N731 URI/ENT

Upper Respiratory Infection (URI) - The Common Cold

• Nature: A benign, self-limiting viral illness.

Transmission: Transmitted by Hand contact, Small or large droplet, Viral inoculation via contact with conjunctiva or nasal mucosa. 

Symptoms: Symptoms start within 1-3 days. Most contagious on 2^nd day, can spread up to 2 weeks, Symptoms peak day 3, Last 3-10 days, sometimes 2 weeks

• Risk: Certain populations are at risk for more severe URI symptoms.

History Taking for URI, ENT & LRI Conditions

• Chief Complaint (CC)

• History of Present Illness (HPI):

  • Recent onset, located nose/face/throat.

  • Duration of a few days.

  • Characterized by stuffed face and misery.

  • Aggravated by life, alleviated by rest.

  • Associated with runny nose, cough, low-grade temperature, fatigue, sore throat.

  • Often worse in the morning.

  • Usually, already tried supportive treatments.

  • Mild to moderately severe.

• Past Medical History (PMH) / Past Surgical History (PSH):

  • Immunocompromised, cancer, diabetes, chronic pulmonary disease, allergies, sinus issues or history of sinus surgery, cardiac disease.

• Gynecological History (Gyn Hx):

  • Last Menstrual Period (LMP), pregnancy status, hormonal contraception.

• Medications

• Allergies

• Social History:

  • Recent travel, ill contacts, young children, daycare, school or institutional environment, workplace exposures, living environment, smoking, support, financial security.

• Family History (FH): Generally noncontributory, with the exception of ill contacts/children.

Physical Exam

• General Survey: Nontoxic with normal vitals, fever absent or low grade.

• HEENOT:

  • Conjunctival injection.

  • Nasal mucosal swelling.

  • Nasal congestion.

  • Normal to purulent nasal discharge.

  • Pharyngeal erythema.

  • Severe facial pain absent, no periorbital swelling, no pharyngeal/tonsillar exudates.

• Neck/Lymph: Full exam, minimal or absent adenopathy.

• Pulmonary: Full exam, clear.

• Cardiac: Normal.

• Abdominal (ABD): No organomegaly.

• Skin: No rashes or cyanosis.

• Extremities: No edema.

Differential Diagnosis (DDX)

• Bronchitis: >5 days of cough, typically starts after URI, lower respiratory wheezing/ronchi.

• Bacterial Pharyngitis/Tonsillitis: Usually does not involve cough or sore throat.

• Allergic/Seasonal Rhinitis: Does not usually involve rhinorrhea/nasal congestion.

• Acute Bacterial Rhinosinusitis: Facial pain, purulent discharge.

• Influenza: High fever, myalgia, severe headache.

• Pertussis: Paroxysmal coughing, vomiting, apnea, exposure.

• Mononucleosis: Fever, tonsillar pharyngitis, and lymphadenopathy.

Diagnostics for URI

• Clinical Diagnosis: Typically a clinical diagnosis.

• Influenza-specific assays: May be warranted.

• Chest X-ray: Only if abnormal pulmonary exam.

• Sinus Radiographs and CT scans: Generally contraindicated.

• Other Viral PCR Swabs & Nasal Bacterial Cultures: Not indicated.

• Procalcitonin testing: May provide evidence of viral infection if trying to avoid unnecessary antibiotics.

Treatment for URI

• Treatment for URI is supportive for symptoms.

• Potential complications to the common cold exist.

Acute Rhinitis

• Definition: Inflammatory condition affecting the nose.

• Etiology: Mainly caused by respiratory viruses, but can also be triggered by allergies or environmental irritants.

• Secondary Bacterial Infection: Occurs in $0.2\%$ to $2\%$ of adults and $5\%$ to $7\%$ of children.

• Antibiotic Use: Antibiotics are used in $70\%$ to $85\%$ of cases, of which up to half are considered inappropriate.

