Sinus Barotrauma (2023)

Sinus barotraumas are among the most common diving injuries. When the paranasal sinuses fail to equalize to barometric changes during vertical travel, damage to the sinus can cause sharp facial pain with postnasal drip or a nosebleed after surfacing. Although sinus barotrauma is a prevalent and generally benign diving injury, some of its complications could pose a significant risk to the diver’s health. Divers should never underestimate difficulties equalizing sinuses.

Anatomy and Functions of the Paranasal Sinuses

The paranasal sinuses are gas-filled cavities in your facial bones and skull. They have several functions: They lighten the weight of your head, play a significant role in the resonance of your voice, serve as collapsible structures that protect vital organs during facial trauma, and may help the turbinates (small structures inside the nose) humidify and heat the air we breathe. There are two sets of four sinus cavities, one set on the right and one on the left.

  • The frontal sinuses (area one) are located within the forehead above your nose and eyes and are surrounded by thick, bony walls.
  • The ethmoid cells (area two) are located within the ethmoid bone between your eyes and nose and are formed by a variable number of connected individual cells.
  • The sphenoidal sinuses (area three) are centrally located behind the nasal cavity and vary in size and shape.
  • The maxillary sinuses (area four) are located within the maxillary bone below your eyes and lateral to your nose and are the largest pair of paranasal sinuses.
Sinus Barotrauma (1)

The paranasal sinuses communicate with the nasal cavity via small orifices called ostia (singular: ostium). The ostia can easily be blocked by inflammatory processes, like colds or allergies, and in divers by improper attempts at equalization. Ostia blockage can impair drainage and make both descents and ascents troublesome.

Mechanisms of Injury

Every foot of descent in water adds approximately one-half pound of pressure on each square inch of tissue. The pressure diminishes by the same amount on ascent. According to Boyle’s Law, as the ambient pressure increases while descending, the volume of the gas in an enclosed space decreases proportionately. As the ambient pressure decreases while ascending, the volume of the gas increases proportionately.

(Video) Ears and Sinuses: Barotrauma for the Dive Professional

While descending, it is imperative that divers actively or passively equalize all enclosed air-filled spaces to avoid injury. While ascending, the increasing volume usually vents itself passively.

The mechanisms of injury of sinus barotraumas depend on whether it happened during descent or ascent.

During Descent (Squeeze)

Failure to equalize pressures on paranasal sinuses while descending keeps these cavities at atmospheric pressure, which results in a relative negative pressure (vacuum) as you descend to depth. The first sign of this type of sinus barotrauma is generally a sharp pain. The capillary vessels of the mucous membranes lining the sinuses engorge and burst, likely filling the sinuses with blood until the negative pressure is equalized. At this point the pain usually resolves or diminishes, and the diver continues the dive. While ascending, any remaining gas within the sinus expands and forces out this blood and mucus. These barotraumas usually manifest as postnasal drip or bloody discharge from the nose, depending on the sinuses involved. The bleeding can increase if you are taking blood thinners that include aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).

During Ascent (Reverse Block)

Sinus barotrauma can also happen during ascent, known as a reverse block. Equalization of ears and sinuses during ascent is usually a passive event, which means active attempts should not be necessary. However, mild swelling and inflammation of the mucous membranes (as caused by a cold or by seasonal allergies) can compromise the narrow passages through which air escapes, trapping gas, mucus and blood. If a sinus fails to vent during ascent, the increasing pressure can apply significant tension to the mucosal lining and bony walls of the sinus. As the diver continues to ascend, one of the sinus walls can burst into an adjacent sinus that did vent correctly (the point of least resistance), effectively relieving the excess pressure. This type of sinus barotrauma manifests as a sharp facial pain during ascent, followed by a nosebleed or postnasal drip depending upon the sinus cavities involved.

(Video) Sinus Pain While Flying


The most common manifestations of sinus barotrauma are sharp facial pain during descent or ascent and blood dripping from the nose after surfacing. It is not uncommon for sinus barotrauma to be painless and manifest only as bloody mucus in the mask or the back of the throat.

Signs and Symptoms


  • Pain is usually facial in the region corresponding to the compromised sinus. In most cases the pain has a direct relation with changes in pressure on descent or ascent. In some cases the pain is delayed for a few hours; for example, when a sinus remains slightly over-pressurized following a dive.
  • Sharp pain in your forehead above and between the eyebrows is often a sign of barotrauma to your frontal sinuses. It is often described as an “ice-cream headache.” This type of sinus barotrauma usually has a direct relationship with changes in depth.
  • Pain behind your eyes is usually the result of a compromise to the ethmoidal sinus. You may also experience sharp pain, associated with changes in depth, behind and above the eyes.
  • Sharp pain beside your nose and below your eyes (upper maxillary region) is often a sign of maxillary sinus barotrauma. With changes in depth the pain might radiate to the upper molars or gums on the same side as the facial pain. The maxillary sinus and the upper jaw are supplied by the same nerve (trigeminal nerve).
  • Pain in the back (occipital region) or top of the head is the most intriguing, as its connection with the deeper sphenoidal cells is not obvious. When compared to the other sinuses, pain in the occipital region is often duller, like a normal headache. The association with changes in depth should be a clue that leads to a sinus origin.


  • You may notice some blood mixed with mucus and saliva in your mask after surfacing. You might not have been aware of it while diving. Minor bleeding that drips from the nose (technically not a nosebleed) or from the nose to the throat is typical of sinus barotrauma.
  • Minor bleeding is seldom a severe problem, but if you take an anticoagulant medication, be cautious when diving in a remote location. Uncontrolled bleeding without timely access to a medical facility prepared for such emergencies could be a severe health threat.

Coughing or Spitting Up Blood

While a nosebleed is not usually a manifestation of a life-threatening condition, postnasal drip usually results in blood in the diver’s mouth. This might be disconcerting to divers as it could be interpreted as the diver coughing up or spitting up blood. While there may be clues to determine whether this bloody discharge is of pulmonary origin or the result of sinus barotrauma, it is beyond the scope of what someone without medical training should attempt to evaluate. When in doubt, seek medical evaluation immediately.


  • Do not dive when congested.
  • Refrain from diving when feeling fullness, pressure or pain in your paranasal sinuses.
  • Learn and use proper equalization techniques.


Talk to your doctor if you feel you need medication to dive. An ENT doctor is ideal for both ear and sinus problems, but your primary care physician can help with common problems. Using nasal sprays containing antihistamines and decongestants before diving may reduce swelling in the nasal and ear passages. Some are prescription only, while some are over the counter (OTC). With either option, your doctor may have special instructions on how to use them while diving.

Antihistamines prevent the effects of histamine, a substance produced and released by your body during the inflammations that cause nasal congestion, swelling of the mucous lining, and sneezing. While some of these drugs may cause drowsiness, second-generation antihistamines like cetirizine, loratadine and fexofenadine do not.

Decongestants relieve symptoms caused by the already-released histamine, clearing nasal and sinus congestion. Decongestants are not suitable for use by everyone. Some cardiovascular and central nervous system side effects could be concerns while diving.

(Video) Frontal & Sphenoid Sinuses Demonstration by Zara Patel, MD

Most nasal sprays work best if used one to two hours before the descent. They last from eight to 12 hours, so there is no need to take a second dose before a repetitive dive. Take short-acting nasal sprays like oxymetazoline 30 minutes before the descent; these usually last for 12 hours. Repeated use of short-acting OTC sprays can result in a rebound reaction that may set the stage for a reverse block. Steroid nasal sprays do not have this rebound effect but are slow-acting drugs, so you need to start them about a week in advance and use them regularly.

Whether you have a prescription or not, always check with your doctor before attempting to treat any condition.

Risk Factors

If you have a history of sinus trouble, allergies, a broken nose or deviated septum, or you currently have a cold, you may find the clearing procedure challenging to accomplish and may experience a problem with nosebleeds. It’s always best not to dive with a cold or any condition that may block the sinus air passages. If you experience difficulties during descent, this is the time to abort the dive. Remember that you can only abort a descent, never an ascent.

A good way to assess whether your paranasal sinuses are clear is by paying attention to your voice. You will sound like you have a stuffy nose due to a lack of appropriate nasal airflow while speaking.

Being able to breathe through your nose only proves your nasal passages are clear. It does not indicate anything about your paranasal sinuses.


With this type of injury, blood can run down the back of the throat or pool in the sinuses below the eyes and emerge later (even days after diving) as a thick, black, bloody discharge. The collected blood can also act as a growth medium for bacteria and result in sinus infections.

(Video) FAQ Sinus Squeeze & Diving

Pneumocephalus (air between the skull and the brain) and orbital emphysema (air behind and around the eyeball) are rare but important complications of sinus barotraumas. If not adequately treated, they may cause serious neurological and life-threatening complications. Never underestimate sinus barotrauma.

First Aid

  • Use a nasal decongestant spray or drops. Thismightreduce the swelling ofthe mucous membranes, which may help to open the ostiaand drain fluid from the sinuses.
  • Seek professional medical evaluation. Any doctor should be able to help, regardless of any dive medicine knowledge or training.

Implications in Diving

For the Diver

  • You can consider a return to diving if a physician determines that the injury hashealed,and the risk of further injury is no greater than normal.
  • Do not neglect these injuries. Some of the complications could negatively affect you for the rest of your life.

For the Dive Operator

  • Provide first aid treatment, as described above. As the expedition’s leader, you have a duty of care for a diver injured during your trip.
  • Be skeptical of any folkloric first aid treatments. Use common sense, and don’t attempt any magic solutions. Remember that you might be liable.
  • Have them evaluated by a medical professional in a timely fashion.
  • Don’t worry about referring them to a doctor with dive medicine experience. An ENT specialist is ideal, but any doctor should be able to help.
  • Do not allow any further diving once the injury has occurred until they are cleared by a physician.

For the Physician

  • Provide symptomatic treatment (anti-inflammatory drugs, decongestants, mucolytic agents).
  • Prophylactic antibiotic therapy is controversial. Although a middle-ear infection is a plausible secondary complication, this is not always the case in the acute phase.
  • Assess concomitant middle-ear barotrauma.
    • If present, consider referring the patient to an ENT specialist.
    • Use the O’Neill grading system or detail what you observe.
  • Assess the cranial nerve function.

Fitness to Dive

Do not dive until swelling and inflammation have resolved, and you can adequately equalize, preferably under otoscopic evaluation. Assess why the problem occurred (lack of training, allergy, etc.) and address each factor. The inability to equalize properly is disqualifying.

(Video) Ears and Sinuses: Barotrauma for the Dive Professional

If you are unable to clear your sinuses or you have frequent nosebleeds when diving, you should see your primary care physician or an ear, nose and throat (ENT) specialist (otolaryngologist) for evaluation.


How do you get rid of sinus barotrauma? ›

Drug treatment for sinus and middle ear barotrauma is identical. Decongestants (usually oxymetazoline 0.05%, 2 sprays each nostril twice a day for 3 to 5 days or pseudoephedrine 30 to 60 mg orally 2 to 4 times a day up to a maximum of 240 mg/day for 3 to 5 days) can help open occluded chambers.

Does sinus barotrauma go away? ›

The pain should go away shortly after returning to sea level; regardless, you should see a doctor and soon. If you are bleeding uncontrollably or if severe pain doesn't subside, go to an emergency room. Barotrauma of the sinuses can usually be treated successfully by an ENT doctor without long-term damage.

How long does sinus barotrauma last? ›

Grade I causes a mild transient sinus discomfort. Grade II is characterized by localized pain lasting up to 24 hours. Grade III, like in our case, exhibits severe pain lasting for more than one day.

What does sinus barotrauma feel like? ›

The most common manifestations of sinus barotrauma are sharp facial pain during descent or ascent and blood dripping from the nose after surfacing. It is not uncommon for sinus barotrauma to be painless and manifest only as bloody mucus in the mask or the back of the throat.

Can barotrauma be permanent? ›

Ear barotrauma is a type of ear damage. It is caused by pressure differences between the inside of the ear and the outside of the ear. It can cause pain and sometimes lifelong (permanent) hearing loss.

Can barotrauma be fixed? ›

Ear Barotrauma Treatment

Serious damage, such as a burst eardrum, may take a few months to heal. Sometimes you may need surgery to repair the eardrum or the opening into your middle ear. For a mild case, you can usually treat your symptoms yourself.

How long does barotrauma take to heal? ›

If barotrauma is caused by allergies or respiratory infections, it will often be resolved when the underlying cause has been resolved. Mild to moderate cases take an average of up to two weeks for a full recovery. Severe cases can take six to 12 months for a full recovery after surgery.

How do you reverse barotrauma? ›

You can try certain maneuvers, called Valsalva maneuvers, such as yawning or trying to blow with your nose and mouth closed, to open the tube and equalize the pressure. Inner ear barotrauma occurs from the sudden development of pressure differences between the middle and inner ear.

What is the best decongestant for barotrauma? ›

Decongestants are used to reduce the pressure differential. Administer oxymetazoline (Afrin) 0.05%, 2 squirts each nostril bid. Performing the Valsalva maneuver immediately after spray forces the medication into the osteo and helps to open them quickly.

What is the most severe form of barotrauma? ›

The most serious form of ascent barotrauma is pulmonary injury. Additionally, injury to the lung from positive airway ventilation is a special case of barotrauma. The most serious consequence of barotrauma is a pulmonary alveolar rupture with antecedent air gas embolism.

What is the cure for barotrauma? ›

How do healthcare providers treat ear barotrauma? Your healthcare provider may recommend you take an over-the-counter decongestant. They may prescribe steroids to ease your symptoms. If your eardrum ruptured, causing you to lose some of your hearing, they may do surgery.

How is Barosinusitis treated? ›

Treatment is based on the underlying etiology of nasal obstruction. Mucosal edema and irritation can be managed with topical steroid nasal sprays as well as topical decongestants. Prophylactic antibiotics can reduce mucosal edema and purulent obstructive nasal drainage.

What is the most common sinus involved in barotrauma? ›

Sinus barotrauma most often affects the frontal sinuses, followed by the ethmoid and maxillary sinuses. Divers experience mild pressure to severe pain, with a feeling of congestion in the involved sinus compartments during ascent or descent and sometimes epistaxis.

What are the symptoms of barosinusitis? ›

Physical findings may be relatively sparse in mild cases of barosinusitis. In severe cases, the patient may have marked pain in the forehead, face, and upper teeth. This pain is typically unilateral. Erythema, edema, congested mucous membranes, epistaxis, and tenderness to palpation of the face may occur.

When should I see a doctor for barotrauma? ›

Barotrauma may be severe in these situations. If self-care steps do not ease discomfort within a few hours or the problem is severe, you may need to see a provider. You may need medicine to relieve nasal congestion and allow the eustachian tube to open.

Is barotrauma fully released? ›

Barotrauma was released onto early access on June 5, 2019, with initial plans for the full release later in the year. The game would remain in early access indefinitely until January 2023, when the full release date was announced as March 13, 2023. The developers host a public development roadmap on their Trello page.

Do beds heal you barotrauma? ›

Beds and Bunks are Installations that can be slept in. They slowly heal the sleeping crewmate over time.
BedAfflictionHeal Rate (per second)
All bedsDamage (affliction type) Bloodloss Bleeding Nausea Opiate Withdrawal Opiate Addiction Drunk0.05
Jan 2, 2023

Does Sudafed help with barotrauma? ›

Treatment with 120 mg pseudoephedrine at least 30 minutes before flying appears to decrease the incidence of barotrauma in adults with a history of recurrent ear pain during air travel.

How common is barotrauma? ›

Barotrauma is the most common medical problem reported by air travelers. It is much more likely to happen to people who have colds, allergies or infections when they are flying. It is common in children because their Eustachian tubes are narrower than those of adults and become blocked more easily.

How deep can you go in barotrauma? ›

Generally, fish caught deeper than 33 feet can experience barotrauma, but some species, such as bull red drum, may show signs at shallower depths. Barotrauma is most common in depths greater than 90 feet.

Does barotrauma have progression? ›

The campaign is progression based but not in for far as your character. They can do anything from the get-go but its a little harder. The progression comes in the way of gear mostly and subs/upgrades that cost money or you find in salvaging wrecks.

How do you treat barotrauma naturally? ›

These techniques include: Chewing gum, sucking on a lozenge, swallowing, or yawning. Using the mouth helps to open up the eustachian tube. Taking an over-the-counter (OTC) nasal decongestant, antihistamine, or both.

How do you cheat on barotrauma? ›

  1. Press to toggle the console (for Mac, press File:Key Dark.png and ).
  2. Enter enablecheats to enable cheats and disable achievements for the game session. This is only required for cheat commands, marked with a green checkmark in the table below.
  3. Press to autofill and cycle through identifiers.
Sep 12, 2022

How do you drain your sinuses from the eustachian tube? ›

Popping your ears can help open the eustachian tube, allowing fluid to drain. The simplest way to pop your ears is to yawn, chew, or swallow. You may also want to try popping your ears using something called the Valsalva maneuver: Take a deep breath and hold it.

Will Sudafed PE unclog my ears? ›

Pseudoephedrine is used to relieve nasal or sinus congestion caused by the common cold, sinusitis, and hay fever and other respiratory allergies. It is also used to relieve ear congestion caused by ear inflammation or infection.

What medicine opens eustachian tube? ›

A common course of treatment for Eustachian tube dysfunction is the use of decongestants or antihistamines. In some cases, this treatment may make the condition worse. If decongestants or antihistamines do not provide relief, contact your doctor. You may need to see an ear, nose and throat specialist for treatment.

What are the complications of barosinusitis? ›

Complications of barosinusitis are unusual, but they may include the following:
  • Orbital cellulitis, abscess, or hematoma.
  • Pneumocephalus or subcutaneous emphysema.
  • Complications associated with paranasal sinusitis.
Jun 19, 2019

What causes barosinusitis? ›

Flying and Diving. As previously noted, secondary shifts in barometric pressure due to altitude changes during flight and diving are the most common causes of barosinusitis.

How do I get rid of sinus pressure forever? ›

Medical therapies for chronic sinus infections
  1. Intranasal corticosteroids. Intranasal corticosteroids reduce inflammation in the nasal passages. ...
  2. Oral corticosteroids. Oral corticosteroids are pill medications that work like intranasal steroids. ...
  3. Decongestants. ...
  4. Saline irrigation. ...
  5. Antibiotics. ...
  6. Immunotherapy.
Jun 18, 2019

Can you fly with sinus barotrauma? ›

If suffering from a sinus infection while flying, you may experience severe sinus pressure and pain. We recommend avoiding air travel when possible if you have a sinus infection.

Can air get trapped in your sinuses? ›

Each sinus cavity has an opening into the nose to allow a free exchange of air and mucus. But if something causes swelling within the nose, air can be trapped inside a sinus cavity, along with pus and other secretions, causing increased pressure on the wall of the sinus.

How do you unlock sinus pressure? ›

Home Treatments
  1. Use a humidifier or vaporizer.
  2. Take long showers or breathe in steam from a pot of warm (but not too hot) water.
  3. Drink lots of fluids. ...
  4. Use a nasal saline spray. ...
  5. Try a Neti pot, nasal irrigator, or bulb syringe. ...
  6. Use a micro-current wave device. ...
  7. Place a warm, wet towel on your face. ...
  8. Prop yourself up.
Jan 31, 2022

Is sinus pressure curable? ›

Most cases of acute sinusitis get better on their own. Self-care techniques are usually all you need to ease symptoms.

What causes sinus pressure build up? ›

Infections in your respiratory tract — most commonly colds — can inflame and thicken your sinus membranes and block mucus drainage. These infections can be caused by viruses or bacteria. Allergies such as hay fever. Inflammation that occurs with allergies can block your sinuses.

What nasal spray for barotrauma? ›

Administer oxymetazoline (Afrin) 0.05%, 2 squirts each nostril bid. Performing the Valsalva maneuver immediately after spray forces the medication into the osteo and helps to open them quickly. Administer pseudoephedrine (Sudafed) 60-120 mg PO bid/qid. Anti-inflammatory medications treat the pain.

Can barotrauma cause sinusitis? ›

Barotrauma is tissue injury caused by a pressure-related change in body compartment gas volume. It can affect the ear (causing ear pain, hearing loss, and/or vestibular symptoms) or the sinuses (causing pain and congestion).

How long does it take Flonase to unclog eustachian tube? ›

Nasal steroid (Flonase, Nasonex, Nasacort) – 2 sprays into each nostril twice daily. This may take a few weeks to show any effect Neil Med Sinus rinses - 3-5x daily into each nostril Try to pop your ears 5-10x daily (this is called auto-insufflation).

What nasal spray opens airways? ›

Afrin (oxymetazoline) and Flonase (fluticasone propionate) are each nasal sprays that can provide a relief of symptoms related to nasal congestion.

How long does it take for Eustachian tubes to unblock with nasal spray? ›

These sprays decrease swelling in your nose and your Eustachian tubes to help them pop open. Nasal steroid sprays must be used everyday to be effective and often take 5-7 days before you will notice their benefit.


1. Flying With a Cold or Sinus Infection: Is It Dangerous?
(The Dr. Bob Show)
2. Equalization Problems In Freediving. How To Equalize Sinuses
3. How to relieve sinus pressure and sinus pain with self massage (INSTANT!)
(Amber Lynn Vitale)
4. What Is The Definition Of Sinus barotrauma Medical School Terminology Dictionary
(Medical Dictionary Online)
(Foheid ٍSobei)
6. Divers React to Horrible Barotrauma
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