Presented at the Meeting of the Middle Section of the American Laryngological, Rhinological and Otological Society, Inc., Cincinnati, Ohio, January 21, 2000.
The Aspiration-Irrigation Maneuver†
Article first published online: 2 JAN 2009
Copyright © 2000 The Triological Society
Volume 110, Issue 8, pages 1271–1276, August 2000
How to Cite
Martin, R. A. (2000), The Aspiration-Irrigation Maneuver. The Laryngoscope, 110: 1271–1276. doi: 10.1097/00005537-200008000-00009
- Issue published online: 2 JAN 2009
- Article first published online: 2 JAN 2009
- Manuscript Accepted: 12 APR 2000
- Needle aspiration;
- aspiration-irrigation maneuver;
- aspiration-irrigation apparatus;
- Proetz maneuver.
Objectives/Hypothesis To compare cultures obtained from the aspiration-irrigation maneuver (AIM) with other reports and compare diagnostic and therapeutic value after AIM versus the Proetz maneuver and needle aspiration-irrigation.
Study Design Patients with radiographic evidence (mucous membrane thickness greater than 6 mm, air-fluid levels, or complete opacification) and symptoms (nocturnal cough, fever, postnasal drainage [PND], otitis, mucopurulent discharge from the nose) of sinus disease who were referred from pediatrician and/or family physician and who otherwise would be candidates for surgery were selected to receive treatment with AIM. The study was divided into three separate groups (54 patients who were age 8 years and younger, 54 patients who were age 9 years and older, and 32 adult patients who were treated with both needle aspiration and AIM.
Methods Using Bernoulli's principle and the Venturi effect, saline and a vacuum apparatus were used to capture the contents of the sinuses for culture, and results were compared with results of needle aspirate cultures.
Results Children's cultures from group 1 compared favorably with the literature (Haemophilus influenzae,Moraxella catarrhalis, and Streptococcus pneumoniae or a combination of these); cultures in patients age 9 years and older revealed a greater variety of bacteria, depending on chronicity of infection, and a high incidence of Staphylococcus aureus (β-lactamase positive). There was a 66% correlation of AIM with needle aspiration.
Conclusions AIM was found to be a safe, simple, painless, and inexpensive adjunct to the diagnosis and treatment of sinus disease.
The treatment of sinus disease can be broadly categorized as either medical or surgical. Medical management includes the use of antibiotics, systemic or topical decongestants, mucolytic agents, or systemic and topical allergic agents. The literature is replete with new and old methods of surgical sinus procedures. However, as Arthur W. Proetz 1 stated in The Displacement Method of Sinus Diagnosis and Treatment in 1931, “Despite all of the sophisticated surgical procedures, we are not far ahead of the ancients in the simple treatment of an abscess with adequate drainage.”
This study describes a means of mechanically removing the contents of the sinuses for both diagnostic and therapeutic purposes that is similar to the Proetz displacement maneuver but affords significant advantages. The displacement maneuver has significant limitations. It is contraindicated in acute infection for fear of gravitationally contaminating uninvolved sinuses. It is performed with the patient in the supine position with the head hanging down, which is poorly tolerated by the arthritic patient and frequently requires placing the very young patient in a papoose. The principle of the Proetz maneuver is that of true displacement of mucus, pus, or air in the sinus with medicated saline (decongestants or antibiotics). The aspiration-irrigation maneuver (AIM) is based on Bernoulli's principle 2 and the Venturi effect and therefore does not risk contamination of other sinuses; it is performed with the patient in the upright position and therefore is tolerated by elderly patients and leaves the small child in his or her parent's arms.
MATERIALS AND METHODS
The nasal passages are cleaned with a cotton-tipped swab stick and peroxide (Fig. 1) and prepared with vasoconstrictive agent (Fig. 2). Saline is introduced to one side of the nose with a bulb syringe and aspirated from the opposite side by the aspiration-irrigation apparatus (Figs. 3 and 4). As the patient repeatedly says the letter “K” throughout the procedure to close the velopharynx, the water dribbles down the afferent side of the nasopharynx and the vacuum from the apparatus “pulls” the saline more rapidly along the efferent side of the nose (Fig. 5), thereby creating a Venturi effect as it passes by the ostium. The aspirated contents are caught in a trap (Fig. 6) and can be used for Gram stain or cultures or disposed of by tilting the apparatus back into the suction tube. After two to three aspirations, the instrument is reversed to the opposite side. The procedure is somewhat side specific in that the efferent side is the one that is emptied. The contents are pipetted for culture (Fig. 7). This study was divided into the following groups. In group 1, 54 cultures were obtained from patients age 8 years and younger; in group 2, 54 cultures were obtained from patients age 9 years and older; and in group 3, 32 cultures were obtained from adults, first, by needle aspiration and, second, by AIM, and these cultures were compared with each other.
Group 1: Patients Age 8 Years and Younger
The methods and materials for parts 1 and 2 were essentially identical. In the 54 children who were age 8 years and younger, the average age was 3½ years; 14 patients were 18 months of age or younger and had a history of recurrent otitis media and/or chronic serous otitis, nocturnal cough, fever, and physical evidence of a mucopurulent discharge from the nose with postnasal drainage. Patients more than 18 months of age had similar symptoms and, in addition, had documentation by radiographic evidence of sinus disease with thickness of mucous membranes of 6 mm or greater, air-fluid levels, or complete opacification (Fig. 8). All patients had failed medical therapies, had been referred by pediatricians and/or family physicians, and would have otherwise been candidates for surgery (adenoidectomy, tympanustomy tube placement, adenotonsillectomy, functional endoscopic sinus surgery [FESS]).
Group 2: Patients Age 9 Years and Older
Patients age 9 years and older were separated from patients in part 1, not by the materials or methods, but rather, by the results (see “Results”).
Group 3: Needle Aspiration Versus Aspiration-Irrigation Maneuver
Patients with all the previously mentioned signs and symptoms documented by either radiographic examination or computed tomography (CT) underwent, first, needle aspiration for culture, and, second, AIM for culture. Then the needle was reinserted and the sinus was irrigated with normal saline.
The number of attempted cultures was 64. Four of these were abandoned because of inability to pass saline beyond large adenoids (one of the four was a case of mononucleosis and the other three cases were nonspecific adenoidal hypertrophy). Five attempts to obtain a culture specimen were abandoned because of a lack of cooperation (patient ages, 3–5 y), and one child was found to have a unilateral choanal atresia at the time of surgery.
Of the 54 cultures obtained (Table I), 23 grew a combination of two bacteria in “heavy growth” (>104 organisms) and 14 showed three separate bacteria in heavy growth (>104 organisms). The three cultures of group A Streptococcus pyogenes were all in association with symptomatic “strep throat”/tonsillitis. If we eliminated patients with strep throat and postoperative sinus surgery irrigation, less than 10% of cultures grew anything other than Streptococcus pneumoniae,Haemophilus influenzae, and Moraxella catarrhalis as the primary pathogens in children's sinus disease. It is interesting to note the heavy growth of “mixed cultures” (or combinations of these three organisms).
*All three associated with symptomatic tonsillopharyngitis (strep throat).
The materials and methods remained the same for group 2 as for group 1; the two groups were separated primarily to demonstrate the differences in the results of cultures (Table II) (see “Discussion”). The primary differences were as follows: 1) a wider variety of bacteria were captured in group 2; 2) there was a high incidence of Staphylococcus aureus, which in all cases was coagulase positive, and 3) 10 “control” AIM cultures were obtained. The characteristic of a control AIM specimen in the present study amounted to approximately 2 mm of captured mucus of clear or slightly turbid color, which cultured low growth of either “normal flora” or “Staphylococcus species, coagulase negative.”
†Postoperative functional endoscopic sinus surgery.
Growth = colonies/mL purulent material. Very light = 101/mL of material; light = 102/mL of material; light-moderate = 103/mL of material; moderate = 104/mL of material; moderate-heavy = 105/mL of material; heavy = 106/mL of material.
Thirty-two cultures were obtained, first, by placing an 18-gauge trocar across the wall of the inferior meatus into the maxillary sinus after topical anesthesia with 3% lidocaine with phenylephrine and 2% injected lidocaine with epinephrine 1:100,000. The aspiration of the sinus contents were cultured. The needle was removed. Second, the AIM was performed, and the material obtained was cultured. The needle was then reinserted and the sinus was irrigated. The irrigated material was noted and observed, but not cultured (Table III). Bacteria that were captured by both the needle aspirate and the AIM cultures are shown as “correlations” in Table III, as are bacteria that were not correlative. It should be noted, however, that when “laudable pus” was found with the AIM, the correlation was in the range of 75%.
Nine partial culture correlations agreed with one or more “mixed cultures” (66% correlation of needle aspiration versus AIM).
