> Table of Contents > Barotrauma of the Middle Ear, Sinuses, and Lung
Barotrauma of the Middle Ear, Sinuses, and Lung
Stephen L. Cook, MD
J. David Honeycutt, MD, FAAFP, FAWM
image BASICS
DESCRIPTION
  • Barotrauma is tissue damage resulting from the direct effects of pressure changes or imbalances between ambient pressure and pressure within an enclosed body cavity.
  • Body cavities at greatest risk for barotrauma
    • Middle ear (otic barotrauma)
    • Paranasal sinuses (sinus barotrauma)
    • Lungs (pulmonary barotrauma)
  • Dental barotrauma
    • Dental work can create small pockets of air, which can damage teeth in scuba divers or aviators during ambient pressure changes.
  • Synonym(s): dysbarism; aerotitis; otitic barotrauma; middle ear barotrauma; barotitis; barosinusitis
EPIDEMIOLOGY
Incidence
  • Pulmonary barotrauma is second only to drowning as a leading cause of death among divers.
  • Pulmonary barotrauma affects 2-3% of mechanically ventilated patients (1).
  • Otic barotrauma is common in air travel, particularly among flight personnel (2).
Pediatric Considerations
  • Children have difficulty opening the eustachian tube and commonly develop upper respiratory infections. This combination results in higher risk for otic and sinus barotraumas with smaller pressure changes than adults.
  • Mechanical ventilation of neonates is associated with barotrauma and contributes to bronchopulmonary dysplasia.
Pregnancy Considerations
Increased nasal congestion in pregnancy increases the risk of barotitis media (barotrauma of the middle ear).
ETIOLOGY AND PATHOPHYSIOLOGY
  • Boyle law relating volume and pressure of gases applies to all forms of barotrauma. When gas is trapped in a confined space, such as the middle ear, paranasal sinus, or lungs, a sudden decrease in ambient pressure causes expansion of the gas within the cavity.
  • Otalgia (earache) and hearing loss occur as a result of stretching and deformation of the tympanic membrane.
  • Sudden pressure differentials between middle and inner ear may lead to rupture of the round or oval window. This can create a labyrinthine fistula, which consequently can allow leakage of perilymph. Damage to inner ear may be permanent.
  • When the transalveolar pressure disrupts the structural integrity of the alveolus, the alveolar wall can rupture, leading to interstitial emphysema, pneumothorax, or pneumomediastinum.
  • Otic and sinus barotrauma:
    • Associated with rapid or extreme changes in ambient pressure: air travel, mountain climbing, scuba diving
      • Nasal congestion or eustachian tube dysfunction increases risk of damage.
      • Failure of eustachian tube to equilibrate pressure may distort the tympanic membrane, causing discomfort or rupture.
      • Rupture of round or oval membrane may cause inner ear barotrauma, vertigo, and sensorineural hearing loss.
  • Pulmonary barotrauma
    • Iatrogenic complication of mechanical ventilation or hyperbaric oxygen treatment
    • Complication of rapid ascent or descent during scuba diving
RISK FACTORS
  • Otic or sinus
    • Participation in high-risk activities without adequate pressure equilibration
      • Scuba diving, especially with rapid ascent or breath-holding
      • Airplane flight
      • Sky diving
      • High-altitude travel
      • High-impact sports: boxing, soccer, water skiing
    • Upper respiratory infections
    • Nasal congestion or allergic rhinitis
    • Eustachian tube dysfunction
    • Blast exposure
    • The most common complication of hyperbaric oxygen treatment is middle ear barotrauma, which can lead to permanent hearing loss and vertigo.
    • Pregnancy (associated nasal congestion)
    • Anatomic obstruction in the nasopharynx
      • Deviated nasal septum
      • Nasal polyps
      • Congenital anomalies, including cleft palate
    • Previous history of ear trauma
  • Pulmonary
    • Iatrogenic:
      • Mechanical ventilation, especially in the presence of asthma, chronic interstitial lung disease, acute respiratory distress syndrome
      • Hyperbaric oxygen therapy
    • Scuba diving or other underwater activities
    • Air travel with preexisting pulmonary pathology
GENERAL PREVENTION
  • Pulmonary barotrauma
    • Cautious use of mechanical ventilation, employing lung-protective vent settings (lower end-inspiratory airway pressures, lower tidal volumes of 6 mL/kg, higher positive end-expiratory pressures of 6 to 12 cm H2O) (1)[A]
    • Cautious use of hyperbaric oxygen therapy
    • Avoid breath holding during ascent while scuba diving.
