administered incorrectly more often than sprays. The height
of children receiving prolonged treatment with nasal
corticosteroids should be monitored; if growth is slowed,
referral to a paediatrician should be considered.
Nasal polyps
Short-term use of corticosteroid nasal drops helps to shrink
nasal polyps; to be effective, the drops must be administered
with the child in the‘head down’position. A short course of
a systemic corticosteroid may be required initially to shrink
large polyps. A corticosteroid nasal spray can be used to
maintain the reduction in swelling and also for the initial
treatment of small polyps.
Pregnancy
If a pregnant woman cannot tolerate the symptoms of
allergic rhinitis, treatment with nasal beclometasone
dipropionate p. 699 , budesonide p. 699 ,fluticasone p. 700 ,or
sodium cromoglicate may be considered.
Topical nasal decongestants
Sodium chloride 0. 9 % given as nasal drops or spray may
relieve nasal congestion by helping to liquefy mucous
secretions in children with rhinitis. In infants, 1 – 2 drops of
sodium chloride 0. 9 % solution in each nostril before feeds
will help relieve congestion and allow more effective
suckling.
Inhalation ofwarm moist airmay be useful in the
treatment of symptoms of acute nasal congestion in infants
and children, but the use of boiling water for steam
inhalation is dangerous for children and shouldnotbe
recommended. Volatile substances such as menthol and
eucalyptus may encourage inhalation of warm moist air (see
also Aromatic inhalations, cough preparations and systemic
nasal decongestants p. 187 ).
Topical nasal decongestants containing
sympathomimetics can cause rebound congestion (rhinitis
medicamentosa) following prolonged use (more than 7 days),
and are therefore of limited value in the treatment of nasal
congestion.
Ephedrine hydrochloride below nasal drops is the least
likely of the sympathomimetic nasal decongestants to cause
rebound congestion and can provide relief for several hours.
The more potent sympathomimetic drugsoxymetazoline
and xylometazoline hydrochloride p. 696 are more likely to
cause a rebound effect.
Non-allergic watery rhinorrhoea often responds well to
treatment with the antimuscarinic ipratropium bromide.
Recurrent, persistent bleeding may respond to the use of a
sympathomimetic nasal spray; if infection is present,
chlorhexidine and neomycin (Naseptin®) cream may be
effective.
Nasal preparations for infection
There isnoevidence that topical anti-infective nasal
preparations have any therapeutic value in rhinitis; see
elimination of nasal staphylococci. In children, acute
complications such as periorbital cellulitis require hospital
treatment.
Nasal staphylococci
Elimination of organisms such as staphylococci from the
nasal vestibule can be achieved by the use of a cream
containingchlorhexidineandneomycin(Naseptin®), but
re-colonisation frequently occurs. Coagulase-positive
staphylococci are present in the noses of 40 %ofthe
population.
A nasal ointment containing mupirocin p. 697 is also
available; it should probably be held in reserve for resistant
infections. In hospitals or in care establishments, mupirocin
nasal ointment should be reserved for the eradication (in
both patients and staff) of nasal carriage of meticillin-
resistantStaphylococcus aureus(MRSA). A sample should be
taken 2 days after treatment to confirm eradication. The
course may be repeated if the sample is positive (and the
throat is not colonised). To avoid the development of
resistance, the treatment course should not exceed 7 days
and the course should not be repeated on more than one
occasion. If the MRSA strain is mupirocin-resistant or does
not respond after 2 courses, consider alternative products
such as chlorhexidine and neomycin cream.
For eradication of MRSA also consult local infection
control policy. See also MRSA p. 360.1 Nasal congestion
SYMPATHOMIMETICS›VASOCONSTRICTOR
Ephedrine hydrochloride
lINDICATIONS AND DOSE
Nasal congestion|Sinusitis affecting the maxillary antrum
▶BY INTRANASAL ADMINISTRATION
▶Child 12–17 years:Apply 1 – 2 drops up to 4 times a day as
required for a maximum of 7 days, to be instilled into
each nostril, administer ephedrine 0. 5 % nasal dropsIMPORTANT SAFETY INFORMATION
CHM/MHRA ADVICE
The CHM/MHRA has stated that non-prescription cough
and cold medicines containing ephedrine can be
considered for up to 5 days’treatment in children aged
6 – 12 years after basic principles of best care have been
tried; these medicines should not be used in children
under 6 years of age.lCAUTIONSAvoid excessive or prolonged use.
cardiovascular disease.diabetes mellitus.hypertension.
hyperthyroidism
lINTERACTIONS→Appendix 1 : sympathomimetics,
vasoconstrictor
lSIDE-EFFECTS
▶Common or very commonAnxiety.headache.insomnia.
nausea
▶Frequency not knownAppetite decreased.arrhythmia.
circulation impaired.dermatitis.dizziness.drug
dependence.drug tolerance.dry mouth.dyspnoea.
hallucination.hyperglycaemia.hyperhidrosis.
hypersalivation.hypertension.hypokalaemia.
hypotension.irritability.muscle weakness.mydriasis.
pain.palpitations.paranoia.piloerection.rebound
congestion.syncope.thirst.tremor.urinary disorders.
vasoconstriction.vasodilation.vomiting
lPREGNANCYManufacturer advises avoid.
lBREAST FEEDINGPresent in milk; manufacturer advises
avoid—irritability and disturbed sleep reported.
lPRESCRIBING AND DISPENSING INFORMATIONFor nasal
drops, the BP directs that if no strength is specified 0. 5 %
drops should be supplied.
lPROFESSION SPECIFIC INFORMATION
Dental practitioners’formulary
Ephedrine nasal drops may be prescribed.
lEXCEPTIONS TO LEGAL CATEGORYEphedrine nasal drops
can be sold to the public provided no more than 180 mg of
ephedrine base (or salts) are supplied at one time, and
pseudoephedrine salts are not supplied at the same time;
for conditions that apply to supplies made at the request of
a patient, seeMedicines, Ethics and Practice, London,
Pharmaceutical Press (always consult latest edition).BNFC 2018 – 2019 Nasal congestion 695
Ear, nose and oropharynx12