Objectives: To investigate the local effects in a nasal cavity and its adjacent sinuses of long-term detention of an endonasal tube, with special attention to inflammatory pathology and microbiology. Study Design: Experimental rabbit study. Methods: Four groups of 4 rabbits, in all 16, were unilaterally nasally intubated and evaluated macroscopically, histopathologically, and bacteriologically after 1, 2, 4, and 8 weeks, respectively. Results: At first, in the 1- and 2-week groups to the 4-week group, histopathology, such as degeneration of olfactory mucosa, squamous cell metaplasia, and polyp formations, was observed together with frequent opportunistic bacterial findings in the nasal cavity. Later, in the 4- and 8-week groups, inflammatory mucosal changes, such as septal increase of connective tissue, goblet cell hyperplasia, and epithelial invaginations, were found in the nasal cavity containing a tube. A concomitant increase was found of commensal bacteria adjacent to Lire tube and the similar bacterial findings in the ipsilateral maxillary sinuses. However, there were no signs of inflammatory reactions in the sinuses. Conclusions: Our investigation points to the tube as the cause of local goblet cell hyperplasia with an increased mucus production, and as a food source for the commensals with a marked increase of the amount of bacteria. The positive bacterial cultures from the maxillary sinuses might be considered to be colonization. However, because of the possibility of contamination, improved sampling techniques are required, as are further studies.

A common foreign body of the nose in intensive care, the nasotracheal tube, has for 20 years been cited as a cause of bacterial infection of the paranasal sinus. High frequencies of bacterial culture positivity have occurred in several studies. However, the state of critically ill patients has to be evaluated before conclusions about cause of infection can be made. Nosocomial colonization with intensive care unit flora, in combination with use of antibiotics, precludes the use of procedures that are standard in office practice and microbiological diagnostics. New methods of sampling and quantitative culturing for the specific purpose of intensive care antral diagnostics, in combination with endoscopic inspection, have enlarged our knowledge of sinusitis. Among patients ventilator-treated for > or = 1 week, the occurrence of bacterial sinusitis is < 10%. For 80% of the examined antra there were similar inflammatory reactions without clinical signs of infection. Sporadically in these, cultures of antral specimens were positive for bacteria, which, by definition, would represent colonization.

We tested the reliability of visual clinical sinoscopic observations by using video recordings. An edited video tape was made from the video-recorded bilateral antral sinoscopies of nine patients included in a prospective case series of inflammatory maxillary sinus disease in critically ill patients. An expert panel of four consultant ENT surgeons made individual appraisals of the video using a structured form. They had only been informed in general about the study, but had no further case knowledge in order to avoid all biases. Concordance and interobserver variabilities in the expert panel were compared in pairs. The assessments of the expert panel were compared with the observations of the performer, who was biased through individual case knowledge. Nine patients, either nasotracheally intubated or tracheotomized, had ventilator treatment for more than 7 days. One ENT surgeon performed all sinoscopies and made the direct observations. Satisfactory agreement was found on mucosal alterations. The concordance of recognizing bacterial infection was almost perfect. However, the assessment of redness from a video recording displayed only chance agreement. The differences between κ statistic values within the expert panel group compared to the comparisons of performer versus expert panel were not significant. The case knowledge of the sinoscopist did not alter the assessments markedly and thus seemed only to have minor influence. Video recording as a method for second opinion was shown to be a useful technique, but will have to be further developed.

The objective of this study was to investigate maxillary sinus infectious or inflammatory disease in long-term mechanically ventilated patients, using a prospective case series design. The subjects were 33 critically ill patients receiving ventilator treatment for more than 7 days, in the general and neurosurgical intensive care units of a tertiary care hospital. Bilateral antroscopies were performed, and antral secretion and mucosal samples were collected for bacterial culturing. Different stages of inflammatory disease were found in 85% of the antra. Infectious sinusitis was diagnosed in 6%, with a predominance of mixed anaerobic infections. Monoisolates of anaerobic or facultative anaerobic bacteria were found in 5% of the antra without clinical signs of infection. In conclusion, more stringent requirements are needed for the diagnosis of infectious sinusitis in ventilator-treated patients. With improved diagnostic techniques there was a significantly lower frequency of infectious sinusitis than presented in previous reports. The bacteria predominating as infectious agents were different to those in previous reports. Furthermore, reactive inflammatory disease with bacterial colonization occurred.

Summary We have examined the accuracy of our present CSF sampling technique in 14 referred patients with suspect shunt dysfunction. The study was performed comparing culture results from shunt reservoir punctures and sham samples from skin tissue fluid close to the reservoirs. Propionebacterium acnes (P acnes) was found in five of fifteen cultures from reservoir punctures and in five of fifteen sham procedures. Positive cultures correlated in two cases. Thirteen of the fourteen patients included in the study were followed clinically and their symptoms disappeared without antibiotic or surgical treatment. One patient was treated surgically. We conclude that bacterial growth in cultures from shunt reservoirs in cases with P acnes should be interpreted with great caution, as our findings indicate that they may be skin contaminations.

