EAR, NOSE AND THROAT MEDICINE
During the flu season, the majority of respiratory illnesses are caused by organisms other than the flu (rhinoviruses, coronaviruses, parainfluenza, etc.). While the common cold and influenza share many clinical features, acute cold symptoms typically appear gradually over one to two days, whereas influenza symptoms (high fever, severe muscle aches, dry cough, severe headache) are typically more severe and abrupt in onset, often developing within hours.
Symptoms in otherwise healthy individuals include:
• Sore throat and sneezing occur early in the course of the infection and usually resolve in 3 – 6 days.
• Low grade fever and muscle aches commonly accompany these initial symptoms and usually resolve within a week.
• Nasal congestion, sinus pressure, ear pressure are common symptoms and usually persist through the first week of illness. About 30% of patients still have these symptoms at 2 weeks, although they should be improving after 7 – 10 days.
• Nasal or post-nasal drainage is usually clear and watery the first few days, but often becomes thick and discolored (green to yellow) after several days. Discolored secretions do not automatically imply that a bacterial infection is present; most improve after 5-7 days.
• Cough occurs in the majority of colds and is usually more productive than seen with the flu. Sputum varies from clear to yellow-green and usually resolves within 2-3 weeks, although a lingering dry cough can persist 4 weeks in up to 25% of infections.
Treatment of Acute Upper Respiratory Infections
Avoid multi-drug cold formulas since many contain unnecessary medications that cause unwanted side-effects. It is best to take only the medication(s) that will alleviate predominant respiratory symptoms. Antibiotics will not hasten the resolution of acute cold symptoms.
Certain medications should be avoided by persons with certain medical conditions, drug allergies, or who are taking medicines that could cause unwanted drug interactions.
Temperature monitoring: Fever greater than 38ᵒC can be a distinguishing feature of influenza, as well as an indicator for determining when to seek medical attention for complications of a respiratory infection. If you do not own a thermometer, it is recommended that you obtain one to monitor your illness.
Analgesics: may be used to control fever, muscle aches, headache, and sore throat. These include: Acetaminophen (Tylenol), Ibuprofen (Advil), Naproxen (Naprosyn), and Aspirin. Aspirin use should be avoided in children and teenagers if influenza is suspected.
Decongestants: help alleviate nasal congestion, sinus pressure and ear pressure from inflamed/swollen sinus passages caused by most acute respiratory infections. Decongestants are chemically related to adrenalin and can cause side-effects that include increased pulse, jitteriness, insomnia, and loss of appetite.
Pseudoephedrine (PSE) is the most effective oral decongestant for adults. While it is a non-prescription item, illegal use to produce methamphetamine has required it to be moved behind the counter at pharmacies.
Phenylephrine (PE) is a weaker, less effective decongestant available over the counter.
Oxymetazoline is a potent topical nasal decongestant that does not cause the systemic side effects seen with oral agents. Because rebound nasal congestion can occur with this agent, multi-daily use should be limited to less than or equal to 3 days, 6 if only used at night.
Nasal Drainage: To properly clear nasal secretions, one should blow gently, one nostril at a Time. For tenacious secretions one can use nasal decongestants to decrease the blockage, and instill saline into the nasal passages to thin the mucus, making them easier to clear with gentle blowing.
Expectorants help loosen thick secretions and facilitate drainage from the sinuses and chest.
Cough Suppressants have demonstrated modest success in alleviating the cough which commonly accompanies acute respiratory infections.
Antihistamines are commonly found in over-the-counter cough/flu formulas and in allergy medications. The elevated histamine levels seen in allergic conditions are not present in most viral respiratory infections, so the benefits of 1st generation antihistamines are in large part due to their anti-cholinergic properties (increasing the viscosity of nasal secretions).
1st Generation Antihistamines include Carbinoxamine, Diphenhydramine, Tripelennamine, Chlorpheniramine, Brompheniramine, and Clemastine.
Benefits include: decreasing the cough when due to post-nasal drainage, decreasing sneezing, decreased runny nose in cold sufferers. They are not effective in treating nasal congestion, sinus pressure, sore throat, headache, or malaise from infections.
2nd Generation Antihistamines (Loratidine, Fexofenadine, Cetirizine) lack anti-cholinergic properties and have no proven benefit in relieving cold and flu symptoms.