  • Otic barotrauma
    • Avoid altitude changes or scuba diving with eustachian tube dysfunction.
    • Treat upper respiratory congestion.
  • Equilibration of pressure: Valsalva maneuver, yawning, swallowing, drinking, or chewing gum
image DIAGNOSIS
PHYSICAL EXAM
  • Otic barotrauma
    • Otoscopic exam: otorrhea, pneumotoscopy
    • Assess balance and hearing.
    • Palpate eustachian tube for tenderness.
  • Otic (middle ear) barotrauma
    • Conductive hearing loss with Weber and Rinne tests
    • Transient facial paralysis
  • All patients with middle ear barotrauma should be evaluated for inner ear barotrauma:
    • Sensorineural hearing loss with Weber and Rinne tests
  • Sinus barotrauma
    • Facial tenderness
  • Pulmonary barotrauma
    • Hypoxia, hypotension
    • Auscultation, percussion
    • Assessment of respiratory distress
DIFFERENTIAL DIAGNOSIS
  • Acute and chronic otitis media
  • Otitis externa
  • Temporomandibular joint syndrome
  • Pulmonary: pulmonary embolism; complications of mechanical ventilation
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Otic or sinus
    • CT to rule out underlying pathology, if suspected
      • Nasopharyngeal tumor (if enlarging facial/neck mass with or without nasal obstruction, recurrent epistaxis)
      • Chronic sinus disease (sinus pain, pressure, fullness, chronic posterior nasal drip/congestion)
  • P.111

  • Pulmonary
    • Chest radiograph
    • Chest CT if unclear diagnosis by CXR
    • Arterial blood gases (ABG)
  • Other: ultrasound
Diagnostic Procedures/Other
  • Otic barotrauma
    • Tympanometry
    • Audiometry: conductive (middle ear) versus sensorineural (inner ear) hearing loss
    • Surgical exploration to rule out inner ear involvement, if suspected
  • Pulmonary barotrauma: chest tube insertion, if clinically indicated, for pneumothorax
Test Interpretation
  • Tympanic membrane (TM) retraction or bulging
    • Teed 0: no visible damage
    • Teed 1: congestion around umbo
    • Teed 2: congestion of entire TM
    • Teed 3: hemorrhage into middle ear
    • Teed 4: extensive middle ear hemorrhage; TM may rupture.
    • Teed 5: entire middle ear filled with deoxygenated blood
  • Inner ear involvement with rupture of the round or oval windows, perilymphatic fistula, and leakage of perilymph into the middle ear
  • Pulmonary barotrauma
    • Alveolar rupture may progress to interstitial emphysema, pneumoperitoneum, and pneumothorax.
  • Petechial hemorrhages in area covered by diver's mask, as well as subconjunctival hemorrhages
image TREATMENT
GENERAL MEASURES
  • Prevention/avoidance is best: Avoid flying or diving when risk factors are present.
  • Autoinflate the eustachian tube during pressure changes (3)[B].
    • Valsalva during ascent and descent in air travel
    • Infants: breastfeeding, pacifier use, or bottle feed
    • ≥4 years: chewing gum
    • ≥8 years: blowing up a balloon
    • Adults: chewing gum, swallowing, or yawning
  • The nasal balloon is effective for prevention (4)[B].
  • Pressure-equalizing earplugs are not recommended in air travel and do not prevent ear barotrauma (5)[B].
  • For inner ear barotrauma
    • Bed rest with head elevated to avoid leakage of perilymph
    • Tympanotomy and repair of round or oval window may be necessary.
    • Sudden or progressive sensorineural hearing loss accompanied by dizziness following barotrauma should prompt consideration of a perilymph fistula. Early surgical exploration is recommended to improve hearing and vestibular symptoms (6)[C].
  • Lung protective settings during mechanical ventilation (1)[A]
    • Acute lung injury: NNT = 16
    • Lung injury: NNT = 11
  • Treatment of pneumothorax
    • Removal of air from pleural space (chest tube; Heimlich valve)
  • Correct iatrogenic cause (e.g., adjustment of mechanical ventilation).
