What is the treatment for ear barotrauma?

Treatment of Ear Barotrauma

The primary treatment for ear barotrauma includes decongestants, analgesics, and pressure equalization techniques, with more severe cases requiring medical intervention such as myringotomy or surgical repair. 1

Understanding Ear Barotrauma

Ear barotrauma occurs when there is difficulty equalizing pressure between the middle ear and the external environment after changes in ambient pressure. This condition commonly results from:

• Air travel (particularly during descent) 2
• Diving activities (both recreational and professional) 1, 3
• Underwater exercises even at shallow depths 4

The primary mechanism involves failure of the eustachian tube to equalize middle ear and atmospheric pressures, leading to pressure differences that cause traumatic inflammation 2.

Clinical Presentation

Patients with ear barotrauma typically present with:

• Ear fullness and otalgia (ear pain) 2
• Hearing loss or decreased hearing 2, 3
• Tinnitus in some cases 4
• Vertigo and gait instability in cases involving inner ear damage 4
• Haemotympanum (blood in the middle ear) 5
• In rare cases, facial nerve paralysis if the tympanic segment of the facial nerve is dehiscent within the middle ear 5

Treatment Algorithm

1. Mild to Moderate Ear Barotrauma:

• Oral decongestants: Pseudoephedrine has shown effectiveness in reducing otalgia in adults with recurrent ear pain during air travel 2
• Nasal decongestant sprays: Though oxymetazoline nasal spray has been studied, it did not show statistically significant reduction in symptoms when taken 30 minutes before descent 2
• Analgesics: For pain management 2
• Pressure equalization techniques: Proper education on equalizing techniques (Valsalva maneuver, yawning, swallowing) to prevent recurrence 3

2. Moderate to Severe Ear Barotrauma:

• Conservative management is the recommended first-line therapy for inner ear barotrauma 3
• Steroids: Often used in clinical practice, although high-level evidence is lacking 3
• Myringotomy: Simple myringotomy (surgical incision in the tympanic membrane) may be necessary in cases with significant middle ear effusion or to relieve pressure 5

3. Severe Ear Barotrauma with Complications:

• Exploratory surgery: Indicated for severe or persisting vestibular symptoms, significant hearing loss, deterioration of symptoms, or lack of improvement over 10 days 3
• Surgical repair: For tympanic membrane perforation or round window membrane rupture that doesn't heal spontaneously 2
• Recompression therapy: While primarily used for decompression sickness, it does not appear to cause harm if the diagnosis between inner ear barotrauma and inner ear decompression sickness is uncertain 3

Special Considerations

Diving-Related Barotrauma:

• Differentiate between inner ear barotrauma and inner ear decompression sickness, which requires:
  • Dive-risk stratification 3
  • Careful assessment of diving-related ear events 3
  • Pure tone audiometry 3
  • Fistula testing 3
  • Electronystagmography (ENG) 3

Return to Diving After Ear Barotrauma:

Contrary to traditional advice that permanently restricts diving after inner ear barotrauma, limited evidence suggests that return to diving may be possible under specific conditions:

• Stable and non-severe sensorineural hearing loss 6, 3
• No vestibular involvement (confirmed via ENG) 3
• High-resolution CT scan excluding anatomical predisposition to inner ear barotrauma 3
• Proper education on equalizing techniques 6, 3

Prevention of Recurrence:

• Proper instruction on methods to maximize eustachian tube function 6
• Avoidance of diving or flying when congested 2
• Proper equalization techniques during pressure changes 1, 3

Complications to Monitor

• Tympanic membrane perforation 2
• Round window membrane rupture 2
• Perilymph fistula 3
• Inner ear hemorrhage 3
• Permanent hearing loss 3, 4
• Facial nerve paralysis (rare) 5

Pitfalls to Avoid

• Failing to differentiate between inner ear barotrauma and inner ear decompression sickness in divers, which require different treatments 3, 4
• Delaying treatment for severe symptoms, which may lead to permanent damage 3
• Overlooking the possibility of facial nerve involvement in middle ear barotrauma 5
• Using high-pressure oxygen insufflation, which can cause further barotrauma 1