URTI and SINUSITISURTI and SINUSITIS
Trevor Langhan PGY-1
January 28, 2004
OBJECTIVESOBJECTIVES
Review common URTI’s presenting to the emergency department
Evidence supporting current URTI management
Complications of URTISinusitis
CASECASE
8 year old boy brought in by mother with 3 day history of runny nose. Started as a scratchy throat, now resolved. Symptoms primarily runny nose, feeling unwell, dry cough. Otherwise healthy.– Further history?– Investigations?– Recommendations for parents?
TONSILLOPHARYNGITISTONSILLOPHARYNGITIS
Among most common reasons for seeking medical attention
Inflammatory syndrome of the oropharynx Transmission mainly via contact with respiratory
secretions Infection localizes to lymphatic tissue
Suppuration and swelling of tonsils Tender cervical lymph nodes Fever
PHARYNGITISPHARYNGITIS
Complications range from:– OM due to eustachian tube occlusion– life-threatening airway obstruction– dehydration due to decreased PO intake
PHARYNGITISPHARYNGITIS
Most common pathogen viral infection Bacterial pathogen differs between children and
adults: Children:
– Group A beta-hemolytic strep 30% Adults:
– 23% GABHS– Mycoplasma pneumoniae 9%– Chlamydia pneumoniae 8%
PHARYNGITISPHARYNGITIS
Most common clinical symptom is pharyngeal pain radiating to ears
Clinically differentiating offending organism has been shown to be virtually impossible
Exam will reveal: pharyngeal erythema tonsillar exudates and enlargement tender cervical lymphadenopathy
PHARYNGITISPHARYNGITIS
Systemic viral infections may manifest clinical symptoms of pharyngitis
Measles, CMV, rubella, HIV, EBV Influenza Often with concomitant rhinorhea, headache, stomatitis,
conjunctivitis, exanthem, odynophagia
Herpes virus may also cause pharyngitis Painful superficial vesicles +/- ulcerations May be primary or reactivation of herpes infection
PHARYNGITISPHARYNGITIS MANY other potential pathogens of pharyngitis:
Corynebacterium diphtheriae– white/gray membranous tonsillitis, potentially lethal due to toxin that causes: myocarditis, vascular collapse, diffuse focal organ necrosis
Arcanobacterium hemolyticum (corynebacterium) – 10-30 year age group, typically with associated rash
Anaerobic pharyngitis (Vincent’s angina) Gonococcal pharyngitis – STD, NB source of gonococcemia Tuberculosis – usually advanced TB disease Candidial pharyngitis - immunocompromised Mycolasma pneumoniae – mild pharyngitis, epidemics due
to overcrowding, may include LRTI Chlamydia pneumoniae, Chlamydia trachomatis - STD
DIAGNOSTIC STRATEGIESDIAGNOSTIC STRATEGIES
Monospot test positive during mononucleosis infection in:
95% of adults 90% of children older that 5 75% of children 2-4 30% of children 0-20 months
EBV nuclear antigens develop in 100% of cases by 3-6 weeks (useful if an original negative test becomes positive)
Atypical mononuclear cells in 75% of pts (peaks in 2-3 weeks of illness)
GABHSGABHS
Primarily a disease of children 5-15 years <15% of pharyngitis in patients over 15 years, and
rare in age <3 years Viral symptoms tend to be absent
Cough, rhinorhea, coryza Fever >38.3, tonsillar exudates, uvular edema and
erythema, tender anterior cervical lymphadenophathy (all 4 <10% of cases)
Recent exposure to other pt’s with GABHS pharyngitis increases risk of infection
GABHSGABHS
Clinical prediction rules for pharyngitis– Centor criteria cite a sensitivity and specificity of
75% if three or four of following are present: Tonsillar exudates Tender anterior cervical adenopathy History of fever >38 Absence of cough
– University of Michigan Prediction rule Add score if +3 likely GABHS, if –1 or –2 unlikely, if 0,1,2
consider testing +1 for each fever, tonsillar exudates, cervical adenopathy -1 for each cough, post-nasal drip
GABHSGABHS Rapid diagnostic tests for GABHS exist Rapid Strep Test (RST)
Specificity 70-100%, sensitivity 31-100% Actual practice S&S lower than reported trials
Positive RST usually indicates presence of S. pyogenes in pharynx (?carriers)
Currently should only use RST if Hx consistent with GABHS infection
A negative result must be followed by a confirmatory culture
Searching for GABHS as bacterial pathogen is insufficient Other treatable organisms must be ruled out
MANAGEMENTMANAGEMENT
GABHS often treated empirically May shorten course of disease
RST not always accurate Clinical judgment is insufficient Arguments against empiric treatment:
Increased recurrences Increased bacterial drug resistance Decreased immune response Patient expectation for antibiotics with subsequent
episodes
MANAGEMENTMANAGEMENT
Why treat GABHS? Untreated lasts 3-4 days Early treatment leads to 13% earlier resolution of
symptoms (shortens by 1 day) Must treat within 9 days to prevent rheumatic fever
(RF) Incidence of RF mirrors GABHS infection (mostly 5-
15 years old) RF complicates 0.3% of GABHS infections Post-strep infection glomerulonephritis?
