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

Sphenoid sinus barotrauma after scuba diving

Jin Hyeok Jeong, MD, Kuk Kim, MD, Seok Hyun Cho, MD, Kyung Rae Kim, MD
Department 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
scuba diving. The patient attended our emergency department because of intractable headache but
did not improve with conservative treatment. After computed tomography and magnetic resonance
imaging 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 pressure
change [1]. Most cases of barotrauma are related to air travel
and 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 sports
such as scuba diving or diving are uncommon, and sinus
barotrauma caused by diving generally involves the frontal
sinus or maxillary sinus [3].
Recently, we encountered a case of barotrauma of the
sphenoid sinus after scuba diving, which progressed to a
septal abscess and was treated by surgical management.
Sinus barotrauma is thought to have increased significantly
with the diversification of leisure activities and greater public
involvement in marine sports.

2. Case
A previously healthy 18-year-old male patient visited
our hospital emergency department because of a bilateral
temporo-occipital area headache that had gradually worsened. The headache had been caused by scuba diving

No financial disclosures and no conflict of interest.

Corresponding author. Department of Otolaryngology-Head and
Neck Surgery, College of Medicine, Hanyang University, 17 Haengdangdong, Seongdong-gu, Seoul 133-792, South Korea. Tel.: +82 31 560 2368;
fax: +82 31 566 4884.
E-mail address: ent@hanyang.ac.kr (J.H. Jeong).
0196-0709/$ see front matter 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjoto.2011.10.017

without a pressure control device 3 weeks previously, and

immediately, after the scuba diving, mild epistaxis had
occurred. As the patient's symptoms improved after
symptomatic treatment, he was discharged without admission. After returning home, his headache worsened, so he
was admitted to the department of neurology. He had been
treated with oral antibiotics and analgesics for a week
before admission, but the treatment was not effective. Past
history and family history were unremarkable, and there
were no symptoms except for bilateral temporo-occipital
headache. Brain computed tomography (CT) taken the
previous week in the emergency department showed no
abnormal findings except for soft tissue density of the
bilateral sphenoid sinus. Paranasal sinus (PNS) CT and
brain magnetic resonance imaging (MRI) were performed
after admission to the neurology department. Because there
were no abnormal findings other than the sphenoid sinus
lesion, the patient was transferred to the department of
otorhinolaryngology (Fig. 1). Left-sided nasal septal
deviation and bulging of the mucosa in the posterior
portion of the right nasal septum were observed on
endoscopic examination (Fig. 2). Aspiration was performed
at the bulging portion of the right nasal septum, and bloody
pus was aspirated. There were no polyps or postnasal drips
around the openings of the bilateral sphenoid sinus.
We performed the surgery immediately after transfer to
our department because of the nasal septal abscess. The
submucosal pus collected in the posterior portion of the right
nasal septum was drained with septoplasty, and the deviated
nasal septum was corrected. Then, the pus and necrotic soft
tissue inside both sphenoid sinuses were removed by

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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 sinusitis
extends to the right septal area (B, arrow).

bilateral sphenoidotomy (Fig. 3) via endoscopic

surgery. Biopsy of the necrotic soft tissue inside the
noid sinus revealed acute inflammatory exudates.
discharge, the patient failed to attend our outpatient

sinus
spheAfter
clinic

and only visited 2 months after discharge. Endoscopic

examination at that time revealed a small septal perforation
in the area where pus had collected. The openings of the
sphenoid sinus were well maintained with well-healed sinus

Fig. 2. Endoscopic findings. The right nasal cavity shows septal mucosal bulging in the posterior portion of the nasal septum (A). The left nasal cavity shows
septal deviation to the left (B).

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479

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

mucosa and no mucosal swelling (Fig. 4). The headache of

which the patient had complained no longer occurred, and
there were no other symptoms.

3. Discussion
Sinus barotrauma is an inflammatory disease of the
paranasal sinus related to rapid pressure change and
associated with obstruction of the sinus opening due to
upper airway infection, allergy, nasal polyp, or chronic
sinusitis[1]. This disease readily occurs in professional pilots
and divers but can also affect airplane passengers and people
who 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 the
frontal area. If the maxillary sinus is affected, toothache of
the 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 examined by an otorhinolaryngologist soon after exposure [4,5].
Plain x-ray, CT, and MRI can be helpful in the diagnosis.

The radiologic findings include fluid level and mucosal

thickening in the affected sinus. In severe cases, there can be
total opacification of the affected sinus [6]. A common
symptom arising during descent with positive pressure is a
sharp facial pain or headache, and epistaxis can occur,
accompanied by other symptoms. If the trigeminal nerve,
especially the infraorbital nerve area, is affected, then
neurologic symptoms can arise [5].
Sinus barotrauma follows Boyle Law [1] (P1 V1 = P2
V2, where P is pressure, V is volume, and temperature is
constant). During a descent accompanied by obstruction of a
sinus opening due to any cause, the volume of the affected
sinus decreases. To compensate for the decreased volume,
mucosal swelling and submucosal hematoma occur, and
tissue fluid or blood collects in the sinus. During the
subsequent ascent, the blood and tissue fluid accumulated
during the descent may be discharged, causing epistaxis.
Tissue fluid or blood remaining in the affected sinus and
detached necrotic mucosa acts as a medium of propagation
for bacteria and can cause acute sinusitis [1]. When the diver
reaches the surface, obstruction of the sinus opening by the
affected sinus wall causes leakage of air to surrounding

Fig. 4. Follow-up endoscopic findings. A small septal perforation can be seen in the posterior portion of the nasal septum (A). The left sphenoid sinus ostium (B)
and well-healed sinus mucosa (C) are evident.

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organs, and this can cause rare complications such as

pneumocephalus, subcutaneous emphysema, orbital emphysema, and meningitis [7].
In mild cases, sinus barotrauma can be treated with
topical decongestants, analgesics, and antibiotics. In
moderate 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 avoided
for at least a week.
Prevention of sinus barotrauma is important. For
prevention, frequent periodic Valsalva maneuvers that push
air into the sinus are needed during descent, as well as
slowing down rates of descent and ascent. Scuba diving or
flying should be avoided when there is any upper airway
infection, chronic sinusitis, or nasal polyps. Surgical
correction of nasal septal deviation is also helpful [1].
In the present case, acute sphenoid sinusitis was caused
by scuba diving without proper management, and treatment
with antibiotics and analgesics was delayed and without
effect. Eventually, a septal abscess formed. This was
treated by septoplasty to drain the pus collected in the
posterior portion of the right nasal septum together with
endoscopic sinus surgery to widen the opening of the
sphenoid sinus and remove the purulent pus collected in the
sinus and the necrotic detached mucosa. The patient did not
receive any dressings or medication after discharging
himself against our recommendation. Two months after
discharge, he visited our clinic for a checkup. In the sinus
endoscopy performed at that time, the mucosa of the
sphenoid sinus was seen to be well healed without mucosal
swelling, but a small septal perforation was observed in the
posterior portion of the nasal septum. This nasal septal

perforation is thought to have occurred not because of

surgical trauma but because of necrosis of the periosteum
caused by the septal abscess. The perforation was small,
without crust or bleeding, and the patient did not complain
of any symptoms such as headaches.
4. Conclusion
Sinus barotrauma can be easily diagnosed by detailed
history taking and physical and radiologic examination.
Rapid diagnosis is important for treatment, so physicians
should be aware of this disease. Because sinus barotrauma is
expected to increase with the diversification of leisure
activities and the increase in marine sports, we need to be
concerned with the diagnosis and treatment of this disease.

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