Tag Archives: Myth

Sinus Precautions: Another Trauma Urban Legend?

The trauma service typically helps our facial surgery colleagues manage patients from time to time. Every now and again, I see their request/instructions for “sinus precautions” when patients have certain fracture patterns or undergo surgery involving sinuses.  Where did these “precautions” come from? Do they really make sense?

The paranasal sinuses shown above are the most commonly injured after facial trauma. They are lined with mucosa, and like the rest of our body, colonized with bacteria. They are interconnected with each other and the nasal cavity via tiny ostia that allow for normal drainage into the nose. Facial surgeons worry that these bacteria may seep out of fractured areas into clean tissue and cause deep infections. This may occur spontaneously, and could be accelerated if the pressure in the sinuses is increased in any way.

If you do a simple internet search on “sinus precautions”, it seems like every facial surgery group in the country has a set in their patient information sheet. And they all look suspiciously similar. As if they’ve been copied from each other and over, and from the same very, very old document.

As noted above, the main issue to be avoided is increasing pressure across the sinuses. Here’s the usual list of precautions, and my comments on their utility.

  • Avoid blowing your nose. This one actually makes sense. Closing the nose and mouth, pressurizing the pharynx and releasing through the nose will certainly increase sinus pressures. And there are actually reported cases of new onset cellulitis after this maneuver. True
  • Avoid sneezing. Good luck on this one. Who actually does this on purpose anyway? Sneezing will certainly increase sinus pressures, but this can be minimized by avoiding trying to stifle the sneeze. True
  • Do not drink through a straw. What? This causes a low pressure zone in the oropharynx so that fluids can be sipped, but the nasopharynx is isolated. If it weren’t you’d have beverages pouring out of your nose. False
  • Do not smoke. Well, this is certainly a good idea for many reasons, but has little impact on nasopharyngeal pressures. If anything, it decreases them slightly on inhalation, and works the same on exhalation as breathing out without the smoke. False
  • Do not blow musical instruments, balloons, … Yes, this can increase pressures. True
  • Do not push or lift heavy objects.  Hmm. The natural tendency is to perform a Valsalva maneuver (holding breath against a closed glottis) when doing this. In theory, this shouldn’t impact the sinuses because they are not attached to the trachea in any way. And even though it is possible to let some air escape the glottis and keep your mouth closed, it immediately exits the nose. Exhaling through the nose rapidly could increase pressures slightly. Most people don’t do this. Mostly false
  • Do not bend over, keep your head above your heart, sleep with your head slightly elevated. Come on, now. Sinuses are rigid, air-filled cavities. They don’t compress. False
  • Do not fly in a plane.  Definitely an issue. Everybody experiences popping ears and sinuses when flying. And it’s the descent that is of most concern. The increasing air pressure during this phase of flight can push fluid and air out of the sinuses. True
  • Do not spit. Okay, this goes without saying. It’s rude, but doesn’t do a thing to your sinuses. False

Bottom line: I was unable to find any seminal paper or book chapter as the source for “sinus precautions”. Most of the items on the list are bogus. But a few do actually increase sinus pressures and could result in fluid, air, and bacteria moving out of sinuses and into areas where they don’t belong. Pare down the list before you hand it to your patients.

Myth: Motorcycle Helmets and Cervical Spine Injury

The number of motorcyclists has been increasing over the past decade. At the same time, the number of states repealing their helmet laws is increasing. The evidence is convincing that the number and severity of brain injuries is decreased with helmet use. But what about spine injury?

Many arguments against wearing helmets given by riders are derived from a report in 1986 by Goldstein*. One of the issues cited in this paper is the potential increase in cervical spine injuries due to the weight of the helmet. A recently published study using the National Trauma Data Bank (NTDB) corroborates several smaller studies which show that this just isn’t so.

All motorcycle collisions in the NTDB involving adults were analyzed by logistic regression. Missing data was compensated for using standard statistical techniques. Nearly 41,000 cases had complete records for analysis. About 77% of riders were wearing helmets, and the overall mortality was 4%. 

Nonhelmeted riders suffered the following statistically significant differences:

  • A higher proportion of severe head injury (19% vs 9% with helmets)
  • Higher incidence of shock on admission (6% vs 5% with helmets)
  • Higher injury severity score (ISS) (14.7 vs 13.4 with helmets)
  • Higher crude mortality (6.2% vs 3.5% with helmets)
  • Higher incidence of cervical spine injury (5.4% vs 3.5% with helmets)

Bottom line: Motorcyclists wearing helmets had a 22% reduction in the likelihood they would sustain a cervical spine injury in a crash. This is in addition to decreases in shock, injury severity and death. These data need to be considered when the future of helmet laws is considered in any state looking at repealing them.


  • Motorcycle helmets associated with lower risk of cervical spine injury: debunking the myth. J Amer Col Surgeons 212(3):295-300, 2011.
  • *The effect of motorcycle helmet use on the probability of fatality and the severity of head and neck injury. Evaluation Rev 10:355-375, 1986.