ABX don’t affect renal disease
MANAGEMENTMANAGEMENT
Treatment of GABHS in children based on evidence of infection
RST or positive culture
Four possible ED strategies Culture all pharyngitis pts and treat the +ves Treat all patients, obtain culture and stop treatment if –ve Perform RST and treat the +ve results Treat all pts with clinically possible GABHS
MANAGEMENTMANAGEMENT Antibiotic choices:
IM injection of 1.2 million U benzathine penicillin 10 day course of Pen V 250 mg TID – QID Erythromycin for pts allergic to Penicillin Alternative choices cephalosporins, clindamycin, macrolide should be
reserved for non-responders
Complications may include: Airway compromise Rheumatic Fever, post-strep GN Peri-tonsillar abscess (Quinsy) Cervical lymphadenitis Mastoiditis Sinusitis Otitis media Transmission to others
MANAGEMENTMANAGEMENT
Most cases of pharyngitis are benign and self-limited Many of the other pathogens covered by Penicillin or
Erythro, but some require specific antibiotics NB considerations of EBV mono infections
Avoid contact sports for 6-8 weeks
OTHER URTI’sOTHER URTI’s
Lingual Tonsillitis Laryngitis Epiglottitis Peri-tonsillitis (cellulitis and/or abscess) Ludwig’s Angina Retro-pharyngeal abscess Pre-vertebral space abscess Para-pharyngeal abscess
COMMON COLDCOMMON COLD
MOST common reason for seeking medical evaluation
Second most common reason for antibiotic prescriptions in outpatient setting
A benign self-limited syndrome Represents a group of diseases caused by several
families of viruses
COMMON COLDCOMMON COLD
Enormous economic burden of illness– Lost productivity– Expenditures for treatment– U.S. $3.5 billion per year– 26 million lost work days, 23 million lost school
days per year– 40% of all job time lost– 5-7 episodes/year pre-school children– 2-3 episodes/year adulthood
COMMON COLDCOMMON COLD
10 – 40% Rhinovirus – 100 serotypes 28% Coronaviruses 10% Respiratory Syncytial Virus (RSV) Influenza, parinfluenza, adenoviruses may cause
URTI cold symptoms, but predominantly have LRTI effects
Clinically can’t differentiate pathogen
COMMON COLDCOMMON COLD
Most viral pathogens that can produce cold symptoms have ability to re-infect
Second or third course of illness symptoms are milder and illness is of shorter duration
Three routes of transmission: Direct contact Small particle aerosol Large particle aerosol
COMMON COLDCOMMON COLD
Direct contact most efficient mechanism Related to time spent together Amount of shed virus Close quarters (school, homes) Second attack rate 25-75%
Hand to hand contact NB role in transmission Mucoid secretions to own hand, then someone else’s
hand who contacts their own mucus membranes Virus viable on skin for up to 12 hours Studies have shown rhinovirus on skin in 40-90% of
people exhibiting cold symptoms 6-15% of inanimate objects in pt’s immediate surroundings
COMMON COLDCOMMON COLD
Aerosol particles– Study locked volunteers in room with susceptible
hosts– Hands restrained from self or person to person
contact– 56% of susceptible hosts became infected– ?re-circulated air in planes
1100 passengers in LA – Denver flights 53% re-circulated air, 47% fresh vented air No difference in self-reporting of cold symptoms, runny
nose or constellation of 8 other symptoms
COMMON COLDCOMMON COLD
Incubation period 24-72 hours from time of contact to onset of symptoms
RSV particularly highly contagious High aerosol infectivity leads to concerns over
nosocomial spread Virus is stable at 37 degrees for ~1 hour Saliva is not an effective transmission vector of most
cold viruses No detectable virus in saliva of 90% of symptomatic
patients
COMMON COLDCOMMON COLD Most common symptoms rhinorhea, sneezing and scratchy
throat Cough develops 4th – 5th day of illness Symptoms persist for 3-7 days 25% of cases may persist for 2 weeks Risk factors for more significant disease
Young age Low birth weight Prematurity Chronic disease Crowding Malnutrition Immunodeficiency disorders
COMMON COLDCOMMON COLD
URTI progression to LRTI RSV most concerning pathogen
2-9% of pneumonia in elderly Exacerbations of CHF, COPD
Viral URTI implicated in 40% of adult acute asthma attacks
Rhinovirus induces increased airway hyper-reactivity Changes may persist for up to 4 weeks Via local inflammation of epithelial cells in LRT Inflammation of URT with inflammatory mediators acting
distally
TREATMENT OPTIONSTREATMENT OPTIONS
Ipatromium Bromide Cromolyn Sodium Anti-histamines Anti-tussives Decongestants Zinc Vitamin C Echinacea
TREATMENT OPTIONSTREATMENT OPTIONS
Ipatropium Bromide– Rhinorhea and sneezing improved by intranasal
injection– RCT, n=411, age 14-56, inclusion criteria cold
symptoms <36 hours– Decreased volume nasal discharge 26%– Decreased severity of rhinorhea 31%– Lower sneezing frequency days 2 & 4– Mildly increased rates of blood-tinged mucus and
nasal discharge
TREATMENT OPTIONSTREATMENT OPTIONS
Cromolyn Sodium– Mast cell stabilizer– Placebo controlled, RCT– Inclusion if cold symptoms <24 hours– N=118, age 21-63– Taken q2h for day 1-2 then QID day 3-7– Faster symptom resolution (p<0.001)– Decreased symptom severity in last three days of
illness
TREATMENT OPTIONSTREATMENT OPTIONS
Anti-histamines (I.e. Benadryl)– May alleviate rhinorhea/sneezing, limited by
sedation and drying of eyes, nose, mouth– Broad review article findings
3 of 5 studies had statistically significant improvements in sneezing frequency
3 of 7 improvement in nasal discharge No overall improvement in total symptom
scores Little support in literature for use of
antihistamines
TREATMENT OPTIONSTREATMENT OPTIONS
Anti-tussives– Cough secondary to nasal obstruction or post-
nasal drip– Dextromethorphan (DM)
No better than placebo during day DM and B2 agonist improved night cough vs.
DM or placebo alone– Codeine
Effective in suppressing chronic cough Little efficacy compared with placebo in acute
cough
TREATMENT OPTIONSTREATMENT OPTIONS
Decongestants (I.e. pseudoephedrine)– Nasal congestion may be alleviated by topical and
oral adrenergic agents– Large meta-analysis 13% decrease in subjective
symptoms after decongestant Nasal congestion Headache Nasal discharge
TREATMENT OPTIONSTREATMENT OPTIONS
Zinc– 1970’s zinc ions inhibit rhinovirus replication in vitro– ? Value of zinc lozenge to treat common cold– Some studies have found decreased duration of cold
symptoms– Improved benefit if start Zinc treatment <24 hours after
symptoms onset– Cleveland Clinic trial with hosp staff
Earlier resolution of headache, cough, throat and nasal symptoms
4.4 vs. 7.6 days, p<0.001– Large meta-analysis shows inconsistent evidence, at best
limited benefit
TREATMENT OPTIONSTREATMENT OPTIONS
Vitamin C– Numerous RCT’s– Vitamin C of no benefit to prevent common cold
infections– But amalgamation of findings in 21 studies show:
23% decrease symptom duration Decrease in symptom severity scores
TREATMENT OPTIONSTREATMENT OPTIONS
Echinacea– Review of 16 placebo-control prevention trials failed to
demonstrate effective cold symptom treatment or prevention
– Treatment: RCT, n=148, symptoms <36 hours Symptom duration similar (6.27/5.75 – plac/ech)
– Prevention: RCT, n=109, 3 or more URTI past 1 year Insignificant proportional reduction in incidence of colds RR 0.88
– Safe, but no evidence of treatment or preventative benefits
TREATMENT OPTIONSTREATMENT OPTIONS
Summary of options: Ipatromium Bromide and Cromolyn Sodium
show most evidence for symptomatic relief of viral URTI
Anti-histamine and anti-tussive therapy limited to improvement in symptomatology at night
Decongestants appear to have some beneficial effects for daytime symptoms
Vitamin C and Echinacea are safe, but have no preventative effects in acquisition of URTI
COMPLICATIONS of URTICOMPLICATIONS of URTI
Acute sinusitis– Definition: inflammation of the mucosa of
the paranasal sinuses, regardless of cause Most common risk factors for acute sinusitis:
– pre-ceding viral URTI– allergic rhinitis– Trauma– dental infections
