Barotrauma to the ear, lungs, eye.

Barotrauma is tissue damage caused by a change in the volume of gases in body cavities associated with a change in pressure.

Damage to air-containing spaces occurs, including the lungs, ears, sinuses, gastrointestinal tract, air spaces in the teeth, and the space under a diving mask. Symptoms may include ear pain, dizziness, hearing loss, sinus pain, nosebleeds, and abdominal pain. Respiratory distress and loss of consciousness are life-threatening and may develop due to alveolar rupture and pneumothorax. Diagnosis is clinical but may require imaging studies. Treatment of barotrauma is generally supportive but may include decongestants and analgesics for ear and sinus barotrauma, or O2 inhalation and pleural drainage for pneumothorax. If arterial gas embolism develops after pulmonary barotrauma, recompression therapy (in a hyperbaric chamber) is indicated. Following safety rules when diving and taking prophylactic decongestants can reduce the likelihood of barotrauma.

The highest risk of barotrauma begins at 30 feet. The risk is increased by any condition that may prevent pressure equalization (e.g., sinusitis, blocked eustachian tube, congenital anomalies, infection) in the air-containing cavities of the body. Ear barotrauma accounts for about one-third of all injuries in divers. If a diver takes even a single breath of air or other gas at depth and does not allow it to escape freely upon ascent, the expanding gas can overinflate the lungs.

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Symptoms of barotrauma

Manifestations depend on the location of the injury. All types of barotrauma develop almost immediately after the pressure change. Some non-fatal disorders, if they occur at depth, can incapacitate, disorient the swimmer and thus lead to drowning.

Pulmonary barotrauma

During a dive with very long deep breath-holding, compression of the lungs can in some cases reduce the lung volume below the residual volume, causing mucosal edema, vascular stasis and bleeding, which during ascent is clinically manifested by respiratory failure and hemoptysis.

When people breathe compressed air, the increase in lung volume due to too rapid ascent or insufficient exhalation can cause overinflation and rupture of the alveoli, leading to pneumothorax (causing dyspnea, chest pain, and unilateral decreased breath sounds) or pneumomediastinum (causing a feeling of fullness in the chest, neck pain, pleuritic chest pain that may radiate to the shoulder, respiratory distress, cough, dysphonia, and dysphagia). Tension pneumothorax, although rare with barotrauma, can cause hypotension, distended neck veins, a hyperresonant percussion sound over the lungs, and tracheal deviation. Pneumomediastinum may be accompanied by crepitus in the neck due to subcutaneous emphysema, the crackling sound of which can also be heard on auscultation of the heart during systole (Hamman sign). When the alveoli rupture, air often enters the pulmonary venous system, resulting in arterial gas embolism.

The above symptoms require neurologic examination to detect signs of brain damage due to gas embolism. In the absence of neurologic symptoms, a standing chest radiograph (presence of a contrast band along the cardiac outline) is performed to exclude pneumothorax or pneumomediastinum. If chest radiograph is inconclusive but clinical suspicion remains, CT is indicated, which may be more sensitive than plain radiographs and may aid in diagnosis.

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Ear barotrauma

Diving can cause trauma to the outer, middle, and inner ear. Typically, the diver experiences ear congestion and pain during descent. If the pressure is not quickly equalized, bleeding from the middle ear or rupture of the eardrum is possible. When examining the external auditory canal, there may be a blood clot behind the eardrum, hemotympanum, and insufficient mobility of the eardrum during air insufflation from a pneumatic otoscope. Conductive hearing loss is usually noted.

Inner ear barotrauma often involves rupture of the round or oval window, causing tinnitus, sensorineural hearing loss, dizziness, nausea, and vomiting. Formation of a labyrinthine fistula and leakage of the tympanic membranes may cause permanent damage to the inner ear. Patients undergo routine audiometry. Neurological examination should focus on vestibular testing.

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Barotrauma of the paranasal sinuses

Barotrauma most commonly involves the frontal sinuses, which communicate with the ethmoid and maxillary sinuses. Divers may experience moderate pressure to severe pain, with a feeling of fullness in the affected sinuses during ascent or descent, and sometimes nosebleeds. The pain may be severe, sometimes with facial tenderness on palpation. Rarely, a paranasal sinus may rupture, causing pneumocephalus with facial or oral pain, nausea, dizziness, or headache. Clinical examination may reveal sinus tenderness or nosebleeds. Diagnosis is clinical. Imaging studies (eg, plain radiography, CT) are not indicated, although CT may be helpful if sinus rupture is suspected.

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Dental barotrauma

During descent or ascent, the pressure in the air bubbles in or near the roots of carious teeth can change rapidly and cause pain or even damage to the tooth. The damaged tooth is very sensitive to percussion with a spatula. The diagnosis is based primarily on clinical data.

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Barotrauma of tissues under the mask

If the pressure in the space between the mask and the face is not equalized during descent, a relative vacuum occurs, which can lead to local pain, conjunctival hemorrhages, and skin ecchymosis where the mask touches the face. Diagnosis is based on clinical findings.

