URTI and SINUSITIS Trevor Langhan PGY-1 January 28, 2004

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


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%


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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)


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)


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


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


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?

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URTI and SINUSITIS Trevor Langhan PGY-1 January 28, 2004