COMPLICATIONS of URTICOMPLICATIONS of URTI
Acute bacterial sinusitis develops in 0.5-2.5% of adult pts after viral URTI
Viral sinusitis far more common 197 pts with cold symptoms had X-rays taken on days 1,
7, 21 No associated symptoms suggestive of bacterial sinusitis
– Maxillo-facial or upper teeth pain 39% of 197 pts had radiographic evidence of sinusitis on
day 7 More likely to have purulent d/c on day 7 All evidence of sinusitis on x-ray resolved by day 21 with
no antibiotic therapy
SINUSITISSINUSITIS
Most likely bacterial pathogens: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis
Complications of untreated bacterial sinusitis very uncommon
Orbital cellulitis Tooth abscess meningitis
SINUSITISSINUSITIS
Para-nasal sinuses (frontal, maxillary, ethmoid, sphenoid) named for facial bones they occupy
Maxillary sinus triangular with base on lateral nasal wall and apex in zygoma
Ethmoid sinus can be divided into anterior and posterior air cells (between 2 and 8 in each)– Blood supply of ethmoid cells directly connected
with ophthalmic vessels and cavernous sinus– Risk of spread of infection to CNS or orbit
SINUSITISSINUSITIS
Focal point of sinus disease is the ostiomeatal complex
Located between the inferior and middle nasal turbinates
Site of drainage for the maxillary, anterior ethmoid and frontal sinuses
Healthy sinus requires patent ostia with free air exchange and mucus drainage
Inflammation of mucosa and obstruction of tubes commonly inhibits sinus drainage
Also affected by ciliary dismotility disorders
SINUSITISSINUSITIS
SINUSITISSINUSITIS
SINUSITISSINUSITIS
Bacterial is suggested over viral by: persistent symptoms worsening after 5 days “double sickening”
Best predictors of diagnosis of acute bacterial sinusitis
Duration of symptoms >7 days (sensitive, but not specific predictor)
Purulent nasal discharge Maxillary tooth or facial pain (esp. unilateral) Unilateral maxillary sinus tenderness Lack of response to decongestants
SINUSITISSINUSITIS
Physical exam best performed after topical decongestant
Note mucosal edema and erythema May see purulent drainage from nasal meatus if ostia
is not completely obstructed Diagnosis is usually clinical Nasal and nasopharyngeal cultures usually differ
from culture result after surgical correction Radiography should be limited to:
– questionable diagnosis– unresponsive disease– search for complications
SINUSITISSINUSITIS
Clinical exam findings found by review of literature to improve sensitivity include:– Purulent secretions– Pain in teeth– Two phases to illness history– Elevated ESR or C-reactive protein– Symptoms >7 days
Varonen et al. reviewed 11 evidence based studies– Clinical exam has 75% sensitivity– Radiographic methods >80%
SINUSITISSINUSITIS
Lau et al. reviewed 14 studies to compare various imaging studies to clinical exam
Sinus puncture with +ve culture was used as gold standard for diagnosis of sinusitis
Technique Sensitivity Specificity
X-ray Variable Variable
CT scan High Poor
MRI High Poor
Sinus Puncture
High High
Clinical exam
High moderate
SINUSITISSINUSITIS
Lau et al. reviewed 14 studies to compare various imaging studies to clinical exam
Sinus puncture with +ve culture was used as gold standard for diagnosis of sinusitis
Technique Sensitivity Specificity
X-ray Variable Variable
CT scan High Poor
MRI High Poor
Sinus Puncture
High High
Clinical exam
High moderate
SINUSITISSINUSITIS
CT scan preferred imaging method but expensive Limit use to complicated cases May have high false positive rates
Accuracy of plain films much higher in maxillary sinusitis compared with other sinuses
Water’s view alone can evaluate the maxillary sinus May miss pathologic conditions in other sinuses Positive findings on plain films include:
Sinus opacity Air-fluid level Mucosal thickening of 6 mm or more
SINUSITISSINUSITIS
SINUSITISSINUSITIS
Burke et al. Comparison of sinus x-rays with computed tomography scans in acute sinusitis. Acad Emeg Med. 1994 May-Jun;1(3):235-9.
