SUPPURATIVE SINUSITIS IN CRITICALLY ILL PATIENTS: A CAS REPORT AND REVIEW OF THE LITERATURE Ronnie S. Lum Cheong, MD, and Edward E. Cornwell, III, MD Washington, DC
Nosocomial sinusitis is occasionally overlooked as a source of sepsis in critically ill patients. Physical examination is usually unreliable and purulent nasal discharge is absent up to 73% of the time. Computed tomography scans of the sinuses and aspiration and culture of sinus fluid are the hallmark of diagnosis. Therapy consists of removal of tubes and packing, appropriate antibiotics, and drainage. Risk factors for nosocomial sinusitis include nasotracheal tubes, nasogastric tubes, prior steroid and antibiotic therapy, and facial fractures. This article reports a case of suppurative sinusitis following prolonged intubation and reviews the literature. (J Nati Med Assoc. 1992;84:1 057-1059.) Key words * sinusitis * nasotracheal intubation * sepsis Adequate control of sepsis remains a major determinant in the ultimate outcome of the critically ill patient. This article reports on a critically ill patient who developed suppurative sinusitis and subsequent sepsis.
CASE REPORT A 62-year-old woman was admitted to the surgical intensive care unit at Howard University, Washington, DC, following a coronary artery bypass graft procedure. She experienced a stormy postoperative course marked From the Department of Surgery, Division of Trauma and Critical Care, Howard University College of Medicine, Washington, DC. Requests for reprints should be addressed to Dr Edward E. Cornwell, Ill, Dept of Surgery, Howard University Hospital, 2041 Georgia Ave, NW, Washington, DC 20060. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
by sepsis of pulmonary and central venous catheter origin, respiratory failure requiring prolonged mechanical ventilation, prolonged ileus requiring parenteral nutritional support and nasogastric suctioning, and nasal hemorrhage requiring packing. After she was successfully treated for a septic episode with broad-spectrum antibiotics, the patient developed recurrent fever (102°F) and leukocytosis (white blood cell count of 25 000/cu mm) around postoperative day 25. She also had other parameters of sepsis including a high cardiac output and a low systemic vascular resistance. Blood, urine, and sputum cultures were negative at this time. Nasal drainage was present and a complete septic work-up included computed tomography (CT) scan of the abdomen and paranasal sinuses. Fluid-filled maxillary sinuses were confirmed by CT (Figure). Percutaneous drainage of the maxillary sinuses yielded 100 mL of a thick yellow fluid, which was cultured positive for Enterococcus. Blood cultures subsequently grew Enterococcus. The patient transiently responded to percutaneous drainage of her maxillary sinuses, removal of nasal tubes and packing, and broad-spectrum antibiotic therapy (Table). Despite these measures, however, she ultimately developed Candida sepsis, multisystem organ failure, and hemorrhagic gastritis. The patient died on the 61st postoperative day.
DISCUSSION Sinusitis is occasionally overlooked as a potential source of sepsis in the critically ill patient. ' The reasons for this are varied. Low index of suspicion exists due to the disease's relative infrequence. The physical examination in the critically ill patient is frequently unreliable; an elevated temperature may be of little diagnostic 1057
SUPPURATIVE SINUSITIS
_
s
_~~~~~~.'
TABLE. PATIENT RESPONSE TO TREATMENT Pretreatment Posttreatment 27 25 Intensive care unit day 1020 980 Maximum temperature (F) 20 000 25 500 White blood cell count 6.2 9.3 Cardiac output (Uminute) 942 585 Systemic vascular resistance (dyn-
sec/cm5)
Figure. Computed tomography scan demonstrating fluid-filled maxillary and ethmoid sinuses.
value in a setting with many possible causes.2'3 Additionally, purulent nasal discharge is absent in the majority of patients with suppurative sinusitis. Caplan reports an incidence of only 27%.~ Our index of suspicion has been raised by several authors who have described sinusitis as a potential source of lethal sepsis.2'4'6'7 The risk factors for sinusitis are multiple. One of the more commonly reported risk
factors in the critically ill patient is nasotracheal intubation. This type of intubation directly irritates the nasal mucosa, causing edema that occludes the ostium of the sinuses. Additionally, a large nasotracheal tube can serve as direct mechanical obstruction of the sinus ostia.1'7 Other risk factors for development of sinusitis include nasogastric tube placement, nasal packing, facial and cranial fractures, corticosteroid and other immunosuppressive therapy, mechanical ventilation, sedation, and unconsciousness.35 In our case, the patient was nasotracheally intubated, had a nasogastric tube, and had nasal packing for hemorrhage. All were removed, with the nasogastric and nasotracheal tubes being placed via the oral route, when the diagnosis of sinusitis was first entertained. In community-acquired sinusitis, the most commonly isolated organisms arecotcsteodaphylococteacteriandceae,aStaphlcoccsrares, Streptococcus pneumoniae and Haemophilus influenzae. However, in the critical care setting, where often there is inadequate ventilation, closed-space bacterial overgrowth secondary to chronic mucosal inflammation, and growth of resistant organisms, sinusitis is caused by other pathogens. Infections are often gram-negative, anaerobic, and polymicrobial. The more common isolates include Pseudomonas aeruginosa, Kiebsiella pneumoniae, En-
1058
cus epidermidis, Escherichia coli, Enterococcus species, Serratia marcescens, Bacteroides species, and other anaerobes."2'4-7 In the case reported here, the patient grew Enterococcus from the sinus and blood cultures. The diagnosis of sinusitis in the critical care setting is best made noninvasively by radiologic methods and clinical suspicion. Sinus roentgenograms, including a Waters view and a lateral view, provide useful information for maxillary sinusitis and anteroposterior projection for ethmoidal and frontal sinusitis.5 The diagnosis is strongly suggested with the findings of air-fluid levels and areas of complete opacification. However, it has been reported that to optimally assess the paranasal sinuses, at least five views must be performed.8 Such a study in an intensive care unit would be time consuming and difficult. Additionally, traditional radiologic studies are inadequate to assess the sphenoid sinuses. Computed tomography scans are more sensitive and specific, especially if ethmoid or sphenoid sinusitis is suspected. Computed tomography scanning of the sinuses also may be more pragmatic in the patient being scanned for other sources of sepsis. Radiographic signs include mucosal thickening, opacification, and air-fluid levels.5-7 Treatment of sinusitis also varies. Some authors report that simply removing the tube (in the case of nasotracheally intubated patients) is curative.6 Others advocate surgical drainage or aggressive treatment with decongestants and vasoconstrictors.7 Antibiotic therapy should be guided by Gram's stain of sinus aspirates until final culture and sensitivities are available. The patient reported here responded to surgical drainage, removal of tubes and packs, and broad-spectrum antibiotics. Several known complications can result from sinusiJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
SUPPURATIVE SINUSITIS
tis. These include orbital cellulitis, meningitis, subdural and epidural abscesses, and cavernous sinus thrombosis.9 Among the more serious sequelae that can result from delayed recognition and treatment of sinusitis is sepsis. Naschitz and Yeshurun strongly advocate thorough examination of the facial area for occult infections in the evaluation of fever of unknown origin. '0 Major policy changes directed at reducing the incidence of an already uncommon disease would be unjustified and difficult to evaluate in a controlled prospective trial. However, patients with the need for prolonged intubation can just as easily have these tubes placed via the oral route.
SUMMARY Diagnosis of suppurative sinusitis in the critical care setting requires a high index of suspicion and is aided by sinus films or CT scans. Treatment should consist of aspiration, drainage, removal of tubes, and antibiotic therapy. In the patient at high risk for sinusitis (ie, facial and cranial fractures, corticosteroid and other immunosuppressive therapy, prolonged mechanical ventilation, unconsciousness, and indwelling nasogastric tube), treatment would be best directed at prevention. Specifi-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
cally, the oral route for gastric and tracheal intubation should be used. Literature Cited 1. Pope TL, Stelling CB, Leitner YB. Maxillary sinusitis after nasotracheal intubation. South Med J. 1981;74:610-612. 2. Gallagher TJ, Civetta JM. Acute maxillary sinusitis complicating nasotracheal intubation: a case report. Anesth Analg. 1976;55:885-886. 3. Stillwell M, Caplan ES. The septic multiple-trauma patient. Crit Care Clin. 1988;4:155-183. 4. Caplan ES, Hoyt NJ. Nosocomial sinusitis. JAMA. 1 982;247:639-641. 5. Perlman DM, Caplan ES. Nosocomial sinusitis: a new and complex threat. The Joumal of Critical Illness. 1987;2:219225. 6. Deutschman CS, Wilton PB, Sinow J, Thienprasit P, Konstantinides FN, Cerra FB. Paranasal sinusitis: a common complication of nasotracheal intubation in neurosurgical patients. Neurosurgery. 1985;17:296-299. 7. O'Reilly MJ, Reddick EJ, Black W, Carter PL, Erhardt J, Fill W, et al. Sepsis from sinusitis in nasotracheally intubated patients: a diagnostic dilemma. Am J Surg. 1984; 147:601-604. 8. Chidekel N, Jensen C, Axelsson A, Grebelius N. Diagnosis of fluid in the maxillary sinus. Acta Radiol. 1 970;1 0:433-440. 9. Paparella M, Shumrick D, eds. Otolaryngology. Philadelphia, Pa: WB Saunders Co; 1980. 10. Naschitz JE, Yeshurun D. Occult infection in the facial area presenting as fever of unknown origin. lsr J Med Sci. 1 985;21 :995-998.
1059
Nosocomial sinusitis is occasionally overlooked as a source of sepsis in critically ill patients. Physical examination is usually unreliable and purulent nasal discharge is absent up to 73% of the time. Computed tomography scans of the sinuses and aspiration and culture of sinus fluid are the hallmark of diagnosis. Therapy consists of removal of tubes and packing, appropriate antibiotics, and drainage. Risk factors for nosocomial sinusitis include nasotracheal tubes, nasogastric tubes, prior steroid and antibiotic therapy, and facial fractures. This article reports a case of suppurative sinusitis following prolonged intubation and reviews the literature. (J Nati Med Assoc. 1992;84:1 057-1059.) Key words * sinusitis * nasotracheal intubation * sepsis Adequate control of sepsis remains a major determinant in the ultimate outcome of the critically ill patient. This article reports on a critically ill patient who developed suppurative sinusitis and subsequent sepsis.
CASE REPORT A 62-year-old woman was admitted to the surgical intensive care unit at Howard University, Washington, DC, following a coronary artery bypass graft procedure. She experienced a stormy postoperative course marked From the Department of Surgery, Division of Trauma and Critical Care, Howard University College of Medicine, Washington, DC. Requests for reprints should be addressed to Dr Edward E. Cornwell, Ill, Dept of Surgery, Howard University Hospital, 2041 Georgia Ave, NW, Washington, DC 20060. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
by sepsis of pulmonary and central venous catheter origin, respiratory failure requiring prolonged mechanical ventilation, prolonged ileus requiring parenteral nutritional support and nasogastric suctioning, and nasal hemorrhage requiring packing. After she was successfully treated for a septic episode with broad-spectrum antibiotics, the patient developed recurrent fever (102°F) and leukocytosis (white blood cell count of 25 000/cu mm) around postoperative day 25. She also had other parameters of sepsis including a high cardiac output and a low systemic vascular resistance. Blood, urine, and sputum cultures were negative at this time. Nasal drainage was present and a complete septic work-up included computed tomography (CT) scan of the abdomen and paranasal sinuses. Fluid-filled maxillary sinuses were confirmed by CT (Figure). Percutaneous drainage of the maxillary sinuses yielded 100 mL of a thick yellow fluid, which was cultured positive for Enterococcus. Blood cultures subsequently grew Enterococcus. The patient transiently responded to percutaneous drainage of her maxillary sinuses, removal of nasal tubes and packing, and broad-spectrum antibiotic therapy (Table). Despite these measures, however, she ultimately developed Candida sepsis, multisystem organ failure, and hemorrhagic gastritis. The patient died on the 61st postoperative day.
DISCUSSION Sinusitis is occasionally overlooked as a potential source of sepsis in the critically ill patient. ' The reasons for this are varied. Low index of suspicion exists due to the disease's relative infrequence. The physical examination in the critically ill patient is frequently unreliable; an elevated temperature may be of little diagnostic 1057
SUPPURATIVE SINUSITIS
_
s
_~~~~~~.'
TABLE. PATIENT RESPONSE TO TREATMENT Pretreatment Posttreatment 27 25 Intensive care unit day 1020 980 Maximum temperature (F) 20 000 25 500 White blood cell count 6.2 9.3 Cardiac output (Uminute) 942 585 Systemic vascular resistance (dyn-
sec/cm5)
Figure. Computed tomography scan demonstrating fluid-filled maxillary and ethmoid sinuses.
