APPROACH TO PATIENT WITH

UPPER RESPIRATORY TRACT INFECTION

(URTI)

Dr. Othman Beni Yonis

Clinical associate professor of family medicine.
2023
URTIs Inflammation of the respiratory mucosa from the nasal cavity down to the
bronchus. (above the level of the carina).

Includes: Common Colds, Influenza, Sinusitis, Rhinitis, Tonsillitis, Otitis Media,

Pharyngitis, Laryngitis, Epiglottitis, Tracheitis And Croup.
 EPIDEMIOLOGY:

• Children: 5 URTIs/year.
• Adults 2-3/year.
• 70-80 % of these infections are caused by viruses
(rhinoviruses and adenoviruses) are the most common.
Management principles:

Viral infections need ONLY symptomatic treatment , NO need for antibiotics(Abs).

Viral URTIs :
1. Influenza
2. Common cold
3. Mild acute sinusitis
4. Mild acute otitis media

Bacterial URTIs :
5. GABHS pharyngitis
6. Moderately to severe acute sinusitis
7. Moderately to severe acute otitis media
8. Pertussis and epiglottitis
Why not to use Abs for viral infections ?
1. Promotes Abs resistance.
2. Adverse reactions (allergy and anaphylaxis).
3. Cost.

Why to use Abs for bacterial infections?

4. To prevent suppurative complications
5. To prevent rheumatic fever
6. To speed up recovery
7. To reduce spread to others
COMMON COLD
Common cold is a self-limiting , viral infectious disease of the upper respiratory
system.

Incidence:
• Most frequent infectious disease in humans
• 2-4 infections /year in adults and 6-12 in children.
• Transmitted by droplets and close personal contact.( no mask, >15 min,<2 m)
• usually occurs in the fall and winter months.
Causative agents:
Rhinovirus (50%), coronavirus (10-20%), adenovirus (5%),
others: RSV, parainfluenza virus.

Bacterial infections are unlikely:

Mycobacterium leprae, Klebsiella rhinoscleromatis, Pseudomonas mallei (glanders),
Rhinosporidium seeberi (rhinosporidiosis), Leishmania mexicana (leishmaniasis).
Symptoms:
• The first symptom is usually a sore or “scratchy throat” , followed soon after by nasal
stuffiness and discharge ( rhinorrhea ) , sneezing and coughing.
• The throat is usually sore for a brief time. The cough symptoms are usually worse on
the 4th or 5th day of illness , while the nasal symptoms improve.
• Symptoms generally last for 7 to 10 days. Cough may continue up to 4 weeks.

*If the nasal discharge becomes viscous and green with time ; it doesn’t mean
superimposed bacterial infection . It’s a normal course of common cold.
Management: Symptomatic Treatment :
comfort is the goal of treatment which may include:

 steam/mist inhalation
 nasal irrigation/suction.
 humidified air
 Extra fluids (warm fluids may be soothing for irritated throats)
 Nutritious diet as tolerated
 Salt water gargle for sore throat .
 Adequate rest

*Vitamin C & Zinc syrup may reduce duration of common cold in children.
*Honey may reduce nocturnal cough and sleep disruption in children with acute cough, and might be more effective
than dextromethorphan or diphenhydramine
Medication :
1. Antipyretics : Ibuprofen appears more effective than acetaminophen for reducing fever in single-

dose comparisons and they are appear to have similar analgesic effects .

*Combined or alternating acetaminophen and ibuprofen regimens may be more effective than either

monotherapy for reducing fever in children.

*No evidence that fever or antipyretic treatment affects illness course or neurologic complications.

*Ibuprofen approved for use by FDA after 6 months of age.

*Paracetamol: may be used after 2-3 months of age.

*Aspirin is contraindicated in children with viral infections due to association with increased risk for Reye
Syndrome
2. Nasal Decongestants and Antihistamines:
*Nonprescription medicines (antihistamines and antitussives) do not appear effective for acute cough in
children )

*FDA recommends against use of nonprescription cough and cold products in children < 2 years old
and supports not using them in children < 4 years old.

*nonprescription cough and cold preparations may not be safe in children

3. Antibiotics :
*Abs do not appear to reduce symptoms of common cold or acute purulent rhinitis.

* No role of antibiotics in common cold ( viral infection ).

Complications:
1. Acute otitis media (most common in children)
2. Pharyngitis

3. Sinusitis

4. Bronchitis and pneumonia

5. Conjunctivitis

6. Adenitis

7. Aggravation of asthma

Prevention:
• Wash hands after contact with common cold patients.
• Do not touch any surfaces or objects that may have been contaminated.
• Keep fingers out of eyes and nose.
INFLUENZA
Influenza: is a viral infection that affects mainly the nose , throat , bronchi , and occasionally
lungs.
*Influenza causes annual epidemics that peak during winter.

Seasonal influenza:
*Acute viral infection caused by influenza type A , B and C.

*Type A and B are constantly changing due to mutations (antigenic drift and shift) , more serious than type
C.

*Type C is stable , it’s cases occur much less frequently than type A and B.

*Currently influenza A (H1N1) and A (H3N2) subtypes are circulating among humans.

*Transmitted by droplets and close person contact .

Signs and symptoms

• Following an incubation period of 1-2 days, flu presents with abrupt onset of fever
(39-40c), myalgia , arthralgia , headache and fatigue.
• The individual may have respiratory symptoms such as a dry cough , sore throat , and
occasionally a runny nose.
• Other symptoms related to systemic illness include chills and sweats , loss of appetite ,
diarrhea and vomiting
Prognosis:

• Generally improve over two to five days, though may last one or more weeks.

• Some patients experience post-influenzal asthenia (persistent weakness or becoming

tired easily) which may be present for several weeks following the illness.

• A dry cough (post viral cough syndrome) may also persists for several weeks.
Common cold Vs Influenza:

• Influenza is different from the common cold in that it causes a more severe illness , with
fever , headache , significant fatigue and myalgia , arthralgia and systematic
manifestations include chills , rigors and sweats, loss of appetite , diarrhea and vomiting

• It’s less likely to cause sneezing or a blocked nose with thick nasal discharge.
Complications Highest risk of complications occurs
1. Bronchitis among :
2. Sinus infections 6. Children < 2 years
3. Ear infections 7. Adults 65 years or older
4. Pneumonia 8. Medical chronic illnesses
5. Encephalitis 9. Pregnant women
10. Immunocompromised patients
Treatment:

Supportive care mainstay of treatment for most patients

1. Bed rest
2. Antipyretic/Analgesics
3. Fluid intake

Antiviral treatment:
 antiviral treatment recommended as soon as possible (and not delayed while awaiting
diagnostic confirmation) for patients with confirmed or suspected influenza who:
 Have severe, complicated, or progressive illness
 Require hospitalization
 Are at higher risk for influenza complications
Antiviral treatment:
1- Oseltamivir(Tamflu).
adult dosing 75 mg orally twice daily for 5 days
weight-based dosing used for oseltamivir in children up to age 12
2- Zanamivir
not approved for children aged < 7 years
3- Peramivir
not approved for children or adolescents.
Amantadine and rimantadine not recommended due to widespread resistance.
Prevention:
1. Frequent hand washing.
2. Wear masks and gloves.
3. Isolation of patient until 24 hours of afebrile period.
4. Vaccination : most effective measure of prevention.

 Influenza vaccine (Annual vaccine)

• Two types : Injectable : killed vaccine

• Nasal spray : live but weakened virus
• 70% protection in 1 year.
• Reduces severe complications by 60% , and death by 80%.
Recommended for:

• All children aged 6-59 months.

• All persons ≥ 50 years old.

• Persons who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension),

renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus)

• persons with immunosuppression due to medications or disease.

• Persons with morbid obesity (body mass index ≥ 40 kg/m2)

• Persons who live with or care for persons at high risk of influenza-related complications healthcare

personnel household contacts and caregivers of children < 5 years old.

PHARYNGITIS / TONSILLITIS
Pharyngitis/Tonsillitis: It is an inflammation of the pharynx, w/o tonsilles.
most commonly caused by viral or bacterial infection.

• Causative agents :
• Viral : adenovirus (80% most common ) , enterovirus , EBV , herpes simplex virus.
• Bacterial : GABHS (5-15%), mycoplasma.

• GAS uncommon in children younger than 2-3 years, and the peak is between 5-11 years.
• Peak Winter to early Spring.
• Spread by direct contact.
Clinical presentation:
*The main symptom is a sore throat.
*Other symptoms may include:
- Fever
- Odyno/dysphagia
- Headache
- Joint pain and muscle aches
- Skin rashes
- Swollen lymph nodes in the neck
Bacterial Vs. Viral

*Viral Infection:
Clinically: Gradual, more likely to have rhinorrhea, cough, diarrhea, hoarseness of voice.

- Adenovirus: conjunctivitis(Pink eye), most common cause in children < 3 years of age.
- Coxsackieviruses: ulcer on posterior pharynx, herpangina (mouth blisters).

- EBV(Glandular fever): prominent tonsils with white exudates, posterior cervical LN

enlargement, Palatal rash, Hepatosplenomegaly, high fever and fatigue.
Bacterial Infection:

* Clinically: Rapid onset fever, prominent throat pain, headache, abdominal pain, vomiting,
dysphagia and malaise.( Patients appear more ill)

* On exam: Pharynx are erythematous, tonsils enlarged with yellow-blood tinged exudate,
petechia may be present on soft palate, anterior cervical lymph nodes enlarged and tender.
Age-modified Centor score (McIsaac score):
 1 point for each of:
• tonsillar exudate
• swollen tender anterior cervical nodes
• absence of cough
• history of fever or measured temperature > 38 degrees C (100.4 degrees F)

 age modification
• 1 point if age < 15 years
• -1 point if age > 45 years
Why we treat GAS pharyngitis ?

• Decrease risk of Rheumatic fever(through molecular mimicry ,

Anti-M AB) (but not of PSGN).
• Shorten duration of illness.
• Decrease risk of complication (mainly abscess).
Rapid Antigen Test (RAT)
• Sensitivity of RAT against culture varies between 61-95%.
• Specificity of RAT 88-100%
• -ve results should be confirmed by culture.
Throat Culture
• Positive culture makes the Dx of GABHS, but –ve culture does not rule out.
• *** We can do FBC ;
• -Neutrophillia  Bacterial LymphocytosisViral
Differential diagnosis:
•
Infectious mononucleosis(Glandular fever) , when a membranous exudate is
present.

• Diphtheria, especially in the unimmunized.

• Herpangina , with many vesiculoulcerative lesions in the anterior pillars &

soft palate.

• Kawasaki disease.
Complication of GAS pharyngitis:

 1-Suppurative complications (e.g., peritonsillar abscess).

2- Scarlet fever (Sandpaper like rash)
3- Rheumatic fever.
4- Impetigo.

5- Necrotizing Fasciitis.
6-Streptococcal Toxic Shock Syndrome.
7-Post-Streptococcal Glomerulonephritis.
 Treatment
Supportive Measures
• Encourage fluid intake
• Acetaminophen or NSAID may reduce pain.
• Benzydamine oral rinse or mouth spray may reduce pain and improve symptoms.

*Other supportive measures without direct evidence include:

• Topical analgesics (such as nonprescription throat sprays) and anesthetics (such as

viscous lidocaine 2%)
• Warm salt water gargles
• Soft foods or cold thick liquids such as ice cream.
• Humidifier.
Bacterial Pharyngitis:
Antibiotics: First line
 Penicillin V 500mg twice daily for 10 days oral or once IM benzathine penicillin 1.2
million unit.
safe , cheap , narrow spectrum , no resistance.

or amoxicillin 500mg twice daily for 10 days.

