Lecture 2 upper respiratory tract
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The document discusses various upper respiratory infections including the common cold, influenza, pharyngitis, and sinusitis. It describes the epidemiology, clinical presentation, causative agents, and treatment for each condition. The respiratory tract's defenses against infection are also outlined. The common cold is usually viral in origin and self-limiting, while influenza can be caused by different virus subtypes and sometimes causes pneumonia. Pharyngitis may be due to viruses or Group A Streptococcus bacteria. Sinusitis is classified by duration and can be caused by various bacteria.
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Lecture 2 upper respiratory tract
- 1. Disorders of the Upper Respiratory System Dr. MohanadDr. Mohanad QPT20303QPT20303
- 2. ObjectiveObjective • To learn the epidemiology and various clinical presentation of URT • To identify the common etiological agents causing these syndromes • To study the laboratory diagnosis of these syndromes • To determine the antibiotic of choice for treatment
- 3. The Respiratory Tract and Its DefensesThe Respiratory Tract and Its Defenses Most common place for infectious agents toMost common place for infectious agents to gain access to the bodygain access to the body Upper respiratory tract: mouth, nose, nasalUpper respiratory tract: mouth, nose, nasal cavity, sinuses, pharynx, epiglottis, larynxcavity, sinuses, pharynx, epiglottis, larynx Lower respiratory tract: trachea, bronchi,Lower respiratory tract: trachea, bronchi, bronchioles, lungs, alveolibronchioles, lungs, alveoli DefnesesDefneses Nasal hairNasal hair CiliaCilia MucusMucus Involuntary responses such as coughing, sneezing,Involuntary responses such as coughing, sneezing, and swallowingand swallowing MacrophagesMacrophages Secretory IgA against specific pathogensSecretory IgA against specific pathogens
- 4. Defenses of the Respiratory SystemDefenses of the Respiratory System
- 5. The classification of upper respiratory tract infections includes: The common cold Pharyngitis Epiglotitis Acute laryngitis Acute laryngotracheobronchitis Sinusitis Otitis externa, otitis media and mastoiditis
- 6. General symptoms of Respiratory Disease Hypoxia : Decreased levels of oxygen in the tissues Hypoxemia : Decreased levels of oxygen in arterial blood Hypercapnia : Increased levels of CO2 in the blood Hypocapnia : Decreased levels of CO2 in the blood Dyspnea : Difficulty breathing Tachypnea : Rapid rate of breathing Cyanosis : Bluish discoloration of skin and mucous membranes due to poor oxygenation of the blood Hemoptysis : Blood in the sputum
- 7. Respiratory infections Infections of the respiratory tract can occur in: 1. The upper respiratory tract or 2. The lower respiratory tract, or 3. Both. Organisms capable of infecting respiratory structures include: 1. Bacteria. 2. Viruses: the majority of upper respiratory tract infections are caused by viruses as rhinovirus and parainfluenza virus. 3. Fungi. Depending on the organism and extent of infection, the manifestations can range from mild to severe and even life threatening.
- 8. FForms of Rhinitisorms of Rhinitis Rhinoviruses,Rhinoviruses, Adenoviruses,Adenoviruses, RSVRSV Coxsackie'sCoxsackie's Viruses.Viruses. allergic rhinitis (hay fever) nonallergic rhinitis (common cold) Pollen Dust mites Mold Animal dander
- 9. Endothelial cell activation Leukocyte infiltration and activation (lymphocytes, eosinophils, basophils) IMMEDIATE (early) RESPONSE LATE-PHASE RESPONSES preformed & newly formed mediators/cytokines mast cell Sneezing Pruritus Rhinorrhea Nasal obstruction Ocular symptoms Nasal obstruction Rhinorrhea Nasal hyperresponsiveness To allergens (priming) To irritants and to atmospheric changes IgE allergen dendritic cell T-lymphocyte cytokines chemokines allergen B-lymphocyte IgE IL-4 IL-13 The nasal allergic response glands (mucous)
- 10. Clinical manifestationsClinical manifestations:: Fever,Fever, Rhinorrhea,Rhinorrhea, Sore throat,Sore throat, CoughCough Similar cases in the familySimilar cases in the family
- 11. Complications:Complications: Acute otitis media,Acute otitis media, Pharyngitis,Pharyngitis, Sinusitis,Sinusitis, Conjunctivitis,Conjunctivitis, Pneumonia,Pneumonia, Adenitis.Adenitis.
- 12. Treatment (Symptomatic) :Treatment (Symptomatic) : Fever antipyretics Nasal obstruction decongestants Rhinorrhea antihistamines saline nasal drops/solution Chlorpheniramine Acrivastine/ Claritin (loratadine)
- 13. House dust mite allergen avoidanceHouse dust mite allergen avoidance Provide adequate ventilation toProvide adequate ventilation to decrease humiditydecrease humidity Wash bedding regularly at 60°CWash bedding regularly at 60°C Encase pillow, mattress and quilt inEncase pillow, mattress and quilt in allergen impermeable coversallergen impermeable covers Use vacuum cleaner with HEPA filterUse vacuum cleaner with HEPA filter Dispose of feather beddingDispose of feather bedding Remove carpetsRemove carpets Remove curtains, pets and stuffedRemove curtains, pets and stuffed toys from bedroomtoys from bedroom
- 14. Nonspecific Infections of The UpperNonspecific Infections of The Upper Respiratory TractRespiratory Tract They are identified by a variety of descriptiveThey are identified by a variety of descriptive names, includingnames, including acute infective rhinitisacute infective rhinitis,, acuteacute rhinopharyngitis/nasopharyngitisrhinopharyngitis/nasopharyngitis, as well as by, as well as by the inclusive labelthe inclusive label Common ColdCommon Cold..
- 15. EtiologyEtiology Influenza virus (3 immunotypes)Influenza virus (3 immunotypes) For instance, rhinoviruses (~30 to 40% of cases) consist ofFor instance, rhinoviruses (~30 to 40% of cases) consist of at least 100 immunotypesat least 100 immunotypes Parainfluenza virus (4 immunotypes)Parainfluenza virus (4 immunotypes) Coronavirus (at least 3 immunotypes)Coronavirus (at least 3 immunotypes) Adenovirus (47 immunotypes)Adenovirus (47 immunotypes) Respiratory syncytial virus (RSV)Respiratory syncytial virus (RSV) Enteroviruses, rubella virus, and varicella-zoster virus)Enteroviruses, rubella virus, and varicella-zoster virus)
- 16. / 42 16 CauseCause • 80 % Influenzae virus • Parainfluenza %2-9 • Rhinovirus %3 • Adenovirus %4
- 17. These viruses tend to have seasonal variations in their peak incidence. They gain entry to the body through the nasal mucosa and the surfaces of the eye. They are readily spread from person to person via respiratory secretions. Manifestations of the common cold include: Rhinitis: Inflammation of the nasal mucosa Sinusitis :Inflammation of the sinus mucosa Pharyngitis : Inflammation of the pharynx and throat Headache Nasal discharge and congestion, coughcough Sore throat, sneezing, and hoarsenessSore throat, sneezing, and hoarseness Fever, malaise, fatigue , fever are more commonFever, malaise, fatigue , fever are more common among infants and young.among infants and young. Thecommoncold
- 18. TREATMENTTREATMENT Antibiotics to prevent bacterial infection (Antibiotics to prevent bacterial infection (amoxicillinamoxicillin)) Treatment remains entirely symptom-basedTreatment remains entirely symptom-based Decongestants:Decongestants: Phenylephrine and AntihistaminesPhenylephrine and Antihistamines ((Claritin/ AcrivastineClaritin/ Acrivastine)) Nonsteroidal anti-inflammatory drugs (Nonsteroidal anti-inflammatory drugs (ibuprofenibuprofen)) Dextromethorphan for coughDextromethorphan for cough
- 19. Influenza is a viral infection that can affect the upper or lower respiratory tract. The influenza virus is a highly transmissible respiratory pathogen. Influenza A virusInfluenza A virus FamilyFamily OrthomyxoviridaeOrthomyxoviridae Negative-stranded RNA genomeNegative-stranded RNA genome Influenza B & C virusesInfluenza B & C viruses only circulate in humansonly circulate in humans Type A is the most common and causes the most serious illness. Upper respiratory tract Infections Influenza
- 20. InfluenzaInfluenza Because the organism has a high tendency for genetic mutation, new variant of the virus are constantly arising in different places around the world. Serious pandemics (spread of infection across a large region) of influenza are seen every 8 to 10 years as a result of this genetic mutation .
- 22. Influenza A Transmission CycleInfluenza A Transmission Cycle Circulates with limited pathology Transmission to domestic fowl Adaptation/ reassortment with swine influenza viruses Transmission to humans
- 23. PathogenesisPathogenesis Acquired through inhalation of infectedAcquired through inhalation of infected respiratory secretionsrespiratory secretions Virus attaches to host cells via hemagglutininVirus attaches to host cells via hemagglutinin spikesspikes Once attached viral envelope fuses with host membrane,Once attached viral envelope fuses with host membrane, leading to viral replication within the cellleading to viral replication within the cell Mature virusesMature viruses budbud from host cellfrom host cell Budding allows mature virus to pick up envelopeBudding allows mature virus to pick up envelope Infected cellsInfected cells die and slough offdie and slough off Host immunity quickly controls viral spreadHost immunity quickly controls viral spread Anti-HA neutralizing IgGAnti-HA neutralizing IgG is protectiveis protective Mortality rate is lowMortality rate is low Seasonal Influenza
- 24. Symptoms of influenza infection: Headache Fever, chills Muscle aches Nasal discharge Unproductive cough Sore throat Influenza infection can cause marked inflammation of the respiratory epithelium leading to acute tissue damage and a loss of ciliated cells that protect the respiratory passages from other organisms As a result may lead to co-infection of the respiratory passages with bacteria. It is also possible for the influenza virus to infect the tissues of the lung itself to cause a viral pneumonia. Upper respiratory tract Infections Influenza
- 26. TREATMENTTREATMENT Antibiotics to avoid bacterial infectionAntibiotics to avoid bacterial infection Antiviral (Amantadine)Antiviral (Amantadine) Treatment remains entirely symptom-basedTreatment remains entirely symptom-based Decongestants (Decongestants (Phenylephrine)Phenylephrine) Nonsteroidal anti-inflammatory drugsNonsteroidal anti-inflammatory drugs Dextromethorphan for coughDextromethorphan for cough Influenza vaccine: The influenza vaccine is particularly indicated in elderly people, in individuals weakened by other disease and in health-care workers
- 28. Drugs for Treating Influenza: Amantadine Used orally or by aerosol administration Effective only against type A influenza Inhibits viral fusion, assembly and release from the infected host cell Neuraminidase inhibitors (Zanamavir, Oseltamivir) New drugs that can be used by inhalation (Zanamavir) or orally (Oseltamivir) Effective against both type A and B influenza Inhibits the activity of viral neuraminidase enzyme that is necessary for spread of the influenza virus Upper respiratory tract Infections Influenza
- 29. PharyngitisPharyngitis Definition:Definition: Inflammatory syndrome of theInflammatory syndrome of the pharynx caused by several microorganismspharynx caused by several microorganisms Causes:Causes: most viral but may also occur as part ofmost viral but may also occur as part of common cold or influenza syndromecommon cold or influenza syndrome The most bacterial cause is Group AThe most bacterial cause is Group A Streptococcus (Streptococcus pyogenes)-5-20%Streptococcus (Streptococcus pyogenes)-5-20%
- 31. Pharyngitis Clinical PresentationPharyngitis Clinical Presentation Clinical presentation withClinical presentation with soreness of the throat,soreness of the throat, may be dysphagia andmay be dysphagia and pain on swallowingpain on swallowing FeverFever additional upperadditional upper respiratory symptoms mayrespiratory symptoms may also be present,also be present, tendertender cervical lymphadenopathycervical lymphadenopathy
- 32. Figure 21.3
- 33. SinusitisSinusitis Acute BacterialAcute Bacterial : Bacterial Infection of the paranasal sinuses: Bacterial Infection of the paranasal sinuses lasting less than 30days in which symptoms resolvelasting less than 30days in which symptoms resolve completelycompletely Subacaute Bacterial SinusitisSubacaute Bacterial Sinusitis: Lasting between 30 and 90: Lasting between 30 and 90 days in which synptoms resolve completelydays in which synptoms resolve completely Recurrent acute bacterial sinusitisRecurrent acute bacterial sinusitis: Each episode lasting: Each episode lasting less than 30 days and separated by intervals of at leastless than 30 days and separated by intervals of at least 10days during which the patient is asymptomatic10days during which the patient is asymptomatic Chronic SinusitisChronic Sinusitis: Episode lasting longer than 90 days: Episode lasting longer than 90 days .Patients have persistent residual respiratory stmptomssuch.Patients have persistent residual respiratory stmptomssuch as cough, rhinnorrhoea or nasal obstruction.as cough, rhinnorrhoea or nasal obstruction.
- 34. / 42 34
- 35. Bacterial SinusitisBacterial SinusitisBacterial SinusitisBacterial Sinusitis Acute sinusitis S.pneumoniae H.infuenza M.catarrhalis Chronic sinusitis S.pneumoniae H.infuenza M.catarrhalis Oral anaerobes
- 36. Clinical Presentations of SinusitisClinical Presentations of Sinusitis
- 37. Bacterial sinusitisBacterial sinusitisBacterial sinusitisBacterial sinusitis Acute sinusitis Children Mainly clinical diagnosis Aspiration in case T failure Dx X-rays CT/MRI Periorbital cellulitis R/O sinusitis by CT/MRI Post-septal involvement treat as meningitis Chronic sinusitis Less local symptoms Mimic allergic rhinitis Dx Image less useful than acute (changes persist after T and to R/O tumor Obtain odontogenic X- rays if maxillary sinus
- 38. ManifestationsManifestations Nasal drainage and congestionNasal drainage and congestion Facial pain or pressureFacial pain or pressure Headache.Headache. Thick, purulent or discolored nasal dischargeThick, purulent or discolored nasal discharge Is often thought to indicate bacterial sinusitis, butIs often thought to indicate bacterial sinusitis, but it also occurs early in viral infections such as theit also occurs early in viral infections such as the common coldcommon cold Other nonspecific symptoms include cough,Other nonspecific symptoms include cough, sneezing, and feversneezing, and fever Tooth pain, most often involving the upper molars,Tooth pain, most often involving the upper molars, is associated with bacterial sinusitisis associated with bacterial sinusitis
- 39. ManifestationsManifestations Sinus pain or pressure often localizes and beSinus pain or pressure often localizes and be worse when the patient bends over or is supine.worse when the patient bends over or is supine. Symptoms of advanced sphenoid or ethmoidSymptoms of advanced sphenoid or ethmoid sinus:sinus: severe frontal or retroorbital painsevere frontal or retroorbital pain radiatingradiating to the occiput, thrombosis of the cavernousto the occiput, thrombosis of the cavernous sinus, and signs of orbital cellulitissinus, and signs of orbital cellulitis Advanced frontal sinusitis,Advanced frontal sinusitis, swelling and pittingswelling and pitting edema over the frontal bone ,subperiostealedema over the frontal bone ,subperiosteal abscessabscess
- 40. Symptoms associated withSymptoms associated with RhinosinusitisRhinosinusitis Major symptoms: Minor symptoms: Facial pain/pressure Headache Facial congestion/fullness Fever Nasal obstruction/blockage Halitosis Nasal discharge/purulence/postnasal drip Fatigue Hyposmia/Anosmia Dental pain Fever Cough Ear pain/fullness
- 41. SinusitisSinusitis Diagnosis is based on clinical criteria whoDiagnosis is based on clinical criteria who have upper RT symptoms that arehave upper RT symptoms that are persistent or severepersistent or severe Diagnosis: > or = 10,000 cfu/ml from theDiagnosis: > or = 10,000 cfu/ml from the cavity of paranasal sinus- but this iscavity of paranasal sinus- but this is invasiveinvasive
- 42. X-ray of SinusesX-ray of Sinuses
- 43. Nasal endoscopic view showing Aspergillus fungal mass arising from the sphenoid sinus
- 44. TreatmentTreatment Antibiotics are recommended for AcuteAntibiotics are recommended for Acute Bacterial Sinusitis to achieve a more rapidBacterial Sinusitis to achieve a more rapid clinical cureclinical cure AmoxicillinAmoxicillin at 45 or 90 mg/kg.day orat 45 or 90 mg/kg.day or CeftriaxoneCeftriaxone Most response in 48-72 hoursMost response in 48-72 hours Duration : until symptom free plus 7 daysDuration : until symptom free plus 7 days Chronic treatment Same as acute sinusitis (Duration For 2-4 weeks) If not resolving in 24 to 48 hours of Rx may need surgical intervention ( frontal sinus trephination or external sinusectomy)
- 45. Support TherapySupport Therapy DecongestantsDecongestants Short duration 3-5 daysShort duration 3-5 days AntihistaminesAntihistamines If allergyIf allergy Normal salineNormal saline Local steroidsLocal steroids
- 46. List of Complications from Acute Sinusitis ƒ Mucocele or mucopyocele ƒ Osteomyelitis ƒ Facial cellulitis ƒ Oroantral fistula ƒ Orbital cellulitis ƒ Cavernous sinus thrombosis ƒ Septic thrombophlebitis ƒ Meningitis ƒ Epidural, subdural, or intracerebral abscess
- 47. LARYNGITISLARYNGITIS Inflammatory process involving the larynxInflammatory process involving the larynx Are acuteAre acute By the same viruses responsible for manyBy the same viruses responsible for many other URIother URI
- 48. EtiologyEtiology Rhinovirus, influenza virus, parainfluenza virus,Rhinovirus, influenza virus, parainfluenza virus, adenovirus, coxsackievirus, coronavirus.adenovirus, coxsackievirus, coronavirus. Acute bacterial respiratory infections, such asAcute bacterial respiratory infections, such as group Agroup A streptococcusstreptococcus oror C. Diphtheriae ,C. Diphtheriae , M. CatarrhalisM. Catarrhalis
- 49. Chronic laryngitisChronic laryngitis Mycobacterium tuberculosisMycobacterium tuberculosis HistoplasmaHistoplasma andand BlastomycesBlastomyces may causemay cause laryngitislaryngitis CandidaCandida species :thrush or esophagitis andspecies :thrush or esophagitis and particularly in immunosuppressed patients toparticularly in immunosuppressed patients to CoccidioidesCoccidioides andand CryptococcusCryptococcus.. Acid Reflux (GERD)Acid Reflux (GERD) AllergiesAllergies AgingAging Voice stressVoice stress
- 51. ManifestationsManifestations HoarsenessHoarseness Other symptoms and signs of URI, includingOther symptoms and signs of URI, including rhinorrhea, nasal congestion and coughrhinorrhea, nasal congestion and cough Sore throat, Dry throatSore throat, Dry throat Direct laryngoscopyDirect laryngoscopy :: Diffuse laryngeal erythemaDiffuse laryngeal erythema and edema, along with vascular engorgement ofand edema, along with vascular engorgement of the vocal foldsthe vocal folds Tuberculous laryngitis, mucosal nodules andTuberculous laryngitis, mucosal nodules and ulcerations visible on laryngoscopyulcerations visible on laryngoscopy These lesions are sometimes mistaken forThese lesions are sometimes mistaken for laryngeal cancerlaryngeal cancer
- 52. TREATMENTTREATMENT Humidification,Humidification, Increase fluidsIncrease fluids Voice restVoice rest Antibiotics are not recommended exceptAntibiotics are not recommended except when group Awhen group A streptococcusstreptococcus is culturedis cultured Chronic laryngitis usually requires biopsyChronic laryngitis usually requires biopsy with culture.with culture. Avoid smoking, recreational drugs, andAvoid smoking, recreational drugs, and alcoholalcohol
- 53. CROUPCROUP Viral respiratory illnessesViral respiratory illnesses Characterized by marked swelling of theCharacterized by marked swelling of the subglottic region of the larynxsubglottic region of the larynx Croup primarily affects children <6 years oldCroup primarily affects children <6 years old Signs and symptoms Barking cough or hoarseness. Worse at night and can last 5 to 6 days. Decrease breath sounds. Dyspnea Fever
- 54. Nursing interventionsNursing interventions Exposure of child to cool water.Exposure of child to cool water. Cool humidification during sleep with cool mist tent orCool humidification during sleep with cool mist tent or room humidifier.room humidifier. Encourage clear liquid intake to keep mucus thin.Encourage clear liquid intake to keep mucus thin. Monitor vital signs and pulse oximetry.Monitor vital signs and pulse oximetry. Administer medication (Antipyretic, antibiotics,Administer medication (Antipyretic, antibiotics, corticosteroids.corticosteroids. Oxygen administration if necessary.Oxygen administration if necessary. IV fluid to prevent dehydration.IV fluid to prevent dehydration.
- 55. Strep ThroatStrep Throat Upper RespiratoryUpper Respiratory Infection: inflamedInfection: inflamed mucous membranes ofmucous membranes of the throatthe throat Caused by Group ACaused by Group A ββ-- hemolytic streptococcihemolytic streptococci ((Streptococcus pyogenesStreptococcus pyogenes)) Virulence factors: resistanceVirulence factors: resistance to phagocytosisto phagocytosis Streptokinases: lyse fibrinStreptokinases: lyse fibrin clotsclots Streptolysins: cytotoxic toStreptolysins: cytotoxic to tissue cells, RBCs, andtissue cells, RBCs, and protective leukocytesprotective leukocytes
- 56. Strep ThroatStrep Throat Transmission:Transmission: Person to person by direct contact with saliva or nasal discharge. Most people do not get group a strep infections from casual contact with others, but a crowded environment like a dormitory, school, or an institutional setting can make it easier for the bacteria to spread.
- 57. A person becomes sick within 3 days after being exposed to the germ. Once people become infected, they can pass the infection to others for up to 2 to 3 weeks even if they don't have symptoms. After 24 hours of antibiotic treatment, a person will no longer spread the bacteria to others.
- 58. Strep ThroatStrep Throat Throat may be red with white patchesThroat may be red with white patches Trouble swallowingTrouble swallowing Have tender swollen glands (lymph nodes) on the sides ofHave tender swollen glands (lymph nodes) on the sides of your neck, toward the frontyour neck, toward the front Usually the tonsils are red and enlargedUsually the tonsils are red and enlarged May also have white craters or specks of pus on yourMay also have white craters or specks of pus on your tonsils or your tonsils may be covered with a gray or whitetonsils or your tonsils may be covered with a gray or white coating. Headachecoating. Headache Abdominal (lower stomach) painAbdominal (lower stomach) pain Fever , RashFever , Rash General discomfort, uneasiness, or ill feelingGeneral discomfort, uneasiness, or ill feeling Loss of appetite and nauseaLoss of appetite and nausea Muscle pain ,Joint stiffnessMuscle pain ,Joint stiffness
- 59. Strept Throat DxStrept Throat Dx Diagnosis:Diagnosis: Throat swabThroat swab Rapid testRapid test Indirect agglutinationIndirect agglutination diagnostic testsdiagnostic tests Use microscopic latexUse microscopic latex particles coated with Absparticles coated with Abs against group A streptococci.against group A streptococci. Negative tests are doubleNegative tests are double checked by culturingchecked by culturing organismorganism
- 60. Strept Throat TxStrept Throat Tx No treatment or incomplete treatment of strep throat alsoNo treatment or incomplete treatment of strep throat also increases your risk of complications, such as rheumaticincreases your risk of complications, such as rheumatic fever (which can cause permanent damage to your heart),fever (which can cause permanent damage to your heart), scarlet fever, blood infection, or kidney disease.scarlet fever, blood infection, or kidney disease.
- 61. Question?Question? Show in diagram the nasal allergic response. Identify the causes and treatment of Chronic laryngitis.
- 62. 62
Editor's Notes
- The common cold, also called viral rhinitis, is one of the most common infectious diseases in humans. The common cold is an upper respiratory infection that is caused by a wide variety of viruses. More than 200 viruses that can cause the common cold have been identified. The biggest offender, called the rhinovirus, causes up to 40% of colds and has 100 distinct types. Other important upper respiratory viruses include coronaviruses, adenovirus and respiratory syncytial virus. This incredible diversity has made the development of a vaccine for the common cold almost impossible. Rhinoviruses, the most likely agents to cause colds, have a well-established seasonal pattern, peaking in the early fall and spring. Other viruses tend to cause winter colds, which are usually more debilitating. Despite popular belief, cold temperatures do not appear to increase either the incidence or severity of the common cold. There is no evidence that exposure to cold or rainy weather makes you more likely to catch a cold.
- The common cold causes a group of symptoms that are easily recognized by patients and doctors. High fevers are rare with the common cold. About 50% of patients will develop a sore throat, which is often the first symptom to appear because it can occur as early as 10 hours after infection. This is followed by congestion in the nose and sinuses, a runny nose and sneezing. Hoarseness and cough can also occur and may last longer than other symptoms, sometimes for several weeks. The symptoms of allergic rhinitis are similar to those of nonallergic rhinitis, except that they are usually much longer lasting and are rarely accompanied by a fever. These symptoms often occur at specific times of year if they are not constant.
- Periorbital edema Cellulitis Nasal mucosa is reddened or swollen Percussion or palpation tenderness over a sinus Nasal discharge, thick, sometimes yellow or green Postnasal discharge in posterior pharynx Difficult transillumination Swelling of turbinates Boggy pale turbinates
- Microbiology and treatment of acute bacterial sinusitis in children Author Ellen R Wald, MDSection Editors Sheldon L Kaplan, MDEllen M Friedman, MDRobert A Wood, MDDeputy Editor Mary M Torchia, MDLast literature review version 17.2: May 2009 | This topic last updated: May 24, 2009 (More) INTRODUCTION — Acute sinusitis is a disease that results from infection of one or more of the paranasal sinuses. A viral infection associated with the common cold is the most frequent etiology of acute sinusitis, more properly called viral rhinosinusitis. Approximately 6 to 13 percent of viral rhinosinusitis in children is complicated by acute bacterial sinusitis (ABS). Uncomplicated viral rhinosinusitis usually resolves without treatment in 7 to 10 days. Although untreated ABS also may resolve without treatment, treatment with antibiotics hastens recovery and may decrease the risk for orbital and intracranial complications. Distinguishing between acute viral rhinosinusitis and ABS is important so that antibiotics, which are ineffective in uncomplicated viral rhinosinusitis, can be used judiciously. The treatment of ABS in children will be discussed here. The clinical features and diagnosis of ABS in children and acute sinusitis and rhinosinusitis in adults are discussed separately. (See &quot;Clinical features; evaluation; and diagnosis of acute bacterial sinusitis in children&quot; and see &quot;Acute sinusitis and rhinosinusitis in adults&quot;). MICROBIOLOGY — Streptococcus pneumoniae, Haemophilus influenzae (non-typeable), and Moraxella catarrhalis are the predominant causes of ABS [1-3]. Few data regarding the microbiology of acute sinusitis in children have been generated since 1986 [4]. However, because of the similarity of the pathogenesis and microbiology of acute otitis media (AOM) and ABS, it is acceptable to regard data generated from cultures of middle ear fluid, obtained by tympanocentesis, from children with AOM as a surrogate for cultures of the paranasal sinuses [5,6]. The microbiology of AOM in the United States is changing. Since the mid-1990s there has been an increasing prevalence of penicillin-resistant S. pneumoniae. Many isolates of H. influenzae (35 to 50 percent), and M. catarrhalis (55 to 100 percent) also are beta-lactamase producing and resistant to penicillin [7,8]. In addition, perhaps related to the near universal immunization of infants with the pneumococcal conjugate vaccine in the United States, there has been a slight decrease in isolates of S. pneumoniae and an increase in isolates of H. influenzae recovered from middle ear aspirates [9]. However, an increase in the recovery of serotype 19A S. pneumoniae (a multiply-antibiotic resistant non-vaccine strain of pneumococcus) from tympanocentesis isolates of AOM has been reported in several case series [10,11]. Similar changes can be presumed to occur in the paranasal sinuses. (See &quot;Resistance of Streptococcus pneumoniae to beta-lactam antibiotics&quot; and see &quot;Acute otitis media in children: Epidemiology, pathogenesis, clinical manifestations, and complications&quot;, section on Microbiology). ANTIBIOTIC THERAPY — The goals of antibiotic therapy of ABS are to hasten recovery and prevent suppurative complications [12]. Successful antibiotic treatment depends upon administration of an appropriate antibiotic, in adequate doses, for a sufficient period of time [3]. Most children with ABS can be treated as outpatients. Those with severe symptoms, underlying immunodeficiency (primary or secondary), or potential orbital or intracranial complications should be hospitalized for intravenous antibiotic therapy and/or specialty or surgical care (show figure 1) [3]. Efficacy — There is some controversy in the literature regarding the effectiveness of antibiotics in the treatment of ABS. Some have argued that the difficulty in distinguishing viral rhinosinusitis from ABS and the high spontaneous cure rate of ABS obviate the need for antibiotics [13,14], whereas others are of the opinion that antimicrobial therapy is the cornerstone of management [12]. (See &quot;Clinical features; evaluation; and diagnosis of acute bacterial sinusitis in children&quot;). The data regarding antibiotic therapy for the treatment of ABS in children are unsatisfactory. Nonrandomized studies in adults have suggested that appropriate antibiotics at appropriate doses are effective in eradicating or reducing bacterial growth [1,15]. However, there have been no randomized, placebo-controlled trials of antibiotic treatment for ABS that have used pre- and post-treatment sinus aspirate culture as the standard for diagnosis and cure. Studies that use clinical and/or radiologic criteria for diagnosis and outcome may underestimate the benefit of antibiotic therapy because they are likely to include at least some patients with self-limited uncomplicated viral URI. Only two prospective placebo-controlled studies regarding the efficacy of antibiotics in the treatment of ABS have been performed in children since 1986 [4,13]. The first study was published in 1986, before the widespread development of antibiotic-resistant pneumococci. In this study, 136 children (mean age 6 years) with radiologically confirmed clinical ABS (nasal discharge or daytime cough, or both of 10 to 30 days&apos; duration) were randomly assigned to treatment with amoxicillin (40 mg/kg per day), amoxicillin-clavulanate (40 mg/kg per day of the amoxicillin component), or placebo. They underwent clinical assessment at 3 and 10 days [4]. Children with throat cultures positive for group A Streptococcus (n=28) and who did not complete their medication (n=15) were excluded from analysis. More children in the treatment groups than in the placebo group were cured or improved on days 3 and 10 of therapy (83 versus 51 percent and 79 versus 60 percent, respectively). The overall cure rates were 67 percent, 64 percent, and 43 percent for amoxicillin, amoxicillin-clavulanate, and placebo, respectively. The second study was published in 2001. In this study 188 children (aged 1 to 18 years, mean age 8 years) from community pediatric practices who had 10 to 28 days of persistent sinus symptoms were randomly assigned to receive amoxicillin (40 mg/kg/day), amoxicillin-clavulanate (45 mg/kg per day of the amoxicillin component) or placebo [13]. The rate of improvement (79 to 81 percent), relapse (12 to 13 percent), recurrence (9 to 13 percent), and adverse effects (10 to 19 percent) were similar among groups. The lack of benefit with antibiotic therapy in this study may have been related to the use of a relatively low dose of amoxicillin in an era of potentially resistant S. pneumoniae, the exclusion of more seriously ill children (temperature &gt;39ºC or facial pain), and a relatively older population [12,14,16]. A meta-analysis of six randomized controlled trials that compared antibiotics versus placebo or standard therapy in 562 children with rhinosinusitis for ≥10 days (eg, acute, subacute, and chronic sinusitis) found that antibiotics decreased overall clinical failure, defined as nasal discharge at follow up or no substantial improvement (risk ratio of 0.75 [95% CI, 0.63 to 0.92]), without significantly increasing adverse effects [17]. Whether treatment of ABS prevents serious complications has not been adequately studied [18]. Choice of antibiotic — Antibiotics that are used to treat ABS must provide antibacterial coverage for S. pneumoniae, H. influenzae, and M. catarrhalis. Additional factors to be considered include the severity of clinical illness, recent exposure to antibiotics, and other factors that increase the likelihood of infection with a resistant bacterial species. Because of its general effectiveness, safety, low cost, and narrow spectrum, amoxicillin, with or without clavulanate, generally is considered to be the first line agent for the treatment of ABS in children [12,19]. There are few adequately powered studies that compare the efficacy of various antibiotics in the treatment of ABS. Guidelines for antibiotic therapy provided by the Sinus and Allergy Health Partnership used a mathematical model based on the best available evidence for pathogen distribution in ABS, pharmacokinetic and pharmacodynamic data, mechanisms of antimicrobial resistance, and antimicrobial resistance surveillance data [20-22]. Similarly, guidelines published by the American Academy of Pediatrics (AAP) developed suggestions for antimicrobial therapy based on theoretical calculations rather than on existing evidence [12]. They conclude that in the absence of any risk factors for resistant organisms, approximately 80 percent of children with ABS will respond to amoxicillin. Outpatient therapy — We agree with the AAP guideline for the management of ABS in children (show figure 1) [12], and make the following recommendations for outpatient therapy: For children with uncomplicated ABS that is of mild to moderate severity, who do not attend day care, and have not been treated with an antimicrobial in the preceding 90 days, we suggest one of the following regimens: Amoxicillin (45 to 90 mg/kg per day in two divided doses), or Amoxicillin-clavulanate (45 to 90 mg/kg per day of the amoxicillin component in two divided doses) The dose range permits some individual judgment [12,23]. As an example, a lower dose may be used for a child who has his or her first sinus infection in October (when the rate of antibiotic resistance is low) [24]; later in the viral respiratory season, a higher dose (90 mg/kg per day) may be more appropriate. For children who have uncomplicated ABS of at least moderate severity, have received an antimicrobial agent in the preceding 90 days, or who attend day care, we suggest one of the following regimens (show figure 1): Amoxicillin-clavulanate (80 to 90 mg/kg per day of amoxicillin and 6.4 mg/kg per day of clavulanate in two divided doses), or Cefdinir (14 mg/kg per day in 1 or 2 doses), or Cefuroxime (30 mg/kg per day), or Cefpodoxime (10 mg/kg per day once daily) A single dose of ceftriaxone (at 50 mg/kg per day), given either intravenously or intramuscularly, can be used in children with vomiting that precludes administration of oral antibiotics [12]. Therapy with an oral antibiotic should be initiated 24 hours later, provided the vomiting has resolved. Children with allergy to penicillins — Regimens for children with non-type 1 hypersensitivity reactions to penicillin (show table 1) include (show figure 1): Cefdinir (14 mg/kg per day in 1 or 2 doses), or Cefuroxime (30 mg/kg per day), or Cefpodoxime (10 mg/kg per day once daily) In patients with type 1 hypersensitivity reactions to penicillins (show table 1), appropriate regimens include: Clarithromycin (15 mg/kg/day in 2 divided doses), or Azithromycin (10 mg/kg per day on day 1 followed by 5 mg/kg per day as a single dose for 4 days) Clindamycin (30 to 40 mg/kg per day) is another alternative, but should be reserved for patients with type 1 hypersensitivity reactions to penicillin who are known to be infected with penicillin-resistant pneumococci [12]. (See &quot;Allergy to penicillins&quot; and see &quot;Use of cephalosporins, carbapenems, and monobactams in penicillin allergic patients&quot;). Hospitalized patients — Seriously ill children with ABS should be hospitalized for intravenous antibiotics. Empiric therapy should provide coverage for highly resistant pneumococci and penicillin resistant H. influenzae and M. catarrhalis. Appropriate regimens include: Cefotaxime (100 to 200 mg/kg per day every divided every 6 hours), or Ceftriaxone (100 mg/kg per day divided every 12 hours) Therapy should be adjusted based upon clinical response and culture results. Duration — The optimal duration of therapy for patients with ABS has not received systematic study. Empiric recommendations are typically made for 10, 14, 21, or 28 days of therapy. As an alternative, we suggest that antibiotic therapy be continued until the patient becomes free of symptoms and then for an additional seven days [12,25]. This strategy, which individualizes treatment for each patient, guarantees a minimum duration of 10 days of therapy and prolongs therapy in children in whom the response to antibiotics has been more sluggish. Treatment failure — Most patients with ABS who are treated with an appropriate antimicrobial agent respond within 48 to 72 hours with a diminution of respiratory symptoms and an improvement in general well-being [4]. If a child fails to improve, either the antimicrobial is ineffective or the diagnosis of sinusitis is not correct [12]. Sinus imaging and/or sinus aspiration may be indicated to confirm the diagnosis and tailor therapy. Refractory sinusitis may be a clue to immune deficiency [26]. (See &quot;Approach to the child with recurrent infections&quot;). For children with mild to moderate symptoms who do not improve while receiving an adequate dose of amoxicillin, antibiotic therapy may be changed to one of the following regimens (show figure 1): Amoxicillin-clavulanate (80 to 90 mg/kg per day of amoxicillin and 6.4 mg/kg per day of clavulanate in 2 divided doses), or Cefdinir (14 mg/kg per day in 1 or 2 doses), or Cefuroxime (30 mg/kg per day), or Cefpodoxime (10 mg/kg per day once daily) If patients with mild to moderate symptoms fail to improve with one of these regimens, a trial of intravenous therapy with ceftriaxone (100 mg/kg per day divided every 12 hours) or cefotaxime (100 to 200 mg/kg per day) may be initiated (show figure 1). Sinus imaging (plain radiographs in anteroposterior, lateral, and occipitomental views) should be performed before initiation of intravenous therapy to confirm the diagnosis (for patients who were not previously imaged). Sinus imaging, with contrast enhanced computed tomography (CT), should be performed in patients with symptoms or signs of intracranial or orbital complications. Sinus aspiration also may be indicated to appropriately tailor antibiotic therapy. (See &quot;Clinical features; evaluation; and diagnosis of acute bacterial sinusitis in children&quot;, section on Complications of ABS). Failure to improve in hospitalized patients who are receiving empiric antibiotic therapy warrants additional evaluation. Contrast enhanced CT imaging should be obtained to exclude orbital and intracranial complications. Sinus aspirate cultures should be obtained if they were not obtained at the time of admission. Antimicrobial therapy should be modified according to results of sinus aspirate cultures as soon as the results are available. If sinus aspirate cultures are unavailable or if no pathogens are isolated in an ill child who has not improved despite therapy with a third generation cephalosporin, the addition of vancomycin with or without metronidazole may be warranted. Consultation with an infectious disease specialist and/or otolaryngologist is suggested. INDICATIONS FOR REFERRAL — Children with uncomplicated ABS can usually be managed by their primary care provider. Consultation with a specialist (eg, infectious disease, otolaryngology, immunology) may be warranted in the following circumstances [18,27]: Intracranial or orbital complications Need for sinus aspiration Isolation of resistant or rare pathogens from sinus aspirate Diagnosed or suspected immunodeficiency Recurrent ABS, particularly if it exacerbates underlying pulmonary conditions (eg, asthma) ADJUNCTIVE THERAPY — Adjunctive therapies for ABS, which may be used to reduce or improve sinus drainage, include [12,28,29]: Saline nasal irrigation Decongestants (topical or systemic) Antihistamines Intranasal corticosteroids There are limited data regarding the efficacy of these therapies in children with ABS [29,30]. Saline nose drops and/or saline nasal sprays may be helpful in preventing crust formation and liquefying sinus secretions. Although the potential benefits are unproven, saline nasal irrigation is unlikely to be harmful or impede recovery and is suggested. Decongestants may reduce tissue edema, improve ostial drainage, and provide symptomatic relief [28]. However, these benefits may be offset by an increased viscosity of secretions and decreased blood flow to the nasal mucosa, which may impair delivery of antibiotics to the sinuses. Similarly, antihistamines have the potential to dry secretions and impair sinus drainage. There are no data to support the use of antihistamines in children with ABS who do not have an underlying allergic component [12,28]. The use of a combination antihistamine-decongestant in the treatment of children with presumed ABS was evaluated in a single prospective study [31]. Children (aged 1 to 18 years) with presumed ABS were randomly assigned to treatment with a decongestant-antihistamine or placebo in addition to amoxicillin. Symptoms improved in all children within three days of initiation of antibiotics; there were no differences in symptom scores between groups on days 1, 3, or 14 of therapy. We do not suggest the use of decongestants or antihistamines in children with ABS. Nasal corticosteroids theoretically may decrease inflammation of the mucous membranes, which contributes to obstruction of the ostia and impaired mucociliary clearance [32]. Only one study has evaluated the benefits of intranasal corticosteroids in addition to antibiotics in young children with presumed ABS [33]. In this study 151 children (1 to 15 years) with clinical and radiographic sinusitis were treated with amoxicillin-clavulanate and randomly assigned to budesonide or placebo nasal spray for three weeks. At the end of therapy, symptoms in patients in both groups were improved from baseline. Intranasal budesonide had a modest effect on cough and nasal discharge, but the effect was only noted during the second week of therapy. A study of intranasal corticosteroids in patients &gt;14 years with ABS demonstrated a similar marginal effect [34]. We do not suggest the use of intranasal corticosteroids in children with ABS. SUMMARY AND RECOMMENDATIONS Streptococcus pneumoniae, Haemophilus influenzae (non-typeable), and Moraxella catarrhalis are the predominant causes of uncomplicated acute bacterial sinusitis (ABS) in otherwise healthy children. (See &quot;Microbiology&quot; above). Most children with ABS can be treated as outpatients. Hospitalization is indicated for those with severe symptoms, underlying immunodeficiency (primary or secondary), or potential orbital or intracranial complications. (See &quot;Antibiotic therapy&quot; above). We suggest children with ABS be treated with antimicrobial therapy (Grade 2A). The choice of antibiotic is based upon the degree of severity of illness, recent exposure to antibiotics, and the likelihood of infection with a resistant bacterial species. (See &quot;Choice of antibiotic&quot; above). Respiratory symptoms of children with ABS typically improve within three days of initiation of appropriate antimicrobial therapy. Children whose symptoms fail to improve within this time-frame may require sinus imaging and/or sinus aspiration to confirm the diagnosis and/or tailor antibiotic therapy. (See &quot;Treatment failure&quot; above). We suggest antimicrobial therapy be continued for seven days after the child is free of symptoms. (See &quot;Duration&quot; above). We suggest saline nose drops and/or saline nasal sprays for children with ABS (Grade 2C). We suggest not using decongestants, antihistamines, or nasal corticosteroids (Grade 2B). (See &quot;Adjunctive therapy&quot; above).