Upper respiratory tract infection (Rhinitis, Sinusitis)

Question 1

Define rhinitis

Answer 1

Common cold, acute and self-limiting inflammation of URT mucosa, involving nose, throat, sinuses or larynx

o Most common infection of childhood

o Rhinovirus (50%); coronavirus (10%); influenza (5%); parainfluenza (5%); respiratory syncytial virus, RSV (5%)

This can be atopic or non-atopic
* It is classified according to the pattern and severity of symptoms experienced

Pattern: intermittent or persistent
Severity: mild, moderate, severe

It can also be classified as seasonal (related to seasonal grass, weed or tree pollens) or perennial (related to perennial allergens e.g. house dust mite or pets)

Question 2

Signs & symptoms of rhinitis:

Answer 2

• clear/mucopurulent discharge and nasal block
• coryza and conjunctivitis
• It can also present with a cough due to post-nasal drip or chronically blocked nose leading to sleep disturbance causing impaired daytime behav/ conc

It is associated with eczema, sinusitis and adenoidal hypertrophy

Closely associated with asthma

Question 3

Management of rhinitis

Answer 3

Health education → self-limiting (no ABx; virus) → may reduce anxiety and unnecessary visits to doctor
* Cough may last 4 weeks after cold
* Generally, recovery after 2 weeks
* Pain → paracetamol or ibuprofen
* Potentially decongestants or antihistamines

Long-term:
1. Assess for symptoms of asthma
2. Try to identify the most likely causative allergen
3. Look for signs of chronic nasal congestion (e.g. mouth breathing, cough or halitosis)
4. Examine the nose for nasal polyps, deviated nasal septum, mucosal swelling or depressed or widened nasal bridge

For those who want ‘as required’ treatment for occasional symptoms
* If aged 2-5 years or preference of PO treatment= oral antihistamines (e.g. cetirizine)
* All others= intranasal azelastine (antihistamine)

For those who want preventative treatment for frequent symptoms
* Avoid the causative agent
* If main issue is nasal blockage or nasal polyps= intranasal corticosteroid (e.g. beclomethasone)
* If the main issue is sneezing or nasal discharge= oral antihistamine or intranasal corticosteroid

For people requiring rapid relief whilst waiting for preventative treatment to take effect
* Intranasal corticosteroids for up to 7 days
* Consider adding PO antihistamine

If symptoms are severe and/or impairing quality of life, prescribe a 5-10 day course of prednisolone

Question 4

Complications of rhinitis

Answer 4

Complications → otitis media, acute sinus

Question 5

Define sinusitis

Answer 5

Infection of the maxillary sinuses from viral URTIs -> can get a secondary bacterial infection

• Frontal sinuses do not develop until late childhood, so frontal sinusitis uncommon until after 10yo

Types:

Acute sinusitis:
* resolves in 12 weeks completely
* Usually triggered by a viral URTI (e.g. rhinovirus, RSV, parainfluenza or influenza), following a common cold.
* Defined as an increase in symptoms after 5 days or persistence of symptoms beyond 10 days but less than 12 weeks.
* Can be followed by a bacterial infection

Recurrent acute sinusitis
* ≥ 4 episodes without persistent symptoms in the intervening periods in a year

Chronic sinusitis
* causes symptoms > 12 weeks
* More likely to be inflammatory than infectious, but likely to be multifactorial

RFs: Air pollution, Damp housing, winter months, exposure to tobacco smoke/ other allergens

Question 6

Presentation of rhinitis

Answer 6

Nasal blockage- obstruction, congestion

Discoloured nasal discharge (anterior/ posterior nasal drip) with facial pain/ pressure

Swelling and tenderness on the front of the face

Cough (day or night)

Influenza like illness

Secondary bacterial infection (maximally sinus infection)- pain, swelling, tenderness over the cheek

Investigations:
Basic observations
Examine the maxillofacial area
Anterior rhinoscopy
clinical diagnosis

Question 7

Management

Answer 7

Refer to hospital if there are symptoms and signs of:
* Severe systemic infection
* Intraorbital or periorbital problems (e.g. periorbital cellulitis, displaced eyeball, double vision)
* Intracranial complications (e.g. features of meningitis)

o Symptoms lasting <10 days:
* No antibiotic
* Advice – virus, takes 2-3 weeks to resolve, only 2% get bacterial complication, simple analgesia
* Some people may find some relief using nasal saline or nasal decongestants
* Medical advice if symptoms worsen rapidly, do not improve in 3w, systemically unwell

o Symptoms lasting >10 days:
* High-dose nasal corticosteroid for 14 days (if >12yo; e.g. mometasone)
* May improve symptoms but unlikely to affect duration of illness
* Could cause systemic side-effects

ABx not indicated (as per guidelines) but can give back up prescription (if given, only use if symptoms don’t get better in 7 days or if symptoms get rapidly worse):

· 1st line: phenoxymethylpenicillin (clarithromycin if penicillin-allergic)

· 2nd line: co-amoxiclav

Question 8

Complications of sinusitis

Answer 8

Orbital, intracranial, bony complications

Progression to chronic sinusitis