*AIM—no growth or light growth (Corynebacterium, not Jeikeium; diptheroids, Coagulase-negative Staphylococcus).
In part 1, cultures were consistent with previous reports 3–9 showing S pneumonia,H influenzae, and M catarrhalis as the primary culprits in children's sinus disease. There was a heavy growth of “mixed cultures.” The only cultures of S pyogenes were in patients with obvious streptococcal tonsillitis/strep throat.
In part 2, the control cultures demonstrated only light growth (<103 organisms) of either “normal flora” or “Staphylococcus species, coagulase negative.” The average thickness of the mucus layer in the controls was 2 mm of clear or slightly turbid mucus. Interestingly, in older children (group 2) and adults, 20% (11/54) of cultures had growth of S aureus (β-lactamase positive).
H influenzae,S pneumoniae, and M catarrhalis made up 55% of the total of group 2. Pseudomonas putida was found in a patient with atrophic rhinitis. The rest of the cultures showed a variety of species as noted.
The AIM is generally tolerated by the vast majority of patients. Children age 6 and older were generally found to be reluctantly cooperative. Children age 3 and younger were held by the parents and assistants. The most difficult ages were 3 to 6 years, and approximately 10% of AIM in this age group were unsuccessful because of a lack of cooperation.
All patients in this study were referred by pediatricians or family physicians and therefore were originally candidates for surgical intervention. After AIM, 16 patients avoided surgery altogether and those who did come to surgery were considered better risks with less reactive airways.
The comparison of needle aspirates to the AIM specimens revealed a correlation similar to needle aspirates and needle washings (66%). 10 There was a higher growth of culture with AIM specimens than with the needle aspirate, perhaps attributable to the contaminated nasal washings. However, in the case of gross purulence, preservation in saline may have helped in capturing the viable growth. Nevertheless, AIM harvests valuable information in many cases, particularly when “laudable pus” is obtained and culture results are greater than 104 organisms per culture.
The AIM was not as effective in draining the maxillary sinus in acute infections. Indeed, an open ostium must be present before AIM can be effective. On several occasions, grossly purulent material was needle aspirated (without irrigation) followed by AIM with very limited material captured. The needle was then reinserted, and the irrigation revealed more grossly purulent material. These experiences demonstrate the need for an open ostium and the limited value of the AIM in acute infection. However, there were cases in which AIM reaped significant quantities of purulent material after needle irrigation was completed, probably associated with the drainage of infected ethmoid and sphenoid sinuses. The significant bloody mucoid material was frequently captured after needle aspiration, indicating that the AIM is a helpful cleaning device to reduce the potential culture media and blood after needle procedures. After a week of antibiotics, AIM was a welcome therapy for patients who were unwilling to consider repeated needle aspiration and yielded much higher results than initially, when the ostium was acutely swollen closed.
The diagnostic possibilities of the procedure have not been fully appreciated by this study. The patient who presents with all of the symptoms of acute or chronic sinusitis usually reveals grossly purulent material with the AIM. Gram strain can further delineate the causative organisms (polymorphic nuclear leukocytes vs. eosinophils, bacteria such as pleomorphic rods, cocci and chains, diplococci, and so forth).
The normal amount of mucus in an otherwise healthy individual is approximately 2 mm, as shown by the control specimens. The content is clear or slightly turbid and, when cultured, shows light growth of “normal flora.” An amount of 4 to 5 mm indicates increased activity of the sinuses (i.e., allergy or early or resolving upper respiratory tract infection). It is thought that this material from the control specimens could be examined for immunoglobulins by electrophoresis and, possibly, be valuable in the identification of cystic fibrosis or other mucus-related diseases.
Because success of AIM requires the ability to close the velopharynx and an open ostium to the sinuses, limitations include cleft palate, perforated septum, exceedingly hypertrophic adenoids, and choanal atresia. In the case of acute sinusitis with an occluded ostium, drainage may not be adequate, but the drainage from the surrounding sinuses offers both information and therapy. The bloody aftermath after needle aspiration can be treated with AIM in these cases. In addition, follow-up AIM is tolerated much better by patients than repeated needle aspirations. Complications appear to be limited to anterior epistaxis attributable to direct trauma on Kiesselbach's plexus; these are almost uniformly associated with previous recent nose bleeds.
Aspiration-irrigation maneuver is a simple, safe, painless, inexpensive, therapeutic, and diagnostic procedure with many uses in the treatment of acute and chronic sinus disease. It is a painless means of irrigation for acute sinusitis 1 week after needle aspiration.
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