Ear and Sinus Barotrauma
Diving can affect the external, middle, and inner ear. Typically, divers experience ear fullness and pain during descent; if pressure is not quickly equilibrated, middle ear hemorrhage or tympanic membrane rupture may occur. Inflow of cold water to the middle ear may result in vertigo, nausea, and disorientation while submerged. On examination of the ear canal, the tympanic membrane may show congestion, hemotympanum, perforation, or lack of mobility during air insufflation with a pneumatic otoscope; conductive hearing loss is usually present.
Inner ear barotrauma often involves rupture of the round or oval window, which causes tinnitus, sensorineural hearing loss, vertigo, nausea, and vomiting. The resulting labyrinthine fistula and perilymph leakage can permanently damage the inner ear.
Sinus barotrauma most often affects the frontal sinuses, followed by the ethmoid and maxillary sinuses. Divers experience mild pressure to severe pain, with a feeling of congestion in the involved sinus compartments during ascent or descent and sometimes epistaxis. Pain can be severe, sometimes accompanied by facial tenderness on palpation.
Rarely, the sinus may rupture and cause pneumocephalus with facial or oral pain, nausea, vertigo, or headache. Rupture of a maxillary sinus can cause retro-orbital air with diplopia due to oculomotor dysfunction. Compression of the trigeminal nerve in the maxillary sinus can cause facial paresthesias. Physical examination may detect tenderness in the sinuses or nasal hemorrhage.
Imaging (eg, plain x-rays, CT) is not necessary for diagnosis of uncomplicated sinus barotrauma, but CT is useful if sinus rupture is suspected.
Most ear and sinus barotrauma injuries resolve spontaneously and require only symptomatic treatment and outpatient follow-up.
Drug treatment for sinus and middle ear barotrauma is identical. Decongestants (usually oxymetazoline 0.05%, 2 sprays each nostril twice a day for 3 to 5 days or pseudoephedrine 30 to 60 mg orally 2 to 4 times a day up to a maximum of 240 mg/day for 3 to 5 days) can help open occluded chambers. Severe cases can be treated with nasal corticosteroids. Pain can be controlled with nonsteroidal anti-inflammatory drugs or opioids.
If bleeding or evidence of effusion is present, antibiotics are given (eg, amoxicillin 500 mg orally every 12 hours for 10 days, trimethoprim/sulfamethoxazole 1 double-strength tablet orally twice a day for 10 days).
For middle ear barotrauma, some physicians also advocate a short course of oral corticosteroids (eg, prednisone 60 mg orally once a day for 6 days, then tapered over 7 to 10 days).
Referral to an otorhinolaryngologist is indicated for severe or persistent symptoms. Urgent surgery (eg, tympanotomy for direct repair of a ruptured round or oval window, myringotomy to drain fluid from the middle ear, sinus decompression) may be necessary for serious inner or middle ear or sinus injuries.
During a dive, ear barotrauma during descent may be avoided by frequently swallowing or exhaling against pinched nostrils to open the eustachian tubes and equalize pressure between the middle ear and the environment. Pressure behind ear plugs cannot be equalized, so they should not be used for diving.
Prophylaxis with oxymetazoline 0.05% nasal spray, 2 sprays per nostril twice daily or pseudoephedrine 30 to 60 mg orally 2 or 4 times a day up to a maximum of 240 mg/day, beginning 12 to 24 hours before a dive, can reduce the incidence of ear and sinus barotrauma. Diving should not be done if congestion does not resolve or if an upper respiratory infection or uncontrolled allergic rhinitis is present.
If patients have tinnitus, hearing loss, or vertigo, arrange urgent audiometry and vestibular testing.
Consider CT if sinus rupture is suspected.
If symptoms are severe, prescribe an analgesic and a decongestant.
Decrease risk of ear and sinus barotrauma by counseling against diving when the nose is congested and sometimes by prescribing prophylactic oxymetazoline or nasal pseudoephedrine.
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