The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
© 2000 The American Laryngological,
Rhinological and Otological Society, Inc.
Neurological Consequences of Scuba Diving
With Chronic Sinusitis
G. Joseph Parell, MD; Gary D. Becker, MD
Sinus barotrauma from scuba diving is relatively
common, usually self-limiting, and often the result of
transient nasal pathology. We describe serious neuro-
logical sequelae occurring in two scuba divers who
had chronic sinusitis. We suggest guidelines for eval-
uating and treating divers who have chronic sinus-
itis. Divers with nasal or sinus pathology should be
aware of the potentially serious consequences associ-
ated with scuba diving even after endoscopic sinus
surgery to correct this condition. Key Words: Baro-
trauma, diving, neurological manifestations, sinus-
itis, Valsalva’s maneuver.
Laryngoscope, 110:1358 –1360, 2000
INTRODUCTION
The two most common medical injuries that can occur
as a result of scuba diving are middle ear barotrauma and
sinus barotrauma.1,2 Barotrauma (tissue injury resulting
from pressure differences) results from failure of ambient
pressure to equalize the pressure in the ears and sinuses.
At descent, restricted gas flow into the sinus or ear causes
a relative negative pressure, thus inducing an attempt at
equalization of the pressure by decreasing the volume of
the middle ear or sinus cavity (according to the physical
principles known as Boyle’s Law). Depending on its mag-
nitude, the pressure difference can cause mucosal edema,
contusion, hemorrhage, or separation of the mucosa from
the periosteum. Similarly, blockage of the sinus ostium or
eustachian tube at ascent may prevent expanding gas
from exiting these areas and thus induce the gas to escape
injuriously via other pathways.
Most barotraumatic injury of the ear and sinus re-
sults from diving with nasal congestion but is self-limiting
or requires only analgesic medication. Rare neurological
sequelae of sinus barotrauma include cerebral empyema,3
pneumocephalus,4 blindness,5 and involvement of the fifth
cranial nerve.6 In these cases, chronic sinusitis is not
thought to be an underlying cause of the barotrauma. In
From the University of Florida, Department of Otolaryngology, Head
and Neck Surgery (G.J.P.), Gainesville, Florida, and the Department of
Otolaryngology, Head and Neck Surgery (G.D.B.) Kaiser Permanente Med-
ical Center, Panorama City, California.
Editor’s Note: This Manuscript was accepted for publication April
24, 2000.
Send Correspondence to G. Joseph Parell, MD, 330 W. 23rd Street,
Suite E, Panama City, Florida, 32405-4540, U.S.A.
Laryngoscope 110: August 2000
1358
this report, we alert physicians of the serious neurological
sequelae that may result from scuba diving with chronic
sinusitis and we recommend strategies for avoiding these
sequelae.
CASE STUDY
Case 1
A 33-year-old commercial diver made a surface-supplied
dive to repair a ruptured gas line. At a depth of 55 ft, a mechan-
ical malfunction caused his face mask to become suddenly over-
pressurized, an event resulting in severe pain in the right ear.
Repeated, forceful Valsalva maneuver resulted in severe vertigo
and disorientation that resolved within 90 minutes after surfac-
ing. Three days later, he became febrile and lethargic, had severe
headache, and was given a diagnosis of pneumococcal meningitis.
Despite aggressive treatment, permanent neurological sequelae
developed.
The patient’s medical history included chronic sinusitis
treated with functional endoscopic sinus surgery that included
partial bilateral ethmoidectomy and middle meatal antrostomy
about 4 months before onset of the meningitis. No surgical com-
plications were reported, and the patient made many dives with-
out difficulty after surgery. A computed tomography (CT) scan
taken after surgery (but before onset of meningitis) showed a
questionable unilateral defect in the cribriform plate. Because of
sinusitis persisting 6 months after meningitis, a second otolaryn-
gologist did complete bilateral ethmoidectomy. No defects were
noted in the cribriform plate. Several months after the second
surgery, a clear nasal drainage specimen was identified as cere-
brospinal fluid. Endoscopic and transcranial repair of a cribri-
form plate defect corrected this condition.
Case 2
In a 12-month period during 1993, a 42-year-old navy diver
had 5 episodes of loss of vision and facial paralysis on the right
side while scuba diving. These symptoms resolved within 30
minutes of surfacing. To avoid the possibility of losing his diving
status, he did not seek medical treatment. Forceful Valsalva
maneuver was required to equalize pressure in the ears, and
blood in the face mask was observed frequently. A long history of
recurrent sinusitis (during which time x-ray films documented
clouding of one or both maxillary sinuses) was successfully
treated by medical therapy, which included cessation of smoking.
Three years later, another episode of sinusitis did not respond to
medical management. A CT scan showed a 2 ⫻ 3-cm mucocele in
the middle of the right ethmoid sinus as well as bilateral maxil-
lary and ethmoid sinusitis. Bilateral complete endoscopic eth-
moidectomy and middle meatal antrostomy showed hyperplastic
Parell and Becker: Scuba Diving With Chronic Sinusitis
granular mucosa in the ethmoid and maxillary sinuses and a
mucocele full of creamy, tenacious fluid in the middle of the right
ethmoid. The patient was advised that he was still at high risk for
sinus and ear barotrauma. Despite this fact, he made more than
100 dives during which the sinuses and ears were cleared with
much less difficulty. After a dive in 1990, total sensorineural
hearing loss developed in the right ear and resolved spontane-
ously after 1 month. The next year, total sensorineural hearing
loss developed in the left ear and resolved spontaneously after 6
weeks.
