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Ear Nose and Throat Problems - Sinuses

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - I went on a 23 metre, 50 minute dive about two weeks ago. The profile was fine, I didn't
yo-yo, didn't come up too quickly and did my stop at 5 metres for well over 3 minutes. When I came up, I had a numb mouth (top quarter) including teeth, my sinus then started to hurt (guess I hadn't equalized properly) and then when I got back to the hotel, I had the most terrible headache for 3 days (nothing would shift it). I phoned the doctor's on my return to the UK, approximately 2 weeks ago, and they thought it was no great problem, but advised that I should come in if I was worried. I decided that I wasn't that worried and thought that the symptoms would go away of their own accord. Today, my problem is that the numbness still exists, though the facial aches and the headaches have gone. Any thoughts? Should I come in and see you guys or go to the dentist?

A - This is an unusual story but similar cases have been reported in the past. The explanation is probably this. Your maxillary sinus is an air space that sits in your cheek, just below the eye socket. For some reason on this dive, the air inside got trapped and caused some damage to the sinus, most likely as it expanded on ascent. There is a nerve that passes through a canal just under the eye, called the infra-orbital nerve, and I suspect that the expanding gas put some pressure on it, bruising it. This nerve supplies sensation to the teeth and upper gums, as well as part of the nose and upper lip. So in essence this is much like bashing your funny bone – a bruised nerve can’t carry its normal sensory messages, so numbness is the result. Fortunately sensory nerves tend to heal fully, but it does take time, usually several weeks. During this time you may find things get temporarily worse as the healing nerve sometimes becomes more sensitive. So don’t panic just yet. By all means see your dentist just to check there is nothing wrong with the teeth that might be affecting the nerve too. But I reckon things will sort themselves out if left alone.

Q - Recently on a dive holiday in Mexico I experienced some strange symptoms that I wanted to run by you. I did 6 dives over 3 days. My 5th dive was to about 30 metres for about 30 minutes, nothing unusual in the profile, but at the safety stop I had a dull ache in my left cheek and my upper left teeth and gums felt numb. This persisted during the surface interval (about 2 hours), but went away on my next (and last) dive. Fine I thought, but on ascending it came back. Over the next 2 days the sensation (or lack of) hung around, and on the flight home it got worse, nothing unbearable, but it's still there, now 3 days after I've returned to the UK. I had no colds or congestion prior to the diving, but I'm wondering whether it's a sinus issue, and why this would affect my teeth? And will my teeth stop feeling numb?

A - You’ve hit the nail on the head, this has all the hallmarks of a sinus barotrauma. There are a couple of big air-filled spaces in the cheeks, called the maxillary sinuses. Running in very close proximity is the infra-orbital nerve, which wends it way through a canal under the eye (“infra-orbital”) on each side. It supplies the sensation to the upper teeth, gums and upper lip, and also part of the nose and lower eyelid. I’d guess that the air in the left sinus couldn’t find its way out on your ascent, and put some pressure on this nerve as you came up. By now the trapped gas would have probably oozed it way out, so I doubt there is any ongoing barotrauma occurring, but a “bruised” nerve can sometimes take quite a while to recover. It would be worth a trial of decongestants or steroid nose spray to accelerate the healing but I expect the sensation will return spontaneously over the next week or so. If not, then a trip to the ENT docs for a CT scan of the sinuses may be on the cards.

Q - I have just returned from a trip to Sharm, where one of our group had some sinus congestion at the beginning of the trip. They used Sudafed on the first day, and all was well, but when this was mentioned in conversation at the dive centre they (the dive centre staff) stated that under no circumstances whatsoever should Sudafed be used before diving.

The story went along the lines that there was some adverse reaction from an ingredient. I was unable to ascertain what the ingredient in question was and whether this reaction was supposed to be due to the use of compressed air or as a result of the pressure, as although they were very definite in their comments no-one who had been involved in the discussion with the centre seemed to know why it shouldn't be used.

I have noted on several occasions you mention the use of Sudafed and I personally know many divers use it; can you enlighten us as to what the Egyptians may be referring?

A - A very common question. Funnily enough I was nearly arrested whilst innocently trying to buy Sudafed in New Zealand, for reasons which will become clear… I thought I ought to deal with this once and for all, as Sudafed and the like are so often used and talked about. The active ingredient in Sudafed is something called pseudoephedrine. Its therapeutic effect occurs by stimulating receptors on the muscles of blood vessel walls, causing them to constrict. This means that the vessels leak less fluid, and so congestion in the sinuses and nasal passages is in theory reduced. The other handy benefit for us divers is that it also opens up the Eustachian tubes. All well and good, but as with most drugs the effects are not limited to the airways alone – the same receptors being stimulated elsewhere can cause the heart to race, blood pressure to rise, and generate anxiety, excitability and insomnia. Generally this would only occur with consumption of elephantine quantities, but nevertheless these side effects are what lead to its use being discouraged.

As far as diving with Sudafed goes, the usual caveats apply – there has been little rigorous scientific research on it and so many of the recommendations are based on anecdotal case reports and extrapolation. Some research on rats in the 60's suggested that sympathomimetics (the class of drug to which Sudafed belongs) can enhance oxygen toxicity. So taking Sudafed and diving on gas mixes with high partial pressures of oxygen (eg. Nitrox) is not recommended.

The reason I was nearly arrested? Owing to its structural similarity to amphetamines, pseudoephedrine is a sought-after chemical precursor in the illegal manufacture of crystal meth – hence it was classified as a Class C controlled drug in NZ. I was diving with a group of friends, and unaware of its status I tried to buy rather a lot of it...

Q - I was doing my Rescue Diver class recently and on descent of about 3-4 metres I felt a sharp pinch over my left eye. I went up then tried again and the pain was much less. We only went to about 6.5 meters for a bottom time of 15 minutes. On surfacing I had blood in my mask. My DM said not a big deal and if I felt okay I could continue. Did 3 more dives of similar depth and time. No pain on subsequent dives, but bloody nose continued. Bleeding stopped about 5 minutes after surfacing.

However I had blood coming up in my throat the next day, I went to see GP who referred me to ENT. I had a CT which showed a 1.5mm polyp in the left frontal sinus, no other abnormality or fluid. MRI revealed same findings.

ENT were not sure what caused the bleeding, but the radiologist who was familiar with diving felt it was due to having mucus in the sinus and trauma from the dive. I have never had any problems before even at 35 metres. Any thoughts?

A - Polyps in the nose or sinuses can lead to excessive mucus production, and we all know what a bunged up nose or sinus means for equalising. 1.5mm is pretty small for a polyp, but if one has been found in the left frontal sinus (the site of your initial pain) then it's quite possible that this is what bled. Mucus and congestion often build up in the sinuses with repetitive diving, and the more forceful equalising that results can also cause bleeding. Blood in the throat the next day, without any other obvious source, is commonly swallowed blood from the previous nose or sinus bleed. It should all settle down spontaneously but if the bleeding occurs on future dives then you may need to have something done to the polyp. It’s a bit of an eye-watering procedure though, so hold off if you can.

Q - I have been given your e-mail by Kitty at Dive Solutions, she suggested you might be able to give me some advice. I want to do an open water referral course in March, but have been suffering from (mild) chronic sinusitis. I have been referred to an ENT specialist but have to wait for 2 months. Will my sinus condition affect me in the early part of the course (i.e. pool-based work)? I don't expect to complete the course until the summer when I'm somewhere hot and sunny (with no sinus problems!). I have been swimming recently and haven't suffered any discomfort.I'd really appreciate any advice,

A - As I am the Prince of Sinus Suffering, I can help you here. You should be fine for the pool based dives. In reality a 3 meter dive is not going to really need you to equalize that area, and you can get down to that depth without any pain.

If there is any aggro there, have a toot of Otrivine to help in the pool. But before you hit the 18m depths, it would be a good idea to get the ENT doc to have a look at your issues. Sometimes polyps in the sinuses can affect equalizing and cause your problem, likewise the structure of your nose where the sinal canals empty into. These could cause problems with diving in the future, and it's best to get it sorted first, rather than enjoy the agony of a sinus squeeze. My most painful moment, after watching that Essex girl Beckham sky the penalty against our oldest allies.

Q - I learned to dive in 1996 and in the following two years managed over 70 dives including the cool dark depths of Scapa Flow with no ear or sinus problems at all. In November 1998 I went to the Red Sea and on our orientation dive they made us do a mask removal and replace to test our abilities. Unfortunately the salt water got into my nose and the subsequent inflammation meant that I managed only 7 dives in the whole week. The holiday ended with a visit to a dive doctor in Sharm after a reverse block in my nose and a resultant sinus blow out.

On my return to the UK I consulted a specialist in hyperbaric medicine in Harley Street who put me on a course of Beconase and anti-inflammatories. 5 months later I returned to diving, and although I suffered minor discomfort between my eyes and in my front teeth, there were no recurrences of what had happened in Egypt. Last year however things started to escalate during my Dive Master training and I also felt discomfort when I flew, so I went back to Harley Street for x-rays to see what was causing the problem. The specialist's diagnosis was polyps, so I consulted my GP who referred me to an ENT specialist at our local hospital. He used a probe to establish where the polyps were and found none. His diagnosis was that the sinus linings were getting inflamed during a dive or flight and not settling as most other peoples would. He told me to use Sudafed and Beconase before a dive and if that didn't work, then give up diving!

I took a year off diving and tried again last week. The pain was excruciating even with the Sudafed and half a bottle of spray up my nose. I really don't want to give up diving, (and would like to actually finish my DM course at some point!), and with the discomfort that I feel when I fly I would like to know what else (if anything) I can do or if there are any operations that can be done to get rid of this problem once and for all.

A - It seems that you have done the rounds of experts but still not come up with a solution to your problem.
If a GP, a diving doctor and a regular ENT surgeon haven't nailed it yet then there's only 1 place left you can go to.
That would be an ENT surgeon who specialises in Diving Medicine. They're thin on the ground but I am slowly working up the database and can recommend you one to go and see.

