Signs of Barotrauma
Barotrauma presents with distinct clinical patterns depending on the anatomical location affected, with pulmonary barotrauma manifesting as respiratory symptoms (pneumomediastinum, pneumothorax) or life-threatening arterial gas embolism with neurological signs, while ear and sinus barotrauma cause localized pain and dysfunction. 1
Pulmonary Barotrauma Signs
Respiratory Manifestations
- Central chest discomfort, hoarseness, and dyspnea are the classic triad for pneumomediastinum 1
- Hemoptysis occurs in 27.2% of cases, representing alveolar hemorrhage and wall rupture 2
- Subcutaneous emphysema presents in 22.7% of cases as gas tracks from the mediastinum into soft tissues 2
- Chest pain manifests in 9.1% of pulmonary barotrauma cases 2
- Cough and dyspnea result from alveolar exudation and hemorrhage during lung compression 1
Arterial Gas Embolism (Most Severe Presentation)
Arterial gas embolism represents the most life-threatening complication, occurring when gas enters the pulmonary venous system and embolizes systemically. 1
- Altered consciousness is the most common neurological sign, occurring in 54.5% of cases 2
- Motor deficits present in 22.7% of cases, manifesting as weakness or paralysis 2
- Any combination of major neurological symptoms and signs can occur, mimicking stroke 1
- Convulsions may develop from cerebral gas embolism 1
- Sudden death can result from coronary artery embolism 1
- Paraparesis has been documented even after shallow dives (5 meters depth) 1
Distribution of Presentations
In a 20-year review of 140 pulmonary barotrauma cases: 1
- 23 cases (16%) had respiratory manifestations only
- 58 cases (41%) presented with arterial gas embolism signs
- The remainder had arterial gas embolism without initial respiratory symptoms
Inner Ear Barotrauma Signs
Vestibular Symptoms
- Vertigo is the predominant symptom in inner ear decompression illness, reported in 94% of cases (17 of 18 divers) 3
- Dizziness occurs in only 35% of inner ear barotrauma cases (9 of 26 patients), and is rarely the main complaint 3
Auditory Symptoms
- Tinnitus is reported in 81% of inner ear barotrauma cases (21 of 26 patients) 3
- Hearing loss occurs in 77% of cases (20 of 26 patients), ranging from subtle 10 dB differences between ears to complete deafness 3
- Bilateral manifestation is rare but documented 3
Long-term Sequelae
Residual cochleovestibular damage persists in 78% of both inner ear decompression illness and barotrauma cases, emphasizing the serious morbidity of these injuries. 3
Other Anatomical Sites
Organs at Risk
Barotrauma can affect multiple gas-containing spaces: 1
- Ear (external, middle, and inner ear)
- Sinuses (paranasal sinuses)
- Intestine (gas expansion in bowel)
- Skin (from diving suit compression)
- Teeth (abscess cavities)
Gas Tracking Patterns
When lung rupture occurs, gas can track to: 1
- Hilum and mediastinum (causing pneumomediastinum)
- Retroperitoneum
- Pleural space (causing pneumothorax, with risk of tension pneumothorax during continued ascent)
- Pulmonary venous system (causing systemic gas embolism)
Clinical Pitfalls and Important Considerations
Severity Independent of Depth
Serious barotrauma can occur after shallow dives due to pressure-volume relationships requiring large volume changes near the surface. 1 Cases of pneumomediastinum, bilateral pneumothorax, and air embolism with paraparesis have occurred after dives to only 5 meters depth. 1
Distinguishing IEBt from IEDCS
Inner ear barotrauma may be difficult to distinguish from inner ear decompression sickness, requiring careful dive-risk stratification, clinical assessment, pure tone audiometry, fistula testing, and electronystagmography. 4
Recurrence Risk
Recurrent barotrauma tends to be more severe than the original incident, emphasizing the critical importance of prevention and proper documentation in medical records. 5
Risk Factors
Patients with less distensible lungs and airways face higher risk due to increased elastic stresses in peribronchial alveolar tissue, with relative airway stiffness increasing the likelihood of alveolar rupture. 1, 5