HEENT - Upper Respiratory Infections - Exam 2 Flashcards
What virology contributes the most to the common cold?
Rhinovirus (30-50%)
What are the common symptoms associated with the common cold?
- Rhinorrhea
- Nasal congestion
- Sore throat (dry, “scratchy”)
- Non-productive cough
- Malaise
- Low-grade fever
What are clinical signs of the common cold during a physical exam?
- Nasal mucosal swelling
- Nasal discharge (clear, purulent, watery)
- Conjunctival injection
- Pharyngeal erythema (mild)
- No adenopathy
What is the treatment for the common cold?
- Self-limiting (1-2 weeks)
- Supportive care: rest, stay home
- Antibiotics are of no value
What medications are recommended during the common cold?
- Analgesics
- Antihistamines
- Expectorants
- Antitussives (if patient has cough)
What is the etiology of influenza?
Influenza A and B viruses
What is death commonly due to with influenza?
Secondary bacterial pneumonia
What are the common seasonal outbreaks for influenza?
Fall and winter months
What are the pre-dominant symptoms seen with influenza?
- Abrupt onset
- Fever (can be extremely elevated)
- Myalgia
- Sore throat (can be severe)
What are clinical signs seen with influenza?
- Flushing
- Post pharynx typically unremarkable (even if patient has sore throat)
- Mild cervical lymphadenopathy
What populations should be tested for influenza?
- Influenza symptoms with no known outbreak
- Immunocompetent patients with symptoms after hospital admission
- High risk patients with symptoms
- Healthcare workers with symptoms
What populations are considered high risk for influenza related complications?
- Children < 5 years, but especially < 2 years
- Immunosuppression
- Chronically ill
- Pregnant women or post-partum (within 2 weeks)
- Residents of nursing homes
- Native Americans
- BMI of 40 or greater
- Adults >65
What are in-office screening tests for influenza?
Rapid Influenza Detection Tests (RIDTs)
What are lab screening tests for influenza?
- Rapid Molecular Assay
- RT-PCR
- Viral culture
What is the gold standard for lab diagnosis of influenza?
Viral culture
What are indications to treat with an antiviral for influenza?
- Illness requiring hospitalization
- Progressive, severe, or complicated illness
- High risk
- Uncomplicated influenza, but high-risk household contacts
- Uncomplicated influenza in health care provider who cares for high risk patients
Within what time frame should antivirals be given for influenza?
Within 48 hours from onset of symptoms
What neuraminidase inhibitors are given for influenza A/B?
- Oseltamivir (Tamiflu)
- Zanamivir (Relenza)
- Peramivir (Rapivab)
- Baloxavir (Xofluza)
What should a pregnant woman with influenza be prescribed?
Antiviral
Zanamivir is contraindicated in what populations?
Patients with asthma, respiratory conditions, milk protein allergy
Who should receive the influenza vaccine?
Everybody > 6 months old
How long does it take for antibodies to develop after receiving the influenza vaccine?
Two weeks
What are potential contraindications for the influenza vaccine?
- Current moderate to severe illness (fever)
- Hx of Guillain-Barre Syndrome within 6 weeks of previous vaccine
- Hx of allergic reaction to vaccine
- Hx of severe allergic reaction to eggs
What is the most common etiology of pharyngitis?
Viral
While respiratory viruses are less likely to cause pharyngeal exudates, what are the exceptions?
- Adenovirus
- Mononucleosis
If pharyngitis is caused by Herpes Simplex (HSV 1 and HSV 2), what is the treatment?
- Acyclovir
- Famciclovir
- Supportive care
What is typical management of viral pharyngitis?
- Supportive care with hydration, antipyretics, “Magic Mouthwash”
- HIV needs antivirals and ID consult
What are clinical signs of pharyngitis caused by the virus Mononucleosis?
- Sore throat, pharyngeal erythema
- Tonsillar exudates
- Enlarged cervical lymph nodes
- Fever
- Fatigue
- Splenomegaly (50%)
How do you diagnose pharyngitis caused by the virus Mononucleosis?
- Monospot
- CBC with differential (increased atypical lymphocytes)
How long does pharyngitis caused by the virus Mononucleosis typically last for and how long is someone contagious?
Duration of 2-4 weeks, but contagious up to 3 months
What is the management for pharyngitis caused by the virus Mononucleosis?
- Supportive care
- Avoid contact sports
What are clinical signs of pharyngitis caused by bacterial Corynebacterium diphtheriae?
- Gray exudate tightly adherent to throat, nasal passageway
- Consider in unvaccinated patients, especially with recent travel
What is the treatment for pharyngitis caused by bacterial Corynebacterium diphtheriae?
- Diphteria anti-toxin + penicillin or erythromycin
What is the treatment for pharyngitis caused by bacterial Mycoplasma pneumoniae?
Azithromycin (Zithromax)
What is pharyngitis caused by bacterial Mycoplasma pneumoniae typically associated with?
- Lower respiratory infection
- Headache
What population is highest risk for pharyngitis caused by bacterial Neisseria gonorrhoeae?
Homosexual men
What is treatment for pharyngitis caused by bacterial Neisseria gonorrhoeae?
