Upper Respiratory Diseases

Question 0

Cough types

Answer 0

1. acute (3 wks)

if benign, resolves in a few weeks; if cough lasts > 1 month, investigate!

Question 1

Postnasal drip

Answer 1

mucosal receptors in pharynx and larynx are stimulated by secretions of the nose and sinuses that drain into the hypopharynx

Question 2

Causes of cough: conditions associated with other symptoms and signs

Answer 2

1. Upper respiratory infections (URIs): most common cause of acute cough
2. Pulmonary disease: pneumonia, COPD, pulmonary fibrosis, lung abscess, tuberculosis
3. CHF with pulmonary edema

Question 3

Causes of cough: isolated cough in patients with normal chest xray

Answer 3

1. smoking
2. postnasal drip: caused by URIs (viral infections), rhinitis (allergic or nonallergic), chronic sinusitis, or airborne irritants
3. GERD: esp if nocturnal cough (when lying flat, reflux worsens due to position and decreased lower esophageal sphincter tone)
4. asthma: cough may be only symptom in 5% of cases
5. ACE inhibitors: may cause dry cough due to bradykinin production

Question 4

Diagnosis of cough

Answer 4

1. usually no tests in pt with acute cough
2. CXR only if pulmonary cause suspected, pt has hemoptysis, or pt has chronic cough ; maybe also in longterm smoker with suspected COPD or lung cancer
3. CBC if infection suspected
4. Pulmonary function test if asthma suspected (or cause unclear in pt with chronic cough)
5. bronchoscopy (if no dx after above workup): look for tumor, foreign body, or tracheal web

Question 5

Causes of chronic cough in adults

Answer 5

smoking, postnasal drip, GERD, asthma

Question 6

Treatment of cough

Answer 6

• underlying cause
• smoking cessation (if smoking is cause)
• postnasal drip: treat w 1st gen antihistamine/decongestant preparation. if sinusitis also present: antibiotics. for allergic rhinitis, consider nonsedating long-acting oral antihistamine (loratadine)
• nonspecific antitussive treatment: unnecessary most cases (cough usually resolves with specific treatment of cause)
  may be helpful if:
• cause unknown
• specific therapy ineffective
• cough serves no “useful” purpose (eg clearing excessive sputum production or secretions)
  –> nonspecific meds:
  codeine,
  dextromethorphan (no analgesic or addictive properties, no action through opioid receptors; acts centrally to elevate threshold for coughing),
  benzonatate (Tessalon Perles) capsules (local anesthetic, acts peripherally by anesthetizing stretch receptors in respiratory passages, lungs, pleura –> reduce cough reflex at its source)
  expectorants such as guaifenesin and water can be used to improve effectiveness of antitussive medications

Question 7

Distinguishing bw Viral and Bacterial infection (in context of cough especially!)

Answer 7

Common features of viral vs. bacterial Upper Respiratory Infections
Viral: rhinorrhea, myalgias, headache, fever, cough,
NO yellow sputum
Bacterial: fever, cough yellow sputum
NO rhinorrhea, myalgias, headache

Question 8

Acute bronchitis characteristics

Answer 8

Viruses –> majority of cases
labs not indicated
obtain: CXR only if suspect pneumonia

*there is no infiltrate or consolidation in acute bronchitis, THUS
presence of fever, tachypnea, crackles, egophony on auscultation, or dullness to percussion suggests pneumonia

Question 9

Clinical features of acute bronchitis

Answer 9

1. cough (w or without sputum) = predominant symptom!
   - -> lasts 1-2 wks (cough may last 1 month or longer in many pts)
2. chest discomfort and shortness of breath may be present
3. fever may or may not be present

Question 10

Treatment of acute bronchitis

Answer 10

1. antibiotics usually not necessary (bc most cases viral)
2. cough suppressants (codeine-containing cough meds) effective for symptomatic relief
3. bronchodilators (albuterol) may relieve symptoms

Question 11

The common cold!

Answer 11

1. most common URI; children more frequently affected than adults
   susceptibility depends on preexisting antibody levels
2. caused by viruses (identifying virus not important)
   - rhinoviruses most common (>=50% of cases; >100 antigenic serotypes so reinfection w another serotype can –> symptoms, w no cross-immunity among serotypes)
   - other viruses: coronavirus, parainfluenza virus (types A, B, C), adenovirus, coxsackievirus, and RSV
3. hand to hand transmission most common route
4. complications: secondary bacterial infection (bacterial sinusitis or pneumonia); 2ndary infections (esp pneumonia) very rare
5. most resolve within 1 wk, but symptoms may last up to 10-14 days

Question 12

Clinical features of the common cold

Answer 12

1. rhinorrhea, sore throat, malaise, nonproductive cough, nasal congestion
2. fever uncommon in adults (would suggest bacterial complication or influenza) but not unusual in children

Question 13

Common cold = viral/acute rhinosinusitis

Answer 13

Common cold = acute rhinosinusitis = inflammation and congestion of mucous membranes of nasal and sinus passages

–> in most cases its hard to distinguish bw common cold (viral rhinosinusitis) and acute bacterial sinusitis on basis of clinical features

why?
bc features of both include: sneezing/rhinorrhea, nasal discharge (whether clear, purulent, or colored), nasal obstruction, and facial pain/headaches

Question 14

Treatment of the common cold

Answer 14

1. adequate hydration: loosens secretions, prevents airway obstruction; increase fluid intake and inhale steam
2. rest and analgesics (aspirin, acetaminophen, ibuprofen) to relieve malaise, headache, fever, aches
3. cough suppressant (dextromethorphan, codeine)
4. nasal decongestant spray (neo-synephrine) for <3 days
5. oral 1st gen antihistamines for rhinorrhea/sneezing

Question 15

Common cold vs influenza

Answer 15

many similar symptoms, but influenza more severe than common cold
–> fever, headache, myalgias, and malaise more pronounced with influenza

Question 16

Sinusitis

Answer 16

• inflammation of lining of paranasal sinuses, often due to infection; mucosal edema obstructs sinus openings (ostia), trapping sinus secretions
• most cases of acute sinusitis occur as complication of common cold or other URIs (but acute sinusitis)
• acute sinusitis may also be caused by nasal obstruction due to polyps, deviated septum, or foreign body

Question 17

Classification of sinusitis

Answer 17

1. acute bacterial sinusitis-usually due to streptococcus pneumoniae, haemophilus influenzae, or anaerobes
2. other types: viral, fungal, allergic

most common sinuses involved: maxillary sinuses

Question 18

Sinusitis morbidity

Answer 18

Usually self limited but can be associated w high morbidity
–> can be life-threatening if infection spreads to bone or CNS

Question 19

Clinical features acute sinusitis + pearl

Answer 19

Acute sinusitis:

• nasal stuffiness, purulent nasal discharge, cough
• sinus pain or pressure (location depends on which sinus involved); pain worsens with percussion or bending head down
• -> maxillary sinusitis (most common): pain over cheeks that may mimic pain of dental caries
• -> frontal sinusitis: pain in lower forehead
• -> ethmoid sinusitis: retroorbital pain, or pain in upper lateral aspect of nose
• fever in 50% of cases

Question 20

“Double sickening” and acute bacterial sinusitis

Answer 20

if pt has cold beyond 8-10 days or if cold symptoms improve then worsen after a few days (“double sickening”), consider acute bacterial sinusitis (may be secondary bacterial infection after primary viral illness)

Question 21

Clinical features chronic sinusitis

Answer 21

• nasal congestion, postnasal discharge
• pain and headache usually mild or absent; fever uncommon
• by def: sx shoudl be present for at least 2-3 months
• pts with hx of multiple sinus infexns (and course of abx) are at risk for infexn with staphylococcus aureus and gram neg rods

Question 22

Dx sinusitis

Answer 22

1. based on clinical findings; consider acute bacterial sinusitis if pt has cold for >8-10 days or has prolonged nasal congestion
2. physical exam
   - purulent discharge draining from one of turbinates
   - perform transillumination of maxillary sinuses (note impaired light transmission)
   room must be completely dark w strong light source
   - palpate over sinuses for tenderness (not reliable finding)
3. imaging studies
   - usually not indicated in routine community acquired infexn
   but just for fun:
   - conventional sinus radiographs: look for air fluid levels in acute dz
   - CT scan (coronal view) > plain radiograph; do in complicated dz or if sx planned

Question 23

Management of suspected sinusitis

Answer 23

1. treat with abx + decongestants for 1-2 weeks, depending on severity
2. if no improvement after 2 wks of therapy: sinus films + penicillinase resistant antibiotic
3. consider ent consult
4. course of acute sinusitis takes longer to resolve than other URIs bc of anatomic difficulties in drainage

Question 24

Complications of sinusitis

Answer 24

1. mucocele (mucous retention cysts), polyps
2. orbital cellulitis-originate ethmoid sinus
3. osteomyelitis of frontal bones or maxilla
4. cavernous sinus thrombosis (rare)
5. very rare: epidural abscess, subdural empyema, meningitis, brain abscess
   (due to contiguous spread thru bone or via venous channels

Question 25

Antihistamine effect on sinusitis/congestion

Answer 25

Antihistamines have drying effect (make secretions thicker) and can sometimes worsen congestion!
–> solution: avoid decongestants with antihistamines if this happens

Question 26

Treatment of acute sinusitis

Answer 26

1.general measures/advice for pt: saline nasal spray (aids drainage), avoid smoke and other envt pollutants
2. decongestants (pseudoephedrine or oxymetazoline)
- facilitate sinus drainage, relieve congestion
- available in both topical and systemic preparations
- give no more than 3-5 days
3. antibiotics
amoxicillin, amoxicillin-clavulanate, TMP/SMX, levofloxacin, moxifloxacin, cefuroxime
4. antihistamines
- reserve for pts w allergies; use discriminately bc of “drying effect”
- loratadine (claritin), fexofenadine (allegra), chlorpheniramine (chlor-trimeton)
5. nasal steroids
–> i stopped the madness here

Question 27

Laryngitis

Answer 27

common cause of hoarsness
moraxella catarrhalis, h.influenzae
rest voice until laryngitis resolves to avoid formation of vocal nodules

Question 28

Sore throat

Answer 28

main concern: infection with group A beta-hemolytic streptococcus due to possibility of rheumatic fever

Question 29

Ddx sore throat

Answer 29

• viral infection
• tonsillitis (usually bacterial)
• strep throat
• mononucleosis

Question 30

Pharyngeal exudates and strep throat

Answer 30

• only 50% of patients with pharyngeal exudates have strep throat
• only 50% of pts with strep throat have exudates

Question 31

Dx sore throat

Answer 31

throat culture takes 24 hrs but more accurate than rapid strep test
rapid strep test –> results in 1 hr but doesnt indicate whether cause is bacterium other than streptococcus or if its virus