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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.

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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
slide19
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, +++
slide30
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

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