Guidelines for the use of eye medications:

Before medication is prescribed, tell your doctor if:

•You are allergic to any medications.
•You are currently taking any other medications (including over-the-counter
medications).
•You are pregnant or think you might be pregnant.
•You have problems taking any medications.
When taking medication:
•Read all labels carefully.
•Know exactly why you are taking each medication.
•Keep a list of all your medications and their dosages with you. Eye drops, skin lotions,
and vitamins are considered medication and should be included on your list.
•Take your medications exactly as prescribed by your doctor.
•Review possible drug side effects. Most reactions will occur when a new drug is
started, but this is not always the case. Some reactions may be delayed or may occur
when a new medication is added.
•Do not stop taking medication unless you talk to your doctor first or you are
experiencing a serious side effect. Call your doctor as soon as possible if you feel you
need to stop the medication. Stopping your medication too early can cause the illness to
return or make it more difficult to treat.
•Do not double the dose of your medication.
•If you miss a dose of your medication at the scheduled time, don’t panic. Take it as soon as you
remember. However, if it is almost time for you next dose, skip the missed dose and return to
your regular medication schedule.
•Do not keep medication that is outdated or no longer needed.
•Store medications in a dry area away from moisture (unless your doctor or pharmacist tells you
the medicine needs to be refrigerated).
•Always keep medications out of the reach of children.
•Contact your doctor immediately if you experience any unusual side effects after taking your
medication.
•Do not share your medications with others.
•If you store your medications in a container, label it with the medication name, dose,
frequency, and expiration date.
•Anticipate when your medications will be running out and have your prescriptions renewed as
necessary.
•Use one pharmacy, if possible.
•Keep your medications in your carry-on luggage when you travel. Do not pack them in a
suitcase that is checked, in case your baggage is lost.
•Take extra medication with you when you travel in case your flight is delayed and you need to
stay away longer than planned.
•Always follow your doctor’s instructions exactly and take medications according to the label.
•If you have any questions about your medication, ask your doctor.
 Instillation of Eye Drops
• Wash hands before and after instilling eye drops.
• Shake eye drops before using.
• Open eye and tilt head backward and look toward ceiling.  This may be easier to do lying
down.
• Gently pull down the lower lid to form a pouch.
• Approach the eye from the side and hold the bottle near the lid but do not touch the eyelid or
lashes.
• Instill one drop into the pouch.
• Close the eyes gently for one minute (do not rub the eyes.)
• Blot excess solution below the eye with a tissue if necessary.
• Do NOT use solution if it is discolored or has changed in any way since being purchased.
• If possible, have another person administer the eye drops for you.
• If this medication causes blurred vision, do not drive a car or operate machinery.
• Contact your physician if the medication irritates your eye(s) for more than just a few minutes
after use.  Many eye medications sting for a short time immediately after instillation.
• If you are having difficulty in determining if the drops actually go into the eye, the medication
can be refrigerated.  If the drops are kept cool, it is easier to determine when the solution is
instilled.
 Instillation of Eye Oinment
• Wash your hands.
• Sit in front of a mirror so you can see what you are doing.
• Take the lid off the ointment.
• Tip your head back.
• Gently pull down your lower eyelid and look up.
• Hold the tube above the eye and gently squeeze a 1cm line of ointment along the inside of the lower
eyelid, taking care not to touch the eye or eyelashes with the tip of the tube.
• Blink your eyes to spread the ointment over the surface of the eyeball.
• Your vision may be blurred when you open your eyes - DON'T rub your eyes. The blurring will clear
after a few moments if you keep blinking.
• Wipe away any excess ointment with a clean tissue.
• Repeat this procedure for the other eye if you have been advised to do so by your doctor or
pharmacist.
• Replace the lid of the tube.
• Take care not to touch the tip of the tube with your fingers.
• If you are using more than one type of ointment, wait for about half-an-hour before using the next
ointment, to allow the first to be absorbed into the eye.
• If you are also using eye drops use them first, then wait for five minutes before applying the eye
ointment.
Anatomy & Physiology of Nose
The nose is made up two different sections, the part that elongates from the nasal cavity
and projects from the face and the cavity which in at its base and allows for the passage
of air. The external portion of the nose is created by skin, cartilage, and two supporting
nasal bones. The nasal bones create the basic structure and form the bridge of the nose.
The pliable cartilage forms the protrusion, and of course the entire visible package is
then covered in skin, nerve ending, and a thin layer of muscle.

Functions:
smell
purification of air
humidification of air
warming of air

The anterior section of the nasal septum is created by septal cartilage. Lateral cartilage
on either side and alar cartilages form the basic framework around the nasal cavity,
creating the nostrils. The framework for the nasal septum is formed by the vomer and
perpendicular plate of the ethmoid bone. Septal cartilage then contributes to the
framework of the nasal septum, which segregates the nasal cavity in half laterally. Each
of these halves is referred to as a nasal fossa.
The nasal fossa expands anteriorly to create the nasal vestibule. The individual nasal
fossas each also widens anteriorly through the nostril. The fossas each communicate
with the posterior nasopharnyx via the choana, or the internal nares.

The frontal bone and the two nasal bones create the anterior roof of the nasal cavity.
The cribriform plate belonging to the ethmoid bone forms the medial portion, and the
sphenoid bone forms the posterior section of the nasal roof. The floor of the nasal
cavity is created by the palatine and maxillary bones.

Three boney structures jut out along the internal lateral walls of the nasal cavity. These
are referred to as the superior, middle, and inferior nasal conchae or turbinates. In
between each conchae are the nasal meatuses, or air passages. The conchae are lined
with cilia, technically referred to as the pseudostratified ciliated columnar epithelium.
The anterior openings of the nasal cavity are lined with the stratified squamous
epithelium. Both regions are amply supplied with mucous secreting goblet cells.

The nasal cavity performs three basic functions. The conchae are covered with nasal
epithelium which is designed to warm the air, cleanse the air, and moisten the air as it
in inhaled. The significantly vascular nasal epithelium covers a vast area throughout the
nasal cavity. While being highly vascular means that it is effective at warming the
incoming air, it also creates the hazards of nose bleeds when it dries out and cracks.
The nasal cavity performs three basic functions. The conchae are covered with nasal
epithelium which is designed to warm the air, cleanse the air, and moisten the air as it
in inhaled. The significantly vascular nasal epithelium covers a vast area throughout the
nasal cavity. While being highly vascular means that it is effective at warming the
incoming air, it also creates the hazards of nose bleeds when it dries out and cracks.

The vibrissae are the nasal hairs which line the outer edge of nostril and are responsible
for the filtering of macro-particles that may enter the airway and cause difficulties
concerning the passage of air. The combination of the cilia and the moist mucous
membrane trap potentially dangerous particles such as smoke, pollen, dust, and other
common allergens before it enters the lungs.

The sense of smell, as it relates to the respiratory system, is contributed to by the

olfactory epithelium which is located in the upper medial portion of the nasal cavity.

The nasal cavity also contributes to vocalization, as part of the process of voice comes
from the resonation of sound against the cavity.
 Diagnostic Test
• Physical examination
-Blood pressure. High blood pressure may be a cause of
bleeding nose
-After nasal trauma, must always inspect inside the nose
for a blood clot in the septum because it may be later
complicated by abscess formation and collapse of the
nasal septum causing a permanent deformity
-Full examination of the ears, nose and throat
-Feel the lymph nodes in the neck for enlargement.
•Blood tests
-Full blood count and ESR
-Electrolytes
-Growth hormone level (high level in Acromegaly which causes an
enlarged nose)
-RAST allergy testing for specific allergens in allergic rhinitis
-Serum ANCA for Wegener's granulomatosis
-Syphilis serology, if indicated
-Coagulation profile, if recurrent nose bleeds with porthrombin time,
partial thromboplastin time (PTT), bleeding time, platelet count
-Raised Immunoglobulin levels and presence of certain autoantibodies
may suggest diagnosis of Sjogren's syndrome which causes a dry nose -
e.g. Rheumatoid factor, antinuclear antibodies, antimitochondrial
antibodies, Anti-Ro (SSA) antibodies.

•Radiological investigations
-Sinus X-Ray
-CT Scan of nasal cavity and sinuses may be indicated .
Nasal smear and culture
-for bacteria and fungi detection.

•Biopsy of nose
-may help diagnose rhinophyma, rosacea and nasal tumor.

•Skin smear from the skin or nasal lining

- for detecting the organism responsible for leprosy, if suspected.

•Skin prick allergy testing

-for specific allergens in allergic rhinitis

•Nasopharyngoscopy
- by ears, nose and throat specialist may be indicated.

