Approved: 1 May 2013. Last amended: 30 Jul 2024.

12.1 Drugs acting on the ear

12.1.1 Otitis externa

Treatment Guidelines

See Chapter 5 for treatment guidelines

12.1.1.1 Anti-infective preparations

Recommended

  • Non-specialist or Specialist
    Acetic Acid 2%

    Spray (EarCalm®)

  • Specific Indication

  • Non-specialist or Specialist
    Clotrimazole 1%

    Solution – confirmed fungal infection. Contains propylene glycol which causes hypersensitivity in 10% of patients.

  • Non-specialist or Specialist
    Ciprofloxacin 0.2%

    Ear Drops

  • 12.1.1.2 Anti-infective plus corticosteroid

    Topical aminoglycoside antibiotics should only be used for a maximum of one week.

    Recommended

  • Non-specialist or Specialist
    Dexamethasone 0.1% and neomycin 3250units/ml

    Spray (Otomize®)

  • Alternative

  • Non-specialist or Specialist
    Betamethasone 0.1% and neomycin 0.5%

    Drops (Betnesol-N®)

  • Non-specialist or Specialist
    Ciprofloxacin 0.3% and dexamethasone 0.1%

    Drops (Cilodex®)

  • Specific Indication

  • Non-specialist or Specialist
    Flumetasone 0.02% and Clioquinol 1%

    Drops (Locorten Vioform®)
    Reserved for when recommended options are ineffective or unsuitable based on culture sensitivities

  • Non-specialist or Specialist
    Hydrocortisone 1% and gentamicin 0.3%

    Drops (Gentisone HC®)
    Reserved for when recommended options are ineffective or unsuitable based on culture sensitivities

  • 12.1.1.3 Corticosteroids

    Recommended

  • Non-specialist or Specialist
    Betamethasone 0.1%

    Drops (Vista-methasone®)

  • Alternative

  • Non-specialist or Specialist
    Prednisolone 0.5%

    Drops (Predsol®)

  • 12.1.2 Otitis media

    Treatment Guidelines

    See Chapter 5 for treatment guidelines

  • Non-specialist or Specialist
    Otigo®

    Ear drops (lidocaine hydrochloride 40mg/g, phenazone 10mg/g)

  • 12.1.3 Removal of ear wax

    Recommended

  • Non-specialist or Specialist
    Sodium bicarbonate 5%

    Drops

  • Alternative

  • Non-specialist or Specialist
    Olive oil drops
  • Non-specialist or Specialist
    Cerumol® drops
  • 12.2 Drugs acting on the nose

    12.2.1 Drugs used in nasal allergy

    12.2.1.1 Antihistamines

    Recommended

  • Non-specialist or Specialist
    Azelastine

    Nasal spray (Rhinolast®)

  • 12.2.1.2 Corticosteroids

    Alternatives and specific indications are for use in patients who experience adverse effects to recommended nasal preparations.

    Recommended

  • Non-specialist or Specialist
    Beclometasone

    Nasal spray

  • Non-specialist or Specialist
    Budesonide

    Nasal spray

  • Non-specialist or Specialist
    Betamethasone 0.1%

    Drops (Vista-methasone®)

  • Alternative

  • Non-specialist or Specialist
    Fluticasone furoate

    (Avamys®) nasal spray

  • Specific Indication

  • Non-specialist or Specialist
    Dymista®

    (azelastine/fluticasone propionate) nasal spray

    • patients who are already using this combination in separate nasal sprays.
    • patients for whom the maximum tolerated dose of intranasal corticosteroid is insufficient.

  • Non-specialist or Specialist
    Ryaltris®

    (olopatadine/mometasone) nasal spray

    • patients who are already using an antihistamine and corticosteroid in separate nasal sprays.
    • patients for whom the maximum tolerated dose of intranasal corticosteroid is insufficient.
  • Specialist initiated or advised (without Shared Care Guideline)
    Fluticasone propionate

    (Flixonase Nasule®) nasal drops – ENT only, for nasal polyps

  • 12.2.1.3 Cromoglicate

    Specific Indication

  • Non-specialist or Specialist
    Sodium cromoglicate 4%

    (Rynacrom®) nasal spray - Resistant rhinitis

  • 12.2.1.4 Ectoin

    Specific Indication

  • Hospital or Specialist only
    Ectoin 2%

    Fusion Allergy® nasal spray

    (Red classification until listed in Drug Tariff)

  • 12.2.2 Topical nasal decongestants

    12.2.2.1 Sympathomimetics

    Specific Indication

  • Non-specialist or Specialist
    Xylometazoline 0.1%

    Drops or spray – only where non-pharmacological measures have failed. Max. 7 day duration.