30 consecutive ED pts with clinical diagnosis of sinusitis X-ray same day and CT within 72 hours Films read in blinded fashion by 2 radiologists, or 2
radiologists and 2 EM 21 +ve on CT by radiologists Frequent missed diagnosis on plain films when
inflammation was in sinus other than maxillary Concluded plain films not reliable enough to assist
clinical decision making
SINUSITISSINUSITIS
SINUSITISSINUSITIS
Decongestant therapy used to reduce tissue edema, facilitate drainage, and maintain patency of ostia
No good adult evidence for decongestants, but routinely recommended
Simultaneous use of topical and systemic decongestants
Limit topical agents to 3-5 days Extended use leads to rebound vasodilatation and nasal
obstruction (rhinitis medicamentosa)
SINUSITISSINUSITIS
Large proportion of viral and bacterial sinusitis resolve spontaneously
Should start antibiotic therapy if suspicious of bacterial disease Must consider beta-lactamase producing organisms and
penicillin resistant streptococcus pneumoniae species 10 day course of amoxicillin first line agent Failure of symptom resolution after 7 days of Antibiotics
mandates change to broader spectrum Amox-clav, cefuroxime for 10-14 days Consider adding flagyl fro anaerobic coverage
Clinical practice guidelines (Clinical practice guidelines (Pediatrics,Pediatrics, September 2001) were September 2001) were prepared by the Subcommittee on Management of Sinusitis and the prepared by the Subcommittee on Management of Sinusitis and the Committee on Quality Improvement of the American Academy of Committee on Quality Improvement of the American Academy of Pediatrics (AAP).Pediatrics (AAP).
Recommendations on diagnosis based on limited scientific evidence and strong consensus of the panel
Based on clinical criteria in children with persistent or severe upper respiratory symptoms– Persistent symptoms are defined as those lasting longer than
10-14 days (and <30 days)– namely nasal or postnasal discharge (of any quality)– daytime cough or both– Severe symptoms are defined as a temperature of >102° F
(39° C)– purulent nasal discharge present concurrently for >3-4 days in
a child who appears ill Imaging studies are not necessary to confirm a diagnosis of
clinical sinusitis in children <6 years of age.
Clinical practice guidelines (Clinical practice guidelines (Pediatrics,Pediatrics, September 2001) were September 2001) were prepared by the Subcommittee on Management of Sinusitis and the prepared by the Subcommittee on Management of Sinusitis and the Committee on Quality Improvement of the American Academy of Committee on Quality Improvement of the American Academy of Pediatrics (AAP). Pediatrics (AAP).
Adhere to the described diagnostic criteria to avoid antibiotic use for viral URIs
I.e. not using antibiotics for symptoms lasting <10 days, a presumed viral infection
Recommend antibiotics to achieve a more rapid clinical cure – strong recommendation based on good evidence and strong
consensus panel– Specific antibiotics recommended in the guideline’s algorithm are
based upon several criteria: severity of symptoms (mild/moderate or severe) attendance at day care recent (<90 days) antibiotic use
Attendance at day care or recent antibiotic use have been shown in published studies to be significant risk factors for acquisition of drug-resistant S. pneumoniae (DRSP)
Clinical practice guidelines (Clinical practice guidelines (Pediatrics,Pediatrics, September 2001) were September 2001) were prepared by the Subcommittee on Management of Sinusitis and the prepared by the Subcommittee on Management of Sinusitis and the Committee on Quality Improvement of the American Academy of Committee on Quality Improvement of the American Academy of Pediatrics (AAP).Pediatrics (AAP).
