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Introduction: Decongestants are commonly used drugs in clinical practice, and they can relieve nasal congestion caused by factors like influenza, rhinitis, and acute upper respiratory tract infection. Areas covered: In this article, we review the research outcomes about decongestants, which aim to provide beneficial information that can guide the clinical application of decongestants for clinicians. Expert opinion: Although the use of nasal decongestants is increasingly limited, caution rather than prohibition is now advocated. Scientific and accurate use of nasal decongestants can achieve satisfactory clinical effectiveness on nasal congestion, and it is not easy to produce adverse reactions. Patients with severe nasal congestion may use nasal decongestants solely or in combination with nasal corticosteroids or nasal antihistamines to exert a synergistic effect. The concentration, dose, frequency, and time of nasal decongestants determine whether drug-induced rhinitis will occur. Additionally, we recommend patients not to buy nasal sprays with unknown ingredients on the internet or in pharmacy, so as to avoid the risk of rhinitis medicamentosa. For patients with rhinitis medicamentosa, the use of nasal decongestants should be stopped immediately. However, more evidence is still needed to standardize the clinical use of nasal decongestants. [ABSTRACT FROM AUTHOR]

Tetrahydrozoline is an alpha agonist imidazole derivative found in over-the-counter decongestive eye and nasal drops. The drug was patented in 1954 and was available for medical use in 1959. This drug recently gained the attention of law enforcement as it has been utilized in criminal activity such as homicide and drug-facilitated sexual assault. The aim of this scoping review is to scope the literature for all mentions of tetrahydrozoline eye/nasal drops use in a non-medical context to delineate areas of future research and development. We used Google Scholar and PUBMED/Medline databases to search for non-medicinal and criminal uses of THZ. The search word used was "tetrahydrozoline." A total of 15 articles matched our criteria. Among the case reports, two (11.1%) cases reported on drug-facilitated sexual assault, and two (11.1%) cases used THZ eyedrops to attempt suicide. Incidental ingestion of THZ eyedrops was reported in eight (44.4%) cases, three (16.7%) cases of attempted murder were reported, two (11.1%) cases of intentional ingestion were reported, and one (5.5%) case was a combination of drug-facilitated sexual assault and attempted murder. The most common clinical presentation was unexplained and resistant bradycardia and hypotension. THZ eye drops can be used to produce false negative results on drug tests. This study recognizes that THZ can be used in non-medicinal and criminal uses. There is room for future research and development. More studies should be conducted to better understand the mechanism of action, therapeutic window, and toxicity levels among various age groups at different methods of intake and to find an effective treatment in case of overdose. Eyedrop and nasal decongestant bottles should be designed with child proofing to prevent incidental ingestion and should contain warning labels. A fast and alternative test to GC/MS can be developed to ease the diagnosis of THZ toxicity. Purchases of this medication may need to be monitored. [ABSTRACT FROM AUTHOR]

Over-the-counter drugs are medicines that are available to consumers without a prescription. The most common оver - the-counter preparations in self - medication are nasal decongestants that can be used systemically or locally in the form of drops or nasal sprays. The most common indications for nasal decongestants are viral infections and allergic conditions in order to alleviate the symptoms so it is necessary to inform the users about the type of drug, the active substance it contains and the correct dosage regimen. Given their availability and the prevailing safety precaution, these preparations can lead to numerous prolonged conditions and complications. The mechanism of action of nasal decongestants is based on the reduction of blood vessels' swelling in the nose, which helps the opening of the airway. As a result, most nasal decongestants cause vasoconstriction (narrowing of blood vessels). There are nasal decongestants that block histamine and have a good effect on people who suffer from seasonal allergies. Availability (free sale) and prolonged use of the decongestant lead to a decrease in the sensitivity of the alpha receptor, which leads to the need to increase the dose at shorter time intervals to achieve the same effect. As a consequence, patients use excessive, uncontrolled doses of nasal decongestants, which is a public problem and warns of the necessity of identification and the taking of measures to prevent their uncontrolled procurement and use. [ABSTRACT FROM AUTHOR]

Mohammad M Mokhatrish,1 Sharif D Almatrafi,1 Turki M Aldrees,1 Turki A Aldriweesh,1 Fahad M AlGhamdi,2 Abdullah S Al-Dosary,3 Naif K Alhumaydani,3 Osamah Z Aldakkan,3 Naif Alrudian,3 Ali Hassan Ali3 1Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Prince Sattam bin Abdulaziz University, Alkharj, Saudi Arabia; 2Department of Family Medicine & Polyclinics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; 3College of Medicine, Prince Sattam Bin Abdulaziz, Alkharj, Saudi ArabiaCorrespondence: Mohammad M Mokhatrish, Department of Otolaryngology-Head and Neck Surgery College of Medicine, Prince Sattam bin Abdulaziz University, AlKharj, 5721, Saudi Arabia, Tel +966500689852, Email mokatresh@hotmail.comBackground: Rhinitis medicamentosa is a nonallergic inflammation of the nasal mucosa caused by topical decongestants overuse. It mainly affects young and middle-aged adults. Therefore, the aim of this study was to investigate the attitudes of pharmacists regarding the utilization of over-the-counter intranasal decongestants.Methods: An online cross-sectional study was conducted from November 2021 to January 2022. The target population of the study included pharmacists who work in community pharmacies in Saudi Arabia. Binary logistic regression analysis was used to identify predictors of having positive attitude towards controlling the use of decongestant.Results: A total of 220 participants were included in this study. Around 15.0% of them reported that ND come with a physician prescription. The majority of the participants (87.3%) reported that the less than 5 days is the maximum safe duration for the use of NDs. Overall, the study participants demonstrated moderately positive attitude towards controlling the use of decongestant with a mean attitude score of 2.5 (standard deviation: 1.2) out of 5; which represents 50.0% of the maximum score. Binary logistic regression analysis identified that pharmacists aged 31– 40 years were two-folds more likely to have positive attitude towards controlling the use of decongestant compared to others (p< 0.05). Around 45.9% of them reported that they recommend other over-the-counter treatments like nasal irrigation, nasal steroids, or antihistamine if they see a patient with RM asking for ND with or without prescription.Conclusion: The majority of pharmacists in Saudi Arabia demonstrated sufficient awareness and understanding on the adverse effects associated with the excessive use of NDs. Rhinitis medicamentosa can be avoided by appropriate measures, highlighting the importance of raising awareness about the excessive use of decongestants among healthcare professionals and patients alike.Keywords: rhinitis medicamentosa, pharmacist, attitude, nasal decongestants, Saudi Arabia

The infraorbital nerve is responsible for the sensory innervation of the lower eyelid, the lateral nose, the cheek, the upper lip, and the maxillary teeth. It passes along the infraorbital canal, which runs superior to the maxillary sinus. Dehiscence of the infraorbital canal and its ectopic course in the maxillary sinus is a rare variation. A nerve with these variations may be affected by pathologies in the maxillary sinus and this may constitute a rare cause of facial pain. In this report, we present the clinical symptoms of a 29-year-old male patient who had an infraorbital nerve with an ectopic course and dehiscence in light of the literature.

Sinonasal inflammatory disease is very common and all clinicians who care for these patients should understand the topical treatment options available. This article reviews the utility and application of steroidal, saline, decongestant, antihistamine and anticholinergic preparations for the treatment of sinonasal disease, with a particular focus on evidence-based guidelines for use in both specialist and non-specialist healthcare settings. [ABSTRACT FROM AUTHOR]

Allergic reactions are quite common in pregnant women. The most common manifestations of an allergic reaction during pregnancy are: from the respiratory tract – allergic rhinitis and bronchial asthma, from the skin and subcutaneous tissue (allergodermatosis) – urticaria, angioedema, atopic dermatitis. As a rule, allergies do not affect the course of pregnancy, and pregnancy does not affect the allergic process, however, allergic reactions in pregnant women can cause difficulties associated with the selection of pharmaceuticals. The article discusses practical issues of pregnant women with allergic diseasesmanagement. Attention is paid to the place of non-drug methods: hypoallergenic diet and enterosorbents for food allergies, the use of sprays based on saline solutions for allergic rhinitis. Medication management of pregnant women suffering from allergic diseases is a compromise between the potential adverse effect of medications on the fetus and the course of pregnancy and the consequences of uncontrolled allergy. If it is necessary to prescribe antihistamines in the secondthird trimesters, it should be assumed that category B according to the FDA classification («no evidence of risk») includes chlorpheniramine, ciproheptadine (Peritol), diphenhydramine (Dimedrol), chlorotripelenamine (Suprastin), cetirizine (Zirtek, Cetrin), loratadine (Claritin), levocetirizine (Xizal). It is contraindicated to take astemizole, terfenadine, Tavegil (klemastin) because of the teratogenic or fetotoxic effect, desloratadine and ketotifen due to their ability to penetrate the placenta. Glucocorticosteroids are the drugs of choice in the treatment of severe forms of allergic diseases in pregnant women. Nasal corticosteroids are widely used in the treatment of moderate and severe allergic rhinitis. Inhaled glucocorticosteroids occupy a central place as a basic means for bronchial asthma. The drug of choice is budesonide, which has the best safety profile and has the greatest evidence base. Topical glucocorticosteroids (Advantan, Locoid, Elokom) in the form of creams and ointments are widely used in atopic dermatitis in pregnant women. If it is necessary to prescribe oral glucocorticosteroids (generalized urticaria, angioedema, severe exacerbation of atopic dermatitis), prednisone is preferred. Deposited glucocorticosteroids are categorically contraindicated. The use of cromoglycic acid, monoclonal antibodies, decongestants, bronchodilators is also discussed.

The infraorbital nerve is responsible for the sensory innervation of the lower eyelid, the lateral nose, the cheek, the upper lip, and the maxillary teeth. It passes along the infraorbital canal, which runs superior to the maxillary sinus. Dehiscence of the infraorbital canal and its ectopic course in the maxillary sinus is a rare variation. A nerve with these variations may be affected by pathologies in the maxillary sinus and this may constitute a rare cause of facial pain. In this report, we present the clinical symptoms of a 29-year-old male patient who had an infraorbital nerve with an ectopic course and dehiscence in light of the literature. [ABSTRACT FROM AUTHOR]

Post‐acne erythema (PAE) is one of the most common sequelae of acne inflammation. Unfortunately, the treatment of PAE remains challenging due to limited effective topical treatments. The objectives of this study were to evaluate the efficacy and safety of topical oxymetazoline hydrochloride (OxH) 0.05% solution for PAE. This study was a split‐face, participants‐and investigators‐blinded, randomized, placebo‐controlled trial conducted between December 2021 and March 2022 in Bangkok, Thailand. Healthy adults aged from 18 to 45 years with mild to severe PAE, according to the Clinician's Erythema Assessment (CEA), on both sides of the face were eligible. After randomization, each participant applied the OxH to one side of their face and a placebo to the contralateral face twice daily for 12 weeks. The primary outcome was PAE lesion counts. The secondary outcomes were erythema index, clinical response rate at week 12 ("clear," "almost clear," or "at least two‐grade improvement" by CEA), and patient satisfaction scores. A total of 30 participants were enrolled. The OxH‐treated skin showed a significantly greater mean difference (MD) reduction in PAE lesion counts than the placebo after 8 weeks of treatment (4.30, 95% confidence interval [CI] 1.42–7.18). Similarly, the MD reduction of the erythema index was higher in the OxH‐treated skin from the second week (11.82, 95% CI 8.48–15.15). Additionally, the OxH‐treated side also achieved a higher clinical response rate after 8 weeks of treatment (40.00% vs. 6.67%; p = 0.002) and rated higher satisfaction than those using the placebo at the end of the study (mean [standard deviation] satisfaction score 8.30 [0.18] vs 7.40 [0.18], P < 0.001). There were no serious adverse events or flares of erythema during the study. In conclusion, our study demonstrated that the topical OxH 0.05% solution was effective, well‐tolerated, and safe for reducing PAE without a rebound effect. It could be a choice of PAE management. Trial Registration: Thai Clinical Trials Registry No. TCTR20211207004. [ABSTRACT FROM AUTHOR]

Background: Nasal decongestant drugs are widely used as potent vasoconstrictive agents to reduce congestion of nasal and ocular mucous membranes in disease such as allergic rhinitis. These drugs are easily accessible to the people over the counter without prescription. The ease in access may lead the population in believing that the drugs are risk free and free from side effects. The purpose of this study was to determine the level of awareness of the people in Unaizah Al-Qassim province in Saudi Arabia on the use of nasal decongestants ad their side effects. Methodology: After gaining the Institutional Review Board (IRB) approval, the study was a questionnaire-based cross-sectional study conducted on the people Unaizah Al-Qassim province in Saudi Arabia. It was explorative in nature as such a study has never been done in Unaizah before and hence descriptive statistics was mainly used to establish significance and reference. The questionnaires assessed the demographical characteristics of the population, participants' history on the usage of nasal decongestants, health condition of the participants, and knowledge on nasal congestion and use nasal decongestants. Results: Out of 385 participants, 54% were male and 46% are female. With regards to age, majority of the participants were between the age of 20 and 40 years 56%, followed by 40--60 years old (33%). 79% of the participants had acquired a baccalaureus level in education. When assessed on the usage of nasal decongestants, 32.5% currently use the decongestants, 64.4% have ever used the drugs now and in the past. In terms of knowledge of the drugs, 16.6% of the participants are aware of the side effects, 25.2% are aware of the medically recommended period to use the drugs, 21.3% have heard of the nasal congestion addiction, and 21.6% are aware of the medication that may cause nasal congestion. Conclusion: The study established that the level of awareness on the use nasal decongestants and the side effects is not significant. There needs to be a sensitization campaign to educate the population on the use of nasal decongestants.

Introduction and purpose: Acute rhinosinusitis is a common condition worldwide, usually caused by respiratory viruses. Nasal epithelium is their primary point of entry and an active responder to the infection. Therefore, it seems reasonable for the treatment approach to include locally applied drugs. Our purpose is to bring forward up-to-date recommendations of intranasal treatment options for acute rhinosinusitis, and assess their efficacy and safety. Description of the state of knowledge: Rhinosinusitis is an inflammation of the mucosa present in the nose and the paranasal sinuses. It affects many patients yearly, bearing significant adverse effects on quality of life, productivity and healthcare expenditure. Acute rhinosinusitis lasts less than 12 weeks and is divided into viral, post-viral and acute bacterial rhinosinusitis. It is one of the prevailing reasons for unfounded antibiotics prescription, although it is usually self-limiting. Its treatment depends on the clinical stage of the infection, however, each of them encloses medications administered intranasally. Based on EPOS2020 and scientific publications it seems that nasal decongestants may be prescribed in viral rhinosinusitis, nasal corticosteroids in post-viral rhinosinusitis and nasal saline can prove beneficial in all clinical stages of rhinosinusitis. While used appropriately all aforementioned medications prove to be safe. Conclusions: In the light of the findings presented in this paper, it can be concluded that acute rhinosinusitis should be treated not only with oral, but also with intranasal drugs. Nasal decongestants are to be considered in viral rhinosinusitis mainly. Nasal corticosteroids show some positive effect in post-viral rhinosinusitis. Nasal saline can be administered in all clinical stages of acute rhinosinusitis. It is crucial to caution the patients against misuse of the medications, in order to prevent their adverse effects.

Nasal congestion is one of the most common symptoms of common colds and rhinitis, due to an inflammatory reaction, vasodilation, increased nasal blood flow and vascular permeability. Nasal obstruction is often a multifactorial problem, in addition to infectious causes, it can be caused by a combination of anatomical aberrations, swelling of the nasal mucosa and enlargement of the turbinates. Anatomical and structural problems, such as nasal septum deviation and nasal valve collapse, are usually treated surgically. Drug therapy of nasal obstruction is aimed at reducing edema and inflammation of the nasal mucosa. Pharmacotherapy of nasal obstruction is aimed at reducing inflammation and/or swelling of the mucous membrane. Decongestants are widely prescribed to relieve symptoms. The drugs used have different mechanisms of action and include systemic and topical drugs. This article discusses decongestants as a treatment for nasal obstruction. When applied topically, the drugs of this group act directly on the α2 and α1-adrenergic receptors of the nasal cavity, causing vasoconstriction, a decrease in the volume of the nasal conch, an increase in nasal patency, and relieving the symptoms of obstruction. The existing risk of developing side effects, both systemic and local, is reduced with atopic exposure and proper dosing of the drug used. Preferably, the use of drugs with low bioavailability. The suppression of the ciliated epithelium can be caused not only by the pathological process, but also by the composition of drugs. The value is given to the acidity of the buffer system. The optimal pH value of intranasal agents is about 6 (neutral range). The combination with anticholinesterase substances reduces the production of pathological discharge. The use of multi-component medicines allows you to restore nasal breathing and suppress excessive nasal secretion. One of the effective and safe drugs of topical action is Xylometazoline, as a monocomponent agent or in combination with ipratropium bromide.

Nasal decongestants are ones of the most popular and widespread medicines due to high frequency of respiratory infections. But on the other hand they are characterized by significant abuse potential for users seeking such effects as euphoria, psychostimulation, less of appetite and lose the weight. The affections of the cardio-circulation and nervous systems are the most frequent complications after overdosing of the nasal decongestants. The development of the strikes in the young age was associated with the nasal decongestants abuse in every tenth patient. The cases of the malignant arterial hypertension, cerebral hemorrhages, ischemic strokes, heart decompensation after the nasal decongestants abuse is known as nasal decongestants poisoning. And although the side effects more often develop when nasal decongestants are used orally, intranasal way could not be considered as absolutely safe, especially in cases of overdosing. The development of the psychotic disorders is one of the most frequent nasal decongestants adverse effects. The elderly people with organic brain damage, drug addiction, mental illness are in the risk group for the development of psychotic complications. Misuse of the nasal decongestants in children is especially dangerous because of the high risk of the development of the life-threatening toxic poisoning. Fatal cases of poisoning were associated with small age of a child, using several medicines with the same ingredient, using decongestants in a daycare setting, mistakes in measuring and identification the medicine, the absence of the doctor’s prescription, use of the product for adult age. Using nasal decongestants in supine position of the patient may lead to the significantly dose increase inside the nasal cavity and may cause toxic poisoning. Adolescents are quite sensitive to the development of nasal decongestants side effects with such risk factors as age, gender, family income, physical and mental health, use of other medicines and alcohol. The special type of the adverse effects of the long-term using of the nasal decongestants is the rhinitis medicamentosa taking place in adult persons with predisposition to the nasal hyperreactivity. The diagnosis of the rhinitis medicamentosa is based on the nasal hyperactivity and swelling of the nasal mucous membrane in combination with poor response on treatment caused or exaggerated by long-term use of topical nasal decongestants. The development of the rhinitis medicamentosa depends on a number of factors such as the type of nasal decongestants, the type of preservative, the presence of risk factors that determine the patient's predisposition to the development of nasal hyperreactivity. Here we review the existing literature concerning the adverse effects of the nasal decongestants including the development of the rhinitis medicamentosa.

