Definition, etio-pathogenesis, Clinical presentation, Diagnosis and treatment of major URTIs

1. Upper Respiratory Tract
Infections

4. Introduction
• The vast majority of these illnesses are caused
by viruses of which acute coryza is by far the
most common
• Bacterial infection is the usual cause of acute
tonsillitis, otitis media and epiglottitis

5. Introduction
• Acute epiglottis represents a medical
emergency because of the risk of asphyxia
• X-rays of the sinuses may be required if an
underlying chronic sinusitis is suspected
• Throat swabs may also be helpful if
streptococcal pharyngitis is suspected

6. Common cold
• The common cold is not a single infectious
disease, but rather a group of self-limiting viral
upper respiratory infections (URIs) producing
a similar clinical syndrome
• The average preschool child contracts
approximately 6 to 10 colds per year, and the
average adult has 2 to 4 colds annually

7. Common cold
• The common cold is generally regarded as a
mild condition that rarely causes significant
morbidity
• Patients with the common cold are also more
susceptible to acquiring otitis media and
sinusitis

8. Causes
• Rhinovirus
• Coronaviruses
• respiratory syncytial virus
• parainfluenza virus
• Adenovirus
• Enterovirus
• influenza A virus B virus

9. Causes
Bacteria:
• Chlamydia pneumoniae
• Mycoplasma pneumoniae
• Streptococcus pneumoniae
• Haemophilus influenzae

10. Trnasmission
• Direct contact with nasopharyngeal secretions
or by inhalation of small and large airborne
particles
• simple touch or handshake
• Inanimate objects

11. Signs and Symptoms
• Sore throat
• nasal obstruction
• nasal stuffiness
• Mild fever
• Sneezing
• watery eyes
• hoarseness
• Cough
• headache, malaise, myalgia, sinus pain, and
postnasal discharge

12. Signs and Symptoms
• Infection caused by adenoviruses and
enteroviruses is more often associated with fever,
pharyngitis
• Usually, influenza presents with high fever (38.5°C
or higher), pronounced malaise and myalgia, but
mild cases of influenza may mimic cold-like
symptoms
• The common cold may last 2 to 14 days; about 7
to 10 days is most common

13. Diagnosis
• The common cold is diagnosed based on
clinical signs and symptoms and exclusion of
more serious illnesses
• Because of the self-limiting nature of the
common cold and the lack of effective
treatment, there is no indication for
performing viral cultures or other specific
diagnostic testing

14. Treatment
• Symptomatic
• NSAIDS
• Anti-histamines

15. Otitis Media
• Infection of the middle ear may present as
acute otitis media (AOM) or as otitis media
with effusion (OME or serous otitis media)
• AOM is extremely prevalent in young children,
occurring in most children at least once within
the first 6 years of life

16. Otitis Media
• Many of these children also develop chronic
OME, which may be associated with hearing
impairment and learning disability
• Care of otitis media is estimated to account
for over 24.5 million physician office visits
annually

17. Otitis Media
• Tympanostomy for the management of OME
is the most common surgical procedures
involving children
• Treatment of AOM also accounts for the
largest single use of antibacterial drugs in
children

18. Epidemiology
• As early as 6 months of age, 48% of infants
experience at least one episode of AOM
• By 1 year of age, 62% to 79% of infants
experience one or more episodes of otitis
media, and almost 20% have had three or
more episodes

19. Risk factors
• socioeconomic status and contact with a large
number of other children (common in day-
care settings)
• The risk of AOM and OME appears to be
higher in infants who are not breastfed,
African-American children who live in urban
environments, boys, and children exposed to
secondhand smoke

20. Risk factors
• Children who contract AOM early in life are
more likely to have recurrent otitis media
• The presence of a viral respiratory tract
infection or seasonal allergic rhinitis may also
contribute to eustachian tube dysfunction.

21. Etiology
• S. pneumoniae – 30%
• H. influenzae – 47%
• M. catarrhalis - 14-35%

22. Signs and Symptoms
• Acute onset of ear pain
• Fever
• middle-ear effusion
• Ear pulling, crying, irritability, anorexia,
vomiting, and diarrhea

23. Signs and Symptoms
• This disease is characterized by excessive fluid
in the middle ear, mild symptoms including
ear pain and discomfort, and a hearing deficit
• Spontaneous rupture of the tympanic
membrane, discharge in the external ear
canal, and vertigo may occur

24. Diagnosis
• The most common symptoms associated with
AOM in children include earache, sore throat,
night restlessness, and fever
• In infants, the most common symptoms are
irritability/lethargy (69%), fever (52%), cough
(36%), vomiting (21%), diarrhea (20%),
tachypnea (20%), and anorexia (18%)

25. Diagnosis
– The diagnosis of AOM is made on the basis of
acute symptoms, middle ear effusion, and middle
ear inflammation
– Techniques used to demonstrate reduced
tympanic membrane mobility are important to
confirm diagnosis

26. Diagnosis
• Tympanometry is another technique that may be
used
• Diagnostic tympanocentesis

27. • Mastoiditis with
subperiosteal abscess..

28. GENERAL TREATMENT OPTIONS
Antimicrobial Therapy
NSAIDs
Tympanostomy tubes

30. Treatment
• Amoxicillin – Drug of choice
• There was no evidence that extended-spectrum
drugs (amoxicillin/clavulanate,
sulfamethoxazole/trimethoprim,
erythromycin/sulfasoxazole,
penicillin/sulfasoxazole, or any cephalosporin)
performed better than standard-spectrum drugs
(amoxicillin, penicillin, or erythromycin).

31. Treatment
• Oral cephalosporins (cefdinir, cefprozil,
cefuroxime, and cefpodoxime) provide similar
percentage time above the MIC in middle ear
fluid. These agents may be better tolerated
and more convenient for some situations, but
they are more

32. Treatment
• Because of the increased prevalence of penicillin-
resistant S. pneumoniae, higher doses of
amoxicillin (80 to 90 mg/kg/day) are now
recommended
• Cefdinir, cefuroxime, and cefpodoxime are
alternatives that can be used in patients with
penicillin allergy only if the reaction was not a
type 1 hypersensitivity reaction and provided the
reaction was not serious.

33. Treatment
• Antibacterial therapy should be administered
for 10 days in children less than 6 years of age
and in older children with severe symptoms.
Otherwise, treatment for 5 to 7 days appears
to provide similar outcomes

34. Treatment
• Forty-eight to 72 hours after starting
antibacterial therapy, some improvement in
symptoms should be apparent. If the patient is
not improved, the diagnosis needs to be
reevaluated and a change in the antibacterial
therapy considered.
• It is reasonable to use amoxicillin/clavulanate or
a cephalosporin (cefuroxime, cefdinir, or
cefpodoxime) in patients who fail to respond to
amoxicillin.

35. Treatment
• For patients with refractory disease where
penicillin-resistant S. pneumoniae is proven or
suspected, treatment with intramuscular
ceftriaxone (50 mg/kg daily for 3 days) should
be considered
• In adult patients, one of the newer
fluoroquinolones (e.g., levofloxacin,
moxifloxacin, gatifloxacin, or gemifloxacin) with
improved S. pneumoniae coverage may be used.

36. Complications
• Otogenic complications of AOM include tympanic
membrane perforation, cholesteatoma (middle
ear cyst), ossicular fixation or destruction,
labyrinthitis, and chronic otitis media
• Because of persistent hearing loss associated
with OME, impairment of speech/language
acquisition and delayed cognitive development
may result

37. Complications
• The incidence of intracranial complications after AOM is
estimated to be 0.04% to 0.15%
• Acute mastoiditis was the most common serious
complication in the preantibiotic era. This infection is
typically caused by S. pneumoniae, and more than 60% of
patients require surgery (mastoidectomy) for management
• There has been concern that more restrictive use of
antimicrobial agents may lead to an increased frequency of
complications, but this has not been observed to date.

38. Acute Rhinosinusitis

39. Introduction
• Infection of the paranasal sinus mucosa
• The majority of these infections are viral
in origin
• Bacteria may be involved

40. Causes
• S. pneumoniae (41%)
• H. influenzae (35%)
• Moraxella catarrhalis (4%)
• Various streptococcal species and anaerobes
from oral flora represented 14% of the
isolates, and Staphylococcus aureus accounted
for 3%

41. Causes
• Many of these patients with negative bacterial
cultures are considered to have viral sinusitis
associated with the common cold
• In children with acute maxillary sinusitis, S.
pneumoniae (41%) is the most common
cause, followed by H. influenzae (19%) and M.
catarrhalis (19%)

42. Signs and Symptoms
• Sinus tenderness
• Cough
• Sinus pressure
• Nasal obstruction
• Headache
• postnasal drainage
• discolored nasal discharge, and sore throat
• Halitosis, malaise, fever, chills, maxillary
toothache
• periorbital swelling

43. Diagnosis
• The presence of thick, colored, mucopurulent
secretions is consistent with acute
rhinosinusitis

44. Diagnosis
• Sinus tenderness, sinus pressure, and postnasal
discharge are often used as criteria for diagnosing
sinusitis
• Characteristics associated with greater than 70%
sensitivity include colored nasal discharge, cough,
and sneezing
• The presence of a maxillary toothache and
painful chewing were quite specific

45. CT-scan

46. Management
• For Bacterial sinusitis
• For severe and persistent sinusitis
• Not for uncomplicated sinusitis

47. Treatment
• Anti-microbial therapy
• Nasal decongestant
• Irrigation of the nasal cavity
• Mucolytics

48. Antimicrobial Therapy
• Two meta-analyses have demonstrated that
antimicrobial therapy is superior to placebo in
reducing or eliminating symptoms in acute
sinusitis, with a reduction in clinical failure of 25%
to 30% reported
• Of two randomized, controlled, double-blind
studies, one demonstrated that amoxicillin
provided no benefit over placebo, while the other
demonstrated that amoxicillin or penicillin were
more effective than placebo

49. Antimicrobial Therapy
• Amoxicillin is first-line treatment for acute
bacterial sinusitis
• If a patient is penicillin-allergic, trimethoprim-
sulfamethoxazole, doxycycline, azithromycin,
or clarithromycin may be used

50. Antimicrobial Therapy
• Respiratory FQs
• Cephalosporins

51. Antimicrobial Therapy
• If drug-resistant S. pneumoniae is highly
suspected (daycare attendance, recent
antibiotic use, age younger than 2 years),
high-dose amoxicillin should be given
• Some recommend clindamycin, but it is
important to note that this drug is not active
against H. influenzae and M. catarrhalis

52. Antimicrobial Therapy
• In the case of treatment failure with amoxicillin (i.e., no
improvement in symptoms 72 hours after starting
therapy) or in patients who have received antimicrobial
therapy in the prior 4 to 6 weeks, limitations of initial
treatment coverage must be considered
• Improved coverage of H. influenzae and M. catarrhalis
with either high-dose amoxicillin plus clavulanate or a
β-lactamase–stable cephalosporin that covers S.
pneumoniae (e.g., cefprozil, cefuroxime, or
cefpodoxime) is an option

54. Other Therapy
• Nasal Decongestants
• Irrigation
• Mucolytics

55. Pharyngitis
• Acute pharyngitis is a common infectious
disease, particularly in children
• This infection may be caused by a variety of
viral and bacterial pathogens

56. Etiology
• Group A β-hemolytic streptococci (S.
pyogenes)
• Rare causes of bacterial pharyngitis that also
require treatment include Neisseria
gonorrhoeae, Francisella tularensis, Yersinia
pestis, and Corynebacterium diphtheriae

57. Etiology
• Acute bacterial pharyngitis may also be caused by
group C and G streptococci, Arcanobacterium
hemolyticum, and possibly M. pneumoniae and
Chlamydia pneumoniae
• In addition, viral causes include rhinovirus,
coronavirus, adenovirus, parainfluenza virus,
herpes simplex virus, influenza virus,
coxsackievirus, Epstein-Barr virus, and
cytomegalovirus

58. Epidemiology
• The presence of sore throat is associated with
more than 10% of primary care physician
visits, yet less than 20% of patients with a sore
throat actually visit a heath care provider

63. Diagnosis
• Clinical presentation
• Cutler test
• RADT
• Criteria for clinical prediction of Group A
streptococcal involvement

64. Diagnosis

65. Treatment
Antipyretics and Analgesics
Definitive Antimicrobial Treatment

66. Analgesics
• PCM
• Avoid: NSAIDS (risk for necrotizing
fasciitis/toxic shock syndrome)

67. Antibiotics
• Penicillin
• Macrolide
• Cephalosporins

68. Macrolide Resistance
• In cases of documented macrolide resistance
(owing to low-level macrolide resistance—
erythromycin MIC 1 to 8 mcg/mL—because of
expression of the mefA/E gene leading to
efflux of macrolide out of the bacterial cell),
• Clindamycin is an alternative

70. Acute Laryngotracheobronchitis
• Viral croup is a common, usually self-limiting
illness of young children. The disease is
characterized by noisy breathing (inspiratory
stridor) and a dry bark-like cough
• The cough and abnormal breathing sounds
result from inflammation and edema of the
tracheal walls and impaired mobility of the vocal
cords. In the most severe forms, the
inflammation is extensive enough to obstruct
the airway

71. Epidemiology
• Viral croup occurs in children between 1 and 6 years of
age, with the highest incidence during the second year of
life
• Up to 5% of children contract viral croup between their
first and second birthday
• The peak incidence occurs in the late fall and winter, and
boys are affected at a disproportionately higher rate than
girls. Although most cases of viral croup are caused by the
parainfluenza virus, croup may also be caused by
adenovirus, respiratory syncytial virus, and influenza A
virus

72. Signs and Symptoms
• Viral croup usually begins with mild cold-like symptoms, including
rhinorrhea, mild pharyngitis, cough, and low-grade fever
• As inflammation and edema of the tracheal wall develop, the lumen
narrows, thereby restricting airflow
• Inspiratory stridor occurs due to air passing through the narrowed
opening, and this is often audible from a distance. The child's
speech is hoarse because of the swelling and altered mobility of the
vocal cords. Expiratory stridor and wheezing may also be present,
but lung breath sounds are normal
• Most children show improvement after 1 to 2 days and resolution
of symptoms by 3 to 7 days

73. Diagnosis
• Foreign bodies lodged in the trachea must also be considered.
Most children with viral croup have a normal oxygen saturation as
determined by pulse oximetry
• The presence of hypoxia and a low oxygen saturation indicates
severe obstruction and the need for immediate treatment.
Radiologic studies, including a radiograph of the neck and a
limited CT scan, may support the clinical diagnosis
• A CT scan provides the most sensitive and specific confirmation,
but the procedure is not routinely necessary. Laryngoscopy is
particularly helpful when a foreign body or acute epiglottitis is
suspected. However, this procedure should not be performed in
children with hypoxia or severe respiratory distress

74. Treatment
• The management of viral croup should focus on
assessment of airway obstruction and maintenance of
an open airway. Emergency airway management and
hospital admission may be required in severe cases
• Symptomatic treatment may include analgesics
(acetaminophen or ibuprofen) and adequate
hydration. Cool mist therapy has been used to elevate
humidity, which is believed to decrease the viscosity
of mucous secretions and soothe inflamed mucosa.
Humidified air is not routinely recommended

75. Treatment
Aerosolized epinephrine delivered by nebulizer should
be used in children with severe airway narrowing as
assessed by a decreased oxygen saturation and
labored breathing.147 The epinephrine decreases
swelling and edema through α-receptor stimulation
and constriction of small arterioles. Caution is
advised in children with tachycardia and underlying
congenital heart disease. Children given this
treatment should be observed during and for 2 hours
after administration. Aerosolized epinephrine may
reduce the need for intubation and tracheostomy

76. Treatment
Corticosteroids (e.g., dexamethasone 0.6 mg/kg) are
recommended in children with croup. Most children can
be managed with a single dose of oral dexamethasone. A
one-time repeat dose is warranted if the child vomits
after the first dose. Intramuscular dexamethasone may
be used in children who cannot tolerate the oral dose.148
Nebulized budesonide (2 mg) is equivalent to oral or
intramuscular dexamethasone for moderate to severe
viral croup.149 Corticosteroids reduce the need for
intubation, shorten the time to improvement and the
duration of the emergency room or hospital stay, and
reduce the need for repeated aerosol epinephrine
administration

77. Acute Epiglottitis
• Acute epiglottitis is a very serious condition
involving cellulitis and swelling of the
epiglottis
• Children with acute epiglottis are at significant
risk for acute airway obstruction and death if
endotracheal intubation or emergency
tracheostomy is not performed

78. Etiology
• Acute epiglottitis is usually caused by
infection with H influenzae type B.
Fortunately, the availability and widespread
use of Haemophilus type B vaccine in
children has almost eliminated acute
epiglottitis

79. Etiology
• In addition to H. influenzae type B, acute
epiglottitis may be caused by S. pneumoniae,
β-hemolytic streptococci, S aureus, and
aerobic gram-negative bacteria. Most cases of
acute epiglottitis due to organisms other than
H. influenzae occur in immunocompromised
individuals

80. Acute Laryngotracheobronchitis
• Viral croup is a common, usually self-limiting
illness of young children. The disease is
characterized by noisy breathing (inspiratory
stridor) and a dry bark-like cough
• The cough and abnormal breathing sounds
result from inflammation and edema of the
tracheal walls and impaired mobility of the vocal
cords. In the most severe forms, the
inflammation is extensive enough to obstruct
the airway

81. Epidemiology
• Viral croup occurs in children between 1 and 6 years of
age, with the highest incidence during the second year of
life
• Up to 5% of children contract viral croup between their
first and second birthday
• The peak incidence occurs in the late fall and winter, and
boys are affected at a disproportionately higher rate than
girls. Although most cases of viral croup are caused by the
parainfluenza virus, croup may also be caused by
adenovirus, respiratory syncytial virus, and influenza A
virus

82. Signs and Symptoms
• Viral croup usually begins with mild cold-like symptoms, including
rhinorrhea, mild pharyngitis, cough, and low-grade fever
• As inflammation and edema of the tracheal wall develop, the lumen
narrows, thereby restricting airflow
• Inspiratory stridor occurs due to air passing through the narrowed
opening, and this is often audible from a distance. The child's
speech is hoarse because of the swelling and altered mobility of the
vocal cords. Expiratory stridor and wheezing may also be present,
but lung breath sounds are normal
• Most children show improvement after 1 to 2 days and resolution
of symptoms by 3 to 7 days

83. Diagnosis
• Foreign bodies lodged in the trachea must also be considered.
Most children with viral croup have a normal oxygen saturation as
determined by pulse oximetry
• The presence of hypoxia and a low oxygen saturation indicates
severe obstruction and the need for immediate treatment.
Radiologic studies, including a radiograph of the neck and a
limited CT scan, may support the clinical diagnosis
• A CT scan provides the most sensitive and specific confirmation,
but the procedure is not routinely necessary. Laryngoscopy is
particularly helpful when a foreign body or acute epiglottitis is
suspected. However, this procedure should not be performed in
children with hypoxia or severe respiratory distress

84. Treatment
• The management of viral croup should focus on
assessment of airway obstruction and maintenance of
an open airway. Emergency airway management and
hospital admission may be required in severe cases
• Symptomatic treatment may include analgesics
(acetaminophen or ibuprofen) and adequate
hydration. Cool mist therapy has been used to elevate
humidity, which is believed to decrease the viscosity
of mucous secretions and soothe inflamed mucosa.
Humidified air is not routinely recommended

85. Treatment
Aerosolized epinephrine delivered by nebulizer should
be used in children with severe airway narrowing as
assessed by a decreased oxygen saturation and
labored breathing.147 The epinephrine decreases
swelling and edema through α-receptor stimulation
and constriction of small arterioles. Caution is
advised in children with tachycardia and underlying
congenital heart disease. Children given this
treatment should be observed during and for 2 hours
after administration. Aerosolized epinephrine may
reduce the need for intubation and tracheostomy

86. Treatment
Corticosteroids (e.g., dexamethasone 0.6 mg/kg) are
recommended in children with croup. Most children can
be managed with a single dose of oral dexamethasone. A
one-time repeat dose is warranted if the child vomits
after the first dose. Intramuscular dexamethasone may
be used in children who cannot tolerate the oral dose.148
Nebulized budesonide (2 mg) is equivalent to oral or
intramuscular dexamethasone for moderate to severe
viral croup.149 Corticosteroids reduce the need for
intubation, shorten the time to improvement and the
duration of the emergency room or hospital stay, and
reduce the need for repeated aerosol epinephrine
administration