Recurrent sinus squeeze - nasal spray + antihistamine to shrink polyps?

[anchochile]

I consistently have trouble equalizing my right sinus on descent. I have to descend very slowly, though usually I am able to eventually clear it (with fairly forceful blowing with pinched nose). Occasionally the sinus won’t clear and i have to abort the dive. A couple times I’ve surfaced with blood in my mask. Mucinex before diving doesn’t help much.

Based on advice from DAN and this forum, I saw my primary care provider and asked for a referral to an ENT so I could be evaluated for polyps or other obstructions.

She said that she would recommend first that I do a 6-week regimen of steroid nasal spray (Flonase) and antihistamine (loratadine or cetirizine). She said this can often shrink any polyps down, and it’s likely what an ENT would recommend I try anyhow before resorting to surgery or other options.

Curious if others have been down this path before. I’m happy to try the drugs first, but I want to make sure it’s worth the time and effort. Does this sound like a reasonable approach?

 

[rsingler]

Paging @doctormike...

 

[doctormike]

If you have localized pain in your "sinus" (I'm assuming that you mean the area under your eye on one side?) on descent, then there is a good chance that there is some chronic inflammatory disease causing thickening of the lining of the drainage pathway of that maxillary sinus. This can interfere with equalization. It is possible that nasal steroids alone could help shrink some of this polypoid mucosa, although if there is really significant obstruction within the sinus cavity, that's less likely to help.

I don't like using antihistamines for sinusitis, they are more for allergies, and they can work against your natural host defenses. Things like nasal irrigation (neti-pot) can help, and there are various indications for oral steroids or antibiotics, depending on the details of the case.

I guess you could try the nasal steroids, but if you mainly have symptoms on descent, you might not be able to tell if it was working without going diving again. The bottom line is that for something localized like that which is persistent, you probably will need a CT scan of the sinuses at some point, and possibly some sort of procedure to open the sinus drainage pathways. That's the only way to really diagnose this problem...

Good luck, and dive safe!

 

[anchochile]

Thanks very much for the detailed reply. Some comments below.

If you have localized pain in your "sinus" (I'm assuming that you mean the area under your eye on one side?) on descent, then there is a good chance that there is some chronic inflammatory disease causing thickening of the lining of the drainage pathway of that maxillary sinus.

Actually, the pain is above my eye, not below, in the area of my right forehead. Would that still be considered the sinus, or is their a different gas pocket up there?

It often (but not always) occurs on descent, and never on ascent. Repetitive dives on the same day or consecutive days seem to make it worse and more difficult to clear. When it starts, I usually ascend a few feet and try to equalize by pinching my nose and blowing. Sometimes it takes more forceful blowing than usual to get it to equalize (when it finally equalizes, I hear a little squeak/hiss sound coming from that area).

Would that change any of your advice?

 

[doctormike]

Thanks very much for the detailed reply. Some comments below.



Actually, the pain is above my eye, not below, in the area of my right forehead. Would that still be considered the sinus, or is their a different gas pocket up there?

Yup, frontal sinus. My son has exactly that, a polyp in the frontal sinus on CT scan, causing him pain on descent due to problems equalizing. He actually stopped diving because of that - wasn't really that interested in scuba anyway, and I think that he was glad to have an excuse to quit!

It often (but not always) occurs on descent, and never on ascent. Repetitive dives on the same day or consecutive days seem to make it worse and more difficult to clear. When it starts, I usually ascend a few feet and try to equalize by pinching my nose and blowing. Sometimes it takes more forceful blowing than usual to get it to equalize (when it finally equalizes, I hear a little squeak/hiss sound coming from that area).

Would that change any of your advice?

Nope, sounds very typical for sinus squeeze. It's possible to get a reverse squeeze (on ascent), but much less common.

 

[anchochile]

Yup, frontal sinus. My son has exactly that, a polyp in the frontal sinus on CT scan, causing him pain on descent due to problems equalizing. He actually stopped diving because of that - wasn't really that interested in scuba anyway, and I think that he was glad to have an excuse to quit!

Oh, no way am I quitting over a little sinus problem!

So, would a reasonable summary of your recommendation (understanding that you are not my doctor, of course) be:

• Skip the antihistamine
• The nasal steroid might help, and could be worth trying, but if you were me, you'd go straight to the ENT for a CT scan instead

I guess it feels a bit uncomfortable to tell my doctor I'd like to take a different course of action than what she recommended (she said if she sent me to an ENT now, they'd just say to try the nasal spray first and then come back if it doesn't work). But I also don't want to waste my time, and I do have some dive trips planned in August and again in October so it would be great to have this addressed one way or another beforehand.

On a side note, I'm a Kaiser member and thus limited to seeing Kaiser doctors, and haven't been able to identify any in my area with training in hyperbaric or diving medicine. Not sure whether that would make a difference.

 

[IncreaseMyT]

Can I ask is the pain pretty severe? On your forehead? This is happening to my son, never happened to him before. Mainly on ascent. Sounds like a round of flonase is in order but if that doesn't help its time to see the doctor.

My son is devastated, he never has any issues.

 

[doctormike]

Oh, no way am I quitting over a little sinus problem!

OK, I need to have you talk to my son...

So, would a reasonable summary of your recommendation (understanding that you are not my doctor, of course) be:

• Skip the antihistamine
• The nasal steroid might help, and could be worth trying, but if you were me, you'd go straight to the ENT for a CT scan instead

I guess it feels a bit uncomfortable to tell my doctor I'd like to take a different course of action than what she recommended (she said if she sent me to an ENT now, they'd just say to try the nasal spray first and then come back if it doesn't work). But I also don't want to waste my time, and I do have some dive trips planned in August and again in October so it would be great to have this addressed one way or another beforehand.

On a side note, I'm a Kaiser member and thus limited to seeing Kaiser doctors, and haven't been able to identify any in my area with training in hyperbaric or diving medicine. Not sure whether that would make a difference.

I mean, I obviously can't diagnose or make recommendations for care online, but it sure sounds typical for chronic frontal sinusitis when it's that localized, reproducible with descent, and one sided. I don't know what the deal is with your relationship with your primary care doc or your insurance company, but maybe follow your doc's advice for a month, then try diving to the bottom of a swimming pool, and if you have the same problem, just ask for a CT and/or an ENT referral. That way, at least you might be done with everything by August.

You don't need a hyperbaric doc for this. You just need an ENT doc. Hopefully one for whom you don't have to explain how equalization works!

 

[anchochile]

I mean, I obviously can't diagnose or make recommendations for care online, but it sure sounds typical for chronic frontal sinusitis when it's that localized, reproducible with descent, and one sided. I don't know what the deal is with your relationship with your primary care doc or your insurance company, but maybe follow your doc's advice for a month, then try diving to the bottom of a swimming pool, and if you have the same problem, just ask for a CT and/or an ENT referral. That way, at least you might be done with everything by August.

This sounds very reasonable and very achievable. And I don't need a swimming pool when Monterey's two hours away. I was planning on making a day trip for diving in mid-May anyway, so that'll probably be a good time to test things out, conditions permitting.

Thanks for the advice and fingers crossed for clear and open sinuses a month from now.

 

[doctormike]

This sounds very reasonable and very achievable. And I don't need a swimming pool when Monterey's two hours away. I was planning on making a day trip for diving in mid-May anyway, so that'll probably be a good time to test things out, conditions permitting.

Thanks for the advice and fingers crossed for clear and open sinuses a month from now.

Yup! And I know that I'm not supposed to recommend anything online, but the NetiPot is one of the few things in medicine that is safe, cheap and works. Cleans out the crusts, and the salt promotes nasal drainage by acting as an osmotic decongestant. Just use sterile water!