Barotrauma

Brandon G. Bentz, MD, and C. Anthony Hughes, MD

Page last modified: 10/2012

What is Barotrauma?

What Causes Barotrauma?

How is Barotrauma Diagnosed?

How is Barotrauma Treated?

How Might Barotrauma Affect My Life?

Research Studies on Barotrauma

References

What is Barotrauma?
Barotrauma refers to injury sustained from failure to equalize the pressure of an air-containing
space with that of the surrounding environment. The most common examples of barotrauma
occur in air travel and scuba diving. Although the degree of pressure changes are much more
dramatic during scuba diving, barotraumatic injury is possible during air travel.
Barotrauma can affect several different areas of the body, including the ear, face and lungs. Here
we will focus on barotrauma as it relates to the ear.
What are the Symptoms of Barotrauma?
Symptoms of barotrauma include clogging of the ear, ear pain, hearing loss, dizziness, ringing
of the ear (tinnitus), and hemorrhage from the ear.
Dizziness (or vertigo) may also occur during diving from a phenomenon known as alternobaric
vertigo. It is caused by a difference in pressure between the two middle ear spaces, which
stimulates the vestibular (balance) end organs asymmetrically, thus resulting in vertigo. The
alternobaric response can also be elicited by forcefully equalizing the middle ear pressure with
the Politzer maneuver, which can cause an unequal inflation of the middle ear space.
Inner Ear Decompression Sickness

Inner ear decompression sickness (IEDCS) is an injury that closely resembles inner ear
barotrauma; however, the treatment is different. This injury is more common among commercial
and military divers who breathe a compressed mixture of helium and oxygen. Symptoms include
hearing loss, ringing of the ears, and/or dizziness during ascent or shortly thereafter.
IEDCS most often occurs during decompression (ascent), or shortly after surfacing from a dive.
In contrast, barotrauma most often occurs during compression (descent) or after a short, shallow
dive. Patients with IEDCS should be rapidly transported to a hyperbaric chamber for
recompression. A significant correlation exists between early recompression and recovery.

What Causes Barotrauma?

Barotrauma is caused by a difference in pressure between the external environment and the
internal parts of the ear. Since fluids do not compress under pressures experienced during diving
or flying, the fluid-containing spaces of the ear do not alter their volume under these pressure
changes. However, the air-containing spaces of the ear do compress, resulting in damage to the
ear if the alterations in ambient pressure cannot be equalized. Rarely, barotrauma may be the
result of hyperbaric oxygen therapy. Slow compression hyperbaric oxygen therapy is associated
with a lower risk of otic barotraumas than traditional hyperbaric oxygen therapy (Vahidova et al
2006).
Barotrauma can affect the outer, middle, or inner ear.
Outer Ear
The outer ear is an air-containing space that can be affected by changes in ambient pressure (see
Figure 1). During diving, water normally replaces the air in the external ear canal. An obstruction
such as wax, a bony growth, or earplugs can create an air-containing space that can change in
volume in response to changes in ambient pressure. During descent, the volume of this space
decreases causing the tympanic membrane to bulge outward (toward the outer ear canal). This
can cause pain, small hemorrhages in the ear drum, or blebs (small blisters).

Figure 1
Middle Ear
The most common problem that occurs in diving and flying is the failure to equalize pressure
between the middle ear and the ambient environment (see Figure 2). Equalization of pressure
occurs through the eustachian tube, which is the soft tissue tube that extends from the back of the
nose to the middle ear space. The extent of injury depends upon the degree and speed of the
ambient pressure changes. The greatest relative pressure changes in diving occur near the
surface. Therefore, the largest proportional volume changes, and thus the most injuries, occur at
shallow depths.

Figure 2: Equalization of pressure

As a diver descends to only 2.6 feet with difficulty equalizing the pressure of his middle ear
space, the tympanic membrane and ossicles are retracted, and the diver experiences pressure and
pain (see Figure 3). At higher pressures the eustachian tube may become locked closed by the
negative pressure in the middle ear. This can occur at about 3.9 feet of water. Further increases in
pressure, at depths of only 4.3 to 17.4 feet of water, can cause the tympanic membrane to
rupture.

Figure 3: Effect of blocked eustachian

tube
Inner Ear
Inner ear injury during descent is directly related to impaired ability to equalize the middle ear
pressure on the affected side. Sudden, large pressure changes in the middle ear can be transmitted
to the inner ear, resulting in damage to the delicate mechanisms of the inner ear. This can cause
severe vertigo and even deafness. More material about inner ear damage is available here. Two
mechanisms are theorized to explain inner ear barotrauma: the implosive and the explosive
mechanisms.
The implosive mechanism theory (see Figure 4) involves clearing of the middle ear during
descent. The pressure is transmitted from an inward bulging eardrum, causing the ossicles to be
moved toward the inner ear at the oval window. This pressure wave is transmitted through the
inner ear and causes an outward bulging of the other window, the round window membrane. If a
diver performs a forceful Politzer maneuver and the eustachian tube suddenly opens, a rapid
increase in middle ear pressure occurs. This causes the ossicles to suddenly return to their normal
positions, causing the round window to implode.

