Common Cold , Rhino sinusitis,
Influenza
Dr. Shahid PervaizDr. Shahid Pervaiz
Postgraduate RegistrarPostgraduate Registrar...
Definition: the common cold
benign self-limited
syndrome
caused by members of
several families of
viruses
Mild upper respi...
Symptoms: the common cold
Day 1 : sore or “scratchy” throat, +/- low grade fever
Day 2-3 : nasal obstruction, rhinorrhea, ...
Symptoms: the common cold*
Day 1
Symptoms: the common cold*
Day 2 to 3
Symptoms: the common
cold*
Day 4 to 5
• thick
purulent
nasal
discharge
does NOT
mean
bacterial
sinusitis!
50%
15%
15%
5%
5%
10% Rhinovirus
Coronavirus
Influenza
RSV
Parainfluenza
Adeno, Entero
Virology *4,5
Seasonal Patterns
Fall, late spring : Rhinovirus
Parainfluenza
Winter, spring: RSV, coronavirus
Summer: Enterovirus (year)...
Facts: the common cold
• Incubation period 24 to 72 hours
• Average duration 3 – 7 days
•Virus-induced changes in airway
r...
Diferential diagnosis: the common cold
•Allergic or seasonal rhinitis
•Bacterial pharyngitis or tonsillitis
•Sinusitis
•In...
But how do I know it’s just a cold?
COLD INFLUENZA
Fever Rare 39-40o
Headache Rare Usual
Myalgia Mild Severe
Malaise Mild ...
Facts: Influenza
•Patients with illnesses which involve the
cardiovascular
or pulmonary systems
•Patients with diabetes me...
Facts: Influenza Vaccine
All of the mentionated before
Plus
Health care workers
Pregnant women in second or third
trimestr...
But how do I know it’s just a cold?
• Acute Bacterial Sinusitis
• complicate 0.5-2% of colds
• Diagnosis = persistent URTI...
But how do I know it’s just a cold?
• Pneumonia =
1. 2 of: fever, new cough, pleuritic chest pain, SOB
+
2. Auscultatory f...
•Asthma
Airway reactivity
Vs
Acute asthma attacks exacerbations
Up to 40% of viral upper resp infection
Complications
Sinusitis:
Acute bacterial sinusitis develops in 0.5 to
2.5 percent of adult patients after viral *1
Lower r...
FACTS: transmission*
• Hand –to- hand
• most efficient = direct contact
• virus can survive for 2 hours on human skin
• al...
FACTS: the common cold
• You can be re-infected by the
same virus, but subsequent illness
will be milder and shorter
• NO ...
Treatment: the common cold
• the ONLY “A”
recommendation is
NOT to use
antibiotics to treat
the common cold.
• everything ...
Treatment: what might work
COUGH:
• dextromethorphan (DM) – cough suppressant
• Cochrane review: 2 studies: benefit, 1 stu...
Treatment: what might work
NASAL CONGESTION:
• topical or oral decongestant (pseudoephedrine =
Sudafed)
• small benefit of...
Treatment: what WON’T work
COUGH:
• codeine – works for chronic
cough, NOT for acute cough
• antihistamines – no benefit
Treatment: what WON’T work
NASAL CONGESTION:
• Antihistamines *1
• no benefit, significant adverse effects
• Saline nasal ...
Treatment: the common cold
COMPLEMENTARY/ ALTERNATIVE:
• Vitamin C
• no effect if started after onset of symptoms
• incons...
Treatment: the common cold
COMPLEMENTARY/ ALTERNATIVE:
• Echinacea
• no evidence in well-designed
studies
• Zinc
• inhibit...
QUIZ: the common cold
What is the most common culprit?
a. rotavirus
b. coronavirus
c. rhinovirus
d. echovirus
e. influenza...
QUIZ: the common cold
What is the most common culprit?
a. rotavirus
b. coronavirus
c. rhinovirus
d. echovirus
e. influenza...
QUIZ: the common cold
Patient wants to spend his money on treatments that he
can be sure will help his symptoms. What do y...
QUIZ: the common cold
a. Antibiotics
b. Antihistamine
c. Codeine
d. Dextromethorphan
e. Pseudoephedrine
f. D. or E.
g. Non...
RHINO-SINUSITISRHINO-SINUSITIS
SINUSITIS AND ITS MANAGEMENT
Anatomy of sinuses
• Where are theWhere are the
sinuses?sinuses?
• Four pairs ofFour pairs of
paranasal sinusesparanasal sinuses
• Frontal-ab...
EMBRYOLOGICAL
DEVELOPMENT
• The sinuses are hollow air-filledThe sinuses are hollow air-filled
sacs lined by mucous membra...
EMBRYOLOGICAL
DEVELOPMENT
• At birth, the ethmoid, sphenoidAt birth, the ethmoid, sphenoid
and maxillary sinuses are tiny ...
