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Upper Respiratory Tract Infection

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Upper Respiratory Tract Infection
Author: Anne Meneghetti, MD; Chief Editor: Zab Mosenifar, MD more... Updated: Oct 15, 2012

Practice Essentials
The VIDARIS trial, a randomized, placebo-controlled study from New Zealand that enrolled 322 adults older than age 18 years who were in good health, found that adding vitamin D supplements to the diet neither prevented upper respiratory tract infections (URIs) nor hastened recovery from them.[1, 2] Before this study, it had been unclear whether vitamin D supplementation played a role in preventing or mitigating URIs. Several previous observational studies showed an inverse association between 25-hydroxyvitamin D levels and the presence of URIs, and basic research suggested that vitamin D could help clear bacteria, build up epithelial barriers to infection, and enhance antigen-presenting cells. However, there had been no definitive trial to determine whether vitamin D therapy actually reduces URI rates in adults. Participants in the trial were randomly assigned to 1 of the following 2 groups: Active intervention group – An initial oral vitamin D3 dose of 200,000 IU, followed by a second dose of 200,000 IU the following month and then by monthly doses of 100,000 IU for 16 months Placebo group – Matched placebo on the same dosing schedule Researchers determined the number, duration, and severity of URI episodes, as well as their effect on the patient’s productivity at work (quantified in terms of days missed because of URIs). Results were as follows: No significant difference between treatment and placebo groups in total number of URIs (593 events in the intervention group and 611 in the placebo group) No significant difference in number of URIs per person (mean, 3.7 per person in the intervention group and 3.8 per person in the placebo group) No significant difference in symptom duration per URI episode (mean, 12 days in each group) No significant difference in severity of URIs No significant difference in number of days missed from work because of URIs (mean, 0.76 days in each group) The findings did not change significantly when the analysis was repeated by season and by baseline 25-OHD (25hydroxyvitamin D) levels. Although the authors did not find a benefit of vitamin D supplementation in their study, they note that other populations (eg, a population with a higher prevalence of vitamin D deficiency) might benefit from vitamin D supplementation. Although at present, clear evidence of the benefit of vitamin D exists only for bone health, investigation into ways in which vitamin D intake might be related to improving immune function and preventing infection remains an important area for future research. 1/10

pharynx. self-limited. and tracheitis are specific manifestations of URIs.medscape. maxillary. and larynx. uvula. Inoculation by bacteria or viruses begins when secretions are transferred by touching a hand exposed to pathogens to the nose or mouth or by directly inhaling respiratory droplets from an infected person who is coughing or sneezing. and tonsils Epiglottitis (supraglottitis) . Viruses account for most URIs.Inflammation of the pharynx. including physical. hypopharynx. Patients with bacterial infections may present in similar fashion. The upper respiratory tract includes the sinuses.Inflammation of the superior portion of the larynx and supraglottic area Laryngitis . bronchi. emedicine. humoral. nasal 2/10 . trapping potential invaders. Hair lining the nose filters and traps some pathogens. laryngitis. hypopharynx. Bacterial primary infection or superinfection may require targeted therapy. or they may present with a superinfection of a viral URI. and sphenoid Nasopharyngitis (rhinopharyngitis or the common cold) .Inflammation of the nasal mucosa Rhinosinusitis or sinusitis . Person-to-person spread of viruses accounts for most URIs. URIs range from the common cold--typically a mild. epiglottitis. trachea. see the following: Presentation Workup Treatment See also the image below: Seasonal variation of selected upper respiratory tract infection pathogens. and Group A Strept is group A streptococcal disease.Inflammation of the nares and paranasal sinuses. Further information can be found in the Medscape Reference articles Emergent Management of Acute Otitis Media. and cellular immune defenses.Inflammation of the larynx Laryngotracheitis . pharynx.08/06/13 Upper Respiratory Tract Infection For further information. The angle resulting from the junction of the posterior nose to the pharynx causes large particles to impinge on the back of the throat. from there they are swallowed into the stomach. Bronchiolitis. viruses and bacteria encounter several barriers. mechanical. RSV is respiratory syncytial virus. pharyngitis. uvula. PIV is parainfluenza virus. Rhinitis.Inflammation of the nares. After inoculation.Inflammation of the trachea and subglottic area Pathophysiology URIs involve direct invasion of the mucosa lining the upper airway. Common URI terms are defined as follows: Rhinitis . Mucus coats much of the upper respiratory tract. Background URI represents the most common acute illness evaluated in the outpatient setting. sinusitis. which serve as gateways to the trachea. including frontal.Inflammation of the larynx. and in articles about specific infectious agents. and tonsils Pharyngitis . and subglottic area Tracheitis . MPV is metapneumovirus. Ciliated cells lower in the respiratory tract trap and transport pathogens up to the pharynx. catarrhal syndrome of the nasopharynx--to life-threatening illnesses such as epiglottitis. and Bronchitis. ethmoid. and pulmonary alveolar spaces.

laryngitis. and respiratory syncytial virus (RSV) may incubate for a week.[5] Epiglottitis Epiglottitis occurs at a rate of 6-14 cases per 100.[8] The occurrence of epiglottitis has decreased dramatically in the United States since the introduction of the Haemophilus influenzae type B (Hib) vaccine. help defend against potential pathogens. Patients with suboptimal humoral and phagocytic immune function are at increased risk for contracting a URI. erythema. especially in children. and bacterial adherence factors. Pertussis typically incubates for 7-10 days or even as long as 21 days before causing symptoms. Most symptoms of URIs. as well as the formation of capsules that resist phagocytosis. URIs are the leading reasons for people missing work or school. Pathogens resist destruction by a variety of mechanisms. and people older than 60 years have fewer than 1 cold per year. and pneumonia. epiglottitis. influenza and parainfluenza may incubate for 1-4 days. secretions. Beyond 3/10 . Humoral immunity (immunoglobulin A) and cellular immunity act to reduce infections throughout the entire respiratory tract. Pharyngitis Acute pharyngitis accounts for 1% of all ambulatory office visits. Laryngitis and laryngotracheitis emedicine. Rhinosinusitis Sinusitis is common in persons with viral URIs.[3] The incidence of viral and bacterial pharyngitis peaks in children aged 4-7 years.medscape. bacterial rhinosinusitis occurs as a complication in only about 2% of persons with viral URIs. including various staphylococcal and streptococcal species. Rhinoviruses and group A streptococci may incubate for 1-5 days. resulting in sinusitis. including the production of toxins. otitis media. including local swelling. posing challenges to immune defense. based on estimates from other countries. Resident and recruited macrophages. tracheobronchitis.[4] However. and they transfer infection to those who care for them. which undergo frequent changes in antigenicity. Epidemiology Frequency United States URIs are the most common infectious illness in the general population. Inflammatory narrowing at the level of the epiglottis and larynx may result in a dangerous compromise of airflow. and they represent the leading acute diagnosis in the office setting.[7] Epiglottitis is estimated to occur at annual incidence of 9. Normal nasopharyngeal flora. result from the inflammatory response of the immune system to invading pathogens and from toxins produced by pathogens. Adolescents and adults have approximately 2-4 colds a year.[3] Nasopharyngitis The incidence of the common cold varies by age. monocytes. Rates are highest in children younger than 5 years.[6] This condition typically occurs in children aged 2-7 years and has a peak incidence in those aged 3 years. A host of inflammatory cytokines mediates the immune response to invading pathogens. Diphtheria incubates for 1-10 days. in whom a small reduction in the luminal diameter of the subglottic larynx and trachea may be critical. and fever. and they are at increased risk for a severe or prolonged course of disease. Transient changes in the paranasal sinuses are noted on CT scans in more than 80% of patients with uncomplicated viral URIs. Viral agents include a vast number of serotypes. Children have about 3-8 viral respiratory illnesses per year.7 cases per million adults. laryngotracheal inflammation may also pose serious threats to individuals with congenital or acquired subglottic stenosis. An initial nasopharyngeal infection may spread to adjacent structures. Incubation times before the appearance of symptoms vary among pathogens.08/06/13 Upper Respiratory Tract Infection Adenoids and tonsils contain immune cells that respond to pathogens. edema. proteases. The incubation period of Epstein-Barr virus (EBV) is 4-6 weeks.000 children. and eosinophils coordinate to engulf and destroy invaders. neutrophils. Children who attend school or daycare are a large reservoir for URIs.

or laryngotracheobronchitis. Seasonality Although URIs may occur year round. Human PIV type 2 may cause annual or biennial fall outbreaks. Rhinoviruses. Human PIV type 1. and early summer. Seasonal variation of selected upper respiratory tract infection pathogens. currently causes autumnal outbreaks in the United States during odd-numbered years.[14] Epidemics and miniepidemics are most common during cold months.medscape. rates of colds increase over several weeks and remain elevated until March or April. at work. summer. MPV is metapneumovirus. the enlarging caliber of the airway reduces the severity of the manifestations of subglottic inflammation. and early autumn. Adenoviral respiratory infections are most common in the late winter. Approximately 5-20% of Americans have the flu during each flu season. Peak activity for human PIV type 3 is during the spring and early summer months. or croup.827 reported cases of pertussis in the United States. Challenges in laboratory diagnosis and overreliance on polymerase chain reaction (PCR) tests have resulted in reports of respiratory illness outbreaks mistakenly attributed to pertussis.3 cases per 100. The figure below illustrates the peak incidences of various agents by season. the leading cause of croup in children. however.[13] Human metapneumovirus (hMPV) infection may also occur year round. home. peaking emedicine.[7] Thereafter. PIV is parainfluenza virus. accounting for several million cases of streptococcal pharyngitis each year. Childhood EBV infection is indistinguishable from other transient childhood infections.000 population in 2006.[11] Early presentations include symptoms of URI. reaching 5. in the United States. spring. most colds occur during fall and winter. Beginning in late August or early September. the virus may be isolated throughout the year. with a peak incidence in late winter to early spring. but usually occurs in children aged 6 months to 6 years.[13] Diphtheria remains endemic in developing countries. when other URI pathogens are at a nadir. The peak incidence is in the second year of life. the prevalence has been approximately 0. the incidence of whooping cough cases in the United States has increased in recent 4/10 . and Group A Strept is group A streptococcal disease. Sporadic cases have recently affected adults. increasing a person's susceptibility to infection. In 2004.000 population. adults aged 19-64 years accounted for 7. Approximately 35-50% of adolescents and young adults who contract EBV infection have mononucleosis. Vaccination has dramatically reduced rates of pertussis. yet they can occur throughout the year. RSV is respiratory syncytial virus. including whooping cough.[12] After the advent of the diphtheria vaccine.08/06/13 Upper Respiratory Tract Infection Croup. H1N1 influenza activity was present throughout summer and autumn. may affect people of any age. However.[9] Adolescents and infants younger than 5 months account for many of these cases.[10] Frequency of selected pathogens Group A streptococcal bacteria cause approximately 5-15% of all pharyngitis infections. case rates dramatically decreased in the United States. Cold weather means more time spent indoors (eg.001 case per 100. which account for a substantial percentage of URIs. Some parainfluenza viruses (PIVs) have a biennial pattern. Seasonality does not affect rates of epiglottitis. In 2009. overlapping with seasonal influenza. Seasonal influenza typically lasts from November until March.008 (27%) of 25. Coronaviral URIs manifest primarily in the winter and early spring. This infection is rarely diagnosed in children younger than 2 years. Enteroviral URIs are most noticeable in summer and early fall. Low indoor air moisture may increase friability of the nasal mucosa. Humidity may also affect the prevalence of colds. EBV infection affects as many as 95% of American adults by age 35-40 years. Since 1980. because most viral URI agents thrive in the low humidity characteristic of winter months. Laryngotracheobronchitis. occurs in fall and winter. school) and close exposure to others who may be infected. are most active in spring.

