Barosinusitis Treatment & Management

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 therapy is designed to restore sinus ventilation. Conventional therapy with septoplasty, turbinectomy, antral windows, the 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. ^[10]

  • 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. ^[11] 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).

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.