Acute upper respiratory symptoms Flashcards
1
Q
What are the differential diagnoses for acute upper Resp symptoms/ sore throat?
A
- Acute sore throat
- Acute pharyngitis (Most common cause of sore throat)
- acute tonsillitis
- common cold
- acute rhino- sinusistis
- acute cough
- acute bronchitis
2
Q
Relevant anatomy to URTI/ sore throat:
What are the 4 paranasal sinuses?
What are they lined by and where do they drain?
Role of paranasal sinuses?
A
- Frontal, ethmoid, sphenoidal and maxillary
- Paranasal sinuses - lined by respiratory epithelium and all drain into the nasal cavity
- role is to warm & humidify air, and reduce the weight of the skull.
-
Drainage:
- Sphenoid sinus –> drains into the roof of the nasal cavity via sphenoethmoidal recess, pituitary gland can be accessed through nasal roof into sphenoid sinus and throught sphenoid bone
- Frontal sinus –> drains via frontonasal duct into middle meatus (at hiatus semilunaris)
- Ethmoidal sinus –> ethmoid air cells separated from orbit by thin layer of bone - lamina papyracea (infection can spread into orbit causing periorbital cellulitis). Drains via hiatus semilunaris in middle meatus.
- Maxillary sinus –> drains against gravity, again via hiatus semilunaris at middle meatus. Close relationship to maxillary teeth - inflammation of this sinus can present with toothache.
3
Q
Differentail : Acute pharyngitis/ acute sore throat
Pathophysiology?
Common causitive organisms?
A
Acute pharyngitis - infection & inflammation of the pharynx most commonly due to viral organisms or group A streptococcus.
Common viral causes:
- Epstein barr virus (mononucleosis) (do not miss) - often mild inflammation of mesenteric lymph nodes therefore abdo pain
- adenoviruses - high fever and non exudative pharyngo-conjunctival inflammation
- enteroviruses
- influenza A &B
- parainfluenza
Group A streptococcus - spread from person-person via resp droplets (only 1/3 cases). Can also be caused by other streptococci - B/C/G.
STI - HIV/chlamydia/ gonorrhoea may be implicated in sexually active adolescents
Candida - immunocompromised individuals
4
Q
RF’s for acute pharyngitis?
Demographics?
A
Risk factors:
- Nasal colonisation w group A Streptococcus
- contact with a person with group A streptococcus
- sexual activity/ abuse
- ingestion of non domestic meats
- immunocompromisation/ inhaled steroids - candida pharyngitis
- lack of vaccination - diptheria or measles
Commonly affected:
- Age 5-15 yrs - Group A streptococcus common
- Winter or spring - Group A streptococcus common
- Summer or autumn - Enteroviral pharyngitis more common
5
Q
Acute pharyngitis:
Key features on the history?
A
- Age - 5-15 yrs - acute GAS pharyngitis common in this age group
- GAS pharyngitis more common in winter or early spring
- Enteroviral more common in summer and autumn
-
Symptoms:
- Sore throat
- pharyngeal exudate - common with GAS, other streptococci, EBV
- painful anterior cervical adenopathy (predict streptococcal)
- fever (temp > 37)
- headache
- N&V + abdominal pain common in children
- rhinorrhoea & nasal congestion + cough - typically present in viral pharyngitis ABSENT in bacterial pharyngitis
6
Q
Acute pharyngitis:
Key features on examination?
A
Key signs of group A streptococcal pharyngitis:
- Pharyngeal exudate
- oedemtaous
- erythematous
- cervical adenopathy (painful anterior cervical adenopathy is common in GAS)
- Fever
- lack of cough or rhinorrhoea
Viral infection - presence of rhinorrhoea, nasal congestion and cough
Gonococcal infection also be anterior cervical lymphadenopathy
Rashes - scarlatinform rash can present in children, suggestive of GAS
Koplik spots - bluish-white raised lesion on red base on buccal mucosa (like grains of white sand surrounded by red ring) - measles. Plus maculopapular rash.
7
Q
Acute pharyngitis:
Investigations?
A
- Rapid antigen detection tests for Group A Streptococcal infection / throat swab and culture
- Used in under 5’s only, not recommended above clinical criteria for older patients
- negative GAS rapid antigen test in children should be followed by throat swab and culture as increased risk rheumatic fever
- Monospot test - rapid identification test for EPV (infectious mononucleosis)
- Adults w pharyngitis:
- Use Centor criteria
- screen for hx of fever/ lack of cough/ tonsillar exudates/ tender anterior cervical adenopathy
- adults with none/ only 1 of these criteria should not be tested or treated for GAS
- Use Centor criteria
8
Q
Management of acute pharyngitis?
A
- Analgesia / local anaesthetics/ salt water gargle for sx
- Avoid aspirin in children - associated with Reye’s syndrome
- Abx –> only for microbiologically confirmed (w +ve rapid antigen test or culture for group A streptocci)
- Group A streptococcus pharyngitis:
- Prevent acute rheumatic fever
- reduce severity and transmission
- Treatment of choice = penoxymethylpenicillin -10 days
- if penicillin allergy –> macrolide/ cephalosporin or clindamycin
- Retropharyngeal abscess –> surgical drainage, ABX,
9
Q
Causes URTI/sore throat:
Tonsillitis
Define
A
- Acute tonsillitis = acute infection of parenchyma of the palatine tonsils
- tonsilitis may occur in isolation or as part of generalised pharyngitis
- clinical distinction between acute tonsillitis and pharyngitis = unclear, often referred to as “acute sore throat”
Pathophysiology:
Local inflammation results in oropharyngeal swelling, oedema, erythema and pain, swelling can progress to soft palate and uvular (uvulitis) or inferiorly to region of supraglottis ( this is rarer).
10
Q
Relevant anatomy to tonsillitis:
Waldeyer’s ring is formed of that tissue collections?
A
- Tonsils = collections of lymphatic tissue located within the pharynx - collectively form ring arrangement called Waldeyer’s ring.
- Formed of:
- Pharyngeal tonsil
- Tubal tonsils x 2
- Palatine tonsils x 2
- Lingual tonsil
- Tonsils = MALT - mucosa associated lymphoid tissue- contain T cells/ B cells/ macrophages - first line of defence in pathogens entering nasopharynx or oropharynx.
- Lingual tonsil - numerous lymphoid nodules within submucose of posterior third of the tongue, inferior part of waldeyer’s ring
- Pharyngeal tonsil - collection of lymphoid tissue within mucosa of roof of nasopharynx - when enlarged known as the adenoids - forms superior aspect of waldeyer’s ring. Covered in ciliated pseudstratified epithelium,
- Tubal tonsils –> lymphoid tissue surrounding opening of eustachian tube in lateral wall of nasopharynx - forms lateral aspect of waldeyers ring - ciliated pseudostratified epithelium
- Palatine –> often referred to as “tonsils” - located within tonsillar bed lateral oropharynx wall between palatoglossal arch and palatopharyngeal arch - form lateral part of waldeyers ring.
11
Q
Causative organisms for tonsillitis?
A
- Usually viral:
- Rhinovirus
- coronavirus
- adenovirus
- Less common:
- parainfluenza
- enterovirus
- herpes virus
- EBV - infectious mononucleosis
- Bacterial:
- beta haemolyti and other streptococci - most common Group A beta-haemolytic streptococci - more common in children
- Group C beta haemolytic streptococci less commn
- Mycoplasma pneumoniae
- neisseria gonorrhoea - sexually active adolescents
12
Q
How can we differentiate between viral and bacterial aetiolology in Tonsillitis?
A
The Centor criteria: predicts likelihood of patient > 14 yrs having GABHS infection
- History of fever over 38
- tonsillar exudate
- absence of cough
- tender anterior cervical lymphadenopathy
If 3/4 of centor criteria are met - PPI of Group A beta haemolytic streptocci infection
If abscence of 3 met - highly unlikely group A beta haemolytic streptococci infection
Or FeverPAIN criteria: 1 point for each, higher score more likely streptococcal cause
- Fever - past 24 hrs
- Purulence - pus on tonsils
- attend rapidly - w/in 3 days onset of sx
- severely inflamed tonsils
- no cough or coryza
13
Q
Key signs/ symptoms in hx of tonsillitis?
A
- pain on swallowing
- fever > 38
- tonsillar exudate/ erythema/enlargement
- Sudden onset sore throat
- headache
- abdo pain
- N&V
- presence of cough or runny nose –> suggest viral URTI
- enlarged painful anteriot cervical lymph nodes =–> common in group A beta haemolytic streptococcal tonsilitis
14
Q
RF for tonsillitis?
Demographics?
A
- RF’s –> age between 5- 15 yrs (More likely to be streptococcal infection)
- contact w infected individuals in enclosed spaces - e.g. childcare centre/school/ prison
15
Q
Examination in tonsillitis?
Investigations?
A
- Examination:
- tonsilar erythema/ enlargement/ purlent exudate
- enlarged anterior cervical lymph nodes
- fever > 38
- Investigation:
- usually based off clinical presentation
- if severe = rapid streptococcal Ag test +/- throat swab culture
- only in children > 3 yrs and adults w high probability of Strep infection
16
Q
Management of tonsillitis?
A
- Analgesia –> paracetamol/NSAID/ local A spray/lozenges (Lidocaine)/ salt gargle
- Abx –> only in Group A beta haemolytic streptococci infections / indicated in critically unwell or from vulnerable population where rheumatic fever is high ( south adrica/ australian indiginous/maori/ developing country)
- Penicillin 10 day course 1st line
- Macrolide = erythromycin/ azithrpmycin/ clarithromycin
- cephalosporin or clindamycin
- Tonsillectomy –> patients w recurrent tonsillitis
17
Q
What are the complications of bacterial tonsillitis?
A
-
Peritonsilar abscess = quinsy
- sx - dysphagia, worsened sore throat
- unilateral bulge with deviation of the uvula
- Robot voice - dont want to intonate properly
- degree of lock jaw
- IV abx - steroids - LA and needle aspiration or incision and drainage
18
Q
Causes of acute URTI/ sore throat:
Common cold - define
A
Common cold = acute self limiting inflammation of mucus membranes of the upper resp tract - may involve all of nose/ throat/ sinuses/ pharynx
19
Q
Common cold RF/ demographics?
A
- RF’s:
- exposure to affected individuals
- young age
- winter season
- day care attendance
- exposure to cigarette smoke
20
Q
Common cold –> common organisms?
Pathophysiology?
A
- 50% caused by rhinoviruses
- 15% coronavirus
- 15% influenza
- 5% parainfluenza
- 5% RSV - resp sycytial virus
- adenoviruses (pharyngitis) / enteroviruses
Pathophysiology: influx of polymorphonuclear leukocytes in nasal submucuosa within a few days of viral infection causes sx
21
Q
Key features in the history for common cold?
A
- Onset 1/2 days
- fever
- rhinorrhoea - clear or purulent
- sneezing
- sore throat
- hoarseness
- decreased taste/ smell
- pressure in ears/ sinus
- coughing - day 4/5 due to PN drip
22
Q
Common cold:
exam
investigations
management
A
- exam:
- may have pharyngeal exudate
- check centor criteria to exclude bacterial cause
- Investigation:
- unnecessary - diagnosis supported by negative culture
- Management:
- symptomatic –> steam/ vapour rubs/ salt gargle/ lozenges
- Fluids, rest, avoid aspirin in children
- avoid abx –> self limiting
23
Q
Causes of acute UR symptoms / sore throat:
Acute (rhino)sinusitis - define
A
- Acute rhinosinusitis = symptomatic inflammation of mucosal lining of the nasal cavity and paranasal sinuses, clinical sx present for 4 weeks or less. Caused by either viral or bacterial infection.
24
Q
Acute (rhino)sinusitis:
causative organisms?
Pathophysiology?
A
Causative organisms:
- Viral most common: rhinovirus, influenza, parainfluenza, adenovirus
- viral sinusitis often resolves within 10 days
- Bacterial less common: in small number of cases viral sinusitis will progress to bacterial (0.5-2%)
- streptococcus pneumoniae
- haemophilus influenzae
- moraxellla catarrhalis
- Bacterial sinusitis often more severe, takes > 10 days to resolve
25
Acute (rhino)sinusitis:
Pathophysiology?
* Inflammatory changes to the sinuosal mucosa due to viral infection --\> inflammation causing mucosal oedema, neutrophil recruitment, increase mucus production.--\> polyps develop which trap mucus in
* Leads to blocking of sinus drainage & increased pressure in sinus --\> further inflammation
* bacteria can take advantage of static mucociliary clearance --\> leads to bacterial growth, epithelial cell death, further inflammatory cell infiltration, leading to pus formation
* Added bacterial infection with strep pneumonia/ haemophilus influenza/ moraxella catarrhalis
26
Key features of Acute (rhino)sinusitis in history?
(symptoms)
* Symptom severity distingushes between bacterial vs viral
* Sx present less than 10 days - viral
* sx present \> 10 days - bacterial
* sx that get better then worse - secondary bacterial infection
* Bacterial sx:
* facial pain/ pressure
* headache
* nasal obstruction w purulent nasal discharge
* dental pain
* Viral:
* fever
* sore throat
* myalgia
* clear nasal discharge
* Cough common sx in both viral and bacterial - PND or asthma exacerbation
27
Examination features for Acute (rhino)sinusitis?
* Head & neck examination:
* facial tenderness on palpation
* post nasal pharyngeal secretions or exudate
* tender maxillary dentition
* middle ear effusion
* Nasal cavity:
* mucosal erythema or purulent discharge
* unilateral purulent secretion/ oedema erythema + facial tenderness -- \> think bacterial
* Nasal Endoscopy: in patients not improving
* visualise nasal cavity and sinus drainage pw/s
* RF's --\> periorbital or malar oedema, orbital proptosis, visual disturbance, abnormal extra ocular movements or neurological sings -- complications likely
28
Investigations for Acute (rhino)sinusitis?
**EPOS guideline criteria: Acute sinusitis can be diagnosed with symptoms and either endscopic or CT findings**
**Key sx: congestion/ rhinorrhoea/ facial pain or pressure/ reduced or total loss of smell (anosmia or cacosmia)**
**Nasal endocscopy -**-\> may show mucosal erythema and purulent discharge if diagnosis is unsure - pt not responding to abx. May also see polyps or obstruction of the middle meatus (where frontal maxillary and ant/ lat ethmoid sinuses drain)
Sinus culture --\> to tailor abx if resistance suspected
CT sinuses: if complications are suspected
29
Rf's for Acute (rhino)sinusitis?
Allergic rhinitis (leads to inflammation of mucosa, can block sinus ostium (opening of sinus drainage) or recent upper resp tract infection - proceeds to bacterial sinusitis
30
Management of Acute (rhino)sinusitis?
Viral:
* rest, warm facial packs, steam inhalation
* analgesia/ antipyretic: paracetaol, ibuprofen, codeine
* Decongestant: oxymetazoline, pesudoephedrine
* intranasal corticosteroid
* intranasal saline:
* mucolytic
Bacterial:
* Abx: co-amoxiclav OR clindamycin AND a cephalosporin OR doycycline OR fluroquinolone
* Treatment as above (viral)
severe or recurrent --\> ENT referral
31
Acute rhinositis:
What are the complications that can develop?
* Frontal mucocele
* subperiosteal abscess - pots puff tumour = abcess under periosteum
* intracerebral infection
* orbital abscess
* cavernous sinus thrombosis
32
Causes of acute upper resp symptoms/ sore throat
Acute bronchitis - define
key features?
* Acute bronchitis = self limiting low RTI. Refers specifically to infections causing inflammation in the bronchial airways (e.g NOT in actual lung tissue, pneumonia denotes infection in lung parenchyma)
* Acute illness \< 21 days
* cough predominant symptoms
* 1 other lower RT symptoms --\> sputum production/ wheezing / chest pain
33
Causitive organisms of acute bronchitis?
Pathophysiology?
* Most cases of acute bronchitis are viral infections --\> coronavirus, rhinovirus, RSV, adenovirus
* Can be caused by bacteria - chlamydia pneumoniae and mycoplasma pneumoniae
**_Pathophysiology:_**
* acute inflammation of bronchial wall due to infection
* increased mucus production and oedema of bronchus
* leads to productive cough - hallmark of LRTI
* infection may clear in days, repair of bronchial wall may take several weeks
* During repair, patients continue to cough (half of patients continue to cough \> 2 weeks).
34
Key features on hx for acute bronchitis?
* Acute Cough - productive
* symptoms suggestive of bronchial obstruction --\> intermittent wheeze or SOB
* Other signs of resp infection:
* rhinorrhoea
* sore throat
* low grade fever
* illness last less than 3 weeks, cough can last for uo to two weeks (50%) and up to 4 weeks (25%)
* look for more severe sx of pneumonia --\> pain/fever/malaise/ rigours/ haemoptysis
* RF's --\> cough \> 30 days, haemoptysis, weight loss
* PMH: Clarify chronic resp conditions --\> e.g. asthma
* Medication: ACE i (Can induce cough)
* SH: smoking
* Occupational Hx: any exposure to dusts / chemicals
35
Key examination features for chronic bronchitis?
* Nasal congestion
* Coryza (inflammation of mucuous membrane in nose)
* pharyngeal hyperameia (excess blood in vessels) - looks oedematous/ erythematous
* Wheeze - prolonged expiratory
* Rhonchi - low pitched contiunuous rattling lung sounds (like snoring) due to obstruction or secretions in larger airways
* rales - pneumonia or CHF
36
Investigations for acute bronchitis?
* Clinical diagnosis based off hx and exam
* persistent cough, fever, abscence of other symptoms suggestive of alternative diagnosis
* Consider:
* CXR --\> pneumonia
* CRP --\> if abx considereing
* viral identification --\> rapid test for influenza can be used if available
37
Management of acute bronchitis?
No significant wheeze with cough: observation and symptomatic - ibuprofen paracetamol
significant wheeze and cough : SABA salbutamol and antitussive
cough \> 4 weeks - evaluate for other causes, salbutamol, consider ABX
38
LO: consider probability of glandular fever and peritonsillar abscess (quinsy)
Define glandular fever
* **Glandular fever = infectious mononucleosis - clinical syndrome commonly caused by Epstein barr virus (EBV) in 80-90% of cases**
* **Infectious mononucleosis** ---\> used when syndrome caused by **EBV**
* **"mononucleosis syndrome" --\> used when non EBV agent**
* Typically manifest in adolescents/ young adults as febrile illness **w sore throat and enlarged lymph nodes**
39
LO: consider probability of glandular fever and peritonsillar abscess (quinsy)
What is the pathophysiology of glandular fever (infectious mononucelosis)?
* 80-90% of IM cases caused by EBV (also known as human herpes 4)
* Remaining EBV negative cases - Human herpes virus 6, cytomegalovirus, herpes simplex virus 1
* Most commonly transmitted through saliva hence - "kissing disease".
* EBV primarily infects the oropharyngeal B cells via the tonisllar crypts
* Circulating infected B cells then spread the infection to liver/spleen/peripheral lymph nodes
* Initiates humoral and cellular immune responses to the virus - rapid T cell response crucial for suppression
* Antibodies produced directed against EBV structural proteins = viral capsid, early antigens, EBC nuclear antigen.
* Primary infection (lytic stage) then followed by the latent stage - EBV immortalises in infected lymphocytes
* low level of ongoing viral replication and infection of B cells in tonsillar and lymphoid tissues, controlled by EBV specfic T cells.
40
LO: consider probability of glandular fever and peritonsillar abscess (quinsy) :
Key signs/ symptoms of glandular fever?
* Diagnosis confirmed by classic triad of: ***Fever, pharyngitis and lymphadenopathy*** (plus atypical lymphocytosis (abnormal morphology of the WBC's), a positive agglutination test for heterophile antibodies and positive serological test for EBV specific AB's)
* Commonly **10-30 yrs old**
* **fatigue/ malaise= very common**
* **Rash -** (10% adults, 1/3rd paediatric patients) - appears first few days of illness up to a week. Rash can appear due to viral infection itself, can be due to Abx - amoxicillin/ penicillin.
