Value of Antral Puncture in the Intensive Care Patient With Fever of Unknown Origin

Abstract

Objective: To evaluate the use of maxillary sinus puncture as a routine diagnostic procedure to exclude or confirm purulent sinusitis in intensive care unit (ICU) patients presenting with fever or a septic state of unknown origin. Study Design: Retrospective. Methods: All patients admitted to the ICU at the University Hospital Ghent who required ENT examination to exclude acute sinusitis as possible cause of their otherwise inexplicable fever or septic state underwent maxillary sinus puncture via the inferior meatus. The results of clinical examination and the relation between the presence of foreign bodies (e.g., nasogastric tubes) and culture results from the middle meatus and sinuses were analyzed. Results: One hundred five punctures were performed in 53 patients. Macroscopic purulent effusions were obtained from 25 and nonpurulent effusions from 19 sinuses. The presence of a nasogastric tube did not influence puncture results but significantly increased colonization of the middle meatus. Staphylococcus aureus and Gram-negative agents were frequently cultured from sinus aspirates. Although purulent secretions often reveal no growth, most patients present with a multibacterial (40%) or monobacterial (28%) infection. Simple anterior rhinoscopy reduces the need for antral puncture. Only 8% of punctures in patients with a normal clinical examination were positive. Conclusions: Antral puncture proves to be a simple, fast, safe, inexpensive, and effective procedure for immediate diagnosis of acute nosocomial sinusitis in ICU patients and is therefore recommended as first procedure in these patients, even when only minor clinical abnormalities are present.

The diagnosis and management of sinusitis: A practice parameter update

“…34,36 In contrast to community-acquired sinusitis, the usual pathogens in nosocomial sinusitis are gram-negative enterics (eg, P aeruginosa, K pneumoniae, Enterobacter species, P mirabilis, and S marcescens) and gram-positive cocci (occasionally streptococci and staphylococci). [40][41][42] It has been suggested that staphylococcal enterotoxin acting as a superantigen might trigger an enhanced immune response, resulting in polypoid formation and chronic sinusitis. 43 Fungal.…”

Staphylococcus aureus superantigens and airway disease

“…Although studies, particularly in patients suffering from rhinosinusitis, have documented the presence of S. aureus as one of the more common and predominating bacteria in the nasal airways [48,49], there is a very marked paucity of studies documenting an association between S. aureus or its superantigens and exacerbation of upper airways/nasal disease, particularly allergic rhinitis or chronic sinusitis. One recent study, however, has provided some information which suggests that S. aureus superantigens may aggravate disease in patients suffering from perennial allergic rhinitis (PAR) [50•].…”

Prevalence of Serum IgE Antibodies to the <i>Staphylococcus aureus </i>Enterotoxins (SAE, SEB, SEC, SED, TSST-1) in Patients with Persistent Allergic Rhinitis

“…Studies in patients suffering from rhinosinusitis have documented the presence of S. aureus as one of the common and predominating bacteria of the upper respiratory tract [8, 9, 10, 11]. An important mechanism by which S. aureus contributes to the disease pathogenesis of the respiratory tract is through the secretion of toxins known as SAgs [12].…”