Sinus Inflammation

I was not going to miss a glass-off in Northern California just because I couldn’t clear my ears the night before – or the morning of. Sudafed and visions of large, toothy, holed up Lingcod helped me push past stuffy sinuses; until I came up from a dive with my mask filled with blood.

The purpose of this article is: (1) To give you confidence in the anatomy, so that when your face or ears feel like they are going to explode, you know exactly what is going on. (2) Short-term patches and long-term remedies to get through sinus inflammation, as well as the risks.

*If you experience a fever with sinus or ear pain, don’t dive, go see a doctor.

Circles represent openings to each sinus.

There are 5 chambers in each side of your face, 4 sinuses and 1 middle ear cavity. Like grapes on a stalk, they all connect to a central nasal cavity and nasopharynx via millimeter wide canals. Everything is lined with a secretory mucosa. When inflamed and filled with mucus, these canals plug easily – making your sinuses air-tight compartments. The sensitivity of the sinus is critical, as it triggers the front-line immune response to allergens, bacteria, and bat viruses.

Let’s enter the nose as though we were entering a lobster cave, straight back through someone’s right nostril.  On the middle side there is a vertical, cartilaginous-bony nasal septum. Looking towards the ear, we see three stacked shelves (concha), pictured above. Between each concha we observe a hole (ostium), an opening for the canal to each sinus. You can illuminate each sinus by putting a flashlight in your mouth in a dark room.

Circles are ostium under each concha. These dots  connect as canals to the dots in Figure 1. Ethmoid sinus is in front of the page and maxillary sinus is behind the page.

 In a study of active-surfers versus surfers-who-stopped-surfing, if you spend time in the ocean, you are more likely to get a sinus infection, ear pain, diarrhea, gastrointestinal infection, and infection to an open wound. This rate increased following wet weather. Interestingly, the rate of fevers decreases significantly in those who spend time in the ocean (Arnold et al., 2017).

Sinus inflammation can happen because (1) bacteria inside the sinus (2) clogged sinus canal (3) nasal polyps (4) immunosuppressants (5) pro-inflammatory diet including dairy, tomatoes, red meat, and refined sugars (6) dry climates (dry sinuses are twice as likely to attract bacteria – hydrogen peroxide is risky) (7) history of asthma and allergies.

With sinus inflammation, you may experience: Runny nose, heat, pressure, pain in the face, tooth ache to the back or upper teeth, failure to clear ears, low energy, fever, and pus from nose. In the water - tightness in your face, bloody nose, and maybe damage to the nerves in your nose (ant. ethmoidal) that trigger your mammalian dive reflex (McCulloch & DiNovo, 2018).

The ginger ninja, Eryk Slupski after aborting a dive due to sinus squeeze.

Sinus Squeeze

When you duck dive and kick to the bottom, increased pressure causes sinus mucosa to be pulled inward. During inflammation you can’t vent the pressure, so vessels in the sinuses tear and blood can drain out of the nose. In an upright position, drainage of frontal, ethmoid, and sphenoid sinuses are aided by gravity, as their openings are at the bottom of the chamber. The maxillary sinus has its opening on top. You may need to invert yourself to drain the maxillary sinus. If the blood doesn’t drain, the pain will be far worse.

Reverse Sinus Block

Your sinuses should vent passively during ascent. If your Sudafed wore off mid-dive and your sinus canals close at depth you can get into trouble. Positive pressure builds in a closed sinus and the bony walls can burst into another well vented sinus, including the middle ear cavity. If everything goes well, you will feel sharp pain on ascent and definitely a bloody nose. Alternatively, you can have defacement of the mucosa from underlying bone which can lead to long term scarring. Alternatively, you can rupture an eardrum followed by such an intense vertigo and nausea you may not know which way is up. You may also vomit mid breath hold which is fatal. 

Plugged Ears 

The eustachian tube connects the middle ear cavity to the nasopharynx. The Valsalva maneuver creates pressure in pharynx to open these tubes. The Tensor Veli Palatini muscle opens it as well. When this canal swells shut and you dive, negative pressure pulls the tympanic membrane inward, like a plastic bag over a busted car window. Pushing this too far and it may rupture, allowing communication to the precious middle ear cavity. Irritation to the small internal structures can occur by repeatedly pushing your limits. Infection in the middle ear cavity is otitis media and the eardrum will bulge outwards. An unresolved middle ear infection can cause mastoiditis and serious harm. 

Lifestyle Modifications

Despite the pain with sinus inflammation, a full blown sinus infection (sinusitis) is rare, and before antibiotics, it is probably better to try at home remedies – especially if you want to dive. 

Eat well. Fruits, vegetables, fish, nuts, chocolate. Avoid pro-inflammatory foods mentioned earlier. Keep your nasal canals clean of the ocean’s microorganisms. Rinse your face, eyes, ears, and nostrils with fresh water. Over the sink, snort some warm slightly salted water and blow it out – don’t choke. Use a Neti-pot for high volume low pressure. The Neti-pot is especially helpful if you mix in 1-2 drops of J&J baby shampoo as it releases the mucus from the walls of your sinus. Lay a hot compress on your face.

You Sinuses are Clogged but you Want to Dive

A 30mg tablet of pseudoephedrine (Sudafed) works wonders if you have an opportunity at the fish of a lifetime - but has serious disadvantages. There are 3 issues with pseudoephedrine (1) It rapidly decreases in effectiveness with continual use. (2) It increases your heart rate and shortens your breath hold. (3) It puts you at risk for reverse sinus block. If you are allergic to Sudafed, alternatives are, 4mg of chlorphenamine, or oxymetazoline hydrochloride (Afrin). Afrin nasal spray is handy because by pinching your nose shut and blowing hard 5 times, you can get it into your eustachian tubes which will relieve your ears. The most recommended drug to use however, is Guaifenesin (Mucinex). It thins out your mucus and makes equalization much easier, but you must use it 2-3 days in advance and stay hydrated.

If you do not experience relief with these techniques there may be something more at play, commonly, nasal polyps or an infection. In these circumstances it is best to stay out of the water and consult a physician.