Barotitis Media

By admin Last updated Nov 26, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Barotitis Media

Carter W. Muench

Rob Johnson

Basics

Injury to the body as a result of the expansion and contraction of gas in an enclosed space
Boyle's law states that at a constant temperature, pressure (P) is inversely related to volume (V):
- PV = K (constant) or P₁V₁ = P₂V₂.
- Increase in pressure mandates a reduction in volume by same factor.
Gas-filled cavities in the body are subject to expansion/contraction:
- Lung
- Middle ear
- Sinus
Solid and liquid-filled spaces distribute the pressure equally.
Volume changes experienced during diving are greatest in the few feet nearest the surface.

Alert

For barotrauma of descent, unless an air-filled cavity has ruptured, no progression of the disease on return to normal atmospheric pressure expected.
If patient transport requires air evacuation, maintain air cabin pressure at 1 atm or fly below 1,000 ft to avoid aggravating barotrauma.

General Prevention

Avoid diving with upper respiratory infection, which may not allow for equalization of pressures across the tympanic membrane because of eustachian tube blockage.
Predive medical examination can help to identify individuals at increased risk for barotrauma.
Taking pseudoephedrine 60 mg PO 30 min prior to diving was shown to decrease the incidence and severity of middle ear barotrauma.

Etiology

Middle ear:
- Barotrauma of descent
- Most common type of barotrauma
- Seen in 30% of inexperienced divers and 10% of experienced divers
- Results from inadequate equalization of pressure between the middle ear and the external ear canal
- Eustachian tube provides the sole route of pressure equalization for the middle ear.
- Upper respiratory infections may cause blockage or dysfunction of the eustachian tube.
External ear:
- Barotrauma of descent
- Due to the presence of a tight-fitting hood, ear plugs, or a cerumen plug
- Pressure cannot equalize throughout the canal, and a relative intracanal vacuum is created as the pressure differential across the obstruction increases.
Inner ear:
- Barotrauma of descent
- Results from forceful attempts at equalizing middle ear pressure
- Increased middle ear pressure can raise intracranial pressure and cause rupture of the round or labyrinth windows, allowing perilymph to enter the middle ear.
Paranasal sinus:
- Barotrauma of descent
- Nasal ostia act as a valve to regulate sinus pressure.
- If the ostia fail to allow pressure equalization, congestion, edema, and hemorrhage can occur.
External objects: Air pockets in dive suit/mask expand and contract.
Teeth: Air trapped inside a filling
GI:
- Barotrauma of ascent
- Swallowed air in the GI tract expands as external pressure decreases.
Pulmonary barotrauma [PBT or pulmonary overpressurization syndrome (POPS)]:
- Occurs with ascent
- Lungs expand against a closed glottis.
- Cause for arterial gas embolism
- Divers with decrease lung compliance/increased lung volumes at increased risk [chronic obstructive pulmonary disease (COPD), asthma]
- Taking a breath from a SCUBA tank at a shallow depth and surfacing without exhaling is enough to cause pulmonary barotrauma.

Diagnosis

Essential Workup

HEENT exam with particular attention paid to the tympanic membrane to determine if rupture has occurred
Pulmonary exam looking for signs of SC emphysema and pneumothorax
Neurologic exam looking for signs of inner ear pathology or arterial gas embolism

Physical Exam

Signs and symptoms:

Middle ear (barotitis media):
- Begins as a clogged sensation
- Increasingly painful as the pressure differential across the tympanic membrane (TM) increases
- Associated symptoms include nausea, vertigo, tinnitus, conductive hearing loss, and occasionally, facial nerve palsy.
- Progresses to rupture of the TM: Appearance: TM congestion → TM edema → gross hemorrhage → TM rupture
External ear: Canal mucosa becomes edematous, then hemorrhagic, and ultimately may tear.
Inner ear:
- Sudden, severe vertigo
- Tinnitus
- Sensorineural hearing loss in the affected ear
- Symptoms begin or are associated with forceful attempt to equalize pressures of middle ear during descent.
- Normal external canal and TM exam with isolated inner ear barotrauma
Paranasal sinuses:
- Sinus congestion
- Pain
- Epistaxis

P.47

External objects:
- Mask: Conjunctival hemorrhage, facial edema, and swelling
- Tight-fitting dive suit: Edema and erythema of the skin
Teeth (barodontalgia): Severe tooth pain
GI (aerogastralgia):
- Excessive belching
- Flatulence
- Abdominal distension
Pulmonary:
- Dyspnea
- Chest pain
- Cough with a frothy red sputum
- SC emphysema of the neck and chest
- Delayed symptoms including a bull neck appearance, dysphagia, and changes in voice character

Diagnostic Tests & Interpretation

Sinus imaging:
- CT scan
- Plain films
Chest X-ray for pneumothorax and pneumomediastinum
Abdominal series (upright, decubitus) for free air from a ruptured viscus

Lab

Arterial blood gas determinations for pulmonary symptoms

Differential Diagnosis

Decompression sickness
Otitis media
Otitis externa
Sinusitis
Arterial gas embolism

Treatment

Hospital admission criterion: Pulmonary barotrauma

ED Treatment

Establish IV access for unstable patients.
Control bleeding from the ear or nose.
Oral decongestants for middle ear or sinus congestion
Antibiotics with TM or sinus rupture
Analgesics
Consult Divers Alert Network (DAN): 1–919–684–4DAN (4326).

Medication

Amoxicillin 250–500 mg (children: 40 mg/kg/24 hr) PO t.i.d.
Bactrim DS 1 tablet (children: 40/200 per 5 mL-5 mL/10 kg/dose) PO b.i.d.
Pseudoephedrine (Sudafed) 60 mg (children: 6–12 yrs of age, 30 mg; 2–5 yrs of age, 15 mg/dose) PO q4–6h

In-Patient Considerations

Initial Stabilization

Airway, breathing, and circulation (ABCs):

100% oxygen for ill-appearing patients
Intubation in patients with massive SC emphysema of the neck
Immediate needle thoracostomy for evidence of tension pneumothorax

Admission Criteria

Pulmonary barotrauma

Discharge Criteria

Nonpulmonary barotrauma
ENT follow up for severe TM or sinus pathology

Ongoing Care

No diving until TM has healed and other symptoms have resolved
Predive medical clearance is recommended for anyone with prior pulmonary barotrauma or decompression illness.

Follow-Up Recommendations

ENT referral for severe TM, inner ear, or sinus pathology

Additional Reading

Bradley ME. Pulmonary barotrauma. In: Bove AA, Davis JC. Diving medicine. 2nd ed. Philadelphia: WB Saunders, 1990:188–191.

Brown M, Jones J, Krohmer J. Pseudoephedrine for the prevention of barotitis media: a controlled clinical trial in underwater divers. Ann Emerg Med. 1992;21:849–852.

DeGorordo A, Vallejo-Manzur F, Chanin K, et al. Diving emergencies. Resuscitation. 2003;59:171–180.

Edmonds C, Lowry C, Pennefather J. Diving and subaquatic medicine. Oxford: Butterworth-Heinemann, 1992.

Jerrard DA. Diving medicine. Emerg Med Clin North Am. 1992;10:329–338.

McMullin AM. Scuba diving: what you and your patients need to know. Cleve Clin J Med. 2006;73:711–712, 714, 716 passim.

Raymond LW. Pulmonary barotrauma and related events in divers. Chest. 1995;107:1648–1652.

www.diversalertnetwork.org

Codes

ICD9

993.0 Barotrauma, otitic
993.1 Barotrauma, sinus