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URTI

Upper respiratory tract infections including otitis media
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katie doucet

on 1 March 2013

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Transcript of URTI

Upper Respiratory
Tract Infections
& Otitis Media OBJECTIVES Management Describe the presentation of URTI and OM in office or ED
Describe the epidemiology of URTI/OM
Using a patient centered approach, describe the appropriate history taking questions
Perform an appropriate physical examination for a patient presenting with URTI/OM
Discuss the levels of evidence supporting the Mx of URTI/OM
Non-pharmacological
Pharmacological including OTC, alternative therapy, prescription choices
Describe the potential complications of URTI/OM
Discuss indications for specialist referral for URTI/OM URTI Key Feature 1. Given an appropriate history and/or physical examination:
Differentiate life threatening conditions (epiglottitis, retropharyngeal abscess) from benign conditions
Manage the condition appropriately
2. Make the diagnosis of bacterial sinusitis by taking an adequate history and performing an appropriate physical examination, and prescribe appropriate antibiotics for the appropriate duration of therapy
3. In a patient presenting with URTI symptoms
differentiate viral from bacterial (through history and physical examination)
diagnose a viral URTI
manage the condition appropriately (no antibiotics unless clear indication)
4. Given a history compatible with OM, differentiate it from OE and mastoiditis, according to the characteristic physical findings
5. In high risk patients (HIV, COPD, cancer) with URTI look for complications more aggressively and follow up more closely
6. In a presentation of pharangitis look for mononucleosis
7. In high risk groups:
take preventive measures (flu and pneumococcal vaccines)
treat early to decrease individual and population impact (Tamiflu, amantadine) Resident Presentation Objectives for URTI/AOM REFERENCES Zhanel et al., Paediatric Child Health 2009;14(7):457-460
McWilliams and Goldman, Canadian Family Physician 2011;57:1283-1285
Al-Mutairi and Kirk. Paediatric Child Health 2004;9(1):25-30
Grover. NEJM 2011;365:5
Zoorob, Am Fam Phys 2011;83(9):1067-1073
Salour. Radiology 2000;216:428-429
McLeod and Stanley, Western Journal of Emergency Medicine 2008;9:55
Rosen's Emergency Medicine ; 2009:chp 73 and 166
Steyer, Am Fam Phys 2002;65(1):93-96
Frye et al., J Fam Pract 2001;60(5):293-294
Cooper et al., Ann Internal Med. 2001;134(6):509-517
Ebell MH., Fam Pract Manag. 2003;10(8):68-69
Choby BA., Am Fam Physician. 2009;79(5)383-390
McIsaac et al., CMAJ;1998:158(1):75-83
Bluestone CD, Pediatr Infect Dis J 2000;19(5Suppl):S37-46
Glynn et al., J Laryngol Otol 2008;122(3):233-7
Rosenfeld et al., Otolaryngol Head Neck Surg. 2007; 137(3 suppl):S1-S31
Arroll et al., Cochrane Database Syst Rev. 2005;(3):CD000247
Zoorob et al., Am Fam Phys 2012;86(9):817-822
C PS Hui Paediatric Child Health 2013;18(2):96-98R
Sander. A Fam Physician 2001;63:927-36
Lieberthal et al., Pediatrics 2013;131(3):964-998
Kalyanakrishnan et al., AFP 2007;76(11):1650-1658
Forgie et al., Paediatr Child Health 2009;14(7):457-60
Gozales et al., Annals of Internal Medicine 2001:134(6):490-4
Fashner et al., American Family Physician, 2012;86(2):153-159 Bacterial Tracheitis secondary bacterial infection of trachea -> mucopurulent exudates may acutely obstruct airway
consider in child with upper airway obstruction or child diagnosed with croup but unresponsive to treatment
Dx via bronchoscopy (direct visualisation)
AP and lateral neck x-ray: steeple sign and candle dripping sign
start IV empiric Abs, pain management, airway clearance, observation and monitoring
secure airway if acute respiratory failure, ENT consult, ICU Epiglottitis medical emergency, potentially life threatening

H. influenzae type B (uncommon now due to HiB vaccine)

2-6 years (rarely adults), rapid onset, toxic looking, fever, anorexia, restless
drooling, dyspnea, dysphagia, dysphonia, tripod sitting, cough uncommon

Do not examine oropharynx or upset patient
Anaesthesia, ENT consult, immediate intubation
lateral neck xray (thumb sign) (Do not get if unstable)
IV fluids, Abs, blood cultures Sinusitis acute <4 weeks, subacute 4 weeks - 3 months, chronic >3 months
most cases due to viral infection (7-10 days)
consider bacterial if Sx present >7days

ACUTE SINUSITIS
viral or bacterial
maxillary sinuses most commonly affected

major symptoms: facial pain, facial fullness/congestion, purulent nasal discharge, hyposmia/anosmia, fever
minor symptoms: H/A, halitosis, fatigue, dental pain, cough, ear pressure/fullness

Complications: periorbital cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess, cavernous sinus thrombosis, meningitis, intracranial abscess, osteomyelitis

CHRONIC SINUSITIS
bacterial or fungal
similar symptoms as acute sinusitis but less severe
antibiotics 3-6 weeks if infective cause Pharangitis/Tonsillitis Sx: sore throat, dysphagia/odynophagia, malaise, fever, otaligia, tender cervical LNs, enlarged tonsils (exudate), strawberry tounge, scarlet fever, plalatal petechiae

90% adults and 70% children with pharangitis due to viral infection
bacterial pharangitis leading cause group A beta-hemolytic streptococcus

Treatment with antibiotics to decrease rheumatic fever, alleviate symptoms and decrease communicability

Antibiotic treatment DOES NOT prevent glomerulonephritis, inconsistent results in prevention of peritonsilar abscess (Qunisy)

COMPLICATIONS: rheumatic heart disease, arthritis, scarlet fever, quinsy CROUP child 6-36 months presents with abrupt onset barking cough, hoarsness and inspiratory stridor (clinical diagnosis)
labs, xray (CXR or lateral neck) not essential, maybe useful in those with severe or atypical presentation
viral: para-influenza, influenza, RSV Common Cold common presentation to office (sore throat, nasal Sx, cough)
majority caused by virus (rhinovirus, adenovirus etc)

transmitted: sneezing, coughing, or nose blowing

Signs & Sx: fever, cough, rhinorrhea, nasal congestion, sore throat, H/A, myalgias

Colds self-limiting (up to 10-14 days); complicated by bacterial infection in 2%

management symptom relief Acute Otitis Media MASTOIDITIS Upper Respiratory Tract Infections Tips to Reduce Antibiotic use tell patient antibiotics increase risk of antibiotic resistant infection
identify and validate patient concern
recommend specific symptom therapy
spend time answering questions; offer contingency plan
provide patient education material on antibiotic resistance
Effective communication more important than an antibiotic for patient satisfaction Gozales et al., Annals of Internal Medicine 2001:134(6):490-4 Fashner et al., Treatment of the Common Cold in Children and Adults. American Family Physician, 2012;86(2):153-159 Fashner et al., Treatment of the Common Cold in Children and Adults. American Family Physician, 2012;86(2):153-159 Fashner et al., Treatment of the Common Cold in Children and Adults. American Family Physician, 2012;86(2):153-159 sinus x-rays not indicated for routine evaluation
Most cases of acute bacterial sinusitis improve with out antibiotics (watchful waiting, follow up must be ensured)
consider not prescribing antibiotics for mild cases
moderate of severe symptoms may benefit from antibiotics
narrow spectrum coverage for S. pneumoniae and H. influezae -> amoxicillin -> consider second line agent if no improvement in 72 hours
antibiotic treatment: short course (5d) = long course (10d)
rarely patient with severe symptoms less than 7 days duration -> consider referral to ENT for evaluation and drainage Management Rosenfeld et al., Clinical Practice Guideline: Adult Sinusitis. Otolaryngol Head Neck Surg. 2007; 137(3 suppl):S1-S31

Arroll et al., Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev. 2005;(3):CD000247

