Acute Respiratory: URTI, Allergic rhinitis, Rhinosinusitis, Nasal obstruction Flashcards
Spectrum of URTI
URTI
Microbiology
URTI
Transmission
URTI
Clinical presentation
Ddx cough and sputum
- P: URTI
- R: Pneumonia, TB, CA Lung, CHF
- O: Allergic Rhinitis (PND), Asthma, COPD,
Bronchiectasis, GERD, Drugs (ACEI)
Ddx rhinorrhea and nasal congestion
- P: URTI (Common Cold)
- R: NPC
- O: Allergic Rhinitis, Polyps, Foreign body,
Sinusitis
Ddx sore throat
- P: URTI (Pharyngitis), Strep. Throat
- R: Acute Epiglottitis (Drooling saliva)
- O: Postnasal drip, Irritation, Foreign body,
Infectious Mononucleosis
Ddx hoarseness of voice
- P: URTI (Laryngitis), Vocal cord polyp/
nodule - R: Acute Epiglottitis, CROUP, CA Larynx
- O: Sputum, Laryngeal injury/ compression,
Trauma from intubation
Natural course of simple viral URTI
Differentiate viral pharyngitis vs GAS pharyngitis
Diagnostic criteria for GAS pharyngitis
GAS pharyngitis
Diagnostic tests
GAS Pharyngitis
Complications
GAS pharyngitis
Antibiotics function
Options/ prescriptions
Acute rhinosinusitis
Spectrum of diseases
Symptoms
Acute rhinosinusitis
Diagnostic criteria
Influenza
Clinical features
Influenza complications
Management
Non-pharmacological advice
Prevention
Non-pharmacological advice (Murtagh)
- Rest and fluid
- Analgesics: ibuprofen or paracetamol
- Fresh lemon juice with honey/ Nip of whisky with fruit juice
- Monitor for symptoms
URTI
Management principles
Non-pharmacological advice
Non-pharmacological advice (Murtagh):
- Rest
- Fluid: 2L per day
- Analgesics: Paracetamol, ibuprofen and aspirin (avoid for under 16)
- Inhale steam +/- menthol or friar’s balsam. Inhale with towel over head, breathe through nose and exhale through mouth
- Gargle aspiring in water or lemon juice for sore throat
- Monitor for red flags: SOB, Ear pain, green purulent sputum, high fever refractory to paracetamol
Sore throat treatment
Cough symptomatic treatment
Sputum treatment
Treatment of Rhinorrhoea, Sneeze & Nasal Congestion
Treatment of Coryza
Combined preparation for URTI
Common combination prescription
Benefit and risks
Common prescriptions for URTI
- Paracetamol tablet 500mg PO q.i.d.
- Chlorpheniramine tablet 4mg (Piriton®) PO Q4-6h (max. 24mg/d)
- Loratadine tablet 10mg PO q.d.
Prevention of URTI
Allergic rhinitis
Clinical presentation
Allergic rhinitis
Diagnosis
Allergic rhinitis
General management
Allergic rhinitis
Medication/ prescription
Prevention
Avoid allergens
Drug options:
- Oral antihistamine
- Intranasal steroid
- Leukotriene receptor antagonists (especially in patients with asthma)
- Saline douching (wash away allergen in mucus)
- Refractory: short-term systemic steroid (S/E), decongestant
- Immunotherapy
Surgery
Chronic rhinosinusitis
Types
Clinical presentation
Chronic rhinosinusitis
Associated diseases
Asthma
Allergic fungal sinusitis
Cystic fibrosis
Aspirin -induced (Samter’s triad)
Chronic rhinosinusitis
Diagnostic criteria
Chronic rhinosinusitis
Management
Key question in history taking for nasal conditions
Nose:
* Congestion/ blockage/ obstruction
* Nasal discharge
* Sneezing, itchiness (allergy)
* Olfactory disturbances/ anosmia
* Epistaxis (anterior/ posterior)
* Snoring
Associated features:
* Facial pressure/ pain
* Eye itchiness, Visual disturbances
* Otalgia/ aural fullness (connected to nasopharynx via Eustachian tube)
* Dental pain
* Fever
* Atopy, asthma
* Smoking, drugs, social
* Family history of NPC, Allergies
Outline exams for the nose
External nose:
- Skin changes, wounds, scars
- Frontal: Nasal bridge
- Base: Rhinoplasty scar
- Side: Nasal ridge, proportion
Internal nose:
- Anterior rhinoscopy (speculums)
- Nasoendoscopy (nasopharynx)
Ddx Nasal obstruction in adults
Nasal deformities:
- Crooked, deviated nose, saddle nose
- Injuries: Septal haematoma, Fracture nasal bone, Fracture/ dislocation of the septum
Mucosal swelling:
