Volume 2, Issue 3 , Pages 151-153, September 2007
Severe maxillary sinus barotrauma associated with car travel
Article Outline
Summary
Barotrauma secondary to flights or diving is relatively common but severe maxillary sinus barotrauma, caused by car travel, has not been reported yet. Herein we present the case of a 16-year-old girl, who suffers from severe pain in the left maxillary, frontal and parietal region and numbness, involving the upper palate, upper lip and teeth on the left side, and occurring during car travels. Computerized tomography of the paranasal sinuses revealed a long uncinate process that extends up to middle turbinate and covers the entire middle meatus. The patient underwent endoscopic sinus surgery and her pain episodes completely disappeared in the postoperative six months follow-up period.
Keywords: Barotrauma, Maxillary sinus, Endoscopic surgery
Introduction
Sinonasal trauma results from rapid change of environmental air pressure. Impaired or completely blocked communication between the sinus cavities and the nasal passage causes abnormal pressure gradient in the sinuses that injures the tissue around it. Aviation and diving is the two common cause of sinus barotrauma [1], [2], [3], [4]. Hyperbaric chamber is another reported ethiologic factor of this condition [5], [6]. Maxillary sinus is the most common site for barotrauma among the paranasal sinuses [7], [8]. However, the frontal, ethmoid and sphenoid sinuses may also be affected. The infraorbital nerve may rarely be involved due to its course through the maxillary sinus [9], [10]. Severe barotrauma of the paranasal sinuses may cause important morbidities and loss of work-time.
Herein we present a rare case of maxillary sinus barotrauma, which has recurred several times during car travels and reviewed the literature.
Case report
A 16-year-old girl was referred with severe and recurrent pain attack, occurring in the left orbit, left frontal, parietal and maxillary region and lasting more than 24
h. Numbness accompanying with pain and continuing several days to one month in the upper left palate, teeth and lip was also noted. First attack had begun two years ago and had recurred many times with almost every car travel while passing over mountains. She said that she was afraid of car travel because of severe pain and numbness, accompanied with change of altitude. She has no prior history of allergies, sinusitis, maxillofacial trauma and nasal surgery. She had a previous medical record of sinoscopy, performed elsewhere through the fossa canine, that revealed submucosal hematoma at the roof of the maxillary sinus. Findings of anterior rhinoscopy were normal. Computerized tomography (CT) of the paranasal sinuses revealed a long uncinate process, extending up to the middle turbinate (Fig. 1). CT taken one year ago, just after an attack of barotrauma, revealed a soft tissue density, located at the roof of the left maxillary sinus (Fig. 2). The patient underwent endoscopic sinus surgery under local anesthesia. The middle turbinate was bent medially under endoscopic guidance. The uncinate process was seen covering entire free surface of the ethmoid bulla (Fig. 3). The uncinate process and inferior half of the ethmoid bulla were resected. Middle meatal antrostomy was performed. The patient had no attacks of maxillofacial pain or numbness during her several car travels and during diving, in the postoperative six months follow-up period.
Fig. 1.
The long uncinate process, seen on CT. ↑: The uncinate process.
Fig. 2.
Soft tissue density, seen at the roof of left maxillary sinus just after an attack of barotrauma.
Fig. 3.
The uncinate process, covering entire free surface of the ethmoid bulla on diagnostic endoscopy. ↔: Extension of the uncinate process between the lateral nasal wall and the middle turbinate.
: The middle turbinate.
Discussion
Positive and negative air pressure cause tissue damage, defined as barotrauma. Inflammatory mucosal thickening, nasal polyps, tumors in the nasal passage and anatomical abnormalities of the lateral nasal wall interfere with normal air flow through the sinus ostia and result in pressure gradient between the inside and the outside of the sinuses. If someone is unable to equalize the intrasinus pressure with rising ambient pressure during descending from altitude in an airplane or from surface to depth in water, squeeze type injury occurs with negative intrasinus pressure. Vacuum effect may lead to mucosal edema, serosanguineous exudate and submucosal hematoma. The opposite of this condition is referred to as reversed squeeze. Trapped air in the sinus applies positive pressure to the sinus walls and symptoms occur during ascent. Weissman et al. graded the sinus barotrauma according to its severity [11]. In grade-I injury, there are transient clinical symptoms that disappear promptly. Findings of X-rays are normal and histopathologic examination may show a slight edema of the sinus mucosa. In grade-II injury, there is pain continuing up to 24h. Plain radiography shows mucosal thickening. There may be serosanguinous nasal discharge. In grade-III, a squeeze type injury occurs during descent. Severe pain begins suddenly and lasts several days. Involved sinus is seen radiolucent and submucosal hemorrhages are common. The presented case was accepted as grade-III barotrauma because of severe pain lasting more than 24h and submucosal hematoma confirmed by sinoscopy.
Numbness over the cutaneous distribution of the infraorbital nerve is another common symptom of maxillary sinus barotrauma [9], [10], [12]. Second branch of fifth cranial nerve (maxillary nerve) travels across the roof of maxillary sinus in the infraorbital canal and emerges as infraorbital nerve. Infraorbital canal sometimes may be merely a sulcus covered by mucosa of the sinus. CT of the paranasal sinuses may be used to detect the anatomic abnormalities of the infraorbital nerve canal but negative results cannot exclude a small dehiscence. In the presented case, numbness was one of the main complain because of its longer lasting time.
The diagnosis of sinus barotrauma is usually made clinically. The association between acute pain and rapid change of atmospheric pressure is important. Magnetic resonance imaging of the paranasal sinuses can demonstrate submucosal hematoma, which is seen hyperintense on both T1 and T2-weighted images [1]. CT of the paranasal sinuses may be taken for investigation of anatomic abnormalities of the ostiomeatal complex, polyps or other mass in the middle meatus (Fig. 1). Diagnostic nasal endoscopy may also reveal pathologic changes of the lateral nasal wall. However, normal findings on both diagnostic endoscopy and radiologic imaging do not rule out sinus barotrauma.
Reestablishment of normal sinus ventilation is the aim of the treatment in patients with barotrauma. Conservative treatment including decongestants, analgesics, nasal steroids, saline irrigants, and absolute restriction of altitude change may be advocated initially. However, if barotrauma recurs frequently, surgical treatment has to be considered for permanent relief. Contemporary management of paranasal sinus barotrauma is endoscopic sinus surgery [13], [14]. During the surgery, the pathologic changes that blocks middle meatus should be removed and natural ostium of the maxillary sinus should be widened.
Sinus barotrauma is a relatively common occupational disease of pilots and divers but rarely results from car travel. Severity of symptoms and recurrence of condition may prevent patients’ daily activities. Endoscopic sinus surgery is a reliable method of the treatment in these patients.
References
- . MR imaging appearance of frontal sinus barotrauma. Am J Neuroradiol. 2003;24:346–347
- . Headache associated with airplane travel: report of six cases. Cephalalgia. 2006;26:707–711
- . Barotrauma of the ears and sinuses after scuba diving. Eur Arch Otorhinolaryngol. 2001;258:159–163
- . Barotrauma secondary to inflammatory maxillary sinus polyp: a case report. Aviat Space Environ Med. 2002;73:1127–1131
- . Complications and side effects of hyperbaric oxygen therapy. Aviat Space Environ Med. 2000;71:119–124
- . Risk factors for symptomatic otic and sinus barotrauma in a multiplace hyperbaric chamber. Undersea Hyperb Med. 1999;26:243–247
- . Sinus barotrauma in divers. Ann Otol Rhinol Laryngol. 1976;85(1 Pt 1):61–64
- . Barotrauma. Injury. 2004;35:359–370
- . Maxillary sinus barotrauma with fifth cranial nerve involvement. J Laryngol Otol. 1991;105:217–219
- . Infraorbital hypesthesia after maxillary sinus barotrauma. Undersea Hyperb Med. 1999;26:257–259
- . Frontal sinus barotrauma. Laryngoscope. 1972;82:2160–2168
- . Maxillary sinus barotrauma—case report and review. Aviat Space Environ Med. 1985;56:796–802
- . The application of endoscopic sinus surgery to the treatment of recurrent sinus barotrauma. Clin Otolaryngol Allied Sci. 1996;21:528–532
- . Long-term follow-up of aviators after functional endoscopic sinus surgery for sinus barotrauma. Aviat Space Environ Med. 1997;68:1029–1034
PII: S1871-4048(07)00030-5
doi:10.1016/j.pedex.2007.04.004
© 2007 Elsevier Ireland Ltd. All rights reserved.
Volume 2, Issue 3 , Pages 151-153, September 2007
