II. Risk Factors
- Nasotracheal Intubation (more than orotracheal intubation)
- Nasogastric Tubes (more than Orogastric Tubes)
- Orotracheal Intubation
III. Causes
- Nosocomial Bacterial Sinusitis
- May be responsible for up to 40% of unexplained fever in Intensive Care patients
- Gram Negative Bacteria (e.g. Pseudomonas, Klebsiella) account for up to 50% of cases
- Gram Positive Bacteria (e.g. Streptococcus, Staphylococcus) account for another 35% of cases
- Invasive Fungal Sinusitis (Immunocompromised patients)
- Rapidly progressive over hours
- Requires emergent surgical management
IV. Labs
- Gram Stain and Culture of sinus aspirate (by ENT)
- Nasal PCR for MRSA
V. Imaging
- CT Sinus
-
Sinus XRay has poor Test Specificity
- Most patients with 7 days of Nasogastric Tubes or nasotracheal tubes will have sinus fluid on XRay
- Fluid is sterile in nearly two thirds of those with xray findings
- Rouby (1994) Am J Respir Crit Care Med 150(3):776-83 +PMID: 8087352 [PubMed]
VI. Management
-
General measures
- Consult Otolaryngology
- Intravenous Fluids (if Sepsis, follow guidelines)
- Empiric Antibiotics
- Imipenem (or Meropenem) or Ceftazidime (or Cefepime)
- Add Vancomycin if MRSA suspected (e.g. MRSA Nasal PCR or culture positive)
- Empiric Antifungal management (as indicated in Immunocompromised patients)
- Suspected invasive fungal Sinusitis requires emergent otolaryngology Consultation
- Amphotericin B (covers Mucor and Aspergillus) AND
- Triazole such as Posaconazole or Isavuconazole (covers Scedosporium)