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1. Eye Ear Nose Throat & Upper Respiratory tract Infection Jittipon Tantivit BCPS
Faculty of Pharmaceutical Science
Khon Kaen University
2. Outline Eye
Glaucoma
Conjunctivitis
Ear
Otitis media
Vertigo
Nose
Sinusitis
Throat
Pharyngitis
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7. Glaucoma
8. Glaucoma Intra ocular pressure ???????
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9. Physiology Epithelium of Ciliary body produce aquaous humor
Flow to Posterior chamber and Anterior chamber
Flow out of the eye by Trabecular meshwork
Flow into Schlemm’s canal
12. Classification of Glaucoma Primary Glaucoma
Subacute close angle glaucoma
Acute close angle glaucoma
Chronic close angle glaucoma
Chronic open angle glaucoma
Secondary Glaucoma
Congenital Glaucoma
13. Symptom Close angle glaucoma
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Open angle glaucoma
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16. Cause of Glaucoma Genetic
Age
Trauma
Disease
Drug
17. Drug induce Glaucoma
18. Treatment Non pharmacologic(Surgery,Laser)
Pharmacologic
Decrease aquaous humor production
Increase outflow of aquaous humor
19. Drug for Open angle Glaucoma Beta blockers
Alpha-2 selective Adrenergic Agonists
Carbonic Anhydrase Inhibitor
Prostaglandin analogs
Miotics
Mydriatics
22. Pilocarpine(+/-Timolol) plus
Acetazolamide plus
Mannitol Drug for Close angle Glaucoma
23. Beta blockers Timolol(Glauco oph,NS),Betaxolol(Betoptic S,Beta1),Carteolol(Arteoptic,NS+ISA), Levobunolol(Betagan,NS)
Decrease aquaous humor production
S/E:Stinging,Dry eye,Blurred vision,Corneal anesthesia,Blepharitis,BP&HR drop,Bronchospasm,CNS effects
Precaution
Pulmonary diseases
Bradycardia,Heart block,CHF
DM
24. Alpha-2 selective Adrenergic Agonists Brimonidine(Alphagan)
Decrease aquaous humor production
Increase aquaous humor outflow by uveoscleral route
Allergy(lid edema,eye discomfort,Itching)
S/E:Dizziness,Fatigue,Somnolence,Dry mouth
Precaution:CVD,Renal compromise
DI:Antihypertensive drugs,MAOIs,TCAs
25. Carbonic Anhydrase Inhibitor Acetazolamide(Diamox) :Systemic Brinzolamide(Azopt) :Topical Dorzolamide(Trusopt):Topical
Decrease aquaous humor production
S/E(topical):Burning,Stinging,Ocular discomfort,Blurred vision
S/E(systemic)Anorexia,N/V,Hypokalemia, Acidosis,Fatigue,Taste alteration
Precaution:Sulfa Allergy,Respiratory acidosis,Renal calculi,E’Lyte imbalance
26. Prostaglandin analogs Latanoprost(Xalatan),Travoprost(Travatan), Bimatoprost(Lumigan)
Increase aquaous humor outflow by uveoscleral route
Give OD
S/E:Alter iris pigmentation,Uveitis
Precaution:Ocular inflammatory conditions
27. Miotics Pilocarpine(Isopto Carpine), Carbachol(Miostat)
Open&Close angle glaucoma
Increase aquaous humor outflow by Trabecular meshwork
Frequent dosing requirement
S/E:Decrease night vision,Visual field constriction,Eyelid twiching,Conjunctival irritation,Headache,Diarrhea,Abdominal pain,Cholinergic effect
28. Mydriatics Epinephrine,Dipivefrin
Increase aquaous humor outflow by Trabecular meshwork and uveoscleral route
S/E:Tearing,Burning,Ocular discomfort,Allergic blepharoconjunctivitis,Stenosis of the nasolacrimal duct,Blurred vision,Deposition of pigment in conjunctiva&cornea,Headache,Increase BP,HR,Tremor
May precipitate acute CAG in Pt with narrow anterior chamber
Precaution:CVD,Celebrovascular disease,Aphakia,DM,Hyperthyroid
30. Conjunctivitis
31. Bacteria
Virus
Allergy Conjunctivitis
34. Allergic Conjunctivitis
No pain , vision changes
Marked pruritus
Bilateral watery eyes
Treatment :antihistamine or steroid drops
35. Herpes Conjunctivitis
36. Comparison
38. Cataract Lens opacity
Blurred vision ,progressive over months or years
No pain or redness
Treatment :surgery
Prednisolone 15mg/day for 1 year
40. Macular degeneration Age-related
Painless loss of visual acuity
No Tx , but patient often retains adequate peripheral vision
Non Pharmacologic therapy
VitC 500mg+ VitE 400 U+ Vit A 25,000U(Beta-Carotene 15 mg) +Copper 2 mg
Pharmacologic therapy
Pegaptanib, Bevacizumab, Ranibizumab
Verteporfin
Triamcinolone
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46. The Ear
47. ????????????? ?????
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51. OTITIS EXTERNA Presents with otalgia
Pruritus
Purulent discharge
h/o recent water exposure or mechanical trauma
Examination reveals : erythema and edema of the ear canal and pulling on pinna or pushing on tragus cause pain
52. Pseudomonas is usual cause
Treatment:
Protection of the ear from additional moisture
Otic drops containing a mixture of aminoglycoside antibiotic and anti-inflammatory corticosteroid( eg. Neomycin sulfate , polymyxin B , and hydrocortisone OTITIS EXTERNA
53. Otitis Media
57. ????????????????????????????????? Acute OM < 3 ???????
Subacute OM 3 ???????- 3 ?????
Chronic OM > 3 ?????
Recurrent >3 ?????????? 6 ????????? >4?????????? 1 ??
59. ATB for OM DRSP risk ??? ?????? ATB ?????? 3 ?????????????? ???????????? 2 ?? ??????????????????????????DRSP risk ??? ?????? ATB ?????? 3 ?????????????? ???????????? 2 ?? ??????????????????????????
60. Duration Assess at 48-72 hrs
10 days vs 5-7 days
Age>6 yrs
Age 2-6 yrs
Age<2 yrs
62.
??????????????????????????? ?????????????????????????????????? ????????????????????? ADR
????????????????? (Paracetamol,Ibuprofen)
63. Vertigo
64. Vertigo A false sensation of movement associated with difficulty in balance or gait
The perceived motion is rotary, spinning, whirling
Feel as the environment is moving
65. The Inner Ear
66. Vestibular Labyrinth
Pathophysiology
Complex interaction of visual, vestibular and proprioceptive inputs that the CNS integrates as motion and spatial orientation
3 semicircular canals
rotational movement
cupula
2 otolithic organs
utricle & saccule
linear acceleration
Macula
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68. Medical Treatment Symptomatic
Specific therapy
Vestibular rehabilitation
69. Drug use in vertigo Vestibular suppresants
- inh. vestibular signals to brain stem autonomic centre
- inh. Neurotransmitters ( vestibular signal)
Antihistamine, anticholinergic, antidopamine
70. Mechanism involved in Vertigo
71. Mechanism involved in Emesis
72. Symptomatic Pharmacotherapy Predominant targeted vestibular neurotransmitters:
Cholinergic
Histaminergic
GABA neurotransmitters - negative inhibition
Vomiting center transmitters:
Dopaminergic (D2)
Histaminergic (H1)
Serotonergic
Multiple classes of drugs effective
73. Symptomatic Pharmacotherapy Some drugs of the antihistamine class are useful for symptomatic control of vertigo
Have anti-motion sickness properties in large part due to inhibition of vestibular system H1 histaminergic neurotransmitters
Examples include dimenhydrinate (Dramamine) and promethazine (Phenergan)
Also suppress the vomiting center
74. Anticholinergics Reduce firing rate of vestibular neurons
Muscarinic cholinergic stimulation of the vestibular neuron inhibit by atropine
Scopolamine(Hyoscine), Atropine
75. Phenothiazine
D2 antagonist at CTZ, weak antihistaminic, anticholinergic, alpha blocker-reduce firing rate of vestibular neurons and vomiting center via CTZ
Chlorpromazine(Lagactil): 25mg q 4-6 h
Prochloperazine(Stemetil):5-10 mg po tid
Butyrophenone
Haloperidol(Haldol):1-2mg po q 4-6 hr
More EPS
Antidopaminergics
76. Tranquilizers Vestibular suppression through RF system
Crossed vestibular&cerebello-vestibular inhibitory transmission
GABA agonist
Phenobarbital,Clonazepam
Diazepam 5-10 mg po q 4-6hr
77. Histamine H1-vasodilator,flushing
H2-proton in stomach
H3-presynaptic
78. Antihistamines Promethazine(Phenergan): 25-50 mg q4-6 h
Dimenhydrinate(Dramamine): 50 mg 1-2tab tid-qid
79. Histamine analogue Potent H3 autoreceptor antagonist on histaminergic neuron: release of histamine
Weak H1&H2 agonist, Ca antagonist
Control release of histamine at nerve terminal
Cochlear & labyrinthine vasodilator
Cholinergic system involved
Betahistine mesylate(Merislon):6-12mg tid
Betahistine dihydrochloride(Serc):8-16mg 1-2tab tid,24mg 1tab bid
80. Calcium Antagonists Class IV blocker, non specific slow CCB in myocardium but specific in brain tissue
Reduce excitatory neurotransmitter, Ca influx
Antihistamine, anticholinergic, antidopaminergic
EPS
Cinnarizine(Stugeron): 25mg po q8 h
Flunarizine(Sibelium): 5-10mg po od
81. Miscellaneous Vasodilator
Almitrine/Raubasine(Duxaril) 1tab od-bid
Ergoline derivatives:Nicergoline(Sermion) 10mg tid or 30mg bid, Dihydroergocristine(Hydergine) 3-6mg/day
82. Medical treatment ???????????????????
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83. ?????????????????????????????? Meniere’s disease
Benign paroxysmal positional vertigo (BPPV)
Vertibular neuritis
84. Meniere’s disease Peripheral vestibular disorder with intermittent excessive accumulation of endolymphatic fluid
Dilation of membrane labyrinth due to excess endolymph
Most common in adult (men ages 30-60 yrs)
85. Meniere’s Disease Hallpike and Cairns - 1938 found endolymphatic hydrops by histology
Implicated a disturbance of salt and water as pathology
Classic triad
Episodic vertigo lasting several hours
Tinnitus
Hearing loss
86. Sign and symptom Tinnitus
Vertigo
Feeling of fullness or blockage in the ear
Hearing loss
Attacks from 10 minutes to several hour
Occur over a few days or weeks
87. Widely accepted medical treatment
Dietary salt restriction(1g/day)
Diuretics
Thiazide diuretics
Decrease Na absorption is distal tubule
Side effects - hypokalemia, hypotension, hyperuricemia, hyperlipoproteinemia
Combination potassium sparing agents
Maxzide, Dyazide
Avoids hypokalemia
88. Vasodilators
Based on hypothesis - pathogenesis results from ischemia of stria vascularis
Rationale - improve metabolic function
IV histamine, ISDN, cinnarizine (CA antagonist), betahistine (oral histamine analogue)
Benzodiazepines Drug treatment
89. BPPV Inner ear problem that results in short lasting, but severe, room-spinning vertigo.
Benign: not a very serious or progressive condition
Paroxysmal: sudden and unpredictable in onset
Positional: comes with a change in head position
Vertigo: causing a sense of dizziness.
