BAROTITIS MEDIA

BAROTITIS MEDIA - Tyeese Gaines-Reid, DO, MA
BASICS
DESCRIPTION
• Inflammation of the middle ear space (tympanic cavity, eustachian tube, and mastoid air cells) secondary to changes in negative pressure between the external canal and middle ear
• Caused by the inability of the eustachian tube to adequately equilibrate the middle ear air pressure with the moment-to-moment changes in environmental atmospheric pressures while descending or ascending in air (flight) or in water (diving)
- Causes the retraction or protraction of the tympanic membrane, with subsequent inflammation and/or rupture
- May cause asymmetric pressure stimulation of the inner ear and vestibular end organ
- Negative pressure can also cause serous fluid or blood to pool in the middle ear.
• System(s) Affected: Nervous; ENT
• Synonym(s): Dysbarism; Aerotitis; Otitic barotrauma; Middle ear barotrauma
ALERT
Valsalva maneuver can spread nasopharyngeal infection into the middle ear.
Pediatric Considerations
Children have difficulty dilating the eustachian tube even at small pressure changes and therefore are at higher risk (especially with upper-respiratory infection).
Pregnancy Considerations
The nasal congestion often associated with pregnancy increases risk of barotitis media.
GENERAL PREVENTION
• Avoid altitude changes when any risk factors are present for eustachian tube dysfunction.
• Use methods of autoinflation during pressure changes.
EPIDEMIOLOGY
• Predominant age: All ages
• Predominant sex: Male = Female
Incidence
• The most common medical disorder experienced by SCUBA divers
• Also highly prevalent among aircraft flight personnel (especially high-performance jet aircraft), passengers, and sky divers
RISK FACTORS
• Participating in high-risk activities without adequate eustachian tube autoinflation (Valsalva maneuver, swallowing, yawning)
• Any causes of eustachian tube and external ear canal dysfunction
- SCUBA diving
- Airplane flight (especially high performance)
- Sky diving
- High-altitude mountain traveling
- High-altitude elevator rides
- Hyperbaric oxygen chamber therapy
- High-impact sports
• Infants and young children (especially with upper-respiratory infection)
• Upper respiratory infections
• Nasal congestion or allergic rhinitis
• Pregnancy
• Anatomic obstruction in the nasopharynx
ETIOLOGY
• Rapid descent or ascent with eustachian tube obstruction
- Upper-respiratory infections: Sinusitis, rhinitis, tonsillitis, adenoiditis, otitis media
- Overzealous forceful Valsalva maneuver (in ascent with vestibular stimulation)
- Allergic rhinitis
- Nonallergic rhinitis with eosinophilia
- Obstructing nasal polyps
- Deviated nasal septum
- Congenital abnormalities of inner/middle ear (cleft palate)
- Nasopharyngeal tumors
• Rapid descent or ascent with external ear canal occlusion
- Otitis externa (swimmer's ear)
- Impacted cerumen
- Ear plugs
• Trauma to external and middle ear
- Boxing, soccer, water skiing, accidents, etc.
- Overzealous use of cotton swab in cleaning ear canals
• Otalgia and hearing loss occurs as a result of stretching and malformation of the tympanic membrane.
ASSOCIATED CONDITIONS
• Aerosinusitis
• Aerodontalgia
• Face mask squeeze
• Epistaxis
• Alternobaric vertigo
• Unequal caloric stimulation vertigo
• Anxiety (leading to panic attack)
• Temporomandibular joint syndrome
• Inner ear cochlear damage and/or perilymph fistula


DIAGNOSIS
SIGNS AND SYMPTOMS
• Abrupt onset
• Otalgia (ear pain)
• Feeling of fullness or pressure in ear
• Conductive hearing loss
• Dizziness
• Tinnitus, pulsating or constant
• Vertigo
• Nausea and vomiting
• Transient facial paralysis
• With tympanic membrane rupture, leakage of air or fluid from the ear during sneezing or Valsalva
• Crying in children (which is a means of autoinflation)
TESTS
Tympanometry
Imaging
Only to rule out suspected nasopharyngeal tumor or sinusitis
Diagnostic Procedures/Surgery
• Otoscopic exam
• Audiogram: Conductive (middle ear) vs. mixed (inner ear) hearing loss
• Surgical exploration to rule out inner ear involvement if suspected
Pathological Findings
• Tympanic membrane retraction or protraction with hemotympanum or rupture
• Edema of mucosal lining and capillary engorgement with transudation of middle ear effusion
• Inner ear involvement with rupture of the round or oval windows and leakage of perilymph into the middle ear and perilymphatic fistula development
DIFFERENTIAL DIAGNOSIS
• Inner ear barotrauma
• Serous otitis media
• Acute and chronic otitis media
• External otitis
• Myringitis bullosa
• Temporomandibular joint syndrome
TREATMENT
GENERAL MEASURES
• Prevention/avoidance is best
- Avoid flying or diving while risk factors exist, if possible
• Autoinflate the eustachian tube during pressure changes
- Valsalva method (1)[B]
 Patient occludes nose with thumb and index finger pressure on nasal alae, then carefully exhales with mouth closed until ears "pop." This will equalize pressures, relieve pain, and restore hearing. This usually must be repeated several times during descent or ascent.
- Infants: Breastfeeding, or sucking on pacifier or bottle
- 4 years: Chewing gum
- 8 years: Blowing up a balloon
- Adults: Chewing gum, sucking hard candy, or yawning
• Nasal balloon (1)[B]
• If the suggested maneuvers are unsuccessful, return to baseline altitude if possible; autoinflate then resume ascent/descent
• If associated bacterial upper respiratory infection, treat with appropriate antibiotics
• If inner ear exposed, bed rest with head of bed elevated to help drainage
Diet
Avoid food allergens that cause rhinitis.
Activity
• No flying or diving until complete resolution of all signs and symptoms and Valsalva maneuver can be performed
• In severe cases, bed rest
MEDICATION (DRUGS)
First Line
• Antihistamines
- Pseudoephedrine. Start 30-60 minutes prior to exposure
 Studies showed oral pseudoephedrine decreased otalgia in adults but not in children (2)[C].
- Oxymetazoline nasal spray (Afrin, Afrin 12-Hour)
 Beware of rebound congestion after 3-5 days of use
 No statistical significance that it prevents symptoms (2)[C]
- Phenylephrine nasal spray (Neo-Synephrine)
- Antihistamines for allergic component (no data demonstrate benefit except to relieve allergy symptoms)
 Diphenhydramine (Benadryl)
 Loratadine (Claritin)
 Fexofenadine (Allegra)
• Precautions
- All medications must be used on the ground to rule out idiosyncratic reactions that could incapacitate in an airplane or underwater environment.
- Elderly are more susceptible to drug side effects, especially with diphenhydramine
- Caution with hypertension
• Analgesics for pain control
• Tinnitus can be treated with high-dose steroids if given within 3 weeks of onset (3)[C].
SURGERY
If necessary, myringotomy or tympanoplasty
FOLLOW-UP
DISPOSITION
Admission Criteria
Patients with complicating emergencies (e.g., incapacitating pain requiring myringotomy, large tympanic perforation requiring tympanoplasty)
Issues for Referral
Refer to otolaryngology if
• Inner ear is exposed
• Perilymphatic fistula
• Sensorineural hearing loss
PROGNOSIS
• Untreated, simple barotitis media resolves on its own unless secondary to diving.
• Ear block: Hours-days, with complete resolution and return to flight or diving within days-weeks
• Tympanic rupture: Recovery within weeks-months
COMPLICATIONS
• Permanent hearing loss
• Ruptured tympanic membranes
• Serous otitis media
• Chronic tinnitus, vertigo
• Bruising of or bleeding into tympanic membrane
• Fluid exudate in middle ear
• Perilymphatic fistula
• Sensorineural hearing loss
PATIENT MONITORING
• Otoscopic until symptoms clear
• In severe cases, audiograms
REFERENCES
1. Stangerup SE, Klokker M, Yesterhauge S. Point prevalence of barotitis and its prevention and treatment with nasal balloon inflation: A prospective, controlled study. Otol Neurol. 2004;25(2):89-94.
2. Mirza S, Richardson H. Otic barotrauma from air travel. J Laryngol Otol. 2005;119(5):366-370.
3. Duplessis C, Hoffer M. Tinnitus in an active duty navy diver: A review of inner ear barotrauma, tinnitus, and its treatment. Undersea Hyperbaric Med. 2006;33(4):223-230.
ADDITIONAL READING
Internet references
• Emedicine, www.emedicine.com
• MedlinePlus Medical Encyclopedia www.medlineplus.gov
• Up to Date, www.uptodate.com