The problem of long-term and uncontrolled use of decongestants remains one of the most relevant problems of modern otorhinolaryngology. To date vasoconstrictors are the most actively used drugs for the treatment of acute and chronic rhinitis, as well as other diseases accompanied by nasal congestion. Most of the topical decongestants are selective α2-adrenergic agonists that act on postsynaptic α2-adrenergic receptors, which perform the main function in the implementation of sympathetic stimuli in the nasal cavity. Sympathomimetic drugs in addition to the main vasoconstrictor effect also have their own anti-inflammatory and antioxidant effects. Topical decongestants are included in the treatment guidelines for acute and chronic rhinitis, rhinosinusitis, allergic rhinitis, acute and chronic otitis media, eustachitis. The recommended duration of decongestants is usually limited to 5–7 days. Longer use of this drug class can lead to paresis of the nasal mucosa vessels or an allergic reaction, to the development of rhinitis medicamentosa. Side effects that occur with the use of topical decongestants are divided into 2 groups: local symptoms and general toxic reactions. However, with strict adherence to the recommended dosing regimen of topical decongestants, to the method of use and to the duration of use, undesirable side effects are rare. The group of vasoconstrictor drugs received a new development as a result of the combination of decongestants with other drugs, which lead to the reducing local side effects and the elimination of not only nasal congestion, but also other symptoms of the common cold.

Xylometazoline, a sympathomimetic available as over the counter drug, acts as a nasal decongestant and has been reported as an independent risk factor for hemorrhagic and ischemic stroke. The chronic use of xylometazoline leads to either increased release of more potent vasoconstrictor norepinephrine in the presynaptic region, or acts directly on central adrenoreceptors which leads to dysfunction resulting in chronic progressive vasculopathy that manifests as an ischemic stroke. Sympathomimetics also activate 12-lipoxygenase pathways which induce proliferation and migration of vascular smooth muscle cells. 12-lipoxgenase also plays a significant role in regulating the degree and stability of platelet activation, as its activation significantly strengthens platelet activation and uncontrolled platelet activation, which may lead to myocardial infraction and stroke. The present case reports a rare case of young adult suffering from isolated left medial cerebellar peduncle infarct related to the chronic use of xylometazoline. Acute cerebellar stroke is rare, especially in young adults and represent only 3% of total ischemic and hemorrhagic strokes. Clinical symptoms, patient age at the onset of stroke, and lesion size had no significant effect on the clinical outcome. Symptoms are frequently underestimated and misdiagnosed which further lead to serious complications and poor functional outcomes. [ABSTRACT FROM AUTHOR]

Background: Nasal decongestant drugs are widely used as potent vasoconstrictive agents to reduce congestion of nasal and ocular mucous membranes in disease such as allergic rhinitis. These drugs are easily accessible to the people over the counter without prescription. The ease in access may lead the population in believing that the drugs are risk free and free from side effects. The purpose of this study was to determine the level of awareness of the people in Unaizah Al-Qassim province in Saudi Arabia on the use of nasal decongestants ad their side effects. Methodology: After gaining the Institutional Review Board (IRB) approval, the study was a questionnaire-based cross-sectional study conducted on the people Unaizah Al-Qassim province in Saudi Arabia. It was explorative in nature as such a study has never been done in Unaizah before and hence descriptive statistics was mainly used to establish significance and reference. The questionnaires assessed the demographical characteristics of the population, participants' history on the usage of nasal decongestants, health condition of the participants, and knowledge on nasal congestion and use nasal decongestants. Results: Out of 385 participants, 54% were male and 46% are female. With regards to age, majority of the participants were between the age of 20 and 40 years 56%, followed by 40--60 years old (33%). 79% of the participants had acquired a baccalaureus level in education. When assessed on the usage of nasal decongestants, 32.5% currently use the decongestants, 64.4% have ever used the drugs now and in the past. In terms of knowledge of the drugs, 16.6% of the participants are aware of the side effects, 25.2% are aware of the medically recommended period to use the drugs, 21.3% have heard of the nasal congestion addiction, and 21.6% are aware of the medication that may cause nasal congestion. Conclusion: The study established that the level of awareness on the use nasal decongestants and the side effects is not significant. There needs to be a sensitization campaign to educate the population on the use of nasal decongestants. [ABSTRACT FROM AUTHOR]

Introduction: Sinus barotrauma is a common occurrence in diving and subaquatic medicine, potentially compromising dive safety. To gain a more thorough understanding of the condition, an in-depth investigation is justified. Methods: This was a survey study. An anonymous, electronic questionnaire was distributed to 7,060 recipients: professional divers of the Finnish Border Guard, the Finnish Rescue Services, and the Finnish Heritage agency, as well as recreational divers registered as members of the Finnish Divers' Association reachable by email (roughly two-thirds of all members and recreational divers in Finland). Primary outcomes were self-reported prevalence, clinical characteristics, and health effects of sinus barotrauma while diving. Secondary outcomes were adjusted odds ratios (OR) for frequency of sinus barotrauma with respect to possible risk factors. Results: In total, 1,881 respondents participated in the study (response rate 27%). A total of 49% of the respondents had experienced sinus barotrauma while diving and of those affected, 32% had used medications to alleviate their symptoms. The factors associated with sinus barotrauma were pollen allergies (OR 1.59; 95% CI 1.10-2.29), regular smoking (OR 2.04; 95% CI 1.07-3.91) and a high number of upper respiratory tract infections per year (= 3 vs. < 3 infections per year: OR 2.76; 95% CI 1.79-4.24). Conclusions: Sinus barotrauma is the second most common condition encountered in diving medicine, having affected 49% of the respondents. Possible risk factors include allergies to pollen, regular smoking, and a high number of URTIs per year. [ABSTRACT FROM AUTHOR]

