Specialist article: Nose
SinusitisWhen the sinuses get no air
Pressure in your face, your nose is blocked and the sinusitis keeps coming back? Here you can find out how the sinuses are ventilated, what happens in them during sinusitis, what medical treatments can do and why nasal breathing is a pattern of breathing, swallowing and head balance.
Does this sound familiar?
Pressure in your face and a blocked nose?
What applies to you?
Tap whatever applies to you.
If several of these apply to you, it is worth looking at how your sinuses are ventilated. Sinusitis often begins with an infection. In our view, whether it clears up or comes back also depends on how much air flows through your nose, day and night.
Where the pressure comes fromWhen you need medical adviceThe key points at a glance
- The paranasal sinuses are air-filled spaces connected to the nose by narrow openings. If the mucous membrane there swells shut, secretions build up and pressure develops in the face.
- In many cases, acute sinusitis begins with a viral infection and often clears up on its own. Chronic sinusitis is the term used when symptoms last longer than twelve weeks.
- Ventilation and drainage of the sinuses depend on nasal breathing, and constant mouth breathing is, in our view, a link in this chain. Nasal breathing is a pattern of breathing, swallowing and head balance, and patterns can be trained.
Video
Paranasal sinuses: chronic inflammation and ventilation
Das Video lädt erst nach dem Klick. Dann werden Daten an YouTube (Google) übertragen.
Anatomy
What are the paranasal sinuses?
Around the nose there are several cavities in the skull. Their condition plays a part in whether a cold turns into sinusitis.
The paranasal sinuses are paired, air-filled spaces in the facial skeleton. There are four groups: the frontal sinuses above the eyebrows, the maxillary sinuses in the cheeks, the ethmoid cells between the eyes and the sphenoid sinuses deep behind the nose. They are lined with mucous membrane that merges with the mucous membrane of the nose. This is why the specialist literature today refers to rhinosinusitis.
The passages of the frontal sinus, maxillary sinus and anterior ethmoid cells open into the middle nasal meatus in a confined space, beneath the middle nasal concha. If the mucous membrane swells at this point, it can affect several sinuses at once. Where you feel the pressure often indicates which sinus is involved.
Where do you feel the pressure when you lean forward?
The nose as a laboratory
The sinuses are not an empty space
For a long time, the sinuses were regarded as cavities without a clear function, for instance as a resonance chamber for the voice. Today we know that something is continuously being produced in them.
In 1995, a research group led by Jon Lundberg at the Karolinska Institute in Stockholm showed that the mucosa of the paranasal sinuses produces nitric oxide, or NO for short. It was present in very high concentrations in the air of the sinuses. In the mucosa of the main nasal cavity, by contrast, the NO-producing enzyme showed only weak activity1.
The sinuses are not an empty cavity. They are a laboratory.They continuously produce a messenger substance that reaches the airways with nasal breathing.
NO inhibits the growth of bacteria. The authors saw this as one reason why healthy sinuses remain low in germs1. With the inhaled air, the NO from the sinuses reaches the throat, windpipe and lungs. With mouth breathing, the air bypasses this route. In our view, this is one of the reasons why the nose is the intended entrance for the air we breathe.
Ventilation and drainage
Why a narrow passage makes such a difference
Healthy sinuses need two things. Fresh air has to get in, and mucus has to get out. Both pass through the same narrow opening.
The mucosa of the sinuses carries fine cilia. They beat in coordinated waves and push the mucus film, along with everything caught in it, towards the opening of the sinus and on towards the throat. This is called mucociliary clearance. For it to work, the mucosa needs moisture, warmth and air.
The openings of the sinuses are narrow. Even slight swelling of the mucosa can block them. Then no fresh air gets in, the mucus no longer drains, and pathogens find good conditions in the closed-off space.
In 2002, the Stockholm research group led by Eddie Weitzberg and Jon Lundberg summarised that the blockage of this opening is a central event in the development of sinusitis2.
was the increase in nasal NO during humming compared with quiet exhalation, measured in ten healthy people. In the model, the oscillating air markedly improved gas exchange between the nose and the sinus2
Like a basement room with a small window
A basement room with a small window stays dry as long as the window is open and the air circulates. If the window is blocked, the air stagnates and the room becomes damp and musty. This is roughly how we see the sinuses. What matters is not their size, but that air and mucus can pass through the opening unhindered.
Causes
Paranasal sinuses: causes of inflammation
Sinusitis rarely has just one cause. It often starts with an infection, combined with conditions that make ventilation more difficult.
In many cases, acute sinusitis begins with a viral infection, in other words a common cold. A study at the University of Virginia showed how closely a runny nose and the sinuses are connected. There, young adults with a fresh cold were examined using computed tomography.
of the 31 adults with a cold that was two to four days old showed changes in one or both maxillary sinuses on CT3
had a blocked ethmoid infundibulum, the narrow point through which several sinuses drain into the nose3
showed markedly fewer or no changes two weeks later, without antibiotics3
So a cold reaches the sinuses almost as a rule and in many cases clears up on its own. Whether it turns into persistent or recurring sinusitis depends on further conditions. They have one thing in common: they make ventilation and drainage more difficult.
Allergies
Hay fever and other allergies make the mucosa swell and can additionally narrow the openings of the sinuses.
Smoking
In a European survey, chronic sinusitis was markedly more common among smokers than among people who do not smoke4.
Narrow points
Polyps, enlarged turbinates or a markedly deviated nasal septum can obstruct drainage.
Mouth breathing
If little air flows through the nose, its mucosa lacks the stimulus of the airflow. In our view, this is a frequently overlooked factor; more on this below.
Incidentally, a slightly crooked nasal septum is the norm. You can read why its shape alone says little about how clear the nose is in the article Deviated nasal septum.
Symptoms and course
Acute or chronic sinusitis?
The symptoms are similar. What differs is their duration and course.
Pressure in the face
Above the forehead, in the cheeks or between the eyes, often worse when bending forward.
Blocked nose
The nose is blocked, on one or both sides.
Secretions
Mucus runs out of the front of the nose or down the back of the throat.
Smell
The senses of smell and taste are reduced.
Head and teeth
Headaches or a pulling sensation in the upper molars.
Fatigue
You feel tired and unwell, sometimes with a fever in the case of acute inflammation.
If the symptoms subside within a few weeks, this is referred to as acute sinusitis. Chronic sinusitis is the term used when several of these symptoms persist for longer than twelve weeks, including a blocked or runny nose. A large European survey applied these criteria to the population4.
of the 57,128 respondents in 19 European centres met the criteria for chronic sinusitis, around one in ten people4
was the proportion, depending on the centre. The differences between the regions were large4
See a doctor if you have a high fever or very severe, one-sided pain, if your eyelids or the skin around your eyes become red or swollen, if you see double or your vision gets worse, if you have a severe headache with a stiff neck, or if you get markedly worse again after initially improving. Bacterial sinusitis with fever and severe pain requires medical treatment.
Mouth breathing and mucosa
When the nose is no longer used
A blocked nose leads to mouth breathing. Conversely, mouth breathing deprives the nose of what keeps it healthy.
The nasal mucosa depends on the airflow. It stimulates the erectile tissue, glands and cilia and carries the NO from the sinuses with it. In our view, the tissue of the airways behaves like muscles and connective tissue everywhere in the body. Whatever is involved in a function is used and keeps its tone. Whatever is not used becomes slack.
With mouth breathing, the air takes the shorter route. It bypasses the nasal turbinates and sinuses, reaches the throat colder and drier, and the airflow through the nose becomes weaker.
How closely mouth breathing and sinus infections are directly linked has so far been little studied. The mechanisms behind it, namely ventilation, cleansing and NO, are, by contrast, well described. Our view is based on them.
The nose is used little
It often starts with an infection, an allergy or with mouth breathing as early as childhood.
The airflow is missing
The mucous membrane and erectile tissue receive less stimulation, and cleansing slows down.
The mucous membrane swells
The narrow openings of the sinuses become even narrower. Air gets in less easily, and mucus gets out less easily.
The mouth steps in
The nose feels blocked, and the air takes the easier route through the mouth.
The circle closes
Every new infection meets poorly ventilated sinuses. In this way, many colds can turn into recurrent or chronic sinusitis.
In our understanding, constant mouth breathing is a link in this chain. If hardly any air flows through the nose, the openings of the sinuses are also less ventilated, the mucous membrane swells shut more easily, and secretions build up. The conclusion suggests itself that mouth breathing promotes inflammation of the sinuses. In our view, at the start of these causal chains there is usually a disturbed basic function, and anyone who wants to leave the cycle needs a breathing pattern that uses the nose, by day and by night.
Treatment
What helps with sinusitis
Medical treatment of sinusitis aims to relieve swelling and symptoms and to improve drainage. Here we give an objective overview of the most common remedies.
Antibiotics work against bacteria, not against viruses. A Cochrane review analysed 15 studies with 3,057 adults who were treated as outpatients for acute sinusitis. For uncomplicated cases, the authors see no place for antibiotics. However, children, people with weakened immune systems and severe cases were not represented in the studies5.
had recovered without antibiotics after one week; after 14 days it was 64 %5
recovered faster with antibiotics than without5
additionally had side effects with antibiotics5
The evidence on nasal rinses with saline solution is thin. Another Cochrane review found only two suitable studies for chronic sinusitis. Daily rinses with a larger volume showed a certain benefit, but the quality of the evidence was low6. Decongestant nasal sprays provide short-term relief and are intended for a few days only. Cortisone sprays are often prescribed for longer periods in chronic sinusitis.
In pronounced chronic sinusitis, for example with polyps, surgery is sometimes performed. An operation widens the openings of the sinuses, but it does not change the breathing pattern. In a large analysis from Utah with 33,090 adults, 10.8 % of those operated on for chronic sinusitis later had another operation, and 21.5 % of those who also had asthma7. In our view, every operation should therefore be preceded by a look at nasal breathing, but the training does not rule out an operation.
If you use nasal spray, cortisone spray or other remedies on medical advice, do not stop them on your own and discuss changes with your practice. Training the basic functions can be combined with medical treatment, including before or after an operation.
The triad
Nasal breathing is a pattern
Treatment relieves the inflammation. Whether the sinuses stay well ventilated afterwards is decided in everyday life, with every breath and every swallow.
Breathing
Calm nasal breathing warms, humidifies and cleans the air and keeps the exchange between the nose and sinuses going. With it, the NO from the sinuses reaches the airways.
Swallowing
You swallow many hundreds to a thousand times a day. Afterwards, the tongue rests against the palate, the base of the tongue seals the oral cavity off from the throat, and the airflow stays in the nose. The starting point is the tongue reference position.
Head balance
When the head is balanced above the body, the space in the throat stays open. If it moves forward, in our view the mouth opens more easily and the nose is used less.
So nasal breathing needs more than a clear nose. It needs a sealed oral cavity. If the mouth is open, pressure equalises through the mouth even when the nose is clear, and a large part of the air takes the shorter route. The sinuses then lack precisely the airflow on which their ventilation depends.
It is not the open nose that ventilates the sinuses, but the one that is used.How often the nose is used is determined by the interplay of breathing, swallowing and head balance. This interplay is a stored sequence, and that is why it can be trained.
If sinusitis keeps coming back, in our view the cause as a rule lies not only in the mucous membrane but also in the breathing pattern. The triadic functional circuit is at the start of many of these causal chains.
Training
Training nasal breathing: creating the conditions
The resolution to breathe through the nose often only lasts until the next conversation or until you fall asleep. A breathing pattern is a stored sequence, and it changes through repetition. FaceFormer training addresses breathing, swallowing and head balance and aims at the switch from mouth to nasal breathing, by day and by night. If you follow this logic, a nose with air flowing through it again can create the conditions under which the sinuses are better ventilated and the mucous membrane can carry out its cleansing again.
During training, the FaceFormer sits in the oral vestibule, i.e. between the lips and teeth. The tip of the tongue finds its place on the small ridge just behind the upper front teeth. The head is upright, and you breathe through your nose.
The basic exercise consists of three steps: the lips close firmly around the lip wedge, the back teeth bite together briefly, then you swallow once. This creates a slight negative pressure in the mouth that draws the tongue up to the palate. The mouth stays sealed, and the air flows in and out through the nose.
From around week 6, the breathing exercise is added. You breathe in through your nose for around six seconds, briefly hold your breath, bite and swallow, and then breathe out for six seconds. You extend the pause after that in small steps, only as far as feels comfortable.
- From day 1
Basic exercise
A few minutes three times a day with the FaceFormer ZERO; you increase the repetitions week by week.
- From around week 3
Pull exercise and night
The pull exercise is added. At night you wear the FaceFormer ZERO as soon as you have mastered the basic exercise.
- After a few weeks
Switching to the ONE
During the day, you train with the FaceFormer ONE. It is the same size and shape as the ZERO, just made of firmer material.
- From around week 6
Breathing exercise
The breathing exercise combines the training with calm nasal breathing and breathing pauses that become longer over time.
- Over months
The pattern runs by itself
The exercise manual allows six to twelve months until the new sequences run without thinking.
The free FaceFormer app guides you through the basic exercises, and all modules are on the exercise pages. If you have a fever, severe facial pain or complaints that do not subside, have your sinuses examined by a doctor first. Children practise according to a separate plan, more on this under FaceFormer for children.
Everyday life
Good for your sinuses in everyday life
The nose as the normal route
Lips loosely closed, tip of the tongue at the reference point. This keeps the oral cavity sealed, and the air naturally takes the route through the nose.
Humming
Humming makes the air vibrate and, in measurements, improves the exchange between the nose and the sinuses. Whether this has any effect in sinusitis has not been studied.
Calm rather than forceful
If your nose feels narrow, breathe more slowly rather than harder. Calm breaths pass through a narrow nose more easily than hurried ones.
Moist mucous membranes
Dry heated air takes its toll on the mucous membranes. Airing rooms regularly and drinking enough support them in their work.
Avoid smoke
Tobacco smoke irritates the mucous membranes of the nose and sinuses. This also applies to passive smoking.
Head balance at the screen
Set up your screen and seat so that your head balances over your body and does not drift forwards.
Do not stop prescribed treatment on your own
If you use nasal spray or other remedies on medical advice, discuss any changes with your practice. The training can be combined with them.
Questions
Frequently asked
What is sinusitis?
Sinusitis is the medical term for inflammation of the paranasal sinuses, that is, inflammation of the mucous membrane in the frontal sinuses, maxillary sinuses, ethmoid cells or sphenoid sinuses. Because the mucous membrane of the nose is usually involved as well, the specialist literature also refers to rhinosinusitis.
What causes sinusitis?
In many cases it starts with a viral infection. What matters then is whether the narrow openings of the sinuses stay clear. Allergies, smoking, polyps or other narrowings can make ventilation and drainage more difficult. In our view, a nose that is used too little, for example because of habitual mouth breathing, also belongs on this list.
How can I tell if I have chronic sinusitis?
Typical signs are a blocked or runny nose, pressure in the face and a reduced sense of smell. If several of these symptoms last longer than twelve weeks, this is referred to as chronic sinusitis. In a European survey, this applied to around one in ten adults.
When should I see a doctor about sinusitis?
If you have a high fever, very severe or one-sided pain, swelling or redness around the eyes, visual disturbances, severe headache with a stiff neck, or if things get worse again after initially improving. Bacterial sinusitis with fever and severe pain needs medical treatment.
Do you need antibiotics for sinusitis?
In many cases of uncomplicated acute sinusitis, no. A Cochrane review found that without antibiotics, just under two thirds of people were well after 14 days, and that antibiotics brought faster recovery for only a few people, with more frequent side effects. Whether you need an antibiotic is decided by a medical examination.
Do nasal rinses help with sinusitis?
For chronic sinusitis there is some evidence of a certain benefit from daily rinsing with larger volumes of saline solution, but the evidence is of low quality. Rinses relieve symptoms. They do not change the habits with which the nose is used in everyday life.
Can mouth breathing contribute to sinusitis?
There are few direct studies on this. But it is well described that ventilation, mucosal cleansing and the NO of the sinuses depend on the airflow through the nose. With constant mouth breathing, this airflow is missing, the openings of the sinuses are less well ventilated, and secretions build up more easily. The conclusion suggests itself that mouth breathing promotes inflammation of the sinuses. In our view, it is usually one component when sinusitis recurs.
Can I train with the FaceFormer while I have sinusitis?
The training can be combined with medical treatment. During an acute inflammation with fever, the treatment takes priority; afterwards you pick up the training again. If your nose has been blocked for a long time, have this checked before you start training.
More articles from the knowledge section
Experiences on this topic
Where to go next
Sources
- Lundberg JO, Farkas-Szallasi T, Weitzberg E, Rinder J, Lidholm J, Änggård A, Hökfelt T, Lundberg JM, Alving K (1995). High nitric oxide production in human paranasal sinuses. Nature Medicine 1(4):370-373. PMID 7585069. Source
- Weitzberg E, Lundberg JO (2002). Humming greatly increases nasal nitric oxide. American Journal of Respiratory and Critical Care Medicine 166(2):144-145. PMID 12119224. Source
- Gwaltney JM Jr, Phillips CD, Miller RD, Riker DK (1994). Computed tomographic study of the common cold. New England Journal of Medicine 330(1):25-30. PMID 8259141. Source
- Hastan D, Fokkens WJ, Bachert C et al. (2011). Chronic rhinosinusitis in Europe, an underestimated disease. A GA2LEN study. Allergy 66(9):1216-1223. PMID 21605125. Source
- Lemiengre MB, van Driel ML, Merenstein D, Liira H, Mäkelä M, De Sutter AI (2018). Antibiotics for acute rhinosinusitis in adults. Cochrane Database of Systematic Reviews 9:CD006089. PMID 30198548. Source
- Chong LY, Head K, Hopkins C, Philpott C, Glew S, Scadding G, Burton MJ, Schilder AG (2016). Saline irrigation for chronic rhinosinusitis. Cochrane Database of Systematic Reviews 4:CD011995. PMID 27115216. Source
- Gill AS, Smith KA, Meeks H, Oakley GM, Curtin K, LeClair L, Howe H, Orlandi RR, Alt JA (2021). Asthma increases long-term revision rates of endoscopic sinus surgery in chronic rhinosinusitis with and without nasal polyposis. International Forum of Allergy & Rhinology 11(8):1197-1206. PMID 33629540. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
