Please confirm that you would like to log out of Medscape If you log out you will be required to enter your username and password the next time you visit Log out Drugs Diseases Neurology FoixAlajouanine Syndrome Updated Oct 04 2018 Author Cheryl Ann Palmer MD Chief Editor Helmi L Lutsep MD Sections Overview Presentation DDx Workup Treatment Medication Media Gallery References Background FoixAlajouanine syndrome is an arteriovenous AV malformation of the spinal cord predominantly affecting the lower thoracic andor lumbosacral levels cervical cord involvement is rare Findings include necrosis of the affected cord regions Grey matter as compared with white matter structures are more severely involved See Etiology Masses of enlarged tortuous thickwalled subarachnoid veins are observed overlying the surface of the cord primarily on the posterior aspect Smaller blood vessels with thickened fibrotic walls also are present within the affected spinal cord segments see the image below See Workup Gross photograph of the dorsal surface of the spinal cord showing dilated and tortuous vessels View Media Gallery Foix and Alajouanine first described the syndrome in 2 young men aged 29 y and 27 y in 1926 3 Historically eponymic the syndrome now has many other names in the literature including angiodysgenetic necrotizing myelopathy subacute necrotizing myelopathy and venous congestive myelopathy 4 Epidemiology FoixAlajouanine syndrome is a rare entity No specific statistics are available with regard to its frequency in the United States but the condition is likely underdiagnosed Patient education Patients should be taught proper bladder and bowel care Education regarding the identification of early symptoms and signs of disease recurrence also is required Educate the patients family andor caregiver about proper skin care and nutrition and about patient transfer requirements See Presentation Etiology The etiology of FoixAlajouanine syndrome is not well understood Most patients have an AV fistula in the lower thoracic dura One etiologic hypothesis is that the higher arterial pressure within the dura is transmitted to the spinal venous plexus via the intradural venous system compromising perfusion and leading to infarction of the spinal cord parenchyma Arterial blood originating from the dural fistula enters the venous system increasing pressure and impairing normal drainage from the cord parenchyma 4 Thrombosis may occur but not until late in the course of the disease Venous stasis not thrombosis may be the primary cause of infarction The preferential involvement of the distal cord is presumably due to orthostasis The onset in middle age suggests that the syndrome is acquired in contrast to other vascular malformations which are presumed to be congenital abnormalities although the specificity for the spinal cord is not easily explained Prognosis FoixAlajouanine syndrome is a subacute disorder that gradually evolves over 15 years 2 Affected patients initially are spastic but eventually develop flaccid paralysis of the limbs and may become wheelchair bound Death can occur with terminal sepsis or other sequelae The prognosis is poor if treatment is not administered before neurologic deterioration occurs Successful embolization andor surgical interruption of the draining veins can halt the progression of symptoms and provide clinical improvement in many patients Operations if successful are permanent modalities of treatment After embolization recanalization may occur but this is rarely seen if the draining vein is filled with glue 5 Complications Patients may suffer recrudescence of symptoms lack of improvement or rapid neurologic deterioration eg flaccid areflexic paraplegia with complete loss of sensation below the lesion Angiographic examination contains an element of risk especially in older patients it may compromise local circulation which can aggravate neurologic deficits With regard to surgery a fatal postoperative outcome is not uncommon Pathophysiology The enlarged abnormal veins are associated with dural AV shunts or fistulas usually intradurally but rarely extradurally 1 These AV shunts are associated with reflux of arterial blood into the venous drainage of the cord This leads to congestion of venous outflow and results in increased venous pressure in the affected regions of the spinal cord often leading to ischemic injury See Etiology and Treatment 2 5 Epidemiology Frequency United States No recent data exists describing the incidence or prevalence of patients with or treated for FoixAlajouanine Syndrome in the United States or across other countries A retrospective study from 2001 in Germany estimated a prevalence of 510 cases per one million people in the general population though this disease is probably underdiagnosed 12 MortalityMorbidity Outcomes after diagnosis and treatment depend on factors such as the duration of symptoms the pretreatment disability and the success of the procedure to close the fistula Symptoms that generally improve after treatment are gait difficulties and muscle strength Micturition pain and muscle spasms are symptoms that often do not respond as well 5 Race No data is currently available indicating if FoixAlajouanine syndrome is more prevalent in specific ethnicracial groups Sex The male to female ratio for FoixAlajouanine syndrome is approximately 51 5 Age FoixAlajouanine syndrome usually occurs in older patients 50 y Patients younger than 30 years are rarely reported 2 5 Clinical Presentation What to Read Next on Medscape Sections FoixAlajouanine Syndrome Overview Presentation DDx Workup Treatment Medication Media Gallery References Recommended Diseases Conditions Epidural Hematoma Procedures Vascular Malformations of the Spinal Cord

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I


Please confirm that you would like to log out of Medscape If you log out you will be required to enter your username and password the next time you visit Log out Drugs Diseases Pulmonology Upper Respiratory Tract Infection Treatment Management Updated Jun 21 2018 Author Anne Meneghetti MD Chief Editor Zab Mosenifar MD FACP FCCP Sections Overview Presentation DDx Workup Treatment Medication Questions Answers Media Gallery Tables References Approach Considerations Most upper respiratory tract infections URIs are selfdiagnosed and selftreated at home Patients who present with URIs often benefit from reassurance education and instructions for symptomatic home treatment Symptombased therapy represents the mainstay of URI treatment in immunocompetent adults although antimicrobial or antiviral therapy is appropriate in selected patients see Medication Several URIs warranting special attention are described in this section In November 2013 The American Academy of Pediatrics released a set of three basic principles for the effective use of antibiotics to treat pediatric URIs including acute otitis media acute bacterial sinusitis and streptococcal pharyngitis 40 41 The principles are as follows Accurate diagnosis of a bacterial infection Consideration of the risks vs benefits of antibiotic treatment and Implementation of judicious prescribing strategies including selection of the most effective antibiotic prescription of an appropriate dose and treating for the shortest possible duration These principles will help healthcare providers distinguish bacterial infections from viral infections Little et al evaluated the effectiveness of delayed antibiotic prescribing strategies for respiratory tract infections in 889 United Kingdom primary care patients age 3 y assessed as not requiring immediate antibiotics They reported that using strategies of either no or delayed prescription resulted in fewer than 40 of the patients across 25 practices using antibiotics 42 Delayed prescribing strategies consisted of recontact for a prescription postdated prescription collection of the prescription and giving the prescription patient led Moreover no or delayed prescription strategies were associated with patients having less strong beliefs in the use of antibiotics and symptomatic outcomes were similar to those observed in patients who received immediate prescription 42 Epiglottitis The risk for airway compromise is notable especially in