Diseases of Upper

Respiratory System (URTI)

Dr Sarwar Hussain, Assistant Professor

Department Of Pediatrics, NBU
Anatomy of the Respiratory system
 URTI
Etiology & characteristics:
Viruses cause the largest number of respiratory
infections. Other organisms that may be involved in
primary or secondary invasion are group A beta-
hemolytic streptococcus, hemophiles influenza, &
pneumococci.
Infections are seldom localized to a single anatomic
structure, it tends to spread to available extent as a
result of the continuous nature of the mucous
membrane lining the respiratory tract.
 URTI
 Most URTIs are caused by viruses & are self-
limited.

 Acute cold & pharyngitis (including

tonsillitis) are extremely common in pediatric
age groups.
 URTI
1. Common cold. Viral infection of the nose
& throat with rhinorrhea and nasal
obstruction more correctly termed as
rhinosinusitis 6-7 colds/year (young
children)
Sign and Symptoms:
A. Younger child; Fever, sneezing, irritability,
vomiting & diarrhea
B. Older child; Dryness & irritation of nose &
throat, sneezing, & muscular aches.
 URTI
Complications of Common cold are:
 Otitis media
 Sinusitis
 Orbital cellulitis
 Lower respiratory tract infections
 Treatment: Acetaminophen, antibitics if
secondary infection, saline drops for
nasal congestion, avoid atihistamine &
decongestants in young children < than
6 years old
 URTI

Pharyngitis;
Bacteria; Group A beta hemolytic
Streptoccocus
Group C streptococcus (also β-hemolytic)
Arcanobacterium haemolyticum (β-hemolytic,
gram-positive rod)
Francisella tularensis (gram-negative
coccobacillus and cause of tularemia)
Staphylococcus aureus
Haemophilus influenzae, and
 viruses

Many viruses cause acute Tonsillopharyngitis;

1.Adenoviruses
2.Rhinoviruses
3.Epstein-Barr virus
4.Enteroviruses (herpangina)
5.Herpes simplex virus
6.(HIV)
 EPIDEMIOLOGY
1. Sore throat is the primary symptom
in1/3 of URI
2. Streptococcal pharyngitis is
uncommon before 2 to 3 years of age,
3. It increases in young school-age
children and then declines in late
adolescence and adulthood.
4. Streptococcal pharyngitis is on peak
during the winter and early spring.
5. Viral infections generally spread via
close contact with an infected person
•
Tonsillitis
Palatine tonsils
 CLINICAL
MANIFESTATIONS-1
Streptococcal pharyngitis is associated with
prominent;
1. Sore throat
2. Moderate to high grade fever, Headache, nausea
3. Red pharynx; Tonsils enlarged & membrane covered with
a yellow, blood tinged exudate.
4. Petechiae or doughnut-shaped lesions on the soft palate
and posterior pharynx, uvula red, stippled, and swollen.
If viral then;
1.Conjunctivitis,
2.Cough,
3.Coryza,
4.hoarseness, or ulcerations
 CLINICAL
MANIFESTATIONS-2
Scarlet fever: In addition to sore throat and
fever, some patients exhibit;
1.Scarlet fever
2.Circumoral pallor
3.Strawberry tongue, and a fine diffuse
erythematous macular-papular rash that has the
feeling of goose flesh.
4.White strawberry tongue white coating
5.Red strawberry tongue is beefy red with
prominent papillae.
 LABORATORY
EVALUATION
Difficult to distinguish pharyngitis caused by group A
streptococcus and nonstreptococcal (usually viral);
1. A rapid streptococcal antigen test
2. A throat culture, or both; Many rapid diagnostic
techniques for streptococcal pharyngitis are available with
excellent specificity of 95% to 99%.
3. Negative rapid tests should be confirmed by a throat
culture.
4. Throat culture is the diagnostic gold standard.
5. False-positive cultures can occur if other organisms are
incorrectly identified as group A streptococcus.
4. 20% of positive cultures in children during winter
months reflect streptococcal carriers not acute
pharyngitis.
 DIFFERENTIAL
DIAGNOSIS-1
DIFFERENTIAL ;
1.Retropharyngeal abscesses (S. aureus streptococci,
anaerobes)
2.Diphtheria
3.Peritonsillar abscesses (with quinsy sore
throat or unilateral tonsil swelling caused by
streptococci, anaerobes, or, rarely, S. aureus),
4. Epiglottitis
5. Neutropenic mucositis (leukemia, aplastic anemia)
6. Thrush (candidiasis secondary to T-cell immune
deficiency)
 DIFFERENTIAL
DIAGNOSIS-2
Vincent infection; (acute necrotizing
ulcerative gingivitis); a virulent form of
anaerobic pharyngitis;
Gray pseudomembranes on the tonsils.
Autoimmune ulceration (systemic lupus
erythematosus,
Kawasaki disease may cause
pharyngitis.
Epstein-Barr virus-associated
pharyngitis
 DIFFERENTIAL
DIAGNOSIS-3
Lemierre syndrome; Acute pharyngitis
complicated by thrombosis of the internal jugular
vein and septic emboli (most often to the lungs).
It occurs primarily in adolescents and is caused
by Fusobacterium necrophorum.
 DIFFERENTIAL
DIAGNOSIS-4
Ludwig angina;
Mixed anaerobic bacterial cellulitis of the submandibular
and sublingual regions.
a rapidly spreading bilateral cellulitis of the sublingual
and submandibular spaces.
It typically is due to spreading from a periapical abscess
of the second or third mandibular molar.
 It also has been associated with tongue piercing.
A propensity for rapid spread, glottic and lingual
swelling, and consequent airway obstruction makes
prompt intervention imperative.
A syndrome of;
 periodic fever, aphthous stomatitis, pharyngitis, and
cervical adenitis is a rare cause of recurrent fever in
children.
 Recurring nonspecific pharyngitis is accompanied by
fever and painful solitary vesicular lesions in the mouth.
The fevers begin at a young age (usually <5 years).
Episodes last approximately 5 days, with a mean of 28 days
between episodes.
Episodes are shorter with oral prednisone and
unresponsive to nonsteroidal anti-inflammatory drugs or
antibiotics.
The syndrome resolves in some but persists in other
children.
Long-term sequelae do not develop
 TREATMENT
1. Early antimicrobial therapy prevent acute rheumatic fever
2. If instituted within 9 days of illness is virtually 100%
successful in preventing rheumatic fever.
Antibiotic therapy should be started promptly in children with
1. A positive rapid test for group A streptococcus,
2. scarlet fever,
3. Symptomatic pharyngitis whose sibling has documented
streptococcal pharyngitis,
4. Apast history of rheumatic fever or
5. Arecent family history of rheumatic fever, or symptomatic
pharyngitis and living in an area experiencing an epidemic
of acute rheumatic fever or
6. Poststreptococcal glomerulonephritis
7. A variety of antimicrobial agents can be used to treat
streptococcal pharyngitis. Cephalosporins have superior
pharyngeal bacterial eradication rates compared to
 TREATMENT
A variety of antimicrobial agents can be used to
treat streptococcal pharyngitis;

1. Cephalosporins have superior pharyngeal

bacterial eradication rates compared to Penicillin
2. Oral penicillin V (2–3 times daily for 10 days) 10
mg/kg/dose,
maximum dose 250 mg/dose
3. Intramuscular benzathine penicillin G (single
dose)
For children ≤27 kg: 600,000 U
For larger children and adults: 1.2 million U
 TREATMENT
For persons allergic to penicillin;
Cephalexin 20 mg/kg/dose BID, maximum dose 500 mg/dose ×
10 days
Cefadroxil 30 mg/kg OD maximum, maximum dose 1 g × 10 days
Clindamycin 7 mg/kg/dose TID, maximum dose 300 mg/dose × 10
days
For persons allergic to β-lactams
Erythromycin
Erythromycin ethyl succinate: 40–50 mg/kg/day (max 1 g/day) in
3–4 doses for 10 days
Erythromycin estolate: 20–40 mg/kg/day in 2–4 doses (max 1
g/day) for 10 days
Azithromycin, children: 12 mg/kg orally once daily for 5 days (to
maximum adult dose); adults: 500 mg orally on day 1, then 250 mg
 TREATMENT
Tonsillectomy:
If a child has severe tonsillitis that is recurrent,
persistent and troublesome, i.e; in cases where the
child is subjected to around 4 attacks a year for two
years or more, then surgery should be considered as
an option.
Surgery might also be considered if the tonsils were so
large that they are causing breathing problems at
night.
 COMPLICATIONS AND
PROGNOSIS
Pharyngitis caused by streptococci or respiratory viruses
usually resolves completely.

