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5.01 Upper Respiratory Infection (Common Cold)


Presentation

Most patients with colds do not visit emergency departments, unless they are unusually ill; the cold is prolonged more than a week, or it is progressing into bronchitis or serous otitis with new symptoms. The patient may want a note from a physician excusing him from work; or a prescription for antibiotics, which "seemed to help" the last time he had a cold.

The common denominator of URIs is inflammation of the respiratory mucosa. The nasal mucosa is usually red, swollen, and wet with reactive mucous. The pharynx is inflamed directly or by drainage of mucous from the nose, and swallowing may be painful. Pharyngitis secondary to nasal drainage is typically worse upon arising in the morning, and signs and symptoms may be localized to the side that is dependent during sleep.

Occlusion of the ostia of paranasal sinuses permits buildup of mucous and pressure, leading to pain and predisposing bacterial superinfection. Occlusion of the orifices of the eustachian tubes in the posterior pharynx permits imbalance of middle ear pressure and serous otitis. The larynx can be inflamed directly or secondarily to drainage of mucus or forceful coughing, lowering the pitch and volume of the voice or causing hoarseness. The trachea can also be inflamed, producing coughing, and the bronchi can develop a bacterial superinfection or bronchospasm with wheezing. In addition to all these ills of the upper respiratory mucosa, there can be reactive lymphadenopathy of the anterior cervical chain, diffuse myalgias, and side effects of self medication.

What to do:

What not to do:

Discussion

Colds are produced by over a hundred different adeno and rhinoviruses, and influenza, coxsackie, and measles can also present as a URI. Especially during the winter, when colds are epidemic, it certainly helps to keep abreast of what is "going around," so that you can intelligently advise patients on incubation periods, contagiousness, expected symptoms, and duration; and also be able to pick an unusual syndrome out of the background.

Some of the medications recommended here are available in various combinations over the counter, but when is more than symptomatic treatment indicated? Bacterial superinfections require antibiotics. Mycoplasma pneumonia can present with headache, cough, myalgias, and perhaps bullous myringitis, and may respond to erythromycin. Coughing can precede wheezing as an early sign of asthma, and response to beta agonists helps make the diagnosis. Antibiotics have not turned out to be very useful for acute bronchitis, and vitamin C as prophylaxis for colds has also not done well in controlled trials.


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD