236
At teaching institutions, the use of ultrasound can
enhance the resident physician’s understanding of anatomy
and facilitate mastery of new skills. Often, ultrasound-
guided vascular access and nerve blockade serve as a bridge
to performing such procedures bblindlyQ as the resident
physician’s skills grow.
It is foreseeable that such technology can also assist in
epidural placement, not only as a prepuncture diagnostic
tool but also to guide epidural placement in real time.
As technology improves and our acceptance of it in-
creases, ultrasound-guided epidural placement could become
a valuable tool both for resident and experienced physician.
References
[1] Chan VW, Perlas A, Rawson R, Odukoya O. Ultrasound-guided
supraclavicular brachial plexus block. Anesth Analg 2003;97:
1514 - 7.
[2] Grau T, Leipold RW, Delorme S, Martin E, Motsch J. Ultrasound
imaging of the thoracic epidural space. Reg Anesth Pain Med 2002;27:
200 - 6.
[3] Grau T, Leipold RW, Horter J, Conradi R, Martin E, Motsch J. The
lumbar epidural space in pregnancy: visualization by ultrasonography.
Br J Anaesth 2001;86:798 - 804.
[4] Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of
ultrasound imaging in obstetric epidural anesthesia. J Clin Anesth
2002;14:169 - 75.
[5] Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for
presumed difficult epidural puncture. Acta Anaesthesiol Scand
2001;45:766 - 71.
[6] Yeo ST, French R. Combined spinal-epidural in the obstetric patient
with Harrington rods assisted by ultrasonography. Br J Anaesth
1999;83:670 - 2.
[7] Grau T, Leipold RW, Horter J, Conradi R, Martin EO, Motsch J.
Paramedian access to the epidural space: the optimum window for
ultrasound imaging. J Clin Anesth 2001;13:213 - 7.
Mir E. Ali, MD
Charles E. Laurito, MD
Department of Anesthesiology
University of Illinois at Chicago
Chicago, IL 60612, USA
doi:10.1016/j.jclinane.2005.02.002
Middle ear barotrauma in general anesthesia:
special care
To the Editor:
Hearing loss, tinnitus, and vertigo are rarely considered
as potential complications of general anesthesia (GA),
despite several cases of postoperative hearing and/or
vestibular impairment that have been reported [1 -7].
We reviewed 4988 adults (mean age 47 years) submitted
to GA in the last year at Campus Bio-Medico University for
both major and minor surgery. Among them, 21 (0.4%)
experienced tinnitus, conductive hearing loss, and aural
fullness immediately after recovery from GA, which was
suggestive of middle ear barotrauma. At a more accurate
Correspondence
anamnesis, all of them referred transient episodes of aural
fullness and hearing loss during their life, which was
compatible with a diagnosis of eustachian tube dysfunction
(ETD). No significant relation between the incidence of
middle ear barotrauma and other parameters, such as age,
sex, surgical procedure, medical therapy, and anesthesia
duration, was noted. Nineteen (90.5%) of 21 patients
experiencing GA-related middle ear barotrauma had spon-
taneous resolution of their symptoms within 1 month.
Hearing symptoms following anesthesia in nonotolog-
ical procedures are more often associated with cardiac and
orthopedic surgery [6]. The pathogenesis of such symp-
toms may be related to several events. In cardiopulmonary
bypass procedures, the most likely etiology is emboli of
particulate matter generated by the cardiopulmonary
bypass pump [3], whereas in orthopedic surgery, it is
probably related to fat embolism [4]. In case of nitrous
oxide (N2O) anesthesia, changes in middle ear pressure
may take place: during induction, N2O enters the air-filled
cavity of the middle ear and produces an increased
pressure. When the N2O supply is stopped, the reverse
process takes place, producing a considerable subatmo-
spheric pressure. Pressure changes can be overcome by
either active tubal opening, such as swallowing or
yawning, or passive venting by forcing opening. These
physiological mechanisms of middle ear pressure regula-
tion are not active during GA, while they progressively
recover as long as the patient’s consciousness level
improves. However, some patients may suffer from ETD,
which interferes with venting of the tube [2,6]. In these
cases, obstruction of the eustachian tube generates a
negative pressure during recovery from anesthesia, causing
ear fullness, autophony, transient conductive hearing loss,
and traction on the round window membrane with
consequent irritation of the vestibular system and possible
rupture of the membrane [2,5,6,8]. Furthermore, resuscita-
tive procedures with positive pressure mask ventilation
may cause injury to the tympano-ossicular system by
excessive pressure transmitted rapidly through the eusta-
chian tube, with a consequent rapid increase in middle ear
pressure [1]. During anesthesia, manual positive pressure
ventilation is performed, and patients with ETD might be
particularly vulnerable [6].
Although GA-related hearing symptoms secondary to
middle ear pressure changes are not common (0.4%, in our
experience) and often resolve spontaneously within a few
days, extremely rapid variations may be responsible for
rupture of the round window membrane, with severe
consequences such as perilymph fistula [5]. Because
patients with ETD are at higher risk for middle ear
barotrauma [6], we suggest estimating tube function in all
patients candidates to GA through an easy evaluation of
aural fullness and Valsalva maneuver before hospitalization.
If ETD is suspected, an otolaryngological assessment is
recommended, and in cases of deferrable surgery, we
suggest resolving the ETD with an adequate ENT therapy
Correspondence 237

before the procedure. Finally, we suggest introducing
the augmented risk of hearing disorders in the informed
consent of all patients with ETD who will be submitted to
general anesthesia.
[7] O’Neill G. Prediction of post-operative middle ear pressure changes
after general anaesthesia with nitrous oxide. Acta Otolaryngol 1985;
100:51 - 7.
[8] Iwano T, Kinoshita T, Hamada E, Ushiro K, Yamashita T, Kumazawa
T. Sensation of ear fullness caused by eustachian tube dysfunctions.
Auris Nasus Larynx 1991;18:343 - 9.

References
Fabrizio Salvinelli, MD (Professor, Director)
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[3] Plasse HM, Mittleman M, Frost JO. Unilateral sudden hearing loss after
Felice Agrò, MD (Professor, Director)
open heart surgery: a detailed study of seven cases. Laryngoscope Department of Anesthesia
1981;91:101 - 9. Campus Bio-Medico University –School of Medicine
[4] Millen SJ, Toohill RJ, Lehman RH. Sudden sensorineural hearing loss: 00155 Rome, Italy
operative complication in non-otologic surgery. Laryngoscope
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[5] Segal S, Man A, Winerman I. Labyrinthine membrane rupture caused
Luca D’Ascanio, MD
by elevated intratympanic pressure during general anesthesia. Am J Department of Otolaryngology
Otolaryngol 1984;5:308 - 10. Campus Bio-Medico University –School of Medicine
[6] Hochermann M, Reimer A. Hearing loss after general anaesthesia (a 00155 Rome, Italy
case report and review of literature). J Laryngol Otol 1987;101:
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