Upper Respiratory tract infection

Question 1

What are some of the normal flora of the URT?

Answer 1

Streptococcus viridans, commensal Neisseria spp., diphtheroids, anaerobes.

Question 2

What are some respiratory pathogens that may be carried asymptomatically?

Answer 2

Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae, Streptococcus progenies

Neisseria meningitidis
(not respiratory)

Question 3

What are some examples of transient colonisation post antibiotics?

Answer 3

Coliforms, Pseudomonas, Candida

Question 4

What are some examples of bacterial pathogens that affect the URT?

Answer 4

Bordetella pertussis
Corynebacterium diphtheriae
Haemophilus influenzae
Moraxella catarrhalis
Streptococcus pneumoniae
Streptococcus pyogenes (Lancefield Group A β haemolytic strep)
Staphylococcus aureus
Group F β haemolytic strep (milleri group)

Question 5

What are some examples of viral pathogens that affect the URT?

Answer 5

Adenovirus
Epstein-Barr virus (EBV)
Herpes Simplex (HSV)
Influenza and parainfluenza viruses
Respiratory syncytial virus (RSV)
Rhinovirus
Enteroviruses
Coronaviruses
Human Metapneumovirus (hMPV)

Question 6

How are respiratory diseases spread?

Answer 6

droplet transmission

“Coughs and sneezes spread diseases”

Question 7

What is the epidemiology of URTIs?

Answer 7

Most often v. young children/teenagers
Winter/viral. Bacterial and viral common in children.
(Also immunosuppressed - Very ill with seemingly less pathogenic viruses in adults e.g. RSV)

Question 8

Which viral pathogens can cause colds?

Answer 8

mainly Rhinovirus

also:
Coronoviruses
RSV,
Parainfluenza viruses
Enteroviruses
Adenovirus

Question 9

What are the symptoms of rhino-sinusitis?

Answer 9

Facial pain, nasal blockage, reduction of smell

Question 10

What pathogens can cause rhino-sinusitis?

Answer 10

post viral-inflammation

Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus milleri group, anaerobes, fungal

Question 11

What are the complications of chronic sinusitis?

Answer 11

Osteomyelitis, meningitis, cerebral abscess

Question 12

What are the causes of tonsillitis?

Answer 12

Viral: RSV, Influenza, Adenovirus, EBV, HSV1

Bacterial: Streptococcus pyogenes, Rarely - Neisseria gonorrhoeae, Corynebacterium diphtheria

(Mycoplasma pneumoniae and Chlamydophila pneumoniae)

Question 13

What are the signs and symptoms of pharyngitis/tonsilitis?

Answer 13

Symptoms and signs

S/T, dysphagia, fever, headache, red tonsillar/uvular area +/- exudate. Lymphadenopathy

Question 14

What are the complications of group A streptococcal infection?

Answer 14

acute glomerulonephritis/ rheumatic fever/scarlet fever.

Aim to prevent this rheumatic fever by giving penicillin and prevent suppurative complications too (e.g. otitis media and quinsy (peritonsillar abscess))

Question 15

What are the features of glandular fever?

Answer 15

Epstein-Barr virus (EBV)
Teenagers and older. Often asymptomatic.
S/T, fever, cervical lymphadenopathy
Complications e.g. splenic rupture
Avoid ampicillin (mac-pap rash, not a true allergy)
Serology – IgM/IgG, Paul Bunnell Test/PCR

Question 16

What are the features of Diphtheria?

Answer 16

Corynebacterium diphtheriae
Malaise, fatigue, fever +/- sore throat
Complications
Erythromycin/ penicillin/antitoxin
Immunisation/travel history/CCDC

Question 17

What are the features of epiglottitis?

Answer 17

Cellulitis of epiglottis (“cherry red”) – airway obstruction
Child (2-4 yrs), fever, irritable, difficulty speaking (“hot potato”) and swallowing. Leans forward, drools. Stridor, hoarse.
Lateral neck X-ray – enlarged epiglottis

Question 18

What is the treatment of epiglottitis?

Answer 18

Treatment - maintain airway, cefotaxime

Must send blood cultures. DO NOT swab or examine epiglottis unless already intubated, or can intubate immediately (theatre).

Previously most commonly caused by H. influenzae type B prior to immunisation. Now rarer and variety causes – esp. resp. bacteria and S. aureus

Question 19

What are the features of acute laryngitis?

