6-35
Objective: Signs
Using Basic Tools: Patient is generally in obvious distress. Otoscopic exam will reveal blocked EAC in
barotitis externa and retracted TM in barotitis media. Blood may be visualized behind the TM in severe
cases of barotitis media. Symptoms of URI may also be present given the association of barotitis with URI
and seasonal allergies.
Assessment:
Differential Diagnosis
Acute otitis media of infectious etiology - bulging, red TM with poor temporal correlation of symptoms to
altitude changes.
Acute trauma to the EAC or TM - e.g., insect or arthropod bite, usually visualized on otoscopic exam.
Other barotrauma to the ear (inner or middle), including cochlear tear and/or round window rupture - may be
present if blood behind TM, vertigo, or no relief of symptoms upon return to original altitude.
Plan:
Treatment
Primary: Change cabin altitude to decrease pressure differential and alleviate pain (increase altitude if
symptoms presented on descent, or vice versa). Spray nasopharynx with decongestant spray (e.g., Afrin)
to decrease swelling of Eustachian tube in barotitis media. Remove EAC obstruction in barotitis externa.
Slowly descend while using modified Valsalva maneuver (i.e., pinch nose and exhale against closed nostrils) to
equalize pressure in sinuses. Use a Politzer bag, a device similar in appearance to an Ambu bag (and often
carried on medical evacuation aircraft), to force air into the nasopharynx while the patient swallows. This will
probably be more effective than the modified Valsalva maneuver. Myringotomy may be necessary in extreme
cases of barotitis media.
Alternative: PO decongestants (e.g., pseudoephedrine) prior to and during flight decrease risk of barotitis
in patients with URI.
Primitive: Modified Valsalva maneuver (as above)
Patient Education
General: It is easier to prevent an ear "block" than to treat one. Use modified Valsalva maneuver to equalize
pressure in middle ear frequently during descent; do not wait until pain develops to attempt to equalize.
Prevention: Whenever possible, do not fly while suffering from an upper respiratory infection.
Follow-up Actions
Return evaluation: Patient should be followed and decongestants (po or nasal) should be used for several
days following an episode of barotitis. If large hemorrhagic bullae are present in the EAC in barotitis
externa, evacuation of blood with a syringe and sterile needle should be performed; small hemorrhages do
not require treatment. Manage TM rupture like that from any other cause; empiric antibiotic treatment is not
recommended.
Consultation Criteria: Consult ENT specialist for TM rupture, suspected middle/inner ear barotrauma, or
after myringotomy.
*NOTES: An uncomplicated ear squeeze may not require restriction of special duty status. An underlying URI
or other ear problem or barotitis with secondary bleed or inner/middle ear trauma, however, should temporarily
restrict affected personnel from special duty involving flying or diving operations until cleared by a Flight
Surgeon or Diving Medical Officer.
Aerospace Medicine: Decompression Sickness
LTC Brian Campbell, MC, USAIntroduction: Nitrogen makes up approximately 80% of the atmosphere. An inert gas, it saturates all tissues