Inflammation of paranasal sinuses
INFLAMED SINUSES
DEFINATION AND
INCIDENCE
• An acute inflammatory processAn acute inflammatory process
involving one or more of theinvolvin...
PATHOGENESIS:
• Usually follows rhinitis, which may be viral orUsually follows rhinitis, which may be viral or
allergic.al...
PATHOGENESIS:
• With inflammation, the mucosal lining ofWith inflammation, the mucosal lining of
the sinuses produce mucoi...
PREDISPOSING FACTORS
• Allergies, nasal deformities, cysticAllergies, nasal deformities, cystic
fibrosis, nasal polyps, an...
AETIOLOGY
• 70% of bacterial sinusitis is caused by:70% of bacterial sinusitis is caused by:
• Streptococcus pneumoniaeStr...
SYMPTOMS:
• History of URI or allergic rhinitisHistory of URI or allergic rhinitis
• History of pressure changeHistory of ...
SYMPTOMS:
• Persistent nasal discharge, oftenPersistent nasal discharge, often
purulentpurulent
• Postnasal dripPostnasal ...
CLINICAL FEATURES:
• Periorbital edemaPeriorbital edema
• CellulitisCellulitis
• Nasal mucosa is reddened or swollenNasal ...
DIAGNOSTIC TESTS:
• Imaging studies, such as sinusImaging studies, such as sinus
radiographs, ultrasonograms, or CTradiogr...
DIFFERENTIAL DIAGNOSIS
• septum deviation)septum deviation)
• Nasal foreign body Allergic rhinitisNasal foreign body Aller...
MEDICAL TREATMENT
• Acetaminophen or ibuprofen to relieveAcetaminophen or ibuprofen to relieve
painpain
• DecongestantsDec...
ANTIBIOTIC TREATMENT:
• Antimicrobials-treat for 10-14 days,Antimicrobials-treat for 10-14 days,
depending upon severity, ...
TREATMENT
• SEPTRAN: CO-SEPTRAN: CO-
TRIMOXAZOLE+TRIMETHOTRIMOXAZOLE+TRIMETHO
PRIMPRIM
• CEFACLOR:500MG:1 *TDSCEFACLOR:500...
FOLLOW UP INSTRUCTIONS
Humidifier to relieve the drying ofHumidifier to relieve the drying of
mucous membranes associated ...
PATIENT EDUCATION:
• Child should not dive.Child should not dive.
• Child should not travel by airplane.Child should not t...
ALLERGIC
RHINITIS
ALLERGIC
RHINITIS
Def. of Rhinitis: Is an
inflammation of the nasal
mucous membranes.
However, with
allergic rhinitis, oth...
ALLERGIC RHINITIS
•-Is an Immunologic Hypersensitivity
Disorder Type I
•-Is often a predisposing factor or
exacerbation of...
Impact of Allergic Rhinitis
•Most common form of atopic disease
•Affects 40 million Americans
•Prevalence estimates: 10/30...
Impact of Allergic Rhinitis
•Direct costs per year of about 6 billion dollars
•Increase absenteeism and reduced productivi...
Classification:
Seasonal:
Yearly intervals, periodic symptoms, often
due:
to outdoor allergens-pollens, tree pollens
(spri...
Classification:
Perennial:
Throughout the entire year, due to multiple
seasonal allergies or continue exposure to:
indoors...
PATHOPHYSIOLOGY
Allergens bind to specific IgE on Mast cells
in Respiratory mucosa Enzymatic
reactions occurs within the ...
There are 2 phases of allergic response:
Early phase response to antigen: < 5- 30 minutes
after allergen exposure.
-Allerg...
Late phase response to antigen: 2-12 hours
after allergen exposure
Characterized by sx beginning 4-8 hours
after allergic ...
S/S:
Seasonal:
Clear and watery drainage from
nose (rhinorrhea)
tearing of the eyes and
red eyes
frequent sneezing
Lesser ...
Perennial:
Year round symptoms,
nasal congestion
(major complaint)
post-nasal drainage (dry
cough)
mouth breather
decrease...
“allergic shiners” Dark circles
under the eyes (Moonshiners).
Chronic venous stasis from
sinus congestion
“Dennie-Morgan”:...
Allergic crease: Transverse line
near the tip of the nose,
secondary to rubbing
Nasal mucosa: Pale color, edema
of turbina...
Upper Respiratory
Infection-Common
Cold
Etiology: Rhinoviruses, Parainfluenza, RSV,
Adenovirus
Risk factors: Day care, smo...
Upper Respiratory
Infection-Common Cold
S/S: Nasal/throat irritation
Sneezing, nasal congestion, rhinorrhea
Sore throat, p...
INFECTIOUS RHINITIS
Most common cause of nasal symptoms
in children is viral URI.
Specially in day
care/kindergarten/winte...
INFECTIOUS RHINITIS
Clear mucus discharge, changing to green/yellow
after a few days, Cough post nasal drip
Turbinates ca...