However my thoughts here are that a plain X-ray is considered a fairly rough tool in trying to diagnose sinus problems. A far more accurate and sensitive method is to use either CT or MRI scanning. This is because things like polyps which can block the flow of air in and out of the sinus are made of soft tissue, which can be very hard to visualise in an X-ray.
So what would an ENT surgeon consider?

Well the most probable diagnosis is that of a very chronic inflammation that has built up since your incident in the Red Sea which has almost closed off the sinal canals that drain the sinuses. Using steroid nasal sprays will only work in the short term as soon the tissue that you are trying to get rid of the inflammation in becomes "refactory" to it. This means you have to use more and more of the medication to have the same desired effect. Sometimes a cure can be effected in problems like yours by having a sinal washout and scraping away all the inflammed lining to the sinuses.

But all this would be a decision that the ENT surgeon would make after consultation with you.

Q - I qualified as a Padi advanced diver in November 1998. Since my initial qualifying dive in March 1998 I have 70 logged dives.

During a handful of those dives (most under 20m shore dives) I have experienced sinus pain, usually after about 30 minutes or on an ascent. I read a bit about the reasons for sinus pain on your site.

Last summer I had to abort a dive during descent, due to sever sinus pain and had a string of sinusitis problems treated with antibiotics by my G.P.

Frustrated that this was making me feel rotten and preventing my usually regular weekend diving and diving holidays abroad, I asked for a referral to an ENT specialist. A CT sinus scan revealed 3 problems which are all being treated by surgery in early April. The problems include chronic sinus infection, which needs draining, a cyst, which needs draining or removing and a slight 'trimming' of a poorly shaped sinus on one side. I am advised to take two weeks off work, though the actual hospital stay will only be one night.

As a precaution, I have cancelled our dream holiday to Mexico, which was due to begin 4 weeks after the operation. My husband (a keen diver) was concerned that a 10 hour flight and an ambitious diving and partying schedule, may be a bit adventurous so soon after this surgery. The surgeon has said I can fly after 2 weeks, but agreed the long haul + diving would be a bit daring.

Any advice on how long I should wait until I try some pool practice with Scuba? Also, would a wait of 10 weeks be enough before a less ambitious diving holiday in Lanzarote?

Your advice would be very welcome - my hubby and I are craving for some underwater recreation!!

A - Well with a poor degree of drainage, a cyst and chronic sinusitis it was obvious something was going to give at some point, so its just as well you had that CT and the operation as your dream Mexican holiday would have ended on dive 1 with what you had before which was the beginnings of a sinus squeeze. This is where the air in the sinus contracts and as you cannot equalize any more into the sinus, the contracting air causes the blood vessels lining the sinus to swell up and become engorged with blood until they burst. This causes a dramatic relief from the pain described as like having a hot nail hammered into your head. The blood generally gets expelled as you surface when the reexpanding air forces out the bloody sinal contents into your mask.

So I think you did the right thing and by the time 10 weeks has passed you will be fine to dive as any post surgical inflammation would have settled by then. I would though at least have a pool dive before you go to check that the operation has been a complete success and you should check with the ENT surgeon as to the earliest you can go back to the pool without risking post operative infection. It should be in the region of 5 to 6 weeks.

Q - My problem is, for the last four years, whenever I dive I get severe headaches during the dive and after I surface. They last for about 20 mins to half an hour, and then disappear without the need for any medication.

Sometimes they are so severe that I have to abort the dive which is very awkward being a Divemaster and disappointing for the divers with me.

Something that might help you with my problem is that whenever I get a cold I never get a streaming nose, but I get a badly blocked one and the same headaches as when I am diving. My G.P. thinks it might be sinus problems but can't really suggest anything.

I hope very much that you may be able to help me with this very frustrating problem.

A - I can see what a problem this must be for you and your buddied divers, there's nothing worse than having to abort a dive for an annoying pain like this.

I agree with your GP here. The fact that the pain is similar when you dive and when you have a cold points to it being a sinal problem. As you probably remember from when you learned to dive, on descent the air in your sinuses contracts and you need to equalise them as much as you do your middle ears. If you cannot do this for some reason, like a blockage in the canal that links the sinus to the nose, then the resulting pain can be excruciating. It's normally localised in your forehead above each eye where the main sinuses are found.

This is called a sinus squeeze, and if air cannot get into the sinus at all what happens next is pretty revolting!

The blood vessels lining the inner sinus begin to expand as they are sucked inwards, they fill with blood, and when the negative pressure gets too much, they burst inward filling the sinus with blood, and thus equalising it.

You wont realise this until later, on ascent from your dive the small amount of air in the sinus still will expand and blast the blood from your sinus, out of your nose and into the blue, or red as it will then be.

To try to prevent this from happening, I suggest you try to unblock your sinal passages with a Vicks inhaler an hour before you dive, but if this doesn't work you may well need a Sinal CT scan to see what else could be preventing equalisation.

(other dive medical questions)



   


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