SA Fam Pract 2006;48(4)38

CPD Article

IntroductionWhat to do for the child with anotherupper respiratory tract infection is ac o m m o n p r a c t i c e d i l e m m a .Unfortunately, upper respiratory tractconditions, especially infections, arecommonly mismanaged and a commonerror is the use of antibiotics for viraldisease. However, of similar concern isthe use of oral corticosteroids, oftenwith antihistamines, for both viralinfections and allergic disease. Thereis a clear place for both antibiotics andcorticosteroids in upper respiratory tractdisease but these indications are limitedto clearly defined states. Unnecessaryantibiotic usage can be reduced bycareful medical and patient education.1,2

Acute rhinopharyngitisThis is the ‘common cold’ and is themost common type of upper respiratorytract infection (URTI) in children. In factit is the most common condition in bothchildren and adults.

Most infants and young childrenhave a mean number of 6 such illnessesa year.3 Almost all ‘colds’ are causedby viruses.4 Usually due to the rhinovirusbut also coronavirus, respiratory syncitialvirus, parainfluenza virus, influenza virus,coxsackie virus and adenovirus.4 Somenew respiratory viruses have recentlybeen described, including Humanmetapneumovirus and Boca virus. Onoccasions these viruses cause upper(sinusitis and otitis media) and lower(bronchitis and pneumonia) airway

complications. There is much debateabout the actual mode of transmissionof these viral infections but clearly bothaerosol transmission as well as directcontact of contaminated hands with theairway occur.5 These viruses have anincubation period of 2-5 days and asick individual is ‘contagious’ for somehours before to a few days aftersymptoms.5

Symptoms are typical in olderchildren and adults. They include sorethroat, runny nose, nasal congestion,sneezing, dry cough and mild fever andsome degree of malaise. In infantssymptoms may be more subtle and non-specific, including restlessness, crying,anorexia, vomiting, poor sleep and evenrespiratory distress due to a blockednose.5

Bacterial complications of viral upperrespiratory tract infections do occur.Usually acute sinusitis or acute otitismedia. Occasionally lower respiratorytract infections occur with respiratorydistress. It must always be rememberedthat viral infections are the most commonreason for an acute exacerbation ofasthma.6 Therefore lower respiratorysigns are not necessarily due tobacterial super-infection. Likewise thepresence of recurrent URTI’s andespecially symptoms in spring andsummer should raise the possibility thatthe condition is allergic rhinitis and notinfective in origin.7

Treatment of a viral URTI is sympto-matic.5 Rest and adequate fluid intake

is the most helpful strategy. Antipyreticand pain relief medication in the formof paracetamol is usually given andtopical nasal decongestants mayprovide some relief. However, all othertherapies have never been proven towork.8 These include antihistamines,oral decongestants and antitussivesand especially combination prepa-rations. Their role is strictly placebo.Both oral corticosteroids (and especiallysteroid/antihistamine combinations) andantibiotics have no place. Today, withthe emergence of antimicrobialresitance, antibiotics must be thoughtof as contra-indicated. They should notbe given routinely to prevent secondarybacterial infection. HIV-positive childrenare managed no differently. There arealso no conclusive studies showing thebenefit of vitamin C in either preventionor treatment of URTI’s. Only in the UnitedStates is routine universal influenzavaccination practiced.9 Here it is givento all children between 6 and 23 months.Elsewhere influenza vaccination isrecommended for high risk children.

A general approach to children witha sore throat is outlined in figure 1.

Acute sinusitisThe vast majority of infectious episodesof sinusitis (or rhino-sinusitis) are viralin aetiology. Acute bacterial infection ofthe sinuses is commonly due to Strepto-coccus pneumoniae, non-typableHaemophilus influenzae and Moraxellacatarrhalis.10 Predisposing factors to

Symptomatic treatment of upperrespiratory tract symptoms in children

Green RJ, PhD, Dip Allerg (SA)Associate Professor, Department of Paediatrics, University of Pretoria

Most upper respiratory tract infections are viral and treatment of a viral URTI is symptomatic. Today, with the emergence ofantimicrobial resitance, antibiotics must be thought of as contra-indicated. Acute bacterial sinusitis may complicate a viral URTI.All special investigations for diagnosing acute sinusitis are unhelpful. Treatment of pain and fever are usually the only non-specific measures that help. Antimicrobial treatment has become a mainstay of acute sinusitis but there are studies suggestingthat antibiotics do not alter the course of the disease. Since hearing loss is a risk of untreated and severe acute otitis media,this conditionis usually treated with antibiotics. However, a recent Cochrane Review has concluded that the number of patientsneeded to treat with antibiotics for a benefit is 15. The picture of itching, sneezing and profuse rhinorrhoea are classic of earlyallergic rhinitis but with time, and especially in perennial allergic rhinitis, nasal obstruction is a prominent symptom. It is thepathology which gives rise to both the classic facial appearance of patients (especially children) with perennial allergic rhinitisand the many complications. The most effective therapy of allergic rhino-sinusitis (as the disease should correctly be called)involves the topical nasal steroids.

(SA Fam Pract 2006;48(4): 38-42)

Abstract

SA Fam Pract 2006;48(4)40

CPD Article

bacterial colonization of the sinuses areviral rh inopharyngi t is , a l lergicrhinosinusitis, adenoiditis, smoking(active and passive), septal deviation,nasal foreign body, immunodeficiencystates, cystic fibrosis and diving.5

The pointers to acute sinusitis maybe subtle but usually nasal symptomsof a viral URTI that persist for more than10 days or nasal secretions becomepurulent. Halitosis, fever, cough andheadache are variably present(especially in children).5 All specialinvestigations for acute sinusitis are

unhelpful. Nasal swab and culture doesnot help to identify the organism asthere is lack of correlation betweensites.11 Both plain x-ray and CT scanare not helpful for acute disease.12

Treatment of pain and fever areusually the only non-specific measuresthat help. Antimicrobial treatment hasbecome a mainstay of acute sinusitisbut there are studies suggesting thatthese agents do not alter the course ofthe disease.13 Amoxycillin (90 mg/kg/daygiven 8 hourly for 14-21 days) is thedrug of choice. Alternatives are

amoxycillin/clavulanate, cefuroxime ora macrolide.11

Topical corticosteroids have beenshown in at least 3 studies to improvesymptoms.14-16 Some authors are nowr e c o m m e n d i n g t h a t t o p i c a lcorticosteroids form the basis of therapyand that antibiotics be reserved for moresevere disease, complications orsymptoms beyond 7-10 days.17 Oralcorticosteroids may be useful if thesinusitis is complicated by allergicrhinitis and/or asthma.18 Since acutesinusitis and especially repeatedinfections are complications of allergicrhinosinusitis children and adults whohave episodes of sinusitis should beevaluated for allergy and treatedaccordingly.19 This is a useful approachto limiting the cost and quality of lifeimpairment of many pat ients.Prophylactic treatment of allergic rhinitiswith a regular topical corticosteroid oftenstops further episodes of sinusitis.19

Chronic sinusitis is defined assymptoms attributable to the facialsinuses for 2 - 3 months or longer.Intermittently during chronic sinusitis,sinus obstruction and internal metabolicchanges lead to bacterial overgrowthand acute infective sinusitis. This acutesinusitis may complicate upperrespiratory tract infections in up to 5%of cases.5

The anatomical relationships of nasalpassages to sinuses, and nose toeustachian tubes, throat, tonsils andadenoids has resulted in the upperairway (nose, sinuses and ears)functioning as an interconnected unit.Therefore, in chronic rhinitis the sinusesand middle ear cavities are ofteninvolved. The paired facial sinuses (2frontal, 2 ethmoid and 2 maxillary) areaircells lined by respiratory mucousmembrane. They drain into the noseclose to the middle turbinate throughthe ostiomeatal complex. Likewise themiddle ear cavity is continuous with theupper airway through the eustachiantube which opens into the posteriornasal pharynx in the region of theadenoids. Thus it would seem importantto describe the pathological process ofthe upper airway in relation to allstructures that may be involved, with acommon epithelium which is subject toboth intrinsic inflammatory processes

Table II: Situations where antibiotics should not be routinely indicated

Green mucusA ‘cold’PharyngitisAsthmaticsRecurrent ‘colds’Influenza

Table I: Indications for antibiotic use in URTI’s

Child less than 3 months of agePrimary immunodeficiency states (not routinely in HIV infection)Proven Strep. throatSevere symptoms of acute otitis media andSevere acute rhinosinusitis or disease lasting longer than 7-10 days

Figure 1: Suggested approach to a sore throat

Sore throat

Previously well child Child with animmunodeficiency

state/PreviousRheumatic Heart

Disease

Pen VK

Swab throatImmunofluorescence/

culture

PositiveStrep.

pyogenes

NegativeStrep.

pyogenes

Pen VK Symptomatictreatment

Note: All children with a sore throat must be fully examined for presence of significant disease includingchecking for fever, post-nasal drip, lymphadenopathy and a pseudo-membrane.

CPD Article

and also to obstruction by the vascularengorgement and mucous plugging.Many authors would thus believe that,especially in the case of the sinuses,chronic allergic sinusitis alwaysaccompanies allergic rhinit is.2 0

Acute otitis media (AOM)Since hearing loss is a risk of untreatedand severe AOM, this condition isusually treated with an antibiotics.However, a recent Cochrane Reviewhas concluded that the number ofpatients needed to treat with antibioticsfor a benefit is 15.21 US guidelines arerecommending a delay in antibiotic usefor children over 6 months for thiscondition and only using antibiotics forseverer disease or a more protractedillness. A similar antibiotic selection tothat of acute sinusitis is sufficient.

Chronic middle ear disease is a riskfactor of acute infection and this is morecommon in allergic children.

Allergic rhinitisAllergic diseases are becomingepidemic. Of particular interest to theepidemiological trend of r isingprevalence of allergic diseases is theso-called “Hygiene Hypothesis” ofallergy aetiology. It has now been welldocumented that improvements inhygiene together with reduction in ratesof respiratory infections in infancy arestrongly associated with increasingprevalence of atopic diseases inWestern countries.22 The mechanism ofthis finding is through influence on theTh1/Th2 cellular pathways of the immunesystem. Interferon gamma (IFN-γ) drivesTh1 development; away from the Th2 or

atopic pathway. Greater exposure tobacteria or bacterial products duringearly life increases IFN-γ, which isnormally present in lower circulatinglevels in atopic infants. Clearly theartificial reduction in bacterial exposure,through improvements in public healthand hygiene, changes in infant diets,early use of antibiotics and smallerfamily size, contributes to a reductionin IFN-γ. The importance of viralinfections in protection versus causationof atopy, and especially asthma, is hotlydebated. Respiratory viruses may, infact, lead to significant continuation ofthe asthma phenotype.6

An atopic link between allergicrhinitis, chronic sinusitis and otitis mediawith effusion has been confirmed invarious studies.23 In infants with chronicor recurrent middle ear disease nasal

Figure 2: Suggested approach to a child with recurrent rhinitis

Frequent runny nose,blocked nose, sneezing

Positive family/personnalhistory of atopy Negative history of atopy

SPT (or nasal eosinophils)

Positive Negative

Allergic rhinitis

Conclusion

Topical corticosteroid

Trial of topicaldecongestant/oral

antihistamine

Positive response Negative response

‘Creche syndrome’(non-specific recurrent

viral URTI’s)