Diagnosed with sinusitis of mild/moderate severity– Children who attend day care– Have been prescribed a recent course of antibiotics– who present with severe symptoms should receive high-
dose amoxicillin-clavulinic acid, cefuroxime, cefpodoxime, or cefdinir
Diagnosed with sinusitis of mild/moderate severity– does not attend day care– has not recently been prescribed antibiotics– should receive usual or high-dose amoxicillin (45 mg/kg/day
to 90 mg/kg/day divided twice daily)
Clinical practice guidelines (Clinical practice guidelines (Pediatrics,Pediatrics, September 2001) were September 2001) were prepared by the Subcommittee on Management of Sinusitis and the prepared by the Subcommittee on Management of Sinusitis and the Committee on Quality Improvement of the American Academy of Committee on Quality Improvement of the American Academy of Pediatrics (AAP).Pediatrics (AAP).
High-dose regimens of amoxicillin or amoxicillin-clavulinic acid – Result in sinus concentrations above the minimum inhibitory
concentration (MIC) for S. pneumoniae that have intermediate resistance to penicillin
– Amoxicillin-clavulinic acid and cephalosporins all have good activity toward ß-lactamase producing H. influenzae and M. catarrhalis
– Duration of antibiotic therapy has not been well studied– Empiric durations of 10-28 days are described– Another strategy suggests continuing therapy for 7 days
beyond the resolution of symptoms
Clinical practice guidelines (Clinical practice guidelines (Pediatrics,Pediatrics, September 2001) were September 2001) were prepared by the Subcommittee on Management of Sinusitis and the prepared by the Subcommittee on Management of Sinusitis and the Committee on Quality Improvement of the American Academy of Committee on Quality Improvement of the American Academy of Pediatrics (AAP).Pediatrics (AAP).
Extent of resistance to penicillin by S. pneumoniae varies throughout the country
average rate of approximately 25% (50% intermediate resistance and 50% highly resistant)
adjust guidelines accordingly (i.e., greater use of high-dose amoxicillin therapy with higher rates of resistance)
Approximately 50% of H. influenzae and nearly 100% of M. catarrhalis organisms produce ß-lactamase enzymes, and thus are resistant to usual or high-dose amoxicillin
Clinical practice guidelines (Clinical practice guidelines (Pediatrics,Pediatrics, September 2001) were September 2001) were prepared by the Subcommittee on Management of Sinusitis and the prepared by the Subcommittee on Management of Sinusitis and the Committee on Quality Improvement of the American Academy of Committee on Quality Improvement of the American Academy of Pediatrics (AAP).Pediatrics (AAP).
Several adjuvant therapies have been recommended for sinusitis
Due to a lack of data on their efficacy, the panel did not offer specific recommendations on these therapies
Such therapies include:– nasal irrigation– Antihistamines– Decongestants– mucolytic agents– intranasal steroids
The panel offered no recommendations on either the use of antibiotic prophylaxis or complementary/alternative medicine
SINUSITIS COMPLICATIONSSINUSITIS COMPLICATIONS
Failure of definitive outpatient antibiotic therapy suggests sinusitis has become chronic
Requires referral to otolaryngologist Usually receive 3-6 weeks course antibiotics
Frontal or sphenoid sinusitis with air-fluid level requires admission if patient has poor home supports
Admission and IV antibiotics for patients who: Appear toxic Have compromised immune system Poor home resources Severe headache Neurologic or visual changes
SINUSITIS COMPLICATIONSSINUSITIS COMPLICATIONS
Complications can be severe Infections may involve bones and soft tissues of face
and orbit Patients with orbital complications have:
marked swelling decreased ocular motility decreased visual acuity
Intracranial involvement possible: Meningitis cavernous sinus thrombosis epidural or subdural empyema brain abscess
QUESTIONS?QUESTIONS?