Drug Use in EENT Drug induced EENT toxicities

1. Drug Use in EENT Drug induced EENT toxicities Pharmacotherapy 2 for Year 3rd October 28, 2008 Thananan Rattanachotphanit

4. ?????????????? ??: ???????????? ???????????? (optic nerve): ????????????????????? ?????????????????????: ???????????? ?????????????? 3 ???? ?????????????? ???????????? ?????????????

5. ?????????????? ???? fibrous layer ???? sclera (?????): ?????????????????????? ??????????? sclera ??? cornea (???????) ?????????????????????? ?????????????????????? ???????????????????????????????? ????????????????? ??????? (??????? ???? conjuntiva) ???????????????????????? ?????????? ???????? sclero-corneal junction / limbus ?????????????? trabecular meshwork ??? canal of Schalem Trabecular meshwork: ???? aqueous ??????????? canal of Schalem ????????????????????? ??????????????????????????????? (14-16 mmHg)

6. ???????? uvea ?????????????????????????????? ???????? 3 ???? ??? ?????? (iris) ????????????????; ciliary body ????????????; Choroid ???????????? Iris: ????????????????????????????????? ???????????? 2 ????? ??? dilator papillae ??? sphincter papillae ????????????????????????????????????????? Dilator papillae: ???????????????????????????????? ?????????????????????? sympathetic ??????????????? ? ??????????????? ? ???????????? (mydriasis) Sphincter papillae: ???????????????????????????? ?????????????????????? parasympathetic ??????????????? ? ??????????????? ? ?????????????? (myosis) ????????????

7. Ciliary body ?? 2 ???? ??? ciliary process ??? ciliary muscle Ciliary process: ????? aqueous humor Ciliary muscle: ??????????????????????????????????????? Lens: ???????? ??????????????? ?????????????????? ???????????????????????????????????? ciliary body ???????????????? ????????????????????????????? ????????? Choroid ?????????????????????????????? ????????????????????? (retina) ?????????????????????: vitreous humor ????????? ????????????

8. ??????????????????? Topical Anesthetics Local anesthetics for injection Mydriatics & Cycloplegics Topical corticosteroids NSAIDS Anti-infective ophthalmic drugs Topical Antifungal Agents Topical Antiviral Agents

9. ??????????????????? Topical Anesthetics: ?????????????????? : tonometry, removal of foreign bodies or sutures, gonioscopy, conjunctival scraping, minor surgical operations on the cornea and conjunctiva Proparacaine Hydrochloride: Solution, 0.5% Tetracaine Hydrochloride: Solution, 0.5%, and ointment, 0.5% Benoxinate Hydrochloride: Solution, 0.4% ????????????????????????????????????????????????????????? corneal ???????????????? ocular disease ????????????

10. ??????????????????? Local anesthetics for injection: ???????????????????? Longer acting agents ???? bupivacaine ??? etidocaine ????????????????? local anesthetics ???????????????????????????????? ?????????? hyaluronidase ???????????????????????????????????? ???????????? onset ????????????? Injectable anesthetics ?????????????????????????????????????????????????? cardiac arrhythmias Lidocaine Hydrochloride Procaine Hydrochloride Solution, 1%, 2%, and 10%. Mepivacaine Hydrochloride: Solution, 1%, 1.5%, 2%, and 3% Bupivacaine Hydrochloride (duration 6�10 hours): Solution, 0.25%, 0.5%, and 0.75% Etidocaine Hydrochloride (duration 4�8 hours): Solution, 1% and 1.5%

11. ??????????????????? Mydriatics and cycloplegics: ??????? pupil ????????????????????? ophthalmoscopy ????? paralysis of muscle accommodation ????????? pupil ??? paralysis of muscle accommodation ?? uveitis ??????????????????????????????????????????????????????????? narrow anterior chamber angles ?????????????????????????????????? angle-closure glaucoma

12. ??????????????????? Mydriatics (Sympathomimetics): Phenylephrine Hydrochloride: Solution, 0.12%, 2.5%, and 10% Cycloplegics (Parasympatholytics): Atropine Sulfate: Solution, 0.5�3%; ointment, 0.5% and 1% Scopolamine Hydrobromide: Solution, 0.25% Homatropine Hydrobromide: Solution, 2% and 5% Cyclopentolate Hydrochloride: Solution, 0.5%, 1%, and 2% Tropicamide

