1 UPPER RESPIRATORY TRACT INFECTIONSSore Throat, Sinusitis, Otitis Media Fahad Al-Qahtani Mouaiad Ghabban Abdulaziz Islam Ahmed Al-Jadeed

2 Objectives Sore Throat (clinical features, differential diagnosis, complications, management) Sinusitis including Allergic Rhinitis (Clinical features and management) Otitis Media in children (AOM and Secretory OM, Features, management) How can we differentiate between Viral and Bacterial Infections? Update in management and role of Antibiotics How can we modify help seeking behavior of patients with flu illness?

3 Quiz Q.1: One of the differences between bacterial and viral pharyngitis is that in Bacterial pharyngitis there is usually: A. No fever B. Coughing and Wheezing C. Conjunctivitis D. Whitish spots on the tonsils

4 Quiz Q.2: The duration of symptoms in subacute sinusitis is ?A. Less than 4 weeks. B. Between 3 and 4 weeks. C. Between 4 weeks and 3 months. D. Between 5 weeks and 5 months.

5 Quiz Q.3: An irritable 3 year old patient came with ear pain, difficulty in hearing , and fever. What is the diagnosis? A. Pharyngitis B. Otitis Media C. Mastoiditis D. Sinusitis

6 Quiz Q.4: Which of the following patients who present with a sore throat should you start on immediate antibiotics therapy: A. 37.5c fever, conjunctivitis, runny nose, and a very bad headache. B. An 80 year old man with history of congestive heart failure. C. No fever. Congested nose and very painful to swallow solids and liquids. D. No fever, clear discharge from the nose, coughing and shortness of breath.

8 What is sore throat? A sore throat is pain, scratchiness or irritation of the throat that often worsens when you swallow.

9 Clinical features Pain or a scratchy sensation in the throat.Pain that worsens with swallowing or talking. Difficulty swallowing. Sore, swollen glands in your neck or jaw. Swollen, red tonsils. White patches or pus on your tonsils. Hoarse or muffled voice.

10 causes Infectious: Non Infectious: 1- Viral: 2- Bacterial: Flu.Pharyngitis. Tonsillitis. Mononucleosis(kissing disease), caused by EBV. Non Infectious: Measles. chickenpox. GERD, allergiens. 2- Bacterial: The most common is Streptococcus pyogenes, or group A streptococcus.

11 Differential diagnosis1- Viral infections: 2- Bacterial infections: Herpes simplex virus (HSV)1 and 2 GABHS Influenza A and B Group C beta-hemolytic streptococci Epstein-Barr virus (EBV) Neisseria gonorrhoeae Cytomegalovirus (CMV) Corynebacterium diphtheriae Human herpesvirus (HHV) 6 Mycoplasma pneumoniae HIV

12 Tonsillitis Inflammation of tonsils.Commonly caused by: Streptococcus Infection. Could be caused by viral infections, such as: influenza virus, ebv. The main symptom is Throat Pain.

13 Pharyngitis Pharyngitis is inflammation of the pharynx.Sudden and usually self limiting. Commonly caused by viral infections such as: common cold, influenza virus and mononucleosis. Less commonly caused by bacterial infection, such as: Group A streptococcus.

14 When to see your doctor??? Difficulty Breathing. Joint Pain.Difficulty Swallowing. A Rash. A Fever Over 101˚F. Bloody Mucus. A Lump In The Throat. Hoarseness That Lasts Longer Than Two Week.

15 Complications Related to strep infection:Middle ear infection (Otitis Media). Sinusitis. Rare complications: Retreopharyngeal abscess. Peritonsillar abscess. Toxiv shock syndrome.

17 Q-when do u have to use Antibiotics?Treatment Viral infections: Usually its self limited and don’t required medications. For the fever and pain , use acetaminophen. Do not give aspirin for pain or fever to children younger than 12 year (reyes syndrome) Bacterial infection: First line tx is penicillin. Drink plenty of cool or warm fluids, and avoid very hot drinks. Eat cool, soft foods. Avoid smoking and smoky place. Q-when do u have to use Antibiotics?

