Maxillary sinuses

[bluebanded goby]

While freediving about a year ago, I noticed a tendency to get blockages of my left frontal sinus which caused very sharp pains around my left eyebrow if I tried to descend more than a few feet. An ENT had my nose scanned, said I had an S-shaped septum which was probably pressing against that sinus opening, and suggested me as a candidate for septoplasty. Around that time the problem miraculously resolved on its own, and I had several months of sinus-problem-free diving.

The last couple of times I've gone out freediving, I've noticed a sharp pain that develops in my teeth on the upper left side when I descend. Since there don't appear to be any issues with the teeth themselves, this seemed to be an issue with the maxillary sinus. I went back to see the ENT who said that on the scans the year before the maxillary sinuses actually looked pretty good. "A septoplasty might help a little by getting more air up there, but I don't think it would directly address a maxillary sinus block," she said. She recommended taking 30 mg of pseudoephedrine a day for _two weeks_ (she was emphatic on this point) before each diving day to try to shrink the sinuses. I shared with her that I don't react all that well to pseudoephedrine, but she suggested that I at least give it a try.

I'll give this a go, but I'm curious about any other self-treatments that people may have found effective for this, or any other treatment approaches that I might explore with the ENT. I'm already taking Allegra daily and regularly run saltwater through my nostrils. I've tried Flonase and large doses of guaifenesin in the past without much beneficial effect. I've also tried Claritin instead of Allegra in the past without any detectable benefit. I've thought of trying Afrin spray on dive days, although I understand the precautions about habituation and rebound. Thanks for any comments.

 

[Hallmac]

You said "freediving" are you talking breath hold freediving? and what equalization technique are you using.

Hallmac

 

[bluebanded goby]

Hi Hallmac,

Yes, I'm talking about relatively shallow (to ~20 ft depth) breathhold diving. I follow the fairly common practice of pinching my nose with one hand as I descend and gently inflating my eustachian tubes/middle ears. I don't have any trouble at all with ear equalization (knock on wood), just the sinuses.

The sinus problems do typically emerge a few freedives into a diving session, and it isn't lost on me that freediving puts more stress on the sinuses than scuba, since there's more up and down.

 

[Hallmac]

I'm Not a Doctor so don't take my comments OVER one. with that said I have a similar pain that occurs after several repeated ascents and decents. I made several trips to my doctor and failed to find the trouble. While at a dental check up I was talking diving to my dentist and he informed me it might be a nerve problem linked to the jaw and teeth and some earlier dental surgery.
I now take a single pain reliever before I start the series. So far so good.

I recommend asking your dentist and ENT since they have a better back ground of your condition.

Hope that helps!

Hallmac

 

[Laurence Stein DDS]

Hi BBG,

The tooth pain you describe is, most likely from the maxillary sinuses. The root ends of upper molar, some bicuspid and rarely, canine teeth may be situated along the border of the maxillary sinuses.

Pressure from the sinuses is transmitted through to the root tips and that in turn stimulates the tooth nerve to respond. You will swear you are having tooth pain. The maxillary sinuses are also innervated by another branch of the same nerve (Trigeminal) that innervates the teeth. So, a referred pain can also occur.

Conversely, dental pain can refer to the sinuses. Checking to make sure the teeth are OK would be helpful.

As a diver who spent every weekend for the first thirty free diving, a couple of points. The more cycles of compression and decompression of the ears and sinuses I experienced the harder it was to clear. I believe the act of clearing "irritated" the mucosal lining...the lining would become engorged with blood and as the day wore on it became more difficult to dive.

It was MY experience that aspirin taken about an hour before diving delayed the swelling and allowed me to dive comfortably for longer. Certainly, if you are allergic to aspirin or have stomach problems or gastric bleeding, aspirin is not recommended. The same is true if you have any bleeding problems or bruise easily.

I do not know of any literature that will bear out my personal experience so this is offered as an "old wive's tale"

Larry Stein

 

[bluebanded goby]

Larry, thanks much for the as always very helpful information. Like you, I do find that the sinuses get progressively trickier in the course of a freediving session. I'm fine with aspirin, so I'll see how that fares with me. Do you take a full analgesic dose (as opposed to, say, the smaller doses often used for blood thinning)?

Also, if I can prevail on you a bit further, I'm still a little unclear on the mechanism of how this flavor of sinus squeeze occurs on descent. I was assuming that if the sinus openings are gummed up, as I descend the afflicted sinus cavity would remain at surface pressure while most nasal passages would go to a higher pressure. How does this translate into pressure that ends up getting to the tooth nerves? Do these nerves pass close to the area around the sinus opening that I assume are stressed during such a pressure imbalance? Thanks again for the help.

 

[Laurence Stein DDS]

BBG,

The aspirin dose is just a normal dose...650 to 1000mg, lots of water.

