Understanding Nosebleeds During Scuba Diving
Before we giant stride entry into understanding nosebleeds during scuba diving, let’s consider the general statistics on nosebleeds (medically termed epistaxis) in adults annually. Approximately 1 in 7 adults (14%) experience a nosebleed annually, with most cases being mild. Of these individuals, around 5% experience recurrent episodes. There are no specific statistics on frequency of nosebleeds while scuba diving. This is likely due to their non-critical nature and not being reported. However, given the increased risk factors, it would not be surprising to observe a higher frequency of nosebleed incidences within scuba divers. In this month’s safety topic, we’ll explore why nosebleeds occur while scuba diving, preventive measures to reduce their likelihood, and practical steps for managing a nosebleed if one occurs during a dive.
Why Nosebleeds Happen While Diving
Nosebleeds can happen for various reasons during scuba diving, two of which overlap with causes seen when still on terra firma.
Digital Trauma (Nose Picking)
This occurs when the nasal lining is damaged through physical irritation. As my Uncle Jack humorously put it: “You can pick your nose, and you can pick your friends—but you shouldn’t pick your friend’s nose.” While amusing, this advice serves as a reminder that keeping your fingers out of your nose helps prevent spontaneous nosebleeds.
Dry Nasal Passages
Dryness in the nasal lining is a frequent issue for scuba divers. For example, air travel to a dive destination can dehydrate nasal mucosa due to prolonged exposure to dry cabin air. Coupled with repetitive diving over several days, these conditions may worsen nasal dryness, leading to nosebleeds.
Sinus Barotrauma
The Diver’s Alert Network (DAN) reports that “Sinus barotraumas are among the most common diving injuries. When the paranasal sinuses fail to equalize to barometric changes during vertical travel, damage to the sinus can cause sharp facial pain with postnasal drip or a nosebleed after surfacing.”1 Pressure equalization within the paranasal sinuses is different than middle-ear equalization. Clearing one’s ears is an active process and divers use various techniques (e.g., Valsalva) to accomplish the goal. The paranasal sinuses clear passively without muscular manipulation2. They are connected to the nasal airways via small openings known as ostia. The ostia can become swollen or blocked due to congestion preventing passive equalization.3, 4
Understanding Sinus Barotrauma
To better understand what is happening in a compromised paranasal sinus cavity during descent, consider what happens when a diver experiences mask squeeze. If the gas in the mask is not equalized during descent by softly exhausting out the nose or performing a mask clear, the gas inside the mask will remain at 1 atmosphere. As the diver descends the surrounding water pressure increases and a negative pressure gradient is established. A vacuum is created inside the mask which can cause the capillary vessels in the eye or skin covered by the mask to burst resulting in discomfort and bruising.
A similar process can happen within the paranasal sinuses (i.e., sinus squeeze). If not able to equalize during descent, a vacuum is established resulting in burst capillaries within the sinuses. Depending on the sinuses involved, this may not result in a nosebleed until the diver ascends. Upon ascent and pressure equalization the sinuses may drain resulting in a bloody discharge or postnasal drip.
Another way sinus barotrauma can manifest is known as a reverse block. In this scenario, the diver may descend without any issues. The paranasal sinuses adjust during descent and equilibrate to the surrounding pressure at depth (e.g., 99 feet (30 meters) or 4 atmospheres). However, during ascent the paranasal sinuses may not allow for pressure equalization due to the same root cause explained above (i.e., blocked ostia). There are two possible outcomes to this scenario depending on the path of least resistance. The high-pressure sinus cavity could force its contents out the nasal cavity manifesting as what has been described as “A sudden explosion of blood and snot into my mask.”5 Alternatively, the sinus with excess pressure can burst into an adjacent sinus that was able to equalize during ascent resulting in a more serious injury.
Prevention of Nosebleeds While Diving
Preventing nosebleeds during scuba diving involves addressing both general health and dive-specific precautions. By combining these preventative steps, divers can minimize their chances of experiencing nosebleeds while underwater. Here are some steps divers can take to minimize the risk:
Stay Hydrated
Maintaining proper hydration before and after dives helps keep nasal passages moist, reducing dryness-related nosebleeds. Plus, staying hydrated benefits overall dive performance and safety.
Nasal Moisturization
To prevent irritation in the nasal lining, consider using Vaseline around the nostrils or saline nasal spray to hydrate tissues. For added protection, a humidifier can be used while at home or in your accommodation to prevent drying out the nasal passages before diving.
Avoid Diving While Congested
Congestion from a cold, allergies, or other causes increases the risk of sinus barotrauma. If you’re congested and having trouble equalizing at the surface, it’s wise to postpone the dive to avoid complications.
Equalize Early and Often
When descending or ascending, remember to equalize frequently. This prevents pressure gradient build-up in the sinuses and reduces the likelihood of sinus barotrauma. Equalization should always feel comfortable; never force it if it becomes painful.
