Barosinusitis in pressure-exposed populations: a systematic review and meta-analysis of clinical features, risk factors, and management

BACKGROUND: Barosinusitis is a pressure-related sinonasal disorder resulting from impaired sinus ventilation during ambient pressure changes. It is most frequently encountered in aviation and diving environments but is increasingly relevant in military and hyperbaric settings. Although often clinically misclassified as inflammatory rhinosinusitis, barosinusitis represents a distinct pathophysiological entity primarily driven by mechanical pressure gradients and sinus ventilation dynamics. The aim of this article is to systematically review and quantitatively synthesize the available evidence on barosinusitis, focusing on clinical presentation, risk factors, imaging findings, and management strategies in pressure-exposed populations.METHODS: A systematic literature search was conducted in accordance with the PRISMA 2020 guidelines. Observational and case-control studies reporting extractable clinical data on barosinusitis were eligible for inclusion. Study selection, data extraction, and risk-of-bias assessment were performed using design-appropriate methodological tools. When sufficient homogeneous data were available, quantitative synthesis was conducted using random-effects models.RESULTS: Sixty-three publications were included in the qualitative synthesis, among which thirty-seven represented primary clinical investigations. Although six studies were included in the quantitative synthesis, only three provided directly comparable prevalence estimates suitable for pooled meta-analysis. The remaining studies contributed to the qualitative synthesis of risk factors, imaging findings, and clinical characteristics. Meta-analysis suggested a measurable prevalence of barosinusitis in pressure-exposed populations and identified prior sinonasal disease, recurrent pressure exposure, and rapid pressure-transition kinetics as significant risk factors. Substantial statistical heterogeneity was observed, likely reflecting variability in exposure environments, study populations, and diagnostic definitions across studies.CONCLUSIONS: Barosinusitis represents a pressure-induced sinonasal injury that is pathophysiologically distinct from inflammatory rhinosinusitis. Both individual susceptibility and characteristics of pressure exposure contribute to the clinical manifestation of barosinusitis. A broader biomechanical framework may help explain variability in disease severity across aviation, diving, and military environments. Standardized diagnostic criteria and prospective exposure-stratified studies are needed to improve risk assessment and guide optimal management.