title: Hospital-acquired sinusitis is a common cause of fever of unknown origin in orotracheally intubated critically ill patients.
abstract: BACKGROUND
  Sinusitis is a well recognised but insufficiently understood complication of critical illness. It has been linked to nasotracheal intubation, but its occurrence after orotracheal intubation is less clear. We studied the incidence of sinusitis in patients with fever of unknown origin (FUO) in our intensive care unit with the aim of establishing a protocol that would be applicable in everyday clinical practice.
  
  
  METHODS
  Sinus X-rays (SXRs) were performed in all patients with fever for which an initial screening (physical examination, microbiological cultures and chest X-ray) revealed no obvious cause. All patients were followed with a predefined protocol, including antral drainage in all patients with abnormal or equivocal results on their SXR.
  
  
  RESULTS
  Initial screening revealed probable causes of fever in 153 of 351 patients (43.6%). SXRs were taken in the other 198 patients (56.4%); 129 had obvious or equivocal abnormalities. Sinus drainage revealed purulent material and positive cultures (predominantly Pseudomonas and Klebsiella species) in 84 patients. Final diagnosis for the cause of fever in all 351 patients based on X-ray results, microbiological cultures, and clinical response to sinus drainage indicated sinusitis as the sole cause of fever in 57 (16.2%) and as contributing factor in 48 (13.8%) patients with FUO. This will underestimate the actual incidence because SXR and drainage were not performed in all patients.
  
  
  CONCLUSIONS
  Physicians treating critically ill patients should be aware of the high risk of sinusitis and take appropriate preventive measures, including the removal of nasogastric tubes in patients requiring long-term mechanical ventilation. Routine investigation of FUO should include computed tomography scan, SXR or sinus ultrasonography, and drainage should be performed if any abnormalities are found.
authors.affiliation: Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands. zantena@zgv.nl
authors.forename: Arthur R H
authors.initials: AR
authors.lastname: van Zanten
authors.forename: J Mark
authors.initials: JM
authors.lastname: Dixon
authors.forename: Martine D
authors.initials: MD
authors.lastname: Nipshagen
authors.forename: Remco
authors.initials: R
authors.lastname: de Bree
authors.forename: Armand R J
authors.initials: AR
authors.lastname: Girbes
authors.forename: Kees H
authors.initials: KH
authors.lastname: Polderman
mesh_terms: D002985:Clinical Protocols; D003422:Critical Care; D003428:Cross Infection / Q000150:complications*; D005260:Female; D005335:Fever of Unknown Origin / Q000209:etiology*; D006801:Humans; D015994:Incidence; D007442:Intubation, Intratracheal / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000009:adverse effects; D012852:Sinusitis / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology