Barotitis Media

Ovid: 5-Minute Sports Medicine Consult, The

Barotitis Media
Carter W. Muench
Rob Johnson
  • 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.
  • 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.
  • 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.
Essential Workup
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
Arterial blood gas determinations for pulmonary symptoms
Differential Diagnosis
  • Decompression sickness
  • Otitis media
  • Otitis externa
  • Sinusitis
  • Arterial gas embolism
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.
  • 993.0 Barotrauma, otitic
  • 993.1 Barotrauma, sinus

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