| Otitis media |
| Classification and external resources |
|
A view of the tympanic membrane showing acute otitis media
|
| ICD-10 |
H65-H67 |
| ICD-9 |
017.40, 055.2, 381.0, 381.1, 381.2, 381.3, 381.4, 382 |
| DiseasesDB |
29620 serous,
9406 suppurative |
| MedlinePlus |
000638 acute, 007010 with effusion, 000619 chronic |
| eMedicine |
emerg/351
ent/426 complications, ent/209 with effusion, ent/212 Medical treat., ent/211 Surgical treat. ped/1689 |
| MeSH |
D010033 |
Otitis media (Latin for "inflammation of the middle ear") or tympanitis is the medical term for middle ear inflammation. There are 2 major types of otitis media: acute otitis media and otitis media with effusion. The former is usually symptomatic, especially ear pain (otalgia), whereas the latter is most commonly without acute symptoms. Chronic suppurative otitis media, incorrectly called “chronic otitis media,” is less common and is a complication of acute otitis media, and is associated with perforation of the ear drum, with or without drainage; all 3 of these conditions are most frequently associated with hearing loss. Otitis Media is very common in childhood but can occur at any age.
All otitis media is middle-ear disease, but all middle-ear diseases and disorders are not otitis media, such as cholesteatoma, congenital malformations of the middle-ear.
Contents
- 1 Signs and symptoms
- 2 Causes
- 3 Diagnosis
- 3.1 Acute otitis media
- 3.2 Otitis media with effusion
- 3.3 Chronic suppurative otitis media
- 3.4 Adhesive otitis media
- 4 Prevention
- 5 Management
- 5.1 Antibiotics
- 5.2 Tympanostomy tube
- 5.3 Alternative medicine
- 6 Outcomes
- 6.1 Membrane rupture
- 6.2 Hearing loss
- 7 Epidemiology
- 8 References
- 9 External links
Signs and symptoms
An integral symptom of acute otitis media is ear pain; other possible symptoms include fever, and irritability (in infants). Since an episode of otitis media is usually precipitated by an upper respiratory tract infection (URI), there often are accompanying symptoms like cough and nasal discharge.[1]
Otorrhea, which is a discharge from the ear, can be caused by acute otitis media with perforation of the ear drum, chronic suppurative otitis media, tympanostomy tube otorrhea, or acute otitis externa. Trauma, such as a basilar skull fracture, can also lead to otorrhea due to cerebral spinal drainage from the brain and its covering (meninges).
Causes
The common cause of all forms of otitis media is dysfunction of the Eustachian tube.[2] This is usually due to inflammation of the mucous membranes in the nasopharynx, which in turn can be caused by a viral URI or possibly by allergies.[3] Because of the dysfunction of the Eustachian tube, the gas volume in the middle ear is trapped and parts of it are slowly absorbed by the surrounding tissues, leading to negative pressure in the middle ear. Eventually the negative middle-ear pressure can reach a point where fluid from the surrounding tissues is sucked in to the middle ear's cavity (also called tympanic cavity), causing a middle-ear effusion. This is seen as a progression from a Type A tympanogram to a Type C to a Type B tympanogram.
By reflux or aspiration of unwanted secretions from the nasopharynx into the normally sterile middle-ear space, the fluid may then become infected - usually with bacteria. The virus that caused the initial URI can itself be identified as the pathogen causing the infection in the middle ear.[3]
Diagnosis
As its typical symptoms overlap with other conditions, such as acute external otitis, clinical history alone is not sufficient to predict whether acute otitis media is present; it has to be complemented by visualization of the tympanic membrane.[4] Using a pneumatic otoscope with a rubber bulb attached to assess the mobility of the tympanic membrane.
Acute otitis media in children with moderate to severe bulging of the tympanic membrane or new onset of otorrhea (drainage) is not due to external otitis. Also, the diagnosis may be made in children who have mild bulging of the ear drum and recent onset of ear pain (less than 48 hours) or intense erythema (redness) of the ear drum.
To confirm the diagnosis, middle-ear effusion and inflammation of the eardrum have to be identified; signs of these are fullness, bulging, cloudiness and redness of the eardrum.[1] Viral otitis may also result in blisters on the external side of the tympanic membrane, which is called bullous myringitis (myringa being Latin for "eardrum")[5]
However, sometimes even examination of the eardrum may not be able to confirm the diagnosis, especially if the canal is small. If wax in the ear canal obscures a clear view of the eardrum it should be removed using a blunt cerumen curette or a wire loop. Also, an upset young child's crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media.
Acute otitis media
The most common bacteria isolated from the middle ear in AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.[1]
Otitis media with effusion
Otitis media with effusion (OME), also known as serous otitis media (SOM) or secretory otitis media (SOM), and commonly referred to as glue ear,[6] is simply a collection of effusion (fluid) that occurs within the middle-ear space due to the negative pressure produced by dysfunction of the Eustachian tube. This can occur purely from a viral URI, with no pain or bacterial infection, or it can precede and/or follow acute bacterial otitis media.[7] Fluid in the middle ear frequently causes conductive hearing impairment, but only when it interferes with the normal vibration of the eardrum by sound waves. Over weeks and months, middle-ear fluid can become very thick and glue-like, which increases the likelihood of its causing conductive hearing impairment. Early-onset OME is associated with feeding of infants while lying down, early entry into group child care, parental smoking, lack, or too short a period of breastfeeding and greater amounts of time spent in group child care, particularly those with a large number of children, increases the incidences and duration of OME in the first two years of life.[8]
Chronic suppurative otitis media
Chronic suppurative otitis media involves a perforation (hole) in the tympanic membrane and active bacterial infection within the middle-ear space for several weeks or more. There may be enough pus that it drains to the outside of the ear (otorrhea), or the purulence may be minimal enough to only be seen on examination using the otoscope or more effectively with a binocular microscope by an otolaryngologist. This disease is much more common in persons with poor Eustachian tube function, and very common in certain races such as Native North Americans. Hearing impairment often accompanies this disease.
Adhesive otitis media
Adhesive otitis media occurs when a thin retracted ear drum becomes sucked into the middle-ear space and stuck, i.e. adherent, to the ossicles and other bones of the middle ear.
-
-
-
Acute otitis media - Myringitis bullosa
-
Myringitis bullosa in influenza
-
Chronic otitis media (otitis media chronica mesotympanalis)
-
Otitis media chronica mesotympanalis
-
Otitis media chronica mesotympanalis
-
Otitis media chronica mesotympanalis
Prevention
Long term antibiotics while they decrease rates of infection during treatment, have an unknown effect on long term outcomes such as hearing loss.[9] This method of prevention has been associated with emergence of antibiotic-resistant otitic bacteria. They are thus not recommended.[1]
Pneumococcal conjugate vaccines when given during infancy decrease rates of acute otitis media by 6–7% and if implemented broadly would have a significant public health benefit.,[1][10] Influenza vaccine is recommended annually.[1]
Risk factors such as season, allergy predisposition and presence of older siblings are known to be determinants of recurrent otitis media and persistent middle-ear effusions (MEE).[11] Previous history of recurrence, environmental exposure to tobacco smoke, use of daycare, and lack of breastfeeding have all been associated with increased risk of development, recurrence, and persistent MEE.[12][13] Thus, cessation of smoking in the home should be encouraged, daycare attendance should avoided or daycare facilities with the fewest attendees should be recommended, and breast feeding should be promoted.[12][13]
There is some evidence that breastfeeding for the first twelve months of life is associated with a reduction in the number and duration of OM infections.[14][15] Pacifier use, on the other hand, has been associated with more frequent episodes of AOM.[16]
Evidence does not support zinc supplementation as an effort to reduce otitis rates except maybe in those with severe malnutrition such as marasmus.[17]
Management
Oral and topical pain killers are effective to treat the pain caused by otitis media. Oral agents include ibuprofen, paracetamol (acetaminophen), and opiates. Topical agents shown to be effective include antipyrine and benzocaine ear drops.[18] Decongestants and antihistamines, either nasal or oral, are not recommended due to the lack of benefit and concerns regarding side effects.[19] Half of cases of ear pain in children resolves without treatment in three days and 90% resolves in seven or eight days.[20]
Antibiotics
It is important to weigh the benefits and harms before using antibiotics for acute otitis media. As over 80% of acute episodes settle without treatment, about 20 children must be treated to prevent one case of ear pain, 33 children to prevent one perforation, and 11 children to prevent one opposite side ear infection. The harms include, for every 14 children treated one child has an episode of either vomiting, diarrhea or a rash.[21] If pain is present, treatment to reduce it should be initiated.
- Antibiotics should be prescribed for severe bilateral or unilateral disease in all infants and children with severe signs and symptoms, such as moderate to severe ear pain and high fever.
- For bilateral acute otitis media in infants younger than 24 months of age, without severe signs and symptoms, antibiotics should be prescribed.
- When non-severe unilateral acute otitis media is diagnosed in young children either antibiotic therapy is given, or observation with close follow-up based on joint decision making between parent(s)/caregiver in infants 6 to 23 months of age, and if the child worsens or fails to improve within 2 to 3 days antibiotics should be administered.
- In children 24 months or older with non-severe disease can have either antibiotics or observation.
The first line antibiotic treatment, if warranted, is amoxicillin.[1] If there is resistance or use of amoxicillin in the last 30 days then amoxicillin-clavulanate or another penicillin derivative plus beta lactamase inhibitor is recommended.[1] While less than 7 days of antibiotics have less side effects, more than seven days appear to be more effective.[22] If there is no improvement after 2–3 days of treatment a change in therapy may be considered.[1]
A treatment option for chronic suppurative otitis media with discharge is topical antibiotics. A Cochrane review found that topical quinolone antibiotics can improve discharge better than oral antibiotics.[23] Safety is not really clear.[23]
Tympanostomy tube
Tympanostomy tubes (also called a "grommet") are recommended in those people who have 3 or more episodes of acute otitis media in 6 months or 4 or more in a year, with at least one episode or more attacks in the preceding 6 months.[1] In chronic cases with effusions, insertion of tympanostomy tube into the eardrum reduces recurrence rates in the 6 months after placement[24] but have little effect on long term hearing.[25] A common complication of having a tympanostomy tube is otorrhea, which is a discharge from the ear.[26] Oral antibiotics should not be used to treat uncomplicated acute tympanostomy tube otorrhea.[26] Oral antibiotics are not a sufficient response to bacteria which cause this condition and have significant side effects including increased risk of opportunistic infection.[26] In contrast, topical antibiotic eardrops can treat this condition.[26]
Alternative medicine
Complementary and alternative medicine is not recommended for otitis media with effusion because there is no evidence of benefit.[7] An osteopathic manipulation technique called the Galbreath technique[27] was evaluated in one randomized controlled clinical trial; one reviewer concluded that it was promising, but a 2010 evidence report found the evidence inconclusive.[28]
Outcomes
Disability-adjusted life year for otitis media per 100,000 inhabitants in 2004.
no data
< 10
10-14
14-18
18-22
22-26
26-30
|
30-34
34-38
38-42
42-46
46-50
> 50
|
Complications of acute otitis media consists of perforation of the ear drum, infection of the mastoid space behind the ear (mastoiditis), and more rarely intracranial complications can occur, such as bacterial meningitis, brain abscess, or dural sinus thrombosis.[29] It is estimated that each year 21 thousand people die due to complications of otitis media.[30]
Membrane rupture
In severe or untreated cases, the tympanic membrane may perforate, allowing the pus in the middle-ear space to drain into the ear canal. If there is enough of it, this drainage may be obvious. Even though the perforation of the tympanic membrane suggests a highly painful and traumatic process, it is almost always associated with the dramatic relief of pressure and pain. In a simple case of acute otitis media in an otherwise healthy person, the body's defenses are likely to resolve the infection and the ear drum nearly always heals. An option for severe acute otitis media in which analgesics are not controlling ear pain is to perform a tympanocentesis, i.e. needle aspiration through the tympanic membrane to not only relieve the ear pain but to identify the causative organism(s).
