Middle ear barotrauma
Middle ear barotrauma is injury to the tympanic membrane and middle ear from a pressure gradient the eustachian tube cannot equalize, typically during aircraft descent or diving. Most cases are mild and resolve with decongestion and pressure avoidance, but severe cases progress to hemotympanum or tympanic membrane rupture.
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What this article covers
- Overview
A pressure-gradient injury of the middle ear: middle ear barotrauma occurs when a rapid change in ambient pressure (aircraft descent, diving descent, or, less often, ascent) is not matched by air…
- Epidemiology
Common with air travel and diving: barotrauma of the middle ear is a recognized complication of activities that involve a rapid ambient pressure change, principally aircraft descent and underwater diving.
- Risk factors
Active or recent upper respiratory infection: nasopharyngeal inflammation narrows the eustachian tube orifice, the same mechanism that predisposes to acute otitis media.
- Pathophysiology
Normal equalization depends on active eustachian tube opening: swallowing, yawning, and jaw movement briefly open the eustachian tube, letting air move between the nasopharynx and middle ear so…
- Clinical features
Ear pain and pressure during descent, the hallmark: pain typically begins during descent (aircraft landing or diving descent), progressively worsening if equalization is not achieved.
- Differential diagnosis
Acute otitis media: fever and a bulging, erythematous tympanic membrane, but no pressure-change trigger and usually a preceding upper respiratory infection; the two can coexist since both involve eustachian tube compromise.
- Diagnosis
Middle ear barotrauma is a clinical diagnosis confirmed by otoscopy: the history of ear pain or pressure developing during a rapid ambient pressure change (aircraft descent, diving descent), combined…
- Management
Stop further descent or diving immediately once symptoms begin: halting the pressure change is the first and most effective step, since continuing to descend without equalization worsens the injury.
- Complications
Tympanic membrane perforation: the most common significant complication of severe barotrauma, presenting with sharp pain, audiosensitivity, and possible otorrhagia.
- Prognosis
Most cases resolve fully with conservative management: mild to moderate barotrauma (retraction, erythema, or effusion) typically resolves within days of stopping the pressure exposure and starting decongestion.
- Prevention
Avoid flying or diving during an active upper respiratory infection or significant nasal congestion, since eustachian tube function is impaired and the risk of barotrauma during descent is substantially higher.
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Related articles
- Eustachian tube dysfunction
Failure of the eustachian tube to equalize middle ear pressure causes aural fullness, popping, and muffled hearing, confirmed by a retracted, hypomobile tympanic membrane on pneumatic otoscopy, and is managed first with autoinflation and intranasal steroid or decongestant therapy before escalating to tympanostomy tubes or balloon tuboplasty for refractory cases.
- Tympanic membrane perforation
A full-thickness defect in the eardrum from trauma or infection, causing sudden ear pain, conductive hearing loss, and otorrhea. Diagnosis is by otoscopy. Most heal spontaneously with dry-ear precautions; a draining ear is treated with ofloxacin otic drops, and a perforation that fails to close by 3 months is referred for myringoplasty or tympanoplasty.
- Acute otitis media
Acute otitis media is a suppurative middle ear infection, mostly in young children, diagnosed by otoscopy showing a bulging, erythematous tympanic membrane with an effusion, and it is treated with observation or amoxicillin depending on age and severity.
- Cholesteatoma
Cholesteatoma is an abnormal growth of keratinizing squamous epithelium in the middle ear that erodes the ossicles, mastoid, and adjacent skull base; it is confirmed on otoscopy, staged by CT, and requires mastoidectomy with tympanoplasty because no medical therapy is curative.
- Hearing loss
Hearing loss is evaluated with the Weber and Rinne tuning fork tests to sort conductive from sensorineural loss at the bedside, then confirmed with audiometry; treatment ranges from cerumen removal or hearing aids to urgent oral prednisone and otolaryngology referral for sudden sensorineural loss.