key: cord-0720152-lsoj6gut
authors: Morris, Peter S.
title: Upper Respiratory Tract Infections (Including Otitis Media)
date: 2009-01-08
journal: Pediatr Clin North Am
DOI: 10.1016/j.pcl.2008.10.009
sha: 2706c559ba505d2c8327164e9dafef256fd8e73a
doc_id: 720152
cord_uid: lsoj6gut

Upper respiratory tract infections (including otitis media) are the most common illnesses affecting children. Most illnesses are mild and resolve completely without specific treatment, but the frequency of infection and association with fever and constitutional symptoms creates significant distress for the child and the family. By understanding the evidence available from high-quality studies, the clinician can advise the families on appropriate action. The goal of this article is to support clinicians in answering the following questions: (1) What happened to children with these conditions when no additional treatment was provided? (2) Which interventions have been assessed in well-designed studies? (3) Which interventions have been shown to improve outcomes? (4) How large is the overall benefit?

Peter S. Morris, MBBS, PhD, FRACP a,b,c, * Upper respiratory tract infections (including otitis media) are the most common illnesses affecting children. 1 On average, children experience around six to eight upper respiratory tract infections (URTIs) each year. 2 Although these infections usually are mild and self limiting, they occasionally lead to complications that can be life threatening. Most URTIs can be placed within three main categories of infection: rhinosinusitis, pharyngitis, and otitis media. Within each category of illness there is a range of related conditions that may have similar or overlapping clinical presentations. 3 Some judgment is required in determining which part of the respiratory mucosa is most affected. In this article, the term ''rhinosinusitis'' is used to describe illnesses with predominantly nasal symptoms (including the common cold, nasopharyngitis, and sinusitis). The term ''pharyngitis'' is used to describe illnesses when sore throat is most prominent (including tonsillitis). The term ''otitis media'' is used to describe illnesses with predominantly middle ear symptoms (including acute otitis media [AOM] , otitis media with effusion [OME], and chronic suppurative otitis media [CSOM] ). Children who have cough as the predominant symptom are considered to have bronchitis (a lower respiratory tract infection). To make matters more complicated, all areas of the respiratory mucosa may be affected, simultaneously or at different times, during one illness.

The cause of these respiratory mucosal infections most commonly is viral but can be bacterial (Table 1) , 4 and many infections involve both viruses and bacteria. 5 In developed countries, both viral and bacterial infections are likely to be self limited. Persistent disease is most likely to indicate a bacterial infection.

The frequency of infection and association with fever and constitutional symptoms creates significant distress for the child and the family. By understanding the evidence available from high-quality studies, the clinician can advise the families on appropriate action. 6 The goal of this article is to support clinicians in answering the following questions:

1. What happened to children with these conditions when no additional treatment was provided? 2. Which interventions have been assessed in well-designed studies? 3. Which interventions have been shown to improve outcomes? 4. How large is the overall benefit?

URTIs are extremely common in children, and there is a long list of potential interventions. Because URTIs are common illnesses, there is no reason why high-quality randomized, controlled trials (RTCs) should not be conducted. 7 In addition, all families experience these conditions and may have strong personal preferences about treatment. The challenge for the clinician is to make an accurate diagnosis and then to match the effective treatment options with the preferences of the family. This article initially considers the effects of an intervention compared with no intervention. Because each condition covers a spectrum of disease, the acute presentation of the initial URTI is discussed first and then, when appropriate, interventions for persistent disease or complications of the initial complaint are addressed. Because of the focus on trial evidence, not all the information relevant to an individual decision may be discussed. Furthermore, because the clinical course of participants enrolled in RCTs may be different from the clinical course observed in one's own practice, the overall effects of an intervention may need to be adjusted. Despite these limitations, clinicians using this article should be confident that they understand which interventions have been rigorously assessed and the overall findings of these assessments.

The GRADE Working Group has described the steps required to review evidence. 8, 9 Ideally, explicit criteria should be used. Although this process has many advantages in terms of transparency, it does not guarantee that recommendations will be consistent across different sets of evidence-based guidelines (although this consistency is the long-term aim). 10 The GRADE Working Group proposes that a recommendation should indicate the decision that the majority of well-informed individuals would make. 8 It is difficult to be dogmatic about interventions for self-limited conditions with a low risk of complications. Therefore, the author has tried to provide a summary of evidence to assist discussions with families (Tables 2-4 ). The author's approach (informed by the best available evidence) is described in Box 1.

The self-limiting nature of these conditions is of the utmost importance in determining which treatments are indicated. The outcomes the author considers important are (1) persistent disease (short term, % 14 days; medium term, >2 weeks to 6 months; and long term >6 months), (2) time to cure, and (3) complications arising from progressive disease. The author considered interventions to have very large effects if they were associated with a reduction in the outcome of interest of more than 80%; large effects were associated with a reduction in outcome of interest of at least 50%. 11 Reductions in outcome of interest between 20% and 50% were considered modest, and reductions of less than 20% were considered slight (or small). Because only a proportion of children who have URTIs experience bad outcomes, even large relative effects may not translate to clinically significant absolute benefits.

The author's search targeted evidence-based guidelines, evidence-based summaries, systematic reviews, and RCTs of interventions for rhinosinusitis, pharyngitis, and otitis media (Box 2). Even this simple strategy identified more than 6500 sources using PubMed alone. Inclusion as an evidence-based guideline, summary, or systematic review required an explicit search strategy and criteria for study inclusion. Inclusion as a clinical trial required randomization. The author used three primary sources to identify relevant information: Clinical Evidence; 11 the Cochrane library 12 and Medline (last accessed via PubMed on June 16, 2008) . The evidence-based summaries in Clinical Evidence have links to major guidelines and use the GRADE Working Group approach to assess quality of evidence and strength of recommendations. 11 

The search identified more than 50 evidence-based guidelines, evidence summaries, and systematic reviews (and many more additional RCTs) published since 2000. This Upper Respiratory Tract Infections article does not include interventions that have been assessed in nonrandomized studies, interventions that have been assessed in studies with fewer than 200 participants (sparse data), 11 or studies of interventions that are available only experimentally.

Rhinosinusitis is an URTI that predominantly affects the nasal part of the respiratory mucosa. [13] [14] [15] Common cold infections are caused mainly by viruses (typically rhinovirus, but also coronavirus, respiratory syncytial virus, metapneumovirus, and others). 2 For many colds, no infecting organism can be identified. Common colds usually have a short duration. Symptoms peak within 1 to 3 days and generally clear by 7 to 10 days, although an associated cough (bronchitis) often persists. 2 Most people who have acute rhinosinusitis are assessed and treated in a primary-care setting. A preceding viral URTI often is the trigger for acute sinusitis; about 0.5% to 5% of common colds become complicated by the development of acute sinusitis. 16 Acute sinusitis is defined pathologically by transient inflammation of the mucosal lining of the paranasal sinuses lasting less than 30 days. 17, 18 Clinically, acute sinusitis is characterized by nasal congestion, nasal discharge, and facial pain. 19 The diagnosis of acute sinusitis in infants and children usually is made in children who have purulent nasal drainage persisting beyond 10 days. 17 In straightforward cases, no investigations are required. 17 In more complicated (or frequent) presentations, possible underlying factors include nasal airway obstruction, immunodeficiencies, ciliary dysfunction, cystic fibrosis, and allergic rhinitis. The usual pathogens in acute bacterial sinusitis are Streptococcus pneumoniae and Haemophilus influenzae, with occasional infection with Moraxella catarrhalis and Staphylococcus aureus. Rarely, bacterial sinusitis in children leads to rare, life-threatening complications, such as meningitis, cavernous venous thrombosis, and orbital cellulitis. 4

