INFECTIONS OF THE UPPER RESPIRATORY TRACT

1. INFECTIONS OF THE UPPER RESPIRATORY TRACT They are among the most common reasons for visits to primary care Providers the illnesses are typically mild Even though the minority (~25%) of cases are caused by bacteria, URIs are the leading diagnoses for which antibiotics are prescribed on an outpatient basis in the United States Dr. Farzin khorvash

2. Although most URIs1 are caused by viruses, distinguishing patients with primary viral infection from those with primary bacterial infection is difficult • Signs and symptoms of bacterial and viral URIs are, in fact, indistinguishable • Because routine, rapid testing is neither available nor practical for most syndromes, acute infections are diagnosed largely on clinical grounds. Dr. Farzin khorvash

3. NONSPECIFIC INFECTIONS OF THE UPPER RESPIRATORY TRACT • Nonspecific URIs, by definition, have no prominent localizing features • They are identified by a variety of descriptive names, including acute infective rhinitis, acute rhinopharyngitis/nasopharyngitis, acute coryza, and acute nasal catarrh, as well as by the inclusive label common cold. Dr. Farzin khorvash

4. Etiology • Nearly all nonspecific URIs are caused by viruses spanning multiple virus families • For instance, rhinoviruses (~30 to 40% of cases) consist of at least 100 immunotypes • influenza virus (3 immunotypes) • parainfluenza virus (4 immunotypes) • coronavirus (at least 3 immunotypes) • adenovirus (47 immunotypes) • Respiratory syncytial virus (RSV) • enteroviruses, rubella virus, and varicella-zoster virus) Dr. Farzin khorvash

5. Manifestations • rhinorrhea (with or without purulence) • nasal congestion • cough • sore throat • fever, malaise, sneezing, and hoarseness, are more variable • fever more common among infants and young children • myalgias and fatigue, for example, are sometimes seen with influenza and parainfluenza infections, while conjunctivitis may suggest infection with adenovirus or enterovirus • Findings on physical examination are frequently nonspecific Dr. Farzin khorvash

6. secondary bacterial infections • 0.5 and 2% of colds are complicated • rhinosinusitis, otitis media, and pneumonia • infants, elderly persons, and chronically ill patients • prolonged course of illness, worsening of illness severity, and localization of signs and symptoms • purulent secretions from the nares or throat : sinusitis or pharyngitis • these secretions are also seen in nonspecific URI and, in the absence of other clinical features, are poor predictors of bacterial infection Dr. Farzin khorvash

7. TREATMENT • Antibiotics have no role In the absence of clinical evidence of bacterial infection • treatment remains entirely symptom-based • decongestants • nonsteroidal anti-inflammatory drugs • dextromethorphan for cough • Clinical trials of zinc, vitamin C, echinacea, no consistent benefit for the treatment of nonspecific URI. Dr. Farzin khorvash

8. INFECTIONS OF THE SINUS • most cases of sinusitis involve more than one sinus • the maxillary sinus is most commonly involved, the ethmoid, frontal, and sphenoid sinuses • respiratory epithelium produces mucus, is transported out by ciliary action into the nasal cavity • Normally remain sterile despite their adjacency to the bacterium-filled nasal passages • the sinus ostia are obstructed or ciliary clearance is impaired • The retained secretions may become infected with a variety of pathogens, including viruses, bacteria, and fungi. Dr. Farzin khorvash

9. ACUTE SINUSITIS • sinusitis of <4 weeks' duration • occur primarily as a consequence of a preceding viral URI • Differentiating acute bacterial and viral sinusitis on clinical grounds is difficult • antibiotics are prescribed frequently (in 85 to 98% of all cases) Dr. Farzin khorvash

10. Etiolog • acute obstruction of the sinus ostia or impairment of ciliary • Noninfectious causes include allergic rhinitis barotrauma or chemical irritants • nasal and sinus tumors • granulomatous diseases (e.g., Wegener's granulomatosis or rhinoscleroma) • altered mucus content (e.g., cystic fibrosis) • In the hospital setting, nasotracheal intubation Dr. Farzin khorvash

11. organisms • viruses, bacteria, and fungi • Viral is far more common than bacterial • viruses alone and with bacteria • rhinovirus, parainfluenza virus, and influenza virus. Dr. Farzin khorvash

12. Bacterial causes • S. pneumoniae and nontypable Haemophilus influenzae are the most common ,50 to 60% • Moraxella catarrhalis (20%) of children but less often in adults • streptococcal species and Staphylococcus aureus • Anaerobes are with infections of the roots of premolar teeth that spread into the adjacent maxillary sinuses • Chlamydia pneumoniae and Mycoplasma pneumoniae ,unclear Dr. Farzin khorvash

13. Nosocomial cases • S. aureus • Pseudomonas aeruginosa • Serratia marcescens • Klebsiella pneumoniae, • Enterobacter species • polymicrobial ,highly resistant Dr. Farzin khorvash

