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 Formulary Chapter 12: Ear, nose and oropharynx - Full Chapter
Notes:

Review date: March 2022

Non-formulary drugs: Any drug or formulation not listed in the formulary is deemed to be non-formulary.

Off-label use: Drugs are included in the formulary for their licensed indications – where inclusion of off-label use is considered to be included in the formulary this is specifically stated in the formulary entry for the drug N.B. also see Paediatrics note below.

Paediatrics: Drugs are included in the formulary for paediatric use for their BNF for Children recommended indications (indicated by symbol View childrens BNF) which may be off-label, unless otherwise stated. All drugs are deemed to have the same RAG status as they have for adults unless stated otherwise.

NHS England Specialised Commissioning
Drugs carrying the NHS England logo are commissioned by them. Links to key documents, national programmes of care, and clinical reference groups are found below.

NHSE NHS England Specialised Commissioning: Key documents

NHSE NHS England Specialised Commissioning: National programmes of care and clinical reference groups

Chapter Links...
 Details...
12.01  Drugs acting on the ear
12.01.01  Otitis externa
 note 

Advice on the management of otitis externa can be found on the NICE CKS website (see link below) and the antimicrobial guidelines.

BNF warning

Caution: in view of reports of ototoxicity, manufacturers contraindicate treatment with drops containing aminoglycosides (e.g. gentamicin) or polymixins in patients with a perforated tympanic membrane (eardrum) or patent grommet. However, some specialists do use these drops in the presence of a perforation or patent grommet in patients with chronic suppurative otitis media and when other measures have failed for otitis externa; treatment should only be considered by ENT specialists in the following circumstances:

  • Drops should only be used in the presence of obvious infection.
  • Treatment should be for no longer than 2 weeks.
  • Patients should be counselled on the risk of ototoxicity and given justification for the use of these topical antibiotics.
  • Baseline audiometry should be performed, if possible, before treatment is commenced.

Clinical expertise and judgement should be used to assess the risk of treatment versus the benefit to the patient in such circumstances.

12.01.01  Astringent preparations
Acetic acid
View adult BNF View SPC online
First Choice
Green

2% spray

Acts as an antifungal and antibacterial in the external ear canal and may be useful to treat mild otitis externa
Can be purchased OTC

 
12.01.01  Anti-infective preparations
Ciprofloxacin
View adult BNF View SPC online View childrens BNF
Second Choice
Green

2mg/ml ear drops 15 dose pack

Second line in the management of otitis externa after Acetic Acid 2% spray.

 
   
Clotrimazole
View adult BNF View SPC online View childrens BNF
Formulary
Green

1% solution
Anti-fungal preparation

 
   
12.01.01  Anti-inflammatory preparations to top
Dexamethasone with Neomycin and Glacial Acetic Acid
View adult BNF View SPC online View childrens BNF
Formulary
Green

Dexamethasone 0.1%, neomycin 3250units/mL, glacial acetic acid 2% spray

Avoid in children < 2 years 

 
   
Betamethasone sodium phosphate
View adult BNF View SPC online View childrens BNF
Formulary
Green

0.1% ear/eye/nose drops

 
   
Dexamethasone with Ciprofloxacin
View adult BNF View SPC online View childrens BNF
Formulary
Green

Dexamethasone 1mg/ml with Ciprofloxacin 3mg/ml ear drops

 
   
Prednisolone sodium phosphate
View adult BNF View SPC online View childrens BNF
Formulary
Green

0.5% ear / eye drops

 
   
12.01.02  Otitis media
 note 

Uncomplicated cases resolve without antibacterial treatment and a simple analgesic, such as paracetamol, may be sufficient. Systemic antibacterial agents may be indicated in some cases – consult relevant antimicrobial guidelines for advice.

12.01.03  Removal of ear wax
 note 

The following products can be used to soften ear wax.

N.B. Consider for "self-care". Refer to local self-care policy.

