ENT

Dr Alan Shortt

41 ENT examination routines

ENT diagnostic sets

Ear anatomy and physiology

Ear drum anatomy

youtu.be/krNXVWa8QTg

doctorsgates.blogspot.com anatomy of the ear drum

Ear examination and otoscopy

youtu.be/KfHW3ES0IA4

Tympanic membrane appearances

A Mini-Atlas of Ear-drum Pathology NCBI

Tuning fork tests

Rinnes test – hold vibrating tuning fork on mastoid until it is no longer heared. Then move it to EAM where it will be heared again ie AC is better than BC (normal or sensineural deafness). If BC is better than AC then a conduction defect (wax, otosclerosis) may be present.

Webers test – place vibrating tuning fork in middle of forehead. It should be heared equally in both ears. In conduction deafness it will be heared better in the affected ear. In sensineural deafness it will not be heared in the affected ear.

Rinnes and Weber tuning fork tests
Result	Rinne	Weber loudest in
Normal Hearing	+ve	Both Ears
Left Conductive Loss	-ve	Left Ear
Left Parial sensineural loss	+ve	Right Ear
Left Complete sensineural loss	-ve	Right Ear

youtu.be/4WzGmDD0Zq8

youtu.be/LwM6lktYpsw

Congenital ear problems and deafness

ASHA congenital hearing disorders

National Childrens Deaf Assosciation org.uk

Hearing Loss

Action on Hearing GP Support

Audiograms

Age related deafness presbyacusis

Age-related hearing loss Medlineplus

agingcare.com Hearing-Loss

Sudden sensineural hearing loss

Sudden hearing loss medscape

ENT care wordpress.com Management of sudden sensorineural hearing loss

Sudden deafness should be treated as an emergency.
History: how long, URTI, trauma, previous ear problems
Examination: ear, nose, PNS, throat
Investigations
FBC U+E’s TFT syphillis serology ESRANCAECG Audiometry AC + BC

If cause can be identified the treatment is specific to the cause.
Management of idiopathic sudden SNHL is controversial but includes prednisolone 60mg/daily 2w Famcyclovir 500mg tds p.o. 1 week Diuretics and low salt diet +/- Carbogen

Hearing aids

How to speak to a deaf person

Dizziness (ENT)

Acute viral labrynthitis

Acute viral labrynthitis aka Vestibulitis Vestibular Neuronitis

Symptoms include severe vertigo, nausea and vomiting, but no tinnitus or hearing loss.

Tinnitus

tinnitus.org

Meniere’s disease

Dix Hallpike testing

Epley’s manoevre

canalith repositioning procedure

youtu.be/ZqokxZRbJfw

Epleys manoeuvre entcare.co.uk

Dix Hallpike = testing
Epleys = treatment

Acoustic neuroma

Unilateral (or unequal) sensineural hearing loss with vertigo then dizzyness and unsteadyness

BPPV

Benign paroxysmal positional vertigo

Ear pain earache

Ear trauma

Perichondral Haematoma Boxers Ear
Blunt trauma causes bleeding between auricular cartilage and the perichondrium.
Untreated will lead to cauliflower ear deformity from proliferative fibrosis.
Aspirate under LA consider instillation of 0.5ml Depo-medrone, pack firmly and closely with cotton wool/soft foam under turban dressing and refer next ENT clinic.
Rx fluclox 500ng qds to prevent perichondritis.
Large bleeds or those involving cartlidge itself refer ENT/Plastics directly.

FB ear

Most commonly occurs in children under the age of 5 years. Beads, small stones, beans, corn, and dry cereal are also common. Insects may also fly into the ear causing distress and anxiety. Suctioning, irrigation, or use of special tools can be used to remove foreign objects. A few drops of olive will kill live insects.
Any irrigants should be warmed to 37 degrees Celsius before installation to prevent dizziness, nausea, and vomiting.

FB may cause pain deafness and discharge if left
Remove under direct vision if possible. May need GA especially children.
Use loop, blunt hook, skill experience. Suction +/microscope will help.
If in doubt about chances to remove slickly then offer ENT first chance to remove.

Insect
Drown with warm olive oil or liquid paraffin before removing with forceps or syringe.

Chondrodermatitis nodularis helicis

Wax and srynging

Ear syringing is a procedure commonly used to remove impacted wax (and occasionally FBs) from the external auditory canal.
Its use has declined recently due to the high incidence of litigation for perforation and other injuries, and patients are encouraged to try using olive oil or other cerumen solvents prior to and as an alternative to srynging.
Where possible removal of wax with an ear probe under direct vision /magnification by a trained practitioner is preferred.

Red Flags
Known h/o Perforated tympanic membrane, or
Prior middle ear surgery; tympanostomy tubes or grommets
Acutely Vertigo, nausea or vomiting

Otitis externa

CKS otitis_externa

Inflammation of the external ear canal and auricle.
Can be caused by swimming in contaminated water (swimmers ear – more common in summer), exposure to chemical irritants, cleaning/poking the ear canal with a foreign object, regular use of ear devices, and a perforated tympanic membrane.

Resistant otitis externa may be due to a fungal infection or organisms such as psuedomonas. Take swabs.

Symptoms include pain, swelling, redness, and purulent drainage of the auricle and ear canal.
Chewing or movement of the tragus or pinna usually increases pain.
Usually resolves in 7 days but can reoccur become chronic in some.

Bacterial or fungal infection.
May follow exposure to water (swimmers ear).
Pain (especially on pressing tragus) desquamation of skin and a thin scanty discharge that may become purulent.
Chronic OE can lead to narrowing and stenosis of the canal.

Management
Aural toilet using cotton wick to gently remove debris.
Give antibiotic/steroid drops or spray.
Refer ENT follow up as appropriate

Treatment of otitis externa
Betnesol® drops (betamethasone 0.1%)
Dose: Ear, apply 2-3 drops every 2-3 hours, reduce frequency when relief obtained.

Gentisone-HC® drops (gentamicin 0.3%/hydrocortisone 1%)
Dose: Apply 2-4 drops into the ear 3 to 4 times daily and at night.

Locorten-Vioform® drops (flumetasone pivalate 0.02%/clioquinol 1%)
Dose: Apply 2-3 drops into the ear twice daily.

These preparations should be used for no longer than 7 days to prevent fungal overgrowth. Preparations containing aminoglycosides or polymyxin should not be used if the eardrum is perforated.

Antifungal preparations
Clotrimazole solution 1%
Dose: Apply 2-3 drops daily continuing for at least 14 days after disappearance of infection

Malignant otitis externa

malignant OE @ medscape.com

Furuncle external ear

youtu.be/kAJIM33LIaI

Very painful boil or pimple in outer part of external auditory canal.
Pain worse on moving examining the ear.
Hearing not usually affected.

Management
Insert wick soaked in 10% ichthammol in glycerine to encourage discharge of pus.
Rx flucloxaciilin 500mg qds and strong analgesic.
Check urine for glucose.

Swimmers osteoma

Ear discharge

Aural polyp

Perforated ear drum

youtu.be/qujUtu4UOjA

Causes
Bacterial infection
Trauma – skull fracture, foreign body insertion, instrumentation/srynging
Barotrauma – explosions, direct blows, or deep sea diving

Most ruptured TM’s occur in children with chronic ear infections.
Symptoms include pain, bloody or purulent discharge, hearing loss, vertigo, and fever.
Patients may be pain free if the membrane has already ruptured.
The TM will appear slit-shaped or irregular.

Tympanosclerosis

Otosclerosis

Acute otitis media (ENT)

Acute otitis media JAMA 2010;304:2161–9

Infection of the middle ear occurring most often in children between 6 months and 3 years of age.
Usually preceded by a viral upper respiratory infection.
Symptoms include rapid onset of pain, headache, tinnitus, hearing loss, and nausea or vomiting.
Pediatric patients may present with irritability, crying, rubbing or pulling the ears, restless sleep, and lethargy.
Visualization of the tympanic membrane usually reveals a dull light later becoming red and bulging.

Uncommon but serious complications include ruptured tympanic membrane, meningitis, acute mastoiditis, intracranial or neck abscess, facial nerve damage, or permanent hearing damage. Chronic or persistent OM may require myringotomy tube placement in pediatric patients.

Many infections are viral.
Illness will resolve within 4 days in 80% of cases with no antibiotics. Ensure adequate analgesia available.
Antibiotics will not reduce pain in the first 24 hours, subsequent attacks or deafness though will reduce duration particularly in young children
Children with otorrhoea, or <2 years with bilateral acute otitis media, may have greater benefit from antibiotics but delayed prescribing may still be considered.

Organism S.pneumoniae. H.influenzae. M.catarrhalis
1st line Amoxicillin 40mg/kg/day, five days treatment. Clarithromycin in penicillin allergic individuals.
2nd line Co-amoxiclav or azithromycin (if penicillin allergic) for 5 days..

