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2012-10-10 Examining of respiratory system Prof. dr hab. n. med. Anna Wasilewska 1 Respiratory system examination • Inspection • Palpation • Percussion • Auscultation • Accessory invastigations 2 1 2012-10-10 Characteristics of Normal Breathing • • • • • Normal rate and depth Regular inhalation and exhalation pattern Audible on each side of chest Equal rise and fall of each side Movement of the abdomen Sign of Abnormal Breathing • Rate slower than 8 per minute or faster than 24 per minute • Muscle retractions above clavicles, between ribs and below rib cage (especially in children) • Pale or cyanotic skin • Shallow or irregular • Pursed lips • Nasal flaring 2 2012-10-10 Inspection of respiratory system 1. chest – shape – symmetry – mobility 2. respiratory rate 3. dyspnoea 4. respiratory type 5. respiratory path 6. Hypoxia symptoms 5 1. Chest shape (1) • Physiology: • infant – round on the cross-section, ribs at a right angle from the spine • elderly children – flattened, anteroposterior dimension smaller than transverse 6 3 2012-10-10 Chest shape (2) • Deviations: • Barrel chest (bronchial asthma, emphysema) • Funnel chest – developmental disorders, depression in the center of the chest over the sternum • Rachitic chest - pigeon breast (the chest wall held in an outward position) - cobbler’s chest (depression of the sternum) 7 Chest shape (3) • Conical chest - abdominal tumours, ascites dilated at the base • Asymmetrical chest - one -side dilated (exudative pleuritis, mediastinalis tumors, heart, liver, spleen enlargement) - one - side hollowed (pulmonary fibrosis or hypoplasia) 8 4 2012-10-10 Bronchial asthma Severe dysponoea, characteristic posture of child with bronchial asthma 9 (Hertl, 1999) Breathing Considerations Age Pediatric Respiratory Rates Rate (breaths per minute) Preterm: Term Preschooler (5 years) School-age (10 years) Adolescent (12–18 years) Adult 50-60 30-40 25 20 16 12 A silent chest is an ominous sign of low blood oxygen in the pediatric patient. 10 5 2012-10-10 2. Respiratory rates Tachypnoe – – – – – – – pneumonia bronchitis foreign body in the airway bronchial asthma mediastinal tumors fever, anaemia, metabolic acidosis circulatory failure 11 3. Dyspnoea - difficulty breathing (1) 1. Inspiratory dyspnoea (difficulty breathing) • obstruction of the upper respiratory tract including larynx • use of accessory respiratory muscles (alae nasi, sternocleidomastoid muscle, intercostal muscles, diaphragm) • causes: inflammation, foreign body, spasm (tetany, Quincke’s oedema), outside pressure 12 6 2012-10-10 Dyspnoea - difficulty breathing (2) 2. Expiratory dyspnoea (laboured expiratory phase) • larynx and bronchi obstruction • use of accessory respiratory muscles (diaphragm, abdominal muscles) • causes: bronchial spasm, swelling of mucous membrane, excretion, outside pressure, foreign body (bronchial asthma, bronchitis, tumors, foreign body) 13 Dyspnoea - difficulty breathing (3) 3. Inspiratory and expiratory dyspnea • upper and lower airways obstruction • pneumonia 14 7 2012-10-10 4. Respiratory type (1) 1. Physiological - regular • irregular during falling asleep only in premature infants and small childrens 2. Pathological • Kussmaul’s breath - acidotic (deep and rapid) • Cheyne - Stockes breath - respiratory centre injury (crescendo- decrescendo pattern, apnoea) 15 Respiratory type (2) • Biot's breath - CNS injury (deep breath and apnoea) • agonal breath (gasping respiration) • groaning breath- expiratory groaning (expiratory dyspnoea) • stridor (whooping cough, tetanus) 16 8 2012-10-10 5. Respiratory path • Physiology: • abdominal in infants • chest 2-7 years • over 7 years old: - girls - chest - abdominal - boys - abdominal - chest 17 6. Signs of hypoxia 1. Skin paleness 2. Grey shadow around the nose ang mouth. 