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Upper respiratory tract infection (URI) is the most common acute illness in the United States, and almost everywhere, the most common reason for absence from school or work, and a frequent problem encountered in the ambulatory setting. The vast majority of URIs are mild, self-diagnosed and self-treated at home. However, in evaluating the patient there should be differentiation between trivial from serious and potentially treatable infections. Is this an allergic or infectious problem? With acute infections, is there evidence for bacterial infection or superinfection? Have the symptoms lasted more than three weeks? Has a fever lasted longer than a week? Is there purulent nasal discharge with sinus pain, ear pain with discharge, severe odynophagia, purulent sputum, chest pain, dyspnea, hemoptysis, stridor or difficulty breathing? These questions and others should give you clues to create a differential diagnosis.




The term “common cold” refers to a mild, self-limited syndrome caused by viral infection of the upper respiratory tract mucosa. Peak incidence is from early fall until spring, although colds are seen throughout the year. Cardinal features include malaise, nasal discharge and obstruction, sneezing and sore or “scratchy” throat. Headache, mild conjunctivitis, hoarseness and cough may also be seen. High fever is uncommon in the adult. While two to three percent of colds may be complicated by secondary bacterial infection, including sinusitis and otitis media, these are usually evidenced by additional findings in the history and physical exam and are rarely subtle. Symptoms generally last one week, although some patients (particularly smokers) may be ill for up to two weeks.

The majority of colds are caused by five different families of viruses - rhinovirus, parainfluenza, influenza B/C, coronavirus and respiratory syncytial virus. There is seasonal variation in infection rates of the different viruses, but all produce the same general syndrome. While the mechanisms of viral transmission are not well established, most colds are thought to be spread by hand contamination with infectious secretions and subsequent auto-inoculation.

Unfortunately for most patients, the old saying that “the treated cold lasts seven days and the untreated cold lasts a week” is still a truism. Symptoms may be treated in a variety of ways including combination decongestant/antihistamines, warm saline gargles, lozenges and cough suppression with dextromethorpan or codeine. Sipping hot chicken soup (the only soup studied) increases the clearance of nasal mucous. Careful analysis of the available evidence does not support the use of high dose vitamin C. Antibiotics have no role in treating uncomplicated colds.




The flu syndrome is a severe illness, lasting from three days to two weeks with convalescence over one to four weeks. Symptoms include the abrupt onset of malaise, prominent myalgia, headache and high fever (up to 106� F, lasting three to seven days), followed by cough, rhinorrhea, pharyngitis and weakness.

Complications include prolonged airway hyper-reactivity, particularly in patients with asthma and chronic bronchitis. Secondary bacterial bronchitis and pneumonia are seen in up to ten percent of patients, and usually present as purulent or bloody sputum and increased fever after a few days of apparent clinical improvement. The most common cause is Streptococcus pneumoniae, although Hemophilus influenza and Staphylococcus aureus infections (associated with a 50 percent mortality) are also seen. Rare nonpulmonary complications include myositis (with or without myoglobinuria and acute renal failure), Guillain-Barre syndrome, encephalitis, transverse myelitis and Reye’s syndrome. Since the flu syndrome can be severe, patients who are elderly, debilitated by chronic disease, immunocompromised or those with severe dehydration or secondary complications may require hospitalization.

While may viruses can cause “flu,” including parainfluenza, respiratory syncytial virus and adenovirus, 85 percent of cases are caused by influenza A or B. Epidemic spread of the influenza virus is due to the appearance of new antigenic variations of the virus in nonimmune populations. Major antigenic variations lead to pandemics and minor antigenic changes cause the nearly annual winter epidemics. Viral transmission takes place through the aerosol route, by sneezing, coughing and talking; the virus has an extremely high attack rate.

Treatment of the flu consists of symptomatic and supportive care, including bed rest, hydration, analgesics, antipyretic agents and antibiotics for secondary bacterial infection. Amantadine and rimantadine are approved for the treatment of influenza A infections, but must be administered within the first 24 to 48 hours if they are to have any effect. In general, patients at high risk for morbidity and mortality who have the “flu syndrome” should be treated with these agents - unvaccinated patients with chronic pulmonary, cardiovascular, neuromuscular, metabolic and immunodeficiency diseases. It may also be appropriate to treat patients involved in critical jobs, such as policemen, firemen and selected health care personnel. Amantadine and rimantadine are not curative; they attenuate disease in patients with influenza A infection by shortening the duration of acute illness by one to two days and decreasing fever by 50 percent.

