Conditions Of The Ear, Nose And Oropharynx

These include:

• Dental caries
• Periodontal disease
• Oral candidiasis
• Herpes simplex stomatitis
• Mouth ulcers

Dental caries This is a sugar-dependent disease, which by a combination of chemical and bacterial action, progressively destroys the enamel of the tooth. Many bacteria ferment sugar to produce acid, which in turn causes lesions on the enamel of the tooth.

Clinical features

• Chalky white spots on the chewing surface of the tooth
• Sensitivity of tooth to cold or hot drinks and foods
• Cavity on the tooth
• Pain
• Swelling at the base of the tooth if pulp nerve roots are involved
• Fever

Treatment
Treatment aims to preserve the tooth as far as possible.

Drugs used in infections, complicated extractions or prophylaxis:

• Phenoxymethyl penicillin, adults; 250-750mg orally 6 hourly, children; 1 – 5 years; 125mg orally 6 hourly, 6 – 12 years; 250mg orally 6 hourly
• Paracetamol, adults; 500mg -1g orally 3 times daily, children; 10-20mg/kg orally 3 times daily or
• Aspirin, adults; 600mg orally 3 times daily (Not recommended for children)

Conservation

• Tooth filling
• Root canal treatment if the pulp is affected

Surgical

• Extraction
• Apicectomy

Prevention

• Encourage maintenance of good oral hygiene
• Reduce the intake of sugary foods
• Use of fluoride-containing toothpaste
• Use of mouth rinses containing fluoride
• Use of topical fluoride applications
• Use of sealants in children, where available
• Dental check at least twice a year

Periodontal disease This is a pathological condition of the periodontium and refers to inflammatory diseases which are plaque-induced.
These fall into two groups:

• Gingivitis
• Periodontitis

Gingivitis

• This is an inflammatory condition of the free gingivae. It is caused by dental plaque and supragingival calculus or tartar. In this condition, there is no destruction of the supporting tissue.

Clinical features

• Red mucosa
• Loss of gum texture
• Gums bleed easily

Treatment

Scaling and prophylaxis

Drugs

• Metronidazole, adults; 200mg orally 3 times daily for 5 days, children; 7.5mg/kg orally 8 hourly for 5 days
• Phenoxymethylpenicillin, adults; 250-500mg orally 6 hourly for 5 days, children; 12.5 -25mg/kg orally 6 hourly for 5 days or
• Erythromycin, adults; 250-500mg orally 6 hourly for 5 days, children; 2-8 years; 12.5 - 25mg/kg orally 6 hourly, 8-12 years; 25 – 50mg/kg 6 hourly for 5 days

Preventive

• Encourage maintenance of good oral hygiene
• Gargle warm salty water or mouthwash after every ‹ meal
• Brush teeth at least twice daily
• Flossing

Periodontitis

This is an inflammatory response of the free gingivae affecting all the periodontal structures. It is caused by plaque and supra or subgingival calculus. It results in the destruction of the attachment apparatus and the development of a periodontal pocket. Halitosis is usually present.

Treatment

• Scaling and prophylaxis
• Subgingival curettage

Drugs

• Metronidazole, 200mg orally 3 times daily for 5 days Refer patient to the next level

Prevention

• Encourage maintenance of good oral hygiene
• Use of mouthwash containing fluoride

Oral candidiasis This is an infection of the mouth caused by Candida albicans. It is commonly known as oral thrush. The infection sometimes also affects the pharynx.

The predisposing factors include trauma, denture wearing, dryness of the mouth, inhaled steroids, radiotherapy, diabetes mellitus, antibiotic therapy, HIV/AIDS.

Clinical features

• Creamy white or yellow plaques on normal mucosa
• Patches on the palatal and buccal mucosa and dorsum ‰ of the tongue
  and gums.
• Removal of plaques reveals bleeding surface.

Treatment
Drugs

• Gentian violet solution, topically 2 times daily for 7 days or
• Nystatin oral suspension or lozenges, 2 times daily for up to 10 days or
• Miconazole oral gel applied 2 times daily for 10 days or

Refer to a specialist in case of:

• No improvement
• Painful or difficulty in swallowing or
• Affected pharynx.

Supportive

• Remove or treat the predisposing factor.
• Use snuggly-fitting dentures.
• Good oral hygiene.
• Gargle warm salty water after every meal.

Herpes simplex stomatitis This is inflammation of the mucosal area due to infection by the herpes simplex virus. It is usually a self-limiting condition clearing up after 7 - 10 days. It is characterised by painful, shallow ulcers around the lip area, gums and tongue. It is common in small children who usually present with high fever and refusal of food because it is too painful to eat.