Middle ear barotrauma (MEB) is a common complication of hyperbaric oxygen (HBO2) therapy. It has been reported in more than 40% of HBO2 treatments and can interrupt the sequence of HBO2. MEB may lead to pain, tympanic membrane rupture, and even hearing loss. The aim of this study was to determine if pretreatment with intranasal fluticasone and oxymetazoline affected the incidence of MEB. We conducted a retrospective chart review of subjects undergoing HBO2 at our institution between February 1, 2014, and May 31, 2019. Subjects in the fluticasone/oxymetazoline (FOT) treatment group used intranasal fluticasone 50 mcg two times per day and oxymetazoline 0.05% one spray two times per day beginning 48 hours prior to initial HBO2. Oxymetazoline was discontinued after four days. Fluticasone was continued for the duration of HBO2 therapy. A total of 154 unique subjects underwent 5,683 HBO2 treatments: 39 unique subjects in the FOT group underwent 1,501 HBO2; 115 unique subjects in the nFOT (no oxymetazoline or fluticasone treatment) group underwent 4,182 HBO2 treatments. The incidence of MEB was 15.4% in the FOT group and 16.2% in the nFOT group. This was not a statistically significant difference (OR = 0.77; p = 0.636). Treatment pressure, age over 65 years, male sex, and BMI were not associated with a difference in MEB incidence. In summary, pretreatment with intranasal oxymetazoline and fluticasone in patients undergoing HBO2 did not significantly reduce MEB. More investigation with larger numbers of participants and prospective studies could further clarify this issue. [ABSTRACT FROM AUTHOR]

Introduction Nasal decongestants are one of the drugs commonly prescribed by otorhinolaryngologists in their day to day practice. The excessive or inappropriate use of nasal decongestant due to rapid symptomatic relief leads to drug misuse or abuse. Inadequate knowledge about the drug usage leads to inappropriate drug usage. Materials and Methods A cross sectional study was done among 90 patients who were using topical nasal decongestants. A pre tested, pre validated questionnaire was used to assess the patient’s knowledge, the utilization pattern and the attitude towards the drug usage. Results The mean age of presentation in our study was 38.4 years. Only 14.4% of the people knew the appropriate duration of drug usage. Only 33.3% knew about the probable side effects of prolonged drug usage. There was a significant correlation between knowledge and utilisation pattern of topical nasal decongestants usage and the literacy level. Though most of the people (46.7%) started using the drug after being prescribed by a doctor, only 14.3% among them strictly adhered to doctor’s instructions.82% of the users were not much worried about the prolonged usage as 73.3% believed that prolonged use may or will surely improve their symptoms. Though 66.7% users wanted to stop prolonged usage of the drug, 76.9% had varying difficulties in stopping the drug. Conclusion The knowledge and the utilization pattern regarding the drug usage were very low. The same was found to be better with increase in literacy level. Health professionals should play a major role in establishing a rational drug usage.

Introduction Nasal decongestants are one of the drugs commonly prescribed by otorhinolaryngologists in their day to day practice. The excessive or inappropriate use of nasal decongestant due to rapid symptomatic relief leads to drug misuse or abuse. Inadequate knowledge about the drug usage leads to inappropriate drug usage. Materials and Methods A cross sectional study was done among 90 patients who were using topical nasal decongestants. A pre tested, pre validated questionnaire was used to assess the patient’s knowledge, the utilization pattern and the attitude towards the drug usage. Results The mean age of presentation in our study was 38.4 years. Only 14.4% of the people knew the appropriate duration of drug usage. Only 33.3% knew about the probable side effects of prolonged drug usage. There was a significant correlation between knowledge and utilisation pattern of topical nasal decongestants usage and the literacy level. Though most of the people (46.7%) started using the drug after being prescribed by a doctor, only 14.3% among them strictly adhered to doctor’s instructions.82% of the users were not much worried about the prolonged usage as 73.3% believed that prolonged use may or will surely improve their symptoms. Though 66.7% users wanted to stop prolonged usage of the drug, 76.9% had varying difficulties in stopping the drug. Conclusion The knowledge and the utilization pattern regarding the drug usage were very low. The same was found to be better with increase in literacy level. Health professionals should play a major role in establishing a rational drug usage.

Introduction: Amniotic band syndrome (ABS) includes limb deficiencies accompanied by fibrous strands originating from the amniotic lining. Terminal transverse limb deficiencies (TTLD) appear to be similar but lack fibrous strands. Both are hypothesized to result from vascular disruption. For ABS, limb deficiencies are considered secondary to amnion rupture. We explored an alternative possibility—that TTLD is the primary defect and ABS is secondary. Methods: Using data from the National Birth Defects Prevention Study, we expanded on a previous study. We examined smoking, alcohol, and medications categorized by indicated vasoactivity as markers of vascular disruption. Logistic regression models with Firth's penalized likelihood were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results: Use of bronchodilators and aspirin appeared to increase the risk of ABS, while decongestants and nonaspirin NSAIDs increased the risk of TTLD. The risk of ABS was markedly increased in cases reporting combinations of vasoactive exposures, particularly alcohol and aspirin (aOR 3.7, 95% CI 1.6, 7.8), and alcohol and bronchodilators (aOR 3.4, 95% CI 1.4, 7.5). Increased risk of TTLD due to combinations of vasoactive exposures was only observed for smoking and decongestants (aOR 2.3, 95% CI 1.4, 3.6). Conclusions: Exposures associated with increased risk of ABS had no apparent association with TTLD, supporting previous evidence that these may be distinct phenotypes. ABS appears to be associated with combined exposures with vasodilation properties, such as alcohol and bronchodilators, while increased risk of TTLD may be associated with smoking and decongestants, both vasoconstrictive exposures. [ABSTRACT FROM AUTHOR]

Objective:Intranasal steroid sprays (INSS) are frequently prescribed for treating inferior turbinate hypertrophy (ITH). Complications due to the long-term application of INSS such as crusting, epistaxis, nasal mucosa dryness, and septal perforation may occur. Predicting patients who would benefit from INSS early might lower treatment costs and complication rates. We examined the predictive value of nasal decongestant response rates for the outcomes of INSS in ITH.Methods:Fifty patients with bilateral ITH were included in two groups: patients benefiting from INSS and those not benefiting. Nasal airflow was assessed by peak nasal inspiratory flow (PNIF) measurement in all cases. Measurements were taken three times: before and after the application of nasal decongestant sprays and after the application of INSS.Results:In both groups, the nasal air flow rates significantly increased after the application of nasal decongestant sprays; however, the nasal decongestant response rates were higher in the group with patients benefiting from INSS. There was a strong correlation between the nasal air flow rates measured after the application of nasal decongestant sprays and after the application of INSS. The cut-off value for the relationship between increased nasal air flow rates after the application of nasal decongestant sprays and outcomes of INSS was 23%.Conclusion:Measurement of nasal airflow increase rate after the application of nasal decongestant sprays is a simple and easy method for the early prediction of the outcomes of INSS in ITH. A higher than 23% increase in nasal air flow rates after the application of nasal decongestant sprays indicates much better outcomes of INSS for patients.

