Middle Ear Barotrauma among Licensed Para-pilots of a Metropolitan City: A Descriptive Cross-sectional Study.

Introduction: Middle ear barotrauma is a tissue injury to the ear secondary to inadequate pressure equalisation between the middle ear and the external environment. Paragliding, though an exciting sport, has its own risks and hazards. Para-pilots experience a variety of ear-related symptoms due to pressure discrepancies between the middle ear and ambient air. Middle ear barotrauma amongst para-pilots is a common yet neglected problem. The aim of this study was to find the prevalence of middle ear barotrauma among licensed para-pilots of a metropolitan city. Methods: A descriptive cross-sectional study was conducted amongst para-pilots practising in different paragliding companies in a metropolitan city. The study was conducted from 10th October, 2021 to 22nd October, 2021 after getting ethical approval from the Institutional Review Committee (Reference number: 0410202109/2021). A sample size of 76 participants was taken using convenience sampling technique. Data was collected from participants after performing an otoscope examination. The data were entered into Microsoft Excel version 2016 and analysed using the Statistical Package for the Social Science Version 22.0. Point estimate at a 95% Confidence Interval was calculated along with frequency and proportion for binary data and mean and standard deviation for continuous data. Results: Out of 76 participants, the prevalence of middle ear barotrauma was 10 (13.2%) (5.58-20.81 at 95% Confidence Interval). Conclusions: The prevalence of middle ear barotrauma was similar to other studies done in similar settings. Keywords: barotrauma; eustachian tube; Nepal; pilots.

The effect of total compression time and rate (slope) of compression on the incidence of symptomatic Eustachian tube dysfunction and middle ear barotrauma: a Phase II prospective study.

Eustachian tube dysfunction (ETD) and middle ear barotrauma (MEB) are common reported complications during hyperbaric oxygen treatment. Our Phase I study data was the first to demonstrate a statistically significant decrease in the occurrence of symptomatic ETD and MEB. The Phase I Trial suggested the total time interval and rate (slope) of compression (ROC) may be a determining factor in ETD and MEB. This Phase II study investigates an optimal rate of compression to reduce ETD and MEB when considering each multiplace treatment (with multiple patients) as the unit of observation as a group, rather than for each individual patient. Data were collected prospectively on 1,244 group patient-treatment exposures, collectively including 5,072 individual patient-treatment/exposures. We randomly assigned patient-treatment group exposures to four different time interval and rate (slope) of compression. These compression rates and slopes were identical to those used in the Phase I trial. All patients experiencing symptoms of MEB requiring compression stops were evaluated post treatment for the presence of ETD and MEB using the O'Neill Grading System (OGS) for ETD. Data were analyzed using the IBM-SPSS statistical software program. A statistically significant decrease in the number of compression holds was observed in the 15-minute compression schedule, correlating to the results observed in the Phase I trial. The 15-minute linear compression profile continues to demonstrate the decreased need for patient symptomatic compression stops (as in the Phase I trial) using a USN TT9 during elective hyperbaric oxygen treatments in a Class A multiplace hyperbaric chamber. Trial Registration: ClinicalTrials.gov Identifier: NCT04776967.

Eustachian tube function test as a predictor of middle ear barotrauma.

BACKGROUND: Most of the cases of middle ear barotrauma in divers are due to the impassability of the Eustachian tube. The aim of our study is to compare the results of tympanometry and Valsalva part of Eustachian Tube Function test (ЕТF-test) with the ability of divers to compensate for the change in ambient pressure in a hyperbaric chamber. MATERIAL AND METHODS: The study included 35 professional divers undergoing annual medical examination. For all subjects is measured first intratympanal pressure at rest, then after the maneuver of Valsalva with impedancemeter. Then a barofunction test (BFT) was performed to assess the diving fitness and the passability of the Eustachian tubes. It consists of divers compressing and decompressing in a hyperbaric chamber to a pressure of 2.2 ATA for 1 minute. Based on results from previous studies we are using a 20 DaPa cutoff point on the ETF test to predict Eustachian tube passability and a successful barofunction test. RESULTS: In the current study 24 divers have ETF test results higher than 20 DaPa. 3 divers have ETF test values lower than 20 DaPa in both ears, but none of them displayed difficulties in the BFT. 8 divers have ETF values lower than 20 DaPa in one ear and higher than 20 DaPa in the other. 7 of the last group displayed difficulties with the BFT in the ear with poor ETF result. CONCLUSIONS: We consider that the ETF test can be used to assess diving fitness as a screening method before performing a BFT, as values above 20 DaPa guarantee Eustachian tube function sufficient for diving activities. Values of 20 DaPa and less are not a definite predictor of the BFT results. The results of the ETF test can also be used in the usual work of an otorhinolaryngologist to evaluate Eustachian function in cases of unilateral disease of middle ear.

Balloon Eustachian tuboplasty in a professional Navy SEAL diver: case report.

Middle ear barotrauma due to dilatory Eustachian tube dysfunction (ETD) is probably the most common medical disorder related to diving. Moreover, ETD makes divers prone to other diving-related accidents, including inner ear barotrauma and alternobaric vertigo. Until the development of Eustachian tube balloon dilation no diving-compatible surgical options existed to effectively and safely prevent recurrence. We present a case of an Israeli Navy SEAL diver who dives in extreme strenuous combat-related closed-circuit rebreather (CCR) dives. Due to repeated middle ear barotrauma, the patient underwent Eustachian tube balloon dilation of the affected side. Following surgery, the patient returned to both CCR and scuba dives but still suffered from middle ear symptoms and repeated barotrauma hence was eventually disqualified from further combat diving.

Dynamic Rabbit Model of Ear Barotrauma.

BACKGROUND: Establishing animal models of ear barotrauma (EB) to provide evaluation criteria for Eustachian tube dysfunction.METHODS: Using expansive sponges, 70 rabbits' right pharyngeal openings of the auditory tubes were blocked to cause dysfunction in the right Eustachian tubes. The right tympanic cavities of 65 rabbits were the Model Group (Subgroups 1-13) and these rabbits' left tympanic cavities were the Nonblockage Group. Hypobaric chamber tests (HCTs) at various vertical speeds (100 m · s-1, 75 m · s-1, 50 m · s-1, and 15 m · s-1) and altitudes (13,123 ft and 6562 ft) were conducted. The remaining five rabbits' right tympanic cavities were the Control Group and no HCTs were conducted. After HCTs, observations were made on rabbits' behavioral changes, oto-endoscope and tympanometry results, and pathological changes of the tympanic mucosae.RESULTS: 1) Rabbits in Subgroups 1-12 demonstrated EB, while Subgroup 13 and the Control Group did not. 2) Histopathology showed EB caused by rapid ascent/descent at 100 m · s-1 was more severe than that of 75 m · s-1 and 50 m · s-1 (P < 0.01), and that there were no significant differences in EB caused by rapid ascent/descent at 75 m · s-1 and 50 m · s-1 (P > 0.05). There were no significant differences in pathological injuries at the altitudes of 6562 ft and 13,123 ft (P > 0.05). 3) Based on tympanic membrane structures, tympanometry, and histopathological results, rabbits' EB can be classified into mild, moderate, and severe.DISCUSSION: EB's dynamic models could be established through HCTs on rabbits with Eustachian tube dysfunction.Wang B, Xu X, Lin J, Jin Z. Dynamic rabbit model of ear barotrauma. Aerosp Med Hum Perform. 2019; 90(8):696-702.

The effect of compression rate and slope on the incidence of symptomatic Eustachian tube dysfunction leading to middle ear barotrauma: a Phase I prospective study.

Introduction: Symptomatic Eustachian tube dysfunction (ETD) and middle ear barotrauma (MEB) are the most common reported complications during hyperbaric oxygen (HBO2) treatment. There is no standardized rate of compression (ROC) reported to decrease the incidence rates of ETD and MEB during hyperbaric treatments. Few studies actually demonstrate that the ROC decreases the incidence of ETD or MEB. Methods: Our study was designed to determine an optimal hyperbaric chamber compression rate that might reduce the incidence of symptomatic ETD leading to MEB during the compression phase of treatment in a multiplace hyperbaric chamber. Data was collected prospectively over 2,807 elective patient treatments compressed using a U.S. Navy Treatment Table 9 (USN TT9) with a modified ROC. ROC was assigned using two variables, time (10 vs.15 minutes) and slope (linear vs. non-linear compression). Patients were exposed to all four compression schedules in a consecutive daily fashion. We recorded any patient requiring a stop during initial compression due to ear discomfort. Anyone requiring a stop was evaluated post treatment for MEB. Findings were compared to our standard 10-minute linear ROC. Evaluation of the tympanic membrane was accomplished using video otoscopy. Barotrauma when present was classified using both the Teed and O'Neill grading systems. Data was analyzed using basic statistical methods. Results: When comparing four different rates of compression during an elective USN TT9 in a multiplace (Class A) chamber there is a decreased incidence for symptomatic ETD when using a 15-minute linear compression schedule (p-value ⟨0.05). Conclusion: Using a 15-minute linear compression schedule is associated with less symptomatic ETD and less MEB when performing an elective 45 fsw (USN TT9) hyperbaric treatment in a Class A chamber. Asymptomatic ETD and MEB were not considered in this study.

Tympanometric evaluation of Eustachian tube function in Polish scuba divers.

BACKGROUND: Scuba divers are subjected to relatively high ambient pressures while descending. Equalizing maneuvers (e.g., Valsalva) are necessary to open the Eustachian tube (ET) and allow air into the middle ear (ME) cavity. Insufficient opening of the ET leads to ME barotrauma, which is the most common injury related to scuba diving. The study aims were to assess the incidence of ME barotrauma and to compare tympanometric parameters and stapedial reflexes in scuba divers and non-diving individuals. MATERIAL AND METHODS:: 60 scuba divers participated in the study; control consisted of 90 non-diving volunteers without a history of otolaryngologic problems. All participants were examined with the use of otoscopy and tympanometry with evaluation of ipsilateral stapedial reflexes. The group studied was surveyed regarding occurrence of ME barotrauma and diving competence. RESULTS: 51.7% of the divers experienced ME barotrauma, the most common symptoms being earache and hearing loss. Comparison of the group studied and control revealed significantly lower ME pressure and compliance in scuba divers. In scuba divers with ME barotrauma, longer time from injury correlates directly with greater ME pressure and compliance, indicating tissue recovery. At 4,000Hz 100dB percentage of present stapedial reflexes among scuba divers was significantly lower than in controls; moreover, a greater number of dives correlated inversely with percentage of present stapedial reflexes at 4000Hz 100dB. The reduced thresholds at high intensities suggest a negative effect of scuba diving on hearing. CONCLUSIONS: ME pressure and compliance, however still within the norm, are significantly lower in scuba divers than in non-diving healthy volunteers. This may be attributed to a subclinical form of barotrauma.

Alternobaric vertigo and facial baroparesis caused by scuba diving and relieved by chewing pineapple: a case report.

Equalization of middle ear pressure is an important consideration for scuba divers. When middle ear pressure is asymmetric, a diver may experience alternobaric vertigo. Moreover, individuals with an underlying temporal bone dehiscence are predisposed to facial baroparesis. An understanding on behalf of fellow divers and emergency responders to recognize and differentiate facial baroparesis from decompression illness is critical. Misdiagnosis may lead to inappropriate treatment or unwarranted stoppage of diving. There have been a few dozen reported cases of facial baroparesis in the literature, but few have included firsthand accounts. This report describes an incidence of unilateral facial baroparesis preceded by alternobaric vertigo, with commentary from divers who witnessed the individual experiencing the facial paresis. The facial weakness in this case resolved within 15 minutes after the diver chewed on fresh pineapple. This report suggests that alternobaric vertigo may be a harbinger of facial baroparesis. Upon resurfacing divers should consider prophylactic measures that help to dilate the Eustachian tube such as chewing, yawning and swallowing in order to minimize the risk of middle ear pressure-induced vertigo or facial paresis.

The O'Neill grading system for evaluation of the tympanic membrane: A practical approach for clinical hyperbaric patients.

Eustachian tube dysfunction (ETD) and middle ear barotrauma (MEB) are the two most common complications of clinical hyperbaric oxygen (HBO2) treatment. The current grading system, the Teed's Classification, was first described in 1944 with modifications to this system over the years, but none are specific for the evaluation and treatment of patients undergoing clinical HBO2 therapy. Currently, the standard of care is a baseline otoscopic examination performed prior to starting HBO2 therapy. Repeat otoscopy is required for patients having ETD, pain or other symptoms during the compression and/or decompression phase of the treatment. Results from these examinations are used to determine the proper course of treatment for the ETD or MEB. The Teed's classification was not intended to correlate with the consistency of diagnosis, the clinical approach to relieving symptoms or the treatment of the inflicted trauma. It is not a practical tool for the modern hyperbaric team. We describe a newer grading system, the O'Neill Grading System (OGS), which allows simple, practical and consistent classification of ETD and MEB by all members of the clinical hyperbaric medicine team. Based on the O'Neill Grade assigned, evidence supported suggestions for appropriate actions and medical interventions are offered.

Patulous eustachian tube after percutaneous balloon microcompression for trigeminal neuralgia: case report.

OBJECTIVE: To report a case of patulous eustachian tube which occurred after percutaneous balloon microcompression of the Gasserian ganglion. METHOD: Retrospective case review. RESULTS: A 41-year-old man was referred to our audiovestibular medicine department following episodes of autophony. These symptoms appeared two weeks after percutaneous balloon microcompression performed to treat severe trigeminal neuralgia secondary to multiple sclerosis. A diagnosis of patulous eustachian tube was indicated by clinical examination and tympanometry. The symptoms were present for less than six months and improved without any specific treatment. CONCLUSION: Percutaneous balloon microcompression is a procedure used for refractory trigeminal neuralgia that can cause transient sensory and motor deficits of any of the trigeminal nerve branches. It is proposed that injury to the mandibular division in this case caused temporary tensor veli palatini dysfunction with consequent patulous eustachian tube.

Middle ear effusion in patients with sinonasal cancer treated by surgery with or without radiotherapy.

OBJECTIVE: To identify the prevalence and risk factors of eustachian tube dysfunction after surgery for sinonasal cancer by observing the occurrence of middle ear effusion. STUDY DESIGN: Historical cohort study. SETTING: Academic university hospital. SUBJECTS AND METHODS: Clinical records of 112 patients surgically treated for sinonasal cancer over a 16-year period were evaluated. Initial bivariate analysis was followed by a multivariate logistic regression model. RESULTS: The best model included 2 variables: posterior extension of surgical resection (nasopharynx, soft palate, eustachian tube, pterygomaxillary fossa, parapharyngeal space) with an odds ratio of 5.662 (95% confidence interval [CI], 1.877-9.447) and postoperative radiotherapy with an odds ratio of 8.691 (95% CI, 4.187-13.194). CONCLUSION: Despite the limited number of patients, the study gives a prediction of middle ear effusion based on 2 well-defined factors: surgical resection of anatomic structures involved in tubal function and adjuvant radiotherapy.

[A study of the Eustachian tube function in patients with a scuba diving accident].

The scuba diving population has increased very much recently, bringing with it a rise in barotrauma. Ninety-seven patients with scuba diving-related accidents (34 males and 63 females; mean +/- SD: 36.6 +/- 10.3 years) and 39 healthy volunteers (9 males and 30 females; mean +/- SD: 41.1 +/- 16.9 years) without a history of Eustachian tube dysfunction participated in this study. All patients underwent audiometric measurements, including hearing testing, tympanometry, and Eustachian tube function testing (sonotubometry and impedance test). The tympanometry results of the majority of the patients were normal (Jerger A type), however, 83 of 97 patients (85.6%) were diagnosed as having Eustachian tube dysfunction: all patients had tubal stenosis. Compared with healthy volunteers, the Eustachian tube function in scuba diving patients was significantly lower. According to whether the affected parts were one ear or both ears, we classified these patients into 2 types, that is, the unilateral group and the bilateral group. The symptoms in the unilateral group were more serious than those in the bilateral group. In the unilateral group, the Eustachian tube functions of the affected ear did not always show lower than those of the healthy ear, so we thought that excessive positive pressure at the mesotympanum caused by the Valsalva maneuver might have affected not only the affected ear but also the healthy ear and have resulted in healthy ears being severely impaired by excessive positive pressure. To prevent scuba divers from pressure injury, we think that divers should have their Eustachian tube dysfunction accurately evaluated and any problems should be treated well.

[Extensive lower clivus chordomas. Removal using the unilateral transmandibular approach]. / Chordomes extensifs du clivus inférieur. Exérèse par voie transmandibulaire unilatérale.

BACKGROUND AND PURPOSE: Clival chordomas are rare skull-base tumors with local malignant behavior. Their control and removal remain difficult because of their anatomical location and because of their extensions. The goal of the treatment is complete surgical removal in a single stage if possible, with minimal deficits, followed by proton therapy. If the tumor remains extradural for a while, it finally progresses through the dura backwards to reach and displace the brain stem and upper cervical cord. Its anterior extension in the retropharyngeal space offers a logical opportunity and many advantages to use an anterior approach. METHODS: With three consecutive cases, we try to demonstrate that the unilateral transmandibular approach offers a large exposure of the lower clivus, the foramen magnum in its ventral part, the ipsilateral infratemporal fossa and C1 to C3. Surgical complications concern the lower cranial nerves, including the hypoglossal. Serous otitis media is possible in case of opened Eustachian tube. Tracheostomy is needed because of a transient tongue oedema. RESULTS: The unilateral transmandibular approach enabled to anatomical and physiological nasal preservation, large operative field facilitating dural closure and tumor removal, with acceptable cosmetic results and sequellae considering the natural course and prognosis of the tumor. CONCLUSIONS: This approach seems to be very useful to reach and removed extensive lower chordomas.

Recurrent diving-related inner ear barotrauma.

OBJECTIVE: To present two cases of recurrent diving-related inner ear barotrauma (IEB) and to discuss the possible cause and pathogenesis of the increased inner ear vulnerability. STUDY DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: Two scuba divers suffering from repeated cochleovestibular barotrauma. INTERVENTIONS: Neurotological evaluation, perilymphatic fistulae repair, and conservative treatment. MAIN OUTCOME MEASURE: The increasing popularity of scuba diving expose the individuals involved in this sport to unique pathologies that are not common under terrestrial conditions. The otolaryngologist who is involved in the care of these patients is required to diagnose and treat diving-related ear injuries and to consider the risk for recurrent inner ear injury when diving is resumed. CONCLUSION: IEB carries a risk for permanent hearing loss and chronic vestibulopathy. We recommend complete neurotological evaluation including high-resolution CT of the temporal bones as a routine workup for IEB. The presence of a significant residual sensorineural hearing loss, evidence for noncompensated vestibular damage, and CT findings of possible enhanced cerebrospinal fluid-perilymph connection should be considered when a return to diving activity is considered.

Barotrauma during air travel: predictions of a mathematical model.

Middle ear barotrauma during flight is a painful disorder experienced by passengers who cannot properly regulate their middle ear pressure in response to the changing cabin pressures during ascent and descent. Previous reports emphasized the important role of poor eustachian tube function in disease pathogenesis but paid little attention to other moderating factors. Here we describe a mathematical model of middle ear pressure regulation and simulate the pressure response to the changes in cabin pressure experienced over typical flights. The results document buffering mechanisms that decrease the requisite efficiency of active, muscle-assisted eustachian tube opening for disease-free flight. These include the relative difference between destination and departure elevations and the ratio of maximum tympanic membrane volume displacement to middle ear volume, where greater absolute values require lesser efficiencies for disease-free flight. Also, the specific type of functional deficit is important since ears with a completely obstructed eustachian tube can be less susceptible to barotrauma than those with a eustachian tube that passively opens but fails to dilate in response to muscle activity. These buffering systems can explain why some children and adults with poor eustachian tube function do not experience middle ear barotrauma.

Nasogastric tube misplacement into Eustachian tube.

Paediatric nasogastric tube placement can occasionally be difficult to perform. A unique case in a child is described where the tip of the nasogastric tube managed to travel via the Eustachian tube through the attic and into the mastoid cavity of the middle ear. To the best of the authors' knowledge, this has never been reported in the literature before.

Central incisor width as a predictor of appropriate curette size in adenoidectomy.

As inadvertent eustachian tube injury during adenoidectomy can have serious short- and long-term implications, a simple anatomic correlate that could predict the optimal curette choice for adenoidectomy, especially in severely hypertrophic cases, is beneficial. This study evaluates the correlation of the distance between the lateral borders of the upper central incisors and the distance between the tori tubarius in the nasopharynx. One hundred one consecutive patients undergoing adenoidectomy at a pediatric tertiary care hospital were enrolled in this study. The patients ranged in age from 7 months to 15 years. No complications were noted in any of the procedures. During the operation, the distance between the central upper incisors was measured in millimeters, as was the inter-tubarius width (ITW). A multiple regression analysis was completed to assess the correlation between central incisor width and ITW. Age and inter-incisor width were positively correlated with ITW in a statistically significant manner (p = .007 and p = .006, respectively). The distance between the lateral borders of the upper central incisors predicts the distance between the tori tubarius in the nasopharynx. Therefore, an adenoid curette the window of which does not overlap the lateral aspects of the central upper incisors can be used relatively safely, even in fields with poor visualization.