ICL 2.2: Upper Airway Infections

Question 1

what is otitis media?

Answer 1

an infection of the middle ear between the eustachian tube and the tympanic membrane

Question 2

what causes otitis media?

Answer 2

viral upper respiratory infection can cause edema of the eustachian tube, which often leads to middle ear infection

the most common organisms are:
1. strep pneumoniae (35−40%)

2. H. influenzae (nontypeable; 25−30%)
3. moraxella catarrhalis (15−20%).

this is roughly the same breakdown of organism type and frequency that occurs in bronchitis and sinusitis!!

Question 3

what is the hallmark clinical presentation of otitis media?

Answer 3

the most sensitive clinical finding is immobility of the membrane on insufflation of the ear with air

it’s NOT usually redness!! don’t be fooled

Question 4

how do you treat otitis media?

Answer 4

oral therapy with amoxicillin is still the best initial therapy = 2nd generation penicillin

amoxicillin/clavulanate is used if there has been recent amoxicillin use

other alternatives to amoxicillin-clavulanate are second-generation cephalosporins, such as cefuroxime

patients with severe penicillin allergies should receive macrolides such as azithromycin

Question 5

what is sinusitis?

Answer 5

an infection of the sinuses

the most common site is the maxillary sinus, followed by ethmoid, frontal, and sphenoid sinuses

can diagnose with CT scan which would show mucous thickening in the sinus

Question 6

what causes sinusitis?

Answer 6

viruses are responsible for most of the cases –> they come in and cause edema and infiltrate in the mucosa which allows bacteria to come in and cause more infection

bacterial organisms that cause sinusitis are the same ones causing otitis media = strep pneumoniae, H. influenzae, moraxella catarrhalis (15−20%).

Question 7

what are the symptoms of sinusitis?

Answer 7

1. facial pain
2. headache
3. postnasal drainage
4. purulent nasal drainage (green, yellow color)

Question 8

how do you treat sinusitis?

Answer 8

mild or acute uncomplicated sinusitis which means no colored sputum, can be managed with decongestants, such as oral pseudoephedrine or oxymetazoline sprays

more severe sinusitis, since it’s the same organisms as otitis media, it’ the same treatment! oral therapy with amoxicillin is still the best initial therapy = 2nd generation penicillin

amoxicillin/clavulanate is used if there has been recent amoxicillin use

other alternatives to amoxicillin-clavulanate are second-generation cephalosporins, such as cefuroxime

patients with severe penicillin allergies should receive macrolides such as azithromycin

Question 9

what imagining do you use for sinusitis?

Answer 9

CT scan

Question 10

what is pharyngitis?

Answer 10

inflammation of the pharynx

Question 11

what causes pharyngitis?

Answer 11

80% is caused by viruses but the most important cause is group A B-hemolytic streptococci = S. pyogenes

this is because of the possibility of the organism progressing on to rheumatic fever or glomerulonephritis

Question 12

what are the symptoms of pharyngitis?

Answer 12

sore throat with cervical adenopathy and inflammation of the pharynx with an exudative covering is highly suggestive of S. pyogenes

most viruses do not give an exudate, although the Epstein-Barr virus can

hoarseness and cough are NOT suggestive of bacterial pharyngitis

Question 13

how do you diagnose pharyngitis?

Answer 13

rapid streptococcal antigen test is 80% sensitive but >95% specific

a positive test can be considered the equivalent of a positive culture, whereas a negative test should be confirmed with a culture

Question 14

how do you treat pharyngitis?

Answer 14

penicillin

macrolides and oral, second-generation cephalosporins are alternatives in the penicillin-allergic patient

Question 15

what is influenza?

Answer 15

a systemic viral illness from influenza A or B, usually occurring in an epidemic pattern and transmitted by droplet nuclei – so they’ll have URI symptoms but also systemic symptoms like body pain etc.

droplet nuclei = sneezing, shared saliva, etc.

influenza can lead to damage to the respiratory epithelium leading to sinusitis, otitis media, bronchitis, and pneumonia

Question 16

what are the symptoms of influenza?

Answer 16

URI symptoms:

1. runny nose
2. nonproductive cough
3. sore throat
4. conjunctival injection

AND

systemic illness:

1. fever
2. myalgias
3. headache
4. fatigue

Question 17

how do you test for influenza?

Answer 17

confirmation is best achieved initially with rapid antigen detection methods of swabs or washings of nasopharyngeal secretion

Question 18

how do you treat influenza?

Answer 18

1. symptomatic therapy with acetaminophen and antitussives is useful
2. specific antiviral medications for both influenza A and B are the neuraminidase inhibitors oseltamivir and zanamivir –> they should be used within 48 hours of the onset of symptoms to limit the duration of symptoms, doesn’t actually kill the virus (better for influenza A than B)

influenza vaccine is recommended annually in the general public

Question 19

which populations really need to get the influenza vaccine?

Answer 19

1. chronic lung and cardiac disease = COPD, CHF
2. pregnant women in any trimester
3. residents of chronic care facilities
4. health care workers
5. immunosuppressed
6. DM
7. renal dysfunction

it’s recommended in the general public but these patients reallyyyyyy need the vaccine

Question 20

in which patients is the influenza vaccine contraindicated?

Answer 20

those who are highly allergic to eggs and which would result in anaphylaxis

Question 21

what is bronchitis?

Answer 21

an infection of the lung, which is limited to the bronchial tree with limited involvement of the lung parenchyma = you can’t see it on a CXR!

acute exacerbations of chronic bronchitis (COPD) are often difficult to distinguish from a pneumonia until after a chest x-ray is performed

Question 22

which organisms cause acute bronchitis?

Answer 22

the majority of cases are caused by viruses

S. pneumoniae and H. influenzae have not been implicated

a small percentage of non viral cases are due to M. pneumoniae, C. pneumoniae, and B. pertussis

Question 23

which organisms are most commonly responsible for chronic bronchitis?

Answer 23

1. streptococcus pneumoniae
2. non-tapeable haemophilus influenzae
3. moraxella

Question 24

what is the clinical presentation of acute bronchitis?

Answer 24

cough with sputum production

a bacterial etiology is suggested by discolored sputum; clear sputum means viral cause

signs of respiratory infection, such as cough and sputum, with a normal chest x-ray confirm the diagnosis

Question 25

how do you treat acute bronchitis?

Answer 25

mild acute cases often do not require therapy because they are often caused by viruses that resolve spontaneously; just give tylenol and antitussive medication acute or chronic cases require treatment with oral antibiotics that cover the most causative organisms --> amoxicillin first then if it doesn't work give amoxicillin-clavulanate or cefuroxime; give macrolide if allergic to amoxicillin

Question 26

what is an acute cough?

Answer 26

cough in the first 3 weeks of developing it! if it's 3 weeks-3 months = subacute 3+ months = chronic

Question 27

what causes acute cough?

Answer 27

mild viral infections treat the symptoms, no other treatment

Question 28

what are the 2 types of cough receptors?

Answer 28

1. mechanical receptors - touch = mucus, saliva, food, foreign body - displacement = abscess, submucosal adenopathy 2. chemical receptors - acid - temperature - capsaicin - TRPV1

Question 29

what is a subacute cough?

Answer 29

cough that lasts from 3-8 weeks classically associated with Bordetella pertussis this post-infectious phase follows the catarrhal and precedes the convalescent phases

Question 30

how do you treat subacute cough?

Answer 30

macrolide or trimethoprim/sulfamethoxazole (bactrim) but this probably only helps if administered in the first or second week of symptom

Question 31

what is the prophylaxis measurement taken against subacute cough?

Answer 31

booster vaccines for adolescents and adults in the Tdap combination

Question 32

what is a chronic cough?

Answer 32

cough lasting longer than 8 weeks is dominated by three conditions that may occur in isolation (75%) or in combination (25%) hard to treat because it's not just caused by one thing, it's a combination of conditions

Question 33

what are the 4 conditions that mainly cause chronic cough?

Answer 33

1. upper airway cough syndrome (UACS) = aka postnasal drip, hay fever, allergic rhinitis 2. gastroesophageal reflux disease (GERD) 3. asthma 4. medication; ACE inhibitors!! the next three most common causes are chronic bronchitis, bronchiectasis, and non-asthmatic eosinophilic bronchitis

Question 34

what is UACS?

Answer 34

UACS = upper airway cough syndrome due to irritation of afferent receptors in the upper airway usually caused by allergies!

Question 35

how do you treat UACS?

Answer 35

after avoidance measures of potential environmental factors (pets, perfumes, allergens), an empiric course of a first-generation antihistamine (benadryl) combined with a decongestant is typically recommended before extensive investigation if the patient doesn't improve: of all medical therapies, intranasal corticosteroids appear the most effective, but patient education is essential to ensure compliance during the 3 to 4 weeks necessary to achieve full medical benefit failure to respond suggest the presence of chronic sinusitis

Question 36

what are the causes of UACS?

Answer 36

1. allergic 2. drug-induced = NSAIDS, antihypertensives 3. environmental 4. bacterial

Question 37

which antihistamines are useful in treating allergic rhinitis?

Answer 37

newer antihistamines (claritin, allegra) may help with UACS but not other forms of rhinosinusitis, most likely because they lack substantive anticholinergic properties 1st generation = anticholinergic = dryness which is why they help with UACS but they're sedatives so....

Question 38

what symptoms are associated with GERD?

Answer 38

cough when they bend over coughing at night GERD has been implicated in nearly 40% of patients with chronic cough, either as the sole cause or in combination with other etiologies, and often without the traditional symptoms of dyspepsia and heartburn

Question 39

how do you treat GERD?

Answer 39

1. lifestyle and dietary changes 2. acid suppression 3. prokinetic agent often takes 2 – 3 months before cough begins to improve, and 5 – 6 months before it resolves if cough continues, consider 24-hour pH probe

Question 40

if someone has a post-viral cough, what do you need to be cognizant of?

Answer 40

UACS or asthma also remember to consider Bordetella pertussis consider a short course of prednisone, inhaled ipratroprium, 1st generation antihistamine, nasal steroids, or a nasal rinse sputum cultures usually not recommended

Question 41

what often causes hoarseness?

Answer 41

common respiratory causes are dominated by upper respiratory infections from viruses gastroesophageal and laryngopharyngeal reflux are also common suspects, but it remains uncertain that therapies known to alleviate dyspepsia will also be effective when reflux is associated with dyspnea more unusual causes encountered by pulmonologists include recurrent laryngeal nerve damage from bronchogenic lung cancer and associated Horner syndrome, tuberculosis, granulomatosis with polyangiitis affecting the upper airway, use of inhaled corticosteroids, and trauma from items such as endotracheal tube

Question 42

21 year old male previously healthy presented to the urgent care c/o fever, runny nose, and sore throat. He has severe allergy to penicillin. Q1. What is the most likely diagnosis? Q2. What is the sensitivity and specificity of a rapid streptococcal antigen test? Q3. Name three signs and symptoms that can differentiate a viral from bacterial infection?

Answer 42

1. pharyngitis 2. 80% sensitive and 95% specific 3. exudate, cervical lymphadenomy, absence of hoarseness and cough = bacterial

Question 43

Q1. Three days later, he developed left ear pain and high grade fever, what exam you would like to do to diagnose Otitis media? Q2. What other complications do you expect to develop? Q3. 5 days later, he c/o facial pain and colored nasal discharge, A CT scan showed maxillary sinusitis, what antibiotics you want to prescribe?

Answer 43

Q1. air test; absence of tympanic membrane movement with air Q2. meningitis; untreated otitis media can lead to mastoiditis which can then lead to meningitis Q3. macrolide because allergic to penicillin

Question 44

A 63-year-old man comes to the office with a cough productive of yellowish sputum for the last several days. He has smoked 1 pack of cigarettes a day for the last 30 years. This is his fourth episode in the last 2 years. On physical examination, he has clear lungs and a temperature of 101°F. His chest x-ray is normal Q1. What is the diagnosis? Q2. What are the most common causative organisms? Q3. What is the treatment?

Answer 44

Q1. acute exacerbation of chronic bronchitis Q2. strep pneumonia, H. influenza, and moraxilla catarhalis Q3. amoxicillin

Question 45

A 42 year old female with history of childhood allergies present with dry cough of 12 weeks duration Q1. What is your differential diagnosis? Q2. Throat exam showed the presence of post nasal drip, what is the initial treatment? Q3. What is the long term treatment?

Answer 45

Q1. chronic cough = asthma, GERD, UACS, medications --> probably asthma because she had childhood allergies Q2. 1st generation antihistamine + decongestant Q3. intranasal corticosteroid