3. Cyanosis, decreasing during child’s crying 4. Clubbed finger (chronic hypoxia) 18 9 2012-10-10 Clubbed finger in hypoxia 19 Nail cyanosis in hypoxia 20 10 2012-10-10 Palpation of respiratory system 1. Respiratory mobility 2. Pectoral fremitus 3. Pleural rub 21 1. Chest mobility 22 11 2012-10-10 2. Pectoral fremitus (1) Diminished: • pneumothorax • pleural exudate and transudate • lung tumour 23 Pectoral fremitus (2) Increased (non-obstructed bronchus) • lobar pneumonia • pulmonary cavity • above pleural exudate 24 12 2012-10-10 Estimation of pectoral fremitus 25 3. Pleural rub - sound heard during the inspiratory and expiratory phases - causes: – adhesive pleurisy – suppurative or wet pleurisy outcome 26 13 2012-10-10 Percussion of respiratory system Target: 1. Estimation of lower lung borders 2. Estimation of breath lung mobility 3. Estimation of percussion sound 27 1. Estimation of lung borders (1) • Midclavicular line: left • 0-2 years II c • 2-5 years II ic • >5 years III c • Midaxillary line • 0-2 years VIII ic • 2-5 years VIII ic • >5 years IX c right V ic VI ic VI c VI ic VII ic VII ic 28 14 2012-10-10 Estimation of lung borders (2) • Scapular line • 0-2 years • 2-5 years • > 5 years left IX c Xc X ic right IX c Xc X ic 29 Lowering of lower lung borders • Emphysema in course of: -obstructive bronchitis -bronchial asthma -whooping cough 30 15 2012-10-10 High position of lower lung borders a) abdominal flatulence b) peritoneal fluid c) considerable hepato-, splenomegaly (concomitant) 31 High position of one lung lower border a) phrenic nerve paralysis b) hepato-, splenomegaly 32 16 2012-10-10 2. Estimation of percussion sound: • vesicular resonance - physiological • dull percussion sound - pleural changes (exudative pleuritis, transudate in nephrotic syndrome, in circulatory failure) - changes in lung parenchyma (lobar pneumonia, atelectasis, abscess, malignant infiltration, aspirtaion of amnioclepsis, lung agenesis or aplasia) 33 Respiratory system auscultation 34 17 2012-10-10 Auscultatory sounds 1. Basic sounds: • normal alveolar • bronchial 35 Normal alveolar breath sound • only expiratory phase is heard • physiological 36 18 2012-10-10 Louder alveolar breath sound • heard inspiratory and expiratory phase • physiologically in infants • in bronchitis 37 Diminished or absent alveolar breath sound • • • • lobar pneumonia pleural fluid pneumothorax atelectasis (airlessness of the lungs) 38 19 2012-10-10 Bronchial breath sound • Physiologically in interscapular area and above trachea • Lobar pneumonia with non-obstructed big bronchus • Exudative pleuritis 39 Laryngeal-tracheal Stridor,Grunting Tracheal-bronchiole Rhonci,Wheezing Bronchiol-alveoli Rales 20 2012-10-10 Auscultatory sounds 2. Accessory sounds • Wheezing • Stridor • Rhonchi • Fine rales • Crepitatnt rales (Crackles) • Pleural rub 41 Auscultatory sounds 2. Abnormal sounds Breath sounds are considered abnormal if they are heard outside their usual location in the chest or if they are qualitatively different from normal breath sounds (e.g. decreased or absent). They are divided into two categories: (1) continuous wheeze, rhonchus, pleural rub (2) non-continuous lung sounds - fine rales, cracles 21 2012-10-10 Abnormal lower airway (adventitious) sounds • include rhonchi, wheezes, and crackles. • A sonorous rhonchus is an inspiratory or expiratory noise (r/o transmission of upper respiratory stertor) which suggests the presence of fluid or exudate in larger airways, as with bronchitis or pneumonia. • Wheezes (sibilant rhonchi) are high-pitched expiratory sounds typical of bronchial narrowing. The usual associations are bronchial disease (bronchitis, asthma) or attenuation of a main bronchus caused by left atrial dilation, hilar lymphadenopathy, primary bronchial collapse, or a pulmonary mass lesion. Abnormal lower airway (adventitious) sounds • Crackles (“rales”) are discontinuous sounds similar to radio static • These sounds are caused by the explosive opening of collapsed small airways. Though there is a tendency to relate these to “fluid in the lungs,” there is not a consistent correlation as crackles may be detected with pulmonary edema, pneumonia, bronchitis, or pulmonary fibrosis. The loudest crackles are typically detected in primary lung diseases. Subtle crackles are evident only after a deep breath. 