Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Upper Respiratory

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Upper Respiratory Tract Infection - Key Features

1. Given an appropriate history and/or physical examination:
a) Differentiate life-threatening conditions (epiglottitis, retropharyngeal abscess) from benign conditions.
b) Manage the condition appropriately.

Clinical Presentation Diagnosis Treatment
Croup -Common, 6 mos to 4 yrs

-Fall, early winter
-Hoarse voice, barking cough, stridor, worse at night

-Clinical

-Atypical presentation: CXR → ‘steeple sign’

-Humidified O2; dexamethasone; epinephrine

-Intubation if unresponsive to treatment

Bacterial Tracheitis -Rare, all age groups

-Similar to croup, but more rapid deterioration and fever
-Toxic appearance
-Not respond to croup trt

-Clinical

-Definitive Dx via endoscopy

-Start croup therapy

-Often requires intubation
-Antibiotics

Epiglottitis -Rare

-Toxic appearance, rapid progression, severe airway obstruction, drooling, stridor, tripod position, anxiety

-Clinical diagnosis

-Avoid throat exam to avoid further exacerbation

-Intubation

-Antibiotics

  • Prevented with Hib vaccine
Retropharyngeal Abscess -Sore throat, fever, torticollis, dysphagia, neck pain, muffled voice

-Respiratory distress, stridor, neck edema, cervical lymphadenopathy

-Contrast CT neck - IV hydration

-IV Antibiotics (clinda 600-900mg, cefoxitin 2gm, or pip/tazo)
-+/- Surgical intervention

Peritonsillar Abscess -Fever, sore throat, odynphagia, dysphagia, otalgia

-Trismus, muffled/’hot potato’ voice, inf & med displacement tonsil, contralateral deflection uvula, drooling, lymphadenopathy

-Often clinical

-Needle aspiration purulent material if dx in question
-CT with contrast to confirm and/or if concern of spread

-Needle aspiration, I&D, or, rarely, tonsillectomy

-Although polymicrobial, most common grp A Strept → 10 d course Abx against GAS and oral anaerobes (amox/clav, PenV+metronidazole, clinda)
-Single dose IV methylprednisolone
-F/up 24 hrs post aspiration

Ludwigs Angina -Dysphagia, odynphagia, trismus, edema upper neck & floor of mouth

-Tongue may displace → airway compromise
-Stridor, cyanosis

-Clinical

-Ct with contrast may augment clinical findings

-Definitive airway management (fiberoptic intubation/tracheostomy)

-Systemic antibiotics (clinda or amp + nafcillin, PCN + metronidazole until Cx available)
-+/- I&D


2. Make the diagnosis of bacterial sinusitis by taking an adequate history and performing an appropriate physical examination, and prescribe appropriate antibiotics for the appropriate duration of therapy.

FYI: Most common sinus involved: MAXILLARY > Ethmoid > frontal > sphenoid

ACUTE RHINOSINUSITIS (< 4 WEEKS)
-VIRAL > bacterial

-Viruses: rhinovirus, parainfluenza, influenza
-Bacterial: S. pneumo, nontypable H. Flu, Moraxella Caterhalis (children), small % staph aureus
-Fungal: most common in immunocompromised, repetitive & invasive infections

SIGNS & SYMPTOMS:

-Nasal drainage, congestion, facial pain/pressure, headache, cough, sneeze, fever
-Tooth pain & halitosis associated with bacterial sinusitis
-Symptoms may localize with further invasion of sinus: increased symptoms when bending/supine

-COMPLICATIONS: meningitis, epidural abscess, cerebral abscess
-DIAGNOSIS: clinical

-Recommended reserve bacterial diagnosis to: PERSISTENT SYMPTOMS (>10d in adult, >10-14d in children), PRURULENT DISCHARGE, NASAL OBSTRUCTION, AND, FACIAL PAIN
-CT Sinuses: to evaluate persistent, chronic, or recurrent symptoms

-TREATMENT:

-Decongestants, nasal saline lavage, nasal glucocorticoids
-Suspect bacterial/persistent: Antibiotics:
-Amoxicillin 500 mg tid x 10 d
-If PCN allergy: Doxycycline 100 mg bid Day 1, then 100 mg daily for 10-14 d course
-Suspect fungal: REFER (may need biopsy)
-Severe/intracranial complications: IV antibiotics +/- surgical intervention


CHRONIC RHINOSINUSITIS (> 12 WEEKS)
-more commonly bacterial/fungal; high morbidity
-constant congestion, sinus pressure, intermittent increase in severity for YEARS
-CT may identify extent of disease, detect underlying defects/obstruction, assess response to therapy
-TREATMENT: difficult

-Refer to Otolaryngologist for endoscopic exam +/- biopsy
-Repeated culture guided antibiotics 3-4 wks duration, intranasal glucocorticoids, sinus irrigation, +/- surgery


3. In a patient presenting with upper respiratory symptoms:
a) Differentiate viral from bacterial infection (through history and physical examination).
b) Diagnose a viral upper respiratory tract infection (URTI) (through the history and a physical examination).
c) Manage the condition appropriately (e.g., do not give antibiotics without a clear indication for their use).

-Etiology of Nonspecific URTI:

-Rhinovirus (30-40%), influenza, parainfluenza, coronavirus, adenovirus, RSV (pediatric, elderly, immunocompromised)

-Viral URTIs lack anatomic localization of signs and symptoms
-Course is acute, mild and self limited; median duration approx. one week (2-10d)
-Signs & Symptoms may include: rhinnorhea, nasal congestion, cough, sore throat, fever, malaise, sneezing, lymphadenopathy, hoarseness
-Secondary Bacterial infections complicate approx. 0.5-2% of viral URTI (e.g. sinusitis, OM, pneumonia)

-Infants, elderly, chronically ill are at higher risk
-Present with prolonged course, increased severity, anatomic localization of signs and symptoms, often as a rebound after clinical improvement

-TREATMENT:

-Symptom based: decongestants, NSAIDS, dextromethorphan, lozenges with topical anaesthetic
-Zinc, vitamin C, Echinacea have not shown consistent benefit in clinical trials
-Antibiotics are NOT indicated for nonspecific/viral URTI without other specific indication


4. Given a history compatible with otitis media, differentiate it from otitis externa and mastoiditis, according to the characteristic physical findings.

OTITIS MEDIA (Streptococcus pneumonia, Haemophilus influenza, Streptococcus pyogenes)
-HISTORY: Often preceded by URTI; Otalgia, aural pressure, pyrexia, decreased hearing, otorrhea
-PHYSICAL EXAM:

AOM: thickened, hyperemic, immobile TM;
OME: dull gray- or yellow tinged, immobile TM, if TM clear may see bubble/air-fluid levels

-TREATMENT: Analgesia & Antipyretics

-Antibiotics: for all children < 6 mos, children 6 mos – 2 years with certain diagnosis, and all children with severe infection (moderate to severe otalgia or temperature > 39 deg C); Otherwise Abx may be deferred provided reliable observation and ready access to medical care/f-up
-Amoxicillin 80-90 mg/kg/d div bid; Macrolides/Clinda/Cephalosporin in PCN allergy/resistant infection


OTITIS EXTERNA (gm neg: pseudomonas, proteus; fungi: aspergillus)
-HISTORY: often history of recent water exposure (e.g. swimming) or mechanical trauma (e.g. scratching/cotton swabs); otalgia, pruritis
-PHYSICAL EXAM: Erythema & edema of external canal, purulent exudate, pain with manipulation of auricle
-TREATMENT: Acidification with drying agent (50/50 mix isopropyl alcohol/white vinegar)

-infection: acidic otic antibiotic drops containing aminoglycoside/fluoroquinolone +/- corticosteroid (e.g. neomycin sulf ate, polymyxin B sulfate; used abundantly – 5 or more drops tid-qid to penetrate the canal)


MASTOIDITIS (S pneumoniae & S pyogenes, with S aureus and H influenzae occasionally)
-HISTORY: usually follows weeks of inadequately treated OM; post-auricular pain & erythema, spiking fever
-PHYSICAL EXAM: Postauricular pain, edema & erythema; fever; down & outward displaced pinna; OM on otoscopy
-TREATMENT: IV Antibiotics: ceftriaxone + nafcillin or clindamycin until Cx results; then Cx guided for 2-3 weeks

-Myringotomy for Cx +/- drainage
-Failure of medical therapy → mastoidectomy


5. In high-risk patients (e.g., those who have human immunodeficiency virus infection, chronic obstructive pulmonary disease, or cancer) with upper respiratory infections: Lood for complications more aggressively, and follow up more closely.

6. In a presentation of pharyngitis, look for mononucleosis.

-SIGNS & SYMPTOMS:

-fever, pharyngitis, fatigue, anorexia, myalgia
-tonsillar exudates, splenomegaly (in up to 50% cases), lymphadenopathy (especially posterior cervical chain), maculopapular (occasionally petechial) rash in <15% of patients (>90% cases if ampicillin has been given)
-symptoms generally resolve over 2-3 weeks, fatigue may persist for months

-DIAGNOSIS:

-CBC: lymphocytosis (>50% lymphocytes), atypical lymphocytes on smear
-Monospot: identifies heterophile antibodies thought to be diagnostic of EBV infection
-may be negative early in course (i.e. specific, but not sensitive early on, usually positive by 4 wks)
-sensitivity also decreased in infants and elderly

-COMPLICATIONS: Secondary bacterial pharyngitis (often streptococcal), splenic rupture, acalculous cholecystitis, hepatitis, pericarditis, myocarditis, transverse myelitis, encephalitis, Guillain-Barre syndrome
-TREATMENT: rest and analgesia (acetaminophen/NSAIDS)

-AVOID all contact sports for minimum 4 weeks after illness onset to avoid splenic injury
*Note: Use of corticosteroids is associated with increased complications and is recommended only for patients with severe disease, such as upper airway obstruction, neurologic disease, or hemolytic anemia
*Note: Acyclovir decreases viral shedding but with no clinical benefit


7. In high-risk groups:
a) Take preventive measures (e.g., use flu and pneumococcal vaccines).
b) Treat early to decrease individual and population impact (e.g., with oseltamivir phosphate [Tamiflu], amantadine).

INFLUENZA VACCINE CANDIDATES IN BC 2011 SEASON:
www.healthlinkbc.ca/healthfiles/hfile12d.stm

PNEUMOCOCCAL VACCINE
PNEUMOCOCCAL CONJUGATE (PCV13) VACCINE
www.healthlinkbc.ca/healthfiles/hfile62a.stm
PNEUMOCOCCAL POLYSACCHARIDE VACCINE
http://www.healthlinkbc.ca/healthfiles/hfile62b.stm

USE OF ANTIVIRAL DRUGS FOR INFLUENZA
www.bccdc.ca/resourcematerials/guidelinesandforms/guidelinesandmanuals/antiviraldrugsinfluenza.htm

Study Guide

Upper Respiratory Tract Infection

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