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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. EAC squeeze Sinus squeeze Mask squeeze Middle Ear Barotrauma. Elastic Cavity.

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Otologic Manifestations of Barotrauma

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  1. Otologic Manifestations of Barotrauma David M. Kaylie, MD FACS Otolaryngology – Head and Neck Surgery

  2. ENT Manifestations of Barotrauma • EAC squeeze • Sinus squeeze • Mask squeeze • Middle Ear Barotrauma

  3. 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

  4. Inelastic Cavity • Constant volume • Pressure changes 1 atm surface 33ft 4 atm 30 m

  5. Cavities Surface 3 ATM 1 atm Lungs (elastic) 33ft Bony Cavity (inelastic)) 4 atm 132 ft

  6. 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

  7. External Ear Canal Squeeze • Hood • Cerumen • Plug • Elderly • Congenital small ear canals • Swimmers (Surfers) Ear → Exostoses

  8. Exostoses • Cold water exposure • Benign • Trap cerumen

  9. Osteoma

  10. External Ear Canal Barotrauma

  11. Inside: Hemotympanum and Hemorrhage of Ear Canal Skin

  12. 1 Month: Exfoliation

  13. 6 Weeks: Otitis Externa

  14. 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

  15. Barosinusitis • Descent 68%, Ascent 32% (Fagan 1976) • Pain • Nosebleed

  16. Barosinusitis • Frontal > maxillary > ethmoid • Blindness and meningitis (Parell and Becker, 2000)

  17. Treatment of Barosinusitis • Elevate head • Heat • Oxymetazoline (Afrin) • Pseudoephedrine (Sudafed) • Avoid antihistamine – not beneficial • Antibiotics for secondary bacterial infection • Analgesia

  18. Middle Ear Barotrauma • Most common medical condition of divers • Occurs mainly on descent • Symptoms- pain, conductive hearing loss • Signs- hemotympanum, perforation

  19. MEBT • 4 fsw pressure > tensor tympani strength • 10–69 fsw Dimeric TM rupture • Keller, 1958 • Jensen, 1993

  20. Normal Ear Canal and TM

  21. Acute Hemotympanum

  22. Resolving Hemotympanum

  23. Perforation

  24. 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.

  25. 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

  26. Equalizing Techniques • Swallow, jaw thrust • pseudoValsalva: • Alar balloon • Lowry: • pValsalva+swallow • Edmonds: • pValsalva+jaw thrust

  27. 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

  28. Equalizing Middle Ear:Managing Difficult Cases • Dry land practice • Anchor line – helps control decompression stop in rough water • Private lesson • No bouncing • Medication

  29. 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, +++

  30. TMJ • 25 – 65% of SCUBA divers • Sea Cure • Right Bite • Custom mouth piece • Check hose length

  31. 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

  32. Meniere’s Disease • Spontaneous vertigo at depth • Emphasize risk of aspiration, death • One year symptom free without treatment chamber/rescue diver • Simultaneous (C°)

  33. Dive with perforation/cavity • Pro Ear 2000

  34. Dive with perforation

  35. Dive with perforation/cavity • Dry Hood

  36. Diving After Ear Surgery • Tympanoplasty 3 months • PORP yes • TORP +/- • Cochlear Implant 3 atm (device 4 atm) • PLF +/- • Acoustic neuroma No

  37. Dive after Sinus Surgery • -6 weeks • -Healed ostia

  38. Practical Approach to Stings • Hot water (as tolerated, 110°) • Ammonia, alcohol, papain, peroxide • Vibrio vulnificus – gram negative • Ceftriaxone, Cipro, Septra, Doxycycline

  39. The Dizzy Diver

  40. Differential • Hangover • Motion sickness • Disembarkment • Diving disorders • Heart • Circulation • CNS, Endocrine

  41. 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

  42. 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

  43. 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 +

  44. Diving Disorders Causing Dizziness Four categories of IEBT During compression At Stable Depths During decompression Noise trauma

  45. Diving Disorders Causing Dizziness Inner ear barotrauma Perilymph fistula Inner ear DCI Alternobaric vertigo Gas toxicity Isobaric counter-diffusion

  46. 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

  47. Oval and Round Windows • Sudden insufflation of middle ear snaps TM laterally, displacing stapes laterally and RW medially.

  48. Incidence of IEBT • 76 of 15,000 (0.5%) logged dives • Molvaer (1988) • 26 of 319 (8%) patients with dive-ENT disorders • Klingmann (2006)

  49. Recurrent IEBT • Israel Naval Medical Institute • 2 of 44 (5%) of IEBT seen in 18 years (Shupak, 2006)

  50. 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

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