Upper respiratory tract infections

Chronic Upper Respiratory Tract Infections (URTIs)

• Chronic sinustis with postnasal drip is the most common cause of chronic pharyngitis and laryngitis
• Chronic tonsillitis is also common in children and responsible for rheumatic heart disease

Diagnosis and Management

• Diagnosis is essentially clinical due to long duration of symptoms
• Investigations can help in proper management
• Antibiotics must be given on culture and sensitivity basis
• Surgery plays an important role in treatment, including: • Tonsilectomy • Correction of deformities in sinuses • Resection of laryngeal nodes

Complications

• Postnasal drip can cause recurrent pneumonia, lung abscess, or bronchiectasis
• Chronic streptococcal pharyngitis can cause rheumatic fever
• Obstructive sleep apnea and its sequelae
• Mucosal metaplasia and dysplasia with malignant transformation, especially in the larynx
• Acts as a septic focus causing poor general health
• Cervical lymph node ++ with chronic abscess formation

Review Questions

• Infections in upper airways include the following except: tracheitis
• Upper respiratory tract infections are the commonest among human infections, have many risk factors, and can be caused by viruses, bacteria, and fungi
• Acute infective epiglottitis is a disease of children, caused by viruses and hemophilus influenzae, and a medical emergency as it could be fatal
• Chronic upper respiratory infections almost follow poorly treated acute infections

Examination

• General: • Fever • Aches • Prostration • Skin rashes • Red wet eyes
• Local: • Evidence of inflammation in nasal mucosa • Pharynx is red and swollen with white spots in follicular tonsillitis • Laryngeal redness and swollen vocal cords and/or epiglottis on indirect laryngoscopy
• In diphtheria: • Marked swelling of neck lymph nodes • A pseudomembrane covers the pharynx, which bleeds when removed

Investigations

• General lab: • CBC: leukocytosis with neutrophilia in bacterial and lymphocytosis in viral and chlamydial infections • Increase in IgM against causative virus, chlamydia, and mycoplasma • Rise of acute phase reactants: ESR, CRP, and ferritin
• Swabs from nasal, pharyngeal, or laryngeal secretions: • Examined for gram stain, bacterial culture • Viral markers and PCR
• Sinoscopy and laryngoscopy: • Direct inspection of mucosal inflammation in nasal sinuses and larynx • Direct sampling: secretions, swabs, biopsy

Differential Diagnosis

• The main differential diagnosis is from upper respiratory allergy, which is characterized by: • Other allergic manifestations like asthma, urticaria, eczema, or conjunctivitis • Relation to allergens, e.g., cats, hay • Seasonal recurrence • High IgE or positive skin tests for specific allergens

Treatment

• In bacterial infections: • Start with broad-spectrum antibiotics, like amoxycillin clavulinate, macrolides, or quinolones • If response is poor, give according to culture and sensitivity
• In viral infections: • Antiviral drugs, e.g., isoprinosine, oseltamivir, famivir
• In paranasal sinusitis: • Decongestants and antihistamines help clearance of secretions • Alkaline nasal wash helps in killing organisms and healing of mucosa
• Epiglottitis: • Hospitalize the patient • Steam inhalation soothes the airways • Racemic epinephrine inhalation by a nebulizer • Oxygen must be ready • Corticosteroids (iv & inhalation) reduce edema and improve the critical airways • Intubation or tracheostomy if the patient suffocates (stridorous) • Antibiotics to cover hemophilus influenzae & streptococci (amoxycillin clavulinate, 3rd gen cephalosporins) • Antivirals in viral causes

اللهم ارحم شهداء فلسطين والسودان