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Sinus Barotrauma

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Other Names

  • Paranasal Sinus Barotrauma
  • Sinonasal barotrauma
  • Sinus Squeeze
  • Barosinusitis
  • Aerosinusitis

Background

  • 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

History

  • First described in WW2 aviation literature[1][2]
  • Pathophysiology first described by Campbell in 1942[3]
  • First case reported in the diving literature by Flottes in 1965[4]

Epidemiology

  • Overall, lack of good epidemiological data
  • Diving
    • One study estimates the prevalence at 34%[5]
    • Incidence estimated at 26%[6]
  • Flying
    • Among pilots, prevalence estimated 19.5-25%[7][8]
    • If concurrent sinonasal inflammation, that number increases to 55% in commercial pilots, 34% in high performance pilots[8]
  • Hyperbaric oxygen
    • Prevalence of sinus barotrauma in patients who undergo hyperbaric oxygen exposure is reported to be around 3%[9]

Pathophysiology

Illustrations depicting normal sinus pressure equalization. (A) Normal sinus equalization at sea level. (B) Normal sinus equalization during flight. (C) Normal sinus equalization during diving.[10]
Illustrations that depict scenarios of sinus barotrauma. (A) Reverse squeeze or compression injury in an inflamed or partially obstructed sinus. Increased air expansion and elevated intrasinus pressure during ascent, without compensated pressure release, produces an outward, “expansile” compression injury of the sinus mucosa against the bony sinus outer walls; this results in mucosal edema and rupture. (B) A squeeze or decompression injury in an inflamed or partially obstructed sinus. Decrease in gaseous volume within the sinuses during descent creates intrasinus decompression without inward pressure equalization; this results in “pulling” forces within the sinus cavity that can cause mucosal edema, avulsion of the mucosal surface from the bone, and hematoma formation, depending on the degree and rapidity of the pressure shifts. (C) Type 3 frontal cell that compromises sinus outflow; a reverse squeeze or compression injury may occur in both the frontal sinus and obstructing type 3 cell, producing severe, but focal, symptoms.[10]
  • General
    • 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[11]
    • It also generally takes longer to ascend/descend in air than water

Etiology

  • General
    • 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[12]
    • 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[13]
    • 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
    • Gaseous general anesthetic agents[14]
    • Hyperbaric oxygen therapy[15]
    • Chinook wind exposure[16]
    • Prolonged high altitude exposure[17]
    • Automobile travel[18]
    • Submarine decompression[19]
    • Nasal blowing[20]
    • Vigorous Valsalva maneuver[21]

Acute Barosinusitis

  • General
    • 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[22]
    • 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%)[23]
    • 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[24]
    • 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

  • General
    • 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[25]

Chronic Barosinusitis

  • General
    • Most poorly described in the literature
    • Often confused with chronic rhinosinusitis
    • Detailed history of occupational or recreational causes of barotrauma needed to make diagnosis
    • Can see muscosal thickening on MRI[26]
    • Risk appears to increase with number of dives performed[27]

Pathoanatomy

  • 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

Risk Factors

  • Sports
  • Occupation
    • Pilot
  • ENT
    • Concurrent Sinonasal inflammation[28]
    • Coexisting Upper Respiratory Tract Infection[24]

Differential Diagnosis

Differential Diagnosis Dive Medicine

Illustration of the paranasal sinus anatomy where patients may develop or report pain.[29]

Clinical Features

  • History
    • 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

Evaluation

  • General
    • Imaging findings are thought to be related to submucosal hemorrhage
    • This occurs during the squeeze or revere squeeze injury to the sinonasal mucosa

CT

  • Indications
    • 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

MRI

  • Indications
    • Chronic or recurrent symptoms
  • Potential Findings
    • Hyperintensity on both T1 and T2 without contrast enhancement

Classification

Proposed Classification by Vaezeafshar

  • Based on clinical presentation of acute, recurrent acute or chronic[10]
    • 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.

Management

Prevention

  • Avoid diving when sick with
    • Rhinitis
    • Sinusitis
    • Upper Respiratory Infection
  • Avoid medications which can cause vasoconstriction for 12 hours prior to dive
    • This is to avoid rebound congestion, subsequent barotrauma[30]
  • 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[31]
  • Pseudoephedrine
    • 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[32]

Nonoperative

  • Medications
    • Saline irrigations
    • Decongestants
    • Topical corticosteroids
    • Analgesics
  • Antibiotics
    • Roll is unclear, not well defined
    • Consider for patients who's symptoms persist >24 hours
  • Steroids
    • 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[33]
    • 1 month course of antibiotics suggested for active duty pilots
  • Imaging
    • Should be considered on recurrent or chronic presentations to evaluate for anatomic disease that may have a surgical correction

Operative

  • Indications
    • 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
  • Procedure
    • Septoplasty
    • Concha bullosa reduction
    • Uncinectomy
    • Targeted sinus surgery
    • Bilateral endonasal surgery
    • Maxillary antrostomy
    • Sphenoethmoidectomy
    • Wide frontal recess clearance +/- septal and turbinate surgery
    • Balloon catheter dilation (BCD)

Rehab and Return to Play

Rehabilitation

  • 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

Prognosis

  • Nonoperative management
    • One study indicated that 49% of divers with chronic rhinosinusitis responded well to medical therapy, could return to diving duties[33]
  • Surgical intervention
    • When medical therapy failed, 92-95% of patients report long term success[34]

Complications

  • Compression of the Optic Nerve
    • Reported in one diver, leading to permanent vision loss[35]
  • 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

See Also

References

  1. ↑ 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.
  2. ↑ Hermann A. “Laceration of the Mucous Membrane and Hematoma of the Nasal Sinuses in Aviators.” Ztschr. f. Hals-, Nasen-u. Ohrenh. 47:103–112, 1940.
  3. ↑ Campbell PA. Aerosinusitis. Arch Oto 35:107–114, 1942.
  4. ↑ Flottes L. Barotrauma of the ear and sinuses caused by underwater immersion [in Spanish]. Acta Otorinolaryngol Iber Am 16:453–483, 1965.
  5. ↑ Taylor DM, O'Toole KS, Ryan CM. Experienced scuba divers in Australia and the United States suffer considerable injury and morbidity. Wilderness Environ Med 14:83–88, 2003.
  6. ↑ Uzun C. Paranasal sinus barotrauma in sports self-contained underwater breathing apparatus divers. J Laryngol Otol 123:80–84, 2009.
  7. ↑ Rosenkvist L, Klokker M, Katholm M. Upper respiratory infections and barotraumas in commercial pilots: A retrospective survey. Aviat Space Environ Med 79:960–963, 2008.
  8. ↑ 8.0 8.1 Ulanovski D, Barenboim E, Raveh E, et al. Sinusitis in pilots of different aircraft types: Is allergic rhinitis a predisposing factor? Am J Rhinol 22:122–124, 2008.
  9. ↑ Fitzpatrick DT, Franck BA, Mason KT, Shannon SG. Risk factors for symptomatic otic and sinus barotrauma in a multiplace hyperbaric chamber. Undersea Hyperb Med 26:243–247, 1999.
  10. ↑ 10.0 10.1 10.2 Vaezeafshar, Reza, et al. "Barosinusitis: Comprehensive review and proposed new classification system." Allergy & Rhinology 8.3 (2017): ar-2017.
  11. ↑ Becker GD, Parell GJ. Barotrauma of the ears and sinuses after scuba diving. Eur Arch Otorhinolaryngol 258:159–163, 2001.
  12. ↑ Edmonds CB, Bennett M, Lippmann J, Mitchell S. Diving and Subaquatic Medicine. 5th ed. Florida: CRC Press; 2015. p. 865.
  13. ↑ Tseng W, Lee H, Kang B. Periorbital emphysema after a wet chamber dive. Diving Hyperb. Med. 2017; 47:198–200. PMID: 28868601.
  14. ↑ Salvinelli F, Rinaldi V, D'Ascanio L. Paranasal sinus barotrauma in general anesthesia: Special attention. J Clin Anesth 17:323, 2005.
  15. ↑ Ambiru S, Furuyama N, Aono M, et al. Analysis of risk factors associated with complications of hyperbaric oxygen therapy. J Crit Care 23:295–300, 2008.
  16. ↑ Rudmik L, Muzychuk A, Oddone Paolucci E, Mechor B. Chinook wind barosinusitis: An anatomic evaluation. Am J Rhinol Allergy 23:e14–e16, 2009.
  17. ↑ Prasad BK. ENT morbidity at high altitude. J Laryngol Otol 125:188–192, 2011.
  18. ↑ osun F, Durmaz A, Kıvrakdal C, et al. Severe maxillary sinus barotrauma associated with car travel. Int J Pediatr Otorhinolaryngol Extra 2:151–153, 2007.
  19. ↑ Slisković Z. Cases of barotrauma of paranasal sinuses in diving, submarine and flying services [in Serbian]. Vojnosanit Pregl 25:567–569, 1968.
  20. ↑ 20.0 20.1 García de Marcos JA, del Castillo-Pardo de Vera JL, Calderon-Polanco J. Orbital floor fracture and emphysema after nose blowing. Oral Maxillofac Surg 12:163–165, 2008.
  21. ↑ Babl FE, Arnett AM, Barnett E, et al. Atraumatic pneumocephalus: A case report and review of the literature. Pediatr Emerg Care 15:106–109, 1999.
  22. ↑ Fagan P, McKenzie B, Edmonds C. Sinus barotrauma in divers. Ann Otol Rhinol Laryngol 85(pt. 1):61–64, 1976.
  23. ↑ Plafki C, Peters P, Almeling M, et al. Complications and side effects of hyperbaric oxygen therapy. Aviat Space Environ Med 71:119–124, 2000.
  24. ↑ 24.0 24.1 Weissman B, Green RS, Roberts PT. Frontal sinus barotrauma. Laryngoscope 82:2160–2168, 1972.
  25. ↑ Parell GJ, Becker GD. Neurological consequences of scuba diving with chronic sinusitis. Laryngoscope 110:1358–1360, 2000.
  26. ↑ Sonmez G, Uzun G, Mutluoglu M, et al. Paranasal sinus mucosal hypertrophy in experienced divers. Aviat Space Environ Med 82:992–994, 2011.
  27. ↑ Klingmann C, Praetorius M, Baumann I, Plinkert PK. Otorhinolaryngologic disorders and diving accidents: An analysis of 306 divers. Eur Arch Otorhinolaryngol 264:1243–1251, 2007.
  28. ↑ Edmonds C. Sinus barotrauma: a bigger picture. J South Pac Underwater Med Soc J 24:13–19, 1994.
  29. ↑ Image courtesy of dan.org, "sinus barotrauma"
  30. ↑ Livingstone DM, Lange B. Rhinologic and oral-maxillofacial complications from SCUBA diving: a systematic review with recommendations. Diving. Hyperb. Med. 2018; 48:79–83. doi:10.28920/dhm48.2.79-83.
  31. ↑ Stewart TW., Jr Common otolaryngologic problems of flying. Am Fam Physician 19:113–119, 1979.
  32. ↑ Jones JS, Sheffield W, White LJ, Bloom MA. A double-blind comparison between oral pseudoephedrine and topical oxymetazoline in the prevention of barotrauma during air travel. Am J Emerg Med 16:262–264, 1998.
  33. ↑ 33.0 33.1 Skevas T, Baumann I, Bruckner T, et al. Medical and surgical treatment in divers with chronic rhinosinusitis and paranasal sinus barotrauma. Eur Arch Otorhinolaryngol 269:853–860, 2012.
  34. ↑ Parsons DS, Chambers DW, Boyd EM. Long-term follow-up of aviators after functional endoscopic sinus surgery for sinus barotrauma. Aviat Space Environ Med 68:1029–1034, 1997.
  35. ↑ arell GJ, Becker GD. Neurological consequences of SCUBA diving with chronic sinusitis. Laryngoscope. 2000; 110:1358–60. doi:10.1097/00005537-200008000-00026.
  36. ↑ Javan R, Duszak R, Jr, Eisenberg AD, Eggers FM. Spontaneous pneumocephalus after commercial air travel complicated by meningitis. Aviat Space Environ Med 82:1153–1156, 2011.
  37. ↑ Jeong JH, Kim K, Cho SH, Kim KR. Sphenoid sinus barotrauma after scuba diving. Am J Otolaryngol 33:477–480, 2012.
  38. ↑ Mahabir RC, Szymczak A, Sutherland GR. Intracerebral pneumatocele presenting after air travel. J Neurosurg 101:340–342, 2004.
  39. ↑ Bellini MJ. Blindness in a diver following sinus barotrauma. J Laryngol Otol 101:386–389, 1987.
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