Zoorob et al., Antibiotic Use in Acute Upper Respiratory Tract Infection. 2012;86(9):817-822 Cooper et al. Ann Internal Med. 2001;134(6):509-517
Ebell MH. Fam Pract Manag. 2003;10(8):68-69
Choby BA. Am Fam Physician. 2009;79(5)383-390
McIsaac et al. CMAJ;1998:158(1):75-83 Peritonsillar abscess 75% of children have at least one episode of AOM by age 1

viral infection -> inflammation of nasal mucosa -> eustachian tube dysfunction -> obstruction -> retained secretions -> secondary bacterial infection

Why kids get AOM:
child's eustachian tube: shorter, more horizontal and more prone to obstruction by enlarged adenoids
viral infections and allergies common in children
kids with recurrent AOM may have decreased IgA levels (IgA inhibits bacterial adherence in nasopharynx)
RISK FACTORS: younger kids and those in daycare greater risk AOM
cleft palate, exposure to smoke, premature, nil breastfed, immunodeficiency, family history AOM,
First Nations and Inuit children Forgie et al., Management of acute otitis media. Paediatr Child Health 2009;14(7):457-60 mononucleosis Diagnosis and Treatment of Otitis Media. AFP 2007;76(11):1650-1658 diagnose AOM in children who present with moderate to severe bulging of theTM or new onset of otorrhea not due to acute otitis externa. (Grade B. Recommendation).

may diagnose AOM in children who present with mild bulging of the TM and recent (less than 48 hours) onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal child) or intense erythema of the TM. (Grade C. Recommendation)

should not diagnose AOM in children who do not have MEE (based on pneumatic otoscopy and/or tympanometry). (Grade B. Recommendation)

management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain. (Grade B. Strong Recommendation)

Severe AOM: The clinician should prescribe antibiotic therapy for AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (ie, moderate or severe otalgia or otalgia for at least 48 hours or temperature 39°C [102.2°F] or higher). (Grade B.Strong Recommendation)

Nonsevere bilateral AOM in young children: The clinician should prescribe antibiotic therapy for bilateral AOM in children 6 months through 23 months of age without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]). (Grade B. Recommendation)

Nonsevere unilateral AOM in young children: either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision making with the parent(s)/caregiver for unilateral AOM in children 6 months to 23 months of age without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]). When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms. (Grade B. Recommendation)

Nonsevere AOM in older children: The clinician should either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision-making with the parent(s)/caregiver for AOM (bilateral or unilateral)in children 24 months or older without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]). When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms. (Grade B. Recommendation)

prescribe amoxicillin for AOM when a decision to treat with antibiotics has been made and the child has not received amoxicillin in the past 30 days or the child does not have concurrent purulent conjunctivitis or the child is not allergic to penicillin. (Grade B. Recommendation)

prescribe an antibiotic with additional β-lactamase coverage for AOM when a decision to treat with antibiotics has been made, and the child has received amoxicillin in the last 30 days or has concurrent purulent conjunctivitis, or has a history of recurrent AOM unresponsive to amoxicillin. (Grade C. Recommendation)

reassess the patient if the caregiver reports that the child’s symptoms have worsened or failed to respond to the initial antibiotic treatment within 48 to 72 hours and determine whether a change in therapy is needed. (Grade B. Recommendation)

should not prescribe prophylactic antibiotics to reduce the frequency of episodes of AOM in children with recurrent AOM. (Grade B. Strength: Recommendation.)

offer tympanostomy tubes for recurrent AOM (3 episodes in 6 months or 4 episodes in 1 year with 1 episode in the preceding 6 months). (Grade B. Option)

should recommend pneumococcal conjugate vaccine to all children according to the immunisation schedule (Grade B. Strong Recommendation)

recommend annual influenza vaccine to all children according to the immunization (Grade B. Recommendation)

encourage exclusive breastfeeding for at least 6 months. (Grade B. Recommendation)

encourage avoidance of tobacco smoke exposure. (Grade C. Recommendation.) Recommendations Lieberthal et al., Clinical Practice Guidelines: The Diagnosis and Management of Acute Otitis Media. Pediatrics 2013;131(3):964-998 Forgie et al., Management of acute otitis media. Paediatr Child Health 2009;14(7):457-60 commonly caused by infection (usually bacterial, occasionally fungal),
also associated with a variety of noninfectious systemic or local dermatologic processes

Consider AOE if:
1. Rapid onset (last 3 weeks, typically 48h)
2. ear canal inflammation (otalgia, itching, fullness) with or without hearing loss or jaw pain
3. signs of ear canal inflammation including tenderness of tragus, pinna or both
OR diffuse ear canal edema, erythema or both with or without otorrhea, regional lymphadenitis, tympanic membrane erythema or cellulitis of the pinna and adjacent skin

Excessive moisture and trauma, impair the canal’s natural defenses, are the two most common precipitants, and avoidance cornerstone of prevention
Thorough cleansing of the canal is essential for diagnosis and treatment, flushing should be avoided.