Epiglottitis: A male predominance is reported. and mediastinitis. hormonal effects on the nasal mucosa may also play a role. However. meningitis. subdural abscess.[11] CDC estimates the overall death rate associated with 2009 H1N1 influenza was 0. Sinusitis The condition itself is rarely life threatening. although URIs may serve as a gateway to infection of adjacent structures.[14] This frequency may represent increased exposure to small children. who represent a large reservoir for URIs. sepsis. peritonsillar abscess. Alaskan Natives have rates of Hib disease higher than those of other groups. Alone.000 people die from seasonal influenza and its complications. more than 200. bronchitis. empyema. Fatality rates up to 20% are reported in patients younger than 5 years or older than 40 years. resulting in otitis media. emedicine.[16] Approximately 5-10% of patients with diphtheria die. epiglottitis has a fatality rate of approximately 1%. Selected pathogens Approximately 3-6% of cases of Hib disease are fatal. frontal and maxillary osteomyelitis. However. pneumonia. especially those aged 20-30 years.000 people are hospitalized for influenza and approximately 36. meningitis. intraorbital. including septic arthritis. URIs rarely cause permanent sequelae or death.[16] Race No notable racial difference is observed with URIs. and 42 (75%) were among infants younger than 2 months.medscape. and other infections. and brain abscess. Examples include orbital cellulitis.08/06/13 Upper Respiratory Tract Infection between December and February. Nasopharyngitis: The common cold occurs frequently in women. In adults.[15] Complications from whooping cough. Each year. Fifty-one (91%) of these deaths were among infants younger than 6 months.000 persons across all age groups. with a male-to-female ratio of approximately 3:2. or pertussis. bronchiolitis. Mortality from group A streptococcal pharyngitis is rare. Common cold This is the leading cause of acute morbidity and missed days from school or work. retropharyngeal. orbital abscess. URI may be superimposed over these baseline changes and may increase the intensity of symptoms in some women. reported from 2001-2003 included 56 pertussis-related deaths. acute glomerulonephritis. intracranial abscess.97 per 100. but sinusitis can lead to serious complications if the infection extends into surrounding deep tissue.[17] Sex Rhinitis: Hormonal changes during the middle of the menstrual cycle and during pregnancy may produce hyperemia of the nasal and sinus mucosa and increase nasal secretions. Epiglottitis This infection poses a risk of death due to sudden airway obstruction and other complications. and toxic shock syndrome. Untreated group A streptococcal pharyngitis This infection can result in acute rheumatic fever (ARF). Mortality/Morbidity URIs cause people to spend time away from their usual daily activities. meningitis. The common cold is also the leading acute cause of office visits to a physician in the United States. or intracranial abscesses may cause serious sequelae. However. but serious morbidity or death may result from one of its complications. subperiosteal abscess. Pharyngitis without complications rarely poses significant risk for 5/10 . Serious complications may result in clinically significant morbidity and rare deaths.

[7] Laryngitis and laryngotracheitis: Croup. National health statistics reports. 2008. Priest PC. Oct 3 2012. American College of Physicians.[7] Age Nasopharyngitis: The incidence of the common cold varies by Anne Meneghetti. 3. American Federation for Medical Research. Los Angeles. MD is a member of the following medical societies: American College of Chest Physicians.[7] Contributor Information and Disclosures Author Anne Meneghetti. PharmD. MD Director. Available at http://www. et al. may affect people of any age. MD Assistant Professor of Medicine. Rechtsteiner EA. Accessed October 15. 2012. MD is a member of the following medical societies: Alpha Omega Alpha. Department of Medicine. [Full Text]. Hyattsville. RealForMe. Children have approximately 3-8 viral respiratory illnesses per year. emedicine. or laryngotracheobronchitis. Chief Editor Zab Mosenifar. Francisco Talavera. PhD Adjunct Assistant Professor. American College of Physicians. Editor-in-Chief. 