Upper Respiratory Tract Infections

1. Upper Respiratory Tract Infections Etiopathogenesis and Management

2. URTIs • Rhinitis • Sinusistis • Pharyngitis • Otitis Media

3. URT

4. Rhinitis • Allergic rhinitisis the most common illness presenting as nasal itching, sneezing, discharge or nasal blocking.

5. Rhinitis • Seasonal allergic rhinitis : Pollens of importance include tree pollens in spring and grass pollens during summer, pollens and moulds.

6. Rhinitis • Perennial rhinitis : • House-dust mite are the commonest cause of perennial allergic symptoms. • These are found in every house and accumulate in carpets, bedding, fabric and furniture. • Domestic pets, e.g. cats, dogs and even cockroaches cause rhinitis.

7. Rhinitis • Chronic nonallergic rhinitis : • The symptoms are chronic and no specific cause for the rhinitis can be determined. • Approximately 15% to 20% of patients with this syndrome have an increase in eosinophils. • These patients respond to topical corticosteroids

8. Clinical features • Allergic basis is suggested by dominant itching, sneezing, watery discharge and associated eye or chest symptoms. • Seasonality of symptoms and relation to work-place are also suggestive. • A personal or family history of atopy (The genetic tendency to develop the classic allergic diseases) is extremely common. • The presence of facial pain, fever, systemic upset and mucopurulent discharge suggest infective aetiology.

9. Physical findings • On examination, allergic rhinitis is associated with a pale, bluish, boggy appearance during active symptoms. • Structural abnormalities such as polyps, deflected nasal seputum or enlarged turbinates (conchae) are important since surgical treatment may be required.

10. Treatment • The main principles are • (i) avoidance of allergens • (ii) use of topical corticosteroids and • (iii) oral H1-selective antihistaminics

11. Treatment • Beclomethasone and budesonide are available as aqueous solutions which are better tolerated, have better local distribution in nose and side-effects are minor. • Histamine H1 - receptor antagonists have low anticholinergic and sedative profile and are particularly effective for sneezing, itching and rhinorrhoea but they have little effect on nasal blockage. • loratidine and cetrizine have been in use. These drugs should be avoided during pregnancy.

12. Precautions • driving with closed windows, afternoon or evening walk in parks, etc. might help. • House-dust and mite control measures may include avoidance of nonsynthetic bedding, restriction of soft toys, use of mattress covers, thorough vacuum cleaning and damp dusting at least once a week.

13. Sinusitis

14. Sinuses • The sinuses are hollow air-filled sacs lined by mucous membrane. • The sinuses contain defenses against viruses and bacteria (germs). • The sinuses are covered with a mucous layer and cells that contain tiny hairs on their surfaces (cilia). These help trap and propel bacteria and pollutants outward.

15. Sinus • Each sinus has an opening into the nose for the free exchange of air and mucus, and each is joined with the nasal passages by a continuous mucous membrane lining. • Therefore, anything that causes a swelling in the nose-an infection, an allergic reaction, or an immune reaction-also can affect the sinuses. • Air trapped within a blocked sinus, along with pus or other secretions, may cause pressure on the sinus wall. The result is the sometimes intense pain of a sinus attack. • Similarly, when air is prevented from entering a paranasal sinus by a swollen membrane at the opening, a vacuum can be created that also causes pain.

16. Sinuses • Sinuses have small orifices (ostia) which open into recesses (meati) of the nasal cavities. • Meati are covered by turbinates (conchae). • Turbinates consist of bony shelves surrounded by erectile soft tissue. • There are 3 turbinates and 3 meati in each nasal cavity (superior, middle, and inferior).

17. Nasal conchae

18. Sinuses - Location • Four pairs of paranasal sinuses • Frontal-above eyes in forehead bone • Maxillary-in cheekbones, under eyes • Ethmoid-between eyes and nose • Sphenoid-in center of skull, behind nose and eyes

19. Paranasal Sinuses

20. Development • Maxillary and ethmoid sinuses develop during 3rd and 4th gestational month and grow in size until late adolscence. • Sphenoid sinus presents by 2 yrs of age • Frontal sinus develops during 5 and 6 years.

21. Sinusitis • Inflammation of paranasal sinuses

22. Sinusitis • An acute inflammatory process involving one or more of the paranasal sinuses. • A complication of 5%-10% of URIs in children. • Persistence of URI symptoms >10 days without improvement. • Maxillary and ethmoid sinuses are most frequently involved.

23. Pathogenesis • Usually follows rhinitis, which may be viral or allergic. • May also result from abrupt pressure changes (air planes, diving) or dental extractions or infections. • Inflammation and edema of mucous membranes lining the sinuses cause obstruction. • This provides for an opportunistic bacterial invasion.

24. Pathogenesis contd… • With inflammation, the mucosal lining of the sinuses produce mucoid drainage. Bacteria invade and pus accumulates inside the sinus cavities. • Postnasal drainage causes obstruction of nasal passages and an inflamed throat. • If the sinus orifices are blocked by swollen mucosal lining, the pus cannot enter the nose and builds up pressure inside the sinus cavities.

25. Predisposing Factors • Allergies, nasal deformities, nasal polyps, and HIV infection. • Cold weather • High pollen counts • Day care attendance • Smoking in the home • Reinfection from siblings • pollen counts :The average number of pollen grains, usually of ragweed, in a cubic yard or other standard volume of air over a 24-hour period at a specified time and place.

26. Etiology of Sinusitis 70% of bacterial sinusitis is caused by: • Streptococcus pneumoniae • Haemophilus influenzae • Moraxella catarrhalis Other causative organisms are: • Staphylococcus aureus • Streptococcus pyogenes, • Gram-negative bacilli • Respiratory viruses

27. Classification of Bacterial Sinusitis • Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely • Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely • Chronic sinusitis- symptoms lasting more than 12 weeks

28. Differentiating Sinusitis from Rhinitis Sinusitis • Nasal congestion • Purulent rhinorrhea • Headache • Facial pain • Anosmia • Cough, fever Rhinitis • Nasal congestion • Rhinorrhea clear • Runny nose • Itching, red eyes • Nasal crease • Seasonal symptoms

29. Nasal polyps

30. Road to Bacterial Sinus Infections • Obstruction of the various ostia • Impairment in ciliary function • Increased viscosity of secretions • Impaired immunity • Mucus accumulates • Decrease in oxygenation in the sinuses • Bacterial overgrowth

31. Allergic Stimuli Causing Rhinosinusitis • Pollens • Tree, grass, weeds • House dust mite • Animal danders • Cat, dog, mice, gerbil, other animals with fur • Molds • Allergic foods and beverages

32. Nonallergic Stimuli Causing Rhinosinusitis • Tobacco smoke • Perfumes • Cleaning solutions • Burning candles • Cosmetics • Car exhaust, diesel fumes • Hair spray • Cold air • Dry air • Changes in barometric pressure • Auto exhaust • Gas, diesel fuel • Nonallergic foods • Nonallergic beverages

33. Acute Bacterial Sinusitis • Usually begins with viral upper respiratory illness • Symptoms initially improve, but then … • Symptoms become persistent or severe • Persistent… 10-14 days but fewer than 4 weeks • Severe…temperature of 102°, purulent nasal discharge for 3-4 days, child appears ill • Disease clears with appropriate medical treatment

34. Physical Findings • Mucopurulent nasal discharge • Highest positive predictive value • Swelling of nasal mucosa • Mild erythema • Facial pain (unusual in children) • Periorbital swelling

35. Diagnosis • Rhinoscopy • CT Scan (Ethmoid & Maxillary sinuses) • MRI for tumors and not for sinusitis

36. CT scan • A CT scan may indicate a sinus infection if any of these conditions is present: • Air-fluid levels in one or more sinuses • Total blockage in one or more sinuses • Thickening of the inner lining (mucosa) of the sinuses • Mucosal thickening can occur in people without symptoms of sinusitis. Therefore, CT scan findings must be correlated with a person's symptoms and physical examination findings to diagnose a sinus infection.

37. Objectives of Treatment of Acute Bacterial Sinusitis • Decrease time of recovery • Prevent chronic disease • Decrease exacerbations of asthma or other secondary diseases

38. Treatment of Acute Sinusitis • Antihistamines recommended if allergy present • Oral or topical • Decongestants • Oral or topical • Antibiotic when indicated (bacteria) • Nasal irrigation • Hydration

39. Decongestants • Topical nasal sprays (limit use to 3-7 days) • Phenylephrine • Oxymetazoline • Naphthazoline • Tetrahydrozoline • Zylometazoline • Topical nasal spray (unlimited daily use) • Ipatropium • Oral • Pseudoephedrine 30-60 mg • Phenylephrine 2-4 times/day

40. Antibiotics for Acute Bacterial Sinusitis • Amoxicillin 500 mg tid for 10-14 days • First line choice in most areas • Local differences in antibiotic resistance occur • Where beta-lactamase resistance is an issue • Amoxicillin/clavulanate • Cefuroxime • Cefpodoxime • Cefprozil

41. Additional Antibiotics for Acute Bacterial Sinusitis • Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum (45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days) • If penicillin-allergic clarithromycin or azithromycin • Erythromycin does not provide adequate coverage • Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistance

42. Chronic Sinusitis • Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in children • Eosinophilic inflammation or chronic infection • Associated with positive CT scans • Poor (if any) response to antibiotics

43. Sx of Chronic Sinusitis • Nasal discharge • Nasal congestion • Headache • Facial pain or pressure • Olfactory disturbance • Fever • Cough (worse when lying down)

44. Evaluation of Chronic Sinusitis • CT or MRI scanning • Anatomic defects, tumors, fungi • Allergy testing • Inhalants, fungi, foods • Sinus aspiration for cultures • Bacterial • Fungal

45. Treatment of Chronic Sinusitis • Nasal steroid spray • Decongestants • Steam inhalation • Nasal irrigation • Antibiotics with exacerbations

46. Non-pharmacological treatment • Humidifier to relieve the drying of mucous membrances associated with mouth breathing • Increase oral fluid intake • Saline irrigation of the nostrils • Moist heat over affected sinus • Prolonged shower to help promote drainage

47. Patient Education • Child should not dive. • Child should not travel by airplane. • Urge parent to eliminate triggers in the home (dust, smoking) • Have all members of the family treated, if indicated.

48. Pharyngitis

49. Pharyngitis • Infl ammation of the pharynx most commonly caused by acute infection. • Group A streptococcus is a focus of diagnosis due to its potential for preventable rheumatic sequelae. • Chronic low grade symptoms usually related to refl ux disease or vocal abuse.

50. System(s) affected: Pulmonary • Genetics: Individuals with a positive family history of rheumatic fever have a higher risk of rheumatic sequelae following an untreated group A beta hemolytic streptococcal infection