Professional Documents
Culture Documents
Upper Respiratory
Tract Infection
Otitis Medis
Tonsillitis
Pharyngitis
Epiglottits
Laryngitis
Tracheitis
Importance of URTI
• Very commonly encountered condition in all age
groups and all geographic regions.
• Common cause for loss of school or work days.
• Though a viral etiology is the most common,
inappropriate antibiotic use has been a major
contributor to the development of antibiotic resistance.
Up to 70% of patients with sore throat seen in 1ry care
settings receive prescriptions for antibiotics, while only
20 – 30 % are likely to have streptococcal pharyngitis.
• Though most infections are mild and self limited, they
may have important complications, particularly in
pediatric age (infectious and non- infectious
complications).
Respiratory Infections are the Most
Common Reason for Office Visits
180
161
100
Number of Office Visits (millions)
80
60 73
40 55
20 35
26
0
Mucolytics
Improve sinus drainage.
Decongestants
produce transient symptomatic relief of nasal obstruction that may be followed
by rebound congestion.
Antihistaminics
Decrease rhinorrhoea and sneezing but may produce drowsiness, xerostomia.
Causes of Treatment Failure
• Inadequate dosing or non- compliance.
• Non- Infectious etiology.
• Resistant organism.
• Structural abnormalities as nasal polyps, deviated septum.
• Suppurative complications
Cavernous
Sinus
Thrombosis
Orbital Cellulitis
)Chronic Rhinosinusitis (CRS
Symptoms
• Similar to ABRS but more subtle.
• Pain is much less whereas hyposmia/amosmia are more
common, esp. in CRSwNP.
Investigations
• Aeroallergen testing.
• Sinus culture: in patients with persistent sinus
discharge despite antibiotic treatment.
• CT Scan: in unilateral cases to exclude tumours,
anatomic defects, foreign bodies.
• Tests for underlying disorders as cystic fibrosis and
ciliary dyskinesia.
Systemic Antibiotics Treatment of CRS
• Their role is controversial, but they should be used in acute
exacerbations.
• Usually continued for > 14 days.
• Anaerobic pathogens may need to be considered.
• Long- term systemic macrolide antibiotics may have anti-
inflammatory effects, but clinical studies indicating their
benefit are limited.
Topical Antibiotics esp. if culture directed, eg, for S. aureus:
Mupirocin or gentamycin irrigation.
Topical aminoglycosides should be used cautiously and for
a defined period only. Some patients may develop
sensorineural hearing loss.
Adjunctive Measures as in ABRS.
CRSwNP Some medical measures may help reduce
polyp size “medical polypectomy”
Vasomotor Rhinitis
• It is a diagnosis of exclusion.
• No prospective studies had explicitly differentiated allergic from non-
allergic rhinitis. Since there is significant overlap in treatment,
differentiation is primarily significant only when considering
environmental control, oral antihistaminics and immunotherapy,
which have proven benefit only in allergic rhinitis.
Etiology unknown.. Theories:
• Runners: increased cholinergic glandular secretory activity.
• Dry Patients: increased sensitivity to usually innocent stimuli
Triggering factors include odours, fumes, emotions, changes in
temperature and pressure.
Clinical Picture a highly diverse group of rhinitis syndromes.
Symptoms may be seasonal or perennial.
There are 2 subgroups:
• Runners: rhinorrhoea mainly.
• Dry Patients: nasal obstruction mainly.
Treatment
- Avoid triggering factors.
- Runners: nasal anticholinergics as Ipratropium bromide (Atrovent).
- Dry Patients: nasal steroids
- Both: nasal antihistamincs as Azelastine (Azelast drops, Zalastin spray)
- Pregnant women: Symptoms of rhinitis ↑ during pregnancy, possibly
due to VD induced by pregnancy hormones and hypervolaemia
(gestational rhinitis). Intranasal saline instillatin is safest.
Other topical agents are pregnancy category B or C.
- No evidence for: oral antihistaminics, oral decongestants.
Rhinitis Medicamentosa
)Rebound, Chemical, Drug- Induced Rhinitis (
• It is a condition induced by overuse of nasal decongestants.
• Also used to describe the adverse nasal congestion that develops
when using other medications as:
o Antihypertensives: α, β, ACEI, central sympathetic blockers.
o PDE5Is.
o Oestrogens (including hormonal contraceptives).
o NSAIDs.
o Major tranquilizers.
• It is a relatively common condition, more in young, middle- aged adults.
Diagnostic Criteria (not validated)
• History of prolonged use of nasal decongestants (or use of other
drugs). The condition develops after 3 to 30 days of decongestant use.
(10 days is a rational compromise).
• Constant nasal obstruction with little or no other nasal symptoms.
2ry Effects of Chronic Nasal Obstruction
- Mouth breathing → dry mouth, sore throat.
- Insomnia, snoring.
- Loss of nasal physiologic functions such as filtration of particles and
regulation of temperature and humidity → predisposition to:
• Atrophic rhinitis.
• Nasal polyposis.
• Chronic sinusitis.
• Otitis media.
- Psychological dependence → Cessation produces an abstinence
syndrome characterized by headache, restlessness, anxiety.
Some authors used the word : “addiction” when describing this
syndrome.
Pathogenesis unknown.. Theories:
• Downregulation of nasal mucosal α adrenoceptors (tachyphylaxis).
• Feedback inhibition of endogenous noradrenaline secretion, which
may persist even after discontinuation of the exogenous
sympathomimetic.
• Benzalkonium chloride, a preservative used to prevent bacterial
contamination in many nasal sprays may ↑ the risk of RM by inducing
mucosal swelling.
In all cases, ↓ vasoconstrictor response to the nasal decongestant
encourages the patient to ↑ the dose which further augments the
problem (vicious circle).
Pathology Nasal mucosa shows:
• Nasociliary loss.
• Squamous metaplasia.
• Epithelial oedema.
• Epithelial cell denudation.
• Inflammatory cell infiltration.
Treatment
• Stop nasal decongestant (or other offending drug):
It is difficult and not recommended to stop the nasal decongestant
abruptly. Gradual cessation may be done by:
- Instilling into one nostril only at a time.
- Decreasing the nasal decongestant dose and frequency.
- Replacing the decongestant with a lower concentration or saline.
- Nasal steroids ↓ nasal inflammation, oedema, obstruction.
They should be continued for several weeks to obtain maximal
benefit.
• Other options as antihistaminics (oral/nasal), mast cell stabilizers:
no significant evidence to support their use.
Prevention RM is a preventable condition.
This highlights the importance of increasing awareness of both
patients and health care providers.
Group A Streptococcal (GAS) Pharyngitis
IDSA Guidelines, 2012
Pharyngeal Congestion Palatal Petechae
Anti-Streptolysisn O Titre
* Not useful in diagnosis of acute pharyngitis bec. Ab titre may not peak
until 3 - 8 weeks after infection, and may remain elevated for months
or years without active GAS infection.
* Useful in diagnosis of non- infectious sequelae.
Infectious (Suppurative) Complictions
• GAS pharyngitis is the only commonly occurring form of acute pharyngitis
for which antibiotic therapy is definitely indicated. This need is mainly due to
the risk of complications.