Upper Respiratory Infections (URIs) & Sinusitis

Common Cold: Upper Respiratory Infection

A common (self-limited) viral infection affecting the nose and throat, characterized by symptoms such as coughing, sneezing, and nasal congestion.

Common Pathogens: Rhinovirus, Coronavirus,
Peak viral shedding: 2-3 day of illness
Incubation period: 24-72 hrs
Duration of illness: 3-10 days, can last up to 2 weeks
Smokers more likely to experience prolonged sx duration

Risk Factors: Exposure to children in daycare, psychological stress, poor sleep
Risk for increased severity: Smoking, chronic illness, immunodeficiency, malnutrition

Myth: colder climate increases susceptibility to respiratory illness

Sx: Rhinitis, Nasal Congestion (clear and/or purulent discharge), Sore throat (scratchy or dry), Cough (usually 1-2 days after nasal sx), Malaise, Fever uncommon in adults but may occur in children

Clinical dx: PE usually unremarkable, no dx tests are routinely indicated

PE findings: Conjunctival injection, nasal mucosal swelling, throat redness

Don’t judge nasal mucus by it’s color, not sputum!

Diff dx:
- Allergic or seasonal rhinitis

- Bacterial pharyngitis (strep) or tonsillitis

- Acute bacterial rhinosinusitis

- COVID-19

- Influenza

- Pertussis

Tx: treat based on sx

F/u in office: persistent fever > 100.5, SOB, persistent dark colored secretions

Acute Rhinosinusitis (ARS)

A condition characterized by inflammation of the nasal cavity and sinuses, often resulting from a viral infection (0.5-2% bacterial infection), typically lasting less than 4 weeks, chronic greater than 12 weeks.

Bacterial etiology comes secondarily and inflames the sinus cavity

Sx: 4 cardinal signs: purulent nasal discharge, nasal obstruction, facial pain/pressure, hyposmia/anosmia (must last >12 weeks).. halitosis, headache, referred dental pain, may have sore throat, cough, nausea (post-nasal drip)

Common pathogens for AVRS: Rhinovirus, Influenza, parainfluenza

Common pathogens for ABRS: S. pneumoniae most common (all ages), H. influenzae, Moraxella catarrhalis

Physical exam:

• Assess HEENT, lymph, chest, teeth, VS

• Anterior rhinos copy: mucosal edema, erythema, inferior turbinate hypertrophy, rhinorrhea, purulent discharge

• Post-nasal drip, cobblestoning

• Tenderness to palpation over sinuses is not diagnostic!

Tx: largely supportive of symptoms and sx should improve 7-10 days, increase fluids, analgesics OTC prn, nasal saline irrigation, steam therapy, intranasal decongestants (oxymetazoline - use max 2-3 days to avoid rhinitis medicamentosa (rebound congestion)), intranasal steroids, systematic decongestants, mucolytics and antihistamines.

Acute Bacterial Rhinosinusitis

Persistent symptoms of ARS lasting > 10 days, specifically purulent discharge, fever, facial/dental pain. Symptoms of typical AVRS that are slowly improving but then worsen with more severe sx and signs after 5-6 days.

“Double worsening” “Double sickening”

Onset of severe sx (high fever >102F, purulent discharge or facial pain) for at least 3-4 consecutive days at the beginning of illness.

SYMPTOMS DO NOT ACCURATELY DISTINGUISH VIRAL FROM BACTERIAL INFECTION.

Risk factors: Chronic nasal congestion, asthma, cigarette smoking/exposure, anatomical abnormalities (polyps, deviated septum)

Complications: Orbital/periorbital cellulitis, osteomyelitis, sinus thrombus, intracranial/epidural abscess and meningitis

Tx: many patients have self-limited disease that resolves w/o abx, if abx needed, Augmentin first-line (resistent: 2gm PO bid for like 10 days), Amoxicillin also used.

- If PCN allergic, doxycycline or respiratory fluoroquinolone (avoid if possible, especially in pregnancy (fetal cartilage, bones, & teeth)

- Duration of therapy: 5-7 days, may see 10 days but that generally ocmes with AE ex. diarrhea, yeast infections

Risk factors for resistance: living in an area with >10% rate of S.pneumo resistance, >65yrs, hospitalized in past 5 days, abx use in previous month, immunocompromised, multiple comorbidities, severe infection

Urgent referral indications:

• Persistent high fevers

• Abnormal vision/EOM

• Change in mental status

• Periorbital edema

• Cranial nerve palsies

• Meningeal signs