Objectives To identify the optimal pharmacological method of preparing patients for nasal endoscopy. Methods Twenty healthy volunteers were enrolled in this prospective, randomized, double-blind study. Four types of medications were applied in their nostrils with binary combinations of spray bottles on four different days in a random order: placebo (normal saline [NS]+NS), decongestant (NS+oxymetazoline), anesthetic (NS+lidocaine), and decongestant plus anesthetic (oxymetazoline+lidocaine). Rigid nasal endoscopy was performed 10 minutes after spray application. The volunteers evaluated the discomfort caused by each spray application, and nasal pain scores due to the passage of the endoscope. The physicians quantified nasal decongestion using a visual analogue scale. Endoscopy duration as well as pulse and mean blood pressure (MBP) before spray application, 10 minutes after the application, and immediately after endoscopic examination were also recorded. Results The discomfort caused by lidocaine was significantly higher than that caused by the other sprays (P

Objective: Rhinitis medicamentosa is drug-induced rhinitis which occurs by prolonged and overdose usage of topical nasal decongestants. There is not much of treatment choice rather than nasal steroids. In this pathological study, we have been aimed to represent the healing effects of xylitol on damaged nasal mucosa due to rhinitis medicamentosa. Method: 30 Wistar rats were separated into 5 groups. During 2 months, oxymetazoline was given to the first group, and saline was given to second group intranasally. First and second group animals were examined at the end of 2 months and rhinitis medicamentosa was detected. Oxymetazoline was given to the third, fourth, and fifth groups during 2 months. Then xylitol solution, mometasone, and saline were applied, respectively, for 15 days. After the experiment, rats' nasal mucosas were evaluated histopathologically. Results: Xylitol and mometasone were found to be more effective than the control group in terms of histopathological changes. Effectivity of xylitol and mometasone was compared and not a significant value was determined. Conclusions: According to the results, xylitol solution is effective as mometasone, usable and well-priced in the treatment of rhinitis medicamentosa. More comprehensive and ultrastructural studies on animals and human studies with rhinometric evaluation should be performed. [ABSTRACT FROM AUTHOR]

Purpose: The use of nasal decongestant and nasal anaesthesia is currently not recommended during drug-induced sleep endoscopy (DISE) according to the European position paper. The evaluation of the effects of nasal decongestant/anaesthesia on DISE has not been performed before and our aim is to perform a pilot study to determine whether nasal decongestants/anaesthesia affects DISE outcomes. Methods: 27 patients undergoing DISE for OSA or for simple snoring were included. On each patient, DISE was performed twice, before and approximately 10 min after the administration of two puffs of co-phenylcaine nasal spray (lidocaine hydrochloride 5%, phenylephrine 0.5%, and benzalkonium chloride 0.01%) into each nostril. A nasal peak inspiratory flow was used for the objective assessment of nasal airway obstruction. During the first and the second DISE the loudness of the snoring was also recorded. Results: Change in DISE total grading after nasal spray administration was not statistically significant. For the same grading, changes in percentage of contribution to collapse were not statistically significant. Sex, AHI, BMI, tonsils grade, presence of rhinitis, turbinate hypertrophy, nasal septal deviation, or nasal peak inspiratory flow limitation had no influence on the effect of nasal spray. Co-phenylcaine did not significantly influence the loudness of snoring. Conclusions: Our pilot study supports the use of co-phenylcaine nasal spray during DISE and the positive effects of the nasal spray do not influence the grading outcome. Importantly, the decongestant enhances the nasal assessment during DISE and potentially aids in the diagnosis of nasal obstruction while the nasal anaesthetic component may be beneficial by reducing nasal discomfort during DISE and thereby helping to reduce the total dose of intravenous anaesthetic administered. However, further studies on a larger population are needed to confirm our results. [ABSTRACT FROM AUTHOR]

The article presents current data on acute rhinosinusitis, its essence, classification, etiology, pathogenesis, treatment approaches in children. It is emphasized that the key to successful treatment of this disease is the impact on all parts of pathogenesis. Given the leading etiopathogenetic links of acute rhinosinusitis, its comprehensive treatment requires prescribing of preparations with anti-infection, anti-inflammatory, secretolytic and immune-stimulating action, as well as nasal decongestants — to eliminate the swelling of the nasal mucosa and to improve the quality of life of the patient. The detailed description of nasal decongestants is presented, the attention is paid to the next generation drug without preservatives — dosed nasal drops Nasivin® Sensitive.

Objective: Rhinitis medicamentosa (RM) is a common condition resulting from overuse of topical nasal decongestants. Despite the prevalence in otolaryngologic practice, a clear treatment protocol has not been established. Our objective was to review the current published literature pertaining to the treatment of RM with the possibility of finding data that support one treatment over another.Data Sources: PubMed, Embase, Cochrane, and Web of Science databases were examined for patients diagnosed with RM resulting from chronic use of topical nasal decongestants.Review Methods: The PRISMA standard (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was utilized to identify English-language studies reporting treatment of patients with the primary diagnosis of RM after chronic use of a topical decongestant. Outcome measures of interest included patient-reported symptom relief and objective parameters. MINORS criteria (methodological index for nonrandomized studies) were used to assess the quality of articles.Results: A total of 350 articles were identified, 9 of which met final inclusion criteria for qualitative analysis. Outcomes defined in each publication were highly varied and relied on several unstandardized measures. The most commonly reported treatment option was topical nasal steroids, although overall there was limited evidence on which to base treatment recommendation.Conclusions: There is not adequate evidence to develop a standardized treatment protocol for RM. The development of a uniform questionnaire, standard outcomes to be measured, and a method of assessing such outcomes is necessary. Prospective randomized controlled studies are warranted to determine the optimal treatment regimen following diagnosis of RM. [ABSTRACT FROM AUTHOR]

