Neurological consequences of scuba diving with chronic sinusitis

Facial and trigeminal nerves neuropathy induced by atmospheric pressure changes: A meta-analysis

BACKGROUND

Barometric pressure changes during flight or diving may cause facial barotrauma. Neuropathy of the fifth (CN5) or the seventh (CN7) cranial nerves is a rare manifestation of this condition. The aim of this study was to analyze risk factors for baroneuropathies of CN5 and CN7.

METHODS

A search of PubMed and Cochrane Library databases was conducted to identify all published cases of CN5 and CN7 neuropathies. Only original case reports and series that documented events of neuropathies associated with the trigeminal nerve or facial nerve while flying, diving, or mountain climbing were included. Assessed variables included sex, medical history, age, setting (flight or diving), atmospheric pressure changes, number of episodes, symptoms, treatment, and recovery.

RESULTS

We identified a total of 48 articles described >125 episodes in 67 patients. Mean age was 33.5 ± 12.1 years with a male predominance (76.1 %). Cases were equally distributed between flight and diving (50.7 %, 46.3 %, respectively). CN5 involvement was observed in 77.6 % of patients, with ear pain and facial numbness as the most common symptoms. The latter was correlated with positive otolaryngology medical history. CN7 was involved in 88.1 % of patients. Flying, as opposed to diving was correlated with spontaneous resolution of symptoms (86.7 % vs. 42.3 % of cases resolved spontaneously, respectively, p = 0.001).

CONCLUSIONS

Flight is an equal risk factor to diving with respect to CN5 and CN7 barotrauma. Involvement of CN7 was observed in most cases, but possibly due to report-bias. Positive medical history is a risk factor for facial numbness.

Diagnosis and Management of Barosinusitis: A Systematic Review

OBJECTIVE

To perform a systematic review to investigate the common presenting symptoms of barosinusitis, the incidence of those findings, the methods for diagnosis, as well as the medical and surgical treatment options.

METHODS

A review of PubMed/MEDLINE, EMBASE, and Cochrane Library for articles published between 1967 and 2020 was conducted with the following search term: aerosinusitis OR "sinus squeeze" OR barosinusitis OR (barotrauma AND sinusitis) OR (barotrauma AND rhinosinusitis). Twenty-seven articles encompassing 232 patients met inclusion criteria and were queried for demographics, etiology, presentation, and medical and surgical treatments.

RESULTS

Mean age of patients was 33.3 years, where 21.7% were females and 78.3% were males. Causes of barotrauma include diving (57.3%), airplane descent (26.7%), and general anesthesia (0.4%). The most common presentations were frontal pain (44.0%), epistaxis (25.4%), and maxillary pain (10.3%). Most patients received topical steroids (44.0%), oral steroids (28.4%), decongestants (20.7%), and antibiotics (15.5%). For surgical treatment, most patients received functional endoscopic sinus surgery (FESS) (49.6%). Adjunctive surgeries include middle meatal or maxillary antrostomy (20.7%), septoplasty (15.5%), and turbinate surgery (9.1%). The most efficacious medical treatments are as follows: 63.6% success rate with oral steroids (66 treated), 50.0% success rate with topical steroids (102 treated), and 50.0% success rate analgesics (10 treated). For surgical treatments received by greater than 10% of the sample, the most efficacious was FESS (91.5% success rate, 108 treated).

CONCLUSION

Oral and topical steroids should be first line therapies. If refractory, then functional endoscopic sinus surgery is an effective treatment.

The surgical management of recurrent acute and chronic barosinusitis in sports self-contained underwater breathing apparatus (scuba) divers

PURPOSE

The aim of this retrospective study is to evaluate the feasibility of functional endoscopic sinus surgery (FESS) with supplementary surgical procedures in scuba divers with recurrent acute barosinusitis (RABS) and chronic barosinusitis (CBS).

METHODS

In this retrospective study, 25 divers were classified into RABS (n:11) and CBS (n:14) groups. The presentation of divers have been reviewed. The PNS CT images were scored according to Lund-Mackay (L-M) system. A score has been assigned to the extent of endoscopic procedures performed. The outcome of surgery and life quality were determined by SNOT-22 and dive-related questions (DRQ) tests.

RESULTS

The average L-M score was 3.8 ± 2 for RABS and 12.2 ± 3.4 for CBS groups. L-M score of CBS group was found to be statistically higher than RBS group (p < 0.05). The FESS score of CBS group (8.7 ± 2.4) was higher than RABS group (5.6 ± 2) which showed that the endoscopic sinus procedures were performed more extensively in CBS group (p < 0.05). The difference between the preoperative and postoperative SNOT-22 scores indicates that the degree of sinus symptoms improved better in RABS group than CBS group (p < 0.05). When DRQ test was evaluated, RABS group showed a better improvement in diving performance symptoms than the CBS group (p < 0.05).

CONCLUSION

Our study demonstrated that divers with RABS and CBS can be managed successfully with FESS and supplementary surgical procedures. The improvement in the RABS group was superior to the CBS group, a difference attributed to the severity of chronic inflammation in CBS.

Dive Medicine: Current Perspectives and Future Directions

As SCUBA diving continues to rapidly grow in the United States and worldwide, physicians should have a fundamental working knowledge to provide care for an injured diver. SCUBA divers are faced with many hazards at depths that are normally well compensated for at sea level. Pressure gradients, changes in the partial pressure of inhaled gases and gas solubility can have disastrous effects to the diver if not managed properly. Many safety measures in SCUBA diving are governed by the laws of physics, but some have come under scrutiny. This has prompted increased research concerning in water recompression and flying after diving. This article will give physicians an understanding of the dangers divers encounter and the current treatment recommendations. We will also explore some controversies in diving medicine.

Rhinologic and oral-maxillofacial complications from scuba diving: a systematic review with recommendations

Rhinologic and oral maxillofacial complications from scuba diving are common, representing approximately 35% of head and neck pathology related to diving. We performed a systematic and comprehensive literature review on the pathophysiology, diagnosis, and treatment of rhinologic and oral maxillofacial pathology related to diving. This included complications due to sinus barotrauma, barodontalgia, odontocrexis, temporomandibular joint dysfunction, partially dentulous patients, and considerations for patients following major head and neck surgery. Of 113 papers accessed, 32 were included in the final synthesis. We created a succinct summary on each topic that should inform clinical decision making by otolaryngologists, dive medicine specialists and primary care providers when faced with pathology of these anatomic sub-sites.

Barosinusitis: Comprehensive review and proposed new classification system

Background:

Barosinusitis, or sinus barotrauma, may arise from changes in ambient pressure that are not compensated by force equalization mechanisms within the paranasal sinuses. Barosinusitis is most commonly seen with barometric changes during flight or diving. Understanding and better classifying the pathophysiology, clinical presentation, and management of barosinusitis are essential to improve patient care.

Objectives:

To perform a comprehensive review of the available literature regarding sinus barotrauma.

Methods:

A comprehensive literature search that used the terms “barosinusitis,” “sinus barotrauma,” and “aerosinusitis” was conducted, and all identified titles were reviewed for relevance to the upper airway and paranasal sinuses. All case reports, series, and review articles that were identified from this search were included. Selected cases of sinus barotrauma from our institution were included to illustrate classic signs and symptoms.

Results:

Fifty-one articles were identified as specifically relevant to, or referencing, barosinusitis and were incorporated into this review. The majority of articles focused on barosinusitis in the context of a single specific etiology rather than independent of etiology. From analysis of all the publications combined with clinical experience, we proposed that barosinusitis seemed to fall within three distinct subtypes: (1) acute, isolated barosinusitis; (2) recurrent acute barosinusitis; and (3) chronic barosinusitis. We introduced this terminology and suggested independent treatment recommendations for each subtype.

Conclusion:

Barosinusitis is a common but potentially overlooked condition that is primed by shifts in the ambient pressure within the paranasal sinuses. The pathophysiology of barosinusitis has disparate causes, which likely contribute to its misdiagnosis and underdiagnosis. Available literature compelled our proposed modifications to existing classification schemes, which may allow for improved awareness and management strategies for barosinusitis.

Sphenoid sinus barotrauma in diving: case series and review of the literature

About 50% of scuba divers have suffered from barotrauma of the ears and about one-third from barotrauma of paranasal sinuses. The sphenoid sinuses are rarely involved. Vital structures, as internal carotid artery and optic nerve, adjoin the sphenoid sinus. Thus, barotrauma could lead to serious neurologic disorders, including blindness. After searching the literature (Medline) and other sources (Internet), we present some cases of sphenoid sinus barotrauma, because these injuries may be underreported and misdiagnosed due to the lack of awareness and knowledge. Therefore, information is provided, e.g. on anatomical and pathophysiological features. Divers and physicians should have in mind that occasional headache during or after diving sometimes signals serious neurological disorders like vision loss. We show that injuries can develop from both negative and positive pressures in the sinuses. Because visual recovery depends on prompt diagnosis and proper therapy, physicians like otolaryngologists, ophthalmologists and neurologists need to closely collaborate.

Neurological complications of underwater diving

The diver's nervous system is extremely sensitive to high ambient pressure, which is the sum of atmospheric and hydrostatic pressure. Neurological complications associated with diving are a difficult diagnostic and therapeutic challenge. They occur in both commercial and recreational diving and are connected with increasing interest in the sport of diving. Hence it is very important to know the possible complications associated with this kind of sport. Complications of the nervous system may result from decompression sickness, pulmonary barotrauma associated with cerebral arterial air embolism (AGE), otic and sinus barotrauma, high pressure neurological syndrome (HPNS) and undesirable effect of gases used for breathing. The purpose of this review is to discuss the range of neurological symptoms that can occur during diving accidents and also the role of patent foramen ovale (PFO) and internal carotid artery (ICA) dissection in pathogenesis of stroke in divers.

Medical and surgical treatment in divers with chronic rhinosinusitis and paranasal sinus barotrauma

Aim of the study is to evaluate the effects of medical and surgical treatment in divers with paranasal sinus barotrauma (PSB) secondary to chronic rhinosinusitis (CRS). In this retrospective, cross-sectional, descriptive study 40 adult divers with CRS were included. Treatment of divers implied a 5-day course of a systemic steroid and a 6-week course of saline nasal irrigations and topical nasal steroid with mometasone in maximal dosage. If symptoms persisted, functional endoscopic sinus surgery (FESS) was performed. Questionnaires included the Sinonasal Outcome Test-20 German Adapted Version (SNOT-20 GAV), dive-related questions (DRQ) and general questions. Questionnaires were completed retrospectively by recalling the symptoms before and after therapy. Forty of 82 divers completed the questionnaires. Mean follow-up was 42 months (range 13-95 months). There was a statistically significant improvement of the Total score (TS) and of every subscore, except the General Quality of Life score, in the SNOT-20 GAV as well as of the TS in the DRQ. Before treatment, divers who required surgery reported significantly more symptoms than divers who were treated conservatively. Post treatment there were no significant differences between the medical and surgical group. Overall, 35 divers could resume diving after therapy even though PSB still occurred but without complications. Divers with sinus problems can successfully be managed medically and if conservative treatment fails, FESS shows a statistically significant improvement of symptoms and no serious long-term hazards for diving.

[Infraorbital lesion after scuba diving with chronic sinusitis: diagnosis and treatment of reverse block]

A 32-year-old diver repeatedly reported pain in the right side of the face after diving. He felt strong pain on pressure over the right face combined with hypaesthesia of the infraorbital nerve. In addition, he reported nasal breathing obstruction and problems regulating pressure in the middle ear. ENT consultation revealed a septal deviation to the right side of the nasal cavity. CT diagnosis showed the typical picture of chronic pansinusitis with total transfer of the right frontal sinus, subtotal transfer of the right ethmoid and subtotal transfer of the right maxillary sinus. Following successful functional sinus surgery (FESS), combined with septal surgery, the patient was able to dive again symptom-free.

Orbital fracture deterioration after scuba diving

Sinus barotrauma is a common disease in divers. However, it is not familiar to maxillofacial surgeon. We presented orbital fracture deterioration by sinus barotrauma in scuba diving and a review of literatures. We also discussed the clinical features, the prevention, and the possible mechanism of orbital fracture deterioration after scuba diving.

Transient facial nerve baroparesis: case report

We present a rare case of facial paralysis that was unusual not only in its causation but also in its rapidity of onset and recovery. We describe a rare case history of this accruing in 35 years old women traveling at the high altitude mountain road referred to ENT clinic with sudden symptoms of middle ear effusion and facial nerve paralysis. Patient had undergone medical systemic steroid treatment and after 3-4 weeks she had a good recovery of facial palsy with a minimum remnant of sensory neural hearing loss. Facial nerve paralysis resulting from a barotrauma of the middle ear is suggested. The correct diagnosis of this condition is important and unnecessary treatment should be avoided.

[Fitness to dive in the otorhinolaryngological field]

In line with the rising number of recreational divers, the otorhinolaryngologist has to deal with growing numbers of diving-associated disorders of the ear, nose and throat (ENT). Nevertheless, the majority of divers present to their ENT doctor for assessment of their fitness to dive. On the basis of long-term follow-up examinations and increasing experience in diving medicine, even divers with a history of ENT problems can be considered fit to dive. Therefore, diving is possible after tympanoplasty, surgery to improve hearing including stapesplasty, after implantation of middle ear amplifiers or cochlear implants, after sinus or scull base surgery and even after canal wall down mastoidectomy, provided that certain requirements are fulfilled. Assessing fitness to dive after inner ear barotrauma as well as after inner ear decompression illness requires meticulous consideration of residual damage and possible underlying conditions like vascular right-to-left shunts. This article is based on the new recommendations of the German Undersea and Hyperbaric Medical Society for the assessment of fitness to dive in the otorhinolaryngological field.

Paranasal sinus barotrauma in sports self-contained underwater breathing apparatus divers

OBJECTIVE

TO evaluate potential pre-dive parameters in relation to paranasal sinus barotrauma in sports self-contained underwater breathing apparatus divers.

STUDY DESIGN

The pre-dive and follow-up records of 46 healthy sports self-contained underwater breathing apparatus divers were analysed.

METHODS

In the routine pre-dive examination of diving candidates with no symptoms of rhino-sinus disease, rhinoscopy, sinus radiography and nasal endoscopy indicated no signs of rhinitis and/or sinusitis. Any signs of paranasal sinus barotrauma were noted, and several parameters were evaluated in relation to occurrence of barotrauma.

RESULTS

Of the studied parameters, a history of sinusitis and of middle-ear barotrauma was significantly more frequent in divers in the barotrauma group (p < 0.05).

CONCLUSIONS

In divers undergoing a routine pre-dive examination, paranasal sinus barotrauma was not related to sex, alcohol consumption, smoking, decongestant use, mild nasal septal deviation, or inability to perform the Valsalva or Toynbee manoeuvres. However, divers with a history of sinusitis or middle-ear barotrauma may be more prone to paranasal sinus barotrauma. A more detailed pre-dive examination may be useful for such individuals.