APPROACH TO SORE THROAT AND

URTI IN ADULT AND CHILDREN

PRESENTED BY : DR.SARAH ALSAYEL , R2

SUPERVISED BY : DR. MOHAMMED MADI
OCT 2019 15
 SORE THROAT
:Definition

Pain or discomfort in the throat

.(Pharynx)
 EPIDEMIOLOGY

One of the most common four reasons of visiting family •

.physicians
.of consultations are due to sore throat 5% •
Most of the sore throat (50-80%) is caused by viral agents, 5-35% •
.caused by bacterial agents and less than 1% caused by candida
.Th e most common affected age group is 4-8 years •
Bacterial agents cause 15-30% of sore throat in children and •
.about 5-15 % in adults
.Sore throat occurs more frequently during winter and fall seasons •
Transmission usually occurs due to hand contact with infected •
.nasal discharge
 RISK FACTORS

.Age group 4-8 years old •

.Over crowding •
.Smokers •
.Immuno-compromised persons •
.Low socio-economic status •
.Homosexuals (Viral and fungal infection) •
.Drug abusers (HIV infection) •
.Diabetics (Fungal infection) •
.Inhaler steroid (Fungal infections) •
Mouth breathers due to nasal obstruction •
 :DIFFERENTIAL DIAGNOSIS

Life-1 Acute,-3
Serious and-2
Threatening and common and
rare causes
rare causes serious causes

Acute and-4
Chronic or-5
common but
recurrent but Other Causes-6
not serious
:common causes
causes
 :DIFFERENTIAL DIAGNOSIS

:Life Threatening and rare causes-1

.Epiglottitis (2-4 years old) •
.Peritonsillar abscess (Quinsy) •
.Foreign body (acute pain, dysphagia) •
.Burn (Chemical agents) •

:Serious and rare causes-2

. Oro-pharyngeal cancer •
Diphtheria •
.AIDS •
.Coronary Heart Diseases. • Thyroiditis. • Leukemia •
 :DIFFERENTIAL DIAGNOSIS

:Acute and common but serious causes -3

. Streptococcal pharyngitis and tonsillitis •
:Acute and common but not serious causes -4
.Viral pharyngitis (50-80%) •
:Chronic or recurrent but common causes -5
.Irritant pharyngitis •
. Aphthous ulcer •
. Stomatitis •
. Post-nasal drip •
.Gastro-esophageal reflux disease (GERD) •
Other Causes: • Malingering • Dental pain-6
HISTORY & PHYSICAL EXAMINATION
 : INTERVIEWING AIMS

.To establish and maintain good rapport with patient •

.To rule out serious and life threatening diagnosis •
.To differentiate between viral and bacterial pharyngitis •
To guide management plan •
 CHIEF COMPLAINT

.Sore throat or deep pain or neck pain (location) •

Duration (serious pathology has long duration such as •
.tumor)
Severity (severe pain may indicate bacterial •
.pharyngitis or epiglottitis)
.Aggravating factors (smoking, cold water) •
.Relieving factors (neck extension, drugs) •
 : SYSTEMIC REVIEW (ENT) (RESPIRATORY)

.Headache, face pain, ear pain -

. Runny nose -
.Cough (most likely the sore throat is caused by viral agents) -
. Dyspnea -
. Dysphagia -
. Hoarseness -
.Vomiting -
.Abdominal pain -
.Ear pain -
.Fever (high grade fever may indicate bacterial sore throat) -
.Fatigue (most likely associated with viral sore throat) -
:Past History

:Medical history •
Same complaints (help physician to decide referral for -
.tonsillectomy)
.Chronic problems (diabetes mellitus, bronchial asthma) -
Rheumatic fever -

:Surgical history •
.Tonsillectomy -
:Family history
. Same attacks in the family (common in viral sore throat) -

:Drug history
.Use of antibiotics in previous and current sore throat -
.Use of anti-allergics or antibiotics -
.Use of other medications such as inhalers -
.History of immunization -
:Life style
.Diet (cold fl uid may induce sore throat -
.Exercise (dry mouth) -
.Smoking (dry and irritated throat) -
Sex (kissing is a risk factor for infectious mono-nucleosis and -
.homosexuality may lead to HIV infection)