90. Symptoms Starts suddenly
first noticed in bed, when waking from sleep.
Any turn of the head bring on dizziness.
Patients often describe the occurrence of vertigo with
tilting of the head,
looking up or down (top-shelf vertigo)
rolling over in bed.
nausea and vomiting.
There is no new hearing loss or tinnitus.
91. Medications Antiemetic
Antihistaminic
Anticholinergic
92. BPPV Head movements
Looking up
Lying down
Rolling onto affected ear
Result in displacement of “sludge” / otoconia
Vertigo lasting a few seconds
Treatment approaches
Liberatory maneuvers
Particle repositioning
Habituation exercises
93. Epley maneuver
94. Vestibular Neuritis Sudden onset of peripheral vertigo
Usually without hearing loss
Period of several hours - severe
Lasts a few days, resolves over weeks
Inflammation of vestibular nerve - presumably of viral origin
Spontaneous, complete symptomatic recovery with supportive treatment
Treatment aimed at stopping inflammation
96. EPISTAXIS Bleeding from Kiesselbach’s plexus, a vascular plexus on the anterior nasal septum.
Predisposing factors :
Nasal trauma (nose picking, foreign bodies, forceful nose blowing)
Rhinitis, drying of the nasal mucosa ,deviation of the nasal septum, alcohol , bone spurs, antiplatelet medication.
97. Treatment = direct pressure, topical nasal constriction (phenylephrine 0.125-1% solution), consider anterior nasal packing if unable to stop.
98. Sinusitis
99. Sinusitis Sinus ostial obstruction
Mucus accumulation
Anaerobic environment
Commonly viral
Bacterial sinusitis
S.Pneumoniae
H.Influenzae
M.Catarrhalis
100. Onset of disease ????????? 30???
????????????? 30-90 ???
???????? 90 ???
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???????? ??????????????????????????????? 3 ????? ?????? ?????? ????????????????? ???????? ?????????????????
101. Symptom of Bacterial Sinusitis Duration 10-14 days without improvement
Nasal congestion
Purulent rhinorrhea
Postnasal drainage
Facial pain(especially when unilateral)
Headache
Symptom worse at night
Sinus tenderness on palpation
Periorbital edema
Olfactory disturbances
102. Treatment of Bacterial Sinusitis Symptom should be present at least 10 days before ATB are considered
Earlier ATB may be necessary in patients with worsening or severe symptom
10-14 day course is recommended
If symptoms do not improve after 3-5 days of any treatment, an alternative ATB should be considered
104. Adjunctive Therapy Intranasal Glucocorticoids
Antihistamine
Decongestants
Mucolytics
Nasal Saline Irrigation
105. Throat
106. Throat Dental
Canker sores
Herpes simplex
Candidiasis
Xerostomia
Halitosis
107. ???????????????????? ??????????????????????????????? ????????????????????
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109. Principles of Management of Genital Herpes Counseling should include natural history, sexual and perinatal transmission, and methods to reduce transmission
Antiviral chemotherapy
Partially controls symptoms of herpes
Does not eradicate latent virus
Does not affect risk, frequency or severity of recurrences after drug is discontinued
110. Antiviral Medications Systemic antiviral chemotherapy includes 3 oral medications:
Acyclovir
Valacyclovir
Famciclovir
Topical antiviral treatment is not recommended
111. Management of First Clinical Episode of Genital Herpes Manifestations of first clinical episode may become severe or prolonged
Antiviral therapy should be used
Dramatic effect, especially if symptoms <7 days and primary infection (no prior HSV-1)
112. CDC-Recommended Regimens for First Clinical Episode Acyclovir 400 mg orally 3 times a day for 7-10 days,
or
Acyclovir 200 mg orally 5 times a day for 7-10 days,
or
Famciclovir 250 mg orally 3 times a day for 7-10 days,
or
Valacyclovir 1 g orally twice a day for 7-10 days
113. Severe Disease IV acyclovir should be provided for patients with severe disease or complications requiring hospitalization
CDC-Recommended Regimen:
Acyclovir 5-10 mg/kg IV every 8 hours for 2-7 days or until clinical improvement
Follow with oral antiviral therapy to complete at least 10 days total therapy
114. Fungal (candida) Dysphagia
Sore throat with white ,cheesy patches in oropharynx (oral thrush)seen in AIDS and small children
Dx : clinical or endoscopy
Tx : nystatin ,clotrimazole
115. Second Line Therapy for Refractory Cases Fluconazole 100 mg po daily for 7–14 days after clinical improvement (preferred)
Itraconazole 200 mg po daily for 7– 14 days after clinical improvement
Alternative therapies are indicated for patients who fail to respond to the first line topical treatments.
