An 18-year-old male came to clinic 24 hours after sustaining direct barotrauma to his left ear. He had been playing football with friends and was hit by the wide part of the ball right after the ball had been kicked. He was knocked to the ground but could describe in detail that he had no loss of consciousness but had some decrease in acuity, tinnitus and mild imbalance right after impact. At presentation he described no imbalance but still had his “ears plugged up a bit like a cold.” He watched his friends play the rest of the game and drove himself home. He described some pain right after the event that gave way to a headache later that evening. The headache resolved after sleeping and he denied ear pain currently. He did not describe any head injury symptoms at presentation. The review of systems had no otorrhea, rhinorrhea, dental or neck pain. The pertinent physical exam showed normal vital signs. HEENT revealed mild hemorrhage around the long process of the left malleus (ie umbo) but had otherwise normal landmarks, mobility and no fluid or perforation visible. Neurological examination showed normal gross auditory acuity, and normal cerebral and cerebellar function. Skin had no bruising or edema of the ear or head was noted.
The diagnosis of direct barotrauma to the left ear was made. Otolaryngology was contacted and because there was no obvious physical damage to the outer or middle ear and his symptoms were slowly improving, they recommended to followup with an audiogram in 2 weeks. They also recommended giving the patient head injury instructions and to call immediately if he had any worsening of the acuity problems or a reoccurrence of the vestibular problems. The patient’s clinical course at two weeks showed a normal audiogram.
Most ear barotrauma discussions are directed toward diving barotrauma where patients may have sudden nausea, headache, ear pain, tinnitus, deafness and vertigo. The tympanic membrane itself is evaluated on the Teed scale:
- 0 – Normal ear
- 1 – Congestion around the umbo, (happens with pressure differential of 2 pounds per square inch)
- 2 – Congestion of entire tympanic membrane (happens with a pressure differential of 2-3 pounds per square inch)
- 3 – Middle ear hemorrhage
- 4 – Extensive middle ear hemorrhage with visible blood bubbles behind the tympanic membrane, and tympanic membrane may rupture.
- 5 – Entire middle ear filled with deoxygenated (dark) blood
The patient above would be a Teed 1 who had congestion around the umbo and not the entire ear or middle ear hemorrhage. Another type of barotrauma is blast injury which the above patient’s injury was more consistent with.
Primary blast injury is due to the high-pressure blast wave acting on the body. This has the most effect on air containing organs such as the ear, lung and bowel. Secondary blast injury is due to flying debris from the blast itself. Tertiary blast injury is due to impact with another object such as being thrown by the blast wind. Obviously all 3 types of injuries can occur in a patient and severity depends on many factors especially distance from the blast.
With blast injuries the most common symptoms are hearing loss, tinnitus (most improve but may be permanent) and otalgia (temporary but may last for weeks) and fortunately most of these improve with time. Vertigo is uncommon. Rupture of the tympanic membrane is the most common middle ear injury and can vary from a mild tear to gross defects. Depending on the blast type, 2-94% of blast patients will have a tympanic membrane rupture. For example, 8% of British service personnel evacuated for blast injuries had tympanic membrane rupture and 48% of the July 2005 London bombing survivors had rupture. Tympanic membrane rupture does not appear to correlate with the most severe lung blast injury.
Ear barotrauma treatment depends on the mechanism of injury, severity of the ear injury, and concomitant injuries (particularly head injury). In general, less severe injuries generally resolve with time and/or anti-histamines/inflammatory medication to decrease swelling/congestion in the middle. If tympanic rupture is evident then antibiotic drops and/or steroid drops are indicated, along with monitoring for additional complications such as cholesteatoma. With diving injuries in the Teed 3-5 range, myringotomy may be indicated. Obviously whenever acute trauma occurs such as direct barotrauma, blast injury, etc. then searching for concomitant injuries and treating them is extremely important. Consultation by an otolaryngologist is often needed for more severe injuries. Followup audiograms should also be considered for most patients.
Questions for Further Discussion
1. At what noise level (decibels) can there be temporary or permanent hearing loss?
2. What patient education should wearers of head phones/ ear buds be given?
- Disease: Ear Barotrauma | Ear Disorders
- Symptom/Presentation: Ataxia, Dizziness, and Vertigo | Hearing Problem | Ear Pain
- Specialty: Emergency Medicine | Otolaryngology
- Age: Young Adult
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Ear Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Kaplan J. Barotrauma in Emergency Medicine. Medscape.
Available from the Internet at http://emedicine.medscape.com/article/768618-overview (rev. 3/9/11, cited 11/13/12).
Okpala N. Management of blast ear injuries in mass casualty environments. Mil Med. 2011 Nov;176(11):1306-10.
Akin FW, Murnane OD. Head injury and blast exposure: vestibular consequences. Otolaryngol Clin North Am. 2011 Apr;44(2):323-34, viii.
Breeze J, Cooper H, Pearson CR, Henney S, Reid A. Ear injuries sustained by British service personnel subjected to blast trauma. J Laryngol Otol. 2011 Jan;125(1):13-7.
Radford P, Patel HD, Hamilton N, Collins M, Dryden S. Tympanic membrane rupture in the survivors of the July 7, 2005, London bombings. Otolaryngol Head Neck Surg. 2011 Nov;145(5):806-12.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital