Barotrauma is the pain or discomfort that you feel when there is a difference in air pressure between the outside environment and the inside of your body. You may experience this discomfort when you fly in an airplane or go scuba diving.

The air inside your body squeezes together or expands (swells) as the outside pressure (from water or air pressure) increases or decreases. The squeezing and the swelling can cause pain and damage. Barotrauma can affect the ear, face (sinuses), and lungs—any part of the body with air inside.

• Ear Barotrauma: Barotrauma most commonly affects the middle ear because that is where there is a pocket of air that is sensitive to changes in air pressure.

• • In the ear, you have a thin layer of skin (or membrane) at the end of the ear canal that vibrates and transmits sound to your middle ear. This is called the eardrum.

• • Normally, the air pressure inside and outside your ear is the same. The eustachian tube, the tube that connects the middle ear and the throat, works to balance the air pressure on both sides of your eardrum by allowing air to flow into or out of the middle ear.

• • Ear barotrauma is caused when the eustachian tube gets blocked and your body is not able to equalize the air pressure inside and outside the eardrum.

• • Ear barotrauma is usually not severe or dangerous and is easily treatable but occasionally there are complications such as loss of hearing, ear infection, dizziness, or a perforated (punctured) eardrum.

• Sinus Barotrauma: Sinuses are air-filled pockets in the bone around the nose.

• • Sinus barotrauma occurs when there is a difference in pressure between the air in the sinuses and the pressure outside.

• • You may experience pain around your cheek bones or above your eyes.

• • You may also experience headaches.

• Pulmonary (Lung) Barotrauma: Pulmonary barotrauma is the injury that is caused when outside pressure is different than the pressure of the air in your lungs.

• • Scuba divers swim with canisters of compressed air for breathing under water. If a diver has too much compressed air and ascends without properly exhaling, the lungs may overinflate. One complication is that the lung could collapse.

• • Another complication is “decompression sickness” (often referred to as “the bends”).

• • • Decompression sickness occurs when nitrogen, a chemical dissolved in blood by high pressure, forms bubbles as pressure decreases (such as when you swim up to the surface when diving). These bubbles may leak out into your blood stream as air bubbles called air embolisms.

• • • Air embolisms can travel to any organ in the body and are dangerous when they block blood vessels that feed an organ, especially the heart, lungs, and the brain.

• • • Decompression sickness is classified as Type 1 or Type 2. Type 1 is when the bubbles affect the tissues around joints. Knees, elbows, and shoulders are most often affected. Type 2 is more serious and involves the central nervous system (brain and spinal cord) or the lung and heart.

Barotrauma can even be due to equipment. The equipment, such as a mask or dry suit that you use for scuba diving, can block and trap air against the skin. If such an air pocket exists when you dive, you may become injured. Dry suits can painfully pinch your skin. Masks can cause blood vessels in the eyes to burst.

Contact your doctor if you think you may have some type of barotrauma.

Causes

Barotrauma is caused when the air pressure inside and outside the body are different, causing discomfort. Causes include:

• Flying

• Scuba diving

• • Ascending (going up to the surface) without exhaling freely

• • Swimming quickly to the surface when diving

• • Holding your breath when ascending

• • Length of time spent underwater diving

• • Repeated dives within 24 hours

• • Flying in an airplane after diving

• Air pockets in equipment (eg, scuba diving equipments such as masks and dry suits)

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition.

The following factors increase your chance of developing barotrauma:

• Congested nose from allergies or colds

• Congenital (present before birth) blockage of the eustachian tubes

• Smoker

• Young age–eustachian tubes in children are smaller and more likely to become blocked

• Damaged eustachian tube, caused by scarring or a tumor

• Obstructions in the ear

• Cleft palate or lip–may affect balance of pressure in the middle ears

• Holding your breath while diving

• Deeper dives

• Long amounts of time spent underwater diving

• Repeated dives within 24 hours

• Flying in an airplane after diving

• Rapid climb to the surface when diving

• Fatigue

• Dehydration

• Cold water

• Obesity

• Older age

• Ill-fitting equipment used for scuba diving

• Congenital (present before birth) blockage or narrowing of the sinuse drainage system

Symptoms

If you have symptoms of an air embolism (an air bubble in your blood stream) due to pulmonary barotrauma, you need to seek treatment immediately. Symptoms of an air embolism to the brain are usually identified very quickly after you surface from the water.

