ALOK SINHA Department of Medicine Manipal College of Medical Sciences Pokhara , Nepal

1. UPPER RESPIRATORY TRACT INFECTIONS ALOK SINHA Department of Medicine Manipal College of Medical Sciences Pokhara, Nepal

2. The upper respiratory tract includes nose paranasal sinuses pharynx upper part of the larynx above the level of the true vocal cords

3. Infections of the Upper Respiratory Tract Site Disease Agents Nasal cavityCoryza (common cold) Many different viruses Chronic atrophic rhinitis Bacteria (Klebsiella ozaenae) Rhinoscleroma Klebsiella rhinoscleromatis Invasive fungal infections Mucor, Aspergillus Nasal diphtheria Corynebacterium diphtheriae Mucocutaneous leishmaniasis Leishmania braziliensis Syphilis (tertiary) Treponema pallidum Lepromatous leprosy Mycobacterium leprae Rhinosporidiosis Rhinosporidium seeberi Paranasal sinuses Acute sinusitis Pyogenic bacteria Chronic sinusitis Pyogenic bacteria Aspergilloma ("fungus ball") Aspergillus species  Pharynx, tonsilAcute pharyngitis Many different viruses Streptococcus pyogenes Diphtheria Corynebacterium diphtheriae Pharyngeal gonorrhea Neisseria gonorrhoeae Peritonsillar abscess (quinsy) Pyogenic bacteria Infectious mononucleosis Epstein–Barr virus Retropharyngeal space Abscess Pyogenic bacteria Tuberculosis Mycobacterium tuberculosis Larynx Acute laryngitis Many different viruses Acute epiglottitis and laryngitisHaemophilus influenzae

4. ? Which specialty should treat & there for teach these diseases

5. . The Common Cold .

6. CORYZA • An estimated 2 of every 5 persons are affected each year (40%) • World population: 6,775,235,741 • 40% of this = 2,710,094,296 • Some experience multiple episodes in 1 year

7. Rhinoviruses: most common agents • Over 100 serotypes have been implicated • Other viruses implicated included • coronaviruses • influenza C • parainfluenza virus • adenoviruses • respiratory syncytial virus

8. Highly contagious: 75% of patients infected with Rhinovirus will have symptoms • Respiratory droplets spread by • sneezing, coughing • hand contact with nose, eyes, or face • Fomite - Skin cells, hair, clothing (hanky) bedding

9. Contributing factors: • Change in weather • Loss of sleep • Going outside with wet hair • Fatigue

10. Signs and symptoms • Incubation period: 2 – 4 days • May last from 6 – 10 days or possibly up to 3 weeks after incubation period

11. Initial complaints • sneezing • clear, watery rhinorrhea @ nasal obstruction • general malaise but no fever • Subsequently • Headache • nasal congestion • scratchy throat

12. After 2 – 3 days • nasal discharge becomes thicker, cloudy, and yellowish in color • systemic symptoms improve • Hoarseness, cough, and sore throat may last up to 7 – 10 days

13. Diagnosis: • Made on clinical grounds • Pt’s symptoms • nasal exam showing • reddened, edematous mucosa • narrowed nasal passages • watery discharge • Laboratory and/or imaging only indicated if other conditions are strongly suspected • Viral isolation/culture is not practical

14. Treatment

15. No curative treatment • Supportive therapy – 10 treatment • Rest • Fluids & humidification • Decongestants (Phenylephrine - α1-adrenergic receptor agonist) • Analgesics • Cough suppressants • Mucolytics • Antihistamines

16. Zinc Gluconate • Short term use of zinc lozenges (zinc gluconate10-15 mg q 2 hrs) shown to reduce duration of subjective symptoms if begun early in course of disease

17. ? • Role of antibiotics • Antibiotics should be considered if symptoms last longer than 10-14 days (secondary bacterial infection) • Inappropriate prescribing of antibiotics is common • Due to patient beliefs/misinformation of cold being bacterial in origin

18. Pharyngitis

19. May be of bacterial or viral origin • Most common cause Rhinovirus • Self-limiting; usually lasts 3-4 days • Group A, beta-hemolytic strep is the primary bacterial pathogen • in 1/3 cases - early detection reduces incidence of acute rheumatic fever

20. Signs and symptoms: • Inflammation of pharynx & lymphoid tissue results in • Fever & malaise • sore throat • rhinorrhea • Tonsillar exudates • Anterior cervical adenopathy • There is usually a lack of cough

21. Diagnosis • On PE: observe throat for tonsillar exudates; obtain throat swab • Rapid streptococcal identification tests are most commonly used • Sensitivity – 80% • Specificity – 95% • Throat cultures may be collected if rapid strep screen is negative

