ENT medicines: ear drops, nasal sprays, decongestants and gargles
- Topic
Topical ENT drugs work well when the right one is used the right way, and some cause harm when misused.
What it is
Many ENT problems are treated with drugs placed directly where the disease is: drops in the ear, sprays and rinses in the nose, mouthwashes and lozenges in the throat. They deliver high local concentrations with few systemic effects, but each class has a classic trap. Aminoglycoside ear drops can damage the inner ear when the eardrum is perforated; topical nasal decongestants cause rebound congestion (rhinitis medicamentosa) when used for more than a few days; oral decongestants raise blood pressure; first-generation antihistamines sedate. This page reviews the classes, what they are for, how to use them and what to avoid. Antibiotic choice for infections and ototoxic drugs have their own pages. Generic names only; doses are not given.
Key facts
- Clean the canal before ear drops (aural toilet); a swollen canal needs a wick so the drug reaches the skin.
- Warm drops to body temperature (cold drops can cause caloric vertigo); lie with the ear up for a few minutes and press the tragus to push the drops in.
- Topical antibiotic drops give far higher concentrations than oral antibiotics and are preferred for otitis externa and discharging chronic otitis media; prolonged use favours otomycosis.
- Neomycin can cause allergic contact dermatitis of the canal: suspect it when otitis externa worsens on treatment.
- Rhinitis medicamentosa treatment: stop the decongestant (gradually or one side at a time) and replace it with an intranasal corticosteroid.
- Montelukast carries a warning about neuropsychiatric effects (mood, sleep, suicidal thoughts): it is not first-line for allergic rhinitis.
- Chlorhexidine mouthwash can stain teeth and change taste; it does not replace brushing.
Structure
- Ear: antibiotic drops (quinolones; aminoglycoside or polymyxin combinations), corticosteroid-antibiotic combinations, antiseptic and acidifying drops (acetic acid, aluminium acetate), antifungals (clotrimazole), wax softeners (water, saline, sodium bicarbonate, oils, carbamide peroxide).
- Nose: saline sprays and irrigation, intranasal corticosteroids, intranasal antihistamines (azelastine, olopatadine), topical and oral decongestants, ipratropium, cromoglicate.
- Systemic for the nose: second-generation antihistamines, leukotriene receptor antagonists (montelukast), short oral corticosteroid courses for selected nasal polyposis.
- Throat and mouth: analgesics (paracetamol, NSAIDs), anaesthetic or anti-inflammatory lozenges and sprays (benzydamine), antiseptic mouthwashes (chlorhexidine), salt-water gargles.
- Vertigo (short term only): vestibular suppressants (antihistamines, benzodiazepines) and antiemetics.
ENT medicines: use and main caution
| Class | Examples (generic) | Main use | Key caution |
|---|---|---|---|
| Quinolone ear drops | Ciprofloxacin, ofloxacin (± steroid) | Otitis externa, discharging chronic otitis, tube otorrhoea | Prolonged use favours fungal infection |
| Aminoglycoside ear drops | Neomycin, gentamicin (± polymyxin, steroid) | Otitis externa with intact eardrum | Ototoxic if the drum is perforated; contact allergy |
| Acidifying and antifungal ear drops | Acetic acid, clotrimazole | Otomycosis, mild otitis externa, prevention in swimmers | Stinging on inflamed skin |
| Wax softeners | Water, saline, sodium bicarbonate, oils, carbamide peroxide | Wax impaction, before irrigation | Not with perforation or infection |
| Intranasal corticosteroids | Fluticasone, mometasone, budesonide | Allergic rhinitis, chronic rhinosinusitis, polyps | Epistaxis, septal irritation; full effect takes days |
| Topical decongestants | Oxymetazoline, xylometazoline, phenylephrine | Short-term blockage, before nasal exam or packing | Rebound congestion after a few days |
| Oral decongestants | Pseudoephedrine, phenylephrine | Short-term congestion | Hypertension, palpitations, insomnia, urinary retention |
| Antihistamines | Cetirizine, loratadine; azelastine spray | Allergic rhinitis (itch, sneeze, rhinorrhoea) | First generation: sedation, anticholinergic effects |
| Anticholinergic spray | Ipratropium | Watery rhinorrhoea | Dry nose, epistaxis; no effect on blockage |
| Throat products | Benzydamine, chlorhexidine, salt water | Symptom relief of sore throat and mouth ulcers | Do not hide red flags of deep infection or cancer |
In clinical practice
- A patient using nasal decongestant sprays for weeks with worse blockage: rhinitis medicamentosa.
- Ear drops that sting badly and cause vertigo: possible perforation; check the drum and change to a non-ototoxic drop.
- Self-medication with oral decongestants in a hypertensive patient: elevated blood pressure and palpitations.
- Sore throat lozenges do not treat a peritonsillar abscess: look for trismus, drooling and a displaced uvula.
Next step / Initial management
- Before prescribing: look at the eardrum (perforation, tube), ask about allergies, blood pressure, heart disease, glaucoma, prostate disease and pregnancy.
- First-line choices: quinolone drops after cleaning for otitis externa or chronic discharge; intranasal corticosteroid and saline for allergic rhinitis and chronic rhinosinusitis; decongestant sprays only for a few days; analgesics for sore throat.
- Refer routinely to ENT when symptoms persist despite correct topical treatment (chronic discharge, nasal blockage, suspected polyps or septal deviation) or when rhinitis medicamentosa does not settle.
- Refer the same day if treatment of an ear or throat infection is followed by facial palsy, vertigo, neck swelling, trismus, stridor or inability to swallow.
Test yourself
Think of the answer, then tap the question to see it.
A man with a perforated eardrum and discharge is prescribed neomycin-polymyxin drops. What is the risk and the better choice?
Aminoglycoside ototoxicity through the perforation; a quinolone drop (ciprofloxacin or ofloxacin) after cleaning is safer.
A student has used oxymetazoline spray every day for six weeks and her nose is more blocked than ever. Diagnosis and management?
Rhinitis medicamentosa: stop the decongestant (gradually or one side at a time) and start an intranasal corticosteroid.
Which nasal spray best controls watery rhinorrhoea but has no effect on nasal blockage?
Ipratropium (an anticholinergic) nasal spray.
Why should a patient warm ear drops to body temperature before use?
Cold drops stimulate the lateral semicircular canal (caloric effect) and can cause vertigo and nausea.
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Rhinitis Medicamentosa (StatPearls Publishing (NCBI Bookshelf), 2026); Allergic Rhinitis (StatPearls Publishing (NCBI Bookshelf), 2023); Antihistamines (StatPearls Publishing (NCBI Bookshelf), 2025); Phenylephrine (StatPearls Publishing (NCBI Bookshelf), 2023); Ipratropium (StatPearls Publishing (NCBI Bookshelf), 2024); Ciprofloxacin (StatPearls Publishing (NCBI Bookshelf), 2023); Otitis Externa (StatPearls Publishing (NCBI Bookshelf), 2023); Ear Irrigation (StatPearls Publishing (NCBI Bookshelf), 2026).
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Representative model, for educational purposes only.