Sinusitis as a Source of Sepsis in Critical Care

Epidemiology and Risk Factors

Sinusitis can progress to sepsis, particularly in critically ill patients with nasotracheal tubes, nasal devices, or immunocompromised status, and may cause significant mortality if not promptly diagnosed and treated. 1, 2
Nosocomial sinusitis occurs predominantly in patients with nasotracheal intubation (and also possible with orotracheal intubation) and those with fine‑bore nasogastric tubes. 1, 2
In a surgical intensive‑care unit cohort with hidden‑source sepsis, sinusitis was the sole infection focus in 1 of every 19 patients. 1, 2

Specific physical signs are often absent when sinusitis is the source of sepsis; the most common clue is mucopurulent nasal discharge. 1, 2

The predominant pathogens are gram‑negative enterobacteria (including Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterobacter spp., Proteus mirabilis, Serratia marcescens) and gram‑positive cocci, which have a high potential for systemic dissemination. 3, 4

Intracranial complications of sinusitis are rare but can lead to substantial morbidity and mortality. 5
Reported intracranial complications include meningitis, encephalitis, epidural and subdural empyema, brain abscess, and dural sinus thrombophlebitis. 5
Low socioeconomic status and limited access to healthcare are positively associated with a higher risk of intracranial complications. 5
Frontal sinusitis is the most common origin of intracranial complications, typically spreading via septic thrombi through valveless diploic veins that penetrate the dura mater. 5
Warning signs of intracranial involvement comprise Pott’s tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsies. 5
Isolated sphenoid sinusitis is uncommon in children (≈ 1–3 % of sinonasal disease) but carries a very high mortality and morbidity when diagnosis is delayed. 5

In any septic patient who has a nasotracheal tube, a fine‑bore nasogastric tube, or recent cranial trauma, acute sinusitis should be suspected. 1, 2
Initial imaging should be a maxillary sinus radiograph to assess for fluid accumulation. 1, 2
If the radiograph does not reveal fluid, a computed tomography (CT) scan is recommended. 1, 2
When imaging demonstrates sinus fluid, an antral puncture should be performed for definitive diagnosis and therapeutic drainage before initiating antibiotic therapy. 1, 2

Simple nasopharyngeal swabs or nasal aspirates are not useful for diagnosing acute sinusitis because they cannot reliably differentiate normal nasal flora colonization from true sinus infection. 5