Barotrauma is tissue injury caused by a pressure-related change in body compartment gas volume. It can affect the ear (causing ear pain, hearing loss, and/or vestibular symptoms) or the sinuses (causing pain and congestion). Diagnosis sometimes requires audiometry and vestibular testing. Treatment, when required, may involve decongestants, analgesics, and sometimes oral corticosteroids or surgical repair of serious inner or middle ear or sinus injuries.
Deep-water diving can affect the external, middle, and inner ear. Typically, divers experience ear fullness and pain during descent; if pressure is not quickly equilibrated, middle ear hemorrhage or tympanic membrane rupture may occur. Inflow of cold water to the middle ear may result in vertigo, nausea, and disorientation while submerged. On examination of the ear canal, the tympanic membrane may show congestion, hemotympanum, perforation, or lack of mobility during air insufflation with a pneumatic otoscope; conductive hearing loss is usually present. When pressure within the middle ear remains elevated during or after ascent from a dive, the facial nerve can be compressed (facial baroparesis), resulting in ipsilateral upper and lower facial paresis. Weakness of both upper and lower face distinguishes facial baroparesis from stroke or arterial gas embolism (1).
Middle ear barotrauma (MEBT) is common in divers occurs when the pressure is not equalized between the middle ear and the external environment (2). This pressure differential can cause ear pain, decreased hearing, and tympanic membrane rupture.
Inner ear barotrauma (IEBT) occurs due to rupture of the labyrinthine window (round or oval window) or tears of the Reissner, basilar, or tectorial membranes. Symptoms, which include tinnitus, hearing loss, dizziness, disequilibrium, vertigo, nystagmus, ataxia, nausea, and vomiting, often worsen with activity and loud noise, and improve with rest. Symptoms usually start during a diver's descent when there is difficulty equalizing middle ear pressure, but can occur during ascent, possibly due to air expansion within the cochlea or vestibular apparatus. Symptoms can also occur days after a dive, often provoked by lifting or straining (3). Neurosensory hearing loss and tympanic membrane rupture can occur.
Sinus barotrauma most often affects the frontal sinuses, followed by the ethmoid and maxillary sinuses (4). Divers experience mild pressure to severe pain, with a feeling of congestion in the involved sinus compartments during ascent or descent and sometimes epistaxis. Pain can be severe, sometimes accompanied by facial tenderness on palpation. Maxillary sinus overpressurization can compress the maxillary branch of the trigeminal nerve, causing hyperesthesia over the cheek. Overpressurization in the sphenoid sinus occasionally compresses the optic nerve, causing decreased vision or blindness (5).
Rarely, the sinus may rupture and cause pneumocephalus with facial or oral pain, nausea, vertigo, or headache. Rupture of a maxillary sinus can cause retro-orbital air with diplopia due to oculomotor dysfunction. Compression of the trigeminal nerve in the maxillary sinus can cause facial paresthesias. Physical examination may detect tenderness in the sinuses or nasal hemorrhage.
Barotrauma can also occur due to the reduction in ambient pressure during ascent to altitude is rare.
References
1. Molvaer OI, Eidsvik S. Facial baroparesis: A review. Undersea Biomed Res. 14(30):277-295, 1987. PMID 3307083
2. Lindfors OH, Raisanen-Sokolowski AK, Suvilehto J, et al. Middle Ear Barotrauma in Diving. Diving Hyperb Med. 51(1): Mar 31, 2021: 44-52.
3. Elliott EJ, Smart DR. The assessment and management of inner ear barotrauma in divers and recommendations for returning to diving. Diving Hyperb Med. 44(4):208-22, 2014. PMID: 25596834
4. Schipke JD, Cleveland S, Drees M, Sphenoid sinus barotrauma in diving: Case series and review of the literature. Res Sports Med. 26(1):124-137. doi: 10.1080/15438627.2017.1365292
5. Hanasono MM, Norbash AM, Shepard K, et al. Sphenoid pneumoceles cause episodic pressure-related blindness. West J Med. 169(5):295-299, 1998. PMID: 9830365 PMCID: PMC1305327
Diagnosis of Ear and Sinus Barotrauma
Primarily history and physical evaluation
Sometimes, audiometry and vestibular testing
Barotrauma causing only pain in the ear or sinuses is usually diagnosed clinically.
Patients with symptoms of inner ear barotrauma (eg, tinnitus, hearing loss, or vertigo) should be examined for signs of vestibular dysfunction and undergo urgent formal audiometry, vestibular testing, and possibly surgery (1). These patients should be referred to an otolaryngologist because prompt surgical treatment of labyrinthine window tears can reverse hearing loss.
Imaging (eg, plain radiographs, CT) is not necessary for diagnosis of uncomplicated sinus barotrauma, but CT is useful if sinus rupture or cranial nerve compression is suspected.
Diagnosis reference
1. Rozycki SW, Brown MJ, Camacho M. Inner ear barotrauma in divers: an evidence-based tool for evaluation and treatment. Diving Hyperb Med. 48(3):186–193, 2018. PMID 30199891.
Treatment of Ear and Sinus Barotrauma
Decongestants and analgesics
Sometimes oral corticosteroids, surgical repair, or both
Most ear and sinus barotrauma injuries resolve spontaneously and require only symptomatic treatment and outpatient follow-up.
Decongestants (usually oxymetazoline nasal spray or oral pseudoephedrine) can help open occluded chambers. Patient who do not respond to decongestants may be treated with nasal corticosteroids. Pain can be controlled with nonsteroidal anti-inflammatory drugs or opioids. Decongestants (usually oxymetazoline nasal spray or oral pseudoephedrine) can help open occluded chambers. Patient who do not respond to decongestants may be treated with nasal corticosteroids. Pain can be controlled with nonsteroidal anti-inflammatory drugs or opioids.
If bleeding or evidence of effusion is present, antibiotics are given (eg, amoxicillin 500 mg orally every 12 hours for 10 days, trimethoprim/sulfamethoxazole 1 double-strength tablet orally twice a day for 10 days).If bleeding or evidence of effusion is present, antibiotics are given (eg, amoxicillin 500 mg orally every 12 hours for 10 days, trimethoprim/sulfamethoxazole 1 double-strength tablet orally twice a day for 10 days).
Referral to an otorhinolaryngologist is indicated for severe or persistent symptoms. 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.
Prevention of Ear and Sinus Barotrauma
During a dive, ear barotrauma during descent may be avoided by frequently swallowing or exhaling against pinched nostrils to open the eustachian tubes and equalize pressure between the middle ear and the environment. Pressure behind ear plugs cannot be equalized, so they should not be used for diving.
Prophylaxis for people with nasal congestion or who have trouble equalizing middle ear pressure with oxymetazoline 0.05% nasal spray, 2 sprays per nostril twice daily beginning 12 to 24 hours before a dive, can reduce the incidence of ear and sinus barotrauma. A person should not dive if congestion does not resolve or if an upper respiratory infection or uncontrolled allergic rhinitis is present.Prophylaxis for people with nasal congestion or who have trouble equalizing middle ear pressure with oxymetazoline 0.05% nasal spray, 2 sprays per nostril twice daily beginning 12 to 24 hours before a dive, can reduce the incidence of ear and sinus barotrauma. A person should not dive if congestion does not resolve or if an upper respiratory infection or uncontrolled allergic rhinitis is present.
Key Points
If patients have tinnitus, hearing loss, or vertigo, arrange urgent audiometry and vestibular testing.
Consider CT if unsure of clinical assessment or if sinus injury is complicated by cranial nerve compression.
If symptoms are severe, prescribe an analgesic and a decongestant.
Decrease risk of ear and sinus barotrauma by counseling against diving when the nose is congested and sometimes by prescribing prophylactic oxymetazoline or nasal pseudoephedrine.Decrease risk of ear and sinus barotrauma by counseling against diving when the nose is congested and sometimes by prescribing prophylactic oxymetazoline or nasal pseudoephedrine.
More Information
The following English-language resource may be useful. Please note that The Manual is not responsible for the content of this resource.
Divers Alert Network: 24-hour emergency hotline, 919-684-9111
Duke Dive Medicine: Physician-to-physician consultation, 919-684-8111
