17/9/2017 Barosinusitis: Background, Pathophysiology, Epidemiology

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Barosinusitis
Updated: Aug 08, 2017
Author: J Kim Thiringer, DO; Chief Editor: Arlen D Meyers, MD, MBA more...

OVERVIEW

Background
Barotrauma of the paranasal sinuses is a risk factor for anyone exposed to ambient pressure
changes. These pressure changes most often result from travel through mountainous regions,
flying, or diving. [1, 2] Barosinusitis is characterized by inflammation of one or more of the paranasal
sinuses. Inflammation is caused by a pressure gradient, almost always negative, between the
sinus cavity and the surrounding ambient environment.

Pathophysiology
The paranasal sinuses have rigid walls with relatively small ostia for gas exchange and mucus
transport. Physical gas laws, particularly Boyle's Law, apply to this space. Boyle's Law states that
at constant temperature, the volume of a gas is inversely proportional to the pressure placed upon
it.

To show how Boyle's Law affects the sinuses, consider the case of an individual with normal
sinuses exposed to pressure changes while flying in an unpressurized aircraft. As the individual
transitions to higher altitude, the ambient pressure surrounding the sinus cavity decreases, and the
air in the sinuses expands and equalizes through the natural ostium. Upon descent, ambient air
pressure increases, the air in the sinuses contracts, and air moves into the sinus cavity, preventing
a pressure gradient from developing.

Now consider the same flight in someone who has an upper respiratory tract infection (URTI) with
tissue edema and secretions blocking the natural sinus ostia. In this individual, tissue edema and
debris will not allow free pressure equalization. Again, as the individual moves up in altitude, the
ambient pressure decreases, and volume in the sinus cavity increases. A positive pressure
develops in the sinus. With this positive pressure, tissue edema gradually decreases enough to
allow debris and air to escape the natural ostium. Air pressure then equalizes. When the individual
descends, the ambient pressure increases. Pressure cannot equalize across the nasal cavity to the
sinus because of blockage at the ostium. Air volume decreases in the sinus cavity, creating a
negative pressure.

At this point, a condition exists in which the volume of the sinus must be filled if the pressure
gradient is to be eliminated. In mild-to-moderate cases, vascular engorgement and generalized
submucosal edema occur. Over time, transudate and mucus fill the volume, reducing negative
pressure and decreasing symptoms. In severe cases, especially with rapid onset, the sinus
mucosa is stripped from the subjacent bone, resulting in severe pain and hematoma formation.

Epidemiology
Frequency

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17/9/2017 Barosinusitis: Background, Pathophysiology, Epidemiology

United States

Prevalence is approximately 3-4 episodes per 100,000 exposures in a generally healthy

population.

In contrast, middle ear barotrauma (aerotitis media) is approximately 6-10 times more
prevalent than barosinusitis.
Frontal sinuses are most often affected, followed by maxillary sinuses.
Ethmoid sinuses are infrequently affected as isolated events.
Data are heavily skewed toward people who participate in activities subject to rapid pressure
changes.

International

A Danish study conducted via questionnaire determined that compared with pilots who had
answered the same questionnaire 10 years earlier, the proportion of responding pilots in whom one
or more ear-nose-throat (ENT) barotraumas had occurred had increased from 19.5% to 27.9% for
barosinusitis and from 37.4% to 55.5% for barotitis media. [3]

Race
Race predilection is not widely reported.

Sex

Sex predilection is not widely reported.

Age
Barosinusitis is not typically reported in children. Frontal sinuses are most frequently affected, and
these do not fully develop until late adolescence. In addition, children do not routinely participate in
activities that lend themselves to rapid pressure changes.

Clinical Presentation

References

1. Sonmez G, Uzun G, Mutluoglu M, Toklu AS, Mutlu H, Ay H, et al. Paranasal sinus mucosal
hypertrophy in experienced divers. Aviat Space Environ Med. 2011 Oct. 82(10):992-4.
[Medline].

2. Prasad BK. ENT morbidity at high altitude. J Laryngol Otol. 2011 Feb. 125(2):188-92.
[Medline].

3. Boel NM, Klokker M. Upper Respiratory Infections and Barotrauma Among Commercial
Pilots. Aerosp Med Hum Perform. 2017 Jan 1. 88 (1):17-22. [Medline].

4. Gunn DJ, O'Hagan S. Unilateral optic neuropathy from possible sphenoidal sinus barotrauma
after recreational scuba diving: a case report. Undersea Hyperb Med. 2013 Jan-Feb.
40(1):81-6. [Medline].

5. Wang B, Xu X, Jin Z, Zhang Y. [The clinical research of aviatic nasal diseases with medical
evaluation prevention and control intervention]. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za
Zhi. 2015 Mar. 29 (5):433-6, 440. [Medline].

6. Smerz RW. The relationship of decongestant use and risk of decompression sickness; a
case-control study of Hawaiian scuba divers. Hawaii J Med Public Health. 2014 Feb. 73
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17/9/2017 Barosinusitis: Background, Pathophysiology, Epidemiology

(2):61-5. [Medline].

7. Parsons DS, Chambers DW, Boyd EM. Long-term follow-up of aviators after functional
endoscopic sinus surgery for sinus barotrauma. Aviat Space Environ Med. 1997 Nov.
68(11):1029-34. [Medline].

8. Vaughan WC. Review of balloon sinuplasty. Curr Opin Otolaryngol Head Neck Surg. 2008
Feb. 16(1):2-9. [Medline].

9. Jones JS, Sheffield W, White LJ, et al. A double-blind comparison between oral
pseudoephedrine and topical oxymetazoline in the prevention of barotrauma during air travel.
Am J Emerg Med. 1998 May. 16(3):262-4. [Medline].

10. Sonmez G, Uzun G, Mutluoglu M, Toklu AS, Mutlu H, Ay H, et al. Paranasal sinus mucosal
hypertrophy in experienced divers. Aviat Space Environ Med. 2011 Oct. 82(10):992-4.
[Medline].

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Contributor Information and Disclosures

Author

J Kim Thiringer, DO Otolaryngologist, Ear, Nose, and Throat Associates

J Kim Thiringer, DO is a member of the following medical societies: American Academy of

Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of

Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership,
American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of
Colorado School of Medicine
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17/9/2017 Barosinusitis: Background, Pathophysiology, Epidemiology

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of
Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck
Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for:
Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians
Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians
Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for
consulting; .

Additional Contributors

Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery,
Columbia University College of Physicians and Surgeons

Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha,
American Head and Neck Society, American Academy of Facial Plastic and Reconstructive
Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of
Physicians, American Laryngological Association, New York Academy of Medicine

Disclosure: Nothing to disclose.

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