Most children who have rhinosinusitis improve spontaneously within 14 days, and complications from this illness are uncommon. There is evidence about the preventive effects of vitamin C and Echinacea on the onset of the illness. 20, 21 Neither of these interventions has been proven to be effective. There is evidence about the treatment effects of antihistamines, vitamin C, antibiotics, decongestants, zinc lozenges, and Echinacea (see Table 2 ). [20] [21] [22] [23] [24] [25] [26] [27] [28] Of these interventions, only decongestants have been proven to be effective, but their beneficial effect is small. 26 Decongestants have not been tested in young children. Antibiotics seem to be effective in individuals who have purulent rhinosinusitis, but the beneficial effect is modest. 24 Given the available evidence from RCTs, most well-informed individuals choose a course of watchful waiting. Symptomatic relief using analgesic agents has not been assessed in RCTs but would be a reasonable in children who have pain or discomfort. Antibiotics are an option for children who have purulent nasal discharge but provide only a modest benefit. Decongestants are an option for older children who have nasal obstruction. It probably is worth persisting with decongestants only when there is symptomatic relief with the first dose.

A small proportion of children go on to develop persistent rhinosinusitis or classic sinusitis. There is evidence about the treatment effects of intranasal corticosteroids (from adult studies) and antibiotics. 17, 18, [29] [30] [31] [32] [33] Both of these interventions seem to be beneficial, but the beneficial effects are modest. If antibiotics are to be used, there no consistent evidence that a longer course of treatment (R 7 days) is more effective than a shorter course. 32 There is no evidence to support the belief that any one of the commonly used antibiotics is more effective than the others (although the cephalosporin class of antibiotics does seem to be inferior to amoxicillin-clavulanate). 32 Given the available evidence from RCTs, most well-informed individuals choose either watchful waiting or a trial of antibiotics. Intranasal corticosteroids are a reasonable option in older children, particularly those who have any features of atopy.

Pharyngitis is an acute URTI that affects the respiratory mucosa of the throat, resulting in a predominant symptom of pain that may be associated with headache, fever, and general malaise. 3, 34, 35 In the United States, acute pharyngitis accounts for about 1% of primary care consultations and ranks in the top 20 diagnoses. 34 Infections leading to pharyngitis can be viral or bacterial ( Table 5 ). It is difficult to distinguish bacterial infections from viral infections clinically. Studies have found that tonsillar or pharyngeal exudate, tender cervical lymphadenopathy, and recent exposure to streptococcal throat infection are most useful in predicting bacterial infection. 36 A useful clinical prediction rule found that streptococcal infection was present in 50% of children if three of the following features were positive: fever higher than 38 C; tonsillar swelling or exudate; tender cervical lymphadenopathy; and absence of cough. Even without treatment, sore throat resolves in 40% of cases by 3 days and in 85% of cases by 1 week. 3 A small proportion of children experience progression of the illness. Suppurative complications include peritonsillar abscess (quinsy), AOM, and acute sinusitis. Nonsuppurative complications include acute rheumatic fever and acute glomerulonephritis.

Most children who have pharyngitis improve spontaneously within 14 days, and complications from this illness are uncommon. There is evidence about the Box 2 A simple PubMed search strategy to identify evidence-based guidelines, evidence-based summaries, systematic reviews, and randmoized controlled trials on common upper respiratory tract infections treatment effects of antibiotics, analgesics, and corticosteroids on the onset of illness (see Table 3 ). 3, 35, [37] [38] [39] [40] [41] The beneficial effect of analgesics is large and persists over several days of treatment. 3, 40 Antibiotics also have been proven to be effective, 3, 37, 38 with large to very large beneficial effects for preventing complications (peritonsillar abscess, rheumatic fever, and otitis media). These complications generally affect less than 2% of children, however. Antibiotics have a modest, short-term beneficial effect in improving the sore throat itself. If oral penicillin is used for treatment, there is evidence that a full 10-day course is more effective than shorter courses. 39 There is some evidence that systemic corticosteroids reduce pain within 12 to 24 hours. 3, 41 Given the available evidence from RCTs, most well-informed individuals choose symptomatic relief with analgesics and either watchful waiting or antibiotics. Antibiotics would be most appropriate in children at increased risk of complications, those who have features more consistent with a bacterial infection (fever higher than 38 C, tonsillar exudate, enlarged tender cervical nodes, and absence of nasal discharge and cough), and those who have severe pain that does not respond to analgesics. Corticosteroids are an option for children who have severe pain not responding to analgesics or who have very large tonsils that may lead to obstruction.