13. ??????????????????? Topical corticosteroids: ???????????????????????? allergic conjunctivitis, uveitis, episcleritis, scleritis, phlyctenulosis, superficial punctate keratitis, interstitial keratitis ?????????????????????????????????????????? relative potency of prednisolone to hydrocortisone is 4 times; of dexamethasone and betamethasone, 25 times) ?????????????????????????????????????????? ???? exacerbation of herpes simplex keratitis, fungal keratitis, cataract formation (unusual), and open-angle glaucoma (common)

14. ??????????????????? Topical ophthalmic corticosteroids: Hydrocortisone ointment, 0.5%, 0.12%, 0.125%, and 1% Prednisolone acetate suspension, 0.125% and 1% Prednisolone sodium phosphate solution, 0.125% and 1% Dexamethasone sodium phosphate suspension, 0.1%; ointment, 0.05% Medrysone suspension, 1% Fluorometholone suspension, 0.1% and 0.25%; ointment, 0.1% Rimexalone suspension, 1%

15. ??????????????????? Nonsteroidal anti-inflammatory agents (NSAIDS): Flurbiprofen 0.03%, and suprofen 1%: for inhibition of miosis during cataract surgery Ketorolac 0.5%: for use in seasonal allergic conjunctivitis Diclofenac and ketorolac: for postoperative inflammation following cataract surgery; for relief of pain & photophobia in patients undergoing laser corneal refractive surgery

16. ???????????????????

17. ??????????????????? Bacitracin: Ointment, 500 U/g, combinations with polymyxin B Polymyxin B: Ointment, 10,000 U/g; suspension, 10,000 U/mL. Erythromycin: ointment, 0.5% Neomycin: Solution, 2.5 and 5 mg/mL; ointment, 3.5�5 mg/g. Combinations with bacitracin and polymyxin B. Gentamicin: Solution, 3 mg/mL; ointment, 3 mg/g. Tobramycin: Solution, 3 mg/mL; ointment, 3 mg/g. Tetracyclines: Suspension, 10 mg/mL; ointment, 10 mg/g. Chloramphenicol: Solution, 5 and 10 mg/mL; ointment, 10 mg/g. Ciprofloxacin: Solution, 3 mg/mL Gatifloxacin: Solution, 3 mg/mL Moxifloxacin: Solution, 5 mg/mL Norfloxacin : Solution, 3 mg/mL Ofloxacin: Solution, 3 mg/mL Sulfacetamide Sodium: solution, 10%, 15%, and 30%; ointment, 10% Sulfisoxazole: solution, 4%; ointment, 4%.

18. ??????????????????? Topical Antifungal Agents: Natamycin Suspension, 5% Nystatin (not available in ophthalmic ointment form, but the dermatologic preparation (100,000 U/g) is not irritating to ocular tissues and can be used in the treatment of fungal infection of the eye) Amphotericin B (not available in ophthalmic ointment form. A solution (1.5�8 mg/mL of distilled water in 5%�dextrose must be made up in the pharmacy from the powdered drug) Miconazole (1% solution is available in the form of IV preparation that may be instilled directly into the eye ) Fluconazole (0.2% parenteral preparation is available and may be instilled into the eye)

19. ??????????????????? Topical Antiviral Agents: Idoxuridine: solution, 0.1%; ointment, 0.5% Vidarabine: ointment, 3% Trifluridine: Solution, 1% Acyclovir: Tablet 200, 400, and 800 mg Ganciclovir: Intravitreal implant, 4.5 mg

20. ??????????????????? Tear replacement & Lubricating agents: Artificial tears Ocular emollients Artificial tears: contains demulcent (high molecular weight compounds water-soluble polymers) which act like mucin: coat the surface of irritated mucous membranes wetting of the cornea & prevent drying of the affected tissue through increasing volume of fluid

21. ??????????????????? Artificial tears: Cellulose derivatives (common used and safe): carboxymethylcellulose, hydroxyethylcellulose, hydroxypropyl methylcellulose, methylcellulose Polyvinyl alcohol: lower viscosity than cellulose derivatives Povidone and dextran 70: transient stinging Gelatin: not be used as a single ingredient, can be added to another demulcent to raise the protein content of tears. 1-2 drops as needs (twice daily is sufficient) Instillation > 6 times a day may wash away natural tears & cause a rippled appearance on the ocular surface

