The document discusses upper respiratory tract infections (URTIs) in pediatrics, detailing transmission, classification, etiology, pathophysiology, clinical features, and management strategies. It emphasizes the distinction between uncomplicated and complicated URTIs, common viral agents involved, and various clinical presentations like pharyngitis and sinusitis. Management is primarily supportive as antibiotics are generally ineffective against viral URTIs, focusing on hydration, symptom relief, and, when necessary, specific interventions for bacterial infections.

1. PAEDIATRICS
UPPER RESPIRATORY TRACT INFECTION
Presented by : GWAIVU DASANI -2021-08-05232
Moderator: DR. OKELLO NELSON

2. INTRODUCION
The upper respiratory tract consists of the airways from the nostrils to
the vocal cords in the larynx, including the paranasal sinuses.

3. TRANSMITION
URTI can easily be spread to another person when the sick person
coughs or sneezes. It can also be spread if the child touches things,
like toys, that a person with an infection has touched

4. CLASIFICATION
UNCOMPLICATED:
• Acute nasopharyngitis
• pharyngitis
-Pharyngotonsilitis with vesicles or ulceration.
-Pharyngotonsilitis with exudates or membrane.
• laryngitis
COMPLICATED:
• Adenoiditis
• Otitis media.
• Sinusitis and Peritonsilla abscess.

5. COMMON COLD
is an acute, self-limiting viral infection of the UPRT.
• The common cold is frequently referred to as infectious rhinitis but
may also include self-limited involvement of the sinus mucosa and is
more correctly termed rhinosinusitis.

6. Etiology
Virus
Proportion
of cases
Predominant months of circulation
Rhinoviruses
(more than 100
serotypes)
30 to 50 %
Present year round with a peak in September and a
smaller peak in March and April
Respiratory
syncytial virus
5% November to March
Influenza viruses 5 to 15% Winter months, with peak in February
Parainfluenza
viruses
5 %
September to January with peak in October and
November
Adenoviruses <5 % September to May
Enteroviruses
(echoviruses and
coxsackieviruses)
<5 % Present year round, with a peak during the summer
Coronaviruses 10 to 15 % November to February
Human
metapneumovirus
Unknown Late winter and early spring

7. Pathogenesis
Viruses that cause colds are spread by two mechanisms:
• Hand contact – Self-inoculation of one's own nasal mucosa after touching an object contaminated with
cold virus.
• Droplet transmission : Inhalation of small particle droplets that become airborne from coughing
• Rhinoviruses, adenoviruses, influenza viruses, and enteroviruses produce lasting immunity, but
immunity does little to prevent subsequent colds because there are so many serotypes. RSV,
parainfluenza viruses, and coronaviruses do not produce lasting immunity. Reinfection may occur, but
subsequent infection with the same agent is generally milder and of shorter duration.

8. Pathophysiology
• After deposition on nasal lining, cold viruses destroy the epithelial cell ciliated lining, attach to receptors on
epithelial cells in the nasopharynx and enter the cells.
• The infected cells release cytokines, including interleukin (IL)-8, which attracts polymorphonuclear cells
(PMNs) causing inflammation. Inflamed nasal cavity produces excessive mucus that drains the back of the
throat(post nasal drip). This mucus irritates the throat and stimulates the cough reflex to try clear the arway.
• Large numbers of PMNs accumulate in the nasal secretions and mucociliary clearance is slowed.
• Symptoms usually appear one to two days after viral inoculation, coinciding with the influx of PMNs in the
nasal submucosa and epithelium.
• A change in the character of the nasal discharge from clear to yellow/white or green correlates with the
increase in PMNs.

9. Clinical features
Fever
• May be the predominant manifestation during the early
phase of infection in young children.
• It is uncommon in older children.
• New onset of fever or recurrence of fever may indicate
secondary bacterial infection
• Influenza viruses, RSV, MPV, and adenoviruses are more
likely to be associated with fever.
Sore or scratchy throat.
• Is often the first symptom noted
• The sore throat usually resolves quickly (2nd
or 3rd
day
of illness)
Cough
• is associated with two-thirds of colds in children
• Cough may persist for an additional 1-2 wk after
resolution of other symptoms.
Nasal manifestations
• Nasal congestion, nasal discharge, and sneezing
are common in children.
• Nasal discharge may be clear initially but often
becomes colored (yellow or green) within a few
days.

10. Clinical features
• Nasal secretion :
• A change in the color or consistency of the secretions is common during the
course of the illness
• Examination of the nasal cavity
• Might reveal swollen, erythematous nasal turbinates,
• This finding is nonspecific and of limited diagnostic value.
• Anterior cervical lymphadenopathy or conjunctival injection
• May also be noted on exam.

11. Deferential diagnosis
• Foreign body in view of nasal congestion.
• Sinusitis in view of nasal congestion, cough, sore throat, loss of smell
or taste .
• Pertussis in view of cough .
• Congenital syphilis in view of nasal congestion and running nose.

12. Complications
• Acute otitis media
• Asthma exacerbation
• Sinusitis
• Lower respiratory tract disease
• Other complications
• Epistaxis,

13. Management
Antibacterial therapy is of no benefit in the treatment of the common cold and should be avoided to minimize possible
adverse effects and the development of antibiotic resistance.
The management is primarily of supportive:
• Steam inhalation
• Maintaining adequate oral hydration:
• To prevent dehydration and to thin secretions
• To soothe respiratory mucosa.
• Treat fever : Paracetamol
• Zinc : Possible antiviral effects.
• Rhinorrhea : The 1st-generation antihistamines may
reduce rhinorrhea by 25–30%.
Nasal obstruction
• Saline nose drops (wash, irrigation) can improve nasal
symptoms and may be used in all age groups.
• Adrenergic agents :
• Eg. Xylometazoline, oxymetazoline, or phenylephrine
• They are not recommended for use in children younger
than 6 yr old
Cough
• Honey (5-10 mL in children ≥1 yr old) has a modest effect
on relieving nocturnal cough by soothening the nasopharynx
• Bronchodilator may be useful in case of virus-induced
reactive airways disease .

14. PHARYNGITIS
• Pharyngitis refers to inflammation of the pharynx
• If the inflammation includes tonsillis →Pharyngotonsilitis
14
Pharyngeal inflammation can be related to:
• Environmental exposures: Tobacco smoke, air pollutants, and allergens;
• Contact with caustic substance, hot food, and liquids;
• Inflammatory conditions : Aphthous stomatitis,Kawasaki disease, SLE, Etc.
• Infectious agents.
Etiology

15. Etiology
15
VIRUSES
• Adenovirus
• Coronavirus
• Cytomegalovirus
• Epstein-Barr virus
• Enteroviruses
• Herpes simplex virus (1 and 2)
• Human immunodeficiency virus
• Human metapneumovirus
• Influenza viruses (A and B)
• Measles virus
• Parainfluenza viruses
• Respiratory syncytial virus
• Rhinoviruses
• Streptococcus pyogenes (Group A streptococcus)
• Arcanobacterium haemolyticum
• Fusobacterium necrophorum
• Corynebacterium diphtheriae
• Neisseria gonorrhoeae
• Group C streptococci
• Group G streptococci
• Francisella tularensis
• Yersinia pestis
• Chlamydophila pneumoniae
• Chlamydia trachomatis
• Mycoplasma pneumoniae
• Mixed anaerobes (Vincent angina)
BACTERIA
Infectious agents.

16. Clinical presentation
16
GENERAL
• Headache
• Fever
• Anorexia and malaise
LOCAL
• Sore throat( red, congested)
• Dysphagia
• Inflamed tonsils with white or yellow exudates.
• Enlarged tender lymph nodes on the front of the neck.
SPECIFIC FEATURES
• Erythematous(red) or exudative (red throat and whitish exudate) pharyngitis :
• Very common in GAS and viral pharyngitis
• Pseudomamembraneous pharyngitis
• Red tonsil/pharynx covered by an adherent greyish white false membrane
• Seen in diphtheria
• Vesicular pharyngitis
• Clusters of tiny blisters or ulcers on the tonsils
• Always viral (coxsackie virus or primary herpetic infection)
• Ulcero-necrotic pharyngitis:
• Hard and painless syphilitic chancre of the tonsil;
• Tonsillar ulcer soft on the palpation in a patient with poor oral hygiene and malodorous breath
(Vincent tonsillitis)

17. Clinical presentation
17
BACTERIA
Sudden onset of sore throat.
• Fever
• Tonsillopharyngeal inflammation
Patchy tonsillopharyngeal exudates
• Palatal petechiae
• Anterior cervical adenitis (tender nodes)
• Scarlatiniform rash
VIRUSES
• Coryza
• Cough
• Diarrhea
• Hoarseness
• Viral exanthema

18. Diagnosis criteria
CRITERIA DEVELOPED FOR ADULTS BY CENTOR AND MODIFIED FOR CHILDREN BY
MCISAAC
• Give 1 point for each of the following criteria:
• History of temperature >38°C (100.4°F),
• Absence of cough,
• Tender anterior cervical adenopathy,
• Tonsillar swelling or exudates,
• Age 3-14 yr. It subtracts a point for age ≥45 yr.
• At best, a McIsaac score ≥4 is associated with a positive laboratory test for GAS in < 70% of children
with pharyngitis. so it, too, overestimates the likelihood of GAS 18

19. Diagnosis
• Laboratory testing is essential for accurate diagnosis
• Throat culture (the gold standard)
• Rapid antigen-detection tests (RADTs)
• specific GAS molecular tests
19

20. Treatment
Symptomatic therapy
• Oral antipyretic/analgesic agent (acetaminophen or ibuprofen)
• Anesthetic sprays and lozenges (often containing benzocaine, phenol, or
menthol) can provide local relief in children
• Systemic corticosteroids (mononucleosis). 20

21. Pharyngotonsilitis with vesicles or
ulcerations(viral tonsilitis)
• The infection is always viral
1. Coxsackie A infection
-Its characterized by fever vomiting and inability to eat.
-Ph/Ex ; the vesicles or ulcerations appear above the tonsil pillars
and palate
2. Herpes virus.
-Gingivostomatitis is typical with blisters on the lips, gums and
oral mucosa with salivation, bad smell from the mouth and denial
to eat. They may have painful cervical lymphadenopathy.

22. MANAGEMENT
NOT lab exam
1. Supportive care:
Abundant fluids
Steam inhalation
Paracetamol (rectal or oral) 15mg/kg/dose
2. Acyclovir orally, 20 mg / kg / day in 2 sub-doses for 10
days (Herpetic Gingivostomatitis)

23. Pharyngotonsilitis with exudates or
membranes
Etiology
•Bacterial
Diphtheria bacillus
Beta-hemolytic streptococcus
Pneumococcus
Meningococcus.
NOTE-LEMIERRE’S SYNDROME- spread of the infection to juglar
veins where it causes thrombphlebetis ( inflammation and form
blood clot)
•Viral-Adenovirus

24. Features Viral Bacterial
Age Less than 3 years More than 3 years
Cough Yes No
Throat pain No Yes
Flu Yes No
Cervical lymphadenopathy Small Great
Petechiae on the palate No Yes
Scarlatiniform rash No Yes
Conjunctivitis Yes No
Dysphagia No Yes
Hoarseness Yes No
Leukocyte count Less than 12 500(Lynpho) More than 12 500(Nueut)
CPR Negative Positive
Throat culture Negative Positive

25. Treatment Pharyngotonsilitis with exudates or membranes
Bacterial etiology
Support care
• Rest
• Diet
• Antipyretic treatment
Specific care
•Saline gargle 0.9%.
•Benzathine penicillin intramuscularly as a single dose of 600 000 U for patients less than 30 kg and 1.2 million U
for those weighing more than 30 kg.
Oral penicillin: amoxicillin at doses of 50 mg // kg / dose every 8 h, Phenoxymethylpenicillin at 25 mg / dose 2
times a day for 10 days. In cases of penicillin allergy follows: erythromycin 15 mg / kg / dose every 8 hours
clarithromycin 7.5 mg / kg / dose every 12 h, azithromycin of 10 to 15 mg / kg / day on the first day and continue
with doses of 5 to 7.5 mg / kg / day for 5 days.
Oral cephalosporin: cephalexin 25-50 mg / kg / day 3 doses and cefuroxime 15 to 20 mg / kg day 2 doses

26. Peritonsillar abscesses
• Collection of purulent exudates between the tonsillar capsule and the
surrounding tissues.
• May develop after an acute tonsillar infection that progresses to local
cellulitis and abscess
• Its life threatening with mediastinitis, intracranial abscess resulting
from spread of infection.
• ETIOLOGY
• Recurrent attack of tonsillitis
• Foreign bodies

27. Clinical presentation
• Tender and enlarged cervical lymphnodes
• Odynophagia-severe sensation of burning, squeezing pain while
swallowing
• Dribbling saliva
• Trismus –inability to open the mouth
• Muffled voice

28. Diagnosis and management
Dx
• History taking
• Physical examination
• Intraoral ultrasound and transcutaneous cervical ultrasound scan
Management
• Antibiotics ( usually penicillins)
• Use of topical anaesthetics
• Needle aspiration
• Incision and drainage
• Tonsillectomy
• Procedures like tracheostomy, intubation, cricothyroidectomy in acute airway
obstruction

29. LARYNGITIS
• This is defined as inflammation of the larynx from an infection.
ETIOLOGY
Infection is usually viral
Viral causative agents include;
• Rhinoviruses
• Respiratory syncytial virus
• Corona virus
• Influenza

30. Clinical presentation
• Hoarseness
• Sore throat
• loss of voice
• Dry cough
• Fever

31. Management
• Usually self limiting
• No role of antibiotics.
• Note
• Seek advanced medical if there is;
-Difficulty in breathing
-Hemoptysis
-Difficult swallowing and excessive drooling

32. SINUSITIS
• Sinusitis is defined as inflammation of tissue lining the sinuses which
are air filled cavities with in the bones of the face and skull
• The combined term “Rhinosinusitis” was coined by 1997 Task Force
of Rhinology and Paranasal Sinus Committee because sinusitis is
invariably accompanied by rhinitis.

33. TYPES OF SINUSES

34. SINUSITIS cont…
• Acute rhinosinusitis
• Acute sinusitis is defined by a duration of < 4 weeks,
• Subacute rhinosinusitis:
• When symptoms are present for 4–12 weeks.
• Chronic rhinosinusitis”
• When symptoms persist for more than 12 weeks.

35. Etiopathogenesis
• The sinus cavity is normally sterile.
• Its secreted mucus contains antimicrobicidal polypeptides and lipids which
function as innate defence for the airways.
• The continuous movements of the cilia towards the sinus orifice generate currents
which clear the mucus from the sinus into the nasal cavity.
• The main area of sinus drainage is the “ostiomeatal complex” present in the
middle meatus on the lateral wall of the nasal cavity.

36. Etiopathogenesis
• Ciliary dysfunction syndromes such as primary ciliary
dyskinesia
• Prolonged nasogastric tube;
• Gastroesophageal reflux
• Smoking: active and/or passive;
• Environmental pollution and irritants;
• Hormonal : puberty, pregnancy, oral contraceptive use
• Anatomic abnormalities : adenoidal hypertrophy, deviated
nasal septum,…
• Mucosal edema : viral rhinitis, allergic rhinitis
• Nonallergic rhinitis : vasomotor rhinitis, rhinitis
medicamentosa,…
• Nasal polyps;
• Unattended nasal foreign bodies;
The “ostiomeatal complex” obstruction could be due to:

37. Etiology
• There are 2 common types of acute sinusitis : viral and bacterial
• Viral
• The common cold produces a viral, self-limited rhinosinusitis.
• Approximately 0.5–2% of viral URTI in children and adolescents are
complicated by acute symptomatic bacterial sinusitis

38. Etiology
Acute bacterial sinusitis
• Common causes: S. pneumoniae (~30% ), nontypeable Haemophilus
influenzae (~30% ), Moraxella catarrhalis (~10% ).
Chronic sinus disease.
• H. influenzae , α- and β-hemolytic streptococci, M. catarrhalis , S.
pneumoniae , and coagulase-negative staphylococci.

39. Clinical manifestations
Nonspecific complaints :
• Nasal congestion,
• Purulent nasal discharge (unilateral or bilateral),
• Fever
• Cough.
• Less-common symptoms :
• Bad breath (halitosis),
• Decreased sense of smell (hyposmia),
• Periorbital edema.
• Headache and facial pain (Rare in children).
• Additional symptoms
• Maxillary tooth discomfort
• Pain or pressure exacerbated by bending forward.

40. Clinical manifestations
Physical examination
• Erythema and swelling of the nasal mucosa
• Purulent nasal discharge.
• Sinus tenderness (adolescents and adults).
• Transillumination reveals an opaque sinus that transmits light poorly.

41. Clinical manifestations
Conventional criteria for the diagnosis of Sinusitis
The Presence of at least
 2 Major symptoms or
 1 Major + ≥2 Minor symptoms
MAJOR SYMPTOMS MINOR SYMPTOMS
• Purulent anterior nasal discharge
• Purulent posterior nasal discharge(post nasal
drip)
• Nasal congestion or obstruction
• Facial congestion or fullness
• Facial pain or pressure
• Hyposmia or anosmia
• Fever (for acute sinusitis only)
• Headache
• Ear pain, pressure, or fullness
• Halitosis
• Dental pain
• Cough
• Fever (for subacute or chronic sinusitis)
• Fatigue

42. Investigations
• Sinus aspirate culture
• is the only accurate method of diagnosis
• But is not practical for routine use for immunocompetent patients.
• Radiographic studies (sinus plain films, CT scans)
• Are not diagnostic and are not recommended in otherwise healthy children.

43. Treatment
• Major guidelines recommend antimicrobial treatment for acute bacterial
sinusitis with severe onset to promote resolution of symptoms and prevent
suppurative complications.
• 50–60% of children with acute bacterial sinusitis may recover without
antimicrobial therapy.

44. Treatment
• Saline nasal washes or nasal sprays can help liquefy secretions and act as
a mild vasoconstrictor
• The use of decongestants, antihistamines, mucolytics, and intranasal
corticosteroids has not been adequately studied in children and is not
recommended for the treatment of acute uncomplicated bacterial sinusitis.

45. Complications
• Orbital complications
• Periorbital cellulitis
• orbital cellulitis
• Intracranial complications
• Epidural abscess,
• Meningitis,
• Cavernous sinus thrombosis,
• Subdural empyema,
• Brain abscess
• Other complications
• Pott puffy tumor : Osteomyelitis of the frontal bone
• Mucoceles (chronic inflammatory lesions commonly located in the frontal sinuses)

46. Prevention
• Frequent handwashing
• Avoiding persons with colds.
• Immunization or chemoprophylaxis against influenza

47. ACUTE ADENOIDITIS
It is the infection of the lymphatic tissue occupying
nasopharynx and that forms lymphoid part of Waldeyer’s ring.
Etiology:
Bacterial
Group A streptococcus
Streptococcus pneumoniae
Staphylococcus aureus
Viral (less common)

48. AAD Clinic Features
1. Sustained high fever
2. Obstruction that hinders breastfeeding and sleep.
3. Halitosis
4. Cough and snoring

49. Diagnosis and management
• Diagnosis;
• History taking and physical examination
• Throat swab culture
• Management;
• Antibiotics
• Antipyretics
• Analgesics
• Anti-inflammatory and corticosteroids
• Adenoidectomy( surgical removal of adenoids)

50. OTITIS MEDIA (AOM)
It is infection of the middle ear that mostly occurs in infants and young children <15 yrs
though can occur at any age
It can be;
Acute –infection of the middle ear which causes inflammation and purulent fluid
accumulation usually lasting <6 weeks
Chronic –it results from repeated infection in middle ear or inappropriate treatment of
AOM causing permanent perforation of tympanic membrane. It can be supprative or non
supprative (serous otitis media)

51. ETIOLOGY
70% have bacterial origin and 20% are aseptic otitis related to a viral cause.
Bacterial
Streptococcus pneumonia Virus: RSV
Haemophilus influenza
Moraxella catarrhalis
Staphylococcus aureus,
viridans streptococci,
Pseudomonas aeruginosa
Streptococcus pyogenes
Haemophilus influenza

52. ACUTE OTITIS MEDIA (AOM)
C/C
•Signs of inflammation in the tympanic membrane
•Bulging in the posterior quadrants of the tympanic membrane
•Perforated tympanic membrane (most frequently in posterior or inferior
quadrants)
•otorrhea
•oltagia
•Hearing loss
•Irritability( bobbing head)
•Fever

53. DIAGNOSIS
• Thoroughly history taking
• Physical examination
• Otoscopic examination- a procedure that examines the auditory canal
and tympanic membrane for infection or blockage
• Audiometry to test the ability to hear sounds

54. Management
• Antibiotics
• Analgesics
• Antihistamines
• Surgical management
-Careful sunctioning of the ear under microscopic guidance
-Tympanotomy (incision in the tympanic membrane to relieve pressure caused by
excessive build up of fluid and also to drain pus from the ear )
-Tympanoplasty -reconstruction of the eardrum
-Ossiculoplasty - surgical reconstruction of the middle ear bones to restore hearing.
-Mastoidectomy –removal of diseased mastoid cells

55. AOM CONT….
Pink Tympanic Membrane, often seen
with upper respiratory tract infections
Normal tympanic membrane

56. 56
References
• Nelson paediatrics textbooks, 21th
edition, 2020.
• Basic paediatrics protocol 5th
edition 2022
• Paediatrics Moses Kazevu