Xylitol for preventing acute otitis media Cochrane Nov 2011

Otitis media NNT

Glue ear

CSOM / otitis media with effusion / glue ear

Tympanograms

Grommets and T-tubes

Cholesteatoma

Cholesteatoma = a ball of skin trapped in the middle ear
Grows as result of chronic inflammatory process and destroys structures (ossicles, inner ear, balance organ, facial nerve, brain)
Can lead to intracranial complications

Treatment = Mastoidectomy

Mastoid Cavity
Mastoid Cavity ENT Houston
http://youtu.be/_jFJz46y3Wc
Mack’s Ear dryer

Mastoiditis

Nose anatomy

Nose examination

youtu.be/6oPWLn6rvJc

Nasendoscopy

youtu.be/vLd5LkzjbZY

FB nose

FB Nose medscape

FBs may be difficult to remove particularly if the patient is unable to co-operate.
Beads can sometimes be pushed further in by the wrong technique or instrument.

Broken nose

Nasal fractures ncemi.org

Nasal deformity is the important sign and radiology is early indicated.
ENT review for nasal deformity assessment should be when ST swelling is reducing at approx. day 4.

Septal haematoma requires evacuation ASAP.

Nose bleeds epistaxis

Local causes
Trauma, infection, foreign bodies, surgery, chemical irritants,
Benign neoplasms: juvenile NP angiofibroma
Malignant neoplasms

Systemic causes
Haematologic disorders:NSAID, Haemophilias, Leukaemias
Osler-Weber-Rendu disease

Management
Digital pressure on soft part of nose
Barrier creams/Naseptin
Cautery under L.A.
Packing
Bipolar diathermy under G.A.

Epistaxis first aid

Blocked nose

http://www.youtube.com/watch?v=pPPCqnCCxyQ

Broken Nose

FB Nose

Rhinitis

Adenoidal hypertrophy (children, teenagers)
Nasal polyps

Septal deformity
Choanal atresia

Deviated nasal septum

entnet.org Deviated Septum

Nasal polyps

BSACI guidelines for the management of rhinosinusitis and nasal polyposis

Management
Nasal steroid sprays/drops
Systemic steroids
Surgery

Rare in children – Usually associated with cystic fibrosis
Bilateral
•Respiratory distress at birth
•Requires neonatal ventilation
•Opening of atresia at day 5-7
•Stenting for 3 months minimum
Unilateral
•May be undetected for years
•Unilateral nasal discharge ? FB
•Surgery age 3-5

Rhinitis

BSACI guidelines for the management of allergic and non-allergic rhinitis

Infective
Allergic
Vasomotor
Enlarged inferior and middle turbinates
Management
Identify cause and treat
Nasal steroid sprays
Saline nasal douches
Antibiotics if infective

Allergic rhinitis

Asthma and rhinitis

Asthma and rhinitis usually co-exist, with symptoms of rhinitis found in 75–80% of patients with asthma
Rhinitis is a risk factor for the development of asthma
Treatment of rhinitis is associated with benefits for asthma

Rhinitis in pregnancy

Self-limiting condition affecting at least 20% of pregnancies. Can start at any time.

Regular nasal douching may be helpful
Most medications cross the placenta, and should only be prescribed when the apparent benefit is greater than the risk to the foetus
beclomethasone, fluticasone and budesonide appear to have good safety records as they are widely used in pregnant asthmatic women
cromoglicate may be helpful
chlorphenamine, loratidine and cetirizine may be added cautiously if additional treatment is needed but decongestants should be avoided
Some antihistamines may increase the risk of spontaneous abortion or congenital malformation
Topical corticosteroids have shown no evidence of harmful effects

BSACI guidelines for the management of allergic and non-allergic rhinitis. Clinical and Experimental Allergy 2008; 38:19–42

http://www.bsaci.org/index.php?option=com_content&task=view&id=117&Itemid=139

Acute sinusitis

Acute sinusitis DTB 2009;47:26–30

Organism S.pneumoniae
1st line Penicillin V 1g twice daily or 500mg four times daily for seven days.
2nd line Doxycycline 200mg stat and then 100mg daily for a total of seven days.