:Hidden agenda
.Other problems (For sick leave) -
.Referral (asking referral for tonsillectomy) -
Asking for antibiotics (patient has used antibiotics and insists for -
.prescribing it again)
:General exam
Temperature: febrile or not (high grade fever could be caused by •
.bacterial sore throat)
.Toxic, drooling of saliva (indicate epiglottitis) •
Blood pressure •
.Barking cough (croup) •
Respiratory distress (upper respiratory obstruction in epiglotitis •
.and croup)
.Stridor (croup or epiglottitis or foreign body) •
Cyanotic (upper airway obstruction) •
:Ear, Nose and Throat Exam
:Tonsil and pharynx appearance
Redness (More severe congestion and red discoloration of the pharynx could be due to •
.bacterial sore throat)
.Exudate (Most likely due to bacterial or infectious mononucleosis) •
.Quinsy (Peri-tonsilar abscess) •
.Cobbling appearance of pharynx (Post-nasal drip) •
.Runny nose (Viral infection) •
.Sinus tenderness (Sinusitis ) •
.Drooling of saliva (Epiglotitis) •
.Greyish pharynx (Diphtheria) •
.White patches (Candida infection) •
.Strawberry tongue (Scarlet fever) •
.Enlarged tonsils (Tonsillitis) •
.Enlarged, tender anterior cervical lymph nodes (Bacterial pharygitis) •
Enlarged, tender posterior cervical lymph nodes (infectious mononucleosis) •
Pharyngitis, visible redness
• Exudate (Most likely due to bacterial or infectious
mononucleosis).
Right sided peritonsillar abscess
Cobbling appearance of pharynx (Post-nasal drip)
thumb printing sign epiglottitis
An adherent, dense, grey pseudo membrane covering the tonsils is
classically seen in diphtheria.
White patches (Candida infection)
 The rash of scarlet fever Strawberry tongue is a characteristic of scarlet fever

Result of a group A streptococcus (group A strep) infection, also known as Streptococcus pyogenes.
 The signs and symptoms include a sore throat, fever, headaches, swollen lymph nodes, 
• Enlarged tonsils (Tonsillitis).
MANAGEMENT
 DIAGNOSTIC TESTS

A. Rapid strep test; if negative, then perform throat

culture and sensitivity. Throat culture and sensitivity
.are the gold standard for diagnosis
B. Monospot test
C. Complete blood count with differential
D. Gonorrhea culture
E. Blood cultures if sepsis is suspected
F. Radiograph of neck if possible trauma
:Advice-1

.To take rest and to drink adequate amount of fluid •

.To use drugs regularly (compliance) •
.To avoid frequent weather changes •
To use tissue during sneezing and coughing and wash •
hands in order to reduce transmission of infections to
.contacts
To do gargle with luke warm salt water to minimize the •
. severity of sore throat
:Analgesics-2

Paracetamol 15 mg/ kg /dose in children and -

500-1000 mg per dose in adults (to relieve sore
.throat and fever)

Normal saline nasal drops four times daily (to -

.reduce nasal discharge if present)
ANTIBIOTIC - 3
:Prevention-4
.Avoid cold fluids •
.Avoid sudden change of weather •
Avoid contact with patients suffering from •
.cold, cough or sore throat
Washing hands •
:Referral-5
Recurrent pharyngitis or tonsillitis (> six •
.attacks per year for tonsillectomy)
.Quinsy (urgent referral) •
.Epiglottitis (urgent referral) •
.Severe croup (urgent referral) •
.Foreign body (urgent referral) •
 EPIGLOTTITIS

: Definition-
Epiglottitis is the inflammation and swelling of
.the epiglottis and is a medical emergency
Epiglottitis is almost always caused by-
H. influenzae, although Streptococcus
.pneumoniae and Streptococcus pyogenes
Epiglottitis usually occurs in children-
between ages 2 and 8 years, but it may also
.occur in adults
Predisposing Factor
A. Upper respiratory infection
Common Complaints
A. Sudden onset of fever
B. Sudden onset of dysphagia
C. Sudden onset of drooling
D. Sudden onset of muffled voice
Other Signs and Symptoms
A. Respiratory distress
B. Stridor
C. Very ill appearance
 PHYSICAL EXAMINATION

.A. Check temperature, pulse, respirations, and blood pressure

B. Inspect
.Observe overall appearance .1
.Check nail beds and lips for cyanosis .2
.Note drooling or diffi culty in swallowing .3
.Note breathing pattern and rhythm .4
.Note cough if present .5

Do not examine the throat— airway .6

.occlusion may result
.C. Auscultate heart and lungs
: Diagnostic Test-
A. Lateral neck radiograph confirms diagnosis.
However, this test may delay the establishment
.of an airway

Thumb printing sign

A. General interventions

.Immediate referral to hospital .1

While awaiting transport to hospital, establish patent .2
airway, start oxygen, and assemble airway equipment. Move
.the child as little as possible
Insert IV access for fluids and antibiotic administration .3
If a respiratory arrest occurs, you may not be able to see the
airway to intubate. An Ambu bag and mask may work
temporarily, but nasogastric (NG) tube insertion may be
.necessary to prevent gastric distension
B-Pharmaceutical therapy

:In-hospital treatment
IV fluids .1
Antibiotics; IV antibiotics after physician consultation .2
Blood and epiglottis cultures obtained before starting antibiotics .3
: Drug of choice .4
a. Cefotaxime (Claforan) 100 to 200 mg/ kg/ d every 8 hours IV
b. Ceftriaxone (Rocephin) 50 to 100 mg/ kg/ d every 12 hours IV
c. Ampicillin- sulbactam (Unasyn) 150 mg/ kg/ d every 6 hours IV
d. Amoxicillin- clavulanic acid 100 mg/ kg/ d every 8 hours IV
 INDIVIDUAL CONSIDERATIONS

A. Pediatrics: 1. Never place a child in supine position

.because respiratory arrest has been reported

All close contacts (including children and adults) .2

exposed to a child diagnosed with epiglottitis should be
treated with prophylactic antibiotics, such as rifampin,
. 20 mg/kg, not to exceed 600 mg/day for 4 days
 RETROPHARYNGEAL ABSCESS

.DEFINITION: INFECTION OF THE RETROPHARYNGEAL SPACE

:Epidemiology
Incidence most common in children < 5
years of age
in adults, the most common cause is
:Microbiology
trauma
Streptococcus
:Risk factors
: recent infection, such as
pyogenes
otitis media Staphylococcus aureus
pharyngitis
sinusitis respiratory anaerobes
immunosuppression
 RETROPHARYNGEAL ABSCESS

: Sign and symptoms

Sore throat, fever, dysphagia, odynophagia, neck pain stiff neck (e.g., torticollis or an inability-
.to extend the neck)and dyspnea
patients usually have a history of trauma; posterior pharyngeal edema and lymphadenopathy; -
abnormal lateral neck radiography

: Diagnostic test-
,Radiographs: obtained with the patient sitting-
 demonstrate soft tissue swelling posterior to the pharynx, with a widening of the
.prevertebral soft tissue stripe
 Lateral
Marked widening of the pre-vertebral soft tissue
between C2 and C7, with multiple gas foci within at the
C3-C4 level.
 MANAGEMENT

Medical-1 Operative-2
empiric intravenous antibiotics surgical drainage
indication indication
abscess < 2.5 cm2 signs of severe respiratory distress
presence of phlegmon well defined abscess > 2.5 cm2
comment
3-Procedural antibiotic choice should target S.
emergent intubation pyogenes, S. aureus, and respiratory
Indication: anaerobes
in patients with signs of significant airway obstruction :
"tripod positioning" e.g., ampicillin-clavulanate and
respiratory distress vancomycin
cyanosis
unable to speak or cough
OTITIS MEDIA
 :Acute otitis media AOM •
Moderate to severe bulging of the tympanic
membrane or new onset of otorrhea not due
to acute otitis externa accompanied by acute
signs of illness and signs or symptoms of
 middle ear inflammation
DEFINITIONS
: Otitis media with effusion OME •
Middle ear fluid that is not infected. It is also
called serous, secretory, or nonsuppurative
otitis media. OME frequently precedes the
development of AOM or follows its resolution
 AOM is primarily an infection of childhood -
It is the most common reason for-
administration of antibiotics in children
It is slightly more common in boys than -
EPIDEMIOLOGY girls
Most cases of AOM occur in young-
children ages 6 to 24 months, with the
incidence of AOM declining significantly
 after age 5
The most common bacterial pathogens-
are Streptococcus pneumoniae and
nontypeable Haemophilus influenza,
with Moraxella catarrhalis the third most
 RISK FACTORS

