- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications and Prognosis
- 12 See Also
- 13 References
- Paranasal Sinus Barotrauma
- Sinonasal barotrauma
- Sinus Squeeze
- This page refers to sinus barotrauma, which can occur during scuba diving or air flight due to changes in pressure within a non-draining sinus
- First described in WW2 aviation literature
- Pathophysiology first described by Campbell in 1942
- First case reported in the diving literature by Flottes in 1965
- Overall, lack of good epidemiological data
- Hyperbaric oxygen
- Prevalence of sinus barotrauma in patients who undergo hyperbaric oxygen exposure is reported to be around 3%
- Describes the varying degrees of sinonasal injury and/or inflammation that result when the aerated spaces of the nose and sinuses are exposed to an uncompensated change in ambient pressure
- Obstruction of the nasal sinuses combined with the increased pressures of diving may result in sinonasal barotrauma
- Frontal sinus most commonly affected, followed by maxillary sinus
- May be difficult to distinguish from other causes of sinusitis due to lack of familiarity with condition, paucity of literature
- Water and air
- Difference between properties of water and air explains why it is more common in divers
- Because air is more compressible than water, it takes much greater changes in elevation to achieve the same pressure change as water depth
- Example: pressure change from rapid 5 m underwater dive is equivalent to a 5500 m descent above sea level
- It also generally takes longer to ascend/descend in air than water
- Can occur during diving or flight
- Secondary shifts in barometric pressure due to altitude changes are the most common cause
- During Ascent
- In an aircraft or after deep dive
- Ambient pressure decreases (decrease in gravity), results in intrasinus gaseous expansion, increased intrasinus pressure
- Normal sinus: change typically compensated by pressure equilibration between the sinus ostia and the nasal cavity (i.e. pressure-release valve)
- Reverse squeeze: when inflamed or partially obstructed sinus, increased air expansion intrasinus pressure without this compensated pressure release
- Most commonly seen in resurfacing divers, produces an outward, “expansile” compression injury of the sinus mucosa against the bony sinus outer walls
- During Descent
- During descent, decrease in gaseous volume within the nasal cavity and sinuses themselves creates a decompression or squeeze effect
- If there is a closed sinus cavity, a vacuum will form
- May lead to mucosal edema, submucosal hematoma, and serosanguinous exudation
- Barosinusitis from descent is twice as common as ascent
- At Depth
- If the sinus cavity closes while a diver is at depth, during ascent gas will expand
- Can result in vascular compromise, sinus wall fracture, or orbital or periorbital emphysema which could possibly lead to meningitis
- Other causes documented in the literature
- Defined as isolated episode of sinus pain, inflammation lasting a few hours to days
- After exposure to identifiable cause of change in ambient air pressure
- Much more likely to occur if pre-existing sinus or URI pathology
- Often involves single sinus, most commonly frontal (68-100%), followed by maxillary and sphenoid
- Signs and Symptoms
- Sudden onset of pain localized to affected sinus
- In sphenoid sinus, the pain is peri-orbital or temporo-occipital
- Pain is sharp, although dull headache pain is also used (may be same pathology as an "airplane headache")
- Epistaxis is the second most common symptom (33% to 66%)
- Describe craking or popping sensation, though to be mucosal stripping and submucosal hematoma formation
- Rarely, excessive lacrimation, purulent nasal discharge, V2 branch of trigeminal nerve anesthesia, dental pain
- Weissmen Classification of Acute Barosinusitis
- Based on duration of symptoms, plain film radiographic findings
- Not widely accepted, plain films not regularly used anymore, may be helpful to categorize symptoms
- Class 1: lasts <24 hours, with normal sinus radiographs
- Class 2: attack lasts <24 hours, sinus opacification on plain films
- Class 3: attack lasts >24 hours, sinus opacification on plain films
Recurrent Acute Barosinusitis
- Term applied when the acute attacks present frequently
- Patients often asymptomatic between attacks
- One paper suggests these patients may have a higher incidence of sinonasal inflammation, anatomic variants
- Maxillary Sinus
- Pneumatic cavity located in the maxillary bone
- Frontal Sinus
- Air-filled anatomical structure located superior to the orbit and within the frontal bone
- Sphenoid Sinus
- Located centrally and posteriorly within the body of the sphenoid bone
- Ethmoid Sinus
- Formed by a multitude of cells with an intricated structure, through which all the paranasal sinuses drain
Differential Diagnosis Dive Medicine
- Barotrauma of descent
- At depth injuries
- Oxygen Toxicity: harmful effects of breathing oxygen at higher partial pressures than normal
- Nitrogen Narcosis: toxic effects of breathing nitrogen-containing gases while at depth
- Hypothermia: decrease core temperature with prolonged exposure to cold water
- Carbon Monoxide Toxicity: CO toxicity typically results from a faulty air compressor
- Caustic Cocktail: Inhalation of absorbent material used to scrub CO2 mixes with water
- Barotrauma of ascent
- Patients may report sinus pain, headache, epistaxis, and tooth pain
- Bleeding from nares/ epistaxis can occur
- Patients may report expulsion of blood or mucous from nares to mask during ascent
- Numbness to lip and cheek
- Dental pain
- Physical Exam
- Periorbital emphysema may occur through the ethmoid sinus
- Special Tests
- Imaging findings are thought to be related to submucosal hemorrhage
- This occurs during the squeeze or revere squeeze injury to the sinonasal mucosa
- Chronic or recurrent symptoms
- Potential Findings
- Partial to complete opacification of one or more of the paranasal sinuses
- In recurrent sinus barotrauma, signs of chronic mucosal changes
- Chronic or recurrent symptoms
- Potential Findings
- Hyperintensity on both T1 and T2 without contrast enhancement
Proposed Classification by Vaezeafshar
- Based on clinical presentation of acute, recurrent acute or chronic
- ESS: Endoscopic sinus surgery
|Type of Barosinusitis||Frequency of Episodes||Clinical Findings||Imaging||Treatment|
|Acute||Once||Acute focal sinus pain and inflammation with pressure change||Clear imaging to total opacification of involved sinus (spectrum possible)||Conservative medical treatment with decongestants, antibiotics; surgery is reserved for complications such as septal abscess and pneumocephalus|
|Recurrent Acute||More than once without any symptoms between episodes||Acute uni- or bilateral pain and inflammation with barometric changes||Anatomic abnormalities compromising sinus/ pressure equalization (e.g. septal deviation, concha bullosa, fontal cell); the sinuses are clear, especially between attacks||Medical treatment is usually unhelpful due to anatomic issues; surgery can be limited to correcting anatomic abnormalities or targeted ESS|
|Chronic||More than once, with persistence of chronic symptoms between acute episodes||Most often bilateral sinus pain and/or inflammation with pressure changes. Associated symptoms of sinusitis during and between acute sinus barotrauma episodes.||Bilateral mucosal thickening or opacification of sinuses during and between acute barotraumatic events||Long-term medical treatment with antibiotics, local steroids, and tapering course of oral steroids. Complete ESS is often the treatment of choice, sinus outflow tract patency should be optimized via ESS.|
- Avoid diving when sick with
- Upper Respiratory Infection
- Avoid medications which can cause vasoconstriction for 12 hours prior to dive
- This is to avoid rebound congestion, subsequent barotrauma
- Avoid smoking
- Avoid nasal irritants
- Learn and use appropriate equalization techniques
- Use a feet-first position when descending
- Oral decongestants
- Administer before the anticipated event
- Local or topical decongestants at times of anticipated shifts in pressure can often prevent barotrauma
- 120 mg PO taken 30 minutes before exposure to barotraumatic event
- Decreased the incidence of otic trauma in up to 52% of patients with a history of barotitis
- Saline irrigations
- Topical corticosteroids
- Roll is unclear, not well defined
- Consider for patients who's symptoms persist >24 hours
- Roll is unclear, not well defined
- Consider for patients who's symptoms persist >24 hours
- Chronic Barosinusitis
- No standardized medical therapy
- One proposed regimen: 6 weeks of saline solution rinses and fluticasone nasal spray, 5 day course of 100 mg PO prednisone
- 1 month course of antibiotics suggested for active duty pilots
- Should be considered on recurrent or chronic presentations to evaluate for anatomic disease that may have a surgical correction
- Management of complications (e.g. septal abscess, orbital sequelae, pneumocephalus, etc)
- All surgical interventions are tailored to individual patient and any anatomic variants they may have
- Concha bullosa reduction
- Targeted sinus surgery
- Bilateral endonasal surgery
- Maxillary antrostomy
- Wide frontal recess clearance +/- septal and turbinate surgery
- Balloon catheter dilation (BCD)
Rehab and Return to Play
- No clear guidelines
Return to Play/ Work
- Athletes may return to diving in 6 weeks if:
- Imaging shows resolution
- Known risk factors have resolved
Complications and Prognosis
- Nonoperative management
- One study indicated that 49% of divers with chronic rhinosinusitis responded well to medical therapy, could return to diving duties
- Surgical intervention
- When medical therapy failed, 92-95% of patients report long term success
- Compression of the Optic Nerve
- Reported in one diver, leading to permanent vision loss
- Neuropraxia of infraorbital branch of fifth cranial nerve
- Patient will have symptoms at the lip and cheek
- Periorbital emphysema
- Due to ethmoid sinus can dissecting air through lamina papyracea
- Rare complications reported in Acute Barosinusitis
- Surgeon General. Book chapter in: German aviation medicine in World War II. United States Air Force (USAF), US Govt Printing Office, Washington DC: 990–992, 1948.
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- Campbell PA. Aerosinusitis. Arch Oto 35:107–114, 1942.
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- Image courtesy of dan.org, "sinus barotrauma"
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