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American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 477–480www.elsevier.com/locate/amjoto

Sphenoid sinus barotrauma after scuba diving☆

Jin Hyeok Jeong, MD⁎, Kuk Kim, MD, Seok Hyun Cho, MD, Kyung Rae Kim, MDDepartment of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, South Korea

Received 11 October 2011

Abstract We report the case of an 18-year-old male patient operated on for sphenoid sinus barotrauma after

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scuba diving. The patient attended our emergency department because of intractable headache butdid not improve with conservative treatment. After computed tomography and magnetic resonanceimaging examination, he was diagnosed with sphenoid sinusitis that extended to the nasal septum.He therefore underwent surgery for sinus ventilation and abscess drainage.

© 2012 Elsevier Inc. All rights reserved.

1. Introduction

Barotrauma is tissue injury associated with rapid pressurechange [1]. Most cases of barotrauma are related to air traveland cause middle ear and inner ear injury, but sometimes,barotrauma of the paranasal sinus is reported after air travel[2]. Reports of sinus barotrauma related to marine sportssuch as scuba diving or diving are uncommon, and sinusbarotrauma caused by diving generally involves the frontalsinus or maxillary sinus [3].

Recently, we encountered a case of barotrauma of thesphenoid sinus after scuba diving, which progressed to aseptal abscess and was treated by surgical management.Sinus barotrauma is thought to have increased significantlywith the diversification of leisure activities and greater publicinvolvement in marine sports.

2. Case

A previously healthy 18-year-old male patient visitedour hospital emergency department because of a bilateraltemporo-occipital area headache that had gradually worse-ned. The headache had been caused by scuba diving

sclosures and no conflict of interest.author. Department of Otolaryngology-Head ande of Medicine, Hanyang University, 17 Haengdang-Seoul 133-792, South Korea. Tel.: +82 31 560 2368;.t@hanyang.ac.kr (J.H. Jeong).

nt matter © 2012 Elsevier Inc. All rights reserved.011.10.017

without a pressure control device 3 weeks previously, andimmediately, after the scuba diving, mild epistaxis hadoccurred. As the patient's symptoms improved aftersymptomatic treatment, he was discharged without admis-sion. After returning home, his headache worsened, so hewas admitted to the department of neurology. He had beentreated with oral antibiotics and analgesics for a weekbefore admission, but the treatment was not effective. Pasthistory and family history were unremarkable, and therewere no symptoms except for bilateral temporo-occipitalheadache. Brain computed tomography (CT) taken theprevious week in the emergency department showed noabnormal findings except for soft tissue density of thebilateral sphenoid sinus. Paranasal sinus (PNS) CT andbrain magnetic resonance imaging (MRI) were performedafter admission to the neurology department. Because therewere no abnormal findings other than the sphenoid sinuslesion, the patient was transferred to the department ofotorhinolaryngology (Fig. 1). Left-sided nasal septaldeviation and bulging of the mucosa in the posteriorportion of the right nasal septum were observed onendoscopic examination (Fig. 2). Aspiration was performedat the bulging portion of the right nasal septum, and bloodypus was aspirated. There were no polyps or postnasal dripsaround the openings of the bilateral sphenoid sinus.

We performed the surgery immediately after transfer toour department because of the nasal septal abscess. Thesubmucosal pus collected in the posterior portion of the rightnasal septum was drained with septoplasty, and the deviatednasal septum was corrected. Then, the pus and necrotic softtissue inside both sphenoid sinuses were removed by

Fig. 1. PNS CT and brain MRI. Sinusitis in the bilateral sphenoid and posterior ethmoid sinuses demonstrated by CT scan (A). The MRI shows that the sinusitisextends to the right septal area (B, arrow).

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bilateral sphenoidotomy (Fig. 3) via endoscopic sinussurgery. Biopsy of the necrotic soft tissue inside the sphe-noid sinus revealed acute inflammatory exudates. Afterdischarge, the patient failed to attend our outpatient clinic

Fig. 2. Endoscopic findings. The right nasal cavity shows septal mucosal bulgingseptal deviation to the left (B).

and only visited 2 months after discharge. Endoscopicexamination at that time revealed a small septal perforationin the area where pus had collected. The openings of thesphenoid sinus were well maintained with well-healed sinus

in the posterior portion of the nasal septum (A). The left nasal cavity shows

Fig. 3. Operative findings. Pus was expelled during septoplasty (A). Necrotic detached mucosal debris (arrow) was expelled from the widened left sphenoid sinusostium during irrigation (B). Edematous mucosa of the left sphenoid sinus may be noted (C).

479J.H. Jeong et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 477–480

mucosa and no mucosal swelling (Fig. 4). The headache ofwhich the patient had complained no longer occurred, andthere were no other symptoms.

