BNF for Children 2011-2012

BNFC 2011–2012 12.1.2 Otitis media 537FRAMYCETIN SULPHATECautions avoid prolonged use (see notes above)Contra-indications perforated tympanic membrane(see p. 534)Side-effects local sensitivityIndication and doseBacterial infection in otitis externa (see notesabove)Eye section 11.3.1With corticosteroidSofradex c see Dexamethasone, p. 536GENTAMICINCautions avoid prolonged use (see notes above)Contra-indications perforated tympanic membrane(but see p. 534 and section 12.1.2)Side-effects local sensitivityLicensed use licensed for use in children (age rangenot specified by manufacturer)Indication and doseBacterial infection in otitis externa (see notesabove); for dose, see under preparationsGenticin c (Amdipharm) ADrops (for ear or eye), gentamicin 0.3% (as sulphate).Net price 10 mL = £2.13Excipients include benzalkonium chlorideDoseear, instil 2–3 drops 3–4 times daily and at night; eye,section 11.3.1With corticosteroidGentisone c HC see Hydrocortisone, p. 536NEOMYCIN SULPHATECautions avoid prolonged use (see notes above)Contra-indications perforated tympanic membrane(see p. 534)Side-effects local sensitivityIndication and doseBacterial infection in otitis externa (see notesabove)With corticosteroidBetnesol-N c A see Betamethasone, p. 535Otomize c see Dexamethasone, p. 535Otosporin c see Hydrocortisone, p. 536Predsol-N c see Prednisolone, p. 53612.1.2 Otitis mediaAcute otitis media Acute otitis media is the commonestcause of severe aural pain in young children andmay occur with even minor upper respiratory tractinfections. Children diagnosed with acute otitis mediashould not be prescribed antibacterials routinely asmany infections, especially those accompanying coryza,are caused by viruses. Most uncomplicated casesresolve without antibacterial treatment and a simpleanalgesic, such as paracetamol, may be sufficient. Inchildren without systemic features, a systemic antibacterial(Table 1, section 5.1) may be started after72 hours if there is no improvement, or earlier if there isdeterioration, if the child is systemically unwell, if thechild is at high risk of serious complications (e.g. inimmunosuppression, cystic fibrosis), if mastoiditis ispresent, or in children under 2 years of age with bilateralotitis media. Perforation of the tympanic membrane inchildren with acute otitis media usually heals spontaneouslywithout treatment; if there is no improvement,e.g. pain or discharge persists, a systemic antibacterial(Table 1, section 5.1) can be given. Topical antibacterialtreatment of acute otitis media is ineffective and there isno place for ear drops containing a local anaesthetic.Otitis media with effusion Otitis media with effusion(‘glue ear’) occurs in about 10% of children and in90% of children with cleft palates. Antimicrobials, corticosteroids,decongestants, and antihistamines have littleplace in the routine management of otitis media witheffusion. If ‘glue ear’ persists for more than a month ortwo, the child should be referred for assessment andfollow up because of the risk of long-term hearingimpairment which can delay language development.Untreated or resistant glue ear may be responsible forsome types of chronic otitis media.Chronic otitis media Opportunistic organisms areoften present in the debris, keratin, and necrotic bone ofthe middle ear and mastoid in children with chronicotitis media. The mainstay of treatment is thoroughcleansing with aural microsuction, which may completelyresolve long-standing infection. Cleansing may befollowed by topical treatment as for otitis externa (section12.1.1); this is particularly beneficial for dischargingears or infections of the mastoid cavity. Acute exacerbationsof chronic infection may require treatment withan oral antibacterial (Table 1, section 5.1); a swab shouldbe taken to identify infecting organisms and antibacterialsensitivity. Parenteral antibacterial treatmentis required if Pseudomonas aeruginosa or Proteus spp.are present.Manufacturers contra-indicate topical treatment withototoxic antibacterials in the presence of a perforation(section 12.1.1). However, many specialists use eardrops containing aminoglycosides (e.g. neomycin) orpolymyxins if the otitis media has failed to settle withsystemic antibacterials; it is considered that the pus inthe middle ear associated with otitis media carries ahigher risk of ototoxicity than the drops themselves.Ciprofloxacin or ofloxacin ear drops [both unlicensed;available from ‘special-order’ manufacturers or specialistimporting companies, see p. 809] or eye drops usedin the ear [unlicensed indication] are an effective alternativeto aminoglycoside ear drops for chronic otitismedia in patients with perforation of the tympanicmembrane.12.1.3 Removal of ear waxEar wax (cerumen) is a normal bodily secretion whichprovides a protective film on the meatal skin and needonly be removed if it causes hearing loss or interfereswith a proper view of the ear drum.12 Ear, nose, and oropharynx