1. ACUTE VIRAL RHINOSINUSITIS (COMMON COLD)
ESSENTIALS OF DIAGNOSIS
Nasal congestion, clear rhinorrhea, and hyposmia.
Associated malaise, headache, and cough.
Erythematous, engorged nasal mucosa without intranasal purulence.
Symptoms are self-limited, lasting less than 4 weeks and typically less than 10 days.
Because there are numerous serologic types of rhinoviruses, adenoviruses, and other viruses, patients remain susceptible to the common cold throughout life. These infections, while generally quite benign and self-limited, have been implicated in the development or exacerbation of more serious conditions, such as acute bacterial sinusitis and acute otitis media, asthma, cystic fibrosis, and bronchitis. Nasal congestion, decreased sense of smell, watery rhinorrhea, and sneezing, accompanied by general malaise, throat discomfort and, occasionally, headache, are typical in viral infections. Nasal examination usually shows erythematous, edematous mucosa and a watery discharge. The presence of purulent nasal discharge suggests bacterial rhinosinusitis.
There are no effective antiviral therapies for either the prevention or treatment of most viral rhinitis despite a common misperception among patients that antibiotics are helpful. Prevention of influenza virus infection by boosting the immune system using the annually created vaccine may be the most effective management strategy. Oseltamivir is the first neuramidase inhibitor approved for the treatment and prevention of influenza virus infection, but its use is generally limited to those patients considered high risk. These high-risk patients include young children, pregnant women, and adults older than 65 years of age. Oseltamivir is hard to use because it must be started within 48 hours for optimal effect. Other specific antiviral medications are available or in clinical trials but have not achieved significant use. Zinc for the treatment of viral rhinitis has been controversial. A meta-analysis of randomized controlled trials demonstrated no benefit in five studies that used less than 75 mg of zinc acetate daily, but significant reduction in duration of cold symptoms was noted in all three studies that used zinc acetate in daily doses of over 75 mg. The effect with zinc salts other than acetate was also significant at doses greater than 75 mg/day, but not as high as the zinc acetate lozenge studies (20% vs 42% reduction in cold duration). Buffered hypertonic saline (3–5%) nasal irrigation has been shown to improve symptoms and reduce the need for nonsteroidal anti-inflammatory drugs (NSAIDs). Other supportive measures, such as oral decongestants (pseudoephedrine, 30–60 mg every 4–6 hours or 120 mg twice daily), may provide some relief of rhinorrhea and nasal obstruction. Nasal sprays, such as oxymetazoline or phenylephrine, are rapidly effective but should not be used for more than a few days to prevent rebound congestion. Withdrawal of the drug after prolonged use leads to rhinitis medicamentosa, an almost addictive need for continuous usage. Treatment of rhinitis medicamentosa requires mandatory cessation of the sprays, and this is often extremely frustrating for patients. Topical intranasal corticosteroids (eg, flunisolide, 2 sprays in each nostril twice daily), ...