Infeksi Saluran Pernafasan Atas

Upper Respiratory Tract Infection (URI)

dr. Asti Widuri Sp. THT-KL, M.Kes

In humans the respiratory tract is
the part of the anatomy that has to
do with the process of respiration.

The respiratory tract is divided into

3 segments:

• Upper respiratory tract: nose

and nasal passages, paranasal
sinuses, and throat or pharynx
• Respiratory airways: voice box or
larynx, trachea, bronchi, and
bronchioles
• Lungs: respiratory bronchioles,
alveolar ducts, alveolar sacs, and
alveoli
The respiratory tract is a
common site for infections.
Upper respiratory tract
infections are probably the
most common infections in
the world.
URI Diseases

• Acute Rhinosinusitis
• Acute Pharyngitis
• Acute Tonsilitis  Peritonsilar Abces
• Adenoiditis, adenoid hipertropi
• Acute Laryngitis
Acute Rhinosinusitis
• Viruses associated with the common cold
are adenoviruses, parainfluenza virus,
influenza virus, rhinoviruses and
respiratory syncytial virus.
 Acute Rhinosinusitis
• Broad term describing multiple disease processes
affecting the nasal cavity and sinuses with a
duration of <4 weeks
– Allergy
– Infection (viral, bacterial, fungal)
– Polyps
• Frequent: 1 of 7 adults per year seeks medical
attention for acute rhinosinusitis (ARS)

Chow et al. Clin Infect Dis. 2012; 54(8):e72-112

 Acute Viral Rhinosinusitis (Common Cold)
• Pathogens: Viruses similar to acute bronchitis
• Common symptoms: Nasal congestion and mucous
discharge, facial pressure, post-nasal discharge
• Usually symptoms peak at 2-3 days and resolve by
day 7-10
• Diagnosis relies on exam: radiographs not sensitive
or specific
• Treat with topical and oral decongestants, nasal
irrigation, +/- topical corticosteroids
• No indication for antibiotics
Meltzer et. al. Mayo Clin Proc. 2011 86: 427
Chow et al. Clin Infect Dis. 2012; 54(8):e72-112
 Acute Bacterial Rhinosinusitis (ABRS)
• Pathogens: S. pneumoniae, H. Symptoms Suggesting
influenzae, M. catarrhalis, Bacterial Infection
Streptococcus sp, S. aureus, Symptoms > 10 days
anaerobes Unilateral maxillary face pain
• Much less frequent than viral ARS Maxillary tooth ache
• Follows <2.0% of viral ARS cases Unilateral maxillary sinus
tenderness
• Important to attempt to
Unilateral purulent nasal
differentiate from viral ARS
discharge
• CT imaging only indicated for Double sickening (symptoms
severe infection with suspected improve then worsen)
orbital or intracranial extension Green or colored nasal discharge
and cough do not predict ABRS.
Meltzer et. al. Mayo Clin Proc. 2011 86: 427
Chow et al. Clin Infect Dis. 2012; 54(8):e72-112
 ABRS treatment
• First-line antibiotic therapy:
– Amoxicillin-clavulanate (amoxicillin in children)
– Penicillin allergy in adults: doxycycline, levofloxacin or
moxifloxacin
• Adjunctive treatment
– Hydration, analgesics, antipyretics
– Irrigation with physiologic or hypertonic saline
– Intranasal corticosteroids for those with concurrent allergic
rhinitis
– Topical or oral decongestants or antihistamines not
indicated due to lack of effect
Meltzer et. al. Mayo Clin Proc. 2011; 86: 427, Young J et al. Lancet. 2008; 371:908,
Chow et al. Clin Infect Dis. 2012; 54(8):e72-112
Acute Pharyngitis
AP is an inflammation
of the throat or
pharynx. In most
cases it is painful and
the initial infection
can extend for a
lengthy time period,
and is often referred
to as a sore throat.
 Acute Pharyngitis
• Classically the triad of fever, sore throat and
pharyngeal inflammation
• Pathogens:
– Viruses: Epstein-Barr, Cytomegalovirus, respiratory viruses,
enteroviruses, Herpes simplex type I
– Bacteria: Group A Streptococcus (GAS), Non-group A
Streptococcus, Arcanobacterium hemolyticum, and Fusobacterium
spp.
• Pharyngitis in 85-95% of adults and 80-85% of
children is due to viruses
• For uncomplicated pharyngitis, antibacterial therapy is
reserved for GAS infection
Pharyngitis
Acute pharyngitis can result in very
large tonsils which cause trouble
swallowing and breathing. Some cases
are accompanied by a cough or fever.

