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Acute infectious sinusitis - may be indicated if systemic symptoms and/or purulent discharge is present
Plan
Treatment
Primary: Increase cabin altitude to decrease pressure differential in sinus and alleviate pain. Spray
nasopharynx with decongestant spray (e.g., Afrin). Slowly descend while frequently using modified Valsalva
maneuver (i.e., pinch nose and exhale against closed nostrils) as needed to equalize pressure in sinuses.
Alternative: Use of po decongestants (e.g., pseudoephedrine) prior to and during flight may decrease the risk
of barosinusitis in a patient who must fly with a URI.
Primitive: Modified Valsalva maneuver.
Patient Education
General: It is easier to prevent a sinus "squeeze" than to treat one. Use modified Valsalva maneuver to
equalize pressure in sinuses frequently during descent; do not wait until pain develops to attempt to equalize.
Prevention: Whenever possible, do not fly while suffering from a URI.
Follow-up Actions
Return evaluation: Patient should be followed and nasal decongestants (po or topical) should be used for
several days following an episode of barosinusitis. If sinus bleeding occurs, treat with amoxicillin (250 mg
po tid) and manage like acute sinusitis.
Consultation Criteria: No consultation is necessary in uncomplicated cases. Consult dentist if dental
condition is suspected; consult ENT specialist, if possible, for sinus bleeds.
NOTES: An uncomplicated sinus squeeze may not require restriction of special duty status. An underlying
URI or other sinus problem or barosinusitis with secondary sinus bleed, however, should temporarily restrict
affected personnel from special duty involving flying or diving operations until cleared by a Flight Surgeon
or Diving Medical Officer.
Aerospace Medicine: Barotitis
LTC Brian Campbell, MC, USAIntroduction: The middle ear is a bony structure with a fixed volume containing air and water vapor. The
pressure within the middle ear is normally equal to the ambient pressure and equalizes through the Eustachian
tube as ambient pressure changes. Pain results when the pressure cannot be equalized due to malformations
or swelling of the Eustachian tube. This is barotitis media. Barotitis externa can result if a foreign body (e.g.,
ear plug, cerumen plug) blocks the external auditory canal (EAC). Both conditions are more likely to occur with
descent, but a reverse "squeeze" can occur on ascent with similar symptoms. As barotitis may develop during
both diving or flight operations, see Dive Medicine chapter also. Upper respiratory tract infections (URIs) and
untreated seasonal allergic conditions greatly increase the risk of developing an ear "block" during flight.
Smoking may also be a contributory factor.
Subjective: Symptoms
Acute onset of sharp, stabbing pain in the ear on descent is classic. This pain can be quite severe and will
increase in severity with continued descent. Symptoms will abate with return to altitude. In severe cases,
patients will rupture the tympanic membrane (TM), thereby relieving the pressure differential and significantly
reducing the pain. Hearing loss will then result. Vertigo may be associated with barotitis media or with TM
rupture from either condition.
Focused History: When did symptoms start? (Acute onset associated with change in altitude is a key factor
in differentiating from infectious etiology.) Have you had a fever or other signs of illness prior to this flight?
(History of recent illness can illuminate risk factors and/or provide clues to make differential diagnosis.)