Frontal recess surgery for diving-related frontal pain: Case report.
We report the case of a professional scuba diver who was unable to dive because he began experiencing severe frontal pain on descent. Following endoscopic surgery to open the frontal recess, the man was able to resume diving unrestricted by pain. We discuss the causes and treatment of this complaint, and we suggest that this might be considered a new indication for surgery in a limited number of cases.
The frontal recess is an hourglass-shaped passage between the anterior ethmoid cells and the frontal sinus, with the frontal sinus ostium being its narrowest point. This recess is the ethmoid prechamber of the frontal sinus. Hence, any disease or stenosis in this tiny area can lead to frontal sinus infection. 
With the development of endoscopic sinus surgery, frontal recess surgery has become one of the recognized treatments for unresolved frontal sinusitis.  However, many surgeons advise caution against any unnecessary surgical intervention of the frontal recess during routine endoscopic ethmoidectomy.  Surgery increases the risk of intracranial and orbital complications, and the resultant scarring at the frontal recess might lead to secondary frontal sinusitis or even mucocele formation.  Maran suggested that frontal recess surgery should be reserved for more experienced endoscopic sinus surgeons. 
In this article, we describe the case of a professional diver who underwent frontal recess surgery to relieve severe diving-related pain so that he could continue in his occupation. We hope that this "extended" indication for frontal recess surgery might generate some thought and discussion among otolaryngologists who might see patients who are exposed to "unphysiologic" changes in atmospheric pressure in their working environment.
A white 19-year-old man who was a professional diver came to the ENT clinic in January 1999 complaining of severe frontal headache that occurred during and following each dive. He had no history of nasal or sinus disease and he had no nasal symptoms at normal atmospheric pressure. He was a nonsmoker and his medical history was good except for early childhood asthma. His occupation required that he perform repeated, successive dives of more than 40 meters in depth.
During the previous year, the patient began to notice diving-related frontal headache. It began as a mild headache after the first dive and became more severe after the second dive, which prevented him from performing a third dive. During ascent, he experienced a slight headache as he neared the surface. The pain worsened when he was back on board the boat, and was particularly severe when he bent down. He said the pain spread "all over my head," and was most severe above the orbits and worse on the right side. He had been treated with a steroid nasal spray by his general practitioner without success.
We performed nasal endoscopy at the outpatient clinic and found that the patient's nasal septum was deviated superiorly to the left, but he had no obvious abnormality at the lateral nasal wall. A septoplasty was performed, but the patient's symptoms persisted. Computed tomography (CT) of the sinuses showed a mucosal thickening at the frontal recess on both sides, but the other paranasal sinuses appeared to be normal. CT also demonstrated that the uncinate process inserted into the middle turbinate, and the frontal sinus opened into the infundibulum (figure 1). Because of concern that the patient's job was in jeopardy, he was offered frontal recess surgery.
The operation was performed under general anesthesia. The uncinate process was found to bend laterally at its superior portion and insert into the upper end of the middle turbinate. The frontal sinus ostium on each side was exposed by removing the entire uncinate process, including the uppermost portion, with cutting forceps. Extreme care was taken to not avulse the normal-appearing mucosa at the frontal recess. Bilateral anterior ethmoidectomies were also performed. The nose was packed with a small Merocel pack, which was removed 6 hours after the operation. The patient returned to the clinic 10 days following surgery for postoperative nasal cleaning.
The man resumed diving 6 weeks following surgery and did not experience any frontal headache. Postoperative nasal endoscopy at 6 months revealed that the frontal recesses on each side were wide open and the frontal sinus ostium was clearly identified (figure 2). Nine months postoperatively, the patient was still able to perform four successive dives of up to 40 meters, and to date he remains symptom-free.
Boyle's law states that at a constant temperature, the volume of a gas is inversely proportional to its pressure; therefore, if the pressure of gas doubles, its volume is compressed in half. If a given volume of gas descends 10 meters under water, its pressure increases by 1 atmosphere and its volume decreases by half. If the container holding the gas is sealed and not elastic, there will be a relative difference in the internal and external pressures. When this occurs in an air-filled body cavity, barotrauma results.
The most common initial symptom of barotrauma to the sinuses is pain, which can be severe and tends to worsen with further descent. Pain caused by difficulty in equalizing pressure in any air-filled space--such as the sinuses, ears, and filled teeth--are well recognized in scuba diving. Divers call it a squeeze 
Barotrauma to the paranasal sinuses is the second most common complication of sport scuba diving, behind barotrauma to the middle ear, which is by far the most common.  While the sinus ostia remain patent, pressure changes in the environment and nasal cavities are transmitted to air in the sinuses. If a patient has infected material in the nasal cavity while undergoing an increase in pressure, the infection can be forced into the sinus itself, thereby causing sinusitis. The sinuses can also become obstructed by tissue such as polyps or edematous mucosa as a result of an upper respiratory tract viral infection, allergy, or smoking. Anatomic variations--for example, an ethmoid cell encroaching on the frontal recess--can also obstruct the ostium.  Barotrauma to the sinuses that occurs only on ascent might be caused by a ball-valve effect near the sinus ostia. 
The relative vacuum in the sinuses on descent leads to an engorgement of the blood vessels in the sinus mucosa, mucosal edema, and at its worst bleeding into the sinus. It usually affects the frontal and maxillary sinuses.  A reverse sinus squeeze during ascent is usually caused by obstruction of the ostium by redundant mucosa, cysts, or polyps, which leads to overpressurization of the sinuses. This usually causes only pain rather than epistaxis. If the maxillary sinus is affected, barotrauma can cause numbness in the region that is innervated by the infraorbital nerve. 
Clinical or radiologic examination might reveal the cause of the obstruction. In a study by Fagan et al of 50 divers who had experienced sinus barotrauma, 12 (24%) were found to have either septal deviation, polyps, or abnormal nasal secretions, and 17(34%) reported tenderness over the sinuses on palpation.  Of the 43 patients who underwent plain x-ray imaging in the lateral, posteroanterior, and submentovertical positions within 24 hours, 34 (79%) had abnormalities in the form of fluid levels, opacification, or mucosal thickening seen on radiographs. (This article had been written before CT became available.)
No authors of articles about paranasal sinus barotrauma have proposed surgery as an appropriate treatment. Most suggest conservative management with decongestants, but they do not go as far as to suggest that surgery might be indicated for divers who fail to improve over time. Experience confirms the difficulty of surgical treatment of obstruction of the frontal recess.  The importance of avoiding stenosis of the frontal recess was emphasized by Mosher, who wrote, "Respect the virginity of the nasofrontal duct or take the consequences." 
Current treatment obviously depends on the cause of the obstruction. Management by endoscopic examination, CT, endoscopic surgery, and postoperative endoscopic assessment is now considered to be the appropriate method, but paranasal sinus squeeze is not generally thought of as an indication for surgery.
Frontal recess surgery is regarded by many otolaryngologists as one of the most challenging areas of endoscopic sinus surgery. The operation can be made even more hazardous by excessive intraoperative bleeding in patients who have polypoid or inflamed nasal mucosa. Because our patient had normal nasal and sinus mucosa, we were able to maintain a relatively bloodless field throughout the operation.
The enlargement of the frontal sinus ostium in our patient allowed for the free passage of air into his frontal sinuses, which provided for a rapid equalization of pressure. Our patient has returned to work and has experienced no further episodes of frontal pain.
From the Department of ENT Surgery, Ipswich Hospital, Suffolk, England.
Reprint requests: S.E.M. Jones, Department of ENT Surgery, Addenbrookes Hospital, Hills Rd., Cambridge CB2 2QQ, England. Phone: +44-1223-245-151; fax: +44-1473-703-576; e-mail: email@example.com
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(3.) Maran AG. Endoscopic sinus surgery. Eur Arch Otorhinolaryngol 1994;251:309-18.
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(5.) Neblett LM. Otolaryngology and sport scuba diving. Update and guidelines. Ann Otol Rhinol Laryngol Suppi 1985;115:l-12.
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|Comment:||Frontal recess surgery for diving-related frontal pain: Case report.|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Mar 1, 2001|
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