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Eye barotrauma

Small air bubbles trapped under hard contact lenses can damage the eye and cause severe pain, decreased visual acuity, and halos around lights. Diagnosis is based on clinical findings, but a screening eye exam is necessary to rule out other causes.

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Gastrointestinal barotrauma

Incorrect breathing from a regulator or using ear and sinus equalization techniques can cause the diver to swallow small volumes of air during a dive. This air expands during ascent, causing a feeling of abdominal fullness, cramping, pain, belching, and flatulence; these symptoms resolve on their own and do not require examination. Rupture of the gastrointestinal tract is rare, and is characterized by severe abdominal pain and tenderness with tension in the muscles of the anterior abdominal wall. These symptoms require standing abdominal and thoracic radiography or CT scanning to detect free air.

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Diagnostics

The diagnosis is primarily based on clinical data and is sometimes confirmed by imaging studies.

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Treatment of barotrauma

Treatment begins with stabilization of the condition, 100% O2 is given at high flow, intravenous access is provided, and intubation is performed if there are signs of imminent development of respiratory failure. Positive pressure ventilation can cause or worsen pneumothorax.

Patients with neurologic symptoms or other signs of arterial gas embolism are transported immediately to a recompression chamber for treatment. If a patient with suspected pneumothorax is hemodynamically unstable or has symptoms of tension pneumothorax, the pleural space is immediately drained through a large trocar in the second intercostal space at the midclavicular line for decompression. If the pneumothorax is small and there are no signs of hemodynamic or respiratory instability, the pneumothorax may resolve with high-flow 100% O2 for 24 to 48 hours. If this treatment is ineffective or the pneumothorax worsens, the pleural space is drained.

Pneumomediastinum does not require specific treatment. Symptoms usually resolve spontaneously within a few hours to a few days. After a few hours of observation, most patients are discharged for outpatient treatment. Inhalation of 100% O at high flow is indicated, which accelerates the absorption of extraalveolar gas. In rare cases, mediastinotomy is performed to eliminate tense pneumomediastinum.

Patients with gastrointestinal rupture require intensive fluid therapy, treatment with broad-spectrum antibiotics (eg, imipenem + cilastin 500 mg intravenously every 6 hours), and evaluation by a surgeon to determine the indications for possible exploratory laparotomy.

Treatment of paranasal sinus and middle ear barotrauma is the same. Decongestants (0.05% oxymetazoline 2 sprays in each nostril 2 times daily for 3-5 days; pseudoephedrine 60-120 mg orally 2-4 times daily, up to a maximum of 240 mg daily for 3-5 days) can open blocked cavities. In severe cases, intranasal glucocorticoids can be used. The Valsalva maneuver immediately after intranasal spraying can improve the distribution of the decongestant and help open the cavities. NSAIDs and opioid analgesics are prescribed for pain relief. In case of bleeding and signs of effusion, antibiotics are prescribed (for example, amoxicillin orally 500 mg every 12 hours for 10 days; co-trimoxazole [sulfamethoxazole + trimethoprim] 1 double tablet orally for 10 days). In case of barotrauma of the middle ear, some doctors conduct a short course of glucocorticoids orally (prednisone 60 mg orally once a day for 6 days, then reducing the dose in the next 7-10 days).

Surgery (eg, tympanotomy to directly repair a torn round or oval window, myringotomy to drain fluid from the middle ear, sinus decompression) may be needed if there is significant damage to the inner or middle ear or sinuses. Referral to an otolaryngologist is indicated for severe, persistent symptoms.

Prevention of barotrauma

Ear barotrauma can be avoided by swallowing frequently or attempting to exhale with the nostrils and mouth closed, which helps to “blow out” the auditory tubes and equalizes the pressure between the middle ear and the environment. The pressure under the mask is equalized by exhaling air from the nose into the mask. The pressure behind ear plugs and swimming goggles cannot be equalized, so this method cannot be used when diving. In addition, prophylaxis with pseudoephedrine (orally 60-120 mg 2-4 times a day, maximum up to 240 mg per day), starting 12-24 hours before diving, can reduce the degree of barotrauma of the ears and sinuses. Scuba diving is contraindicated in case of upper respiratory tract infection, uncontrolled allergic rhinitis or edema of the upper respiratory tract mucosa of any etiology.

Patients with pulmonary bullae or cysts, Marfan syndrome, or COPD are at high risk for pneumothorax and should not dive or work in high-pressure environments. Patients with asthma are also at risk for pulmonary barotrauma, but many can dive safely after proper evaluation and treatment.

Patients who have previously been treated for diving-related injuries should not resume diving activities without consultation with a diving medical specialist.

Forecast

Most barotraumas resolve spontaneously and require only symptomatic treatment and outpatient observation. Potentially life-threatening barotraumas include alveolar or gastrointestinal rupture, especially if the patient has neurological symptoms, signs of pneumothorax, peritoneal signs, or instability of vital signs.

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