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ENT Disorders

Frontal and Maxillary sinuses

Most ENT problems related to diving are due to barotrauma. Barotrauma is tissue damage that results from the changing volume in air-filled spaces associated with descent and ascent in the water column. This a direct result from the effects of Boyles' Law. Divers describe the effects of this barotrauma as a squeeze of the sinuses or ear.

The most frequent problem for all divers and swimmers, this is an infection of the ear canal caused by water which makes the normally acid environment alkaline.It iis treated simply by changing the pH with an acid solution or treating with an antibiotic that is alkaline. Divers prone to this condition should use an acid-alcohol drop after diving in order to dry the ear canal. (One third vinegar and two thirds rubbing alcohol).

This can be caused by ear wax,a tight-fitting diving hood, or ear plugs that preclude water from entering the ear canal. The lining of the ear canal becomes swollen and bloody and the treatment is directed at the symptoms with ear drops.

If a diver perforates his TM, he should wait at least six weeks after the perforation has healed so that the edema has resolved completely. Treatment with systemic decongestants such as Sudafed, 60 mg. orally three times daily and topical decongestant drops, for not longer than three days.

This occurs due to failure of air to vent via the eustachian tubes as the diver ascends. This is usually associated with trauma from a forced descent and can lead to rupture of the TM or round window. If the diver cannot clear by descending a few feet and swallowing, he may be forced to ascend with the misfortune noted above.
  This is dizziness resulting from unequal pressures. It is due to unequal increase in middle ear pressures on ascent. A similar vertigo can also occur as a result of unequal caloric stimulation of one labyrinth over the other due to diving in a prone position in cold water--the undermost ear being stimulated. 

This most often involves the frontal or maxillary sinuses and the pressure differential usually causes the lining of the sinuses to become swollen and bleeding can ensue.
Nosebleed is a common event with diving and can be caused by negative pressure within the mask or from pressure change after ascent. Dull aching is present and treatment is directed at the use of nasal decingestants and symptomatic pain relief. Antibiotics are also used to treat infection.

 There is really no difference between the damage and pain with descent or ascent. It occurs in both flyers and divers and the pathophysiology is the same--the inability to equilibrate the air pressure as it changes, up and down.

All of this depends mainly on the function of the mucosa of the nose and sinuses. Some people secrete large quantities of mucus, either in response to allergy or to milk drinking. Others have a definite correctible problem, such as nasal septal deviation, polyps or tumors, resulting in blockage of the ostia (openings) of the sinuses.

The frontal sinuses are the most frequently involved, probably because the nasofrontal duct is longer and more tortuous. The damage that is done by the pressure change leads to a series of changes within the sinuses consisting of air absorption, decreased pressure in the sinus; swelling, engorgement, inflammation and fluid collection in the sinus cavity. This decrease becomes greater with descent (as with flying) the changes become greater, more painful and often associated with bleeding into the sinus cavity. On ascent, there is one-way valve blockage of the ostia, resulting in more barotrauma. The next step after all this is usually infection, which increases the blockage by causing it's own swelling and purulent discharge.

Common causes of all this include, allergy; chronic irritation, such as smoking, diesel fumes, chemicals, prolonged use of nose drops or nasal sprays; mechanical blockage; vasomotor problems from chronic tension, stress or anxiety.

It should be obvious that what should be a very simple problem can be stubbornly difficult to diagnose and manage.

Occasionally divers will have pain in the ear caused by referred pain from the TM joint. This is usually caused by biting too firmly on the mouthpiece of the regulator and is treated with nonsteroidal anti-inflammatory medications. are addressed in another section.

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