Acute paranasal sinusitis in critically ill patients: guidelines for prevention, diagnosis, and treatment

Nosocomial sinusitis is common in critical illness. Randomized trials indicate that radiographic sinusitis (RS) occurs in 25%-75% of all critically ill patients and that 18%-32% of endotracheally intubated patients will develop sinusitis. Variability in the estimated incidence of RS stems from the many radiographic techniques used for diagnosis. Critically ill patients with suspected sinusitis should undergo computed tomographic scanning of all paranasal sinuses. If the scans are positive (opacification, mucosal thickening, air-fluid level), aspiration is performed after meticulous nasal disinfection. Infection is confirmed if a pathogen is identified along with neutrophils. Nosocomial sinusitis is usually caused by gram-negative bacilli or is polymicrobial. Pseudomonas aeruginosa, the most common causative organism, represents 15.9% of isolates. The most common gram-positive isolate is Staphylococcus aureus (10.6%); fungi represent 8.5% of isolates. Infection is treated with aspiration and systemic antibiotics. Treatment failures are common; drainage with indwelling catheters is sometimes necessary.