Nosocomial Sinusitis: A Critical Appraisal of the Evidence

Abstract

Nosocomial sinusitis has long been established as a complication of endotracheal intubation, predominantly the nasotracheal route, in critically ill patients. Prolonged intubation causes direct irritation of the nasal mucosa, resulting in sufficient edema to occlude the maxillary sinus ostium. With the advent of low pressure cuffs, prolonged nasotracheal intubation occurs regularly. The combination of these two factors predisposes to the development of paranasal sinusitis. The diagnosis of nosocomial sinusitis is difficult, and often unrecognized, because of its subtle presentation. In contrast to outpatient acute sinusitis, which commonly presents with overt clinical symptoms, paranasal sinusitis in the critically ill is often clinically silent, and the presenting manifestation may be fever or sepsis. Symptoms of headache, facial pain, localized swelling and complaints of purulent nasal discharge are either absent or difficult to elicit in a critically ill intubated patient. Moreover, the sequelae can be catastrophic [1]. There is often a further dilemma in diagnosis since on clinical grounds we do not do routine computerized tomography (CT) scans of the sinuses or sinus aspiration for definitive diagnosis of sinusitis. Consequently, it has been difficult to elucidate the true incidence of nosocomial sinusitis, and the best method of diagnosis. In recent intensive care literature, there has been a resurgence of interest in paranasal sinusitis as an important factor in the etiology of infections in the intensive care unit (ICU), because of new evidence indicating that it is a major risk factor in nosocomial pneumonia [2,3,4].