops 2-3 drops 2-3 times a day.
   Or
   Hydrocortisone nasal drops 2-3 drops 2-3 times a day.
   Or
   Beclomethasone inhaler (50 mcg/puff) 2 puffs 12 hourly.
   Or
   Budesonide (50-100 mcg/puff) 1-2 puff a day.
   Or
   Fluticasone 150 mcg/puff 1-2 puff a day.
   Or
   Topical Azelastine intranasal spray 2-3 times a day.
4. . In case of no response to the treatment outlined above,
   Tab. Prednisolone 5-60 mg/day in 3-4 divided doses for 5-7 days.
   Or
   Tab. Dexamethasone 0.5-5.0 mg/day in 3-4 divided doses for 5-7 days.
   Or
   Tab. Betamethasone 0.5-5.0 mg/day in 3-4 divided doses for 5-7 days.

• This disease is due to hypersensitivity and there is no cure but symptoms can be controlled effectively by the judicious use of drugs and the patient can lead a normal life.
• Prolonged use of topical decongestant nasal drops to be avoided as it can cause atrophic rhinitis, anosmia and rhinitis medicamentosa.
• Chloropheniramine, pheniramine etc can cause sedation, cognitive impairment. Patient should avoid tasks requiring alertness and skill. These drugs can also cause dryness of the mouth and urinary hesitancy.
• Systemic steroids should not be stopped abruptly. Dose to be tapered off before cessation of therapy.
• Medicated nasal drops should not be used for more than seven days.

Mechanism and Treatment of Allergic Rhinitis. In: Scott Brown’s Otolaryngology. JB Booth (ed), 6th Edition, 1997. Butterworth-Heinemann, pp 4/6/1-16.

Common Cold (Coryza)

1. Tab. Chlorpheniramine 4 mg 8 hourly for 5-7 days.
   In Children 0.5 mg/kg/day divided in 3 equal doses.
   Or
   Tab. Pheniramine maleate 25 mg 2-3 times daily for 5-7 days.
   In Children 0.5 mg/kg/day divided in 3 equal doses.
   Or
   Tab. Cetrizine dihydrochloride 10 mg once a day 5-7 days.
   In Children 5 mg once a day.
2. If patient has malaise and fever,
   Tab. Paracetamol 500 mg 3-4 times a day for 2-3 days and then SOS.
   In Children 20-30 mg/kg/day divided in 4 doses or 10 mg/kg/doseSOS.
3. If nasal obstruction or rhinorrhoea is profuse,
   Saline nasal drops, 1-2 drops in each nostril 2-3 times daily.
4. If nasal obstruction is severe.
   Ephedrine 0.75% nasal drops, 1-2 drops in each nostril 3 times a day for 2-3 days.
   In Children 0.5% nasal drops, 1-2 drops in each nostril 2-3 times daily
   Or
   Oxymetazoline HCl 0.05% nasal drops, 1-2 drops in each nostril 2 times a day for 2-3 days.
   In Children 0.025%, 1 drop, 2 times daily.
   Or
   Xylometazoline 0.1%, 1-2 drops in each nostril 2 times a day for 2-3 days.
   In Children 0.05%, 1-2 drops, 1-2 times daily.
   (CAUTION: Not recommended in children below 6 years of age)
   Medicated nasal drops should not be use for more than 7 days.
   Symptomatic improvement occurs within 48 hours in the form of decreased rhinorrhoea, nasal obstruction, paroxysmal sneezing, malaise and fever.

• This is a self limiting viral infection and usually subsides in one week requiring only symptomatic relief.
• Antibiotics have no role.
• Chlorpheniramine and pheniramine can cause sedation and cognitive impairment, therefore, patient should avoid tasks requiring alertness and skill.
• Medicated nasal drops used for longer period can cause rebound congestion and rhinitis medicamentosa.

Acute Rhinosinusitis. In: Logan Turner’s Disease of The Nose, Throat and Ear. 10th Edition, pp 34.

External Ear Furunculosis

1. 10% Ichthammol in glycerine wick pack.
   Or
   Antibiotic steroid cream wick pack (Polymyxin B sulphate 500 IU, Neomycin sulphate 3400 IU, Zinc bacitracin 400 IU, Hydrocortisone 10 mg, per g) wick packing to be done on alternate day till swelling subsides followed by/or
2. Local ear drops (Polymyxin B sulphate 1000 U, Neomycin sulphate 3400 U, Hydrocortisone 10 mg/ml).
3. Systemic therapy with antibiotics (see section on furunculosis in skin diseases)
4. Tab. Nimesulide 100 mg twice a day.In Children 5 mg/kg/day in 2-3 divided doses.
   Incision and drainage may be necessary in some cases.

In patients having recurrent boils, diabetes mellitus should be ruled out and patients are instructed not to do ear picking.

Otomycosis

1. Topical Clotrimazole as 1% powder or liquid 3 – 4 times a day to be continued for at least a week after clinical resolution of the infection.
2. Tab. Nimesulide 100 mg SOS.In children 1.5 mg/kg/dose SOS.
   Or
   Tab. Ibuprofen 400 mg SOS.
   In Children 20 mg/kg/day in 3 divided doses.

• Ear is to be kept dry. Entry of water into the ear should be prevented.

1. Diseases of the External Ear. In: Logan Turner’s Diseases of The Nose, Throat and Ear, 10th Edition, pp 274-275.
2. External Auditory Meatus. In: Scott- Brown’s Otolaryngology, JB Booth (ed) Vol 3, 6th Edition, 1997, Butterworth-Heinemann, pp 3/6/14-15.

Wax

1. Tab. Ibuprofen 400 mg SOS.
   In Children 20 mg/kg/day divided into 3 doses.
2. Wax softener – (Turpentine oil – 15%, Benzocaine – 2.7%), Chlorbutol
   - 5%, Paradichlorobenzene – 2%) 3-4 days before cleaning the ear
   when the wax is hard.
   Followed by surgical removal (to be carried out by an Otolaryngologist).
   Syringing with sterile saline solution at body temperature pushed along the posterior wall of the meatus to take out the wax. The meatus should be mopped dry after syringing. (CAUTION: if there is previous history of ear discharge or perforated drum).
   Or
   Instrumental manipulation with ring probe, hook or forceps and suction cleaning.

• Wax is a normal secretion and provides protection to the ear drumb and should be removed only if it disturbs hearing.
• Cleaning the ear with buds can push the wax to the deeper canal.

1. Diseases of the External Ear. In: Logan Turner’s Diseases of the Nose, Throat and Ear, 10th Edition, pp 265-267

Otitis Media With Effusion

1. Cap. Amoxycillin (as trihyd 250 mg) with Clavulanic acid (as pot. Salt) 375 mg, 1 Tab. thrice daily before meals for up to 21 days.
2. Tab. Psuedoephedrine 120 mg 8 hourly.
   In Children 1-2 mg/kg twice daily.

• Do not instill oil in the ear.

Management of Chronic Otitis Media. In: Scott Brown’s Otolaryngology, JB Booth (ed), Vol. 3, 6th Edition, 1997, Butterworth-Heinemann, pp 3/9/1-15.

Chronic Suppurative Otitis Media (CSOM) (Tubo-tympanic type)

1. Ciprofloxacin HCl 0.3% w/v ear drops 2-3 drops 3-4 times daily
2. When ear infection is associated with marked inflammation combine with Prednisolone 0.5% + Chloramphenicol 5% + Lignocaine 2% + Acetic acid 2% to be used as 3-4 drops 3-4 times daily.
3. In case of profuse mucopurulent discharge and for any associated upper respiratory tract infection give systemic antibiotics
   Cap. Amoxycillin 750-1500 mg in 3 divided doses
   In Children 20-40 mg/kg in 3 divided doses.
   The choice of antibiotic depends on the culture and sensitivity report of the pus.

• The patient should not allow water or dust to enter the ear.
• The patient should take immediate treatment in case of upper respiratory tract infection.
• Do not instill oil if there is a discharge from the ear or if the patient is known to have perforation of ear drum.

1. Diseases of the external ear. In: Logan Turner’s Diseases of the Nose, Throat and ear 10th edition, pp 271-273.
2. Management of chronic suppurative otitis media. In: Scott Brown’s Otolaryngology, JB Boothy (ed), Vol 3, 6th edition, 1997, pp 3/10/1-11.

Acute Suppurative Otitis Media (ASOM)

ASOM is caused by inflammation of the mucous membrane lining the middle ear cleft (consisting of the eustachian tube, tympanic cavity, mastoid antrum and mastoid air cells) produced by pus forming organisms.

1. For fever Tab. Paracetamol 500 mg SOS (for details see section on fever).
2. Cap. Amoxycillin 250-500 mg 8 hourly for 7 days.
   In Children 20-40 mg/kg in 3 divided doses for 7 days.
   Or
   Cap. Cephalexin 250-500 mg 8 hourly.
   In Children 20-40 mg/kg/day in 3 divided doses.
3. Xylometazoline HCl 0.1% 1-2 nasal drops in each nostril 1-2 times daily.
   In Children (0.05%) 1-2 nasal drops 1-2 times daily.
   Or
   Oxymetazoline 0.05% 1-2 nasal drops in each nostril 2 times daily.
   In Children (0.01%) 1-2 drops 2 times daily.

• Treat upper respiratory and sinus infections at the earliest.

1. Acute Suppurative Otitis Media and Acute Mastoiditis. In: Scott Brown’s Otolaryngology, Vol 3, JB Booth (ed) 6th Edition, pp 3/9/1-15.
2. Acute Otitis Media in Adults. In: Logan Turner’s Diseases of the Nose, Throat and Ear 10th edition, pp 280-281.
3. Diseases of the Middle Ear Cleft. In: A synopsis of Otolaryngology 4th edition, pp 91-109.