Transcript 27. INFECTIONS OF THE UPPER RESPIRATORY TRACT

INFECTIONS OF THE UPPER
RESPIRATORY TRACT
•They are among the most common reasons for
visits to primary care Providers
• the illnesses are typically mild
•Even though the minority (~25%) of cases are
caused by bacteria, URIs are the leading
diagnoses for which antibiotics are prescribed on
an outpatient basis in the United States
Dr. Farzin khorvash
• Although most URIs1 are caused by
viruses, distinguishing patients with
primary viral infection from those with
primary bacterial infection is difficult
• Signs and symptoms of bacterial and viral
URIs are, in fact, indistinguishable
• Because routine, rapid testing is neither
available nor practical for most syndromes,
acute infections are diagnosed largely on
clinical grounds.
Dr. Farzin khorvash
NONSPECIFIC INFECTIONS OF THE
UPPER RESPIRATORY TRACT
• Nonspecific URIs, by definition, have no
prominent localizing features
• They are identified by a variety of
descriptive names, including acute
infective rhinitis, acute
rhinopharyngitis/nasopharyngitis, acute
coryza, and acute nasal catarrh, as well
as by the inclusive label common cold.
Dr. Farzin khorvash
Etiology
• Nearly all nonspecific URIs are caused by viruses
spanning multiple virus families
• For instance, rhinoviruses (~30 to 40% of cases)
consist of at least 100 immunotypes
• influenza virus (3 immunotypes)
• parainfluenza virus (4 immunotypes)
• coronavirus (at least 3 immunotypes)
• adenovirus (47 immunotypes)
• Respiratory syncytial virus (RSV)
• enteroviruses, rubella virus, and varicella-zoster
virus)
Dr. Farzin khorvash
Manifestations
• rhinorrhea (with or without purulence)
• nasal congestion
• cough
• sore throat
• fever, malaise, sneezing, and hoarseness, are more variable
• fever more common among infants and young children
• myalgias and fatigue, for example, are sometimes seen with
influenza and parainfluenza infections, while conjunctivitis may
suggest infection with adenovirus or enterovirus
• Findings on physical examination are frequently nonspecific
Dr. Farzin khorvash
secondary bacterial infections
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0.5 and 2% of colds are complicated
rhinosinusitis, otitis media, and pneumonia
infants, elderly persons, and chronically ill patients
prolonged course of illness, worsening of illness
severity, and localization of signs and symptoms
• purulent secretions from the nares or throat :
sinusitis or pharyngitis
• these secretions are also seen in nonspecific URI
and, in the absence of other clinical features, are
poor predictors of bacterial infection
Dr. Farzin khorvash
TREATMENT
• Antibiotics have no role In the absence of
clinical evidence of bacterial infection
• treatment remains entirely symptom-based
• decongestants
• nonsteroidal anti-inflammatory drugs
• dextromethorphan for cough
• Clinical trials of zinc, vitamin C, echinacea, no
consistent benefit for the treatment of
nonspecific URI.
Dr. Farzin khorvash
INFECTIONS OF THE SINUS
• most cases of sinusitis involve more than one sinus
• the maxillary sinus is most commonly involved, the
ethmoid, frontal, and sphenoid sinuses
• respiratory epithelium produces mucus, is
transported out by ciliary action into the nasal cavity
• Normally remain sterile despite their adjacency to
the bacterium-filled nasal passages
• the sinus ostia are obstructed or ciliary clearance is
impaired
• The retained secretions may become infected with a
variety of pathogens, including viruses, bacteria, and
fungi.
Dr. Farzin khorvash
ACUTE SINUSITIS
• sinusitis of <4 weeks' duration
• occur primarily as a consequence of a
preceding viral URI
• Differentiating acute bacterial and viral
sinusitis on clinical grounds is difficult
• antibiotics are prescribed frequently (in
85 to 98% of all cases)
Dr. Farzin khorvash
Etiolog
• acute obstruction of the sinus ostia or
impairment of ciliary
• Noninfectious causes include allergic rhinitis
barotrauma or chemical irritants
• nasal and sinus tumors
• granulomatous diseases (e.g., Wegener's
granulomatosis or rhinoscleroma)
• altered mucus content (e.g., cystic fibrosis)
• In the hospital setting, nasotracheal
intubation
Dr. Farzin khorvash
organisms
• viruses, bacteria, and fungi
• Viral is far more common than
bacterial
• viruses alone and with bacteria
• rhinovirus, parainfluenza virus, and
influenza virus.
Dr. Farzin khorvash
Bacterial causes
• S. pneumoniae and nontypable Haemophilus
influenzae are the most common ,50 to 60%
• Moraxella catarrhalis (20%) of children but
less often in adults
• streptococcal species and Staphylococcus
aureus
• Anaerobes are with infections of the roots of
premolar teeth that spread into the adjacent
maxillary sinuses
• Chlamydia pneumoniae and Mycoplasma
pneumoniae ,unclear
Dr. Farzin khorvash
Nosocomial cases
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S. aureus
Pseudomonas aeruginosa
Serratia marcescens
Klebsiella pneumoniae,
Enterobacter species
polymicrobial ,highly resistant
Dr. Farzin khorvash
Fungi
• immunocompromised patients
• mucormycosis
• occur in diabetic patients with
ketoacidosis
• transplant recipients
• hematologic malignancies
• receiving chronic glucocorticoid or
deferoxamine therapy
• Aspergillus and Fusarium species
Dr. Farzin khorvash
Manifestations
• after or in conjunction with a viral URI
• difficult to discriminate the clinical
• bacterial sinusitis complicates only 0.2
to 2% of these viral infections.
Dr. Farzin khorvash
Manifestations
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nasal drainage and congestion
facial pain or pressure
headache.
Thick, purulent or discolored nasal discharge
is often thought to indicate bacterial
sinusitis, but it also occurs early in viral
infections such as the common cold
• Other nonspecific symptoms include cough,
sneezing, and fever
• Tooth pain, most often involving the upper
molars, is associated with bacterial sinusitis
Dr. Farzin khorvash
Manifestations
• sinus pain or pressure often localizes and
be worse when the patient bends over or is
supine
• symptoms of advanced sphenoid or ethmoid
sinus: severe frontal or retroorbital pain
radiating to the occiput, thrombosis of the
cavernous sinus, and signs of orbital cellulitis
• advanced frontal sinusitis ,Pott's puffy tumor,
swelling and pitting edema over the frontal
bone ,subperiosteal abscess
Dr. Farzin khorvash
Life-threatening complications
• Meningitis
• epidural abscess
• cerebral abscess.
Dr. Farzin khorvash
Diagnosis
• illness duration
• acute bacterial sinusitis is uncommon
in patients whose symptoms have
lasted <7 days
• facial or tooth pain in combination with
purulent nasal discharge that have
persisted for >7 days
Dr. Farzin khorvash
computed tomography, sinus radiography
• patients who meet these criteria, only
40 to 50% have true bacterial sinusitis
• CT or XR is not recommended for
routine cases, particularly early in the
course of illness (i.e., at <7 days)
• persistent, recurrent, or chronic
sinusitis, CT of the sinuses is choice.
Dr. Farzin khorvash
Diagnosis
• illness duration
• acute bacterial sinusitis is uncommon
in patients whose symptoms have
lasted <7 days
• facial or tooth pain in combination with
purulent nasal discharge that have
persisted for >7 days
Dr. Farzin khorvash
Diagnosis
• evidence of fungal hyphal elements and
tissue invasion
• acute nosocomial sinusitis should be
confirmed by a sinus CT scan
• sinus aspirate , if possible, for culture
and susceptibility testing.
Dr. Farzin khorvash
TREATMENT
• Most patients ,improve without antibiotic
therapy
• mild to moderate symptoms of <7 days'
duration
• facilitating sinus drainage, such as oral and
topical decongestants, nasal saline lavage
• in patients with a history of chronic sinusitis
or allergies — nasal glucocorticoids.
Dr. Farzin khorvash
antibiotics
• do not improve after 7 days
• more severe symptoms (regardless of
duration)
Dr. Farzin khorvash
antibiotics
• Empirical therapy ,S. pneumoniae and H.
influenzae
• amoxicillin
• drug-resistant S. pneumoniae
• Up to 10% of patients do not respond to
initial antimicrobial therapy
• these patients should be considered for sinus
aspiration and/or lavage
• prophylactic antibiotics to prevent episodes of
recurrent acute bacterial sinusitis is not
recommended.
Dr. Farzin khorvash
Surgical intervention and intravenous
antibiotics
• severe disease
• intracranial complications, such as
abscess or orbital involvement
• acute invasive fungal sinusitis usually
require extensive surgical debridement
• Intravenous antifungal such as
amphotericin B
Dr. Farzin khorvash
Treatment of nosocomial sinusitis
• broad-spectrum antibiotics to cover
common pathogens such as S. aureus
and gram-negative bacilli
• Therapy should then be tailored to the
results of culture and susceptibility
testing of sinus aspirates.
Dr. Farzin khorvash
CHRONIC SINUSITIS
• symptoms of sinus inflammation lasting >12
weeks
• bacteria or fungi
• clinical cure in most cases is very difficult
• Many patients have undergone repeated
courses of antibacterial agents and multiple
sinus surgeries
• increasing their risk of colonization with
antibiotic-resistant pathogens and of surgical
complications
Dr. Farzin khorvash
chronic bacterial sinusitis
• impairment of mucociliary clearance from
repeated infections rather than to persistent
bacterial infection
• pathogenesis of this condition is poorly
understood
• certain conditions (e.g., cystic fibrosis)
• most patients do not have obvious underlying
conditions that result in the obstruction of
sinus drainage, the impairment of ciliary
action, or immune dysfunction
Dr. Farzin khorvash
chronic bacterial sinusitis
• nasal congestion and sinus pressure,
with intermittent periods for years
• CT scan be helpful in defining the
extent of disease and the response to
therapy
• endoscopic examinations and obtain
tissue samples for histologic
examination and culture.
Dr. Farzin khorvash
Chronic fungal sinusitis
• immunocompetent hosts
• usually noninvasive, although slowly
progressive
• Aspergillus species
Dr. Farzin khorvash
Chronic fungal sinusitis
• In mild, indolent disease
• repeated failures of antibacterial
therapy
• only nonspecific mucosal changes may
be seen on sinus CT
• Endoscopic surgery is usually curative
in these patients, with no need for
antifungal therapy
Dr. Farzin khorvash
Chronic fungal sinusitis
• mycetoma (fungus ball) within the sinus
• Treatment for this condition is also
surgical
• systemic antifungal therapy may be
warranted in the rare case where bony
erosion occurs.
Dr. Farzin khorvash
Chronic fungal sinusitis
• allergic fungal sinusitis
• history of nasal polyposis and asthma
• thick, eosinophilic mucus with the
consistency of peanut butter that
contains sparse fungal hyphae on
histologic examination.
• Patients often present with pansinusitis.
Dr. Farzin khorvash
TREATMENT
• administration of intranasal
glucocorticoids; and mechanical
irrigation of the sinus with sterile saline
solution
• When this management approach fails,
sinus surgery may be indicated
Dr. Farzin khorvash
INFECTIONS OF THE EAR AND
MASTOID
• middle and external ear,skin, cartilage,
periosteum, ear canal, and tympanic
and mastoid cavities
• Both viruses and bacteria
Dr. Farzin khorvash
Acute Otitis Media
• when pathogens from the nasopharynx
are introduced into the inflammatory
fluid collected in the middle ear — e.g.,
by nose blowing during a URI
• The diagnosis of acute otitis media
requires the demonstration of fluid in
the middle ear (with tympanic
membrane immobility) and the
accompanying signs
Dr. Farzin khorvash
ETIOLOGY
• typically ,viral URI
• RSV, influenza virus, rhinovirus, and
enterovirus
• they predispose the patient to bacterial
• S. pneumoniae ,35% of cases
• H. influenzae (nontypable strains) and
M. catarrhalis are
• Viruses,either alone or with bacteria in
17 to 40% of cases.
Dr. Farzin khorvash
MANIFESTATIONS
• Fluid in the middle ear ,pneumatic
otoscopy
• this movement is dampened when fluid
is present
• the tympanic membrane can also be
erythematous, bulging, or retracted
• occasionally can spontaneously
perforate.
Dr. Farzin khorvash
MANIFESTATIONS
• otalgia, otorrhea, diminished hearing,
fever, or irritability
• Erythema of the tympanic membrane is
often evident but is nonspecific
• Other signs and symptoms include
vertigo, nystagmus, and tinnitus.
Dr. Farzin khorvash
TREATMENT
• most cases resolve clinically 1 week after the
onset of illness
• initial observation and aggressive pain
management with anti-inflammatory therapy
• reserving antibiotics for high-risk patients,
patients with complicated disease, or patients
who do not improve after 48 to 72 h.