For mild to moderate AOE:

First line therapy should be topical antibiotics with or without topical steroids for 7 - 10 days
Severe cases should be managed with systemic antibiotics that cover S aureus and P aeruginosa
Adequate pain control with acetominophen, NSAIDs or oral opiods
If ear canal cannot be seen -> expandable wick to decrease canal edema and facilitate topical medication delivery

Clinical response within 48 - 72h, full response up to 6d C PS Hui Paediatric Child Health 2013;18(2):96-98
R Sander. A Fam Physician 2001;63:927-36 Otitis Externa Classically complication of AOM before antibiotics
5-10% of children, mortality rate 2/100000
peak incidence 6-13 months age
immunocompromised patient more prone

Hx or acute or recurrent OM
otaligia and pain behind ear
fever
UNWELL

Tx: high does broad spectrum IV antibiotics (cephalosporin) switch to PO once no fever for 48h, consider mastoidectomy

complications: conductive or sensorineural hearing loss, osteomyelitis, subperiosteal abscess, CN palsies (V, VI, VII), venous sinus thrombosis Bluestone CD, Pediatr Infect Dis J 2000;19(5Suppl):S37-46
Glynn et al., J Laryngol Otol 2008;122(3):233-7 viral infection causing fever, sore throat, swollen LN
caused by EBV and others like CMV

fatigue, general ill feeling, headache and sore throat

Symptomatic Mx: hydration, rest, tylenol or NSAIDs for pain/fever

fever breaks in 10d
LNs and spleen recover in 4 wks
fatigue may linger for 2-3 months Frye et al., J Fam Pract 2001;60(5):293-294 most common deep infection of head and neck in adults (20-40y)
uncommon in young children unless immunocompromised

begins as superficial infection -> tonsillar cellulitis

chronic tonsillitis or multiple trials of oral Abs may predispose

Streptococcus pyogenes and Fusobacterium (aerobic and anaerobic) Mx: aspiration or I&D, gram stain and culture of material and antibiotics

Tx: clindamycin 500mg BID OR
penicillin if no response in 24h add metronidazole 500mg BID Steyer, Am Fam Phys 2002;65(1):93-96 Retropharyngeal Abscess potentially life threatening
generally affects children <5y (can affect anyone)
occur during or immediately after pharangitis

Sx: dyspnea, difficulty swallowing, drooling, high fever, stridor, intercostal retractions, sever throat pain

Ix: throat culture, CBC, x-ray neck, CT neck

Mx: surgical drainage, corticosteroids to reduce airway swelling, high-dose IV antibiotics Upper respiratory tract infections. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th Ed. Mosby; 2006:chp 73 Zoorob, Am Fam Phys 2011;83(9):1067-1073 Zoorob, Am Fam Phys 2011;83(9):1067-1073 Salour. Radiology 2000;216:428-429 Al-Mutairi and Kirk. Paediatric Child Health 2004;9(1):25-30 Grover. NEJM 2011;365:5 Upper airway obstruction and infections. Rosen's Emergency Medicine 2009:chp 166 Kalyanakrishnan et al., Diagnosis and Treatment of Otitis Media. AFP 2007;76(11):1650-1658 Rosenfeld et al., Clinical Practice Guideline: Adult Sinusitis. Otolaryngol Head Neck Surg. 2007; 137(3 suppl):S1-S31Arroll et al., Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev. 2005;(3):CD000247 McLeod and Stanley, Western Journal of Emergency Medicine 2008;9:55 Al-Mutairi and Kirk. Paediatric Child Health 2004;9(1):25-30
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