SPT = Skin prick test

SA Fam Pract 2006;48(4) 41

SA Fam Pract 2006;48(4)42

CPD Article

metachromatic cells were detectedmore frequently, and in a long-termfollow-up of infants and children ingeneral practice, allergy (family history,spasmodic nocturnal cough, bloodhypereosinophilia and maxillaryrhinosinusitis) was shown to be animportant association.24 Findings in otherstudies have been similar.25

Historically the clinical picture ofallergic rhinitis has focused on the directsymptoms and signs in the nose. Thepicture of itching, sneezing and profuserhinorrhoea are classic of early allergicrhinitis but with time and especially inperennial allergic rhinitis, nasalobstruction is a prominent symptom.26

It is the pathology which gives rise toboth the classic facial appearance ofpatients (especially children) withperennial allergic rhinitis and the manycomplications.26

The “allergic facies” arises as aresult of a blocked nose and ischaracterised by:26

• pallor - often appearing remarkablypale;

• allergic shiners - bluish discolorationof the lower eyelids (arising fromobstructed venous drainage fromthis area of the face by boggy nasalmucosa);

• mouth breathing;• long-face syndrome - of maxillary

and dental disordered development,controversially attributed to nasalblockage;

• allergic mannerisms - `allergicsalute’- performed in an attempt toopen the airway.

Complications of allergic rhinitis includethose described earlier: chronic sinusitisand acute infective sinusitis, otitis mediawith effusion, long-face syndrome, and probably the most troublesome of all,impaired quality of life.26

Sleep disturbances caused byallergic rhinitis include sleep-disorderedbreathing, per iodic breathing,hypopneic and hypoventilation episodesand increased micro-arousals. Thesesymptoms have been attributed toincreased upper airway resistance.Disturbed sleep can result in a chronicfatigue syndrome which impacts heavilyon patients’ quality of life by resultingin limitations of activities, emotional

problems and impaired learning abilityin children. The appropriate treatmentof allergic rhinitis will improve sleepquality and thereby quality of life.27

The foregoing discussions can besummarised by a fairly sweepingstatement that allergic rhinitis (and otherchronic rhinitides), are seldom limitedto the nose. Therefore, in theexamination and investigation of apatient with suspected allergic rhinitis,the entire upper airway should beexamined (sinuses, ears, throat). Clinicalexamination of the ears, as well astympanometry frequently revealsmiddle ear disease. X–ray examinationof the sinuses, although oftenperformed, is limited in its ability todemonstrate chronic inflammation.

It must be stated that although therelationship of sinuses and nose seemsobvious and worth treating as a singleentity, there is a strong relationshipbetween upper airway allergy andasthma. More than 75% of asthmaticchildren have co-existing allergicrhinitis.27 Chronic sinusitis shouldtherefore be considered in cases ofasthma resistant to treatment, as thishas frequently been shown to beassociated.27

The most effective therapy of allergicrhino-sinusitis (as the disease shouldcorrectly be called) involves the topicalnasal steroids.27 Other therapeuticmodalities play a role either in relievingacu te symptoms o r t rea t i ngcomplications. The use of antibioticsshould be restricted to acute sinusitisor otitis media, but adequate preventionshould render this unnecessary. It isinteresting to note that topical steroidsdo not predispose to, or aggravate, aninfective process.26

Figure 2 outlines the approach torecurrent rhinitis.

URTI’s are common but so is allergicrhinosinusitis. There is a limited role forantimicrobial agents in upper airwaydisease. There is also a very limited rolefor oral corticosteroids. Antibiotics shouldbe used cautiously and correctly forspecific acute bacterial infection and notprophylactically and corticosteroids(preferably topically) will solve many of theproblems of allergic upper airway disease.It is useful to think of allergy in the childwho is getting repeated upper respiratory

tract ‘infections’ especially when symptoms

occur through summer.

See CPD Questionnaire, page 52

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27. Green RJ, Quality of life, allergic rhinitis and anti-histamines. Paediatric Review 2004;3: 39-47

Ë This article has been peer reviewed