14. Fungi • immunocompromised patients • mucormycosis • occur in diabetic patients with ketoacidosis • transplant recipients • hematologic malignancies • receiving chronic glucocorticoid or deferoxamine therapy • Aspergillus and Fusarium species Dr. Farzin khorvash

15. Manifestations • after or in conjunction with a viral URI • difficult to discriminate the clinical • bacterial sinusitis complicates only 0.2 to 2% of these viral infections. Dr. Farzin khorvash

16. Manifestations • nasal drainage and congestion • facial pain or pressure • headache. • Thick, purulent or discolored nasal discharge • is often thought to indicate bacterial sinusitis, but it also occurs early in viral infections such as the common cold • Other nonspecific symptoms include cough, sneezing, and fever • Tooth pain, most often involving the upper molars, is associated with bacterial sinusitis Dr. Farzin khorvash

17. Manifestations • sinus pain or pressure often localizes and be worse when the patient bends over or is supine • symptoms of advanced sphenoid or ethmoid sinus: severe frontal or retroorbital pain radiating to the occiput, thrombosis of the cavernous sinus, and signs of orbital cellulitis • advanced frontal sinusitis ,Pott's puffy tumor, swelling and pitting edema over the frontal bone ,subperiosteal abscess Dr. Farzin khorvash

18. Life-threatening complications • Meningitis • epidural abscess • cerebral abscess. Dr. Farzin khorvash

19. Diagnosis • illness duration • acute bacterial sinusitis is uncommon in patients whose symptoms have lasted <7 days • facial or tooth pain in combination with purulent nasal discharge that have persisted for >7 days Dr. Farzin khorvash

20. computed tomography, sinus radiography • patients who meet these criteria, only 40 to 50% have true bacterial sinusitis • CT or XR is not recommended for routine cases, particularly early in the course of illness (i.e., at <7 days) • persistent, recurrent, or chronic sinusitis, CT of the sinuses is choice. Dr. Farzin khorvash

21. Diagnosis • illness duration • acute bacterial sinusitis is uncommon in patients whose symptoms have lasted <7 days • facial or tooth pain in combination with purulent nasal discharge that have persisted for >7 days Dr. Farzin khorvash

22. Diagnosis • evidence of fungal hyphal elements and tissue invasion • acute nosocomial sinusitis should be confirmed by a sinus CT scan • sinus aspirate , if possible, for culture and susceptibility testing. Dr. Farzin khorvash

23. TREATMENT • Most patients ,improve without antibiotic therapy • mild to moderate symptoms of <7 days' duration • facilitating sinus drainage, such as oral and topical decongestants, nasal saline lavage • in patients with a history of chronic sinusitis or allergies — nasal glucocorticoids. Dr. Farzin khorvash

24. antibiotics • do not improve after 7 days • more severe symptoms (regardless of duration) Dr. Farzin khorvash

25. antibiotics • Empirical therapy ,S. pneumoniae and H. influenzae • amoxicillin • drug-resistant S. pneumoniae • Up to 10% of patients do not respond to initial antimicrobial therapy • these patients should be considered for sinus aspiration and/or lavage • prophylactic antibiotics to prevent episodes of recurrent acute bacterial sinusitis is not recommended. Dr. Farzin khorvash

26. Surgical intervention and intravenous antibiotics • severe disease • intracranial complications, such as abscess or orbital involvement • acute invasive fungal sinusitis usually require extensive surgical debridement • Intravenous antifungal such as amphotericin B Dr. Farzin khorvash

27. Treatment of nosocomial sinusitis • broad-spectrum antibiotics to cover common pathogens such as S. aureus and gram-negative bacilli • Therapy should then be tailored to the results of culture and susceptibility testing of sinus aspirates. Dr. Farzin khorvash

28. CHRONIC SINUSITIS • symptoms of sinus inflammation lasting >12 weeks • bacteria or fungi • clinical cure in most cases is very difficult • Many patients have undergone repeated courses of antibacterial agents and multiple sinus surgeries • increasing their risk of colonization with antibiotic-resistant pathogens and of surgical complications Dr. Farzin khorvash

29. chronic bacterial sinusitis • impairment of mucociliary clearance from repeated infections rather than to persistent bacterial infection • pathogenesis of this condition is poorly understood • certain conditions (e.g., cystic fibrosis) • most patients do not have obvious underlying conditions that result in the obstruction of sinus drainage, the impairment of ciliary action, or immune dysfunction Dr. Farzin khorvash

30. chronic bacterial sinusitis • nasal congestion and sinus pressure, with intermittent periods for years • CT scan be helpful in defining the extent of disease and the response to therapy • endoscopic examinations and obtain tissue samples for histologic examination and culture. Dr. Farzin khorvash

31. Chronic fungal sinusitis • immunocompetent hosts • usually noninvasive, although slowly progressive • Aspergillus species Dr. Farzin khorvash

32. Chronic fungal sinusitis • In mild, indolent disease • repeated failures of antibacterial therapy • only nonspecific mucosal changes may be seen on sinus CT • Endoscopic surgery is usually curative in these patients, with no need for antifungal therapy Dr. Farzin khorvash

