Ear barotrauma (middle and inner ear)
Ear injury from fast pressure changes when flying or diving if the Eustachian tube cannot equalise. Usually pain and a blocked ear; rarely inner-ear damage.
What it is
Injury to the ear caused by a pressure difference between the surroundings and the ear's air spaces, most often the middle ear during descent when flying or diving. It can affect the external, middle or inner ear.
Who gets it
Middle-ear barotrauma is the most common injury in scuba divers and a frequent problem in air travel, especially in children and in people with colds or allergies. Inner-ear barotrauma is rare but matters because it can cause permanent hearing loss and vertigo.
Causes
- Descent during diving (most common), with the greatest relative pressure change in the first few metres
- Aircraft descent
- Blast injury or a slap on the ear
- Hyperbaric oxygen therapy
- Forceful Valsalva manoeuvre (inner-ear injury)
Risk factors
- Eustachian tube dysfunction
- Upper respiratory infection, allergic rhinitis or sinusitis
- Infants and young children
- Nasal obstruction from septal deviation or polyps
- Rapid descent and poor equalising technique
- Sleeping during aircraft descent
Pathophysiology
By Boyle's law gas volume falls as pressure rises. On descent the outside pressure rises; if the Eustachian tube does not open, middle-ear pressure becomes relatively negative, the eardrum retracts and the mucosal vessels dilate and leak, causing haemorrhage, effusion or haemotympanum and sometimes perforation. External-ear barotrauma occurs when the canal is sealed (earplugs, wax, a tight hood). Inner-ear barotrauma occurs when forceful equalising or a large pressure gradient ruptures the round or oval window (perilymph fistula) or causes bleeding in the labyrinth. On ascent the middle ear usually vents easily; unequal venting between the ears causes brief alternobaric vertigo.
Classification
- By site: external, middle or inner ear
- Middle-ear severity on otoscopy (Teed scale): grade 0 symptoms only, 1 retraction and redness, 2 slight haemorrhage, 3 marked haemorrhage, 4 haemotympanum, 5 free blood with perforation
- By phase: descent (squeeze) or ascent (reverse block)
- Inner-ear barotrauma, which must be separated from inner-ear decompression sickness
Symptoms and signs
- Ear pain during descent
- Fullness and muffled hearing (conductive loss)
- Tinnitus
- Bloody discharge if the eardrum perforates
- Brief vertigo on ascent (alternobaric vertigo)
- Inner-ear injury: sudden sensorineural hearing loss, roaring tinnitus, persistent vertigo with nausea and nystagmus
Diagnosis
- Clinical
- History of a pressure change with symptoms, and otoscopy showing retraction, redness, haemorrhage, haemotympanum or perforation (Teed grading). Tuning forks give a conductive pattern in middle-ear barotrauma; a sensorineural pattern points to inner-ear injury. A positive fistula test (nystagmus with pressure on the tragus or pneumatic otoscopy) suggests a perilymph fistula.
- Tests
- Pure-tone audiometry separates conductive from sensorineural loss; tympanometry; vestibular testing when there is vertigo.
- Imaging
- Not routine; high-resolution CT of the temporal bone can show air in the labyrinth (pneumolabyrinth) with a fistula, and MRI helps when the diagnosis is unclear.
Differential diagnosis
- Inner-ear decompression sickness
- Acute otitis media
- Otitis externa in swimmers
- Sudden sensorineural hearing loss
- Vestibular neuritis
- Benign paroxysmal positional vertigo
- Arterial gas embolism
Goal of treatment
Relieve symptoms, let the middle ear heal, and recognise inner-ear injury early to preserve hearing.
Treatment
- Conservative
- Middle-ear barotrauma: no flying or diving until healed, pain relief, and gentle autoinflation once the acute pain settles; most cases heal within days to weeks.
- Medical
- Treatment of nasal congestion with a short course of decongestants and intranasal corticosteroids when there is allergy; antibiotics only for an infected perforation, and the ear is kept dry while a perforation heals.
- Acute
- Inner-ear barotrauma: urgent referral to otolaryngology, head elevation, rest, and no straining, nose blowing or Valsalva; systemic corticosteroids are often used for sensorineural loss. When decompression sickness cannot be excluded, a hyperbaric medicine specialist decides on recompression, which can harm a perilymph fistula.
- Surgical
- Exploratory tympanotomy to patch a round or oval window fistula when hearing worsens or vertigo persists despite rest; myringoplasty for a perforation that does not close; ventilation tubes for recurrent barotrauma in people who must fly often or receive hyperbaric oxygen.
- Lifestyle
- Prevention: avoiding diving or flying with a cold, equalising early and often (swallowing, yawning, Valsalva or Toynbee manoeuvre), descending slowly, staying awake during aircraft descent, and feeding infants or giving a pacifier during descent.
Complications
- Eardrum perforation and haemotympanum
- Persistent middle-ear effusion
- Perilymph fistula
- Permanent sensorineural hearing loss and tinnitus
- Chronic vertigo
- Facial palsy (rare)
Prognosis
Middle-ear barotrauma usually heals completely within days to a few weeks, and small perforations close on their own. Inner-ear barotrauma can leave permanent hearing loss and tinnitus; early recognition improves the outcome.
Test yourself
Think of the answer, then tap the question to see it.
Why is middle-ear barotrauma most likely in the first few metres of a dive?
By Boyle's law the relative change in pressure and gas volume is greatest near the surface, so failing to equalise there creates the largest gradient.
A diver develops vertigo and sensorineural hearing loss during descent after a forceful Valsalva. What is the likely diagnosis?
Inner-ear barotrauma, possibly with a perilymph fistula of the round or oval window.
How does inner-ear barotrauma differ from inner-ear decompression sickness?
Barotrauma starts during descent, often in shallow dives, and is treated with rest; decompression sickness starts after ascent from deeper dives and is treated with recompression.
Which scale grades middle-ear barotrauma on otoscopy?
The Teed scale, from 0 (symptoms without signs) to 5 (free blood in the middle ear with perforation).
How is ear barotrauma prevented when flying?
Avoid flying with a cold if possible, swallow, yawn or use a Valsalva during descent, stay awake, and let infants feed or suck during descent.
In forensic medicine
Connections
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Ear Barotrauma (StatPearls (NCBI Bookshelf), 2023); Barotrauma (StatPearls (NCBI Bookshelf), 2023).
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