Treatment

• Debridement
• Mouthwash with tetracycline

Medicines

• Paracetamol
• *Metronidazole, adults; 200-400mg orally 3 times daily, children; 100-200mg orally 3 times daily for 5 days or
• *Phenoxymethylpenicillin, adults; 250-500mg orally 4 times daily, children; 125-250mg orally 4 times daily for 5 days.
  *Used in case of secondary infection only.

Supportive

• Increase fluid intake
• In severe cases, a nasogastric tube may be necessary until the child can feed again.
• Saline mouthwash and gargle
• Avoid acidic foods and drinks
• Refer to a specialist if the condition is severe or does not heal within 7-10 days.

Mouth Ulcers This is a condition in which there is damage to the mucosal lining of the mouth, including the tongue. These are similar to ulcers due to the herpes simplex virus. They are painful and may occur singly or in groups. They frequently recur and can be very troublesome.

Treatment

• Paracetamol
• Aspirin for adults only
• Chlorhexidine gluconate, 10-15ml as a mouthwash kept in the mouth for about 30 seconds to 1 minute 2-3 times daily Ulcers that do not heal rapidly should be referred to a specialist.

These are conditions affecting the pharynx. They include:

• Pharyngitis
• Tonsilitis
• Laryngitis
• Laryngopharyngeal Reflux (LPR)

Pharyngitis

Pharyngitis is the inflammation of the pharynx, often leading to a sore throat. It can be caused by viral or
bacterial infections.

Signs and Symptoms

• Sore throat
• Difficulty swallowing
• Red and swollen tonsils
• Fever
• Swollen lymph nodes

Treatment

Supportive
• Warm saline gargles
• Hydration
• Rest

Pharmacological
Pain Management:
• Paracetamol (Acetaminophen):
o Adults: 500 mg to 1 g every 4-6 hours as needed (maximum 4 g per day).
o Children 6-12 years: 250-500 mg every 4-6 hours as needed (maximum 2 g per day).
o Children 1-5 years: 120-250 mg every 4-6 hours as needed (maximum 1 g per day).
• Ibuprofen:
o Adults: 200-400 mg every 4-6 hours as needed (maximum 1.2 g per day).
o Children 4-7 years: 150 mg every 8 hours (maximum 7.5-10 mg/kg daily).
o Children 7-12 years: 200 mg every 8 hours (maximum 7.5-10 mg/kg daily).

Antibiotics: For bacterial pharyngitis (e.g., streptococcal infection).
• Phenoxymethylpenicillin (Penicillin V):
o Adults and children over 12 years: 500 mg every 6 hours for 10 days.
o Children 6-12 years: 250 mg every 6 hours for 10 days.
• Amoxicillin:
o Adults: 500 mg every 8 hours or 1 g every 12 hours for 10 days.
o Children: 50 mg/kg/day in divided doses every 8 hours for 10 days (not to exceed 1 g per dose).
• Clarithromycin (if penicillin-allergic):
o Adults: 250-500 mg every 12 hours for 5-7 days.
o Children: 7.5 mg/kg every 12 hours for 5-7 days (maximum 500 mg per dose).
• Cefuroxime:
o Adult: 250 to 500 milligrams (mg) two times a day for 7 days.
o Children: 20 to 30 milligrams (mg) per kilogram (kg) of body weight per day divided into two doses,
taken for 7 days

Tonsillitis

Description

Tonsillitis is the inflammation of the tonsils, which are two oval-shaped lymph nodes located at the back of
your throat. It can be caused by viral or bacterial infections

Signs and Symptoms

• Sore throat
• Difficulty swallowing
• Red and swollen tonsils
• White or yellow patches on the tonsils
• Fever
• Swollen lymph nodes in the neck
• Bad breath
• Headache
• Ear pain

Treatment

Supportive
• Rest and hydration
• Warm saltwater gargles
• Lozenges for throat pain
• Humidifying the air
• Avoiding irritants like smoke and harsh cleaning products

Pharmacological
Pain Management:
• Paracetamol (Acetaminophen):
o Adults: 500 mg to 1 g every 4-6 hours as needed (maximum 4 g per day).
o Children 6-12 years: 250-500 mg every 4-6 hours as needed (maximum 2 g per day).
o Children 1-5 years: 120-250 mg every 4-6 hours as needed (maximum 1 g per day).
• Ibuprofen:
o Adults: 200-400 mg every 4-6 hours as needed (maximum 1.2 g per day).
o Children 4-7 years: 150 mg every 8 hours (maximum 7.5-10 mg/kg daily).
o Children 7-12 years: 200 mg every 8 hours (maximum 7.5-10 mg/kg daily).

Antibiotics: For bacterial tonsillitis (e.g., streptococcal infection).
• Amoxicillin:
o Adults: 500 mg every 8 hours or 1 g every 12 hours for 10 days.
o Children: 50 mg/kg/day in divided doses every 8 hours for 10 days (not to exceed 1 g per dose).
• Clarithromycin (if penicillin-allergic):
o Adults: 250-500 mg every 12 hours for 5-7 days.
o Children: 7.5 mg/kg every 12 hours for 5-7 days (maximum 500 mg per dose).
• Cefuroxime:
o Adult:250 to 500 milligrams (mg) two times a day for 7 days.
o Children: 20 to 30 milligrams (mg) per kilogram (kg) of body weight per day divided into two doses,
taken for 7 days

Laryngitis

Description

Laryngitis is the inflammation of the larynx (voice box), often leading to hoarseness or loss of voice. It can be acute (lasting less than three weeks) or chronic (lasting more than three weeks).
Causes
• Acute Laryngitis:
o Viral infections (most common)
o Bacterial infections
o Fungal infections (e.g., Candida)
o Vocal strain (yelling, singing, or speaking loudly for long periods)
• Chronic Laryngitis:
o Persistent overuse of the voice
o GERD (chronic acid reflux)
o Smoking
o Allergies (e.g., hay fever, allergic rhinitis)
o Exposure to irritants (e.g., cigarette smoke, alcohol)

Signs and Symptoms

• Hoarseness
• Loss of voice
• Sore throat
• Tickling or rawness in the throat
• Dry cough
• Dry throat

Treatment

Supportive
• Resting the voice as much as possible
• Drinking plenty of fluids to stay hydrated
• Using a humidifier to keep the air moist
• Inhaling steam from a bowl of hot water or a hot shower
• Avoiding whispering, which strains the voice more than normal speech
• Avoiding irritants such as smoke, alcohol, and caffeine
• Sucking on lozenges, gargling with salt water, or chewing gum to moisten the throat
• Self-Care Tips
o Avoid decongestants as they can dry out the throat.
o Maintain good hand hygiene to prevent infections.
o Avoid clearing the throat, which can irritate the vocal cords.
o Eat a well-balanced diet to support overall health.

Pharmacological

Pain Management:
• Paracetamol (Acetaminophen):
o Adults: 500 mg to 1 g every 4-6 hours as needed (maximum 4 g per day).
o Children 6-12 years: 250-500 mg every 4-6 hours as needed (maximum 2 g per day).
o Children 1-5 years: 120-250 mg every 4-6 hours as needed (maximum 1 g per day).
• Ibuprofen:
o Adults: 200-400 mg every 4-6 hours as needed (maximum 1.2 g per day).
o Children 4-7 years: 150 mg every 8 hours (maximum 7.5-10 mg/kg daily).
o Children 7-12 years: 200 mg every 8 hours (maximum 7.5-10 mg/kg daily).

Antibiotics: Only if bacterial infection is confirmed.
• Penicillin V:
o Adults and children over 12 years: 500 mg every 6-8 hours for 10 days.
• Erythromycin:
o Adults: 250-500 mg every 6-8 hours for 10 days.
o Children: 7.5 mg/kg every 6-8 hours for 10 days.
Corticosteroids: Sometimes used to reduce vocal cord inflammation, particularly in urgent cases.
• Prednisolone:
o Adults: 30 mg daily for 5-7 days.
o Children: Dose based on weight, typically 1-2 mg/kg/day

Laryngopharyngeal Reflux (LPR)

Description

Laryngopharyngeal reflux (LPR) is a condition in which stomach acid flows back into the throat (pharynx) and
larynx (voice box), causing irritation and inflammation.
The causes include:
• Dysfunction of the lower esophageal sphincter (LES) allowing acid to escape from the stomach
• Dietary factors (e.g., spicy foods, caffeine, alcohol)
• Obesity
• Smoking

Signs and Symptoms

• Hoarseness
• Chronic cough
• Throat clearing
• Sensation of a lump in the throat
• Sore throat
• Postnasal drip
• Difficulty swallowing

Treatment

Supportive
• Avoid foods and beverages that trigger reflux (e.g., spicy foods, caffeine, alcohol)
• Eat smaller, more frequent meals
• Avoid lying down immediately after eating
• Elevate the head of the bed
• Maintain a healthy weight
• Stop smoking

• Self-Care Tips
o Avoid eating late at night
o Wear loose-fitting clothes to avoid pressure on the stomach
o Stay upright for at least 3 hours after meals
o Use at least 2 pillows when lying in bed

Pharmacological
Proton Pump Inhibitors (PPIs): Reduce stomach acid production.
• Omeprazole: Adults: 20-40 mg once daily before a meal for 4-8 weeks

These include:
• Rhinosinusitis
• Allergic rhinitis

Rhinosinusitis

Description

Rhinosinusitis is the inflammation of the nasal passages and sinuses extending beyond 7-10 days . It can be
acute (lasting less than 4 weeks), subacute (4-12 weeks), chronic (over 12 weeks), or recurrent (four or more
episodes per year).

Signs and Symptoms

• Runny nose
• Postnasal drip
• Nasal congestion
• Sinus pain or pressure
• Headache
• Toothache
• Loss of smell
• Halitosis (bad breath)
• Cough (more common in children)

Treatment

Supportive
• Nasal saline irrigation to reduce congestion and flush out mucus.

Pharmacological
Pain Management: Acute Rhinosinusitis
• Paracetamol (Acetaminophen):
o Adults: 500 mg to 1 g every 4-6 hours as needed (maximum 4 g per day).
o Children 6-12 years: 250-500 mg every 4-6 hours as needed (maximum 2 g per day).
o Children 1-5 years: 120-250 mg every 4-6 hours as needed (maximum 1 g per day).
• Ibuprofen:
o Adults: 200-400 mg every 4-6 hours as needed (maximum 1.2 g per day).
o Children 4-7 years: 150 mg every 8 hours (maximum 7.5-10 mg/kg daily).
o Children 7-12 years: 200 mg every 8 hours (maximum 7.5-10 mg/kg daily).

Nasal Decongestants:
• Pseudoephedrine:
o Adults: 60 mg every 4-6 hours (maximum 240 mg per day).
o Children over 6 years: 30 mg every 4-6hours (maximum 120 mg per day).
• Xylometazoline hydrochloride
o Child 6–11 years: 1–2 drops 1–2 times a day as required for maximum duration of 5 days, 0.05%
solution to be administered into each nostril
o Child 12–17 years: 2–3 drops 2–3 times a day as required for maximum duration of 7 days, 0.1%
solution to be administered into each nostril
o Adult: 2–3 drops 2–3 times a day as required for maximum duration of 7 days, 0.1% solution to be
administered into each nostril

Nasal Corticosteroids:
• Fluticasone:
o Adults: 100 mcg once daily into each nostril, can be increased to 100 mcg twice daily if necessary.
o Children: 50 mcg once daily into each nostril, can be increased to 50 mcg twice daily if necessary.
• Mometasone:
o Adults: 100 mcg once daily into each nostril, can be increased to 200 mcg daily if necessary.
o Children: 50 mcg once daily into each nostril, can be increased to 100 mcg daily if necessary.

Antibiotics: Acute Rhinosinusitis (If bacterial infection is suspected)
• Amoxicillin:
o Adults: 500 mg every 8 hours or 1 g every 12 hours for 7-10 days.
o Children: 50 mg/kg/day in divided doses every 8 hours (not to exceed 1 g per dose) for 7-10 days.
• Doxycycline:
o Adults: 100 mg every 12 hours for 7-10 days

Allergic Rhinitis

Description

Allergic rhinitis (hay fever) is an allergic reaction causing sneezing, congestion, itchy nose, and watery eyes. It is caused by allergens like pollen, pet dander, mold, and insects

Treatment

Supportive
• Environmental control measures and allergen avoidance.

Pharmacological
Nasal Decongestant:
• Xylometazoline Hydrochloride: Indicated for nasal congestion.
o Child 6–11 years: 1–2 drops 1–2 times a day for a maximum of 5 days.
o Child 12–17 years: 2–3 drops 2–3 times a day for a maximum of 7 days.
o Adults: 2–3 drops 2–3 times a day for a maximum of 7 days.

Antihistamines: For mild allergic rhinitis.
• Loratadine: 10 mg once daily.
• Cetirizine: 10 mg once daily.

Nasal Corticosteroids:
• Mometasone Furoate: For prophylaxis and treatment of seasonal allergic or perennial rhinitis.
o Children 3–11 years: 50 mcg daily, sprayed into each nostril.
o Children 12–17 years: 100 mcg daily, increased to 200 mcg if necessary.
o Adults: 100 mcg daily, increased to 200 mcg if necessary.
• Fluticasone: For prophylaxis and treatment of seasonal allergic or perennial rhinitis.
o Children 4–11 years: 50 mcg once daily, increased to 50 mcg twice daily if necessary.
o Children 12–17 years: 100 mcg once daily, increased to 100 mcg twice daily if necessary.
o Adults: 100 mcg once daily, increased to 100 mcg twice daily if necessary.