Figure 4: Effect of Politzer maneuver

The explosive theory (see Figure 5) suggests that when a diver attempts to clear a blocked
middle ear space by performing a Politzer maneuver and the eustachian tube is blocked and
locked, a dramatic increase in the intracranial pressure occurs. Since the fluids surrounding the
brain communicate freely with the inner ear fluids, this pressure may be transmitted to the inner
ear. A sudden rise in the inner ear pressure could then cause the round or oval window membrane
to explode.

Figure 5: Explosive theory

How is Barotrauma Diagnosed?

Diagnosis is initially based on careful history. If the history indicates ear pain or dizziness that
occurs after diving or an airplane flight, barotrauma should be suspected. The diagnosis may be
confirmed through ear examination, as well as hearing and vestibular testing.

How is Barotrauma Treated?

For outer ear barotrauma, the treatment consists of clearing the ear canal of the obstruction, and
restricting diving or flying until the blockage is corrected and the ear canal and drum return to
normal.
For middle ear barotrauma, treatment consists of keeping the ear dry and free of contamination
that could cause infection. Topical nasal steroids and decongestants may be started in an attempt
to decongest the eustachian tube opening. The presence of pus may prompt the use of appropriate
antibiotics. Most tympanic membrane perforations due to barotrauma will heal spontaneously. If
the eustachian tube demonstrates chronic problems with middle ear equalization, the likelihood
of recovery is drastically reduced.
Prevention of air barotraumas to the middle ear has been attempted with dasal decongestants or
vasoconstrictors with mixed results. Pressure equalizing ear plugs claiming to prevent in-flight
barotrauma are available in many airports for purchase (Klokker et al 2005, Mirza & Richardson
2005). A trial evaluating the effect of these earplugs found them to have no effect on eustachain
tube function (Jumah et al 2010).
For inner ear barotrauma, treatment consists of hospitalization and bed rest with the head
elevated 30 to 40 degrees. Controversy exists whether this type of injury needs immediate
surgery, though success has been reported with careful patient selection (Park et al 2012). Once
healed, a diver should not return to diving until hearing and balance function tests are normal.

How Might Barotrauma Affect My Life?

If barotrauma results from diving, you should not to return to diving until your ear examination
is normal, including a hearing test and the demonstration that the middle ear can be autoinflated.

Research Studies on Barotrauma

As of 07/2012, a visit to the National Library of Medicines search engine, Pubmed, revealed
more than 7,362 research articles concerning barotrauma published since 1940 with 236
published in the last year. At the American Hearing Research Foundation (AHRF), we have
funded basic research on barotrauma in the past, and are interested in funding sound research on
barotrauma in the future. Get more information about contributing to the AHRFs efforts to
detect and treat acoustic neuroma..

Acknowledgments
Figures are courtesy of Northwestern University.
This article was revised for this web site by Timothy C. Hain, MD

References

Bennett MH, Lehm JP, Mitchell SJ, Wasiak J. 2012. Recompression and adjunctive
therapy for decompression illness. Cochrane Database Syst Rev 5: CD005277

Bove A. 2004. Bove and Davis Diving Mediciine. pp. 441.

Jumah MD, Schlachta M, Hoelzl M, Werner A, Sedlmaier B. 2010. Pressure regulating

ear plug testing in a pressure chamber. Aviation, space, and environmental medicine 81:
560-5

Klokker M, Vesterhauge S, Jansen EC. 2005. Pressure-equalizing earplugs do not prevent

barotrauma on descent from 8000 ft cabin altitude. Aviation, space, and environmental
medicine 76: 1079-82

Mirza S, Richardson H. 2005. Otic barotrauma from air travel. The Journal of
laryngology and otology 119: 366-70

Park GY, Byun H, Moon IJ, Hong SH, Cho YS, Chung WH. 2012. Effects of early
surgical exploration in suspected barotraumatic perilymph fistulas. Clinical and
experimental otorhinolaryngology 5: 74-80

Vahidova D, Sen P, Papesch M, Zein-Sanchez MP, Mueller PH. 2006. Does the slow
compression technique of hyperbaric oxygen therapy decrease the incidence of middleear barotrauma? The Journal of laryngology and otology 120: 446-9