ent by prof. dr.yasser nour

Dr. Yasser A. Nour M.D, FRCSEd Dr. Yasser A. Nour M.D, FRCSEd Fellow of the Royal College of Surgeons of Edinburgh.Fellow of the Royal College of Surgeons of Edinburgh.

Lecturer of Otolaryngology – Head & Neck Surgery.Lecturer of Otolaryngology – Head & Neck Surgery.

PHARMACOTHERAPY FOR PHARMACOTHERAPY FOR DISEASES OF THE NOSEDISEASES OF THE NOSE

Common ColdCommon Cold

Rhinovirus Coronavirus

The commenst viral infection in human

Mode of TransmissionMode of Transmission

Clinical PictureClinical Picture

Clinical picture:• Fever, headache,malaise.• Dryness of nose.• Sore throat.• Sneezing.• Nasal obstruction.• Watery rhinorrhea.• Mucopurulent Rhinorrhea.• Resolution within 5-10 days.

Complications:• Sinusitis.• Pharyngitis.• Adenoiditis. • Tonsillitis.• Otitis media.• Laryngotrachitis.• Bronchitis.• Pneumonia.• Nephritis.• Rheumatic fever.

Treatment: Bed rest. Vitamins. Fluids. Analgesic. Antipyretics. Antihistaminics. Anticholenergic. Decongestant. Antibiotics.

InfluenzaInfluenza

One of the most common infectious diseases in human.

It is caused by influenza virus that is classified as type A, B & C.

InfluenzaInfluenza

It may occur in epidemics.

Spanish flu epidemic 1918 killed 20 millions all over the world.

• People were struck with illness on the street and died People were struck with illness on the street and died rapid deaths. Four women were playing bridge together rapid deaths. Four women were playing bridge together late into the night. Overnight, three of the women died late into the night. Overnight, three of the women died from influenza. from influenza.

• One physician writes that patients with seemingly One physician writes that patients with seemingly ordinary influenza would rapidly "develop the most ordinary influenza would rapidly "develop the most viscous type of pneumonia that has ever been seen" and viscous type of pneumonia that has ever been seen" and later when cyanosis appeared in the patients, "it is later when cyanosis appeared in the patients, "it is simply a struggle for air until they suffocate,“.simply a struggle for air until they suffocate,“.

Spanish Flu Epidemic Spanish Flu Epidemic

InfluenzaInfluenza

Two types of influenza virus.

Human influenzaAvian influenza

InfluenzaInfluenza

Two types of influenza virus.

Human influenza A person infected with a particular flu virus strain develops antibody against that virus.

As newer virus strains appear through antigenic shift and drift , the antibodies against the older strains no longer recognize the "newer" virus, and infection with a new strain can occur.

FeaturesFeatures InfluenzaInfluenza Common coldCommon cold

OnsetOnset AbruptAbrupt More gradualMore gradual

FeverFever Common up to 40.0°C Common up to 40.0°C Uncommon only 0.5°C Uncommon only 0.5°C

MyalgiaMyalgia Severe, common Severe, common Uncommon Uncommon

ArthralgiaArthralgia Severe, common Severe, common Uncommon Uncommon

AnorexiaAnorexia Common Common Uncommon Uncommon

Headache Headache Severe, common Severe, common Severe, common Severe, common

Cough (dry) Cough (dry) Common, severe Common, severe Mild to moderate Mild to moderate

Malaise Malaise Severe Severe MildMild

Fatigue, weakness Fatigue, weakness More common More common Very mild, short lasting Very mild, short lasting

Chest discomfort Chest discomfort Common, severe Common, severe Mild to moderate Mild to moderate

Stuffy nose Stuffy nose OccasionalOccasional Common Common

Sneezing Sneezing OccasionalOccasional Common Common

Sore throat Sore throat OccasionalOccasional Common Common

CommonCommon UncommonUncommon

Pneumonia Pneumonia

Otitis media Otitis media

Tracheobronchitis Tracheobronchitis

Acute sinusitisAcute sinusitis

Reye's syndrome Reye's syndrome Pericarditis Pericarditis

Myositis Myositis

Myoglobinuria Encephalitis Myoglobinuria Encephalitis

Transverse myelitis Transverse myelitis

Guillain-Barré syndrome Guillain-Barré syndrome

RhabdomyolysisRhabdomyolysis

ComplicationsComplications

• Healthy children six to 23 months of age.

• Adults 65 years and older.

• Persons six months to 64 years with cardiopulmonary, respiratory, renal, metabolic, or immunodeficient conditions.

• Pregnant women

• Children aged 6–23 months. Children aged 6–23 months. • Adults aged ≥50 years. Adults aged ≥50 years. • Persons aged 2–64 years with underlying Persons aged 2–64 years with underlying

chronic medical conditions. chronic medical conditions. • Women who will be pregnant during the Women who will be pregnant during the

influenza season. influenza season. • Residents of nursing homes and long-term Residents of nursing homes and long-term

care facilities. care facilities. • Children aged 2–18 years on chronic Children aged 2–18 years on chronic

aspirin therapy. aspirin therapy. • Health-care workers involved in direct Health-care workers involved in direct

patient care; and patient care; and • Out-of-home caregivers and household Out-of-home caregivers and household

contacts of children aged <6 months. contacts of children aged <6 months.

VaccinationVaccination

Allergic RhinitisAllergic Rhinitis

Dr. Yasser A. Nour, M.D., Dr. Yasser A. Nour, M.D., FRCSEdFRCSEd

Lecturer of Otolaryngology – Head & Neck Surgery. Lecturer of Otolaryngology – Head & Neck Surgery. Alexandria UniversityAlexandria University

Fellow of the Royal College of Surgeons of EdinburghFellow of the Royal College of Surgeons of Edinburgh

Allergic rhinitis is an IgE mediated hypersensitivity of nasal mucous membrane characterized by sneezing, itching, watery

rhinorrhea and a sensation of nasal obstruction. It may also involve the lining of paranasal sinuses.

Allergic rhinitis occurs in atopic individuals who

are exposed to common aeroallergens

Allergens:

• Seasonal rhinitis

• Perennial allergic rhinitis

• Occupational allergens

• Food and drug induced rhinitis

• Role of pollution

Grass Pollen

Allergens:






House dust mites

Allergens:






Domestic animals

Allergens:






Pathogenesis

Pathogenesis

Early, or immediate, phase of the reaction

Pathogenesis

Late-phase response

Vasodilatation. Increase vascular permeability. Increase plasma exudation. Chemoattractants for eosinophils and neutrophils. Potent mucus secretogogue. Histamine also increases the release of acetylcholine. This may account more for increased mucus production in allergic rhinitis than do mast cell-derived mediators.

The biological properties of these mediators include:

Clinical PictureClinical PictureSeasonal Seasonal

allergic rhinitisallergic rhinitisPerennial Perennial

allergic rhinitisallergic rhinitis

• Sneezing & Sneezing & ItchingItching• RhinorrheaRhinorrhea

• Loss of taste Loss of taste and smelland smell• Associated Associated sinusitis sinusitis and and Eustachian Eustachian DysfunctionDysfunction

++++++++

WateryWatery

++

++

++

Mucoid + PNDMucoid + PND

++++++

++++++

Positive personal and family history of other atopic diseasesPositive personal and family history of other atopic diseases

External signs

• Allergic salute.

• Mouth breathing.

• Allergic shiners.

Allergen Avoidance

Mites control

Mattress covers

Allergen Avoidance

Mites control

Mattress covers

Air conditioner

Dehumidifier

Allergen Avoidance

Mites control

Mattress covers

Dust & Pollen mask

Food avoidance

Pets control

Antihistamines

First generationFirst generation Second generationSecond generation

Diphenhydramine

Brompheniramine

Hydroxyzine

Fexofenadine

Cetirizine

Loratadine

Side effectsSide effects

Central nervous system Gastrointestinal Gastrointestinal Anticholinergic Anticholinergic effectseffects

Drowsiness

Cognitive impairment

Impaired reflexes

Constipation

GI upsetGI upset

Blurred visionBlurred vision

Dry mouthDry mouth

Urinary retentionUrinary retention

Intra-Nasal Antihistamine (Azelastine nasal spray)

DrivingUsing machines

GlaucomaProstatic hypertrophy

Decongestants

IntranasalIntranasal SystemicSystemic

Oxymetazoline Pseudoephedrine


LocalLocal SystemicSystemic

Burning

Sneezing

Increased discharge

Rebound congestion

Tachycardia Palpitations

Nervousness Headache

Urine retention

DrowsinessInsomniaDizzinessWeakness

Acute glucoma

Care should be taken in those with:Heart diseaseHypertension

GlaucomaProstatic hypertrophy

Diabetes mellitus

Steroids

IntranasalIntranasal SystemicSystemicFluticasone

Beclomethasone

Budesonide

Prednisone (oral)Prednisone (oral)

Trimacinolone (injection)Trimacinolone (injection)


LocalLocal SystemicSystemicEpistaxis

Burning sensation

Crusting, dryness

Pharyngitis

Septal perforation

Upset stomach Skin rash Swollen faceMuscle weakness Increased appetite

Bone and muscle problems Growth problems in children Increased sugar in the blood

Others

Intra-Nasal Mast Cell Stabilizers

Cromolyn sodium

Intra-Nasal Anticholinergic

Ipratropium bromide

Epistaxis

Nasal irritation: burning, sneezing

IMMUNOTHERAPYIMMUNOTHERAPY

Others

SINGULAIR is indicated for relief of symptoms of allergic rhinitis (seasonal allergic rhinitis in adults and children aged 2 years and older and perennial allergic rhinitis in adults and children aged 6

months and older).

SinusitisSinusitisSinusitis is the

inflammation/infection of 1 or more paranasal sinuses

and occurs with obstruction of the normal drainage

mechanism. It is traditionally subdivided into acute (symptoms lasting <3 wk), subacute (symptoms lasting 3 wk to 3 mo), and

chronic (symptoms lasting > 3 mo).

Several factors may contribute to obstruction: mucosal

swelling, abnormalities of the cilia, structural abnormalities

and overproduction of secretions. Preceding viral

infection or epithelial damage weakens mucosal defenses and

facilitates penetration of bacteria into the sinus mucosa. Although nasal allergies also

contribute to edema and swelling of the nasal mucosa.

A diagnosis of ABS can be made when a viral upper respiratory tract infection

(URI) fails to improve after 10 days or worsens after 5–7 days

and is accompanied by symptoms of persistent anterior and posterior

rhinorrhea, nasal congestion, facial pressure/pain, post-nasal

drainage, reduced sense of smell, fever, cough, fatigue, dental pain in the jaw, or ear

pressure/fullness.

Symptoms associated with acute bacterial rhinosinusitis

Key diagnostic symptomsNonspecific/infrequent

symptoms

Purulent anterior nasal or postnasal discharge

Malaise/fatigue

Unilateral maxillary sinus tenderness

Halitosis

Maxillary tooth or facial pain (especially when unilateral)

Nasal congestion

“Double-sickening” history† Hyposmia/anosmia

Fever

Cough

The most common bacterial pathogens in acute sinusitis are Streptococcus pneumoniae (30-40%),

Haemophilus influenzae (20-30%) Moraxella catarrhalis (12-20%).

Anaerobic organisms have been found in fewer than 10% of patients with acute bacterial

sinusitis, despite the ample environment available for

their growth.

First-line therapy at most centers is usually amoxicillin or a macrolide antibiotic in patients allergic to penicillin because of the low cost, ease of administration, and low toxicity of

these agents.

Antibiotic Dosage

Amoxicillin 500 mg PO tid

Clarithromycin 250-500 mg PO bid

Azithromycin500 mg PO first day, then

250 mg/d PO for 4 days

Patients who live in communities with a high incidence of resistant organisms, those who fail to respond within 48-72

hours of commencement of therapy, and those with persistence of symptoms beyond 10-14 days should be considered for

second-line antibiotic therapy.

Antibiotic Dosage

Amoxicillin/clavulanate 500 mg PO tid

Cefuroxime 250-500 mg PO bid

Cefpodoxime+

cefixime

200 mg PO bid 400 mg/d PO

Ciprofloxacin 500-750 mg PO bid

Levofloxacin 500 mg/d PO

Trovafloxacin 200 mg/d PO

Clindamycin 300 mg PO tid

PHARMACOTHERAPY FOR PHARMACOTHERAPY FOR DISEASES OF THE EARDISEASES OF THE EAR

External Ear

Otitis ExternaOtitis Externa

Otitis externa is a spectrum of Otitis externa is a spectrum of infection of the external infection of the external auditory canal. Although auditory canal. Although

commonly called swimmer’s commonly called swimmer’s ear, it may be caused by ear, it may be caused by

anything that results in the anything that results in the removal of the protective lipid removal of the protective lipid film from the canal, allowing film from the canal, allowing

bacteria to enter the bacteria to enter the apopilosebaceous unit. apopilosebaceous unit.

Otitis ExternaOtitis Externa

• ItchingItching

• Itch/scratch cycleItch/scratch cycle• PainPain• Purulent dischargePurulent discharge• Hearing lossHearing loss• Pain on palpation of the tragusPain on palpation of the tragus

• Edema and redness of the ear canal

• Cellulitis of the face or neck or lymphadenopathy of the unilateral neck

The most common pathogen is Pseudomonas aeruginosa, followed by Staphylococcus aureus,

then other gram-negative organisms.

There are four fundamental principles in the There are four fundamental principles in the treatment of external otitistreatment of external otitis

Frequent and thorough cleaning Frequent and thorough cleaning Judicious use of appropriate antibiotics Judicious use of appropriate antibiotics Treatment of associated inflammation and pain Treatment of associated inflammation and pain Recommendations regarding the prevention of future Recommendations regarding the prevention of future

infections infections

TreatmentTreatment

In the absence of purulence, a brief course of an acidifying In the absence of purulence, a brief course of an acidifying drop such as drop such as Acetic acid in aluminium acetateAcetic acid in aluminium acetate is efficacious in is efficacious in

discouraging bacterial or fungal growthdiscouraging bacterial or fungal growth

Mild StageMild Stage

An antibiotic otic dropAn antibiotic otic drop Neomycin, polymyxin, Neomycin, polymyxin,

dexamethasonedexamethasone (Isoptomaxitrol)(Isoptomaxitrol) Neomycin, polymyxin B, Neomycin, polymyxin B,

dexamethasonedexamethasone (Dexapolyspectran (Dexapolyspectran Otic)Otic)

Tobramycin and dexamethasoneTobramycin and dexamethasone ((Tobradex)Tobradex)

Ciprofloxacin Ciprofloxacin (Ciloxan, Cipro HC (Ciloxan, Cipro HC Otic) Otic)

Ofloxacin Ofloxacin (Floxin otic)(Floxin otic)

TreatmentTreatment

Moderate StageModerate Stage In the moderate stage of In the moderate stage of

inflammation, edema of the canal inflammation, edema of the canal

may interfere with the instillation may interfere with the instillation

of drops. The physician should of drops. The physician should

then insert a gauze strip or wick then insert a gauze strip or wick

into the canal with antibiotic into the canal with antibiotic

ointment and instill drops on it. ointment and instill drops on it.

TreatmentTreatment

Severe StageSevere Stage : : Infection often extends beyond the limit of the Infection often extends beyond the limit of the canal. An oral antibiotic with broad-spectrum coverage is needed. canal. An oral antibiotic with broad-spectrum coverage is needed.

TreatmentTreatment

Drug Name

Ciprofloxacin (Cipro) -- Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms but with no activity against anaerobes.

Adult Dose 250-500 mg PO bid

Pediatric Dose >18 years: Not recommended

PrecautionsIn prolonged therapy, periodically evaluate organ system functions (eg, renal, hepatic, hematopoietic)

Instruct the patient to avoid future infections by not Instruct the patient to avoid future infections by not placing any object or instrument into the canal. placing any object or instrument into the canal.

Patients who have repeated infections are best Patients who have repeated infections are best advised to use an acidifying drop composed of equal advised to use an acidifying drop composed of equal measures of measures of vinegar and watervinegar and water, or , or ethyl alcohol and ethyl alcohol and waterwater, when exposed to high humidity. , when exposed to high humidity.

Custom-made Custom-made ear moldsear molds are useful for these patients. are useful for these patients.

PreventionPrevention

OtomycosisOtomycosis

Otomycosis is a fungal Otomycosis is a fungal infection of the skin of the infection of the skin of the external canal. external canal.

All fungi have three basic All fungi have three basic growth requirements: growth requirements:

- MoistureMoisture- WarmthWarmth- DarknessDarkness


AspergillusAspergillus species are species are most common, and most common, and pruritus pruritus is the primary is the primary clinical manifestation. clinical manifestation.

Physical examination Physical examination commonly shows a commonly shows a white, black, or dotted white, black, or dotted gray membrane.gray membrane.