Objective: Evaluate A-mode ultrasonographic examination of maxillary sinus disease in mechanically ventilated, critically ill patients using sinoscopy as criterion standard. Design: Prospective case series. Setting: The intensive care units of a tertiary care hospital. Patients: 25 mechanically ventilated, critically ill patients with nasotracheal intubation or a tracheotomy were followed up by ultrasonographic examination of the maxillary sinuses in supine and semirecumbent positions. Infectious sinusitis was suspected in 15 patients, who were bilaterally sinoscoped combined with sampling for bacterial culture. Results: The frequency of oedema and/or secretions was high: 29 antra of 30 examined. Only 2 of 30 antra showed bacterial infection. Ultrasonographic examinations were sensitive to general pathological changes but less accurate in specific diagnostics such as the presence of secretions (sensitivity for fluid 75 %, oedema 81 %). The sensitivity of ultrasonographic diagnosis improved when the examination was made in the semirecumbent position (sensitivity for fluid 91 %, oedema 81 %). Conclusions: A-mode ultrasonography is a useful method for daily use, being easy to perform and without discomfort to the patient. It is fast and gives an immediate diagnosis. In intensive care unit patients, it should be the method of choice for day-to-day studies of effects and changes in the upper airways. For the differential diagnosis of oedema and/or secretions, it is not reliable enough to be used as the sole diagnostic method. A complementary investigation, such as computed tomography or sinoscopy, which also provides the opportunity to take samples, is needed for diagnostic confidence.

An integrated method was constructed for the study of in situ clinical reasoning. A meta-analysis of existing theories and an exploratory case study were performed. Twelve physicians at the department of otorhinolaryngology, and three physicians and three biomedical technologists at the clinical microbiological laboratory of an 800-bed university hospital were involved in the evaluation of the method. The meta-analysis identified situations where practitioners face assignments for which they follow no routine strategy as suitable starting points for the development of the method, in which organizational processes are presented as workflow graphs. Using the critical incident technique, problem situations in the processes are identified, and stimulated recall interviews are employed to construct a model of the situation-dependent logic used in decision-making. The case study showed thatthe first levels of the method could easily be used by physicians without training in organizational development or cognitive psychology. It is concluded that the method can be a means for case construction in problem-oriented learning programs that have an empirical background. It can also be used in the development of clinical organization, where training is combined with the establishment of critical paths and computer support.

OBJECTIVE:To investigate the relationship of the clinical appearance, histological characteristics, bacterial culturing, and messenger RNA (mRNA) expression of RANTES, interleukin 6, and interleukin 12, as well as the occurrence of endothelial adhesion molecules, in inflammatory diseased maxillary sinus mucosa in critically ill patients.DESIGN:Prospective case series.SETTING:General intensive care unit and neurosurgical intensive care unit of a tertiary care hospital.SUBJECTS:Seven critically ill patients, nasotracheally intubated or tracheotomized, who received ventilator treatment for more than 7 days and treatment with antibiotics.INTERVENTIONS:Bilateral biopsy specimens of antral mucosa were obtained at sinoscopy. Reverse transcriptase-polymerase chain reaction was used to detect the cytokine mRNAs in situ on paraformaldehyde-fixed tissue, and intercellular adhesion molecule 1, vascular cell adhesion molecule 1, E-selectin, and P-selectin were analyzed by immunochemistry on frozen sections. Sampling of secretion and tissue from the antra was performed for bacterial culturing.RESULTS:Macroscopic and histological appearance varied and showed moderate to pronounced inflammation in 6 antra. All 4 bacterially infected antra showed mRNA RANTES (P=.005). No correlation was found for interleukin 6 and interleukin 12. Up-regulation of P-selectin in all cases and sparse expression of vascular cell adhesion molecule 1 indicate that the inflammation is chronic but nonallergic in type.CONCLUSION:We find an indication that RANTES is more prevalent in bacterial sinusitis.

Objectives: To investigate extracellular concentrations of antibiotics in inflammatory diseased sinus mucosa in critically ill patients and to find out whether there were any correlations between the concentrations of antibiotics in extracellular tissue and the presence of bacterial infection.Design: Prospective case series. Sinoscopic findings were used as the criterion standard.Setting: The general and the neurosurgical intensive care units of a tertiary care hospital.Patients: Critically ill patients, nasotracheally intubated or tracheotomized, who received ventilator treatment (>7 days) and antibiotic therapy.Interventions: Bilateral sinoscopies were performed; antral secretions were collected for bacterial cultures; and serum and tissue samples were obtained for bioassay of antibiotic concentrations.Results: The concentrations of all antibiotics found in extracellular fluid were lower than those found in serum samples.Conclusion: Measurable extracellular tissue concentrations of antibiotics were found in the antral mucosa, demonstrating that inflammatory maxillary sinus disease does nut impede the antibiotic penetration of the mucosa or antibiotic activity in the extracellular tissue.

Bacterial sinusitis is recognized as a complication of prolonged nasotracheal intubation. Verification of the diagnosis, however, requires culture findings from a "true" sample from the maxillary antrum. A "true" antral sample can only be obtained after passing either the nasal or oral mucosae with their rich aerobic and anaerobic bacterial flora. No properly controlled study has been made into the problem of contaminated samples in bacterial sinusitis complicating prolonged nasotracheal intubation. The design of the study was a case series in an intensive care unit. The patients had either had endotracheal tube or tracheal cannula for seven days or were septic, having an endothracheal tube or a tracheal cannula and therefore due to an investigation of infection foci. Antral cultures obtained via the canine fossa were compared with oral cultures to exclude the contribution of oral bacterial contamination and thereby to improve the reliability of diagnosis based on culture results. The contamination rate was lowered significantly from 67% to 5% when an area of free bone was prepared in the canine fossa thus avoiding instrument contact with the oral mucosa. A high contamination risk can be dealt with by adjusting the technique of sampling thereby increasing the culture reliability.