Otorhinolaryngological problems occurring within the intensive care unit

Abstract

Objective

An overview of common otorhinolaryngological (ORL) problems and procedures in the intensive care unit (ICU) is presented.

Focus

Diagnostic, management, and treatment aspects of some conditions are discussed with emphasis on the potential difficulties encountered in the ICU. Approach recommendations are outlined as well as a list of required basic equipment.

Conclusions

Otorhinolaryngology should be included in intensive care continuing medical education programs.

Introduction

Intensive care unit (ICU) patients may be admitted with known otorhinolaryngological (ORL) problems or they can develop such problems during their stay. Multiple trauma patients are often admitted with temporal or facial bone fractures, facial or sinonasal hemorrhage, or airway obstruction. Patients may also present with complications of ear or sinonasal infection, such as fulminant meningitis or cavernous sinus thrombosis. Usually ORL conditions do not present a diagnostic challenge and their follow-up and treatment correspond with the general condition of the patient. Reduction of a nasal fracture, for instance, can be postponed in unstable cases, while facial nerve injury deserves prompt surgical decompression.

Several conditions may develop in patients during their stay in the ICU. Some require special diagnostic procedures and unique treatment modalities. These include rhinosinusitis secondary to intranasal intubation (i.e., endotracheal or nasogastric tube), acute external or middle ear infection (or middle ear effusion), and nasal, oral or hypopharyngeal trauma secondary to invasive procedures such as intubation or suction (the latter are especially common in patients with clotting disorders or anticoagulant therapy). Cardiopulmonary or neurological conditions or prolonged endotracheal intubation may render tracheotomy necessary. In addition, ORL morbidity unrelated to the patient's current serious condition, as seen in the general population, may warrant diagnosis and therapy.

Rhinosinusitis

The presence of foreign bodies (i.e., various tubes) in the nasal cavity predisposes to the development of nose and sinus infection due to mucosal irritation and pressure applied to the turbinates, leading to mucosal edema and poor drainage, all predisposing to infection. Traumatic insertion of tubes, previous local sinonasal conditions and poor general state of the patient are contributing factors [1, 2, 3]. Pathological findings in plain sinus radiography or computed tomography (CT) are very common among ICU patients: antral mucosal thickening, air fluid levels or opacity were found in approximately 90% of nasotracheally intubated patients 8 days after intubation [4, 5, 6], while actual sinonasal disease was diagnosed in 2–26% of patients [2, 7, 8, 9].

Accurate diagnosis of rhinosinusitis in the ICU is difficult: anamnestic information (i.e., pain) is often lacking, and signs such as facial tenderness or postnasal drip are unreliable. More often than not the presenting sign is fever or sepsis, which is quite atypical for sinusitis. Imaging modalities are usually less reliable in ICU patients, since positioning is limited and transfer (to the CT unit) may be dangerous in unstable patients. Ultrasonographic imaging is sometimes recommended [10], but its accuracy is debatable in maxillary involvement [11, 12] and it is questionable in most cases of suspected ethmoid, frontal, or sphenoid involvement [13, 14, 15]. Currently, endoscopic examination, seeking purulent discharge in the middle meatus, in conjunction with sinus CT is considered the most reliable diagnostic approach [8].

Endoscopic rhinoscopy often requires the use of nasal vasoconstrictors (decongestants), thereby posing a potential problem in ICU patients with fragile cardiovascular status [16]. During examination the endoscopist must lean over the patient's bed in an uncomfortable position and usually must apply suction. These working conditions render such a simple procedure an elaborate and prolonged undertaking, sometimes with unreliable results.

Antral lavage is an important diagnostic and therapeutic modality among ICU patients with rhinosinusitis [17]. Routine lavage involves local anesthesia, insertion of a trocar needle into the maxillary sinus via either nose or canine fossa, and flushing the cavity, assisted by negative intranasal pressure applied by the sitting patient. The procedure in the ICU requires certain modifications, such as insertion of two needles to enable flushing in the noncompliant and recumbent patient, meticulous aseptic technique to ensure reliable culture [11], and special attention towards potential hemorrhage following this minimally invasive procedure. When a large amount of pus is aspirated, a fine polyethylene tube may be inserted through the needle and left in the antrum for a few days to allow daily lavage and administration of antimicrobial drugs directly into the diseased sinus.

