Blind Nasotracheal Intubation as a cause of sinusitis.

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Yes.  There is considerable literature that suggests that 
paaranasal sinusitis is a frequent complication of NTI and is not merely a
surgical conceit. A recent study on 70 patients confirmed the greater
likehood of sinusitis in NTI vs OTI patients (1).  Another found evidence
of sinusitis in 6/16 between the second and third day post intubation and
in all by the eighth day (2).  Much of the early literature on this did
indeed come from the surgical specialties, particularly neurosurgical
patients intubated for head injuries and cerebral hemmorhage (4,5). One
study in burn patients confirmed these findings and noted that pre-existing
sinus disease contributed to the increased likehood of developing sinusitis
after NTI but concluded that the morbidity of this complication did not
justify converting them routinely to an oral route (3).  Others have
observed that sinusitis should be considered in the ddx of sepsis of
undetermined etiology in nasotracheally intubated patients (6).  A large
(300 patient) recent study comparing NTI to OTI concluded that although no
statistically significant difference in incidence of sinusitis was present
between the two groups that a trend did indeed favor it's developement in
NTI patients (7).  They also noted that sinusitis was a risk factor for the
developement of pneumonia.  Comparing the lengths of ICU stay or of
mechanical ventilation, however, failed to differentiate between the two.

 In summary, I believe that these concerns are well founded.  
After 48 hours the incidence of sinusitis appears to increase 
substantailly in NTI patients and after one week it is a nearly universal
finding.

 With reagrds to the observations made about it's incidence in 
neurosurgical patients, I would merely observe: why were they intubated by
the nasotracheal route in the first place?  I consider the presence of a
CNS lesion (whether traumatic, ischemic or otherwise) to be a
contraindication to NTI inasmuch as it is generally done without paralysis
and other methods of cerbral protection.  There is no way, in this setting
to avoid undesirable rises in ICP which could, theoretically, be
detrimental to the patient.

 Nevertheless, I think that one needs to consider ALL factors 
involved when evaluating the preferred route of intubation in any given
circumstance.  Trauma patients, for the reasons mentioned above and because
they may be anticipated to require prolonged intubation may not be good
candidates for this method.  Medical patients with readily reversible
conditions such as CHF or acute asthma, in whom only a short period of
intubation is anticipated would be good candidates.  Of course BNTI also
avoids the risks of RSI, aspiration etc. and these factors are not
evaluated when comparing rates of sinusitis between the two methods.

 I agree with your observation aboout tube size. A 7.5 mm ETT is 
the largest that will confortably fit in an adult male.  Attempting to
insert a larger one will almost certainly result in a nasal turbinate
fracture.  Thus, if brochoscopy is anticipated for diagnostic or
therapeutic reasons then the OTI route would be indicated from the start.



H. Louzon MD


(1) 

Bach A Boehrer H Schmidt H Geiss HK Nosocomial sinusitis in ventilated
patients. Nasotracheal versus orotracheal intubation.  In: Anaesthesia
(1992 Apr) 47(4):335-9 A total of 68 postoperative patients whose lungs
were ventilated for
  more than 4 days were studied prospectively during a one-year study
  period to investigate the effect of the mode of intubation on the
  paranasal sinuses. After an initial X ray of the skull showing no
  pathological findings, patients were assigned randomly to one of the
  study groups; the lungs of patients in group A were ventilated via an
  orotracheal tube (n = 32), and patients in group B via a nasotracheal
  tube (n = 36). X ray examinations of the sinuses were performed at
  regular intervals. Diagnosis of sinusitis was confirmed by transantral
  needle puncture and culture of fluids obtained. Antibiotic regimens were
  altered according to laboratory testing. Two patients in group A
  developed signs of sinusitis in comparison to 15 patients in group B (p
  less than 0.01). However, there were significantly more airway
  complications in the orotracheal group, particularly during the period of
  weaning from ventilation. We conclude that orotracheal intubation should
  be preferred as the routine route of intubation.  

(2) 

Fassoulaki A Pamouktsoglou P 
Prolonged nasotracheal intubation and its association with
  inflammation of paranasal sinuses.  
In: Anesth Analg (1989 Jul) 69(1):50-2 
Sixteen critically ill patients whose tracheas were intubated through
  the nasal route were examined for paranasal sinusitis between the 2nd and
  3rd day and again on the 8th day after intubation. Between the 2nd and
  3rd days, 6 of the 16 patients developed either maxillary sinusitis alone
  (3 of them) or sphenoid sinusitis (in the other 3). By the 8th day, all
  patients had developed sinusitis involving at least one sinus. The most
  commonly affected sinuses were the maxillary (87%) and the sphenoid (87%)
  followed by the ethmoid (50%) and frontal (12.5%). On the day 8 after
  intubation, the nasotracheal tubes were removed and replaced by
  orotracheal tubes, or tracheostomies were performed. On day 8 after
  extubation, 10 of the 16 patients were reexamined. Computer tomographic
  (CT) scan at this time revealed persistent sinusitis in two. Long-term
  nasotracheal intubation is associated with sinusitis.  