• recommend antibiotic therapy for children <2
years old and immunocompromised
Dr. Farzin khorvash
TREATMENT
• therapy is generally empirical
• except :tympanocentesis is warranted
,newborns, refractory to therapy,
severely ill immune deficiency
• amoxicillin is as successful as any other
agent, and it remains the drug of first
choice
Dr. Farzin khorvash
TREATMENT
• 5 to 7 days for uncomplicated longer
• courses ( 10 days) should be reserved
for complicated cases or for children <2
years old
Dr. Farzin khorvash
TREATMENT
• A switch in regimen
• there is no clinical improvement by the third
day of therapy
• infection with a ß-lactamase-producing strain
of H. influenzae or M. catarrhalis or with a
strain of penicillin-resistant S. pneumoniae
• Decongestants and antihistamines are
frequently used
• but clinical trials have yielded no significant
evidence of benefit
Dr. Farzin khorvash
Recurrent Acute Otitis Media
• more than three episodes within 6
months
• or four episodes within 12 months
• relapse or reinfection
• the recommended treatment consists of
antibiotics active against ß-lactamaseproducing organisms
Dr. Farzin khorvash
Antibiotic prophylaxis
• TMP-SMX or amoxicillin can reduce
• benefit is small compared with the cost of the
drug and the high likelihood of colonization
with antibiotic-resistant pathogens
• Other approaches :
• placement of tympanostomy tubes,
adenoidectomy, and tonsillectomy plus
adenoidectomy, are of questionable overall
value, given the relatively small benefit
compared with the potential for
complications.
Dr. Farzin khorvash
Serous Otitis Media
• when fluid is present in the middle ear for an
extended period and in the absence of signs
and symptoms of infection
• In general, acute effusions are self-limited;
most resolve in 2 to 4 weeks
• In some cases, in particular after an episode
of acute otitis media, effusions can persist for
months
• often associated with a significant hearing
loss
Dr. Farzin khorvash
TREATMENT
• The great majority resolve spontaneously
within 3 months
• Antibiotic therapy or myringotomy with
insertion of tympanostomy tubes is typically
reserved for
• patients in whom bilateral effusion :
• (1) has persisted for at least 3 months and
• (2) is associated with significant bilateral
hearing loss
Dr. Farzin khorvash
Chronic Otitis Media
• persistent or recurrent purulent otorrhea ,
tympanic membrane perforation
• some degree of conductive hearing loss
• divided into two subcategories: active and
inactive
• Inactive disease is characterized by a central
perforation of the tympanic membrane, which
allows drainage of purulent fluid
Dr. Farzin khorvash
active
• When the perforation is more
peripheral, squamous epithelium from
the auditory canal may invade the
middle ear through the perforation,
forming a mass of cholesteatoma
• This mass can enlarge ,erode bone and
promote further infection, which can
lead to meningitis, brain abscess, or
paralysis of cranialnerve VII
Dr. Farzin khorvash
Treatment of chronic active
• is surgical; mastoidectomy, myringoplasty,
and tympanoplasty
• overall success rate of ~80%
• Chronic inactive ;is more difficult to cure,
• repeated courses of topical antibiotic drops
during periods of drainage
• Systemic antibiotics may offer better cure
rates, but their role remains unclear.
Dr. Farzin khorvash
Mastoiditis
• In typical acute mastoiditis, purulent exudate collects in the
mastoid air cells, producing pressure that may result in erosion
of the surrounding bone and the formation of abscess-like
cavities that are usually evident on CT
• Patients typically present with pain, erythema, and swelling of
the mastoid process along with displacement of the pinna,
usually in conjunction with the typical signs and symptoms of
acute middle-ear infection
• Rarely, patients can develop severe complications if the
infection tracks under the periosteum of the temporal bone to
cause a subperiosteal abscess, erodes through the mastoid tip
to cause a deep neck abscess, or extends posteriorly to cause
septic thrombosis of the lateral sinus.
Dr. Farzin khorvash
Treatment
• Cultures of purulent fluid should be
performed
• Initial empirical therapy :against organisms
associated with acute otitis media,
• severe or prolonged courses : S. aureus and
gram-negative bacilli (including
Pseudomonas)
• Most patients can be treated conservatively
with intravenous antibiotics
• surgery (cortical mastoidectomy) can be
reserved for complicated cases and those in
which conservative treatment has failed.
Dr. Farzin khorvash
ACUTE PHARYNGITIS
• Millions of visits
• the majority by typical respiratory
viruses
• important is with group A ß-hemolytic
Streptococcus (S. pyogenes), which can
progress to acute rheumatic fever and
acute glomerulonephritis
• the risk for both of which can be
reduced by timely penicillin therapy.
Dr. Farzin khorvash
Etiology
• 30% have no identified cause.
• Respiratory viruses :rhinoviruses
,coronaviruses Influenza virus, parainfluenza
virus, and adenovirus the latter as part of the
more clinically severe syndrome of
pharyngoconjunctival fever
• HSV types 1 and 2, coxsackievirus A, CMV,
EBV
• Acute HIV infection
Dr. Farzin khorvash
Acute bacterial pharyngitis
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S. pyogenes, (~5 to 15% of all cases )
children 5 to 15 years of age
Streptococci of groups C and G account
Neisseria gonorrhoeae
Corynebacterium diphtheriae
Corynebacterium ulcerans
Yersinia enterocolitica
Treponema pallidum (in secondary syphilis)
M. pneumoniae
C. pneumoniae
Dr. Farzin khorvash
Anaerobic bacteria
• Vincent's angina
• can contribute to more serious
polymicrobial infections
• peritonsillar or retropharyngeal abscess
Dr. Farzin khorvash
Manifestations
• viruses :not severe and is typically
associated with a constellation of
coryzal symptoms
• Findings on physical examination are
uncommon;
• fever is rare,
• tender cervical adenopathy and
pharyngeal exudates are not seen.
Dr. Farzin khorvash
Manifestations
• influenza virus can be severe with fever as
well as with myalgias, headache, and cough
• pharyngoconjunctival fever due to adenovirus
infection is similar
• Since pharyngeal exudate may be present on
examination
• adenoviral pharyngitis is distinguished by the
presence of conjunctivitis in one-third to onehalf of patients.
Dr. Farzin khorvash
Manifestations
• primary HSV :mimic streptococcal
pharyngitis in some cases, with
pharyngeal inflammation and exudate
• vesicles and shallow ulcers on the
palate
• coxsackievirus ( herpangina):small
vesicles that develop on the soft palate
and uvula and then rupture to form
shallow white ulcers
Dr. Farzin khorvash
infectious mononucleosis
• Acute exudative pharyngitis coupled
with fever, fatigue, generalized
lymphadenopathy, splenomegaly
• CMV,EBV
Dr. Farzin khorvash
HIV
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fever
acute pharyngitis
myalgias, arthralgias, malaise
nonpruritic maculopapular rash
lymphadenopathy
mucosal ulcerations without exudate.
Dr. Farzin khorvash
streptococci A, C, and G
• ranging from a relatively mild illness without
many accompanying symptoms to clinically
severe cases
• pharyngeal pain, fever, chills, and abdominal
pain
• A hyperemic pharyngeal membrane with
tonsillar hypertrophy and exudate is usually
seen
• tender anterior cervical adenopathy
• Coryzal manifestations, including cough, are
typically absent
Dr. Farzin khorvash
scarlet fever
• Strains of S. pyogenes that generate
erythrogenic toxin
• characterized by an erythematous rash
and strawberry tongue
Dr. Farzin khorvash
Diagnosis
• Throat swab culture
• Rapid antigen-detection tests offer good
specificity (>90%) but lower sensitivity
that varies across the clinical spectrum
of disease (65 to 90%)
Dr. Farzin khorvash
RADT
• all negative rapid antigen-detection
tests in children be confirmed by a
throat culture
• do not recommend backup culture
when adults have a negative rapid
antigen-detection test
Dr. Farzin khorvash
Diagnosis
• Cultures and rapid diagnostic tests for
influenza virus, adenovirus, HSV, EBV9,
CMV, and M. pneumoniae, are available
• the monospot test for EBV
• HIV RNA or antigen (p24) when acute
primary HIV infection
• cultures : N. gonorrhoeae, C.
diphtheriae, or Y. enterocolitica
Dr. Farzin khorvash
TREATMENT
• Antibiotic benefit:S. pyogenes
• a decrease in the risk of rheumatic fever
• rheumatic fever is now a rare disease, even
in untreated patients
• When therapy is started within 48 h of illness
onset, however, symptom duration is also
decreased.
• reduce the spread of streptococcal
pharyngitis, overcrowding or close contact
Dr. Farzin khorvash
streptococcal pharyngitis
• single dose of intramuscular benzathine
penicillin
• 10-day course of oral penicillin
• Erythromycin :penicillin
• Testing for cure is unnecessary and may
reveal only chronic colonization.
• Penicillin prophylaxis (benzathine penicillin G,
1.2 million units intramuscularly every 3 to 4
weeks) for patients at risk of recurrent
rheumatic fever
Dr. Farzin khorvash
influenza virus
• amantadine, rimantadine, and the two
newer agents oseltamivir and zanamivir
• All of these agents need to be started
within 36 to 48 h of symptom onset to
reduce illness duration meaningfully
• Of these agents, only oseltamivir and
zanamivir are active against both
influenza A and influenza B
Dr. Farzin khorvash
Complications
• rheumatic feveracute
• glomerulonephritis
• numerous suppurative conditions, such as
peritonsillar abscess ,otitis media, mastoiditis,
sinusitis, bacteremia, and pneumonia
• Therapy of acute streptococcal pharyngitis
can prevent the development of rheumatic
fever
• no evidence that it can prevent acute
glomerulonephritis
Dr. Farzin khorvash
peritonsillar abscess
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severe pharyngeal pain
dysphagia, fever,
medial displacement of the tonsil
therapy :Oral penicillin ,with
clindamycin as an alternative
• Early use of antibiotics in these cases
has substantially reduced the need for
surgical drainage
Dr. Farzin khorvash
Vincent's angina
• acute necrotizing ulcerative gingivitis
• painful, inflamed gingiva
• ulcerations of the interdental papillae that
bleed easily
• halitosis ,fever, malaise, and
lymphadenopathy
• oral anaerobes
• Treatment :debridement and oral penicillin
+ metronidazole
• clindamycin alone as an alternative.
Dr. Farzin khorvash
Ludwig's angina
• is a rapidly progressive, potentially fulminant
cellulitis involving the sublingual and
submandibular spaces
• typically originates from an infected or
recently extracted tooth, most commonly the
lower second and third molars
• dysphagia, odynophagia, and "woody" edema
in the sublingual region, forcing the tongue
up and back with the potential for airway
obstruction.
• Fever, dysarthria, and drooling , speak in a
"hot potato" voice
Dr. Farzin khorvash
treatment
• Intubation or tracheostomy may be
necessary to secure the airway
• asphyxiation is the most common cause
of death
• monitored closely and intravenous
antibiotics directed against streptococci
and oral anaerobes
• ampicillin/sulbactam
• high-dose penicillin plus metronidazole.
Dr. Farzin khorvash
Postanginal septicemia (Lemierre's disease)
• oropharyngeal infection by
Fusobacterium necrophorum
• starts as a sore throat (most commonly
in adolescents and young adults),
exudative tonsillitis or peritonsillar
abscess
Dr. Farzin khorvash
• Infection of the deep pharyngeal tissue
allows organisms to drain into the
lateral pharyngeal space
• which contains the carotid artery and
internal jugular vein
• Septic thrombophlebitis of the internal
jugular vein: pain, dysphagia, and neck
swelling and stiffness
Dr. Farzin khorvash
• Sepsis occurs 3 to 10 days after the onset
• metastatic infection to the lung and other distant
sites
• extend along the carotid sheath and into the
posterior mediastinum
• mediastinitis, erode into the carotid artery, with the
early sign of repeated small bleeds into the mouth
• The mortality rate as 50%
• Treatment : intravenous antibiotics (penicillin G or
clindamycin) and surgical drainage
• The concomitant use of anticoagulants to prevent
embolization remains controversial but is often
advised.
Dr. Farzin khorvash
LARYNGITIS
• inflammatory process involving the
larynx
• are acute
• by the same viruses responsible for
many other URI
Dr. Farzin khorvash
Etiology
• rhinovirus, influenza virus,
parainfluenza virus, adenovirus,
coxsackievirus, coronavirus, and RSV
• acute bacterial respiratory infections,
such as group A Streptococcus or C.
diphtheriae ,M. catarrhalis
Dr. Farzin khorvash
Chronic laryngitis
• Mycobacterium tuberculosis
• Histoplasma and Blastomyces may
cause laryngitis
• Candida species :thrush or esophagitis
and particularly in immunosuppressed
patients
• to Coccidioides and Cryptococcus.