children Immediately admit the patient to the nearest hospital Adults with epiglottitis typically have a relatively gradual course However some older children and adults may have respiratory compromise especially those with congenital or acquired subglottic stenosis The treatment of epiglottitis in adults requires individual tailoring of therapy on the basis of the severity of the disease at presentation and the course of the disease as it unfolds under observation An anesthesiologist or otorhinolaryngologist should be involved early on Avoid instrumentation in suspected epiglottitis Limit the examination to observation and an assessment of the vital signs Insertion of tongue depressors or other instruments may provoke airway spasm and precipitate respiratory compromise Keep the patient comfortable and avoid unnecessary examinations Patients must be monitored for respiratory fatigue visually and with continuous pulse oximetry Because immediate intubation is required in the event of respiratory failure the availability of equipment and qualified personnel is critical If endotracheal intubation is not possible cricothyroidotomy may be required Oxygen is administered according to pulse oximetry results Dry air may worsen inflammation so the use of humidified oxygen or a room humidifier is recommended Medications Presumptive intravenous antibiotics are indicated tailored to results from blood cultures Empiric coverage for Haemophilus influenzae is appropriate Antibiotic therapy should begin after blood cultures and epiglottic cultures if laryngoscopy is performed are taken Common choices include ceftriaxone or other thirdgeneration cephalosporins cefuroxime and cefamandole After culture and sensitivity results are available therapy may be further tailored Close contacts should receive prophylactic oral therapy Either intravenous or inhaled glucocorticoids are sometimes given to reduce inflammation However controlled trials of the effectiveness of this approach in epiglottitis are limited Correct volume deficits with intravenous fluids Avoid sedatives that may suppress the respiratory drive Aerosolized racemic epinephrine is sometimes used to reduce mucosal edema in patients with croup but its value in epiglottitis is not defined and adverse events have been reported in patients with this disorder 43 Beta 2 agonists are not typically used in patients who do not have asthma Laryngotracheitis Hospitalization may be necessary in patients with laryngotracheitis especially in infants and young children who have hypoxemia volume depletion a risk for airway compromise or respiratory fatigue Mild cases of croup ie laryngotracheobronchitis may be managed at home with moist air inhalation Patients with diphtheria may require isolation and hospitalization for airway management Hospitalized patients require monitoring for respiratory fatigue visually and with continuous pulse oximetry Clinicians with the expertise to perform immediate intubation and access to the necessary equipment are required if respiratory failure is a possibility If endotracheal intubation is not possible cricothyroidotomy is indicated for respiratory failure Keep the patient comfortable and avoid unnecessary procedures and examinations Administer humidified oxygen to all hypoxemic patients In patients who do not require oxygen therapy a coolmist humidifier may be used as dry air may worsen inflammation Heliox a mixture of helium and oxygen compared favorably with inhaled racemic epinephrine in a small study of pediatric patients with moderate to severe croup 44 Medication Intravenous or oral glucocorticoids are commonly used to reduce symptoms and shorten hospitalization in patients with moderate to severe croup Inhaled steroids may be considered in cases that are not severe however evidence from large controlled trials regarding the use of inhaled steroids in croup is lacking Inhaled racemic epinephrine may temporarily dilate the airways by relaxing bronchial smooth muscle and causing vasoconstriction that may reduce mucosal inflammation Epinephrine may be considered in patients with persistent stridor Because rebound edema may occur when inhaled epinephrine is stopped monitoring and observation is required for several hours afterward In patients with croup the use of steroids may reduce the need for epinephrine In patients with whooping cough evidence is insufficient to justify the use of longacting beta agonists antihistamines or pertussis immunoglobulin 45 Antibiotics are appropriate for whooping cough pertussis however croup is typically a viral condition Blood cultures should be ordered Correct volume deficits with intravenous fluids Avoid sedatives that may suppress the patients respiratory drive Rhinosinusitis Acute maxillaryandethmoid bacterial rhinosinusitis in immunocompetent adults diagnosed in the outpatient setting is most often related to uncomplicated viral URIs Most cases of acute rhinosinusitis including mild and moderate cases of bacterial sinusitis resolve without antibiotics 6 Data from controlled trials indicated that more than half of adults and children improved within 310 days of treatment with placebo however the data also showed that at both time points the use of amoxicillin increased the percentage of patients who improved The 2012 Infectious Disease Society of America IDSA guidelines on sinusitis recommend considering treatment if symptoms persist without improvement for 10 days or longer or if symptoms are severe or worsen during a period of 34 days or longer 7 The 2013 American Academy of Pediatrics AAP guidelines recommend antibiotic treatment for children with severe onset or a worsening course however in children with persistent illness clinicians should either treat the patient or observe himher for an additional 3 days 3 Antibiotic therapy Firstline antibiotics for 57 days are appropriate in most adults 2012 IDSA guidelines recommend 1014 days of treatment in children Patients at risk for antimicrobial resistance include the following Those younger than 2 years or older than 65 years Children in day care Patients who took antibiotics in the previous month Patients who were hospitalized within the previous 5 days Patients with comorbidities Patients who are immunocompromised For such patients secondline antibiotics for 710 days is recommended If symptoms do not improve in 35 days broadening coverage to another antibiotic class may be considered Treatment should begin with an agent that most narrowly covers likely pathogens including Streptococcus pneumoniae nontypeable H influenzae and Moraxella catarrhalis Initial firstline options include amoxicillinclavulanate 7 Highdose therapy 2 g orally twice daily or 90 mgkgday orally twice daily may be considered in geographic regions where invasive penicillin sensitivity is 10 or greater as well as in patients with any of the following Severe symptoms such as high fever and threat of suppurative complications Daycare attendance Age under 2 or over 65 years Recent hospitalization Antibiotic use in the past month Immunocompromise Per IDSA guidelines in penicillinallergic patients doxycycline is an alternative as are respiratory fluoroquinolones such as levofloxacin or moxifloxacin Macrolides trimethoprimsulfamethoxazole and second or thirdgeneration cephalosporins are not recommended for empirical therapy due to high rates of S pneumoniae resistance In patients who worsen or do not improve after 35 days of empiric therapy guidelines recommend exploration for resistant pathogens structural abnormality or noninfectious etiology In such patients cultures should be obtained by direct sinus puncture or middle meatus endoscopy rather than with nasopharyngeal swabs 7 Adjunctive therapy for adults includes nasal saline irrigation Intranasal steroids may be considered especially for those with a previous history of allergic rhinitis Neither oral nor nasal antihistamines or decongestants are recommended for acute bacterial sinusitis 7 Group A Streptococcal Disease Beginning treatment of group A streptococcal disease before positive results are confirmed is not ideal because therapy is often inadvertently continued even if the results are negative Chronic carriage of group A streptococcus does not warrant antibiotic treatment Oral penicillin or amoxicillin for 10 days is recommended for group A streptococcal pharyngitis in patients without an allergy to penicillin No group A streptococci are resistant to penicillin and this treatment is effective for treating pharyngitis and for preventing acute rheumatic fever 2 If compliance with oral therapy is a concern consider a single intramuscular injection of benzathine penicillin G A firstgeneration cephalosporin may be used in patients with nonanaphylactic penicillin allergy Options for penicillinallergic patients include clindamycin or clarithromycin for 10 days or azithromycin for 5 days 2 For patients with recurrent or complicated group A streptococcal infections cephalosporins may be appropriate In general relapse of group A streptococcal disease may be treated with the same regimen as before or with a different one In cases of relapse determine whether adherence to previous therapy was sufficient If adherence to oral therapy is a concern consider a single injection of benzathine penicillin in patients not allergic to penicillin Patients who experience repeated bouts of acute pharyngitis with laboratory evidence of group A streptococcal infection may be experiencing actual streptococcal pharyngitis episodes However such patients may potentially be chronic pharyngeal streptococcal carriers who are experiencing repeated viral infections The 2012 IDSA guidelines suggest that efforts to identify group A Streptococcus carriers are not ordinarily justified nor do carriers generally require antimicrobial therapy Group A Streptococcus carriers are unlikely to spread streptococcal pharyngitis to close contacts and they are at little or no risk for developing suppurative or nonsuppurative complications themselves 2 Adjunctive therapy for strep pharyngitis includes pain relievers aspirin should be avoided in children due to risk of Reye syndrome Corticosteroids are not recommended 2 Herpetic or Gonococcal Pharyngitis Specific therapies are available for gonococcal and herpes simplex virus HSV pharyngitis Gonococcal pharyngitis may be difficult to eradicate Gonococcal therapy is typically a single intramuscular dose of ceftriaxone Although coincident Chlamydia trachomatis pharyngitis is rare Chlamydia coinfection in gonococcal urethritis cervicitis or proctitis sometimes occurs so treatment for gonococcus and chlamydia are often combined 32 HSV pharyngitis may be treated with antivirals See Herpes Simplex for additional details Other Conditions That May Warrant Specific Treatment Pertussis whooping cough infection warrants treatment with a macrolide antibiotic Close contacts should receive prophylactic treatment Diphtheria warrants treatment with a macrolide or penicillin Diphtheria antitoxin may neutralize circulating unbound toxin Sensitivity testing is required before antitoxin is used The US Centers for Disease Control and Prevention CDC provides guidance on the availability and use of this antitoxin For treatment options in seasonal influenza see Influenza The CDC tests circulating influenza viruses for resistance patterns to antiviral medications and issues treatment guideline updates each influenza season 46 Patients With Immunocompromise Special attention is warranted in patients with suboptimal immune defenses for reasons including the following Lack of a spleen Lowers resistance to infection with encapsulated bacteria HIV infection Cancer or cancer therapy Dialysis Stem cell or organ transplantation Congenital immunodeficiency Appropriate antimicrobial therapy and close followup may be appropriate because a simple URI may quickly progress to a systemic illness in immunocompromised patients Although the threshold for hospitalization is lowered for these patients their risks of nosocomial infections must be weighed against the benefits of close monitoring in the inpatient setting Although antivirals do not generally play a role in most cases of upper respiratory tract disease consider available treatment options for HSV pharyngitis respiratory syncytial virus RSV infection and cytomegalovirus CMV infection in immunocompromised patients HSV infection may be treated with acyclovir famciclovir or valacyclovir For CMV infections consider foscarnet or ganciclovir RSV infections may respond to ribavirin If lower respiratory tract disease is evident these considerations become more compelling than for isolated URI Surgical Care Deep tissue infections of adjacent structures such as a peritonsillar oropharyngeal intraorbital or intracranial abscess warrant hospitalization and immediate consultation with a surgeon These infections may compromise the airway vision or neurologic function Repeated streptococcal infection may be an indication for surgical intervention In patients with 45 confirmed group A streptococcal infections in a single year or in those with chronic sore throat with adenopathy that is not responsive to treatment over 6 months tonsillectomy may be considered For more information see Tonsillectomy In a study from the Netherlands of children aged 16 years with recurrent URI adenoidectomy did not reduce URI episodes compared with initial watchful waiting 47 Adenoidectomy rates in the Netherlands are several times that in the United States Surgery is rarely warranted in acute rhinosinusitis but may be considered under the following circumstances Sinusitis has not responded to months of medical therapy A mucopyocele is present A fungal sinus infection exists Infection extends to the bone If possible the sinus mucosa should be left intact during sinus surgery Functional endoscopic sinus surgery is designed to promote drainage of the sinuses by altering the ostiomeatal complex For surgical management of chronic sinusitis see Chronic Sinusitis Symptomatic Nonpharmacologic SelfCare The following homecare measures may help to provide relief of nasal and sinus symptoms Warm moist air Nasal saline Hydration Warm facial packs Bulb suction for infants Avoidance of nasal irritants eg cigarette smoke indoor and outdoor air pollutants Nasal and paranasal sinus mucosae may become more irritated with dry air The following strategies may maintain the moisture of membranes and loosen nasal secretions Turn on hot shower water close the bathroom door sit down and inhale the steam Take long hot showers Use a vaporizer to increase humidity in rooms If a vaporizer is used the water must be changed daily to prevent microbial growth especially with heated vaporizers Heated systems may pose a risk for scalding injuries One way to provide moist warm air is to pour boiled water into a shallow pan or bowl placed in a stable location eg middle of a kitchen counter and have the patient drape a cloth over hisher head and lean over the bowl to inhale the steam Exercise caution to avoid spilling boiling water which may cause scalding injuries Sipping hot water or warm drinks may be more soothing to the nasal passages than ice cold drinks Avoid extremely cool and dry air Nasal saline may provide temporary relief of congestion by removing nasal crusts and dried secretions A systematic review of nasal saline irrigation as an adjunct in chronic rhinosinusitis symptom management concluded that the evidence shows symptom relief and that irrigation is well tolerated by most patients 48 Patients with sinusitis experienced symptomatic benefit from use of a neti pot method of nasal irrigation 49 Saline drops or sprays are commercially available A homemade normal saline solution can be prepared by placing a quarter of a teaspoon of table salt in 8 oz of water A bulb syringe dropper clean pump spray bottle or squeeze bottle can be used to instill the saline into each nostril while the person inhales and then expels the saline Saline is safe to use as needed Drinking 8 or more 8oz glasses of water juice or noncaffeinated beverages daily may help to thin mucous secretions and replace fluid losses Patients with congestive heart failure or renal or liver disease may need to moderate their fluid intake to avoid volume excess Warm facial packs may provide comfort relieve congestion and promote drainage in cases of rhinosinusitis A warm folded washcloth or hotwater bottle filled with hot water from a tap may be applied directly to the face and cheek for 510 minutes Facial packs may be repeated 34 times a day as needed For infants a bulb syringe can be used to gently suction the nostrils before feeding to ease nasal breathing Parents should clean the bulb after each use with hot soapy water followed by a rinse Drain the bulb and allow it to dry before reuse Homecare measures to relieve throat symptoms include warm saline gargles which may reduce associated edema lozenges popsicles and cold and slushy beverages Avoid choking hazards in small children Homecare measures to relieve cough include reducing irritating stimuli eg cold dry air indoor or outdoor air pollutants that may provoke coughing An upright or semiupright posture such as sleeping with the head and shoulders raised may decrease cough related to pharyngeal secretions A 2007 study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI 50 Homecare measures to improve sleep include sleeping with the head and shoulders slightly elevated which may promote sinus and nasal drainage Many symptoms worsen at night because airway clearance mechanics are relatively ineffective in the prone position In addition distractions from the experience of symptoms are fewer than during the day Under normal circumstances the 2 nares alternate between being open or closed throughout the day Cycles last approximately 4590 minutes per naris When the person is lying recumbent on one side the naris closest to the pillow or surface tends to become congested while the higher nostril is decongested During nasal congestion associated with URI alternating positions or lying with the shoulders and head propped up may increase comfort Symptomatic Pharmacologic Therapy Treatment of an uncomplicated URI is focused on specific measures to reduce symptoms including use of the following Oral or topical decongestants Ipratropium bromide Antihistamines Topical and systemic steroids Saline nasal drops Guaifenesin Topical phenol or lidocaine Cromolyn Oral and topical decongestants Oral decongestants may provide symptom relief for patients with persistent rhinorrhea or sneezing associated with URI However despite common usage evidence regarding the effectiveness of oral decongestants in acute sinusitis is scarce Adverse effects of oral decongestants include the following Anxiousness Insomnia Tachycardia and dysrhythmias Elevated blood pressure Palpitations Tremor Urinary retention Exercise caution in patients with heart disease hypertension prostate enlargement glaucoma anxiety hyperthyroidism or other medical conditions and in pregnant or lactating women Unlike topical nasal decongestants oral decongestants do not appear to cause rebound phenomena after cessation of use The risktobenefit ratio for using cough and cold medicines in children younger than 2 years requires careful consideration because serious adverse events including fatalities have been reported with the use of overthecounter preparations 51 Numerous overthecounter cough and cold preparations are labeled do not use in children younger than 4 years 52 Topical decongestants such as phenylephrine an alpha1 agonist and oxymetazoline a selective alpha2adrenergic agonist may provide rapid temporary relief of nasal obstruction However rebound congestion may occur after cessation of use To avoid this rebound congestion limit topical agents to 34 days of use In addition these decongestants may cause throat irritation in some individuals One study in which oxymetazoline was administered to patients with a nasal bellows suggested that oxymetazoline did not accelerate the rate of healing of acute maxillary sinusitis as judged by sinus radiographs and subjective symptom scores The researchers concluded that decongestion of the sinus ostia may not be of primary importance in the healing of acute sinusitis 53 Ipratropium bromide This agent which is an anticholinergic has been evaluated in adults and young adults with rhinorrhea of moderate or greater severity In one study ipratropium reduced the severity of sneezing and rhinorrhea but it did not appear to reduce nasal congestion Rates of bloodtinged mucus and nasal dryness were higher in the treated group than in the control group 54 Antihistamines Histamines are not thought to play a role in generating URI symptoms therefore newer nonsedating antihistamines are not useful in reducing URI symptoms However firstgeneration oral antihistamines eg diphenhydramine chlorpheniramine clemastine have some anticholinergic effects which in theory could reduce sneezing and rhinorrhea Such effects have been reported for clemastine fumarate in patients with the common cold 55 These older antihistamines however are sedating In nonallergic children with acute bacterial rhinosinusitis data regarding the efficacy of H1 blockers as adjuvants to antibiotics are insufficient 56 In theory antihistamines may thicken secretions and thus reduce sinus drainage Steroids Topical and systemic steroids are often prescribed with the intention of reducing mucosal swelling in patients with acute viral or bacterial rhinosinusitis However little evidence supports their use for this indication In children who are taking antibiotics for acute bacterial rhinosinusitis intranasal steroids do not appear to dramatically improve symptoms 56 However for adults with recurrent acute rhinosinusitis or acute rhinosinusitis superimposed on chronic rhinosinusitis adjunctive use of highdose nasal corticosteroids may decrease symptom duration and improve clinical success rates 1 57 Saline nasal drops Saline nasal drops may provide relief from thick secretions and mobilize nasal crusting Nasal saline irrigation is effective and well tolerated as an adjunct to persistent rhinosinusitis symptoms 48 Guaifenesin The use of guaifenesin a mucolytic is commonly suggested with the intention of thinning secretions However data regarding its effectiveness in reducing secretions and promoting drainage in persons with nasopharyngitis or rhinosinusitis are limited Topical phenol and lidocaine Lozenges gargles or sprays that contain phenol may provide temporary relief of sore throat In young children however lozenges may pose a choking hazard Gargles of viscous lidocaine may numb the throat providing relief however swallowing may be impaired if sensation is reduced Saline gargles may reduce swelling in individuals with pharyngitis Cromolyn Intranasal cromolyn sodium is typically used for relief of allergic rhinitis Data are insufficient however to permit evidencebased recommendations regarding its use to treat URIrelated nasal symptoms in nonallergic patients Cough relief Cough suppression may increase comfort when cough is severe or when it prevents sleep 45 As stated earlier the risktobenefit ratio for using cough and cold medicines in children younger than 2 years requires careful consideration because serious adverse events including fatalities have been reported with the use of overthecounter preparations in young children 51 Since 2008 many nonprescription cough and cold product labels state do not use in children younger than 4 years 52 Cough associated with the common cold may be treated with a firstgeneration antihistamine combined with a decongestant eg brompheniramine with pseudoephedrine Oldergeneration histamines have anticholinergic effects which may account for cough reduction Newergeneration nonsedating antihistamines are ineffective for cough Inhaled ipratropium an anticholinergic may be useful in postinfectious cough 38 wk after the onset of the URI in adults Inhaled steroids may be considered in postinfectious cough 38 wk after URI onset if ipratropium fails to control it If postinfectious cough remains severe and if other causes eg rhinosinusitis cough asthma gastroesophageal reflux disease have been excluded a short timelimited course of oral steroids may be considered Several agents eg codeine guaifenesin dextromethorphan are intended for the symptomatic relief of cough However evidence is mixed regarding effectiveness of these agents While codeine may inhibit cough under various circumstances data are limited regarding its effectiveness in reducing acute cough from URI As an expectorant guaifenesin is intended to mobilize secretions However consistent data