Rhinopharyngitis

Nasopharyngitis (rhinopharyngitis or
the common cold) = Inflammation of
the nares, pharynx, hypopharynx,
uvula, and tonsils
Occur year round, but mostly during
fall and winter. Epidemics is most
common during cold months, with a
peak incidence in late winter to early
spring.
Humidity may also affect the
prevalence of colds, because most viral
URI agents thrive in the low humidity
characteristic of winter months

Etiology of
rhinopharyngitis

Rhinoviruses: These cause approximately 30-50%

RSV
Coronaviruses: Enteroviruses, including
coxsackieviruses, echoviruses, and others: These
are also leading causes of the common cold.
Other viruses: Adenoviruses, orthomyxoviruses
(including influenza A and B viruses),
paramyxoviruses , EBV, account for many URIs.
Varicella, rubella, and rubeola
Bacteria ( very rare): streptococci , staph,
diphteria, B pertussis,Haemophilus,
Pneumococcus, Neisseria, Treponema

Risk factors

Contact: Close contact with small children settings,

such as school or daycare, increases the risk of URI.
Travel: , exposure to large numbers of individuals in
closed settings. Increased exposure to respiratory
pathogens
Environmental factors such as passive smoking and
exposure to pollutants
Immunocompromise that affects cellular or humoral
immunity: Splenectomy, HIV infection, corticosteroids,
immunosuppressive treatment , f amilial predisposition
with immunological defects or anatomical and/or
physiological features
Malnutrition
Atopic status
Lack of breast-feeding
Cilia dyskinesia syndrome and cystic fibrosis
Anatomic changes due to facial dysmorphisms
Upper airway trauma, and nasal polyposis
Anemia, rickets, malnutrition
Carrier state

Pathophysiology

Direct invasion of the mucosa lining the upper

airway
Person-to-person spread of viruses by hand
with pathogens to the nose or mouth or
inhaling respiratory droplets from an infected
person who is coughing or sneezing.
Barriers, including physical, mechanical,
humoral, and cellular immune defenses.
Hair lining the nose filters
Mucus coats
Ciliated cells lower in the respiratory tract trap
and transport pathogens up to the pharynx,
where they are then swallowed into the
stomach
Adenoids and tonsils contain immune cells
that respond to pathogens.

local swelling, erythema, edema, secretions,

and fever, result from the inflammatory
response of the immune system to invading
pathogens and from toxins
initial nasopharyngeal infection may spread
to adjacent structures, resulting in sinusitis,
otitis media, epiglottitis, laryngitis,
tracheobronchitis, and pneumonia
Humoral immunity (immunoglobulin A) and
cellular immunity
Normal nasopharyngeal flora, including
various staphylococcal and streptococcal
species, help defend against potential
pathogens
Suboptimal humoral and phagocytic immune
function have URI increased risk and have
severe or prolonged course of disease.

SYMPTOMS

Nasal obstruction
Congestion of nasal breathing
Sneezing
Rhinorrhea : secretions often evolve from
clear to opaque white to green to yellow
within 2-3 days of symptom onset
Cough
Anorrhexia
Fever
5-10 days
Foul breath: This occurs as resident flora
process the products of the inflammatory
process.
Hyposmia: Also termed anosmia, it is
secondary to nasal inflammation.
Headache

 Sinus symptoms: These may include

congestion or pressure and are common with
viral URIs.
Photophobia or conjunctivitis: adenovirus .
Influenza : pain behind the eyes, pain with
eye movement, or conjunctivitis.
Itchy, watery eyes are common in patients
with allergic conditions.
Fever: This is usually slight or absent, but
temperatures can reach 39.5C in infants and
young children. If present, fever typically lasts
for only a few days.
Gastrointestinalsymptoms: Symptoms such
as nausea, vomiting, and diarrhea may occur
in persons with influenza, especially in
children. Nausea and abdominal pain may be
presentin individuals with strep throat and
viral syndromes.

LABORATORY

CBC, ES, CRP, to find bacterian infection,

Leucocytosis with neutrophilia suggest bacterian,
low level of WBC, lymphocytes raised in viral
infections

Because viruses cause most URIs, the diagnostic

role of laboratory investigations and radiologic
studies is limited. Viral culture, rapid antigen
detection, or polymerase chain reaction (PCR)
assay of influenza virus on a nasopharyngeal
swab could be done if specific antiviral therapy is
recommended. Similar tests are also available for
adenovirus, respiratory syncytial virus, and
parainfluenza virus.

The use of reverse-transcriptase PCR for

the diagnosis of enterovirus and
rhinovirus infections is not currently
available for daily clinical care.
Serologic tests for mononucleosis
Influenza serologies only have
epidemiologic value and should not be
used for clinical care.
A pharyngeal swab for rapid antigen
detection of GABHS (Group A BetaHemolytic Streptococci ) is 90%
sensitive and 95% specific
NOSE AND THROAT cultures

COMPLICATIONS

Sinusitis is a complication in only

approximately 2% of persons with viral URIs
Otitis
Epiglottitis occurs at a rate of 6-14 cases per
100,000 children
Croup, or laryngotracheobronchitis usually
occurs in children aged 6 months to 6 years
with peak incidence in the second year of life
Pneumonia
Digestive complications: anorrhexia,
vomiting, diarrhea, dehidration,
Seizures may appear when fever is more than
38,5 C

Imaging Studies for URTI

A lateral neck radiograph should be taken in a patient with

stridor to assess the airways if epiglottitis is clinically
suspected

Chest radiography should be reserved for patients with acute

tracheobronchitis , those with abnormal vital signs or signs of
consolidation on chest examination, or those with persistent
symptoms for longer than 3 weeks.

Plain radiography has been largely replaced by computed

tomography (CT) in the evaluation of sinusitis, particularly in
preparation for corrective surgery. Complete opacification and
air-fluid level are the most specific findings for acute sinusitis.

However, a large proportion of patients with the common cold

have radiologic abnormalities on CT. Imaging is recommended
for patients who do not respond to treatment with antibiotics
and decongestants, but is not advised for the diagnosis of
uncomplicated sinusitis. Mastoiditis and other intracranial
complications of URIs should be evaluated by CT or magnetic
resonance imaging.

PREVENTION AND
TREATMENT

Prevention : VACCINES, IMMUNOSTIMULANTS,

VITAMINS

Parent education on risk factor modification, in particular

avoiding smoking indoors
General hygiene methods for children attending day care
centres
Breast feeding
Management
Rest
Lot of fluid intake.
Nasal wash with hypertonic salt water or 0.9% saline
Decongestants to unblock the opening of sinuses and reduce
symptoms of nasal congestion in children above 3 years
Paracetamol 30-40 mg/kg/day for fever and pain reliever
Antibiotics to treat the bacterial infection very rare ( fever,
ES high, CRP+leucocytosis, children with immune handicaps)

Bacterial pharyngitis

This may be difficult to distinguish from viral

pharyngitis. Assessment for group A
streptococci warrants special attention.
Physical findings that suggest a high risk for
group A streptococcal disease are erythema,
swelling, or exudates of the tonsils or
pharynx; temperature of 38.3C or higher;
tender anterior cervical nodes (>1 cm); and
an absence of conjunctivitis, cough, or
rhinorrhea, which are suggestive of viral
illness.

Mucosal ulcers, erosions, vesicles: The presence of

palatal vesicles or shallow ulcers is characteristic of
primary infection with HSV.
Ulcerative stomatitis may also occur in coxsackievirus or
other enteroviral infection. Mucosal erosions may also be
seen in primary HIV infection. Small vesicles on the soft
palate, uvula, and anterior tonsillar pillars suggest
infection by coxsackievirus, known as herpangina.
Tonsillar hypertrophy
Foul breath: Halitosis may be noted because resident
florae process the products of the inflammatory process.
Anterior cervical lymphadenopathy: This is seen with viral
and bacterial infections.
Approximately half of EBV mononucleosis cases involve
generalized adenopathy or splenomegaly. An enlarged
liver may also be palpable. Primary HIV infection may also
include lymphadenopathy.

A rash may be seen with group A

streptococcal infections, particularly in
patients younger than 18 years.
This scarlet fever rash appears as tiny
papules over the chest and abdomen,
creating roughness like sunburned
appearance.
The rash spreads, causing erythema in
the groin and armpits. The face may be
flushed, with pallor around the lips.
Approximately 2-5 days later, the rash
begins to resolve. Peeling is often
noted on the tips of toes and fingers

OTITIS MEDIA

The eustachian tubes equalize the pressure

between the middle ear cavity and the outside
atmosphere and allow fluid and mucus to drain out
of the middle ear cavity. Inflammation of the
middle ear causes the tubes to close causing the
fluid to become trapped. Bacteria from the back of
the nose travel through the eustachian tube
directly into the middle ear cavity and multiply in
the fluid. The inflammation can occur as a result of
an infection extending up the eustachian tube.
This tube may become blocked by a bacterial or
viral infection or by enlarged adenoids. Fluid
produced by the inflammation cannot drain off
through the tube and instead collects in the
middle ear.