Most acute cases are caused by viral

Infections (40%–60%), with the
remainder caused by bacterial
infections, fungal infections, or irritants
such as pollutants or chemical substances.
 Clinical Features of Pharyngitis
Features suggestive of GAS Features suggestive of viral etiology
etiology Absence of fever
Sudden onset sore throat Conjunctivitis
Fever Coryza
Headache Cough
Tonsillopharyngeal inflammation Hoarseness
Tonsillopharyngeal exudate Ulcerative mouth lesions
Palatal petechiae Viral type rash
Tender anterior cervical adenopathy
Winter-early spring presentation
Age 5-15 years
History of exposure to GAS pharyngitis

Overlap between GAS and viral pharyngitis may be considerable

McIsaac et al. JAMA. 2004; 291:1587, Bisno et al. Clin Infect Dis. 2002; 35:113
 Table 1. Etiology of pharyngitis
Viral:
-Rhinoviruses
-Adenoviruses
-Herpes simplex virus (type 1
and 2)
-Parainfluenza virus
-Influenza virus
-Coxsackievirus A
--Epstein Barr virus
-Cytomegalovirus
-HIV-1
Bacterial:
-Streptococcus pyogenes (Group A
and C beta-hemolytic
streptococcus)
-N. gonorrhoeae
-Corynebacterium diphteriae
-Yersinia enterocolitica
-Treponema
Chlamydia pneumoniae
Mycoplasma pneumoniae and
hominis
Mixed anaerobic bacterial
infection (Vincent’s angina)
FeverPAIN criteria
•Fever (during previous 24 hours)
•Purulence (pus on tonsils)
•Attend rapidly (within 3 days after onset of symptoms)
•Severely Inflamed tonsils
•No cough or coryza (inflammation of mucus membranes in the
nose)

Each of the FeverPAIN criteria score 1 point (maximum score

of 5). Higher scores suggest more severe symptoms and likely
bacterial (streptococcal) cause.
A score of 0 or 1 is thought to be associated with a 13 to 18%
likelihood of isolating streptococcus.
A score of 2 or 3 is thought to be associated with a 34 to 40%
likelihood of isolating streptococcus.
A score of 4 or 5 is thought to be associated with a 62 to 65%
likelihood of isolating streptococcus
Treatment of sterptococcal pharyngitis:

1. The current recommended treatment for this infection is

penicillin V 25-50 mg/kg/day divided into a 4-dose-per-day
schedule for 10 days.
2. Benzathine penicillin (penicillin G) 50,000 u/kg
intramuscular
3. If a patient is penicillin-allergic: erythromycin 30 mg/kg/day
or azithromycin (given once daily for 5 days only) or
clarithromycin (twice daily for 10 days)

 First-generation cephalosporins
 Second-generation cephalosporins
 Antibiotics for adults aged 18 years and over
ANTIBIOTIC[A] DOSAGE AND COURSE LENGTH FOR ADULTS[B]

First choice

Phenoxymethylpenicillin 500 mg four times a day or 1000 mg twice a day for

5 to 10 days
Alternative first choices for penicillin allergy or intolerance [C]

Clarithromycin 250 mg to 500 mg twice a day for 5 days

Erythromycin 250 mg to 500 mg four times a day or 500 mg to

1,000 mg twice a day for 5 days
A]
 See BNF for appropriate use and dosing in specific populations, for example,
hepatic impairment, renal impairment, pregnancy and breastfeeding.
[B]
 Doses given are by mouth using immediate-release medicines, unless otherwise
stated.
[C] 
 Erythromycin is preferred in women who are pregnant.
 Antibiotics for  children and young people under 18 years
ANTIBIOTIC[A] DOSAGE AND COURSE LENGTH FOR children and
young people under 18 years [B]
First choice

