Upper Respiratory Tract Infection Clinical Presentation

Details of the patient's history aid in differentiating a common cold from conditions that require targeted therapy, such as group A streptococcal pharyngitis, bacterial sinusitis, and lower respiratory tract infections. The table below contrasts symptoms of upper respiratory tract infection (URI) with symptoms of allergy and seasonal influenza (adapted from the National Institute of Allergy and Infectious Diseases). ^{[22, 25]}

Table. Symptoms of Allergies, URIs, and Influenza (Open Table in a new window)

Viral nasopharyngitis

Symptoms of the common cold usually begin 2-3 days after inoculation. Viral URIs typically last 6.6 days in children aged 1-2 years in home care and 8.9 days for children older than 1 year in daycare. Cold symptoms in adults can last from 3-14 days, but most people recover or have symptomatic improvement within a week. If symptoms last longer than 2 weeks, consider alternative diagnoses, such as allergy, sinusitis, mononucleosis, tuberculosis, or pneumonia.

Nasal symptoms of rhinorrhea, congestion or obstruction of nasal breathing, and sneezing are common early in the course. Clinically significant rhinorrhea is more characteristic of a viral infection rather than a bacterial infection. In viral URI, secretions often evolve from clear to opaque white to green to yellow within 2-3 days of symptom onset. ^[7] Thus, color and opacity do not reliably distinguish viral from bacterial illness.

On the other hand, the existence of persistent, purulent nasal discharge, especially if accompanied by crusts or sores in the nares, may indicate bacterial infection, particularly with S aureus. Other indicators of bacterial infection are skin pustules or impetigo and the presence of purulent signs in other family or household members.

Pharyngeal symptoms include sore or scratchy throat, odynophagia, or dysphagia. Sore throat is typically present at the onset of illness, although it lasts only a few days. If the uvula or posterior pharynx is inflamed, the patient may have an uncomfortable sensation of a lump when swallowing. Nasal obstruction may cause mouth breathing, which may result in a dry mouth, especially after sleep.

Cough may represent laryngeal involvement, or it may result from upper airway cough syndrome related to nasal secretions (postnasal drip). Cough typically develops on the fourth or fifth day, subsequent to nasal and pharyngeal symptoms.

Other manifestations are as follows:

• Foul breath: Occurs as resident flora processes the products of the inflammatory process; foul breath may also occurs with allergic rhinitis

• Hyposmia: Also termed anosmia, it is secondary to nasal inflammation

• Headache: Common with many types of URI

• Sinus symptoms: May include congestion or pressure and are common with viral URIs

• Photophobia or conjunctivitis: May be seen with adenoviral and other viral infections; influenza may evoke pain behind the eyes, pain with eye movement, or conjunctivitis; itchy, watery eyes are common in patients with allergic conditions

• Fever: Usually slight or absent in adults, but temperatures can reach 102°F in infants and young children ^[31] ; if present, fever typically lasts for only a few days; influenza can cause fevers as high as 40°C (104°F)

• Gastrointestinal symptoms: Nausea, vomiting, and diarrhea may occur in persons with influenza, especially in children; nausea and abdominal pain may be present in individuals with strep throat and various viral syndromes ^[31]

• Severe myalgia: Typical of influenza infection, especially in the setting of sudden-onset sore throat, fever, chills, nonproductive cough, and headache

• Fatigue or malaise: Any type of URI can produce these symptoms; extreme exhaustion is typical of influenza

Pharyngitis from group A streptococci

The history alone is rarely a reliable differentiator between viral and bacterial pharyngitis. However, persistence of symptoms beyond 10 days or progressive worsening after the first 5-7 days suggests a bacterial illness. Assessment for group A streptococci warrants special attention.

The health status of contacts and local epidemiologic trends are important factors to consider. A personal history of rheumatic fever (especially carditis or valvular disease) or a household contact with a history of rheumatic fever increases a person's risk. Other factors include occurrence from November through May and patient age of 5-15 years.

