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    Add as FriendUpper Respiratory Tract Infections

    by: Gaurav

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    1 : Upper Respiratory Tract Infections Etiopathogenesis and Management
    2 : URTIs Rhinitis Sinusistis Pharyngitis Otitis Media
    3 : URT
    4 : Rhinitis Allergic rhinitis is the most common illness presenting as nasal itching, sneezing, discharge or nasal blocking.
    5 : Rhinitis Seasonal allergic rhinitis : Pollens of importance include tree pollens in spring and grass pollens during summer, pollens and moulds.
    6 : Rhinitis Perennial rhinitis : House-dust mite are the commonest cause of perennial allergic symptoms. These are found in every house and accumulate in carpets, bedding, fabric and furniture. Domestic pets, e.g. cats, dogs and even cockroaches cause rhinitis.
    7 : Rhinitis Chronic nonallergic rhinitis : The symptoms are chronic and no specific cause for the rhinitis can be determined. Approximately 15% to 20% of patients with this syndrome have an increase in eosinophils. These patients respond to topical corticosteroids
    8 : Clinical features Allergic basis is suggested by dominant itching, sneezing, watery discharge and associated eye or chest symptoms. Seasonality of symptoms and relation to work-place are also suggestive. A personal or family history of atopy (The genetic tendency to develop the classic allergic diseases) is extremely common. The presence of facial pain, fever, systemic upset and mucopurulent discharge suggest infective aetiology.
    9 : Physical findings On examination, allergic rhinitis is associated with a pale, bluish, boggy appearance during active symptoms. Structural abnormalities such as polyps, deflected nasal seputum or enlarged turbinates (conchae) are important since surgical treatment may be required.
    10 : Treatment The main principles are (i) avoidance of allergens (ii) use of topical corticosteroids and (iii) oral H1-selective antihistaminics
    11 : Treatment Beclomethasone and budesonide are available as aqueous solutions which are better tolerated, have better local distribution in nose and side-effects are minor. Histamine H1 - receptor antagonists have low anticholinergic and sedative profile and are particularly effective for sneezing, itching and rhinorrhoea but they have little effect on nasal blockage. loratidine and cetrizine have been in use. These drugs should be avoided during pregnancy.
    12 : Precautions driving with closed windows, afternoon or evening walk in parks, etc. might help. House-dust and mite control measures may include avoidance of nonsynthetic bedding, restriction of soft toys, use of mattress covers, thorough vacuum cleaning and damp dusting at least once a week.
    13 : Sinusitis
    14 : Sinuses The sinuses are hollow air-filled sacs lined by mucous membrane. The sinuses contain defenses against viruses and bacteria (germs). The sinuses are covered with a mucous layer and cells that contain tiny hairs on their surfaces (cilia). These help trap and propel bacteria and pollutants outward.
    15 : Sinus Each sinus has an opening into the nose for the free exchange of air and mucus, and each is joined with the nasal passages by a continuous mucous membrane lining. Therefore, anything that causes a swelling in the nose-an infection, an allergic reaction, or an immune reaction-also can affect the sinuses. Air trapped within a blocked sinus, along with pus or other secretions, may cause pressure on the sinus wall. The result is the sometimes intense pain of a sinus attack. Similarly, when air is prevented from entering a paranasal sinus by a swollen membrane at the opening, a vacuum can be created that also causes pain.
    16 : Sinuses Sinuses have small orifices (ostia) which open into recesses (meati) of the nasal cavities. Meati are covered by turbinates (conchae). Turbinates consist of bony shelves surrounded by erectile soft tissue. There are 3 turbinates and 3 meati in each nasal cavity (superior, middle, and inferior).
    17 : Nasal conchae
    18 : Sinuses - Location Four pairs of paranasal sinuses Frontal-above eyes in forehead bone Maxillary-in cheekbones, under eyes Ethmoid-between eyes and nose Sphenoid-in center of skull, behind nose and eyes
    19 : Paranasal Sinuses
    20 : Development Maxillary and ethmoid sinuses develop during 3rd and 4th gestational month and grow in size until late adolscence. Sphenoid sinus presents by 2 yrs of age Frontal sinus develops during 5 and 6 years.
    21 : Sinusitis Inflammation of paranasal sinuses
    22 : Sinusitis An acute inflammatory process involving one or more of the paranasal sinuses. A complication of 5%-10% of URIs in children. Persistence of URI symptoms >10 days without improvement. Maxillary and ethmoid sinuses are most frequently involved.
    23 : Pathogenesis Usually follows rhinitis, which may be viral or allergic. May also result from abrupt pressure changes (air planes, diving) or dental extractions or infections. Inflammation and edema of mucous membranes lining the sinuses cause obstruction. This provides for an opportunistic bacterial invasion.
    24 : Pathogenesis contd… With inflammation, the mucosal lining of the sinuses produce mucoid drainage. Bacteria invade and pus accumulates inside the sinus cavities. Postnasal drainage causes obstruction of nasal passages and an inflamed throat. If the sinus orifices are blocked by swollen mucosal lining, the pus cannot enter the nose and builds up pressure inside the sinus cavities.
    25 : Predisposing Factors Allergies, nasal deformities, nasal polyps, and HIV infection. Cold weather High pollen counts Day care attendance Smoking in the home Reinfection from siblings pollen counts :The average number of pollen grains, usually of ragweed, in a cubic yard or other standard volume of air over a 24-hour period at a specified time and place.
    26 : Etiology of Sinusitis 70% of bacterial sinusitis is caused by: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Other causative organisms are: Staphylococcus aureus Streptococcus pyogenes, Gram-negative bacilli Respiratory viruses
    27 : Classification of Bacterial Sinusitis 27 Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely Chronic sinusitis- symptoms lasting more than 12 weeks
    28 : Differentiating Sinusitis from Rhinitis Sinusitis Nasal congestion Purulent rhinorrhea Headache Facial pain Anosmia Cough, fever Rhinitis Nasal congestion Rhinorrhea clear Runny nose Itching, red eyes Nasal crease Seasonal symptoms 28
    29 : Nasal polyps
    30 : Road to Bacterial Sinus Infections 30 Obstruction of the various ostia Impairment in ciliary function Increased viscosity of secretions Impaired immunity Mucus accumulates Decrease in oxygenation in the sinuses Bacterial overgrowth
    31 : Allergic Stimuli Causing Rhinosinusitis 31 Pollens Tree, grass, weeds House dust mite Animal danders Cat, dog, mice, gerbil, other animals with fur Molds Allergic foods and beverages
    32 : Nonallergic Stimuli Causing Rhinosinusitis Tobacco smoke Perfumes Cleaning solutions Burning candles Cosmetics Car exhaust, diesel fumes Hair spray Cold air Dry air Changes in barometric pressure Auto exhaust Gas, diesel fuel Nonallergic foods Nonallergic beverages 32
    33 : Acute Bacterial Sinusitis 33 Usually begins with viral upper respiratory illness Symptoms initially improve, but then … Symptoms become persistent or severe Persistent… 10-14 days but fewer than 4 weeks Severe…temperature of 102°, purulent nasal discharge for 3-4 days, child appears ill Disease clears with appropriate medical treatment
    34 : Physical Findings 34 Mucopurulent nasal discharge Highest positive predictive value Swelling of nasal mucosa Mild erythema Facial pain (unusual in children) Periorbital swelling
    35 : Diagnosis Rhinoscopy CT Scan (Ethmoid & Maxillary sinuses) MRI for tumors and not for sinusitis
    36 : CT scan A CT scan may indicate a sinus infection if any of these conditions is present: Air-fluid levels in one or more sinuses Total blockage in one or more sinuses Thickening of the inner lining (mucosa) of the sinuses Mucosal thickening can occur in people without symptoms of sinusitis. Therefore, CT scan findings must be correlated with a person's symptoms and physical examination findings to diagnose a sinus infection.
    37 : Objectives of Treatment of Acute Bacterial Sinusitis 37 Decrease time of recovery Prevent chronic disease Decrease exacerbations of asthma or other secondary diseases
    38 : Treatment of Acute Sinusitis 38 Antihistamines recommended if allergy present Oral or topical Decongestants Oral or topical Antibiotic when indicated (bacteria) Nasal irrigation Hydration
    39 : Decongestants 39 Topical nasal sprays (limit use to 3-7 days) Phenylephrine Oxymetazoline Naphthazoline Tetrahydrozoline Zylometazoline Topical nasal spray (unlimited daily use) Ipatropium Oral Pseudoephedrine 30-60 mg Phenylephrine 2-4 times/day
    40 : Antibiotics for Acute Bacterial Sinusitis 40 Amoxicillin 500 mg tid for 10-14 days First line choice in most areas Local differences in antibiotic resistance occur Where beta-lactamase resistance is an issue Amoxicillin/clavulanate Cefuroxime Cefpodoxime Cefprozil
    41 : Additional Antibiotics for Acute Bacterial Sinusitis 41 Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum (45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days) If penicillin-allergic clarithromycin or azithromycin Erythromycin does not provide adequate coverage Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistance
    42 : Chronic Sinusitis 42 Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in children Eosinophilic inflammation or chronic infection Associated with positive CT scans Poor (if any) response to antibiotics
    43 : Sx of Chronic Sinusitis 43 Nasal discharge Nasal congestion Headache Facial pain or pressure Olfactory disturbance Fever Cough (worse when lying down)
    44 : Evaluation of Chronic Sinusitis 44 CT or MRI scanning Anatomic defects, tumors, fungi Allergy testing Inhalants, fungi, foods Sinus aspiration for cultures Bacterial Fungal
    45 : Treatment of Chronic Sinusitis 45 Nasal steroid spray Decongestants Steam inhalation Nasal irrigation Antibiotics with exacerbations
    46 : Non-pharmacological treatment Humidifier to relieve the drying of mucous membrances associated with mouth breathing Increase oral fluid intake Saline irrigation of the nostrils Moist heat over affected sinus Prolonged shower to help promote drainage
    47 : Patient Education Child should not dive. Child should not travel by airplane. Urge parent to eliminate triggers in the home (dust, smoking) Have all members of the family treated, if indicated.
    48 : Pharyngitis
    49 : Pharyngitis Infl ammation of the pharynx most commonly caused by acute infection. Group A streptococcus is a focus of diagnosis due to its potential for preventable rheumatic sequelae. Chronic low grade symptoms usually related to refl ux disease or vocal abuse.
    50 : System(s) affected: Pulmonary Genetics: Individuals with a positive family history of rheumatic fever have a higher risk of rheumatic sequelae following an untreated group A beta hemolytic streptococcal infection
    51 : Epidemiology Estimated 30 million cases diagnosed yearly 11% of all school age children visit a physician annually with pharyngitis • 12-25% of sore throats seen by physicians Incidence of rheumatic fever is decreasing with estimate of 64 cases per 100,000
    52 : Predominant age: • Pharyngitis occurs in all age groups • Streptococcal infection has greatest incidence 5 to 18 years of age Predominant sex: Male = Female
    53 : SIGNS & SYMPTOMS • Sore throat • Enlarged tonsils • Pharyngeal erythema • Tonsillar exudates • Soft palate petechiae • Cervical adenopathy • Absence of cough, hoarseness, or lower respiratory symptoms • Fever (> 102.5°F [39.1°C] suggests Streptococcus) • Scarlet fever rash: punctate erythematous macules with reddened fl exor creases and circumoral pallor (Streptococcal pharyngitis) • Gray pseudomembrane found in diphtheria and occasionally, mononucleosis • Characteristic erythematous based clear vesicles in herpes stomatitis • Anorexia • Chills • Malaise • Headache • Conjunctivitis, more commonly with adenovirus infections
    54 : CAUSES • Acute - bacterial: ? Group A beta-hemolytic streptococci ? Neisseria gonorrhoeae ? Corynebacterium diphtheriae (diphtheria) ? Haemophilus infl uenzae ? Moraxella (Branhamella) catarrhalis ? Group C and G streptococcus, rarely • Acute - virus: ? Rhinovirus ? Adenovirus ? Parainfl uenza virus ? Coxsackievirus ? Coronavirus ? Echovirus ? Herpes simplex virus ? Epstein-Barr virus (mononucleosis)
    55 : • Chronic ? More likely non-infectious ? Irritation from post-nasal discharge of chronic allergic rhinitis or reflux ? Chemical irritation or smoking ? Neoplasms and vasculitides
    56 : RISK FACTORS • Group A beta hemolytic streptococcal epidemics occur • Age (young are more susceptible) • Family history • Close quarters, such as in new military recruits • Immunosuppression • Fatigue • Smoking • Excess alcohol consumption • Oral sex • Diabetes mellitus • Recent illness
    57 : Diagnosis LABORATORY • Blood agar throat culture from swab. Bacitracin disc sensitivity of hemolytic colonies suggest group A streptococci. Specifi c antibody identifi cation available. Rapid screening for streptococci can be done from throat swab with antigen agglutination kits. 5-10% false negatives lead some to suggest routine backup of all negatives with blood agar culture. Newer optical immunoassay tests are more sensitive. • Leukocytosis (if bacterial)
    58 : GENERAL MEASURES • Salt water gargles • Acetaminophen • Dyclonine lozenges • Cool-mist humidifi er
    59 : Drug Therapy For streptococcal pharyngitis, penicillin is the standard. All choices should have complete 10 day course. • Penicillin V 250 mg tid (25-50 mg/kg/day), or • For penicillin allergic patients, erythromycin ethylsuccinate 300 to 400 mg tid (30 mg/kg/day), or • Cephalexin 250 mg tid (30 mg/kg/day)
    60 : POSSIBLE COMPLICATIONS • Rheumatic fever • Post-streptococcal glomerulonephritis • Peritonsillar abscess • Systemic infection • Otitis media Mastoiditis • Septicemia • Rhinitis • Sinusitis • Pneumonia
    61 : Thank You!@
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