MEDICATION
  • Treat predisposing conditions (e.g., upper respiratory congestion prior to air travel):
    • Oral decongestants
    • Nasal decongestants
    • Antihistamines
  • Antibiotics are not indicated for middle ear effusion secondary to barotrauma.
  • Analgesics for pain control
ISSUES FOR REFERRAL
  • Refer to otolaryngology if inner ear is exposed, perilymphatic fistula is present, or sensorineural hearing loss is experienced.
  • Consult with a hyperbaric specialist if recompression is required.
  • Chest tube placement
SURGERY/OTHER PROCEDURES
  • If necessary, myringotomy or tympanoplasty
  • Tympanotomy and repair of round or oval window may be necessary for inner ear barotrauma.
  • Tube thoracostomy for persistent pneumothorax
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Patients with complicating emergencies (e.g., incapacitating pain requiring myringotomy, large tympanic perforation requiring tympanoplasty)
  • Inner ear barotrauma with hearing loss
  • Management of pneumothorax
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • No flying or diving until complete resolution of all signs and symptoms and Valsalva maneuver succeeds in equalizing pressure
  • Complete bed rest for inner ear barotrauma
  • No high-risk activities or air travel until pneumothorax is completely resolved
Patient Monitoring
  • Repeat physical examination until symptoms are clear.
  • Audiograms and tympanometry if tympanic rupture
PATIENT EDUCATION
  • Demonstrate proper Valsalva maneuver.
  • Appropriately treat sinus infections.
  • American Academy of Pediatrics travel safety tips: https://www.aap.org/en-us/about-the-aap/aappress-room/news-features-and-safety-tips/Pages/travel-safety-tips.aspx.
  • Divers Alert Network of Duke University Medical Center information line: (919) 684-2948
PROGNOSIS
  • Mild barotitis media may resolve spontaneously.
  • Tympanic rupture takes weeks to months for healing.
  • Hearing loss may be permanent in barotitis externa.
  • Prognosis of pulmonary barotrauma depends on the extent of underlying pathology.
REFERENCES
1. Sutherasan Y, Vargas M, Pelosi P. Protective mechanical ventilation in the non-injured lung: review and meta-analysis. Crit Care. 2014;18(2):211.
2. Morgagni F, Autore A, Landolfi A, et al. Predictors of ear barotrauma in aircrews exposed to simulated high altitude. Aviat Space Environ Med. 2012;83(6):594-597.
3. Stangerup SE, Klokker M, Vesterhauge S, et al. Point prevalence of barotitis and its prevention and treatment with nasal balloon inflation: a prospective, controlled study. Otol Neurotol. 2004;25(2):89-94.
4. Landolfi A, Autore A, Torchia F, et al. Ear pain after breathing oxygen at altitude: prevalence and prevention of delayed barotrauma. Aviat Space Environ Med. 2010;81(2):130-132.
5. Klokker M, Vesterhauge S, Jansen EC. Pressure-equalizing earplugs do not prevent barotrauma on descent from 8000 ft cabin altitude. Aviat Space Environ Med. 2005;76(11):1079-1082.
6. Park GY, Byun H, Moon IJ, et al. Effects of early surgical exploration in suspected barotraumatic perilymph fistulas. Clin Exp Otorhinolaryngol. 2012;5(2):74-80.
See Also
Algorithm: Ear Pain
Codes
ICD10
  • T70.0XXA Otitic barotrauma, initial encounter
  • T70.1XXA Sinus barotrauma, initial encounter
  • T70.29XA Other effects of high altitude, initial encounter
Clinical Pearls
  • Small children can equalize eustachian tube pressure by breastfeeding or sucking on bottles or pacifiers. Crying also serves as autoinflation.
  • Pulmonary barotrauma is the second leading cause of death among divers.
  • Otic barotrauma is common in air travel, especially among flight personnel.
  • Pulmonary barotrauma is noted in 2-3% of mechanically ventilated patients.
  • Sudden or progressive sensorineural hearing loss accompanied by dizziness following barotrauma suggests a perilymphatic fistula. Early surgical exploration is recommended to preserve hearing and vestibular functions.