AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Barotrauma of the paranasal sinuses is a risk factor for anyone exposed to ambient pressure changes. These pressure changes most often result from travel through mountainous regions, flying, or diving. Barosinusitis is characterized by inflammation of one or more of the paranasal sinuses. Inflammation is caused by a pressure gradient, almost always negative, between the sinus cavity and the surrounding ambient environment.

Pathophysiology

The paranasal sinuses have rigid walls with relatively small ostia for gas exchange and mucus transport. Physical gas laws, particularly Boyle's Law, apply to this space. Boyle's Law states that at constant temperature, the volume of a gas is inversely proportional to the pressure placed upon it.

To show how Boyle's Law affects the sinuses, consider the case of an individual with normal sinuses exposed to pressure changes while flying in an unpressurized aircraft. As the individual transitions to higher altitude, the ambient pressure surrounding the sinus cavity decreases, and the air in the sinuses expands and equalizes through the natural ostium. Upon descent, ambient air pressure increases, the air in the sinuses contracts, and air moves into the sinus cavity, preventing a pressure gradient from developing.

Now consider the same flight in someone who has an upper respiratory tract infection (URTI) with tissue edema and secretions blocking the natural sinus ostia. In this individual, tissue edema and debris will not allow free pressure equalization. Again, as the individual moves up in altitude, the ambient pressure decreases, and volume in the sinus cavity increases. A positive pressure develops in the sinus. With this positive pressure, tissue edema gradually decreases enough to allow debris and air to escape the natural ostium. Air pressure then equalizes. When the individual descends, the ambient pressure increases. Pressure cannot equalize across the nasal cavity to the sinus because of blockage at the ostium. Air volume decreases in the sinus cavity, creating a negative pressure.

At this point, a condition exists in which the volume of the sinus must be filled if the pressure gradient is to be eliminated. In mild-to-moderate cases, vascular engorgement and generalized submucosal edema occur. Over time, transudate and mucus fill the volume, reducing negative pressure and decreasing symptoms. In severe cases, especially with rapid onset, the sinus mucosa is stripped from the subjacent bone, resulting in severe pain and hematoma formation.

Frequency

United States

Prevalence is approximately 3-4 episodes per 100,000 exposures in a generally healthy population.

• In contrast, middle ear barotrauma (aerotitis media) is approximately 6-10 times more prevalent than barosinusitis.
• Frontal sinuses are most often affected, followed by maxillary sinuses.
• Ethmoid sinuses are infrequently affected as isolated events.
• Data are heavily skewed toward people who participate in activities subject to rapid pressure changes.

Race

Race predilection is not widely reported.

Sex

Sex predilection is not widely reported.

Age

Barosinusitis is not typically reported in children. Frontal sinuses are most frequently affected, and these do not fully develop until late adolescence. In addition, children do not routinely participate in activities that lend themselves to rapid pressure changes.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Differentiate sinus barotrauma from other causes of facial pain and headache. The history is particularly important in shortening the differential. In sinus barotrauma, a condition of barometric pressure change always exists either during or shortly after onset of symptoms.

• With mild sinus barotrauma, the patient reports the following:
• • Mild pressure or pain over 1 or more of the sinuses that develops after return to sea level or starting point
  • Worsening congestion
  • Occasional epistaxis
• With more severe sinus barotrauma, the patient notes the following possibly incapacitating symptoms:
• • Sudden onset of typically severe and sharp pain and pressure
  • Pain is typically in the forehead, mid face, or retro orbital.
  • Epistaxis

Physical

Physical findings may be relatively sparse in mild cases of barosinusitis. In severe cases, the patient may have marked pain in the forehead, face, and upper teeth. This pain is typically unilateral. Erythema, edema, congested mucous membranes, epistaxis, and tenderness to palpation of the face may occur.

Causes

The following activities and conditions place individuals at particular risk for barosinusitis:

• Scuba and sport diving
• Sky diving
• Flying in military/high-performance aircraft
• URTI or sinusitis in persons exposed to pressure changes
• Poorly controlled allergies or anatomic abnormalities of the nose and paranasal sinuses

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Seasonal or perineal allergic rhinitis
Mucosal irritation from smoke or other environmental agents
Nasal polyposis
Nasal septal deviation
Concha bullosa
Infraorbital ethmoid cells
Benign or malignant sinus or nasal cavity tumors

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Laboratory assessment adds little to the evaluation of barosinusitis.

Imaging Studies

• Radiologic assessment is not usually necessary to establish the diagnosis but may help to indicate location and to search for underlying causes.
• Plain films are useful to isolate location. The usual finding is mucosal edema, which can range from slight thickening to total opacification of one or more sinuses. There may be air-fluid (ie, blood) levels. Hematoma formations, usually in the frontal sinus, are smooth and oval; they may be small or may nearly fill the sinus.
• CT scans are considered the criterion standard for imaging assessment of barosinusitis. Obtain coronal and axial views. CT scanning accurately defines involved sinuses, extent of any hematoma, and mucosal thickening. The study can suggest predisposing factors (eg, septal deviation, middle meatus and turbinate abnormalities, nasal polyposis, underlying mass). CT scanning is an excellent tool for surgical planning.
• MRI is similar to CT scanning in predicting involved sinuses, but it does not provide bony detail. MRI is better than CT scanning in differentiating paranasal sinus masses, although it is not as useful as CT scanning in surgical planning and can be more time consuming to obtain.

Other Tests

• Other tests (eg, ultrasound) are not typically used to aid in diagnosis or treatment. Transillumination of the sinuses may provide some additional information on location of barotrauma, but it is unreliable and does not change treatment.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Begin treatment at the first sign of barotrauma. Treatment is accomplished most simply by returning to the altitude at which symptoms occurred, or, in the case of diving, returning to the surface. Decongest the nose with liberally applied topical agents, and then gradually descend to ground level. Unfortunately, immediate treatment is not always possible, and treatment often begins after the fact.

Medical therapy is generally directed toward pain control, establishing ventilation, and preventing infection.

• Pain control
  • Oral agents are usually effective.
  • Severe pain may require the use of narcotics.
• Establishing ventilation
• • Topical decongestants include 0.05% oxymetazoline and 0.5-1% phenylephrine.
  • Oral decongestants include phenylpropanolamine (recalled from the US market) and pseudoephedrine.
  • In general, antihistamines are avoided because they tend to dry mucosa and inspissate secretions, although they may be useful if the underlying disease process includes poorly controlled allergies.
• Preventing infection
• • Blood and transudate from traumatized mucosa provide a rich medium for bacterial growth.
  • This environment, combined with damaged mucosa, inability to clear secretions, and altered oxygen tension, sets the stage for secondary bacterial infection (if not already present as the underlying cause of URTI).
  • A course of antibiotics may prevent secondary infection and hasten recovery.
  • In the acute setting, the first-line antibiotic is amoxicillin. In patients who are allergic to penicillin, trimethoprim/sulfamethoxazole is a reasonable first-line medication. Other choices include extended-spectrum penicillins, cephalosporin, clindamycin, extended-spectrum macrolides, and quinolones.

Surgical Care

Surgical therapy is designed to restore sinus ventilation. Conventional therapy with septoplasty, turbinectomy, antral windows, Caldwell-Luc operation, external or transantral ethmoidectomy, nasal polypectomy, and frontal sinus trephination has had variable efficacy. Endoscopic sinus surgery has substantially increased the chance of returning the patient to full activities.

• If oral agents fail to relieve pain and pressure, or if pain and pressure do not resolve over 24 hours, consider antral puncture/washout to rapidly equilibrate pressure and to clear sinus blood and other debris. This has minimal effect on the middle meatus and may not clear symptoms from ethmoid and frontal disease. Septoplasty and turbinectomy may help as a preventive measure, depending upon the clinical presentation.
• Endoscopic sinus surgery
• • Recurrent sinus barotrauma due to anatomic derangement has been managed effectively with endoscopic sinus surgery. Parsons et al reported their results on a group of military aviators, 98% of whom returned to flying after treatment.
  • In another group of military pilots, aircrew, and divers, all patients returned to full duty after approximately 14- to 21-days' recovery time. In general, the surgery is designed to establish ventilation and minimal hole techniques are typically effective; however, the particular surgery must be individualized for optimal results. Nasal septal deflection, if clinically significant, is corrected at the time of endoscopic sinus surgery.
  • These studies use individuals who represent a select group of people who do not have a history of underlying mucosal disease (eg, allergy, polyposis). Individuals with underlying disease may also benefit from endoscopic sinus surgery, but they may require ongoing medical therapy for maximal results. Ongoing medical therapy must be highly individualized and closely monitored. Such medical therapy may disqualify, either temporarily or permanently, the individual from those activities that resulted in sinus barotrauma in the first place. This is especially true for aviators and divers in whom incapacitation from acute sinus barotrauma may be substantially more than an inconvenience.
  • CT scan imagery should determine the extent of sinus surgery; but, in general, limit surgery to minimal dissection and debridement techniques. This minimizes tissue damage and healing time yet establishes patent ostia that prevent recurrence of pressure gradient and sinus symptoms.

