RISK-FACTORS AND CLINICAL RELEVANCE OF NOSOCOMIAL MAXILLARY SINUSITISIN 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 a dmission and were divided into three groups according to the radiologi c aspect of their maxillary sinuses: Group 1 = normal maxillary sinuse s (n = 40), Group 2 = maxillary mucosal thickening (n = 26), Group 3 = radiologic maxillary sinusitis (RMS) defined as the presence of an ai r fluid level and/or opacification of maxillary sinuses(n = 96). Group 1 patients were randomized between nasal and oral endotracheal intuba tion with a gastric intubation performed via the same route and had a second paranasal CT scan 7 d later. Endotracheal and gastric tubes wer e left in their original position in Group 2 patients and a second par anasal CT scan was performed 7 d later. All patients of Group 3 underw ent a transnasal puncture for bacteriologic analysis of maxillary sinu s content. Forty-five spontaneously breathing patients served as a con trol group. In all patients with RMS, the occurrence of bronchopneumon ia (BPN) was prospectively assessed for 7 d following the initial CT s can. Upon inclusion, only 25% of the patients had normal maxillary sin uses 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 f actors for RMS were nasal placement and duration of endotracheal and g astric 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 w ere considered IMS. Qualitatively, 47% of the microorganisms isolated were gram-negative bacteria. Quantitatively, 60% of the isolated micro organisms 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). Followi ng maxillary drainage, signs of sepsis resolved in 47% of patients wit h IMS. In conclusion, IMS is an important focus of infection frequentl y associated with BPN in ventilated critically ill patients. Its incid ence can be markedly reduced by inserting endotracheal and gastric tub es via the oral route.