22. ??????????????????? Ocular emollient: Ophthalmic ointment containing: lanolin, mineral oil, paraffin, petrolatum, white petrolatum, white ointment, white wax, yellow wax Soften tissue by forming an occlusive film on the eye surface Optimal time of use: Bedtime (because it may cause blur vision)

23. ??????????????????? Vasoconstrictive agents: ???????????????????????????????????? superficial vessels ??? conjunctiva ??????????????????????? Ephedrine 0.123% Naphazoline 0.012�0.1% Phenylephrine 0.12% Tetrahydrozoline 0.05�0.15% Astringent: Zinc sulphate 0.25% for relieve discomfort of minor eye irritation

24. ??????????????????? Corneal dehydrating agents: ??????? corneal edema ????? tear film ?????? hypertonic ??? corneal tissues Create an osmotic gradient that draw fluid from the cornea Ex: Anhydrous glycerin solution Hypertonic sodium chloride 2% and 5% ointment and solution

25. ??????????????????? Topical antihistamines : Cromolyn Sodium: Solution, 4%: not useful in the treatment of acute symptoms. Ketotifen Fumarate: Solution, 0.025%:antihistamine and mast cell�stabilizing activity Lodoxamide Tromethamine: Solution, 0.1%:a mast cell stabilizer that inhibits type 1 immediate hypersensitivity reactions. Nedocromil Sodium: Solution, 2%: rapid onset of an antihistamine and true mast cell�stabilizing activity.

26. Topical antihistamines : Olapadine Hydrochloride: antihistamine and mast cell�stabilizing actions Levocabastine Hydrochloride: Suspension, 0.05%:is a selective, potent histamine H1-receptor antagonist. It is useful in reducing acute symptoms of allergic conjunctivitis. Emedastine Difumarate: Solution, 0.05% ???????????????????

27. Instruction for use of eye drop Wash the hand thoroughly with an antibacterial soap. Tilt head back and gently pull lower lid forward to create a pouch. Instill one drop into the pocket without touching the eyelid or lashes with eyedropper or bottle tip Wait a few second, then bring the lid forward, lookdown, and gently lift the lower lid up until it touches the upper lid. Release the lid and keep the eye closed without blinking or squeezing for 1-2 min. Apply gentle pressure over the puncta (opening of tear duct at the inner corner of the eye) for 2 min. to minimize systemic absorption and to prevent drainage of solution from the intended area.

28. Instructions for use of ophthalmic ointments,gels Wash the hand thoroughly with an antibacterial soap. Without touching the tip of the tube, remove the cap form the ointment or gel container. Tilt head slightly backward. With one finger, pull the eyelid down to form a pouch Squeezing the tube carefully to avoid touching it to the eye, apply the recommended amount of ointment or gel to the pouch inside of eyelid. Release eyelid and close the eye, keeping it closed for 1-2 min. While eye is closed, distribute the medication by moving the eye.

29. ????????? (Eye irrigation) Loose foreign material in the eye Eyewash or eye lotion Sterile isotonic solution: boric acid, sodium borate, sodium chloride, purified water (packaged with eyecup (11-12 ml)) How to irrigate: Rinse eyecup with clean water or eyewash before use Eyewash is placed in the cup until it is half filled Patient bends over until the periorbital area is surrounded by the rim of eyecup Open eye and tilts the head back until the eyecup bath ocular tissue Eyeball must be rotated to ensure through bathing Alternatively way, hold the head over a sink, holding eyewash at angle slightly away from the eyes, solution will stream across the surface of eye.

30. Contact lens Major types of lenses: 1) Rigid (gas-permeable): more durable and easier to care but more difficult to tolerate 2) Soft Soft lenses are also available for extended wear Disposable soft lenses to avoid necessity for lens cleaning, and sterilization are available for daily or extended wear. Contact lens care: cleaning and sterilization, removal of protein deposits.

