The Common Cold

The common cold is an acute viral infection of the upper respiratory tract in
which the symptoms of rhinorrhea and nasal obstruction are prominent
Systemic symptoms and signs such as headache, myalgia, and fever are
absent or mild
The common cold is frequently referred to as infectious rhinitis but may also
include self-limited involvement of the sinus mucosa and is more correctly
termed rhinosinusitis.
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Etiology
The most common pathogens associated with the common cold are the
more than 200 types of human rhinoviruses but the disease also can be
caused by many different virus families
Rhinoviruses are associated with more than 50% of colds in adults
and children
In young children, other viral etiologies of the common cold include
respiratory syncytial virus , human metapneumovirus ,parainfluenza
viruses, and adenoviruses
Common cold symptoms may also be caused by influenza viruses,
nonpolio enteroviruses, and human coronaviruses
Epidemiology
Colds occur year-round, but the incidence is greatest from the early fall until the
late spring, reflecting the seasonal prevalence of the viral pathogens associated
with cold symptoms.
Young children have an average of 6-8 colds per year, but 10–15% of children have
at least 12 infections per yr. The incidence of illness decreases with increasing age,
with 2-3 illnesses per year by adulthood.
Viruses that cause the common cold are spread by three mechanisms:
direct hand contact (self-inoculation of one's own nasal mucosa or conjunctivae
after touching a contaminated person or object), inhalation of small-particle
aerosols that are airborne from coughing, or deposition of large-particle aerosols
that are expelled during a sneeze and land on nasal or conjunctival mucosa
Clinical Manifestations
Symptoms of the common cold vary by age and virus.
In infants, fever and nasal discharge may predominate. Fever is uncommon in
older children and adults.
The onset of common cold symptoms typically occurs 1-3 days after viral infection.
The first symptom noted is often sore or scratchy throat, followed closely by nasal
obstruction and rhinorrhea. The sore throat usually resolves quickly, and, by the
2nd and 3rd day of illness, nasal symptoms predominate.
Cough is associated with two-thirds of colds in children and usually begins after
the onset of nasal symptoms. Cough may persist for an additional 1-2 wk after
resolution of other symptoms.
Influenza viruses, RSV, MPV, and adenoviruses are more likely than HRV or
coronaviruses to be associated with fever and other constitutional symptoms.
Other symptoms of a cold may include headache, hoarseness, irritability, difficulty
sleeping, or decreased appetite. Vomiting and diarrhea are uncommon. The usual
cold persists for approximately 1 wk, although 10% last for 2 wk.
The physical findings of the common cold are limited to the upper respiratory
tract. Increased nasal secretion is usually obvious; a change in the color or
consistency of the secretions is common during the course of the illness
and does not indicate sinusitis or bacterial super infection but may indicate
accumulation of polymorphonuclear cells.
Examination of the nasal cavity might reveal swollen, erythematous nasal
turbinates, although this finding is nonspecific and of limited diagnostic value.
Abnormal middle ear pressure is common during the course of a cold. Anterior
cervical lymphadenopathy or conjunctival injection may also be noted on exam
Diagnosis
The most important task of the physician caring for a patient with a cold is
to exclude other conditions that are potentially more serious or treatable.
The differential diagnosis of the common cold includes noninfectious
disorders and other upper respiratory tract infection like allergic rhinitis,
and sinusitis
Routine laboratory studies are not helpful for the diagnosis and
management of the common cold . A nasal smear for eosinophils (Hansel
stain) may be useful if allergic rhinitis is suspected .
A predominance of polymorphonuclear cells in the nasal secretions is
characteristic of uncomplicated colds and does not indicate bacterial
super infection
Self-limited radiographic abnormalities of the paranasal sinuses are
common during an uncomplicated cold; imaging is not indicated for most
children with simple rhinitis.
The viral pathogens associated with the common cold can be detected by
polymerase chain reaction (PCR), culture, antigen detection, or serologic
methods. These studies are generally not indicated in patients with colds,
because a specific etiologic diagnosis is useful only when treatment with an
antiviral agent is indicated , such as for influenza viruses.
Bacterial cultures, PCR, or antigen detection are useful only when group A
streptococcus or Bordetella pertussis is suspected.
The isolation of other bacterial pathogens from nasopharyngeal specimens
is not an indication of bacterial nasal infection and is not a specific
predictor of the etiologic agent in sinusitis
Treatment
The management of the common cold consists primarily of
Supportive Care and Symptomatic Treatment
Supportive interventions are frequently recommended by providers.
Maintaining adequate oral hydration may help to prevent dehydration and
to thin secretions and soothe respiratory mucosa. The common home
treatment of ingesting warm fluids may soothe mucosa, increase nasal
mucous flow, or loosen respiratory secretions. Topical nasal saline may
temporarily remove secretions, and saline nasal irrigation may reduce
symptoms.
Cool, humidified air has not been well studied but may loosen nasal
Secretions.
The World Health Organization
suggests that neither steam nor cool-mist therapy be used in treatment of a cold.
The use of oral nonprescription therapies (often containing antihistamines
antitussives, and decongestants) for cold symptoms in children is controversial.
Although some of these medications are effective in adults, no study
demonstrates a significant effect in children, and there may be serious side effects.
Because of the lack of direct evidence for effectiveness and the potential for
unwanted side effects, it is recommended that nonprescription cough and
cold products not be used for infants and children younger than 6 yr of age.
Zinc, given as oral lozenges to previously healthy patients, reduces the 
duration but not the severity of symptoms of a common cold if begun within 24 hr
of symptoms.
Side effects are common and include bad taste, and nausea.
Fever
Fever is not usually associated with an uncomplicated common cold, and
antipyretic treatment is generally not indicated
NSAIDs may decrease discomfort from cold related headache or myalgia.
Nasal Obstruction
Either topical or oral adrenergic agents may be used as nasal decongestants
in older children and adults
Effective topical adrenergic agents such as xylometazoline, oxymetazoline,
or phenylephrine are available as either intranasal drops or nasal sprays
Reduced-strength formulations of these medications are available for use in
younger children, although they are not recommended for use in children
younger than 6 yr old.
Prolonged use of the topical adrenergic agents should be avoided to
prevent the development of rhinitis medicamentosa, an apparent
rebound effect that causes the sensation of nasal obstruction when
the drug is discontinued
The oral adrenergic agents are less effective than the topical preparations
and are occasionally associated with systemic effects such as central nervous
system stimulation, hypertension, and palpitations. Pseudoephedrine may
be more effective than phenylephrine as an
oral agent to treat nasal congestion. 
Aromatic vapors (such as menthol) for external rub may improve perception
of nasal patency.
Saline nose drops (wash, irrigation) can improve nasal symptoms and may
be used in all age groups.
Rhinorrhea
The 1st-generation antihistamines may reduce rhinorrhea by 25–30%. The effect of
the antihistamines on rhinorrhea appears to be related to the anticholinergic
rather than the antihistaminic properties of these drugs, and therefore the
2ndgeneration or non sedating antihistamines have no effect on common
cold symptoms.
The major adverse effects associated with the use of the antihistamines are
sedation or paradoxical hyperactivity. Overdose may be associated with respiratory
depression or hallucinations.
Rhinorrhea may also be treated with ipratropium bromide, a topical
anticholinergic agent.
This drug produces an effect comparable to the antihistamines but is not
associated with sedation. The most common side effects of ipratropium are nasal
irritation and bleeding
Sore Throat
The sore throat associated with colds is generally not severe, but treatment
with mild analgesics is occasionally indicated, particularly if there is
associated myalgia or headache.
The use of acetaminophen during HRV infection is associated decrease the
severity of sore throat. Aspirin should not be given to children with
respiratory infections, because of the risk of Reye syndrome in
children with influenza.
Non-steroidal anti-inflammatory drugs are somewhat effective in relieving
discomfort caused by a cold, but there is no clear evidence of an effect on
respiratory symptoms
Cough
Cough suppression is generally not necessary in patients with colds. Cough
in some patients appears to be from upper respiratory tract irritation
associated with postnasal drip. Cough in these patients is most prominent
during the time of greatest nasal symptoms, and treatment with a 1st-
generation antihistamine may be helpful.
Cough lozenges or hard candy may be temporarily effective and are
unlikely to be harmful in children for whom they do not pose risk of
aspiration (older than age 6 yr).
Honey (5-10 mL in children ≥1 yr old) has a modest effect on relieving nocturnal
cough and is unlikely to be harmful in children older than 1 yr of age. Honey
should be avoided in children younger than 1 yr of age because of the risk
for botulism.
In some patients, cough may be a result of virus-induced reactive airways disease .
These patients can have cough that persists for days to weeks after the acute illness
and might benefit from bronchodilator or other therapy.
Codeine or dextromethorphan hydrobromide has no effect on cough from colds
and has potential enhanced toxicity.
Expectorants such as guaifenesin are not effective antitussive agents. The
combination of camphor, menthol, and eucalyptus oils may relieve nocturnal
cough, but studies of their effectiveness are limited
Ineffective Treatments

Vitamin C, guaifenesin, and inhalation of warm, humidified air are no more

effective than placebo for the treatment of cold symptoms
There is no evidence that the common cold or persistent acute
purulent rhinitis of less than 10 days in duration benefits from
antibiotics. In fact, there is evidence that antibiotics cause significant
adverse effects when given for acute purulent rhinitis
Complications
The most common complication of a cold is acute otitis media which may
be indicated by new-onset fever and earache after the 1st few days of cold
symptoms. AOM is reported in 5–30% of children who have a cold, with the
higher incidence occurring in young infants and children.
Symptomatic treatment of the common cold symptoms has no effect on the
subsequent development of acute otitis media.
Sinusitis is another complication of the common cold .
Self-limited sinus inflammation is a part of the pathophysiology of the
common cold, but 0.5–2% of viral upper respiratory tract infections in
adults, and 5–13% in children, are complicated by acute bacterial sinusitis.
The differentiation of common cold symptoms from bacterial sinusitis may
be difficult
The diagnosis of bacterial sinusitis should be considered if rhinorrhea or
daytime cough persists without improvement for at least 10-14 days, if acute
symptoms worsen over time, or if acute signs of more severe sinus involvement
such as fever, facial pain, or facial swelling develop.
There is no evidence that symptomatic treatment of the common cold alters the
frequency of development of bacterial sinusitis.
Bacterial pneumonia is an uncommon complication of the common cold.
Exacerbation of asthma is a potentially serious complication of colds. The
majority of asthma exacerbations in children are associated with common cold
viruses. There is no evidence that treatment of common cold symptoms prevents
this complication.
Although not a complication, another important consequence of the common
cold is the inappropriate use of antibiotics for these illnesses and the associated
contribution to the problem of increasing antibiotic resistance of pathogenic
respiratory bacteria, as well as adverse effects from antibiotics
Prevention
Chemoprophylaxis or immunoprophylaxis is generally not available for the
common cold. Immunization or chemoprophylaxis against influenza can prevent
colds caused by this pathogen, but influenza is responsible for only a small
proportion of all colds.
Palivizumab is recommended to prevent RSV lower respiratory infection in
high-risk infants but does not prevent upper respiratory infections from
this virus.
Zinc sulfate taken for a minimum of 5 mo may reduce the rate of cold
development. However, because of duration of use and adverse effects of bad taste
and nausea, this is not a recommended prevention modality in children.
Hand-to-hand transmission of HRV followed by self-inoculation may be
prevented by frequent handwashing and avoiding touching one' s mouth, nose,
and eyes. Some studies report the use of alcohol-based hand sanitizers and
virucidal hand treatments were associated with decreased transmission