OBAT PADA KELAINAN THT

(1)

(2)

1. Acute edematous otitis externa

(Swimmer’s Ear)

2. Eczematoid dermatitis with secondary infections

3. True otomycosis

4. Acute furunculosis

5. Malignant otitis externa

(3)

1. Acute edematous otitis externa

(Swimmer’s Ear)

*

Inflammations edema and pain.

*

Cleansing the ear canal with a suction apparatus.

(acetic acid – corticosteroids – antibacterial

solutions

irigations or topical ear drop 4 times a day).

*

Neomycin, framycetin, polymixin-B, gentamycin or

ciprofloxacin.

(4)

2. Infected eczematoid dermatitis

*

inflammations edema, itching and pain.

*

cleansing the ear canal with a suction apparatus (ethanol 75 –

90%), Burow’s solution (saturated -alumonium acetat) 3 times a day

for 3 days.

-

corticosteroids – antibacterial solutions (7 days)

(5)

3. Otomycosis

*

Ear canal cleansing with antifungal solutions

(tolnaftate 1%, cresylate solutions : merthiolate,

m-cresyl acetate, propylane glycol, boric acid, ethanol)

*

Gentian violet 10%, antifungal powder : nystatin or

clioquinol (iodochlorhydroxyquinoline).

*

Tolnaftate 1% ear drop twice a day

*

Clotrimazole 1% topically for Aspergillus or Candida

(6)

4. Acute Furunculosis

*

Analgesic opiate may be needed at first 24 hours

and to be continued with NSAIDs,

*

Cleansing of the ear canal (70% alcohol).

*

Gentamycin or solution of Burrow may be applied.

5. Malignant otitis externa

*

Rapidly progressive disorders.

(associated with DM, malnutritions or anemia).

*

Parenteral gentamycin.

* Carbenicillin 4 g 6 times a day.

(7)

1. Acute Otitis Media

a. Common in infants.

b Suppurative or effusion (serous or catarrhal).

c. Perforate or nonperforate.

d. Purulent otitis media (suppurative)

* Caused by

Staphylococcus pneumoniae

,

Haemophylus

influenzae

, Moraxella catarrhalis.

(8)

TO TREAT OR NOT TO TREAT?

• Assess severity of infection

• _{May not to treat the older children who are afebrile}

(9)

THE THERAPY OF

ACUTE OTITIS MEDIA:

• _{Amoxicillin remains frst line antibiotic Standard versus}

high doses

• _{Follow up in 48 - 72 days}

• _{Treatment failures should be treated with}

(10)

• Children > 2 years

• symptomatic therapy for 3 days

• re-evaluate if symptoms persist

• antibiotics for 7 days

• Children < 2 years

• symptomatic treatment for 1 day

• re-evaluate if symptoms persist, give antibiotics

(11)

TREATMENT FAILURES

• _{Lack of clinical improvement in signs and symptoms such}

as ear pain, fever and tympanic membrane fndings of redness, bulging or otorrhea after 3 days of therapy

(12)

DURATION OF THERAPY

• _{1 dose versus 5 days versus 10 days}

• _{27 clinical trials show no diference in outcome}

• _{Shorter duration will improve compliance and increase}

(13)

ANTIMICROBIAL RESISTANCE

• S. pneumoniae

30-40% penicillin

resistant

• H. infuenzae

30-40%

_

-lactamase

positive

• M. catarrhalis

80-90%

_

-lactamase

positive

(14)

REASONS FOR INCREASING RESISTANCE

• _{Inappropriate drugs: resistant organism, wrong or}

unusual pathogen

• _{Appropriate drug but inadequate dose} • _{Poor compliance}

• _{Subinhibitory concentrations with inadequate}

(15)

WAYS TO REDUCE RESISTANCE

• Increase accuracy of diagnosis

• New antimicrobials

• Avoid chemoprophylaxis

• _{New vaccines}

(16)

ACUTE OTITIS MEDIA: ANTIBIOTIC

Assess for risk

factors for

(17)

ANTIMICROBIAL SELECTION

Antibiotics

Convenien

ce

Cost

Efficacy

Palatabili

ty

(18)

• _Amoxicillin

• _{Cefuroxime axetil} • _Ceftriaxone

• _{Clarithromycin} • _Clindamycin • Erythro/sulfa

• _TMP/SMX

(19)

AMOXICILLIN

• _{Still drug of choice}

• Safe, well tolerated and inexpensive

• _{Usually efective against}

_{S. pneumoniae}

and

H. infuenzae

• Higher doses have greater efcacy against

more strains of

S. pneumoniae

• _{Studies show comparative clinical efcacy}

(20)

PENICILLINS

S. pneumoniae H. infuenzae

Amoxicillin

+++

Amoxicillin

(80-100

mg/kg/d)

++++

+++

Amoxicillin/

(21)

CEPHALOSPORINS

• _{Clinical efcacy varies}

• _{Cefprozil, cefuroxime, cefpodoxime and ceftriaxone IM}

have greater efcacy against pneumococci

• _{Cefuroxime, cefpodoxime and ceftriaxone IM efective}

(22)

CEPHALOSPORINS

S.pnuemoniae H. infuenzae

(23)

OTHER ANTIBIOTICS

• _{Macrolides, TMP/SMX and clindamycin are}

not as good as the cephalosporins

• _{TMP/SMX has good efcacy against}

_H.

infuenzae

but not

S. pneumoniae

• _{Clindamycin efective against many}

(24)

MACROLIDES/OTHER ANTIBIOTICS

S. pneumoniae H. infuenzae

(25)

CEFTRIAXONE

• _Advantages

• _{short duration 3 days} • _{compliance better}

• _{efcacious against all 3 organisms} • _{alteration of gut fora is less}

• Disadvantages

• painful injections multiple

(26)

ACUTE OTITIS MEDIA: FOLLOW UP

(27)

OTITIS MEDIA: RECURRENT

• _{Defned as 3 or more episodes/6 months}

or 4 or more episodes/12 months

• Reappearance of signs and symptoms

5-14 days after completing treatment

• Due to new infection, not treatment

failure so may be treated with the same

antibiotics

• Prophylaxis 44% reduction of AOM

(28)

(29)

• Defnition

• _{Damage to the cochlea or vestibular apparatus}

from exposure to a chemical source

• _{Many sources}

• Mercury

• Herbs

• _Streptomycin

• _{Dihydrostreptomycin}

(30)

• Some drugs have been associated with impaired auditory or vestibular function.

• The risk of ototoxicity is greatly increased in - patients with impaired renal function

- elderly patients - following

- a high dose

- or a large total dose

(31)

High noise level

Hyperthermia

potentiate damage

Ototoxic drug

potentially nerphrotoxic

adjust the dose of an ototoxic drug on

the basis of renal function.

(32)

AMINOGLYCOSIDES

Enter into inner ear by unknown mechanism

• _{Secreted into the perilymph by spiral ligament or endolymph}

by stria vascularis

• _{Difuse through round window membrane}

(33)

Diferential ototoxicity of

aminoglycosides

Early symptoms

Drug

Vestibular

toxicity

Auditory

toxicity

Tinnitus

Vertigo

(34)

MACROLIDES

• _{Discovered erythromycin 1952 (McGuire)} • _{Mintz (1972) frst report of ototoxicity}

• Reversible 50-55 dB losses in two cases

• Clinically

• Hearing loss with/without tinnitus– 2 days

• All frequencies, recovery after stopping

• Rarely permanent (hepatic)

(35)

MACROLIDES

• _{Mechanism unknown}

• _{Azithromycin and clarithromycin can}

(36)

