UPPER RESPIRATORY TRACT

INFECTIONS
• DEFINITION .
• THE COMMON COLDS,THE PARANASAL SINUSES, PHARYNX,TONSILS
AND ADENOIDS.
• CROUP,EPIGLOTTITIS
UPPER RESPIRATORY
TRACT INFECTIONS
Dr Enas Al Zayadneh
THE COMMON COLD

• DEFINITION :
viral illness in which the symptoms of rhinorrhea and nasal
obstruction are prominent and systemic symptoms and signs such as
myalgia and fever are absent or mild .
• Rhinitis, rhinosinusitis.
• ETIOLOGY : most common is are rhinoviruses .table
Pathogens Associated with
Common Cold
Agents primarily Rhinoviruses Frequent
associated with colds Coronaviruses Occasional
Respiratory Occasional
Agents primarily syncytial virus
associated with other Influenza viruses Uncommon
clinical syndromes
Parainfluenza Uncommon
that also cause
viruses
common cold
symptoms Adenoviruses Uncommon
Enteroviruses Uncommon
• EPIDEMIOLOGY:
• Year round , However :
RV  peaks early fall(august- october) and late
spring (April-May).
• Parainfluenza viruses peaks late fall
• RSV and Influenza (December –Apail)
• Children have average of 6 to 7 colds/year, 10 to
15% have at least 12/year.
• Decrease with age ,2 to 3/year in adults
• More with children in out-of-home daycare centers
by 50% during first three years of life.
 PATHOGENESIS

Spread :
Viruses spread by small-particle aerosols, large-particle
aerosols and direct contact.
• RV and RSV direct contact is more efficient .
• Influenza more spread with the small particle aerosols.
Pathogenesis

• Influena /Adenovirus infection ->

destruction of nasal epith lining
• Rhinovirus ,Coronaviruses and RSV ->
no apperant histologic damage as in nasal epithelium .
 Re-Infection ?

• Rhinoviruses and adenoviruses :

Trigger serotype-specific protective immunity but have large no. of
serotypes of each virus.
• Parainfluenza viruses and RSV have small no. of distinct serotypes .
Host immunity that develops is not protective but moderates
severity of subsequant illness
.
Pathogenesis

- Influenza viruses
able to change the antigens presented on the virus and behave as if
there were multiple virus serotypes
 CLINICAL MANIFESTATIONS

• Onset usually after 1-3 days of acute infection.

• Sore or scratchy throat ,then nasal obstruction and
rhinorrhea.
• Cough in 30% of colds, usually after the onste of
nasal symptoms.
• Fever and other constitutional symptoms more in
influenza ,adeno- and RSV than in rhinoviruses and
coronaviruses.
Physical findings

Limited to the URS:

-increased nasal secretion (change in its color or consistency doesn’t
indicate sinusitis or bacterial superinfection)
- nasal cavity;swollen erythematous turbinates (nonspecific,limited
use)
 DIAGNOSIS:

Exclude other causes that are more serious or treatable.

• DDx :non-infectious disorders ,other URTI’s ,table .
 Conditions that may mimic the
Common Colds
Condition Differentiating Features

Allergic Rhinitis Prominent itching and

sneezing,nasal eosinophelia
Foreign Body unilateral ,foul-smelling
discharge ,bloody nasal
secretions
Sinusitis Headache,facial pain, periorbital
edema,persistance of rhinorrhea
or cough > 10-14 days
Streptococcal Nasal discharge that excorites
nasopharyngitis the nares

Pertussis Onste of persistant or

paroxysmal cough
Congenital Syphilis Persistant rhinorrhea with onset
st
LABARATORY FINDINGS

• Routine labs are not helpful for Dx and Mx of common colds

• Nasal smear for eosinophils usefull for allergic rhinitis ,if
PMN cells predominates in uncomplicated cold doesn’t
indicate bact. Superinfection.
• Viral detection ;culture ,serology for antigen detection ,not
indicated ,only when antiviral therapy is planned to be used.
• Bacterial cultures or antigen detections usefull only when
group A strept. Or bordetella pertussis or nasal diphtheria is
suspected.
TREATMENT

• Symptomatic Treatment .