18 Prevention Avoid contact with sick people. Wash your hands.Identify and avoid irritants . Don’t smoke and avoid exposure to secondhand smoke.

20 Sinusitis Sinusitis and Rhinosinusitis refer to inflammation in the nasal cavity and paranasal sinuses.

21 sinuses Healthy sinuses are filled with air.The mucus produced by the sinuses usually drains into the nose through small channels. When the sinus linings become inflamed, these channels become blocked. After they become blocked and filled with fluid, germs can grow and cause an infection.

22 Classification of SinusitisAcute Sinusitis Less than 4 Weeks. Subacute Sinusitis Between 4 weeks and 12 weeks. Chronic sinusitis More than 12 weeks. Recurrent acute sinusitis Diagnosed when infection occurs 2-4 times per year. Usually starts with cold like symptoms such as a runny, stuffy nose and facial pain.

23 The Maxillary sinuses are the most common site (85%), followed by Ethmoidal (65%), Sphenoidal (39%), and Frontal (32%) involvement.

24 Etiology Infectious: Viral (Rhinovirus, Influenza virus).Begins with viral inoculation via direct contact with the conjunctiva or nasal mucosa. Bacterial (Streptococcus pneumoniae, Haemophilus influenzae). Nosocomial bacterial sinusitis may develop in patients in the intensive care unit, particularly in those with prolonged intubation. Fungal (Aspergillus).

25 Etiology Non-Infectious:Blocking of the sinuses opening due to increased secretion of mucus in response to colds or allergies. Nasal septum Deviation or nasal polyps blocking the opening of the sinuses. Problems within the sinuses due to a Medical condition.

26 Clinical Features Symptoms of sinusitisPain and Tenderness Around Your Cheeks, Eyes or Forehead Nasal Congestion Nasal Discharge A Reduced Sense of Smell Fever Postnasal Drip Cough Fatigue Bad Breath (Halitosis) A Sinus Headache Toothache

27 Diagnoses Physical examination:Altered speech (indicating nasal obstruction) Purulent nasal secretions. Facial erythema. Tenderness overlying sinuses. Mucosal erythema.

28 Diagnoses Labs (Acute sinusitis is a clinical diagnoses):Tests for Immunodeficiency Indicated if history findings indicate recurrent infection. Sweat Chloride Test Should be performed if cystic fibrosis is suggested. Nasal cytology

29 Diagnoses Cultures of Nasal Secretions:Cultures are not routinely done to evaluate acute sinusitis but should be obtained in the following cases: Patients in ICU or that are immunocompromised. Children not responding to appropriate medical management. Patients with complications of sinusitis.

30 Differential DiagnosesCommon cold “Generally do not have facial pain”. Allergic Rhinitis “Common causes of rhinorrhea and nasal congestion”. Any cause of Facial Pain or Headache. Nasal Foreign body. Tonsillitis. Tumors of the Nasal cavity/Sinuses (Sinonasal tumor).

31 Prevention Maintain good sinus hygiene by drinking plenty of fluids to keep nasal secretions thin. Saline nasal sprays help keep the nasal passages moist, helping remove infectious agents. Don’t smoke, and avoid to be too near people who are smoking. Try to stay away from things you know you’re allergic to.

32 Allergic Rhinitis

33 Allergic Rhinitis Rhinitis, which occurs most commonly as allergic rhinitis, is an inflammation of the nasal membranes.

34 Clinical Features Sneezing. Tearing.Itching: Nose, eyes, ears, palate. Fatigue. Rhinorrhea. Drowsiness. Postnasal drip. Malaise. Red eyes. Congestion. Headache.

36 Diagnoses Labs: Total Serum IgE and Total Blood Eosinophil CountBoth are Neither sensitive nor specific for allergic rhinitis, but the results can be helpful in some cases when combined with other factors. Allergy Skin Tests Radioallergosorbent Test (RAST). Immunoassays test to detect allergen-specific IgE antibodies in the serum have limited utility in the diagnosis of allergic rhinitis.

37 Management Environmental control measures and allergen avoidance.Pharmacologic management: Patients are often successfully treated with oral antihistamines, decongestants, or both. Immunotherapy: This treatment may be considered more strongly with severe disease or poor response to other management options.

38 Complications Acute or chronic sinusitis. Otitis media.Sleep disturbance or apnea. Dental problems : Caused by excessive breathing through the mouth. Palatal abnormalities.

40 Anatomy Of The Middle EarLargely formed by the tympanic membrane laterally. Consist of: auditory ossicles : malleus, incus, and stapes. They transmit sound waves from tympanic membrane to the perilymph of the internal ear. Eustachian tube runs through the middle ear originally from the nose to ventilate the middle ear space, ensuring that its pressure remains at near normal environmental air pressure.

41 Otitis Media Definition: Otitis media is an infection of the middle ear that causes inflammation (redness and swelling) and a build-up of fluid behind the eardrum.

42 Classification of Otitis MediaAcute Otitis Media (AOM). Otitis Media With Effusion. Chronic Otitis Media.

43 Etiology Bacteria: Viruses: Uncommon Causes Of AOM Include:Streptococcus Pneumoniae. Non-typable Haemophilus Influenzae. Group A Beta-hemolytic Streptococcus. Staphylococcus Aureus. Moraxella Catarrhalis. Viruses: Respiratory Syncytial Virus. Influenza Viruses. Rhinoviruses. Uncommon Causes Of AOM Include: Chlamydia Trachomatis. Diphtheritic Otitis. Tuberculous Otitis. Otogenous Tetanu.

47 Examination Pneumatic otoscopy remains the standard examination technique for patients with suspected OM. Every examination should include an evaluation and description of the following four Tympanic Membrane characteristics: Color – A normal TM is a translucent pale gray; an opaque yellow or blue TM is consistent with middle ear effusion (MEE). Position – In AOM, the TM is usually bulging; in OME, the TM is typically retracted or in the neutral position. Mobility – Impaired mobility of TM is the most consistent finding in patients with OME . Perforation – Single perforations are most common.

48 Complications Intratemporal: Intracranial: Meningitis.TM perforation (acute and chronic). Mastoiditis : one underneath the ear (the mastoids). Hearing loss. Cholesteatoma: abnormal collection of skin cells inside the ear. Labyrinthitis: spread into the inner ear. Facial paralysis. Intracranial: Meningitis. Subdural empyema. Brain abscess. Extradural abscess. Lateral sinus thrombosis. Otitic hydrocephalus.

49 Management Most cases of AOM improve spontaneously. Cases that require treatment may be managed with antibiotics and analgesics or with observation alone. Amoxicillin is the first drug of choice . Patients who report penicillin allergy : Cefuroxime Ceftriaxone Erythromycin Tympanocentesis is the trans-tympanic needle aspiration of ME contents. Aspiration of fluid reduces ME pressure and is very effective in relieving pain. (Surgical option).

50 Viral vs bacterial Generally in Bacterial infections:Fever Infection spreads to nearby organs Pus or whitish covering of mucous membranes Recurrent infections are common In viral infections: Low grade fever or no fever Mostly contained and self limiting No pus, only clear discharge, if any at all Generalized malaise and fatigue

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52 Nice Guidance to URTI Patients should be given advice about the usual natural history of the illness, including the average total length of the illness : Acute otitis media: 4 days. Acute sore throat/acute pharyngitis/acute tonsillitis: 1 week. Common cold: 1½ weeks. Acute rhinosinusitis: 2½ weeks. Acute cough/acute bronchitis: 3 weeks.

53 Nice Guidance to URTI A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions: Acute otitis media. Acute sore throat/acute pharyngitis/acute tonsillitis. Common cold. Acute rhinosinusitis. Acute cough/acute bronchitis. Depending on clinical assessment of severity, patients in the following subgroups can also be considered for an immediate antibiotic prescribing strategy: Bilateral acute otitis media in children younger than 2 years. Acute otitis media in children with otorrhoea. Acute sore throat/acute pharyngitis/acute tonsillitis when three or more centor criteria are present.

54 Nice Guidance to URTI An immediate antibiotic prescription should only be offered to patients in the following situations: If the patient is systemically very unwell If the patient has symptoms and signs suggestive of serious illness and/or complications If the patient is at high risk of serious complications because of pre-existing comorbidity. If the patient is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria: Hospitalization in previous year. Type 1 or type 2 diabetes. History of congestive heart failure. Current use of oral glucocorticoids.

55 Nice Guidance to URTI When the delayed antibiotic prescribing strategy is adopted, patients should be offered: Reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash Advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs Advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription. A delayed prescription with instructions can either be given to the patient or left at an agreed location to be collected at a later date.

56 How to modify help seeking behavior of patients with flu illness ?

57 How to modify patient help seeking behaviorRaise awareness of the seriousness of seasonal flu in high risk patients. Increase the will to seek help in affected patients. Increase awareness of the ways to protect infection within the household and work environment. Increase the public attitude toward vaccination and encourage high risk people to get vaccinated early.

58 How to modify patient help seeking behaviorProvide incentive to businesses to take care of flu ridden workers, with paid leaves or forced sick leaves. Make flu vaccines available in more health care centers, and provide them for less cost. Raise awareness on personal hygiene and ways to avoid infecting other people or avoiding getting sick from contact with other people. Advise flu patients to stay away from work and public for a day after their symptoms are alleviated.

59 Quiz Q.1: One of the differences between bacterial and viral pharyngitis is that in Bacterial pharyngitis there is usually: A. No fever B. Coughing and Wheezing C. Conjunctivitis D. Whitish spots on the tonsils

60 Quiz Q.1: One of the differences between bacterial and viral pharyngitis is that in Bacterial pharyngitis there is usually: A. No fever B. Coughing and Wheezing C. Conjunctivitis D. Whitish spots on the tonsils

61 Quiz Q.2: The duration of symptoms in subacute sinusitis is ?A. Less than 4 weeks. B. Between 3 and 4 weeks. C. Between 4 weeks and 3 months. D. Between 5 weeks and 5 months.

62 Quiz Q.2: The duration of symptoms in subacute sinusitis is ?A. Less than 4 weeks. B. Between 3 and 4 weeks. C. Between 4 weeks and 3 months. D. Between 5 weeks and 5 months.

63 Quiz Q.3: An irritable 3 year old patient came with ear pain, difficulty in hearing , and fever. What is the diagnosis? A. Pharyngitis B. Otitis Media C. Mastoiditis D. Sinusitis

64 Quiz Q.3: An irritable 3 year old patient came with ear pain, difficulty in hearing , and fever. What is the diagnosis? A. Pharyngitis B. Otitis Media C. Mastoiditis D. Sinusitis

65 Quiz Q.4: Which of the following patients who present with a sore throat should you start on immediate antibiotics therapy: A. 37.5c fever, conjunctivitis, runny nose, and a very bad headache. B. An 80 year old man with history of congestive heart failure. C. No fever. Congested nose and very painful to swallow solids and liquids. D. No fever, clear discharge from the nose, coughing and shortness of breath.

66 Quiz Q.4: Which of the following patients who present with a sore throat should you start on immediate antibiotics therapy: A. 37.5c fever, conjunctivitis, runny nose, and a very bad headache. B. An 80 year old man with history of congestive heart failure. C. No fever. Congested nose and very painful to swallow solids and liquids. D. No fever, clear discharge from the nose, coughing and shortness of breath.

67 References 088§ionid= https://www.uptodate.com/contents/acute-sinusitis-and- rhinosinusitis-in-adults-clinical-manifestations-and diagnosis?source=search_result&search=sinusitis&selectedTitle =2~150 conditions/mononucleosis/symptoms-causes/dxc e.htm overview#showall media/Pages/Introduction.aspx complications-topic-overview. throat/diagnosis-treatment/treatment/txc adults- suppurative-and-serous disorders/ear-nose-and-throat-infections/sore-throat/for- individuals/medicines-and-treatments practice/monograph/39/basics/pathophysiology.html practice/monograph/14/treatment/guidelines.html

68 THANK YOU...