* erythematous
* maculopapular
* morbilliform
* Uncommon signs:
* myalgia
* jaundice
* spleno and hepatomegaly
* Often gradual development of illness, in some patients it may be abrupt onset.
* Sx of IM may resolve within days or persist up to 4 weeks (up to 8 in some)
* For complete resolution of fatigue, it may take several months
* Can present abnormally w guillian barre, facial nerve palsy or encephalitis in children in abscence of typical IM signs.
41
LO: consider probability of glandular fever and peritonsillar abscess (quinsy)
Examination signs in Glandular fever?
**_Common:_**
* Lymphadenopathy - cervical or generalised
* Pharyngitis/ tonsillitis (exudative or non exudative)
* Malaise
* Fever
* Spelenomegaly
* Enlarged tonsils
**_Uncommon:_**
* Myalgia
* Hepatomegaly
* Rash - maculopapular, erythematous, morbilliform
* Jaundice
42
LO: consider probability of glandular fever and peritonsillar abscess (quinsy)
## Footnote
**What are the investigations for glandular fever?**
**Bloods:**
* **FBC -**-\>
* Lymphocytosis with greater than 50% (seen in 70% of cases), highest in second and third week
* Atypical lymphocytosis greater than 10% seen in 90% cases - not specific for EBV
* anaemia and reticulocytosis (increase in reticulocytes (immature RBC's), identifies haemolytic anaemia secondary to EBV infection
* **Heterophile antibodies**
* Non specific for EBV
* IgM AB's agglutinate RBC from other species - monospot test = rapid qualitative slide agglutination test
* false negative in first week = 1/4 , less in 2nd and 3rd week
* **EBV specific AB's:**
* Test has high sensitivty and specificity
* Viral capsid antigen IgM - detectable w symptoms onset, peaks 2-3 weeks, immeasurbale at 4 months
* Viral capsid IgG peaks 2-3 months and persists for life
* Antibodies to early antigens rise in acute phase - undetectable by 3-4 months
* Nucelar antigen - rises in resolution and remains detectable for life - can identify past infection
* **LFT's:**
* Transaminase elevated
* Consider: PCR - to detect EBV, USS abdo - splenomegaly confirm, CT abdo - if suspecting splenic rupture
43
LO: consider probability of glandular fever and peritonsillar abscess (quinsy)
**What is the treatment/ management of glandular fever/ infectious mononucleosis?**
Supportive - paracetamol and ibuprofen, good hydration, antipyretics and analgesia. (x Aspirin in children - Reyes syndrome).
Avoid contact sports for up to 8 weeks due to risk of splenic rupture, avoid alcohol
If airway obstruction or haemolytic anaemia and Thrombocytopenia --\>
admit+ prednisilone + IV Ig (immunoglobulin)
44
**Peritonsilar abscess**
how does it present?
Rare complication of **bacterial tonsillitis ---\> peritonsillitus --\> abscess**
patients present with **severe sore throat** - **worse unilaterally** associated with **severe painful swallowing (odynophagia).**
Plus **stertor** (noise from vibration of pharyngeal tissues - oropharynx, soft palate- due to significant upper resp obstruction ) and **Trismus** (lockjaw)
Other symptoms: fever, drooling, halitosis, ipsilateral earache, stiff neck, headache
45
Peritonsilar abscess:
## Footnote
**Examination features?**
* **Extensive erythema (may have some exudate)**
* **soft palate swelling ipsilateral**, anterior arch pushed medially, **anterior displacement of ipsilateral tonsil** and **deviated uvula**
* **tender ipsilateral cervical lymphadenopathy**
* Asymmetrical twisted neck - torticollis - patient keeps neck tilted on affected side
46
What is the management of a peritonsillar abscess/ quinsy?
* Patients need to be admitted
* start on IV abx
* penicillin/ cephalosporin/amoxicillin/
* regular analgesia/ throat sprays
* require LA needle aspiration or incision and drainage
* culture aspiration to tailer ABX choice
* In severe cases/ recurrent cases tonsillectomy may be indicated
