Eyes puffed-out after dive.

[fredriam]

I started an ascent from 91 FSW on my last of a three-tank dive and experienced a reverse squeeze in my sinuses. (I had no trouble equalizing on descent and no congestion during the dive.) I managed my ascent and a 5-minute SS without experiencing any pain and only slight discomfort. About a 1/2-hour after the dive the area under my eyes puffed out - I mean PUFFED out and felt crackling to the touch; it felt like bubbles to me. I felt no other pain or discomfort. I called DAN and they recommended I see my physician. The puffiness resolved totally, however, within 24 hours and by the time I could get an appt. with my physician, all symptoms were gone. He checked my ears and said I probably had an allergic reaction. I was wondering if over-pressurization of the sinuses could cause such a reaction. Has anyone had a similar experience?

 

[The Iceni]

fredriam once bubbled...
I . . . experienced a reverse squeeze in my sinuses. . . About a 1/2-hour after the dive the area under my eyes puffed out - I mean PUFFED out and felt crackling to the touch; it felt like bubbles to me. . . my physician . . . said I probably had an allergic reaction. I was wondering if over-pressurization of the sinuses could cause such a reaction.

Hi Frediam,

That sounds like it was really frightening and much more like (surgical) emphysema - air under the skin - than any allergy to me.

But where could this air have come from?

I will have to check the anatomy but I am not immediately aware of a direct connection beween the (maxillary) sinuses and subcutaneous tissues - if this air did come from your sinuses.

I think you ought to seek the opinion of a specialist in diving medicine for it to be fully investigated before risking further damage.

I hope you don't think this is alarmist but what you described should not happen.

Have you perhaps had major dental treatment to your upper teeth?

 

[DocVikingo]

Based on the description, "... the area under my eyes puffed out - I mean PUFFED out and felt crackling to the touch; it felt like bubbles to me. I felt no other pain or discomfort. I called DAN and they recommended I see my physician. The puffiness resolved totally, however, within 24 hours and by the time I could get an appt. with my physician, all symptoms were gone," it surely looks more like subcutaneous emphysema (air under the skin) than an allergic reaction.

I suspect that Larry knows facial anatomy rather well. I'm sending this on to him.

Best regards.

DocVikingo

 

[Laurence Stein DDS]

Hi Docs,

I totally agree. There should not be any communication between the periorbital tissues and the sinuses...trying to remember my anatomy.

A dental check-up IS in order. Periodontal abscesses, periapical abscesses, post extraction fistulas all could cause a problem by dissecting externally and upwards between the facial muscles and the infra-orbital border. A sinus fistula could directly penetrate the orbits--just because I haven't heard of it doesn't mean it can't happen.

The crackly feeling is called crepitis and is a sign of air (gas) in the subcutaneous tissues. An old unfinished root canal is open to the air and may get into the tissues. So can a fractured tooth. I have seen subcutaneous air emphysema occur during root canal therapy.

The puzzling part of the description is that the diver indicates both sides. The chance of this being bilateral is between slim and none--unless there are similar problems on both sides.

If the dental check up is negative, then ENT and MRI would be next I believe.

Larry Stein

 

[Lloyd]

The crackling sound was crepitus. We look for that to diagnose blow out fractures of the orbit. You probably blew a hole in the wall of your ethmoid sinus. The walls are paper thin and easily ruptured. If it were me, I would be on antibiotics and possibly get imaging of my sinuses. if it is a ruptered sinus you need to refrain from diving for 6-8 weeks min. An infection in the orbit can spread easily to the brain. This is just an opinion and not a diagnosis and not a Dr. PT. relationship... and other legal disclaimers.
Lloyd

 

[Laurence Stein DDS]

Lloyd,

I agree that something is amiss. For the life of me, I cannot imagine how this would be symmetrical and without other signs or symptoms.

This diver did not report any trauma. Antibiotics and decongestants would be appropriate in the event of a blow out or sub-q emphysema.

Wouldn't this diver be complaining of diplopia with a blow out fracture of this magnitude--this is assuming that the "puffiness" is periorbital. If the swollen tissue and crepitis is superficial, then I would tend to think of a dental cause. But I still can't understand the symmetry--unless the original report is not quite correct.

BTW, are you an Oral, Maxillofacial Surgeon. It would be great to have one on the board for these complex questions.

Regards,

Larry Stein

 

[Lloyd]

Larry,
I agree that the symmetry is puzzling unless both sides were blown. That would be rare but not impossible. It is possible to have a mild blowout without diplopia. You get diplopia in up gaze if the orbital floor is blown out and the inferior rectus is trapped. I would bet on the ethmoid going before the max.. If an infection does not occur, a full recovery would be expected from a ruptured ethmoid.

 

[Laurence Stein DDS]

Good to have you on board. As chief cook and toothwasher, I end up with a lot of these questions.

Keep up the good answers.

Larry Stein

 

[The Iceni]

Lloyd once bubbled...
This is just an opinion and not a diagnosis and not a Dr. PT. relationship... and other legal disclaimers.
Lloyd

Hi Lloyd & Larry,

It's reassuring to learn that I am not the only one who believes this was crepitus. Know about it but never seen it!

I too am confused as to why Fredriam described it as being bilateral. If it was emphysema, it could be the result of a fistula resulting from past trauma, which is why I asked about dental work. A past facial injury from an assault or surgery could have caused one, even bilaterally.

Perhaps Fredriam would kindly let us know how he gets on when he sees the orofacial surgeon.

What's a "PT relationship", Lloyd?

 

[DocVikingo]

(nt)