  • Non-specialist or Specialist
    Ephedrine 0.5%, 1%

    Nasal drops – only where non-pharmacological measures have failed. Max. 7 day duration.

  • 12.2.2.2 Antimuscarinic

    Specific Indication

  • Non-specialist or Specialist
    Ipratropium 0.03%

    Spray (Rinatec®) – for use in the elderly only

  • 12.2.3 Nasal preparations for infection and epistaxis

    12.2.3.1 Nasal staphylococci

    • For MRSA treatment, Mupirocin 2% nasal ointment is the recommended choice.
    • Please refer to your Organisation’s MRSA policy for further information on the treatment of MRSA.

    Recommended

  • Non-specialist or Specialist
    Chlorhexidine 0.1% & neomycin 0.5%

    Cream (Naseptin®)

  • Non-specialist or Specialist
    Mupirocin 2%

    Nasal ointment (Bactroban Nasal®)

  • 12.2.3.2 Epistaxis

    Specific Indication

  • Specialist initiated or advised (without Shared Care Guideline)
    Bismuth subnitrate & iodoform

    Paste – ENT only

  • 12.3 Drugs acting on the oropharynx

    Treatment Guidelines

    12.3.1 Drugs for oral ulceration and inflammation

    Note: A saline mouthwash may relieve the pain of traumatic ulceration. Dissolve half a teaspoon of salt in a glass of warm water.

    Recommended

  • Non-specialist or Specialist
    Benzydamine

    (Difflam®) oral rinse

  • Non-specialist or Specialist
    Benzydamine

    (Difflam®) spray

  • Non-specialist or Specialist
    Hydrocortisone 2.5mg

    Mucoadhesive buccal tablet

  • Non-specialist or Specialist
    Lidocaine 5%

    Ointment

  • Non-specialist or Specialist
    Choline Salicylate

    Oromucosal gel

  • Specific Indication

  • Specialist initiated or advised (with Shared Care Guideline)
    Gelclair®

    Gel – Radiotherapy / chemotherapy-induced painful oral lesions. Shared Care Guideline

  • Specialist initiated or advised (with Shared Care Guideline)
    Episil®

    Spray – Radiotherapy / chemotherapy-induced painful oral lesions where Gelclair® ineffective. Shared Care Guideline

  • Hospital or Specialist only
    Caphosol®

    Mouth Rinse – Prevention of oral mucositis caused by radiotherapy

  • 12.3.2 Oropharyngeal anti-infective drugs

    Recommended

  • Non-specialist or Specialist
    Miconazole

    Oral gel (most cost-effective in primary care)

  • Non-specialist or Specialist
    Nystatin

    Oral suspension (most cost-effective in secondary care)

  • Specific Indication

  • Hospital or Specialist only
    Fluconazole

    50mg capsules – oral candidiasis in radiotherapy

  • 12.3.3 Lozenges and sprays

    There is no convincing evidence that antiseptic lozenges and sprays have a beneficial action and they sometimes irritate and cause sore tongue and sore lips. Some of these preparations also contain local anaesthetics which relieve pain but may cause sensitisation.

    12.3.4 Mouthwashes, gargles, and dentifrices

    Recommended

  • Non-specialist or Specialist
    Chlorhexidine

    Mouthwash

  • Alternative

  • Non-specialist or Specialist
    Chlorhexidine

    Dental gel

  • Non-specialist or Specialist
    Chlorhexidine

    Oral spray

  • Non-specialist or Specialist
    Hydrogen peroxide 6%

    Mouthwash

  • 12.3.5 Treatment of dry mouth

    Recommended

  • Non-specialist or Specialist
    Saliveze®

    Spray

  • Alternative

  • Non-specialist or Specialist
    BioXtra®

    Gel

  • Non-specialist or Specialist
    BioXtra®

    Spray

  • Non-specialist or Specialist
    Salivix®

    Pastilles (acidic – avoid in dentate patients)

  • Specific Indication

  • Specialist initiated or advised (without Shared Care Guideline)
    Pilocarpine

    5mg tablets