Suppurative Complications of group A streptococcal pharyngitis

include;
1.parapharyngeal abscess
2.infections of the deep fascial spaces of the neck,
Nonsuppurative complications;
1.Acute rheumatic fever
2.Acute postinfectious glomerulonephritis.
3.Viral respiratory tract infections (influenza A, adenoviruses,
parainfluenza type 3, and rhinoviruses) may predispose to bacterial
middle ear infections.
 PREVENTION

Antimicrobial prophylaxis with daily oral penicillin V

prevents recurrent streptococcal infections and is
recommended only to prevent recurrences of
rheumatic fever.
 Otitis Media

Background:
Otitis media (OM) is the second most common disease
of childhood, after upper respiratory infection (URI).

Etiology & Definition:

Otitis media is a suppurative infection of the middle ear
cavity.
 Pathophysilogy of Otitisa
Media (OM)
Bacteria gain access to the middle ear when the normal
patency of the eustachian tube is blocked by upper
airway infection or hypertrophied adenoids.
Air trapped in the middle ear is resorbed, creating
negative pressure in this cavity and facilitating reflux of
nasopharyngeal bacteria.
Obstructed flow of secretions from the middle ear to
the pharynx combined with bacterial reflux leads to
infected middle ear effusion.
 Etiology
Causative agents;
Both bacteria and viruses can cause OM. The common
bacterial pathogens are
1.Streptococcus pneumoniae,
2.Haemophilus influenzae,
3. Moraxella catarrhalis, and,
4.group A streptococcus.
5.S. pneumoniae
Viruses;
1.Rhinoviruses,
2.influenza, and
3.Respiratory syncytial virus, in 20%-25% of patients.
 EPIDEMIOLOGY

1. The peak incidence of acute OM is between 6 and 15

months of life.
2. Few first episodes occur after 18 months of age.
3. OM is more common in boys and in patients of lower
socioeconomic status.
4. OM more common in Native Americans and Alaskan
Natives and in children (HIV), cleft palate, and trisomy
21.
5. Peak in January and February due to rhinovirus,
respiratorysyncytial virus, and
 Risk factors

The major risk factors for acute OM are;

1.Young age,
2.Lack of breastfeeding
3. Passive exposure to tobacco smoke
4. Increased exposure to infectious agents (day care).
5.Craniofacial anomalies and immunodeficiencies
CLINICAL MANIFESTATIONS
1. Ear Pain
2. Hearing Loss
3. Otorrhea (ear drainag)
4. Hyperemia, or red coloured tympanic
membrane
5. Purulent drainage confirms perforation
6. Bullae on the lateral aspect of the tympanic
membrane
 LABORATORY AND
IMAGING STUDIES
1. Pneumatic otoscopy; Using an attachment to a
hermetically sealed otoscope, allows evaluation of
ventilation of the middle ear and is a standard for
clinical diagnosis.
2. Tympanometry; Provides objective acoustic
measurements of the tympanic membrane-middle ear
system by reflection or absorption of sound energy
3. Tympanogram; Correlate well with the presence
or absence of middle ear effusion.
4. Acoustic reflectometry
5. Tympanocentesis
 TREATMENT
1. Acetaminophen and ibuprofen are recommended for fever.
2. If < 2 years of age or have fever > 39° C or otalgia;
-Give amoxicillin (80 to 90 mg/kg/day in two divided doses).
Children with an uncertain diagnosis & 2 years of age may be
observed if appropriate follow- up can be arranged.
3. If no improvement after 3 days treatment it suggests infection
with β-lactamase-producing H. influenza, M. catarrhalis or resistant S.
pneumoniae
4. Then give high-dose amoxicillin-clavulanate (amoxicillin 80 to 90
mg/kg/day), or ceftriaxone (50 mg/kg intramuscularly in daily doses
for 1 to 3 days).
5. Recurrent acute OM, 3 months of persistent effusion
with significant bilateral hearing loss is a reasonable
indicator of need for intervention with insertion of pressure
equalization tubes.
 PREVENTION

1. Exclusive breastfeeding
2. Risks of children taking a bottle to bed should be discouraged
3. The home should be a smoke-free environment
4. Children at high-risk need prophylaxis
5. Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50
mg/kg/day) given once daily at bedtime for 3 to 6 months or
longer
6. The conjugate S. pneumoniae vaccine reduces pneumococcal
OM by 50%, all pneumococcal OM by 33%, and all OM by 6%
7. Annual immunization against influenza virus may be helpful in
high-risk children.
 COMPLICATIONS AND
PROGNOSIS

1. Cholesteatoma (mass-like keratinized epithelial

growth)
2. Petrositis, intracranial extension (brain abscess,
subdural empyema, or venous thrombosis)
3. Acute mastoiditis
4. Persistent middle ear effusion
5. Conductive hearing loss