Answer 19

Hoarse/husky voice, globus pharyngeus (lump in throat), fever, myalgia, dysphagia
Usually viral and self-limiting, occas. bacterial (the usual suspects) therefore no need therefore for antibiotics. If severe disease consider antibiotics
In hospital – airway patency if stridor
Non infective causes (voice abuse, malignancy etc.)

Question 20

What are the features of croup/ acute laryngotracheobronchitis?

Answer 20

“… the sharp stridulous voice which I can resemble to nothing more nearly than the crowing of a cock…is the true diagnostic sign of the disease.” Francis Home 1765
Inflammation of larynx and trachea after infection of upper airways
Children
Viral esp. parainfluenza type 2 therefore NO antibiotics (also RSV)

Question 21

What are the features of whooping cough?

Answer 21

Bordetella pertussis - GN coccobacillus

Common, very contagious, adults too.

Pernasal swab and PCR
Incubation period 1-3 wks

Initially catarrhal phase – runny nose, fever, malaise (like any other URTI!).

Later (up to a week), dry non productive cough. This becomes whooping/paroxysms. (short bursts on exhalation, then inspiratory gasp which is the whoop

Question 22

How is whooping cough treated?

Answer 22

Treatment – supportive and erythromycin

May be prolonged convalescence - weeks
Complications – otitis media, pneumonia Often secondary infection or aspiration). Convulsions. Subconjunctival haemorrhages etc.
Immunisation very important. Erythromycin to household contacts/CCDC.

Question 23

What are the features of otitis externa?

Answer 23

Infection of the external auditory canal (EAC) – i.e. like any other skin/soft tissue infection in a way, but it’s a narrow canal!

Pain, itch, swelling and erythema, otorrhoea

Main types - acute OE, chronic OE and malignant OE.

Main organisms – skin types – S. aureus (likely if pustular) and Pseudomonas spp.(esp. after swimming)

Question 24

How is acute otitis externa treated?

Answer 24

Swab EAC
Treatment - toilet with saline and/or alcohol and acetic acid. Wick insertion. Topical drops (these may contain antibiotics, antifungals and steroids)

Question 25

Chronic otitis externa features?

Answer 25

Irritation from drainage from perforated tympanic membrane.

Itchy

Treat underlying cause

Avoid aminoglycosides (gentamicin etc.) if perforation.

Resistance may form and sensitisation occurs with prolonged courses

Question 26

What are the features of malignant otitis externa?

Answer 26

Severe, necrotizing. Spreads from local area more deeply. May invade bone, cartilage and blood vessels. Life threatening – spread to temporal bone, base of skull, meninges and brain. Often Pseudomonas aeruginosa
+++ pain, drainage of pus from canal
Elderly, diabetics, immunosuppressed
Treat 4-6 weeks altogether e.g. with iv ceftazidime then oral ciprofloxacin

Question 27

What are the features of otitis media?

Answer 27

Middle ear inflammation. Fluid present in the middle ear.
V common children
Fever, pain, impaired hearing. Red bulging tympanic membrane
VIRAL. H influenzae, S. pneumoniae, M. catarrhalis
Swab any pus discharging

Question 28

How is otitis media treated?

Answer 28

Treatment, if not unwell WATCH and treat symptomatically (decongestant etc) and review early. If unwell give amoxicillin.

Question 29

What is mastoiditis?

Answer 29

Inflammation of the mastoid air cells after middle ear infection. Pus collects in cells and may proceed to necrosis of bone.
Signs as AOM, but pain/swelling over mastoid too.
Much lower incidence after introduction of antibiotics.

Question 30

How is mastoiditis investigated and treated?

Answer 30

Need bacteriology samples
Imaging – CT helps to assess extent
Similar Rx to acute OM unless Gram negatives are suspected and then need broader spectrum cover as per organism isolated
LTHT 1st line treatment is co-amoxiclav (amoxicillin-clavulanate)

Question 31

What are other important infections to look out for?

Answer 31

Vincent’s angina
Deep fascial space infections of head and neck – e.g. Ludwig’s angina, Lemierre’s Syndrome
(you aren’t dentists BUT…. Don’t forget about such things as gingivitis/peridontal infection)

Question 32

What investigations can be done for suspected URTIs?

Answer 32

Send pus/throat swab/blood cultures
Gram stain 
Culture
Sensitivity testing
Reference laboratory work (typing, toxin detection)
Serology and antibody detection