II. Risk Factors

  1. Nasotracheal Intubation (more than orotracheal intubation)
  2. Nasogastric Tubes (more than Orogastric Tubes)
  3. Orotracheal Intubation

III. Causes

  1. Nosocomial Bacterial Sinusitis
    1. May be responsible for up to 40% of unexplained fever in Intensive Care patients
    2. Gram Negative Bacteria (e.g. Pseudomonas, Klebsiella) account for up to 50% of cases
    3. Gram Positive Bacteria (e.g. Streptococcus, Staphylococcus) account for another 35% of cases
  2. Invasive Fungal Sinusitis (Immunocompromised patients)
    1. Rapidly progressive over hours
    2. Requires emergent surgical management

IV. Labs

  1. Gram Stain and Culture of sinus aspirate (by ENT)
  2. Nasal PCR for MRSA

V. Imaging

  1. CT Sinus
  2. Sinus XRay has poor Test Specificity
    1. Most patients with 7 days of Nasogastric Tubes or nasotracheal tubes will have sinus fluid on XRay
    2. Fluid is sterile in nearly two thirds of those with xray findings
    3. Rouby (1994) Am J Respir Crit Care Med 150(3):776-83 +PMID: 8087352 [PubMed]

VI. Management

  1. General measures
    1. Consult Otolaryngology
    2. Intravenous Fluids (if Sepsis, follow guidelines)
  2. Empiric Antibiotics
    1. Imipenem (or Meropenem) or Ceftazidime (or Cefepime)
    2. Add Vancomycin if MRSA suspected (e.g. MRSA Nasal PCR or culture positive)
  3. Empiric Antifungal management (as indicated in Immunocompromised patients)
    1. Suspected invasive fungal Sinusitis requires emergent otolaryngology Consultation
    2. Amphotericin B (covers Mucor and Aspergillus) AND
    3. Triazole such as Posaconazole or Isavuconazole (covers Scedosporium)

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