PANCE Blueprint EENT (7%)

Barotrauma

Patient will present as → a 17-year-old male who returned from a senior class trip to Mexico. While there, they decided to take scuba classes. After 3 days of shallow diving, they attempted their first 100-foot dive. After 5 minutes on their second dive, his equipment failed. He quickly shared the working breathing equipment of his friend, and they rose rapidly to the surface in a panic for air. The patient noticed immediate pain in his right ear, which resolved somewhat when he forcefully yawned and heard a "pop." Since then, he has reported dizziness and hearing loss in the affected ear.

Symptoms of ear barotrauma may include sensorineural hearing loss and/or vertigo if which of the following develops?
Perilymph fistula – perilymph fistula (PLF) is a tear or defect in the membranes that separate the middle ear from the perilymphatic space in the inner ear. The tear can allow fluid to leak into the middle ear. It can also cause changes in pressure in the middle ear, which will impact the inner ear, causing abnormal symptoms. Symptoms of otic barotrauma are severe pain, conductive hearing loss, and, if there is a perilymph fistula, sensorineural hearing loss and/or vertigo.

Barotrauma is tissue injury caused by a pressure-related change in body compartment gas volume; it affects air-containing areas, including lungs, ears, sinuses, GI tract, air spaces in tooth fillings, and space contained by the diving face mask

  • Symptoms may include ear pain, vertigo, hearing loss, sinus pain, epistaxis, and abdominal pain
  • Dyspnea and loss of consciousness are life-threatening and may result from alveolar rupture and pneumothorax
Dive hand signal-ear.plain

Diving is a common cause of barotrauma

Diagnosis is clinical but sometimes requires imaging tests

  • On exam, will see signs of trauma without signs of infection – redness without building, pus, or effusion

Treatment is supportive (anti-inflammatories), then consider prophylaxis

  • Most barotrauma injuries heal spontaneously
  • Urgent surgery (eg, tympanostomy for direct repair of a ruptured round or oval window, myringotomy to drain fluid from the middle ear, sinus decompression) may be necessary for serious inner or middle ear or sinus injuries
  • Pseudoephedrine or Afrin can be good for prophylaxis for ear barotrauma – you must be careful when recommending this to divers, depending on dive times
    • Risk for overuse – Afrin should not be used for more than 3 days – risk of tachyphylaxis and rhinitis medicamentosa
  • Swallowing to open the eustachian tube, along with chewing gum or sucking on hard candies, helps for adults; sucking on a bottle helps for infants

Question 1
A 17-year-old male presents to your clinic with persistent right ear pain following a high diving incident at a local swimming pool 12 weeks ago. He reports that he landed on his right side when hitting the water. Examination reveals a small, non-infected perforation in the right tympanic membrane. What is the most appropriate next step in management?
A
Continued observation
Hint:
While many tympanic membrane perforations heal spontaneously, the duration of 12 weeks without healing suggests the need for specialist assessment.
B
An audiogram to document hearing
Hint:
While documenting hearing is important, the primary concern at this stage is the non-healing perforation, which requires specialist evaluation.
C
Prescribe steroid otic drops
Hint:
Steroids are not typically used in the management of tympanic membrane perforations and could potentially delay healing or increase the risk of infection.
D
Prescribe antibiotic ear drops and advise against water exposure
Hint:
Antibiotic drops are generally used in the presence of infection, which is not indicated in this case. While avoiding water exposure is generally advised, the main concern here is the non-healing perforation.
E
Referral to an otolaryngologist (ENT specialist)
Question 1 Explanation: 
Given the duration of the condition (12 weeks) with a persistent tympanic membrane perforation, referral to an otolaryngologist is appropriate. An ENT specialist can provide a more detailed assessment and consider interventions such as tympanoplasty if the perforation does not heal spontaneously. Persistent perforations can lead to chronic problems, including hearing loss and recurrent infections, and thus warrant specialist evaluation.
Question 2
Otic barotrauma is ear pain or damage to the tympanic membrane caused by rapid changes in pressure. Symptoms may include sensorineural hearing loss and/or vertigo if which of the following develops?
A
Transudate of fluid in the middle ear
Hint:
With negative middle ear pressure, a transudate of fluid may form in the middle ear.
B
Perilymph fistula
C
Rupture of the tympanic membrane (TM)
Hint:
A very large pressure differential may cause bleeding into the middle ear and TM rupture, as well as the development of a perilymph fistula through the oval or round window.
D
Hemotympanum (bleeding into the middle ear)
Hint:
A very large pressure differential may cause bleeding into the middle ear and TM rupture, as well as the development of a perilymph fistula through the oval or round window.
E
Eustachian tube dysfunction
Hint:
While this can cause discomfort and hearing changes due to pressure differences, it typically does not lead to sensorineural hearing loss and vertigo.
Question 2 Explanation: 
A perilymph fistula (PLF) is a tear or defect in the membranes that separate the middle ear from the perilymphatic space in the inner ear. The tear can allow fluid to leak into the middle ear. It can also cause changes of pressure in the middle ear, which will impact the inner ear, causing abnormal symptoms. Symptoms of otic barotrauma are severe pain, conductive hearing loss, and if there is a perilymph fistula, sensorineural hearing loss, and/or vertigo.
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References: Merck Manual · UpToDate

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