RISK-FACTORS AND CLINICAL RELEVANCE OF NOSOCOMIAL MAXILLARY SINUSITIS IN THE CRITICALLY ILL

The incidence of infectious maxillary sinusitis (IMS) and its clinical relevance was prospectively studied in 162 consecutive critically ill patients who were mechanically ventilated for a period longer than 7 d. All had a paranasal computed tomographic (CT) scan within 48 h of admission and were divided into three groups according to the radiologic aspect of their maxillary sinuses: Group 1 = normal maxillary sinuses (n = 40), Group 2 = maxillary mucosal thickening (n = 26), Group 3 = radiologic maxillary sinusitis (RMS) defined as the presence of an air fluid level and/or opacification of maxillary sinuses(n = 96). Group 1 patients were randomized between nasal and oral endotracheal intubation with a gastric intubation performed via the same route and had a second paranasal CT scan 7 d later. Endotracheal and gastric tubes were left in their original position in Group 2 patients and a second paranasal CT scan was performed 7 d later. All patients of Group 3 underwent a transnasal puncture for bacteriologic analysis of maxillary sinus content. Forty-five spontaneously breathing patients served as a control group. In all patients with RMS, the occurrence of bronchopneumonia (BPN) was prospectively assessed for 7 d following the initial CT scan. Upon inclusion, only 25% of the patients had normal maxillary sinuses whereas all patients in the control group had normal paranasal CT scans. After 7 d, 46% of Group 2 patients had evidence of RMS. Risk factors for RMS were nasal placement and duration of endotracheal and gastric intubation. In Group 1 patients, placement of endotracheal and gastric tubes to the oral route decreased the incidence of RMS from 95.5% to 22.5% (p < 0.001). After transnasal puncture, only 38% of RMS were considered IMS. Qualitatively, 47% of the microorganisms isolated were gram-negative bacteria. Quantitatively, 60% of the isolated microorganisms were found in concentrations greater than or equal to 10(3) cfu/ml. BPN were more frequent in patients with IMS than in those with noninfectious maxillary sinusitis (67% versus 43%, p < 0.02). Following maxillary drainage, signs of sepsis resolved in 47% of patients with IMS. In conclusion, IMS is an important focus of infection frequently associated with BPN in ventilated critically ill patients. Its incidence can be markedly reduced by inserting endotracheal and gastric tubes via the oral route.