(3) 

Bowers BL Purdue GF Hunt JL 
Paranasal sinusitis in burn patients following nasotracheal intubation. 
In: Arch Surg (1991 Nov) 126(11):1411-2 Paranasal sinusitis is a
complication of nasotracheal intubation. Of
  99 nasally intubated adult patients who survived 48 hours after being
  burned, 22 who were intubated for more than 7 days underwent a computed
  tomographic scan of all paranasal sinuses, with timing dictated by the
  patient's clinical condition. Eight pataients had computed tomographic
  and clinical findings consistent with sinusitis. Treatment consisted of
  removal of all nasal tubes, oral and topical nasal decongestants, and,
  when appropriate, culture-specific antibiotics. A subgroup of patients
  with preexisting sinus disease made up 50% of the patients with
  sinusitis; early conversion to an oral airway or a tracheostomy should be
  considered in such patients. Only one patient required surgical drainage
  of the sinuses. The frequency and morbidity of sinusitis in
  nasotracheally intubated burn patients does not justify the risk of
  routine conversion to an oral airway.  


(4) 

Hansen M Poulsen MR Bendixen DK Hartmann-Andersen F
Incidence of sinusitis in patients with nasotracheal intubation.  
In: Br J Anaesth (1988 Aug) 61(2):231-2 
Sinusitis is a complication known to accompany nasotracheal
  intubation, but its frequency has not been well documented. Twelve
  patients suffering from cerebral haemorrhage or from cranial trauma
  and treated with mechanical ventilation were examined for
  radiological and bacteriological signs of sinusitis with CT-scanning, and
  cultures of nasal pus discharge. All patients showed radiological signs
  of sinusitis within 3 days after intubation. They all developed fever,
  six with a known focus outside the sinuses. There was an even
  distribution of Gram-negative and Gram-positive bacteria. It is concluded
  that sinusitis should be considered where fever occurs without known
  focus in patients with nasotracheal intubation.  

(5)

Grindlinger GA Niehoff J Hughes SL Humphrey MA Simpson G 
Acute paranasal sinusitis related to nasotracheal intubation of head-
  injured patients.  
In: Crit Care Med (1987 Mar) 15(3):214-7 
One hundred eleven head-injured patients were examined for paranasal
  sinusitis during early convalescence. Glascow coma scale (GCS) was
  less than 8 in 79 patients. Ninety-three patients had sustained blunt
  injuries, and 18 had penetrating ones. Sixty-five orotracheal intubations
  (OTI) and 31 nasotracheal intubations (NTI) were performed at the scene
  or on hospital arrival. Fifteen patients were not tracheally intubated.
  Paranasal sinus air fluid levels (AFL) were present in 30 patients on
  their admitting computerized tomography scans. Paranasal sinusitis
  developed in 19 patients with a mean GCS of 5.4 +/- 3.3 (SD). Sixteen of
  the 19 had NTI, and three had OTI (p less than .05). Of 30 patients with
  AFL, sinusitis occurred in 13. Ten of these 13 had NTI, and three had OTI
  (p less than .05). Penetrating injury did not increase the risk of
  sinusitis (p greater than .1). Seventeen of the 19 infections were
  polymicrobial. Sinusitis after head trauma is related to NTI, AFL, and
  severity of head injury.  

(6) Deutschman CS Wilton P Sinow J Dibbell D Jr Konstantinides FN
  Cerra FB Paranasal sinusitis associated with nasotracheal intubation: a
  frequently unrecognized and treatable source of sepsis.  
In: Crit Care Med (1986 Feb) 14(2):111-4 
Paranasal sinusitis secondary to prolonged nasotracheal intubation
  represents an infrequently reported source of sepsis. Of 27 nasally
  intubated patients who developed paranasal sinusitis over a 1-yr
  period, 17 patients underwent emergency blind nasotracheal intubation
  post-trauma or shock (group 1) and the remaining ten were intubated
  electively under operating room or ICU conditions (group 2). Group 1
  patients were younger (mean age 33 +/- 6 vs. 57 +/- 5 yr) than those in
  group 2; they also developed sinusitis more quickly after intubation
  (mean time 8 +/- 1 vs. 15 +/- 2 days). Diagnosis was confirmed via sinus
  x-rays (14 cases), computed tomography (five cases), indium scan (two
  cases), or clinical picture. Cultures were obtained in 14 cases.
  Staphylococci predominated in group 1, while nosocomial Gram-negative
  organisms predominated in group 2. Seven patients developed pulmonary
  infections and two developed systemic sepsis with an organism present on
  sinus culture. In all cases treatment was successful with antibiotics and
  tracheostomy or movement of the tube to the oral route. These data
  indicate that patients nasally intubated are at risk for development of
  paranasal sinusitis; this diagnosis should be suspected in sepsis of
  undetermined etiology.  