value in a setting with many possible causes.2'3 Additionally, purulent nasal discharge is absent in the majority of patients with suppurative sinusitis. Caplan reports an incidence of only 27%.~ Our index of suspicion has been raised by several authors who have described sinusitis as a potential source of lethal sepsis.2'4'6'7 The risk factors for sinusitis are multiple. One of the more commonly reported risk
factors in the critically ill patient is nasotracheal intubation. This type of intubation directly irritates the nasal mucosa, causing edema that occludes the ostium of the sinuses. Additionally, a large nasotracheal tube can serve as direct mechanical obstruction of the sinus ostia.1'7 Other risk factors for development of sinusitis include nasogastric tube placement, nasal packing, facial and cranial fractures, corticosteroid and other immunosuppressive therapy, mechanical ventilation, sedation, and unconsciousness.35 In our case, the patient was nasotracheally intubated, had a nasogastric tube, and had nasal packing for hemorrhage. All were removed, with the nasogastric and nasotracheal tubes being placed via the oral route, when the diagnosis of sinusitis was first entertained. In community-acquired sinusitis, the most commonly isolated organisms arecotcsteodaphylococteacteriandceae,aStaphlcoccsrares, Streptococcus pneumoniae and Haemophilus influenzae. However, in the critical care setting, where often there is inadequate ventilation, closed-space bacterial overgrowth secondary to chronic mucosal inflammation, and growth of resistant organisms, sinusitis is caused by other pathogens. Infections are often gram-negative, anaerobic, and polymicrobial. The more common isolates include Pseudomonas aeruginosa, Kiebsiella pneumoniae, En-
1058
cus epidermidis, Escherichia coli, Enterococcus species, Serratia marcescens, Bacteroides species, and other anaerobes."2'4-7 In the case reported here, the patient grew Enterococcus from the sinus and blood cultures. The diagnosis of sinusitis in the critical care setting is best made noninvasively by radiologic methods and clinical suspicion. Sinus roentgenograms, including a Waters view and a lateral view, provide useful information for maxillary sinusitis and anteroposterior projection for ethmoidal and frontal sinusitis.5 The diagnosis is strongly suggested with the findings of air-fluid levels and areas of complete opacification. However, it has been reported that to optimally assess the paranasal sinuses, at least five views must be performed.8 Such a study in an intensive care unit would be time consuming and difficult. Additionally, traditional radiologic studies are inadequate to assess the sphenoid sinuses. Computed tomography scans are more sensitive and specific, especially if ethmoid or sphenoid sinusitis is suspected. Computed tomography scanning of the sinuses also may be more pragmatic in the patient being scanned for other sources of sepsis. Radiographic signs include mucosal thickening, opacification, and air-fluid levels.5-7 Treatment of sinusitis also varies. Some authors report that simply removing the tube (in the case of nasotracheally intubated patients) is curative.6 Others advocate surgical drainage or aggressive treatment with decongestants and vasoconstrictors.7 Antibiotic therapy should be guided by Gram's stain of sinus aspirates until final culture and sensitivities are available. The patient reported here responded to surgical drainage, removal of tubes and packs, and broad-spectrum antibiotics. Several known complications can result from sinusiJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
SUPPURATIVE SINUSITIS
tis. These include orbital cellulitis, meningitis, subdural and epidural abscesses, and cavernous sinus thrombosis.9 Among the more serious sequelae that can result from delayed recognition and treatment of sinusitis is sepsis. Naschitz and Yeshurun strongly advocate thorough examination of the facial area for occult infections in the evaluation of fever of unknown origin. '0 Major policy changes directed at reducing the incidence of an already uncommon disease would be unjustified and difficult to evaluate in a controlled prospective trial. However, patients with the need for prolonged intubation can just as easily have these tubes placed via the oral route.
SUMMARY Diagnosis of suppurative sinusitis in the critical care setting requires a high index of suspicion and is aided by sinus films or CT scans. Treatment should consist of aspiration, drainage, removal of tubes, and antibiotic therapy. In the patient at high risk for sinusitis (ie, facial and cranial fractures, corticosteroid and other immunosuppressive therapy, prolonged mechanical ventilation, unconsciousness, and indwelling nasogastric tube), treatment would be best directed at prevention. Specifi-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
cally, the oral route for gastric and tracheal intubation should be used. Literature Cited 1. Pope TL, Stelling CB, Leitner YB. Maxillary sinusitis after nasotracheal intubation. South Med J. 1981;74:610-612. 2. Gallagher TJ, Civetta JM. Acute maxillary sinusitis complicating nasotracheal intubation: a case report. Anesth Analg. 1976;55:885-886. 3. Stillwell M, Caplan ES. The septic multiple-trauma patient. Crit Care Clin. 1988;4:155-183. 4. Caplan ES, Hoyt NJ. Nosocomial sinusitis. JAMA. 1 982;247:639-641. 5. Perlman DM, Caplan ES. Nosocomial sinusitis: a new and complex threat. The Joumal of Critical Illness. 1987;2:219225. 6. Deutschman CS, Wilton PB, Sinow J, Thienprasit P, Konstantinides FN, Cerra FB. Paranasal sinusitis: a common complication of nasotracheal intubation in neurosurgical patients. Neurosurgery. 1985;17:296-299. 7. O'Reilly MJ, Reddick EJ, Black W, Carter PL, Erhardt J, Fill W, et al. Sepsis from sinusitis in nasotracheally intubated patients: a diagnostic dilemma. Am J Surg. 1984; 147:601-604. 8. Chidekel N, Jensen C, Axelsson A, Grebelius N. Diagnosis of fluid in the maxillary sinus. Acta Radiol. 1 970;1 0:433-440. 9. Paparella M, Shumrick D, eds. Otolaryngology. Philadelphia, Pa: WB Saunders Co; 1980. 10. Naschitz JE, Yeshurun D. Occult infection in the facial area presenting as fever of unknown origin. lsr J Med Sci. 1 985;21 :995-998.
1059
