Br. J. Anaesth. (1988), 61, 231-232

INCIDENCE OF SINUSITIS IN PATIENTS WITHNASOTRACHEAL INTUBATION

M. HANSEN, M. R. POULSEN, D. K. BENDIXEN ANDF. HARTMANN-ANDERSEN

Nasotracheal intubation (NTI) is a procedurefrequently used in connection with mechanicalventilation. Sinusitis is one of the complicationsthat may arise after intubation. The incidence hasbeen described as ranging up to 26% [1].Grindlinger and colleagues [2] studied 111neurosurgical patients. NTI had been performedin 31 and 16 of these developed sinusitis. However,it has been our impression that the incidence ishigher than previously stated and, consequently,we have undertaken a prospective study of theincidence of sinusitis following NTI.

METHODS AND RESULTS

The incidence of radiological sinusitis wasexamined in consecutive patients with cerebralhaemorrhage or cranial trauma in whom com-puterized tomographic scanning (CT-scanning)and NTI had been performed, and who weretreated with subsequent mechanical ventilation.It was not possible to obtain informed consentbecause the patients were unconscious on admis-sion, but the design was approved by the localEthics Committee.

CT-scans showing thickening of the mucosawithout air/fluid levels were considered to benegative. Radiological changes such as air/fluidlevels or opacification of the paranasal sinuseswere considered positive findings (fig. 1). Assess-ment of the scans was undertaken by tworadiologists, one participating in the study (MP),and controlled by a radiologist otherwise notparticipating in the study.

MORTEN HANSEN, M.D., DIANA K. BENDIXEN, M.D.,FLEMMING HARTMANN-ANDERSEN, M.D. (Department ofAnesthesiology); METTE R. POULSEN, M.D. (Department ofRadiology); Senderborg Hospital, DK-6400 Senderborg,Denmark. Accepted for Publication: January 27, 1988.

SUMMARY

Sinusitis is a complication known to accompanynasotracheal intubation, but its frequency hasnot been well documented. Twelve patientssuffering from cerebral haemorrhage or fromcranial trauma and treated with mechanicalventilation were examined for radiological andbacteriological signs of sinusitis with CT-scanning, and cultures of nasal pus discharge.All patients showed radiological signs of sinusitiswithin 3 days after intubation. They all developedfever, six with a known focus outside the sinuses.There was an even distribution of Gram-negativeand Gram-positive bacteria. It is concluded thatsinusitis should be considered where feveroccurs without known focus in patients withnasotracheal intubation.

The first CT-scan was made either before NTIor immediately after. Patients with positivefindings at the first scanning, or patients who weretransferred to another hospital before rescanning,were excluded. The remaining patients wererescanned after 1, 2 and 3 days following theintubations, which were performed as emergencyprocedures.

If there was discharge of pus from the nostrilinvolved, samples were obtained for bacterio-logical examination.

Of 41 patients in whom CT-scanning andintubation were performed because of cranialtrauma or cerebral haemorrhage, 29 were ex-cluded because they had signs of sinusitis at thefirst scanning or because they were transported toa neurosurgical department for operation beforerescanning. Of the 12 remaining patients in thestudy (median age 39.9 yr, range 4-77), sixsuffered cerebral haemorrhage and six cranial

232 BRITISH JOURNAL OF ANAESTHESIA

FIG. 1. CT-Scanning 24 h after nasotracheal intubationshowing air/fluid level in the right maxillary sinus.

trauma. All showed signs of sinusitis at controlscanning 1 or 2 days after intubation. In sevenpatients, the maxillary sinus on the same side asthe NTI was affected primarily. Nine patientsdeveloped polysinusitis. In one patient the patternwas atypical, since he first developed opacificationof the sinus opposite the intubation, but anasogastric tube (NTG) was situated on the sideof the sinusitis. Nasogastric tubes were inserted inseven patients.

All patients developed fever (temperature> 38.5 °C), six with a known focus of infectionoutside the sinuses. None of these developedsepsis during the period of investigation. Most ofthe patients had mildly increased white blood cellcounts. Positive cultures of nasal pus dischargewere found in seven patients. The culturesconsisted mostly of a single predominant species,and with an even distribution of Gram-negativeand Gram-positive bacteria.

COMMENT

Sinusitis in connection with NTI is caused bydirect irritation followed by oedema and blockingof the ducts in addition to direct obstructioncaused by the tube. In this study, we found thatall patients showed radiological signs of sinusitisafter intubation of 72 h duration.

Seven of the patients also showed clinical signsas discharge of pus around the nasotracheal tube.This incidence is much higher than previouslyobserved. An explanation of this high incidencemay be that our patients were exposed to severalpredisposing factors such as NGT, heavy seda-tion, supine positioning, immobilization andpossibly emergency NTI [2, 3].

The fact that we used CT-scans in all patientsmay also explain the high incidence. In additionto providing a high diagnostic level of identi-fication (> 90%), CT-scanning makes it possibleto evaluate the frontal, sphenoid and ethmoidsinuses. The diagnosis of sinusitis may be madeby ordinary x-ray examination using fourstandard projections. This provides positiveidentification in 25 % of patients. If Water's viewis added, identification increases to approximately90% [1].

The development of sinusitis seems to be adynamic process since, in most patients, theair/fluid level or opacification was found first on theside where the tube was positioned, and sub-sequent scannings showed reactions in the othersinuses.

The aim of treatment is primarily to improvethe size of the nasal passage (removal of the tube,oral intubation or tracheotomy). These measuresseem curative within 48 h in most patients [4].Topical treatment with decongestants may betemporarily useful. Further treatment comprisesadministration of antibiotics. Surgical drainageshould be considered only in patients in whomconservative treatment is unsuccessful.

It is suggested that the diagnosis of sinusitisshould be considered when fever is presentwithout a known cause in patients with naso-tracheal intubation.

REFERENCES1. O'Reilly MJ, Reddick EJ, Black EJ, Carter PL, Erhardt

JE, Fill W, Sado A, Klatt GR. Sepsis from sinusitis innasotracheally intubated patients. Americal Journal ofSurgery 1984; 147: 601-604.

2. Grindlinger GA, Niehoff J, Hugehes SL, Humphrey MA,Simpson G. Acute paranasal sinusitis related to naso-tracheal intubation of head-injured patients. Critical CareMedicine 1987; 15: 214-217.

3. Kronberg FG, Goodwin WJ. Sinusitis in intensive careunit patients. Laryngoscope 1985; 95: 936-938.

4. Caplan ES, Hoyt NJ. Nosocomial sinusitis. Journal of theAmerican Medical Association 1982; 247: 639-641.