Phenoxymethy 1 to 11 months, 62.5 mg four times a day or 125 mg twice a day for 5 to 10
lpenicillin days
1 to 5 years, 125 mg four times a day or 250 mg twice a day for 5 to 10 days
6 to 11 years, 250 mg four times a day or 500 mg twice a day for 5 to 10 days
12 to 17 years, 500 mg four times a day or 1,000 mg twice a day for 5 to 10
days

Alternative first choices for penicillin allergy or intolerance[C]

Clarithromycin 1 month to 11 years:

Under 8 kg, 7.5 mg/kg twice a day for 5 days
8 to 11 kg, 62.5 mg twice a day for 5 days
12 to 19 kg, 125 mg twice a day for 5 days
20 to 29 kg, 187.5 mg twice a day for 5 days
30 to 40 kg, 250 mg twice a day for 5 days
or
12 to 17 years, 250 mg to 500 mg twice a day for 5 days

Erythromycin 1 month to 1 year, 125 mg four times a day or 250 mg twice a day for 5 days
2 to 7 years, 250 mg four times a day or 500 mg twice a day for 5 days
Acute Tonsilitis

• Mainly a disease of childhood but is

also seen in adults.
Acute tonsillitis Organisms:
• Beta-haemolytic
• May occur streptococcus
primarily as • Staphylococcus
infection of the • Haemophilus
tonsils themselves influenzae
or may
secondarily occur • Pneumococcus
as a result of • The part played
URTI following by viruses in
viral infection. acute tonsillitis
is unknown.
 Pathology-1
• The process of inflammation
originating within the tonsil is
accompanied by hyperemia
and oedema with conversion
of lymphoid follicles in to
small abscesses which
discharge into crypts.
• When inflammatory exudate
collects in tonsillar crypts
these present as multiple
white spots on inflamed
tonsillar surface giving rise to
clinical picture of follicular
tonsillitis.
 Catarrhal tonsillitis
• When tonsils are
inflamed as part
of the
generalised
infection of the
oropharyngeal
mucosa it is
called catarrhal
tonsillitis.
 Membranous tonsillitis.
• Some times
exudation from
crypts may
coalesce to form
a membrane
over the surface
of tonsil, giving
rise to clinical
picture of
membranous
tonsillitis.
 Parenchymatous tonsillitis

• When the whole

tonsil is
uniformly
congested and
swollen it is
called acute
parenchymatous
tonsillitis
 Differential Complications
Diagnosis • Chronic tonsillitis
• Scarlet fever • Peri tonsillar
Abscess
• Diphtheria • Para Pharyngeal
• Vincent's Space Abscess
infection • Acute SOM
• Agranulocytosis • Acute nephritis
• RHEUMATIC Fever
• Glandular fever • Laryngeal edema
• Septicemia
Symptoms: Signs:
• Discomfort in • Swollen
throat congested tonsils
with exudates
• Difficulty in
swallowing • Enlarged tender
Jugulo-diagastric
• Generalised lymph nodes
body ache
• Fever
• Earache and
Thick speech
 Peritonsilar Abces
• is one of the complications of acute
tonsillitis and its development means
that infection has spread outside
tonsillar capsule.
• Spread of infection from tonsil or more
usually from a peritonsillar abscess
through the superior constrictor muscle
of the pharynx first results in cellulitis
of the neck and later in parapharyngeal
space abscess.
Peritonsillar Abscess or Quinsy
• It is a collection of
pus between fibrous
capsule of the tonsil
usually at its upper
pole and the superior
constrictor muscle of
pharynx.
• It usually occurs as a
complication of the
acute tonsillitis or it
may apparently arise
de novo with no
preceding tonsillitis.
Bacteriology
• The bacteriology of acute
tonsillitis and peritonsillar
abscess is different although one
is a complication of the other.
• The bacteriology of the quinsy is
characterized by mixed flora with
multiple organisms both aerobic
and anaerobic.
Clinical Features
• Fit and young adult with a prior history of
repeated attacks of acute tonsillitis.
• Preceded by a sore throat for 2-3 days
which gradually becomes severe and
unilateral.
• At this stage patient is ill with fever, often
a headache and severe throat pain made
worse by swallowing.
• There might be referred otalgia, pain and
swelling in the neck due to infective
lymphadenopathy. The patient’s voice
develops a characteristic ‘plummy’ quality.
Signs
• Ill looking patient
• Pyrexia
• Often with severe
trismus
• Striking asymmetry
with oedema and
hyperaemia of the soft
palate.
• Enlarged hyperaemic
and displaced tonsil
• Usually enlarged lymph
nodes in JD region.
Treatment
• Preferably admitted to hospital and
treated with analgesics and antibiotics.
• In a patient with an early peritonsillar
abscess which is really a peritonsillar
cellulitis incision and drainage are not
recommended.
• Indications for I/D
include marked
bulging of soft palate
or failure of an
assumed PTab to
respond to adequate
antibiotics. This is
undertaken at the
point of maximum
bulge.
• Interval tonsillectomy
after 6 weeks.
• Abscess tonsillectomy.
Complications