3. Discussion

Sinus barotrauma is an inflammatory disease of theparanasal sinus related to rapid pressure change andassociated with obstruction of the sinus opening due toupper airway infection, allergy, nasal polyp, or chronicsinusitis[1]. This disease readily occurs in professional pilotsand divers but can also affect airplane passengers and peoplewho enjoy scuba diving as a leisure sport.

The frontal sinus is the most commonly involved sinus,and if the frontal sinus is affected, headache occurs in thefrontal area. If the maxillary sinus is affected, toothache ofthe maxilla can occur, and if the sphenoid sinus is affected,there can be pain around the retro-orbital or occipital areas.

Sinus barotrauma can be easily diagnosed when exam-ined by an otorhinolaryngologist soon after exposure [4,5].Plain x-ray, CT, and MRI can be helpful in the diagnosis.

Fig. 4. Follow-up endoscopic findings. A small septal perforation can be seen in theand well-healed sinus mucosa (C) are evident.

The radiologic findings include fluid level and mucosalthickening in the affected sinus. In severe cases, there can betotal opacification of the affected sinus [6]. A commonsymptom arising during descent with positive pressure is asharp facial pain or headache, and epistaxis can occur,accompanied by other symptoms. If the trigeminal nerve,especially the infraorbital nerve area, is affected, thenneurologic symptoms can arise [5].

Sinus barotrauma follows Boyle Law [1] (P1 × V1 = P2 ×V2, where P is pressure, V is volume, and temperature isconstant). During a descent accompanied by obstruction of asinus opening due to any cause, the volume of the affectedsinus decreases. To compensate for the decreased volume,mucosal swelling and submucosal hematoma occur, andtissue fluid or blood collects in the sinus. During thesubsequent ascent, the blood and tissue fluid accumulatedduring the descent may be discharged, causing epistaxis.Tissue fluid or blood remaining in the affected sinus anddetached necrotic mucosa acts as a medium of propagationfor bacteria and can cause acute sinusitis [1]. When the diverreaches the surface, obstruction of the sinus opening by theaffected sinus wall causes leakage of air to surrounding

posterior portion of the nasal septum (A). The left sphenoid sinus ostium (B)

480 J.H. Jeong et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 477–480

organs, and this can cause rare complications such aspneumocephalus, subcutaneous emphysema, orbital emphy-sema, and meningitis [7].

In mild cases, sinus barotrauma can be treated withtopical decongestants, analgesics, and antibiotics. Inmoderate to severe cases or when topical treatment fails,endoscopic sinus surgery is needed for sinus ventilation[4,7]. Scuba diving and air travel should then be avoidedfor at least a week.

Prevention of sinus barotrauma is important. Forprevention, frequent periodic Valsalva maneuvers that pushair into the sinus are needed during descent, as well asslowing down rates of descent and ascent. Scuba diving orflying should be avoided when there is any upper airwayinfection, chronic sinusitis, or nasal polyps. Surgicalcorrection of nasal septal deviation is also helpful [1].

In the present case, acute sphenoid sinusitis was causedby scuba diving without proper management, and treatmentwith antibiotics and analgesics was delayed and withouteffect. Eventually, a septal abscess formed. This wastreated by septoplasty to drain the pus collected in theposterior portion of the right nasal septum together withendoscopic sinus surgery to widen the opening of thesphenoid sinus and remove the purulent pus collected in thesinus and the necrotic detached mucosa. The patient did notreceive any dressings or medication after discharginghimself against our recommendation. Two months afterdischarge, he visited our clinic for a checkup. In the sinusendoscopy performed at that time, the mucosa of thesphenoid sinus was seen to be well healed without mucosalswelling, but a small septal perforation was observed in theposterior portion of the nasal septum. This nasal septal

perforation is thought to have occurred not because ofsurgical trauma but because of necrosis of the periosteumcaused by the septal abscess. The perforation was small,without crust or bleeding, and the patient did not complainof any symptoms such as headaches.

4. Conclusion

Sinus barotrauma can be easily diagnosed by detailedhistory taking and physical and radiologic examination.Rapid diagnosis is important for treatment, so physiciansshould be aware of this disease. Because sinus barotrauma isexpected to increase with the diversification of leisureactivities and the increase in marine sports, we need to beconcerned with the diagnosis and treatment of this disease.

References

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[4] Bourolias C, Gkotsis A. Sphenoid sinus barotrauma after free diving.Am J Otolaryng 2011;32:159-61.

[5] Murrison A, Smith D, Francis T, Counter R. Maxillary sinus barotraumawith fifth cranial nerve involvement. J Laryngol Otol 1991;105:217-9.

[6] Yanagawa Y, Okada Y, Ishida K, Fukuda H, Hirata F, Fujita K.Magnetic resonance imaging of the paranasal sinuses in divers. AviatSpace Envir Med 1998;69:50-2.

[7] Moon RE. Treatment of diving emergencies. Crit Care Clin 1999;15:429-56.