(7) 

Holzapfel L Chevret S Madinier G Ohen F Demingeon G Coupry A Chaudet M
Influence of long-term oro- or nasotracheal intubation on nosocomial
  maxillary sinusitis and pneumonia: results of a prospective,
  randomized, clinical trial [see comments] 
In: Crit Care Med (1993 Aug) 21(8):1132-8 
OBJECTIVE: To compare the occurrence rate of nosocomial maxillary
  sinusitis and pneumonia in patients who have undergone nasotracheal
  vs. orotracheal intubation. DESIGN: Randomized, clinical trial. 
  SETTING: General adult intensive care unit (ICU) in a nonteaching
  public hospital. PATIENTS: A total of 300 (209 male, 91 female)
  patients were included. The mean age was 59 +/- 17 (SD) yrs. The
  simplified acute physiologic score was 14 +/- 6. Reasons for
  admission to the ICU were: coma (n = 78), pneumonia (n = 46),
  infection (n = 35), surgery (n = 34), multiple trauma (n = 20), head
  trauma (n = 12), other (n = 75). Among the 300 patients, 149 were
  randomized into the nasotracheal group and 151 into the orotracheal
  group. No statistical difference was found between initial
  characteristics of the two groups. INTERVENTIONS: Patients were
  randomized between nasal and oral endotracheal intubation. Gastric
  intubation was performed via the same route as endotracheal intubation.
  Sinus computed tomography (CT) scans were performed every 7 days or
  earlier in case of fever and/or purulent nasal discharge. Criteria for
  nosocomial sinusitis were as follows: fever of > 38 degrees C,
  radiographic (sinusal air-fluid level or opacification on CT scan) signs
  and presence of purulent aspirate from the involved sinus puncture with
  10(3) colony-forming units (cfu)/mL. Diagnosis of pneumonia was based on
  classical criteria and a protected brush specimen with 10(3) cfu/mL.
  MEASUREMENTS AND MAIN RESULTS: Radiographic evidence of sinusitis was
  observed in 78 patients, 45 from the nasal group and 33 from the oral
  group (p = .08, log-rank test). Among these patients, 54 fulfilled the
  sinusitis criteria stated above, 29 in the nasal group and 25 in the oral
  group (p = .75, log-rank test). Nosocomial pneumonia was observed in 26
  patients, 17 in the nasal group and 9 in the oral group (p = .11, log-
  rank test). A multivariable analysis considering sinusitis as a time-
  dependent factor has suggested that sinusitis increased the risk of
  nosocomial pneumonia by a factor of 3.8. Nosocomial septicemia was
  observed in 33 patients, 22 episodes in the nasal group and 13 episodes
  in the oral group (p = .11, log-rank test). Overall mortality rate was
  37% in the nasal group vs. 41% in the oral group (p = .37, log-rank
  test). Episodes of atelectasis and accidental extubations, and doses of
  sedative drugs and antibiotics were not different between the two groups.
  Length of mechanical ventilation did not differ between the two
  intubation groups. The mean length of stay in the ICU was 11 +/- 15 days
  in the nasal group vs. 9.5 +/- 11 days in the oral group (p = .27,
  Student's t-test). CONCLUSIONS: In patients undergoing prolonged
  mechanical ventilation, there was no statistically significant difference
  in the occurrence rate of nosocomial sinusitis or pneumonia between
  patients undergoing tracheal intubation via the nasal vs. oral route. A
  trend (p = 0.008) suggests less sinusitis in the orotracheal group. 

(Harvey Louzon)

I found only one reference which supports the 2 to 3 day concept.  The
remainder I found refer to 5 to 7 day periods of intubation and it seems
the incidence with orotracheal intubation is less but still substantial.

Michelson, A. et al. Anaesthetist 40 (2):100-4 1991 Feb.

Lawrence J. Carley
CARLEY@medcolpa.edu