22 2012-10-10 Wheezing – bronchi obstruction • Changes more intense during expiratory phase • Bronchial asthma • Obstructive bronchitis 45 Wheezing • Asthma in 8 years old patient 46 23 2012-10-10 Wheezing • 11 years old child severe asthmatic state 47 Stridor – respiratory tract obstruction at the larynx and trachea level • Mostly during inspiratory phase • Laryngitis • Bronchiolitis in infants 48 24 2012-10-10 Rhonchi - moist sounds in bronchi • Presence of excretion in bronchi • Heard in bronchitis 49 Fine resonant rales - moist sounds in small bronchi • Presence of excretion in small bronchi • Heard in pneumonia 50 25 2012-10-10 Crepitant rale - pulmonary alveolus unsticking by air • Haerd during the inspiratory phase • Lobar pneumonia • Alveolar atelectasis (near spine in new borns, liver and heart pressure) • Tuberculotic infiltration 51 Crepitant rale Pneumonia in course of systemic lupus erythematosus in 18 years old female patient 52 26 2012-10-10 Crepitant rale • 9 years old patient pneumonia 53 Pleural rub • exudative pleuritis regression • dry pleuritis 54 27 2012-10-10 Right - sided pneumothorax 55 Lobar pneumonia 56 28 2012-10-10 Bronchitis 57 Pleurisy 58 29 2012-10-10 Tasks for independent solution 59 Lung auscultation - Quiz 60 30 2012-10-10 Bronchial sound • What kind of sound is it? • In what situations is heard? 61 Stridor • What kind of sound is it? • In what situations is heard? 62 31 2012-10-10 Wheezing - bronchial obstruction • What kind of sound is it? • In what situations is heard? 63 Inflammatory changes in lungs • What kind of sound is it? • In what situations is heard? 64 32 2012-10-10 Normal breath sound • What kind of sound is it? • In what situations is heard? 65 Rhonchi - bronchitis • What kind of sound is it? • In what situations is heard? 66 33 2012-10-10 Pleural rub • What kind of sound is it? • In what situations is heard? 67 Examples of X – rays changes Quiz Wilhelm Roentgen 68 34 2012-10-10 Question 1. 69 • What X-ray presents? • What kind of auscultatory changes can be expected? • What is the diagnosis? Lobar pneumonia 70 35 2012-10-10 Question 2. 71 • What X-ray presents? • What kind of auscultatory changes can be expected? • What is the diagnosis? Right lung abscess 72 36 2012-10-10 Question 3. 73 • What X-ray presents? • What kind of auscultatory changes can be expected? • What is the diagnosis? Left- sided pneumothorax 74 37 2012-10-10 Question 4. 75 • What X-ray presents? • What kind of auscultatory changes can be expected? • What is the diagnosis? Pleural exudate 76 38 2012-10-10 Question 5. 77 • What X-ray presents? • What kind of auscultatory changes can be expected? • What is the diagnosis? Lymphoma 78 39 2012-10-10 Question 6. 79 • What X-ray presents? • What kind of auscultatory changes can be expected? • What is the diagnosis? Lobar pneumonia in the right lung 80 40 2012-10-10 Question 7. 81 • What X-ray presents? • What kind of auscultatory changes can be expected? • What is the diagnosis? Radiological changes in the interstitial pneumonia 82 41 2012-10-10 Question 8. 83 • What X-ray presents? • What kind of auscultatory changes can be expected? • What is the diagnosis? • What is the procedure? Persistent thymus 84 42 2012-10-10 Question 9. 85 • What X-ray presents? • What kind of auscultatory changes can be expected? • What is the diagnosis? • What is the procedure? Mycoplasmatic pneumonia 86 43 2012-10-10 Viral and bacterial infections of upper respiratory tract in children. Why is this subject so important? • The respiratory system is the most commonly infected system. • Health care providers will see more respiratory infections than any other type. 44 2012-10-10 Overview The respiratory system • A major portal of entry for infectious organisms • It is divided into two tracts – upper and lower. – The division is based on structures and functions in each part. • The two parts have different types of infection. 45 2012-10-10 Anatomy of the Respiratory system Anatomy of the Respiratory system • The upper respiratory tract: – Nasal cavity, sinuses, pharynx, and larynx – Infections are fairly common. – Usually nothing more than an irritation • The lower respiratory tract: – Lungs and bronchi – Infections are more dangerous. – Can be very difficult to treat 46 2012-10-10 Anatomy of the Respiratory system • The most accessible system in the body – Breathing brings in clouds of potentially infectious pathogens. • The body has a variety of host defense mechanisms. – Innate immune response -the cells and mechanisms that defend the host from infection by other organisms, in a non-specific manner – Adaptive immune - it is adaptive immunity because the body's immune system prepares itself for future challenges. Anatomy of the Respiratory system • Upper respiratory tract is continuously exposed to potential pathogens. • Lower respiratory tract is essentially a sterile environment. 47 2012-10-10 Pathogenes of the Respiratory system • Many bacterial organisms infect the respiratory system. • Upper respiratory tract also portal of entry for viral pathogens. • Vaccination has eliminated many respiratory infections. – Some still seen in underdeveloped parts of the world. Pathogenes of the Respiratory system 48 2012-10-10 Pathogenes of the Respiratory system Respiratory pathogens are easily transmitted from human to human. They circulate within a community. Infections spread easily. Some respiratory pathogens exist as part of the normal flora. Others are acquired from animal source, water, air etc Fungi are also a source of respiratory infection. Usually in immunocompromised patients Most dangerous are Aspergillus and Pneumocystis. Pathogenes of the Respiratory system • Some pathogens are restricted to certain sites. – Legionella only infects the lung. • Other pathogens cause infection in multiple sites. – Streptococcus can cause: • Middle ear infections. • Sinusitis. • Pneumonia. 49 2012-10-10 Sites of infections • Frequent sites of infection are: – Middle ear. – Mastoid cavity. – Nasal sinuses. – Nasopharynx. Defences of respiratory system • The respiratory system has significant defenses. • The upper respiratory tract has: – Mucociliary escalator. – Coughing. • The lower respiratory tract has: – Alveolar macrophages. 50 2012-10-10 Defences of respiratory system Bacteria infecting the respiratory system 51 2012-10-10 Bacterial infections of the upper repiratory tract • • • • • Laryngitis & Epiglottitis Otitis media, mastoiditis, and sinusitis Pharyngitis Scarlet fever Diphtheria Laryngitis & Epiglottitis • Laryngitis is swelling and irritation (inflammation) of the voice box (larynx) that is usually associated with hoarseness or loss of voice-Haemophilus influenzae & Streptococcus pneumoniae, could be fungal and viral. • Epiglottitis- Inflammation of the cartilage that covers the trachea (windpipe)-Haemophilus influenzae, Streptococcus pneumoniae or Streptococcus pyogenes. 52 2012-10-10 Otitis media Infection or inflammation of the ear-fluid/exudates/pus/in the middle ear due to Haemophilus influenzae, Streptococcus pneumoniae or Streptococcus pyogenes. Organisms reach ME cavity by: • REFLUX from nasopharynx Particularly if drum is perforated. • ASPIRATION: due to high –ve ME pressure • INSUFFLATION during: Crying Nose- blowing Sneezing Swallowing 53 2012-10-10 Anatomic position of Eustachian tube in adult 54 2012-10-10 Otitis media, mastoiditis, sinusitis Middle ear, mastoid cavity, and sinuses are connected to the nasopharynx. Sinuses and eustachian tubes have ciliated epithelial cells. ◦ A virus initially invades the ciliated epithelium. ◦ This destroys the ciliated cells, allowing bacteria to invade. Mastoiditis is uncommon but very dangerous. Mastoid cavity is close to the nervous system and large blood vessels. Sinusitis- Inflammation of the sinuses and nasal passages, upper respiratory tract infection, the most common three causative agents are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis Pharyngitis A variety of bacteria can cause infection in the pharynx. A classic infection is strep throat. Caused by Streptococcus pyogenes Contains M proteins which inhibits phagocytosis Produces pyrogenic toxins which cause the symptoms seen with pharyngitis Group A streptococci can cause abscesses on the tonsils. S. pyogenes can cause scarlet fever and toxic shock syndrome. 