Barotitis The 5 Minute Pediatric Consult


	Barotitis

Laura N. Sinai

Database
Differential Diagnosis
Data Gathering
Physical Examination
Laboratory Aids
Therapy
Follow-Up
Common Questions and Answers
Bibliography

DATABASE

DEFINITION

Barotrauma of the middle or inner ear, most often caused by scuba diving or flying.

PATHOPHYSIOLOGY

The eustachian tube is responsible for equalizing pressure of middle ear to external ear or environment. Differences in the atmospheric pressure between the inner ear, middle ear, and the environment result in injury to the middle and/or inner ear. When ambient pressure decreases (e.g., airplane ascent) the tympanic membrane bulges outward and the eustachian tube vents the excess middle ear pressure. (With a functioning eustachian tube, barotitis does not develop; the pressure is easily equalized.) When ambient pressure increases (e.g., scuba diving, airplane descent) the tympanic membrane bulges inward and the eustachian tube resists inward flow of air to the middle ear. (Even with a normally functioning eustachian tube, pressure equalization is difficult.)
Middle ear barotitis results in vascular engorgement, bleeding, and exudate formation.
Inner ear barotrauma can cause labyrinthine window rupture.
At a pressure differential of 60 mm Hg (greater ambient to middle ear pressure), subjective discomfort is reported. At a pressure differential of 90 mm Hg, the eustachian tube becomes “locked,” because the palatal musculature is not strong enough to open the tube and air will not be able to enter the middle ear to equalize the pressure. The tympanic membrane can rupture at pressure differentials over 100 to 500 mm Hg.
Barotitis is sometimes classified using Teed’s classification of disease severity; see Physical Examination section.

EPIDEMIOLOGY

Significant disease is uncommon in commercial (pressurized) aircraft, although mild negative pressure of the middle ear is common after flying.
Significant symptoms or injury can occur in scuba divers, and those who fly military aircraft and experience rapid altitude changes during tactical maneuvers.

COMPLICATIONS

Vertigo
Hearing loss
Tympanic membrane rupture
Oval or round window rupture
Hemorrhage

PROGNOSIS

Complete spontaneous resolution in mild cases
Rarely, tympanotomy or tympanostomy is required to relieve pressure and pain, as well as prevent complications.
Variable outcome for auditory and vestibular symptoms and injuries to inner ear

DIFFERENTIAL DIAGNOSIS

INFECTION

Otitis media with effusion can cause decreased hearing, sensation of fullness, tympanic membrane hyperemia, and pain.

TRAUMA

Blunt trauma to the tympanic membrane (e.g., cotton swabs) can cause rupture and bleeding.
Exposure to extremely loud noise can result in pain and hearing loss.

DATA GATHERING

HISTORY

Questions regarding exposure to pressure change (diving or flying) or trauma (ear clapping, “heavy metal” concert) are critical to making the proper diagnosis.
Ear pain, sensation of pressure, and decreased hearing are the most common symptoms.
Symptoms of inner ear damage may include vestibular and/or auditory complaints.

PHYSICAL EXAMINATION

Teed’s Classification:

Grade 0: Normal

Grade 1: Retraction, redness in Schrapnell membrane and along manubrium

Grade 2: Retraction, with redness of entire ear drum

Grade 3: Grade 2 plus hemotympanum or clear exudate

Grade 4: Perforation of tympanic membrane

Nystagmus
Hearing loss

LABORATORY AIDS

TESTS

Hearing Tests

Should be performed on all patients who have signs of barotrauma, and on patients with normal physical examinations but who are symptomatic.

Radiographic Studies

MRI: may be indicated in patients with vestibular symptoms or hearing loss to rule out inner ear damage.

THERAPY

When diving or descending in an airplane, performing a Valsalva maneuver (blowing the nose while pinching the nostrils closed) will force air into the middle ear via the eustachian tube, thereby equalizing the pressure between the middle ear and the environment.
Swallowing, yawning, and chewing can aid release of pressure through the eustachian tube when ascending in an airplane or when returning to the surface when scuba diving.
A Politzer bag is an instrument used for clearing pressure disequilibrium that has not improved with Valsalva maneuvers and a trial of decongestants. (See Brown, 1994, for a description of the device and its use.)
Otovent is another instrument that can be used for treatment or prevention. Usage can be taught to children as young as 2 to 6 years of age.
Severe disease may require tympanotomy or tympanostomy to relieve pressure.
For the patient with excruciating pain or unrelenting eustachian tube dysfunction, myringotomy is effective. It is best performed by an otorhinolaryngologist.

DRUGS

Nasal decongestant sprays may be helpful by constricting mucosal arterioles and enhancing eustachian tube function. Topical decongestants are used 1 hour prior to plane travel/diving and one-half hour prior to plane descent.
Oral decongestants may be helpful through the same physiologic pathway as topical agents. They should be initiated 1 to 2 days prior to the expected pressure change.
Antihistamines may also be helpful by reducing mucosal edema and enhancing the eustachian tube orifice. They can be used on the day of the expected pressure change.

FOLLOW-UP

Pressure differential without damage to the middle or inner ear usually resolves within a few days of returning to normal atmospheric pressure.
Barotitis that resulted in injury to the middle or inner ear has a variable rate of improvement; some damage is permanent (e.g., organ of Corti), while other injury is reversible (e.g., tympanic membrane).

PREVENTION

Travel in commercial aircraft will generally not result in severe barotitis.
Most items in the Therapy section can be used as prevention: antihistamines, decongestants, avoidance of dehydration, frequent Valsalva maneuver, Otovent use, and so on.
Ascend and descend carefully when scuba diving.
Avoid dehydration and the resulting thickened secretions that may interfere with eustachian tube function.

COMMON QUESTIONS AND ANSWERS

Q: Is the Valsalva maneuver also effective on plane ascent?
A: Yes, creating even greater pressure in the middle ear by performing the Valsalva maneuver can overcome a resistant eustachian tube and result in sudden venting of increased middle ear pressure.

Q: Can children with otitis media travel in airplanes?
A: Yes, Weiss and Frost (1987) have shown that commercial air travel did not result in worsening of symptoms, and, in fact, the presence of otitis media with effusion seemed protective against barotitis.

Q: How can I help my baby not have ear pain when traveling in an airplane?
A: Have the child nurse, take a bottle, or eat during ascent and descent. This will result in pharyngeal movements that will repeatedly open the eustachian tube and equalize middle ear pressure to environmental pressure. Also, if the child is currently experiencing an upper respiratory infection, use of decongestants prior to flight may be helpful.

ICD-9-CM 993.0

BIBLIOGRAPHY

Brown TP. Middle ear symptoms while flying: ways to prevent a severe outcome. Postgrad Med 1994;96:135–142.

Nakashima T, Itoh M, Sato M, Watanabe Y, Yanagita N. Auditory and vestibular disorders due to barotrauma. Ann Otol Rhinol Laryngol 1988;97:146–152.

Stangerup SE, Tjernstrom O, Harcourt J, Klokker M, Stokholm J. Barotitis in children after aviation: prevalence and treatment with Otovent. J Laryngol Otol 1996;110:625–628.

Weiss MH, Frost O. May children with otitis media with effusion safely fly? Clin Pediatr 1987;26:567–568.

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