regarding its effectiveness in reducing discomfort from cough associated with URIs are scarce Dextromethorphan a centrally acting cough suppressant may be considered for the treatment of postinfectious cough in adults if other medications fail However this agent may have limited efficacy in treating cough related to acute URI One study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI 50 Overthecounter cough suppressants may cause notable adverse effects in young children Additional data are required to permit evidencebased recommendations for the use of centralacting antitussives in URIrelated cough in children 58 Codeine is an effective centrally acting cough suppressant in adults As with other centrally acting antitussives additional evidence is required to create evidencebased recommendations for the use of codeine in URIrelated cough in children 58 Clinically significant respiratory and nonrespiratory adverse events have been reported Sedatives should be avoided in patients with chronic obstructive pulmonary disease and in others at risk of respiratory depression Beta agonists are not thought to be helpful in URIrelated cough including that due to pertussis However betaagonists are recommended in the setting of asthma or chronic obstructive pulmonary disease exacerbated by URI Nonsteroidal antiinflammatory drugs NSAIDs may be used to reduce discomfort due to cough Avoid aspirin in children with viral illness because aspirin is associated with Reye syndrome Inhaled cromolyn sodium is used for control of chronic asthma Data are insufficient to permit evidencebased recommendations regarding the use of inhaled cromolyn sodium to treat URIrelated cough in patients without asthma Fever and discomfort relief Fever may be physiologically helpful in eliminating pathogens from the body In some individuals however fever poses a risk of provoking underlying illness In a fragile cardiac patient for example increased metabolic demands associated with fever may increase the work of the heart In children with a history of febrile seizures avoiding high fevers may reduce the risk of seizure Acetaminophen rather than aspirin is recommended for the relief of fever sore throat myalgias facial pain and other uncomfortable sensations in pediatric patients because aspirin is associated with Reye syndrome Avoid the use of respiratory depressants in patients with serious airway congestion or compromise Steroids should not be routinely used for pharyngitis pain relief An analysis of steroids added to usual care for pharyngitis potentially caused by group A streptococcus noted a 45hour reduction in time to pain relief and improved pain relief at 24 hours with oral or injected steroids 59 However significant heterogeneity was reported in the pooled results Complementary and alternative therapies Alternative therapies and traditional folk remedies are widely used to treat URIs While some may provide symptomatic relief current studies are insufficient to permit evidencebased conclusions regarding effectiveness Zinc Studies of oral zinc have yielded mixed results and data on children are limited Unpleasant taste and nausea have been reported Zinc nasal gel has been studied for the common cold 60 However the US Food and Drug Administration FDA has issued a public health advisory against the use of intranasal zinc because of reports of longlasting or permanent loss of smell associated with its use In some cases anosmia occurred with the first dose in others it occurred after multiple uses of intranasal zinc 61 Oral zinc has been studied as a supplement to prevent colds and as an acute remedy A metaanalysis of randomized trials of oral zinc lozenges syrup tablets concluded that statistically healthy people who took oral zinc supplements for 5 months or more experienced fewer colds 62 The study also found that when oral zinc was taken as an acute remedy within 24 hours of symptom onset it statistically improved symptom duration and severity However firm recommendations regarding routine use in healthy individuals are difficult to make due to variability inherent in the course of URIs the variability in dosing timing and formulations studied and the balance required against side effects such as nausea Echinacea Echinacea preparations are widely used for common colds A metaanalysis noted that echinacea preparations tested in clinical trials differ greatly but found some evidence that Echinacea purpura preparations may be effective in the early treatment of colds in adults 63 In a randomized study of common cold symptom severity in older children and adults standardized echinacea tablets started within the first 24 hours of symptoms were not superior to placebo 64 Vitamin C Highdose oral vitamin C supplementation for the attenuation of URI symptoms has been studied Results have been inconsistent Traditional folk remedies Folk remedies include sipping hot water with a teaspoon of honey and fresh lime or lemon juice However the acids in fresh citrus may be irritating to sore throat Honey has more demulcent qualities One study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI 50 Honey should not be given to infants because of the rare possibility that it may contain Clostridium botulinum spores which may germinate in the intestine and produce toxin that causes infant botulism Teas made from demulcent herbs are traditionally used to soothe sore throats Such herbs include slippery elm bark Ulmus rubra marshmallow root Althea officinalis and licorice root Glycyrrhiza glabra A study of 60 adults revealed a temporary favorable trend toward improvement of pharyngitis symptoms when the patients drank a tea containing these herbs compared with placebo 65 Prolonged excessive use of licorice may affect potassium levels and volume status Diet Increased fluids are warranted to replace insensible losses and reduced oral intake However alcohol may cause swelling of the nasal and paranasal sinus mucosae Antibiotics alter the gastrointestinal flora and some foods may not be as digestible for days or weeks after antibiotics are used Consumption of yogurt containing active cultures has been advocated as an aid to restoring normal flora after antibiotic therapy A metaanalysis suggests that probiotics may prevent antibioticassociated diarrhea Saccharomyces boulardii and lactobacilli may be particularly useful in this situation 66 Activity Patients with the common cold may consider returning to their usual physical activity including aerobic activity if their symptoms are limited to the nose and throat However if cough fever or other systemic symptoms are present rest is indicated to aid in recovery from the URI Patients with infectious mononucleosis should be instructed to avoid contact sports for 6 weeks because of the possibility of splenic rupture Voice rest is indicated for patients with laryngitis or laryngotracheitis Patients may experience increased discomfort from upper airway infection during air travel As atmospheric pressure drops during takeoff expansion of soft tissues may block the eustachian tubes and increase pressure sensations in the sinuses Chlorine from pools may be irritating to inflamed nasal membranes Diving especially at depth may cause uncomfortable pressure and impair drainage of the paranasal sinuses DeterrencePrevention Several measures can reduce susceptibility to URIs In newborns the practice of breastfeeding transfers protective antibodies through the mothers milk providing passive immunization against numerous pathogens In older children adolescents and adults an adequate diet is necessary for overall health and optimal immune function Eating 5 servings of fruits and vegetables each day is commonly recommended Various vitamins and minerals are necessary for immunity Obtaining these from food may have more nutritional benefit than taking individual supplements Lifestyle measures such as smoking cessation and reduction of exposure to secondhand smoke may reduce the incidence of URIs Regular moderate exercise may reduce susceptibility to URIs whereas intensive training in highperformance endurance athletes may increase susceptibility 67 Stress has deleterious effects on the immune system Measures to reduce stress may include changing schedules