1. Dr. Yasser A. Nour M.D, FRCSEd Fellow of the Royal College of Surgeons of Edinburgh. Lecturer of Otolaryngology – Head & Neck Surgery. PHARMACOTHERAPY FOR DISEASES OF THE NOSE

3. Common Cold Rhinovirus Coronavirus The commenst viral infection in human

4. Mode of Transmission

9. Influenza One of the most common infectious diseases in human. It is caused by influenza virus that is classified as type A, B & C.

10. Influenza It may occur in epidemics. Spanish flu epidemic 1918 killed 20 millions all over the world.

12. Influenza Two types of influenza virus. Human influenza Avian influenza

13. Influenza Two types of influenza virus. Human influenza A person infected with a particular flu virus strain develops antibody against that virus. As newer virus strains appear through antigenic shift and drift , the antibodies against the older strains no longer recognize the "newer" virus, and infection with a new strain can occur.

14. Common Occasional Sore throat Common Occasional Sneezing Common Occasional Stuffy nose Mild to moderate Common, severe Chest discomfort Very mild, short lasting More common Fatigue, weakness Mild Severe Malaise Mild to moderate Common, severe Cough (dry) Severe, common Severe, common Headache Uncommon Common Anorexia Uncommon Severe, common Arthralgia Uncommon Severe, common Myalgia Uncommon only 0.5°C Common up to 40.0°C Fever More gradual Abrupt Onset Common cold Influenza Features

17. Allergic Rhinitis Dr. Yasser A. Nour, M.D., FRCSEd Lecturer of Otolaryngology – Head & Neck Surgery. Alexandria University Fellow of the Royal College of Surgeons of Edinburgh

18. Allergic rhinitis is an IgE mediated hypersensitivity of nasal mucous membrane characterized by sneezing, itching, watery rhinorrhea and a sensation of nasal obstruction . It may also involve the lining of paranasal sinuses . Allergic rhinitis occurs in atopic individuals who are exposed to common aeroallergens

25. Pathogenesis

26. Pathogenesis Early, or immediate, phase of the reaction

27. Pathogenesis Late-phase response

31. Allergen Avoidance Mites control Mattress covers

32. Allergen Avoidance Mites control Mattress covers Air conditioner Dehumidifier

33. Allergen Avoidance Mites control Mattress covers Dust & Pollen mask Food avoidance Pets control

34. Antihistamines Driving Using machines Glaucoma Prostatic hypertrophy Blurred vision Dry mouth Urinary retention Constipation GI upset Drowsiness Cognitive impairment Impaired reflexes Gastrointestinal Anticholinergic effects Central nervous system Intra-Nasal Antihistamine (Azelastine nasal spray) Side effects Fexofenadine Cetirizine Loratadine Diphenhydramine Brompheniramine Hydroxyzine Second generation First generation

35. Decongestants Care should be taken in those with: Heart disease Hypertension Glaucoma Prostatic hypertrophy Diabetes mellitus Local Systemic Drowsiness Insomnia Dizziness Weakness Acute glucoma Tachycardia Palpitations Nervousness Headache Urine retention Burning Sneezing Increased discharge Rebound congestion Side effects Pseudoephedrine Oxymetazoline Systemic Intranasal

37. Others IMMUNOTHERAPY Epistaxis Nasal irritation: burning, sneezing Intra-Nasal Anticholinergic Ipratropium bromide Intra-Nasal Mast Cell Stabilizers Cromolyn sodium

38. Others SINGULAIR is indicated for relief of symptoms of allergic rhinitis (seasonal allergic rhinitis in adults and children aged 2 years and older and perennial allergic rhinitis in adults and children aged 6 months and older).

39. Sinusitis Sinusitis is the inflammation/infection of 1 or more paranasal sinuses and occurs with obstruction of the normal drainage mechanism. It is traditionally subdivided into acute (symptoms lasting <3 wk), subacute (symptoms lasting 3 wk to 3 mo), and chronic (symptoms lasting > 3 mo).

40. Several factors may contribute to obstruction: mucosal swelling, abnormalities of the cilia, structural abnormalities and overproduction of secretions. Preceding viral infection or epithelial damage weakens mucosal defenses and facilitates penetration of bacteria into the sinus mucosa. Although nasal allergies also contribute to edema and swelling of the nasal mucosa.

41. A diagnosis of ABS can be made when a viral upper respiratory tract infection (URI) fails to improve after 10 days or worsens after 5–7 days and is accompanied by symptoms of persistent anterior and posterior rhinorrhea, nasal congestion, facial pressure/pain, post-nasal drainage, reduced sense of smell, fever, cough, fatigue, dental pain in the jaw, or ear pressure/fullness.

42. Symptoms associated with acute bacterial rhinosinusitis Nonspecific/infrequent symptoms Malaise/fatigue Purulent anterior nasal or postnasal discharge Cough Fever Hyposmia/anosmia “ Double-sickening” history † Nasal congestion Maxillary tooth or facial pain (especially when unilateral) Halitosis Unilateral maxillary sinus tenderness Key diagnostic symptoms

43. The most common bacterial pathogens in acute sinusitis are Streptococcus pneumoniae (30-40%), Haemophilus influenzae (20-30%) Moraxella catarrhalis (12-20%). Anaerobic organisms have been found in fewer than 10% of patients with acute bacterial sinusitis, despite the ample environment available for their growth.