While rhinosinusitis alone is a sufficiently serious condition in ICU patients, it may also be a contributing factor in the development of ventilator-associated pneumonia and septicemia [18, 19, 20, 21]. Prompt diagnosis and appropriate treatment (antibiotics, decongestants, mucolytics) can therefore prevent complicated scenarios that may require surgical intervention.

Ear problems

Debilitated patients may easily develop external or middle ear infection. In addition to the associated pain, discomfort, and hearing loss, these conditions may also lead to severe complicated infections such as mastoiditis, sigmoid sinus thrombosis, petrositis and facial nerve dysfunction with potential life-threatening implications [22, 23, 24]. Diagnosis requires otoscopy by an experienced otolaryngologist. Simple outpatient procedures such as cleaning cerumen or myringotomy, readily performed under a microscope, become cumbersome in the ICU setting. Usually a microscope cannot be transported to the ICU, forcing the surgeon to use a hand-held surgical otoscope. In more complicated cases, especially when insertion of ventilating tubes is contemplated in addition to plain myringotomy and obtaining culture [25], the patient must be transferred to the operating room for performing this delicate procedure under optimal conditions.

Hearing loss among ICU patients is a frequent, often neglected, problem [26, 27], caused by accumulation of secretions or cerumen in the external ear canal, middle ear effusion, traumatic tympanic membrane perforation (i.e., trauma cases involving cranial fractures or blast injury), drug ototoxicity, acoustic trauma, hypoxia or brain dysfunction. Patients may also suffer from tinnitus and vestibular dysfunction. These handicaps in communication and balance can be very debilitating, yet they may be easily missed in the critically ill patient.

The approach to such problems requires awareness and sensitivity, a high level of suspicion, inclusion of otoscopy in the routine follow-up examination, routine screening hearing tests (i.e., otoacoustic emissions), and frequent ORL consultations.

Lacerations and bleeding

Oral or nasal bleeding secondary to trauma, anticoagulant therapy, liver or bone marrow failure are not infrequent occurrences. Identifying the source and controlling the bleeding are procedures requiring proper inspection tools and facilities, plus correct use of therapeutic modalities such as anterior and posterior nasal packs, use of vasoconstrictor solutions, chemical or electrical cautery, and suturing. Oral lacerations, involving the lips, mucosa, gingiva, tongue, soft and hard palate are common injuries, the extent of which may be missed by superficial examination, while proper inspection and suturing may prevent late infection or deformity. Hypopharyngeal insults may cause severe edema, deep neck infection and mediastinitis. Nasal injuries resulting from endonasal tubes are common. They include ulcerations of the nostrils and septum and fractures of the turbinates [28]. These injuries can easily lead to adhesions and subsequent nasal obstruction, or to infection, ranging from local to cavernous sinus thrombosis. All such (often iatrogenic) lesions can be avoided by delicate and careful handling of feeding, suction or airway tubes. Deficient awareness to such lesions is attested by the lack of published information on their incidence and complications.

Salivary glands

Diseases of salivary glands are not common in ICU patients. However, sometimes sialadenitis, parotitis, or parotid abscess may underlie fever and/or sepsis. Careful examination of the submandibular, sublingual and parotid areas is warranted in such cases, as well as oral inspection of the orifices of the glands for signs of infection. Debilitated general state and poor oral hygiene may both lead to stasis of saliva and development of infection. Clinical examination is generally sufficient for correct diagnosis; for suspected abscesses, ultrasonography or CT of the salivary glands may prove helpful [29]. Therapy includes antibiotics, improved hydration, and oral cleansing.

Dental problems

Dental problems are also encountered in the ICU. Dental caries should be noted, preventively treated and followed up daily. Periodontal infection and gingivostomatitis are very painful conditions, which may also result in bacteremia or abscess formation [30]. These may be a significant cause for exacerbated diabetes mellitus. Dental trauma following intubation is not a rare occurrence; unless treated promptly, it might cause loss of a tooth or a permanent deformity, particularly in children.

Airway

Replacing prolonged endotracheal intubation with tracheostomy is a common procedure that improves safety, comfort, and communication. There is an increasing trend to perform the operation in the ICU, with some recent publications attesting to the safety and cost-effectiveness of bedside tracheotomy [31, 32, 33]. Increased availability of the procedure shortens the translaryngeal intubation period thus minimizing long-term laryngotracheal injuries typically encountered in prolonged intubation.

Standard surgical equipment is usually less available in the ICU than in the operating room, and dedicated instruments and lighting fixtures, various suturing materials and an electrosurgical unit must be brought in by special order. A particularly important issue is ergonomics. A standard ICU bed is 100 cm wide, and its maximal height is 100 cm (mattress included). With the patient lying in the bed center it is quite difficult to reach out and operate on the neck. An operating room table, in comparison, is normally only 45 cm wide and its height is adjustable. Bedside tracheotomy in the ICU is therefore a strained experience for the surgeon that interferes with the quality of performance [34, 35]. This is particularly true when the procedure is performed by overworked, less experienced young residents, or nowadays when new percutaneous tracheotomy techniques [36] are being considered by ICU personnel.

One approach to warrant ergonomically improved ICU tracheotomy is to move the patient cephalad toward a narrow board placed under the head of the bed. Pillows are used to ensure proper position and to equalize the difference in height. The overall board height is finally adjusted by changing the height of a supporting under-the-board swivel chair and of the bed [37, 38]. This approach, based on easily available means, enables comfortable performance of any (nonmajor) head and neck procedure. The advantages are: (a) fewer patients require transportation out of the unit, (b) witnessing the procedure or actively participating in performance offers excellent training experience for ICU medical and nursing staff. It also provides direct and useful feedback information on the condition of the trachea following prolonged endotracheal intubation.

Percutaneous dilational tracheotomy is becoming a frequent procedure [39, 40]. While seemingly easy, complications might and do occur [40, 41]. Indeed, their incidence may be higher than with open tracheotomy [42], mainly due to an inability to reinsert a tracheostomy tube following accidental extrusion. It is therefore strongly recommended to ensure the presence of ORL backup during the procedure. It is also advisable to position an endoscope just below the vocal folds to ensure correct positioning of the tracheostomy tube.

Complications of tracheotomy include hemorrhage (requiring exploration of the neck), pneumothorax, tracheal/laryngeal/esophageal injury and wound infection.

While the airway is a salient issue in any ICU patient, it is particularly problematic in those with severe maxillofacial injuries [43, 44, 45]. In such cases airway management options include oral or nasal (fiberoptic) intubation, tracheotomy, or submental intubation [46].

The use of a simple fiberoptic endoscopic examination allows confirmation of the position of the tracheostomy tube within the trachea and its relation to the carina. It allows visualization of the larynx and trachea above and below the tracheostomy to assess the degree of mucosal damage secondary to prolonged intubation and provides information as to whether any subsequent decannulation may give rise to problems.

Another not infrequent problem, following prolonged care, is laryngeal or tracheal stenosis, and tracheomalacia. These conditions are a reflection and often a consequence of diseased airway walls. They may be avoided by strict adherence to routine measures such as good tube fixation, frequent deflation of the tube's balloon, gentle and patient suctioning and meticulous hydration of inspired air [47, 48, 49, 50, 51]. Once these conditions are found, complicated surgical interventions are often warranted, involving laser ablation, segmental resections and stenting [52, 53, 54], with a great risk to the usually unstable patients.

The issue of tracheostomy goes beyond the scope of this article, and not all aspects of tracheostomy are covered in this review.

Conclusions and recommendations

Confronted with imminent, often life threatening medical conditions, ORL issues are, in many cases, not a first-line concern for ICU staff. This is attested by the scarcity of relevant information in textbooks and journals of critical care medicine. Some of these problems might backfire in a most unpredictable manner, leading to severe or even catastrophic complications. Increased awareness and routine ORL screening and follow-up examination are likely to prevent unwanted surprises, as may inclusion of ORL in the continuing medical education programs of the ICU staff.

ORL procedures often require specific and dedicated instrumentation and equipment that are usually unavailable in the ICU. Preparatory and expectant awareness to those needs may increase efficient management when such issues are encountered. Table 1 lists some (relatively inexpensive) recommended equipment, which may help the ICU staff and the consultant otolaryngologist to work in an enhanced environment.

Table 1. Recommended equipment for ORL procedures in the ICU