• Quinsy is a
potentially lethal
condition
• Pharyngeal &
Laryngeal
oedema
• Parapharyngeal
space abscess
Adenoiditis, adenoid hipertropi
Acute Laryngitis

It is the acute
inflammation of
larynx leading to
oedema of
laryngeal mucosa
and underlying
structures.
AETIOLOGY
INFECTIOUS:
Viral
Bacterial
NON INFECTIOUS
Inhaled fumes
Allergy
Polluted atmospheric conditions
Vocal abuse
Iatrogenic trauma
Predisposing factors
• Smoking

• Psychological strain

• Physical stress
PATHOLOGY
• The mucosa of the larynx becomes
congested and may become oedematous.
• A fibrinous exudate may occur on the
surface.
• Sometimes infection involves the
perichondrium of laryngeal cartilages
producing perichondritiis.
CLINICAL PRESENTATION
• Hoarseness or change in voice.
• Discomfort in throat, pain.
• Dysphagia, Dyspnoea.
• Dry irritating paroxysmal cough.
• Fever, Malaise.
CLINICAL DIAGNOSIS
• Signs of acute URTI.
• Dry sticky secretions.
• Congested and swallon vocal cords.
• Diffuse congestion of laryngeal
mucosa.
DIFFERENTIAL DIAGNOSIS
• Acute epiglottitis
• Acute laryngo tracheo bronchitis.
• Laryngeal perichondritis
• Laryngeal oedema
• Laryngeal diphtheria
• Reinke’s oedema
Chronic Laryngitis
Presents as diffuse lesion or produce localized effects
in larynx

– Chronic infections
– vocal abuse
– smoking,
– alcohal,
– irritant fumes.

.
Chronic Laryngitis
Histopathologically
there are mucosal thickining and
infilteration of plasma cells and
leukocytes. connective tissue elements
are increased.
chronic laryngitis differential
Reinkes oedema
vocal nodules
vocal cord polyp
Contact ulcer
Hyperkeratosis and leukoplakia
Atrophic laryngitis
Laryngeal lupus
tuberculous laryngitis
Vocal nodules
• Nodular thickining of the free edge of vocal
cord
• More common in females
• Usually are bilateral,symmetrical occuring at
the junction of anterior and middle third
• Develop as hyperplastic thickining of
epithelium because of vocal abuse
• Focal haemorrhage in subepithelial tissue
Vocal cord polyp
• Polypoidal lesion of cords
• More in male
• localised vascular engorgement
and microhaemorrhage followed
by oedema.
• Gelatinous,fibrous, talengiectatic
Tuberculous laryngitis
• Almost always to secondary to
pulmonary TB
• Infected sputum
• Younger age group
• Tubercle formation is characteristic
• Infilteration stage followed by
proliferative stage
• Posterior part of larynx involved
Voice Therapy

• Voice therapy is an approach to treating

voice disorders that involves vocal and
physical exercises coupled with behavioral
changes.
• The purpose of voice therapy is to help
attain the best possible voice and the
most relief from the vocal symptoms that
are bothering the patient
To improve vocal hygiene
• Drinking lot of fluids - Drink 7-9 glasses of water per day;
also good are herbal tea and chicken soup.
• maintaining good general health - Exercise regularly.
• Avoiding smoking - They are bad for the heart, lungs and
vocal tract.
• Eating a balanced diet - Include vegetables, fruits and whole
grain foods.
• Avoid dry, artificial interior climates.
• Do not eat late at night - may have problems when stomach
acid backs up on the vocal cords.
• Use a humidifier to assist with hydration.