A small proportion of children go on to develop recurrent tonsillitis. There is evidence on the treatment effects of tonsillectomy. 35, 42, 43 Tonsillectomy has a large beneficial effect, but the rates of tonsillitis also reduce spontaneously without treatment, so absolute benefits are modest. In addition, the operation itself is associated with postoperative pain and some risk of complications. High-quality trials of prophylactic antibiotic treatment have not been done, but this treatment would be a reasonable option for families who want treatment but decide against surgery. Surgery is likely to be most beneficial in children who have very frequent severe infections. If surgery is the chosen treatment option, cold steel tonsillectomy is associated with less postoperative pain and bleeding than operation by diathermy. 35, 44 

Otitis media is an acute URTI that affects the respiratory mucosa of the middle ear cleft. It is a common illness in young children and occurs much less frequently in children more than 6 years old. 45, 46 In developed countries, otitis media is the most common indication for antibiotic prescribing and surgery in young children. In the United States, annual costs associated with otitis media were estimated to be $3 to $5 billion in the 1990s. 45 Otitis media is best regarded as a spectrum of disease. The most important conditions are OME, AOM without perforation (AOMwoP), acute otitis media with perforation (AOMwiP), and CSOM. Unfortunately, there currently is a lack of consistency in definitions of different forms of otitis media (especially AOM). 47 Generally, AOM is defined as the presence of a middle ear effusion plus the presence of the symptoms (especially pain) or signs (especially bulging of the tympanic membrane or fresh discharge). The diagnostic criteria used in studies of AOM vary. Some use symptomatic criteria, some use otoscopic criteria, and some require that both symptomatic and otoscopic criteria be met. OME usually is defined as the presence of a middle ear effusion without symptoms or signs of an acute infection. CSOM usually is defined as discharge through a perforated tympanic membrane for longer than 2 to 6 weeks.

Children who have immunodeficiency or craniofacial abnormalities (eg, cleft palate, Down's syndrome) are at increased risk of otitis media. Other risk factors that have been identified in epidemiologic studies include recent respiratory infection, family history, siblings, child care attendance, lack of breast feeding, passive smoke exposure, and use of a pacifier. 48 Most children experience at least one episode of AOM. 45 The peak incidence of infection occurs between 6 and 12 months. Although the pathogenesis of AOM is multifactorial, both viruses and bacteria are implicated. 45 Bacteria infection with the common respiratory pathogens (S. pneumoniae, H. influenzae, and M. catarrhalis) often is preceded by a viral infection. Viruses (especially respiratory syntactical virus and influenza) can cause AOM without coinfection with bacteria. 45 The pain associated with AOM resolves within 24 hours in around 60% of cases and within 3 days in around 80%. 46 AOM is less likely to resolve spontaneously in children younger than 2 years. 49 Complications of AOM include CSOM, mastoiditis, labyrinthitis, facial palsy, meningitis, intracranial abscess, and lateral sinus thrombosis. 50 Mastoiditis was the most common life-threatening complication in the pre-antibiotic era. It occurred in 18% of children admitted to hospital with AOM in one study. 51 Mastoiditis and all other complications now are rare in developed countries.

CSOM is the most severe form of otitis media. 52 Although there is a lack of well-designed longitudinal studies, CSOM is the type of otitis media most likely to persist without treatment. In developing countries, CSOM occurs as a complication of AOM with perforation and can be a major health issue. The range of bacterial pathogens associated with CSOM is considerably broader than those seen in AOM. Pseudomonas, Staphylococcus, Proteus, and Klebsiella species are the most commonly isolated pathogens, and mixed infections are common. 52 Multidrug antibiotic resistance is seen often in Pseudomonas infections. The associated hearing loss usually is greater than seen in OME, and CSOM is the most important cause of moderate conductive hearing loss (>40 dB) in many developing countries. 53 In developed countries, CSOM now is very uncommon. A recent risk factor study in Holland found that most cases of CSOM now occur as a complication of tympanostomy tube insertion. 54 Children who have immunodeficiency and some indigenous populations also are at greatly increased risk. In rural and remote communities in northern Australia, more than 20% of young children are affected. 55 OME is the most common form of otitis media. The point prevalence in screening studies is around 20% in young children. 45 OME can occur spontaneously, as a component of rhinosinusitis, or following an episode of AOM. The same respiratory bacterial pathogens associated with AOM have been implicated in the pathogenesis of OME. Most children who have OME improve spontaneously within 3 months, and complications from this illness are uncommon. 45 The average hearing loss associated with OME is around 25 dB. 45 Despite large numbers of studies, a causal relationship between OME and speech and language delay has not been proven. 50, 56 Children who have otitis media usually present with features related to (1) pain and fever (AOM); (2) hearing loss (OME); or (3) ear discharge (AOMwiP or CSOM). In some children, otitis media is detected as part of a routine examination. Making an accurate diagnosis is not easy. Generally a good view of the whole tympanic membrane and the use of either pneumatic otoscopy or tympanometry are required to confirm the presence of a middle ear effusion. 47, 57 Studies of diagnostic accuracy in AOM have found ear pain to be the most useful symptom, but it is not very reliable on its own. Bulging, opacity, and immobility of the tympanic membrane are highly predictive of AOM. Normal color (pearly gray) of the tympanic membrane makes AOM unlikely. 58

