Limits of stability among patients with Chronic Maxillary Sinusitis:

A Cross-sectional Comparative study

 

Veena Kirthika S.¹*, Nabeena N.², Padmanabhan K.³, Selvaraj Sudhakar⁴, Jibi Paul⁵, Senthil Selvam P.⁶

¹MPT (Phd), Vice Principal/Professor, Faculty of Physiotherapy,

Dr. M.G.R. Educational and Research Institute, Maduravoyal, Chennai – 600095.

²BPT Faculty of Physiotherapy, Dr. M.G.R. Educational and Research Institute,

Maduravoyal, Chennai – 600095.

³MPT, MBBS, (PhD) Faculty of Physiotherapy, Dr. M.G.R. Educational and Research Institute,

Maduravoyal, Chennai – 600095.

⁴MPT, (PhD) Faculty of Physiotherapy, Dr. M.G R. Educational and Research Institute,

Maduravoyal, Chennai – 600095.

⁵PhD Faculty of Physiotherapy, Dr. M.G.R. Educational and Research Institute,

Maduravoyal, Chennai – 600095.

⁶PhD School of Physiotherapy, Vels Institute of Science, Technology and Advanced Studies,

Chennai, Tamil Nadu.

 

ABSTRACT:

Background: Sinusitis also known as Rhino sinusitis is the inflammation of sinuses that involves one or more cavities that could be due to bacterial or viral infection or even due to allergies. The patients may experience pain and tenderness around eyes, cheeks, nose and forehead, facial swelling, headache may be severe with nasal congestion. The secretions could have an impact on the vestibular apparatus which possibly may cause balance impairment. This study is intended to analyze the effect of chronic maxillary sinusitis (CMS) on balance. Objective: The aim of the study is to analyze the impact of CMS on the limits of stability. Materials and Methods: Thirty participants within the age group 20-40 were selected. Group A consisted of 15 patients with chronic maxillary sinusitis (CMS). Group B were matched controls (n=15) with the same age group, as that of the sinusitis group. Both male and female subjects within the age group of 20-40 years were included. Subjects with any other illness like trigeminal neuralgia, tension type headache, cervicogenic headache and other types of sinusitis were excluded. Functional Reach Test (FRT) between two groups were analysed Results: The mean FRT in patient with CS is 32.5 ± 9.5 cm. While in matched controls is 36.8 ± 7.9 cm. There exists significance difference (p=0.002) between them. Conclusion: Patient with chronic maxillary sinusitis has less functional reaching capability and thereby decreased limits of stability when compared to the matched peers.

 

 

 

 

INTRODUCTION:

Sinusitis, also known as rhino sinusitis, is inflammation of the sinuses resulting in the common signs and symptoms that include thick nasal mucus, a plugged nose, and facial pain.¹ Other signs and symptoms may include fever, headaches, poor sense of smell, sore throat, and cough. Sinusitis can be caused by infection, allergies, air pollution, or structural problems in the nose. The incidence of acute maxillary sinusitis ranges from 15 to 40 episodes per 1000 patients per year, depending on the setting. Most acute maxillary sinusitis is caused by the same viruses that cause the common cold.² It has been found that 75% or more of patients with sinusitis in the placebo groups of antibiotic trials get better spontaneously within 7 to 10 days.³ Complications from acute bacterial sinusitis are very rare.

 

Chronic maxillary sinusitis (CMS) may be defined as persistent inflammation and suppuration of the paranasal sinuses for more than 3 months. Nasal congestion with obstruction and production of thickened nasal secretions are the commonest clinical symptoms⁴. Facial pain and pressure are lesser features.⁵ Migraine and tension headaches are often confused with sinus headache. chronic sinusitis often causes anosmia⁶. Tenderness over the sinuses was not a significant feature and examination of sinuses is limited as they cannot be examined directly. ⁷ It is characterised by polypoid and thickened mucosa. Mucopurulent discharge may be seen around the middle meatus. Erythema and oedema of the mucosa over the sinuses are rarely present in chronic disease. Rhinorrhoea may or may not be present.⁸

 

Serious loss in Eustachian tube functions is considered as a consequence of impaired function of nasal, and paranasal sinuses. Inflammation of the sinonasal mucosa leads to obstruction of the ostiomeatal complex coupled with gravity and decreased mucociliary clearance, and inspissations of secretions occurs in the sinuses forming a culture medium for bacterial growth. The bacteriology of chronic sinusitis is now well documented although the interpretation of results is controversial.⁹ Of various methods of obtaining sample, endoscopic aspiration is useful. Gold SM et al demonstrated a strong correlation between middle meatal and maxillary sinus cultures.¹⁰ The inflammatory processes of nasal, and paranasal sinuses ensued in obstruction, inflammation, and resultant dysfunction of Eustachian tube is also been demonstrated.¹¹ The role of sinonasal abnormalities and allergic rhinitis in the pathogenesis of chronic otitis media is prevalent.¹² Sinonasal pathology frequently leads to ear disease. This study is an attempt to see if balance impairment is observed in patients with chronic sinusitis.

 

METHODOLOGY:

Recruitment and allocation:

The study protocol was approved by the university research and ethics committee (ACS/2019/34) and the study was done strictly in accordance with the guidelines of Helsinki declaration, revised 2013¹³. A total of 15 patients with CMS and 15 matched controls (MC) in the age group, 20 to 40 years were recruited by the simple random sampling (lottery method) to participate in this cross-sectional comparative study. 15 MC recruited were matched for age, height and weight among patients with CMS. Participants with any other illness like trigeminal neuralgia, tension type headache, cervicogenic headache and other types of sinusitis were excluded. Signed informed consent form was obtained from all the participants, before their enrollment. After the demographics, recruited patient with CMS and MC were allotted into two groups, group A and group B respectively.

 

Measurement of functional reach test (FRT):

Recruited patient with CMS and MC were assessed for their limits of stability by the functional reach test (FRT). FRT determines the level of anterior displacement within the limits of stability. For measuring FRT, they were instructed to stand with normal base of support and lean forward against the wall as much as they can from the standing position. Their shoulders were maintained at 90 degrees flexion with elbow extension, maintaining the third metacarpal at starting reference line. The difference between the observed distances traveled by the third metacarpal from reference line and end along the linear axis, were measured. FRT between patients with CMS and MC were compared and analyzed.

 

Outcome measures:

Both the group were measured for their limits of stability by FRT.

 

Data analysis:

The collected demographic and outcome measures were assessed for their normality using Shapiro-Wilk test. As the data follow normal distribution, all the descriptive data were expressed in mean±standard deviation. Independent t-test was adopted to find out the significance differences in FRT between the patient with CMS and MC. The data was analyzed using statistical software, statistical package for social science (SPSS), IBM SPSS version 20.0 (Armonk, NY: IBM Corp.). The p-value ≤0.05 was considered to be statistically significant.

 

RESULTS:

A total of 30 patients with CMS and MC, (27.6±2.4 years old; 165.3±6.4cm; 63.1±7.6kg; 24.1±2.4kg/m²) were identified as potential participants for this study and were allocated into two groups, group A and group B. Among them, 47% were females and 53% were males. The detailed demographic characteristic of the recruited participants were displayed in Table 1. The difference in FRT among the patient with CMS and MC were displayed in Figure 1. There exists significance difference (p=0.002) between two groups in their limits of stability established by FRT.

 

Table 1: Demographic characteristics of the subjects recruited in Group A (patient with chronic maxillary sinusitis) and Group B (Matched controls).

Parameters	Patient with chronic sinusitis	Matched controls	p-value
N	19	19	-
Age (years)	27.7±2.9	26.7±3.1	0.91
Weight (kg)	63.9±8.5	65.2±7.6	0.67
Height (cm)	168.2±6.2	166.5±6.9	0.42
BMI (kg/m2)	24.4±2.1	23.3±2.9	0.96

 

Graph 1: Functional Reach Test values between Group A (patient with chronic maxillary sinusitis) and Group B (Matched controls)

 

DISCUSSION:

Allergy related sinus congestion can lead to dizziness and thereby it makes the subjects feel that they are out of balance. It is already known that the Eustachian tube connects the middle ear to the back of the throat, which helps in regulating the balance and equalizing the pressure in the middle ear with the ambient air pressure. When this regular mechanism is altered, that is when the Eustachian tube is blocked with mucus it will no longer be able to equalize pressure in the middle ear and maintain the body in balance. Increase in nasal resistance resulting from mucosal congestion or airway deformity are the main factors in producing the complaint of nasal obstruction.¹⁴ Nasal obstruction was the commonest clinical symptom while nasal discharge is also common and it thereby correlates well with American Academy of Otolaryngologist - Head and Neck Society Task Force which includes these two as major factors. The increase in nasal resistance leads to higher static middle ear, and closing pressures of the Eustachian tube pressure with resultant formation of mucosal edema and finally Eustachian tube dysfunction.26 when nasal congestion, and all other symptoms are common, the symptom that requires importance is the loss of balance. The intension of the study was to analyze the balance impairments among the subjects with chronic sinusitis. This study showed that the subjects with chronic sinusitis had problems in maintaining the balance and thereby shows that the balance impairment should be considered while treating patients with chronic sinusitis.

 

CONCLUSION:

The patients with chronic maxillary sinusitis have decreased limits of stability when compared to their matched peers group. This highlights the importance of screening for balance disorders among them.

 

CONFLICT OF INTEREST:

The authors have no competing interests declared.

 

REFERENCES:

1.      Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Kumar KA, Kramper M, et al. Clinical practice guideline (update): Adult Sinusitis Executive Summary. Otolaryngol Head Neck Surg 2015;152: 598-609.

2.      Gwaltney JMJ, Scheld WM, Sande MA, Sydnor A. The microbial etiology and antimicrobial therapy of adults with acute community-acquired sinusitis: a fifteen-year experience at the University of Virginia and review of other selected studies. J Allergy Clin Immunol 1992;90: 457-61; discussion 462.

3.      de Bock GH, Dekker FW, Stolk J, Springer MP, Kievit J, van Houwelingen JC. Antimicrobial treatment in acute maxillary sinusitis: a meta-analysis. J Clin Epidemiol 1997;50: 881-90.

4.      Chester AC. Chronic sinusitis. Am Fam Physician 1996;53: 877-887.

5.      Hadley JA, Schaefer SD. Clinical evaluation of rhinosinusitis: history and physical examination. Otolaryngol Head Neck Surg 1997;117: S8-11.

6.      Downey LL, Jacobs JB, Lebowitz RA. Anosmia and chronic sinus disease. Otolaryngol Head Neck Surg 1996;115: 24-28.

7.      Havas TE, Motbey JA, Gullane PJ. Prevalence of incidental abnormalities on computed tomographic scans of the paranasal sinuses. Arch Otolaryngol Head Neck Surg 1988;114: 856-59.

8.      Stammberger H. An endoscopic study of tubal function and the diseased ethmoid sinus. Arch Otorhinolaryngol 1986;243: 254-59.

9.      Brook I. Microbiology of acute and chronic maxillary sinusitis associated with an odontogenic origin. Laryngoscope 2005;115: 823-25.

10.   Gold SM, Tami TA. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis. Laryngoscope 1997;107: 1586-89.

11.   Takahashi H, Miura M, Honjo I, Fujita A. Cause of eustachian tube constriction during swallowing in patients with otitis media with effusion. Ann Otol Rhinol Laryngol 1996;105: 724-28.

12.   Bozkus F, Bozan N, Iynen I, Sakin YF, Kiris M. Analysis of sinonasal, pharyngeal and allergy-related risk factors for chronic suppurative otitis media. Acta Medica Mediterr 2013; 29:47-52.

13.   World Health Organisation. Declaration of Helsinki World Medical Association Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects. J Am Med Assoc 2013;310: 2191-94.

14.   Ballenger J. Chronic rhinitis and nasal obstruction. In: Otorhinolaryngology head and neck surgery, 15th edn. Williams and Wilkins Co; 1996: 129-34.sssss

 

 

 

Received on 03.10.2019           Modified on 22.01.2020

Accepted on 25.02.2020         © RJPT All right reserved