Ceftriaxone (Rocephin)
What complications can pharyngitis caused by bacterial Group A Streptococcus lead to?
- Local invasion
- Immune mediated responses
What are symptoms associated with pharyngitis caused by bacterial Group A Streptococcus?
- Odynophagia (pain on swallowing)
- Sore throat
- Fever, malaise, anorexia
- Arthralgias, myalgias
- Nausea/vomiting
- Neck discomfort; swollen glands
What symptom complex carries a 40-60% positive predictive value for Group A Streptococcus pharyngitis (GAS)?
[Centor Criteria]
- Fever by history
- Absence of cough
- Tonsillar exudates
- Tender anterior cervical adenopathy
GAS = FATT
What should the next step be if your patient meets Centor criteria but has a negative Rapid antigen detection test for Group A Strep?
- If a child or adolescent, order culture
- Clinical judgement for adults, can treat without culture
- Empiric antibiotics until culture results
What is the first line treatment for Group A Strep pharyngitis?
- Penicillin G benzathine (Bicillin L-A) 1.2 million units IM x 1
- Penicillin V 500 mg PO TID x 10 days
- Amoxicillin (Amoxil) 500 mg PO BID x 10 days
- Cephalexin (Keflex) 500 mg PO BID x 10 days
“Playful puppies always cuddly”
What is the second line treatment for Group A Strep pharyngitis?
- Azithromycin (Zithromax) 500 mg PO day 1 followed by 250 mg PO days 2-5
- Clindamycin 300 mg PO TID x 10 days
What is the typical course of Group A Strep pharyngitis?
- Improvement in clinical symptoms within 3-4 days of initiating antibiotics therapy
- No longer considered contagious after 24 hours of antibiotic treatment
- May return to daycare, work and school
What are major complications that can occur due to Group A Strep pharyngitis?
- Rheumatic fever
- Post-streptococcal glomerulonephritis
- Streptococcal toxic shock syndrome
- Scarlet fever
Rappers Go To School
What is associated with Scarlet fever?
- Requires previous exposure to Strep pyogenes infection
- Delayed hypersensitivity reaction
- Rash, desquamation, Pastia’s lines, facial flushing with circumoral pallor and “strawberry tongue”
Scarlet Reads Dirty Porn For Corny Stories
How can you distinguish peritonsillar abscess from cellulitis?
- Abscess will have of a collection of pus while cellulitis will not
- Cellulitis has an absence of trismus and uvular deviation
What are symptoms associated with peritonsillar abscess?
- Severe sore throat (usually unilateral)
- Drooling
- Trismus
- Fever
- Neck swelling/pain
- Ipsilateral ear pain
- Decreased PO intake
What are clinical exam findings of peritonsillar abscess?
- Swelling pushing tonsil with deviation of uvula to the opposite side
- Fullness of posterior soft palate with palpable fluctuance
- Cervical lymphadenopathy
- “Hot Potato,” muffled voice
If unable to diagnose a peritonsillar abscess clinically, what imaging studies should you obtain?
- CT with IV contrast to rule out spread of infection, or if exam is limited due to trismus
- US helpful, but no definitive in distinguishing abscess from cellulitis
What is the management for peritonsillar abscess?
- Monitor for airway obstruction
- Drainage of abscess
- Antimicrobial therapy in adults
- +/- hospitalization
- Supportive care with fluids and pain control
What parenteral antibiotics should be used for an adult with a peritonsillar abscess?
- Ampicillin-sulbactam (Unasyn)
- Clindamycin
- Consider vancomycin if high rates of MRSA
Until afebrile and improving
What oral antibiotics should be used for an adult with a peritonsillar abscess?
- Amoxicillin-clavulanate (Augmentin)
- Clindamycin
What are signs/symptoms of epiglottitis?
- Drooling (difficulty swallowing)
- Stridor (respiratory distress)
- Severe sore throat
- Toxic appearance
If patient presents with respiratory distress, what should be your first concern?
Secure airway before examining
What imaging studies can help you diagnose epiglottitis?
- Lateral neck xray (“Thumb Sign”)
- CT/MRI
What is the management for epiglottitis?
- Hospitalization
- Intubation
- Antibiotics
What is the most common etiology of laryngitis?
Virus
What are some non-infectious causes of laryngitis?
- Vocal abuse
- Vocal cord trauma
- Toxic exposure
- GERD with gastric acid aspiration
- Vocal cord nodules or laryngeal polyps
What are symptoms associated with laryngitis?
- Hoarseness (key symptom)
- Dysphonia (variation in vocal quality)
- URI symptoms
What are clinical exam signs associated with laryngitis?
URI related
- nasal edema
- congestion
Direct laryngoscopy reveals:
- laryngeal erythema and edema
- vascular engorgement of vocal cords
- nodules or ulcerations
When would you refer to ENT with laryngitis?
Hoarseness greater than 2 weeks in the absence of URI symptoms (especially with history of tobacco or alcohol use)
What is the management for laryngitis?
