Paranasal Sinusitis: A Common Complication of Nasotracheal Intubation in Neurosurgical Patients

Abstract

Sinusitis secondary to nasotracheal intubation has not been reported to occur in neurosurgical patients. Over a 1-year period, 11 patients admitted to the Intensive Care/Trauma Unit at St. Paul Ramsey Medical Center developed this entity. The mean age of these patients was 36 +/- 4 years; 7 were trauma victims, 3 had each had a subarachnoid hemorrhage, and 1 had suffered hypertensive hemorrhage. The patients presented with fever of unknown origin (FUO) and evidence of persistent hypermetabolism without an obvious cause. In 8 cases, the diagnosis was not suspected until mucopurulent nasal discharge was noted. Three additional cases were evaluated for suspected sinusitis before the occurrence of discharge. The mean duration of intubation before the diagnosis of sinusitis was 7.8 +/- 1.5 days. The diagnosis was confirmed by sinus films with a Waters view in 7 cases or by computed tomographic scanning in 4 cases and by bacteriological cultures. Two cases involved only the maxillary sinus on the side of intubation; the rest were polysinusites. The organisms involved included gram-positive and gram-negative species; all were polymicrobial with a single organism predominant. Secondary pulmonary involvement was common, and 4 patients revealed a bacteremia consistent with the major sinus organism. One patient developed septic shock. Treatment involved either orotracheal intubation or tracheostomy. This was curative in all cases. It is concluded that neurosurgical patients nasally intubated are at risk for sinusitis, which can have untoward effects such as septicemia or pulmonary infection. A high degree of suspicion will permit early diagnosis and treatment.

Papel da punção do seio maxilar no diagnóstico e no tratamento de pacientes com rinossinusite hospitalar

“…Onset of defervescence (reduction on the number of daily peaks of fever) within 48 to 72 hours 16,17 or abolition of fever within five days of the procedure 17 where used to characterize the success of the puncture procedure. The same criteria was used to assess the success of FESS 16,17,22,23 . Fifty-four nasal cavities were analyzed through CT scans.…”

“…Various papers have described nasal devices as one of the main risk factors for the development of IRS 8,[14][15][16] . These devices may press against the ostiomeatal complex and mechanically block the sinus ostium.…”

“…Presence of air-fluid level, complete sinus opacification or mucosal thickening greater than 6 mm combined with purulent secretion in the middle meatus visualized during endoscopic examination are deemed as important signs in the diagnosis of sinusitis 13 . Patients with FUO and radiologic signs of rhinosinusitis are first advised to remove all nasal devices 6,[14][15][16] . Additionally, topical nasal vasoconstrictors are administered for at least 72 hours before they are offered an invasive procedure 17 .…”

“…Critical rhinosinusitis patients with fever refractory to the procedure are traditionally referred to functional endoscopic sinus surgery. They are given general anesthesia to allow for the removal of all infected secretion, excision of local inflammatory tissue, and ventilation of the involved paranasal sinuses 16,17,19 . However, ICU patients are at a higher risk for surgery, as they are immunocompromised and unstable from the hemodynamic and metabolic standpoints.…”

Eficácia da endoscopia nasal no diagnóstico da rinossinusite aguda em pacientes de terapia intensiva

“…A incidência de rinossinusite é mais elevada em UTI neurocirúrgica e menor em pacientes de UTI clínicas e cirúrgicas pós-operatórias. Relatos sobre pacientes neurocirúrgicos ou aqueles com trauma crânio-facial, provavelmente superestimam a incidência de rinossinusite, especialmente se considerarem, exclusivamente, os achados radiográficos (Deutschman et al, 1985;Grindlinger et al, 1987).…”