The Eustachian tube is

a canal that connects
the middle ear to the
throat. It is lined with
mucus, just like the
nose and throat; it
helps clear fluid out of
the middle ear and
into the nasal
passages. Cold, flu,
and allergies can
irritate the Eustachian
tube and cause the
lining of this
passageway to
become swollen.

Ear Infection

diagnose an ear
infection by
looking at the
outer ear and
the eardrum
with a device
called an
otoscope. A
healthy
eardrum (shown
here) appears
transparent and
pinkish-gray. An
infected
eardrum looks
red and swollen.

If the Eustachian tube

becomes blocked, fluid
builds up in the middle
ear. This creates an
environment for bacteria
and viruses, which can
cause infection; fluid is
detected in the middle
ear with a pneumatic
otoscope. This device
blows a small amount of
air at the eardrum,
making the eardrum
vibrate. If fluid is
present, the eardrum will
not move as much as it
should.

Ruptured Eardrum
When too much fluid
builds up in the middle
ear, it can put pressure
on the eardrum until it
ruptures (shown here).
Signs of a ruptured
eardrum include
yellow, brown, or white
fluid draining from the
ear. Pain may
disappear suddenly
because the pressure
of the fluid on the
eardrum is gone.
Although a ruptured
eardrum sounds
frightening, it usually
heals itself in a couple
of weeks.

SIGNS AND SYMPTOMS

Ear Infection Symptom

Sudden, piercing pain in the ear which may be worse
when lying down, making it difficult to sleep.
Trouble hearing.
A fever of up to 40 C .
Tugging or pulling at one or both ears.
Fluid drainage from ears.
Loss of balance.
Nausea, vomiting, or diarrhea.
Congestion.
Ear Infection Symptoms: Babies
It can be difficult to identify an ear infection in
babies or children :crankiness, trouble sleeping,
and loss of appetite. Babies may push their
bottles away because pressure in the middle ear
makes it painful to swallow.

Laboratory

WBC, ES, Fg, CRP, high if

bacterian
Local exam with otoscope
Cultures of otic discharge
Imagery when progresses through
otomastoiditis

COMPLCATIONS

CRONIC OTITIS
OTOMASTOIDITIS
DEAFNESS
CEREBRAL VENOUS TROMBOSIS
CEREBRAL ABCESS
MENINGITIS
DIARRHEEA, DEHIDRATION
SEIZURES

PREVENTION OF OTITIS
MEDIA

Encouraging breast-feeding
Feeding child upright if bottle fed
Avoiding exposure to passive smoke
Teaching adults and children careful
hand washing technique
Limiting exposure to viral upper
respiratory infections
Ensure immunizations are up-to-date;
including influenza and 7 valent
conjugated polysaccharide vaccine
(PCV7)

One solution is for your doctor to

insert small tubes through the
eardrum. Ear tubes let fluid drain out
of the middle ear and prevent fluid
from building back up. This can
decrease pressure and pain, while
restoring hearing. The tubes are
usually left in for 8 to 18 months until
they fall out on their own.

Treatment of otitis
media

Desinfection of nasopharynx
Analgesics (oral and topical pain
killing therapy)
Paracetamol, ibuprophene, NO aspirin
Children with low risk be treated with
a wait-and-see approach.
Low-dose amoxicillin (40 mg/kg/day)
may be used if low risk (greater than
two years, no day care, and no
antibiotics for the past three months)

Failure to respond to initial treatment drug

(resistant or persistent acute otitis media)

amoxicillin/clavulanate potassium,
cefuroxime axetil,
cefpodoxime proxetil.
Trimethoprim sulfamethoxasone: Bactrim, biseptol 6-8
mg/kg in 2 daily doses
Clarithromycin 15-20 mg/kg
Erythromycin ethylsuccinate and sulfisoxazole acetyl: 3040mg/kg
Azithromycin
a single dose of ceftriaxone 50 mg/kg could be
equivalent to a 10-day course of oral antibiotics for
new cases of acute otitis media
ceftriaxone sodium: prescribe one dose for new onset otitis
media and a three-day course for a truly resistant pattern of
otitis media or if oral treatment cannot be given, 5 days