- Treat underlying cause such as removal of offending agent or managing underlying disease
- Voice rest
- Humidification
- Increase fluid intake
- Advise to discontinue smoking
- No abx unless bacterial infection
- Referral to ENT as needed
What is the most common etiology of acute rhinosinusitis (ARS)?
Acute viral rhinosinusitis
- Rhinovirus
- Influenza
- Parainfluenza
What symptoms are associated with rhinosinusitis?
Purulent nasal drainage AND nasal obstruction and/or facial pain, pressure, or fullness
What are the classifications of rhinosinusitis?
- Acute: < 4 weeks
- Subacute: 4-12 weeks
- Chronic: > 12 weeks
What classifies recurrent acute rhinosinusitis?
4 or more episodes of acute rhinosinusitis per year
What are clinical exam sings of acute rhinosinusitis?
- Purulent drainage in nose or posterior pharynx
- Nasal mucosal edema
- Tenderness to percussion of upper teeht
- Sinus tenderness to palpation
- Tranillumination of frontal or maxillary sinuses - may show opacity, unreliable
How do you diagnose acute viral rhinosinusitis?
- Clinically
- < 10 days of symptoms that are not worsening
What is the management for acute viral rhinosinusitis?
Supportive care
Days 1-9:
- analgesics
- saline irrigation
- mucolytics
- intranasal decongestants
- intranasal glucocorticoids
What is the basic pathophysiology of acute bacterial rhinosinusitis (ABRS)?
Viral infection followed by secondary bacterial infection
When would you prescribe abx for acute bacterial rhinosinusitis?
Persistent symptoms/signs lasting > 10 days with no clinical improvement
OR
Onset with severe symptoms: fever > 102; purulent nasal discharge, facial pain lasting at least 3-4 consecutive days at the beginning of illness
OR
Viral URI that lasted 5-6 days and was initially improving, followed by severe symptoms, “double worsening”
What is the primary management for acute bacterial rhinosinusitis?
First-line antimicrobial management, patient is NOT high risk for abx resistance:
- Amoxicillin-clavulanate (Augmentin) 875/125 mg BID
- Doxycycline 100 mg BID
- Levofloxacin (Levaquin) 500 mg QD
- Moxifloxacin (Avelox) 400 mg QD
IDSA guidelines recommend 5-7 days
If your patient is diagnosed with acute bacterial rhinosinusitis and has no response to initial antibiotic treatment, OR has worsening of symptoms after 7 days of empiric antibiotic treatment, OR has a high risk of antibiotic resistance, what should you treat with?
Second-line antimicrobial management:
- Amoxicillin-clavulanate (Augmentin) 2000/125 mg BID
- Doxycycline 100 mg BID
- Levofloxacin (Levaquin) 500 mg QD
- Moxifloxacin (Avelox) 400 mg QD
IDSA guidelines recommend 7-10 days
What are complications of acute bacterial rhinosinusitis?
Extension of infection from paranasal sinuses to CNS, orbits, or surrounding tissues:
- Osteomyelitis
- Meningitis
- Brain or epidural abscess
- Preseptal or orbital cellulitis
When would you order radiology studies for acute bacterial rhinosinusitis and what is the most appropriate study to order?
You would order radiology studies if suspected complicated acute bacterial rhinosinusitis.
- CT scan with contrast
- MRI can be used for soft tissue detail/suspected extra sinus involvement
What is the gold standard in regards to lab testing for complications of acute bacterial rhinosinusitis?
Sinus Aspirate Culture
What is the management for complications of acute bacterial rhinosinusitis?
- Admit to hospital
- Urgent ENT/ID consult
- Empiric antibiotics
What are the four cardinal symptoms of chronic rhinosinusitis (CRS) in adults?
- Mucopurulent nasal discharge
- Nasal obstruction and congestion
- Facial pain, pressure, fullness
- Reduction/loss of sense of smell
What are the four cardinal symptoms of chronic rhinosinusitis (CRS) in children?
- Mucopurulent nasal discharge
- Nasal obstruction and congestion
- Facial pain, pressure, fullness
- Cough
What is the diagnositc criteria for chronic rhinosinusitis (CRS)?
- Presence of at least 2 of the 4 cardinal symptoms
AND - Infection lasting 12 weeks or greater with medical management
PLUS EITHER
- Sinus mucosal disease with imaging (CT) with mucosal thickening, or partial/complete opacification of the paranasal sinuses
OR
- Direct visualization (nasal endoscopy) of mucosal inflammation, polyps in the nasal cavity or meatus, and/or purulent mucus and edema
How do you diagnose chronic rhinosinusitis (CRS)?
- Non-contrast CT
- Referral to ENT for possible nasal endoscopy or sinus aspirate culture
What is the management for chronic rhinosinusitis (CRS)?
- Nasal saline lavage
- Intranasal corticosteroids
- Oral corticosteroids
- Oral antimicrobials
- Antihistamines
- Topical or systemic antifungals
- Endoscopic sinus surgery
What are clinical exam findings associated with pharyngitis caused by bacterial Group A Streptococcus?
- Pharyngeal erythema
- Tonsillar hypertrophy
- Purulent exudate
- Tender and/or enlarged anterior cervical lymph nodes
- Palatal petechiae
