Barotrauma

Background

• Barotrauma = tissue injury caused by pressure changes, typically during diving (descent or ascent) or air travel
• Affects gas-filled spaces: middle ear, sinuses, lungs, GI tract
• Most common form: middle ear barotrauma (ear squeeze) during descent
• Most dangerous form: pulmonary barotrauma during ascent → pneumothorax, pneumomediastinum, arterial gas embolism

Types

Barotrauma Types

• Otic barotrauma
• Pulmonary barotrauma
• Sinus barotrauma
• Mask squeeze
• Barodentalgia (trapped dental air causing squeeze)

Middle Ear Barotrauma (Most Common)

• Occurs during descent (failure to equalize pressure through eustachian tube)
• Ear pain, hearing loss, tinnitus, vertigo
• Exam: TM hemorrhage, hemotympanum, or TM rupture
• Management: decongestants, analgesics; ENT follow-up for TM rupture

Sinus Barotrauma

• Frontal sinus most commonly affected
• Facial pain/pressure, epistaxis
• Management: decongestants, analgesics; antibiotics if sinusitis develops

Pulmonary Barotrauma

• Occurs during ascent (gas expansion per Boyle's law), especially with breath-holding
• Can cause: pneumothorax, pneumomediastinum, subcutaneous emphysema, arterial gas embolism (AGE)
• AGE: most serious complication — gas enters pulmonary vasculature → cerebral/coronary embolism
  • Presents within minutes of surfacing: sudden LOC, stroke-like symptoms, seizures, cardiac arrest
  • Management: 100% O2, supine positioning, emergent hyperbaric oxygen therapy
• Pneumothorax: manage per standard protocol (may need chest tube — avoid needle decompression only if diving-related and hyperbaric treatment available)

GI Barotrauma

• Abdominal pain, bloating from gas expansion during ascent
• Rarely significant unless diving with obstruction

Dental Barotrauma

• Tooth pain from gas-filled spaces in dental work
• Usually self-limited

Evaluation

• History: timing (descent vs. ascent), diving profile, symptoms
• Otoscopic exam for middle ear
• CXR: pneumothorax, pneumomediastinum
• CT head if concern for AGE with neurologic symptoms
• ABG if respiratory compromise

Management

• Arterial gas embolism: 100% FiO2, IV fluids, supine position, contact nearest hyperbaric chamber immediately
• Decompression sickness: see Decompression sickness — also treated with hyperbaric oxygen
• Pneumothorax: standard management; 100% O2 helps resorb gas
• Ear barotrauma: decongestants, analgesics, no diving until healed

Disposition

• Admit: pulmonary barotrauma, arterial gas embolism, decompression sickness (transfer to hyperbaric facility)
• Discharge: uncomplicated ear/sinus barotrauma with ENT follow-up, no diving until cleared

See Also

• Diving Emergencies
• Decompression sickness
• Arterial gas embolism
• Pneumothorax