URI - Sore Throat, Earache, and Upper Respiratory Symptoms Flashcards
What is the most common reasons for visit to primary care providers?
Infection of the upper respiratory tract (URIs)
URI =
upper respiratory tract
How are the URIs usually classified?
Mild
What is the leading cause of time lost from work or school?
URIs
What is the the leading diagnoses for which antibiotics are prescribed on an outpatient basis?
URIs are the leading diagnoses for which antibiotics are prescribed on an outpatient basis
-> it has contributed to the rise in antibiotic resistance among community aquired pathogens (i.e. S. pneumoniae)
What is the percentage of the URIs that are cause by bacteria?
A minority (~25%) of cases are caused by bacteria
What are most URIs caused by?
viruses
- Distinguishing patients with primary viral infection from those with primary bacterial infection is difficult
- Signs and symptoms of bacterial and viral URIs are typically indistinguishable.
How are acute infections usually diagnosed?
acute infections are usually diagnosed on clinical grounds
Nonspecific infections of the upper respiratory tract?
- broadly defined group of disorders that constitutes the leading cause of ambulatory visit
- no prominent localizing featrures
- specific diagnostic tests are generally unnecessary
Nonspecific infections of the upper respiratory tract has other names including:
- acute infective rhinitis
- acute rhinopharyngitis
- common cold
nearly all URIs are caused by…..
- viruses spanning multiple virus families
What is the most common cause of URI?
The most common cause (30%-40%) of URI is Rhinovirus which has at least 100 immunotypes
What are other causes of URI:
- influenza virus (3 types)
- parainfluenza virus (4 types)
- adenovirus (47 types)
- RSV
- Enterovirus
Where are the Nonspecific infections of the upper respiratory tract localized?
lack of localization in one particular anatomical area, such as the sinuses, pharynx, lower airway
For how long does the Nonspecific infections of the upper respiratory tract last?
it is usually self-limited catarrhal syndrome with a median duration of 7 days (range 1-10 days)
The same viruses -
variety of signs and symptoms
What are the principal signs of Nonspecific infections of the upper respiratory tract?
- rhonrrhea (+/- purulence)
- nasal congestion
- cough
- sore throat
What are the other manifestation Nonspecific infections of the upper respiratory tract?
- fever
- malaise
- sneezing
- lymphadenopathy
- hoarseness
- fever (more common among the children)
What are the finding of Nonspecific infections of the upper respiratory tract on physical examination?
nonspecific
0.5-2% of colds are complicated by…..
secondary bacterial infection
Purulent secretions from the nares or throat are (without other clinical findings)…..
often misinterpreted as an indication of bacterial sinusitis or pharyngitis
Nonspecific infections of the upper respiratory tract - treatment:
- DO NOT USE ANTIBIOTICS!
- Symptomized treatment
- Non-steroidal anti-inflammatory drugs (e.g. ibuprofen), decongestants
- Zink, vitamin C, echinacea - no consistent benefit in the treatment of nonspecific URI
Rhinosinusitis -
Inflammatory condition involving the nasal sinuses (often more than 1)
Which sinus is the most commonly involved in infections of the sinus?
maxilary
Which sinuses are involved in the infections of the sinuses?
maxillary>ethmoid>frontal>sphenoid
For how long does acute sinusitis last?
<4 weeks duration
Why is antibiotics prescribed very frequently when it comes to the infection of the sinuses?
differentiating bacterial from viral sinusitis on clinical ground is difficult, that´s why antibiotics are prescribing very frequently (85%-98% of cases)
What are the non-infectious causes of sinusitis?
