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The upper respiratory tract (URT) consists of:
Therefore, the respiratory tract above the larynx is called the upper respiratory tract.
The lower respiratory tract consists of:
Therefore, the respiratory tract from the larynx down is called the lower respiratory tract.
The common cold (coryza or acute viral rhinitis) is an acute viral infection of the nasal passages. It is the commonest infection in childhood. The throat, middle ear and sinuses may also be involved. Many children have five or more common colds a year.
Many young children have five or more common colds a year.
Usually a rhinovirus. However, many other viruses can also cause the common cold. Children get repeated common colds as immunity to one virus does not give protection against other viruses. The viruses causing the common cold are infectious and can be passed from person to person by sneezing and coughing (droplet spread). The virus is then inhaled and infects the lining of the nasal passages. The virus can also be spread by hand to hand contact. One person coughs into their hand, and later hold hands with someone else who then rubs their nose. In this way the virus is spread from the nose of one person to another. The common cold is particularly frequent in young children who attend a crèche or play group, nursery school or school for the first time. Here children are exposed to viruses they have not met before. The patient is often infectious for a day or two before the signs and symptoms of a common cold appear.
Usually the common cold presents with a runny nose, nasal discharge and sneezing. The eyes become watery and a mild fever is common. Initially the nasal discharge is clear and watery but later becomes thicker and white or yellow. After a few days the nose becomes blocked and nasal breathing may be difficult, especially at night or while breastfeeding. Sleep is commonly interrupted. A mild cough is common and caused by mucous running down the back of the throat (post-nasal drip). The symptoms and signs of a common cold clear up in a week. Usually there are no complications of a common cold.
A very sore throat suggests pharyngitis or tonsillitis while high fever, muscle pains and feeling very unwell suggest influenza rather than a common cold.
A blocked nose with a green (purulent) discharge on one side in a generally well child suggests a foreign body.
The viral infection may spread to:
The viral infection may become complicated by a bacterial infection. Then the clear nasal discharge will become purulent (green).
The viral infection may also trigger an asthma attack in children who suffer from asthma.
Viral complications are most common in infants as they have an immature immune system with little resistance to many viruses.
There are no practical methods of avoiding the common cold other than trying to avoid contact with other people suffering from a common cold. It is best if children with a common cold be kept at home for a few days to recover and avoid infecting others.
Usually no treatment is needed. Make sure the child drinks enough fluid. Frequent, small feeds are best. Appetite is often poor for a few days. Older children can blow their nose, but saline nose drops help to clear the nose in infants and young children. Keeping the room warm and raising the head with pillows may help at night. Paracetamol syrup will lower fever. Aspirin should not be used in children.
Decongestant nose drops for a few days or an oral decongestant (e.g. Actifed) are only practical to help a blocked nose in older children. Antibiotics are not indicated unless there is a secondary bacterial infection. Suspect a complication if the child develops a high fever, severe cough or breathes fast.
Antibiotics are not indicated for a common cold.
This is an infection of the lining of one or more of the air sinuses that develop around the nasal cavity in older children (especially the maxillary sinuses). Sinusitis is usually caused by a bacterial infection, which complicates a common cold. The common cold virus causes swelling of the mucus membranes lining the sinuses. As a result, mucous in the sinuses cannot drain normally and secondary bacterial infection starts a few days after the signs of the common cold.
Acute sinusitis is uncommon in preschool children as their facial sinuses are not yet fully formed. Sinusitis is usually acute but can become chronic. Less commonly sinusitis may complicate allergy.
Acute sinusitis only occurs in older children.
If the sinusitis does not disappear in 10 days or becomes recurrent, refer the patient to an ENT specialist/clinic. Repeated sinusitis suggests an allergy. Chronic sinusitis is not common in children.
Allergic rhinitis is an allergy of the lining (mucosa) of the nose and may present like a common cold. There are two forms of allergic rhinitis:
Both forms of allergic rhinitis present with:
Seasonal rhinitis also has itching of the nose, eyes, ears and soft palate. Itching is uncommon in persistent rhinitis.
Children with persistent allergic rhinitis usually have a pale face with blue colouration of the lower eyelids. Due to upward rubbing of the nose they often have a crease at the base of the nose.
Usually pollens or fungal spores inhaled from the atmosphere in seasonal allergic rhinitis. Pets or house dust mite which are present all year usually cause persistent allergic rhinitis. Commonly there is a family history of allergies (rhinitis, asthma and eczema).
There is usually a family history of allergy in allergic rhinitis.
Infection and inflammation of the pharynx (throat). This is a common condition.
Usually a virus (about 90% of cases). Pharyngitis may also be caused by a bacteria such as Group A Streptococcus. It is not possible to clinically differentiate between a viral and streptococcal pharyngitis.
It is not possible clinically to distinguish viral from bacterial pharyngitis.
Pharyngitis presents with:
The symptoms usually disappear within 5 days.
On examination the throat is very red (inflamed). The mucus membrane of the back of the throat appears swollen and granular.
Often it is difficult to differentiate between pharyngitis and a common cold as the symptoms overlap. However, a sore throat without a blocked or runny nose suggests a pharyngitis.
If a child with enlarged tonsils gets pharyngitis, the tonsils also become inflamed. This is called tonsillitis. Tonsillitis is usually seen in children between the age of 2 and 10 years. It may be caused by either a viral or bacterial (Streptococcal) infection.
The same as pharyngitis. However, both tonsils are swollen and red. There may be yellow spots (follicles) or an exudate (yellow mucoid covering) on the tonsils. With very swollen and inflamed tonsils, the airway may become narrow.
The tonsils normally grow and enlarge in young infants as part of the development of their immune system. Normally the size of the tonsils decreases by 10 years of age. Tonsillitis is more common in children with large tonsils. However, many children have enlarged tonsils without repeated attacks of tonsillitis.
Usually tonsillitis recovers within a week. However, tonsillitis may become recurrent or chronic.
Enlarged, swollen tonsils may obstruct the airway.
The indications for tonsillectomy are:
Unless there is severe airway obstruction, enlarged tonsils alone is usually not an indication for tonsillectomy.
Tonsillectomy for repeated attacks of tonsillitis remains controversial. While occasional tonsillitis is not an indication for tonsillectomy, it has been suggested that more than 5 attacks of tonsillitis per year is a reasonable indication for tonsillectomy.
Adenoids are situated at the back of the nose and cannot be seen without special instruments. They enlarge up to the age of about 7 years and then spontaneously become smaller. Enlarged adenoids may obstruct the nasal airway. This causes snoring, frequent waking at night, mouth breathing, nasal speech, and chronic secretory otitis media. Poor sleep may affect schooling. Mild enlargement of the adenoids requires no treatment but adenoidectomy (removing the adenoids) is indicated for signs of severe upper airway obstruction, especially snoring and sleep apnoea (stopping breathing during sleep).
Snoring and sleep apnoea are important reasons for adenoidectomy.
It is an infection and inflammation of the middle ear. Usually otitis media is acute but it can become chronic. Otitis media is more common in bottle-fed infants, especially with ‘bottle-propping’, when milk can run into the eustachian tube (the narrow tube connecting the middle ear to the pharynx).
Acute otitis media is caused by viruses and bacteria that reach the middle ear from the pharynx via the eustachian tube. The important bacteria are Pneumococcus, Haemophilus, Moraxella and Streptococcus. With a common cold, swelling of the mucosa may block the eustachian tube and cause a build up of fluid in the middle ear where bacteria can thrive.
This is a common infection in children, especially children under 5 years of age. Acute otitis media presents with:
Acute otitis media presents with sudden, severe earache and fever.
With correct treatment, perforation of the eardrum should heal within 2 weeks. Failure or incorrect treatment may lead to chronic suppurative or secretory otitis media.
The most important treatment in otitis media is pain control and antibiotics in young children.
Chronic suppurative otitis media is diagnosed if pus has been draining from a perforation in the eardrum for more than 2 weeks. The hole in the eardrum is now unlikely to heal on its own. Complications of chronic suppurative otitis media include destruction of the bones in the middle ear leading to conductive deafness, mastoiditis and bacterial meningitis or brain abscess.
It is very important to prevent chronic suppurative otitis media by the correct management of children with acute otitis media. Always be alert for signs of mastoiditis (swelling and tenderness over the bone behind the ear), especially in older children. Mastoiditis (infection of the mastoid bone) is a dangerous condition which needs urgent referral to hospital for antibiotics and possible surgical drainage.
The aim is to treat the infection and keep the ear dry so that the perforation in the eardrum can heal:
Refer to an ENT specialist/clinic if the ear continues to drain after 2 weeks of treatment, if the condition recurs or if you suspect a complication.
Chronic suppurative otitis media may result in serious complications.
Chronic secretory otitis media or ‘glue ear’ is a common and important cause of deafness in young children. Chronic infection in the middle ear and enlarged adenoids can lead to obstruction of the eustachian tube with the collection of a thick, sticky effusion in the middle ear. This results in the eardrum being sucked inwards due to the absorption of the air in the middle ear. The thick fluid prevents the bones in the middle ear from vibrating normally. This interferes with normal hearing. Chronic secretory otitis media can delay speech development and result in learning difficulties at school. On examination, the eardrum is dull and retracted. Either one or both ears may be affected. Pain is uncommon. Chronic secretory otitis media is uncommon over the age of 10 years as the eustachian tube becomes wider with improved drainage of the middle ear with increasing age.
Chronic secretory otitis media is a common cause of deafness in young children.
Otitis externa is an infection of the external ear canal (not a true upper respiratory tract infection). It may be caused by a viral, bacterial or fungal infection, a complication of a skin condition (e.g. eczema) or a foreign body. Otitis externa may complicate chronic suppurative otitis externa as the draining pus irritates the skin of the external canal.
A boil in the external canal or mumps may also present with earache.