A number of treatment options exist for the management of refractory cases of oropharyngeal candidiasis.
Fluconazole is the drug of choice. The patient should be prescribed 100mg a day to be taken orally for 7 to 14 days after clinical improvement.
Itraconazole can also be used as an alternative to fluconazole, taken 200 mg daily orally and continued for 7 to 14 days after clinical improvement. Alternative therapies are indicated for patients who fail to respond to the first line topical treatments.
A number of treatment options exist for the management of refractory cases of oropharyngeal candidiasis.
Fluconazole is the drug of choice. The patient should be prescribed 100mg a day to be taken orally for 7 to 14 days after clinical improvement.
Itraconazole can also be used as an alternative to fluconazole, taken 200 mg daily orally and continued for 7 to 14 days after clinical improvement.
116. Second Line Therapy for Refractory Cases Topical amphotericin B OR
Amphotericin B 0.3 mg/kg per day IV for 7–14 days after clinical improvement
Patients who are refractory or cannot take azoles, can also be treated with topical or intravenous amphotericin. Clinicians should check the local pharmacopeia to obtain dosing information, strengths and formulations for locally available topical amphotericin B. Patients who are refractory or cannot take azoles, can also be treated with topical or intravenous amphotericin. Clinicians should check the local pharmacopeia to obtain dosing information, strengths and formulations for locally available topical amphotericin B.
117. Pseudomembranous Candidiasis
White/Grey Plaques on the Hard Palate (Pseudomembranous candidiasis) This slide shows a patient with oropharyngeal candidiasis with white/gray plaques on the hard palate known as pseudomembranous candidiasis. This is the most common clinical presentation of oral candidiasis. The white/gray plaques can be easily removed by scraping them off with a tongue depressor. Occasionally, there is an erythematous area and/or bleeding under the area that was previously covered by the white/gray plaque. This slide shows a patient with oropharyngeal candidiasis with white/gray plaques on the hard palate known as pseudomembranous candidiasis. This is the most common clinical presentation of oral candidiasis. The white/gray plaques can be easily removed by scraping them off with a tongue depressor. Occasionally, there is an erythematous area and/or bleeding under the area that was previously covered by the white/gray plaque.
118. Erythematous Candidiasis
Erythematous Candidiaisis Affecting the Hard Palate This slide shows erythemathous candidiasis affecting the hard palate. This is a less common presentation of oropharyngeal candidiasis. These lesions have a red appearance and cannot be scraped off. This slide shows erythemathous candidiasis affecting the hard palate. This is a less common presentation of oropharyngeal candidiasis. These lesions have a red appearance and cannot be scraped off.