Hearing loss
Children with recurrent episodes of acute otitis media and those with otitis media with effusion or chronic suppurative otitis media, have higher risks of developing conductive and sensorineural hearing loss. Globally approximately 141 million people have mild hearing loss due to otitis media (2.1% of the population).[31] This is more common in males (2.3%) than females (1.8%).[31]
This hearing loss is mainly due to fluid in the middle ear or rupture of the tympanic membrane. Prolonged duration of otitis media is associated with ossicular complications, and together with persistent tympanic membrane perforation contributes to the severity of both the disease and the hearing loss. When a cholesteatoma or granulation tissue is present in the middle ear, the degree of hearing loss and ossicular destruction is even greater.[32]
Periods of conductive hearing loss from otitis media may have a detrimental effect on speech development in children.[33] Some studies have also linked otitis media to educational problems, attention disorders, and problems with social adaptation.[34] Furthermore it has been demonstrated that patients suffering from otitis media have more depression/anxiety-related disorders compared to individuals with normal hearing.[35] Once the infections resolve and hearing thresholds return to normal, childhood otitis media may still cause minor and irreversible damage to the middle ear and cochlea.[36]
Epidemiology
Acute otitis media is very common in childhood. It is the most common condition warranting medical therapy in children under five years of age in the US.[37] The acute otitis media incidence rate is 10.85% i.e. 709 million cases each year with 51% occurring in age below five years; chronic suppurative otitis media incidence rate is 4.76% i.e. 31 million cases, with 22.6% of cases occurring annually under the age of five years.[30]
References
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- ^ Bluestone, CD (2005). Eustachian tube: structure, function, role in otitis media. Hamilton, London: BC Decker. pp. 1–219. ISBN 9781550090666.
- ^ a b John D Donaldson. "Acute Otitis Media". Medscape. Retrieved 17 March 2013.
- ^ Laine MK, Tähtinen PA, Ruuskanen O, Huovinen P, Ruohola A; Tähtinen; Ruuskanen; Huovinen; Ruohola (May 2010). "Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age". Pediatrics 125 (5): e1154–61. doi:10.1542/peds.2009-2689. PMID 20368317.
- ^ Roberts DB (April 1980). "The etiology of bullous myringitis and the role of mycoplasmas in ear disease: a review". Pediatrics 65 (4): 761–6. PMID 7367083.
- ^ "Glue Ear". NHS Choices. Department of Health. Retrieved 3 November 2012.
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- ^ Leach AJ, Morris PS; Morris (2006). Leach, Amanda J, ed. "Antibiotics for the prevention of acute and chronic suppurative otitis media in children". Cochrane Database Syst Rev (4): CD004401. doi:10.1002/14651858.CD004401.pub2. PMID 17054203.
- ^ Jansen AG, Hak E, Veenhoven RH, Damoiseaux RA, Schilder AG, Sanders EA; Hak; Veenhoven; Damoiseaux; Schilder; Sanders (2009). Jansen, Angelique GSC, ed. "Pneumococcal conjugate vaccines for preventing otitis media". Cochrane Database Syst Rev (2): CD001480. doi:10.1002/14651858.CD001480.pub3. PMID 19370566.
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- ^ Dewey KG, Heinig MJ, Nommsen-Rivers LA; Heinig; Nommsen-Rivers (1995). "Differences in morbidity between breast-fed and formula-fed infants". J Pediatr 126 (5 Pt 1): 696–702. doi:10.1016/S0022-3476(95)70395-0. PMID 7751991.
- ^ Saarinen UM (1982). "Prolonged breast feeding as prophylaxis for recurrent otitis media". Acta Pediatr Scan 71 (4): 567–571. doi:10.1111/j.1651-2227.1982.tb09476.x. PMID 7136672.
- ^ Rovers MM, Numans ME, Langenbach E, Grobbee DE, Verheij TJ, Schilder AG; Numans; Langenbach; Grobbee; Verheij; Schilder (August 2008). "Is pacifier use a risk factor for acute otitis media? A dynamic cohort study". Fam Pract 25 (4): 233–6. doi:10.1093/fampra/cmn030. PMID 18562333.
- ^ Gulani, A; Sachdev, HS (Jun 29, 2014). "Zinc supplements for preventing otitis media". The Cochrane database of systematic reviews 6: CD006639. doi:10.1002/14651858.CD006639.pub4. PMID 24974096.
- ^ Sattout, A.; Jenner, R. (February 2008). "Best evidence topic reports. Bet 1. The role of topical analgesia in acute otitis media". Emerg Med J 25 (2): 103–4. doi:10.1136/emj.2007.056648. PMID 18212148.
- ^ Coleman C, Moore M; Moore (2008). Coleman, Cassie, ed. "Decongestants and antihistamines for acute otitis media in children". Cochrane Database Syst Rev (3): CD001727. doi:10.1002/14651858.CD001727.pub4. PMID 18646076.
- ^ Thompson, M; Vodicka, TA; Blair, PS; Buckley, DI; Heneghan, C; Hay, AD; TARGET Programme, Team (Dec 11, 2013). "Duration of symptoms of respiratory tract infections in children: systematic review". BMJ (Clinical research ed.) 347: f7027. doi:10.1136/bmj.f7027. PMC 3898587. PMID 24335668.
- ^ Venekamp, Roderick P; Sharon Sanders2, Paul P Glasziou, Chris B Del Mar, Maroeska M Rovers (31 January 2013). "Antibiotics for acute otitis media in children (Systematic Review)". Cochrane Database of Systematic Reviews (1): CD000219 (3rd rev.). doi:10.1002/14651858.CD000219.pub3. PMID 14973951.
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- ^ a b Macfadyen, CA; Acuin, JM; Gamble, C (Jan 25, 2006). "Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations.". The Cochrane database of systematic reviews (1): CD005608. doi:10.1002/14651858.CD005608. PMID 16437533.
- ^ McDonald S, Langton Hewer CD, Nunez DA; Langton Hewer; Nunez (2008). McDonald, Stephen, ed. "Grommets (ventilation tubes) for recurrent acute otitis media in children". Cochrane Database Syst Rev (4): CD004741. doi:10.1002/14651858.CD004741.pub2. PMID 18843668.
- ^ Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ; Rovers; Williamson; Lous; Burton (2010). Browning, George G, ed. "Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children". Cochrane Database Syst Rev (10): CD001801. doi:10.1002/14651858.CD001801.pub3. PMID 20927726.
- ^ a b c d American Academy of Otolaryngology – Head and Neck Surgery, Five Things Physicians and Patients Should Question, Choosing Wisely: an initiative of the ABIM Foundation (American Academy of Otolaryngology – Head and Neck Surgery), retrieved August 1, 2013 , which cites
- Rosenfeld, R. M.; Schwartz, S. R.; Pynnonen, M. A.; Tunkel, D. E.; Hussey, H. M.; Fichera, J. S.; Grimes, A. M.; Hackell, J. M.; Harrison, M. F.; Haskell, H.; Haynes, D. S.; Kim, T. W.; Lafreniere, D. C.; LeBlanc, K.; Mackey, W. L.; Netterville, J. L.; Pipan, M. E.; Raol, N. P.; Schellhase, K. G. (2013). "Clinical Practice Guideline: Tympanostomy Tubes in Children". Otolaryngology -- Head and Neck Surgery 149 (1 Suppl): S1–S35. doi:10.1177/0194599813487302. ISSN 0194-5998. PMID 23818543.
- ^ Pratt-Harrington D (October 2000). "Galbreath technique: a manipulative treatment for otitis media revisited". J Am Osteopath Assoc 100 (10): 635–9. PMID 11105452.
- ^ Bronfort G, Haas M, Evans R, Leininger B, Triano J; Haas; Evans; Leininger; Triano (2010). "Effectiveness of manual therapies: the UK evidence report". Chiropr Osteopat 18: 3. doi:10.1186/1746-1340-18-3. PMC 2841070. PMID 20184717.
- ^ Jung, TT; Alper, CM; Hellstorm, SO; Hunter, LL; Casselbrant, ML; Groth, A; Kemaloglu, YK; Kim, SG; Lim, D; Nittrourer, S; Park, KH; Sabo, D; Sprately, J (April 2013). "Panel 8: Complications and sequelae". Otolaryngol Head Neck Surg E (4 Suppl): E122–43. doi:10.1177/0194599812467425. PMID 23536529.
- ^ a b Monasta, L; Ronfani, I; Marchetti, F; Montico, M; Vrecchi-Brunetti, L; Bavcar, A; Grasso, D; Barbiero, C; Tamburlini, G (April 30, 2012). "Burden of disease caused by otitis media: systematic review and global estimates". PLoS ONE 7 (4): e36226. doi:10.1371/journal.pone.0036226. PMC 3340347. PMID 22558393.