2. Pharyngitis: The incidence of viral and bacterial pharyngitis peaks in children aged 4-7 years. but it usually occurs in children aged 6 months to 6 years. Medscape Medical News. University of California.308(13):1333-9. Cherry DK. and people older than 60 years have fewer than 1 cold per year. Murdoch DR. Medical Broadcaster. University of South Alabama College of Medicine Gregory William Rutecki. with male-to-female ratio of approximately Epiglottitis: This typically occurs in children aged 2-7 years and has a peak incidence in those aged 3 6/10 . and Society of General Internal Medicine Disclosure: Nothing to disclose. The peak incidence is in the second year of life. MD: National Center for Health Statistics. Broder J. is more common in boys than in girls.medscape. and American Thoracic Society Disclosure: Nothing to disclose. or croup. [Medline]. JAMA. Love and Health. MD Professor of Medicine. David Geffen School of Medicine Zab Mosenifar. Stewart AW. Fellow of The Center for Bioethics and Human Dignity. Professor and Executive Vice Chair. Slow S. Division of Pulmonary and Critical Care Medicine. Rates are highest in children younger than 5 years. Vitamin D ineffective for respiratory tract infections. Director.08/06/13 Upper Respiratory Tract Infection Laryngotracheobronchitis. Medscape Drug Reference Disclosure: Medscape Salary Employment References 1. MD is a member of the following medical societies: National Ayurvedic Medical Association Disclosure: Nothing to disclose. Cedars Sinai Medical Center. National Ambulatory Medical Care Survey: 2006 Summary. Women's Guild Pulmonary Disease Institute. Tufts University School of Medicine. Life. Hing E. Additional Contributors Gregory William Rutecki.medscape. Effect of vitamin D3 supplementation on upper respiratory tract infections in healthy adults: the VIDARIS randomized controlled trial. Woodwell DA. Chambers ST. National Kidney Foundation. University of Nebraska Medical Center College of Pharmacy. American Society of Nephrology. Jennings LC. Adolescents and adults have approximately 2-4 colds a year.

Diagnosis and treatment of streptococcal pharyngitis. Utah Department of Health. 2009. [Medline]. Pharyngitis. Nov 15 1999. Wodzinski SF. [Medline].cdc. Centers for Disease Control and Prevention. National Institute of Allergy and Infectious Diseases. Jan 9 2004.niaid.60(8):2289-96. Centers for Disease Control and Prevention. [Medline].cdc. Available at http://www. Centers for Disease Control and Prevention. CDC. Mar 1 2009. 1993:[Full Text]. May 1 1986. 12. Am Fam Physician. 2009.January 30. Gerber MA. Available at http://www. 19. Centers for Disease Control and Prevention. Division of STD Prevention. Available at http://health. [Guideline] University of Michigan Health System. Influenza: The Disease.htm. [Full Text]. 17.nih. Aug 24 2007. In: Grand rounds archives: pediatric otolaryngology. Outbreaks of respiratory illness mistakenly attributed to pertussis--New Hampshire. National Institute of Allergy and Infectious Diseases. Whooping Cough Sound Files. 20. May 20. 6. 7.cdc.medscape. . Epstein-Barr virus and infectious mononucleosis. Division of Bacterial and Mycotic Diseases. Baylor College of Medicine. 2009. Accessed April 30. An eight-year experience in the state of Rhode Island.utah. 9.cdc. Bureau of Epidemiology. Available at http://www. National Center for Health Statistics. 2010. Nov 15 1998. Massachusetts. National Center for Infectious Diseases.56(33):837-42. 11. Morgan WE. [Full Text].htm. Kabat W. 14. Accessed April 30. MayoSmith MF. Fagnan LJ. Diagnosis of stridor in children. Health. Accessed April 30. Haemophilus influenzae serotype b (Hib) disease. 2008 With Chartbook .htm. Flu-Related Hospitalizations and Deaths in the United States from April 2009 .htm. 18. Acute epiglottitis in adults.cdc. [Medline].52(53):1285-6. [Full Text]. [Medline]. National Center for Infectious Diseases. Acute sinusitis: a cost-effective approach to diagnosis and treatment. Bureau of Epidemiology. 2009. 21. [Full Text]. Tex: Grand Rounds Archive. Accessed April 30. Accessed 5/12/2010. Accessed April 2009.[Full Text]. Available at http://www. Centers for Disease Control and Prevention. National Center for Infectious Diseases. Centers for Disease Control and Prevention. Seshadri R.htm. Cho H. Rippe J. 2009. MMWR Morb Mortal Wk ly 15. 23. [Medline].com/article/302460-overview#showall 7/10 . N Engl J Med. 2004-2006. 22. Available at http://www. Schiffman FJ. traveler to Haiti--Pennsylvania. Respiratory and Enteric Viruses Human parainfluenza viruses (common cold and croup). Nonspecific upper respiratory tract infection. 805-6.cdc. Accessed 02/10/2011. CDC.314(18):1133-9. Accessed April 30. Fatal respiratory diphtheria in a U.08/06/13 Upper Respiratory Tract Infection 4.58(8):1795-802. Available at Hyattsville. Leung AK. 2010. Am Fam Physician. 8. Division of Bacterial and Mycotic Diseases. National Guideline Clearinghouse. MMWR Morb Mortal Wk ly Rep. Shulman ST. Gonococcal Infections. and Tennessee. Choby BA. 10. MD: 2009:p 268. Available at http://www. Common Cold. 16. Sexually Transmitted Diseases Treatment Guidelines. 2003. Performance of a rapid antigendetection test and throat culture in community pediatric offices: implications for management of emedicine. Utah Department of Health.79(5):383-90. 13. 2009.aspx. Centers for Disease Control and Prevention. Tanz Accessed April 30. United States. Centers for Disease Control and Prevention. Hirsch PJ. CDC. Am Fam Physician.

Apr 1997. 29. [Medline]. 25. Maberry R. [Medline]. Cochrane Database Syst Rev. 2000. Orr R. Chudnofsky CR. Centers for Disease Control and Prevention. Mar 15 [Medline]. Oral antihistamine-decongestant-analgesic combinations for the common cold.69(6):1465-70. May 3 1999. Berlin CM Jr.161(12):1140-6.1(3):143-4. [Medline]. Brightling CE. Younger JG. Feb 2009. 30. et Acute sinusitis: current status of etiologies.123(2):437-44. 31. [Full Text].106(5A):38S-47S. Food and Drug Administration. Am Fam Physician. BMJ . Centers for Disease Control and Prevention. 2007. Vincent MT. et al. Effect of honey. Poole MD. Rapid Diagnostic Testing for Influenza. Sep 1985. Accessed May 10. Harvey R. Pediatrics . BMJ . 38. 2007. 2009. Jan 2006. 41. 42. Pharyngitis. 2001. Braman SS. 35. Effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections: open randomised controlled trial.324(7350):1361. 27. Cochrane Database Syst Rev [serial online]. van Driel ML. Mitchell 8/10 . Kumar AA. Chest. Available at http://www.97(4):227-9. Lesslar O. Mundt M. Rabago D.cochrane. 39. 34.medscape. Aug 4 2006.08/06/13 Upper Respiratory Tract Infection pharyngitis. Jun 2001. Curr Clin Top Infect Dis . Barrett B. and treatment. Colo: Thomson MicroMedex. 32. [Medline]. Centers for Disease Control and Prevention. diagnosis. Berman SM. A focus on acute sinusitis in adults: changes in disease management. Adverse effects of racemic epinephrine in epiglottitis. Pediatrics . 28. [Medline]. Jun 8 2002. [Full Text].129(1 Suppl):1S-23S. Detweiler MJ. Larkin GL. Pertussis (Whooping Cough) Diagnostic Testing. Boczar M. Available at http://www. Accessed April 30.cdc. Bolser DC. North M. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines.htm. Hussain AN. N Engl J Med. Ragosta KG.cdc. Feb 15 2012. [Best Evidence] Paul IM. Accessed October 14.343:d5154. discussion 48S-52S. [Guideline] Irwin RS. Shaffer ML. 37. Duda L. FDA: U. Sep 6 2011. Available at http://www. 36. [Medline]. [Medline]. 26.107(6):E96. [Medline]. Baumann MH. [Guideline] Workowski KA. Adult epiglottitis: best practice of medicine [Internet database]. FDA Statement Following CHPA's Announcement on Nonprescription Over-the-Counter Cough and Cold Medicines in Children. Wilkerson MD. Schilder AG. 33. Chow AW. Bobula J. Weber JE. [Medline]. Revisiting epiglottitis: a protocol--the value of lateral neck radiographs. Badia L.Issue 3:Available from: The Cochrane Collaboration. and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Over the counter but no longer under the radar--pediatric cough and cold medications. Dec 2007. April. 2008. Skrt A. Dec 6 2007. [Medline]. De Sutter AI. Rajkumar C. Centers for Disease Control and Prevention. Pediatr Emerg Care. van den Aardweg Beiler J. Kissoon N. Am J Med. [Medline]. Sexually transmitted diseases treatment guidelines. Arch Pediatr Adolesc Med.21:31-63. Hoes AW.S. MMWR Recomm Rep. Greenwood Village. Serwint JR. 2006. Rovers MM. D'Souza AL. Nasal irrigation with saline (salt water) for the symptoms of chronic rhinosinusitis. Bulpitt CJ.55:1-94. [Medline]. Celestin N.html. Cooke J. Zgierska A. J Am Osteopath Assoc . [Medline]. Boonacker CW. Available at http://www. 24. Efficacy of daily hypertonic saline nasal emedicine. Food and Drug Administration. A randomized comparison of helium-oxygen mixture (Heliox) and racemic epinephrine for the treatment of moderate to severe croup. Sharfstein JM. McMonagle A. Boulet LP. Accessed 02/10/2011. 40.html. January 24. [Medline].2:CD004976. Scadding G. [Full Text]. Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis. Hannan SA.

[Full Text]. Williams JW Jr. MedWatch Public Health Advisory. emedicine. [Medline]. Pediatrics . O'Connor RR. Feb 16 2011. 59. 2009. et al. Rogers J. Zicam cold remedy nasal products (Cold Remedy Nasal Gel. Sperber SJ. 51. Acad Emerg Med. [Medline]. [Medline]. Greenwood Village. A randomized. Berglund R. Ann Intern Med. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background.99(6):918-20. et al. Effectiveness of clemastine fumarate for treatment of rhinorrhea and sneezing associated with the common cold.CD005149. Quinn H. Infectious Diseases Society of 9/10 . Standish L. [Best Evidence] Zalmanovici A. Antibiotics for acute maxillary sinusitis. Jul 15 1996. 60. Dec 2002. Pediatrics . Apr 16 2008. [Guideline] American Academy of Pediatrics. . American Academy of Pediatrics. Effectiveness and safety of intranasal ipratropium bromide in common colds. Bartlett JG. Bone K. Das RR. [Guideline] Bisno AL. Sorrentino JV. [Medline]. September 28. Varonen H. Borisenko OV. 49. Buckingham J. Hayden FG. Wing A. Ear Nose Throat J . Mar 20 2001.125(2):89-97. [Full Text]. Singh M. McGann M. Oct 2000. Cold Remedy Nasal Swabs. Yaphe J. American Academy of Pediatrics. 53. Sep 1997. Clin Infect Dis . Pharyngitis and tonsillitis: best practice of medicine [Internet database]. Wecker MT. [Medline]. 43. Kovanen N. [Medline].25(3):574-83. Echinacea for treating the common cold: a randomized trial. Committee on Drugs. Rakel D. Sande MA.51(12):1049-55. Zinc nasal gel for the treatment of common cold symptoms: a double-blind. Barron E. Apr 18 2007. Rautakorpi UM. Kaplan EL. 52. 2002. Update: influenza activity . Dec 3 2003. Accessed June 16. Zinc for the common cold. [Medline]. Dec 21 2010. placebo-controlled trial. Steroids for acute sinusitis. double-blind. Ann Intern Med. JAMA. [Medline]. [Medline]. Efficacy and safety of echinacea in treating upper respiratory tract infections in children: a randomized controlled trial. Batouli AR. Weber W. [Medline]. Hickner JM. Cochrane Database Syst Rev. Barlow S.134(6):498-505.58(5):115-9. Nobel S. 46. [Medline]. Barrett B. 1994. Villa-Roel C.515:57-64. [Medline].153(12):769-77.2:CD001364.United States.79(10):778-80. Cochrane Database Syst Rev. [Medline]. Gonzales R. Goesling J. Eskin B. Hoffman JR. Tonnesson M. Jun 1997. et al. 56. Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature. Stierna P. Use of codeine. 57. Gerber MA. [Medline]. Taylor JA. 47. 2009. Westrin KM.108(3):798-808. Wiklund L. and Cold Remedy Saws. 55. 58. [Medline]. placebo-controlled trial. 2008--January 31. Korts DC. Wood PB. August 12. Ann Intern Med. Colo: Thompson Micromedex.CD000243. Yeh B. J Fam Pract. Hirt M. Clin Infect Dis . Diamond L. Sep 2001. Schwartz RH. Diagnosis and management of group A streptococcal pharyngitis: a practice guideline. Cochrane Database Syst Rev. 782.and dextromethorphan-containing cough remedies in children. Rowe BH. Gwaltney JM Jr. Oct 1997. [Full Text]. et al. The efficacy of oxymetazoline administered with a nasal bellows container and combined with oral phenoxymethyl-penicillin in the treatment of acute maxillary sinusitis. MMWR Morb Mortal Wk ly Rep. [Medline]. Acta Otolaryngol Suppl. 44. 50. [Best Evidence] Ahovuo-Saloranta A.08/06/13 Upper Respiratory Tract Infection irrigation among patients with sinusitis: a randomized controlled trial.290(21):2824-30. Feb 13 2009. May 2010. et al.17(5):476-83. Kids Size).medscape. United States Food and Drug Administration. 48. Turner RB. 54. Mundt M. Clinical practice guideline: management of sinusitis. 45. Brown R.25(4):824-30. Besser RE.

President's Council on Physical Fitness & Sports. Upper respiratory tract infections in young children: duration of and frequency of complications. America Academy of Pediatrics. Dec 15 2006. et al. Medscape Reference © 2011 WebMD. Broder KR. et Lee GM. Vinci DM. Mar 2006. 68. [Full Text]. prospective. Available at http://www. US Department of Health and Human Services. MMWR Recomm Rep. Byers C. Broder K. Dec 1990. Kretsinger K. Clinical role of respiratory virus infection in acute otitis media. for use of Tdap among health-care personnel. reduced diphtheria toxoid. Joyce MP. placebo-controlled study. Pediatrics . J Altern Complement Med. 69. 2009.9(2) 2008. [Medline]. 64. 66.51(RR06):1-80. Mertsola J. National Institute of Allergy and Infectious Diseases. randomized. Safety and efficacy of a traditional herbal medicine (Throat Coat) in symptomatic temporary relief of pain in patients with acute pharyngitis: a multicenter. Ruuskanen O. J Appl Physiol. Cortese Smith LL. Guerra N. Cytokine changes after a marathon race. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP.htm. Prevention of pertussis among adolescents: recommendations for use of tetanus toxoid. Apr 2003. et al. and acellular pertussis (Tdap) vaccine. Utter AC. Research Digest. Wald ER. Brinckmann J. Accessed April 30. [Full Text]. MMWR Recomm Rep. Davis JM. supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC). [Medline]. and pertussis among adults: use of tetanus toxoid. Henson DA. Feb 1991. Fiore AE. Pediatrics . et al. Ziegler T.55:1-37.medscape. Accessed 02/10/2011. Levine WC. MMWR. 2009. 65.nih. 62. double-blinded.86(6):848-55. Sexually transmitted diseases treatment guidelines: 2002 [Centers for Disease Control and Prevention Web site]. Näntö-Salonen K. [Medline].pdf. LLC emedicine. Accessed April 30.cdc. Pertussis: Summary of Vaccine Recommendations. Preventing tetanus. [Medline]. Ortega-Sanchez I. Does exercise alter immune function and respiratory infections?. 63. Aug 8 2008. Pediatrics . 71. Available at http://www. Sigwart H. Putto-Laurila A. Safer Healthier PeopleCenters for Disease Control and Prevention. Jul 2001. [Medline].gov/vaccines/vpdvac/pertussis/recs-summary. Arola M. [Guideline] Workowski KA. Is it a cold or an allergy?. Safer Healthier People. 67. Nieman DC. [Medline]. [Full Text].91(1):109-14. 70.117(3):965-78. Shay DK. [Medline].niaid. 10/10 . Available at http://www. 2002.08/06/13 Upper Respiratory Tract Infection 61. van Houten Taylor L.