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UPPER RESPIRATORY
TRACT INFECTIONS
ALOK SINHA
Department of Medicine
Manipal College of Medical Sciences
Pokhara, Nepal
• The upper respiratory tract includes
• nose
• paranasal sinuses
• pharynx
• upper part of the larynx above the level of the
true vocal cords
Infections of the Upper Respiratory Tract
Site
Nasal cavity
Disease
Coryza (common cold)
Chronic atrophic rhinitis
Rhinoscleroma
Invasive fungal infections
Nasal diphtheria
Mucocutaneous leishmaniasis
Syphilis (tertiary)
Lepromatous leprosy
Rhinosporidiosis
Agents
Many different viruses
Bacteria (Klebsiella ozaenae)
Klebsiella rhinoscleromatis
Mucor, Aspergillus
Corynebacterium diphtheriae
Leishmania braziliensis
Treponema pallidum
Mycobacterium leprae
Rhinosporidium seeberi
Paranasal sinuses
Acute sinusitis
Chronic sinusitis
Aspergilloma ("fungus ball")
Pharynx, tonsil Acute pharyngitis
Diphtheria
Pharyngeal gonorrhea
Peritonsillar abscess (quinsy)
Infectious mononucleosis
Retropharyngeal space Abscess
Tuberculosis
Larynx
Acute laryngitis
Acute epiglottitis and laryngitis
Pyogenic bacteria
Pyogenic bacteria
Aspergillus species
Many different viruses
Streptococcus pyogenes
Corynebacterium diphtheriae
Neisseria gonorrhoeae
Pyogenic bacteria
Epstein–Barr virus
Pyogenic bacteria
Mycobacterium tuberculosis
Many different viruses
Haemophilus influenzae
Which specialty should treat & there for teach
these diseases ?
The Common Cold
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CORYZA
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An estimated 2 of every 5 persons are
affected each year (40%)
World population: 6,775,235,741
40% of this = 2,710,094,296
Some experience multiple episodes in 1
year
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Rhinoviruses: most common agents
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Over 100 serotypes have been implicated
Other viruses implicated included
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coronaviruses
influenza C
parainfluenza virus
adenoviruses
respiratory syncytial virus
• Highly contagious: 75% of patients infected with
Rhinovirus will have symptoms
• Respiratory droplets spread by
sneezing, coughing
 hand contact with
nose, eyes, or face
 Fomite - Skin cells, hair, clothing (hanky) bedding


Contributing factors:
Change in weather
 Loss of sleep
 Going outside with wet hair
 Fatigue

Signs and symptoms

Incubation period: 2 – 4 days
 May
last from 6 – 10 days or possibly up to 3
weeks after incubation period
• Initial complaints
• sneezing
• clear, watery rhinorrhea
@ nasal obstruction
• general malaise but no fever
• Subsequently
• Headache
• nasal congestion
• scratchy throat
After 2 – 3 days
• nasal discharge becomes thicker, cloudy,
and yellowish in color
• systemic symptoms improve
• Hoarseness, cough, and sore
throat may last up to
7 – 10 days
Diagnosis:
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Made on clinical grounds
• Pt’s symptoms
• nasal exam showing
 reddened, edematous mucosa
 narrowed nasal passages
 watery discharge
Laboratory and/or imaging only indicated
if other conditions are strongly suspected
Viral isolation/culture is not practical
Treatment
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No curative treatment
Supportive therapy – 10 treatment
• Rest
• Fluids & humidification
• Decongestants (Phenylephrine agonist)
• Analgesics
• Cough suppressants
• Mucolytics
• Antihistamines
α1-adrenergic receptor
Zinc Gluconate
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Short term use of zinc lozenges (zinc
gluconate 10-15 mg q 2 hrs) shown to
reduce duration of subjective
symptoms if begun early in course of
disease
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? Role of antibiotics
Antibiotics should be considered if
symptoms last longer than 10-14 days
(secondary bacterial infection)
Inappropriate prescribing of antibiotics
is common
• Due to patient beliefs/misinformation of
cold being bacterial in origin
Pharyngitis
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May be of bacterial or viral origin
Most common cause Rhinovirus
• Self-limiting; usually lasts 3-4 days
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Group A, beta-hemolytic strep is
the primary bacterial pathogen
 in 1/3 cases - early detection reduces incidence
of
Signs and symptoms:
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Inflammation of pharynx & lymphoid
tissue results in
• Fever & malaise
• sore throat
• rhinorrhea
• Tonsillar exudates
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• Anterior cervical adenopathy
There is usually a lack of cough
Diagnosis
 On PE: observe throat for tonsillar
exudates; obtain throat swab
 Rapid streptococcal identification tests
are most commonly used
• Sensitivity – 80%
• Specificity – 95%
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Throat cultures may be collected if rapid
strep screen is negative
Management/Treatment:
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Symptomatic treatment
• salt-water gargles
• throat lozenges
• Acetaminophen
• cool-mist humidification
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Antibiotics treatment necessary to treat
proven strep infections
• Benzathine penicillin G 1.2 million units as a
single dose, is optimal therapy
• For pen – allergic pts,
 erythromycin 500mg po QID x 10 days
 Azithromycin 500mg once daily x 3 days
Acute epiglottitis
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Bacterial cellulitis of the epiglottis
(supraglottis) and/or surrounding tissue
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Caused by:
• Haemophilus influenzae type b (HiB)- most
likely
• H. parainfluenzae and streptococci some times
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Average age of onset: 1–5 years old
• In most adults the disease is less severe
and of slower onset
Clinical Features
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Sudden onset of
• Sore throat
• Fever
• Head forwardly extended, usually with
drooling
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Stridor - present
Pharyngeal visualization (w/ EXTREME caution)
shows a ‘Cherry red'
epiglottis
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Neutrophil leucocytosis
Epiglottis culture usually (+) for HIB
• result takes long time
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Blood cultures frequently (+) for HIB in
children
• organisms fewer than in meningitis
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Lateral X-Ray neck• enlarged hypopharynx
• forward neck extension
• with “thumbprinting” of epiglottitis
Epiglottitis- Differential diagnosis
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Angioneuropathic edema of
supraglottic structures
Anaphylaxis
Caustic ingestion
Thermal burns of epiglottis
Infectious mononucleosis
Laryngotracheitis
Blunt Trauma
Treatment
• Intubation is often required, but usually
discontinued in less than 24h
• Early antibiotic treatment and intubation may
prevent the need for tracheostomy
• Steroids to reduce inflammation and avert
tracheostomy- unproven but used
• Tracheostomy: may be required in life
threatening conditions
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Drug treatment
• #1 Ceftriaxone
(or cefotaxime, cefuroxime)
• Others - Ampicillin and Sulbactam
• Ticarcillin disodium and clavulanate potassium
• piperacillin/tazobactam
• levaquin
• Gatifloxacin
• Amoxicillin should not be used due to
noted resistance
Prevention

HiB vaccination early!!!
• Prior to HiB, there were roughly 20 K cases
of HiB disease each year (U S data)
• Post-vaccine era = incidence has decreased
by 95%.
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Prophylaxix:
Family Members, day-care workers,
health-care workers
• Rifampin 300 mg q12h x 2d
Acute laryngitis
Healthy Vocal Cords
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Healthy vocal
cords have
smooth straight
edges
Normal healthy vocal cords
•pearly-white color
•in contrast to the
pinkish surrounding tissue
Causes
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Viral (70-80%)
Group A beta-haemolytic
streptococcus (20-30%)
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Often a complication of acute coryza
• Dry sore throat
• Hoarse voice or loss of voice
• Attempts to speak cause pain
• Initially painful and unproductive cough
• Stridor in children (croup) because of
inflammatory oedema leading to partial
obstruction of a small larynx
Croup (Laryngotracheobronchitis) is a group of
respiratory diseases that often affects infants and children[
Complications rare
 Chronic laryngitis
• Downward spread of infection may cause
• Tracheitis
• Bronchitis
• Pneumonia
Treatment
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Rest voice
Paracetamol 0.5-1 g 4-6-hourly for relief
of discomfort and pyrexia
Steam inhalations may be of value
Antibiotics not necessary in simple acute
laryngitis
Influenza
Possible
accounts in 412 BC
Flu
First recorded pandemic in 1580
Destroyed
Charlemagne's
army in 876 A.D.
Killed
thousands in 1647
1918-1919 Spanish Flu pandemic
21
million people died worldwide
out of a billion infected
(total world population at that time 1.8 billion)
8.5 million people died in World War I
Possible
end to war
2009 (H1N1) flu pandemic data
Area
Confirmed
deaths
Worldwide (total)
14,286
European Union and EFTA
2,290
Other European countries
and Central Asia
457
Mediterranean and Middle East
1,450
Africa
116
North America
3,642
Central America and Caribbean
237
South America
3,190
Northeast Asia and South Asia
2,294
Southeast Asia
393
Australia and Pacific
217
Note: The
proportion of confirmed deaths within total deaths due to
Swine
Swine
Flue Flue
(H1N1
(H1N1)
Influenza)
Answer these two questions
 Is the Influenza or Flu caused by
“Influenza” virus ?
 What H. Influenza is
Etiology
• caused by a group of myxoviruses• common types
•A
Influenza A (H1N1) virus is a subtype. causes
•endemic in pigs – swine influenza
•and birds – avian influenza
new H1N1 strain of swine-origin caused pandemic
•B
•C
• New influenza viruses are constantly being
produced by mutation
• antigenic drift:
– small changes in surface antigen
• antigenic shift:
– acquire new antigens by
reassortment between
avian/swine & human strains
Transmission
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Swine influenza virus common throughout
pig populations worldwide
Transmission from pigs to humans is not
common and does not always lead to
human influenza
• People with regular exposure to pigs are at
increased risk of swine flu infection
– Meat of an infected animal poses no risk of infection
when properly cooked
• Transmission from one person to another is by
droplet or fomite
Mild symptoms :
• Fever
• sore throat & cough
• headache, muscle or joint pains
• nausea vomiting, or diarrhea
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Those at risk of a more severe infection:
• asthmatics
• diabetics
• obesity
• heart disease
• immunocompromised
• pregnant women
Symptoms in severe cases :
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Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting
Low temperature
Complications
Abigail & Brittany Hensel March 7, 1990
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Some patients deteriorates around 3 to 5
days after onset
• Respiratory failure
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requiring immediate admission to an intensive
care unit & mechanical ventilation
• myocarditis & collapse - some times
Diagnosis
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Should not wait for laboratory confirmation
• Diagnosis based on clinical & epidemiological
background & start treatment early
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For Confirmation a nasopharyngeal or
oropharyngeal tissue swab tested with
• Real-time or RT-PCR
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not required in most people with flu symptoms.
test results do not affect recommended course of
treatment
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For diagnosis of influenza and not
H1N1/09 flu more widely available tests:
Rapid influenza diagnostic tests (RIDT):
results 30 minutes
• high rate of false negative
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patients should be treated empirically based on
the level of clinical suspicion
Direct & indirect immunofluorescence
assays (DFA & IFA): take 2–4 hours
Role of immunization
The
Natural
Humans
flu virus is constantly mutating
immunity is not very strong
will probably never be immune from the flu
Influenza immunization
Not
100% effective
Scientists
Chosen
choose the predominant strains
the year before
Swine flu vaccines
1. Nasal spray vaccine released in
early October 2009
• live attenuated H1N1 virus
approved for use in healthy individuals age 2
- 49
 not be used in pregnancy or
immunocompromised
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2. Injectable vaccine
• Made from killed H1N1
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used from 6 months to the elderly including
Antiviral agents
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Oseltamivir (Tamiflu) and zanamivir
• used to prevent or reduce influenza A and B
symptoms
• Efficacy reduces if the flu symptoms already
have been present for 48 hours or more
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Supportive measures in severe infection
• ventilation support
• treatment of other infections like pneumonia
Prophylaxis
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Avoid crowded places
Well ventilated houses
Covering mouth & nose while coughing /
sneezing
Avoid touching nose & eyes
Frequent hand washing
That’s all in this session !