Paranasal Sinusitis Associated With Nasotracheal and Orotracheal Long-term Intubation Andreas Michelson, MD; Bernd Schuster, MD; Hans-Dieter Kamp, MD, PhD
The impact of nasotracheal and orotracheal long-term intubation on the development of sinusitis paranasalis was investigated in a prospective study. Daily A-scan ultrasound examinations of the maxillary sinuses were performed on 44 intensive care unit patients (20 nasally, 24 orally intubated) who required prolonged intubation (>24 hours). At the end of the investigation period 19 (95%) of 20 nasotracheally and 15 (63%) of 24 orotracheally intubated patients showed pathologic antral sinus findings. In nasally intubated patients the incidence of bilateral sinusitis was significantly higher and its onset sooner. Pathologic organisms were found in the sinus aspirates in seven of 13 nasotracheally intubated patients, but only in two of nine patients with an oral tube. Thus, the nasotracheal tube can be seen as an adding factor in the development of sinusitis paranasalis. (Arch Otolaryngol Head Neck Surg. 1992;118:937-939) \s=b\
the last few years the number of nasotracheally and In orotracheally long-term intubated patients and the pe¬ riod of intubation the intensive units (ICUs) has in¬ in
care
creased rapidly. Paranasal sinusitis associated with intu¬ bation is reported more frequently and is recognized now as an important factor of infection.1 Complications, several life-threatening, such as bacterial meningitis, pneumonia, and sepsis, caused by nosocomial sinusitis are well documented.2-3 Prolonged nasotracheal intubation with mechanical ob¬ struction of the nose is regarded as a risk factor for the de¬ velopment of sinusitis paranasalis.1 Infection of the paranasal sinuses is reported for nasotracheally as well as for orotracheally intubated patients, but there are little data available comparing both methods. The purpose of this study was to investigate the impact of nasotracheal and orotracheal long-term intubation on sinusitis in ICU patients.
Table
1.—Demographic Characteristics of Patients Nasotracheally
Orotracheally
59 (29-85)
57 (22-88)
16/4
17/7
7, 1 (2-19)
6, 9 (2-19)
11 3 4 6
11 3 2 4
Intubated (n=20)
Age, Sex
y (range) (male/female)
Observation period, d (range) Prolonged intubation after Abdominal Thoracic Posttraumatic Other surgery
Intubated (n=24)
PATIENTS AND METHODS In a prospective study daily -scan ultrasound examinations of the maxillary sinuses were performed on 44ICU patients who re¬ quired prolonged intubation (range, 2 to 19 days; average, 7.0 days) and mechanical ventilation. Due to a scheduled surgery all patients were orally intubated, provided with a nasogastric feeding tube, and underwent their operation. The reasons for admission to the ICU included prolonged recovery from abdominal, thoracic, or posttraumatic surgery. One day postoperatively, while in ICU, the oral tubes were replaced nasotracheally in 20 patients. The tube was placed in the most patent nostril and the feeding tube in the other. There was no observation of substantial septal deflection. In 24 patients the tubes remained orotracheally. This group had their feeding tube in one nostril, the other nostril was free. The patients were distributed to the nasotracheal group on even-numbered days and to the orotracheal group on oddnumbered days. They were comparable with respect to age, sex, reason for admission, and length of observation. Demographic characteristics are noted in Table 1. All patients were intubated with polyethylene tubes with an internal diameter of 7.0 to 8.0 mm
(Mallinckrodt Ine, Athlone, Ireland).
Accepted
for
publication May 6,
1992.
From the Ear, Nose, and Throat Department (Drs Michelson and Schuster) and Institute of Anesthesiology (Dr Kamp), University of
Erlangen-N\l=u"\rnberg(Germany). Reprints not available.
Daily -scan ultrasound examinations ( -scan, MG 4000, Knott Elektronik, München, Germany) of the maxillary sinuses were
performed in a half-sitting position from the day of admission to the ICU until extubation, tracheotomy, death, or transfer. The findings were recorded by a thermal writer. A sonographic echo
Downloaded From: http://archotol.jamanetwork.com/ by a University of Manitoba User on 06/20/2015
of the backwall of the antral sinus was interpreted as either max¬ illary effusion or maxillary sinusitis with no attempt to distin¬ guish between the two conditions on the basis of the sonogram. In the event of a pathologic sonographic finding, a diagnos¬ tic aspiration of the involved antral sinus was carried out. The aspirates were tested for aerobic and anaerobic culture and
sensitivity. All patients were treated initially with systemic antibiotics due to the underlying disease. To prevent airway colonization and nosocomial respiratory infections, a local prophylactic treatment
1.—Sinus findings ( -scan) at the end of the observation period in (A) nasally (n=16) and (B) orally (n=18) intubated patients. Ten patients (four nasally, six orally intubated) with pathologic sinus findings at the beginning of the investigation were excluded.