Pharyngeal symptoms of sore or scratchy throat, odynophagia, or dysphagia are common. If the uvula or posterior pharynx is inflamed, the patient may have an uncomfortable feeling of a lump when swallowing. Nasal obstruction may cause mouth breathing, which may result in dry mouth, especially in the morning. Group A streptococcal infections often produce a sudden sore throat.

Fever increases the suspicion that infection with group A streptococci is present, as does the absence of cough, rhinorrhea, and conjunctivitis, because these are common in viral syndrome; however, symptoms overlap between streptococcal and viral illness.

Other manifestations are as follows:

• Secretions: May be thick or yellow; however, these features do not differentiate a bacterial infection from a viral one

• Cough: May be due to laryngeal involvement or upper airway cough syndrome related to nasal secretions (postnasal drip)

• Foul breath: May occur because resident flora processes the products of the inflammatory process; foul breath may also occur with allergic rhinitis and viral infections

• Headache: While common with group A streptococci and mycoplasma infections, it also may reflect URI from other causes

• Fatigue or malaise: These may occur with any URI; extreme exhaustion is typical of influenza

• Fever: While usually slight or absent in adults, temperatures may reach 102°F in infants and young children

• Rash: A rash may be seen with group A streptococcal infections, particularly in children and in adolescents younger than 18 years

• Abdominal pain: This symptom may occur in streptococcal disease, most commonly in young children, but also in influenza and other viral conditions

A history of recent orogenital contact suggests possible gonococcal rather than streptococcal pharyngitis. However, most gonococcal infections of the pharynx are asymptomatic. ^[32]

Acute viral or bacterial rhinosinusitis

The presentation of rhinosinusitis is often similar to that of nasopharyngitis, because many viral URIs directly involve the paranasal sinuses. Symptoms may have a biphasic pattern, wherein coldlike symptoms initially improve but then worsen. Acute bacterial rhinosinusitis is not common in patients whose symptoms have lasted fewer than 7 days. Unilateral and localizing symptoms raise the suspicion for sinus involvement.

In children with bacterial sinusitis, the most common signs are cough (80%), nasal discharge (76%), and fever (63%). In adults, the classic triad of facial pain, headache, and fever is not common. ^[7]

The 2013 American Academy of Pediatrics (AAP) guidelines define acute bacterial sinusitis in children as a URI with any of the following ^[3] :

• Persistent nasal discharge (any type) or cough lasting 10 days or more without improvement

• Worsening course (new or worse nasal discharge, cough, fever) after initial improvement

• Severe onset (fever of 102°F or greater with nasal discharge) for at least 3 consecutive days

Nasal discharge

Nasal discharge may be persistent and purulent, and sneezing may occur. Mucopurulent secretions are seen with viral and bacterial infections. Secretions may be yellow or green; however, the color does not differentiate a bacterial sinus infection from a viral one, because thick, opaque, yellow secretions may be seen with uncomplicated viral nasopharyngitis. ^[7]

Compared with allergy or viral infection, rhinorrhea may be less predominant, and not respond to decongestants or antihistamines. Congestion and nasal stuffiness predominate in some individuals.

Facial and dental pain

Facial or dental pressure or pain may be present. In older children and adults, symptoms tend to localize to the affected sinus. Frontal, facial, or retro-orbital pain or pressure is common. Maxillary sinus inflammation may manifest as pain in the upper teeth on the affected side. Pain radiating to the ear may represent otitis media, local adenopathy, or a peritonsillar abscess.

Sore throat and dry mouth

Sore throat may result from irritation from nasal secretions dripping down the posterior pharynx. Nasal obstruction may cause mouth breathing, which may result in dry mouth, especially in the morning. Mouth breathing may especially be noted in children. Dry mouth may be prominent, especially after sleep. Foul breath may be noted, because resident flora processes the products of the inflammatory process; this symptom may also occur with allergic rhinitis.

Cough

Frequent throat clearing or cough may develop as a result of nasal secretions (postnasal drip). Rhinosinusitis-related cough is usually present throughout the day. The cough may also be most prominent on awakening, because of secretions that have gathered in the posterior pharynx overnight.

Daytime cough that lasts more than 10-14 days suggests sinus disease, asthma, or other conditions. Nighttime-only cough is common in numerous disorders, in part because of reduced throat clearing and airway mechanics; many forms of cough are most noticeable at night.

Upper airway cough syndrome related to nasal secretions occasionally precipitates posttussive emesis; this may also occur with asthma. Clinically significant amounts of purulent sputum may suggest bronchitis or pneumonia.

Other

Hyposmia or anosmia may result from nasal inflammation. Fatigue or malaise may be seen with any URI.

Epiglottitis

This condition is more often found in children aged 1-5 years, who present with a sudden onset of the following symptoms:

• Sore throat

• Drooling, odynophagia or dysphagia, difficulty or pain during swallowing, globus sensation of a lump in the throat

• Muffled dysphonia or loss of voice

• Dry cough or no cough, dyspnea

• Fever, fatigue or malaise (may be seen with any URI)

• Tripod or sniffing posture

Laryngotracheitis and laryngotracheobronchitis

Nasopharyngitis often precedes laryngitis and tracheitis by several days. Swallowing may be difficult or painful, and patients may experience a globus sensation of a lump in the throat. Hoarseness or loss of voice is a key manifestation of laryngeal involvement.

In adolescents and adults, laryngotracheal infection may manifest as severe dry cough following a typical URI prodrome. Mild hemoptysis may be present; however, hemoptysis may also be seen with tuberculosis and other conditions. Children with laryngotracheitis or laryngotracheobronchitis (croup) may have the characteristic brassy, seal-like barking cough. Symptoms may be worse at night. Diphtheria also produces a barking cough.

Myalgias are characteristic in influenza, especially in the setting of hoarseness with sudden sore throat, fever, chills, nonproductive cough, and headache. Fever may be present, but it is not typical in persons with croup. Fatigue or malaise may occur with any URI.

Whooping cough

In whooping cough, the classic whoop sound ^[4] is an inspiratory gasping squeak that rises in pitch, typically interspersed between hacking coughs. The whoop is more common in children. Coughing often comes in paroxysms of a dozen coughs or more at a time and is often worst at night.

Whooping cough has 3 classic phases, as follows:

• Catarrhal (7-10 days): With predominantly URI symptoms

• Paroxysmal (1-6 weeks): With episodic cough

• Convalescent (7-10 days): Gradual recovery ^[5]

Posttussive symptoms include gagging or emesis after paroxysms of whooping cough. Subconjunctival hemorrhage may result from severe cough. Rib pain with pinpoint tenderness worsening with respiration may reflect rib fracture associated with severe cough.

Dyspnea and increased work of breathing may be worse at night in patients with whooping cough, because of changes in airway mechanics while the patient is recumbent. Apnea may be a chief feature in infants with pertussis. Apnea may also result from upper airway obstruction due to other causes.

Viral nasopharyngitis

Patients with the common cold may have a paucity of clinical findings despite notable subjective discomfort. Findings may include the following:

• Nasal mucosal erythema and edema are common

• Nasal discharge: Profuse discharge is more characteristic of viral infections than bacterial infections; initially clear secretions typically become cloudy white, yellow, or green over several days, even in viral infections

• Foul breath: Halitosis may be noted because resident flora process the products of the inflammatory process

• Fever: Temperature is less commonly elevated in adults with the common cold, but fever may be present in children with rhinoviral infections

Viral pharyngitis

Pharyngeal erythema is typically marked in adenoviral infection. In contrast, rhinoviral and coronaviral infections are not likely to manifest as severe erythema.

