RhinopharyngitisNasopharyngitis (rhinopharyngitis or the common cold) = Inflammation of the nares, pharynx, hypopharynx, uvula, and tonsilsOccur year round, but mostly during fall and winter. Epidemics is most common during cold months, with a peak incidence in late winter to early spring.Humidity may also affect the prevalence of colds, because most viral URI agents thrive in the low humidity characteristic of winter months

Etiology of rhinopharyngitisRhinoviruses: These cause approximately 30-50% RSVCoronaviruses: Enteroviruses, including coxsackieviruses, echoviruses, and others: These are also leading causes of the common cold.Other viruses: Adenoviruses, orthomyxoviruses (including influenza A and B viruses), paramyxoviruses , EBV, account for many URIs. Varicella, rubella, and rubeola Bacteria ( very rare): streptococci , staph, diphteria, B pertussis,Haemophilus, Pneumococcus, Neisseria, Treponema

Risk factors

Contact: Close contact with small children settings, such as school or daycare, increases the risk of URI.Travel: , exposure to large numbers of individuals in closed settings. Increased exposure to respiratory pathogens Environmental factors such as passive smoking and exposure to pollutants Immunocompromise that affects cellular or humoral immunity: Splenectomy, HIV infection, corticosteroids, immunosuppressive treatment , familial predisposition with immunological defects or anatomical and/or physiological features MalnutritionAtopic statusLack of breast-feedingCilia dyskinesia syndrome and cystic fibrosisAnatomic changes due to facial dysmorphismsUpper airway trauma, and nasal polyposisAnemia, rickets, malnutritionCarrier state

Pathophysiology

Direct invasion of the mucosa lining the upper airwayPerson-to-person spread of viruses by hand with pathogens to the nose or mouth or inhaling respiratory droplets from an infected person who is coughing or sneezing. Barriers, including physical, mechanical, humoral, and cellular immune defenses. Hair lining the nose filters Mucus coats Ciliated cells lower in the respiratory tract trap and transport pathogens up to the pharynx, where they are then swallowed into the stomachAdenoids and tonsils contain immune cells that respond to pathogens.

local swelling, erythema, edema, secretions, and fever, result from the inflammatory response of the immune system to invading pathogens and from toxins initial nasopharyngeal infection may spread to adjacent structures, resulting in sinusitis, otitis media, epiglottitis, laryngitis, tracheobronchitis, and pneumoniaHumoral immunity (immunoglobulin A) and cellular immunity Normal nasopharyngeal flora, including various staphylococcal and streptococcal species, help defend against potential pathogensSuboptimal humoral and phagocytic immune function have URI increased risk and have severe or prolonged course of disease.

SYMPTOMSNasal obstructionCongestion of nasal breathingSneezingRhinorrhea : secretions often evolve from clear to opaque white to green to yellow within 2-3 days of symptom onsetCoughAnorrhexiaFever5-10 daysFoul breath: This occurs as resident flora process the products of the inflammatory process. Hyposmia: Also termed anosmia, it is secondary to nasal inflammation. Headache

Sinus symptoms: These may include congestion or pressure and are common with viral URIs. Photophobia or conjunctivitis: adenovirus . Influenza : pain behind the eyes, pain with eye movement, or conjunctivitis. Itchy, watery eyes are common in patients with allergic conditions. Fever: This is usually slight or absent, but temperatures can reach 39.5C in infants and young children. If present, fever typically lasts for only a few days. Gastrointestinalsymptoms: Symptoms such as nausea, vomiting, and diarrhea may occur in persons with influenza, especially in children. Nausea and abdominal pain may be presentin individuals with strep throat and viral syndromes.

LABORATORYCBC, ES, CRP, to find bacterian infection, Leucocytosis with neutrophilia suggest bacterian, low level of WBC, lymphocytes raised in viral infections

Because viruses cause most URIs, the diagnostic role of laboratory investigations and radiologic studies is limited. Viral culture, rapid antigen detection, or polymerase chain reaction (PCR) assay of influenza virus on a nasopharyngeal swab could be done if specific antiviral therapy is recommended. Similar tests are also available for adenovirus, respiratory syncytial virus, and parainfluenza virus.