33. Chronic fungal sinusitis • mycetoma (fungus ball) within the sinus • Treatment for this condition is also surgical • systemic antifungal therapy may be warranted in the rare case where bony erosion occurs. Dr. Farzin khorvash

34. Chronic fungal sinusitis • allergic fungal sinusitis • history of nasal polyposis and asthma • thick, eosinophilic mucus with the consistency of peanut butter that contains sparse fungal hyphae on histologic examination. • Patients often present with pansinusitis. Dr. Farzin khorvash

35. TREATMENT • administration of intranasal glucocorticoids; and mechanical irrigation of the sinus with sterile saline solution • When this management approach fails, sinus surgery may be indicated Dr. Farzin khorvash

36. INFECTIONS OF THE EAR AND MASTOID • middle and external ear,skin, cartilage, periosteum, ear canal, and tympanic and mastoid cavities • Both viruses and bacteria Dr. Farzin khorvash

37. Acute Otitis Media • when pathogens from the nasopharynx are introduced into the inflammatory fluid collected in the middle ear — e.g., by nose blowing during a URI • The diagnosis of acute otitis media requires the demonstration of fluid in the middle ear (with tympanic membrane immobility) and the accompanying signs Dr. Farzin khorvash

38. ETIOLOGY • typically ,viral URI • RSV, influenza virus, rhinovirus, and enterovirus • they predispose the patient to bacterial • S. pneumoniae ,35% of cases • H. influenzae (nontypable strains) and M. catarrhalis are • Viruses,either alone or with bacteria in 17 to 40% of cases. Dr. Farzin khorvash

39. MANIFESTATIONS • Fluid in the middle ear ,pneumatic otoscopy • this movement is dampened when fluid is present • the tympanic membrane can also be erythematous, bulging, or retracted • occasionally can spontaneously perforate. Dr. Farzin khorvash

40. MANIFESTATIONS • otalgia, otorrhea, diminished hearing, fever, or irritability • Erythema of the tympanic membrane is often evident but is nonspecific • Other signs and symptoms include vertigo, nystagmus, and tinnitus. Dr. Farzin khorvash

41. TREATMENT • most cases resolve clinically 1 week after the onset of illness • initial observation and aggressive pain management with anti-inflammatory therapy • reserving antibiotics for high-risk patients, patients with complicated disease, or patients who do not improve after 48 to 72 h. • recommend antibiotic therapy for children <2 years old and immunocompromised Dr. Farzin khorvash

42. TREATMENT • therapy is generally empirical • except :tympanocentesis is warranted ,newborns, refractory to therapy, severely ill immune deficiency • amoxicillin is as successful as any other agent, and it remains the drug of first choice Dr. Farzin khorvash

43. TREATMENT • 5 to 7 days for uncomplicated longer • courses ( 10 days) should be reserved for complicated cases or for children <2 years old Dr. Farzin khorvash

44. TREATMENT • A switch in regimen • there is no clinical improvement by the third day of therapy • infection with a ß-lactamase-producing strain of H. influenzae or M. catarrhalis or with a strain of penicillin-resistant S. pneumoniae • Decongestants and antihistamines are frequently used • but clinical trials have yielded no significant evidence of benefit Dr. Farzin khorvash

45. Recurrent Acute Otitis Media • more than three episodes within 6 months • or four episodes within 12 months • relapse or reinfection • the recommended treatment consists of antibiotics active against ß-lactamase-producing organisms Dr. Farzin khorvash

46. Antibiotic prophylaxis • TMP-SMX or amoxicillin can reduce • benefit is small compared with the cost of the drug and the high likelihood of colonization with antibiotic-resistant pathogens • Other approaches : • placement of tympanostomy tubes, adenoidectomy, and tonsillectomy plus adenoidectomy, are of questionable overall value, given the relatively small benefit compared with the potential for complications. Dr. Farzin khorvash

47. Serous Otitis Media • when fluid is present in the middle ear for an extended period and in the absence of signs and symptoms of infection • In general, acute effusions are self-limited; most resolve in 2 to 4 weeks • In some cases, in particular after an episode of acute otitis media, effusions can persist for months • often associated with a significant hearing loss Dr. Farzin khorvash

48. TREATMENT • The great majority resolve spontaneously within 3 months • Antibiotic therapy or myringotomy with insertion of tympanostomy tubes is typically reserved for • patients in whom bilateral effusion : • (1) has persisted for at least 3 months and • (2) is associated with significant bilateral hearing loss Dr. Farzin khorvash

49. Chronic Otitis Media • persistent or recurrent purulent otorrhea , tympanic membrane perforation • some degree of conductive hearing loss • divided into two subcategories: active and inactive • Inactive disease is characterized by a central perforation of the tympanic membrane, which allows drainage of purulent fluid Dr. Farzin khorvash

50. active • When the perforation is more peripheral, squamous epithelium from the auditory canal may invade the middle ear through the perforation, forming a mass of cholesteatoma • This mass can enlarge ,erode bone and promote further infection, which can lead to meningitis, brain abscess, or paralysis of cranialnerve VII Dr. Farzin khorvash