•Schirmer tear test

-if have dry eyes and nose, a strip of filter paper is placed on the inside of the
lower eyelid and wetting of less than 10mm in 5 minutes indicated defective
tear production and thus dry eyes. This test will help diagnose Sjogren's
syndrome.
Nasal Polyp
 - it is a mass of gelatinous tissue
which usually forms from allergy. If
only on one side, one must rule out a
carcinoma or cancer.  Allergic nasal
polyps can be treated by topical nasal
steroids or by surgical removal.  Often
endoscopic sinus surgery is needed for
their removal.
Sign & Symptoms:
•A runny nose
•Persistent stuffiness
•Postnasal drip
•Decreased or no sense of smell
•Loss of sense of taste
•Facial pain or headache
•Snoring
•Itching around your eyes
 Causes:
•A continuous inflammatory process within the nose and sinuses
- This is thought to be the main source of nasal polyps. This
inflammation could be related to allergies; allergens in the
atmosphere (pollution, dust etc.) or can be caused by a sinus
infection.
•The overproduction of fluid in the sinus and nasal membranes
cause polyps to become swollen and engorged with fluid - This is
referred to as edema. These bags of fluid can enlarge and pop out
through the sinus openings into the nasal cavity. These bulging
tissues are referred to as nasal polyps.
•Engorged nasal membranes - Irritants such as alcohol and
tobacco may expose membranes to infection
 Management
• Nasal polyps are most often treated with steroids or topical, but can also be
treated with surgical methods.
• Pre-post surgery, sinus rinses with a warm water (240 ml / 8 oz) mixed with a
small amount (teaspoon) of salts (sodium chloride & sodium bicarbonate)
can be very helpful to clear the sinuses. This method can be also used as a
preventative measure to discourage the polyps from growing back and should
be used in combination with a nasal steroid.
• The removal of nasal polyps via surgery lasts approximately 47 minutes to
1 hour. The surgery can be done under general or local anaesthesia, and the
polyps are removed using endoscopic surgery. Recovery from this type of
surgery is anywhere from 1 to 3 weeks.
• Mometasone furoate, commonly available as a nasal spray for treating
common allergy symptoms, has been indicated in the United States by the
FDA for the treatment of nasal polyps since December 2005.
 Pathophysiology
Nasal polyposis results from chronic inflammation of the nasal and sinus
mucous membranes. Chronic inflammation causes a reactive hyperplasia of
the
intranasal mucosal membrane, which results in the formation of polyps. The
precise mechanism of polyp formation is incompletely understood.
In 1990, Tos reported 10 pathogenic theories of nasal polyp formation:

• Adenoma and fibroma theories

• Necrosing ethmoiditis theory
• Glandular cyst theory
• Mucosal exudate theory
• Cystic dilatation of the excretory duct and vessel obstruction theory
• Blockade theory
• Periphlebitis and perilymphangitis theory
•Glandular hyperplasia theory
•Gland new formation theory
•Ion transport theory
•Multiple chemical mediators have been identified in nasal polyps but their
significance has not been completely elucidated.  Some of these mediators may be
released by the polyps themselves and others by the eosinophils found in certain
subsets of polyps. Cysteinyl leukotriene receptors and interleukin-5 (IL-5) appear to
be the most well studied.
Epistaxis
- Also known as nosebleed.
-It is the relatively common
occurrence of hemorrhage from the
nose, usually noticed when the
blood drains out through the
nostrils.

There are two types:

