Sinusitis in the nasotracheally intubated patient

Maxillary sinusitis as a complication of nasotracheal intubation has long been recognized as difficult to diagnose and equally difficult to treat. To better define this problem from a diagnostic and therapeutic standpoint, we studied patients admitted to the surgical intensive care unit at the University of Texas Health Science Center at Houston-Hermann Hospital over a six-month period. During this time, we identified 19 cases of maxillary sinusitis. Diagnostic criteria included fever, leukocytosis, purulent rhinorrhea, and maxillary sinus opacification or air fluid level noted on sinus roentgenograms. Patients who met these criteria underwent maxillary sinus aspiration. Sixteen patients were receiving antibiotic therapy when sinusitis was diagnosed. All patients had their endotracheal tubes replaced orally, had diseased maxillary antra lavaged, and underwent appropriate antibiotic therapy guided by culture and sensitivity studies. Four of 19 patients required more than one sinus lavage, but all patients had their sinus disease resolve. These data suggest an aggressive approach to diagnosing sinusitis in the nasotracheally intubated patient is needed. A maxillary sinus aspiration and lavage should be an integral part of the diagnosis and treatment of these patients.     

Clinical characteristics of nosocomial sinusitis

Paranasal sinusitis is an important source of sepsis and morbidity in head injury victims and requires aggressive pursuit and therapy. Of 208 head-injured patients, 24 developed paranasal sinusitis. The Glasgow Coma Scale score of the sinusitis patients was 7.1 +/- 3.9. Nineteen patients were intubated nasotracheally, and five were intubated orally. Sinus air fluid levels, indicative of bleeding into the sinus, were seen on 17 initial computed tomographic scans. Maxillary sinus suppuration occurred in 23 patients; in 20 it was the initial sinus involved. Twenty-one patients developed polymicrobial sinusitis. Coexisting infections were common. In 15 patients with concurrent tracheobronchitis or pneumonia, organisms identical to those in sinus aspirations were recovered from the sputum. Seven patients had associated bacteremia. Meningitis in six patients shared a common pathogen with their sinusitis. Nonoperative management successfully resolved sinus infection in 19 cases. Five patients required open sinusotomy.     

Sinusitis during nasotracheal intubation

Sinusitis is mentioned as one complication of nasotracheal intubation. 30 patients admitted to the I.C.U. and prolonged intubated (+5 days) underwent clinical examination and C.T. scan: 23 C.T. scan revealed anomalies and 5 sinusitis. One patient had blood cultures positive for the organism present on nasal cultures. Patients nasally intubated are at risk for sinusitis which can have adverse effects.     

Incidence of maxillary sinusitis in intensive care patients with nasal intubation--ultrasonic diagnosis as a screening test

Acute maxillary sinusitis due to nasotracheal intubation during intensive care is seldom considered as a cause of fever of unknown origin. Forty six patients admitted to a post-operative intensive care unit had their maxillary sinuses examined using a mobile "A-scan" ultrasonic scanner. Follow-up examinations were performed regularly. As early as the 5th day of treatment 36 out of 46 patients who had undergone nasotracheal intubation showed pathological ultrasonic results. Bilateral involvement was most frequent. In unilateral findings at the first examination, the intubated side was three times as often affected as the other side. Early extubation, early partial mobilisation and/or early administration of antibiotics did not prevent the occurrence of pathological ultrasonic findings. Acute maxillary sinusitis must thus be considered a frequent complication of nasotracheal intubation.     

Neonatal nasotracheal intubation: An evaluation

A retrospective review of 100 surviving infants, all requiring nasotracheal intubation in the neonatal period for greater than 24 hr. was performed to assess the morbidity of this form of airway management. Seventy infants needed only one intubation, 22 were intubated twice and 8 infants required 3 intubations. No infant had evidence of laryngeal or tracheal sequelae, either in the immediate newborn period or on follow-up. Nasotracheal intubation by an experienced practitioner with appropriate tube fixation and toilet coupled with the use of low pressure ventilation and a consistent extubation routine will result in very low long-term tracheal morbidity in the neonate.     