31. Drug used in glaucoma ????????????????????????????????????????????????????? tonometric ??????????????????? ?????????????????????????????? intraocular pressure ??????????????????????????? optic nerve ??? 1.???????????????? parasympathomimetics ???????? intraocular pressure ??????????? outflow of aqueous humor ??????? trabecular meshwork Direct-Acting Cholinergic (Parasympathomimetic) Drugs Pilocarpine Hydrochloride & Nitrate: Solution, 0.25%, 0.5�6%, 8%, and 10%; gel, 4%. Carbachol: Solution, 0.75%, 1.5%, 2.25%, and 3% Indirect-Acting Anticholinesterase Drugs Physostigmine Salicylate & Sulfate: Solution, 0.25%, and ointment, 0.25%

32. Eyes' drainage system

34. Drug used in glaucoma 2.Adrenergic (Sympathomimetic) Drugs; Nonspecific Epinephrine ?????????????????? outflow of aqueous humor ??????????????????? aqueous humor ??????????????????? long term use ?????????? ??????????? 12-72 ??. ??????????????? miosis S/E ??? local allergies ??????????? 25% ????????????? ??????????????? headache and heart palpitation ??????????????????? ?????????????????????????????? Epinephrine borate 0.5%, 1%, and 2% Epinephrine hydrochloride 0.25%, 0.5%, 1%, and 2% Dipivefrin hydrochloride 0.1%

35. Drug used in glaucoma 3. Adrenergic (Sympathomimetic) Drugs; Relatively Alpha 2�Specific Apraclonidine Hydrochloride: Solution, 0.5% and 1% Brimonidine Tartrate (Alphagan-P): Solution, 0.15% 4. Beta-Adrenergic Blocking (Sympatholytic) Drugs Timolol Maleate: Solution, 0.25% and 0.5%; gel, 0.25% and 0.5% Betaxolol Hydrochloride: Solution, 0.25% and 0.5%. Levobunolol Hydrochloride: Solution, 0.25% and 0.5% Metipranolol Hydrochloride: Solution, 0.3% Carteolol Hydrochloride: Solution, 1%

36. Drug used in glaucoma 5. Carbonic Anhydrase Inhibitors ??????????????? carbonic anhydrase ?? ciliary body ??????????????? aqueous ?????????????????????? 2 ??. ??????????????????? 4-6 ??. ??????????????????????????????????????????????? 20 ???? S/E: ????????????????????, gastric distress, diarrhea, exfoliative dermatitis, renal stone formation, shortness of breath, fatigue, acidosis, tingling of the extremities

37. Drug used in glaucoma 5. Carbonic Anhydrase Inhibitors Oral: Acetazolamide (Diamox): Tablets, 125 mg and 250 mg; give 125�250 mg two to four times a day Methazolamide: Tablets, 25 and 50 mg; 50�100 mg two or three times daily Dichlorphenamide: Tablets, 50 mg: usual maintenance dosage for glaucoma is 25�50 mg three or four times daily Topical: Dorzolamide Hydrochloride: Solution, 2% Brinzolamide Ophthalmic Suspension: Suspension, 1%

38. Drug used in glaucoma 6. Prostaglandin Analogs: ???????? intraocular pressure ??????????? outflow of aqueous humor ??????? uveoscleral pathway ???????? Adverse effects: increased brown pigmentation of the iris, conjunctival hyperemia, punctate epithelial keratopathy, and a foreign body sensation, ?????????????? ocular inflammation Latanoprost: Solution, 0.005% Travoprost: Solution, 0.004% Bimatoprost: Solution, 0.03% Unoprostone Isopropyl: Solution, 0.15%

39. Drug used in glaucoma 7. Hyperosmotic Agents: ????? intraocular pressure ???????????? plasma hypertonic ????????????? aqueous humor ????????????? acute (angle-closure) glaucoma ????????????? intraocular pressure ??????????????????

