Derbyshire Medicines Management, Prescribing and Guidelines
DERBYSHIRE PRIMARY CARE FORMULARY
CHAPTER 12: EAR, NOSE AND OROPHARYNX
Updated: October 2016
The following prescribing guidelines are relevant to the ENT chapter and can be found here:
 Management of chronic rhinosinusitis with or without nasal polyps
 Referral guide for Allergic Rhinitis in adults and adolescents over 12 years of age
12.1 DRUGS ACTING ON THE EAR
12.1.1 Otitis externa
Investigation is not routinely recommended for the initial diagnosis of chronic externa
Group
Astringent/acidic preparations
Antibiotic preparations
Combined corticosteroid and
aminoglycoside antibiotic
preparations
Corticosteroid preparations
Ingredients
Aminoglycoside
Brand name
Products
EarCalm
Genticin
With neomycin
Betnesol-N
Betametasone &
neomycin
Otomize
Dexemethasone ,neomycin
& acetic acid
Dexamethasone,
framycetin & gramicidin
Prenisolone 0.5% drops
Betamethasone 0.1% drops
With framycetin
Sofradex
Lower potency
Higher potency
Predsol
Betnesol
Antifungal preparations
Canestan
Acetic acid 2% spray*
Gentamicin 0.3% drops
Clotrimazole 1% solution
20ml (with dropper)
Bold indicates in current formulary
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Hydrocortisone acetate 1%/gentamicin 0.3% ear drops have been classified as BROWN by JAPC.
Flumetasone pivalate 0.02%/clioquinol 1% ear drops have been classified as BROWN by JAPC.
o Both products are not for first line empirical use and should only be used when sensitivity is
confirmed through swab results.
Chloramphenicol 5%, 10% ear drops 10ml (GREEN on specialist recommendation)
How should I treat acute diffuse otitis externa? (CKS)
 Remove or treat any precipitating or aggravating factors.
 Prescribe or recommend a simple analgesic for symptomatic relief.
 Treat inflammation using a topical ear preparation for 7 days:
- For mild cases (discomfort and/or pruritus; no pain, deafness, discharge), topical acetic acid 2%
(EarCalm) spray* can be used first-line. Self-care patients can be advised to purchase this ‘over
the counter’
- For more severe cases (pain, deafness, discharge), or if treatment with acetic acid for mild otitis
externa is not effective, a topical antibiotic with or without corticosteroid should be used.
 Only consider adding an oral antibiotic for people with severe infection.
Treatment failure

If there are systemic signs of infection or if the infection is spreading outside the ear canal, prescribe
a 7 day course of an oral antibiotic (flucloxacillin or erythromycin if penicillin sensitive; or
clarithromycin if others contraindicated)
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The formulary lists the most clinically and cost effective choices for prescribing in primary care
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If this is ineffective consider the possibility of a fungal infection and treat with topical antifungal such
as clotrimazole 1% ear drops (Canestan) or flumetasone pivalate 0.02%/clioquinol 1% ear drops.
Chronic Otitis Externa
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If mild to moderate fungal infection is suspected (signs of fungal growth in ear canal)
- A topical antifungal: clotrimazole 1% solution.
- Acetic acid 2% spray (unlicenced use)
- A topical preparation containing clioquinol and corticosteroid: flumetisone/clioquinol ear drops
If the cause seems to be seborrhoeic dermatitis treat topically with antifungal-corticosteroid
combination
If no cause is evident prescribe a 7 day course of topical preparation containing only a corticosteroid
without antibiotic.
Clinoquinol can also be considered as it possesses antibacterial and antifungal activities.
12.1.2 Otitis media
See local antimicrobial treatment guideline
Ciprofloxacin 0.3% /dexamethasone 0.1% (Cilodex) has been classified as GREEN for use in
children with acute otitis media with tympanostomy tubes(grommets) or tympanic perforation in
adults and children over 6 months of age.
12.1.3 Removal of ear wax
Olive oil 10ml (Arjun oil drops)
Sodium bicarbonate 5% ear drops 10ml
Sodium Chloride 0.9% nasal drops (off license use- CKS)
1. When should earwax be removed? (CKS)
 If earwax is totally occluding the ear canal and any of the following are present:
- hearing loss
- earache
- tinnitus
- vertigo
- cough suspected to be due to earwax
 If the tympanic membrane is obscured by wax but must be viewed to establish a diagnosis.
 If the person wears a hearing aid, wax is present and an impression needs to be taken of the ear
canal for a mould, or if wax is causing the hearing aid to whistle.
