BNF for Children 2011-2012

538 12.2 Drugs acting on the nose BNFC 2011–201212 Ear, nose, and oropharynxEar wax causing discomfort or impaired hearing may besoftened with simple remedies such as olive oil eardrops or almond oil ear drops; sodium bicarbonateear drops are also effective, but may cause dryness ofthe ear canal. If the wax is hard and impacted, the dropscan be used twice daily for several days and this mayreduce the need for mechanical removal of the wax. Thechild should lie with the affected ear uppermost for 5 to10 minutes after a generous amount of the softeningremedy has been introduced into the ear. Proprietarypreparations containing organic solvents can irritate themeatal skin, and in most cases the simple remediesindicated above are just as effective and less likely tocause irritation. Docusate sodium or urea hydrogenperoxide are ingredients in a number of proprietarypreparations for softening ear wax.If necessary, wax may be removed by irrigation withwater (warmed to body temperature). Ear irrigation isgenerally best avoided in young children, in childrenunable to co-operate with the procedure, in childrenwho have had otitis media in the last 6 weeks, in otitisexterna, in children with cleft palate, a history of eardrum perforation, or previous ear surgery. A child whohas hearing in one ear only should not have that earirrigated because even a very slight risk of damage isunacceptable in this situation.For administration of ear drops, see p. 535.Almond Oil (Non-proprietary)Ear drops, almond oil in a suitable containerAllow to warm to room temperature before useOlive Oil (Non-proprietary)Ear drops, olive oil in a suitable containerAllow to warm to room temperature before useSodium Bicarbonate (Non-proprietary)Ear drops, sodium bicarbonate 5%, net price 10 mL =£1.25Cerumol c (Thornton & Ross) UEar drops, chlorobutanol 5%, arachis (peanut) oil57.3%. Net price 11 mL = £1.76Exterol c (Dermal) UEar drops, urea–hydrogen peroxide complex 5% inglycerol. Net price 8 mL = £1.75Molcer c (Wallace Mfg) UEar drops, docusate sodium 5%. Net price 15 mL =£5.60Excipients include propylene glycolOtex c (DDD) UEar drops, urea–hydrogen peroxide 5%. Net price8 mL = £2.64Waxsol c (Norgine) UEar drops, docusate sodium 0.5%. Net price 10 mL =£1.2112.2 Drugs acting on the nose12.2.1 Drugs used in nasal allergy12.2.2 Topical nasal decongestants12.2.3 Nasal preparations for infectionRhinitis is often self-limiting but bacterial sinusitis mayrequire treatment with antibacterials (Table 1, section5.1). Many nasal preparations contain sympathomimeticdrugs (section 12.2.2) which can give rise torebound congestion (rhinitis medicamentosa) and maydamage the nasal cilia. Sodium chloride 0.9% solutionmay be used as a douche or ‘sniff’ following endonasalsurgery.Administration To administer nasal drops, lay thechild face-upward with the neck extended, instil thedrops, then sit the child up and tilt the head forward.Nasal polyps Short-term use of corticosteroid nasaldrops helps to shrink nasal polyps; to be effective, thedrops must be administered with the child in the ‘headdown’ position. A short course of a systemic corticosteroid(section 6.3.2) may be required initially to shrinklarge polyps. A corticosteroid nasal spray can be used tomaintain the reduction in swelling and also for the initialtreatment of small polyps.12.2.1 Drugs used in nasalallergyMild allergic rhinitis is controlled by antihistamines(see also section 3.4.1) or topical nasal corticosteroids;systemic nasal decongestants (section 3.10) are notrecommended for use in children. Topical nasaldecongestants can be used for a short period to relievecongestion and allow penetration of a topical nasalcorticosteroid.More persistent symptoms can be relieved by topicalnasal corticosteroids; cromoglycate is an alternative,but may be less effective. The topical antihistamine,azelastine, is useful for controlling breakthrough symptomsin allergic rhinitis. Azelastine is less effective thannasal corticosteroids, but probably more effective thansodium cromoglicate. In seasonal allergic rhinitis (e.g.hay fever), treatment should begin 2 to 3 weeks beforethe season commences and may have to be continuedfor several months; continuous long-term treatmentmay be required in perennial rhinitis.Montelukast (section 3.3.2) is less effective than topicalnasal corticosteroids; montelukast can be used in childrenwith seasonal allergic rhinitis (unresponsive toother treatments) and concomitant asthma.Children with disabling symptoms of seasonal rhinitis(e.g. students taking important examinations), may betreated with oral corticosteroids (section 6.3.2) forshort periods. Oral corticosteroids may also be used atthe beginning of a course of treatment with a corticosteroidspray to relieve severe mucosal oedema andallow the spray to penetrate the nasal mucosa.Sometimes allergic rhinitis is accompanied by vasomotorrhinitis. In this situation, the addition of topicalnasal ipratropium bromide (section 12.2.2) can reducewatery rhinorrhoea.Pregnancy If a pregnant woman cannot tolerate thesymptoms of allergic rhinitis, treatment with nasalbeclometasone, budesonide, fluticasone propionate, orsodium cromoglicate may be considered.