LAB:
CBC- Eosinophilia
Nasal cytology- Eosinophilia. Greater than 10% is
(+)
Skin testing- Prick/puncture in skin 10-20 al...
LAB:
RAST– Radio Allergo Absorbent Test:
Measure allergen- specific IgE, measure
specific IgE
to individual allergen in a ...
TX:
Environmental control: Avoidance
of specific allergens.
1-Outdoor allergents:
Pollens/outdoor molds: limit
outdoor act...
2-Indoors:
Use dust mite anti-allergic pillow and mattress
plastic covers
Reduce indoor heat and humidity decreasing
proli...
Nasal Steroids: Effective for itching, sneezing,
rhinorrhea,
nasal congestion
More effective than oral antihistamine.
Bude...
Second generation:
H1 antagonist with no/less
anticholinergic sedating effect.
Effective for most symptoms, improved
but n...
Topical cromolyn sodium (Nasalcrom-Intal):
Mast cell stabilizer
Used above 6 years of age
Oral decongestants:
alpha-1-adre...
Combined oral decongestant and
antihistamines:
Extendryl / Rondec- chlorpheniramine
Mucolytics: Thin mucus, improving
muco...
POS
ALLERGIC RHINITIS
INFLUENZA
Define influenza
Influenza commonly calledInfluenza commonly called
“the flu” is a highly contagious“the flu” is a highly ...
Infective agent
• Influenza is caused by viruses that infect theInfluenza is caused by viruses that infect the
respiratory...
How do people get influenza
• Influenza occurs world wide. TheInfluenza occurs world wide. The
major types of influenza vi...
Signs and symptoms
• Abrupt feverAbrupt fever
• Muscle achesMuscle aches
• Severe tirednessSevere tiredness
• CoughCough
•...
How is influenza diagnosed
• Health care provider willHealth care provider will
diagnose influenza based ondiagnose influe...
Who is at risk for influenza
Any one can get. but the risk of complication inAny one can get. but the risk of complication...
Treatment for influenza
• There is no cure for influenza.There is no cure for influenza.
• Rest and liquids are main treat...
Common cold,rhino sinusitis,influenza
Common cold,rhino sinusitis,influenza
Common cold,rhino sinusitis,influenza
Common cold,rhino sinusitis,influenza
Common cold,rhino sinusitis,influenza
Common cold,rhino sinusitis,influenza
Common cold,rhino sinusitis,influenza
Common cold,rhino sinusitis,influenza
Common cold,rhino sinusitis,influenza
Common cold,rhino sinusitis,influenza
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  • Representing a group of diseases Involving to a variable degrees
  • QUITAR DE LA PRESENTACION
  • Common cold,rhino sinusitis,influenza

    1. 1. Common Cold , Rhino sinusitis, Influenza Dr. Shahid PervaizDr. Shahid Pervaiz Postgraduate RegistrarPostgraduate Registrar Pulmonology DepartmentPulmonology Department Nishtar Hospital MultanNishtar Hospital Multan
    2. 2. Definition: the common cold benign self-limited syndrome caused by members of several families of viruses Mild upper respiratory viral illness
    3. 3. Symptoms: the common cold Day 1 : sore or “scratchy” throat, +/- low grade fever Day 2-3 : nasal obstruction, rhinorrhea, sneezing.  Thick purulent nasal discharge does NOT mean bacterial sinusitis! Day 4-5: cough becomes bothersome, nasal symptoms less severe • Average duration: 3-7 days • Virus-induced changes in airway reactivity can persist for up to 4 weeks
    4. 4. Symptoms: the common cold* Day 1
    5. 5. Symptoms: the common cold* Day 2 to 3
    6. 6. Symptoms: the common cold* Day 4 to 5 • thick purulent nasal discharge does NOT mean bacterial sinusitis!
    7. 7. 50% 15% 15% 5% 5% 10% Rhinovirus Coronavirus Influenza RSV Parainfluenza Adeno, Entero Virology *4,5
    8. 8. Seasonal Patterns Fall, late spring : Rhinovirus Parainfluenza Winter, spring: RSV, coronavirus Summer: Enterovirus (year) Adenovirus: Outbreaks in Military facilities daycare centers, hospital
    9. 9. Facts: the common cold • Incubation period 24 to 72 hours • Average duration 3 – 7 days •Virus-induced changes in airway reactivity can persist for up to 4 weeks (Rhinovirus ) • 2 to 3 episodes /per year*
    10. 10. Diferential diagnosis: the common cold •Allergic or seasonal rhinitis •Bacterial pharyngitis or tonsillitis •Sinusitis •Influenza
    11. 11. But how do I know it’s just a cold? COLD INFLUENZA Fever Rare 39-40o Headache Rare Usual Myalgia Mild Severe Malaise Mild May last 3 wks Extreme fatigue Unusual Usual Nasal congestion Common Common Sneezing Common Sometimes Sore throat Common Common Chest discomfort/ cough Mild Mod-Severe
    12. 12. Facts: Influenza •Patients with illnesses which involve the cardiovascular or pulmonary systems •Patients with diabetes mellitus, renal disease, hemoglobinopathy, or immunosuppression. •Residents of nursing homes or chronic care facilities •Otherwise healthy individuals over age 50
    13. 13. Facts: Influenza Vaccine All of the mentionated before Plus Health care workers Pregnant women in second or third trimestrer
    14. 14. But how do I know it’s just a cold? • Acute Bacterial Sinusitis • complicate 0.5-2% of colds • Diagnosis = persistent URTI with no improvement >10-14 days OR worsening after 5 days + • nasal congestion/ purulent nasal discharge AND • facial pain
    15. 15. But how do I know it’s just a cold? • Pneumonia = 1. 2 of: fever, new cough, pleuritic chest pain, SOB + 2. Auscultatory findings + 3. New opacity on CXR
    16. 16. •Asthma Airway reactivity Vs Acute asthma attacks exacerbations Up to 40% of viral upper resp infection
    17. 17. Complications Sinusitis: Acute bacterial sinusitis develops in 0.5 to 2.5 percent of adult patients after viral *1 Lower respiratory tract disease : RSV, elderly (CHF) and immunocompromised Acute otitis media: Eustachian tube dysfunction; .
    18. 18. FACTS: transmission* • Hand –to- hand • most efficient = direct contact • virus can survive for 2 hours on human skin • also aerosol • NOT via saliva (in 90% of people with colds, no detectable virus in saliva)
    19. 19. FACTS: the common cold • You can be re-infected by the same virus, but subsequent illness will be milder and shorter • NO evidence that cold climate increases susceptibility to respiratory illness
    20. 20. Treatment: the common cold • the ONLY “A” recommendation is NOT to use antibiotics to treat the common cold. • everything else is “B” (inconsistent or limited quality evidence)
    21. 21. Treatment: what might work COUGH: • dextromethorphan (DM) – cough suppressant • Cochrane review: 2 studies: benefit, 1 study: no benefit • guaifenesin (Benylin E, Robitussin) – expectorant •1 study: benefit, 1 study: no benefit
    22. 22. Treatment: what might work NASAL CONGESTION: • topical or oral decongestant (pseudoephedrine = Sudafed) • small benefit of single dose, NO benefit of repeated use over several days • topical intranasal Atrovent (0.06% spray) • 2x 42ug sprays per nostril TID-QID x 4 days • decreased nasal discharge by 26% : only 1 study, expensive • humidified air and fluid intake
    23. 23. Treatment: what WON’T work COUGH: • codeine – works for chronic cough, NOT for acute cough • antihistamines – no benefit
    24. 24. Treatment: what WON’T work NASAL CONGESTION: • Antihistamines *1 • no benefit, significant adverse effects • Saline nasal spray • no benefit
    25. 25. Treatment: the common cold COMPLEMENTARY/ ALTERNATIVE: • Vitamin C • no effect if started after onset of symptoms • inconsistent results if started before: may slightly decrease cold duration if 200mg daily • Exercise • decreased incidence in overweight postmenopausal women who exercised 5x/week
    26. 26. Treatment: the common cold COMPLEMENTARY/ ALTERNATIVE: • Echinacea • no evidence in well-designed studies • Zinc • inhibits viral growth in vitro • inconsistent study results
    27. 27. QUIZ: the common cold What is the most common culprit? a. rotavirus b. coronavirus c. rhinovirus d. echovirus e. influenza virus
    28. 28. QUIZ: the common cold What is the most common culprit? a. rotavirus b. coronavirus c. rhinovirus d. echovirus e. influenza virus
    29. 29. QUIZ: the common cold Patient wants to spend his money on treatments that he can be sure will help his symptoms. What do you suggest? a. Antibiotics b. Antihistamine c. Codeine d. Dextromethorphan e. Pseudoephedrine f. D. or E. g. None of the above – just rest and fluids
    30. 30. QUIZ: the common cold a. Antibiotics b. Antihistamine c. Codeine d. Dextromethorphan e. Pseudoephedrine f. D. or E. g. None of the above – just rest and fluids
    31. 31. RHINO-SINUSITISRHINO-SINUSITIS
    32. 32. SINUSITIS AND ITS MANAGEMENT
    33. 33. Anatomy of sinuses
    34. 34. • Where are theWhere are the sinuses?sinuses? • Four pairs ofFour pairs of paranasal sinusesparanasal sinuses • Frontal-above eyes inFrontal-above eyes in forehead boneforehead bone • Maxillary-inMaxillary-in cheekbones, under eyescheekbones, under eyes • Ethmoid-between eyesEthmoid-between eyes and noseand nose • Sphenoid-in center ofSphenoid-in center of skull, behind nose andskull, behind nose and eyeseyes
    35. 35. EMBRYOLOGICAL DEVELOPMENT • The sinuses are hollow air-filledThe sinuses are hollow air-filled sacs lined by mucous membrane.sacs lined by mucous membrane. • The ethmoid and maxillaryThe ethmoid and maxillary sinuses are present at birth.sinuses are present at birth. • The frontal sinus develops duringThe frontal sinus develops during the 2the 2ndnd year and the sphenoid sinusyear and the sphenoid sinus develops during the 3develops during the 3rdrd yearyear
    36. 36. EMBRYOLOGICAL DEVELOPMENT • At birth, the ethmoid, sphenoidAt birth, the ethmoid, sphenoid and maxillary sinuses are tiny andand maxillary sinuses are tiny and cause problems in infants andcause problems in infants and toddlers.toddlers. • Frontal sinuses develop betweenFrontal sinuses develop between 4-7 years of age, causing problems4-7 years of age, causing problems in school aged children andin school aged children and adolescents.adolescents.
    37. 37. Inflammation of paranasal sinuses
    38. 38. INFLAMED SINUSES
    39. 39. DEFINATION AND INCIDENCE • An acute inflammatory processAn acute inflammatory process involving one or more of theinvolving one or more of the paranasal sinuses.paranasal sinuses. • A complication of 5%-10% of URIs inA complication of 5%-10% of URIs in children.children. • Persistence of URI symptoms >10Persistence of URI symptoms >10 days without improvement.days without improvement. • Maxillary and ethmoid sinuses areMaxillary and ethmoid sinuses are most frequently involvedmost frequently involved
    40. 40. PATHOGENESIS: • Usually follows rhinitis, which may be viral orUsually follows rhinitis, which may be viral or allergic.allergic. • May also result from abrupt pressure changesMay also result from abrupt pressure changes (air planes, diving) or dental extractions or(air planes, diving) or dental extractions or infections.infections. • Inflammation and edema of mucousInflammation and edema of mucous membranes lining the sinuses causemembranes lining the sinuses cause obstruction.obstruction. • This provides for an opportunistic bacterialThis provides for an opportunistic bacterial invasioninvasion
    41. 41. PATHOGENESIS: • With inflammation, the mucosal lining ofWith inflammation, the mucosal lining of the sinuses produce mucoid drainage.the sinuses produce mucoid drainage. Bacteria invade and pus accumulatesBacteria invade and pus accumulates inside the sinus cavities.inside the sinus cavities. • Postnasal drainage causes obstruction ofPostnasal drainage causes obstruction of nasal passages and an inflamed throat.nasal passages and an inflamed throat. • If the sinus orifices are blocked by swollenIf the sinus orifices are blocked by swollen mucosal lining, the pus cannot enter themucosal lining, the pus cannot enter the nose and builds up pressure inside thenose and builds up pressure inside the sinus cavities.sinus cavities.
    42. 42. PREDISPOSING FACTORS • Allergies, nasal deformities, cysticAllergies, nasal deformities, cystic fibrosis, nasal polyps, and HIV infection.fibrosis, nasal polyps, and HIV infection. • Cold weatherCold weather • High pollen countsHigh pollen counts • Day care attendanceDay care attendance • Smoking in the homeSmoking in the home • Re-infection from siblingsRe-infection from siblings
    43. 43. AETIOLOGY • 70% of bacterial sinusitis is caused by:70% of bacterial sinusitis is caused by: • Streptococcus pneumoniaeStreptococcus pneumoniae • Haemophilus influenzaeHaemophilus influenzae • Moraxella catarrhalisMoraxella catarrhalis • Other causative organisms are:Other causative organisms are: • Staphylococcus aureusStaphylococcus aureus • Streptococcus pyogenes,Streptococcus pyogenes, • Gram-negative bacilliGram-negative bacilli • Respiratory virusesRespiratory viruses
    44. 44. SYMPTOMS: • History of URI or allergic rhinitisHistory of URI or allergic rhinitis • History of pressure changeHistory of pressure change • Pressure, pain, or tenderness overPressure, pain, or tenderness over sinusessinuses • Increased pain in the morning,Increased pain in the morning, subsiding in the afternoonsubsiding in the afternoon • MalaiseMalaise • Low-grade temperatureLow-grade temperature
    45. 45. SYMPTOMS: • Persistent nasal discharge, oftenPersistent nasal discharge, often purulentpurulent • Postnasal dripPostnasal drip • Cough, worsens at nightCough, worsens at night • Mouthing breathing, snoringMouthing breathing, snoring • History of previous episodes ofHistory of previous episodes of sinusitissinusitis • Sore throat, bad breathSore throat, bad breath • HeadacheHeadache
    46. 46. CLINICAL FEATURES: • Periorbital edemaPeriorbital edema • CellulitisCellulitis • Nasal mucosa is reddened or swollenNasal mucosa is reddened or swollen • Percussion or palpation tenderness over aPercussion or palpation tenderness over a sinussinus • Nasal discharge, thick, sometimes yellowNasal discharge, thick, sometimes yellow or greenor green • Postnasal discharge in posterior pharynxPostnasal discharge in posterior pharynx • Difficult trans-illuminationDifficult trans-illumination • Swelling of turbinatesSwelling of turbinates
    47. 47. DIAGNOSTIC TESTS: • Imaging studies, such as sinusImaging studies, such as sinus radiographs, ultrasonograms, or CTradiographs, ultrasonograms, or CT scanning – indicated if child isscanning – indicated if child is unresponsive to 48 hours ofunresponsive to 48 hours of antibiotics and if the child has a toxicantibiotics and if the child has a toxic appearance, chronic or recurrentappearance, chronic or recurrent sinusitis, and chronic asthma.sinusitis, and chronic asthma. • Laboratory studies, such as culture ofLaboratory studies, such as culture of sinus puncture aspirates.sinus puncture aspirates.
    48. 48. DIFFERENTIAL DIAGNOSIS • septum deviation)septum deviation) • Nasal foreign body Allergic rhinitisNasal foreign body Allergic rhinitis • Non-allergic rhinitisNon-allergic rhinitis • Infectious rhinitisInfectious rhinitis • Drug-induced rhinitisDrug-induced rhinitis • Nasal polypsNasal polyps • Dental abscessDental abscess • Carcinoma of sinusCarcinoma of sinus • Cluster headacheCluster headache • Structural defectsStructural defects
    49. 49. MEDICAL TREATMENT • Acetaminophen or ibuprofen to relieveAcetaminophen or ibuprofen to relieve painpain • DecongestantsDecongestants • AntihistaminesAntihistamines • Nasal salineNasal saline
    50. 50. ANTIBIOTIC TREATMENT: • Antimicrobials-treat for 10-14 days,Antimicrobials-treat for 10-14 days, depending upon severity, with one ofdepending upon severity, with one of the following:the following: • Amoxicillin:20-40mg/kg/d in 3Amoxicillin:20-40mg/kg/d in 3 divided doses(>20kg, 250mg tid)divided doses(>20kg, 250mg tid) • CLAVUNATED AMOXICILLIN:CLAVUNATED AMOXICILLIN:25-25- 50mg/kg/d in 2 divided doses,50mg/kg/d in 2 divided doses, UseUse suspension if child is less than 40kg.suspension if child is less than 40kg.
    51. 51. TREATMENT • SEPTRAN: CO-SEPTRAN: CO- TRIMOXAZOLE+TRIMETHOTRIMOXAZOLE+TRIMETHO PRIMPRIM • CEFACLOR:500MG:1 *TDSCEFACLOR:500MG:1 *TDS • STEAM INHALATIONSTEAM INHALATION
    52. 52. FOLLOW UP INSTRUCTIONS Humidifier to relieve the drying ofHumidifier to relieve the drying of mucous membranes associated withmucous membranes associated with mouth breathingmouth breathing • Increase oral fluid intakeIncrease oral fluid intake • Saline irrigation of the nostrilsSaline irrigation of the nostrils • Moist heat over affected sinusMoist heat over affected sinus • Prolonged shower to help promoteProlonged shower to help promote drainagedrainage
    53. 53. PATIENT EDUCATION: • Child should not dive.Child should not dive. • Child should not travel by airplane.Child should not travel by airplane. • Urge parent to eliminate triggers in the homeUrge parent to eliminate triggers in the home (dust, smoking)(dust, smoking) • Have all members of the family treated, ifHave all members of the family treated, if indicated.indicated. • Instruct parent to call in 48 hours if condition ofInstruct parent to call in 48 hours if condition of child has not improved.child has not improved. • Instruct parent to bring child in for a recheck inInstruct parent to bring child in for a recheck in 2 weeks.2 weeks.
    54. 54. ALLERGIC RHINITIS
    55. 55. ALLERGIC RHINITIS Def. of Rhinitis: Is an inflammation of the nasal mucous membranes. However, with allergic rhinitis, other organs or tissues are involved, such as
    56. 56. ALLERGIC RHINITIS •-Is an Immunologic Hypersensitivity Disorder Type I •-Is often a predisposing factor or exacerbation of asthma, rhinosinusitis, nasal polyps. •-Characterized by one or more nasal Sx- sneezing, itching, congestion, rhinorrhea. •-Diagnosis is based on Hx, physical findings, and Lab.
    57. 57. Impact of Allergic Rhinitis •Most common form of atopic disease •Affects 40 million Americans •Prevalence estimates: 10/30% of adults, 40% of children •Peak incidence in childhood and adolescence •Almost 70% of the patients have nasal congestion •Nearly 17 million office visits a year
    58. 58. Impact of Allergic Rhinitis •Direct costs per year of about 6 billion dollars •Increase absenteeism and reduced productivity •75/80% of patients with asthma have allergic rhinitis. Genetics: High incidence in families with atopic disease
    59. 59. Classification: Seasonal: Yearly intervals, periodic symptoms, often due: to outdoor allergens-pollens, tree pollens (spring), grass (summer), ragweed (mid August). Mold spores
    60. 60. Classification: Perennial: Throughout the entire year, due to multiple seasonal allergies or continue exposure to: indoors allergen: Dust mite (Dermatophagoides), animal dander, cigarette smoke, hair ,spray, paint, mold, cockroaches outdoor allergens: Pollens, tree pollens (spring), grass (summer), ragweed (mid August).Mold spores
    61. 61. PATHOPHYSIOLOGY Allergens bind to specific IgE on Mast cells in Respiratory mucosa Enzymatic reactions occurs within the cell  Release of mediators (histamine, leukotrienes, prostaglandins) from mast cells  triggering IgE, leads to a complex interaction of inflammatory mediators, causing inflammation of the mucous membranes of eyes, nose, Eustachian tube, sinuses and/or pharinx.
    62. 62. There are 2 phases of allergic response: Early phase response to antigen: < 5- 30 minutes after allergen exposure. -Allergen comes in contact with IgE-primed mast cells and basophils -Caused by the immediate release of histamine and other mediators (leukotrienes). -Causing bronchoconstriction, edema, and stimulation of mucous gland that leads to: Production of secretions: Increase in vascular permeability leads to plasma exsudation Vasodilation leads to nasal congestion and sinus pressure
    63. 63. Late phase response to antigen: 2-12 hours after allergen exposure Characterized by sx beginning 4-8 hours after allergic exposure. This phase occurs because of inflammation resulting from the recruitment of inflammatory cells (Cytotoxic proteins released by neutrophils, eosinophils, macrophages, lymphocytes – damaging the Epithelial cells) to the mucous membranes. This phase has more congestion, rhinorrhea and less sneeze/itching.
    64. 64. S/S: Seasonal: Clear and watery drainage from nose (rhinorrhea) tearing of the eyes and red eyes frequent sneezing Lesser mouth breather
    65. 65. Perennial: Year round symptoms, nasal congestion (major complaint) post-nasal drainage (dry cough) mouth breather decreased sense of smell/or taste. Other SX: ↓ in physical functioning,
    66. 66. “allergic shiners” Dark circles under the eyes (Moonshiners). Chronic venous stasis from sinus congestion “Dennie-Morgan”: single or double lines under the eyes due to chronic edema. Allergic salute: Rubbing of the tip of the nose upward to ↓ itching
    67. 67. Allergic crease: Transverse line near the tip of the nose, secondary to rubbing Nasal mucosa: Pale color, edema of turbinates (inferior), clear watery secretion, colored mucus secretion Nasal polyps: Gray color, peeled- grape appearance, insensitivity to touch
    68. 68. Upper Respiratory Infection-Common Cold Etiology: Rhinoviruses, Parainfluenza, RSV, Adenovirus Risk factors: Day care, smoking, crowding, temperature changes
    69. 69. Upper Respiratory Infection-Common Cold S/S: Nasal/throat irritation Sneezing, nasal congestion, rhinorrhea Sore throat, postnasal drip Low grade fever, HA, malaise, myalgia Can lead to AOM, Sinusitis, asthma TX: Fluids, supportive
    70. 70. INFECTIOUS RHINITIS Most common cause of nasal symptoms in children is viral URI. Specially in day care/kindergarten/winter months Last between 7-14 days, symptoms resolving around the 7th/8th day Fever may or may not appear
    71. 71. INFECTIOUS RHINITIS Clear mucus discharge, changing to green/yellow after a few days, Cough post nasal drip Turbinates can be swollen and erythematous. Secretions are watery or thick, clear or colored. Complicated by sinusitis or obstruction by adenoidal hypertrophy TX: ATB (purulent mucus), mucolitics, cough syrup
    72. 72. LAB: CBC- Eosinophilia Nasal cytology- Eosinophilia. Greater than 10% is (+) Skin testing- Prick/puncture in skin 10-20 allergens. Immediate hypersensitivity with immediate results. There is a small chance of triggering a severe allergic reaction in someone highly allergic.
    73. 73. LAB: RAST– Radio Allergo Absorbent Test: Measure allergen- specific IgE, measure specific IgE to individual allergen in a sample of blood. Is less sensitive than skin testing. Total IgE: Elevated in allergic rhinitis
    74. 74. TX: Environmental control: Avoidance of specific allergens. 1-Outdoor allergents: Pollens/outdoor molds: limit outdoor activity during allergy season Keep windows and doors closed Wear a mask while doing yard work.
    75. 75. 2-Indoors: Use dust mite anti-allergic pillow and mattress plastic covers Reduce indoor heat and humidity decreasing proliferation of mites Eliminate carpeting, and use linoleum, tiles. Avoid feathers in pillows and covers. Molds: Eliminate areas of dampness and standing water Clean mold area Pets : Avoid as much as possible or don’t have them Use HEPA filters and A/C Eliminate cockroaches
    76. 76. Nasal Steroids: Effective for itching, sneezing, rhinorrhea, nasal congestion More effective than oral antihistamine. Budesonide (Rhinocort), flonase, nasonex Antihistamine: Block H1 receptors suppressing most of symptoms First generation: H1 antagonist with anticholinergic effects (sedating, dry mouth, tachycardia) Effective for most Sx. of allergic rhinitis, but on congestion is limited. Benadryl (dyphenhydramine)
    77. 77. Second generation: H1 antagonist with no/less anticholinergic sedating effect. Effective for most symptoms, improved but not efficient on congestion. Zyrtec (cetirizine), Clarinex (desloratidine) Singulair (montelukast-Leukotrienes blockers)
    78. 78. Topical cromolyn sodium (Nasalcrom-Intal): Mast cell stabilizer Used above 6 years of age Oral decongestants: alpha-1-adrenergic agonists: phenylephrine, phenylpropalamine.- Sudafed Cause vasoconstriction, ↓ blood supply to nasal mucosa / edema Topical decongestants: Sympathomimetics. Side effects-drying and burning of the mucosa. Using more than 5 days- rebound vasodilation and congestion. Oxymetazoline -Afrin
    79. 79. Combined oral decongestant and antihistamines: Extendryl / Rondec- chlorpheniramine Mucolytics: Thin mucus, improving mucociliary flow. Steam, NS drops, Guaifenesin, N-acetylcysteine Immunotherapy: Given to patients that not responded to drug therapy and good environmental control
    80. 80. POS ALLERGIC RHINITIS
    81. 81. INFLUENZA
    82. 82. Define influenza Influenza commonly calledInfluenza commonly called “the flu” is a highly contagious“the flu” is a highly contagious infection of the nose, throat,infection of the nose, throat, bronchial tubes, and lungs.bronchial tubes, and lungs.
    83. 83. Infective agent • Influenza is caused by viruses that infect theInfluenza is caused by viruses that infect the respiratory tract.respiratory tract. • Two main types:-Two main types:- 1.Influenza type-A1.Influenza type-A 2.Influenza type-B2.Influenza type-B • These viruses can under go two types ofThese viruses can under go two types of changes.changes. • ““Antigenic drift” – gradual evaluation ofAntigenic drift” – gradual evaluation of virus.virus. • ““Antigenic Shift” _ occurs only occasionally.Antigenic Shift” _ occurs only occasionally.
    84. 84. How do people get influenza • Influenza occurs world wide. TheInfluenza occurs world wide. The major types of influenza virus livemajor types of influenza virus live and change inside animals,and change inside animals, primarily birds, pigs, and horses.primarily birds, pigs, and horses. • It spreads through the Air, mostIt spreads through the Air, most often when an infected personoften when an infected person sneezes, cough, or speaks.sneezes, cough, or speaks.
    85. 85. Signs and symptoms • Abrupt feverAbrupt fever • Muscle achesMuscle aches • Severe tirednessSevere tiredness • CoughCough • Sore throatSore throat • Runny or stuffy noseRunny or stuffy nose • HeadacheHeadache These symptoms typically appear 1-5These symptoms typically appear 1-5 days after infection.days after infection.
    86. 86. How is influenza diagnosed • Health care provider willHealth care provider will diagnose influenza based ondiagnose influenza based on typical symptoms of fever,typical symptoms of fever, chills, headache, cough andchills, headache, cough and body aches.body aches.
    87. 87. Who is at risk for influenza Any one can get. but the risk of complication inAny one can get. but the risk of complication in highest in these groups.highest in these groups. 1.Person aged 65 years and older1.Person aged 65 years and older 2.Residents of nursing home2.Residents of nursing home 3.Adults and children with long lasting disorders of3.Adults and children with long lasting disorders of the lungs or heart.the lungs or heart. 4.Adults and children with diabetes, kidney disease, or4.Adults and children with diabetes, kidney disease, or weakened immune systemsweakened immune systems 5.Health-care workers, house hold members and5.Health-care workers, house hold members and others who are contact with persons at high risk forothers who are contact with persons at high risk for influenza.influenza.
    88. 88. Treatment for influenza • There is no cure for influenza.There is no cure for influenza. • Rest and liquids are main treatment.Rest and liquids are main treatment. • Antiviral drug- Tamiflu is licensed forAntiviral drug- Tamiflu is licensed for treatment of both the main types oftreatment of both the main types of influenza in humans (type A and type B)influenza in humans (type A and type B) it may prevent or reduce the severity ofit may prevent or reduce the severity of influenza.influenza.
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