Exudates may occur in half the patients with adenovirus infections. Exudative pharyngitis and tonsillitis may be seen with mononucleosis caused by Epstein-Barr virus (EBV), while exudates are uncommon in rhinoviral, coxsackievirus, and herpes simplex virus (HSV) pharyngitis. Yellow or green secretions do not differentiate a bacterial pharyngitis from a viral one. Thick, yellow secretions are commonly seen with uncomplicated viral nasopharyngeal infections.

The presence of palatal vesicles or shallow ulcers is characteristic of primary infection with herpes simplex virus. Ulcerative stomatitis may also occur in coxsackievirus or other enteroviral infections, and mucosal erosions may also be seen in primary HIV infection. Small vesicles on the soft palate, uvula, and anterior tonsillar pillars suggest herpangina, which is caused by coxsackieviral infection.

Profuse nasal discharge is more characteristic of viral infections than bacterial infections. Initially clear secretions typically become cloudy white, yellow, or green over several days, even in viral infections. Halitosis may be noted, because resident flora processes the products of the inflammatory process.

Anterior cervical lymphadenopathy is seen with viral and bacterial infections. Approximately half of EBV mononucleosis cases involve generalized adenopathy or splenomegaly. An enlarged liver may also be palpable. Primary HIV infection can be another cause of lymphadenopathy.

Conjunctivitis may be seen with adenoviral pharyngoconjunctival fever and is present in one half to one third of all adenoviral URIs. Watery, injected conjunctiva may also be seen with allergic conditions.

Other signs that may accompany viral pharyngitis include the following:

• Tonsillar hypertrophy

• Cough: This is more suggestive of a viral, rather than a bacterial, etiology

• Diarrhea: If associated with a URI, diarrhea suggests a viral etiology

• Fever: Can be caused by EBV infections and influenza

Bacterial pharyngitis

This may be difficult to distinguish from viral pharyngitis. Assessment for group A streptococcal infection warrants special attention. The following physical findings suggest a high risk for group A streptococcal disease ^[1] :

• Erythema, swelling, or exudates of the tonsils or pharynx

• Temperature of 38.3°C (100.9°F) or higher

• Tender anterior cervical nodes (≥1 cm)

• Absence of conjunctivitis, cough, and rhinorrhea, which are symptoms that may suggest viral illness ^[2]

Less common findings in streptococcal pharyngitis are petechiae of the palate and a scarlatiniform rash. These are not uniquely specific to this disorder.

Exudates manifest as white or yellow patches. A whitish coating may appear on the tongue, causing the normal bumps to appear more prominent. Yellow or green coloration does not differentiate bacterial pharyngitis from a viral disease, because thick, yellow secretions may be seen with uncomplicated viral nasopharyngitis. Foul breath may be noted because resident flora processes the products of the inflammatory process.

A whitish adherent membrane forming on the nasal septum, along with a mucopurulent blood-tinged discharge, should prompt consideration of diphtheria. Pharyngeal and tonsillar diphtheria may manifest as an adherent blue-white or gray-green membrane over the tonsils or soft palate; if bleeding has occurred, the membrane may appear blackish.

A peritonsillar abscess may manifest as unilateral palatal and tonsillar pillar swelling, with downward and medial tonsil displacement; the uvula may tilt to the opposite side. Bulging of the posterior pharyngeal wall may signal a retropharyngeal abscess.

Tender anterior cervical adenopathy may be part of the presentation in patients with streptococcal or viral infections. In persons with diphtheria, submandibular and anterior cervical edema may be present along with adenopathy.

Fever is more likely to occur in group A streptococcal infections than in other URIs, although it may be absent. Temperatures around 38.3°C (101°F) may occur in group A streptococcal infection.

Rash may be seen with group A streptococcal infections, particularly in patients younger than 18 years. The scarlet fever rash appears as tiny papules over the chest and abdomen, creating roughness similar to sandpaper and producing a sunburned appearance. The rash spreads, causing erythema in the groin and armpits. The face may be flushed, with pallor around the lips. Approximately 2-5 days later, the rash begins to resolve. Peeling is often noted on the tips of toes and fingers.