Inflammatory process involving lining of paranasal sinuses
Initially viral rhinosinusitis then Secondary bacterial infection -Streptococci, Staphylococci H.Influenza
Other causes: Dental infections, facial trauma, immotile cilia syndrome, neoplasia

Treatment
-Broad spectrum antibiotic (Amoxycillin+/-Clavulanic Ac.) for 2/52
-Analgesia
-Topical/systemic decongestants
-Decongestant pack in MM/sinus puncture

Complications of acute sinusitis
•Cranial (osteomyelitis)
•Orbital (cellulitis, abscess, endophthalmitis)
•Intracranial (cavernous sinus thrombosis, brain abscess)

Diagnosing sinus tenderness (Murtagh)
http://youtu.be/8Lo3bENDqzs

Eliciting sinus tenderness is important in the diagnosis and follow-up of sinusitis.
Firm pressure over any facial bone, particularly in the patient with an upper respiratory infection, may cause pain. It is important to differentiate sinus tenderness from non-sinus bone tenderness

Method
1. This is best done by palpating a non-sinus area first and last, systematically exerting pressure over the temporal bones (T), then
the frontal (F), ethmoid (E) and maxillary (M) sinuses, and finally zygomas (2), or vice versa.
2. Differential tenderness both identifies and localises the main sites of infection.

Diagnosis of unilateral sinusitis
A simple way to assess the presence or absence of fluid in the frontal sinus, and in the maxillary sinus (in particular), is the use of transillumination.
It works best when one symptomatic side can be compared with an asymptomatic side.
It is necessary to have the patient in a darkened room and to use a small, narrow-beam torch.

Frontal sinuses
Shine the torch above the eye in the roof of the orbit and also directly over the frontal sinuses, and compare the illuminations.

Maxillary sinuses
Remove dentures (if any). Shine the light inside the mouth, on either side of the hard palate, pointed at the base of the orbit. A dull glow seen
below the orbit indicates that the antrum is airfilled.
Diminished illumination on the symptomatic side indicates sinusitis.

Snoring

Snoring BMJ 2005

Obstructive sleep apnoea

Obstructive sleep apnoea in adults BMJ 2009;338:b1165

Throat anatomy

Throat examination

Cervical lymphadenopathy

Swollen glands / enlarged cervical lymph nodes / Cervical Lymphadenopathy

http://hacking-medschool.com/lymphadenopathy-lymph-node-examination

http://www.youtube.com/watch?v=aAdB0A42qas

Causes of generalized lymphadenopathy

ALL AML

Lymphoma

Infections – glandular fever, secondary syphilis, miliary TB.

CTD – SLE, Still’s, rheumatoid Arthritis

Sarcoid

Sore throat

http://hacking-medschool.com/sore-throat-kids

http://www.cks.nhs.uk/sore_throat_acute/evidence/references

Sore throats MeReC 2006;17(3)

History
duration
fever/malaise
recurrent problems
immunocompromised
on medication which may cause agranulocytosis, e.g. carbimazole, mirtazapine

Examination
examine throat asking the patient to yawn or pant may improve the view.
Consider using a tongue depressor if the back of throat is not visible (but beware of epiglottitis)
assess inflammation of pharynx
look for exudates on tonsils
check neck for lymphadenopathy
look for a macular rash (small red flat patches)

Tests
FBC and Paul Bunnell for glandular fever, if symptoms persist for longer than a week
Urgent FBC should be requested if patient on drugs causing agranulocytosis

Action
antibiotics are of marginal benefit in most cases, and at best will only shorten the illness by 24 h.
Give antibiotics if immunocompromised, or if severe malaise or macular rash (scarlatina) present
Avoid amoxicillin if glandular fever a possiblity

Prescription
symptomatic treatment for most patients – ibuprofen or paracetamol, benzydamine spray
if an antibiotic is indicated in adults and children aged 10 years and over, give penicillin V for 10 days
if an antibiotic is indicated in children under 10 years, Rx amoxicillin suspension for 7 days. Although it is more likely to cause side-effects than penicillin V, in our experience young children find the taste of penicillin V suspension unpleasant and often refuse to take it
if allergic to penicillin, use erythromycin /clarithromycin

Refer immediately if:
child very sick, drooling, cannot swallow (possible epiglottitis, do not examine throat)
large swelling around one tonsil (possible quinsy, may need surgery)
on drugs that can cause agranulocytosis

Tonsillitis

SIGN 117 QRG Sore Throat/Tonsillectomy Jun 10

Penicillin is recommended by the American Academy of Paediatrics and American Heart Association as first-line therapy for GABHS infections;
erythromycin is recommended for those allergic to penicillin.
Treatment duration with penicillin should be 10 days to optimize cure in GABHS infections.
A five day regimen is advised for azithromycin (a macrolide).
Prevention of rheumatic fever is the primary objective for antibiotic therapy of GABHS infections

Tonsillitis/Pharyngitis/Acute Sore Throat
Average length of illness 1 week. Consider delayed antibiotic strategy.
75% of infections are viral not bacterial, both may have exudate.
If 3 or 4 centor criteria (fever, purulent tonsils, cervical lymphademopathy, no cough) or history of otitis media then antibiotics may be of more benefit.