22. Management/Treatment: • Symptomatic treatment • salt-water gargles • throat lozenges • Acetaminophen • cool-mist humidification

23. Antibiotics treatment necessary to treat proven strep infections • Benzathine penicillin G 1.2 million units as a single dose, is optimal therapy • For pen – allergic pts, • erythromycin 500mg po QID x 10 days • Azithromycin 500mg once daily x 3 days

24. Acute epiglottitis

26. Bacterial cellulitis of the epiglottis (supraglottis) and/or surrounding tissue • Caused by: • Haemophilus influenzae type b (HiB)- most likely • H. parainfluenzae and streptococci some times • Average age of onset: 1–5 years old • In most adults the disease is less severe and of slower onset

27. Clinical Features • Sudden onset of • Sore throat • Fever • Head forwardly extended, usually with drooling • Stridor - present

28. Pharyngeal visualization (w/ EXTREME caution) shows a ‘Cherry red' epiglottis

29. Neutrophil leucocytosis • Epiglottis culture usually (+) for HIB • result takes long time • Blood cultures frequently (+) for HIB in children • organisms fewer than in meningitis • Lateral X-Ray neck- • enlarged hypopharynx • forward neck extension • with “thumbprinting” of epiglottitis

30. Epiglottitis- Differential diagnosis • Angioneuropathic edema of supraglottic structures • Anaphylaxis • Caustic ingestion • Thermal burns of epiglottis • Infectious mononucleosis • Laryngotracheitis • Blunt Trauma

31. Treatment • Intubation is often required, but usually discontinued in less than 24h • Early antibiotic treatment and intubation may prevent the need for tracheostomy • Steroids to reduce inflammation and avert tracheostomy- unproven but used • Tracheostomy: may be required in life threatening conditions

32. Drug treatment • #1 Ceftriaxone (or cefotaxime, cefuroxime) • Others - Ampicillin and Sulbactam • Ticarcillin disodium and clavulanate potassium • piperacillin/tazobactam • levaquin • Gatifloxacin • Amoxicillinshould not be used due to noted resistance

33. Prevention • HiB vaccination early!!! • Prior to HiB, there were roughly 20 K cases of HiB disease each year (U S data) • Post-vaccine era = incidence has decreased by 95%. • Prophylaxix: Family Members, day-care workers, health-care workers • Rifampin 300 mg q12h x 2d

34. Acute laryngitis

35. Healthy Vocal Cords • Healthy vocal cords have smooth straight edges

36. Normal healthy vocal cords • pearly-white color • in contrast to the • pinkish surrounding tissue

37. Causes • Viral (70-80%) • Group A beta-haemolytic streptococcus (20-30%)

38. Often a complication of acute coryza • Dry sore throat • Hoarse voice or loss of voice • Attempts to speak cause pain • Initially painful and unproductive cough • Stridor in children (croup) because of inflammatory oedema leading to partial obstruction of a small larynx Croup (Laryngotracheobronchitis) is a group of respiratory diseases that often affects infants and children[

39. Complications rare • Chronic laryngitis • Downward spread of infection may cause • Tracheitis • Bronchitis • Pneumonia

40. Treatment • Rest voice • Paracetamol 0.5-1 g 4-6-hourly for relief of discomfort and pyrexia • Steam inhalations may be of value • Antibiotics not necessary in simple acute laryngitis

41. Influenza

42. Flu • Possible accounts in 412 BC • First recorded pandemic in 1580 • Destroyed Charlemagne's army in 876 A.D. • Killed thousands in 1647

43. 1918-1919 Spanish Flu pandemic • 21 million people died worldwide out of a billion infected(total world population at that time 1.8 billion) 8.5 million people died in World War I • Possible end to war

45. Swine Flue (H1N1) Swine Flue (H1N1 Influenza)

46. Answer these two questions • Is the Influenza or Flu caused by “Influenza” virus • What H. Influenza is ?

47. Etiology • caused by a group of myxoviruses- • common types • A • B • C • Influenza A (H1N1) virusis a subtype. causes • endemic in pigs – swine influenza • and birds – avian influenza • new H1N1 strain of swine-origin caused pandemic

48. New influenza viruses are constantly being produced by mutation • antigenic drift: • small changes in surface antigen • antigenic shift: • acquire new antigens by reassortment between avian/swine & human strains

49. Transmission • Swine influenza virus common throughout pig populations worldwide • Transmission from pigs to humans is not common and does not always lead to human influenza

50. People with regular exposure to pigs are at increased risk of swine flu infection • Meat of an infected animal poses no risk of infection when properly cooked • Transmission from one person to another is by droplet or fomite