The use of reverse-transcriptase PCR for the diagnosis of enterovirus and rhinovirus infections is not currently available for daily clinical care.Serologic tests for mononucleosis Influenza serologies only have epidemiologic value and should not be used for clinical care. A pharyngeal swab for rapid antigen detection of GABHS (Group A Beta-Hemolytic Streptococci ) is 90% sensitive and 95% specificNOSE AND THROAT cultures

COMPLICATIONSSinusitis is a complication in only approximately 2% of persons with viral URIsOtitisEpiglottitis occurs at a rate of 6-14 cases per 100,000 childrenCroup, or laryngotracheobronchitis usually occurs in children aged 6 months to 6 years with peak incidence in the second year of lifePneumoniaDigestive complications: anorrhexia, vomiting, diarrhea, dehidration, Seizures may appear when fever is more than 38,5 C

Imaging Studies for URTI

A lateral neck radiograph should be taken in a patient with stridor to assess the airways if epiglottitis is clinically suspected

Chest radiography should be reserved for patients with acute tracheobronchitis , those with abnormal vital signs or signs of consolidation on chest examination, or those with persistent symptoms for longer than 3 weeks.

Plain radiography has been largely replaced by computed tomography (CT) in the evaluation of sinusitis, particularly in preparation for corrective surgery. Complete opacification and air-fluid level are the most specific findings for acute sinusitis.

However, a large proportion of patients with the common cold have radiologic abnormalities on CT. Imaging is recommended for patients who do not respond to treatment with antibiotics and decongestants, but is not advised for the diagnosis of uncomplicated sinusitis. Mastoiditis and other intracranial complications of URIs should be evaluated by CT or magnetic resonance imaging.

PREVENTION AND TREATMENTPrevention : VACCINES, IMMUNOSTIMULANTS, VITAMINSParent education on risk factor modification, in particular avoiding smoking indoors General hygiene methods for children attending day care centresBreast feedingManagementRest Lot of fluid intake.Nasal wash with hypertonic salt water or 0.9% salineDecongestants to unblock the opening of sinuses and reduce symptoms of nasal congestion in children above 3 yearsParacetamol 30-40 mg/kg/day for fever and pain relieverAntibiotics to treat the bacterial infection very rare ( fever, ES high, CRP+leucocytosis, children with immune handicaps)

Bacterial pharyngitis This may be difficult to distinguish from viral pharyngitis. Assessment for group A streptococci warrants special attention. Physical findings that suggest a high risk for group A streptococcal disease are erythema, swelling, or exudates of the tonsils or pharynx; temperature of 38.3C or higher; tender anterior cervical nodes (>1 cm); and an absence of conjunctivitis, cough, or rhinorrhea, which are suggestive of viral illness.

Mucosal ulcers, erosions, vesicles: The presence of palatal vesicles or shallow ulcers is characteristic of primary infection with HSV. Ulcerative stomatitis may also occur in coxsackievirus or other enteroviral infection. Mucosal erosions may also be seen in primary HIV infection. Small vesicles on the soft palate, uvula, and anterior tonsillar pillars suggest infection by coxsackievirus, known as herpangina. Tonsillar hypertrophyFoul breath: Halitosis may be noted because resident florae process the products of the inflammatory process. Anterior cervical lymphadenopathy: This is seen with viral and bacterial infections.Approximately half of EBV mononucleosis cases involve generalized adenopathy or splenomegaly. An enlarged liver may also be palpable. Primary HIV infection may also include lymphadenopathy.

A rash may be seen with group A streptococcal infections, particularly in patients younger than 18 years. This scarlet fever rash appears as tiny papules over the chest and abdomen, creating roughness like sunburned appearance. The rash spreads, causing erythema in the groin and armpits. The face may be flushed, with pallor around the lips. Approximately 2-5 days later, the rash begins to resolve. Peeling is often noted on the tips of toes and fingers

OTITIS MEDIAThe eustachian tubes equalize the pressure between the middle ear cavity and the outside atmosphere and allow fluid and mucus to drain out of the middle ear cavity. Inflammation of the middle ear causes the tubes to close causing the fluid to become trapped. Bacteria from the back of the nose travel through the eustachian tube directly into the middle ear cavity and multiply in the fluid. The inflammation can occur as a result of an infection extending up the eustachian tube. This tube may become blocked by a bacterial or viral infection or by enlarged adenoids. Fluid produced by the inflammation cannot drain off through the tube and instead collects in the middle ear.