Organism S.pyogenes, beta-haemolytic Strep
Samples Clinically suspicious of glandular fever, consider laboratory investigation.
1st line Penicillin V 1g twice daily or 500mg four times daily ten days
Clarithromycin 500mg twice daily for 10 days in penicillin allergic patients.

Quinsy – peritonsillar abcess

Unilateral Tonsillar Swelling
Recurrent acute infection
Peritonsillar abscess
Neoplasia
–Lymphoma (children)
–Salivary gland tumours
–SCC (adults)
Parapharyngeal space mass
Tonsillar Cancer

Glandular fever

http://hacking-medschool.com/glandular-fever-ebv-monospot

Glandular Fever (Epstein –Barr virus tonsillitis)
Transmission through infected saliva
Oral secretions transmit for up to 6 months
Petechiae at junction of soft–hard palate
FBC: monocytosis with 10% atypical monocytes
Serologic studies may be negative for 2 weeks

Management
Cephalosporins to avoid bacterial infection
Steroids
Avoid ampicillin
Avoid contact sports for 2 months – hepatosplenomegaly
Look for thrombocytopenia

Complications
Meningoencephalitis
Guillain-Barre Syndrome
Bell’s Palsy
Pneumonitis
Pericarditis, Myocarditis
Syndrome of inappropriate Antidiuretic Hormone (SIADH)
Splenic rupture (days 4-21): 0.1-0.2%
Airway Obstruction
Strep Pharyngitis

Tonsillectomy

•Recurrent acute tonsillitis
•Peritonsillar abscess
•Suspected malignancy
•OSA

Adenoidectomy

Adenoid surgery entuk.org
youtu.be/RyLs8rntYYQ
youtu.be/G2l_-YUwOuY

Obstruction:
•Chronic nasal obstruction or obligate mouth breathing
•OSA
•Dysphagia
•Speech problems
Infection:
•Recurrent/chronic adenoiditis (3 or more episodes/year)
•Recurrent/chronic OME

FB Throat

Foreign Bodies in the Ear, Nose, and Throat AAFP 2007

youtu.be/w3_Sicq7-bk

Neck lumps

http://hacking-medschool.com/thyroid-exam

Neck lumps jameshfshaw.co.nz

Midline

Thyroglossal cyst

Midline dermoid

Anterior triangle (anterior to sternomastoid)

Thyroid

Branchial cysts

Pharyngeal pouch

Salivary gland swellings

Lymph nodes

Carotid body tumour

Cervical rib

Posterior (posterior to sternomastoid)

lymphadenopathy

Goitre

Any swelling of thyroid gland

Croup epiglottitis stridor

Hoarseness

Dysphagia (ENT)

Parotid and salivary gland disorders (ENT)

Warthins

Pleomorphic adenoma

Pleomorphic Adenoma

Head and neck cancer

Thyroid Cancer

Papillary
Follicular
Anaplastic
Medullary
Lymphoma

ENT Prescribing

Otitis externa
Betnesol® drops (betamethasone 0.1%)
Dose: Ear, apply 2-3 drops every 2-3 hours, reduce frequency when relief obtained.
Gentisone-HC® drops (gentamicin 0.3%/hydrocortisone 1%)
Dose: Apply 2-4 drops into the ear 3 to 4 times daily and at night.
Locorten-Vioform® drops (flumetasone pivalate 0.02%/clioquinol 1%)
Dose: Apply 2-3 drops into the ear twice daily.

These preparations should be used for no longer than 7 days to prevent fungal overgrowth. Preparations containing aminoglycosides or polymyxin should not be used if the eardrum is perforated.

Removal of ear wax
Almond or Olive Oil
Dose: This patient should lie with the affected ear uppermost for 5 to 10 minutes after a generous amount of oil has been introduced into the ear. Oils should be warned (e.g. by pouring onto a warmed teaspoon) before administration.

