ICL 2.2: Upper Airway Infections Flashcards
what is otitis media?
an infection of the middle ear between the eustachian tube and the tympanic membrane
what causes otitis media?
viral upper respiratory infection can cause edema of the eustachian tube, which often leads to middle ear infection
the most common organisms are:
1. strep pneumoniae (35−40%)
- H. influenzae (nontypeable; 25−30%)
- moraxella catarrhalis (15−20%).
this is roughly the same breakdown of organism type and frequency that occurs in bronchitis and sinusitis!!
what is the hallmark clinical presentation of otitis media?
the most sensitive clinical finding is immobility of the membrane on insufflation of the ear with air
it’s NOT usually redness!! don’t be fooled
how do you treat otitis media?
oral therapy with amoxicillin is still the best initial therapy = 2nd generation penicillin
amoxicillin/clavulanate is used if there has been recent amoxicillin use
other alternatives to amoxicillin-clavulanate are second-generation cephalosporins, such as cefuroxime
patients with severe penicillin allergies should receive macrolides such as azithromycin
what is sinusitis?
an infection of the sinuses
the most common site is the maxillary sinus, followed by ethmoid, frontal, and sphenoid sinuses
can diagnose with CT scan which would show mucous thickening in the sinus
what causes sinusitis?
viruses are responsible for most of the cases –> they come in and cause edema and infiltrate in the mucosa which allows bacteria to come in and cause more infection
bacterial organisms that cause sinusitis are the same ones causing otitis media = strep pneumoniae, H. influenzae, moraxella catarrhalis (15−20%).
what are the symptoms of sinusitis?
- facial pain
- headache
- postnasal drainage
- purulent nasal drainage (green, yellow color)
how do you treat sinusitis?
mild or acute uncomplicated sinusitis which means no colored sputum, can be managed with decongestants, such as oral pseudoephedrine or oxymetazoline sprays
more severe sinusitis, since it’s the same organisms as otitis media, it’ the same treatment! oral therapy with amoxicillin is still the best initial therapy = 2nd generation penicillin
amoxicillin/clavulanate is used if there has been recent amoxicillin use
other alternatives to amoxicillin-clavulanate are second-generation cephalosporins, such as cefuroxime
patients with severe penicillin allergies should receive macrolides such as azithromycin
what imagining do you use for sinusitis?
CT scan
what is pharyngitis?
inflammation of the pharynx
what causes pharyngitis?
80% is caused by viruses but the most important cause is group A B-hemolytic streptococci = S. pyogenes
this is because of the possibility of the organism progressing on to rheumatic fever or glomerulonephritis
what are the symptoms of pharyngitis?
sore throat with cervical adenopathy and inflammation of the pharynx with an exudative covering is highly suggestive of S. pyogenes
most viruses do not give an exudate, although the Epstein-Barr virus can
hoarseness and cough are NOT suggestive of bacterial pharyngitis
how do you diagnose pharyngitis?
rapid streptococcal antigen test is 80% sensitive but >95% specific
a positive test can be considered the equivalent of a positive culture, whereas a negative test should be confirmed with a culture
how do you treat pharyngitis?
penicillin
macrolides and oral, second-generation cephalosporins are alternatives in the penicillin-allergic patient
what is influenza?
a systemic viral illness from influenza A or B, usually occurring in an epidemic pattern and transmitted by droplet nuclei – so they’ll have URI symptoms but also systemic symptoms like body pain etc.
droplet nuclei = sneezing, shared saliva, etc.
influenza can lead to damage to the respiratory epithelium leading to sinusitis, otitis media, bronchitis, and pneumonia
what are the symptoms of influenza?
URI symptoms:
- runny nose
- nonproductive cough
- sore throat
- conjunctival injection
AND
systemic illness:
- fever
- myalgias
- headache
- fatigue
how do you test for influenza?
confirmation is best achieved initially with rapid antigen detection methods of swabs or washings of nasopharyngeal secretion
how do you treat influenza?
