OTOLARYNGOLOGY

Professor: Dr. Vion Guzman I March 11, 2023 Trans by: Anapen, Angeles
TOPIC: PHARMACOLOGY OF ENT

OUTLINE ● Primary goal of treatment is to control the pain.

Antibiotics are chosen based on the fact that
I.Treatment Options And II.Antibiotic Surgical infections are polymicrobial in nature. Even though
Recommendations Prophylaxis there are discharges in the ears, it doesn't warrant
A. Acute Otitis Media III.Corticosteroids culture and sensitivity. In cases of resistance, we
B. Chronic Prednisone/Methylprednisol use macrolides such as clarithromycin.
Suppurative Otitis oneIV. Anticholinergics
Media V. Vasoconstrictors
B. CHRONIC SUPPURATIVE OTITIS MEDIA
C. Acute Otitis A. Epinephrine
Externa B. Phenylephrine ● Bacteriology: mixed and includes S. aureus,
D. Acute Bacterial C. Ephedrine Pseudomonas aeruginosa, anaerobic bacteria,
Rhinosinusitis VI. Treatment For Control Of and others in addition to those commonly found in
E. Chronic Gastric Acidity acute otitis media
Rhinosinusitis VII. Hemostatic ● Treatment:
F. Acute Bacterial VIII. Ototoxic Medications → Antimicrobial/antiseptic topical therapy
Tonsillitis/ IX. Botulinum-A Toxin combined with an aural toilet is better
Pharyngitis X. Mucolytics And than aural toilet alone.
G. Deep Neck Expectorants → Adding oral antibiotics and the choice
Infections XI. References of topical antibiotics is controversial.
→ Vinegar (Acetic acid)/alcohol (70%),
quinolone topical antibiotics, and
neomycin-polymyxin-steroid otic drops are
safe and effective.
I. TREATMENT OPTIONS AND RECOMMENDATIONS
→ Aminoglycoside (such as ciprofloxacin)
● Varies from country to country or depending on topical antibiotics may be ototoxic.
guidelines ▪ Note: Not given to children or when the
tympanic membrane is perforated ( can
A. ACUTE OTITIS MEDIA travel from the middle ear to inner ear,
which can be ototoxic)
● Bacteriology: Non-typeable Haemophilus influenza
(50% penicillin resistant), S. Pneumoniae (40%
C. ACUTE OTITIS EXTERNA
penicillin resistant), Moraxella catarrhalis (nearly
100% penicillin resistant) . ● Inflammation of external ear/ear canal (Mas
→ Causative organisms of rhinosinusitis masakit compared to OM)
● Treatment: ● Bacteriology: P. aeruginosa, S. aureus, (less than
→ First line of treatment for AOM is 2% of AOE are fungal infections, viral infections, or
analgesic (pain control) eczema)
→ Usual treatment for otitis media is ● Treatment: Antiseptic topical therapy (acetic
observation, but if indicated, acid/alcohol, topical antimicrobials) and debris
■ First line of choice (mild infections) removal/wicking(to maintain patency of the ear
is amoxicillin 80-90 mg/kg canal)
■ First choice (moderate to severe ○ Acetic acid/ alcohol- pang rescue if
infections) is augmentin topical antibiotics are not available. You
→ Omnicef for penicillin-allergic patients can prepare this by using Datu Puti
→ Antibiotics may relieve pain and speed Vinegar
recovery
→ Antibiotic use in polymicrobial mucosal D. ACUTE BACTERIAL RHINOSINUSITIS
biofilm infections do not follow classic
culture and sensitivity testing ● Bacteriology: H. influenza, S. pneumonia, M.
catarrhalis, rarely Streptococcus pyogenes, S.

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 aureus, P. aeruginosa (often in cystic fibrosis),
anaerobic (odontogenic sinusitis)
● Treatment:
→ many resolve without antibiotics
→Amoxicillin for 10 to 14 days is a
reasonable first-line agent.
→ Bactrim or doxycycline is reasonable in
true penicillin-allergic patients
→Amoxicillin/clavulanate, currently a
second-line antibiotic, is currently more
effective than cephalosporins.
→The benefit of culture-directed
antibiotics is limited in polymicrobial
mucosal biofilm infections.
E. CHRONIC RHINOSINUSITIS
● Untreated acute bacterial rhinosinusitis
● Bacteriology
→Chronic bacterial rhinosinusitis, a subset
of chronic rhinosinusitis (CRS), is
multifactorial and poorly understood.
→Innate immune dysfunction and
anatomic obstruction are often
contributors if not the cause.
→Bacteria detected in sinuses with CRS
are mixed and include S. aureus, P.
aeruginosa, and a large mix of aerobic
and anaerobic bacteria.
● Treatment:
→ Multiple oral/topical antibiotics have
been used. Generally, longer-term
antibiotic use leads to longer symptom
relief; however, it has been difficult to cure
CRS with antibiotic use alone.
→ Polymicrobial biofilms share resistance
genes through extensive horizontal gene
transfer, decreasing effectiveness of oral
antibiotics.
→ Cell wall synthesis inhibiting antibiotics
may be less-effective than non-cell wall
synthesis-inhibiting antibiotics.
→Combined use of quinolone and steroids
may lead to more tendinopathy.
→ It is more toxic treating this. Fluticasone
spray- because you want to reduce
inflammation
F. ACUTE BACTERIAL TONSILLITIS/ PHARYNGITIS
● Bacteriology:
→ S. pneumonia, group A-betahemolytic
Streptococcus (S.pyogenes), H. influenza
● Treatment:
→ Antibiotics may be held for up to 9
days without increasing the risk for acute
rheumatic fever, post-streptococcal
glomerulonephritis (sequelae)
→ Penicillin (Drug of choice) is currently
effective for S. pyogenes, penicillin-
resistant S. pneumoniae becoming highly
prevalent.
→ Amoxicillin will cause rash in patients
with EBV pharyngitis
G. DEEP NECK INFECTIONS
● Bacteriology:
▪ Mixed, often with both aerobic (Streptococcus,
Staphylococcus) and anaerobic bacteria (foul
smelling, poorly detected in culture)
● Treatment
○ → Broad-spectrum IV antibiotics followed
by blood and/or abscess culture-directed
antibiotics
○ → Before IV antibiotics - we do drainage
of abscess
○ → We initially give Broad spectrum
antibiotics, after the Culture and sensitivity
is done, we shift to the Specific Antibiotic
where the organism is sensitive
II. ANTIBIOTIC SURGICAL PROPHYLAXIS
● As per current guidelines, antibiotics should be
administered no more than 1 hour prior to incision,
infusions should be completed prior to surgical
incision, and antibiotics should be discontinued
within 24 hours of surgical closure.
● For skin incisions, cefazolin is recommended to
cover against S. aureus.
● For mucosal incisions, clindamycin or
ampicillin/sulbactam may be used to cover a
broad spectrum of aerobic and anaerobic
bacteria (Dr Notes: Or even metronidazole)
● For dirty/infected wounds, antibiotic use should not
be discontinued until clinically appropriate.
III. CORTICOSTEROIDS
A. PREDNISONE/ METHYLPREDNISOLONE
● Tapering
→ Prolonged courses of systemic corticosteroid
suppress the hypothalamic pituitary axis ability to
signal innate corticosteroid production
→ Usually we do tapering kunwari nilagay mo siya
ng 16 mg BID for 3 days then after 1 day or 2 days
gagawin mo siyang once a day. We would want
to prevent the side effects of steroids
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● Side effects of systemic steroids: increased risk of
reduced bone density (osteoporosis), increased risk B. PHENYLEPHRINE
of fungal infection, and reduction in bone growth
● Commonly employed as a topical nasal
in children.
decongestant; it can be used as a vasopressor in
critical care situations.
Phenylpropanolamine
TOPICAL PREPARATIONS- OTHER
● Oxymetazoline (Afrin) – Nasal spray
oxymetazoline if symptomatic or immediate relief
of nasal obstruction.
○ Used to decongest nose prior to
endoscopic procedures
● Phenylephrine (Neo-Synephrine only in US)
● Chronic use beyond 3 to 5 days may result in
tachyphylaxis and rhinitis medicamentosa
(Rebound rhinitis).
Example: Neozep etc.- It is used in asthma or could also
be used as nasal spray or ophthalmic solutions. The mode
of action is mucous membrane pallor or shrinkage. Used
in sinonasal surgery to reduce bleeding

IV. ANTICHOLINERGICS C. EPHEDRINE

● Nasal preparation ● Nonselective, non-catecholamine

● Systemic preparations
● Common side effects of anticholinergic treatment
include tachycardia, xerostomia, urinary retention,
constipation, headache, blurred vision, and acute
glaucoma.
● Only anticholinergic agent available is ipratropium
bromide
V. VASOCONSTRICTORS
sympathomimetic
→ Causes release of stored catecholamines and
direct receptor stimulation
→ Available orally in addition to topically
→ Analog pseudoephedrine (Sudafed) is an
effective oral decongestant.
→ The US government has placed increased
regulations on its sale as it is a chemical precursor
in the illicit manufacturing of methamphetamine.
→ This is not usually used. Can have Off brand uses.

A. EPINEPHRINE
VI. TREATMENT FOR CONTROL OF GASTRIC ACIDITY
● In addition to vasoconstrictors via a-receptors,
● Laryngopharyngeal reflux- Chronic cough, throat
potent stimulatory effects on b1 and b2 receptors
clearing, hoarseness, globus sensation are often
cause increased cardiac contractility (b1) and
presenting symptoms. Additionally, the control of
vasodilation in skeletal muscle and bronchodilation
reflux is important in the postoperative period for
(b2).
airway wound healing (Example can be glottis
● Administered via aerosol (bronchospasm), topical
excision of mass)
(nasal) ophthalmic, subcutaneous, or parenteral
● Lifestyle modifications are the first-line therapy for
routes, not orally.
uncomplicated GERD.
● Topical application produces mucous membrane
○ Modifications include elevation of the
pallor and shrinkage with rapid onset particularly
bed, decreased fat intake, avoidance of
useful in sinonasal surgery
certain foods which loosen the
● Note: 1:1000 epinephrine or 1:2000 epinephrine
esophageal sphincter (chocolate,
should be used in adult patients. A safe amount
peppermint, alcohol, coffee) cessation of
cannot be recommended due to difficulty
smoking, and avoiding recumbency for 3
measuring absorption rates
hours postprandially.
● In ENT- Aside from Lidocaine, we add IV 0.1 or 0.2
● Antacids (hydroxides of aluminum and
epinephrine- mas reduced yung bleeding, in
magnesium, sodium bicarbonate; calcium
addition to vasoconstriction
carbonate) and alginic acid

