6-3
Dive Medicine: Barotrauma, Other
(Dental, Sinus, GI, Skin, and Face Mask)
CPT Jeffrey Morgan, MC, USAIntroduction: The volume of a gas changes inversely to air pressure-gas expands as pressure drops and
compresses as pressure rises. An enclosed, gas-filled cavity in the body is susceptible to injury from the
expansion or compression of the gas if it cannot equalize to the outside pressure. Middle ear injuries are the
most frequent, but several other areas are subject to barotrauma, primarily on descent. Dental fillings or caries
that have air trapped in the teeth can cause pain called dental barotrauma. The lining of the sinuses can be
pulled off the bone allowing the cavity to fill with blood. In very rare circumstances, the bone forming the sinus
may fracture. Large amounts of gas in the intestines may expand on ascent and cause intestinal pain (GI
barotrauma). Poorly fitting dry suits can have air trapped in folds and wrinkles that will compress at depth,
sucking skin in to fill the vacuum (skin barotraumas/suit squeeze). If a diver does not equalize the vacuum in
the facemask during descent, a mask squeeze may result.
Subjective: Symptoms
Dental barotrauma (barodontalgia): Pain in teeth usually presents on descent. Once pain is felt, patient
normally ascends and relieves pressure. Tooth may implode if diver continues to descend through initial pain.
Often patient cannot point out exact tooth. History typically includes recent fillings or poor dental health.
Sinus barotrauma: Usually occurs in maxillary and frontal sinuses and presents with pain over affected sinus
or in maxillary teeth. Blood may be seen in the mask. Pressure on ascent can occur (reverse squeeze),
usually secondary to mucosal polyps or plugs. Ascending or descending to decrease sinus pressure relieves
pain. Predisposing conditions include sinusitis, upper respiratory infections, mucosal polyps, deviated septum,
nasal polyps, smoking, persistent use of topical decongestants, and allergies.
GI barotrauma: Flatulence and diffuse pain in abdomen (usually mild) present on ascent. History often
includes pre-dive carbonated drinks and gas-producing foods.
Skin barotrauma: Pain and bruising on skin in areas of fold from a poorly fitting dry suit.
Facemask squeeze: Pain in area of mask, headache, transient blurring vision. History may include diving
with goggles instead of mask.
Objective: Signs
Using Basic Tools:
Sinus barotrauma: Pain over sinus with percussion. Transient, bloody nasal discharge, or blood in mask,
transillumination of sinus can occasionally reveal fluid in the sinus.
GI barotrauma: Tympanic sound on abdominal percussion possible.
Skin barotrauma: Bruising on skin typically at folds in the ill-fitting dry suit.
Facemask squeeze: Bruising in area of mask seal, conjunctival and scleral hemorrhages.
Using Advanced Tools: Dental barotrauma: air in tooth chamber on XR, Facemask squeeze: funduscopic
exam for retinal damage
Assessment:
Differential Diagnosis
Dental barotrauma - sinus barotrauma, tooth abscess
Sinus barotrauma - sinus infection, dental barotrauma
GI barotrauma - gastritis, acute abdominal disorders
Skin barotrauma - rash, bleeding disorders, jelly fish stings
Facemask squeeze - facial trauma, jellyfish stings
Plan:
Treatment
Primary: