Sinus Barotrauma: Treatment

Most of the effects of sinus barotrauma are minor and rapidly regress if diving is suspended and the underlying or consequential inflammatory disorder of the sinus is treated. Patients with a sinus or upper respiratory tract infection may require antibiotics and decongestants. Surgical drainage of acute lesions is rarely indicated, unless there are neurological or other sequelae. Attention is best paid to prevention.

Even mucoceles and chronic sinus disease usually resolve without intervention, if diving is suspended.

In the ‘serious’ cases (the second Australian series), the treatment could be divided into groups of patients:

  1. Those whose disorder cleared up spontaneously and who were advised to not dive until this had happened.
  2. Those who were using inappropriate diving techniques. These have been described previously. These patients usually responded to appropriate regimens of: a. Feet-first descent. b. Positive pressure manoeuvres to autoinflate both middle ears and sinuses, on the surface (immediately before descent) and then at regular intervals of half to 1 metre or so during descent. This is equalization ahead of the dive (see Chapter 7). c. Avoidance of diving exposure during respiratory tract inflammations.
  3. Those who responded to medical treatment of the nasal disorders. This included the topical use of steroid nasal sprays, cromoglycate, topical or generalized decongestants, avoidance of nasal irritants and allergens and cessation of smoking (tobacco or marihuana).
  4. Patients with infective sinusitis, who required treatment of the infections, usually by decongestants and antibiotics. The authors of this text so treat any persistence of symptoms following sinus barotrauma, i.e. symptoms commencing hours after the dive or persisting into the following day.
  5. The intractable group, who required sinus exploration, usually with endoscopy and reconstruction, or nasal surgery. In some cases surgery was required to produce patency of the ostia and to remove polyps, mucocoeles or redundant mucosa that caused obstruction to the ostia. Other times it was needed to improve nasal air flow. Reference in the literature, by Bolger, Parsons and Matson26 in 1990, has been made to the value of surgery in aviators with sinus barotrauma. The guarded enthusiasm of these investigators for functional endoscopic sinus surgery was tempered by the possible complications of this procedure. Nevertheless, endoscopic sinus surgery is advancing rapidly and may offer value to patients with the more serious and chronic cases. With current endoscopic surgical procedures22, the maxillary, ethmoid and sphenoid sinuses can be treated to widen the sinus ostia, thus preventing sinus barotrauma. It is considered the treatment of choice in military aviators in the United States. The frontal sinus is less amenable to this treatment but may be explored in some cases.
  6. The sixth group continued to have difficulties and usually ceased diving.

All patients were strongly advised to not dive during times of upper respiratory tract inflammation (e.g. infections, allergic or vasomotor rhinitis). As with the original series, more than 50 per cent of the divers in the second series had a history of diving with such conditions at the time of the barotrauma.

Some clients were moved between treatments because various measures failed to resolve or prevent problems completely.

Our general impression was that approximately equal numbers fell into each ‘treatment’ group. Various attitudes to the current treatments are discussed in the previously cited references and diving medical texts.