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 ○ Next steps in LPR treatment algorithm and
both serve as protective coatings over
gastroesophageal mucosa.
● Gaviscon is unique in that it combines aluminum
hydroxide and magnesium trisilicate with alginic
acid to create a “Raft foam buffer” on the surface
of gastric contents which is preferentially refluxed
into the esophagus.
○ These medications can be taken 1 hour
after meals, at bedtime, or as needed in
between. Antacids and alginic acid are
relatively safe and effective for mild GERD.
● Acid Suppression in the form of histamine-2
receptor antagonists (H2RA) and proton pump
inhibitors (PPIs) are indicated in the medical
management of persistent GERD.
○ Over-the-counter (OTC) H2RA prevents
histaminergic stimulation to the acid
secreting parietal cell.
○ Ranitidine (Zantac) and famotidine
(Pepcid) are most commonly used other
drugs.
● There are five available PPIs:
○ Omeprazole (Prilosec), lansoprazole
(Prevacid), rabeprazole (Aciphex),
esomeprazole (Nexium), and
pantoprazole (Protonix).
○ These medications act on the luminal
surface of the parietal cell by inhibiting the
H+/K+ATPase, the site of acid entry into
the gastric lumen.
● These medications are most effective if
taken 30 to 60 minutes before meals and
are relatively safe. Several Long-term side
effects (including B12 deficiency and
fracture risk) have been reported in the
literature from observational studies but
stronger evidence is lacking.
● Given the complicated course of
postoperative wound breakdown in the
airway, PPIs are often prescribed as first-
line postoperative therapy following vocal
fold injections, supraglottoplasty, or other
airway surgeries, or other airway surgeries
VII. HEMOSTATICS
● Desmopressin acetate (DDAVP) temporarily
increases the concentration of factor VIII:C
antihemophilic factor and Von Willebrand factor in
blood.
○ It is useful in minor surgical procedures in
patients with Hemophilia A, type I von
Willebrand disease or prolonged bleeding
times secondary to renal failure.
● Fibrin Sealants
→ Bovine thrombin (Tisseel, Hemaseel), human
thrombin (Crosseal)
● Gelatin Hemostatic agents
→ Gelfoam (purified pork gelatin) and surgifoam.
Provides physical obstruction can expand up to
200% in vivo. Can appear as abscess on imaging.
● Combined thrombin/gelatin agents
→ FloSeal, human thrombin, and bovine gelatin
matrix are combined at time of use.
● Oxidized regenerated cellulose
→ Surgicel/Surgicel Fibrillar, pure plant oxidized
cellulose provides scaffold for clot formation. Can
also appear as abscess on imaging.
● Microfibrillar collagen
→ Avitene, purified bovine collagen provides
hemostasis by stimulating intrinsic pathway
● Cyanoacrylate adhesives
→ Dermabond, 2-octyl cyanoacrylate, works as
water- containing human tissue activates the
polymerization of cyanoacrylate monomers. Useful
in skin closure.
VIII. OTOTOXIC MEDICATIONS
● Drugs commonly implicated in ototoxic side effects
are:
→ Aminoglycosides, loop diuretics, cisplatin,
quinine, and salicylates.
Very important!
Ototoxic sa inner and middle ear structures While the ear has
its developing period (embryonic to children) you would not like
to administer these ototoxic medication. Kunyare, na-ICU yung
bata, wag ibigay kasi magiging ototoxic. Meaning, masisira
yung inner ear structures (sensorineural hearing loss)
Memorize the above table-laging lumalabas sa board
● Stria vascularis = produces the
lymphCochleotoxic = sinisira yung cochlea
● Chemotherapeutic agents = cisplatin and
carboplatin
● Quinine and chloroquine = used in malaria
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● Salicylate = aspirin
● Tinnitus and hearing loss with salicylate use is X. MUCOLYTICS AND EXPECTORANTS
reversible (2.5g/day para di magkahearing
● The ―bread and butter‖ of ENT
damage)
● Mucolytic agents act by depolymerizing
mucopolysaccharides and increasing their
IX. BOTULINUM-A TOXIN solubility.
○ Acetylcysteine (mucomyst) is used as an
● Potent neurotoxin produced by gram-positive
adjunct therapy in the treatment of
anaerobe clostridium botulinum
asthma to thin secretions.
● Mechanism: cleaves snap-25, enzyme involved in
○ Acetylcysteine = tutunawin sa tubig tapos
presynaptic release of acetylcholine.
iinumin 2x a day.
● Temporary paralysis, return of function via
■ Prescribe when the patient has
collateral connections within 3 months at motor
globus sensation na parang di
endplates.
lumalabas yung mucous
● Clinical indications: effacement of rhytids,
treatment of facial dystonias, spastic dysphonia
(vocal cord spasm), and sialorrhea (action at
presynaptic membrane of parasympathetic XI. REFERENCES
nerves).
Doc Vion’s PPT
● Ginagamit pantanggal ng eyebags or mga K.J. Lee’s Essential Otolaryngology Head and Neck Surgery by K. J. Lee,
wrinkles (Botox). Also used in facial dystonias, used Yvonne Chan, John C. Goddard 12th Edition
to paralyze. Marilag ENT Trans

APPENDIX
● Antimicrobial Therapy in Otolaryngology—Head and Neck Surgery

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