The epiglottis is positioned at the opening of the larynx to prevent the inhalation of fluids and solids when swallowing. It lies at the meeting point of the upper and lower respiratory tract.
An acute infection of the epiglottis, is usually caused by Haemophilus influenzae. The epiglottis becomes very swollen and may obstruct the airway. This is a rare but very serious condition which may rapidly cause death unless correctly diagnosed and rapidly treated. Children with acute epiglottitis also have a Haemophilus influenzae septicaemia. Acute epiglottitis due to Haemophilus influenzae can be prevented by Hib immunisation of all children. Do not confuse Haemophilus influenzae (a bacteria) with the influenza virus.
Acute epiglottitis is an extremely serious condition which can be prevented with Hib immunisation.
It usually occurs in children between two and 5 years of age. The onset is sudden with:
Acute epiglottitis is the one upper respiratory tract condition that can present with respiratory distress due to airways narrowing.
With the correct antibiotics, the swelling of the epiglottis decreases and the child can usually be extubated after 48 hours.
Acute epiglottitis is a medical emergency.
Influenza, or ‘flu’, is a common upper respiratory tract infection caused by the influenza virus. However, many other viruses can present with similar symptoms and signs of a ‘flu-like’ illness. Influenza usually occurs in epidemics. These may be very serious and cause many deaths. Like the common cold, the influenza virus is spread by coughing, sneezing and direct hand-to-hand contact. Influenza usually presents 1 to 3 days after infection.
The onset is usually sudden, with:
The symptoms are worse for the first 5 days and usually recover by 10 days. Complications of influenza include otitis media, bronchitis and pneumonia. Children may develop convulsions caused by the high fever (pyrexial fits).
Influenza can be prevented by a recent influenza immunisation (especially if given just before the winter months).
A number of important steps can be taken to both prevent and reduce the severity of acute upper and lower respiratory tract infections:
A 4-year-old child is taken to a family doctor. The mother says he has had a blocked nose, is eating poorly and sleeping badly for the past 2 days. On examination he has a mild fever and is generally unwell. There are no signs of pneumonia or otitis media. He attends a crèche where a number of children have been sick.
A common cold
Other children at the crèche. Many children have at least 5 common colds a year.
No. There is no indication that the child has a bacterial infection.
Paracetamol for fever. Make sure he has enough to drink. Keeping the room warm and raising to head of the bed may reduce nasal obstruction at night. Most colds get better in a few days. Nose drops, other than saline drops, and oral decongestants are usually not helpful in young children.
Secretory otitis media, with a collection of fluid behind the ear drum.
A 5-year-old boy presents with fever and a very sore throat. On examination his tonsils are enlarged and swollen. The mother reports that this is the second sore throat he has had in 6 months and asks that his tonsils be removed.
Probably a viral or bacterial infection. However, as there is no history of a common cold, the tonsillitis may be due to a bacterial (Streptococcal) infection.
It is very difficult clinically to differentiate between a viral and bacterial infection of the pharynx and tonsils. Therefore, many doctors would give an antibiotic.
Acute glomerulonephritis and acute rheumatic fever. Tonsillitis can also result in a tonsillar abscess.
Probably not. The indications for tonsillectomy are severe airway obstruction, tonsillar abscess and repeated tonsillitis (more than 5 attacks a year).
Acute epiglottitis. They have a high fever, often drool and keep their head in a fixed position. This is an acute emergency as they may totally obstruct their airway.
Emergency referral for intubation or tracheotomy under general anaesthetic. Allow the child to hold his head in any position that he prefers. Start intravenous antibiotics.
Following a runny nose for 3 days, a young infant develops a high fever and severe pain in one ear. The next day the child seems better and pus is seen in the external canal of that ear.
Due to acute otitis media.
The ear drum ruptured.
As a complication of a common cold. Bacteria can reach the middle ear via the eustachian tube. Blockage of the eustachian tube during a common cold causes an ideal environment for bacteria to grow in the middle ear.
A course of antibiotics. This probably would have avoided the ruptured ear drum.
With antibiotic treatment it should heal within 2 weeks. If not, the child must be referred. If the hole in the ear drum does not heal, the child will have chronic suppurative otitis media. This may lead to deafness with destruction of the bones in the middle ear.
Mastoiditis. This presents with tenderness over the mastoid bone behind the ear. Mastoiditis is dangerous as it may result in a brain abscess or bacterial meningitis.
A 10-year-old child has been ill for 4 days with a high temperature, headache, blocked nose and muscle pains. His younger brother had a similar illness the week before.
The influenza virus.
Because the child has a high fever, headache and muscle pains.
By coughing and sneezing (droplet spread). It may also be spread by hand to hand contact. One person coughs into their hand, and later hold hands with someone else who then rubs their nose. In this way the virus is spread from the nose of one person to another. The influenza virus almost certainly was spread from the younger brother.
Bed rest, plenty of fluids and paracetamol. Usually an antibiotic is not needed unless a complication develops such as pneumonia.
Influenza immunisation in autumn greatly reduces the risk of infection.
Febrile convulsions (pyrexial fits).