- URTI
- Nasal vestibulitis
- Acute/ Chronic bacterial rhinosinusitis
- Allergic rhinitis
- Non-allergic rhinitis
- Mucoceles
Neoplasm:
- Sinonasal tumors
- NPC
Acute bacterial rhinosinusitis
Causes
Causative pathogens
Risk factors
Causes:
Upper respiratory tract infection
Dental abscess, extraction (pre- molar/ molar teeth: infection spreads upward to maxillary sinus)
Trauma
Organisms:
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Anaerobic organisms (look for dental source)
Predisposing factors:
Poor drainage, e.g. septal deviation, turbinate hypertrophy, nasal polyposis
Poor immunity
Acute bacterial rhinosinusitis
S/S
Symptoms:
- Symptoms of viral URTI >10 days or worsening after 5-7 days (double sickening)
- Nasal obstruction
- Nasal discharge (anterior/ post- nasal drip)
- Anosmia
- Facial pain (collection of fluid distends sinus)
- Fever
Signs:
Facial tenderness
Edema, mucopurulent discharge in middle meatus/ nasopharynx
Acute bacterial rhinosinusitis
Complications
Treatment
Complications need urgent surgical intervention:
Orbital cellulitis, abscess
cavernous sinus thrombosis (Posteriorly along sinus drainage)
Intracranial infection: meningitis, encephalitis, abscesses (Superiorly: ethmoid
and frontal sinus separated from brain by only thin bone)
Treatment:
Analgesics
Antibiotics (if bacterial)
Intranasal steroid spray
Short-term (<7 days) nasal decongestant, e.g. oxymetazoline, ephedrine
Nasal douching (rinsing with saline)
Nasal mucoceles
Histological structure and pathogenesis
Common site of occurence
Presentation
Treatment
epithelial-lined sac containing mucus:
Drainage of paranasal sinus is blocked»_space; mucus collects inside mucocele which expands and erodes bone
Most common in the fronto-ethmoidal region
Symptoms: orbital displacement, proptosis, nasal obstruction
Treatment: Surgical marsupialization (open up blocked pathway for drainage to nose)
Drug-induced rhinitis
Causative drugs
Treatment
Drugs:
Anti-hypertensive (β blockers, calcium channel blockers)
Sedatives
Antidepressants
Oral contraceptives
Prolonged use of topical sympathomimetic agents nasal decongestants*)»_space;> rhinitis medicamentosa
Treatment:
Prevention (do not use decongestants for extended period of time)
Intranasal steroid
Surgery, e.g. turbinate reduction/ turbinectomy
Red flag signs of nasal neoplasm
Red flags:
Unilateral obstruction
Epistaxis
Bleeding
Cacosmia (sensation of bad smell)
Proptosis, diplopia, epiphora (overflow of tear (obstruction of nasolacrimal duct))
Neurological symptoms (tumor spreads superiorly to brain (frontal lobe))
NPC
Prevalence in HK
Demographics
Risk factors
Prevalence in HK = 10th most common
Demographics = middle age, male predominant
Risk factors:
1) Epstein-Barr virus infection
2) Host genetics (family history)
3) Environmental factors:
Preserved foods (nitrosamines; salted fish)
Alcohol
Poor oral hygiene
Active and passive tobacco smoking
NPC
Screening and investigations
Screening:
1) Anti-EBV IgA antibodies (out of favor):
Early antigen (EA-IgA)
Viral capsid antigen (VCA-IgA)
Nuclear antigen 1 (EBNA1-IgA)
(Low sensitivity, low specificity for asymptomatic participants)
2) EBV DNA (expensive; higher sensitivity and specificity)
Investigations:
o Nasoendoscopy + biopsy
o Ultrasound neck +/- fine needle aspiration cytology (if enlarged LN)
o Magnetic resonance imaging with contrast (better for soft tissue)
NPC
Histological subtypes
a) Non-keratinizing:
Differentiated
Undifferentiated (>95% cases in endemic area, EBV infection)
b) Keratinising squamous
c) Basaloid squamous
NPC
Treatment options
o Early stage: intensity-modulated radiotherapy
o Late stage: radiotherapy + concurrent chemotherapy
o Residual disease/ recurrence:
Surgery, e.g.:
Open maxillary swing
Endoscopic/robotic nasopharyngectomy
If not fit for surgery:
Chemotherapy, second-dose radiotherapy
Immunotherapy