• Antiviral therapy
SYMPTOMATIC TREATMENT

• No study to prove benefit in children.

• Balance againts side effects of the drugs.
• FEVER;infrequantly associated with uncomplicated
CC ,antipyretics generally not indicated.
• NASAL OBSTRUDTION;topical/systemic
• Topical;oxymetazoline or phenylphrine as
intranasal drops or nasal spray ,not approved <2
yrs.
Symptomatic treatment

• Side effects:
-Topical : Imidazolines rarely bradycardi,hypotension and coma.
RHINITIS MEDICAMENTOSA ,apparent rebound effect with
prolonged use of topical adrenergics.
-oral ;CNS stimulation,HTN and palpitations.
• RHINORRHEA :
• 1st generation anti hist. Reduce by 25-30%,non-
sedating aren’t effictive for cc syp.
• Topical ipratropium bromide-no sedation(se;nasal
irritation,bleeding)
• SORE THROAT: analgesia,usu. Mild
.acetaminophin .Aspirin NOT used (Reye syndrome
in children with influenza).
• COUGH : cough suppression not necessary, usu.
Due to PND ,antihistamine is beneficial
Symptomatic Treatment :cough

• Cough ,can be due to reactive airway disease(viral induced),may

persist days to weeks aftr acute infectin ,benefit bronchodilators.
• Codeine ,dextromethorphan -no benefit
• Expectorants –not effective.
• Ineffective treatment ;Vit.C ,guaifenesin,huidified warm air,zink
COMPLICATIONS

• OTITIS MEDIA ;most common,5-30%

• SINUSITIS ; 5-13% in children ,0.5-25 %in adults as
bacterial sinusitis,(other than self limited sinus
involvement in the pathophysiology of viral illness)
• EXACERBATION of ASTHMA ;relatively uncommon.
• Antibiotic resistance of pathogenic respiratory
pathogens.
PREVENTION

• CHEMOPROPHYLAXIS ,immunoprophylaxis generally not available for

common colds.
• Influenza vaccine may be usefull ,but infl. Reonsible for small % of
CC.
• Interruption of direct contact ;handwashing,face sheilds .
SINUSITIS

• Common illness of childhood and

adolescence,potential for serious
complication,significant morbidity .
• Viral / Bacterial ;0,5-2% of viral URTI complicated by
acute bacterial sinusitis.
• Development ; ethmoid and maxillary present at
birth,but only ethmoidal is pneumatized.maxillary
pneumatized at 4yrs. Sphenoids by 5 years.frontal
sinuses 7-8 yrs.they are normally sterile
• ETIOLOGY:
• Streptococcus pneumoniae 30%(25% Beta
L(actamase positive.
• Nontypable haemophilus influenza 20%(50%
Blmase positive)
• Moraxella catarrhalis 20%(100% Blmase positive.
• Others ;staphylococcus aureus ,other streptococci
and anaerobes ,uncommon.
• Chronic infx; h.influenza,coagulase neg. Staph
M.cat. S.pneum. ,alfa-hemolytic strept.
EPIDEMIOLOGY

• Occur at any age.

• Predisposing conditions: URTI(with out-of-home
day-care,school aged sibling) ,allergic rhinitis
,cigarette smoke exposure .chronic disease develop
in children with immune deficiencies ,cystic
fibrosis ,ciliary dysfunction, phagocytic disorders
,GERD,anatomic defects(cleft palate} nasal foregn
bodies .
PATHOGENESIS

• TYPICALLY OCCURS AFTER VIRAL ILLNESS;viral rhinosinusitis-fluid in

the sinuses,nose blowing forces nasal secretions into sinus cavity and
introduce bacteria to the nasopharynx ,impaired
immunity(inflammation and edema during viral illness block sinus
drainage and impair mucociliary fxn).
CLINICAL MANIFESTATION

• NONSPECIFIC,nasal congestion ,discharge ,fever,cough.

• Less common ;bad breath ,decreased smell ,priorbital edema.
• Headache and facial pain ,rare in children.
• P/E mild erythema –swelling of nasal mucosa-discharge ,sinus
tenderness(adolescents and adults).
DIAGNOSIS

• Based solely on history;persistant hx of RTI

including cough ,nasal discharge for>10-15 days
without improvement OR severe symptoms
;temp.>39 *C and purulant nasal dicharge for 3-4
days.
• Bacteria isolated from maxillary s. in70%with severe
symptoms
• Chronic sinusitis ;persistant ccough-discharge >90
days.
Diagnosis

• Sinus aspirate cx is the only accurate method,not

practical.
• Translumination of sinus cavity,difficult in
children,unreliable.
• Radiography; plain film :thickening,air-fluid level

• DDx ; viralURTI,ALLERGIC RHINITIS,NASAL FB.

TREATMENT

• Debate about benefit of AB therapy for clinically Dx

sinusitis 50-60% self limited
• Promote resolution of sym. And prevent supporative
complications.
• Initial amoxicillin(45mg/kg/day)
• Ulternative ;cfuroxime axetil,cefpodxime,clarithromycin
or azithromycin
• Failure of therapy-ent evaluation for sinus aspiration-Cx.
• Duration;individualized ,7 days after resolutionof
symptoms.
• Frontal sinus ;ceftriaxone initially till clinical improvement.
• Decogestants,mucolytics intranasal GCS ,not studied ,not
recommendedin acute bacterial sinusitis.
COMPLICATIONS

• ORBITAL COMPLICATIONS,periorbital cellulitis and

orbital cellulitis-acute bacterial ethmoditis.(CT of orbits
and sinuses ,ophthalmo-ent Cx)
• INTRACRANIAL COMPLICATIONS, meningitis,cavernous
sinus thrombosis ,subdural empyema ,epidural abscess
and brain abscess.(s,s:altered mentality,signs of incr.
ICP require immediate scanning of brain/orbit and
sinus.
• TX ; Broad spectrum antibiotics(cefotaxime/ceftriaxone
with vancomycin)
• Brain abscesses may require surgical drainage.
• BONE COMPLICATIONS ;osteomylitis of frontal bone(Pott Puffy
Tumor)and mucoceles-surgical drainage.
• PREVANTION OF SINUSITIS:
• Frequant hand washing ,avoid patients with colds,influenza
vaccine(small proportion)
ACUTE PHARYNGITIS

• SORE THTOAT is the primary symptom.1/3 of URTI.

• ETIOLOGY :
• viruses
• Groub A B-hemolytic strep(GABHS).
• OTHRS; group C strept. ,Arcanobacterium
hemolyticum,Francisella tularensis,Mycoplasma
pneumoniae ,Nissera
gonorrhoeae,Corynebacterium diphtheriae .
EPIDEMIOLOGY

• Viral URTI mostly in winter and spring,spread by

close contact.
• Streptococcal pharyngitis uncommon <2-3 yrs.
• Incidence increases among children then declines
late adolescents and adults.
• Throughout the year ,often spring/winter
• Pharyngitis with group C strep.,A.hemolyticum most
frequantly in aduls and adolescents.
PATHOGENESIS

• Colonization with GABHS may result in acute infx or carrier state.

• M Protein is magor virulance,resist phagocytosis by PMN cells
• Type spicific immunity against particular M protein.
• Scarlet fever ,GABHS produce SPE-A,B and C,induce fine rash
CLINICAL MANEFISTATION

• Onset often rapid;sore throat ,fever.

• Headache ,GI symptoms ;frequant.
• P/E :red pharynx ,tonsils enlarge with yellow blood
tenged exudate, possible to have petechiae
‘doughnut’lesions on soft palate and post. Pharynx .
Uvula-red swollen.
• Ant. Cervical L.N enlarged,tender.
• Scarlet fever;circumoral pallor,strawberry tonge
,fine red papular rash ‘sand paper’
Viral pharyngitis:

• More gradual, more with rhinorrhea

,cough,diarrhea.
• Adenovirus may have concurrent
conjunctivitis,fever
• Coxsackievirus ‘hrpangina ‘;small grayish vesicles
,punched –out ulcers on post. Pharynx,or acute
lymphonodular pharyngitis.
• EBV ;prominent tonsillar enlargement,cervical
lymphadenitis ,HSM ,fatigue –IM.
• PRIMARY HERPES SIMPLEX ,young children ,high
feve ,gingivostomatitis.
Herpangina IM
Primary herpetic gingivostomatitis
DIAGNOSIS

• IDENTIFY GABHS; throat culture (imperfect),false

pos./neg., rapid antigen decting tests ;specificity is
high,less sensitive.
• Special media of cx for some organisms ,prolonged
incubation (A.hemolyticum).
• Viral cx;unreliable,expensive
• CBC ,many lymphocytes-positive slide aggltn.(SPOT)
–EBV infectious mononucleosis.
TREATMENT

• Mostly self limited(streptococcal infx)

• Early AB therapy –quick recovery by 12 –24 houers.
• Primary AIM TO PREVENT ACUTE RHEUMATIC
FEVER ,if Tx within 9 days of illness.
• AB without waiting culture in(symptomatic with
pos. rapid AG detecting test,scarlet fever,household
contact of documented strept.infx,recent hx of
acute rheumatic fever in family member)
• GABHS ;
• Penicillin V ,cheap,bid or tid ,250mg/dose,oral
amoxicillin 250mg tid (tastes better ,tabs avilable)
,single IM Penicillin G,benzathine, Erythromycin (40
mg/kg/day),first generation CPS,azithromycin
.clindamycin(irradication carrier state).
• Nonspecific tx;antipyretics; acetamenophin
,ibuprofen,gargling warm salt water/phenol-mentol
sprays .
RECURRENT PHARYNGITIS

• EITHER relapse with identical strain (IM penicillin

advised if compliance poor)
• OR resistance ,non-penicillin AB considered.
• OR different strain from new exposure.
• TONSILLECTOMY ;lower % OF PHARYNGITIS FOR 1-2
YRS.;( those with culture positive ,severe, frequant :
> 7 episodes in the previous year ,or >5 in each of
the preceding two years.
COMPLICATIONS-PROGNOSIS

• Viral URTI predispose to Bacterial Middle Ear Infections.

• Streptococcal infx complications;
• supporative local complications(parapharyngial abscesses)
• later ,nonsupporative ones (ARF ,acute post infectious
glomeriolonephritis)
PRAVENTION

• ANTIMICROBIAL PROPHYLAXIS ,oral penicillin only in preventing

recurrence of ARF.
• Multivalent streptococcal vaccine;under development.
Retropharyngial and Lateral
pharyngial abscess
• Reropharyngial abscess; usu. Less than 3-4 yrs of
age.boys>girls(retroph. Lymph nodes involute
>5yrs.)
• Clinical; nonspecific :fever ,irritability.dec. oral
intake,drooling.neck stiffness ,torticollis ,refusal to
move neck..sore throat neck pain .others ;muffled
voice ,stridor ,respiratory distress.
• P/E : bulging of post. pharyng. Wall (<50%) ,cervical
LAP ,
• LATERAL PHARYNGIAL ABSCESS ; fever ,dysphagia
,prominent bulge on lateral wall of pharynx
,sometimes medially displaced tonsil.
• DDX ; acute epiglttitis ,FB aspiration …
others;lymphoma,hematoma and veriebral
osteomylitis.
• DIAGNOSIS ; incision FOR drainage and culture of
abscess or node….CT SCAN(with contrast) also
useful ,plain soft tissue neckfilms inspiratory
• ETIOLOGY ;both are caused by plymicrobial
infx(GABHS ,anaerobes,staphylococcus aureus)
,others;klebsiella ,H.influenza )
• TREATMENT : IV antibiotics with/without surgical
drainage.
• Third generation CPS plus ampicillin-sulbactam or
clinamycin(anaerobes)
• Surgical drainage necessary in pts with respiratory
distress ,failure to improve with iv AB treatment
complications

• Significant upper airway obstruction

• Rupture leads to Aspiration Pneumonia
• Extension to mediastinum
• Thrombophlebitis of the int. jugular vein
• Erosion of carotid artery sheath
• Lemierre disease ,uncommon infx oropharynx—
septic metastatic abscesses in lungs ,spetic infx of
int. JUGULAR VEIN(ANAEROBE)
PERITONSILLAR
CELLULITIS/ABSCESS

• RELATIVELY COMMON DEEP INFX OF NECK.

• Direct invasion of bacteria through capsule of
tonsils to surrounding tissues.
• Usually adolescent recent hx of acute
pharyngotonsillitis.
• Sore throat,fever,trismus dysphagia.
PERITONSILLAR
CELLULITIS/ABSCESS
• P/E asymmetrical bulge of the tonsil with
displacement of uvula .
• CT scan
• GABHS and Anaerobes
• Antibiotic therapy and surgical needle
aspiration(90%)
• 5% INCISION DRAINAGE.
• TONSILLECTOMY ; Failure of combined AB –needle
aspiration ,recurrent peritonsillar
(10%)abscesses,complications
TONSILS AND ADENOIDS

Dafinintion ; Waldeyer ring;palatine tonsils ,pharyngeal tonsils or

adenoids ,lymphoid tissue around austachian tube orifice,lingual tonsil
,scattered lymphoid tissue /pharynx…..
• Mostly immuinologically active 4-10yrs(produce secretory immunity)...
• Acute Infection; most are viral,bacterial :GABHS(most common),group
C,staph. Aureus ,G-ve organisms,mycoplasma pneumoniae,rare” nisseria
gonorrhoeae ,C.diphtheria ,oral candidiasis (immune compromised).
• Clinical ; dry throat,fevrf malaise,odynophagia,dysohagia,referred
otalgia,headache,ms. Acches,LAP
• Chronic Infection polymicrobial,may include high incidence of B
lactamase producing organisms (aerobic : strptococci
,H.influenza.anaerobic :peptostreptococcus ,prevotella
,fusobacterium.the tonsillar crypts will accumulatesesquamated
epith. Cells,lymphocytes ,bacteria and debres, cuasing crypt tonsillitis
• CLINICAL;halitosis ,chronic sore throats ,foreign body sensation,foul-
taste sensation.P/E: tonsils any size,contain copious debres within
crypts.throat cx. Usually –ve (not GABHS).
• Tx.clinamycin/amoxicillin with clavulanate,penicillin v plus rifambin,
Tonsillectomy curative.
• Airway obstruction ;tonsils-adenoid major
cause,clinical:chronic mouth breathers,hyposomnia,nasal
obstruction,hyponasal speech,decreased appetite,poor
school performance..rare right sided heart failure. night
;loud snoring ,choking ,frank apneas ,restless
sleep,gasping,night terrors,enuresisdiaphoresis.
• p/e ;large tonsils ‘no correlation with severity’ ,lateral neck
radiograph.
• Tx. Adenotonsillectomy.
• Indications for adenoidectomy ;chronic nasal
infections,recurrent otitis media ,chronic sinus infection not
responding to medical tx.,airway obstruction.
INFECTIOUS UPPER AIRWAY
OBSTRUCTION
• CROUP (laryngotracheobronchitis):most common cause
.viral infx of glottic and subglottic region
• Etiology ;most are viral :
• Parainfluenza(I,2,3)-75%
• Others ,Influenza A and B( A severe infx)
,adenovirus,RSV ,measles .
• Mycoplasma pneumoniea (rare).
• Age ; between 5months and 5 years, peak in 2nd year of life.
• Males > females. More in winter ,recurrence frequant 3-6
years then declines…15% strong family Hx of croup.
• CLINICAL ;
• URTI some rinorrhea ,pharyngitis ,mild cough,low grade fever for 1-3
days before s ans s of upper airway obstructio become apperant
.then barking cough ,hoarseness ,Inspiratory stridor
• fever,usually low grade and may persist ,may reach 39-
40 ,some are afebrile.

• Worse sympyoms at night often recur with decreasing

intensity over days and resolve within a week. Agitation
and crying greatly aggravate symptoms and sign ,may
prefer to sit up or held upright. the older the milder.most
are mild illness.
Diagnosis

• Radiography only considered After stabilization of Airways for those

who have atypical presentation.
• Helpful to differentiate croup from epiglottitis .
steeple sign
ACUTE EPIGLOTTITIS

• DRAMATIC ,POTENTIALLY LETHAL.

• acute fulminating course of high grade fever
,dyspnea ,sore throat ,rapidly progressive
respiratory obstruction,degree variable.
• Rapid course sore throat,fever in houers –
toxic,difficult swallowing ,difficult
breathing.Drooling ,neck hyper extended to
maintain airways.Tripod position :sitting upright –
leaning forward with chin up mouth open and
bracing on the arms.
Epiglottitis

• Air hunger and restlessness followed by rapidly increasing CYANOSID

AND COMA . STRIDOR –LATE near complete AO.

• DEATH unless proper airway mx.

etiology

• H.influenza type b ,most common before vaccine introduction.

(reduced by 90%).
• Streptococcus pyogens,S.pneumoniea ,staph. Aureus ,now larger
proportion.
• Age was 2-4 (before vaccination) but as early as 1st year and late as 7
years have been seen.
DIAGNOSIS

• CLINICAL,HX

• Laryngoscopy ‘cherry-red’ swollen epiglottis,other

surrounding tissue involved.performed in theatre or
ICU.

• Lateral radiograph films show ‘thumb sigh’ :Patient

suspected to have EPI should always be accompanied
by physician skilled in intubation,airway mx.
Epiglottitis
• Avoid anxiety provoking ( opening mouth,forcing supne position
,phelebetomy,IV line placement..)

• ESTABLISH AIRWAY by nasotracheal intubation ,or less often

trachiostomy ,REGARDLESS DEGREE OF RESPIRATORY DISTRESS
..WHY ?
• 6% of patients die without artificial airway while only 1% in those
with.
• Pulmonary edema may occur with acute airway obstruction.
• Intubation usually lasts for 2-3 days
• Bacteremia ,mostly present,occasionally others; pneumoniea
,meningitis ,arthritis,cervical LAP ,otits media and other infx caused
by H.influenza b.
treatment

• CROUP
• Airway management.
• Cool mist(moistens secretionsjclearance,comfort-reassurance ,soothens
mucosa).
• Nebulized epinephrine,(constriction arterioles-decrease edema).racemic
solution1:1 ,or l-epinephrine(5cc of 1:1,000)
• Indications ;moderate to severe stridor at rest,
• need for intubation
• hypoxia
• stridor not responding to mist
• Observe 2-3 houers (provided no stridor at rest)
• GCS ,dexamethasone ,single dose 0.6mg/kg IM (or oral )
• Admit :orogressive stridor ,severe stridor at rest,resp.
distress,cyanosis.altered mental status,,needfor reliable observation
• Epiglottitis ,medical emergency
• Admit to ICU ,artificial airway
• Oxygen mask
• Culture of blood,epiglottic surface (selected cases
CSF).
• Ceftriaxone,cefotaxime or ampicillin sulbactam .
(therapy for 7-10 days)
• Chemoprophylaxis :given to contacts if there is a
child <2 years or immune compromised(Rifambin)