During the flu season, the majority of respiratory illnesses are caused by organisms other than the flu (rhinoviruses, coronaviruses, parainfluenza, etc.). While the common cold and influenza share many clinical features, acute cold symptoms typically appear gradually over 1-2 days, whereas influenza symptoms (high fever, severe muscle aches, dry cough, severe headache) are typically more severe and abrupt in onset, often developing within hours.
Symptoms in otherwise healthy individuals include:
• Fever: Influenza causes higher temperatures for 3-5 days in most adults, while the common cold causes lower-grade fevers. The majority of healthy adults diagnosed with the flu (novel H1N1 or seasonal flu) have had abrupt onset of fever greater than 38ᵒC, along with one of the following symptoms.
• Muscle aches are more severe with influenza than with colds, and improve within 3-5 days.
• Cough: a dry cough, sometimes’ severe for 3-5 days, is common with the flu. A milder, but improving cough may linger another 2-4 weeks.
• Headache: a severe generalized headache is common with the flu, and is milder with colds.
• Fatigue: is most severe during the acute febrile stage of the flu, but can sometimes’ linger another several weeks.
• Sore throat, runny nose, and nasal congestion are generally milder with influenza, and are more typical features of the common cold.
• Diarrhea, nausea and/or vomiting are uncommon flu symptoms in adults, but can occur in almost a third of infants/young children.
Antibiotics will not hasten the resolution of acute cold symptoms.
Analgesics may be used to control fever, muscle aches, headache, and sore throat. These include: Acetaminophen, Ibuprofen, Naproxen, and Aspirin. Aspirin use should be avoided in children and teenagers if influenza is suspected.
Decongestants help alleviate nasal congestion, sinus pressure and ear pressure from inflamed/swollen sinus passages caused by most acute respiratory infections. Decongestants are chemically related to adrenalin and can cause side-effects that include increased pulse, jitteriness, insomnia, and loss of appetite.
The current novel H1N1 influenza strain that is circulating globally appears to have the same severity as seasonal influenza. Most otherwise healthy adults who are experiencing flu-like symptoms do not need to be tested for influenza or treated with an anti-viral medication. Persons in the following groups are at higher risk for complicated illness and death from the H1N1 and seasonal flu.
Immediate medical attention is needed for adults with flu-like symptoms who have:
• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with fever and worse cough
Immediate medical attention is needed for children experiencing:
• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• Flu-like symptoms improve but then return with fever and worse cough
The best way to avoid the flu is to get vaccinated!
Annual Seasonal Flu Vaccine: Almost all seasonal influenza A (H3N1) currently circulating globally is resistant to Oseltamivir (Tamiflu). The majority of adults will develop antibody protection against the anticipated seasonal influenza viruses within 2 weeks after vaccination. For optimal protection against the seasonal flu, it is recommended to receive the vaccine in October/November, before peak flu season hits later in the winter.
Rhinosinusitis is defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. The term rhinosinusitis is preferred because sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa.
Rhinosinusitis may be classified by duration as acute rhinosinusitis (ARS) if less than 4 weeks duration or as chronic rhinosinusitis (CRS) if lasting more than 12 weeks, with or without acute exacerbations. ARS may be classified further by presumed etiology, based on symptoms and time course, into acute bacterial rhinosinusitis (ABRS) or viral rhinosinusitis (VRS). Distinguishing presumed bacterial vs viral infection is important because antibiotic therapy is inappropriate for the latter. When patients have 4 or more annual episodes of rhinosinusitis, without persistent symptoms in between, the condition is termed recurrent ARS.
The American Academy of Otolaryngology-Head and Neck Surgery Foundation has updated its clinical practice guidelines for the treatment of adult rhinosinusitis. The recommendations to clinicians are as follows:
Acute bacterial rhinosinusitis (ABRS) should be distinguished from acute rhinosinusitis due to viral respiratory infections and noninfectious conditions. ABRS should be diagnosed when signs and symptoms of acute rhinosinusitis (ARS) (purulent nasal drainage plus nasal obstruction, facial pain-pressure or both) persist without improvement for at least 10 days or if signs and symptoms worsen within 10 days after initial improvement.
Radiographic imaging should not be performed in patients with ARS unless a complication or alternative diagnosis is suspected.
Analgesics, intranasal steroids and/or nasal saline irrigation may be recommended for symptomatic relief of viral or bacterial rhinosinusitis. Adults with uncomplicated ABRS should be either offered watchful waiting or prescribed antibiotic therapy. Patients undergoing watchful waiting should be prescribed antibiotics if their symptoms fail to improve after 7 days or worsen at any time.
