eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Barosinusitis: Treatment & Medication

Author: J Kim Thiringer, DO, Otolaryngologist, Ear, Nose, and Throat Associates
Contributor Information and Disclosures

Updated: Nov 11, 2008

Treatment

Medical Care

Begin treatment at the first sign of barotrauma. Treatment is accomplished most simply by returning to the altitude at which symptoms occurred, or, in the case of diving, returning to the surface. Decongest the nose with liberally applied topical agents, and then gradually descend to ground level. Unfortunately, immediate treatment is not always possible, and treatment often begins after the fact.

Medical therapy is generally directed toward pain control, establishing ventilation, and preventing infection.

• Pain control
  • Oral agents are usually effective.
  • Severe pain may require the use of narcotics.
  • Products that contain aspirin should probably be avoided in the short term to minimize the risk of worsening hematoma formation.
• Establishing ventilation
  • Topical decongestants include 0.05% oxymetazoline and 0.5-1% phenylephrine.
  • Oral decongestants include phenylpropanolamine (recalled from the US market) and pseudoephedrine.
  • In general, antihistamines are avoided because they tend to dry mucosa and inspissate secretions, although they may be useful if the underlying disease process includes poorly controlled allergies.
• Preventing infection
  • Blood and transudate from traumatized mucosa provide a rich medium for bacterial growth.
  • This environment, combined with damaged mucosa, inability to clear secretions, and altered oxygen tension, sets the stage for secondary bacterial infection (if not already present as the underlying cause of URTI).
  • A course of antibiotics may prevent secondary infection and hasten recovery.
  • In the acute setting, the first-line antibiotic is amoxicillin. In patients who are allergic to penicillin, trimethoprim/sulfamethoxazole is a reasonable first-line medication. Other choices include extended-spectrum penicillins, cephalosporin, clindamycin, extended-spectrum macrolides, and quinolones.

Surgical Care

Surgical therapy is designed to restore sinus ventilation. Conventional therapy with septoplasty, turbinectomy, antral windows, Caldwell-Luc operation, external or transantral ethmoidectomy, nasal polypectomy, and frontal sinus trephination has had variable efficacy. Endoscopic sinus surgery has substantially increased the chance of returning the patient to full activities.

• If oral agents fail to relieve pain and pressure, or if pain and pressure do not resolve over 24 hours, consider antral puncture/washout to rapidly equilibrate pressure and to clear sinus blood and other debris. This has minimal effect on the middle meatus and may not clear symptoms from ethmoid and frontal disease. Septoplasty and turbinectomy may help as a preventive measure, depending upon the clinical presentation.
• Endoscopic sinus surgery
  • Recurrent sinus barotrauma due to anatomic derangement has been managed effectively with endoscopic sinus surgery. Parsons et al reported their results on a group of military aviators, 98% of whom returned to flying after treatment.¹
  • In another group of military pilots, aircrew, and divers, all patients returned to full duty after approximately 14- to 21-days' recovery time. In general, the surgery is designed to establish ventilation and minimal hole techniques are typically effective; however, the particular surgery must be individualized for optimal results. Nasal septal deflection, if clinically significant, is corrected at the time of endoscopic sinus surgery.
  • These studies use individuals who represent a select group of people who do not have a history of underlying mucosal disease (eg, allergy, polyposis). Individuals with underlying disease may also benefit from endoscopic sinus surgery, but they may require ongoing medical therapy for maximal results. Ongoing medical therapy must be highly individualized and closely monitored. Such medical therapy may disqualify, either temporarily or permanently, the individual from those activities that resulted in sinus barotrauma in the first place. This is especially true for aviators and divers in whom incapacitation from acute sinus barotrauma may be substantially more than an inconvenience.
  • CT scan imagery should determine the extent of sinus surgery; but, in general, limit surgery to minimal dissection and debridement techniques. This minimizes tissue damage and healing time yet establishes patent ostia that prevent recurrence of pressure gradient and sinus symptoms.
  • One more recent addition to surgical therapy of the paranasal sinuses is the balloon sinuplasty.² This technique may be uniquely suited to establishing sinus ventilation, with the minimum tissue manipulation of any surgical techniques currently available. Potential advantages include reduced healing time and reduced risk of delayed surgical complications (obstructive scarring/stenosis).

Activity

Depending upon the extent of surgery, most patients can return to full activity within 1-3 weeks following surgery.

Commercial airline travel is generally permitted within 2-3 days, as is swimming on the water surface.

Medication

The goal of pharmacotherapy is to reduce morbidity and prevent complications.

Decongestants

Decongestants establish ventilation of the sinuses and relieve pressure, pain, and edema. Combine topical and oral decongestants in most cases, especially for acute symptoms. Topical agents are frequently useful when oral agents are contraindicated.

Oxymetazoline 0.05% (Afrin, Allerest, Chlorphed, Dristan)

First-line therapy for topical decongestion. Applied directly to mucous membranes, stimulating alpha-adrenergic receptors and causing vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.

Phenylephrine 0.5-1% (Neo-Synephrine)

First-line topical decongestant if a shorter-acting agent is preferred. Strong postsynaptic alpha-receptor stimulant with little beta-adrenergic activity that produces vasoconstriction of arterioles in the body.

Phenylpropanolamine (Rhindecon, Unitrol, Phenyldrine)

Recalled from US market. First-line oral decongestant. Epinephrine stores are released under phenylpropanolamine stimulation and produce alpha- and beta-adrenergic stimulation. These effects may increase outlet resistance.

Pseudoephedrine (Actifed, Sudafed, Afrin)

First-line oral decongestant. Stimulates vasoconstriction by directly activating alpha-adrenergic receptors of the respiratory mucosa. Induces bronchial relaxation and increases heart rate and contractility by stimulating beta-adrenergic receptors.

Antibiotics

Antibiotics control infection either as an inciting factor in the barosinusitis or as a sequela of the barosinusitis.

Amoxicillin/clavulanate (Augmentin)

Drug combination treats bacteria resistant to beta-lactam antibiotics. First-line therapy for persons not allergic.

Trimethoprim/sulfamethoxazole (Bactrim, Septra)

First-line therapy in patients allergic to penicillin, although adverse effect profile may make other agents more desirable.

Cefuroxime (Ceftin, Zinacef)

Second-line therapy, but may be first-line therapy in patients who are allergic to penicillin.

Amoxicillin (Trimox, Amoxil)

Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria.

Analgesics

Acetaminophen, with or without codeine, is useful for pain control.

Acetaminophen with codeine (Tylenol and codeine)

First-line analgesic for severe pain. Fixed combination Tylenol #3 is 300-mg acetaminophen with 30-mg codeine.

Acetaminophen (Feverall, Tempra, Tylenol)

DOC for pain in patients with documented hypersensitivity to aspirin, NSAIDs, upper GI disease, or on oral anticoagulants.

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