Otologic Manifestations of
Barotrauma
David M. Kaylie, MD FACS
Otolaryngology – Head and Neck Surgery
ENT Manifestations of
Barotrauma
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EAC squeeze
Sinus squeeze
Mask squeeze
Middle Ear
Barotrauma
Elastic Cavity
• The pressure of a gas is
inversely proportional to
volume at constant
temperature
• Boyle’s law
P1V1=P2V2
1 atm
surface
2 atm
10 m
4 atm
30 m
Inelastic Cavity
• Constant volume
• Pressure changes
1 atm
surface
33ft
4 atm
30 m
Cavities
Surface
1 atm
3 ATM
Lungs (elastic)
33ft
Bony Cavity (inelastic))
4 atm
132 ft
Changing Pressure
• 33 feet of seawater (fsw)=1 atmosphere
pressure (14.7 psi)
• Balloon (or Lungs) at surface
– If pressure is 3x, volume is 1/3 and density is
3x
– When breathe at depth, gas at higher
pressure than surface
– If hold breath as resurface
• Volume expands and lungs overinflate.
– DON’T HOLD BREATH
External Ear Canal Squeeze
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Hood
Cerumen
Plug
Elderly
Congenital small ear canals
• Swimmers (Surfers) Ear → Exostoses
Exostoses
• Cold water
exposure
• Benign
• Trap cerumen
Osteoma
External Ear Canal Barotrauma
Inside: Hemotympanum and
Hemorrhage of Ear Canal Skin
1 Month: Exfoliation
6 Weeks: Otitis Externa
Treatment of EAC Barotrauma
• Dry ear precautions x 6 weeks (cotton/vas)
• Topical antibiotic/steroid drops (Ciprodex)
• Oral antibiotics if cellulitis
(amox/clav)
• Wick if obstructed
(merocel)
• Analgesia
Barosinusitis
• Descent 68%, Ascent 32% (Fagan 1976)
• Pain
• Nosebleed
Barosinusitis
• Frontal > maxillary > ethmoid
• Blindness and meningitis (Parell and
Becker, 2000)
Treatment of Barosinusitis
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Elevate head
Heat
Oxymetazoline (Afrin)
Pseudoephedrine (Sudafed)
Avoid antihistamine – not beneficial
Antibiotics for secondary bacterial infection
Analgesia
Middle Ear Barotrauma
• Most common medical condition of divers
– Occurs mainly on descent
– Symptoms- pain, conductive hearing loss
– Signs- hemotympanum, perforation
MEBT
• 4 fsw pressure > tensor tympani strength
• 10–69 fsw Dimeric TM rupture
– Keller, 1958
– Jensen, 1993
Normal Ear Canal and TM
Acute Hemotympanum
Resolving Hemotympanum
Perforation
Management of MEBT
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Usually resolves without treatment
Oxymetazoline < 1 wk
Antibiotics in advanced cases
No diving until sx free, normal TM and
able to autoinflate x 3 mo.
Equalizing
General Recommendations
• Avoid diving with URI, allergies
• Avoid medications causing
nasal congestion (turbinate ↑)
• Antihypertensives
• BPH (Hytrin)
• ED (Viagra)
• Descent feet first
• Autoinflate 1-2 ft. No pain is acceptable
Equalizing Techniques
• Swallow, jaw thrust
• pseudoValsalva:
– Alar balloon
• Lowry:
– pValsalva+swallow
• Edmonds:
– pValsalva+jaw thrust
Other Equalizing Techniques
Courtesy Allen Dekelboum, MD
• Toynbee:
– Swallow with mouth and nose closed
– Good for ascent
• Frenzel:
– pValsalva with throat contraction
• Neck twitch:
– Sudden lateral motion with nose closed
Equalizing Middle Ear:
Managing Difficult Cases
• Dry land practice
• Anchor line – helps control decompression
stop in rough water
• Private lesson
• No bouncing
• Medication
Medication for
Eustachian Tube Dysfunction
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Otolaryngology examination
Rarely: Allergy, Septum, CT or MRI
Topical nasal steroid
Afrin 12 hour
• Rebound
• Sudafed 120 mg ER
• Cardiac, High blood pressure, Urinary retention
• Oral corticosteroids (prednisone, medrol)
• Diabetes, Peptic ulcer, GERD, Infection, CNS, +++
TMJ
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25 – 65% of SCUBA divers
Sea Cure
Right Bite
Custom mouth piece
Check hose length
Otolaryngology clearance to
dive
• Normal examination, able to auto inflate
• Diving with ENT disorders
– Meniere’s disease (1 year rule, asymmetrical C°)
– Prior IEBT (hearing loss, vertigo)
– S/P Surgery
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Tympanoplasty
Mastoidectomy
Ossiculoplasty
Stapedotomy
Cochlear Implant
Acoustic Neuroma
ESS
Laryngeal surgery
(C°)
(C°)
(C°)
Meniere’s Disease
• Spontaneous vertigo at depth
• Emphasize risk of aspiration, death
• One year symptom free without treatment
chamber/rescue diver
• Simultaneous (C°)
Dive with perforation/cavity
• Pro Ear 2000
Dive with perforation
Dive with perforation/cavity
• Dry Hood
Diving After Ear Surgery
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Tympanoplasty
PORP
TORP
Cochlear Implant
PLF
Acoustic neuroma
3 months
yes
+/3 atm (device 4 atm)
+/No
Dive after Sinus Surgery
• -6 weeks
• -Healed ostia
Practical Approach to Stings
• Hot water (as tolerated, 110°)
• Ammonia, alcohol, papain, peroxide
• Vibrio vulnificus – gram negative
– Ceftriaxone, Cipro, Septra, Doxycycline
The Dizzy Diver
Differential
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Hangover
Motion sickness
Disembarkment
Diving disorders
Heart
Circulation
CNS, Endocrine
Motion Sickness
• Mechanism: sensory mismatch
(adaptation)
– Yaw (0.2 Hz) vertical linear motion
– Susceptibility: Ages: 2- 10; 40-50
• Non-pharmacologic therapy
– Sea Band
(P6, Nei Kuan point)
• = placebo
• Some studies show it works
MEDICAL TREATMENT OF
MOTION SICKNESS
• Pharmacologic therapy
– Diminhydrinate
(50-100mg)
antihistamine
2hrs
8hrs
(25 mg)
antihistamine
2hrs
6hrs
(25-50mg)
phenothiazine 2hrs
18hr
(0.5 mg)
antimuscarinic 8hrs
anticholinergic
72hr
drowsy
– Meclizine
drowsy
– Promethazine
drowsy
– Scopolamine
drowsy
– D-amphetamine
(5-10mg)
amphetamine 1hr
abuse, palpitation, HBP, arrhythmia, psychosis, insomnia,
euphoria, use in pregnancy, MAOI, hyperthyroid
6hr
Disembarkment Syndrome
(Mal de debarquement)
• Tal (2005)
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Swaying, swinging, unsteadiness after return to land
Symptoms appear after landing
Associated with sea sickness while onboard
No objective measures available
Mostly women
• Hain (1999)
– 26 of 27 women (age = 49.3)
– Duration 3.5 years
– Treatment
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Meclizine
Scopolamine
Vestibular rehab
Benzodiazapines
+
Diving Disorders Causing
Dizziness
•Four categories of IEBT
–During compression
–At Stable Depths
–During decompression
–Noise trauma
Diving Disorders Causing
Dizziness
•Inner ear barotrauma
•Perilymph fistula
•Inner ear DCI
•Alternobaric vertigo
•Gas toxicity
•Isobaric counter-diffusion
INNER EAR BAROTRAUMA
(IEBT)
• Usually with MEBT
• Cochlear 90%, Vestibular 60%, Both 50%
(Molvaer, 1988)
• Mechanism
– Forced inflation on descent
– Sudden equilibration
– TM snaps, pressure wave from stapes to
RWM
Oval and Round Windows
• Sudden insufflation of
middle ear snaps TM
laterally, displacing
stapes laterally and RW
medially.
Incidence of IEBT
• 76 of 15,000 (0.5%) logged dives
– Molvaer (1988)
• 26 of 319 (8%) patients with dive-ENT
disorders
– Klingmann (2006)
Recurrent IEBT
• Israel Naval Medical Institute
– 2 of 44 (5%) of IEBT seen
in 18 years (Shupak, 2006)
Treatment of IEBT
• Bed rest, head elevated
• Control B.P., discontinue aspirin
• Prednisone
• Observe (dial tone, etc.), serial audio
• Explore if strong suspicion of PLF
PERILYMPH FISTULA
MECHANISM: - RWM or OW ligament
- Implosion
- Explosion
Rupture on descent
Symptoms on ascent
gas from ME to IE
(Molvaer, 1988)
Perilymph Fistula
• Increased CSF
pressure without
equilibration = OW
• Sudden forced
insufflation with snap
of TM = OW or RW
PERILYMPH FISTULA
• Pneumolabyrinth
PERILYMPH FISTULA
TREATMENT:
1. Bedrest, head elevated x 5d
2. Explore if SNHL progresses
3. Explore immediately if significant
SNHL occurs with barotrauma
4. Explore vertigo > 5 days (normal MR and neuro)
PERILYMPH FISTULA
Middle ear exploration
• 30 minutes
• Local or G.A.
PERILYMPH FISTULA
INNER EAR
DECOMPRESSION ILLNESS
(IEDCI)
• Any depth, any diver
• More common in decompression
diving
– Dives >130 feet require special gas
mixtures
INNER EAR
DECOMPRESSION ILLNESS
(IEDCI)
• Vertigo (most common), HL, tinnitus
• Type II DCI
– Associated with systemic DCI: spinal cord symptoms,
pain, itching, rash, dyspnea, LOC, death
– Inner ear: bubble formation → hemorrhage
tissue rupture (Antonelli, 1993)
Recurrent IEDCI
• 5 of 24 IEDCI (21%)
• Nachum (2001)
• 2 of 18 IEDCI (11%)
• Klingman (2006)
Management of IEDCI
• HBO, fluids, steroids, n-acetyl cysteine
– HBO within 1 hr → 50% complete resolution
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5 hr → 10%
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10 hr → 22%
• Do not dive for 3 months
(Nachum, 2001)
(Shupak, 2003)
(Klingmann, 2006)
(Molvaer, 2003)
– Do not dive if SNHL, RVR persist?
• Recompression with fistula safe
– Guinea pigs
– Human experience
– Tubes
(Stevens, 1991)
(Dekelboum 2005; Klingmann 2004)
Right to Left Shunt (PFO)
• R/O PFO in patients with DCI
– Right to left shunt in IEDCI 82%
• in controls 25%
(Cantais, 2003; Klingmann, 2006)
– German Diving Medical Society—’Unfit to
Dive’
ALTERNOBARIC VERTIGO
• Asymmetric ME pressure
Onset during ascent
Duration up to 20 minutes
(Lundgren, 1965)
• Human study: 20 mm Hg asym→NYS
(Henrickson, 1966)
Incidence of Alternobaric Vertigo
• 10% of Swedish divers
(Lundgren, 1974)
• 33% of Norwegian divers (n = 194)
(Molvaer, 1988)
• 14% sport divers (OME or ET)
(Uzun, 2003)
ASYMMETRIC CALORIC
STIMULATION
• Stimulus:
– Unilateral EAC obstruction
(cerumen, plug, hood, squeeze)
– ME/Mastoid asymmetry
(bone, OME, squeeze)
• Response:
– Compensated RVR
GAS TOXICITY
• Nitrogen narcosis (rapture)
Dizziness, hallucination
>100 feet
• O² toxicity: Seizure, death
VENTID (vision, ears, nausea,
twitching, irritaion, death
C0², CO contamination
COUNTERDIFFUSION
• Physiologic effect of diffusion of different
gases in opposite directions under
constant ambient pressure
• Two gases with different diffusion and
solubility coefficients
– Rapidly diffusing gas moves into tissues
– More soluble gas diffuses slower
• Local supersaturation and bubbles
• Occurs at perilymph/endolymph boundaries
• Skin lesions and vertigo most common
Counterdiffusion
• Occurs in divers
– Immersed in lighter rapidly diffusing gas
(helium)
– Breathes slower gas (neon or nitrogen)
• Prevent by
– Recompressing when switching from N to He
rich mixes (other way around ok)
– Avoiding helium rich gases for breathing when
surrounded by nitrogen rich gases
DIFFERENTIAL DIAGNOSIS
DIAGNOSIS
IEBT
Fistula
IEDCI
Asymmetric caloric
Alternobaric vertigo
Gas toxicity
Counter diffusion
Hearing loss
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Onset
Descent
D/A
Ascent
Descent
Ascent
Stable
Stable