- ^ a b Vos, T; Flaxman, A. D.; Naghavi, M; Lozano, R; Michaud, C; Ezzati, M; Shibuya, K; Salomon, J. A.; Abdalla, S; Aboyans, V; Abraham, J; Ackerman, I; Aggarwal, R; Ahn, S. Y.; Ali, M. K.; Alvarado, M; Anderson, H. R.; Anderson, L. M.; Andrews, K. G.; Atkinson, C; Baddour, L. M.; Bahalim, A. N.; Barker-Collo, S; Barrero, L. H.; Bartels, D. H.; Basáñez, M. G.; Baxter, A; Bell, M. L.; Benjamin, E. J. et al. (Dec 15, 2012). "Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010". Lancet 380 (9859): 2163–96. doi:10.1016/S0140-6736(12)61729-2. PMID 23245607.
- ^ Da Costa SS; Rosito, Letícia Petersen Schmidt; Dornelles, Cristina (February 2009). "Sensorineural hearing loss in patients with chronic otitis media". Eur Arch Otorhinolaryngol 266 (2): 221–4. doi:10.1007/s00405-008-0739-0. PMID 18629531.
- ^ Roberts K (June 1997). "A preliminary account of the effect of otitis media on 15-month-olds' categorization and some implications for early language learning". J Speech Lang Hear Res 40 (3): 508–18. PMID 9210110.
- ^ Bidadi S, Nejadkazem M, Naderpour M; Nejadkazem; Naderpour (November 2008). "The relationship between chronic otitis media-induced hearing loss and the acquisition of social skills". Otolaryngol Head Neck Surg 139 (5): 665–70. doi:10.1016/j.otohns.2008.08.004. PMID 18984261.
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External links
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Wikimedia Commons has media related to Otitis media. |
- Neff MJ (June 2004). "AAP, AAFP, AAO-HNS release guideline on diagnosis and management of otitis media with effusion". Am Fam Physician 69 (12): 2929–31. PMID 15222658.
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Diseases of the ear and mastoid process (H60–H99, 380–389)
|
|
| Outer ear |
- Otitis externa
- Otomycosis
|
|
Middle ear
and mastoid |
- Otitis media
- Mastoiditis
- Bezold's abscess
- Gradenigo's syndrome
- Tympanosclerosis
- Cholesteatoma
- Perforated eardrum
|
|
Inner ear and
central pathways |
| Common pathway |
- Labyrinthitis/Otitis interna
|
|
| Equilibrioception |
- Vertigo/Balance disorder: peripheral
- Ménière's disease
- BPPV
- Vestibular neuronitis
- Perilymph fistula
- central (Central positional nystagmus)
|
|
| Hearing |
| Hearing impairment |
- Conductive hearing loss
- Otosclerosis
- Superior canal dehiscence
- Sensorineural hearing loss
- Presbycusis
- Cortical deafness
|
|
| Excessive response |
- Tinnitus
- Hyperacusis/Phonophobia
|
|
| Deafblindness |
- Wolfram syndrome
- Usher syndrome
|
|
| Other |
- Auditory processing disorder
- Spatial hearing loss
|
|
|
|
|
|
|
|
Common cold
|
|
| Viruses |
- Rhinovirus
- Coronavirus
- Orthomyxoviruses
- Influenza A virus
- Influenza B virus
- Influenza C virus
- Human parainfluenza viruses
- Human respiratory syncytial virus
- Adenovirus
- Enterovirus
- Metapneumovirus
|
|
| Symptoms |
- Sore throat
- Rhinorrhea
- Nasal congestion
- Sneezing
- Cough
- Muscle aches
- Fatigue
- Malaise
- Headache
- Weakness
- Loss of appetite
|
|
| Complications |
- Acute bronchitis
- Bronchiolitis
- Croup
- Pharyngitis
- Pneumonia
- Sinusitis
- Otitis media
- Strep throat
|
|
| Antiviral drugs |
- Pleconaril (experimental)
|
|
|
|
anat (n, x, l, c)/phys/devp
|
noco (c, p)/cong/tumr, sysi/epon, injr
|
proc, drug (R1/2/3/5/6/7)
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