Fig
performed
with an antimicrobial solution applied to the stomach.4 Statistical evaluations are based on the 2 test. A value of .05 or less was considered significant.
was
mouth,
nose, and
RESULTS At the end of the investigation period 19 (95%) of 20 na¬ sotracheally and 15 (63%) of 24 orotracheally intubated patients showed a unilateral or bilateral pathologic sinus finding (Fig 1) (P
The impact of nasotracheal and orotracheal long-term intubation on the development of sinusitis paranasalis was investigated in a prospective study. Daily A-scan ultrasound examinations of the maxillary sinuses were performed on 44 intensive care unit patients (20 nasally, 24 orally intubated) who required prolonged intubation (>24 hours). At the end of the investigation period 19 (95%) of 20 nasotracheally and 15 (63%) of 24 orotracheally intubated patients showed pathologic antral sinus findings. In nasally intubated patients the incidence of bilateral sinusitis was significantly higher and its onset sooner. Pathologic organisms were found in the sinus aspirates in seven of 13 nasotracheally intubated patients, but only in two of nine patients with an oral tube. Thus, the nasotracheal tube can be seen as an adding factor in the development of sinusitis paranasalis. (Arch Otolaryngol Head Neck Surg. 1992;118:937-939) \s=b\
the last few years the number of nasotracheally and In orotracheally long-term intubated patients and the pe¬ riod of intubation the intensive units (ICUs) has in¬ in
care
creased rapidly. Paranasal sinusitis associated with intu¬ bation is reported more frequently and is recognized now as an important factor of infection.1 Complications, several life-threatening, such as bacterial meningitis, pneumonia, and sepsis, caused by nosocomial sinusitis are well documented.2-3 Prolonged nasotracheal intubation with mechanical ob¬ struction of the nose is regarded as a risk factor for the de¬ velopment of sinusitis paranasalis.1 Infection of the paranasal sinuses is reported for nasotracheally as well as for orotracheally intubated patients, but there are little data available comparing both methods. The purpose of this study was to investigate the impact of nasotracheal and orotracheal long-term intubation on sinusitis in ICU patients.
Table
1.—Demographic Characteristics of Patients Nasotracheally
Orotracheally
59 (29-85)
57 (22-88)
16/4
17/7
7, 1 (2-19)
6, 9 (2-19)
11 3 4 6
11 3 2 4
Intubated (n=20)
Age, Sex
y (range) (male/female)
Observation period, d (range) Prolonged intubation after Abdominal Thoracic Posttraumatic Other surgery
Intubated (n=24)
PATIENTS AND METHODS In a prospective study daily -scan ultrasound examinations of the maxillary sinuses were performed on 44ICU patients who re¬ quired prolonged intubation (range, 2 to 19 days; average, 7.0 days) and mechanical ventilation. Due to a scheduled surgery all patients were orally intubated, provided with a nasogastric feeding tube, and underwent their operation. The reasons for admission to the ICU included prolonged recovery from abdominal, thoracic, or posttraumatic surgery. One day postoperatively, while in ICU, the oral tubes were replaced nasotracheally in 20 patients. The tube was placed in the most patent nostril and the feeding tube in the other. There was no observation of substantial septal deflection. In 24 patients the tubes remained orotracheally. This group had their feeding tube in one nostril, the other nostril was free. The patients were distributed to the nasotracheal group on even-numbered days and to the orotracheal group on oddnumbered days. They were comparable with respect to age, sex, reason for admission, and length of observation. Demographic characteristics are noted in Table 1. All patients were intubated with polyethylene tubes with an internal diameter of 7.0 to 8.0 mm
(Mallinckrodt Ine, Athlone, Ireland).
Accepted
for
publication May 6,
1992.
From the Ear, Nose, and Throat Department (Drs Michelson and Schuster) and Institute of Anesthesiology (Dr Kamp), University of
Erlangen-N\l=u"\rnberg(Germany). Reprints not available.
Daily -scan ultrasound examinations ( -scan, MG 4000, Knott Elektronik, München, Germany) of the maxillary sinuses were
performed in a half-sitting position from the day of admission to the ICU until extubation, tracheotomy, death, or transfer. The findings were recorded by a thermal writer. A sonographic echo
Downloaded From: http://archotol.jamanetwork.com/ by a University of Manitoba User on 06/20/2015
of the backwall of the antral sinus was interpreted as either max¬ illary effusion or maxillary sinusitis with no attempt to distin¬ guish between the two conditions on the basis of the sonogram. In the event of a pathologic sonographic finding, a diagnos¬ tic aspiration of the involved antral sinus was carried out. The aspirates were tested for aerobic and anaerobic culture and
sensitivity. All patients were treated initially with systemic antibiotics due to the underlying disease. To prevent airway colonization and nosocomial respiratory infections, a local prophylactic treatment
1.—Sinus findings ( -scan) at the end of the observation period in (A) nasally (n=16) and (B) orally (n=18) intubated patients. Ten patients (four nasally, six orally intubated) with pathologic sinus findings at the beginning of the investigation were excluded.
Fig
performed
with an antimicrobial solution applied to the stomach.4 Statistical evaluations are based on the 2 test. A value of .05 or less was considered significant.
was
mouth,
nose, and
RESULTS At the end of the investigation period 19 (95%) of 20 na¬ sotracheally and 15 (63%) of 24 orotracheally intubated patients showed a unilateral or bilateral pathologic sinus finding (Fig 1) (P
