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Ear Nose and Throat Problems - Nose

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'm thinking of doing a PADI course in Malaysia next month. However, I have a deviated septum, which results in one nostril being almost completely blocked. I was always told, when younger, that I would have to have an operation to fix it when eighteen, but haven't done so as yet. Any advice on this matter will be greatly appreciated and whether I should see a doctor before diving.

A - I think thatís a good idea. You are symptomatic already if one nosser is already blocked. And where you are going to have problems is equalizing on the way down. As you descend, you have to blow air into your sinuses and middle ears, a septal deviation will decrease one sideís ability to do this resulting in searing facial and ear pain on your first dive. This ainít guaranteed but likely. So, see a dive doc with a bit of ENT experience before shelling out for the full dive holiday. They may refer you to the ENT surgeon for septal straightening. An easy op nowadays, but in Medieval times they used to frighten a horse with a wasp. It kicked out backwards as your nose was tied to an anvil. Half the people ended up with better breathing. The rest were blinded.

Q - Last February I collapsed at home and was rushed to hospital. I was diagnosed as suffering bacterial meningitis and septicaemia and have spent the last 6 months or so off work recuperating. The illness itself was apparently triggered by a severe infection in my left ear. My consultant says I have a problem in my left nostril that is interfering with the passage of air into my 'tubes' and will operate later this year to remove some cartilage that is partly obstructing my airway. This problem may well have exacerbated the ear infection that led to my ear infection in the first place. Apart from that, I have evidently made a really good recovery and will be going back to work next month.

I did my PADI open water course last October and haven't dived since. I am really keen to get back into it but with my recent history and the nasal op coming up I wondered what your views might be?

A - Poor you. To get that sort of problem due to a simple nose anatomical fault is really unlucky. I think you should stay away from diving until its all sorted out. And then leave it a good 3 to 6 months after the nose op, before you try to equalise on a dive.

If this problem is enough to cause you meningitis and a near death experience, then getting it sorted is your main priority. It must be along the Eustachian tube axis for the nose to affect your middle ear and cause an infection, and this is precisely the one you need for equalising on a dive. This could risk causing another infection if you ended up blowing bacteria into the middle ear on a dive. And if that happened you know what happens next. Yup, intensive care and needles in your spine. So leave it for now.

Get the nose op and take it from there.

Q - A patient has approached me asking for a medical to go diving whilst on holiday. 3 years ago he had ligation of his external carotid artery as an emergency following severe left sided epistaxis. Is this a contra-indication to diving (either relative or absolute). The paperwork he wanted me to fill in for him was American and had no helpline for Doctors to phone.

A - Ligation of the external carotid is obviously performed only where all else has failed to stem the bleed from epistaxis, as we docs like to call a nose bleed.

It is a permanent procedure that stops the blood flow directly to Little's area on the nasal septum where all the blood comes from on a bleed.

This should, though prove to be no problem with SCUBA diving at all. Blood flow remains to the head and brain through the internal carotid so there should be no risk of any faints or light headedness underwater.

In fact as there is reduced blood supply to the nasal mucosa it may well prevent a common diving problem. That of nose bleeds after forced equalisation. The diving regulations always say never to dive with a cold, but tell that to a diver in denial on the last day of their holiday.

They will try it and the pressure needed to blow air past a blocked Eustachian tube can pop a vessel in the nose.

The resulting blood in the mask and surrounding water may not interest the sharks, but it certainly does the smaller fish.

Q - I have one question to ask the Doctor - Why do new divers, especially those who have equalization problems, tend to experience nose bleeds? Is there any way to avoid this? Are there any likely complications that may arise if the new diver were to make a repetitive dive the same day?

A - From my experiences the answer to this falls into 2 common reasons.

Firstly the novice diver, I agree, does seem to get a blood filled mask more often than someone with a 100 or so dives under their weight belt. This is because of late and violent equalising. We all remember our first dive. A bit of apprehension perhaps, wishing the mouthy old timer wasn't there telling us of all his near death experiences underwater. That sort of thing.

Well what tends to happen is that in they plop into the blue, all OK on the surface and down they go. However what happens next is all too frequent. Instead of being cool headed and relaxed, and equalising often and little from the surface down something else happens. They check their depth gauge, make sure the octopus is there, double and triple check the air gauge, look for their buddy, look for the instructor. That sort of thing. Suddenly though at 6 or 7 metres they realise they haven't equalized yet, and the deeper they are the harder it is. At about 7 metres if you haven't equalised by now you wont unless you go up. But the first timer is unlikely to call up the group but will try harder and harder to blow some air up the Eustachian tube. By doing this the pressure on the nasal mucosa lining the septum of the nose is enough to blow some capillaries, and hence the bleed. So remember here, if your kit works on the surface check it will as you go down. Equalise a little and often as soon as you go down. Don't leave it late and have to blast it hard.

The other common reason for a big bleed is a sinus squeeze. Novices may not be able to call when and when not to dive if they are a bit stuffy in the nose. If you cannot equalise your sinuses then the negative pressure in these bony cavities will suck the lining off the sinal walls and cause the blood vessels to swell up and explode. The sinus will then equalize, not with air but with the red stuff. Then as you ascend the little air inside still expands, and forces the blood out of the sinus, through the nose and into your mask. So at about 5 to 10 metres you notice a red fluid level ascend towards your eyes. Not nice for the new diver.

The moral here is don't dive with a cold, and if you get searing pain in your forehead on descent, call it a day.