DISCUSSION
Sinus barotrauma is the result of disparate pressure
between the nose and sinuses as a result of ostial insuffi-
ciency. The sinus ostium may be sufficiently large to per-
mit gradual equalization of pressure when a person is in
an aircraft or elevator but may not be able to accommo-
date the rapidly changing pressure that occurs during
scuba diving. Aviational pressure changes are relatively
mild compared with those encountered in diving. Every
33-ft depth of seawater represents an additional atmo-
sphere of pressure, whereas an ascent of 18,000 ft from
sea level represents a pressure change of only 0.5 atm. For
this reason, sinus barotrauma is more commonly observed
in divers.
Barotrauma of the sinuses in aviation and diving was
reported more than 50 years ago.7,8 In a series of 50
consecutive patients with sinus barotrauma resulting
from diving, Fagan et al.9 reported that the most common
symptom is pain referred to the frontal area, although
radiological examination showed that the maxillary sinus
was most affected. X-ray films showed mucosal thickening
and air/fluid levels. Half of the patients in the series had
recent upper respiratory infection or symptoms referable
to nasal disease. Most of these divers required no treat-
ment. A more recent study of 50 scuba divers affected with
sinus barotrauma described the same presenting symp-
toms and radiographic findings.10 Acute sinusitis that
developed in 28% of patients in that series prompted the
author to suggest use of antibiotics in all patients with
symptoms of sinus barotrauma.10 Another 14% of these
patients had preexisting chronic sinusitis, a condition that
predisposed the sinuses to recurrent barotrauma. Other
than maxillary nerve involvement, neurological complica-
tions of sinus barotrauma were not observed. That author
speculated that repeated diving may foster permanent
sinus mucosal changes or progressive ostial insufficien-
cy.10 Another study of 76 commercial divers did not, how-
ever, show a correlation between sinus changes seen on
x-ray films and with length of service.11
When medical management fails, endoscopic sinus
surgery is beneficial for preventing recurrent episodes of
barotrauma in aviators12 or divers11,13 who have recur-
rent or chronic sinusitis. If the thin, bony partitions sep-
arating the nose and sinuses from the brain and orbit were
important in preventing spread of infections from the nose
to the eye or central nervous system, then the complica-
tions reported here would be much more common. Instead,
the important barriers that separate the central nervous
system and ocular globe from the nose and sinuses are
probably the nasal mucosa, periosteum, and dura.
Laryngoscope 110: August 2000
Both of our patients had a history of chronic sinusitis.
An air lock may have formed within the sinuses or nasal
cavity, the hyperplastic polypoid mucosa functioning like
a ball valve, and both circumstances preventing highly
pressurized air inspired at depth from escaping as the
patient ascended. Complicating factors included the re-
peated, forceful Valsalva maneuver by both divers at
depth; this maneuver can produce more than 250 mm Hg
of pressure and could have forced pus through a small
defect in the cribriform plate into the intracranial cavity
(in the first diver) and air into the orbit and middle ear (in
the second diver). As diver 2 ascended, the air in the orbit
and middle ear expanded and compromised blood flow
through the retinal artery. Pressurized air in the middle
ear thus probably caused the inner ear barotrauma in
each diver as well as repeated episodes of facial palsy.14
We believe it helpful to differentiate between recur-
rent sinus barotrauma and chronic sinusitis. Patients
with recurrent sinus barotrauma may have no clinical or
radiological evidence of sinusitis between barotraumatic
episodes. Upper respiratory infection, rhinitis, sinusitis,
and intranasal pathology (e.g., nasal polyps or septal de-
viation) are a few factors that can compromise the capac-
ity of the sinus ostia to accommodate the large, rapid
pressure changes that occur during scuba dives. Ostial
insufficiency always puts patients at risk for development
of barotrauma when scuba diving.
When examining patients with recurrent sinus baro-
trauma, clinicians should first rule out causative pathol-
ogy by examining the nasal cavities endoscopically and
possibly by obtaining a CT scan of the sinuses. Divers with
recurrent sinus barotrauma should be advised not to dive
with a congested nasal cavity (e.g., during an upper respi-
ratory infection or during an episode of either allergic or
nonallergic rhinitis). In addition, intranasal disease (e.g.,
nasal polyps or septal deviation) in these divers may re-
quire correction to avoid compromising the ostiomeatal
complex. Divers with persistent difficulty equalizing pres-
sure in the ear and sinuses should be taught methods of
equalizing this pressure. These divers should be advised
to begin this equalization while at the surface of the wa-
ter, then to descend slowly (with feet descending first) and
to equalize continuously until a depth of 20 ft or more is
reached. Those who have persistent difficulty clearing
their ears and sinuses should be advised not to dive at all.
Patients who show evidence of chronic sinusitis
should be treated with appropriate medical management.
If radiological evidence of disease persists, functional en-
doscopic sinus surgery should be considered. If no clinical
or radiological evidence of ostial insufficiency persists,
then a pressure test should be conducted either in a hy-
perbaric chamber or (more practically) in a 14-ft or deeper
swimming pool. If no pain develops at this depth, diving
may be resumed. However, these patients must be warned
that clearing may still be difficult and that this problem
could result in disabling or life-threatening injuries. Our
experience with several hundred professional divers has
taught us that they continue to dive, no matter how sternly
they are warned. Under such circumstances, it is best to
instruct them on optimal control of their sinus disease and
on nonforceful methods of clearing. We reiterate that scuba
Parell and Becker: Scuba Diving With Chronic Sinusitis
1359
diving with chronic sinusitis may lead to serious neurological
sequelae and that endoscopic sinus surgery may not neces-
sarily obviate these sequelae.
ACKNOWLEDGMENT
The Medical Editing Department, Kaiser Foundation
Research Institute, provided editorial assistance.
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