INFECTIONS OF THE NOSE & PARANASAL SINUSES.
Acute Viral Rhinosinusitis (Common Cold)
ESSENTIALS OF DIAGNOSIS.
- Clear rhinorrhea, hyposmia, and nasal congestion.
- Associated symptoms, including malaise, headache, and cough.
- Erythematous, engorged nasal mucosa on examination without intranasal purulence.
- Symptoms last<4 weeks and typically<10 days.
- Symptoms are self-limited.
Clinical Findings
The nonspecific symptoms of the ubiquitous common cold are present in the early phases of many diseases that affect the upper aerodigestive tract. Because there are numerous serologic types of rhinoviruses, adenoviruses, and other viruses, patients remain susceptible throughout life. These infections, while generally quite benign and self-limited, have been implicated in the development or exacerbation of more serious conditions, such as acute bacterial sinusitis, acute otitis media, asthma, and cystic fibrosis exacerbation, and bronchitis. Nasal congestion decreased sense of smell, watery rhinorrhea, and sneezing accompanied by the general malaise, throat discomfort and, occasionally, headache is typical in viral infections. The nasal examination usually shows erythematous, edematous mucosa and a watery discharge. The presence of purulent nasal discharge suggests bacterial rhinosinusitis.
Treatment
Even though there are no effective antiviral therapies for either the prevention or treatment of viral rhinitis, there is a common misperception among patients that antibiotics are helpful. Zinc for the treatment of viral rhinitis has been controversial. A 2011 meta-analysis of randomized controlled trials demonstrated no benefit in five studies that used ＜75 mg of zinc acetate daily, but significant reduction in duration of cold symptoms was noted in all three studies that used zinc acetate in daily doses of over 75 mg. The effect with zinc salts other than acetate was also significant at doses >75 mg/d, but not as high as the zinc acetate lozenge studies (20% vs 42% reduction in cold duration). Buffered hypertonic saline (3-5%) nasal irrigation has been shown to improve symptoms and reduce the need for nonsteroidal anti-inflammatory drugs. Other supportive measures, such as oral decongestants (pseudoephedrine, 30-60 mg every 4-6 hours or 120 mg twice daily), may provide some relief of rhinorrhea and nasal obstruction. Nasal sprays, such as oxymetazoline or phenylephrine, are rapidly effective but should not be used for more than a few days to prevent rebound congestion. Withdrawal of the drug after prolonged use leads to rhinitis medicamentosa, an almost addictive need for continuous usage. Treatment of rhinitis medicamentosa requires mandatory cessation of the sprays, and this is often extremely frustrating for patients. Topical intranasal corticosteroids (eg, flunisolide, 2 sprays in each nostril twice daily), intranasal anticholinergic (ipratropium 0. 06%nasal sprays, 2-3 sprays every 8 hours as needed) or a short tapering course of oral prednisone may help during the process of withdrawal.
Complications
Other than mild Eustachian tube dysfunction or transient middle ear effusion, complications of viral rhinitis are unusual. Secondary acute bacterial rhinosinusitis may occur and is suggested by persistence of symptoms beyond 10 days, accompanied both by purulent green or yellow nasal secretions and unilateral facial or tooth pain. (Acute Bacterial Rhinosinusitis). While the symptoms of influenza A/HIN1 (swine flu) are much the same as other respiratory viruses, certain persons (including children younger than 5 years, adults older than 65 years, pregnant women, patients with underlying respiratory or immune disorders, and adolescents younger than 19 years receiving aspirin therapy) are at particular risk for the development of hypoxia and acute respiratory distress syndrome(ARDS). Mortality in those in whom ARDS developed was >17%. Diagnosis of influenza A/H1N1 is confirmed by nasopharyngeal, oropharyngeal, or endobronchial swab or aspirate and identification of the virus by reverse transcriptase-polymerase chain reaction (RT-PCR). Treatment with oseltamivir or zanamivir has been effective, but up to date diagnosis, treatment, and containment guidelines should be sought from the Centers for Disease Control and Prevention at http://www.cdc.gov/flu/ if the diagnosis is suspected.