Barosinusitis: Comprehensive review and proposed new classification system

Dynamic radiologic changes in repeated barotraumatic frontal sinusitis: A CARE case report

INTRODUCTION

Flight staff are at particular risk of iterative sinus barotrauma. We here report a case of barotraumatic atelectasic frontal sinusitis with dynamic radiologic change in frontal sinus volume.

CASE REPORT

A 46-year-old air pilot was referred for right frontal pain occurring at each landing. Two sinus CT scans were taken: one after a period of intense flying and the other after a month without flying. In the right frontal sinus, a type-3 Kuhn cell changed in volume from 6×11×12mm to 13×18×19mm. The alteration involved a modification in the medial wall, which was demineralized and changed position within the frontal sinus. Removal during endoscopic frontal sinusotomy allowed complete resolution of pain.

DISCUSSION

This article reports radiologic change in a frontal sinus wall in a setting of repeated barotraumatic frontal sinusitis with a dynamic atelectasic component. In iterative barotrauma, we advocate imaging at different time points. When the ostial obstruction is identified, functional aeration surgery can be applied.

Barosinusitis due to routine weather changes: A cross-sectional analysis of public websites

Background

Sinusitis is a common diagnosis that can be erroneously associated with routine weather-related barometric pressure changes. In actuality, these pressure changes likely exacerbate migraine headaches, which can cause facial pain and pressure rather than true sinus inflammation.

Objective

The present study sought to characterize the representation of both sinusitis and migraine in association with barometric pressure changes across websites on the Internet.

Methods

An Internet search for relevant terms was conducted, and content of the resulting pages was assessed for associations between weather-related pressure changes and either sinusitis or migraine. Variations in reported results across different subtypes of Internet sources were analyzed. The primary outcomes measured were (1) whether a given media source associated barometric weather changes with sinusitis, (2) whether that source associated barometric weather changes with migraine, and (3) treatment options offered by that source.

Results

Of the 116 included webpages, 36 (31.03%) associated sinusitis and routine barometric pressure changes. Of these, 10 (27.77%) were otolaryngology practice sites. Sixty-seven webpages (57.76%) associated migraine and routine barometric pressure changes. Of these, nonotolaryngology webpages were more likely to report this link.

Conclusions

Otolaryngology practice sites were observed to be the most frequent professional medical resource reporting the unsubstantiated claim that routine barometric pressure changes are associated with sinusitis. Nonotolaryngology sources were more likely to link weather-related pressure changes to migraine. These results suggest that opportunities exist for otolaryngology practice sites to educate patients about nonrhinogenic headache etiologies.

Acute Diplopia Following Rhinoplasty: Clearing the Air

Diplopia after rhinoplasty is a rare complication that requires immediate medical attention. Workup should include a complete history and physical examination, appropriate imaging, and consultation with ophthalmology. Diagnosis may be challenging due to the wide differential ranging from dry eyes to orbital emphysema to an acute stroke. Patient evaluation should be expedient, though thorough to facilitate time-sensitive therapeutic interventions. Here, we present a case of transient binocular diplopia presenting 2 days after closed septorhinoplasty. The visual symptoms were attributed to either intra-orbital emphysema or a decompensated exophoria. This is the second documented case of orbital emphysema after rhinoplasty presenting with diplopia. It is the only case with a delayed presentation as well as the only case that resolved after positional maneuvers.

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.

Sinus Barotraumas in Commercial Aircrew

BACKGROUND: Sinus barotraumas are a common condition in aviation medicine, sometimes compromising flight safety and even permanently grounding aircrew. Considering this and the ever-increasing amount of commercial aviation, a thorough examination is required.METHODS: In this survey study, an anonymous, electronic questionnaire was distributed to commercial aircrew of the three major commercial airlines operating in Finland (N 3799), covering 93% of the target population (i.e., all commercial aircrew operating in Finland, N 4083). Primary outcomes were self-reported prevalence, clinical characteristics, and health and occupational effects of sinus barotraumas in flight. Secondary outcomes were adjusted odds ratios (OR) for frequency of sinus barotraumas with respect to possible risk factors.RESULTS: Response rate was 47% (N 1789/3799), with 61% (N 1088) of the respondents having experienced sinus barotraumas in flight. Of those affected, 59% had used medications, 18% had undergone surgical procedures, and 53% had been on sick leave due to sinus barotraumas (38% during the last year) in flight. Factors associated with sinus barotraumas were female sex [OR, 2.47; 95% confidence interval (CI) 1.354.50] and a high number of upper respiratory tract infections (3 vs. <3 URTIs/yr: OR, 3.61; 95% CI 2.654.93).CONCLUSION: Sinus barotraumas were reported by 61% of commercial aircrew. They caused an increased need for medications, otorhinolaryngology-related surgical procedures, and sickness absence from flight duty. The possible risk factors were female sex and a high number of URTIs/yr.Lindfors OH, Ketola KS, Klockars TK, Leino TK, Sinkkonen ST. Sinus barotraumas in commercial aircrew. Aerosp Med Hum Perform. 2021; 92(11):857-863.

The association of active and passive tobacco smoke exposure with chronic rhinosinusitis symptom severity: A cross-sectional study

BACKGROUND

 Chronic rhinosinusitis (CRS) causes a great deal of morbidity. There are a multitude of causal factors, though their precise contribution to symptom severity has yet to be defined.  We hypothesized that exposure to both primary and secondhand tobacco smoke would correlate with more severe symptoms of CRS.

METHODS

This is a prospective cross-sectional study performed at an academic tertiary care medical center from 2010 to 2013. A total of 85 consecutive patients with chronic sinusitis were screened; 70 with medically refractory CRS requiring functional Endoscopic sinus surgery (FESS) were enrolled. Recent tobacco exposure was assessed using serum cotinine levels. Sinonasal mucosa was biopsied to assess ciliary architecture. Demographics, medical history, tobacco and environmental exposures, and computed tomography (CT) imaging were also collected. Two quality of life (QOL) surveys were administered: one disease specific, Sinonasal Outcomes Test-20 (SNOT-20), and one general, Short Form-12 (SF-12). Results were correlated with the aforementioned exposures.

RESULTS

 The 70 patients had an average age of 46 years, and 42% were male.  Variables that correlated with worse SNOT-20 scores included serum cotinine (r = 0.43, p = 0.002), number of cigarettes smoked daily (r = 0.27, p = 0.03), and number of secondhand cigarettes exposed to per day (r = 0.29, p = 0.04). There were no significant correlations between SNOT-20 scores and Lund-MacKay or axonemal ultrastructural abnormalities (AUA)-ciliary scores. The two five-variable models best predicted disease-specific QOL.

CONCLUSIONS

 Increased amounts of serum cotinine and primary and secondhand smoke exposure were associated with worse sinonasal QOL. This study establishes an objective relationship between smoke exposure and patient-perceived severity of CRS, emphasizing the importance of tobacco cessation counseling as part of management.

Trigeminal Neuralgia from Acute Sphenoid Sinusitis: Consideration of Anatomical Sphenoid Sinus Variation - A Case Report

Although the etiology of classical trigeminal neuralgia is clearly understood to be neurovascular compression, the exact etiology of trigeminal neuralgia with continuous pain is often unknown. Mild sphenoid sinusitis is not usually considered to induce trigeminal neuralgia, especially when limited to the maxillary nerve. We report a rare case of trigeminal neuralgia of the maxillary nerve caused only by mild sphenoid sinusitis and discuss the significance of the anatomical structure and diagnostic procedures. A 45-year-old woman noticed a sudden onset of temporal pain followed by numbness on her right cheek. Her right gingiva also experienced sensory disturbance. The symptoms gradually subsided after the initial onset, but they persisted. She visited our hospital for further examinations and had no febrile episodes throughout the course. A tingling sensation and sensory disturbance were only identified in the maxillary nerve. No other neurological symptoms were noted. Magnetic resonance imaging revealed mild sphenoid sinusitis on the right side. The absence of the bony boundary between the sphenoid sinus and maxillary nerve was revealed using thin-sliced computed tomography (CT). The patient's symptoms were diagnosed as maxillary neuropathy caused by mild sinusitis. The bony defect around the maxillary nerve was considered to have affected development of the pathological process. Even mild sphenoid sinusitis can cause inflammation to spread to the maxillary nerve if no bony boundary exists between it and the sphenoid sinus. A coronal CT study is highly beneficial for clarifying the pathophysiological mechanism of trigeminal neuralgia limited to the maxillary nerve.

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.

Air flight barotrauma and meningitis: causality seems real

BACKGROUND

Barotrauma to the middle-ear cavity and paranasal sinuses is a relatively common flight-related health problem. Occasionally, it may result in severe mechanical or infectious intracranial complications; these have been rarely reported to date.

OBJECTIVE

Four cases of acute bacterial meningitis following air travel are presented, and its pathogenesis is briefly described.

CONCLUSION

Neurological symptoms occurring after air flight should prompt proper investigation. Otitis media and sinusitis are common primary focuses of bacterial meningitis. Severe complications of air flight barotrauma may be underreported.

Sherpas, Coca Leaves, and Planes: High Altitude and Airplane Headache Review with a Case of Post-LASIK Myopic Shift

PURPOSE OF REVIEW

High altitude headache is a common neurological symptom that is associated with ascent to high altitude. It is classified by the International Classification of Headache Disorders, 3rd Edition (ICHD-3) as a disorder of homeostasis. In this article, we review recent clinical and insights into the pathophysiological mechanisms of high altitude and airplane headache. We also report a second case of post-LASIK myopic shift at high altitude exposure secondary hypoxia. Headache attributed to airplane travel is a severe typically unilateral orbital headache that usually improves after landing. This was a relative recent introduction to the ICHD-3 diagnostic criteria. Headache pain with flight travel has long been known and may have been previously considered as a part of barotrauma. Recent studies have helped identify this as a distinct headache disorder.

RECENT FINDINGS

Physiologic, hematological, and biochemical biomarkers have been identified in recent high altitude studies. There have been recent advance in identification of molecular mechanisms underlying neurophysiologic changes secondary to hypoxia. Calcitonin gene-related peptide, a potent vasodilator, has been implicated in migraine pathophysiology. Recent epidemiological studies indicate that the prevalence of airplane headache may be more common than we think in the adult as well at the pediatric population. Simulated flight studies have identified potential biomarkers. Although research is limited, there have been advances in both clinical and pathophysiological mechanisms associated with high altitude and airplane headache.