Barotrauma of the ear, lungs, eyes

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

There is damage to airborne cavities, including the lungs, ears, accessory sinuses, gastrointestinal tract, air cavities in the teeth and space under the mask of a diver. Symptoms may include pain in the ears, dizziness, hearing loss, pain in the paranasal sinus, nosebleeds and abdominal pain. Disturbances of breathing and loss of consciousness threaten life and can develop due to rupture of alveoli and pneumothorax. The diagnosis is established clinically, but sometimes requires visualization methods of investigation. Barotrauma treatment in most cases is supportive, but can include decongestants) and analgesics for barotrauma of ears and sinuses, or inhalation of O and drainage of the pleural cavity with pneumothorax. If, following a light barotrauma, arterial gas embolism develops, recompression therapy (in a pressure chamber) is indicated. Compliance with safety rules for scuba diving and preventive use of decongestants can reduce the likelihood of barotrauma.

The highest risk of barotrauma begins at a depth of 30 feet. The risk increases in any condition that may interfere with pressure equalization (for example, sinusitis, auditory tube block, congenital anomalies, infectious process) in air-containing body cavities. The ear barotrauma is about 1/3 of all the injuries of the divers. If the diver does even a single breath of air or other gas at a depth and does not let him free to come out on ascent, the expanding gas can over-express the lungs.

[1], [2], [3], [4]

Symptoms of barotrauma

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

Barotrauma of the lungs

During a dive with a very long deep breathing delay, lung compression may in some cases reduce the volume of the lungs below the residual, causing mucosal edema, vascular stasis and bleeding, which during a rise is clinically manifested by breathing and hemoptysis.

When people breathe compressed air, an increase in lung volume due to too rapid a rise or inadequate exhalation can cause overexpansion and rupture of the alveoli leading to pneumothorax (the cause of dyspnea, chest pain and unilateral easing of respiratory noises) or pneumomediastinum (the cause of a feeling of overflow in the chest, pain in the neck, pleural pain in the chest, which can radiate to the shoulder, breathing disorders, coughing, dysphonia and dysphagia). Tense pneumothorax, although rare in barotrauma, can cause arterial hypotension, swelling of the veins of the neck, box percussion sound over the lungs and deviation of the trachea. With pneumomediastinum, crepitation associated with subcutaneous emphysema can be detected on the neck, a crackling sound that can be heard also with auscultation of the heart during systole (Hammain's symptom). When rupture of the alveoli, air often enters the venous system of the lungs followed by arterial gas embolism.

The above symptoms require a neurological examination to identify signs of brain damage due to gas embolism. In the absence of neurologic symptoms, chest radiography is performed in the standing position (the presence of a contrasting strip along the heart contour) to exclude pneumothorax or pneumomediastinum. If chest X-ray does not work, but the clinical suspicion remains, a CT scan is shown that may be more sensitive than a review radiograph and can help in diagnosis.

[5], [6], [7], [8], [9]

Barotrauma of the ear

Diving can lead to injury to the outer, middle and inner ear. As a rule, a diver experiences stuffiness in the ears and pain during descent. If the pressure does not quickly equalize, bleeding from the middle ear or rupture of the tympanic membrane is possible. When examining the external auditory canal behind the tympanic membrane, there may be blood accumulation, hemotimpanum, insufficient mobility of the membrane during air injection from the pneumatic otoscope. Usually, conductive hearing loss is noted.

Barotrauma of the inner ear often includes a rupture of the round or oval window, which causes tinnitus, sensorineural hearing loss, dizziness, nausea and vomiting. The formation of a labyrinth fistula and the expiration of the railing of the implant may damage the inner ear permanently. Patients undergo conventional audiometry. Neurologic examination should be focused on testing the vestibular apparatus.

[10], [11], [12]

Barotrauma of the paranasal sinuses

In barotrauma, frontal sinuses that are associated with the latticular and maxillary sinuses are most often damaged. Divers can experience moderate pressure up to severe pain, with a feeling of stuffiness in the damaged sinuses during the ascent or descent, sometimes nosebleeds. Pain can be severe, sometimes with a painful face on palpation. In rare cases, it is possible to rupture the paranasal sinus with the development of pneumocephaly with pain in the face or in the oral cavity, nausea, dizziness, or headache. Clinical examination can reveal tenderness in sinuses or nosebleeds. The diagnosis is made on the basis of clinical data. Visualization methods of research (for example, simple radiography, CT) are not shown, although CT can be informative in case of suspected sinus rupture.

[13], [14]

Barotrauma of teeth

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

[15], [16]

Barotrauma of tissues under the mask

If the pressure in the space between the mask and the face is not balanced during the descent, a relative vacuum arises that can lead to local pain, conjunctival hemorrhages and skin ecchymoses in places where the mask touches the face. The diagnosis is based on clinical data.

[17], [18],

Barotrauma eye

Small air bubbles underneath hard contact lenses can damage the eye and cause severe soreness, reduced visual acuity and a halo effect around the light sources. The diagnosis is based on clinical data, but to exclude other causes, a screening ophthalmologic examination is necessary.

[19], [20]

Barotrauma of the gastrointestinal tract

Improper breathing from the regulator or the use of pressure equalization methods in the ears and paranasal sinuses can cause the diver to swallow small amounts of air during the dive. This air expands during the ascent, there is a feeling of overflow in the abdominal cavity, spasms, pain, eructation and flatulence; these symptoms pass by themselves and do not require an examination. Gastric rupture is rare, manifested by severe pain in the abdomen and soreness with the tension of the muscles of the anterior abdominal wall. With these symptoms, radiographs of the abdominal and thoracic cavities in the standing position or CT are performed to detect free air.

[21], [22], [23], [24]

Diagnostics

The diagnosis, in the first place, is based on clinical data, sometimes it is confirmed with the help of visualization methods of research.

[25], [26], [27], [28],

Treatment of barotrauma

Treatment begins with the stabilization of the condition, give 100% O2 in a large flow, provide intravenous access, carry out intubation if there are signs of an imminent development of respiratory failure. Ventilation with positive pressure can cause or exacerbate pneumothorax.

Patients with neurologic symptoms or other signs of arterial gas embolism are immediately transported to the recompression chamber for treatment. If the patient with suspected pneumothorax hemodynamics is unstable or there are symptoms of intense pneumothorax, the pleural cavity is immediately drained by the large trocar in the second intercostal space along the mid-incision line for decompression. If pneumothorax is small, there are no signs of hemodynamic or respiratory instability, pneumothorax can be resolved by inhalation of 100% O2 with a large flow within 24-48 hours. If this treatment is ineffective or pneumothorax increases, the pleural cavity is drained.

Pneumomediastinum specific treatment does not require. Symptoms usually resolve spontaneously for several hours to several days. After several hours of observation, most patients are prescribed for outpatient treatment. Inhalation of 100% is indicated with a large flow, which accelerates the absorption of extra-alveolar gas. In rare cases, mediastinotomy is performed to eliminate strained pneumomediastinum.

Patients with a ruptured gastrointestinal tract need intensive infusion therapy, treatment with broad-spectrum antibiotics (e.g., imipenem + cilastine, 500 mg intravenously every 6 hours) and examination of the surgeon to determine the indications for a possible diagnostic laparotomy.

Treatment of barotraumas of the paranasal sinuses and middle ear is the same. Decongestants (0.05% solution of oxymetazoline 2 injection in each nostril 2 times a day for 3-5 days, pseudoephedrine 60-120 mg orally 2-4 times a day, as much as 240 mg per day for 3-5 days) can open the blocked cavities. In severe cases, glucocorticoids can be administered intranasally. The use of Valsalva immediately after intranasal spraying can improve the distribution of the decongestant and promote the opening of cavities. For anesthesia, NSAIDs and opioid analgesics are prescribed. With bleeding and signs of effusion, antibiotics are prescribed (for example, amoxicillin inside 500 mg every 12 hours for 10 days, co-trimoxazole [sulfamethoxazole + trimethoprim] 1 tablet doubled inside for 10 days). In barotrauma of the middle ear, some doctors carry out a short course of glucocorticoids inside (prednisone 60 mg orally once a day for 6 days, then reducing the dose for the next 7-10 days).

The operation (for example, tympanotomy for direct restoration of a ruptured round or oval window, myringotomy for drainage of fluid from the middle ear, decompression of the sinus) may be required for serious damage to the inner or middle ear, or sinuses. The direction to the otorhinolaryngologist is indicated for severe, persistent symptoms.

Prevention of barotrauma

Barotrauma of the ear can be avoided, often swallowing or making exhalations with closed nostrils and mouth, which helps to "purge" the auditory tubes and equalizes the pressure between the middle ear and the environment. The pressure under the mask is equalized by the exhalation of air from the nose into the mask. The pressure behind the ear plugs and swimming goggles can not be leveled, so when using scuba diving, this method can not be used. In addition, it is recommended that pseudoephedrine prophylaxis (oral 60-120 mg 2-4 times a day, as much as 240 mg per day), starting from 12-24 h before immersion, can reduce the degree of barotrauma of the ears and sinuses. Diving is contraindicated in the infection of the upper respiratory tract, uncontrolled allergic rhinitis, or swelling of the mucosa of the upper respiratory tract of any etiology.

In patients with bulls or lung cysts, Marfan syndrome or COPD, the risk of pneumothorax is very high, they should not be immersed in water or work under conditions of increased atmospheric pressure. Patients with bronchial asthma also have the risk of lung barotrauma, but after adequate examination and treatment, many of them can safely dive under water.

Patients previously treated for damages related to scuba diving should not resume these exercises without consulting a medical expert in underwater medicine.

Forecast

Most barotraumas are resolved spontaneously and require only symptomatic treatment and outpatient monitoring. Potentially life-threatening variants of barotrauma include rupture of alveoli or gastrointestinal tract, especially if the patient has neurologic symptoms, signs of pneumothorax, peritoneal symptoms or instability of vital functions. 

[29], [30],