Symptoms of decompression sickness usually occur within an hour of surfacing from the water but can occur up to six hours later. If you have decompression sickness, it is very important to seek treatment immediately.

If you experience any of these other symptoms do not assume it is due to barotrauma. These symptoms may be caused by other, less serious health conditions. If you experience any one of them, see your physician.

Symptoms include:

Ear Barotrauma

• Discomfort or pain in one or both ears

• Feeling as though your ears are clogged

• Feeling of pressure in your ears

• Dizziness

• Hearing loss (temporary)

• Bleeding from the ear (rare)

• Tinnitus

Sinus Barotrauma

• Sinus pressure and/or pain

• Nasal bleeding

• Headaches

• Tooth pain

Pulmonary Barotrauma

Symptoms from an air embolism to the brain include reactions similar to a stroke:

• Headache

• • Confusion

• • Agitation

• • Partial paralysis

• Sudden loss of consciousness

• Seizures

• Coughing up blood

• Frothy blood at the mouth

• Chest pain

• Shortness of breath

• Hoarseness

• Pneumothorax: a condition in which air escapes from the lungs into the chest cavity and compresses the lungs resulting in a collapsed lung

• Decompression sickness, symptoms include:

• • Swelling

• • Pain in muscles, joints, tendons

• • Problems of the spinal cord–paralysis

• • Problems of the sensory system

• • Problems with lungs–chest pain, cough, shortness of breath (sometimes called the chokes)

• • Rashes or itchy skin

• • Bubbles under your skin

Diagnosis

Your doctor will ask about your symptoms and medical history, and perform a physical exam. If you have been flying or have been diving recently it is important to tell your physician.

If you think that you have pulmonary barotrauma or decompression sickness, seek medical attention immediately through your doctor or a local hospital.

Ear Barotrauma

When you go to your doctor, he or she will look into your ear with a special flashlight called an otoscope. The otoscope allows your doctor to see your eardrum. If you have barotrauma, your doctor may see a bulge of the eardrum due to the difference in pressure between the inside and outside of your eardrum. If your condition is serious, there may even be blood behind the eardrum.

Sinus Barotrauma

There are no tests to diagnose sinus barotrauma. Diagnosis depends on your doctor getting an accurate history and then conducting an appropriate examination.

Pulmonary Barotrauma

To check for air embolisms and possible lung collapse, your doctor may order tests such as:

• Chest X-ray–this is an x-ray that looks for changes in blood vessel patterns.

• Computed Tomography (CT)–an imaging scan that can find small strokes in the brain that may be caused by air embolisms.

• Pulmonary Function Test–a test that measures how much air is in the lungs and how forcefully this air can be exhaled.

• Lung Perfusion scan–this scan tests for pulmonary embolisms. A tiny amount of radioactive substance is injected into a vein and travels to the lungs. The scan allows your doctor to examine the blood supply to the lungs.

• Magnetic Resonance Imaging (MRI)–this is an imagining scan that provides a three-dimensional image of your body and your doctor can look for brain or spinal cord abnormalities.

• Pulse Oximetry–Your doctor will use this instrument to measure the level of oxygen in your blood. This is a simple device that clips on the finger to measure the oxygen level.

If you have been diving recently and show symptoms of decompression sickness, your doctor may choose to treat you immediately without doing any other tests or at least without waiting for test results to return.

Treatment

Talk with your doctor about the best treatment plan for you. The following measures can also prevent the occurrence of barotrauma. Treatment options include the following:

Prevention

To help reduce your chances of getting barotrauma, take the following steps:

Flying:

• Postpone your flight if you have a cold or are congested.

• When flying in an airplane, especially during take-off and landing, do things that will help keep the eustachian tube open to relieve the pressure. Things you can do include:

• • Suck candy

• • Chew gum

• • Yawn

• • Breath with mouth open

• When flying, avoid sleeping during descent because you may not be swallowing enough.