These include:

• Otitis Externa (OE)
•  Middle Ear Inflammatory Disease - Acute Otitis Media

Otitis Externa (OE)

Description

Otitis externa is the inflammation or infection of the external auditory canal (EAC), the auricle, or both. This
condition can be found in all age groups. Types of Otitis Externa:
• Acute diffuse OE: Most common form of OE, typically seen in swimmers.
• Acute localized OE (furunculosis): Associated with infection of a hair follicle.
• Chronic OE: Same as acute diffuse OE but is of longer duration (>6 weeks).
• Eczematous OE: Encompasses various dermatologic conditions that may infect the EAC and cause OE.
• Otomycosis: Infection of the ear canal from a fungal species (e.g., Candida, Aspergillus)

Signs and Symptoms

• Painful ear
• Ear fullness
• Hearing loss
• Occasionally discharging ear (weeping ear)
• Severe cases present with lymph node swelling around the ear and fever

Treatment

Supportive
• Keep the ear dry at all times.
• Plug with a cotton ball smeared with petroleum jelly when taking a bath.
• Avoid inserting anything into the ear (including ear buds).

Pharmacological
Pain Management:
• Paracetamol (Acetaminophen):
o Adults: 500 mg to 1 g every 6-8 hours.
o Children 6-12 years: 250-500 mg every 6-8 hours.
o Children 1-5 years: 120-250 mg every 6-8 hours.
• Ibuprofen:
o Adults: 200-400 mg every 8 hours.
o Children 4-7 years: 150 mg every 8 hours (maximum 7.5-10 mg/kg daily).
o Children 7-12 years: 200 mg every 8 hours (maximum 7.5-10 mg/kg daily).
• Diclofenac:
o Adults: 50-100 mg every 12 hours.

• Topical Medications:
o Betamethasone Sodium Phosphate 0.1% Eye/Ear/Nose Drops: Indicated for inflammation in otitisexterna with eczema present. Instil 2-3 drops in the ear every 2-4 hours, reduce frequency when relief is obtained.
o Dexamethasone Sodium Phosphate 0.1%: Indicated for inflammation in otitis externa with eczema present. Instil 2-3 drops every 2-3 hours, reduce frequency when relief is obtained. Caution: Use under expert supervision, avoid prolonged use.
o Ciprofloxacin 0.3% Ear Drops: Indicated for acute localized OE and chronic OE.
 Children 1–17 years: Apply 0.25 mL twice daily for 7 days.
 Adults: Apply 0.25 mL twice daily for 7 days.
o Otic Clotrimazole 1% Solution: Indicated for otomycosis.
 Children and Adults: Apply 2-3 drops 2-3 times a day, continue for at least 14 days after
disappearance of infection.

• Systemic Antibiotics: For severe otitis externa.
o Amoxicillin: 25 mg/kg three times daily for 5-7 days.
If penicillin-hypersensitive:
o Erythromycin: 10-20 mg/kg orally twice daily.
o Cephalexin: 6.25 mg/kg orally every 6 hours.
o Ciprofloxacin: 10mg/kg orally every 12 hours
• Avoidance of Contributing Factors

Middle Ear Inflammatory Disease - Acute Otitis Media

Description

Acute otitis media is an infection behind the eardrum of an infective origin. It is extremely common in
children

Signs and Symptoms

• Fever
• Ear pain
• Rubbing the ear by infants and toddlers
• Pus drainage from the ear in some cases

Treatment

Pharmacological
Pain Management:
• Paracetamol (Acetaminophen):
o Adults: 500 mg to 1 g every 6-8 hours.
o Children 6-12 years: 250-500 mg every 6-8 hours.
o Children 1-5 years: 120-250 mg every 6-8 hours.
• Ibuprofen:
o Adults: 200-400 mg every 8 hours.
o Children 4-7 years: 150 mg every 8 hours (maximum 7.5-10 mg/kg daily).
o Children 7-12 years: 200 mg every 8 hours (maximum 7.5-10 mg/kg daily).
• Diclofenac:
o Adults: 50-100 mg every 12 hours.

Antibiotics:
• Amoxicillin: 80-100 mg/kg/day.
o Children < 2 years: 10-14 days.
o Children > 2 years: 7 days.
o Adults: 5 days.
• If penicillin-hypersensitive:
o Erythromycin: 10-20 mg/kg orally twice daily.
o Cephalexin: 6.25 mg/kg orally every 6 hours