Should you dive again that day?

If the bleed is minor and due to leaving it until too late to equalise, then you should be fine for the afternoon.

But if you've had a major bleed, I would leave it, inhale some eucalyptus to open up the sinal canals and try tomorrow.

Q - I have a quick question for you. Is it generally permissible to use Beconase nasal spray prior to (days and immediately before) a dive - in this case, a PADI Advanced Course dive to approx. 18metres this coming weekend. Has it been shown to affect your susceptibility to "DCI"? I have had some nasal inflammation, and difficulty in pressure-balancing my ears whilst diving. The former is the reason for possible use, arising mostly after swimming-pool chlorine-related nasal inflammation, which has lasted a week and a half.

The active ingedient in Beconase is a corticosteroid, beclomethasone dipropionate, 50mg per spray.

A - Theres no real problem in using Beconase in the days going up to a dive if as you say you have a chlorine induced bunged up nose. I would far rather you did this then risked a middle ear barotraumas, which would ensue if you couldn't get any air up your Eustachian tubes.

If it is just a chlorine thing then hopefully when you dive in fresh or sea water it shouldn't be needed before a dive.

But there are divers who get this super mucous reaction even when going into sea water which then poses a bit of a dilemma. Do you follow the PADI guidelines for use of nasal clearers, i.e not using them before a dive as the efectrs may wear off underwater and risk a reverse block on ascent or do you just never dive at all as you get snotty during a dive. Well, I would take option 3 where careful use of these sort of products can make equalisation possible for a range of sufferers and the real risk of a medication that is supposed to last for 12 hours [i.e. its used twice a day in normal hay fever cases] running out just as you ascend is really pretty remote if you last for 40 minutes underwater and have had a toot an hour before going in.

To answer your other question about will it predispose you to getting DCS. No not at all, not even if you fell into the Beconase vat at the factory and swallowed the whole lot. So dive on there, just tell your buddy what it is before they hear you snorting away on the boat.

Q - I am a novice diver who have made only 3 diving trips. On the last 2 trips I found that on surfacing, there was some mucus coming out from my nose, which, on the first occasion, was brownish yellow in colour and on the second occasion was red with blood. Apart from this I did not suffer from any other apparent problem or discomfort. What is the possible cause of this phenomenon? Is it dangerous?

A - I think that in your case you will be fine. Having thick coloured mucous come from your nose after a dive is quite a common occurrence for a lot of divers and is a combination of the contents of the sinus being pushed out on ascent, and a reaction in your nose to the salt water that may have been in contact with it in your mask during the dive.

Most divers would agree that we are not a pretty sight a few moments after surfacing, due to this snot effect, so don't worry on that account.

Where problems do arise though is if you dive and have a case of sinusitis at the same time. I assume you didn't as you said you had no pain, but those that do will either experience extreme pain on descent as they cannot equalize the sinuses due to a blocked sinal canal, or when they ascend, the inflammed sinal lining can act as a valve and block the air that needs to escape. This results in a sinal barotrauma which feels like a hot poker being stuck into your forehead.

My call in your case is that you may have had a sinal infection in the past but had yet to clear all the gunk from your sinuses, and the blood was a result of trying to equalize too hard and popping a nasal capillary.

So the conclusion here is don't dive with active sinusitis but get some antibiotics sorted quickly.

Finally we still aren't really sure what a sinus is for yet medically, one theory is that it makes our skulls lighter. Good news as it means we don't all need necks like an All Black Prop forward.

Q - I have just come back from diving and experienced several nosebleeds during the dives which are causing me concern. I have done about 8 dives, the deepest being 15m. On my last trip I did a further 5, the first to 15m, 2nd to 25m, 3rd to 21m, 4th to 15m and 5th to 25m over the space of a week. On dives 2,4,5, I got small amounts of blood coming out of one nostril. Not a heavy bleed but enough to put a small amount into the water. (I have had nasal infections before but these have been heavier flows and cured using Naseptin - it made no difference to this problem). I checked at the dive school and they said that sometimes dead blood cells gather in the sinuses and can get pushed out. I find the situation extremely worrying because of the reaction of sharks on smelling blood etc. What should I do ?

A - Don't worry about the sharks Bob, there are a lot more appetising delicacies in the food chain on the reef than your old red cells.

The main causes for bleeds like this are sinus squeeze where you fail to equalize your sinuses and the lining of blood vessels are dilated by the air contracting inside causing them to burst. The other cause I see a lot of is new divers attempting to equalize too hard and pinching their nostril whilst blowing into it with the force of a strong sneeze. This is too much for the poor nasal lining and bleeding can occur as well as ear damage too.

The key here is to make sure you are equalizing gently and often on descent, and if you get any sinus pain to take it really slowly on the way down too.

If it comes again then its ENT time for you.

Q - I broke my nose 2 weeks ago and am due to be going to Stoney Cove next weekend to dive but need to know can I dive with a broken nose?

A - Funny thing, nose trauma. You can break it and all is fine. Or you cannot break it and it can be disaster. It's all about where the septum lies. That's the bit in the middle that stops you from picking the right nostril when your fingers in the left side. If the septum is left straight then you could well be fine. If the break has thrown it off to one side then you are going to have one hell of a time equalizing. The septal deviation will prevent you from blowing air up that side's Eustachian tube, ergo a full on screaming ear pain on descent.

So I advise you get your doc to have a look up your nose and make sure everything is in the right place. If it is I think you will be OK.

(other dive medical questions)



   


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