Anterior (the most common)
Posterior (less common, more
likely to require medical attention).
 Causes
Local Factors:
• Blunt trauma
-usually a sharp blow to the face, sometimes accompanying a nasal fracture.
• Foreign bodies
-such as fingers during nose-picking.
• Inflammatory reaction
-e.g. acute respiratory tract infections, chronic sinusitis, allergic rhinitis or
environmental irritants
Systemic Factors:
• Allergies
• Infectious diseases
-e.g. common cold
• Hypertension also allergic to aspirin
 Management
▪ Until the bleeding is completely under control, continue to monitor the
patient for signs of hypovolemic shock, such as tachycardia and clammy
skin.
▪ If external pressure doesn't control the bleeding, insert cotton that has been
impregnated with a vasoconstrictor and local anesthetic into the patient's
nose.
▪ If bleeding persists, expect to insert anterior or posterior nasal packing.
▪ Administer humidified oxygen by face mask to a patient with posterior
packing.
▪ Anticipate laboratory tests, such as a complete blood count to evaluate blood
loss and detect anemia and clotting studies, such as prothrombin time and
partial thromboplastin time, to test coagulation time.
▪ Prepare the patient for X-rays if he has had a recent trauma.
 Pathophysiology
Nosebleeds are due to the rupture of a blood vessel within the richly perfused
nasal mucosa. Rupture may be spontaneous or initiated by trauma. Nosebleeds
are reported in up to 60% of the population with peak incidences in those
under the age of ten and over the age of 50 and appears to occur in males more
than females. An increase in blood pressure e.g. due to general hypertension
tends to increase the duration of spontaneous epistaxis. Anticoagulant
medication and disorders of blood clotting can promote and prolong bleeding.
Spontaneous epistaxis is more common in the elderly as the nasal mucosa
lining becomes dry and thin and blood pressure tends to be higher. The elderly
are also more prone to prolonged nose bleeds as their blood vessels are less
able to constrict and control the bleeding.
The vast majority of nose bleeds occur in the anterior front part of the nose
from the nasal septum. This area is richly endowed with blood vessels
Kiesselbach's plexus. This region is also known as Little's area. Bleeding
further back in the nose is known as a posterior bleed and is usually due to
rupture of the sphenopalatine artery or one of its branches. Posterior bleeds are
often prolonged and difficult to control. They can be associated with bleeding
from both nostrils and with a greater flow of blood into the mouth. There are
conflicting opinions in the use of ice or nasal packing in the treatment of nose
bleeds. Most suggest there is no detriment to using ice or nasal packing when
initial efforts to pinch the nose fail.
Anatomy & Physiolgy of Throat
What is the throat?
The throat (pharynx and larynx) is a ring-like muscular tube that acts as the passageway for air, food and
liquid. It is located behind the nose and mouth and connects the mouth (oral cavity) and nose to the
breathing passages (trachea (windpipe) and lungs) and the esophagus (eating tube). The throat also helps
in forming speech.
The throat contains the:
•Tonsils and adenoids - made up of lymph tissue. Tonsils are located at the back and sides of the mouth
and adenoids are located behind the nose. They both help to fight infections. Removal of tonsils and
adenoids, when necessary, will not reduce your child's ability to fight infections since there are many
other tissues to perform that function. Pharynx - is the muscle-lined space that connects the nose and
mouth to the larynx and esophagus (eating tube).

•Larynx - also known as the voice box, the larynx is a cylindrical grouping of cartilages, muscles and soft
tissue that contains the vocal cords. The larynx is the upper opening into the windpipe (trachea), the
passageway to the lungs.

•Epiglottis - a flap of soft tissue and cartilage located just above the vocal cords. The epiglottis folds
down over the vocal cords to help prevent food and irritants from entering the lungs.
•Pharynx - is the muscle-lined space that connects the nose and mouth to the larynx and esophagus
(eating tube).

•Larynx - also known as the voice box, the larynx is a cylindrical grouping of cartilages, muscles and soft
tissue that contains the vocal cords. The larynx is the upper opening into the windpipe (trachea), the
passageway to the lungs.

•Epiglottis - a flap of soft tissue and cartilage located just above the vocal cords. The epiglottis folds
down over the vocal cords to help prevent food and irritants from entering the lungs.
Diagnostic Test
Throat swab
-It is a laboratory test done to isolate
and identify organisms that may cause
infection in the throat.
-A cotton swab is rubbed against the
back of your throat to gather a sample
of
mucus. This takes only a second or two
and makes some people feel a brief
gagging or choking sensation. The
mucus sample is then placed on a
culture
plate that helps any bacteria present in
the mucus grow, so they can be
examined and identified.
Tonsilitis
-An inflammation of the tonsils most
commonly caused by viral or bacterial
infection. Symptoms of tonsillitis include sore
throat and fever.

Symptoms:
•Red and/or swollen tonsils.
•bad breath
•painful or difficult
swallowing coaugh
•fever
 Causes
• The most common causes of tonsillitis are the common cold viruses
(adenovirus, rhinovirus, influenza, coronavirus, respiratory syncytial virus).
• It can also be caused by Epstein-Barr virus, herpes simplex virus,
cytomegalovirus, or HIV
• The second most common causes are bacterial. The most common
bacterial cause is Group A β-hemolytic streptococcus (GABHS), which
causes strep throat.
• Less common bacterial causes include: Staphylococcus aureus,
Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia
pneumoniae, pertussis, Fusobacterium, diphtheria, syphilis, and
gonorrhea
 Management
• Palliative treatments to reduce the discomfort from tonsillitis symptoms
include:
• pain relief, anti-inflammatory, fever reducing medications (acetaminophen,
ibuprofen, aspirin)
• sore throat relief (salt water gargle, lozenges, warm liquids)
• hydration
• rest
• If the tonsillitis is caused by bacteria, then antibiotics are prescribed, with
penicillin being most commonly used. Erythromycin and Clarithromycin
are used for patients allergic to penicillin. When tonsillitis is caused by a
virus, the length of illness depends on which virus is involved. Usually, a
complete recovery is made within one week; however, some rare infections
may last for up to two weeks. Chronic cases may treated with
tonsillectomy (surgical removal of tonsils) as a choice for treatment
 Pathophysiology
Local inflammatory pathways result in
oropharyngeal swelling, oedema,
erythema, and pain. Rarely, the
swelling may progress to the soft
palate and uvula (uvulitis), or
inferiorly to the region of supraglottis
(supraglottitis).
Laryngitis
-An inflammation of the
larynx, manifests in both acute
and chronic forms.

•Acute laryngitis has an abrupt

onset and is usually self-
limited.
•Chronic laryngitis, as the
name implies, involves a
longer duration of symptoms;
it also takes longer to develop.
 Symptoms
The major symptoms of laryngitis are:
•Hoarseness
•Sore throat
•Weak or absent voice
•Sensation of a lump in the throat or constant need to clear the throat
•Dry cough
•Fever

Management
• The treatment for viral laryngitis is supportive: plenty of fluids, humidified air,
acetaminophen or ibuprofen for pain, and the investment of time for recovery.
• For patients with significant laryngitis, a short course of steroids (prednisone,
prednisolone, or dexamethasone) may be used to decrease the inflammation
and shorten the course of symptoms. Dexamethasone as a single dose given
orally (Decadron, DexPak) or by intramuscular injection (Adrenocot, CPC-
Cort-, Decadron Phosphate, Decaject-10, Solurex) may be used to treat croup.
• The treatment of chromic laryngitis will be determined by the cause of the
inflammation or loss of function. Discontinuation of smoking and alcohol use
will always have a positive effect.
 Pathophysiology
Acute laryngitis is an inflammation of the vocal fold mucosa and larynx that
lasts less than 3 weeks. When the etiology of acute laryngitis is infectious,
white blood cells remove microorganisms during the healing process. The
vocal folds then become more edematous, and vibration is adversely affected.
The phonation threshold pressure may increase to a degree that generating
adequate phonation pressures in a normal fashion becomes difficult, thus
eliciting hoarseness. Frank aphonia results when a patient cannot overcome
the phonation threshold pressure required to set the vocal folds in motion.
The membranous covering of the vocal folds is usually red and swollen. The
lowered pitch in laryngitic patients is a result of this irregular thickening along
the entire length of the vocal fold. Some authors believe that the vocal fold
stiffens rather than thickens. Conservative treatment measures, as outlined
below, are usually enough to overcome the laryngeal inflammation and to
restore the vocal folds to their normal vibratory activity.
Laryngealcancer
-also called cancer of the larynx or
laryngeal carcinoma. Most laryngeal
cancers are squamous cell carcinomas,
reflecting their origin from the squamous
cells which form the majority of the
laryngeal epithelium. Cancer can develop
in any part of the larynx, but the cure rate
is affected by the location of the tumor.
For the purposes of tumour staging, the
larynx is divided into three anatomical
regions: the glottis (true vocal cords,
anterior and posterior commissures); the
supraglottis (epiglottis, arytenoids and
aryepiglottic folds, and false cords); and
the subglottis.
 Symptoms
The symptoms of laryngeal cancer depend on the size and location of the
tumor. Symptoms may include the following:
• Hoarseness or other voice changes
• A lump in the neck
• A sore throat or feeling that something is stuck in the throat
• Persistent cough
• Stridor
• Bad breath
• Ear ache
 Diagnostic Test
Diagnosis is made by the doctor on the basis of:
• Medical History
• Physical Assessment
• Chest X-ray
• CT Scan
• MRI
• Tissue Biopsy

Management
• Specific treatment depends on the location, type, and stage of the
tumour. Treatment may involve surgery, radiotherapy, or chemotherapy,
alone or in combination. This is a specialised area which requires the
coordinated expertise of ear, nose and throat (ENT) surgeons
(otolaryngologists) and oncologists.
 Pathopyhsiology
Laryngeal cancer arises from progressive accumulation of genetic alterations
that lead to selection of a clonal population of transformed cells. Head and
neck cancers (including laryngeal cancer) may require more genetic
alterations
in their development than other solid tumours, thus explaining the often long
(20- to 25-year) period of latency after initial toxin exposure. Carcinogenesis
is
induced by DNA damage, mutations, and adducts. Laryngeal squamous cell
carcinoma may appear as a mucosal irregularity, erythroplasia, or leukoplakia.