Dr. Farzin khorvash
Manifestations
• hoarseness
• other symptoms and signs of URI, including
rhinorrhea, nasal congestion, cough, and sore
throat
• Direct laryngoscopy :diffuse laryngeal
erythema and edema, along with vascular
engorgement of the vocal folds
• tuberculous laryngitis, mucosal nodules and
ulcerations visible on laryngoscopy
• these lesions are sometimes mistaken for
laryngeal cancer
Dr. Farzin khorvash
TREATMENT
• humidification
• voice rest
• Antibiotics are not recommended except
when group A Streptococcus is cultured
• chronic laryngitis usually requires biopsy
with culture.
• Patients with laryngeal tuberculosis are
highly contagious
Dr. Farzin khorvash
CROUP
• viral respiratory illnesses
• characterized by marked swelling of the
subglottic region of the larynx
• Croup primarily affects children <6
years old
Dr. Farzin khorvash
EPIGLOTTITIS
• Acute epiglottitis :acute, rapidly progressive
cellulitis of the epiglottis and adjacent
• airway obstruction in both children and adults
• Before the widespread use of H. influenzae
type b (Hib) vaccine, this entity was much
more common among children, with a peak
incidence at ~3.5 years of age
• a medical emergency, particularly in children,
and prompt diagnosis and airway protection
are of utmost importance.
Dr. Farzin khorvash
Etiology
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Hib12
group A Streptococcus
S. pneumoniae
Haemophilus parainfluenzae
S. aureus
Viruses have not yet been established
as a cause of acute epiglottitis.
Dr. Farzin khorvash
Manifestations
• more acutely in young children than in
adolescents or adults
• On presentation, most children have had
symptoms for <24 h, including high fever,
severe sore throat, tachycardia, systemic
toxicity, and drooling while sitting forward
• Symptoms and signs of respiratory
obstruction may also be present and may
progress rapidly
Dr. Farzin khorvash
Physical examination
• moderate or severe respiratory distress
• inspiratory stridor and retractions of
the chest wall
• These findings diminish as the disease
progresses and the patient tires
Dr. Farzin khorvash
diagnosis
• often made on clinical grounds
• direct fiberoptic laryngoscopy is frequently
performed in a controlled environment
:"cherry-red" epiglottis and to facilitate
placement of an endotracheal tube
• Direct visualization in an examination room
(e.g., with a tongue blade and indirect
laryngoscopy) is not recommended
Dr. Farzin khorvash
• Lateral neck radiographs and laboratory tests
• but may delay the critical securing of the
airway
• Neck radiographs :enlarged edematous
epiglottis (the "thumbprint sign"), usually
with a dilated hypopharynx and normal
subglottic structures.
• Laboratory tests :mild to moderate
leukocytosis with a predominance of
neutrophils
• Blood cultures are positive in a significant
proportion of cases.
Dr. Farzin khorvash
TREATMENT
• Security of the airway
• blood and epiglottis specimens have been
obtained for culture
• intravenous antibiotics, particularly H.
influenzae
• Because rates of ampicillin resistance in this
organism have risen
• therapy : a ß-lactam/ß-lactamase inhibitor
combination or a second- or third-generation
cephalosporin
Dr. Farzin khorvash
• ampicillin/sulbactam, cefuroxime, cefotaxime,
or ceftriaxone
• clindamycin and TMP-SMX reserved for
patients allergic to ß-lactams
• continued for 7 to 10 days
• household contacts of a patient with H.
influenzae epiglottitis include an unvaccinated
child under the age of 4, all members of the
household (including the patient) should
receive prophylactic rifampin for 4 days to
eradicate H. influenzae carriage.
Dr. Farzin khorvash
retropharyngeal abscess
• sore throat, fever, dysphagia, and neck pain
and are often drooling , pain with swallowing
• tender cervical adenopathy, neck swelling,
and diffuse erythema and edema of the
posterior pharynx , bulge in the posterior
pharyngeal wall
• A soft tissue mass :by lateral neck
radiography or CT
• Because of the risk of airway obstruction,
treatment begins with securing of the airway
• combination of surgical drainage and
intravenousantibiotic administration
Dr. Farzin khorvash
retropharyngeal abscess
• streptococci, oral anaerobes, and S. aureus
• ampicillin/sulbactam, clindamycin alone, or
clindamycin plus ceftriaxone
• Complications :rupture into the posterior
pharynx, which may lead to aspiration
pneumonia and empyema
• Extension may also occur to the lateral
pharyngeal space and mediastinum:
mediastinitis and pericarditis
• or into nearby major blood vessels
Dr. Farzin khorvash