Scuba Diving Nosebleeds – What are “Mask Squeeze” and “Sinus Squeeze”?

Having a nosebleed while scuba diving is not an uncommon experience – especially with novice divers. The sight of blood in a dive mask may look terrifying, but divers should know that nosebleeds are mostly not a severe problem as long as they spontaneously stop. Blood from the nose is often mixed with mucus and tears, so the amount of blood loss is usually less than it seems (normally less than a tablespoon)!

Nosebleeds are experienced more often with novice divers than with experienced divers simply because of the way a new diver performs Valsalva maneuver as he/she descends. So – for those who do not know – what is Valsalva maneuver? The Valsalva maneuver is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth or pinching one's nose shut while pressing out as if blowing up a balloon. In diving, the Valsalva maneuver is often used on descent to equalize the pressure in the middle ear and sinuses to the ambient pressure.

Nice Youtube video explaining Valsava maneuver.

Barotrauma that is produced by inadequate performance of the Valsalva maneuver is commonly called mask squeeze. Briefly, mask squeeze results from not equalizing the pressure in the mast to match the water pressure, which creates a vacuum in the mask. This vacuum can directly transfer to the nasal passages. In a mucosa near the front of the nasal septum (1 cm away from nostrils) four nasal arteries connect together and form very fragile network of vessels. Affected by the vacuum, those very small and weak blood vessels can rupture and cause the nosebleed. Doing a slow descent while frequently performing the Valsalva maneuver can easily prevent the mask squeeze and nosebleeds. Mask squeeze is usually not accompanied by pain. Most of these nosebleeds will stop immediately as diver comes out of the water and do not need an emergency room visit or medical advice. 

The second (and usually more painful!) cause of scuba diving nosebleeds is due to what is known as a sinus squeeze, caused by a cold/allergy-associated blockage of the sinus openings. Sinus squeeze - also known as sinus barotrauma - occurs when a diver cannot equalize sinus pressure due to nasal congestion. In the case of blocked nose, there is almost always associated blockage of the sinus openings, and there is no gas flow between the nose and sinuses. The bony structure will not collapse under the pressure changes, but the lower pressure in the blocked sinus will draw blood into it. Blood vessels in sinuses will swell and leak. In more severe cases the squeeze results in a blood-filled sinus, which will drain during ascent when the air in the sinus expands. Sinus squeeze can be recognized as pressure or pain in the forehead or around the teeth, cheeks, or eyes. Sometimes – but not always – the nosebleed may occur. Pressure and pain regularly increase with depth.

The most common reasons for nasal congestion and sinus squeeze are colds and allergies, and they should be treated by proper medications. In a case of a sinus squeeze – until the congestion and sinus problems heal – divers should not be diving!

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Dr. Sasa Janjanin is double European Board-certified in ENT and Facial Plastic Surgery. Besides being experienced surgeon and proficient in curing problems related to thyroid gland; facial cosmetic procedures; nose, sinus and snoring complaints; and kids’ ENT problems, Dr. Janjanin’s particular expertise is in sport and diving-related ENT problems – acting many years as an ENT consultant for several professional and national sport teams and athletes, some of them Olympic medal and European championship winners.  

Fine needle aspiration biopsy of the thyroid

About 5 to 10 percent of adults may have palpable lump in their thyroid. This means that it can be felt with the fingers during a physical or self-examination. However, ultrasound imaging is much more sensitive than a pure palpation and able to discover many smaller nodules that cannot be felt with the fingers. With the use of ultrasound, in certain age groups (especially in adult women - thyroid nodularity is much more common in women that in men!) nodules can be found in as much as 40-50 percent of cases! Fortunately, majority of such nodules are benign.

If one or more nodules are detected on ultrasound within the thyroid gland, we will examine the features of these nodules – shape, vascularity, calcifications, diameter, and density in comparison to surrounding normal thyroid tissue. Some features are strongly suggestive that a nodule is benign in nature, and some raise concern that the nodule may be a cancer. In some cases it is impossible to distinguish between benign and malignant nodules with complete certainty. A fine needle aspiration biopsy and review of tissue under a microscope may be recommended for further evaluation, but sometimes a repeat sonogram after a few months looking for stability may be sufficient.

A fine needle aspiration biopsy is technically quite simple and many patients describe it less painful than a common blood draw from a vein. In almost all cases, an ultrasound is used to help guide the biopsy.

Patient requires almost no preparation. There is no need to fast or to withhold medications. Occasionally a patient may be asked not to take blood-thinning medication on the day of the biopsy. As there is very little discomfort during the procedure we do not recommend the use a local anesthetic. Since the needle used for fine needle aspiration biopsy is very fine, anesthesia will simply result in another unnecessary poke. If you are particularly concerned and nervous, we can apply topical anesthetic preparation, which takes 10 to 20 minutes to work. Again, most patients undergoing fine needle aspiration biopsy forego the use of any anesthetic and do very well.

Most patients do not have any problems after fine needle aspiration biopsy. There may be some discomfort in the area for a few hours after, which is usually relieved with regular painkiller. Some patients like to put an ice pack over the area when they get home, but most do well without such measures. Potential risks of fine needle aspiration biopsy of the thyroid include minor bleeding and cyst formation, but these complications are exceedingly rare. If procedure is done by experienced thyroid (head and neck) surgeon who is trained in more complicated thyroid procedures (like total thyroid surgery), any potential complication of the fine needle aspiration biopsy can be easily managed!

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Sasa Janjanin M.D., Ph.D. is double European Board-certified in ENT and Facial Plastic Surgery. He extensively trained in complete surgical and medical treatment of patients with disorders and diseases of the head and neck. However, his major expertise is in facial plastic, aesthetic and reconstructive surgery; problems related to thyroid and parathyroid glands; skin cancer; kid’s ENT problems; nose, sinus and snoring complaints; and sport and diving-related ENT problems.