MANAGEMENT:MANAGEMENT:

1.1.Thorough cleaning with removal of the matted fungal Thorough cleaning with removal of the matted fungal debris is supplemented by the topical application of an debris is supplemented by the topical application of an acidifying solution acidifying solution

2% Acetic acid in aluminium acetate 3% Boric acid in 70% alcohol.2.2.Topical Antifungal:Topical Antifungal:Clotrimazole cream or solution (Canestin or dermatin).Clotrimazole cream or solution (Canestin or dermatin).Nystatin drops (Mycostatin)Nystatin drops (Mycostatin)


FurunculosisFurunculosis

Acute localized otitis externa, also known as furunculosis, is associated with infection of a hair

follicle.

• Analgesics, ant-inflammatory

• Antibiotics

• Ear wick

Wax impactionWax impaction

Cerumen impaction is the most common abnormality found on otoscopic examination. It is the most common cause of hearing loss.

Ceruminolytic agents:

• 3% Hydrogen Peroxide solution

• Triethanolamine (Ceruminex)

• Carbamide peroxide in glycerol

• Olive oil, Mineral oil or Baby oil

MIDDLE EARMIDDLE EAR

Acute Otitis MediaAcute Otitis Media

Otitis media (OM) is the second most common Otitis media (OM) is the second most common disease of childhood after upper respiratory disease of childhood after upper respiratory

tract infections and is one of the most common tract infections and is one of the most common reasons for a child to visit the pediatrician’s reasons for a child to visit the pediatrician’s

office.office.

Acute otitis media usually arises as a complication of

a preceding viral upper respiratory infection

(URI).

Risk factors for otitis media: - Host risk factors include age, prematurity, race, allergy,

craniofacial abnormalities, gastroesophageal

reflux, presence of adenoids, and genetic predisposition.

- Daycare center attendance increases risk of development

of AOM.

- Bottle-feeding increases the incidence compared with

breastfeeding.

- Smoking in the household.


Pneumococcus species, Haemophilus influenzae, and Moraxella species are the bacteria most

commonly involved in otitis media.

• Earache

• Fever (not required for the

diagnosis)

• Accompanying or precedent URI

symptoms (very common)

• Decreased hearing

• Injected tympanic membrane


TreatmentTreatment

"Wait-and-see prescription“ for antibiotics in AOM

The observation option is a 48- to 72-hour period of symptomatic treatment with

analgesics and without antibiotics, followed by reexamination.

TreatmentTreatment

Drug Name Amoxicillin (Amoxil, Biomox)

Adult Dose 250-500 mg PO q8h

Pediatric Dose80-90 mg/kg/d PO divided q8h for 10 d

in younger children and in patients with severe disease

PrecautionsAdjust dose in renal impairment; use in

Ebstein-Barr viral mononucleosis increases risk of severe rash

Drug NameAmoxicillin and clavulanate potassium

(Augmentin)

Adult Dose500-875 mg PO q12h PO or 250-500 mg PO

q8h

Pediatric Dose

90 mg/kg (amoxicillin) with 6.4 mg/kg (clavulanate) divided PO q12h

Precautions

Give for minimum of 10 d to eliminate organism and prevent sequelae (eg,

endocarditis, rheumatic fever); after treatment, perform cultures to confirm eradication of

streptococci

TreatmentTreatment

Drug Name Cefuroxime

Description

Second-generation cephalosporin maintains gram-positive activity of first-generation

cephalosporins; adds activity against Proteus mirabilis, H influenzae, Escherichia coli,

Klebsiella pneumoniae, and M catarrhalis. Condition of patient, severity of infection, and

susceptibility of microorganism determines proper dose and route.

Adult Dose 125-500 mg PO q12h

Pediatric Dose 30 mg/kg PO q12h

TreatmentTreatment

Ceftriaxone 50 mg/kg/d is recommended for

children who are unable to take oral antibiotics and for patients with

compliance problems.

TreatmentTreatment

Bell’s palsyBell’s palsy

The term The term Bell’s palsyBell’s palsy has been used to has been used to describe a facial describe a facial

paralysis of acute onset paralysis of acute onset and limited duration, the and limited duration, the etiology of which was etiology of which was deemed idiopathic.deemed idiopathic.


• Steroids• Antiviral agents

• Eye care: Artificial tears Lubricants Eye glasses or shields

Drug Name Prednisone (Hostacortin)

Adult Dose 1 mg/kg/d PO for 7 d

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic

ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may

occur with glucocorticoid use



Drug Name

Acyclovir (Zovirax) -- Has demonstrated inhibitory activity directed against both HSV-1 and HSV-2, and infected cells selectively take

it up .

Adult Dose 4000 mg/24 h PO for 7-10 d

Pediatric Dose>2 years: Not recommended

>2 years: 1000 mg PO divided qid for 10 d

PrecautionsCaution in renal failure or when using

nephrotoxic drugs

INNER EARINNER EAR

VertigoVertigo

Subjective sensation of disturbed Subjective sensation of disturbed relationship between the individual and his relationship between the individual and his environment in which either the patient or environment in which either the patient or

his environment is moving.his environment is moving.

Meniere’s diseaseMeniere’s disease Vestibular neuronitisVestibular neuronitis

Drug Name Meclizine (Antivert)

Description

Decreases the excitability of the middle ear labyrinth and blocks conduction in the middle ear vestibular-cerebellar pathways. These effects are associated with its therapeutic effects in vertigo.

Adult Dose 25-50 mg PO q4-6h

Precautions

Caution in angle-closure glaucoma, prostatic hypertrophy, pyloric or duodenal obstruction, and bladder neck obstruction

Meniere’s diseaseMeniere’s disease


Drug Name Dimenhydrinate (Dramamine)

Description

Used for treatment and prophylaxis of vestibular disorders that may cause nausea and vomiting. Through its central anticholinergic activity, it diminishes vestibular stimulation and depresses labyrinthine function.

Adult Dose 50 mg PO/IM q4-6h or a 100-mg suppository q8h

Pediatric Dose

Neonates: Do not administer2-6 years: 12.5-25 mg q6-8h; not to exceed 75 mg/d6-12 years: 25-50 mg PO q6-8h; not to exceed 150 mg/d

Drug Name Diazepam (Valium)

Description

Depresses all levels of the CNS, including limbic and reticular formation, possibly by increasing GABA activity, which is a major inhibitory neurotransmitter.

Adult Dose 5-10 mg PO/IV/IM q4-6h


Drug Name Promethazine (Phenergan)

DescriptionAntidopaminergic agent effective in the treatment of emesis.

Adult Dose 25-50 mg PO/IM/PR q4-6h

Pediatric Dose<2 years: Contraindicated>2 years: 0.5 mg/kg q4-6h

Precautions

Can be associated with CNS depression, dry mouth, extrapyramidal symptoms, hypertension, hypotension, and rash; caution in patients with cardiovascular or hepatic disease


• Low-sodium diet (1–1.5 g Na+/day)Low-sodium diet (1–1.5 g Na+/day)• Diuretic:-Diuretic:--Triamterene and hydrochlorothiazide Triamterene and hydrochlorothiazide (Dyazide)(Dyazide)-Acetazolamide (Diamox)Acetazolamide (Diamox)-HydrochlorothiazideHydrochlorothiazide

• Betahistine ( Betaserc)Betahistine ( Betaserc)


DRUGS USED IN VERTIGO AND DRUGS USED IN VERTIGO AND DIZZINESSDIZZINESS

Betahistine (Betaserc,Microserc 8,16 mg ,Verserc 24 mg)

H3 receptor agonist. It dilates blood vessels in H3 receptor agonist. It dilates blood vessels in the inner ear.the inner ear.

Increases serotonin in brain stem leading to Increases serotonin in brain stem leading to decrease in activity of vestibular nuclei.decrease in activity of vestibular nuclei.

Cinnarizine (Stugeron 25 mg): (Stugeron 25 mg):

Calcium channel blocker that decreases Calcium channel blocker that decreases contraction of vascular smooth muscles.contraction of vascular smooth muscles.

Vincamine (Oxybral 30 mg):(Oxybral 30 mg):

Peripheral vasodilator that increases blood Peripheral vasodilator that increases blood supply to the brain.supply to the brain.


Almitrine besmesylate (duxil): (duxil):

Acts on chemoreceptors of the carotid bodies Acts on chemoreceptors of the carotid bodies leading to increase in the arterial oxygen leading to increase in the arterial oxygen tension.tension.

Piracetam (Nootropil): (Nootropil):

It increases blood flow and oxygen consumption It increases blood flow and oxygen consumption in the brainin the brain


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ent by prof. dr.yasser nour

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