Summarised notes of upper respiratory tract infections

1. MANAGEMENT OF URTIs

2. SINUSITIS

3. SINUSITIS
• Inflammation of air sinuses of the skull
Causes
• Allergy
• Foreign body in the nose
• Viruses, e.g. rhinovirus, often as a
complication of URTI
• Dental focal infection
• Bacteria, e.g., Streptococcus pneumonae,
Haemophilus influenzae, Streptococcus
pyogenes

4. SINUSITIS
Clinical features
• Rare in patients <5 years
• Pain over cheek and radiating to frontal region
or teeth, increasing with straining or bending
down
• Redness of nose, cheeks, or eyelids
• Tenderness to pressure over the floor of the
frontal sinus immediately above the inner
canthus
• Referred pain to the vertex, temple, or occiput
• Postnasal discharge
• A blocked nose
• Persistent coughing or pharyngeal irritation

5. SINUSITIS
Differential diagnosis
• Common cold, allergic rhinitis
• Foreign body in the nose
• Nasal polyps, adenoids

6. MANAGEMENT OF SINUSITIS
General measures
• Steam inhalation may help clear blocked
nose
• Analgesics e.g. Paracetamol
• Nasal irrigation with normal saline
If there are signs of bacterial infection
(symptoms persisting > 1 week,
unilateral facial pain, worsening of
symptoms after an initial improvement)
• Amoxicillin 500 mg every 8 hours for 7-10
days

7. MANAGEMENT OF SINUSITIS
If there is a dental focus of infection
• Extract the tooth
• Give antibiotics e.g. Amoxicillin plus
Metronidazole
If there is a foreign body in the nose
• Refer to hospital for removal

8. MANAGEMENT OF SINUSITIS
Notes:
• Do NOT use antibiotics except if there are
clear features of bacterial sinusitis, e.g.,
Persistent (> 1 week) purulent nasal
discharge,
Sinus tenderness,
Facial or periorbital swelling,
Persistent fever

9. OTITIS MEDIA
(SUPPURATIVE)

10. Otitis Media (Suppurative)
• An acute or chronic infection of the middle ear occurring
mostly in children <2years
• It is one of the most common childhood illnesses.
• Acute otitis often has been treated with an antibiotic,
despite controversial evidence in support of the routine
use of antibiotics for this condition.
• About a decade ago, about half of all prescriptions written
for children in the United States were for the treatment of
otitis media; however, more recent data from the Centers
for the Disease Control and Prevention note a 42%
reduction in the number of ambulatory visits and antibiotic
prescriptions for acute otitis media (AOM) in children
younger than 2 years over a 7-year period.
• These decreases probably can be attributed to increased
immunizations with the seven-valent pneumocococcal
conjugate vaccine and more appropriate use of antibiotics

11. Otitis Media (Suppurative)
• The middle ear is the anatomical location of the
hearing apparatus.
• It is separated from the outer ear canal by the
tympanic membrane (eardrum) and drains into the
nasopharynx via the Eustachian tubes.
• The presence of a dull, red, bulging, tympanic
membrane that shows no movement during
insufflation (application of slight changes in air
pressure in the ear canal) on otoscopic examination
is diagnostic of AOM.
• Otitis media peaks between 6 months and 3 years
of age and is thought to be most likely due to
Eustachian tube obstruction and secondarily to the

12. Otitis Media (Suppurative)
Causes:
• Eustachian tube dysfunction has been associated
with upper respiratory tract infections (URIs) and
allergies.
• Viruses cause many otitis media infections alone or
together with bacteria;
• However, it is difficult to distinguish viral from
bacterial etiology based solely on clinical
presentation and otoscopic examination.
• Bacterial infection, e.g., Streptococcus pneumonae,
Haemophilus influenzae
• Commonly follows an acute infection of the upper
respiratory tract

13. Otitis Media (Suppurative)
Clinical features
• Acute onset of pain in the ear, redness of the
ear drum
• Fever
• Pus discharge for <14 days
• Bulging of the eardrum
In chronic otitis media
• On and off pus discharge from one or both
ears for >14 days
• No systemic symptoms

14. Otitis Media (Suppurative)
Differential diagnosis
• Foreign body in the ear
• Otitis externa and media with effusion
• Referred ear pain, e.g. from toothache
Investigations
• Good history and physical examination are
important in making a diagnosis
• Pus swab for microscopy, C&S

15. Treatment of Otitis Media
Acute infection
• Amoxicillin 500 mg every 8 hours for 5
days
• Child: 15 mg/kg per dose
• Or erythromycin 500 mg every 6 hours in
penicillin allergy
• Child: 10-15 mg/kg per dose
• Give analgesics, e.g. Paracetamol as
required

16. Treatment of Otitis Media
Chronic infection
• Systemic antibiotics are NOT recommended:
they are not useful and can create resistance
• Aural irrigation 2-3 times a day
1 spoon of hydrogen peroxide in a glass of clean
lukewarm water
Gently irrigate ear using a syringe without needle
Avoid directing the flow towards the tympanic
membrane
• Dry by wicking 3 times daily for several
weeks, until the ear stays dry
• Each time after drying, apply 2-4 drops of
ciprofloxacin ear drops 0.5% into the ear
• Do NOT allow water to enter the ear

17. Complications of Otitis Media
• Meningitis,
• Mastoid abscess (behind the ear),
• Infection in adjacent areas, e.g., tonsils,
nose

18. Prevention of Otitis Media
• Health education, e.g. advising patients on
recognizing the discharge of otitis media
(believed by some to be “milk in the ear”)
• Early diagnosis and treatment of acute
otitis media and upper respiratory tract
infections
• Treat infections in adjacent area, e.g.
tonsillitis

19. Glue Ear (Otitis Media with
Effusion)
• A non-suppurative otitis media.
Causes:
• Blockage of the Eustachian tube by:
adenoids, infection in the tube, thick
mucoid fluid and tumours of the postnasal
space
• Unresolved acute otitis media
• Viral infection of the middle ear
• Allergy

20. Glue Ear (Otitis Media with
Effusion)
Clinical features
• Hearing impairment (the main feature)
–– Often fluctuant, e.g. in children: “this
child hears when s/he wants to and
sometimes ignores you”
• Presence of non-purulent fluid in middle
ear
• Buzzing noise in ears/head
• Retracted or bulging ear drum
• Loss of usual colour of ear drum (dull

21. Management of Glue Ear (Otitis
Media with Effusion)
• Eliminate known or predisposing causes
• Chlorpheniramine 4 mg every 12 hours for 10 days
• Child 1-2 years: 1 mg every 12 hours
• Child 2-5 years: 1 mg every 6 hours (max: 6 mg
daily)
• Child 6-12 years: 2 mg every 6 hours (max: 12 mg
daily)
• Plus xylometazoline nasal drops 0.1% or ephedrine
2 drops every 8 hours for 2 weeks
• Child: Use 0.05% drops
• Exercises: Chewing, blowing against closed nose
tends to open the tube
If effusion persists >6 weeks in spite of the above:

22. PHARYNGITIS (SORE
THROAT)

23. Pharyngitis (Sore Throat)
• Inflammation of the throat
Causes:
• Most cases are viral
• Bacterial: commonly Group A haemolytic
Streptococci, diphtheria in non-immunized
children
• Gonorrhoea (usually from oral sex)
• May also follow ingestion of undiluted
spirits
• Candida albicans in the

24. Pharyngitis (Sore Throat)
Clinical features
• Abrupt onset
• Throat pain
• Pain on swallowing
• Mild fever, loss of appetite, general malaise
• In children: nausea, vomiting, and diarrhoea
• The presence of runny nose, hoarseness, cough,
conjunctivitis, viral rash, diarrhea suggests viral
infection
• The presence of tonsilar exudates, tender neck
glands,
• high fever, and absence of cough suggest a

25. Pharyngitis (Sore Throat)
Differential diagnosis
• Tonsillitis, epiglottitis, laryngitis
• Otitis media if there is referred pain
Investigations
• Throat examination with torch and tongue
depressor
• Throat swab for microscopy, C&S
• Blood: Full blood count
• Serological test for haemolytic streptococci

26. Management of Pharyngitis
(Sore Throat)
• Supportive care
• Most cases are viral and do not require
antibiotics
• Keep the patient warm
• Give plenty of (warm) oral fluids e.g., tea
• Give analgesics, e.g. Paracetamol for 3
days
• Review the patient for progress

27. Management of Pharyngitis
(Sore Throat)
Notes:
• If not properly treated, streptococcal
pharyngitis may lead to acute rheumatic
fever and retropharyngeal or peritonsillar
abscess
–– Therefore ensure that the full 10-day
courses of antibiotics are completed where
applicable

28. END