• Main Types of Acute Rhinosinusitis:

  1. Common Cold/Acute Viral Rhinosinusitis (AVRS): Most common.

  2. Acute Post-viral Rhinosinusitis (APVRS).

  3. Acute Bacterial Rhinosinusitis (ABRS): Occurs in $0.5\%$- $2\%$ of cases.

• Symptoms: Involve the nose and sinuses.

• Risk Factors: Various risk factors for rhinitis exist.

Differential Diagnosis of Rhinitis

• URI

• Influenza

• Allergic rhinitis

• Idiopathic rhinitis

• Sinusitis (viral/bacterial)

• Medications (NSAIDs, BB, hormones, sedatives, antidepressants, decongestant overuse)

Classifications of Rhinosinusitis (Duration of Symptoms)

• Acute: Symptoms completely resolve in <30 days.

• Subacute: Symptoms completely resolve in $\ge30$ and <90 days.

• Recurrent Acute:

  • At least $3$ acute episodes separated by intervals of $\ge10$ days without symptoms in a $6$-month period.

  • At least $4$ acute episodes in a $12$-month period.

• Chronic: Symptoms last >90 days.

Physical Exam for Viral Acute Rhinosinusitis (ARS)

• Erythema/Edema over cheekbone or periorbital area.

• Tenderness to percussion of cheek and upper teeth.

• Purulent drainage in nose or posterior pharynx.

• Facial pain with percussion of sinuses (not a great test).

• Possibly bluish, grayish, yellowish, reddish, retracted or injected tympanic membrane (TM) with fluid.

• Diffuse mucosal edema, inferior turbinate hypertrophy, copious rhinorrhea, polyps or septal deviation.

Treatments for Viral ARS

• Geared towards relieving symptoms.

Viral URI vs. Acute Bacterial Sinusitis (ABRS)

• Challenge for Clinicians: Symptom overlap, patient satisfaction.

• ABRS Occurrence: Occurs less than $2\%$ of the time, typically as a secondary infection of an already inflamed sinus cavity.

• Factors Impairing Sinus Drainage (can result in ABRS):

  • Allergic or nonallergic rhinitis.

  • Mechanical obstruction of the nose.

  • Dental infection.

  • Impaired mucociliary clearance (e.g., cystic fibrosis, ciliary dysfunction).

  • Immunodeficiency.

URI vs. Acute Sinusitis Comparison

Viral vs. Bacterial Sinusitis

• Acute Rhinosinusitis (ARS): May be bacterial or viral; clinically diagnosed by purulent nasal discharge for <4 weeks and severe congestion and/or facial pain/pressure.

• Acute Bacterial Rhinosinusitis (ABRS): Clinically diagnosed if symptoms are present for $\ge10$ days, OR if initial ARS symptoms improve but then worsen over a $10$-day period (”double worsening”).

• Uncomplicated ABRS: No evidence of infection extension beyond sinuses into surrounding skin, soft tissue, bone, or CNS.

• Management: Substantial number of patients with clinically diagnosed ABRS improve with supportive care alone. Symptomatic care and observation with reliable follow-up are options before antibiotics.

Antibiotic Therapy for ABRS

• Duration: $5$-$7$ days with improvement.

• First-line:

  • Amoxicillin $500$ mg TID

  • Amoxicillin $875$ mg BID

  • Augmentin $500/125$ mg TID

  • Augmentin $875/125$ mg BID

• If PCN Allergic: Doxycycline $100$ mg BID

• Risk Factors for Pneumococcal Resistance/Poor Outcome*:

  • Augmentin $2000$ mg/$125$ mg BID

Further Testing/Referral for Sinusitis

• Diagnostic Testing:

  • None for uncomplicated sinusitis.

  • Sinus CT or MRI if not improved.

• Referral to ENT:

  • No improvement after $2$ courses of antibiotics.

  • Obstruction on imaging.

  • $3$-$4$ episodes/year.

