BEDSIDE DRAINAGE

Otolaryngologic disorders present several peculiarities that pose a formidable challenge to the practicing intensivist. The proximity of sensitive anatomic structures in a relatively narrow space predisposes patients to serious complications from infectious and neoplastic diseases, yet the critical care literature addressing Otolaryngologic problems is conspicuously lacking. Although a thorough discussion of this topic is beyond the scope of this article, we have provided an update on nosocomial bacterial rhinosinusitis, upper airway complications, and otic disorders from a critical care perspective. The now widely used technique of percutaneous dilatational tracheostomy in intensive care units (ICUs) has been described extensively in the recent literature (1, 2) and is not addressed in this review.

NOSOCOMIAL SINUSITIS

According to the National Nosocomial Infection Survey System, infections of the ear, eyes, nose, or throat account for 4% of all nosocomial infections (3). Sinusitis represented 64% of these infections alone. Epidemiologic surveys have linked both nasotracheal and nasogastric intubation to the occurrence of nosocomial sinusitis (4, 5). In a prospective study of 162 patients, Rouby and colleagues (4) demonstrated that after 7 days of nasotracheal intubation and nasogastric tube placement, 95% of patients had evidence of radiologic pansinusitis compared with 25% with orotracheal and orogastric intubation. The principal mechanism responsible for the development of sinusitis in these patients is impaired drainage of the paranasal sinuses as a result of physical irritation and mechanical obstruction of the ostia, which lead to an overgrowth of bacterial flora in the sinuses. Other contributory factors have included nasal colonization with enteric gramnegative bacilli, sedation, use of high-dose corticosteroid therapy, and a Glasgow coma score of 7 or more (6), although none have been proven to be causative.

There is an ongoing debate on whether nosocomial sinusitis can be the source of ventilator-associated pneumonia. In three studies of patients requiring mechanical ventilation (7-9), the incidence of ventilator-associated pneumonia ranged from 29-67% among patients with sinusitis, compared with 5-43% without sinusitis. Similarities between organisms isolated from the lower respiratory tract and the sinuses occurred in 38-56%.

The diagnosis of nosocomial sinusitis involves typically radiographic evaluation. Plain bedside radiography is of little value in the ICU setting because adequate radiographic examination will require at least five views to achieve a confidence level of 88% (10). B-mode ultrasonography has been suggested as a rapid and innocuous tool for the daily monitoring of maxillary sinusitis in critically ill patients with a sensitivity of 50-100% and a specificity of 87-100% when compared with computer tomography scan or standard radiography (11-13). Its accuracy, however, is questionable in suspected ethmoid, frontal, or sphenoid involvement (14). A computer tomography scan remains the most reliable noninvasive diagnostic modality for those deemed stable to be transferred to the radiology suite. The presence of an air fluid level or opacification is considered the hallmark for the diagnosis of radiographic sinusitis. In these cases, the yield of positive cultures on aspiration has ranged from 40-70% (15, 16). When the presence of purulence in the middle meatus on endoscopic examination was combined with radiographic evidence of sinusitis, positive antral lavage increased to 92% (17).

Antral lavage is considered the standard diagnostic and therapeutic procedure among ICU patients with rhinosinusitis (18). The technique is performed either transnasally via the inferior meatus or transorally through the canine fossa. Both methods carry the risk of contamination with the local bacterial flora (19). Even with thorough disinfection of the nasal cavity with povidone-iodine, only 50% of septum swab samples were free of bacteria (4). To avoid contact with the oral mucosa, Westergren and colleagues attempted antral penetration by preparing a free bone area for trocar insertion (20) reducing the rate of contamination to 5% (95% confidence interval, 0-23%). Using 16S ribosomal RNA polymerase chain reaction followed by sequencing, the same group of investigators suggested that induction of maxillary sinus infection could take place within the mucosa and is not necessarily a direct propagation from the antrum (21). Not uncommonly, the diagnostic value of sinus aspirates in patients who are receiving antibiotics is put to question as prior antibiotic therapy may preclude the recovery of organisms in sinus aspirate cultures (6). However, in a prospective study of 24 mechanically ventilated patients with radiographic evidence of sinusitis, Souweine and colleagues were able to isolate at least one etiologic organism in 63% of the cases while receiving antibiotic treatment (22).  Medical Supplies.

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