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ENT Case No 10. Sinusitis

*সিনারিও-৪*

জামাল ২৮ বছর, সর্দি+ কাশি+ মাথা ব্যাথা + পুরো face এ ব্যাথা করে, X-Ray PNS করে দেখলেন

PNS: Paranasal Sinuses

WHY PNS TEST USED ?

Answer is :-The test is used to diagnose diseases such as sinus birth defects, sinus infection in the bone, nasal polyps, sinusitis, sinus infection/inflammation, and sinus tumours. Using X-rays, this test

Sinusitis, Rx কি?

1.. Antihistamine

2. Paracetamol

3. Moxaclav 625 mg TDS (7 daysl

4. Norsol drop

RTI = Amoxicillin Alone or in combination with Clavulanic acid Moxaclav, /Cefuroxime

Management of Treatment:-

Tablet 1:Fexo 120 mg AS A Fexofenadin Hydrochloride AS A Non Sedative.

Tablet 2.Pyrenol 500 mg AS A (Paracetamol+Caffeine) AS A (Non Opipod Analgesic.)

Tablet 3:-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Indications of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Co-amoxiclav is indicated for short-term treatment of bacterial infections at the following sites:

  • Upper respiratory tract infections (including ENT) e.g.tonsillitis,sinusitis,otitis media.
  • Lower respiratory tract infections e.g.acute and chronic bronchitis, lobar and bronchopneumonia.
  • Genito-urinary tract infections e.g.cystitis,urethritis,pyelonephritis.
  • Skin and soft tissue infections.
  • Bone and joint infections e.g.osteomyelitis.
  • Other infections e.g.septic abortion,puerperal sepsis,intra-abdominal sepsis etc.

Composition

  • 375 mg tablet: Each film coated tablet contains Amoxicillin 250 mg as Amoxicillin Trihydrate BP and Clavulanic Acid 125 mg as Diluted Potassium Clavulanate BP.
  • 625 mg tablet: Each film coated tablet contains Amoxicillin 500 mg as Amoxicillin Trihydrate BP and Clavulanic Acid 125 mg as Diluted Potassium Clavulanate BP.
  • 1 gm tablet: Each film coated tablet contains Amoxicillin 875 mg as Amoxicillin Trihydrate BP and Clavulanic Acid 125 mg Diluted Potassium Clavulanate BP.
  • Powder for Suspension: Each 5 ml reconstituted suspension contains Amoxicillin 125 mg as Amoxicillin Trihydrate BP and Clavulanic Acid 31.25 mg as Diluted Potassium Clavulanate BP.
  • Powder for Suspension (Forte): Each 5 ml reconstituted suspension contains Amoxicillin 400 mg as Amoxicillin Trihydrate BP and Clavulanic Acid 57.5 mg as Diluted Potassium Clavulanate BP.
  • 1.2 gm Injection: Each vial contains sterile mixture of Amoxicillin Sodium BP (equivalent to Amoxicillin 1 gm) and Clavulanate Potassium USP (equivalent to Clavulanic Acid 200 mg).
  • 0.6 gm injection: Each vial contains sterile mixture of Amoxicillin Sodium BP (equivalent to Amoxicillin 500) and Clavulanate Potassium USP (equivalent to Clavulanic Acid 100 mg).

Pharmacology of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Pharmacodynamic properties: Co-amoxiclav is an antibacterial combination consisting of the antibiotic Amoxicillin and the (3-lactamase inhibitor Clavulanic Acid. Amoxicillin has a broad spectrum of bactericidal activity against many Gram-positive & Gram-negative microorganisms but it is susceptible to degradation by (3-lactamases and therefore the spectrum of activity does not include microorganisms, which produce these enzymes. Clavulanic acid possesses the ability to inactivate a wide range of beta-lactamase enzymes commonly found in microorganisms resistant to penicillins and cephalosporins. Thus Clavulanic acid in this preparation protects Amoxicillin from degradation by (3-lactamase enzymes and effectively extends the antibiotic spectrum to embrace a wide range of microorganisms.

Pharmacokinetic properties: The pharmacokinetics of the two components of Co-amoxiclav is closely matched. Peak serum levels of both occur about one hour after oral administration. Absorption of Co-amoxiclav is optimized at the start of a meal. Both clavulanate and Amoxicillin have low levels of serum binding; about 70% remains free in the serum. Doubling the dosage of Co-amoxiclav approximately doubles the serum levels achieved.

Dosage of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Adults and children over 12 years:

Tablet:

  • The usual adult dose is one 625 mg Tablet every 12 hours or one 375 mg Tablet every 8 hours.
  • For more severe infections and infections of the respiratory tract, the dose should be one 1 gm Tablet every 12 hours or one 625 mg Tablet every 8 hours.

Suspension:

  • Children 6-12 years: 2 teaspoonful every 8 hours.
  • Children 1-6years: 1 teaspoonful every 8 hours.
  • Children below 1 year: 25 mg/kg/day in divided doses every 8 hours, for example a 7.5 kg child would require 2 ml suspension t.i.d, Treatment should not be extended beyond 14 days without review.

Forte suspension:

  • The usual recommended daily dosage: 25/3.6 mg/kg/day in mild to moderate infections (upper respiratory tract infections e.g. recurrent tonsilitis, lower respiratory infections, and skin and soft tissue infections)।
  • For serious infections: 45/6.4 mg/kg/day for the treatment of more serious infections (upper respiratory tract infections, e.g. otitis media and sinusitis, lower respiratory infections e.g. bronchopneumonia, and urinary tract infections).

Children of 2 to 12 years:
Mild to moderate infections:

  • 25/3.6 mg/kg/day (Suspension)
  • 2-6 years (13-21 kg) 2.5 ml suspension b.i.d
  • 7-12years (22-40kg) 5 ml suspension b.i.d

Serious infections:

  • 45/6.4 mg/kg/day (Forte Suspension)
  • 2-6 years (13-21 kg) 5 ml suspension b.i.d
  • 7-12 years (22-40 kg) 10 ml suspension b.i.d

IV Injection

Adults-

  • Usually, 1.2 gm every 8 hours
  • Increased in more serious infections to 1.2 gm every 6 hours
  • For surgical prophylaxis: The usual dose is 1.2 gm at induction, for high risk procedures (eg. colorectal surgery) up to 2-3 gm may be given every 8 hours.

Children-

  • 0 to 3 months: 30 mg/kg every 8 hours. (every 12 hours in the perinatal period and in premature infants.
  • 3 months to 12 years: Usually 30 mg/kg every 8 hours increased in more serious infection to 30 mg/kg every 6 hours.

Administration of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Oral dosage form: This may be taken without regard to meals; however, absorption of clavulanate potassium is enhanced when Amoxicillin and Clavulanic acid are administered at the start of a meal. To minimize the potential for gastrointestinal intolerance, Amoxicillin and Clavulanic acid should be taken at the start of the meal.

IV injection is not suitable for intramuscular or subcutaneous administration. The reconstituted vial can be administered intravenously by injection (over 2 minutes) or slow intravenous infusion (30 minutes). The contents of the content of the vial must be used within 20 minutes and thereafter any unused material should be discarded.

Interaction of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Prolongation of bleeding time and prothrombin time have been reported in some patients receiving Co-amoxiclav. In common with other broad-spectrum antibiotics, Co-amoxiclav may reduce the efficacy of oral contraceptives and patients should be warned accordingly. Concomitant use of allopurinol during treatment with amoxicillin can increase the likelihood of allergic skin reactions. There are no data on the concomitant use of Co-amoxiclav and allopurinol.

Contraindications of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

History of Penicillin hypersensitivity. Attention should be paid to possible cross-sensitivity with other beta-lactam antibiotics e.g. cephalosporins. Also contraindicated for patients with a previous history of Co-amoxiclav or Penicillin-associated cholestatic jaundice.

Side Effects of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Side effects, as with Amoxicillin, are uncommon and mainly of a mild and transitory nature. Diarrhoea, pseudomembranous colitis, indigestion, nausea, vomiting and candidiasis have been reported, if gastrointestinal side effects occur with oral therapy, that may be reduced by taking Co-amoxiclav at the start of meals. Hepatitis and cholestatic jaundice have been reported rarely but are usually reversible. Urticarial and erythematous rashes sometimes occur. Rarely erythema multiforme, Stevens-Johnson Syndrome and exfoliative dermatitis have been reported. In common with other beta-lactam antibiotics, angioedema and anaphylaxis have been reported.

Pregnancy & Lactation

Animal studies with orally and parenterally administered Co-amoxiclav have shown no teratogenic effect. The drug has been used orally in human pregnancy in a limited number of cases with no untoward effect; however, the use of Co-amoxiclav in pregnancy is not recommended unless considered essential by the physician. During lactation, trace quantities of Amoxicillin can be detected in breast milk.