• Other Concerns (Red Flag Symptoms with ABRS):

  • Acute invasive fungal sinusitis: Fever, facial pain, congestion, vision changes, changes in mentation, facial numbness, diplopia. HIGH SUSPICION in immunocompromised patients.

  • Chronic fungal sinusitis: Older patients, mildly immunocompromised.

  • Nosocomial bacterial sinusitis.

  • Potential complications of ABRS: Orbital cellulitis, Periorbital cellulitis, Intracranial abscess, Meningitis.

Allergic Rhinitis (AR)

• Nature: Seasonal and often chronic condition.

• Symptoms: Characterized by allergic symptoms (e.g., sneezing, rhinorrhea, nasal congestion, itching).

Physical Exam (PE) in Allergic Rhinitis

• Allergic Shiner: Dark circles under eyes.

• Pale, Boggy Nare: Swollen, pale nasal mucosa.

• Cobblestone Appearance: Pharyngeal lymphatic tissue hyperplasia.

Conditions Associated with AR

• Allergic conjunctivitis

• Acute/chronic sinusitis

• Asthma

• Eczema

• Oral allergy syndrome

• Sleep disordered breathing

• Eustachian tube dysfunction/serous otitis

Diagnostics in Allergic Rhinitis

• Initially: None!

• Imaging: Not helpful.

• If No Improvement:

  • Skin testing.

  • Immunoassay (e.g., specific IgE blood test).

Treatment for Allergic Rhinitis

• Nasal Glucocorticoids: Most effective.

  • Examples: Budesonide, triamcinolone, beclomethasone, mometasone (avoid fluticasone with strong CYP3A4 inhibitors due to adrenal suppression risk).

  • Administration: Start at max dose, saline rinse first, tilt head down, spray away from septum.

• Alternatives to Nasal Steroids:

  • Antihistamines:

    • Second generation: Loratadine/desloratadine, fexofenadine.

    • Cetirizine/levocetirizine: Second generation, more sedating.

    • First generation: Diphenhydramine, chlorpheniramine.

  • Montelukast: Useful for asthma/postnasal drip.

• Secondary Pharmacologic Treatment:

  • Intranasal antihistamines: Azelastine or olopatadine.

  • Decongestants: Oral vs. nasal sprays.

  • Immunotherapy (desensitization).

• Combination Therapy

Non-Pharmacologic Treatment of AR

• Allergy avoidance.

• Close bedroom and car windows.

• Pillow/mattress covers.

• Keep pets outdoors/clean/not in the bedroom.

• Shower before bedtime.

• Air filtering.

• Nasal saline/irrigation.

Pharyngitis

Pharyngitis Differential Diagnosis

• Group A Strep (Strep pyogenes)

• Other Strep (particularly C and G)

• Viral URI (“trash throat”)

• Mononucleosis/Epstein Barr virus

• Influenza

• Allergies

• Post nasal drip (PND)

• HIV

• STDs (Gonorrhea, Chlamydia, HSV)

• Other infections

• Non-infectious causes

Diagnosis - Strep Pharyngitis

• Centor Criteria: Sore throat with:

  • Tonsillar exudate.

  • Tender anterior cervical adenopathy.

  • Fever (generally >101 $\,^\circ\text{F}$).

  • No cough.

• Available Tests:

  • Rapid Antigen Detection Test (RADT).

  • DNA test.

  • Throat culture.

When to Culture for Strep

Reserve using culture to confirm a negative RADT in:

• Patients who are at higher risk (e.g., history of acute rheumatic fever or immunocompromising conditions).

• Patients in close contact with individuals at high risk for complications.

• Young adult patients living in college dormitories.

• Patients living in areas where acute rheumatic fever is endemic.

• Patients in whom clinical suspicion for Group A Strep (GAS) is high (Centor scores $\ge3$).

Don’t Miss This!! (Peritonsillar Abscess)

• Severe sore throat (unilateral)

• Fever

• Muffled voice

• Drooling

• Trismus

Strep Pharyngitis Treatment

• Why Treat?: To prevent complications (e.g., acute rheumatic fever).