Medications (If Necessary)
Decongestants or antihistamines may help reduce congestion for those prone to sinus issues. However, consult a medical professional before using any medication while diving, and let them know you’ll be diving. A nasal rinse (e.g., neti pot) can also help clear nasal passages in the days leading up to your dive.
Managing a Nosebleed During a Dive
Regardless of training, certification level, or experience, every diver has the right to call off a dive at any time for any reason. Known as “thumbing the dive,” as it describes the hand signal used to communicate ending the dive. If you notice a nosebleed in your mask or your buddy’s, communicate the issue immediately. Remember, no diver should feel pressured to continue a dive. Nosebleeds during a dive can be alarming, but they are often manageable if addressed calmly and with the right steps. Here’s a breakdown of how to handle the situation:
- Signal Your Dive Buddy – Use the appropriate hand signals to indicate that something is wrong. This can be accomplished with a horizontal open hand, palm down, twisting from thumb up to pinky up to signal something is wrong and point to your nose.
- Stay Calm and Assess – Stop non-essential tasks and evaluate the severity of the nosebleed. If middle-ear equalization was achieved and sinus pain and pressure was not observed during descent, the nosebleed could be preliminarily attributed to a dry, irritated mucosa. This often can be managed without immediate ascent.
- Re-assess the Situation – After a few minutes, re-asses the situation and your comfort level with continuing the dive. Take into consideration the dive plan, depth, and task loading. Upon ascent, be it immediately or as planned, maintain safety or decompression stops with the realization that the nosebleed is likely non-critical.
- Post-Dive Care – If the bleeding continues, pinch the nostrils just below the boney ridge of the nose. Apply an ice pack or place a cold beverage to the face. Avoid tilting the head backwards, which can result in swallowing blood. Consider stopping diving for the day and evaluate if taking an antihistamine or decongestant will help with dives in the immediate future.
Sinus Barotrauma-Specific Scenarios
Sinus Squeeze During Descent
When the sinus cavities fail to equalize during descent, negative pressure builds up, causing capillaries to rupture. While the nosebleed may not be immediately visible, the pressure equalizes during ascent, and blood drains from the sinuses, manifesting as a nosebleed or postnasal drip.
Reverse Block During Ascent
This occurs when pressure in the sinuses equalizes during descent but fails to release on ascent. The sinus contents are either forcefully expelled into the mask or redirected into adjacent sinuses, potentially causing greater injury.
Tips for Managing Sinus Barotrauma
- Signal Your Dive Buddy – As described above.
- Ascend slowly – Ascend slower than normal. If the pain is not alleviated, try descending several feet to equalize the pressure gradient and ascend even more slowly (Consider gas supply and decompression limits).
- Post-Dive Care – As described above.
Increased Risk Factors
Medications such as blood thinners (e.g., aspirin, ibuprofen, Warfarin) or certain antidepressants (SSRIs) can increase the risk of bleeding. If you’re taking medications that may prolong bleeding, discuss your diving plans with your healthcare provider to understand the potential risks.
Maintaining Dive Safety and Awareness
In conclusion, diving is an extraordinary and fulfilling adventure, but it also comes with inherent risks, including nosebleeds. Managing such incidents requires calm decision-making, clear communication, and adherence to safety protocols. By understanding the possible causes and taking swift but measured action, divers can minimize risks and maximize their enjoyment of the underwater world.
Key Takeaways:
- Nosebleeds while scuba diving can be caused by dry, irritated nasal passages or from sinus barotrauma.
- Sinus barotrauma is further categorized as sinus squeeze and reverse block (Both types can result in bloody discharge or postnasal drip.)
- Communicate with your dive buddy and assess the situation without panic.
- Understand the signs of sinus barotrauma and respond appropriately during ascent or descent.
- Terminating the dive is dependent on the severity of the nosebleed and comfort level of the affected diver.
- Address health concerns post-dive by seeking professional advice when needed.
Remember, diving should always remain a safe and enjoyable activity. Proper planning, preparation, and education are the best safeguards against the unexpected, ensuring your diving experiences are memorable for all the right reasons.
References
- Diver’s Alert Network, Sinus Barotrauma, https://dan.org/health-medicine/health-resources/diseases-conditions/sinus-barotrauma/ ↩︎
- There are online references to middle-ear equalization also affecting the sinuses and facilitating equalization. ↩︎
- Thomas, Peter (2024, September 04). How can divers avoid nosebleeds? https://www.narkedat90.com/blog/how-can-divers-avoid-nosebleeds ↩︎
- Radia, Jamil (2023, July 17). Sinus Squeeze. https://www.ncbi.nlm.nih.gov/books/NBK500034/ ↩︎
- Rothschild, Michael. Nosebleeds in Scuba Diving. https://xray-mag.com/content/nosebleeds-scuba-diving ↩︎
Prepared by Lee Miller for the Michigan Sea Snoopers (Michigan SeaSnoopers – Dive the Great Lakes and the World)
January 2025
