Chapter 59: Sore Throat, Earache, and Upper Respiratory Symptoms

INTRODUCTION

• URIs are among the leading causes of lost time from work or school.

• Distinguishing pts with primary viral URI from those with primary bacterial URI is difficult since the signs and symptoms are the same.

• URIs are often treated with antibiotics even though bacteria cause only 25% of cases. Inappropriate prescribing of antibiotics for URIs is a leading cause of antibiotic resistance in common community-acquired pathogens such as Streptococcus pneumoniae.

NONSPECIFIC URIs

• Definition: Nonspecific URIs (the “common cold”) have no prominent localizing features.

• Etiology: A wide variety of viruses (e.g., rhinoviruses, coronaviruses, parainfluenza viruses, influenza viruses, adenoviruses) can cause nonspecific URIs.

• Clinical manifestations: an acute, mild, self-limited catarrhal syndrome, typically characterized by rhinorrhea, nasal congestion, cough, and sore throat

  • Hoarseness, malaise, sneezing, and fever are more variable.

  • The median duration of symptoms is ∼1 week (range, 2–10 days). Cough secondary to upper respiratory inflammation may last 2–3 weeks and does not necessarily indicate a need for antibiotics.

  • Secondary bacterial infections complicate 0.5–2% of colds and are associated with a prolonged course and/or increased severity of illness, often with localization of signs and symptoms. Purulent nasal and throat secretions are poor predictors of bacterial infection.

• Treatment: Symptom-based treatment (e.g., with decongestants, NSAIDs) is typically all that is required. Antibiotics are not indicated.

SINUS INFECTIONS

• Rhinosinusitis is an inflammatory condition most commonly involving the maxillary sinus; next, in order of frequency, are the ethmoid, frontal, and sphenoid sinuses.

• Sinusitis accounts for millions of visits to primary care physicians each year and is the fifth most common diagnosis for which antibiotics are prescribed.

ACUTE SINUSITIS

• Definition: sinusitis of <4 weeks’ duration

• Etiology: Infectious and noninfectious causes lead to sinus ostial obstruction and retention of mucus.

  • Infectious causes include viruses (e.g., rhinovirus, parainfluenza virus, influenza virus) and bacteria (e.g., S. pneumoniae, nontypable Haemophilus influenzae, and—in children—Moraxella catarrhalis).

    • In immunocompromised pts, fungi (e.g., Rhizopus, Mucor, and occasionally Aspergillus) can be involved.

    • Nosocomial cases are often polymicrobial and involve Staphylococcus aureus and gram-negative bacilli.

  • Noninfectious causes include allergic rhinitis, barotrauma, and exposure to chemical irritants.

• Clinical manifestations: Common manifestations include nasal drainage and congestion, facial pain or pressure, and headache.

  • Tooth pain and halitosis can be associated with bacterial sinusitis.

  • Pain localizes to the involved sinus and is often worse when the pt bends over or is supine.

  • Advanced frontal sinusitis can present as Pott’s puffy tumor: swelling and pitting edema over the frontal bone from a communicating subperiosteal abscess.

  • Life-threatening complications include meningitis, epidural abscess, and brain abscess.

• Diagnosis: It is difficult to distinguish viral from bacterial sinusitis clinically, although viral cases greatly outnumber bacterial cases.

  • Only 40–50% of pts with symptoms of >10 days’ duration, purulent nasal drainage, nasal obstruction, and facial pain have bacterial sinusitis.

  • If fungal sinusitis is a consideration, ...