Lack of Tobacco
Family
Age Day care breastfeedin smoke and
history
g air pollution

Social and
Race and Limited Season
Pacifier use economic
ethnicity resources (winter)
conditions

Altered host
defenses and
underlying
disease
 Children with AOM, particularly infants, 
may present with nonspecific symptoms
:and signs
Fever
CLINICAL Irritability
MANIFESTATIONS Headache
Apathy
Disturbed or restless sleep, poor feeding
 Anorexia
Vomiting
Diarrhea
 CLINICAL
MANIFESTATIONS

: ,Although the history of AOM varies with age

Neonates: Irritability or feeding difficulties may be
the only indication of a septic focus
Older children: fever and otalgia, or ear tugging
Older children and adults: Hearing loss
becomes a constant feature of AOM and otitis media with
. effusion (OME), fever and otalgia
 Systematic evaluation of the tympanic
membrane (COMPLETE mnemonic)
Color (eg, gray, white, pale yellow, amber, pink,-
red, blue)
Other conditions (eg, fluid level, bubbles,-
perforation, otorrhea, bullae, tympanosclerosis
[scars], atrophic areas, retraction pockets,
cholesteatoma)
CLINICAL
Mobility-
EVALUATION
Position (eg, neutral, retracted, full, or bulging)-
(OTOSCOPE)
Lighting (a halogen light source and fully-
charged battery should be used)
Entire surface (the four quadrants of the-
tympanic membrane should be examined)
Translucency-
External auditory canal and auricle (eg,-
deformed, displaced, inflamed, foreign body)
 In AOM, the tympanic membrane normally demonstrates
signs of inflammation, beginning with reddening of the
mucosa and progressing to the formation of purulent middle
ear effusion and poor tympanic mobility.
Tympanic membrane of a person with 12 hours of ear pain,

slight tympanic membrane bulge, and slight meniscus of purulent

effusion at bottom of tympanic membrane.
 Diagnostic action statements from American Academy of Pediatrics
: (AAP) guidelines include the following

AOM diagnosed when there is moderate to severe-

tympanic membrane bulging or new-onset otorrhea
not caused by acute otitis externa
DIAGNOSTIC
CRITERIA AOM may be diagnosed from mild tympanic membrane-
bulging and ear pain for less than 48 hours or from
;intense tympanic membrane erythema
in a nonverbal child, ear holding, tugging, or rubbing
. suggests ear pain
AOM should not be diagnosed when pneumatic otoscopy and/or-
tympanometry do not show middle ear effusion
 Some conditions share some of the otoscopic and
:nonotoscopic features of AOM
: Redness of tympanic membrane
Crying
High fever
Upper respiratory infection with congestion and
inflammation of the mucosa lining the entire respiratory
DEFERENTIAL tract
DIAGNOSIS Trauma
.Cerumen removal
:Ear pain
Otitis externa
Ear trauma
Throat infections
Foreign body
Temporomandibular joint syndrome
 Immediate treatment with antibiotics )1
OR
Observation with initiation of antibiotic )2
therapy if the symptoms and signs worsen or fa
MANAGEMEN to improve after 48 to 72 hours
T Analgesics and antipyretics have a definite role in )3
.symptomatic management
Decongestants and antihistamines do not appear to
have efficacy they may relieve coexistent nasal
.symptoms
Systemic steroids have no demonstrated role in the
.acute phase
 :Antibiotic therapy
.Children <6 months with AOM
Children six months to two years with unilateral or
bilateral AOM
Children ≥2 years who appear toxic, have
persistent otalgia for more than 48 hours, have
ANTIBIOTIC temperature ≥102.2°F (39°C) in the past 48 hours,
have bilateral AOM or otorrhea, or have uncertain
VS access to follow-up be immediately treated with
OBSERVATIO .an appropriate antibiotic

N :Observation
Children ≥2 years who are normal hosts (eg,
immune competent, without craniofacial
abnormalities) with mild symptoms and signs and
no otorrhea
When the initial observation strategy is chosen,
caretakers must understand the risks and
benefits, and appropriate follow-up must be
ensured so that antibiotic therapy can be initiated
if symptoms worsen or persist after 48 to 72 hours
 Duration of treatment varies with age,
associated clinical features, and antimicrobial
:agent
For amoxicillin, amoxicillin
clavulanate, clarithromycin, oral
DURATION OF :cephalosporins, clindamycin, and levofloxacin
THERAPY Ten days for children <2 years , and children
(of any age) with tympanic membrane
perforation or history of recurrent AOM
Five to seven days for children ≥2 years of age
with intact tympanic membrane and no history
of recurrent AOM
Azithromycin – Five days 
 Surgery-
Surgical management of AOM can be
divided into the following 3 related
:procedures
MANAGEMEN
T Tympanocentesis
Myringotomy
Myringotomy with insertion of a
ventilating tube
 Intratemporal - Perforation of the
tympanic membrane, acute coalescent
mastoiditis, facial nerve palsy, acute
labyrinthitis, petrositis, acute necrotic
otitis, or development of chronic otitis
media
COMPLICATION
S Intracranial - Meningitis, encephalitis,
brain abscess, otitis hydrocephalus,
subarachnoid abscess, subdural abscess,
or sigmoid sinus thrombosis
Systemic - Bacteremia, septic arthritis,
or bacterial endocarditis
 CONSULTATION/ REFERRAL

A. Consult or refer the patient to a

physician if he or she is less than 6 weeks
.of age, appears septic, or has mastoiditis
B. A patient with persistent otitis media
with a hearing loss of 20 dB or more
.should be referred to an otolaryngologist
 INDIVIDUAL CONSIDERATIONS

A. Pregnancy:  Do not use sulfa medications (sulfonamides) in

.pregnant patients, clients at gestation
B. Pediatrics
Children 6 weeks old or younger:  Consider a blood culture and .1
.lumbar puncture if septicemia is suspected
Do not use sulfa medications (sulfonamides) in children younger.2
than 2 months. The American Academy of Pediatrics does not
recommend the use of over- the- counter (OTC) cough and cold
.medications for children younger than 6 years
C. Geriatrics:  Elderly patients may present with OME and/ or
otitis media secondary to a blocked Eustachian tube and/ or URI
ALLERGIC RHINITIS
 DEFINITION OF
RHINITIS

Rhinitis is inflammation of the lining-

.of the nasal cavity
As the lining of the nasal cavity and
the para nasal sinuses is continuous,
inflammatory process tend to involve
both areas to a greater or lesser
.extent
 CLASSIFICATION OF RHINITIS

: Allergy-
Seasonal ,Perennial, food-
.related ,drug induced

: Infectious-
Acute-
Chronic-
 : R I S K FA C T O R S F O R A L L E R G I C R H I N I T I S

. Family history of atopy-

.Exposure to indoor allergens such as dust mites-
. Birth during the pollen season-
. Early antibiotic use-
. Maternal smoking exposures in the first year of life -
 ALLERGIC RHINITIS

Its an IgE mediated -

hypersensitivity response to
allergen lead to rhinitis
,associated allergic
conjunctivitis and asthma may
.occur
The disease is common -
,prevalence depend on age
,gender, geographical
. distribution
 Intermittent (Seasonal) .1
Persistent (Perennial) .2
Mild .3
ALLERGIC RHINITIS
Moderate - severe .4
CLASSIFICATION
 SEASONAL RHINITIS

Also known as intermittent rhinitis .1

It usually lasts less than 4 days a week .2
The whole disorder lasts for about a month .3
Usually caused due to exposure to seasonal Allergens like .4
pollen
Common during spring when flowers bloom .5
 PERENNIAL RHINITIS