Sodium Bicarbonate drops 5%
If the wax is hard and impacted drops may be used twice daily for several days before syringing (up to 10 days may be required); otherwise the wax may be softened on the day of syringing. Cerumol drops have not been included due to the relatively frequent occurrence of allergic reactions.

Antifungal preparations
Clotrimazole solution 1%
Dose: Apply 2-3 drops daily continuing for at least 14 days after disappearance of infection.

Nasal Allergy
Beclometasone aqueous nasal spray 50micrograms/metered spray
Dose: 100micrograms (2 sprays) into each nostril twice daily; max. total 400micrograms (8 sprays) daily; when symptoms controlled, dose reduced to 50micrograms (1 spray) into each nostril twice daily.

Fluticasone furoate nasal spray ?27.5micrograms/metered spray
Dose: 55micrograms (2 sprays) into each nostril once daily; when control achieved reduce to 27.5micrograms (1 spray) into each nostril once daily.

In seasonal allergic rhinitis (eg hay fever), treatment should begin 2 to 3 weeks before the season commences and may have to be continued for several months.

Corticosteroid nasal preparations should be avoided in the presence of untreated nasal infections, and also after nasal surgery (until healing has occurred); they should also be avoided in pulmonary tuberculosis. Systemic side effects of nasally administered corticosteroids are rare and there are no advantages in using the significantly more expensive fluticasone nasal spray. Many patients using beclometasone can be controlled on once daily dosing.

Topical nasal decongestants
Xylometazoline nasal drops 0.1%
Dose: Instil 2-3 drops into each nostril, 2 to 3 times daily when required; max. duration 7 days; not recommended for children under 12 years.

Topical nasal decongestants often cause rebound congestion and should be used for no longer than 7 days. Sympathomimetics, such as xylometazoline, should be avoided in patients taking monoamine oxidase inhibitors (MAOIs).

Sodium Chloride 0.9% given as nasal drops may relieve nasal congestion by helping to liquefy mucous secretions and may be useful for infants under 3 months.

Anti-infective nasal preparations
Naseptin® (chlorhexidine 0.1%/neomycin) cream
Dose: For eradication of nasal carriage of staphylococci,apply to nostrils 4 times daily for 10 days; for preventing nasal carriage of staphylococci, apply to nostril twice daily.

Mupirocin nasal ointment is reserved for resistant cases. In hospitals, mupirocin nasal ointment should be reserved for the eradication of nasal carriage of MRSA

Oral ulceration and inflammation
Benzydamine oral rinse 0.15%, spray 0.15%
Dose: Oral rinse, rinse or gargle, using 15ml (diluted with water if stinging occurs), every 1½ to 3 hours as required, usually for not more than 7 days; not suitable for children aged 12 years or under. Spray, adult, 4-8 sprays onto affected area every 1½-3 hours.

Triamcinolone acetonide oral paste 0.1%
Dose: Apply a thin layer 2-4 times daily; do not rub in; use limited to 5 days for children and short-term use also advised for elderly.

Benzydamine is effective at relieving oral discomfort and for irradiation mucositis. If the full strength mouthwash causes some stinging, it may be diluted with an equal volume of water. See also PRODIGY Guidance – Sore throat – acute

Oropharyngeal fungal infections

Nystatin suspension 100,000units/ml
Dose: 100,000 units 4 times daily after food usually for 7 days (continued for 48 hours after lesions have resolved). Higher doses may be needed for immunosuppressed patients (eg 500,000 units 4 times daily).

Miconazole oral gel 24mg/ml
Dose: Place 5-10ml in the mouth after food and retain near lesions, 4 times daily. Treatment continued for 48 hours after lesions have resolved. Localised lesions, smear small amount on affected area with clean finger 4 times daily (dental prostheses should be removed at night and brushed with gel).

If candidal infections fail to respond to 1 to 2 weeks of treatment with anticandidal drugs the patient should be sent for investigation to eliminate the possibility of underlying disease.

Mouthwashes
Chlorhexidine mouthwash 0.2%
Dose: Oral hygiene and plaque inhibition, rinse the mouth with 10ml for about 1 minute twice daily. Denture stomatitis, cleanse and soak dentures in mouthwash solution for 15 minutes twice daily.

Chlorhexidine mouthwash causes a reversible brown staining of the teeth. Chlorhexidine gluconate may be incompatible with some ingredients in toothpaste; leave an interval of at least 30 minutes between using mouthwash and toothpaste.

Goitre

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