The Eustachian tube is a canal that connects the middle ear to the throat. It is lined with mucus, just like the nose and throat; it helps clear fluid out of the middle ear and into the nasal passages. Cold, flu, and allergies can irritate the Eustachian tube and cause the lining of this passageway to become swollen.

Ear Infectiondiagnose an ear infection by looking at the outer ear and the eardrum with a device called an otoscope. A healthy eardrum (shown here) appears transparent and pinkish-gray. An infected eardrum looks red and swollen.

If the Eustachian tube becomes blocked, fluid builds up in the middle ear. This creates an environment for bacteria and viruses, which can cause infection; fluid is detected in the middle ear with a pneumatic otoscope. This device blows a small amount of air at the eardrum, making the eardrum vibrate. If fluid is present, the eardrum will not move as much as it should.

Ruptured EardrumWhen too much fluid builds up in the middle ear, it can put pressure on the eardrum until it ruptures (shown here). Signs of a ruptured eardrum include yellow, brown, or white fluid draining from the ear. Pain may disappear suddenly because the pressure of the fluid on the eardrum is gone. Although a ruptured eardrum sounds frightening, it usually heals itself in a couple of weeks.

SIGNS AND SYMPTOMSEar Infection SymptomSudden, piercing pain in the ear which may be worse when lying down, making it difficult to sleep. Trouble hearing.A fever of up to 40 C .Tugging or pulling at one or both ears.Fluid drainage from ears.Loss of balance.Nausea, vomiting, or diarrhea.Congestion.Ear Infection Symptoms: BabiesIt can be difficult to identify an ear infection in babies or children :crankiness, trouble sleeping, and loss of appetite. Babies may push their bottles away because pressure in the middle ear makes it painful to swallow.

LaboratoryWBC, ES, Fg, CRP, high if bacterianLocal exam with otoscopeCultures of otic dischargeImagery when progresses through otomastoiditis

COMPLCATIONSCRONIC OTITIS OTOMASTOIDITISDEAFNESS CEREBRAL VENOUS TROMBOSISCEREBRAL ABCESSMENINGITISDIARRHEEA, DEHIDRATIONSEIZURES

PREVENTION OF OTITIS MEDIA Encouraging breast-feeding Feeding child upright if bottle fed Avoiding exposure to passive smoke Teaching adults and children careful hand washing technique Limiting exposure to viral upper respiratory infections Ensure immunizations are up-to-date; including influenza and 7 valent conjugated polysaccharide vaccine (PCV7)

One solution is for your doctor to insert small tubes through the eardrum. Ear tubes let fluid drain out of the middle ear and prevent fluid from building back up. This can decrease pressure and pain, while restoring hearing. The tubes are usually left in for 8 to 18 months until they fall out on their own.

Treatment of otitis mediaDesinfection of nasopharynxAnalgesics (oral and topical pain killing therapy)Paracetamol, ibuprophene, NO aspirinChildren with low risk be treated with a wait-and-see approach.Low-dose amoxicillin (40 mg/kg/day) may be used if low risk (greater than two years, no day care, and no antibiotics for the past three months)

Failure to respond to initial treatment drug (resistant or persistent acute otitis media)

amoxicillin/clavulanate potassium, cefuroxime axetil, cefpodoxime proxetil. Trimethoprim sulfamethoxasone: Bactrim, biseptol 6-8 mg/kg in 2 daily doses Clarithromycin 15-20 mg/kg Erythromycin ethylsuccinate and sulfisoxazole acetyl: 30-40mg/kg Azithromycin

a single dose of ceftriaxone 50 mg/kg could be equivalent to a 10-day course of oral antibiotics for new cases of acute otitis mediaceftriaxone sodium: prescribe one dose for new onset otitis media and a three-day course for a truly resistant pattern of otitis media or if oral treatment cannot be given, 5 days