• How to Treat?:

  • Penicillin G (Bicillin) $1.2$ million units IM X$1$

  • Penicillin VK $500$ mg PO BID X $10$ days

  • Amoxicillin $500$ mg PO BID X $10$ days

  • Cephalexin $500$ mg PO BID X $5$ days

  • Clindamycin $300$ mg PO Q $8$ hours X $10$ days

  • Azithromycin $500$ mg PO Q day X $5$ days (note increasing resistance).

• Symptom Treatment

Scarlet Fever

• Delayed skin reaction to the Strep exotoxin.

• Requires urgent referral.

Signs of Upper Airway Obstruction

• Muffled or “hot potato” voice.

• Hoarseness.

• Drooling or pooling of saliva.

• Stridor.

• Respiratory distress.

• “Tripod” positions (to help maintain airway patency).

Mononucleosis

• Nature: Viral infection caused by the Epstein-Barr Virus (EBV).

• Symptoms: Characterized by fatigue, sore throat, fever, and swollen lymph nodes.

Physical Exam Findings in Mononucleosis

• Posterior adenopathy.

• Fever.

• Pharyngitis.

• Petechiae on palate.

• Splenomegaly.

• Rash with antibiotics.

Diagnostic Testing in Mononucleosis

• CBC: Absolute Lymphocyte Count >4500

• Elevated ALT/AST.

• Heterophile antibody test (Mono spot).

• EBV specific antibodies if needed.

• Throat culture (to rule out strep).

Mononucleosis Treatment

• Symptomatic: Acetaminophen, NSAIDs.

• Rest.

• Healthy diet.

• Sports: Need to wait (due to splenomegaly risk).

Lower Respiratory Infections (LRI)

Differential Diagnosis of Acute Cough

• Acute bronchitis

• Pneumonia

• Pertussis

• Influenza

• URI

• Acute sinusitis

• Allergic rhinitis

• Asthma exacerbation

• CHF exacerbation

• GERD

• ACE inhibitor cough

• Lung cancer

• Post nasal drip (PND)

• Pulmonary embolism (PE)

Treating Acute Cough

• Guaifenesin

• Benzonatate

• Ipratropium

• Beta $\,2$ agonists

• Honey

Acute Bronchitis

• Nature: Different from chronic bronchitis/COPD.

• Etiology: Acute infection (virally caused in $90$-$95\%$ of cases) of the larger airways.

• Diagnosis: Clinical diagnosis based on signs and symptoms.

• Workup:

  • History and physical exam (clinical diagnosis).

  • Consider chest X-ray if:

    • Abnormal vital signs (pulse >100 beats/minute, respiratory rate >24 breaths/minute, temperature >38\,^\circ\text{C} [$100.4\,^\circ\text{F}$], or oxygen saturation <95\%).

    • Signs of consolidation on chest examination (rales, egophony, or tactile fremitus).

    • Mental status or behavioral changes in patients >75 years old (who may not mount a fever).

Acute Bronchitis Treatment

• Antibiotics: Don’t work (2022 Cochrane Review); $50$-$90\%$ of people receive them inappropriately.

• Treat influenza or pertussis if present.

• Symptom Treatment: Similar to URI management.

• Beta $\,2$ Agonists: For wheezing only (2015 Cochrane Review).

• Patient Education:

  • Duration of cough ($10$-$21$ days).

  • Antibiotics: More harm than good.

  • Rest, fluids, humidification.

Bordetella Pertussis (Whooping Cough)

• Incidence: >50\% of infections occur in adolescents/adults.

• Incubation Period: $7$-$10$ days or longer.

• Three Phases:

  1. Catarrhal: $1$-$2$ weeks.

  2. Paroxysmal: Characterized by severe cough.

  3. Convalescent.

• Complications: Can occur.

• Contagiousness: $3$ weeks after onset of catarrhal stage OR $5$ days after start of antibiotics.

