Infectious DiseasesTier 1Disease (DEADMAN)

Upper respiratory tract infections, such as otitis media and tonsillitis

Description

Infections of the upper airway - otitis media, tonsillitis/pharyngitis, sinusitis - the great majority are viral and self-limiting
The clinical task is identifying the minority with bacterial infection or complications that change management

Otitis media - commonest in young children, incidence falls with age (eustachian tube anatomy)
Pharyngitis/tonsillitis - peak in school-age children and young adults; group A streptococcus (GAS) accounts for ~20-30% of paediatric cases, less in adults
Most URTIs overall are viral (rhinovirus, coronavirus, adenovirus, influenza)

Otitis media

Viral URTI precedes most cases -> eustachian tube dysfunction -> middle ear fluid -> secondary bacterial infection: Streptococcus pneumoniae, non-typeable Haemophilus influenzae, Moraxella catarrhalis

Pharyngitis/tonsillitis

Viral (majority) - rhinovirus, adenovirus, EBV (infectious mononucleosis - exudative tonsillitis + lymphadenopathy + splenomegaly), influenza
Group A Streptococcus (GAS) - the bacterial cause that matters (rheumatic fever risk, scarlet fever, peritonsillar abscess)

Sinusitis

Viral in the majority; bacterial superinfection (same organisms as otitis media) when symptoms persist/worsen beyond the expected viral course

Otitis media

Otalgia, fever, bulging/erythematous tympanic membrane +/- perforation with discharge
Distinguish from otitis media with effusion (fluid without acute inflammation - different management)

Pharyngitis - who to test/treat for GAS

Centor/McIsaac criteria (fever, tonsillar exudate, tender anterior cervical nodes, absence of cough) estimate GAS probability but Australian guidelines favour a low threshold for treating clinically likely GAS pharyngitis in high-risk populations (see Management) given rheumatic fever risk
Throat swab/rapid antigen test where available, particularly relevant in Aboriginal and Torres Strait Islander children/communities and other high-ARF-risk settings
Consider EBV (infectious mononucleosis) if exudative tonsillitis with prominent lymphadenopathy, fatigue, splenomegaly - avoid amoxicillin (provokes a florid rash)

Sinusitis

Clinical - persistent/worsening symptoms beyond 7-10 days, or severe symptoms/high fever, suggest bacterial superinfection; imaging not routinely required for uncomplicated cases

Complications to actively exclude

Peritonsillar abscess (quinsy) - trismus, muffled "hot potato" voice, uvular deviation - needs drainage
Mastoiditis - post-auricular swelling/tenderness, pinna displacement - needs urgent ENT/imaging
Orbital/intracranial extension of sinusitis - periorbital swelling, visual change, severe headache - emergency imaging

A. General principle - most URTIs are viral; treat symptomatically, avoid reflexive antibiotics

B. Otitis media

Watchful waiting first-line for most children >6 months with non-severe symptoms - analgesia, review in 24-48h; antibiotics if not improving, or immediately if <6 months, systemically unwell, bilateral in <2 years, otorrhoea, or high-risk populations (Aboriginal and Torres Strait Islander children, immunosuppressed)
Amoxicillin first-line when antibiotics indicated (high-dose per eTG); amoxicillin-clavulanate if recent antibiotic failure

C. Pharyngitis/tonsillitis

Symptomatic management for likely viral disease
Treat GAS with penicillin (phenoxymethylpenicillin oral, or benzathine penicillin IM as a single dose particularly valuable where adherence is a concern) - primary goal in Australia is rheumatic fever prevention, especially in high-risk populations, not just symptom relief
Avoid amoxicillin if EBV cannot be excluded clinically
Peritonsillar abscess: needle aspiration/incision and drainage + antibiotics (e.g. benzylpenicillin + metronidazole, or amoxicillin-clavulanate), ENT involvement

D. Sinusitis

Symptomatic treatment for the first 7-10 days regardless of appearance
Amoxicillin (or amoxicillin-clavulanate if recent antibiotics/treatment failure) if bacterial superinfection likely (persistent/worsening beyond 10 days, or severe/rapidly worsening symptoms)
Urgent ENT/ophthalmology and imaging if orbital or intracranial complication suspected

Recurrent otitis media - eustachian tube dysfunction, craniofacial abnormality, immunodeficiency, passive smoke exposure
Rheumatic fever - untreated/undertreated GAS pharyngitis, disproportionately affects Aboriginal and Torres Strait Islander communities in Australia
Chronic sinusitis - allergic rhinitis, nasal polyps, immunodeficiency, ciliary dysfunction

Most cases resolve spontaneously within days regardless of antibiotic use
Otitis media: risk of perforation, chronic suppurative otitis media, conductive hearing loss, rarely mastoiditis/intracranial spread
GAS pharyngitis untreated: risk of acute rheumatic fever (particularly in high-risk populations), post-streptococcal glomerulonephritis, peritonsillar/retropharyngeal abscess
Sinusitis: rare but serious complications include orbital cellulitis, cavernous sinus thrombosis, intracranial abscess

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