OSAHS患者手术麻醉中应用纤维喉镜引导经鼻行气管插管

目的 探讨在纤维喉镜引导下经鼻气管插管应用于阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者手术麻醉中的效果。 方法 选取OSAHS患者70例,将其分为纤维喉镜组和麻醉视频喉镜组,每组35例,观察2个组于纤维喉镜或麻醉视频喉镜引导下经鼻气管插管一次插管成功的例数、插管所用时间以及咽部损伤出血、咽后壁损伤、术中鼻腔活动性出血、术后鼻腔粘连、鼻塞等不良反应发生率。 结果 纤维喉镜组全部气管导管一次插管成功,平均所用时间(32.34±6.13)s,位置正确,麻醉全程无需调整。麻醉视频喉镜组5例患者有不同原因需要重新插管,均2次成功,平均所用时间(56.54±23.75)s,失败率14%(5/35)。纤维喉镜组插管所用时间明显优于麻醉视频喉镜组(P<0.05)。纤维喉镜组无1例出现鼻腔、咽喉黏膜损伤,术后患者插管侧鼻腔无鼻塞加重症状出现。麻醉视频喉镜组插管后鼻腔活动性出血3例,术后鼻腔粘连3例,咽后壁损伤3例。 结论 纤维喉镜引导气管插管可作为OSAHS患者困难气管插管首选,方式安全高效。     

Nasally inhaled dornase alfa in the postoperative management of chronic sinusitis due to cystic fibrosis

OBJECTIVE: To determine the benefit of nasally inhaled dornase alfa in cystic fibrosis (CF) sinusitis. DESIGN: Retrospective chart review comparing postsurgical course, radiographic studies, and pulmonary function test results in patients who were treated with nasally inhaled dornase alfa with those in patients who were not treated with dornase alfa. PATIENTS: Twenty consecutive patients with CF who underwent functional endoscopic sinus surgery from 1993 to 1997 were included in the study. Treatment with nasally inhaled dornase alfa was initiated in 5 of the 20 patients after they underwent functional endoscopic sinus surgery. SETTING: Tertiary care academic center. RESULTS: The dornase alfa-treated patients had less mucosal edema and no polyps at serial endoscopy over 3 years compared with the non-dornase alfa-treated patients. The patients who received nasally inhaled dornase alfa also underwent fewer revision functional endoscopic sinus surgical procedures (1.6 vs 3.2), even though there was essentially no change in pulmonary function test results in these patients. CONCLUSIONS: Sinusitis continues to be a major cause of morbidity in patients with CF. Symptomatic patients frequently require multiple drug regimens, including long-term systemic antibiotic therapy, topical and systemic steroid therapy, and antibiotic nasal irrigations. This preliminary study indicates the potential impact of nasally inhaled dornase alfa in controlling postoperative symptoms in CF sinusitis.     

Progression of sinus disease in the intubated patient

BACKGROUND: Sinus disease in the intubated patient remains a frequent reason behind otolaryngological consultation to the Intensive Care Unit. Previous prospective studies often have been limited to only one computed tomography (CT) scan of the sinuses. The purpose of this study was to verify the development of sinus disease in the orotracheally intubated patient and determine a radiographic pattern of its progression if present. METHODS: The charts of all patients admitted to the hospital with a diagnosis of aneurysm or subarachnoid hemorrhage over a 2-year period were evaluated. Patients who were orotracheally intubated with at least one postintubation CT scan of the head were included. CT scans obtained after the initiation of antibiotics or tracheostomy were excluded. The Lund-Mackay staging system was used to evaluate the scans. RESULTS: A total of 50 patients with 172 scans were evaluated. Analysis revealed a significant trend toward increasing severity of radiological sinus disease over the first 7 days of intubation (p < 0.001). The presence of a nasogastric tube (NGT) resulted in an increased Lund-Mackay score, but the trend remained significant for patients without an NGT as well. CONCLUSION: This study shows that the presence and progression of sinus findings is fairly common in the intubated patient and that although the placement of an NGT increased the rate of development of sinus findings, the lack of one did not preclude sinus disease. Clinical exam remains a more important indicator of disease when evaluating the Intensive Care Unit patient for rhinosinusitis.     

Paediatric tracheostomy. Fifty-seven operations on fifty-three children

Fifty-seven operations on 53 patients represents the total experience of tracheostomy in children under 13 years during 1964-1985 in an area with half a million inhabitants. No complication occurred during surgery and no deaths were related to the operations. Complications followed 16 out of 30 (53%) operations on children under three years and four out of 27 (15%) of the remainder, an overall complication rate of 35%. Many fewer operations have been required since 1973 because of the successful employment of nasotracheal intubation in the treatment of upper and lower airway obstruction caused by acute infection. Obstruction by-pass remains the commonest function of tracheostomy, with congenital lesions and trauma now the commonest causes of obstruction as opposed to acute infection in the earlier years. Despite the successful use of nasotracheal intubation there were absolute indications for tracheostomy--blockage of the nasotracheal tube; inability to intubate a child with epiglottitis; and necessity for an artificial airway of long duration.     

The safety of intubation in croup and epiglottitis: An eight-year follow-up.

A series of 815 infectious croup (i.e., laryngotracheobronchitis) cases and 55 epiglottitis cases, encompassing an eight-year interval, is reviewed to determine the incidence of adverse effects of nasotracheal intubation used to manage upper airway obstruction. The racial, sex, and age distributions, in addition to modalities of treatment, are presented. The intubated cases (86 patients), representing 6.5 percent of all croup cases and 60 percent of all epiglottitis cases, are described in more detail with respect to presenting symptoms and physical findings. The average duration of intubation is 55 hours for epiglottitis and 88 hours for croup. The incidence of immediate, reversible complications for the entire intubated series is 7 percent. The incidence of delayed, irreversible complications, as determined by: 1. noting any persistent post-extubation symptoms; 2. measuring peak expiratory flow rates; and 3. laryngeal polytomography, is 1.6 percent. The mortality secondary to intubation is 0 percent. The complication rate (1.6 percent) in this series of nasotracheal intubations is lower than the mortality (3.6 percent) in a large collective series of pediatric tracheotomies performed for airway obstruction in croup or epiglottitis. Other advantages of intubation vs. tracheotomy are described (i.e., shorter hospital stay, dilatatory effect of endotracheal tube). The authors conclude that nasotracheal intubation is safer than pediatric tracheotomy and should be considered the procedure of choice in the management of upper airway obstruction secondary to croup or epiglottitis.     

Intractable pediatric chronic sinusitis with antrochoanal polyp

It has been reported that pediatric chronic sinusitis with antrochoanal polyp is difficult to cure because it tends to recur easily even with surgery. Therefore, in order to improve its cure rate, aggressive treatment combining polypectomy, intra-maxillary intubation through the inferior meatus, macrolide administration, etc., was attempted. Thirty-seven sides of pediatric chronic sinusitis with antrochoanal polyp and 44 sides of chronic sinusitis without polyp were evaluated after the same treatments. The mean age of patients was 9.7 years, and the mean intubation period was 20 months. Since subjective improvements in children are questionable, the efficacy was evaluated strictly on the basis of X-ray alone focusing on the maxillary sinus. Twenty-four percent of the group with antrochoanal polyp showed 'excellent' effect, i.e. almost complete resolution of the sinus findings, while 45% of the group without polyp showed 'excellent' effect, with a mean follow-up period of 3 years and 6 months. This difference was significant (P<0. 01, chi(2)-test). These results further document the intractableness of chronic sinusitis with choanal polyp in children.     

Verhinderung von laryngealen und trachealen Schäden bei Langzeitintubation

Summary With the development of new synthetic disposable materials like silikon and PVC and the low pressure soft cuffs, the risk of laryngeal and tracheal trauma for long-term intubation has decreased. We have seen in regular endoscopic controls that the rate of severe complications like stenosis is considerably reduced. It is no longer problematic to carry out nasotracheal intubation over several weeks in patients requiring artificial ventilation. The results of a study of 1,134 prolonged intubated individuals are presented. We did not find in later examinations after one to three years at surviving patients any laryngeal stenosis and saw only 0.46% tracheal stenosis.     

Middle ear effusion in intensive care unit patients with prolonged endotracheal intubation

OBJECTIVES: The purpose of this study is to explore the factors related to the occurrence of middle ear effusion (MEE) in prolonged endotracheal intubation patients in the intensive care unit (ICU). METHODS: Information about the age, sex, duration of endotracheal intubation, level of consciousness, and placement of nasogastric tube was retrospectively collected from medical charts of 20 prolonged endotracheal intubation (>7 days) patients in the ICU. All patients received otoscopic examination, tympanometry studies, and spectral gradient acoustic reflectometry for evidence of MEE. RESULTS: Among the 40 ears examined in this study, 20 ears had MEE (50%), 14 ears were normal (35%), and 6 ears had negative pressure in the middle ear (15%). In addition, patients with conscious disturbance and those who had been intubated for 14 days had a significantly higher incidence of MEE. Nasogastric tube was not implicated in MEE in this study. No episodes of acute otitis media or systemic infection were encountered in this study. CONCLUSIONS: Prolonged endotracheal intubation (>7 days) in adult ICU patients contributed to the high incidence of MEE (50%). Moreover, conscious disturbance and endotracheal intubation for 14 days were also significant contributing factors of MEE.     

Uncommon injuries of the larynx following intubation. Recurrent paralysis, torsion and luxation of the cricoarytenoid joints

19 laryngeal injuries are reported. 16 were secondary to orotracheal intubation and 3 were sequelae of gastroscopy, laryngoscopy and a nasogastric tube. In 6 patients, the trauma followed prolonged nasotracheal intubation, 10 cases followed a single endotracheal intubation. The main symptom was hoarseness. In 6 cases dislocation of an arytenoid cartilage was diagnosed, in 1 case a vocal cord paresis and in the other cases contusion or distortion of the arytenoid joint. In the cases of subluxation the arytenoid cartilage was dislocated posterolaterally, with the cord in the abducted position. For treatment we recommend closed reduction and injection of Cortison-Crystal-suspension into the joint. The outcome is good after single endotracheal intubation, but bad in prolonged nasotracheal intubation because of ankylosis of the cricoarytenoid joint.     

Aerobic and anaerobic bacteriology of concurrent chronic otitis media with effusion and chronic sinusitis in children

OBJECTIVE: To correlate the aerobic and anaerobic microbiologic findings of concurrent chronic otitis media with effusion and chronic maxillary sinusitis. METHODS: Cultures were obtained from 32 children with concurrent chronic otitis media with effusion and maxillary sinusitis who underwent tympanostomy tube placement. RESULTS: A total of 42 isolates, 24 aerobic and 18 anaerobic, were recovered from 30 patients; 27 were isolated from both sites, 4 from the ear only, and 11 from the sinus only. The most common isolates were Haemophilus influenzae (9 isolates), Streptococcus pneumoniae (n = 7), Prevotella species (n = 8), and Peptostreptococcus species (n = 6). Microbiological concordance between the ear and sinus was found in 22 (69%) of culture-positive patients. CONCLUSION: The concordance in recovery of organisms in more than two thirds of the patients illustrates the common bacterial etiology between chronic otitis media with effusion and chronic sinusitis in children.     

额下入路颅脑术后并发额窦炎的原因及处理

目的 探讨额下入路颅脑手术后并发额窦炎的原因、临床表现和治疗原则.方法额下入路颅脑手术后出现额窦炎的患者共33例,其中7例合并额窦脓肿,4例前额皮肤破溃瘘道.传统鼻外进路额窦手术23例,术后放置鼻额引流扩张管3个月以上;鼻内镜下额窦手术9例,鼻内镜和鼻外联合进路额窦手术1例,引流扩张管在出院前或出院后1个月内拔除.两种术式均需彻底清除额窦内骨蜡异物和炎性肉芽组织.复习颅脑手术病历结合鼻窦CT影像和额窦手术所见探讨并发额窦炎的原因.结果 33例患者均有颅脑术中开放额窦,将额窦黏膜下推或刮除,并以骨蜡填塞额窦的记录,其中5例有发生额窦炎后重新刮除额窦内黏膜并再次以骨蜡彻底封闭额窦的病史.所有患者均在拔除硅胶鼻额引流扩张管后随访半年以上.除2例鼻外进路手术的患者出院后1个月内鼻额引流扩张管脱落,经2次手术外,余31例均为1次手术.33例中30例治愈,3例好转.两种手术方式治疗效果相同.无脑脊液鼻漏等并发症.结论 额下入路颅脑术后并发额窦炎与颅脑术中额窦处理不当、额窦内骨蜡异物存留有关,此类额窦炎易形成额窦脓肿、瘘道等严重临床表现,治疗原则以清除额窦内骨蜡异物、清除炎性肉芽组织、开放额隐窝引流为主.传统鼻外进路额窦外科和鼻内镜额窦外科都可以达到治疗目的,但鼻内镜额窦外科具有微创、不必长期佩戴扩张管等优点.     

Bacterial colonization of endotracheal tubes in intubated neonates

OBJECTIVE: To obtain in vivo bacterial colonization profiles on endotracheal tubes at different sites in the neonatal airway in an attempt to better characterize one potential element of chondritis. DESIGN: A case series in which cultures were obtained from calculated segments of 33 endotracheal tubes immediately following extubation. This allowed for sampling at specific levels of the airway corresponding to the trachea, the subglottis, and the oropharynx. Data collected included gender, race, duration of intubation, use of antibiotic therapy, comorbidities, gestational age at birth and extubation, crown-rump length, weight, radiographic distance from tube tip to carina, and culture results. SETTING: Newborn intensive care unit at a tertiary care medical center. PATIENTS: Twenty-nine neonates intubated for longer than 24 hours (range, 24 hours to 15 days). MAIN OUTCOME MEASURES: Bacterial and fungal cultures obtained from 3 endotracheal tube segments for each extubation. RESULTS: A statistically significant difference (P < .05) was found in colonization rates between patients intubated for less than 4 days and those intubated for longer periods. No significant difference was noted in bacterial profile between the 3 sites. CONCLUSIONS: Data demonstrate that bacterial colonization of an indwelling object in the neonatal airway increases with the duration of intubation. Furthermore, 4 days seems to represent a critical period in the formation of such colonization (possibly in the form of a biofilm). These bacteria may contribute to the chondritis known to precede the development of subglottic stenosis. Further studies are indicated to suggest ways to interrupt this process and reduce the incidence of airway injury.     