Given the potential severity of illness, prophylactic measures are recommended for select patients.

Vaccination is an option where applicable. Amantadine prophylaxis prevents clinical disease in 70 to 90 percent of patients and should be considered for the same high risk groups outlined above, particularly those in closed settings such as nursing homes.




Acute pharyngitis is an inflammatory syndrome of the pharynx, usually caused by a virus but occasionally bacterial in origin. While many viruses and bacteria have been implicated in acute pharyngitis, the main challenge for the primary care clinician is to identify those patients with group A beta-hemolytic streptococcus (Streptococcus pyogenes) which can be associated with scarlet fever, acute rheumatic fever and acute glomerulonephritis and should be treated with antibiotics. Most cases of pharyngitis occur in the colder months, with the peak incidence of streptococcal pharyngitis in late winter to early spring. The severity of illness varies greatly, but cardinal features include sore throat, odynophagia, malaise, fever and headache. Signs of “strep throat” may include an exudative pharyngitis, tender tonsillar lymph nodes and a rare scarletiniform rash. Because these symptoms and signs are not specific, the formal diagnosis of strep throat requires a throat culture. Rapid strep antigen tests have good specificity but lack adequate sensitivity; negative antigen tests should be followed by a throat culture. Occasionally, bacterial pharyngitis is compli- cated by a retropharyngeal or peritonsillar abscess or epiglottitis, which are medical emergencies.


Treatment of viral pharyngitis is mainly symptomatic. Since acute rheumatic fever is very rare in adults, the principle goals of treatment are the amelioration of symptoms and the prevention of local suppurative complications and spread. Symptoms in the untreated patient may last up to five days, and early therapy (in the first 48 hours) is required for moderate symptomatic relief.


The question facing the primary care physician is to decide which patients to culture and which patients to treat with antibiotics. One strategy is to use the clinical prediction rule generated by a large multicenter prospective study which compared the results of throat cultures in patients using three clinical findings; tonsillar exudate, temperature greater than 100� F and tender anterior cervical lymphadenopathy. Of the patients with all three findings, 42 percent had positive throat cultures. Fourteen percent of patients with one finding and three percent of patients with none of these signs had positive throat cultures. Based on these data, it is reasonable to empirically treat patients with all three signs, to culture patients with only one sign and treat based on the results and

to neither culture nor treat (with antibiotics) patients with no signs. All patients with a sore throat and a history of acute rheumatic fever (ARF), or young patients with a sore throat and a strong family history of ARF should be cultured and treated before the cu ture results are known. Treatment consists of parenteral benzathine penicillin 1.2 million units (preferably) or oral penicillin V 250 mg tid for 10 days. For patients allergic to penicillin, an adequate substitute should be given.




A patient comes with a cold that has developed a cold which lasted longer than a week. with trouble breathing through his nose. When leaning forward, he feels throbbing pain in his face. This may not be a simple cold anymore. Instead, he might have devel- oped sinusitis, an infection of the sinus cavities.

Only a small percentage of people with colds develop sinusitis. Still, because colds are so common, millions of Americans (and others) experience sinusitis every year.

Sinuses are air-filled, hollow spaces or cavities within the facial bones around the nose. When their linings become infected, usually due to viruses or bacteria, they may swell, causing an obstruction and interfering with normal drainage of mucus. Sinusitis can cause considerable discomfort and can lead to more serious infections if left untreated.

Although sinusitis can become a chronic condition, most cases are short-lived (acute) and respond to treatment in about 2 weeks.



Sinusitis can aggravate the symptoms of asthma. Effectively treating your sinusitis can reduce the patient’s asthma flare-ups.

Serious complications from sinusitis are rare, but can be life-threatening. If the infection spreads beyond the sinuses, the patient may develop:

* Meningitis. The infection may spread to the bones of the eyes or to the membranes that protect the brain (meninges), causing

brain damage.

* Vision problems. The patient may experience reduced vision or even blindness if the infection spreads to his eye socket.

* Blood vessel complications. Infection that spreads to the veins around the sinuses can cause aneurysms and blood clots that interfere with the blood supply to the brain.



Most people with acute sinusitis — 60 percent to 70 percent — get better without antibiotics. If the patient hasn’t had sinusitis before and his symptoms are mild, he should try using over-the-counter (OTC) decongestants and pain relievers. If the symptoms don’t improve within 3 days, he should contact the doctor.

The doctor may prescribe an antibiotic for 10 to 14 days. If the symptoms persist, there may be a need for a longer course of treatment or a different type of antibiotic. The entire course of the antibiotic prescription should be finished even if the symptoms disappear before all of the pills or capsules are gone. This will ensure that all the bacteria have been destroyed and that your symptoms won’t recur.

The doctor may also recommend:

* Treating an underlying allergic condition that contributes to sinusitis

* Using prescription decongestants, nasal corticosteroid spray or oral corticosteroid pills to relieve stuffiness

* Using over-the-counter medications that contain mucus-thinning agents (mucolytics)

* Taking over-the-counter pain relievers.




Most parents don’t have to be told that middle ear infections — also known as otitis media — are one of the most common ill- nesses affecting infants and young children. Most children have at least one ear infection by age 3. By age 7, almost all children have had an ear infection.

Ear infections usually start with a cold, which can cause fluid to build up behind a child’s eardrum. The fluid itself isn’t necessarily a problem. But it’s an ideal breeding ground for bacteria or viruses that cause infection.

An acutely infected ear is very painful. But interpreting pain in a child who may be too young to communicate verbally can be a

challenge. Signs other than pain may be more apparent. A child with an ear infection may also have a fever and be irritable or listless. Difficulty sleeping is common.

Although ear infections can be extremely worrisome for parents and painful for children, the news is encouraging. Most children stop having multiple ear infections by the time they reach school age. In fact, the ear infection age range is 4 months to 4 years

for the vast majority of children.

Some ear infections require the use of antibiotics, but many ear infections may clear without using antibiotics. Together, the parents and the doctor can decide on the best approach for the child. A few simple measures can greatly reduce the child’s risk of ear infection.



Many untreated ear infections clear on their own with no complications. But long-lasting or recurrent infections can damage the eardrum, ear bones and middle ear structure and may cause permanent hearing loss. In young children, even short-term hearing loss can cause delayed speech development.

In rare cases the pressure of an infected ear may cause the child’s eardrum to rupture. Most likely a discharge of pus and blood will be seen and may be quite alarming. But the rupture actually relieves your child’s pain, and in most cases the eardrum will heal on its own. If the eardrum continues to rupture repeatedly and doesn’t heal, the child may require a surgical procedure to repair the eardrum and ensure that any infection is treated appropriately. It’s also possible that the child’s tonsils or adenoids may be enlarged and blocking the eustachian tubes. Any scar tissue that develops usually won’t affect the child’s hearing. The child’s doctor should be called as soon as possible if a ruptured eardrum is suspected.



Doctors treat ear infections in a number of ways. What’s best for the child depends on many factors, including:

* The diagnosis

* Any additional medical concerns

* How often the child has ear infections

* How long the child has had this ear infection

* The child’s age

* Whether the infection affects the child’s hearing

The options for treatment include a wait-and-see approach and a variety of medical treatments:

* Wait-and-see approach. It’s difficult for parents to see their children in pain. And most parents would do anything to help their child feel better. But it may be in the child’s best interest to focus first on pain relief and to reserve antibiotics for persistent infections. That’s because most ear infections clear on their own in just a few days.


In addition, antibiotics won’t help an infection caused by a virus. They also won’t eliminate middle ear fluid. Furthermore, antibiotics may cause side effects such as nausea, diarrhea, rashes and allergic reactions. And frequent use of antibiotics can create strains of antibiotic-resistant bacteria. This can make it much more difficult to treat serious infections in the future.

If you do decide to hold off on antibiotics, the child should be watched for any sign of increased pain or hearing loss and the doctor should be asked for advice on pain relief.