- allergic rhinitis
- barotrauma (deep-sea diving)
- exposure to chemical irritants
- granulomatous disease
- tumours
- cystic fibrosis
What is the most common reason for sinusitis?
viral (rhino-, influenza-, and parainfluenzaviruses) is much more common than bacterial sinusitis (S.pneumoniae and H.influenzae - up to 60% and M.catarrhalis - 20%, S.aureus, MRSA, anaerobes)
What are the common causes of nosocomial sinusitis (after surgery, tracheal intubation etc):
- s.aureus
- p.aeruginosa
- s.marcescens
- k.pneumoniae
- enterobacter spp
Who usually gets fungal sinusitis?
fungal sinusitis more common in immunocompromised patients, usually more aggressive, invasive, life-threatening infections.
What usually causes fungal sinusitis?
- rhinocerebral mucormycosis
- aspergillosis
When are most cases of sinusitis present?
most cases of sinusitis are present after or in conjunction with viral URI
What are the symptoms of acute rhinosinusitis?
- nasal drainage
- congestion
- facial pain and pressure
- headache
- thick discolored purulent nasal discharge (not specific to bacterial infection)
What are the other symptoms of acute rhinosinusitis?
- cough
- sneezing
- fever
- tooth pain
- retroorbital pain radiating to the occiput
- signs of orbital cellulitis
- soft tissue edema over the frontal bone (a complication of frontal sinusitis)
Where is the sinus pain and pressure localized?
sinus pain and pressure often localizes to the involved sinus (specially when the patient bends over or is supine)
What are the life threatening complications of acute rhinosinusitis?
- meningitis
- epidural abscess
- cerebral abscess
How do we diagnose acute rhinosinusitis?
illness duration is helpful in the therapeutic decision-making
For how long does the acute bacterial sinusitis last in adults and children?
> 10 days in adult and >10-14 days in children + purulent discharge + nasal obstruction + nasal pain
(BUT only 40-50% of patients have true bacterial sinusitis!)
Is the use of CT and RTG recommended in acute rhinosinusitis?
The use of CT and RTG is not recommended for acute disease (exception: nosocomial sinusitis)
Immunocompromised with acute rhinosinusitis?
An immunocompromised patient should be examined by otolaryngologist
What should be done if we suspect fungal acute sinusitis?
if fungal infection is suspected - biopsy specimen should be examined
Nosocomial acute sinusitis suspected -
a sinus aspirate or culture and susceptibility testing should be obtained
How do we treat acute rhinosinusitis?
most patient improve without antibiotic therapy
How do we treat patients with mild and moderate symptoms of acute rhinosinusitis of short duration?
In patients with mild to moderate symptoms of short duration - oral and topical decongestants, nasal saline lavage, at least nasal glucocorticoids
What do we do if there is no improvement after 10 days of symptomatic treatment of acute rhinosinusitis or if the symptoms are severe?
If there is no improvement after 10 days of symptomatic treatment or the symptoms are severe - antibiotic therapy should be considered
How should community-aquired sinusitis be treated?
acute rhinosinusitis
Community-aquired sinusitis should be treated with the narrowest-spectrum antibiotics active against S.pneumoniae and H.influenzae
What do we do if there is no response to initial therapy of acute rhinosinusitis?
No response to initial therapy - consider sinus aspiration or lavage
When should patients be admitted to the hospital?
acute rhinosinusitis
Patients with most serious complications should be admitted to the hospital (facial swelling, orbital involvement, intracranial complications, etc)
“Patients with most serious complications should be admitted to the hospital”: what is considered serious complication?
(acute rhinosinusitis)
- facial swelling
- orbital involvement
- intracranial complications
How do we treat invasive fungal sinusitis?
Invasive fungal sinusitis usually require surgical debridement and treatement with i.v. antifungal agents such as Amphotericin B
Initial therapy:
acute rhinosinusitis
- Amoxicillin, 500 mg PO tid
- or amoxicillin/clavulanate,
- 500/125 PO tid
- or 875/125 mg PO bid – 7-10 days
Penicillin allergy:
acute rhinosinusitis
- Doxycycline, 100 mg PO bid
- or Clindamycin PO, 300 mg tid
If pennicillin-resistant S. pneumoniae etiology is suspected:
(acute rhinosinusitis)
amoxicillin/clavulanate 2000/125 mg PO bid
- or moxyfloxacin, 400 mg PO daily
Chronic sinusitis
Symptoms of sinus inflammation lasting > 12 weeks
What are the most common causes of Chronic sinusitis?
