Upper Respiratory Tract InfectionsUpper Respiratory Tract Infections
Charles S. Bryan, M.D.
November 20, 2007
Burden of URIBurden of URI
 Up to ½ of all
symptomatic illness
 Significant morbidity and
direct health care costs
 Occ...
The Common ColdThe Common Cold
Children average 8 per year, adults 3
Rhinoviruses 30 to 35%; coronaviruses about
10%, misc...
The common coldThe common cold
Transmission of rhinovirusesTransmission of rhinoviruses
Direct contact is the most efficient means of
transmission: 40% t...
Severe acute respiratorySevere acute respiratory
distress syndrome (SARS)distress syndrome (SARS)
Caused by a previously u...
SARS: CDC case definition (2003)SARS: CDC case definition (2003)
Respiratory illness of unknown etiology AND
Measured temp...
SARS: Case definition (2)SARS: Case definition (2)
Clinical findings of respiratory illness:
cough, SOB, dyspnea, hypoxia,...
SARS: Radiographic findingsSARS: Radiographic findings
Early: a peripheral/pleural-based
opacity (ground-glass or
consolid...
SARS: Hypothetical disease modelSARS: Hypothetical disease model
((Emerg Infect DisEmerg Infect Dis 2003; 9: 1064-1069)200...
Dr. Carlo Urbani (1956-2003)Dr. Carlo Urbani (1956-2003)
2/28/03: Recognized
SARS while examining a
patient in Hanoi.
Iden...
Acute bacterial sinusitisAcute bacterial sinusitis
Viral infection--> obstruction of ducts and
compromise of mucocilary bl...
Paranasal sinusesParanasal sinuses
Waters view (left); Coronal CTWaters view (left); Coronal CT
Acute sinusitis: complicationsAcute sinusitis: complications
Maxillary: usually uncomplicated
Ethmoid: cavernous sinus thr...
Acute sinusitis: complications (2)Acute sinusitis: complications (2)
 Sphenoid: Rare, but usually misdiagnosed,
with grav...
Chronic sinusitisChronic sinusitis
 Bacterial: Cultures show a variety of
opportunistic pathogens including
anaerobes but...
Spectrum of fungal sinusitisSpectrum of fungal sinusitis
 Simple colonization
 Sinus mycetoma (fungus
ball)
 Allergic f...
Otitis externaOtitis externa
Acute, localized: often S. aureus or S.
pyogenes
Acute diffuse (swimmer’s ear): gram-
negativ...
Otitis externaOtitis externa
 Acute, localized: often S. aureus
or S. pyogenes
 Acute diffuse (swimmer’s ear):
gram-nega...
Malignant otitis externaMalignant otitis externa
 Diabetes mellitus
 Pseudomonas
aeruginosa
 Osteomyelitis of
the tempo...
Acute otitis mediaAcute otitis media
S. pneumoniae and H. influenzae the
leading causes in all age groups
Moraxella catarr...
Acute otitis mediaAcute otitis media
 Critical role of
eustachian tube as
conduit between
nasopharynx, middle
ear, and ma...
Chronic otitis media and mastoiditisChronic otitis media and mastoiditis
Prolonged middle ear effusions in
patients with p...
Acute pharyngitis: physical examAcute pharyngitis: physical exam
Viral: edema and hyperemia of tonsils
and pharyngeal muco...
Acute pharyngitis: physical exam (2)Acute pharyngitis: physical exam (2)
Adenoviruses: exudate may sometimes be
present
He...
Pharyngoconjuntival feverPharyngoconjuntival fever
Adenoviral pharyngitis
Pharyngeal erythema and exudate may
mimic strept...
HerpanginaHerpangina
Uncommon
Due to coxsackieviruss
Small, 1-2 mm vesicles on the soft
palate, uvula, and anterior tonsil...
Vincent’s angina and QuinsyVincent’s angina and Quinsy
Vincent’s angina: anaerobic
pharyngitis (exudate; foul odor to
brea...
DiphtheriaDiphtheria
Classic diphtheria (Corynebacterium
diphtheriae): slow onset, then marked toxicity
Arcanobacterium he...
Miscellaneous causes of pharyngitisMiscellaneous causes of pharyngitis
Primary HIV infection
Gonococcal infection
Diphther...
Acute laryngotracheobronchitis (croup)Acute laryngotracheobronchitis (croup)
Children, most often in 2nd year
Parainfluenz...
Acute epiglottitisAcute epiglottitis
 A life-threatening
cellulitis of the epiglottis
and adjacent structures
 Onset usu...
Acute suppurativeAcute suppurative
parotitisparotitis
Uncommon, but high
morbidity and mortality
Usually associated some
c...
Deep fascial space infections ofDeep fascial space infections of
the head and neckthe head and neck
Several syndromes acco...
Deep fascial space infections ofDeep fascial space infections of
the head and neck (2)the head and neck (2)
Lemierre syndr...
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
Upper Respiratory Tract Infections Charles S. Bryan, M.D.
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Upper Respiratory Tract Infections Charles S. Bryan, M.D.

  1. 1. Upper Respiratory Tract InfectionsUpper Respiratory Tract Infections Charles S. Bryan, M.D. November 20, 2007
  2. 2. Burden of URIBurden of URI  Up to ½ of all symptomatic illness  Significant morbidity and direct health care costs  Occasionally leads to fatal illness  Excessive use of antibiotics a major issue
  3. 3. The Common ColdThe Common Cold Children average 8 per year, adults 3 Rhinoviruses 30 to 35%; coronaviruses about 10%, miscellaneous known viruses about 20%, presumed undiscovered viruses up to 35%, group A streptococci 5% to 10% Sinusitis often present by CT scan; “rhinosinusitis” might be a better term
  4. 4. The common coldThe common cold
  5. 5. Transmission of rhinovirusesTransmission of rhinoviruses Direct contact is the most efficient means of transmission: 40% to 90% recovery from hands. Brief exposure (e.g., handshake) transmits in less than 10% of instances Kissing does not seem to be a common mode of transmission.
  6. 6. Severe acute respiratorySevere acute respiratory distress syndrome (SARS)distress syndrome (SARS) Caused by a previously unrecognized coronavirus—genome has now been sequenced. Clinical manifestations are similar to those of other acute respiratory illnesses—notably, influenza Cases in U.S.—associated mainly with travel or as secondary contacts
  7. 7. SARS: CDC case definition (2003)SARS: CDC case definition (2003) Respiratory illness of unknown etiology AND Measured temperature > 100.4 degrees F (38 degrees C) AND One or more clinical findings of respiratory illness AND Travel within 10 days of onset of symptoms to an area with documented or suspected cases OR close contact with a case
  8. 8. SARS: Case definition (2)SARS: Case definition (2) Clinical findings of respiratory illness: cough, SOB, dyspnea, hypoxia, or radiographic findings of either pneumonia or ARDS Travel includes certain areas (mainland China, Hong Kong, Hanoi, Singapore) and also airports with documented or suspected community transmission
  9. 9. SARS: Radiographic findingsSARS: Radiographic findings Early: a peripheral/pleural-based opacity (ground-glass or consolidative) may be the only abnormality. Look especially at retrocardiac area. Advanced: widespread opacification (ground-glass or consolidative) tending to affect the lower zones and often bilateral. Pleural effusions, lymphadenopathy, and cavitation are not seen.
  10. 10. SARS: Hypothetical disease modelSARS: Hypothetical disease model ((Emerg Infect DisEmerg Infect Dis 2003; 9: 1064-1069)2003; 9: 1064-1069) Phase 1: viral replication Phase 2: immune hyperactivity with cytokine deregulation (hence, the theoretical justification for corticosteroid therapy) Phase 3: Pulmonary destruction
  11. 11. Dr. Carlo Urbani (1956-2003)Dr. Carlo Urbani (1956-2003) 2/28/03: Recognized SARS while examining a patient in Hanoi. Identified outbreak and raises the alarm. Stayed caring patients despite multiple illnesses in staff—sent wife and three children back to Italy 3/29/03: Died of SARS
  12. 12. Acute bacterial sinusitisAcute bacterial sinusitis Viral infection--> obstruction of ducts and compromise of mucocilary blanket--> acute infection from virulent organisms (most often S. pneumoniae and H. influenzae)--> opportunistic pathogens Complicates 0.5% of common URI More common in adults than in children
  13. 13. Paranasal sinusesParanasal sinuses
  14. 14. Waters view (left); Coronal CTWaters view (left); Coronal CT
  15. 15. Acute sinusitis: complicationsAcute sinusitis: complications Maxillary: usually uncomplicated Ethmoid: cavernous sinus thrombosis (40% mortality) Frontal: osteomyelitis of frontal bone; cavernous sinus thrombosis; epidural, subdural, or intracerebral abscess; orbital extension
  16. 16. Acute sinusitis: complications (2)Acute sinusitis: complications (2)  Sphenoid: Rare, but usually misdiagnosed, with grave consequences; extension to internal carotid artery, cavernous sinuses, pituitary, optic nerves; common misdiagnoses include ophthalmic migraine, aseptic meningitis, trigeminal neuralgia, cavernous sinus thrombosis
  17. 17. Chronic sinusitisChronic sinusitis  Bacterial: Cultures show a variety of opportunistic pathogens including anaerobes but problem is mainly anatomic, not microbiologic  Fungal: suspect especially when a single sinus is involved; syndromes associated with nasal polyposis can have high morbidity
  18. 18. Spectrum of fungal sinusitisSpectrum of fungal sinusitis  Simple colonization  Sinus mycetoma (fungus ball)  Allergic fungal sinusitis  Acute (fulminant) invasive sinusitis (notably, rhinocerebral mucormycosis)  Chronic invasive fungal sinusitis
  19. 19. Otitis externaOtitis externa Acute, localized: often S. aureus or S. pyogenes Acute diffuse (swimmer’s ear): gram- negative rods, especially Ps. aeruginosa Chronic: mainly with chronic otitis media Malignant: life-threatening infection in diabetics; Pseudomonas aeruginosa
  20. 20. Otitis externaOtitis externa  Acute, localized: often S. aureus or S. pyogenes  Acute diffuse (swimmer’s ear): gram-negative rods, especially Ps. aeruginosa  Chronic: mainly with chronic otitis media  Malignant: life-threatening infection in diabetics; Pseudomonas aeruginosa
  21. 21. Malignant otitis externaMalignant otitis externa  Diabetes mellitus  Pseudomonas aeruginosa  Osteomyelitis of the temporal bone  Involvement of vital structures at base of brain
  22. 22. Acute otitis mediaAcute otitis media S. pneumoniae and H. influenzae the leading causes in all age groups Moraxella catarrhalis: ? emerging role Some case may be viral Mycoplasma pneumoniae: inflammation of the tympanic membrane (“bullous myringitis”)
  23. 23. Acute otitis mediaAcute otitis media  Critical role of eustachian tube as conduit between nasopharynx, middle ear, and mastoid air cells  Children have shorter, wider eustachian tubes than adults
  24. 24. Chronic otitis media and mastoiditisChronic otitis media and mastoiditis Prolonged middle ear effusions in patients with previous episodes of acute otitis media. Often “skin flora” or anaerobic organisms Mastoiditis: Less common nowadays. formerly severe complications. Often anaerobic.
  25. 25. Acute pharyngitis: physical examAcute pharyngitis: physical exam Viral: edema and hyperemia of tonsils and pharyngeal mucosa Streptococcal: exudate and hemorrhage involving tonsils and pharyngeal walls Epstein-Barr virus (infectious mono): may also cause exudate, with nasopharyngeal lymphoid hyperplasia
  26. 26. Acute pharyngitis: physical exam (2)Acute pharyngitis: physical exam (2) Adenoviruses: exudate may sometimes be present Herpes simplex virus and some coxsackie A infections: vesiculation and mucosal ulceration may be present Diphtheria: fibrous pseudomembrane with necrotic epithelium and leukocytes
  27. 27. Pharyngoconjuntival feverPharyngoconjuntival fever Adenoviral pharyngitis Pharyngeal erythema and exudate may mimic streptococcal pharyngitis Conjunctivitis (follicular) present in 1/3 to 1/2 of cases; commonly unilateral but bilateral in 1/4 of cases
  28. 28. HerpanginaHerpangina Uncommon Due to coxsackieviruss Small, 1-2 mm vesicles on the soft palate, uvula, and anterior tonsillar pillars which rupture to form small white ulcers Occurs mainly in children
  29. 29. Vincent’s angina and QuinsyVincent’s angina and Quinsy Vincent’s angina: anaerobic pharyngitis (exudate; foul odor to breath) Quinsy: peritonsillitis/peritonsillar abscess. Medial displacement of the tonsil; often spread of infection to carotid sheath
  30. 30. DiphtheriaDiphtheria Classic diphtheria (Corynebacterium diphtheriae): slow onset, then marked toxicity Arcanobacterium hemolyticum (formerly Cornyebacterium hemolyticum): exudative pharyngitis in adolescents and young adults with diffuse, sometimes pruritic maculopapular rash on trunk and extremities
  31. 31. Miscellaneous causes of pharyngitisMiscellaneous causes of pharyngitis Primary HIV infection Gonococcal infection Diphtheria Yersinia entercolitica (can have fulminant course) Mycoplasma pneumoniae Chlamydia pneumoniae
  32. 32. Acute laryngotracheobronchitis (croup)Acute laryngotracheobronchitis (croup) Children, most often in 2nd year Parainfluenza virus type 1 most often in U.S.A. but other agents cause Involvement of larynx and trachea: stridor, hoarseness, cough Subglottic involvement: high-pitched vibratory sounds Can lead to respiratory failure (up to 12%)
  33. 33. Acute epiglottitisAcute epiglottitis  A life-threatening cellulitis of the epiglottis and adjacent structures  Onset usually sudden (as opposed to gradual onset of croup); drooling, dysphagia, sore throat  H. influenzae the usual pathogen both in children (the usual patients) and adults
  34. 34. Acute suppurativeAcute suppurative parotitisparotitis Uncommon, but high morbidity and mortality Usually associated some combination of dehydration, old age, malnutrition, and/or postoperative state S. aureus the usual pathogen
  35. 35. Deep fascial space infections ofDeep fascial space infections of the head and neckthe head and neck Several syndromes according to anatomic planes Can complicate odontogenic or oropharyngeal infection Ludwig’s angina: bilateral involvement of submandibular and sublingual spaces (brawny cellulitis at floor of mouth)
  36. 36. Deep fascial space infections ofDeep fascial space infections of the head and neck (2)the head and neck (2) Lemierre syndrome: suppurative thrombophlebitis of internal jugular vein (Fusobacterium necrophorum) Retropharyngeal space infection: contiguous spread from lateral pharyngeal space or infected retropharyngeal lymph node; complications include rupture into airway, septic thrombosis of internal jugular vein
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