* Antibiotic therapy. If the doctor is concerned that your child’s ear is infected, he or she may recommend using an antibiotic. When the medication is effective, your child should start feeling better in a few days. But even if your child’s symptoms improve, continue giving the medicine for the full length of the prescription, which can last for 10 days depending on the regimen. Stopping medication too soon could allow the infection to come back. It also contributes to the development of antibiotic-resistant strains of bacteria.

Most children may have fluid in their ears for as long as 2 months after an infection has cleared up. This shouldn’t be a problem unless it affects hearing.

* Preventive antibiotics. If the child has recurrent ear infections — three or more ear infections in a 6-month period, or four a year — your doctor might suggest a low-dose antibiotic for a few weeks or months as a preventive measure. Antibiotics won’t clear fluid from the middle ear, but they may help prevent bacteria from growing. Antibiotics won’t prevent viral infections. On the other hand, because many bacteria are resistant to antibiotics, the child could develop an infection even while taking medication. In addition, the longer the child takes antibiotics, the greater is his or her chance of having side effects such as diarrhea, rashes and allergic reactions. Giving children antibiotics as a preventive measure is an increasingly controversial decision. The risks and benefits to the child should be discussed with the pediatrician.

* Drainage tubes. If middle ear fluid is affecting the child’s hearing, or recurrent ear infections don’t respond to antibiotics, the doctor may suggest insertion of a small drainage tube through your child’s eardrum. This helps drain the fluid and equalize the pressure between the middle ear and outer ear. The child’s hearing should improve immediately. As the child’s eardrum grows, the tube is eventually pushed out and the drainage hole heals.


This surgical procedure (myringotomy) requires general anesthesia. About 25 percent of children continue to have problems and need surgery to insert a second set of tubes. A few children require even a third set.

If the child has drainage tubes, the doctor may caution against swimming, which can increase the risk of ear infections.




A sore, scratchy throat is often the first sign of getting sick. In fact, it’s one of the most common reasons people see a doctor. Some sore throats, such as those that accompany a cold or the flu, are caused by viral infections and usually go away on their own in a few days. But others are caused by bacterial infections and typically require medical treatment.

Strep throat is a bacterial throat infection. It occurs most commonly in children between the ages of 6 and 12. In addition to a very sore throat, symptoms typically include a fever and swollen lymph glands. Younger children may even complain of abdominal pain. If the child has these symptoms, the pediatrician should be consulted. A quick test can diagnose strep throat in most cases.

If not treated, some strep throat infections may lead to complications such as rheumatic fever. This serious disease can cause painful and inflamed joints and a skin rash. In more than half of all cases, rheumatic fever also may damage the heart valves and interfere with normal blood flow in the child’s heart. There’s no cure for rheumatic fever. But it can be prevented by promptly treating infections such as strep throat with antibiotics.



Although strep throat isn’t dangerous, it may lead to serious complications if left untreated. These complications include other infections, such as scarlet fever (an illness characterized by a rash), tonsillitis, sinusitis and ear infections. Strep throat may also lead to kidney damage (nephritis) and rheumatic fever. Rheumatic fever, especially, can be quite serious. At one time, this disease had nearly been eradicated in the United States and Europe. But it re-emerged in the 1980s. Rheumatic fever causes inflammatory spots (nodes) to form in various tissues, including the joints, skin and muscles. These nodes also may form on the heart muscle, the lining of the heart and especially the heart valves — causing scarring that can interfere with the flow of blood inside the heart. Although surgery can sometimes repair scarred valves, the damage may often be perma- nent. In some cases this damage may lead to heart failure.



If the child has strep throat, the pediatrician will likely prescribe an oral antibiotic such as penicillin, or any other antibiotic.

Penicillin may be given by injection in some cases — such as if you have a young child who is having a hard time swallowing or is vomiting from strep throat.


Once treatment begins, you can expect the child to start feeling better in just a day or two. But make sure your child finishes the entire course of medicine. Stopping medication early can create strains of bacteria that are resistant to antibiotics. It may also lead to more cases of strep throat and serious complications, such as rheumatic fever.

In addition to antibiotics, your pediatrician may suggest giving your child acetaminophen to relieve throat soreness and reduce a fever. Because of the risk of Reye’s syndrome, a potentially life-threatening illness, don’t give aspirin to children under age 12. You should also be careful with too much acetaminophen. Taken in large doses, it may cause serious liver problems. To be safe, never give the child more than the recommended amount of any medication. Talk to the doctor or pharmacist if you have questions.




Just a generation ago, most young children could count on having their tonsils removed — and eating ice cream afterwards to ease the pain in their throats. In fact, surgery was once the standard treatment for tonsillitis, an infection and inflammation of the tonsils that commonly occurs in preschool and school-aged children.

Today, doctors are far more reluctant to remove tonsils. In part, that’s because tonsillitis often can be treated effectively with home care or antibiotics, which reduce the risk of possible complications. It’s also now known that tonsils — specialized lymph nodes

on either side of the throat — are a normal part of your body’s immune system. They help filter out harmful bacteria and viruses that could cause more serious infections.

If treated with antibiotics, the symptoms of bacterial tonsillitis should disappear in just a few days. Surgery is generally considered only if tonsillitis affects your child’s breathing or is severe enough that bleeding is occurring from the tonsils, or if the condition occurs unusually often.



Left untreated, tonsillitis can lead to a collection of pus (an abscess) between a tonsil and the soft tissues around it (peritonsillar abscess). The abscess may cover a large part of the soft area at the back of the roof of your child’s mouth (soft palate).

Sometimes the swelling can be so severe that the roof of the mouth and tongue meet, blocking air flow and making swallowing extremely difficult. In rare cases the abscess could even spread into the bloodstream or into the neck or chest.

Some strains of streptococcal bacteria that cause tonsillitis can also cause kidney inflammation (nephritis) or rheumatic fever, an inflammation that may affect the heart, joints, nervous system and skin. This is one reason it’s so important for your child to complete the entire course of medication your doctor prescribes for a bacterial infection.



In recent years, treatment for tonsillitis has changed dramatically. The main focus is no longer on surgical removal of your child’s tonsils (tonsillectomy). That’s because it’s now known that tonsils serve an important immune function in the body. Furthermore, the old idea that most children who have their tonsils removed are less susceptible to colds and other respiratory diseases is just that — an old idea. In fact, the opposite may be the case. Still, surgery may be the best option for some children.


Tonsillitis resulting from a streptococcal infection is usually treated with antibiotics such as penicillin. Sometimes, especially in young children having difficulty swallowing, penicillin is given by injection. Antibiotics typically need to be taken for at least 10 days. Although your child will likely feel better in a day or two, it’s important to finish the full course of antibiotics. Stopping medication early helps create strains of bacteria that are resistant to antibiotics. In addition, the infection may come back, causing potentially serious complications.

Unfortunately, there is currently no treatment for the viruses that cause tonsillitis. This means that the parents and the child will need to focus on comfort measures while the viral infection runs its course. It may take from 7 to 14 days until your child is fully recovered.


Sometimes, the doctor may recommend that your child’s tonsils be removed. This option is usually pursued only if bouts of tonsillitis affect the child’s general health or interfere with his or her breathing. In general, the child may be a candidate for tonsillectomy if he or she has one of the following:

* Seven or more episodes of tonsillitis in one year

* Five or more episodes of tonsillitis each year over a period of 2 years

* Three or more episodes of tonsillitis a year for a period of 3 years

* Tonsillitis that doesn’t respond to antibiotics or is severe enough to cause bleeding from the tonsils

Tonsillectomy is usually performed on an outpatient basis. That means the child will be able to go home the day of the surgery. A complete recovery may take up to 2 weeks, however.

Following surgery, the child’s throat may be quite sore. He or she also may have some ear pain. Sucking on an ice cube can relieve some of this discomfort. So can eating ice cream or sherbet — much better options from your child’s point of view — and drinking cold liquids. Using a cool mist humidifier in the child’s room may help too.

During the first week after surgery, try to keep the child away from crowds and from people who may be ill. Your child is more susceptible to infections during this time. Also, keep in mind that removing tonsils may reduce throat infections but won’t necessarily prevent them completely.


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