Precautions & Warnings of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Co-amoxiclav should be used with care in patients on anticoagulation therapy or with severe hepatic dysfunction. In patients with moderate or severe renal impairment, dosage should be adjusted. During the administration of a high dose of Co-amoxiclav adequate fluid intake and urinary output should be maintained to minimize the possibility of crystalluria.

Use in Special Populations of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

The dose should be adjusted in case of patients with renal impairment

Adult:

  • Mild impairment (Creatinine clearance> 30ml/minute): No changein dosage.
  • Moderate impairment (Creatinine clearance 10-30 ml/minute): One 375 Tablet or one 625 Tablet 12 hourly or 1.2 gm IV followed by 0.6 gm IV 12 hourly.
  • Severe impairment (Creatinine clearance <10 ml/minute): Not more than one 375 mg tablet 12 hourly or 1.2 gm IV followed by 0.6 gm IV 24 hourly. Dialysis decreases serum concentrations of Moxaclav and an additional 0.6 gm IV dose may need to be given during dialysis and at the end of dialysis.

Children:

  • A similar reduction in dosage should be made for children.
  • Administration hepatic impairment: Dose with caution; monitor hepatic function at regular intervals.

Overdose Effects of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Problems of overdose with Co-amoxiclav are unlikely to occur, if encountered gastrointestinal symptoms and disturbance of the fluid and electrolyte balances may be evident. Co-amoxiclav may be removed from the circulation by haemodialysis.

Therapeutic Class of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Nasal Drop 4:Norsol 0.9%  25ml drop Sodium Chloride (AS A Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations).

Indications of Nasal Drop :Norsol 0.9%  25ml drop Sodium Chloride (AS A Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations).

Eye/Ear/Nasal solution: is indicated for dry nasal membranes including dry nose resulting from cold and allergy medications. It moistens dry nasal passages from dry climates or from airplane travel, may help dissolve mucus from study noses and clears the nose after surgery. This sterile saline solution is also used to cleanse various parts of the body (wounds, body cavities) and medical equipment (e.g. bandages, catheters, drainage tubes). It is also used as a mixing solution (diluent) for other medications used to irrigate the body (e.g. bacitracin, polymyxin).

Intravenous Solution: For instance, in the management of metabolic alkalosis, in case of gastro-enteritis, during and after surgery. It may also be used as a priming fluid for haemodialysis procedures. Norsol 0.9% infusion is often used as diluents for infusion of drug additives etc. It is widely used for sterile irrigation and dilution process.

Pharmacology of Nasal Drop :Norsol 0.9%  25ml drop Sodium Chloride (AS A Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations).

Nasal drop: Sodium Chloride nasal drop is a non-drug, isotonic saline solution that is used to moisturize nasal membranes. This formulation provides comfort for extensive and continuous use. Sodium Chloride 0.9% nasal wash moistures inside the nose by dissolving and softening thick or crusty mucus thus helps to remove the mucus from the nose and makes breathing easier. Excess sodium is predominantly excreted by the kidneys with small amounts lost in faeces and sweat.

Nasal spray: Sodium Chloride 0.9% Nasal Spray moistens inside the nose by dissolving and softening thick or crusty mucus thus helps to remove the mucus from the nose and makes breathing easier. Excess Sodium is predominantly excreted by the kidneys with small amount lost in faeces and sweat. In babies and young children with stufy noses who cannot blow their noses, using this product helps to make the mucus easier to remove with a nasal bulb syringe. This helps relieve stufness and makes breathing easier.

Dosage of Nasal Drop :Norsol 0.9%  25ml drop Sodium Chloride (AS A Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations).

Nasal drop-

  • Nasal Congestion: In infants, 1-2 drops of Sodium Chloride nasal wash in each nostril before feeds will help relieve congestion and allow more effective suckling.
  • Ear Wax Removal: Allow the Sodium Chloride nasal wash to warm to room temperature before use. It is important to put the drops into the ear carefully. Lie down on one side and fill the ear canal with the drops and wait for a few minutes before standing up. Age: from 6 months onwards. Put 3 to 4 drops into the affected ear(s) 3 to 4 times a day for 3 to 5 days.

Nasal Spray-

  • Newborn to 12 months: 1 spray into each nostril for 2-3 times or as directed by the physician.
  • Children over 12 months & Adults: 1 to 2 sprays into each nostril for 2-3 times or as directed by the physician.


For eye use: 1 or 2 drops in each eye when needed.

For ear use: 3 to 4 drops into the affected ear(s) 3 to 4 times a day for 3 to 5 days.

Intravenous Solution: The concentration and dosage of Sodium Chloride solution for intravenous use is determined by several factors including age, weight and clinical condition of the patient. Usually, the adult dose is about 1000 ml of 0.9% injection.

