Sinusitis in the critical care patient.

A frequently overlooked source of sepsis in the critical care patient is the paranasal sinuses. These patients are typically unable to communicate and, therefore, the usual findings of sinus infection, such as facial pain and complaints of purulent drainage, will be absent. Sepsis may be the first manifestation of such infection. Nasotracheal intubation is the most important predisposing factor to developing sinusitis in these patients. The clinician, therefore, must maintain a high index of suspicion in any patient with fever of unknown origin. Radiologic studies, including plain sinus radiographs, or preferably, a computed tomography scan, will usually show the presence of fluid or inflammation. Lavage of the maxillary sinus is helpful both to verify the presence of infection and to obtain culture material. These infections tend to be polymicrobial, and often display a predominance of Gram-negative organisms, particularly Pseudomonas aeruginosa. Treatment includes removal of all nasal tubes and institution of appropriate antibiotics, along with decongestant therapy. In some cases, surgical drainage will be necessary. For patients who are immunocompromised, or requiring intubation for > 7 days, the nasotracheal route is best avoided.