Olive Oil
View adult BNF View SPC online View childrens BNF
Formulary
Green

Ear Drops

 
   
Sodium bicarbonate
View adult BNF View SPC online View childrens BNF
Formulary
Green

5% ear drops

 
   
12.02  Drugs acting on the nose
 note 

 

12.02.01  Drugs used in nasal allergy
12.02.01  Antihistamines to top
Azelastine Hydrochloride
View adult BNF View SPC online View childrens BNF
Formulary
Green

140 microgram nasal spray

 
   
12.02.01  Corticosteroids
Mometasone furoate
View adult BNF View SPC online View childrens BNF
First Choice
Green

50 micrograms nasal spray
 
** First choice where long-term use likely (i.e. >4-6 weeks course)

Paediatrics: not recommended in children under 3 years

 
Beclometasone dipropionate
View adult BNF View SPC online View childrens BNF
First Choice
Green

50 micrograms aqueous nasal spray

*Short-term use only (i.e. 4-6 weeks or use of a single bottle only). Where long-term use is required, a steroid with low systemic bioavailability (e.g. mometasone (1st choice) or fluticasone should be used.
NB – consider corticosteroids prescribed by other routes. If patient on inhaled or oral steroids, consider using inhaled steroid with low systemic bioavailability.

 Amber Recommended paediatrics < 6 yearsCaution: the risk of growth retardation should be considered when prescribing beclomethasone dipropionate for children.

 
Betamethasone
View adult BNF View SPC online View childrens BNF
Formulary
Green

0.1% nose drops

 
   
Fluticasone propionate
View adult BNF View SPC online View childrens BNF
Formulary
Green

50 micrograms aqueous nasal spray
 

 Amber Recommended paediatrics < 4 years

 
   
Fluticasone furoate
View adult BNF View SPC online View childrens BNF
Formulary
Green

27.5 micrograms nasal spray
 

 Amber Recommended paediatrics < 6 years

 
   
Fluticasone propionate
View adult BNF View SPC online
Formulary
Green

400 micrograms nasal drops
For the treatment of nasal polyps only

Paediatrics: not recommended in children < 16 years

 
   
Fluticasone propionate and azelastine
View adult BNF View SPC online View childrens BNF
Formulary
Green

Nasal spray, fluticasone propionate 50 micrograms, azelastine hydrochloride 137 micrograms/metered spray

Paediatrics: not recommended in children < 12 years  
 
Can be considered as a treatment option for patients in whom symptom control has not been achieved despite an adequate trial of therapy with:
• intranasal azelastine alone, and where the addition of an intranasal corticosteroid is considered appropriate;
• an intranasal corticosteroid alone, and where the addition of an intranasal antihistamine is considered appropriate.
For patients whose symptoms have not improved despite monotherapy with intranasal corticosteroids, consideration should be given to whether an oral or intranasal antihistamine is more appropriate. Intranasal antihistamines do not improve symptoms at other sites e.g. the eye, pharynx, lower airways, skin, whereas oral antihistamines may provide benefit at these sites.

 
   
12.02.01  Cromoglicate
12.02.02  Topical nasal decongestants
 note 

NICE CKS Guidance for chronic sinusitis recommends considering nasal irrigation with saline solution to relieve congestion and nasal discharge. The NHS Choices information on sinusitis (sinus infection) contains instructions on cleaning the nose with a salt water solution.

Saline nasal sprays should not generally be prescribed. Where indicated, large volume saline douches are thought to be more effective than saline nasal sprays. For managing the nasal symptoms of self-limiting conditions, saline nasal sprays can be purchased OTC for self-care by those that wish to try them. Patients can make one-off purchase of a Naso-med nasal douche device.

N.B. Consider for self-care. Refer to local self-care policy.

Sodium chloride
View adult BNF View SPC online View childrens BNF
Formulary
Green

0.9% nasal drops

May relieve nasal congestion by helping to liquefy mucous secretions

 
   
Sodium chloride 0.9% solution  (Sterimar®, Aquamaris®)
Formulary
Red

Nasal spray

Sodium chloride 0.9% solution may be used as a douche or ‘sniff’ following endo-nasal surgery. This should only be used in secondary care for this indication.


 

 
   
12.02.02  Sympathomimetics
Xylometazoline
View adult BNF View SPC online View childrens BNF
Formulary
Green

0.1% nasal drops/spray

Amber Recommended paediatrics < 12 years

 
   
Xylometazoline
View adult BNF View SPC online View childrens BNF
Formulary
Green

0.05% paediatric nasal drops

Amber Recommended Paediatrics < 6 years ; avoid in infants under 3 months old

 
   
Ephedrine
View adult BNF View SPC online View childrens BNF
Formulary
Green

0.5%, 1% nasal drops

Amber Recommended paediatrics < 12 years

 Red paediatrics - 0.25% (extemporaneously prepared)

 
   
12.02.02  Antimuscarinic to top
Ipratropium bromide
View adult BNF View SPC online View childrens BNF
Formulary
Green

21 micrograms nasal spray

 Amber Recommended Paediatrics < 12 years

 
   
12.02.03  Nasal preparations for infection
 note 

NB – Naseptin is contraindicated in patients with peanut or soya allergy. During product shortages of Bactroban®, medical devices marketed for this purpose (Octenisan) are available which are suitable for use in patients with peanut or soya allergy. Contact your local medicines management team for advice.

Chlorhexidine and neomycin
View adult BNF View SPC online View childrens BNF
Formulary
Green

Chlorhexidine 0.1% and neomycin 0.5% nasal cream

 
   
Mupirocin
View adult BNF View SPC online View childrens BNF
Formulary
Green

2% nasal ointment
Prevention or treatment of MRSA infection

 
   
Octenidine
View adult BNF View childrens BNF
Formulary
Green

nasal gel 6mL

Prevention or treatment of MRSA infection 

 
   
12.03  Drugs acting on the oropharynx
12.03.01  Drugs for oral ulceration and inflammation
Benzydamine
View adult BNF View SPC online View childrens BNF
Formulary
Green

oral rinse/spray

 
   
Choline salicylate
View adult BNF View SPC online View childrens BNF
Formulary
Green

8.7% oral gel

For patients aged 16 and over only

 
   
Doxycycline
View adult BNF View SPC online View childrens BNF
Formulary

Dispersible tablets 100mg

For severe recurrent mouth ulceration, dispersed solution can be used as a gargle as directed in BNF / BNFc

Amber Recommended Paediatrics: (avoid in children < 12 years)

 
   
Hydrocortisone sodium succinate
View adult BNF View SPC online View childrens BNF
Formulary
Green

Muco-adhesive buccal tablet 2.5mg

 
   
Lidocaine
View adult BNF View SPC online
Formulary
Green

10% mouth spray

Paediatrics: No BNFc entry - seek specialist advice

 
   
12.03.02  Oropharyngeal anti-infective drugs
Nystatin
View adult BNF View SPC online View childrens BNF
Formulary
Green

100,000units/ml oral suspension

 
   
Miconazole
View adult BNF View SPC online View childrens BNF
Formulary
Green

20mg/g oral gel

 
   
12.03.03  Lozenges and sprays to top
 note  There is no convincing evidence that antiseptic lozenges and sprays have a beneficial action.
12.03.04  Mouthwashes, gargles, and dentifrices
Chlorhexidine gluconate
View adult BNF View SPC online View childrens BNF
Formulary
Green

0.2% mouthwash

 
   
Chlorhexidine
View adult BNF View SPC online View childrens BNF
Formulary
Green

1% dental gel

 
   
12.03.05  Treatment of dry mouth
 note 

Dry mouth products such as artificial saliva or salivary stimulants should only be prescribed if simple measures alone have been inadequate. Where known, address the underlying cause (including drug causes) where possible/clinically appropriate. Initiate dry mouth products as a trial and discontinue if no perceived benefit.

Simple measures for managing dry mouth include:

  • Regular sips of water or an unsweetened drink
  • Sucking sugar-free sweets or chewing sugar-free gum
  • Sucking on ice cubes
  • Avoiding alcohol, caffeine and smoking; all make dry mouth symptoms worse.
12.03.05  Local Treatment
Biotene Oralbalance
View adult BNF View SPC online View childrens BNF
Formulary
Green

gel

 
   
Gelclair®
View adult BNF View SPC online
Formulary
Green

gel

For oral mucositis particularly in cancer patients

 
   
Glandosane®
View adult BNF View SPC online View childrens BNF
Formulary
Green

spray

 
   
Saliva Orthana®
View adult BNF View SPC online View childrens BNF
Formulary
Green

spray

 
   
Saliveze®
Formulary
Green

spray

 
   
12.03.05  Systemic treatment
Pilocarpine
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 5mg

For dry mouth caused by irradiation for head and neck cancers and Sjogren’s syndrome

Paediatrics: No BNFc entry - seek specialist advice

 
   
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection.  Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

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