40. Drug used in glaucoma 7. Hyperosmotic Agents: Glycerin: orally as 50% solution with water, orange juice, or flavored normal saline solution over ice (1 mL of glycerin weighs 1.25 g) (Toxicity: Nausea, vomiting, and headache) Isosorbide: 45% solution Mannitol: 5�25% solution for injection (Problems with cardiovascular overload and pulmonary edema are more common with this agent because of the large fluid volumes required) Urea: 30% solution of lyophilized urea in invert sugar (Toxicity: Accidental extravasation at the injection site may cause local reactions ranging from mild irritation to tissue necrosis)

41. Blepharitis (??????????????) Self-care ????????????????????????? 10 min. ????????????????????? ??????????????? 1-2 ??? ?????????????????????????????? ????????????????????????????????????? Treatment Antibiotic cream or ointment Eyedrops: Antibiotics and steroids Treating an underlying causes: dandruff or rosacea

42. Dry eyes (??????) Determine which factors may be causing symptoms Adding tears: artificial tears (solution, ointment, gel) Preservative-free eyedrops because of its potentially toxic and allergic and it may cause keratitis and conjuntivitis

43. Conjunctivitis/ Pink eye (???????????????) Bacterial conjunctivitis: Antibiotic eyedrops/ ointment A marked improvement in signs and symptoms within 1-2 days. Viral conjunctivitis: A worsening of symptoms in the first three to five days. It can't be treated with antibiotic eyedrops or ointment. Symptomatic treatment

44. Conjunctivitis/ Pink eye (???????????????) Allergic conjunctivitis: Topical antihistamine Topical vasoconstrictor and antihistamines are advocated in Hay fever conjunctivitis Systematic antihistamine may be useful in prolonged atopic keratoconjunctivitis Topical corticosteroids are essential to the control of acute exacerbations

45. Corneal ulcer Bacterial keratitis (P. aeruginosa, Pneumococcus, Moraxella): Topical ATBs: fluoroquinolones such as cipofloxacin, ofloxacin, norfloxacin Fungal Keratitis: Topical natamycin, amphotericin are the most commonly used, oral imidazoles may by helpful. Herpes simplex keratitis: Topical antivirals alone are insufficient, Oral acyclovir, 200-400 mg 5 times/day may be helpful Herpes zoster ophthalmicus: High dose oral acyclovir (800 mg 5 times/day), valacyclovir (1 g 3 times/day), or famciclovir (250-500 mg 3 times/day) start within 72 hrs

46. Uveitis (Intraocular inflammation) Anterior uveitis: Topical corticosteroids Occasionally, periocular corticosteroid injections or systemic corticosteroid may be required Posterior uveitis: Systemic or intravitreal corticosteroid, occasionally systemic immunosuppression such as azathioprine, tacrolimu, cyclosporin or mycophenolate

47. Sty/ hordeolum (?????????) Apply a topical ATB ointment to eyelid. To treat a pus-filled sty that won't rupture or burst on its own, doctor may choose to drain the sty to relieve pain and pressure.

48. Subconjunctival hemorrhage

49. Cataract Cataract removal by surgery is one of the safest, most effective and most common surgical procedures and replacing the lens with a clear lens implant.

50. Blurred vision

51. Common Ear Diseases

52. Anatomy of Ear 1.External ear: aurical & external auditory canal ??????????????????????????? middle ear 2.Middle ear: tympanic membrane (ear drum), tympanic cavity, ossicles (?????? 3 ???? ??? malleus, incus, stapes) ???????????????????????????????????????????? tympanic membrane ??????????????????????????????? ossicles ???????????????? Middle ear ??????????? ???????????????????????????????????????????????????? ??????????????????????????????????????? eustacian tube ????????????????? tympanic cavity ??? nasopharynx ??????????????????????????????? ???????????

53. Anatomy of Ear 3. Inner ear: ??????????????? cochlea ??? ????????? ??? vestibular system canal 2 ??? ?????????????????? ??? Endolymph ??? Perilymph ????? cochlea ?????????????????????????? ??? labyrinth ?????????????????????????????????????????? ???????????????? endolymph ????? cochlear ????????????????????????????????????????????????? ????????????????????? hair ??? sensory cell ??????????????? vestibulocochlear nerve

54. ?????????????? Antibacterial: 1% Chloramphenicol, 0.3%Gentamicin, 0.3% Ofloxacin Antifungal: 1% Clotrimazole ear drop Deawax (Docusate Na) Combination: 1% Chloramphenicol + 2% Lidocaine HCl Dexamethasone phosphate 1 mg/ml + Neomycin 3.5 mg/ml Otosporin (Polymyx B sulfate 10,000 u + Neomycin sulfate 3,400 u+ Hydrocortisone 10 mg ) Prednisolone Na phosphate 0.5% + Gentamicin sulfate 0.3% Sofradex (Dexamethasone 500 mcg + Framycetin sulfate 5 mg + Gramicidin 50 mcg)