and responsibilities increasing time spent doing relaxing activities and increasing sleep time Preventing the spread of infection Hygiene Handwashing is the mainstay for reducing the risk of contracting a URI Wash the hands for 20 seconds with ordinary soap and water include all surfaces of the hands such as in between the fingers and around the nail bed where debris may accumulate People should wash their hands before eating and preparing meals after toileting after changing diapers or handling other waste and after coughing or sneezing Especially during cold season people should wash their hands frequently and avoid touching unwashed hands to their nose and mouth Discourage sharing of items passed from hand to mouth Use of alcoholbased hand sanitizers is acceptable when soap and water are not available Avoid contact with secretions of infected persons Cover coughs and sneezes with a tissue or upper sleeve Rhinoviruses can survive for as long as 3 hours on skin and fomites such as telephones door handles and stair railings Regular cleaning of environmental surfaces with a disinfectant may reduce the spread of infection however optimal cleaning approaches have not been established Avoidance and treatment of the patients contacts People with URI should reduce contact with others to avoid the spread of infection Adults may be infectious from the day before symptoms begin through approximately 5 days after the onset of illness Children may shed virus for several days before their illness begins and they may remain infectious for up to 10 days after symptom onset Patients with pertussis may be contagious for weeks during the coughing phase Severely immunocompromised persons may shed virus for weeks or even months Patients with diphtheria should be isolated Patients with group A strep confirmed with culture or rapid antigen testing should not attend day care school or work for 24 hours after antibiotics are started After 24 hours of antibiotic treatment an infected person is not generally able to spread the bacteria Asymptomatic household contacts of patients with group A streptococcal pharyngitis do not generally require throat culture or rapid antigen testing 2 However in the setting of recurrent group A streptococcal disease rheumatic fever poststreptococcal glomerulonephritis or outbreaks in semiclosed environments testing and treating household contacts who are positive for group A streptococci may be advisable 1 Patients who are ill with influenza or similar infections should remain at home except for receiving medical care and other necessities until at least 24 hours have passed without a fever without the use of feverreducing medication To prevent the spread of epiglottitis consider rifampin prophylaxis for close contacts of a patient with epiglottitis especially when unvaccinated young children are among the contacts To prevent the spread of pertussis patients should be isolated for 5 days All close contacts should receive an antibiotic active against pertussis such as azithromycin erythromycin or trimethoprimsulfamethoxazole regardless of their age or vaccination status All close contacts younger than 7 years who have not received the complete 4dose primary vaccination series should finish the series with minimal intervals between doses Close contacts aged 46 years who have not yet received the second booster dose should be vaccinated 68 To prevent the spread of diphtheria isolation is warranted until 48 hours after antibiotics are started after which diphtheria is not usually contagious Household or other close contacts should receive benzathine penicillin or a 7 to 10day course of oral erythromycin and an ageappropriate diphtheria booster 68 Orogenitally transmitted infections eg HSV infection gonorrhea warrant evaluation of contacts to reduce the spread of infection Partners who have had genital or orogenital contact with an N gonorrhoeae infected patient should be evaluated and treated for N gonorrhoeae and Chlamydia trachomatis This recommendation applies to partners whose last genital or orogenital contact was within 60 days before the patients onset of symptoms or diagnosis Patients should avoid having intercourse until therapy is completed and until both patients and their partners no longer have symptoms 69 Patients with HSV pharyngitis should be counseled about the spread of infection and their contacts should be evaluated Immunization and immunoprophylaxis Vaccination against Haemophilus influenzae type b has dramatically reduced rates of epiglottitis Immunization against diphtheria and pertussis is recommended for nonimmunized patients To address the increased rate of pertussis cases in adolescents whose immunity has waned the American Academy of Pediatrics recommends that adolescents receive a single dose of the tetanus toxoid reduced diphtheria toxoid and acellular pertussis vaccine Tdap 70 Updated CDC recommendations are available including guidance for children pregnant patients and adults including those who may come into contact with young children 71 RSV passive immunoprophylaxis may be given as a monthly administration of antiRSV immunoglobulin or monoclonal antibody to reduce the risk of lower respiratory tract disease and of hospitalization in infants and children at high risk for RSV disease These highrisk patients include premature infants and children younger than 2 years with bronchopulmonary dysplasia Prophylaxis is also considered for infants and young children with hemodynamically significant congenital heart disease For information on influenza vaccination see the Medscape Reference article Influenza as well as the CDC Web page What You Should Know for the 20132014 Influenza Season Chemoprevention is available for influenza however it does not replace vaccination Prevention with complementary and alternative therapies Complementary and alternative therapies and folk remedies are used by some to prevent URIs Common choices include zinc echinacea preparations and vitamin C However conclusive evidence that these strategies reduce URI infection is inconsistent Lactobacillus GG is being studied for a possible connection in reducing the incidence of respiratory infections Consultations Airway obstruction from epiglottitis tonsillar hypertrophy peritonsillar abscess retropharyngeal abscess or other causes of an obstructive mass requires emergency consultation with a surgeon Sleep apnea associated with tonsillar hypertrophy may also prompt surgical consultation Neurologic findings or mental status changes in the setting of suspected intracranial suppurative complications warrant emergency consultation with a neurosurgeon Consider consulting an infectious disease specialist when patients have any of the following HIV infection Cancerrelated or congenital immunodeficiency Other immunocompromise Patients with a chronic cough after a URI may benefit from a consultation with a pulmonologist or otorhinolaryngologist to evaluate persistent infection asthma gastroesophageal reflux disease or other causes of chronic cough Patients who have had 45 confirmed group A streptococcal infections in a single year or those with a chronic sore throat and adenopathy unresponsive to treatment over 6 months should be examined by an infectious disease specialist andor surgeon Persistent hoarseness after 2 weeks warrants consultation with an otorhinolaryngologist Patients with complex persistent cases of rhinosinusitis should also be referred to an otorhinolaryngologist for consideration of sinus puncture and aspiration FollowUp Care In general patients with URI should follow up with a physician if their symptoms do not improve worsen within 72 hours or recur Patients with infectious mononucleosis should be instructed to follow up with their physician after a week In patients with diphtheria elimination of the organism should be documented with 2 consecutive negative culture results after the completion of therapy 28 Followup testing is not routinely necessary in cases of group A streptococcal pharyngitis that resolve However followup may be advisable in the setting of recurrent group A streptococcal disease rheumatic fever poststreptococcal glomerulonephritis or outbreaks in semiclosed environments 1 Medication What to Read Next on Medscape Related Conditions and Diseases Prophylactic Antibiotic Use in Head and Neck Surgery Otolaryngologic Manifestations of Wegener Granulomatosis Hyperparathyroidism in Otolaryngology and Facial Plastic Surgery Allergic Rhinitis in Otolaryngology and Facial Plastic Surgery Pierre Robin Syndrome Fast Five Quiz Do You Know Best Practices for Antibiotic Use in Respiratory Tract Infections News Perspective Diagnostic Error in Patients With Ear Nose or Throat Symptoms Untreated Hearing Loss Linked to Higher Health Costs More Hospitalizations US Quality of Care for Head and Neck Cancers Varies Widely Tools Drug Interaction Checker Pill Identifier Calculators Formulary Slideshow Best Practices Regional Blocks Most Popular Articles According to Pulmonologists Chronic Obstructive Pulmonary Disease COPD Clinical Practice Guidelines 2018 FDA Approves First Digital Inhaler With Tracking App Major Breakthrough in Cystic Fibrosis Treatment LowCost Program Slashes Readmission Rates for COPD AsthmaCOPD Overlap Diagnosing and Managing This Critical Yet Understudied Disease Sections Upper Respiratory Tract Infection Overview Presentation DDx Workup Treatment Medication Questions Answers Media Gallery Tables References Recommended Procedures Otolaryngologic Manifestations of Wegener Granulomatosis Skill Checkup Peritonsillar Abscess Drainage

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O B B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B I I O O O O O B O O O O O O O O O O O O O O O O O O O

treatment
management
upper respiratory tract


Please confirm that you would like to log out of Medscape If you log out you will be required to enter your username and password the next time you visit Log out Drugs Diseases Emergency Medicine Neuroleptic Malignant Syndrome Workup Updated Dec 23 2018 Author Theodore I Benzer MD PhD Chief Editor Gil Z Shlamovitz MD FACEP Sections Overview Presentation DDx Workup Treatment Medication Questions Answers References Approach Considerations No laboratory test result is diagnostic for neuroleptic malignant syndrome NMS However the following laboratory studies may be indicated to assess severity and complications or rule out other diagnostic possibilities Complete blood count CBC Blood cultures Liver function tests LFTs Blood urea nitrogen BUN and creatinine levels Calcium and phosphate levels Creatine kinase CK level Serum iron level Urine myoglobin level Arterial blood gas ABG levels Coagulation studies Serum and urine toxicologic screening eg salicylates cocaine amphetamines General laboratory features in neuroleptic malignant syndrome include leukocytosis thrombocytosis and evidence of dehydration The serum iron concentration might be decreased The cerebrospinal fluid CSF protein concentration might be elevated 40 The rigidity and hyperthermia in neuroleptic malignant syndrome contribute to muscle damage and necrosis which is reflected in elevated blood levels of the following CK LFTs aspartate aminotransferase AST alanine aminotransferase ALT Lactate dehydrogenase LDH Muscle damage and necrosis can progress quickly to rhabdomyolysis with hyperkalemia hyperphosphatemia hyperuricemia and hypocalcemia Elevated levels of myoglobin can be observed in blood and urine and may ultimately lead to renal failure Assessment of the serum CK level is especially frequently used in psychiatric practice for diagnostic evaluation of rhabdomyolysis in patients with possible neuroleptic malignant syndrome Other causes of CK elevation may include prescription drugs alcohol acute coronary syndrome and other medical conditions Other causes of fever should be investigated depending on the clinical scenario This may include urinary tract respiratory and central nervous system CNS infections Cultures from various sites may be indicated A summary of the laboratory abnormalities that may be found in neuroleptic malignant syndrome includes the following Increased LDH Increased CK 50100 of cases Increased AST and ALT Increased alkaline phosphatase Hyperuricemia Hyperphosphatemia Hyperkalemia Myoglobinemia Leukocytosis 7098 of cases Thrombocytosis Proteinuria Decreased serum iron 2 Increased CSF protein Hypocalcemia Myoglobinuria Metabolic acidosis If thromboembolic phenomenon or disseminated intravascular coagulation DIC is suspected the following coagulation studies may be performed Platelet count Prothrombin time PT and international normalized ratio INR Activated partial thromboplastin time aPTT Imaging studies do not yield any diagnostic information for neuroleptic malignant syndrome per se However computed tomography CT or magnetic resonance imaging of the brain may be performed to rule out other conditions such as intracranial hemorrhage ICH trauma or structural lesions Chest radiography is indicated for suspected aspiration pneumonia A lumbar puncture LP is indicated to rule out meningitis as a cause of fever and altered mental status No universal agreement exists on the absolute need for a head CT scan before performing an LP in patients without clinical evidence of a structural lesion of the brain the decision is left to the individual practitioner Treatment Management Sections Neuroleptic Malignant Syndrome Overview Presentation DDx Workup Treatment Medication Questions Answers References Recommended Diseases Conditions Forensic Toxicology Drugs and Chemicals Diseases Conditions Pediatric Iron Toxicity

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O

neuroleptic malignant syndrome
emergency medicine


B Button Blood Type A symbol representing Blood Type B Displayed as the letter B on a red background Sometimes used online to replace the letter C at the start of words in reference to the Bloods street gangs practice of turning words like cool into bool This has expanded in some instances to starting any word with the letter B or more specifically this emoji which makes it more lear that a letter has been replaced B Button Blood Type was approved as part of Unicode 60 in 2010 under the name Negative Squared Latin Capital Letter B and added to Emoji 10 in 2015 Copy and paste this emoji Also Known As Blood Type B Apple Name Blood Type B Unicode Name Negative Squared Latin Capital Letter B Apple iOS 121 iOS 102 iOS 60 iOS 51 iOS 40 iPhone OS 22 Google Android 90 Android 80 Android 70 Android 44 Android 43 Microsoft Windows 10 October 2018 Update Windows 10 Anniversary Update Windows 10 Windows 81 Windows 80 Samsung Experience 95 Experience 90 TouchWiz 71 TouchWiz 70 TouchWiz Nature UX 2 WhatsApp 217 Twitter Twemoji 112 Twemoji 10 Facebook 30 20 EmojiOne 40 31 30 22 20 10 emojidex 1034 1033 1014 Messenger 10 LG G5 G3 HTC Sense 7 Mozilla Firefox OS 25 SoftBank 2014 2010 2008 2006 2001 Codepoints U1F171 UFE0F Shortcodes b See also ℹ Information Input Latin Uppercase AB Button Blood Type A Button Blood Type O Button Blood Type P Button ID Button Syringe Statistics Trends Browse on Instagram on Twitter on Wikipedia on Yelp on YouTube on Google Trends on Nomad List More Surprise me External Links B Button Emoji on Know Your Meme The battle over How one emoji is killing meme culture Categories Smileys People Animals Nature Food Drink Activity Travel Places Objects Symbols Flags Events Australia Day Bastille Day Birthday Black Friday Canada Day Carnaval Chinese New Year Christmas Cinco de Mayo Diwali Dragon Boat Festival Easter Emoji Movie Fall Autumn Fathers Day Festivus Graduation Guy Fawkes Halloween Hanukkah Hearts Holi Independence Day Mothers Day New Years Eve Olympics Pride Queens Birthday Ramadan Spring St Patricks Day Summer Super Bowl Thanksgiving Valentines Day Wedding Marriage Winter Winter Olympics World Cup World Emoji Day

O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Unplugged speaker cant connect now User924251 Contributor I 0 replies This is bullshit 4 replies Oldest first Userlevel 3 3 Dominique Z Prodigy III 2239 replies 4 years ago Hello The Sonos system is designed to reconnect back to the system if is disconnected or loses power temporarily It may be due to a range or interference issue that is not reconnecting after being unplugged and plugged back in Once reconnected to power you should see a flashing white light once this light goes solid it means it has found the network and system Please go through the following troubleshooting guide to get your speaker connected again Another quick troubleshoot you could try would be to Reboot your router Unplug your router from power for about 30 seconds then plug it back in to power Wait for the network to come back up then attempt to reconnect to the speaker again Please submit a diagnostic if you are still experiencing the issue and Ill be happy to take a look Please reply back with your number here Like 0 anniemorrissey Lyricist II 3 replies 1 year ago I followed all of these instructions and my second PLAY 1 still will not play music and no volume control shows up on my App as it did when I first set up the Play 1 in this second room The Room Shows up on Settings And I have successfully retuned at least four times I have also reset the Play 1 and as noted unplugged my cable modem and my router All other devices on my Network are working no problems And my first PLAY 1 is working just fine too Soooo the App works The second PLAY 1 Thank you Annie Morrissey Like 0 anniemorrissey Lyricist II 3 replies 1 year ago Deleted and redownloaded App Controller for Sonos No change White Light still visible on Second Play 1 No Music No volume Control on App Annie Morrissey Like 0 anniemorrissey Lyricist II 3 replies 1 year ago I have no reset the factory settings and the Play 1 will still not play Everything that was described for the reset of Factory Settings occurred from flashing amber to white lights upon simultaneous replug in at wall outlet and hold of playpause button to flashing green for reset I established the position of the Play 1 and then proceeded to set it up as a new player All steps went according to the Apps description The player was tuned And the new room renamed upon completion of tuning Then I tried to play music None Only my first Player Like 0 Share something connect with others Start a conversation ask a question or share your ideas Sign in or create account Active topics icon 3 minutes ago Amazing Slow Downer icon 5 minutes ago New computer doesnt let sonos connect to it icon 17 minutes ago View all active topics Latest questions Amazing Slow Downer icon 1 year ago New computer doesnt let sonos connect to it icon 17 minutes ago Does new Sonos Amp allow you to attach spade terminals from your speaker wire icon 44 minutes ago No sound from speakers icon 11 hours ago View all latest questions Badges flobraeun earned the badge Meet and greet justy dusty earned the badge Almost Famous shawndavid earned the badge Meet and greet Bunny58 earned the badge Meet and greet lordrichard earned the badge Meet and greet View all Badges Top liked Stanley_4 12 likes SHARKB8T 9 likes pwt 8 likes chicks 7 likes jpfarrell 7 likes Whats going on 107251 Topics 549351 Replies 259605 Members Recently online Share Tweet Share 1 Share

B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Photo Graphics Viewers Editors SmartPlant FreeView SmartPlant FreeView by Intergraph Corporation 49 on 11 votes 0 5 stars License Freeware Total downloads 2426 1 last week Operating system Windows XPVista7810 Description SmartPlant FreeView 8000110 can be downloaded from our website for free This free software was originally created by Intergraph Corporation Some of SmartPlant FreeView aliases include SmartPlant FreeView SmartPlant FreeView belongs to Photo Graphics Tools The following version 80 is the most frequently downloaded one by the program users The programs installer file is generally known as SPRFreeViewexe This download was checked by our antivirus and was rated as safe This free PC program was developed to work on Windows XP Windows Vista Windows 7 Windows 8 or Windows 10 and is compatible with 32bit systems SmartPlant FreeView is a program that allows you to open Intergraphs 3D models VUE files for display and navigation of process power and marine projects You can walk through the plant and select any object in the view to see its associated plant properties MDB2 file You may want to check out more software such as Intergraph FreeView Converter 2015 Intergraph SmartPlant PID or SmartPlant Markup which might be to SmartPlant FreeView Download SmartPlant FreeView Latest update Feb 01 2016

O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Home British World English conversion Definition of conversion in English conversion noun mass noun 1 The process of changing or causing something to change from one form to another the conversion of food into body tissues Synonyms The adaptation of a building or part of a building for a new use the conversion of a house into flats count noun they were carrying out a loft conversion Synonyms British count noun A building that has been adapted for a new use highquality cottages and barn conversions Law The changing of real property into personalty or of joint into separate property or vice versa Example sentences Logic The transposition of the subject and predicate of a proposition according to certain rules to form a new proposition by inference Example sentences 2 The fact of changing ones religion or beliefs or the action of persuading someone else to change theirs he insists that real conversion is a matter of the heart count noun his passion for seventeenthcentury literature had led the former atheist to a sudden conversion Synonyms Christian Theology Repentance and change to a godly life the individuals responsibility in conversion is to repent and believe Synonyms 3 Rugby count noun A successful kick at goal after a try scoring two points Gavin Hastings landed one penalty and one conversion American Football An act of converting a touchdown or a down Example sentences 4 in the context of online marketing the proportion of people viewing an advertisement and going on to buy the product click on a link etc youll see better conversion rates for your local advertising if you include your physical address on your website keeping things simple will improve conversion 5 Law The action of wrongfully dealing with goods in a manner inconsistent with the owners rights he was found guilty of the fraudulent conversion of clients monies 6 Psychiatry The manifestation of a mental disturbance as a physical disorder or disease as modifier conversion disorders Origin Middle English in the sense turning of sinners to God via Old French from Latin conversion from convers turned about from the verb convertere see convert Pronunciation conversion kənˈvəːʃən Trending Words Most popular in the world Aql nonferrous ytterbium Chicago Fannie Mae Sign up for our newsletter Stay up to date with our latest news and receive new words updates blog posts and more Choose your country Thanks for subscribing Please check your email and confirm your subscription Click here to see our Privacy Policy Please make sure that your email address is correct and try again

O O O O B O O B O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


We use cookies to enhance your experience on our website This website uses cookies that provide targeted advertising and which track your use of this website By clicking continue or by continuing to use our website you are agreeing to our use of cookies You can change your cookie settings at any time Continue Home British World English invent Definition of invent in English invent verb with object 1 Create or design something that has not existed before be the originator of he invented an improved form of the steam engine More example sentences Make up an idea name story etc especially so as to deceive someone I did not have to invent any tales about my past More example sentences Origin Late 15th century in the sense find out discover from Latin invent contrived discovered from the verb invenire from in into venire come Pronunciation invent ɪnˈvɛnt Trending Words Most popular in the world heitiki hula hoop supraconsciousness sleeping bag powderize Sign up for our newsletter Stay up to date with our latest news and receive new words updates blog posts and more Choose your country Thanks for subscribing Please check your email and confirm your subscription Click here to see our Privacy Policy Please make sure that your email address is correct and try again

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O