If a decision is made to treat ABRS with antibiotics, amoxicillin with or without clavulanate should be prescribed as first-line therapy for 5-10 days. Amoxicillin with clavulanate should be prescribed for patients at high risk of being infected by an organism resistant to amoxicillin.
Patients with an allergy to penicillin should be prescribed doxycycline or a respiratory quinolone as first-line therapy. For patients who fail to improve or worsen by 7 days following initial treatment, they should be reassessed to confirm the diagnosis and to detect complications. If initial treatment involved watchful waiting, antibiotics should be prescribed. If initial treatment included an antibiotic, a different antibiotic should be prescribed.
Chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis should be distinguished from isolated episode of ABRS. The diagnosis of CRS should be confirmed with documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or computed tomography.
Saline nasal irrigation, intranasal corticosteroids, or both should be prescribed for symptom relief in patients with CRS. Testing for allergy and immune function may be obtained when evaluating a patient with for CRS or recurrent ARS.
Acute sinusitis is mostly caused by the common cold. Unless a bacterial infection develops, most cases resolve within a week to 10 days. In most cases, home remedies are all that’s needed to treat acute sinusitis. However, persistent sinusitis can lead to serious infections and other complications.
Acute sinusitis complications are uncommon but if they occur, they might include:
• Chronic sinusitis. Acute sinusitis may be a flare-up of a long-term problem known as chronic sinusitis. Chronic sinusitis lasts longer than 12 weeks.
• Meningitis. This infection causes inflammation of the membranes and fluid surrounding the brain and spinal cord.
• Partial or complete loss of sense of smell. Nasal obstruction and inflammation of the nerve for smell (olfactory nerve) can cause temporary or permanent loss of smell.
• Vision problems. If infection spreads to the eye socket, it can cause reduced vision or even blindness that can be permanent.
Onset with persistent symptoms or signs compatible with acute rhinosinusitis, lasting for ≥10 days without any evidence of clinical improvement. Onset with severe symptoms or signs of high fever (≥39ᵒC) and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness. Onset with worsening symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection (URI) that lasted 5–6 days and were initially improving.
Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in children and adults. A b-lactam agent (amoxicillin-clavulanate) rather than a respiratory fluoroquinolone is recommended for initial empiric antimicrobial therapy of ABRS. Macrolides (clarithromycin and azithromycin) are not recommended for empiric therapy due to high rates of resistance of S. pneumonia.
Chronic rhinosinusitis is a complex inflammatory disease that is not well understood. It is proposed that bacteria contribute to persistence of disease via chronic infection, antibiotic-resistant strains, or the presence of bacterial biofilms. However, the role and contributions of intense inflammation, bacteria, fungi, immunopathologic mechanisms, airway remodeling, susceptibility factors, and environmental contributions remain unclear. Because CRS subtypes present with different pathogenic mechanisms, it has been argued that CRS represents a syndrome of characteristic symptoms rather than a distinct disease.
Diagnosis of chronic rhinosinusitis (CRS) is based on type and duration of symptoms and an objective finding of inflammation of the nasal mucosa or paranasal sinuses. Chronic rhinosinusitis is categorized based on presence or absence of nasal polyps, and this distinction leads to differences in treatment.
Chronic rhinosinusitis with nasal polyps is treated with intranasal corticosteroids. Antibiotics are recommended when symptoms indicate infection (pain or purulence). For CRS without nasal polyps, intranasal corticosteroids and second-line antibiotics (i.e. amoxicillin– clavulanic acid combinations or fluoroquinolones with enhanced Gram-positive activity) are recommended. Saline irrigation, oral steroids, and allergy testing might be appropriate. Failure of response should prompt consideration of alternative diagnoses and referral to an otolaryngologist. Patients undergoing endoscopic sinus surgery require postoperative treatment and follow-up.
Acute laryngitis is an inflammation of the larynx. The most common symptoms are hoarseness, fever, sore throat, postnasal discharge and difficulty in swallowing. Antibiotics are frequently prescribed by physicians.
The use of antibiotics in acute laryngitis has not been shown objectively to have any significant clinical benefit that can justify this use in clinical practice. Despite an overall paucity of evidence, treating acute laryngitis with conservative measures in the first instance is appropriate because antibiotics are associated with side effects and an increased incidence of antimicrobial resistance, which is costly and harmful to the population as a whole. Not using antibiotics for acute laryngitis is likely to lead to productivity savings and reduce the risk of antimicrobial resistance without compromising the clinical care of individual patients.
Antibiotics appear to have no benefit in the treatment of acute laryngitis. Erythromycin may reduce voice disturbance at one week and cough at two weeks, measured subjectively, and fusafungine may improve the rates of cured patients at day five (it is unclear how this was measured), however we consider that these outcomes are not relevant in clinical practice. In addition, acute laryngitis requires laryngoscopic findings for a clear diagnosis as hoarseness by itself is not the sole criterion for the assessment of a disease.
Overall, there is no clear benefit for the primary outcome, which is objective assessment of voice quality, but some improvements are seen in subjective measures (i.e. cough, hoarseness of voice) that could be important to patients. However, according to the NICE trial summary by Cochrane reviewed by Reveitz L et al, it is considered that these modest benefits from antibiotics may not outweigh their cost, adverse effects or negative consequences for antibiotic resistance patterns. The implications for practice are that prescribing antibiotics should not be done in the first instance as they will not objectively improve symptoms.
Ear infection, also called otitis media or inflammation of the middle ear, is an infection of the part of the ear behind the eardrum. Next to the common cold, otitis media is the most common illness diagnosed during childhood. It’s also one of the most common reasons for the prescription of antibiotics and other medications to children.
Middle ear infections are common in children between the ages of 1 month and 6 years, and most common under age 3. Symptoms result from swelling of the middle ear. The child may cry persistently, tug at the ear, have a fever, have trouble sleeping, be irritable and have hearing problems.
Most of the time ear infections clear up without causing any lasting problems. However, if not treated, otitis media can cause problems such as hearing loss, infection of the inner ear, and even meningitis. Fluid may remain in the ear as long as six months after an infection is gone.
Antibiotic use in a child with acute otitis media (AOM) should take into account the age, the severity of the disease, uni- or bilateral otitis, the presence or absence of otorrhea, and the presence of possible risk factors. Delayed antibiotic prescription might be considered in some specific circumstances. The first line antibiotic treatment is amoxicillin, and increased dosage is efficient in case of resistant pneumococci. Pain evaluation is important, and, in every treatment protocols for AOM, pain-relievers use is needed.
Tonsillitis is inflammation of the tonsils. It’s usually caused by a viral infection or, less commonly, a bacterial infection. Tonsillitis is a common condition in children, teenagers and young adults.
The symptoms of tonsillitis include: a sore throat and pain when swallowing; earache; high temperature (fever) over 38ᵒC; coughing; headache. Symptoms usually pass within three to four days.
If tonsillitis is caused by a bacterial infection, antibiotics may be prescribed. Typical signs of a bacterial infection include white pus-filled spots on the tonsils, no cough and swollen or tender lymph glands.
Most cases of tonsillitis are caused by a viral infection, such as the viruses that cause the common cold or influenza. As a child’s immune system develops and gets stronger, the tonsils become less important and usually shrink. In most people, the body is able to fight infection without the tonsils. Removal of the tonsils is usually only recommended if they’re causing problems, such as severe or repeated episodes of tonsillitis.
Viruses known to cause tonsillitis include:
rhinoviruses – which cause the common cold
the influenza virus
parainfluenza virus – which causes laryngitis and croup
enteroviruses – which cause hand, foot and mouth disease
adenovirus – which is a common cause of diarrhoea
the rubella virus – which causes measles
In rare cases, tonsillitis can also be caused by the Epstein-Barr virus, which causes glandular fever.
There’s no specific treatment for tonsillitis, but paracetamol or ibuprofen may help relieve pain. If test results show that your tonsillitis is caused by a bacterial infection, a short course of oral antibiotics may be prescribed. If oral antibiotics are not effective at treating bacterial tonsillitis, intravenous antibiotics (given directly into a vein) may be needed in hospital.
In most cases, tonsillitis gets better within a week. However, a small number of children and adults have tonsillitis for longer, or it keeps returning. This is known as chronic tonsillitis and surgical treatment may be needed. Surgery to remove the tonsils (a tonsillectomy) is usually only recommended if several severe episodes of tonsillitis persist over a long period of time, and repeated episodes are disrupting normal activities
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