55. Instructions for use of otic drops Should read the instructions about amount of product to be placed into the ear. May hold the bottle in the hand for a few minute to warm solution Head should be tilted to the side so that the first ear canal to be treated To straighten the ear canal: Adult: pull the earlobe upward and back Children: pull the earlobe downward and back Squeeze the bottle of otic drops, tip of the bottle should not enter the ear canal, keep head tilted upward following instillation for several minutes.

56. Acute otitis externa/ external otitis (????????????????????????) Goal: Clear up the infection Cleaning: Clearing outer ear and ear canal of any drainage and flaky skin. Topical medications: Infection: antibiotics Itching and inflammation: corticosteroids Oral medications: Severe ear pain: NSAIDs (aspirin or ibuprofen) Lifestyle modifications. Don't swim, fly or scuba dive during treatment

57. Otitis media

58. Treatment About 80 % of children with acute otitis media recover without antibiotics Pain reliever: acetaminophen or ibuprofen Antibiotics ?????????????? first line drug: Amoxycillin 40-45 mg/kg/day ??? 10 ??? ????????????????????? resistant otitis media ??????????? 80-90 mg/kg/day ??? 10 ??? ????????? amoxycillin ??????????? cotrimoxazole, erythromycin ???????????????????????????????? 3-5 ??? ?????????????????????????????????? Drug resistant S.pneumoniae Second line drugs: amoxycillin-clavulanate, cephalosporins

59. Cerumen impaction

60. Otic pruritus Contact dermatitis, seborrhea, psoriasis, external otitis caused by either bacteria or fungi (otomycosis), Lack of normal sebum production (elderly) Otomycosis: ?????????????? ???????? clotrimazole ???? nystatin Ear itching & Contact dermatitis: ?????????? steroid such as 0.1% triamcinolone

61. Furuncle/ Boil Localized infection of hair follicle Staphylococcus aureus Treatment: Warm compress followed by topical antibiotics Incision /drainage

62. Foreign bodies Aqueous irrigation should not be performed for organic foreign bodies because water may cause them to swell. Living insect are best immobilized before removal by filling the ear canal with lidocaine or olive oil

63. ?????????????????????? (Vertigo) ???????????????????? 1 ????? ?????????????????????????? ????????????????? ?????? Vestibular suppressants: 1.1) Anticholinergic agents: ???????????????????????????????????????????????? Vestibular ????????????????????????????? postganglionic muscarinic ??????????????????????????? ??????????? ????????? Atropine 0.4 mg oral q 4-6 hr Scopolamine 0.6 mg oral q 4-6 hr or 0.5 mg ??????????? q 3 day

64. ?????????????????????? (Vertigo) Vestibular suppressants: 1.2) Antihistamine ??????????? local hormone, neurotransmitter ?? receptor 3 subtype (H1, H2, H3 receptor) ????????????????????????????????????? H1 receptor ????????????????????? calcium antagonism Promethazine 25-50 mg IM, IV q 6-8 hr Dimenhidrinate 50 mg oral, IM q 6-8 hr

65. ?????????????????????? (Vertigo) Vestibular suppressants: 1.3) Antidopaminergic ????????????????? CTZ ?????????? VC ??????????? antihistaminic, anticholinergic, adrenoreceptor blocking ???????????????????? ??????? ???????????????? ??????? S/E ???? ??????????????????????????????? ???? postural hypotension, ??????? ??????? EPS (dystonia, esp.child, elderly) Phenothiazine: Chlorpromazine 5-10 mg oral, IM q 4-8 hr; 25 mg rectal q 8-12 hr Prochlorpromazine 25 mg oral, IM q 6-8 hr Bytyrophenone: Droperidol 2.5-10 mg IM, IV q 4-6 hr Haloperidol 1-2 mg IM q 6-8 hr

