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Upper Respiratory Tract Infections. Etiopathogenesis and Management. URTIs. Rhinitis Sinusistis Pharyngitis Otitis Media. URT. Rhinitis. Allergic rhinitis is the most common illness presenting as nasal itching, sneezing, discharge or nasal blocking. Rhinitis .

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upper respiratory tract infections

Upper Respiratory Tract Infections

Etiopathogenesis and Management

  • Rhinitis
  • Sinusistis
  • Pharyngitis
  • Otitis Media
  • Allergic rhinitisis the most common illness presenting as nasal itching, sneezing, discharge or nasal blocking.
  • Seasonal allergic rhinitis :

Pollens of importance include tree pollens in spring and grass pollens during summer, pollens and moulds.

  • 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.
  • 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
clinical features
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.
physical findings
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.
  • The main principles are
  • (i) avoidance of allergens
  • (ii) use of topical corticosteroids and
  • (iii) oral H1-selective antihistaminics
  • 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.
  • 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.
  • 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.
  • 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.
  • 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).
sinuses location
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
  • 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.
  • Inflammation of paranasal sinuses
  • 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.
  • 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.
pathogenesis contd
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.
predisposing factors
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.
etiology of sinusitis
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
classification of bacterial sinusitis
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
differentiating sinusitis from rhinitis
Differentiating Sinusitis from Rhinitis


  • Nasal congestion
  • Purulent rhinorrhea
  • Headache
  • Facial pain
  • Anosmia
  • Cough, fever


  • Nasal congestion
  • Rhinorrhea clear
  • Runny nose
  • Itching, red eyes
  • Nasal crease
  • Seasonal symptoms
road to bacterial sinus infections
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
allergic stimuli causing rhinosinusitis
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
nonallergic stimuli causing rhinosinusitis
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
acute bacterial sinusitis
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
physical findings1
Physical Findings
  • Mucopurulent nasal discharge
    • Highest positive predictive value
  • Swelling of nasal mucosa
  • Mild erythema
  • Facial pain (unusual in children)
  • Periorbital swelling
  • Rhinoscopy
  • CT Scan (Ethmoid & Maxillary sinuses)
  • MRI for tumors and not for sinusitis
ct scan
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.
objectives of treatment of acute bacterial sinusitis
Objectives of Treatment of Acute Bacterial Sinusitis
  • Decrease time of recovery
  • Prevent chronic disease
  • Decrease exacerbations of asthma or other secondary diseases
treatment of acute sinusitis
Treatment of Acute Sinusitis
  • Antihistamines recommended if allergy present
    • Oral or topical
  • Decongestants
    • Oral or topical
  • Antibiotic when indicated (bacteria)
  • Nasal irrigation
  • Hydration
  • 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
antibiotics for acute bacterial sinusitis
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
additional antibiotics for acute bacterial sinusitis
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
chronic sinusitis
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
sx of chronic sinusitis
Sx of Chronic Sinusitis
  • Nasal discharge
  • Nasal congestion
  • Headache
  • Facial pain or pressure
  • Olfactory disturbance
  • Fever
  • Cough (worse when lying down)
evaluation of chronic sinusitis
Evaluation of Chronic Sinusitis
  • CT or MRI scanning
    • Anatomic defects, tumors, fungi
  • Allergy testing
    • Inhalants, fungi, foods
  • Sinus aspiration for cultures
    • Bacterial
    • Fungal
treatment of chronic sinusitis
Treatment of Chronic Sinusitis
  • Nasal steroid spray
  • Decongestants
  • Steam inhalation
  • Nasal irrigation
  • Antibiotics with exacerbations
non pharmacological treatment
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
patient education
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.
  • 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.
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
  • Estimated 30 million cases diagnosed yearly 11% of all school age children visit a physician annually with pharyngitis
  • • 12-25% of sore throats seen by physicians

Incidence of rheumatic fever is decreasing with estimate of 64 cases per 100,000

Predominant age:

• Pharyngitis occurs in all age groups

• Streptococcal infection has greatest incidence 5 to 18 years of age

  • Predominant sex: Male = Female
signs symptoms
  • • Sore throat
  • • Enlarged tonsils
  • • Pharyngeal erythema
  • • Tonsillar exudates
  • • Soft palate petechiae
  • • Cervical adenopathy
  • • Absence of cough, hoarseness, or lower respiratory
  • symptoms
  • • Fever (> 102.5°F [39.1°C] suggests Streptococcus)
  • • Scarlet fever rash: punctateerythematousmacules
  • with reddened fl exor creases and circumoral pallor
  • (Streptococcal pharyngitis)
  • • Gray pseudomembrane found in diphtheria and occasionally,
  • mononucleosis
  • • Characteristic erythematous based clear vesicles in
  • herpes stomatitis
  • • Anorexia
  • • Chills
  • • Malaise
  • • Headache
  • • Conjunctivitis, more commonly with adenovirus infections
  • • Acute - bacterial:
    • ◊ Group A beta-hemolytic streptococci
    • ◊ Neisseriagonorrhoeae
    • ◊ Corynebacteriumdiphtheriae (diphtheria)
    • ◊ Haemophilusinfluenzae
    • ◊ Moraxella (Branhamella) catarrhalis
    • ◊ Group C and G streptococcus, rarely
  • • Acute - virus:
    • ◊ Rhinovirus
    • ◊ Adenovirus
    • ◊ Parainfluenza virus
    • ◊ Coxsackievirus
    • ◊ Coronavirus
    • ◊ Echovirus
    • ◊ Herpes simplex virus
    • ◊ Epstein-Barr virus (mononucleosis)
• Chronic

◊ More likely non-infectious

◊ Irritation from post-nasal discharge of chronic allergic rhinitis or reflux

◊ Chemical irritation or smoking

◊ Neoplasms and vasculitides

risk factors

• Group A beta hemolytic streptococcal epidemics occur

• Age (young are more susceptible)

• Family history

• Close quarters, such as in new military recruits

• Immunosuppression

• Fatigue

• Smoking

• Excess alcohol consumption

• Oral sex

• Diabetes mellitus

• Recent illness



• Blood agar throat culture from swab. Bacitracin disc sensitivity of hemolytic colonies suggest group A streptococci. Specifi c antibody identification available. Rapid screening for streptococci can be done from throat swab with antigen agglutination kits. 5-10% false negatives lead some to suggest routine backup of all negatives with blood agar culture. Newer optical immunoassay tests are more sensitive.

• Leukocytosis (if bacterial)

general measures

• Salt water gargles

• Acetaminophen

• Dyclonine lozenges

• Cool-mist humidifi er

drug therapy
Drug Therapy
  • For streptococcal pharyngitis, penicillin is the standard. All choices should have complete 10 day course.

• Penicillin V 250 mg tid (25-50 mg/kg/day), or

• For penicillin allergic patients, erythromycin ethylsuccinate 300 to 400 mg tid (30 mg/kg/day), or

• Cephalexin 250 mg tid (30 mg/kg/day)

possible complications

• Rheumatic fever

• Post-streptococcal glomerulonephritis

• Peritonsillar abscess

• Systemic infection

• Otitis media


• Septicemia

• Rhinitis

• Sinusitis

• Pneumonia