Otologic manifestations of barotrauma
Download
1 / 68

Otologic Manifestations of Barotrauma - PowerPoint PPT Presentation


  • 132 Views
  • Uploaded on

Otologic Manifestations of Barotrauma. David M. Kaylie, MD FACS Otolaryngology – Head and Neck Surgery. ENT Manifestations of Barotrauma. EAC squeeze Sinus squeeze Mask squeeze Middle Ear Barotrauma. Elastic Cavity.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Otologic Manifestations of Barotrauma' - sue


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Otologic manifestations of barotrauma
Otologic Manifestations of Barotrauma

David M. Kaylie, MD FACS

Otolaryngology – Head and Neck Surgery


Ent manifestations of barotrauma
ENT Manifestations of Barotrauma

  • EAC squeeze

  • Sinus squeeze

  • Mask squeeze

  • Middle Ear

    Barotrauma


Elastic cavity
Elastic Cavity

  • The pressure of a gas is inversely proportional to volume at constant temperature

  • Boyle’s law

    P1V1=P2V2

1 atm

surface

2 atm

10 m

30 m

4 atm


Inelastic cavity
Inelastic Cavity

  • Constant volume

  • Pressure changes

1 atm

surface

33ft

4 atm

30 m


Cavities
Cavities

Surface

3 ATM

1 atm

Lungs (elastic)

33ft

Bony Cavity (inelastic))

4 atm

132 ft


Changing pressure
Changing Pressure

  • 33 feet of seawater (fsw)=1 atmosphere pressure (14.7 psi)

  • Balloon (or Lungs) at surface

    • If pressure is 3x, volume is 1/3 and density is 3x

    • When breathe at depth, gas at higher pressure than surface

    • If hold breath as resurface

      • Volume expands and lungs overinflate.

    • DON’T HOLD BREATH


External ear canal squeeze
External Ear Canal Squeeze

  • Hood

  • Cerumen

  • Plug

  • Elderly

  • Congenital small ear canals

  • Swimmers (Surfers) Ear → Exostoses


Exostoses
Exostoses

  • Cold water

    exposure

  • Benign

  • Trap cerumen







Treatment of eac barotrauma
Treatment of EAC Barotrauma

  • Dry ear precautions x 6 weeks (cotton/vas)

  • Topical antibiotic/steroid drops (Ciprodex)

  • Oral antibiotics if cellulitis (amox/clav)

  • Wick if obstructed (merocel)

  • Analgesia


Barosinusitis
Barosinusitis

  • Descent 68%, Ascent 32% (Fagan 1976)

  • Pain

  • Nosebleed


Barosinusitis1
Barosinusitis

  • Frontal > maxillary > ethmoid

  • Blindness and meningitis (Parell and Becker, 2000)


Treatment of barosinusitis
Treatment of Barosinusitis

  • Elevate head

  • Heat

  • Oxymetazoline (Afrin)

  • Pseudoephedrine (Sudafed)

  • Avoid antihistamine – not beneficial

  • Antibiotics for secondary bacterial infection

  • Analgesia


Middle ear barotrauma
Middle Ear Barotrauma

  • Most common medical condition of divers

    • Occurs mainly on descent

    • Symptoms- pain, conductive hearing loss

    • Signs- hemotympanum, perforation


MEBT

  • 4 fsw pressure > tensor tympani strength

  • 10–69 fsw Dimeric TM rupture

    • Keller, 1958

    • Jensen, 1993






Management of mebt
Management of MEBT

  • Usually resolves without treatment

  • Oxymetazoline < 1 wk

  • Antibiotics in advanced cases

  • No diving until sx free, normal TM and able to autoinflate x 3 mo.


Equalizing general recommendations
EqualizingGeneral Recommendations

  • Avoid diving with URI, allergies

  • Avoid medications causing nasal congestion (turbinate ↑)

    • Antihypertensives

    • BPH (Hytrin)

    • ED (Viagra)

  • Descent feet first

  • Autoinflate 1-2 ft. No pain is acceptable


  • Equalizing techniques
    Equalizing Techniques

    • Swallow, jaw thrust

    • pseudoValsalva:

      • Alar balloon

    • Lowry:

      • pValsalva+swallow

    • Edmonds:

      • pValsalva+jaw thrust


    Other equalizing techniques courtesy allen dekelboum md
    Other Equalizing TechniquesCourtesy Allen Dekelboum, MD

    • Toynbee:

      • Swallow with mouth and nose closed

      • Good for ascent

    • Frenzel:

      • pValsalva with throat contraction

    • Neck twitch:

      • Sudden lateral motion with nose closed


    Equalizing middle ear managing difficult cases
    Equalizing Middle Ear:Managing Difficult Cases

    • Dry land practice

    • Anchor line – helps control decompression stop in rough water

    • Private lesson

    • No bouncing

    • Medication


    Medication for eustachian tube dysfunction
    Medication for Eustachian Tube Dysfunction

