Basics
Description
- Barotrauma of the middle or inner ear, most commonly caused by flying in an airplane or scuba diving but also caused by elevators and high altitudes
- May also be seen in those who have used a hyperbaric oxygen chamber and in people involved in explosions-blast injuries
- Referred to as "middle ear squeeze"Ł by scuba divers
Epidemiology
- Severe disease is uncommon in commercial aircraft because of pressurization.
- Significant disease is more common in scuba divers, in those who fly military aircraft, and during use of hyperbaric oxygen chambers.
- There is wide variation, with studies reporting an incidence of 8-55% for children after a single flight.
- Most studies agree that the incidence is ~20% in adults after a single flight.
- 40% frequency in scuba diving
Risk Factors
- Age: Infants or toddlers are at higher risk because of small eustachian tubes.
- Disease states that impede normal eustachian tube function: otitis media, upper respiratory tract infection (URI), allergic rhinitis
- Smoking
- Vigorous use of Valsalva maneuver
General Prevention
- Gradual descent during scuba diving-never rapid
- When ascending, divers should avoid rising more quickly than their air bubbles.
- Yawning, swallowing, chewing, or doing Valsalva maneuver during takeoff and landing in planes and during ascent and descent when scuba diving
- Gentle Valsalva-never vigorous
- Avoid flying or diving when you have a URI or allergic rhinitis.
- Avoid sleeping on plane during takeoff and landing.
- Break seal of wet suit hood to allow water to fill external canal before descent.
- Avoid use of earplugs.
Pathophysiology
- Boyle's law states that as pressure of a gas decreases, volume increases, and as pressure of a gas increases, volume decreases.
- Ambient pressure decreases during airplane/scuba diving ascent and increases during descent.
- During ascent, the tympanic membrane (TM) bulges outward and the eustachian tube vents the excess middle ear pressure. Pressure is easily equalized.
- During descent, the TM bulges inward and the eustachian tube resists inward flow of air. Pressure equalization is difficult.
- At a pressure differential of 60 mm Hg (greater ambient to middle ear pressure), subjective discomfort is reported.
- At a pressure differential of 90 mm Hg, the eustachian tube collapses and becomes obstructed. Autoinflation is unsuccessful.
- TM can rupture at pressure differentials >100-400 mm Hg.
- Barotitis is sometimes classified using Teed classification of disease severity (see "Physical Exam"Ł).
Etiology
Differences in the atmospheric pressure between the inner ear, middle ear, and environment result in injury to the middle and/or inner ear. á
Diagnosis
History
- Ear pain, pressure sensation, diminished hearing
- Symptoms of inner ear damage may include vestibular and/or auditory complaints including tinnitus, vertigo, nausea, and vomiting.
- History of recent airplane flying, scuba diving, or hyperbaric oxygen chamber use
Physical Exam
- Nystagmus
- Hearing loss
- Teed classification to describe appearance of the TM:
- Grade 0: symptoms without physical signs
- Grade 1: diffuse redness and retraction of TM
- Grade 2: grade 1 plus slight hemorrhage into TM
- Grade 3: grade 1 plus gross hemorrhage into TM
- Grade 4: bulging TM with air-fluid level, blood in TM
- Grade 5: free hemorrhage into TM and ear canal with perforation of TM
Diagnostic Tests & Interpretation
Imaging
CT of the inner ear may be indicated in patients with vestibular symptoms or hearing loss to rule out inner ear damage. á
Diagnostic Procedures/Other
Hearing tests should be performed on all patients who have signs of barotrauma and on patients with normal physical exams but who are symptomatic. á
Differential Diagnosis
- Otitis media with effusion
- Acute otitis media
- Otitis externa
- Blunt trauma to the TM
- Exposure to extremely loud noise
Treatment
Medication
- Nasal decongestant sprays (oxymetazoline [Afrin])
- Have been reported by some to be helpful, but a randomized clinical trial showed no advantage over placebo
- Theory: By constricting mucosal arterioles, eustachian tube function is enhanced.
- Topical decongestants are used 1 hour prior to plane travel/diving and 1/2 hour prior to plane descent.
- 2 drops/sprays per nostril
- Use in children older than 6 years of age.
- Oral decongestants
- 2 randomized controlled trials suggest that oral decongestants may be effective, although a trial in children did not show a beneficial effect.
- May be helpful through the same physiologic pathway as topical agents
- Should be initiated 1-2 days prior to the expected pressure change
- Antihistamines
- May also be helpful by reducing mucosal edema and enhancing the eustachian tube orifice
- Can be used on the day of the expected pressure change
- Nasal surfactants may be useful but ongoing studies are needed.
- Pain relievers such as acetaminophen, ibuprofen, and naproxen may be useful for severe pain.
Additional Therapies
General Measures
- Valsalva maneuver (blowing the nose while pinching the nostrils closed) may be helpful when diving or descending and will force air into the middle ear via the eustachian tube, thereby equalizing the pressure between the middle ear and the environment. This should be done gently.
- Swallowing, yawning, and chewing can help to release pressure through the eustachian tube when descending in an airplane or when returning to the water surface while scuba diving.
- Politzer bag: instrument used for clearing pressure disequilibrium that has not improved with Valsalva maneuvers and a trial of decongestants
- Otovent: Another instrument that may be used for treatment or prevention; usage can be taught to children as young as 2-6 years of age.
- Myringotomy with or without tubes may be required to relieve pressure in severe disease. It may also be used as a preventive measure in those with a history of barotitis.
- Myringotomy is effective for the patient with excruciating pain or unrelenting eustachian tube dysfunction; this is best performed by an otolaryngologist.
Surgery/Other Procedures
Rarely, myringotomy with or without tube insertion is required to relieve pressure and pain as well as prevent complications. Myringotomy is a surgical procedure where a small incision is made in the TM. This opens the middle ear space and equalizes the pressure on both sides of the TM. Myringotomy without tube insertion will relieve pressure, but the opening may close very quickly and may not allow time for the barotrauma to heal; on occasion, myringotomy with tube insertion is necessary. Tympanostomy tubes are not appropriate for scuba divers. á
Ongoing Care
Follow-up Recommendations
Patient Monitoring
Most patients with barotitis can be managed conservatively. Those with complications noted earlier require specialist referral. á
Prognosis
- Complete spontaneous resolution in mild cases
- Middle ear barotrauma is usually self-limited and correctable with the techniques described in the "General Measures"Ł section. In rare instances, where there is severe pain or eustachian tube dysfunction, myringotomy with or without tube insertion will relieve the pressure differential.
- Pressure differential without damage to the middle or inner ear usually resolves within a few days of returning to normal atmospheric pressure.
- Barotitis that results in injury to the middle or inner ear has a variable rate of improvement; some damage may be permanent (e.g., that to the organ of Corti), whereas other injury is reversible (e.g., that involving the TM).
- Variable outcome for auditory and vestibular symptoms and injuries to the inner ear
Complications
- Vertigo
- Tinnitus
- Hearing loss
- TM rupture
- Oval or round window rupture
- Hemorrhage
Additional Reading
- Buchanan áBJ, Hoagland áJ, Fischer áPR. Pseudoephedrine and air travel-associated ear pain in children. Arch Pediatr Adolesc Med. 1999;153(5):466-468. á[View Abstract]
- Janvrin áS. Middle ear pain and trauma during air travel. Clin Evid. 2002;7:466-468. á[View Abstract]
- Jones áJS, Sheffeild áW, White áL, et al. A double-blind comparison between oral pseudoephedrine and topical oxymetazoline in the prevention of barotrauma during air travel. Am J Emerg Med. 1998;16(3):262-264. á[View Abstract]
- Mirza áS, Richardson áH. Otic barotraumas from air travel. J Laryngol Otol. 2005;119(5):366-370. á[View Abstract]
- Rosenkvist áL, Klokker áM, Katholm áM. Upper respiratory infections and barotraumas in commercial pilots: a retrospective survey. Aviat Space Environ Med. 2008;79(10):960-963. á[View Abstract]
- Stangerup áSE, Klokker áM, Vesterhauge áS, 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. á[View Abstract]
- Weiss áMH, Frost áJO. May children with otitis media with effusion safely fly? Clin Pediatr (Phila). 1987;26(11):567-568.
Codes
ICD09
- 993.0 Barotrauma, otitic
- 388.70 Otalgia, unspecified
- 388.30 Tinnitus, unspecified
- 389.9 Unspecified hearing loss
- 780.4 Dizziness and giddiness
ICD10
- T70.0XXA Otitic barotrauma, initial encounter
- H92.09 Otalgia, unspecified ear
- H93.19 Tinnitus, unspecified ear
- H91.90 Unspecified hearing loss, unspecified ear
- H93.13 Tinnitus, bilateral
- R42 Dizziness and giddiness
- H91.92 Unspecified hearing loss, left ear
- H91.93 Unspecified hearing loss, bilateral
- H91.91 Unspecified hearing loss, right ear
- H92.02 Otalgia, left ear
- H93.12 Tinnitus, left ear
- H92.03 Otalgia, bilateral
- H93.11 Tinnitus, right ear
- H92.01 Otalgia, right ear
SNOMED
- 49252004 Otitic barotrauma (disorder)
- 16001004 Otalgia (disorder)
- 60862001 Tinnitus (finding)
- 15188001 hearing loss (disorder)
- 399153001 Vertigo (finding)
FAQ
- Q: Is the Valsalva maneuver also effective on plane ascent?
- A: Yes. Creating even greater pressure in the middle ear by performing the Valsalva maneuver can overcome a resistant eustachian tube and result in sudden venting of increased middle ear pressure.
- Q: Can children with otitis media travel in airplanes?
- A: Yes. Weiss and Frost (1987) have shown that commercial air travel did not result in worsening of symptoms and, in fact, the presence of otitis media with effusion seemed to be protective against barotitis.
- Q: How can I minimize my child's ear pain when traveling in an airplane?
- A: For infants: Have them nurse, take a bottle, or suck on a pacifier during ascent and descent. Older children may eat or chew gum or suck on hard candies. This will result in pharyngeal movements that will repeatedly open the eustachian tube and equalize middle ear pressure to environmental pressure. Children can also be taught the Valsalva maneuver. If the child is currently experiencing a URI, use of decongestants prior to flight may be helpful.