鼻咽癌放疗后并发鼻窦炎的治疗及相关因素探讨

目的:探讨鼻咽癌放疗后并发鼻窦炎的相关因素和治疗方法。方法:回顾性分析45例鼻咽癌患者放疗后并发鼻窦炎的临床资料。结果:45例中治愈22例(48.9%),好转18例(40.0%),无效5例(11.1%),总有效率88.9%。随访期间未发现肿瘤复发者,所有病例未发现手术后的并发症。结论:鼻咽癌放疗后鼻窦炎的发生率极高,鼻窦炎直接影响鼻咽癌放疗的效果。采用鼻内镜下手术并及时开放窦口引流,对放疗后的鼻窦炎具有良好的疗效。     

Herpesvirus type 1-8 in sinus aspirates from HIV-infected patients and immunocompetent individuals

Sinusitis is frequently occurring in HIV-infected patients, but in a substantial number of cases the etiology is unknown. The purpose of this study was by PCR 1) to determine the prevalence of the eight human herpesviruses in sinus aspirates from 24 HIV-positive/AIDS patients with sinusitis 2) to relate the presence of herpesvirus DNA to clinical and immunological parameters and 3) to compare the prevalence of herpesvirus DNA in sinus aspirates from HIV-infected patients with the prevalence observed in 50 immunocompetent patients with sinusitis. DNA from HSV-1, EBV, CMV and HHV-8 was detected in 8 (33%) of the sinus aspirates from HIV-infected patients. In the immunocompetent patients, one of the herpesviruses, HHV-6, was found in one sinus aspirate. These data indicate that herpesviruses are frequently found in sinus aspirates from HIV-infected patients with sinusitis, whereas they do not seem to be related to clinical signs of sinusitis in immunocompetent individuals. The cause of these discrepancies may be due to uncontrolled reactivation of herpesviruses, which is known to occur in immunocompromised individuals. It remains to be established whether the herpesviruses play a pathogenic role in the development of sinusitis in HIV-infected patients.     

Preoperative diagnosis of allergic fungal sinusitis

OBJECTIVES/HYPOTHESIS: Although the diagnosis of allergic fungal sinusitis is mainly based on characteristic histopathological findings, certain preoperative diagnostic criteria have been proposed. However, their usefulness in differentiating allergic fungal sinusitis from other sinus diseases is unknown. The objective of the study was to identify accurate preoperative diagnostic parameters for allergic fungal sinusitis. STUDY DESIGN: Prospective, comparative study. METHODS: Twenty consecutive cases of allergic fungal sinusitis were evaluated prospectively and compared with 16 cases of ethmoidal polyposis and 5 cases of invasive sinus aspergillosis, with regard to various clinical, radiological, and immunological parameters. All patients were categorized based on histopathological findings. RESULTS: Nasal polyps were seen in all 20 cases of allergic fungal sinusitis, all 16 cases of ethmoidal polyposis, and 2 of 5 cases of invasive sinus aspergillosis. Computed tomography (CT) scan hyper-attenuation was seen in all 20 cases of allergic fungal sinusitis but also in 2 (13%) cases of ethmoidal polyposis and 2 (40%) cases of invasive sinus aspergillosis. Serum levels of specific anti-Aspergillus immunoglobulin E were elevated in 14 (70%) cases of allergic fungal sinusitis, 2 (13%) cases of ethmoidal polyposis, and 3 (60%) cases of invasive sinus aspergillosis. The combination of all three (ie, nasal polyps, CT scan hyper-attenuation, and elevated titers of anti-Aspergillus immunoglobulin) was not found in any case of ethmoidal polyposis or invasive sinus aspergillosis. This triad demonstrated a sensitivity of 70% and a specificity of 100% for the preoperative diagnosis of allergic fungal sinusitis. CONCLUSIONS: Nasal polyps, CT scan, and specific immunoglobulin E titers, when considered in combination, have a high preoperative diagnostic value in allergic fungal sinusitis. However, they should not be considered in isolation because considerable overlap occurs with invasive sinus aspergillosis and ethmoidal polyposis.