BACKGROUND: Endoscopic rhinoscopy allows adequate visualization of nasal structures and thus facilitates diagnosis in rhinology. Systematically nasal preparation is performed with topical anesthetic and vasoconstrictor; however, its efficacy and utility have not been measured. OBJECTIVE: To evaluate the effectiveness of the application of two combinations for nasal preparation. PATIENTS A N D METHOD: A prospective, random, simple blind study in which patients of both sexes were recruited in the private consultation of the main author during November 2016; their consent was obtained and they were randomized to receive a combination of lidocaine 10% nasal spray with 0.05% oxymetazoline or 2% lidocaine and epinephrine 0.005 mg/mL prior to performing nasal rigid endoscopy. Patients were asked to assess the degree of discomfort of drug application and the procedure and a comparison of the means for both groups was performed. Likewise, the degree of decongestion was evaluated by the author. RESULTS: A total of 22 patients were studied, 12 men (54.5%) and 10 women (45.5%). The mean age was 41.45 ± 12.85 years. Both groups show very similar means for all variables without significant statistical differences. CONCLUSION: There was no significant advantage of any of the combinations used for routine nasal preparation prior to endoscopy. There are factors that must be taken into account prior to the completion of the study and preparation of the nose with medications, such as pain threshold and patient age. [ABSTRACT FROM AUTHOR]

Objective: Intranasal steroid sprays (INSS) are frequently prescribed for treating inferior turbinate hypertrophy (ITH). Complications due to the long-term application of INSS such as crusting, epistaxis, nasal mucosa dryness, and septal perforation may occur. Predicting patients who would benefit from INSS early might lower treatment costs and complication rates. We examined the predictive value of nasal decongestant response rates for the outcomes of INSS in ITH. Methods: Fifty patients with bilateral ITH were included in two groups: patients benefiting from INSS and those not benefiting. Nasal airflow was assessed by peak nasal inspiratory flow (PNIF) measurement in all cases. Measurements were taken three times: before and after the application of nasal decongestant sprays and after the application of INSS. Results: In both groups, the nasal air flow rates significantly increased after the application of nasal decongestant sprays; however, the nasal decongestant response rates were higher in the group with patients benefiting from INSS. There was a strong correlation between the nasal air flow rates measured after the application of nasal decongestant sprays and after the application of INSS. The cut-off value for the relationship between increased nasal air flow rates after the application of nasal decongestant sprays and outcomes of INSS was 23%. Conclusion: Measurement of nasal airflow increase rate after the application of nasal decongestant sprays is a simple and easy method for the early prediction of the outcomes of INSS in ITH. A higher than 23% increase in nasal air flow rates after the application of nasal decongestant sprays indicates much better outcomes of INSS for patients. [ABSTRACT FROM AUTHOR]

Background: The use of decongestants during the second or third trimesters of pregnancy has been associated with a decreased risk of preterm delivery in two observational studies. This effect may have been subject to immortal time bias, a bias arising from the improper classification of exposure during followup. We illustrate this bias by repeating the studies using a different data source. Methods: The United Kingdom Hospital Episodes Statistics and the Clinical Practice Research Datalink databases were linked to identify all live singleton pregnancies among women aged 15 to 45 years between 1997 and 2012. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals of preterm delivery (before 37 weeks of gestation) by considering the use of decongestants during the third trimester as a time-fixed (biased analysis which misclassifies unexposed person-time as exposed person-time) and time-varying exposure (unbiased analysis with proper classification of unexposed person-time). All models were adjusted for maternal age, smoking status, maternal diabetes, maternal hypertension, preeclampsia, and parity. Results: Of the 195,582 singleton deliveries, 10,248 (5.2%) were born preterm. In the time-fixed analysis, the HR of preterm delivery for the use of decongestants was below the null and suggestive of a 46% decreased risk (adjusted HR=0.54; 95% confidence interval, 0.24-1.20). In contrast, the HR was closer to null (adjusted HR=0.93 95% confidence interval, 0.42-2.06) when the use of decongestants was treated as a time-varying variable. Conclusion: Studies of drug safety in pregnancy should use the appropriate statistical techniques to avoid immortal time bias, particularly when the exposure occurs at later stages of pregnancy. [ABSTRACT FROM AUTHOR]

BACKGROUND: In October 2007, manufacturers voluntarily withdrew over-the-counter (OTC) infant cough and cold medications (CCMs) from the US market. A year later, manufacturers announced OTC CCM labeling would be revised to warn against OTC CCM use by children aged <4 years. We determined whether emergency department (ED) visits for CCM adverse drug events (ADEs) declined after these interventions. METHODS: We used National Electronic Injury Surveillance System- Cooperative Adverse Drug Event Surveillance data from 2004 to 2011 to estimate the number of ED visits for CCM ADEs before and after each intervention. RESULTS: Among children aged <2 years, ED visits for CCM ADEs decreased from 4.1% of all ADE ED visits before the market withdrawal to 2.4% of all ADE visits afterward (difference in proportion: -1.7%, 95% confidence interval [CI]: -2.7% to -0.6%). Among children aged 2 to 3 years, ED visits for CCM ADEs decreased from 9.5% of all ADE ED visits before the labeling revision announcement to 6.5% of all ADE visits afterward (difference in proportion: -3.0%, 95% CI: -5.4% to -0.6%). Unsupervised ingestions accounted for 64.3% (95% CI: 51.1% to 77.5%) of CCM ADE ED visits involving children aged <2 years after the withdrawal and 88.8% (95% CI: 83.8% to 93.8%) of visits involving children aged 2 to 3 years after the labeling revision announcement. CONCLUSIONS: After a voluntary market withdrawal and labeling revision, ED visits for CCM ADEs declined among children aged <2 years and 2 to 3 years relative to ADE ED visits for all drugs. Interventions addressing unsupervised ingestions are needed to reduce CCM ADEs. [ABSTRACT FROM AUTHOR]

Abstract: A method for the simultaneous analysis of antibiotics, antiviral and nasal decongestants in treated sewage effluent and surface water has been developed and validated. The method uses on-line solid phase extraction (SPE) of injected high-volume samples in conjunction with liquid chromatography–tandem mass spectrometry (LC–MS/MS). This method includes a range of antibiotics (Trimethoprim, Oxytetracycline, Ofloxacin, Norfloxacin, Ciprofloxacin, Azithromycin, Doxycycline, Sulfamethoxazole, Erythromycin and Clarithromycin), an antiviral (Oseltamivir) and nasal decongestants (Naphazoline, Oxymetazoline and Xylometazoline). The method''s detection limits (MDLs) ranged from (0.2ngL−1) to (3.1ngL−1), based on a 1mL extraction volume. Its intra-day precision was determined by performing nine runs with 200ngL−1 samples; the intra-day relative standard deviation (RSD) ranged from 1% to 19%. Inter-day precision was determined by analyzing samples in triplicate over the course of three days, yielding relative standard deviations ranging from <5% to <26%. The linearity (R 2) for all compounds tested was >0.90. Spike relative recoveries ranged from 40% to 157% and 40% to 152% for STP effluent and surface water samples, respectively. Finally, the method was used to analyze real effluent and surface water. [Copyright &y& Elsevier]

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic inflammatory disease of the nasal and paranasal sinus mucosa that, despite differing hypotheses regarding its cause, remains poorly understood. Major symptoms are nasal congestion or blockage, loss of smell, rhinorrhea, postnasal drip, and facial pain or pressure. Among the objectives of CRSwNP management are to eradicate nasal polyps from nasal and sinusal cavities, eliminate symptoms, and prevent recurrences. Corticosteroids are the mainstay of treatment and are the most effective drugs for treating CRSwNP. Other potential treatments are nasal saline irrigation and antihistamines (in allergic conditions). Endoscopic sinus surgery is recommended when medical treatment fails. After surgery, medical treatment, including nasal and oral corticosteroids, is recommended. [ABSTRACT FROM AUTHOR]

Objective. Although topical decongestants and anesthetics are widely used in preparation for nasal endoscopy, no controlled trials have evaluated the effects of these agents on olfaction.Study Design. Randomized double-blinded controlled trial.Setting. Tertiary referral hospital.Materials and Methods. The authors recruited 72 healthy subjects and randomly assigned them to 1 of 4 groups (control, phenylephrine group, lidocaine group, and both agents). After baseline tests with the Korean version of Sniffin’ Stick Test II (KVSS II), topical agents were applied to each nostril. Fifteen minutes later, repeat tests were carried out. Pre- and postspray results of the olfactory tests were compared, and the differences among groups were analyzed.Results. The mean ± SD prespray KVSS II score of the study group was 30.2 ± 3.8, and there were no statistically significant differences among the study groups (P = .353). Mean ± SD pre- and postspray KVSS II scores were 29.0 ± 3.5 and 30.7 ± 3.7 (P = .128) in the control group, 30.6 ± 3.6 and 31.7 ± 3.3 (P = .262) in the phenylephrine group, and 31.4 ± 3.6 and 32.1 ± 3.1 (P = .557) in the lidocaine group, respectively. In the phenylephrine and epinephrine spray group, the mean ± SD pre- and postspray scores were 29.9 ± 4.4 and 31.3 ± 3.7 (P = .071), respectively.Conclusions. Neither topical intranasal phenylephrine nor lidocaine use affected the results of the olfactory test, even when the agents were used in combination. [ABSTRACT FROM PUBLISHER]

Background: Oxymetazoline and xylometazoline are locally effective and direct acting drugs that relieve nasal congestion. The aim of this study was to objectively determine and compare the decongestive effects of oxymetazoline and xylometazoline in healthy subjects. Methods: The study population comprised thirty healthy adults. All subjects underwent active anterior rhinomanometry (AARhm) and acoustic rhinometry (AR) tests following the application of oxymetazoline, xylometazoline, or placebo (physiological saline). The change in nasal resistance, nasal airflow, and different cross-sectional areas (CSAs) of the nasal cavity in the subjects were examined for each solution separately. The measurements were obtained over a 1-h period (baseline and 1, 15, 30, and 60 min post-dosing). All results were analyzed using the Kruskal-Wallis test and the Mann-Whitney U test. Results: A total of 6,300 measurements of AARhm and AR were obtained. The application of placebo did not cause a statistically significant change in nasal resistance, nasal airflow, and CSAs (CSA1, 2, and 3, respectively) of the nasal cavity. In contrast, statistically significant changes in nasal resistance (inspiration p = 0.000 and p = 0.004; expiration p = 0.000 and p = 0.000), nasal airflow (inspiration p = 0.000 and p = 0.004; expiration p = 0.000 and p = 0.000), and CSAs of the nasal cavity (CSA2 p = 0.000 and p = 0.000, CSA3 p = 0.000 and p = 0.00), with the exception of CSA1 ( p = 0.982 and p = 0.994), were obtained after the application of oxymetazoline and xylometazoline. A comparison of oxymetazoline and xylometazoline based on nasal resistance, nasal airflow, and CSAs of the nasal cavity demonstrated no statistically significant difference, except for CSA3. Conclusion: Oxymetazoline and xylometazoline are fast-acting and potent topical decongestants that have similar decongestive effects. [ABSTRACT FROM AUTHOR]

OBJECTIVE: A voluntary market withdrawal of orally administered, over-the-counter, infant cough and cold medications (CCMs) was announced in October 2007. The goal of this study was to assess CCM-related adverse events (AE5) among children after the withdrawal. METHODS: Emergency department (ED) visits for CCM-related AEs among children <12 years of age were identified from a nationally representative, stratified, probability sample of 63 US EDs, for the 14 months before and after announcement of withdrawal. RESULTS: After withdrawal, the number and proportion of estimated ED visits for CCM-related AEs involving children <2 years of age were less than one-half of those in the prewithdrawal period (1248 visits [13.3%] vs 2790 visits [28.7%]; difference: -15.4% [95% confidence interval [Cl]: -25.9% to -5.0%]), whereas the overall number of estimated ED visits for CCM-related AEs for children <12 years of age remained unchanged (9408 visits [95% Cl: 6874-11 941 visits] vs 9727 visits [95% Cl: 6649 -12 805 visits]). During both periods, two-thirds of estimated ED visits involved unsupervised ingestions (ie, children finding and ingesting medications). CONCLUSIONS: ED visits for CCM-related AEs among children <2 years of age were substantially reduced after withdrawal of over-the-counter infant CCMs. Further reductions likely will require packaging improvements to reduce harm from unsupervised ingestions and continued education about avoiding CCM use for young children. Monitoring of CCM-related harm should continue because recommendations were updated in October 2008 to avoid the use of CCMs for children <4 years of age. [ABSTRACT FROM AUTHOR]