Most children who have AOM improve spontaneously within 14 days, and complications from this illness are uncommon. There is evidence concerning the preventive effects of conjugate pneumococcal vaccine and influenza vaccine on the onset of illness (see Table 4 ). 46,59-61 Both these vaccines have been shown to be effective, but the beneficial effects in terms of overall rates of infection are slight. The beneficial effects of the conjugate pneumococcal vaccine in reducing the rate of insertion of tympanostomy tubes are modest. 62 Most children do not fall into this risk group. There also is evidence about the treatment effects of antihistamines and decongestants, antibiotics, myringotomy, and analgesics (see Table 4 ). 46, 50, 51, 63 Regular analgesics (paracetamol or ibuprofen) provide a benefit (assessment on day 2), and the beneficial effects are large. 46 Antibiotics also are effective, 49, 51 but in most children the shortterm beneficial effects are slight. The beneficial effects are modest in children younger than 2 years old who have bilateral AOM and are large in those who have AOMwiP. Studies of initial treatment with antibiotics have not documented a long-term effect. If antibiotics are to be used, there is evidence that a longer course of treatment (R 7 days) is more effective, but the beneficial effects are modest (persistent AOM reduced from 22% to 15%). 64 There is no evidence that any one of the commonly used antibiotics is more effective than the others. The use of antihistamines and decongestants has not been shown to be beneficial, and myringotomy seems to be harmful compared with no treatment or antibiotics (see Table 4 ). 46, 50, 63 Given the available evidence from RCTs on AOM, most well-informed individuals choose symptomatic relief with analgesics and either watchful waiting or antibiotics. Antibiotics are most appropriate in children younger than 2 years who have bilateral AOM, children who have AOMwiP, children at high risk of complications, and children who already have had 48 hours of watchful waiting. If the child is not in a high-risk, group, but the family prefers antibiotic treatment, the clinician should discuss ''wait and see'' prescribing. Provision of a script for an antibiotic along with advice to use it only if the pain persists for 48 hours can reduce antibiotic use by two thirds (with no negative effect on family satisfaction). [65] [66] [67] A small proportion of children who have AOM experience recurrent AOM (three episodes within 6 months or four episodes within 12 months). 45 There is evidence about the treatment effects of prophylactic antibiotics, adenoidectomy, and tympanostomy tube insertion. 46, 50, [68] [69] [70] Antibiotics have been proven to be effective, but the beneficial effects are modest. The rates of AOM also reduce spontaneously without treatment, so the absolute benefits are less impressive than anticipated. Insertion of tympanostomy tubes also seems to reduce rates of AOM, and the level of effect is similar to that of antibiotics. Either of these options could be considered in children who have very frequent severe infections, especially infections occurring before the peak of respiratory illness in winter. Children who have tympanostomy tubes may develop a discharging ear, however, so tympanostomy tubes are not a good option in children who are at increased risk of suppurative infections (including those who have immunodeficiency or persistent bacterial rhinosinusitis). In these children, prophylactic antibiotics or prompt antibiotic treatment of infections probably is a more appropriate choice. Adenoidectomy does not seem to be an effective treatment. 50, 69, 70 A small proportion of children who have AOMwiP go on to develop CSOM. In developed countries, CSOM occurs most commonly as a complication of tympanostomy tube placement. There is evidence about the treatment effects of topical antibiotics, topical antiseptics, systemic antibiotics, and ear cleaning. 52, 53, [71] [72] [73] The interpretation of a large number of small studies is challenging, but topical antibiotics have been proven to be effective, although the beneficial effects vary from large to modest. Most studies have not documented a long-term effect. Topical antibiotics also seem to be more effective than antiseptics and systemic antibiotics. 53 The role of topical antibiotics plus systematic antibiotics is unclear. 74 Cleaning the middle ear discharge has not been proven to be effective in RCTs but generally is regarded as necessary before insertion of topical antibiotics (at least in children who have profuse discharge). Although not seen in RCTs, there also is a very small risk of ototoxicity associated with most topical antibiotics (except topical quinolones) and topical antiseptics. 50 For children who do not respond to prolonged courses of topical antibiotics, two small studies (85 participants) have documented high cure rates and large beneficial effects associated with 2 to 3 weeks of intravenous antipseudomonal antibiotics (such as ceftazidime). 75, 76 Given the available evidence from RCTs on CSOM, most well-informed individuals choose topical antibiotic treatment. Even though this treatment is effective, prolonged or repeated courses of treatment often are required. If prolonged or repeated courses of topical antibiotic are needed, topical quinolones provide a slight benefit in terms of risk of ototoxicity. OME affects all children but usually is asymptomatic. 45 A small proportion of children have persistent OME with associated hearing loss. There is evidence that screening to identify young children who have OME or hearing loss associated with OME is not effective in developed countries. 77 There also is evidence on the treatment effects of antibiotics, insertion of tympanostomy tubes, autoinflation devices, antihistamines and decongestants, and antibiotics plus steroids (see Table 4 ). 49, 51, [78] [79] [80] [81] [82] [83] [84] [85] Early insertion of tympanostomy tubes (compared with watchful waiting with the option of later insertion) improves hearing at 6 and 12 months, but the beneficial effect is modest. 78, 79, 81 This improvement in hearing has not been associated with improvement in language development or cognitive assessment scores. 81 Tympanostomy tubes usually last 6 to 12 months, and there is no evidence of any ongoing benefit after they have been extruded. Antibiotics also have been shown to be an effective treatment, but the beneficial effects are slight and do not seem to persist long term. 50, 78, 79 Combining antibiotics with steroids seems to provide short-term benefits, but again the beneficial effect is modest. 78, 85 There is some evidence that autoinflation devices are effective. 78, 83 but the benefits are modest and have been documented to be only short term. Antihistamines and decongestants provide no benefit (see Table 4 ). 78,79,84

Given the available evidence from RCTs on OME, most well-informed individuals initially choose a course of watchful waiting. For children who have persistent OME in both ears associated with hearing loss despite watching waiting for 6 to 12 months, a trial of antibiotics is reasonable. Insertion of tympanostomy tubes is most appropriate in children when the primary concern is conductive hearing loss and communication difficulties. Children who have the most severe conductive hearing loss are most likely to benefit. Children who experience frequent suppurative infections (including those who have immunodeficiency or persistent bacterial rhinosinusitis) are at greatest risk of developing CSOM as a complication of tympanostomy tubes. Families should be informed that a small proportion of children suffer recurrent persistent OME when the tympanostomy tubes are extruded and may need a second operation. In these children, tympanostomy tubes plus adenoidectomy is a reasonable option. 79, 80 SUMMARY URTIs are the most common illnesses affecting children. Most illnesses are mild and resolve completely without specific treatment. Multiple interventions have been assessed in the treatment of rhinosinusitis, pharyngitis, and otitis media. None of the interventions had substantial absolute benefits for the populations studied. Therefore, for most children, symptomatic relief and watchful waiting (including education of the parents about important danger signs) is the most appropriate treatment option. Antibiotics have a role in children who have persistent bacterial infection and those at risk of complications.

Epidemiology of viral respiratory infections

The common cold

Sore throat

Textbook of pediatrics

Incidence of acute otitis media and sinusitis complicating upper respiratory tract infection: the effect of age

Smart health choices: making sense of health advice

Statistics notes. Treatment allocation in controlled trials: why randomise?

Grading quality of evidence and strength of recommendations

GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

Systems for grading the quality of evidence and the strength of recommendations II: pilot study of a new system

Computed tomographic study of the common cold

Sinusitis in the common cold

Cough and the common cold: ACCP evidence-based clinical practice guidelines

Pediatric sinusitis: update

Subcommittee on Management of Sinusitis and Committee on Quality Improvement

Technical report: evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children: a systematic overview

Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination

Vitamin C for preventing and treating the common cold

Echinacea for preventing and treating the common cold

Common cold

Antihistamines for the common cold

Antibiotics for the common cold and acute purulent rhinitis

Are antibiotics effective for acute purulent rhinitis? Systematic review and meta-analysis of placebo controlled randomised trials

Nasal decongestants for the common cold

Meta-analysis of the efficacy of a single dose of phenylephrine 10 mg compared with placebo in adults with acute nasal congestion due to the common cold

Zinc for the common cold

Sinusitis (acute)

Steroids for acute sinusitis

Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data

Update on acute bacterial rhinosinusitis

Antibiotics for persistent nasal discharge (rhinosinusitis) in children

Recurrent throat infections (tonsillitis)

The rational clinical examination. Does this patient have strep throat

Antibiotics for sore throat

Antibiotics for the primary prevention of acute rheumatic fever: a meta-analysis

Metaanalysis of short course antibiotic treatment for group a streptococcal tonsillopharyngitis

How effective are treatments other than antibiotics for acute sore throat?

Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children

Tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis

Adenotonsillectomy for upper respiratory infections: evidence based?

Hot versus cold tonsillectomy: a systematic review of the literature

Otitis media

Otitis media in children (acute)

American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media

A meta-analytic review of the risk factors for acute otitis media

Antibiotics for acute otitis media: a meta-analysis with individual patient data

Evidence-based otitis media

Antibiotics for acute otitis media in children

Chronic suppurative otitis media: a review

Chronic suppurative otitis media

Predictors of chronic suppurative otitis media in children

The burden and outcome of respiratory tract infection in Australian and aboriginal children

Otitis media and speech and language: a meta-analysis of prospective studies

Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion

Does this child have acute otitis media?

Pneumococcal vaccines for preventing otitis media

Vaccines for preventing influenza in healthy children

The efficacy of influenza vaccine for healthy children: a meta-analysis evaluating potential sources of variation in efficacy estimates including study quality

Impact of the pneumococcal conjugate vaccine on otitis media

Decongestants and antihistamines for acute otitis media in children

Short course antibiotics for acute otitis media

Delayed antibiotics for respiratory infections

Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial

Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media

Antibiotics for the prevention of acute and chronic suppurative otitis media in children

Prevention of otitis media by adenoidectomy in children younger than 2 years

Adenoidectomy does not significantly reduce the incidence of otitis media in conjunction with the insertion of tympanostomy tubes in children who are younger than 4 years: a randomized trial

Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations

Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations

Interventions for chronic suppurative otitis media

Effectiveness of trimethoprim/ sulfamethoxazole for children with chronic active otitis media: a randomized, placebo-controlled trial

Medical treatment of chronic suppurative otitis media without cholesteatoma in children-a two-year follow-up

Outpatient management of chronic suppurative otitis media without cholesteatoma in children

Identification of children in the first four years of life for early treatment for otitis media with effusion

Otitis media with effusion

American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion

Surgical prevention of otitis media

Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children

Grommets in otitis media with effusion: an individual patient data meta-analysis

Autoinflation for hearing loss associated with otitis media with effusion

Antihistamines and/or decongestants for otitis media with effusion (OME) in children

Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children