The paranasal air sinuses are all connected together and drain into the nose. If the opening is blocked then it is possible for all the sinuses on one side to be blocked. Partial blockage if a mass of some sort fills a portion of the sinus. Where air can get by, there in no problem but if the mass seals all or part of the sinus, then there is a problem. Sometimes, the opening will be blocked by the mass and create a "one way valve". When this occurs, air can get in but cannot get out and you would be prone to a reverse squeeze.

The reason sinus pressure can create tooth pain is because of 1) direct stimulation of a nerve that innervates a tooth or 2) referred pain by stimulation of part of the nerve branch that innervates the sinus but also has branches to dental nerves.

The sinuses and teeth are both innervated by the Trigeminal nerve. Some of these branches innervate both teeth and sinus. So it is easy to see why a "toothache" may occur.

Check out this site for a schematic...
http://mywebpages.comcast.net/wnor/lesson9.htm

The sinus squeeze works as follows. When you begin to descend, the sinuses are at sea lever pressure. As you decend, and if the opening to the sinus(s) is blocked, then air will not flow into the sinus to equalize and there is lower pressure within the sinus.

The tissues overlying the sinuses are under ambient pressure as it attempts to force it's way into the sinus--increasing the pressure on the outside of the sinus. To make matters worse, the soft tissues can be assumed to be a fluid so the internal fluid pressure is also at ambient pressure while the pressure within the sinus is lower. Blood and tissue fluid begin to be forced into the empty space...Ouch!

The bone surrounding the sinus acts as a supporting structure holding the space open against the increasing pressure. If you were to dive deep enough, the bone would collapse into the sinus!

Soon, everything is being pressed inward and you are experiencing pain and fullness. If something doesn't change, the blood vessels will burst and bleeding will occur into the sinus. While all this is occuring, the pressure around the teeth in the same area has increased and everything, including the teeth are being pushed into the sinus...making your teeth hurt.

The opposite would occur during a reverse block.

I think the aspirin helps reduce the inflammation caused by the cumulative effects of pressure on the soft tissues.

I also think you have to make a distinction here. Constant clearing over time can result in some inadvertent inflammation...with no underlying pathology. On the other hand, using the aspirin to help "get around" a pathological condition or mask the condition would not be a good idea.

Be careful.

Larry Stein

 

[John Reinertson]

Since you describe two separate sinuses and two different time periods, this is more likely congestion that anatomy.

Many ENT's and allergists (and a lot of family docs) would suggest trying Nasal cortisone sprays (Flonase, nasacort aq, or similar) for up to a week ahead of time, and sudafed the day or two before to help the problem. For people who don't do well with sudafed, the sprays alone often work.

It doesn't cure every case of difficult equalizing, but in my experience it's much more consistently effective than sudafed alone or decongestant sprays alone.

Ask your doc about one of those sprays as an option. Of course you could have a medical condition that makes them not a good choice, but that's pretty rare. Ask your doc or ENT.

John

 

[bluebanded goby]

Thanks for the replies. A couple of additional questions.

To John, re nasal cortisone sprays, I tried Flonase for quite a while last year when I had the frontal sinus problem, and it didn't seem to help. Is Nasacort different enough that it's worth seeking out to try as an alternative? (Or I suppose that since this is a different sinus, different time period, it's worth trying Flonase again?)

To Larry, re aspirin masking symptoms ... one concern that I'd have is that I sometimes combine freediving and scuba on the same day (always freediving first so as not to complicate the scuba deco scenario). If I'm not mistaken, I've heard that aspirin at that dosage level could theoretically mask mild symptoms of DCS?

 

[DocVikingo]

1. (Q) "I tried Flonase for quite a while last year when I had the frontal sinus problem, and it didn't seem to help. Is Nasacort different enough that it's worth seeking out to try as an alternative?"

(A) These are very similar products. Given that a fair trial of Flonase used as directed did not provide relief, it seems unlikely that Nasacort would be effective. Of course, one cannot be certain without a trial.

2. (Q) "Or I suppose that since this is a different sinus, different time period, it's worth trying Flonase again?"

(A) This is not unreasonable & a legitimate topic for discussion with a personal physician

3. (Q) "Re aspirin masking symptoms ... one concern that I'd have is that I sometimes combine freediving and scuba on the same day (always freediving first so as not to complicate the scuba deco scenario). If I'm not mistaken, I've heard that aspirin at that dosage level could theoretically mask mild symptoms of DCS?"

(A) Amounts of aspirin in excess of 650mg taken at one time typically would be considered more than just a normal dose. Most certainly 1000mg would. There's a limit to the amount of pain relief one can get with aspirin, and that threshold appears to be about 650mg.

It is correct that aspirin in sufficient amounts could theoretically mask some of the signs & symptoms of DCS. In addition, it possibly could contribute to bleeding secondary to various types of barotrauma.

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

Best regards.

DocVikingo