The nasogastric tube has been used frequently for enteral feeding and as anintranasal oxygen catheter. This practice is however associated with complications. We present a case of rhinosinusitis and sepsis in a diabeticpatient following the insertion of a nasogastric tube. Physicians should be aware of sinusitis as a possible cause of sepsis in patients with nasogastric tube insertion.Key words: Rhinosinusitis, Nasogastric Tub

Abdullahi, H

Adebolajo, AA

Adeosun, AA

Fasunla, AJ

English

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Key words: Rhinosinusitis, Nasogastric TubeINTRODUCTIONRhinosinusitis is a common disease entity and basedon duration of symptoms and signs, it has beenclassified into four sub-types namely acute, subacute,recurrent acute and chronic sinusitis1. This may beinfective or non-infective. Various predisposingfactors to rhinosinusitis have been documented inthe literature2. A number of host factors predisposethe patient to sinusitis and they includeimmunodeficiency, acetylsalicylic acid-asthma-polyposis triad, abnormal mucociliary clearancesecondary to ciliary structural abnormalities, as inKartagener’s syndrome, or secretory disturbances,such as those in cystic fibrosis3. Nasogastric tube asis very often used in medical practice. Inunconscious patients, prolonged nasogastricintubation is often necessary. The risks ofcomplications following its uses are oftenunderestimated and under-reported4. We present acase of nasogastric tube being a cause of acuterhinosinusitis in a diabetic patient.CASE SUMMARY  A 32 year old male driver; a known diabeticpatient who has not been compliant with hismedications. He presented with a day history ofsudden onset abdominal pain, associated withvomiting and altered sensorium. He lapsed intounconsciousness few hours after reporting in thehospital. There was no premorbid history suggestiveof  rhinosinusitis. A diagnosis of  diabeticketoacidosis was made. Blood glucose on admissionwas 557mg/dl. He was adequately re-hydrated withintravenous fluid and also commenced on insulintherapy. He had intranasal oxygen supplementationvia a nasogastric tube inserted into the left nasalcavity. This was removed on the fourth day ofadmission after he regained consciousness. Hisblood glucose was now within normal limits. Hesubsequently developed fever which was associatedwith painful swelling around the left nasal cavity andleft periorbital region, left mucopurulent nasaldischarge and blockage. He was commenced onintravenous antibiotic (Ciprofloxacin andMetronidazole).Examination revealed a young man, pyrexic; withleft cheek swelling, periorbital oedema and swellingof the left side of the nose. There was leftmucopurulent nasal discharge with mucosahyperemia and engorged inferior turbinate. The leftnasal cavity was not patent.Plain x-ray of the sinuses shows opacity of the leftmaxillary antrum. Screening for Human Immunodeficiency virus wasnegative.Microscopy, culture and sensitivity of  the left nasalswab revealed no organism and yielded no growth.The patient was managed conservatively with steaminhalation, naris argotone (mixture ofpseudoephedrine and silver nitrate) and analgesics.His clinical condition improved steadily, the bloodglucose level remained within normal limit and hewas subsequently discharged home.DISCUSSIONRhinosinusitis of viral origin leads to inflammatorychanges and retained secretions which readily lead tobacterial superinfection.5 Sinus drainage andventilation of the paranasal sinuses are dependent onthe patency of the osteomeatal complex2. Nasalforeign bodies such as nasogastric tubes,nasotracheal tubes and nasal packs could result in theblockage of the osteomeatal complex therebyimpeding sinus drainage6. This will cause stasis ofsecretions and reduced oxygen tension with resultantsuperimposed infection and subsequently, pusaccumulation within the sinus5. The involvement ofthe sinus may remain undetected withoutradiological assistance. This may serve has a focusof infection in sepsis that may be missed7.The intranasal oxygen catheter in our patient mighthave irritated the left nasal mucosa with resultantinflammation and local infection. This infectionmight have progressed and spread to the maxillaryantrum in the patient because of depressedimmunity due to the diabetes.Another possibilitycould be a mechanical obstruction of sinus drainagepathways by this tube or the inflammed nasalmucosa. The source of fever in this patient was therhinosinusitis.This disease is usually diagnosed clinically andconfirmed with radiological investigation especiallycomputerized tomography (CT) scan which is morespecific and sensitive than plain x-rays of theparanasal sinuses. In some instances, nasal symptomsmight not be present and it is only on CT scan orplain X-rays that the diagnosis of sinusitis is made8.CASE REPORTRhinosinusitis; A Potential hazard of  Nasogastric tube insertionABSTRACTThe nasogastric tube has been used frequently for enteral feeding and as anintranasal oxygen catheter. This practice is however associated withcomplications. We present a case of  rhinosinusitis and sepsis in a diabeticpatient following the insertion of a nasogastric tube.Physicians should be aware of sinusitis as a possible cause of sepsis inpatients with nasogastric tube insertion.Correspondence to:Dr. A.A. Adeyemo FWACS,Department of  Otorhinolaryngology,University College Hospital,P.M.B. 5116, Ibadan, Nigeria.adebolajo@ yahoo.com+234 803 717 2329Adebolajo A. Adeyemo, Ayotunde J. Fasunla, Aderemi A. Adeosun, Hamisu Abdullahi                                                         Annals of Ibadan Postgraduate  Medicine. Vol.5 No1 June., 2007                                             44CONCLUSIONNasal intubation could predispose to rhinosinusitisespecially in immunocompromised patients. The sinusesshould be considered as a focus of infection in everyunconscious patient who develops fever followingintranasal intubation.Authors’ Affiliation:REFERENCES1. Lanza DC, Kennedy DW: Adult rhinosinusitis defined,Otolaryngol Head Neck Surg 1997; 117: 51 – 57.2. Kennedy DW, Zinreich SJ, Rosenbaum A: Functionalendoscopic sinus surgery, theory and diagnosis. ArchOtolaryngol 1985: 578-582.3. Bailey BJ, Pillsbury III HC, Johnson JT, Kohut RI,Tardy, Jr.ME: Head & Neck Surgery-Otolaryngology.Philadelphia: Lippincott-Raven 1996.4. Metheny NA, Meert KL, Clouse RE, Complicationsrelated to feeding tube placement. Curr OpinGastroenterol 2007 Mar;23(2):178-825. Cummings CW, Fredrickson JM, Harker LA, KrauseCJ, Richardson MA, Schuller DE, Otolaryngology—Head & Neck Surgery 3rd ed. Mosby CD Online.6. Bos AP, Tibboel D, Hazebroek FW, Hoeve H, MeradjiM, Molenaar JC. Sinusitis: hidden source of sepsis inpostoperative pediatric intensive care patients. Crit careMed. 1989; 17: 886 – 888.7. Deutschman CS , Wilton P, Dibbell D Jr,Konstantinides FN, Cerra FB Paranasal sinusitisassociated with nasotracheal intubation: a frequentlyunrecognized and treatable source of sepsis. Crit CareMed. 1986 Feb;14(2):111-4.8. Desmond P, Raman R, Idikula J. Effect of  nasogastrictubes on the nose and maxillary sinus. Crit care Med.1991; 19: 509 – 511.Adebolajo A. Adeyemo*, Ayotunde J. Fasunla*, AderemiA. Adeosun*, Hamisu Abdullahi**Department of  Otorhinolaryngology,University College Hospital, Ibadan, Nigeria.                                                         Annals of Ibadan Postgraduate  Medicine. Vol.5 No1 June., 2007                                             45

Case Report Rhinosinusitis; A Potential hazard of Nasogastric tube insertion

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Case Report Rhinosinusitis; A Potential hazard of Nasogastric tube insertion

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