Upper Respiratory Tract Infections

1. Upper Respiratory Tract Infections Dr. Meenakshi Aggarwal MD Emory Family Medicine

2. Definition Inflammation of the respiratory mucosa from the nose to the lower respiratory tree, not including the alveoli.

3. Objectives • List the various categories of upper respiratory tract infections • Obtain a pertinent history in a patient with a suspected URI. • Perform a targeted and thorough physical examination to confirm the diagnosis of URI. • Perform and interpret selected tests to diagnose URI • Manage and treat uncomplicated URI’s.

5. Categories Acute Rhinosinusitis Acute Pharyngitis Acute Bronchitis

6. Differential Diagnosis Influenza Pneumonia Tuberculosis Asthma

7. Anatomy of Sinuses

8. Acute Rhinosinusitis (Viral) Common Symptoms: Nasal discharge, nasal congestion, facial pressure, cough, fever, muscle aches, joint pains, sore throat with hoarseness. Symptoms resolve in 10-14 days Common in fall, winter and spring. Treatment: Symptomatic

9. Acute Bacterial Sinusitis • Causative agents are usually the normal inhabitants of the respiratory tract. • Common agents: Streptococcus pneumoniae Nontypeable Haemophilus Influenzae Moraxella Catarrhalis

10. Signs and Symptoms Feeling of fullness and pressure over the involved sinuses, nasal congestion and purulent nasal discharge. Other associated symptoms: Sore throat, malaise, low grade fever, headache, toothache, cough > 1 week duration. Symptoms may last for more than 10-14 days.

11. Diagnosis Based on clinical signs and symptoms Physical Exam: Palpate over the sinuses, look for structural abnormalities like DNS. X-ray sinuses: not usually needed but may show cloudiness and air fluid levels Limited coronal CT are more sensitive to inflammatory changes and bone destruction

12. Ethmoid Sinusitis

13. Coronal computed tomographic scan showing ethmoidal polyps. Ethmoid opacity is total as a result of nasal polyps, with a secondary fluid level in the left maxillary antrum.

14. Treatment • About 2/3rd of patients will improve without treatment in 2 weeks. • Antibiotics: Reserved for patients who have symptoms for more than 10 days or who experience worsening symptoms. • OTC decongestant nasal sprays should be discouraged for use more than 5 days • Supportive therapy: Humidification, analgesics, antihistaminics

15. Antibiotics a) Amoxicillin (500mg TID) OR b) TMP/SMX ( one DS for 10 days). c) Alternative antibiotics: High dose amoxi/clavunate, Flouroquinolones, macrolides

16. Acute Pharyngitis Fewer than 25% of patients with sore throat have true pharyngitis. Primarily seen in 5-18 years old. Common in adult women.

17. Etiology A) Viral: Most common. Rhinovirus (most common). Symptoms usually last for 3-5 days. B) Bacterial: Group A beta hemolytic streptococcus (GABHS). Early detection can prevent complications like acute rheumatic fever and post streptococcal GN.

18. Signs and Symptoms • Absence of Cough • Fever • Sore throat • Malaise • Rhinorrhoea • Classic triad of GABHS: High fever, tonsillar exhudates and ant. cervical lymphadenopathy. NO COUGH

19. Diagnosis • Physical Exam: Tonsillar exhudates, anterior cervical LAD • Rapid strep: Throat swab. Sensitivity of 80% and specificity of 95%. Throat Cultures: Not required usually. Needed only when suspicion is high and rapid strep is negative.

20. Exhudates

21. Management A) Symptomatic: Saline gargles, analgesics, cool-mist humidification and throat lozenges. B) Antibiotics: a) Benzathine Pn-G 1.2 million units IM x 1OR Pn V orally for 10 days b) For Pn allergic pts: Erythromycin 500mg QID x 10 days OR Azithro 500 mg Qdaily x 3 days.

23. Acute Bronchitis Inflammation of the bronchial respiratory mucosa leading to productive cough.

25. Acute Bronchitis • Etiology: A)Viral B) Bacterial (Bordetella pertussis, Mycoplasma pneumoniae, and Chlamydia pneumoniae) • Diagnosis: Clinical • S/S: Productive cough, rarely fever or tachypnea.

26. Treatment Symptomatic If cough persists for more than 10 days: Azithro x 5 days OR Clarithro x 7 days

27. Non specific URI’s • Common Cold • Etiology: Rhinovirus Adenovirus RSV Parainfluenza Enteroviruses Diagnosis: Clinical Treatment: Adequate fluid intake, rest, humidified air, and over-the-counter analgesics and antipyretics.

28. Influenza Etiology: Influenza A & B Symptoms: Fever, myalgias, headache, rhinitis, malaise, nonproductive cough, sore throat Diagnosis: Influenza A &B antigen testing Treatment: Supportive care, oseltamivir, amantidine

29. Questions?