• Prevention: Vaccination.

Diagnosis of Pertussis

• WHO Case Definition: $2$ weeks of cough with $\,1+\,$ of:

  • Paroxysms of cough.

  • Whooping.

  • Post-cough emesis.

• Consider current outbreak status.

• Diagnostic Testing: Specific tests available.

• Reportable Disease.

Collecting a Nasopharyngeal Swab

• (Image mentioned, but procedure not detailed).

Treatment of Pertussis

• Antibiotics:

  • Azithromycin $500$ mg day $\,1$, then $250$ mg daily X $4$ days.

  • Clarithromycin $500$ mg BID X $7$ days.

  • Bactrim DS BID X $14$ days.

• Cough Management

Influenza

• Signs and Symptoms: Acute onset fever, cough, sore throat, myalgia, headache, fatigue.

Influenza Testing

Who Experiences Influenza Complications?

• Age >65

• Age <4 (especially <2)

• Immune suppressed

• Compromised respiratory function

• Pregnant or post-partum women

• <18 on chronic ASA

• Institutionalized

• Morbidly obese (BMI >40)

• Native Americans/Alaska Natives

• Underlying Diseases:

  • Pulmonary

  • Cardiac (except HTN)

  • Renal

  • Hepatic

  • Hematologic

  • Metabolic (diabetes)

Primary Complication of Influenza

• Pneumonia

Who to Treat for Influenza?

• Low-risk outpatients: May be treated within $48$ hours of symptom onset.

• Severe illness or high risk of complications: Treat as soon as possible.

Antiviral Agents for Influenza

• Neuraminidase Inhibitors:

  • Oseltamivir: Approved for ages $2$ weeks$+$.

    • Ages $\,\ge13$: $75$ mg PO BID X $5$ days.

    • Side effects: Nausea, vomiting, abdominal pain, diarrhea, ear problems, diaper rash.

  • Zanamivir: Approved for ages $\,\ge7$

    • Dose same for all ages: $2$ inhalations ($10$ mg) daily X $5$ days.

    • Side effects: Nausea, vomiting, diarrhea, headache, dizziness, nasal congestion, cough, ENT infections.

    • Avoid in patients with underlying pulmonary disease.

• Adamantanes (Amantadine, Rimantadine): Not currently recommended due to high levels of resistance.

Prevention of Influenza

• Vaccinate.

• Chemoprophylaxis (pre-exposure and post-exposure).

Vaccines to Recommend

• $2019$-$2020$ Specifics (Historical Context):

  • Two Egg-Free Formulations:

    • Flublok Quadrivalent (licensed for adults $\,\ge18$ years).

    • Flucelvax Quadrivalent (licensed for people $\,\ge4$ years).

  • LAIV (Nasal Spray): Ages $2$-$49$, not for immunocompromised or pregnant people.

  • Quadrivalent IM Vaccine: Ages $\,\ge6$ months.

  • Ages $\,18$-$64$: Intradermal; Jet injector.

  • For people >65 years old:

    • High-dose injectable: Fluzone, trivalent, $4X$ normal dose.

    • Inactivated with adjuvant: Fluad Trivalent.

  • Note for future seasons: All U.S. flu vaccines will be trivalent for the $2024$-$2025$ season.

• What About Egg Allergy?: Persons with egg allergy can receive any flu vaccine!

Epidemiology of Pneumonia

• $8$-th leading cause of death.

• U-shaped age distribution: <5 or >65

• Types: Community-Acquired Pneumonia (CAP) vs. Healthcare-Associated Pneumonia (HCAP).

• Most Common Pathogens:

  • Streptococcus pneumoniae.

  • Haemophilus influenzae.

  • Atypicals: Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella.

  • Viral.

Who Gets Pneumonia? (Risk Factors)

• Age >65

• Persons who smoke

• Native Americans/Alaska Natives

• Chronic lung disease

• Chronic heart disease

• Diabetes

• Chronic renal failure

• Chronic steroids

• Cancer

• Asplenia/sickle cell disease

• Immune suppressed/HIV

• Alcoholism

• Chronic liver disease

• Vaccinate these people!

Pneumococcal Vaccine for Most Adults >65 Years Old

• Assumes previously unvaccinated, immunocompetent adults:

  • Give $\,1$ dose of PCV15 or PCV20.

  • If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. The minimum interval is $8$ weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak.

Important History Points for Pneumonia

• Cough with purulent sputum.

• Pleuritic chest pain.

• Dyspnea.

• Fever/chills/night sweats.

• Travel history and HCAP risk.

• Immunization status (pneumococcal and influenza).

Physical Exam in Pneumonia

• Hypoxia.

• Fever.

• Tachypnea.

• Bronchial breath sounds or crackles.

• Dullness to percussion, egophony (E will sound like A).

• Increased tactile fremitus.

Pearls Based on Pathogen

• S. pneumonia: Rapid onset of symptoms, high fever, shaking chills, purulent sputum, pleuritic chest pain, consolidation.

• H. flu: Similar to S. pneumonia.

• Mycoplasma: Long incubation period, prodromal period, prolonged course. Patients don’t look as ill. No consolidation, may have maculopapular rash.

Diagnostic Testing (Pneumonia)

• Lobar Pneumonia (Image implied).

• Interstitial (Image implied).

• Normal (Image implied).

Other Diagnostics to Consider (Pneumonia)

• CBC with diff.

• Sputum Culture and gram stain: IDSA says not unless certain criteria met.

• BUN.

• Blood cultures: Not in outpatient setting.

• Urine for Legionella and Pneumococcal antigens: Rare in outpatient setting.

• Influenza testing.

• CRP.

• Procalcitonin.

Pneumonia Severity Index (PSI)

• Superior tool for assessing severity (Image implied).

CURB-65 Score (Inferior to PSI)

• Confusion.

• Urea (BUN >20).

• Respiratory rate (>30).

• Blood Pressure (<90/60).

• Age >65

• Score \,>1: Consider admission (not all over $65$s need admission).

Outpatient CAP Treatment Considerations

• Many patients with CAP can be treated as outpatients.

• Most important decision factors: Severity of illness (vital signs, activity tolerance, work of breathing).

• Ability to follow up: Should be seen in one to two days.

• Ability to maintain oral intake.

• Will they take their medications.

• Support at home.

• Substance abuse? Cognitive impairment?

• Admission is best: Unhoused patients should be admitted.

Antibiotics for Outpatient CAP Treatment: ATS/IDSA 2019

• No Co-morbidities:

  • Amoxicillin $1$ g TID.

  • Doxycycline $100$ mg BID.

  • Zpak if local resistance <25\%.

  • Clarithromycin ER $1$ g daily.

• Duration: Treat for at least $5$ days, and until clinical stability.

Outpatient Settings Guideline

• Usually initiate coverage that includes atypical organisms as well as S. pneumoniae.

• Generally, the risk of infection with P. aeruginosa or MRSA is not considered particularly significant in outpatients.

• Prior antibiotic use: Should consider previous oral and parenteral agents. If a particular class of antibiotics was used within the previous $3$ months, drugs from a different class should be used to minimize resistance issues.

• Without comorbidity or resistance risk factors: Amoxicillin alone or Doxycycline is recommended.

• Monotherapy with a macrolide: Recommended in the new guidelines only if there are contraindications to amoxicillin or doxycycline.

Non-Pharmacologic Treatment for CAP

• Check temperature every $8$ hours; report fever >101\,$\^\circ\text{F}$ or if not <99\,$\^\circ\text{F}$ within $48$ hours.

• Fluids.

• Oxygen.

• Chest Physical Therapy (PT).

• Rest.

• Don’t usually need a follow-up chest X-ray for those who improve in $5$-$7$ days.