Activity

Depending upon the extent of surgery, most patients can return to full activity within 2-3 weeks following surgery.

Commercial airline travel is generally permitted within 2-3 days, as is swimming on the water surface.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goal of pharmacotherapy is to reduce morbidity and prevent complications.

Drug Category: Decongestants

Decongestants establish ventilation of the sinuses and relieve pressure, pain, and edema. Combine topical and oral decongestants in most cases, especially for acute symptoms. Topical agents are frequently useful when oral agents are contraindicated.

Drug Category: Antibiotics

Antibiotics control infection either as an inciting factor in the barosinusitis or as a sequela of the barosinusitis.

Drug Category: Analgesics

Acetaminophen, with or without codeine, is useful for pain control.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Depending on the clinical situation, the vast majority of patients undergoing endoscopic sinus surgery may return to full activities within 2-3 weeks following surgery.
• Warn patients to avoid activities that may be hazardous (eg, piloting aircraft, diving) until the attending surgeon is sure the patient is fully recovered.
• Remember that other governing agencies (eg, Federal Aviation Administration, Department of Defense) may have ultimate authority over granting the patient's request to return to work or activity (eg, commercial or military flying or diving).

Deterrence/Prevention

• Prevention is best accomplished by avoiding ambient pressure changes. This is particularly true when the individual attempts to fly or dive while they have a URTI, cold, or poorly controlled nasal allergy.
• Repeated attacks of acute barosinusitis can cause permanent damage of the paranasal sinus mucosa, which leads to recurrent barosinusitis. This condition results from hematoma formation and fibrosis and chronic mucosal thickening, which can further impede adequate sinus ventilation.

Complications

• Complications of barosinusitis are unusual, but they may include the following:
• • Orbital cellulitis, abscess, or hematoma
  • Pneumocephalus or subcutaneous emphysema
  • Complications associated with paranasal sinusitis

Prognosis

• Isolated barosinusitis in a previously healthy individual most commonly is due to flying or diving with acute URTI or sinusitis. These patients generally do quite well with conservative treatment. Recurrent acute barosinusitis suggests fixed pathology of the paranasal sinuses and is more likely to require surgical therapy to establish ventilation. Prognosis is still excellent in previously healthy patients. Those with poorly controlled allergy, nasal polyposis, or extensive mucosal disease may not do as well in terms of returning to full activity.

Patient Education

• Strongly caution individuals involved in work or recreation activities that include acute pressure changes not to participate if they are not 100% physically qualified.
• If symptoms of barosinusitis occur while diving, return to the surface. If flying, return (usually climb) to the altitude at which symptoms first started, use topical decongestants if available, and start a slow descent as symptoms allow. The Valsalva maneuver may be helpful and is more effective after topical decongestion.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Although the patient may be fully recovered and ready to return to work or full activity, authorization for such activity frequently comes from another supervisory agency, not the surgeon. The surgeon's input is important, although other regulations about which he or she may be unaware could be in effect. The patient has the responsibility to know the identity of any supervising authority. Ask the patient about this possibility without fail, and document his or her response.

Special Concerns

• The views or opinions contained within this article are those of the author alone and do not reflect the official position of the US Navy, Department of Defense, Federal Aviation Administration, or any other US governmental agency.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Hanna HH, Tarington CT. Otolaryngology in aerospace medicine. In: DeHart RL, ed. Fundamentals of Aerospace Medicine. Philadelphia:. Lippincott Williams & Wilkins;1985:520-530.
• Jones JS, Sheffield W, White LJ, et al. A double-blind comparison between oral pseudoephedrine and topical oxymetazoline in the prevention of barotrauma during air travel. Am J Emerg Med. May 1998;16(3):262-4. [Medline].
• Parsons DS, Chambers DW, Boyd EM. Long-term follow-up of aviators after functional endoscopic sinus surgery for sinus barotrauma. Aviat Space Environ Med. Nov 1997;68(11):1029-34. [Medline].
• Setliff RC 3d. Minimally invasive sinus surgery: the rationale and the technique. Otolaryngol Clin North Am. Feb 1996;29(1):115-24. [Medline].

Article Last Updated: May 26, 2006