Also known as persistent rhinitis .1

Symptoms last for more than 4 days a week .2
Whole disorder lasts for more than a month .3
This is due to continuous exposure to allergen. eg. .4
House dust mite
 MILD ALLERGIC RHINITIS

Allergic rhinitis is considered to be mild if the

symptoms
:Doesn't cause
Sleep disturbance -
Impairment of daily activity -
Impairment of work -
Troublesome symptoms -
 MODERATE ALLERGIC RHINITIS

:This includes one or more of the following

Sleep disturbance -
Impairment of daily activity -
Impairment of work -
Troublesome symptoms -
 O CCU PAT I O NA L AL L ER GE NS

Rhinitis may occur as a consequence of allergins inhaled in -

.work place frequently associated with asthma

Biological agent include flour (in baker ,grain worker), -

laboratory animal ,wood dust, biological washing powder, latex

:Chemical agent -
paint manufacturer and painter (spray)-
drugs in pharmaceutical worker-
 FOOD INDUCED RHINITIS

It’s a rare cause of allergic rhinitis, symptom of -

rhinitis often associated with urticaria,
. angioedema and GIT symptom

Food may occasionally provoke IgE induced -

:rhinitis
,In children Milk, egg, cheese
In adult nuts ,fish, shellfish, citrus fruit
 CLINICAL FEATURES

COMMON COMPLAINTS OTHER SIGNS AND SYMPTOMS

A. Nasal congestion A. Dry mouth from mouth breathing,

snoring
B. Sneezing
B. Itchy nose
C. Clear rhinorrhea
C. Loss of smell and taste
D. Coughing from postnasal drip
D. Eczema rash
E. Sore throat E. Shortness of breath, difficulty
F. Itchy, puff y eyes with tearing breathing, and wheezing F. Headache
G. Halitosis
 EXAMINATION

A.Inspect B.Palpate
.Examine eyes and conjunctivae
a.Palpate face and frontal
a. Tearing; red, swollen eyelids; and allergic shiners
(dark circles under eyes from venous congestion in maxillary sinuses for tenderness
.maxillary sinuses) are seen with allergies
b. Palpebral conjunctiva pale and swollen, bulbar
b.Examine the head and neck for
.conjunctiva is injected .enlarged lymph nodes
.Examine ears, nose, and throat .3
a. Red, dull, bulging, perforated tympanic
.membrane is seen with otitis media D. Percuss
b. Nasal redness, swelling, polyps, and enlarged
turbinates are seen with upper respiratory infection Sinus cavities and mastoid bone
.(URI)
Chest for consolidation .2
Mucosa appears pale blue, and boggy with clear
.discharge in chronic allergy
c. Cobblestone appearance in pharynx, tonsils, and
.adenoids seen in chronic allergies .E. Auscultate heart and lungs
 EXAMINATION

General-
: Local ENT examination -
allergic nasal mucosa appear pale or
bluish, boggy with swelling and
.watery discharge
There may be polyp, structural
(septal deviation ,prominent
.turbinate)
Systemic -
 INVESTIGATIONS

:Skin Tests -1
it’s a primary tool in the investigation of allergy .its
positive in seasonal rhinitis ,less than 50%in others it
consist of pricking skin ,with special needle few drops of
. allergen
Appearance of wheal and flare in 15-20 min ,the size of
wheal is usually equal or greater than 3mm and
interpreted by positive and negative control
Antihistamine should be discontinued 3-6 days before
test
Intradermal test is rarely used because of extensive
tissue reaction or anaphylaxis
SKIN PRICK TEST
 :L A BO RAT O RY T E S T S

:Laboratory tests
.nasal cytology ,eosinophil count in nasal secretion, blood-2
A specific serum immunoglobulin E (IgE) radioallergosorbent-3
test (RAST)
determine presence of Ig E-
Do it for person who can not tolerate skin test -
RAST testing is less sensitive and more expensive than skin-
- A raised IgE level usually confirm allergic constitution but it is neither sensitive
.testing
nor specific.
- Elevated level seen in smoker and parasitic infestation.
 TREATMENT