If penicillin allergic:

Cephalexin or azithromycin or clarithromycin or clindamycin.

Corticosteroids such as dexamethasone 0.6 mg/kg orally may hasten pain relief in acute
pharyngitis.
Carriers(Asymptomatic):

Small RCTs (Randomized control studies) suggest that intramuscular

benzathine penicillin combined with four days of oral rifampin,or a 10-day
course of oral clindamycin effectively eradicates the carrier state, or
Surgery.
Tonsillectomy

Recommended for recurrent severe sore throat if more than 6

episodes in past year , more than 4 episodes per year in 2 years or
more than 2 per year in 3 years.
Severe Acute Respiratory Syndrome
Coronavirus 2 (Sars-cov-2) 
 Coronavirus disease 2019
(COVID-19)
Coronavirus is an infectious disease caused by the SARS-CoV-2 virus.
disease
(COVID-19)
Symptoms Fever, cough, fatigue, shortness of breath, vomiting, loss of taste or smell; some cases
asymptomatic.
Complications Pneumonia, viral sepsis, acute respiratory distress syndrome, kidney failure, 
cytokine release syndrome, respiratory failure, pulmonary fibrosis, 
paediatric multisystem inflammatory syndrome, long COVID

Usual onset 2–14 days (typically 5) from infection.

Duration 5 days to chronic

Causes Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Diagnostic meth rRT‑PCR testing, CT scan, Rapid antigen test.

od

Prevention Vaccination, face coverings, quarantine, physical/social distancing, ventilation, hand

washing.
Treatment Symptomatic and supportive.
SINUSITIS
Sinusitis: Inflammation of mucosa of paranasal sinuses.
• Most commonly it is viral, especially post common cold,: Rhinovirus , Influenza virus,
parainfluenza virus.
• Could be bacterial: Strep. Pneumoniae, H. Influenzae, M. Catarrhalis, Staph. Aureus.
Risk Factors:
• Allergic rhinitis or hay fever
• Cystic fibrosis.
• Day care, Weakened immune system from HIV or chemotherapy
• Changes in altitude (flying or scuba diving) (swelling in mucosa)
• Large adenoids, Nasal polyps
• Smoking (ciliary dyskinesia)
• Nasogastric and nasotracheal intubation
Clinical presentation
• *The symptoms of acute sinusitis in adults usually follow a cold that does not improve, or
one that gets worse after 5 - 7 days of symptoms.

 Symptoms:
• Mucopurulent Rhinorrea
• Nasal congestion
• Facial pain, pressure and fullness
• Decrease sense of smell

 Exam:
• Looking in the nose for signs of polyps
• Shining a light against the sinus (transillumination) for signs of inflammation
• Tapping over a sinus area to find infection (tenderness), very painful
Diagnosis of Sinusitis:
- Clinically
We use radiological evaluation if there is warning signs:
- Severe swelling and redness of the tissues around the eye
- Limitations of eye movement
- Swelling of the forehead
- High fever
- Altered consciousness
Radiological evaluation:
- Regular x-rays of the sinuses are not recommended.
- CT scan of the sinuses for suspected complications.
Complications of Sinusitis:

• Periorbital cellulites
• Meningitis
• Brain abscesses
• Cavernous sinus thrombosis
• Osteomyelitis of frontal bane.
Treatment of Sinusitis:
• Analgesics and antipyretics as needed
• Intranasal corticosteroids.
• Consider intranasal saline with either physiologic or hypertonic saline.

• Decongestants and antihistamines: lack evidence for effectiveness unless evidence

of allergic component.
Antibiotics for acute bacterial sinusitis:

• Most cases resolve without antibiotic treatment.

• Only consider treatment with antibiotics if patient meets criteria for acute
bacterial sinusitis.
Criteria for acute bacterial sinusitis:

1- Persistent symptoms or signs lasting ≥ 10 days without evidence of clinical improvement .

2- Severe symptoms or signs of high fever (≥ 39 degrees C and purulent nasal discharge or
facial pain lasting for ≥ 3-4 consecutive days at beginning of illness.

3- Worsening symptoms or signs characterized by new onset of fever, headache, or increase

in nasal discharge following typical viral upper respiratory infection that lasted 5-6 days and
were initially improving ("double-sickening").
Antibiotic choice

• Amoxicillin or amoxicillin clavulanate(Augmentin) is preferred first-line treatment.

• Alternative choices: levofloxacin , doxycycline.

• For chronic or recurrent sinusitis addition of intranasal steroid accelerates recovery.

OTITIS MEDIA
 Suppurative or acute otitis media (AOM):
• Usually a complication of eustachian tube dysfunction that occurs during a viral URTI.
• Most Common CA : Bacterial And Viruses, Then Bacterial, Then Viruses.
• Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the
most common bacteria.
 Non-suppurative or secretory otitis media or otitis media with
effusion (OME)
• Usually non infective
• Cultures are sterile, but in 30% same organisms
 Recurrent otitis media

3 times in 6 months or more than 4 times in a year

 Chronic otitis media
Proportion of cases

Virus only 20%–30%

Bacteria and virus 28%–70%

Bacteria*

Streptococcus pneumoniae 25%–50%

Risk factors:
• Age: 6-20 months- decrease with age
• Male gender
• Low socioeconomic status
• Exposure to smoking and day care attendance
• More in cold weather
• Bottle feeding while sleeping, breast feeding (protective)
• Congenital anomalies: Down syndrome , cleft palate.
Clinical Presentation:
• In infants, are nonspecific and include fever, irritability, excessive crying and poor
feeding.
• In older children and adolescents, fever, otalgia (acute ear pain), otorrhea (ear
drainage); after spontaneous rupture of the tympanic membrane.
• Nausea, Vomiting, dizziness, fever.
• TM exam: red, bulge, loss of land marks, decrease mobility (by pneumatic
otoscopy), apparent light reflex, perforation.
Normal tympanic
membrane:

1 . Shiny
2. Translucent.
3. +Ve light reflux
4. No air fluid border
5. No bulge.
Acute otitis media
1 . Red bulging TM
2. Distortion of normal landmarks.
3. Loss of the cone of light.
 ACUTE OTITIS MEDIA

Redness Bulging
Complication of AOM:
• Chronic suppurative otitis media
• Acute mastoiditis
• Facial paralysis
• Cholesteatoma (cyst like lesion in middle ear, tend to expand and cause
bone resorption)
• Intracranial complications: meningitis, abscess, lateral sinus thrombosis
• Conductive hearing loss and possible developmental sequelae.
How to manage AOM?

Natural history of OME is spontaneous resolution … days-months.

• Prompt surgical referral for structural damage to TM or ME (e.g. cholesteatoma).

• Surgical referral for children with OME with hearing loss independent on OME, speech or
language disorder, developmental delay and uncorrectable visual impairment.

• Antihistamines, decongestants, or steroids should not be used in the management of

OME in children.
 Treatment of Otitis Media:
• Analgesics
• Antibiotics : Indications:
 Moderate or severe otalgia
 Otalgia for ≥ 48 hours
 Temperature ≥ 39 degrees C .
 Age < 24 months and bilateral AOM

• Antibiotic therapy can be deferred in children two years or older with mild symptoms.
Antibiotic Choice:

*Amoxicillin 90mg/kg/days…first choice.

*Amoxicillin 90 mg/kg/day plus clavulanate 6.4 mg/kg/day in 2 divided doses…

second choice if not improving on amoxicillin after 2-3 days.

Other choices: if allergy to amoxicillin or not improving.

Cefdinir (omnicef) , cefuroxime (zinat) , ceftriaxone (rocephen) and

Cefpodoxime.
CROUP
Croup:
• LaryngoTracheoBronchitis
• Caused by Parainfluenza virus
• Age: 3 months – 5 years, peak 2 year
• More in males
• More in Winter
Clinical presentation:
• Some Rhinorrhea, mild cough, low grade fever,
• 1-3 days then characteristic barking cough, hoarseness and inspiratory stridor (70%
obstruction)
• Worse at night, usually resolve in 1 week.

• Exam: hoarseness of the voice, mild tachypnea, child prefer to sit upright, more
symptoms with crying and agitation.
• ( seal-like ) Barking cough is the hallmark of croup among infants and young children,
whereas hoarseness predominates in older children and adults.
STEEPLE SIGN:
subglottic narrowing
Diagnosis of Croup
Diagnosis is usually based on history, physical, and response to treatment.

• sudden onset of barking cough, hoarseness, and inspiratory stridor in a child

(especially if aged 6-36 months)
• absence of atypical findings (for example, wheezing, drooling, or toxic
appearance)
• improved respiratory symptoms after treatment with corticosteroids, with or
without nebulized epinephrine
Treatment of Croup:
Airway management is the priority:
• Use cool mist
• Steroids usually indicated for children with croup
• Dexamethasone is preferred first-line treatment
 usual dose is dexamethasone 0.6 mg/kg orally or intramuscularly given once.
• Nebulized budesonide: (usual dose 2 mg [4 mL of 0.5 mg/mL solution])

rarely indicated but may be considered for severe respiratory distress if

unable to tolerate oral medication or in patient with decreased perfusion.

• Single-dose dexamethasone associated with similar symptom duration

as prednisolone for 3 days in children with mild-to-moderate croup.

Nebulized epinephrine

Nebulized epinephrine (in addition to corticosteroids) indicated for

children with severe croup. (2.25% racemic epinephrine, 0.05
mL/kg (maximum 0.5 mL). 
EPIGLOTITIS
Epiglottitis:

• A life-threatening disease.
• Caused by H. Influenzae , S. pneumoniae , S. aureus
• now uncommon , because the H. influenzae type B vaccine is a routine
childhood immunization.
Clinical Presentation:
• High fever and sore throat.
• Dyspnea, progressive upper airway obstruction in hours.
• On Exam: Toxic, ill looking, difficulty swallowing, drooling, hyper extended
neck.
• Stridor is a late sign
• Complications: the airway may become totally obstructed , empyema or
epiglottic abscess.
• Diagnosis:
- clinical
- large cherry red
swollen epiglottis by
laryngoscope
- lateral neck x-ray:
thumb sign

(swollen epiglottis)
Treatment of Epiglottitis:

It is a Medical Emergency : establish airway by intubation, rarely tracheotomy regardless of

the degree of obstruction.

• Antibiotics: broad-spectrum second- or third-generation cephalosporins recommended.

• Corticosteroids: IV dexamethasone or budesonides aerosols.
• Oxygen and IV fluid.
LARYNGITIS
Laryngitis its an inflammation of the larynx, manifests in both acute and
chronic forms.
Acute : less than 3 weeks
Chronic : last more than 3 weeks
• Acute laryngitis has an abrupt onset and is usually self-limited.
• The etiology of acute laryngitis includes vocal misuse, exposure to
noxious agents, or infectious agents.
• The infectious agents are most often viral but sometimes bacterial
Causes:
• Infection (usually viral upper respiratory • Bordetella pertussis
tract infection) Rhinoviruses • Varicella-zoster virus
• Parainfluenza viruses • Gastroesophageal reflux disease
• Respiratory syncytial virus • Environmental insults (pollution)
• Adenoviruses • Vocal trauma
• Influenza viruses • Use of asthma inhalers
• Measles virus
• Mumps virus
• Generally associated with hoarseness or loss of voice.
• Symptoms: hoarseness of the voice , Fever
• Swollen lymph nodes, dysphagia, odynophagia, dyspnea, rhinorrhea,
postnasal discharge, sore throat, congestion, fatigue, and malaise.

• Complications : rarely respiratory distress

• Treatment : voice rest, analgesia , cool mist , hydration.

• Nebulized epinephrine or oral steroid for sever cases.

END OF PRESENTATION