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 reports dizziness and hearing loss in the affected ear.
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
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, tympanotomy 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 19-year-old jumped off the high dive at a local swimming pool and presents to your office complaining of severe right-sided ear pain after landing on that side when he hit the water. You have seen him for this problem for the last 12 weeks, but a small perforation remains in the tympanic membrane. There is no sign of infection. Appropriate treatment at this point consists of
Continued observation Hint: See E for explanation | |
An audiogram to document hearing Hint: An audiogram should be performed after treatment to document the return of hearing. | |
Steroid otic drops Hint: See E for explanation | |
Antibiotic eardrops and no water exposure Hint: Antibiotic eardrops are indicated only if there has been contamination by water or debris. Oral antibiotics can be used prophylactically to prevent infection but are generally unnecessary. | |
Referral to an ear– nose– throat specialist |
Question 1 Explanation:
Rupture of the tympanic membrane can be caused by placing objects (e.g., cotton swabs, twigs, pencils) in the ear canal, excessive positive pressure applied to the ear (e.g., explosions, loud noises), swimming, diving, or excessive negative pressure (e.g., kiss over the ear); it can be iatrogenically produced by a ventilating tube. Symptoms of traumatic rupture include a sudden severe pain followed by, in some cases, bleeding from the ear. Hearing loss and tinnitus are also usually present. Vertigo suggests damage to the inner ear. Treatment involves gentle removal of debris and blood from the otic canal and use of earplugs to provide protection when bathing or shampooing. Antibiotic eardrops are indicated only if there has been contamination by water or debris. Oral antibiotics can be used prophylactically to prevent infection but are generally unnecessary. Pain medication may be necessary for the first few days. Persistent perforation for more than 10 to 12 weeks is an indication for otolaryngology referral. An audiogram should be performed after treatment to document the return of hearing.
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?
Transudate of fluid in the middle ear Hint: With negative middle ear pressure, a transudate of fluid may form in the middle ear. | |
Perilymph fistula | |
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. | |
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. |
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.
There are 2 questions to complete.
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References: Merck Manual · UpToDate
