Nosocomial maxillary sinusitis during mechanical ventilation: A prospective comparison of orotracheal versus the nasotracheal route for intubation

Abstract

Nosocomial maxillary sinusitis during mechanical ventilation may cause life-threatening complications in ICU patients. The aim of this prospective study was to compare the incidence of maxillary sinusitis according to the route of intubation. 111 consecutive adult patients (mean age: 53, mean SAPS: 12) were randomly assigned to receive either orotracheal (n = 53) or nasotracheal (n = 58) intubation. All had a nasogastric feeding tube. Patients with head trauma or mechanical ventilation for less than 48 h were excluded. Sinusitis diagnosis was made by radiography (waters' view) at the bedside. The two groups were similar in age, SAPS, duration of ventilation. Maxillary sinusitis occurred in 1/53 (1.8%) of the orotracheal group (on the nasogastric tube side), and in 25/58 (43.1%) of the nasotracheal group (7 on the nasogastric tube side, 11 on the endotracheal tube side, 7 bilateral; p less than 0.001). Nine of the 26 cases of sinusitis were initially treated by sinus drainage because of signs of infection (3 failures) and the 17 others were treated by tube removal. This procedure proved successful in 12 out of 17 cases but secondary drainage was performed in 5 cases (1 failure). Incidents related to the route for long-term intubation were significantly (p less than 0.001) more frequent in the orotracheal group (8/53 vs 2/58), however no patient died because of them. In this study, long-term orotracheal intubation reduced significantly the incidence of maxillary sinusitis in comparison with nasotracheal intubation.

Complications of Airway ManagementDiscussion

“…In addition, prolonged nasotracheal intubation has been associated with sinusitis, which can develop when the ETT obstructs maxillary sinus drainage. 38 However, other studies have documented no significant difference in the incidence of sinusitis between patients who have prolonged orotracheal intubation and those who have prolonged nasotracheal intubation. 39 Preoperative nasal endoscopy and digital manipulation may be used to determine the most patent nostril in an effort to limit complications from nasotracheal intubation.…”

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

“…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 .…”

“…Additionally, topical nasal vasoconstrictors are administered for at least 72 hours before they are offered an invasive procedure 17 . If the patient fails to respond to these initial measures, it is recommended that the infected secretion be drained from the paranasal sinus 8,12,14,15 . This procedure offers the possibility of confirming the diagnosis of IRS and improving the patient's overall condition.…”

Actualización Consenso Neumonía asociada a ventilación mecánica: Segunda parte. Prevención

“…La intubación naso-traqueal no está exenta de esta situación, más aún, ésta se asocia a mayor incidencia de sinusitis 41,42 y ésta a su vez podría aumentar el riesgo de NAVM 41,43 . Un estudio controlado con un grupo de pacientes intubado por vía naso-traqueal y otro por vía oro-traqueal encontró en el análisis multivariado que la sinusitis es un factor que aumenta en 3,8 veces la frecuencia de NAVM 42 .…”