OTHER ANTIBIOTICS

• _Vancomycin

• _{Believed to be ototoxic}

• _{Penicillin, sulfonamides, cephalosporins} • _{May have topical toxicity in middle ear}

(37)

LOOP DIURETICS

• _{Ethacrinic acid, furosemide, bumetaside} • _{Clinically (6-7%)}

• _{Usually tinnitus, temporary and reversible SNHL}

(sensory neural hearing loss), rare vertigo within minutes

• _{High doses can cause permanent SNHL}

(38)

LOOP DIURETICS

• _{Pathologically}

• _{Edema of stria vascularis}

• _{Ionic gradient changes}

• _{Inhibition of adenylate cyclase and}

(39)

SALICYLATES AND NSAIDS

• _{Most common OTC} • _Mechanism

• Normal histology (no hair cell loss)

• Decreased blood fow, decreased enzymes

• Clinically

• Tonal, high frequency tinnitus (7-9 kHz)

(40)

QUININE

• _{Similar clinical fndings with aspirin}

• _{Usage up for leg cramps}

• _Clinically

• _{High-pitched tinnitus}

• _{Reversible, symmetric SNHL}

• _{Occasional vertigo}

• _Mechanism

• _{Decreased perfusion, direct damage to outer}

(41)

ANTINEOPLASTIC AGENTS

• Cisplatin

• _{Incidence is high (62%-81%)} • _{Pathologically}

• Outer hair cell degeneration

• Clinically

• Bilateral symmetric SNHL, usually high frequency– not reversible, cumulative

• _{Risks factors– age extremes, cranial irradiation, high dose}

(42)

TOPICAL ANTIMICROBIALS

• Commonly prescribed for otorrhea after tubes and CSOM

• Controversial subject

• Agents may enter middle ear and gain access to membranous labyrinth

(43)

TOPICAL ANTIMICROBIALS

• Polymixin B

• Chloramphenicol

• Neomycin

• Gentamicin

(44)

TOPICAL ANTIMICROBIALS

• Remains a possibility in humans

• Patient education important

• Prescribe for only necessary duration

• Avoid in healthy ear

(45)

(46)

* A condition characterized by :

excessive watery secretions of nasal mucosa

infection discharge (become purulent)

(47)

manifestation of nasal irritation caused by :

- chemical inhalants

- allergic reaction in the nasal mucosa - infection (viral or baterial)

(48)

Symptoms – signs - Fever

- Headache / muscleache

- Nasal congestion rhinorrhea - Cough / sore throat

- Malaise

(49)

1. Irritative infamation

antiinfamatory drugs (short term corticosteroids if really necessary)

2. Allergic infammation

anti-allergic – anti-infammatory drugs (H₁-blockers, short term corticosteroids)

3. Infectious infammation

systemic anti-infective (antibiotics / chemotherapy - antiviral)

(50)

- Analgesics – antipyretics

- Antihistamines (H₁-blockers)

- Antitusive (dextrometorphan) or expectorants (bromhexin)

- Sympatomimetics - Antibiotics

- Adjuvants.

(51)

- Sympathomimetics (1-stimulants)

(local – systemics, selectives – nonselectives)

- Antihistamines (H₁-blockers) - Antiinfamatory drugs

* corticosteroids

* ketotifen, chromolyn

DRUGS FOR RHINORRHEA

(52)

SYMPATHOMIMETIC DRUGS

To treat Inflamed nasal, sinus, and eustachian tube mucosa

pseudoephedrine

phenylpropanolamine

phenilephrine,

oxymetazoline, and

xylometazoline



-adrenoceptor agonists

produce

a smooth muscle contraction & an open nasal

airway

(53)

ANTIHISTAMINES

• To treat immediate hypersensitivity

reactions such as allergic rhinitis

First generation

(54)

RATIONAL DRUG USE OF

ANTIBIOTICS

• _{Suspect microorganism (scientifc guessing)} • _{Evidence based – clinical - trial}