119. Pharyngitis
120. Pharyngitis ?????????????????????????????????????? ???????? ???????? ?? ???????? ????? ?????????????? ????? ??????????? ???????????????????? ??????????????(virus)
??????????????? ???????? ?????? ????????? ????? ?????????? ???????????????????? ??????????? ????????????????????? ????????????????? ????? ?????????????????????????????????? ??????????? ?????? ???????????????????????????????????????? ??????????? ??????????????????????????????????????????????????????????????(GABHS)
122. Strep Score for GABHS Pharyngitis
123. Strep Score for GABHS Pharyngitis
124. Complication Rheumatic Fever
Acute glomerulonephritis
Peritonsillar abscess
Bacteremia
Toxic shock syndrome
125. Antibiotics Shorten the course of infection 1-2 days
Prevent complication and the spread of disease
Delay in Tx can be made safely for up to 9 days after symptom onset
Line of Therapy
1st Penicillin
2nd Cefdinir,Cefuroxime,Cefproxil,Cefpodoxime
3rd Azithromycin or Clarithromycin
127. Acute Bronchitis Acute URI lasting 1-3 weeks in healthy adult
Bronchial and tracheal mucosa thicken
Fever, Malaise 3-7 days before develop to cough
Sputum production and wheezing
5-6 weeks for resolution
Virus, M. Pneumoniae, C. Pneumoniae, Normal flora(SP, HI, MC)
128. Complication: Pneumonia(rare)
ATB no recommend(Macrolides, Bactrim)
Adjunctive therapy
Antitussive
Bronchodilator short acting
Inhaled corticosteroids Acute Bronchitis
129. Pertussis ???????? 2-6?? ????????????? ??????????????? ????????
Bordetella pertussis
???????? ???????????????? ??? ?????????????? ????????????? 7-14 ???
???????????? ???????????????????????????????????? ?????????????????????????????????????? ?????????????????????? ????????? ???????? ?????????????????? ??????????????????????????????? ?????????????? ???????? ???????? ????????? ???? 1 ????? ????????????
??????????? ?????????????????????????????????? 3 ?????
?????????????????????????????????????? 1 ??????????????????????????????????????????????????????? ??? Erythromycin 50 ??/??/??? ??????? 4 ???? ???????????? 14 ????????????? Azithromycin, Clarithromycin, Bactrim ???
??????????????????????????????? ?????????????? ????????????????????????????????????????????????
130. Diphtheria Corynebacterium diphtheriae ????? toxin ?????????????????????? ??????????????? ??????????
?????? ?????? ?????????????????? ?????? ????????? ??????????????? ???????? ???????? ???????????(????????????????????????????????????) ???????????(stridor) ????????????? ?????????? ????????
Gray-yellow pseudomenbrane ???????????????? ???????????? ???????? ???????????
???????????????????? ???????? ??????????
Diptheria antitoxin,PenG 1-1.5????????/??/??? ???? Erythromycin 50 ??/??/??? 2 ???????
???????????????????????????????(?????????????? 5 ???????????????) ????????????????????? ??????????? 7 ??? ?????? erythromycin ?????????????????????????????? 7 ???
131. Common Cold ?????????? ??????????? ???????
Rhinovirus,Adenovirus,coronavirus,RSV,Parainfluenza,Influenza,Enterovirus
??????,??????,????? ?????????
?????? 1-3 ???
??????????? ?????????????????? ????????? ?????????? ???????? ??????? ???????? ??? ?????? ?????????????? ???????????????????????????
???????????????????????????????? 4 ??? ???????????????????????????????? 24 ??.?????????????????????
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???????????????? ?????? ????????????? 4 ??? ?????????????????????? 24 ??. ????? ??????
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132. Influenza ????A ????????????????????? Hemagglutinin ??? Neuraminidase
?????? ?????? ????? ??????????????????????????????????????????
??????????????? ?????????? ????????????????????????? ?????? ????? ?????????? ??????? ???????? ?????? ?????????? ???? 1- 7 ??? ???????????????????? 1-4 ???????
???????? ???????????????? ????? ?????? ??????????????? pericarditis myocarditis
??????? ??????????? crepitation rhonchi
???????????: ???? ????? ????????? ???????????? ??????? ?????? ?????? ???????? ?????
???????:??????? 7 ??? ??? ???????????
133. Any Question?