Administration of Nasal Drop :Norsol 0.9%  25ml drop Sodium Chloride (AS A Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations).

How to use the Nasal Spray–

  • Shake the bottle gently and remove the dust cover.
  • Hold the spray with your forefinger and middle finger on either side of the nozzle and your thumb underneath the bottle. Press down until a fine spray appears. If using for the first time or if you have not used it for a week or more, press the nasal applicator several times until a fine moist comes out from the container.
  • Gently blow the nose to clear the nostrils.
  • Close one nostril and carefully insert the nasal applicator into the open nostril. Tilt your head forward slightly and keep the spray upright. Breathe in through your nose and while breathing in, press the white-collar of nasal applicator firmly down once to release a spray.
  • Breathe out through your mouth.
  • Repeat the above steps in the same/ other nostril for consecutive doses.

Cleaning: The nasal spray should be cleaned at least once a week. The procedures are as follows-

  • Remove the dust cover.
  • Gently pull off the nasal applicator.
  • Wash the applicator and dust cover in warm water.
  • Shake off the excess water and leave to dry in a normal place. Avoid to apply additional heat.
  • Gently push the applicator back on the top of the bottle and re-fix the dust cover.

How to use Intravenous Solution–

  • Check infusion set and infusion solution prior to use.
  • Pull moderately to tear off the protective cover of the Eurocap.
  • Hold lightly the Eurocap but not the bottle body.
  • Open the flow regulator fully and hold the giving set on the top white area, but not the memorane venting region.
  • Insert the spike of the administration set to the Eurocap and fit the connector of the administration set firmly to the needle.
  • Gradually allow the fluid to flow down to the needletip and close.
  • Remove the protective cover of the needle.
  • Locate the venpuncture site and clean the site with an antiseptic solution, and then insert the needle.
  • Securely tape the puncture site.
  • Securely tape the wings and tubing
  • Start infusion while adjusting drip speed.

Contraindications of Nasal Drop :Norsol 0.9%  25ml drop Sodium Chloride (AS A Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations).

Do not share this medication with others. Doing so may increase the risk of infection.

Side Effects of Nasal Drop :Norsol 0.9%  25ml drop Sodium Chloride (AS A Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations).

Eye/Ear/Nasal: No side effects are expected to occur. However stinging, sneezing, increased nasal discharge, or salty taste may occur in some cases.

Intravenous: Reactions which may occur because of the solution or the technique of administration include febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation, and hypervolemia. If an adverse reaction does occur, discontinue the infusion, evaluate the patient, institute appropriate therapeutic countermeasures and save the remainder of the fluid for examination if deemed necessary.

Pregnancy & Lactation

Eye/Ear/Nasal: Tell your doctor if you are pregnant before using this medication. It is unknown if this medication passes into breast milk. Consult your doctor before breast-feeding.

Intravenous: Pregnancy Category C. Animal reproductive studies have not been conducted with Sodium Chloride Injection USP 0.9%. It is also not known whether Sodium Chloride Injection USP 0.9% can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Sodium Chloride Injection USP 0.9% should be given to a pregnant woman only if clearly needed.

Precautions & Warnings of Nasal Drop :Norsol 0.9%  25ml drop Sodium Chloride (AS A Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations).

Eye/Ear/Nasal: Tell your doctor about your medical history, especially of heart problems (e.g., congestive heart failure), lung problems (pulmonary edema), kidney problems, low levels of potassium (hypokalemia), high levels of sodium (hypernatremia), and any allergies.

Intravenous: Serum electrolyte concentration should be carefully monitored. Norsol should be administered with caution to patients with congestive heart failure, peripheral or pulmonary oedema, impaired renal function or pre-eclampsia. Care should also be taken when administering Norsol intravenously to very young or elderly patients. Excessive administration should be avoided as this may result in hypokalaemia. Infusion of fluid should be immediately discontinued if rigor arises for any reason during its application. Do not use if the solution is cloudy, contains particles, or after expiry date.

Overdose Effects of Nasal Drop :Norsol 0.9%  25ml drop Sodium Chloride (AS A Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations).

There have been no adverse reports of overdose with Norsol 0.9% nasal wash.

Therapeutic Class of Nasal Drop :Norsol 0.9%  25ml drop Sodium Chloride (AS A Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations).

Intravenous fluid preparations, Nasal Decongestants & Other Nasal Preparations

Raiyyan Tahsan Date:25-01-2025 Saturday Time:8-12-20

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