55 2012-10-10 Streptococcal Pharyngitis-reddened adenoids -side of the throat (URT Bacterial Diseases) 111 Scarlet fever • Caused by Group A streptococci • Usually seen in children under age of 18 years • Symptoms usually begin with appearance of a rash. – Tiny bumps on the chest and abdomen – Can spread over the entire body • Appears redder in armpits and groin – Rash lasts 2-5 days 56 2012-10-10 Scarlet fever • Symptoms can also include: – Very sore throat with yellow or white papules – Fever of 101˚F or higher – Lymphadenopathy in neck – Headache, body aches, and nausea – A variety of antibiotic therapies is available Diphteria • Caused by the toxin produced by Corynebacterium diphtheriae – A potent inhibitor of protein synthesis • It is a localized infection. – Presents as severe pharyngitis – Can be accompanied by plaque-like pseudomembrane in the throat 57 2012-10-10 Corynebacterium diphtheriae Diphteria © Visuals Unlimited Diphteria • Toxemia can make diphtheria life threatening. – Can involve multiple organ systems – Can cause acute myocarditis • Diphtheria is transmitted by: – Droplet aerosol. – Direct contact with skin. – Fomites (to a lesser degree). 58 2012-10-10 Viral infections of the upper repiratory tract • RHINOVIRUS INFECTION -There are several hundred serotypes of rhinovirus. – Fewer than half have been characterized. – 50% that have are all picornaviruses. – Extremely small, non-enveloped, singlestranded RNA viruses • Optimum temperature for picornavirus growth is 33˚C. – The temperature in the nasopharynx Viral infections of the upper repiratory tract • PARAINFLUENZA: There are four types of parainfluenza virus. – All belong to the paramyxovirus group. – Single-stranded enveloped RNA viruses – Contain hemagglutinin and neuraminidase • Transmission and pathology similar to influenza virus, but there are differences. – Parainfluenza virus replicates in the cytoplasm. – Influenza virus replicates in the nucleus. 59 2012-10-10 Parainfluenza • Parainfluenza is genetically more stable than influenza. – Very little mutation – Little antigenic drift – No antigenic shift • Parainfluenza is a serious problem in infants and small children. – Only a transitory immunity to reinfection – Infection becomes milder as the child ages. CASE 1 • JTM is a 15 y boy who presents with 2 days of congestion, runny nose and sneezing. He has a scratchy throat and feels tired. Over the past day he has developed a cough so he came in “before it got too serious”. On exam, he is afebrile, in no distress and his respirations are easy. His oral and nasal passages are red and swollen and his lungs are clear. 60 2012-10-10 Copyright ©2005, The Regents of the University of California. The common cold • The common cold is a viral infection with prominent symptoms of rhinorrhea and nasal obstruction, absent or mild fever, and lacking systemic manifestations. It is often referred to as rhinitis, but usually also involves the sinus mucosa and is more correctly termed rhinosinusitis 61 2012-10-10 Signs and symptoms • • • • • • • • Nasal stuffiness and/or obstruction (80-100%) Sneezing (50-70%) Scratchy throat (50%) Cough (40%) Hoarseness (30%) Malaise (20-25%) Headache (25%) Fever > 100° (0-1%) Causes • Usually due to one of 200 virus strains from 6 families – – – – – Influenza A, B, C virus Parainfluenza virus Respiratory syncytial virus Coronavirus Adenovirus • Often no agent can be identified 62 2012-10-10 Risk factors • Exposure to infected individuals • Touching one’s nose or conjunctiva with contaminated fingers • Allergic disorders Diagnosis • The diagnosis is almost always based on clinical findings • In rare cases, virus is cultured from nasal washings or identified by ELISA or RIA methods 63 2012-10-10 Treatment: General • • • • • Rest, fluids and symptomatic measures Reassurance that the usual course is 6-10 d Humidification of inspired air Discontinue any tobacco or alcohol In infants-use bulb suction, position mattress at 45°, use saline nasal drops Case 2 • 25 year old medical student presents to the office with the c/o sore throat, • He felt febrile 2 days before • One day before he had a presentation at the pediatric rotation at CCH • On the day of visit, the pain got worse and he saw excudate on right tonsil 64 2012-10-10 Pharyngitis Pharyngitis • The inflammation of pharyngitis causes cough, sore throat, dysphagia, and fever. If involvement of the tonsils is prominent, the term tonsillitis or tonsillopharyngitis is often used. 65 2012-10-10 •Etiology •Sore throat is mostly caused by virus or bacteria •GABHS pharyngitis accounts for 15 to 30% of the cases in children and 5 to 15 % of the cases in adults •Also caused by other conditions such as GE reflux, post nasal drip to rhinitis, persistent cough and allergy Epidemiology •Acute pharyngitis is one of the 20 reported primary diagnosis resulting in office visits •Peak season includes late winter and early spring •Transmission of typical viral and GABHS pharyngitis occurs mostly by hand contact and incubation period 1-3 days 66 2012-10-10 GABHS • Sore throat, fever, pharyngeal or tonsillar exudates, anterior cervical lymphadenopathy, and history of exposure to GABHS infections are important symptoms and signs • Usually winter to spring. Age up to 5-25. • However, no single element of history or exam is sensitive or specific enough Modified Centor Score • • • • • • • • Criteria Temp >38 c Absence of cough Swollen, tender node Tonsillar exudate Age: 3-14 15-44 45 or older Points 1 1 1 1 1 0 -1 67 2012-10-10 Score and Risk of GABHS • • • • • • Scores 0 or less 1 2 3 4 or more Risk of GABHS 1-2.5% 5-10 % 11-17% 28-35% 51-53% GABHS • Untreated, GABHS pharyngitis lasts seven to 10 days. Untreated patients are infective during the acute phase of the illness and for one additional week. • Effective antibiotic treatment decreases the infectious period to 24 hours and prevents most complications 68 2012-10-10 Complications of GABHS • Rheumatic Fever: Rare in the U.S. • Peritonsillar abscess: toxic appearance, fluctuant peritonsillar mass and deviation of uvula • Poststreptococcal glomerulonephritis • Scarlet fever: sandpaper like exanthem Recommendations using Centor Criteria and Rapid antigen Test • Empirically treat patients who have four clinical criteria (Fever, tonsillar exudate, tender anterior cervical lymph node, and absence of cough) • Do not treat with antibiotics or perform diagnostic tests on patients with zero or one criterion 69 2012-10-10 CASE 3 • MKR is a 45 yo female with an unremarkable PMHx who presents with frontal headache worsening over the past 4 days; she describes a pressure feeling across her forehead present most of the time; she feels congested and has no rhinitis; she has not had a fever; she is a smoker and states that she “gets these same symptoms once a year about this time.” On exam, she has no fever and is tender across her frontal sinuses. Her exam is otherwise unremarkable. Sinusitis • Incidence/prevalence – – – – 16% of population with annual diagnosis 5% of office visits for young adults 5th leading reason for antibiotic prescription Increases up to age 75 70 2012-10-10 www.musckids.com/.../images/sinusesff.jpg Signs and Symptoms • • • • • Headache Retro-orbital pain Otaglia Halitosis (bad breath) Chronic cough 71 2012-10-10 Causes • Viral etiology as the vast majority – Often rhinovirus, parainfluenza, adenovirus • Bacterial superinfection complicates 0.2-2% of viral cases – Usually S. pneumoniae or H. Influenza • Fungal Risk factors • • • • • • Viral upper respiratory infection Anatomical abnormality Dental infection or procedure Immunodeficiency Asthma and allergies Smoking 72 2012-10-10 Symptoms suggestive of bacterial sinusitis • Symptoms persistent >7-10 days • Purulent nasal discharge • Maxillary tooth or facial pain (especially unilateral) • Worsening of symptoms after initial improvement • Poor response to decongestants Diagnosis • History and physical exam are sufficient for majority of cases • Imaging – Sinus radiographs are discouraged – Limited coronal CT of sinuses—useful in evaluation of recurrent sinusitis—3 to 4 annual episodes or non responders • Transnasal endoscopy 73 2012-10-10 Treatment: General • • • • • • • Patient education!! Adequate hydration (8-10 glasses daily) Steam inhalation (20-30 min) Saline irrigation or nose drops Avoid irritant exposure Avoid dehydrants Symptom relief Treatment: Antibiotics • Indicated with purulent rhinorrhea and/or symptoms greater than 7-10 days • PCN or Sulfa as first line agent – 10-14 day course – Erythromycin or Cephalosporin if PCN allergy • Recurrent/persistent infections 74 2012-10-10 Adjunctive Drugs • • • • Antihistamines Nasal steroids Leukotriene inhibitors Decongestants Patient education • Call if no improvement within one week, symptom worsening or concerning symptoms • Medication side effects • Adjunctive medications 75 2012-10-10 Complications • • • • • Orbital cellulitis Meningitis Osteomyelitis Brain abscess Cavernous sinus thrombosis 76