44. First-line therapy at most centers is usually amoxicillin or a macrolide antibiotic in patients allergic to penicillin because of the low cost, ease of administration, and low toxicity of these agents. * 500 mg PO first day, then 250 mg/d PO for 4 days Azithromycin 250-500 mg PO bid Clarithromycin 500 mg PO tid Amoxicillin Dosage Antibiotic

45. Patients who live in communities with a high incidence of resistant organisms , those who fail to respond within 48-72 hours of commencement of therapy, and those with persistence of symptoms beyond 10-14 days should be considered for second-line antibiotic therapy. 300 mg PO tid Clindamycin 200 mg/d PO Trovafloxacin 500 mg/d PO Levofloxacin 500-750 mg PO bid Ciprofloxacin 200 mg PO bid 400 mg/d PO Cefpodoxime + cefixime 250-500 mg PO bid Cefuroxime 500 mg PO tid Amoxicillin/clavulanate Dosage Antibiotic

46. PHARMACOTHERAPY FOR DISEASES OF THE EAR

47. External Ear

50. The most common pathogen is Pseudomonas aeruginosa , followed by Staphylococcus aureus , then other gram-negative organisms.

61. MIDDLE EAR

64. Pneumococcus species, Haemophilus influenzae, and Moraxella species are the bacteria most commonly involved in otitis media.

66. Treatment &quot; Wait-and-see prescription “ for antibiotics in AOM The observation option is a 48- to 72-hour period of symptomatic treatment with analgesics and without antibiotics, followed by reexamination.

67. Treatment Adjust dose in renal impairment; use in Ebstein-Barr viral mononucleosis increases risk of severe rash Precautions 80-90 mg/kg/d PO divided q8h for 10 d in younger children and in patients with severe disease Pediatric Dose 250-500 mg PO q8h Adult Dose Amoxicillin (Amoxil, Biomox) Drug Name

68. Treatment Give for minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); after treatment, perform cultures to confirm eradication of streptococci Precautions 90 mg/kg (amoxicillin) with 6.4 mg/kg (clavulanate) divided PO q12h Pediatric Dose 500-875 mg PO q12h PO or 250-500 mg PO q8h Adult Dose Amoxicillin and clavulanate potassium (Augmentin) Drug Name

69. Treatment 30 mg/kg PO q12h Pediatric Dose 125-500 mg PO q12h Adult Dose Second-generation cephalosporin maintains gram-positive activity of first-generation cephalosporins; adds activity against Proteus mirabilis , H influenzae , Escherichia coli , Klebsiella pneumoniae , and M catarrhalis . Condition of patient, severity of infection, and susceptibility of microorganism determines proper dose and route. Description Cefuroxime Drug Name

70. Ceftriaxone 50 mg/kg/d is recommended for children who are unable to take oral antibiotics and for patients with compliance problems. Treatment

73. Bell’s palsy Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use Precautions 1 mg/kg/d PO for 7 d Adult Dose Prednisone (Hostacortin) Drug Name

74. Bell’s palsy Caution in renal failure or when using nephrotoxic drugs Precautions <2 years: Not recommended >2 years: 1000 mg PO divided qid for 10 d Pediatric Dose 4000 mg/24 h PO for 7-10 d Adult Dose Acyclovir (Zovirax) -- Has demonstrated inhibitory activity directed against both HSV-1 and HSV-2, and infected cells selectively take it up. Drug Name

75. INNER EAR

77. Meniere’s disease Caution in angle-closure glaucoma, prostatic hypertrophy, pyloric or duodenal obstruction, and bladder neck obstruction Precautions 25-50 mg PO q4-6h Adult Dose Decreases the excitability of the middle ear labyrinth and blocks conduction in the middle ear vestibular-cerebellar pathways. These effects are associated with its therapeutic effects in vertigo. Description Meclizine (Antivert) Drug Name

78. Meniere’s disease Neonates: Do not administer 2-6 years: 12.5-25 mg q6-8h; not to exceed 75 mg/d 6-12 years: 25-50 mg PO q6-8h; not to exceed 150 mg/d Pediatric Dose 50 mg PO/IM q4-6h or a 100-mg suppository q8h Adult Dose Used for treatment and prophylaxis of vestibular disorders that may cause nausea and vomiting. Through its central anticholinergic activity, it diminishes vestibular stimulation and depresses labyrinthine function. Description Dimenhydrinate (Dramamine) Drug Name

79. Meniere’s disease 5-10 mg PO/IV/IM q4-6h Adult Dose Depresses all levels of the CNS, including limbic and reticular formation, possibly by increasing GABA activity, which is a major inhibitory neurotransmitter. Description Diazepam (Valium) Drug Name

80. Meniere’s disease Can be associated with CNS depression, dry mouth, extrapyramidal symptoms, hypertension, hypotension, and rash; caution in patients with cardiovascular or hepatic disease Precautions <2 years: Contraindicated >2 years: 0.5 mg/kg q4-6h Pediatric Dose 25-50 mg PO/IM/PR q4-6h Adult Dose Antidopaminergic agent effective in the treatment of emesis. Description Promethazine (Phenergan) Drug Name

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