In most cases bacterial or fungal etiology
What are the consequences of chronic sinusitis?
Impairment of mucociliary clearance from repeated infections > persistent bacterial infection;
constant nasal congestion and sinus pressure
What is helpful in determining of the extent of the chronic sinusitis?
CT scan helpful in determining of the extent of the disease
Endoscopy is used for:
histologic examination and culture
Chronic fungal sinusitis:
immunocompetent host, usually non invasive e.g. allergic aspergillosis
Invasive fungal sinusitis
complication of prolonged chronic fungal sinusitis oraz in immunocompromised patients
Chronic sinusitis - treatment:
- Repeated culture-guided courses of antibiotic therapy for 3-4 weeks or longer
- Intranasal glucocorticoids
- Mechanical irrigation of the sinus with sterile saline solution
- If no improvement – sinus surgery may be indicated
- Treatment of chronic fungal sinusitis consists of surgical removal of impacted mucus
- Recurrence is common…
Treatment of chronic fungal sinusitis:
Treatment of chronic fungal sinusitis consists of surgical removal of impacted mucus
For how long does the treatment of Chronic sinusitis last?
3-4 weeks or longer
Infections of external ear structures:
- Auricular cellulitis
- Perichondritis
- Otitis externa
- Acute localized otitis externa (furunculosis)
- Acute diffuse otitis externa/swimmer´s ear
- Chronic otitis externa
- Invasive otitis externa: Also known as malignant or necrotizing otitis externa
Auricular cellulitis:
Infection of the skin overlying the external ear and typically follows minor local trauma
Auricular cellulitis - symptoms:
Tenderness, erythema, swelling and warmth of external ear
Auricular cellulitis - treatment:
Treatment consists of warm compresses and oral antibiotics (e.g. cephalexin or dicloxacillin active against S. aureus and Streptococci)
Perichondritis:
An infection of the perichondrium of the auricular cartilage, usually follows local trauma (e.g. piercings, burns)
Perichondritis - symptoms:
Symptoms similar to auricular cellulitis, extreme tenderness of the pinna
Perichondritis - treatment:
antibiotics active against P. aeruginosa (e.g. piperacillin)
Otitis externa:
Disease involving primarly the auditory meatus
What causes Otitis externa?
A result of heat and retained moisture, with desquamation and maceration of the epithelium of the outer ear canal
What are the classifications of Otitis externa?
- localized
- diffuse
- chronic
- invasive
What are the most common pathogens of Otitis externa?
- P. aeruginosa
- S. aureus
Furunculosis =
Acute localized otitis externa (furunculosis)
Acute localized otitis externa (furunculosis) - localization:
Develops in the outer third of the ear canal, where hairfollicles are numerous
Acute localized otitis externa (furunculosis) - usual pathogen:
S. aureus is the usual pathogen
Acute localized otitis externa (furunculosis) - treatment:
- antistaphylococcal penicillin (e.g. dicloxacillin or cephalexin)
- in cases of abscess formation - incision and drainage
Acute diffuse otitis externa (Swimmer’s ear) =
Swimmer’s ear
Acute diffuse otitis externa (Swimmer’s ear)
Heat, humidity, loss of protective cerumen
- > excessive moisture and elevation of the pH in the ear canal
- > skin maceration and irritation
- > infection
Acute diffuse otitis externa (Swimmer’s ear) - pathogen
Predominant pathogen - P. aeruginosa, other gram negative and gram positive organisms also possible
Acute diffuse otitis externa (Swimmer’s ear) - symptoms:
- Erythematous, swollen ear canal, white, clumpy discharge
- Itching, pain during manipulation of the pinna or tragus
Acute diffuse otitis externa (Swimmer’s ear) - treatment:
- Treatement:
cleansing the canal, debridement, hypertonic saline , alcohol with acetic acid – used topically, preparations with neomycin and polymyxin +/- glucocorticoids - Systemic treatment in immunocompromised patients
Chronic otitis externa:
Caused by repeated local irritation, often complication of persistent drainage from a chronic middle-ear infection, insertion of cotton swabs.
- Very rare syphilis, tuberculosis, leprosy
Chronic otitis externa - symptoms:
- Erythematous, scaling dermatitis
- Pruritus and pain
Chronic otitis externa- differential diagnosis:
Differential diagnosis: atopic dermatitis, psoriasis, dermatomycosis
Chronic otitis externa - treatment:
identifying and removing the offending process
Invasive otitis externa =
malignant or necrotizing otitis externa
Invasive otitis externa:
An aggressive and potentially life-threatening disease that occurs in elderly diabetic or immunocompromised patients
Invasive otitis externa - beginning:
Begins in external ear canal as soft tissue infection -> progresses slowly over weeks and months
Invasive otitis externa - symptoms:
- Erythematous and swollen ear and external canal, purulent otorrhea, deep-seated otalgia
- Granulation tissue in the posteroinferior wall of the external canal
Invasive otitis externa - progression:
Infection can migrate to the base of the skull (osteomyelitis), meninges, brain, facial nerve palsy
Invasive otitis externa - pathogen:
P.aeruginosa, …., S. aureus, S. epidermidis, Aspergillus, Actinomyces
Invasive otitis externa - treatment:
surgical cleaning, IV antibiotics for 6-8 weeks (e.g. piperacyllin, cefepime +/- aminoglycosides or fluoroquinolones)
combined with otic glucocorticoids and fluoroquinolones, glycemic control
Otitis media:
Inflammatory condition of the middle ear that results from dysfunction of the eustachian tube in association with a number of illnesses, including URIs and chronic rhinosinusitis
Otitis media - inflammatory response:
The inflammatory response in theses conditions leads to the development of a sterile transudate within the middle ear and mastoid cavities
Otitis media - cause:
Infection may occur if bacteria or viruses from the nasopharynx contaminate the fluid, producing an acute illness
Acute otitis media:
Typically follows a viral URI (most commonly RSV, influenza virus, rhinovirus and enterovirus), which predispose the patient to bacterial otitis media
Acute otitis media - bacterial causes:
S. pneumoniae (~35%), H. influenzae, M. catarrhalis, increasing incidence of MRSA infection
Acute otitis media - viral:
Viruses – alone or with bacteria in 17-40% of cases
Acute otitis media - fluid in the middle ear:
Fluid in the middle ear demonstrated with otoscopy
Acute otitis media - viral causes:
- RSV (most commonly)
- Influenza virus
- Rhinovirus
- Enterovirus
Acute otitis media - TM:
Movement of tympanic membrane (TM) is impaired when fluid is present
Acute otitis media - signs and symptoms:
- local or systemic
- otalgia
- otorhhea
- diminished hearing
- fever
- veritgo
- nystagmus
- tinnitus
Acute otitis media- treatment:
- Initial observation, administering anti-inflammatory agents for pain management, reserving antibiotics for high risk patients or complicated disease
- Patient’s condition does not improve after 48-72h – antibiotic therapy
- A switch in regimen recommended if there is no clinical improvement by the third day of therapy
Acute otitis media - Immediate treatment with antibiotics is indicated for:
- patients <6 months old
- 6 months-2 years old with middle-ear effusion
- > 2 years with bilateral disease
- patients with TM perforation
- immunocompromised, with severe symptoms including fever ≥ 39oC
Chronic otitis media:
Persistent or reccurent purulent otorrhea in the setting of TM perforation
Chronic otitis media - hearing:
Some degree of conductive hearing loss
Chronic otitis media - Inactive disease:
Inactive disease - central perforation of the TM, which allows drainage of purulent fluid from the middle ear
Chronic otitis media - Peripheral perforation:
Peripheral perforation - squamous epithelium from the auditory canal may invade the middle ear trough the perforation forming cholesteatoma at the site of invasion
Chronic otitis media - treatment:
- mastoidectomy
- myringoplasty
- tympanoplasty (in 80% successful)
Mastoiditis:
Because of anatomic connection, a process of fluid collection and infection is usually the same in the mastoid as in the middle ear
Mastoiditis what is the reason that the incidence of acute mastoiditis has declined?
Early and frequent treatment of acute otitis media is probably the reason that the incidence of acute mastoiditis has declined
Mastoiditis - What happens?
Purulent exudate collects in the mastoid air cells -> erosion of the surrounding bone - > abscess-like cavities
Mastoiditis - Symptoms:
- pain
- erythema
- swelling of the mastoid process
- displacement of pinna + symptoms of acute otitis media
Mastoiditis - Serious complications (rarely):
subperiostal abscess of temporal bone, deep neck abscess, septic thrombosis of lateral sinus
Mastoiditis - Etiology:
- S. pneumoniae
- H. influenzae
- M. catarrhalis
- S. aureus
- P. aeruginosa
Mastoiditis - Treatment:
most patients can be treated conservatively with IV antibiotics, some times surgical treatment
Acute pharyngitis - most common causes:
A majority of cases caused by typical respiratory viruses
(Rhinoviruses ~20%, Coronoviruses ~5%, Influenza- Parainfluenza-, Adenoviruses, HSV1/2, coxackievirus A, CMV, EBV, acute HIV infection…)
Acute pharyngitis - % of pts with no identified cause:
30% of pts have no identified cause
Acute bacterial pharyngitis typically caused by:
- Acute bacterial pharyngitis typically caused by S.pyogenes - in 5-15% of adult patients;
- Streptococci of groups C and G - minority of cases
Acute pharyngitis - Fusobacterium necrophorum:
Fusobacterium necrophorum - increasing incidence, acute pharyngitis may precede a life threatening Lemierre’s disease
Acute pharyngitis - The remaining bacterial causes:
- N. gonorhoeae
- Corynebacterium diphteriae
- Corynebacterium ulcerans
- Yersinia enterocolitica
- Treponema pallidum
Acute pharyngitis:
Anaerobic bacteria may cause Vincent’s angina -> peritonsillar and retropharyngeal abscesses
Acute pharyngitis - Signs and symptoms:
Clinical manifestations:
Signs and symptoms are not reliable predictors of the etiologic agent
Acute pharyngitis - Signs and symptoms:
Clinical manifestations:
Disease caused by adenovirus or HSV may be difficult to differentiate from streptococcal pharyngitis - in all pharyngeal exudate may be present
Acute pharyngitis - Adenoviral pharyngitis:
Clinical manifestations:
Adenoviral pharyngitis - in ~50% of cases conjunctivitis
Acute pharyngitis - HSV:
Clinical manifestations:
HSV - presence of vesicles and shallow ulcers on the palate
Acute pharyngitis - Coxackie:
Clinical manifestations:
Coxackie - small vesicles that develop on the soft palate and uvula and after rupturing form shallow white ulcers
Acute pharyngitis - Exudative pharyngitis:
Clinical manifestations:
Acute exudative pharyngitis seen in EBV or CMV mononucleosis
What is the primary goal of pharyngitis diagnosis?
separating acute pharyngitis from pharyngitis of other ethologies
What is the most appropriate test for pharyngitis diagnosis?
throat swab culture is generally regarded as the most appropriate but cannot distinguish between infection and colonisation and requires 24-48h to yield result