Cutaneous diphtheria may appear as a scaling rash or as well-demarcated ulcers with membranes. Neisseria gonorrhoeae infection may also cause a rash.

Uncommon findings in bacterial pharyngitis include the following:

• Drooling: May be noted in cases of peritonsillar abscess, or it may denote epiglottitis

• Distorted speech (“mush mouth”): As if the mouth were filled

• Lower respiratory tract findings (eg, rales): In patients with concomitant URI, these suggest infection with pathogens such as Mycoplasma pneumoniae or Chlamydia pneumoniae or with viruses

• Conjunctivitis, cough, and diarrhea: More common with URIs caused by virus rather than bacteria

• Rhinorrhea: Not a common feature of pharyngitis caused by bacteria such as group A streptococci

In the setting of acute pharyngitis, the presence or absence of preexisting cardiac murmurs should be documented for comparative purposes in case rheumatic fever later develops.

Acute rhinosinusitis

This is most often viral; however, differentiating common viral illnesses from uncommon bacterial cases on clinical grounds alone can be challenging. Suspicion is raised for acute bacterial rhinosinusitis when symptoms last more than 7 days and when the patient has maxillary pain or tenderness in the face or teeth (especially unilateral), headache, and purulent nasal secretions. Occasionally, patients with acute bacterial sinusitis present with severe symptoms, especially unilateral facial pain, even when symptoms have not lasted at least 7 days.

However, the classic triad of fever, headache, and facial pain occurs uncommonly in adults with bacterial sinusitis; in children with bacterial sinusitis, nasal discharge is present in 76% of patients and fever is found in 63%. ^[7] Foul breath may be noted, because resident flora processes the products of the inflammatory process.

The paranasal sinuses develop and enlarge after birth; ethmoid and sphenoid sinuses may not be of significant size until age 3-7 years. The frontal sinuses are the last to develop and may not be of significant size until adolescence.

Exudates

Mucopurulent secretions may be present in the nares with either viral or bacterial sinusitis. A lighted nasal speculum directed posteriorly allows the clinician to view secretions emanating from the area of the middle meatus. Secretions may be thick and yellow; however, color does not differentiate a bacterial sinus infection from a viral one. Thick, yellow secretions may be seen several days into the course of uncomplicated viral nasopharyngitis.

Rhinitis

When rhinitis is present, nasal mucosa may be inflamed. Typical findings include swelling and redness of the turbinates. In many cases of sinusitis, the nares serve only as a conduit for purulent secretions, and the nasal mucosa may not be inflamed. Pallor and edema may be associated with underlying allergic rhinitis. The presence of unilateral signs suggests sinus involvement rather than uncomplicated rhinitis.

Preexisting obstructions

Nasal obstruction due to preexisting polyps or septal deviation may contribute to sinusitis. It is best appreciated upon direct inspection with nasal endoscopy.

Facial tenderness

Facial tenderness to palpation or percussion may be present and most easily appreciated over the frontal or maxillary sinuses. Percuss and apply digital pressure to the forehead above the brow to evaluate frontal sinus area tenderness. The floor of the frontal sinuses may be approached by pressing upward on the supraorbital area of the skull beneath the eyebrows.

Maxillary sinuses are posterior to the cheekbones; use digital pressure and percussion on the cheeks to elicit tenderness. Tapping on the upper teeth with a tongue depressor may evoke pain in the corresponding maxillary sinus. The floor of the maxillary sinuses may be approached by pressing upward on the palate.

Ethmoid sinuses are between the eyes and behind the nasal bridge. Palpate the area around the middle canthus to assess the ethmoids. The sphenoid sinuses are deep to the ethmoids and behind the eyes. Evaluating the ethmoid and sphenoid sinuses during routine physical examination is challenging. Periorbital swelling may be present in ethmoid sinusitis.

Sinus opacity

Sinus cavity opacity on transillumination suggests sinusitis. Opacity is best appreciated in a completely darkened room. Place the illuminator directly on the skin at the level of the infraorbital rim to evaluate the maxillary sinuses and at the medial aspect of the supraorbital rim to evaluate the frontal sinuses. The maxillary sinuses may also be transilluminated by placing a light beam inside the patient's mouth against the palate directed upward.

Bright transmission of light suggests a normal air-filled sinus; absent light transmission suggests the presence of fluid. This approach depends on the examiner's skill and experience, and results are best interpreted along with other findings. Transillumination findings may be unreliable in children. The frontal sinuses may not begin to develop until age 5-8 years.

Intracranial suppurative complications

Suspect an intracranial suppurative complication (eg, abscess) when the examination reveals signs such as the following:

• Proptosis

• Impaired extraocular movements

• Decreased vision

• Papilledema

• Changes in mental status

• Other neurologic findings

Epiglottitis

Direct visualization is the best way to confirm the diagnosis of epiglottitis. However, such examination may compromise the airway. Therefore, in suspected epiglottitis, limit the examination to observation and an assessment of the vital signs. Oropharyngeal examination performed by using a tongue depressor or speculum can provoke laryngospasm. Direct visualization of the upper airway should be performed only when emergency endotracheal intubation or cricothyroidotomy can be safely performed if necessary.

Physical findings associated with epiglottitis include the following:

• Drooling

• Muffled dysphonia or loss of voice

• Stridor: Inspiratory stridor may be notable and best appreciated with auscultation over the anterior trachea; wheezing heard only on expiration is most consistent with bronchial disease

• Mild cough

• Tenderness to gentle palpation over the larynx

• Cervical adenopathy

• Respiratory distress

• Fever

• Tripod or sniffing posture

Respiratory distress in patients with epiglottitis may manifest as tachypnea, tachycardia, and the use of accessory muscles of respiration. Observe the patient for rib retractions, use of strap muscles, and perioral cyanosis. In response to respiratory distress, patients with epiglottitis may assume the classic tripod position: sitting upright, supported by the hands, with the tongue out and head forward.

Laryngitis and laryngotracheitis

Many patients with croup or laryngotracheitis are less ill than they sound. In severe cases, however, children may have respiratory fatigue that leads to respiratory failure.

Hoarseness is a hallmark of laryngeal involvement. Lowered vocal pitch and loss of voice may occur.

Dry cough may be present with laryngeal involvement. Children with laryngotracheitis or croup may have the characteristic brassy, seal-like barking cough. A barking cough may also be present in diphtheria laryngitis. In whooping cough, the classic whoop sound ^[4] is an inspiratory gasping squeak that rises in pitch, typically interspersed between hacking coughs. The whoop is more common in children than in adults.

Inspiratory stridor may be audible with croup or whooping cough. It typically can be heard without a stethoscope, but it is especially obvious with the stethoscope placed on the anterior aspect of the trachea during inspiration.

Mild hemoptysis may be present; however, hemoptysis made also be seen with tuberculosis and other conditions. Clinically significant amounts of purulent sputum may suggest bronchitis or pneumonia.

Respiratory compromise manifests as tachypnea, tachycardia, and the use of accessory muscles of respiration. Diminished breath sounds in association with pallor and cyanosis may indicate impending respiratory failure.

Paroxysms of coughing may produce conjunctival hemorrhages. Petechial hemorrhages may be noted in the upper body, resulting from severe paroxysms of coughing, such as those associated with whooping cough. Rib fracture, with pinpoint tenderness worsening with respiration, may result from severe coughing, such as that seen in whooping cough.

Lymphadenopathy may be present in the anterior cervical nodes. Fever may be present, but it is not typical in persons with croup. Fever may be seen with influenza laryngitis.