- symptomatic therapy with acetaminophen and antitussives is useful
- specific antiviral medications for both influenza A and B are the neuraminidase inhibitors oseltamivir and zanamivir –> they should be used within 48 hours of the onset of symptoms to limit the duration of symptoms, doesn’t actually kill the virus (better for influenza A than B)
influenza vaccine is recommended annually in the general public
which populations really need to get the influenza vaccine?
- chronic lung and cardiac disease = COPD, CHF
- pregnant women in any trimester
- residents of chronic care facilities
- health care workers
- immunosuppressed
- DM
- renal dysfunction
it’s recommended in the general public but these patients reallyyyyyy need the vaccine
in which patients is the influenza vaccine contraindicated?
those who are highly allergic to eggs and which would result in anaphylaxis
what is bronchitis?
an infection of the lung, which is limited to the bronchial tree with limited involvement of the lung parenchyma = you can’t see it on a CXR!
acute exacerbations of chronic bronchitis (COPD) are often difficult to distinguish from a pneumonia until after a chest x-ray is performed
which organisms cause acute bronchitis?
the majority of cases are caused by viruses
S. pneumoniae and H. influenzae have not been implicated
a small percentage of non viral cases are due to M. pneumoniae, C. pneumoniae, and B. pertussis
which organisms are most commonly responsible for chronic bronchitis?
- streptococcus pneumoniae
- non-tapeable haemophilus influenzae
- moraxella
what is the clinical presentation of acute bronchitis?
cough with sputum production
a bacterial etiology is suggested by discolored sputum; clear sputum means viral cause
signs of respiratory infection, such as cough and sputum, with a normal chest x-ray confirm the diagnosis
how do you treat acute bronchitis?
mild acute cases often do not require therapy because they are often caused by viruses that resolve spontaneously; just give tylenol and antitussive medication
acute or chronic cases require treatment with oral antibiotics that cover the most causative organisms –> amoxicillin first then if it doesn’t work give amoxicillin-clavulanate or cefuroxime; give macrolide if allergic to amoxicillin
what is an acute cough?
cough in the first 3 weeks of developing it!
if it’s 3 weeks-3 months = subacute
3+ months = chronic
what causes acute cough?
mild viral infections
treat the symptoms, no other treatment
what are the 2 types of cough receptors?
- mechanical receptors
- touch = mucus, saliva, food, foreign body
- displacement = abscess, submucosal adenopathy - chemical receptors
- acid
- temperature
- capsaicin
- TRPV1
what is a subacute cough?
cough that lasts from 3-8 weeks
classically associated with Bordetella pertussis
this post-infectious phase follows the catarrhal and precedes the convalescent phases
how do you treat subacute cough?
macrolide or trimethoprim/sulfamethoxazole (bactrim)
but this probably only helps if administered in the first or second week of symptom
what is the prophylaxis measurement taken against subacute cough?
booster vaccines for adolescents and adults in the Tdap combination
what is a chronic cough?
cough lasting longer than 8 weeks is dominated by three conditions that may occur in isolation (75%) or in combination (25%)
hard to treat because it’s not just caused by one thing, it’s a combination of conditions
what are the 4 conditions that mainly cause chronic cough?
- upper airway cough syndrome (UACS) = aka postnasal drip, hay fever, allergic rhinitis
- gastroesophageal reflux disease (GERD)
- asthma
- medication; ACE inhibitors!!
the next three most common causes are chronic bronchitis, bronchiectasis, and non-asthmatic eosinophilic bronchitis
what is UACS?
UACS = upper airway cough syndrome
due to irritation of afferent receptors in the upper airway
usually caused by allergies!
how do you treat UACS?
after avoidance measures of potential environmental factors (pets, perfumes, allergens), an empiric course of a first-generation antihistamine (benadryl) combined with a decongestant is typically recommended before extensive investigation
if the patient doesn’t improve: of all medical therapies, intranasal corticosteroids appear the most effective, but patient education is essential to ensure compliance during the 3 to 4 weeks necessary to achieve full medical benefit
failure to respond suggest the presence of chronic sinusitis
what are the causes of UACS?
- allergic
- drug-induced = NSAIDS, antihypertensives
- environmental
- bacterial
which antihistamines are useful in treating allergic rhinitis?
newer antihistamines (claritin, allegra) may help with UACS but not other forms of rhinosinusitis, most likely because they lack substantive anticholinergic properties
1st generation = anticholinergic = dryness which is why they help with UACS but they’re sedatives so….
what symptoms are associated with GERD?
cough when they bend over
coughing at night
GERD has been implicated in nearly 40% of patients with chronic cough, either as the sole cause or in combination with other etiologies, and often without the traditional symptoms of dyspepsia and heartburn
how do you treat GERD?
- lifestyle and dietary changes
- acid suppression
- prokinetic agent
often takes 2 – 3 months before cough begins to improve, and 5 – 6 months before it resolves
if cough continues, consider 24-hour pH probe
if someone has a post-viral cough, what do you need to be cognizant of?
UACS or asthma
also remember to consider Bordetella pertussis
consider a short course of prednisone, inhaled ipratroprium, 1st generation antihistamine, nasal steroids, or a nasal rinse
sputum cultures usually not recommended
what often causes hoarseness?
common respiratory causes are dominated by upper respiratory infections from viruses
gastroesophageal and laryngopharyngeal reflux are also common suspects, but it remains uncertain that therapies known to alleviate dyspepsia will also be effective when reflux is associated with dyspnea
more unusual causes encountered by pulmonologists include recurrent laryngeal nerve damage from bronchogenic lung cancer and associated Horner syndrome, tuberculosis, granulomatosis with polyangiitis affecting the upper airway, use of inhaled corticosteroids, and trauma from items such as endotracheal tube
21 year old male previously healthy presented to the urgent care c/o fever, runny nose, and sore throat. He has severe allergy to penicillin.
Q1. What is the most likely diagnosis?
Q2. What is the sensitivity and specificity of a rapid streptococcal antigen test?
Q3. Name three signs and symptoms that can differentiate a viral from bacterial infection?
- pharyngitis
- 80% sensitive and 95% specific
- exudate, cervical lymphadenomy, absence of hoarseness and cough = bacterial
Q1. Three days later, he developed left ear pain and high grade fever, what exam you would like to do to diagnose Otitis media?
Q2. What other complications do you expect to develop?
Q3. 5 days later, he c/o facial pain and colored nasal discharge, A CT scan showed maxillary sinusitis, what antibiotics you want to prescribe?
Q1. air test; absence of tympanic membrane movement with air
Q2. meningitis; untreated otitis media can lead to mastoiditis which can then lead to meningitis
Q3. macrolide because allergic to penicillin
A 63-year-old man comes to the office with a cough productive of yellowish sputum for the last several days. He has smoked 1 pack of cigarettes a day for the last 30 years. This is his fourth episode in the last 2 years. On physical examination, he has clear lungs and a temperature of 101°F. His chest x-ray is normal
Q1. What is the diagnosis?
Q2. What are the most common causative organisms?
Q3. What is the treatment?
Q1. acute exacerbation of chronic bronchitis
Q2. strep pneumonia, H. influenza, and moraxilla catarhalis
Q3. amoxicillin
A 42 year old female with history of childhood allergies present with dry cough of 12 weeks duration
Q1. What is your differential diagnosis?
Q2. Throat exam showed the presence of post nasal drip, what is the initial treatment?
Q3. What is the long term treatment?
Q1. chronic cough = asthma, GERD, UACS, medications –> probably asthma because she had childhood allergies
Q2. 1st generation antihistamine + decongestant
Q3. intranasal corticosteroid