• Get filtered earplugs–these special earplugs slowly equalize the air pressure against your eardrum.

• For babies on airplanes, have them suck on a bottle or pacifier; do not let the baby sleep during descent.

• Take a decongestant pill or nasal spray a little before the start of the flight to shrink the membranes in the eustachian tube–to help make your ears pop more easily.

• If you are particularly prone to barotraumas, your doctor may suggest having tubes surgically placed in your eardrums to help balance the pressure and prevent the condition.

Scuba Diving:

• Be properly trained.

• Be in good health before diving.

• Make sure all your equipment is working properly.

• Go down and come up slowly in the water when scuba diving. The United States Navy Diving Manual provides guidelines for how often you should stop during your ascent (called decompression stops) and how slowly you should make your ascent.

• Take a decongestant pill or nasal spray a little before diving to unblock you eustachian tubes, your nose, or your sinuses.

• To prevent pulmonary barotrauma, do not hold your breath during ascent (going up).

• Don’t smoke.

• Exhale freely when diving, even in shallow waters of a swimming pool, while ascending to the surface.

• Don’t dive as deep.

• Don’t stay under the water at greater depths for so long.

• Avoid flying or going to a higher altitude for the next 24 hours after diving.

• Know the location of the nearest recompression chamber. The National Diving Alert Network of Duke University provides a 24-hour hotline to get a list of these facilities; the Network can be reached at 919-684-8111.

• Check your dry suit and your facial mask to make sure your equipment is properly vented and your equipment isn’t causing any air to be trapped against the skin.

• Never hold your breath while breathing compressed gas and ascending.

• Never dive alone.

RESOURCES:

American Academy of Audiology
http://www.audiology.org

American Academy of Otolaryngology--Head and Neck Surgery
http://www.entnet.org

Divers Alert Network (DAN)
http://www.diversalertnetwork.org

CANADIAN RESOURCES:

Health Canada
http://www.hc-sc.gc.ca

Canadian Society of Otolaryngology
http://www.csohns.com

References:

Airplane ear. Mayo Clinic website. Available at: http://www.mayoclinic.com/invoke.cfm?objectid=EC298C49-30D6-4BFC-8DA7B069E8272F42. Accessed on September 8, 2005.

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Beers MH, Berkow R. (ed.). Barotrauma. The Merck Manual of Diagnosis and Therapy, Section 24, Chapter 295, Accidents and Injuries. The Merck Manual website. Available at: http://www.merck.com/mmhe/print/sec24/ch295/ch295b.html. Accessed on September 8, 2005.

Beers MH, Berkow R. (ed.). Decompression sickness. The Merck Manual of Diagnosis and Therapy, Section 24, Chapter 295c, Accidents and Injuries. The Merck Manual website. Available at: http://www.merck.com/mmhe/print/sec24/ch295/ch295c.html. Accessed on October 24, 2005.

Beers MH, Berkow R. (ed.). Pulmonary embolism. The Merck Manual of Diagnosis and Therapy, Section 4, Chapter 46, Lung and Airway Disorders. The Merck Manual website. Available at: http://www.merck.com/mmhe/sec04/ch046/ch046a.html. Accessed on October 26, 2005.

Brandt MT. Oral and maxillofacial aspects of diving medicine. Military Medicine. 2004 Feb; 169(2):137-41.

Direct effects of pressure. Florida State University–Academic Diving Program website. Available at http://www.adp.fsu.edu/pennotesfall2003/Section06.pdf. Accessed on October 24, 2005.

Ear barotraumas. National Library of Medicine, NIH website. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001064.htm. Accessed on September 8, 2005.

Ear, sinus, and eye problems. Divers Alert Network website. Available at: http://www.dansa.org/medical/ears.html. Accessed on October 24, 2005.

Ears and altitude. American Academy of Otolaryngology–Head and Neck Surgery website. Available at: http://www.entnet.org/healthinfo/ears/altitude.cfm. Accessed on September 8, 2005.

Newton HB. Neurologic complications of scuba diving. Am Fam Physician. 2001; 63(11):2211-8, 2225-6.