. Avoidance of allergens , patient education -

. Drugs -
. Immunotherapy (desensitization) -
.Surgery -
 PHARMACEUTICAL THERAPY
1-ANTIHISTAMINES1
Antihistamines (H 1 receptor antagonists) are .1
.drugs of choice
a. Azelastine hydrochloride (HCl; Astelin) .
metered nasal spray, 137 mcg per metered dose
i. Children younger than 5  years:  Not
recommended
ii. Children 5 to 11 years: One spray in each
nostril twice daily
iii. Adults: Two sprays per nostril twice daily
b.Loratadine (Claritin) 10 mg by mouth daily
(adults)
i. Children younger than 2  years:  Not
recommended
ii. Children 2 to 5 years: 5 mg daily
iii. Children 6 years and older: 10 mg daily
c. Fexofenadine HCl (Allegra) 60 mg capsules
orally twice daily (adults) or 180 mg daily
Children younger than 6  years:  Not
recommended
ii. Children 6 to 11years: 30 mg twice daily
d.Cetirizine HCl (Zyrtec)
Adults and children 12 years and older: 5 to 10 mg
by mouth daily depending on symptom severity
ii. Zyrtec 5 mg daily for patients with renal or
hepatic impairment
iii. Children 2 to 6 years: 2.5 mg daily
iv.Children 6 to 11  years:  5 to 10 mg (1– 2
teaspoons) by mouth daily depending on symptom
severity
MONTELUKAST - 2
 :Montelukast ( Singulair)
(SINGUL AIR)
Not recommended for children
younger than 6 months
i. Children 6 to 23  months:  One 4-
mg granule packet
ii. Children 2 to 5 years: One 4-mg
chewable tablet or granule packet
iii. Children 6 to 14 years: One 5-
mg tablet
iv. Children older than 15  years and
adults: One 10-mg tablet daily
 STEROID - 3

.Steroid sprays may be used to decrease nasal inflammation

Steroid sprays are not recommended in children younger than 6 years old unless there is an allergic
.component
.cause pharyngeal fungal infections-
a. Beclomethasone dipropionate (Beconase AQ, Vancenase):  Adults and children older than 6  years: 
One to two sprays in each nostril twice daily
.b. Fluticasone propionate (Flonase): Adults: Two sprays daily or one spray twice daily
.Maintenance dosing: One spray in each nostril daily. Children younger than 4 years: Not recommended
Children 4 years and older: One spray in each nostril daily, may increase to two sprays each nostril once
daily. Maintenance: One spray daily
.c. Triamcinolone acetonide (Nasacort AQ):  Adults:  Two sprays daily
.Children 2 to 5  years:  One spray in each nostril once daily
Children 6 to 12 years: One spray in each nostril once daily, maximum one spray in each nostril once
.daily
Reduce dose as condition improves
 STEROID - 3

 :d. Mometasone furoate (Nasonex)

.Adults:  Two sprays in each nostril once daily
Children 2 to 11 years: One spray in each nostril daily
e. Fluticasone furoate (Veramyst)
i. Adults: Two sprays each nostril daily 1) Maintenance:  One spray in each nostril daily
ii. Children 2 to 11 years: One spray in each nostril daily; may increase to two sprays daily
if needed 1) Maintenance dose:  One spray in each nostril daily
f. Budesonide (Rhinocort Aqua): Children younger than 6 years: Not recommended. Adults
and children 6 years and older: Two sprays twice daily
 INTRANASAL ANTICHOLINERGICS - 4