2. How should earwax be removed? (CKS)
 Use OTC ear drops (e.g. sodium bicarbonate 5%, sodium chloride 0.9% or olive oil) for 3-5 days
initially, to soften wax and aid removal.
- do not prescribe drops if you suspect the person has a perforated tympanic membrane
 If symptoms persist, consider ear irrigation, providing that there are no contraindications.
 If irrigation is unsuccessful, there are three options:
- advise the person to use ear drops for a further 3-5 days and then return for further irrigation
- instill water into the ear. After 15 minutes irrigate the ear again
- refer to an Ear Nose and Throat specialist for removal of wax
 Advise anyone who has had earwax removed to return if they develop otalgia, or significant
itching of the ear, discharge from the ear (otorrhoea) or swelling of the external auditory meatus,
as this may indicate infection.
12.2
DRUGS ACTING ON THE NOSE
12.2.1 Drugs used in nasal allergy
Mometasone (generic) 50 micrograms nasal spray – 140 dose
Beclometasone 50 microgram nasal spray – 200 dose
1.
Budesonide aqua (Rhinocort), 64 micrograms nasal spray and Fluticasone 27.5micrograms nasal
spray (Avamys) are ‘GREEN’ 2nd line options for allergic rhinitis and choice should be based on
cost, as per local guidance.
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The formulary lists the most clinically and cost effective choices for prescribing in primary care
2.
3.
4.
Flixonase nasule drops 400micrograms are ‘GREEN’ for the management of chronic rhinitis with
nasal polyps as per local guidance. Remember to step-down treatment.
Intranasal corticosteroids have similar clinical efficacy
Dymista is a combination nasal spray of fluticasone and azelastine and is classified locally as
‘BROWN consultant/specialist initiation’ – see referral guide for Allergic Rhinitis in adults and
adolescents over 12 years of age
12.2.2 Topical nasal decongestants
Sodium chloride 0.9% drops 10ml
Ephedrine 0.5% nasal drops 10ml
Ipratropium bromide 0.03% nasal spray
1.
Ephedrine & xylometazoline are only suitable for short term use (usually not longer than 7 days) and
are available OTC. They are of limited value because they can give rise to a rebound congestion on
withdrawal, due to a secondary vasodilation with a subsequent temporary increase in nasal
congestion. Ephedrine nasal drops is the safest sympathomimetic preparation and can give relief
for several hours, therefore the preferred choice locally.
12.2.3 Nasal preparations for infection
Naseptin cream 15g
1.
For non-allergic rhinitis
For eradication of nasal carriage of staphylococci
Bactroban (mupirocin) only on microbiologist recommendation for decolonisation of MRSA.
12.3
Drugs acting on the oropharynx
12.3.1 Drugs for oral ulceration and inflammation
Hydrocortisone microadhesive buccal tablets 2.5mg
Benzydamine, 300ml 0.15% oral rinse
12.3.2 Oropharyngeal anti-infective drugs
Miconazole oral gel 15g, 80g
Nystatin suspension 30ml
1.
2.
3.
4.
Oral fluconazole is effective for unresponsive infections or if a topical antifungal drug cannot be used
or if the patient has dry mouth. Topical therapy may not be adequate in immunocompromised
patients.
Nystatin prescribed as “Nystan” is a cost effective prescribing option.
JAPC notes Nystatin dosing regimen change and variation with generic manufactures. Nystatin
dosing regimens remains at a 1ml QDS dose
Miconazole oral gel use in children under 4 months is off-licence because of the risk of choking if not
carefully applied, see local guidance.
12.3.3 Lozenges and sprays
There is no convincing evidence that antiseptic lozenges and sprays have a beneficial action and they
sometimes irritate and cause sore tongue and sore lips. Some of these preparations also contain local
anaesthetics which relieve pain but may cause sensitisation.
12.3.4 Mouthwashes, gargles, and dentifrices
Hexetidine 0.1% mouthwash 100ml, 200ml
Chlorhexidine gluconate 0.2% 300ml (As corsodyl)
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GPs should not accept requests from dentists to prescribe medicines that the dentist can prescribe
themselves.
GPs should not accept requests from patients to issue FP10 prescriptions for items prescribed on a
private prescription by their dentist during dental treatment as a private patient.
Patients should be advised of self-care measures and signposted to purchase over the counter
remedies for dental conditions where appropriate
12.3.5 Treatment of dry mouth
See BNF for choices
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The formulary lists the most clinically and cost effective choices for prescribing in primary care