    • Otolaryngology examination

    • Rarely: Allergy, Septum, CT or MRI

    • Topical nasal steroid

    • Afrin 12 hour

      • Rebound

  • Sudafed 120 mg ER

    • Cardiac, High blood pressure, Urinary retention

  • Oral corticosteroids (prednisone, medrol)

    • Diabetes, Peptic ulcer, GERD, Infection, CNS, +++


  • TMJ

    • 25 – 65% of SCUBA divers

    • Sea Cure

    • Right Bite

    • Custom mouth piece

    • Check hose length


    Otolaryngology clearance to dive
    Otolaryngology clearance to dive

    • Normal examination, able to auto inflate

    • Diving with ENT disorders

      • Meniere’s disease (1 year rule, asymmetrical C°)

      • Prior IEBT (hearing loss, vertigo)

      • S/P Surgery

        • Tympanoplasty

        • Mastoidectomy (C°)

        • Ossiculoplasty

        • Stapedotomy (C°)

        • Cochlear Implant (C°)

        • Acoustic Neuroma

        • ESS

        • Laryngeal surgery


    Meniere s disease
    Meniere’s Disease

    • Spontaneous vertigo at depth

    • Emphasize risk of aspiration, death

    • One year symptom free without treatment chamber/rescue diver

    • Simultaneous (C°)





    Diving after ear surgery
    Diving After Ear Surgery

    • Tympanoplasty 3 months

    • PORP yes

    • TORP +/-

    • Cochlear Implant 3 atm (device 4 atm)

    • PLF +/-

    • Acoustic neuroma No


    Dive after sinus surgery
    Dive after Sinus Surgery

    • -6 weeks

    • -Healed ostia


    Practical approach to stings
    Practical Approach to Stings

    • Hot water (as tolerated, 110°)

    • Ammonia, alcohol, papain, peroxide

    • Vibrio vulnificus – gram negative

      • Ceftriaxone, Cipro, Septra, Doxycycline



    Differential
    Differential

    • Hangover

    • Motion sickness

    • Disembarkment

    • Diving disorders

    • Heart

    • Circulation

    • CNS, Endocrine


    Motion sickness
    Motion Sickness

    • Mechanism: sensory mismatch (adaptation)

      • Yaw (0.2 Hz) vertical linear motion

      • Susceptibility: Ages: 2- 10; 40-50

  • Non-pharmacologic therapy

    • Sea Band (P6, Nei Kuan point)

      • = placebo

      • Some studies show it works


  • Medical treatment of motion sickness
    MEDICAL TREATMENT OF MOTION SICKNESS

    • Pharmacologic therapy

      • Diminhydrinate (50-100mg) antihistamine 2hrs 8hrs drowsy

      • Meclizine (25 mg) antihistamine 2hrs 6hrs drowsy

      • Promethazine (25-50mg) phenothiazine 2hrs 18hr drowsy

      • Scopolamine (0.5 mg) antimuscarinic 8hrs 72hr drowsy anticholinergic

      • D-amphetamine (5-10mg) amphetamine 1hr 6hr abuse, palpitation, HBP, arrhythmia, psychosis, insomnia, euphoria, use in pregnancy, MAOI, hyperthyroid


    Disembarkment syndrome mal de debarquement
    Disembarkment Syndrome(Mal de debarquement)

    • Tal (2005)

      • Swaying, swinging, unsteadiness after return to land

      • Symptoms appear after landing

      • Associated with sea sickness while onboard

      • No objective measures available

      • Mostly women

    • Hain (1999)

      • 26 of 27 women (age = 49.3)

      • Duration 3.5 years

      • Treatment

        • Meclizine -

        • Scopolamine -

        • Vestibular rehab -

        • Benzodiazapines +


    Diving disorders causing dizziness

    Diving Disorders Causing Dizziness

    Four categories of IEBT

    During compression

    At Stable Depths

    During decompression

    Noise trauma


    Diving disorders causing dizziness1

    Diving Disorders Causing Dizziness

    Inner ear barotrauma

    Perilymph fistula

    Inner ear DCI

    Alternobaric vertigo

    Gas toxicity

    Isobaric counter-diffusion


    Inner ear barotrauma iebt
    INNER EAR BAROTRAUMA (IEBT)

    • Usually with MEBT

    • Cochlear 90%, Vestibular 60%, Both 50% (Molvaer, 1988)

    • Mechanism

      • Forced inflation on descent

      • Sudden equilibration

      • TM snaps, pressure wave from stapes to RWM


    Oval and round windows
    Oval and Round Windows

    • Sudden insufflation of middle ear snaps TM laterally, displacing stapes laterally and RW medially.


    Incidence of iebt
    Incidence of IEBT

    • 76 of 15,000 (0.5%) logged dives

      • Molvaer (1988)

    • 26 of 319 (8%) patients with dive-ENT disorders

      • Klingmann (2006)


    Recurrent iebt
    Recurrent IEBT

    • Israel Naval Medical Institute

      • 2 of 44 (5%) of IEBT seen

        in 18 years (Shupak, 2006)


    Treatment of iebt
    Treatment of IEBT

    • Bed rest, head elevated

    • Control B.P., discontinue aspirin

    • Prednisone

    • Observe (dial tone, etc.), serial audio

    • Explore if strong suspicion of PLF


    Perilymph fistula
    PERILYMPH FISTULA

    MECHANISM: - RWM or OW ligament

    - Implosion

    - Explosion

    Rupture on descent

    Symptoms on ascent

    gas from ME to IE (Molvaer, 1988)


    Perilymph fistula1
    Perilymph Fistula

    • Increased CSF pressure without equilibration = OW

    • Sudden forced insufflation with snap of TM = OW or RW


    Perilymph fistula2
    PERILYMPH FISTULA

    • Pneumolabyrinth


    Perilymph fistula3
    PERILYMPH FISTULA

    • TREATMENT:

    • Bedrest, head elevated x 5d

    • 2. Explore if SNHL progresses

    • 3. Explore immediately if significant

    • SNHL occurs with barotrauma

    • 4. Explore vertigo > 5 days (normal MR and neuro)


    Perilymph fistula4
    PERILYMPH FISTULA

    Middle ear exploration

    • 30 minutes

    • Local or G.A.



    Inner ear decompression illness iedci
    INNER EAR DECOMPRESSION ILLNESS (IEDCI)

    • Any depth, any diver

    • More common in decompression diving

      • Dives >130 feet require special gas mixtures


    Inner ear decompression illness iedci1
    INNER EAR DECOMPRESSION ILLNESS (IEDCI)

    • Vertigo (most common), HL, tinnitus

    • Type II DCI

      • Associated with systemic DCI: spinal cord symptoms, pain, itching, rash, dyspnea, LOC, death

      • Inner ear: bubble formation → hemorrhage

        tissue rupture (Antonelli, 1993)


    Recurrent iedci
    Recurrent IEDCI

    • 5 of 24 IEDCI (21%)

      • Nachum (2001)

  • 2 of 18 IEDCI (11%)

    • Klingman (2006)


  • Management of iedci
    Management of IEDCI

    • HBO, fluids, steroids, n-acetyl cysteine

      • HBO within 1 hr → 50% complete resolution (Nachum, 2001)

      • 5 hr → 10% (Shupak, 2003)

      • 10 hr → 22% (Klingmann, 2006)

    • Do not dive for 3 months(Molvaer, 2003)

      • Do not dive if SNHL, RVR persist?

    • Recompression with fistula safe

      • Guinea pigs (Stevens, 1991)

      • Human experience (Dekelboum 2005; Klingmann 2004)

      • Tubes


    Right to left shunt pfo
    Right to Left Shunt (PFO)

    • R/O PFO in patients with DCI

      • Right to left shunt in IEDCI 82%

        • in controls 25% (Cantais, 2003; Klingmann, 2006)

      • German Diving Medical Society—’Unfit to Dive’


    Alternobaric vertigo
    ALTERNOBARIC VERTIGO

    • Asymmetric ME pressure Onset during ascent

      Duration up to 20 minutes

      (Lundgren, 1965)

    • Human study: 20 mm Hg asym→NYS (Henrickson, 1966)


    Incidence of alternobaric vertigo
    Incidence of Alternobaric Vertigo

    • 10% of Swedish divers (Lundgren, 1974)

    • 33% of Norwegian divers (n = 194)

      (Molvaer, 1988)

    • 14% sport divers (OME or ET)

      (Uzun, 2003)


    Asymmetric caloric stimulation
    ASYMMETRIC CALORIC STIMULATION

    • Stimulus:

      • Unilateral EAC obstruction

        (cerumen, plug, hood, squeeze)

      • ME/Mastoid asymmetry

        (bone, OME, squeeze)

    • Response:

      • Compensated RVR


    Gas toxicity
    GAS TOXICITY

    • Nitrogen narcosis (rapture)

      Dizziness, hallucination

      >100 feet

    • O² toxicity: Seizure, death

      VENTID (vision, ears, nausea, twitching, irritaion, death

      C0², CO contamination


    Counterdiffusion
    COUNTERDIFFUSION

    • Physiologic effect of diffusion of different gases in opposite directions under constant ambient pressure

    • Two gases with different diffusion and solubility coefficients

      • Rapidly diffusing gas moves into tissues

      • More soluble gas diffuses slower

        • Local supersaturation and bubbles

        • Occurs at perilymph/endolymph boundaries

        • Skin lesions and vertigo most common


    Counterdiffusion1
    Counterdiffusion

    • Occurs in divers

      • Immersed in lighter rapidly diffusing gas (helium)

      • Breathes slower gas (neon or nitrogen)

    • Prevent by

      • Recompressing when switching from N to He rich mixes (other way around ok)

      • Avoiding helium rich gases for breathing when surrounded by nitrogen rich gases


    Differential diagnosis
    DIFFERENTIAL DIAGNOSIS

    DIAGNOSIS

    Hearing lossOnset

    IEBT + + Descent

    Fistula + D/A

    IEDCI + Ascent

    Asymmetric caloric - Descent

    Alternobaric vertigo - Ascent

    Gas toxicity - Stable

    Counter diffusion +/- Stable


    ad