.Ipratropium (Atrovent) has been shown to provide relief only for excessive rhinorrhea
Advantages include that it does not cross the blood-brain barrier and is not
.systemically absorbed
: Adult
Perennial Allergic/allergic Rhinitis
Nasal spray (0.03%): 2 sprays (21 mcg/spray) per nostril q8-12hr; not to exceed 168-252
mcg/day
Seasonal allergic rhinitis: 2 sprays (0.06%) per nostril q6hr
:Pediatric
Allergic/allergic rhinitis
years: Safety & efficacy not established 6<
years: 2 sprays (0.03%) per nostril q6hr 6>
 DECONGESTANTS - 5
Oral and topical decongestants improve the
nasal congestion associated with allergic
rhinitis by acting on adrenergic receptors,
which causes vasoconstriction in the nasal
mucosa, resulting in decreased
inflammation.
A-Oxymetazoline hydrochloride (Afrin) spray or
drops
i. Adults and children 6 years and older: 2 to 3
drops or sprays of 0.05% solution in each nostril
twice daily
ii. Children 2 to 6  years:  2 to 3 drops of 0.025%
solution in each nostril twice daily
Use no longer than 3 to 5 days.
Discontinuing these drugs afterdrops
B-Phenylephrine (Neo- Synephrine) spray
or drops
i. Adults and children 12 years and
older: 2 to 3 drops or one to two sprays in
each nostril, or small amount of jelly
applied to nasal mucosa, every 4 hours as
needed. Do not use for more than 3 to
.5 days
ii. Children 6 to 12 years: 2 to 3 drops or
one to two sprays of 0.25% solution in
each nostril every 4 hours as needed. Do
.not use for more than 3 to 5 days
iii. Children younger than 6  years:  2 to 3
5 daysof 0.125%
may result solution
in a every 4 hours in
.each nostril as needed
Saline spray a. Saline spray is effective in-4
liquefying thick secretions and helps keep
. mucosa moist

Petroleum jelly applied with Q- tip to inside .5

mucosa of nares three to four times a day helps
to provide lubrication and hold in moisture to
prevent nasal dryness and bleeding
Immunotherapy
Immunotherapy should be considered for patients with moderate
or severe persistent allergic rhinitis that is not responsive to usual
.treatments
Targeted immunotherapy is the only treatment that changes the
.natural course of allergic rhinitis, preventing exacerbation
It consists of a small amount of allergen extract given 
sublingually or subcutaneously over the course of a few years,
with maintenance periods typically lasting between three to five
.years
The greatest risk associated with immunotherapy is anaphylaxis
 SURGERY

Polypectomy
Reduction surgery of inferior turbinate
 FOLLOW UP:

• Doctor should instructs patients to come back if:

• Patient should return for follow- up visit in 2 to 3 weeks if
necessary
• No or partial response to treatment occurs
• The symptoms rapidly deteriorate (high temperature,
unilateral local pain), worsen after 3 days of treatment
• He had any complication
 ?WHEN TO REFER

Patients with moderate to severe disease not responding to oral or -

topical treatments should be referred for consideration of
.immunotherapy
Frequent recurrent episodes of sinusitis ( ≥ 3 episodes requiring -
antibiotics/year)
When serious complications are suspected (e.g. periorbital infection) -
Patients with anatomical abnormalities -
If suspected sinonasal tumour (persistent unilateral symptoms, such as -
bloodstained discharge, crusting, or facial swelling)
Failure or partial response of maximal treatment-
.If the patient need surgery, immunotherapy-
 DRUG INDUCED RHINITIS

NSAID
Beta blockers
ACEI
Oral contraceptives
 R H I N I T I S ME D I C A M E N TOS A

The condition is the result of over medication

.with local nasal decongestants

Cause rebound phenomenon occurs resulting in

.turbinate hypertrophy

The treatment is immediate cessation of the

decongestant with replacement by nasal or
.systemic steroid
If this is not successful then inferior
.turbinectomy may be required
 MCQ

Which of the following statements concerning rhinosinusitis is

?(are) true
a. the most common types of sinusitis are allergic sinusitis and
viral sinusitis
b. rhinovirus is the most common cause of viral sinusitis
viral sinusitis is often accompanied by fever, malaise, and
systemic symptoms
d. a and b e. The most common types of acute rhinosinusitis
are allergic and viral. It is often extremely difficult
e. a, b, and c to distinguish between the two types, although a
seasonal sinusitis points to allergic sinusitis, as do
symptoms such as itching and redness of the eyes.
Viral rhinosinusitis may be accompanied by
systemic symptoms including fever, chills, facial
pain, malaise, and fatigue.
THANK YOU
REFERENCES UpToDate
AFPP
Medscape
Family Practice Guidelines