66. ?????????????????????? (Vertigo) Vestibular suppressants: 1.4) Monoaminergic: ????????????????????????????????????? reticulo vestibular pathway ??????????????????????????? vestibular nuclei Amphetamine 5-10 mg oral q 4-6 hr Ephedrine 25 mg oral q 4-6 hr 1.5) GABA agonist ?????????????????????? vestibular nuclei ????? resting activity ???? ???????? ???? reticular facilitatory ???????? ?????????????????????????? vestibular nuclei ?????????????? Diazepam 5-10 mg oral q 8 hr; 10-20 mg IM q 8 hr Lorazepam 1-2 mg oral, IV q 8 hr Phenobarbital 15-30 mg oral q 8 hr

67. ?????????????????????? (Vertigo) Vestibular suppressants: 1.6) Calcium antagonists ????????????????????????? Ca ?????????? ??????????????????????? ????????????????????????????? Cinnarizine 25 mg oral q 8 hr Flunarizine 5-10 mg oral OD 2.Vasodilators: ??????? Histamine analog (H1, H2 receptor agonist ????????? ??? H3 receptor antagonist ???????? ????????? vasodilation of capillaries, arteriole, arteriovenous ?? stria vascularis, spiral ligament ?????????? cerebral blood flow Betahistine dihydrochloride 8 mg oral q 6-8 hr Betahistine mesylate 6 mg oral q 4-6 hr

68. ?????????????????????? (Vertigo) Nootropic drugs: 3.1 ergolin derivatives Nicergoline 10 mg oral q 8 hr : ????? neuronal energy metabolism, dopamine turn over, protein synthesis, phosphatidyl inositol turn over Dihydroergocristine 1.5 mg oral q 8 hr : ??????????? adrenergic ??? dopaminergic, ????????????????? 3.2 ?????????????????????? Pentoxifylline 400 mg oral q 8 hr : ?????????????????? ?????????????????????????????? ????????????? prostacycline ????????????????????????? Piracetam: 800 mg oral q 8 hr : ?????????????????? ?????????????????????????????? ????? neurotransmission, neural metabolism ?????????????????????????????????

69. ?????????????????????? (Vertigo) Nootropic drugs: 3.3 ???????????????????????????? Almitrine/ raubasine oral 1 tab BID 3.4 ???????? free radical Ginkgo biloba 60 mg oral TID : ???????????? oxygen free radical scavengers ??????????? platelet activating factor ????????????????????????????????????????? ??????????????????????????????????

70. Drug use in nasal diseases Antihistamine & decongestant Nasal steroid ATBs

71. Antihistamines and Decongestants

73. Topical decongestants

74. Nasal steroids

75. Acute bacterial sinusitis

76. Acute bacterial sinusitis

77. Nasal polyps Initial Tx with topical nasal corticosteroid for 1-3 month is usually successful for small polyps When medical management is unsuccessful, surgery may be required

78. Drug use in mouth diseases Sore throat Antifungal: oral candidiasis Antiviral: herpes virus Topical steroid: aphthus ulcer Mouthwash

79. Sore throat Dosage form: Lozenge, Spray Lozenge: local anesthetics are released as they dissolve slowly in mouth Permitted ingredient of topical sore throat anesthetics include benzyl alcohol, butacaine, phenol and sodium phenolate, dyclonine, hexylrecinol, and menthol

80. Tyrothricin 2 mg+ benzocaine 2 mg (Trocacin) Dichlorobenzyl alcohol 1.2 mg + amylmetacresol 0.6 mg + lignocaine 10 mg (Strepsils plus anesthetic) Tyrothricin 1 mg + benzocaine 1 mg + benzethonium 0.5 mg (Sigatricin) Neomycin sulfate+bacitracin 100+amylocaine 0.5 (Mybacin) Cetylpyridinium 1.33 mg+ Benzyl alcohol 6 mg (Cepacol) Dissolve 1 loz. Slowly q 2-3 hr (max 8 loz) Sore throat

81. Oral candidiasis (Thrush)

82. Gingivitis

83. Aphthus ulcer: ?????????????? 1-2 wks ?????????????????? (Mouthwash, ???????? Topical corticosteroids: 0.1% Triamcinolone Acetonide Oral corticosteroid: Prednisolone 40-60 mg/day Herpetic stomatitis: Acyclovir cream 5 ?????/??? Acyclovir 200-800 mg 5 time a day