SINUSITIS & PHYSIOTHERAPY

Dr. D. N. Bid MPT, PGDSPT

The Sarvajanik College of Physiotherapy,

Surat, India.

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ANATOMY

Paranasal Sinuses

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Lateral View of Sinuses

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WHAT ARE THE SINUSES?

The sinuses are hollow air-filled sacs lined by mucous membrane.

Each sinus has an opening into the nose for the free exchange of air and mucus, and each is joined with the nasal passages by a continuous mucous membrane lining.

The ethmoid and maxillary sinuses are present at birth. The frontal sinus develops during the 2nd year and the sphenoid sinus develops during the 3rd year. 6

Four pairs of paranasal sinuses Frontal-above eyes in forehead bone Maxillary-in cheekbones, under eyes Ethmoid-between eyes and nose Sphenoid-in center of skull, behind nose and

eyes

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Sinuses have small orifices (ostia) which open into recesses (meati) of the nasal cavities.

Meati are covered by turbinates (conchae). Turbinates consist of bony shelves

surrounded by erectile soft tissue. There are 3 turbinates and 3 meati in each

nasal cavity (superior, middle, and inferior).

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CONSIDERATIONS FOR PEDIATRICS At birth, the ethmoid, sphenoid and maxillary

sinuses are tiny and cause problems in infants and toddlers.

Frontal sinuses develop between 4-7 years of age, causing problems in school aged children and adolescents.

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SINUSITIS

Inflammation of paranasal sinuses

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WHAT IS SINUSITIS? An inflammatory process or infection

involving one or more of the paranasal sinuses.

A complication of 5%-10% of URIs in children. Maxillary and ethmoid sinuses are most

frequently involved.

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PATHOPHYSIOLOGY1-sinuses are normally sterile, but their

proximity to nasopharyngeal flora allows bacterial and viral inoculation following rhinitis.

2-Diseases that obstruct drainage can result in a reduced ability of the paranasal sinuses to function normally. The sinus ostia become occluded, leading to mucosal congestion.

3-The mucociliary transport system becomes impaired, leading to stagnation of secretions and epithelial damage, followed by decreased oxygen tension and subsequent bacterial growth. 12

SOOOOOOOOOOOOOOOOOAnything that causes a swelling in the nose—an infection,

an allergic reaction, or an inflammatory reaction to a chemical to which you may get exposed--can affect your sinuses/ also abrupt pressure changes (air planes, diving) or dental extractions or infections.

This result in a-Inflammation and edema of mucous membranes lining

the sinuses cause obstruction.b-This provides for an opportunistic bacterial invasion.C-Postnasal drainage causes obstruction of nasal passages

and an inflamed throat. D-If the sinus orifices are blocked by swollen mucosal

lining, the pus cannot enter the nose and builds up pressure inside the sinus cavities.

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E-Air trapped within a blocked sinus, along with pus or other secretions may cause pressure on the sinus wall that can cause the intense pain of a sinus attack. Similarly, when air is prevented from entering a paranasal sinus by a swollen membrane at the opening, a vacuum can be created that also causes pain

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CLASSIFICATION

Acute, which last up to 4 weeks Subacute, which last 4 to 12 weeks Chronic, which last more than 12 weeks

and can continue for months or even years Recurrent, with several acute attacks within

a year

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PREDISPOSING FACTORS Allergies, nasal deformities, cystic fibrosis,

nasal polyps, and HIV infection. Cold weather High pollen counts Day care attendance Smoking in the home Reinfection from siblings

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1- ACUTE SINUSITISA- Most cases of acute sinusitis start with a common

cold (acute rhinitis), which is caused by a virus. Colds can inflame your sinuses (damage to cells) and cause symptoms of sinusitis. Both the cold and the sinus inflammation usually go away without treatment within 2 weeks. However, In about 0.5-2% of cases, viral sinusitis can progress to acute bacterial sinusitis

The most common culprits in acute viral rhinosinusitis are rhinovirus, influenza virus, and parainfluenza virus.

The inflammation caused by the cold results in

swelling of the mucous membranes (linings) of your sinuses, trapping air and mucus behind the narrowed sinus openings. When mucus stays inside your sinuses and is unable to drain into your nose, it can become the source of nutrients for bacteria, which then can multiply.

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Most healthy people harbor bacteria, such as

Streptococcus pneumoniae and Haemophilus influenzae, in their noses and throats.

Usually, these bacteria cause no problems. But when sniff or blow your nose when you have

a cold, these actions create pressure changes that can send typically harmless bacteria inside the sinuses.

If your sinuses then stop draining properly, bacteria can begin to multiply in your sinuses, causing acute sinusitis.

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B- People who have allergies or other chronic problems that affect the nose are also prone to episodes of acute sinusitis. Chronic nasal problems cause the nasal membranes to swell and the sinus passages to become blocked. The normally harmless bacteria in your nose and throat again lead to acute sinusitis.

C- In general, people who have reduced immune function, such as those with primary immune deficiencys or HIV infection, or abnormalities in mucus secretion or mucus movement, such as those with cystic fibrosis, are more likely to suffer from sinusitis

D- mechanical obstruction as seen secondary to foreign

bodies, intranasal cocaine use

E- Fungal infections very rarely cause acute sinusitis because the human body has a natural resistance to fungi. However, in people whose immune systems are not functioning properly, fungi can cause acute sinusitis.

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BACTERIAL SINUSITIS70% of bacterial sinusitis is caused by:

Streptococcus pneumoniaeHaemophilus influenzaeMoraxella catarrhalis

Other causative organisms are:Staphylococcus aureusStreptococcus pyogenes,Gram-negative bacilliRespiratory viruses

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SIGNS Sinusitis has 4 main signs

-Mucopurulent rhinorrhea

-Nasal congestion

-Facial pain, pressure, or fullness

-Decreased sense of smell

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SUBJECTIVE SYMPTOMS OF SINUSITIS History of URI or allergic rhinitis History of pressure change Pressure, pain, or tenderness over sinuses Increased pain in the morning, subsiding in the

afternoon Malaise Low-grade temperature Persistent nasal discharge, often purulent Postnasal drip : thick nasal secretions that are yellow,

green, or blood-tinged drain in the back of the throat and are difficult to clear

Cough, worsens at night Mouthing breathing, snoring History of previous episodes of sinusitis Sore throat, bad breath Headache

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SIGNS AND SYMPTOMS OF ACUTE SINUSITIS Ethmoid sinusitis (behind the eyes)

Nasal congestion with discharge or postnasal drip (mucus drips down the throat behind the nose)

loss of smell, and tenderness when you touch the sides of your nose

Pain or pressure around the inner corner of the eye or down one side of the nose

Headache in the temple or surrounding the eye

Pain or pressure symptoms worse when coughing, straining, or lying on the back and better when the head is upright

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Maxillary sinusitis (behind the cheek bones)

Pain across the cheekbone, under or around the eye, or around the upper teeth

Pain or pressure on one side or both

Tender, red, or swollen cheekbone

Pain and pressure symptoms worse with the head upright and better by reclining

Nasal discharge or postnasal drip

Fever common 24

Frontal sinusitis (behind forehead, one or both sides)

Severe headaches in the forehead

Fever common

Pain worse when reclining and better with the head upright

Nasal discharge or postnasal drip25

Sphenoid sinusitis (behind the eyes)

Deep headache with pain behind and on top of the head, across the forehead, and behind the eye

Fever common

Pain worse when lying on the back or bending forward

Double vision or vision disturbances if pressure extends into the brain

Nasal discharge or postnasal drip 26

2- CHRONIC SINUSITISA-In chronic sinusitis, the membranes of both the

paranasal sinuses and the nose are thickened because they are constantly inflamed. Most experts now use the term chronic rhinosinusitis to describe this condition.

B-nasal polyps. (Polyps are grape-size growths of the sinus membranes that protrude into the sinuses or into the nasal passages,more commonly seen in patients with aspirin sensitivity and asthma , results from a localized allergic hyperresponsivity to bacterial endotoxins Polyps make it even more difficult for the sinuses to drain and for air to pass through the nose

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D- An allergic reaction to certain fungi may be

responsible for some cases of chronic rhinosinusitis; this condition is called allergic fungal sinusitis. However, at least half of all people with chronic rhinosinusitis do not have allergies/ or exaggerated immune response to fungi

E- Acute bacterial sinusitis that does not completely resolve can progress to chronic sinusitis, the infecting organisms vary, and a higher incidence of anaerobic organisms is seen (eg, Bacteroides, Peptostreptococcus, and Fusobacterium species 28

G-As with acute sinusitis, other causes of chronic rhinosinusitis may be an immune deficiency disorder

E-Another group of people who may develop chronic rhinosinusitis are those with significant variations in the anatomical structure inside the nose that lead to blockage of mucus (septal deviation).

F-Diseases such as cystic fibrosis, primary ciliary dyskinesia, Wegener granulomatosis, Churg-Strauss vasculitis, and sarcoidosis have also been known to be affiliated with chronic rhinosinusitis 29

SIGNS AND SYMPTOMS OF CHRONIC SINUSITIS Ethmoid sinusitis

- Chronic nasal discharge, obstruction, and low-grade discomfort across the bridge of the nose

- Pain worse in the late morning or when wearing glasses

- Chronic sore throat and bad breath

- Usually recurs in other sinuses30

Maxillary sinusitis

- Discomfort or pressure below the eye

- Chronic toothache - Pain possibly worse with colds, flu, or

allergies

- Increased discomfort throughout the day with increased cough at night 31

Frontal sinusitis

- Persistent, low-grade headache in the forehead

- History of trauma or damage to the sinus area

Sphenoid sinusitis

- Low-grade general headache common32

????????? However, most people with sinusitis

have pain or tenderness in several locations, and their symptoms usually do not clearly point out which sinuses are inflamed.

Pain is not as common in chronic rhinosinusitis as it is in acute sinusitis.

Also, acute and chronic rhinosinusitis are strongly associated with a stuffy nose, as well as with a general feeling of fullness over the entire face.

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DIAGNOSIS1- physical exams, signs and symptoms2- imaging study (x-ray,CT, MRI, ULTRASOUND)3- laboratory tests 4-ENT can directly visualize the nasal passages

and the OMC (passage into the sinuses) with a nasopharyngoscope. This is a fiberoptic, flexible tube that is insertable through the nose and enables the doctor to view the passageways and see if the OMC is open and draining right. Anatomical causes of breathing difficulties may also be found, such as a deviated nasal septum, nasal polyps, and enlarged adenoids and tonsils

5- drain the affected sinus to test for organisms ( culture)

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HISTORY, PHYSICALSinusitis usually a clinical diagnosis Because your nose can get stuffy when

you have a condition like the common cold, you may confuse simple nasal congestion with sinusitis.

A cold, however, usually lasts about 7 to 14 days and goes away without treatment.

Acute sinusitis often lasts longer and typically causes more symptoms than a cold

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IMAGING STUDY ( X-RAY) In the past, doctors relied on x-ray films for

diagnosis because the symptoms of acute sinusitis are very similar to those of an acute upper respiratory tract infection. In fact, most of the time, a viral infection is required to promote sinusitis.

However, these films are not specific and depend on a good technique by the technician.

According to one study, sinusitis is not visible on x-ray films about 55% of the time.

If symptoms continue beyond 7-10 days and are associated with a simple cold, a diagnosis of sinusitis may be possible.

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IMAGING STUDY ( CT, MRI, ULTRASOUND ) A CT scan may indicate a sinus infection if any of these

conditions is present:

1-Air-fluid levels in 1 or more sinuses

2-Total blockage in 1 or more sinuses

3-Thickening of the inner lining (mucosa) of the sinuses

Mucosal thickening can occur in people without symptoms of sinusitis. Therefore, CT scan findings must be correlated with a person's symptoms and physical examination findings to diagnose a sinus infection. 38

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LABORATORY TESTS Laboratory tests your healthcare provider

may use to assess possible causes of chronic sinusitis include

1- Blood tests to rule out conditions

associated with sinusitis, like an immune deficiency disorder

2- A sweat test or a blood test to rule out cystic fibrosis

3- Tests on the material that is inside your sinuses to look for bacterial or fungal infection

4- Biopsy (taking a small sample) of the membranes (linings) of the nose or sinuses to find out the health of the cells lining these cavities

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PHYSIOTHERAPY MANAGEMENT

The physiotherapist has certain options for therapy.

Use can be made of nebulisation, laser therapy, ultrasound therapy, short-wave diathermy, and rinoflow therapy, to mention but a few of the treatment modalities.

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Perhaps the present best known form of therapy is nebulisation.

Use can be made of a compressor type or ultrasonic nebuliser.

Physiological saline solutions are nebulised, which has a hydrating effect on the mucous in the sinus cavities.

Nasal cannulae can be used, or in the case of an ultrasonic nebuliser, the rate of flow is set at 'high'. 43

Laser therapy is used directly over the sinus cavities to reduce inflammation of the mucosal lining of the sinus.

Alternatively, ultrasound therapy makes use of sound waves conducted through a hypoallergenic gel to reduce inflammation of the mucosal lining as well as to loosen the accumulated mucous. 44

A fairly new option is called rinoflow therapy, which is basically a micronised endonasotracheal wash.

Rinoflow is a specific compressor microniser chamber system used for the treatment of diseases of the upper respiratory tract where catarrh, mucous and purulent and crusty secretions are present. 45

Besides use in treatment of sinusitis, it can be used to treat rhinitis, pharyngitis, laryngitis, chronic rhino-sinusitis, chronic purulent rhinitis, adenoidism and secretory otitis media.

Physiological saline or medicated saline is used to hydrate the mucosal lining of the nasal cavities, rhino-pharynx and the paranasal sinuses, which assists with drainage of the sinus cavities.

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Excellent results are normally achieved in two to three treatments with the abovementioned physiotherapy techniques.

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Bear in mind, however, that results depend on the state of the sinusitis (i.e. acute or chronic), patient compliance (i.e. whether cutting down on smoking, attending treatment) and most importantly, early referral achieves quicker results which inevitably saves on medical costs.

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Thank you………for being so attentive.

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