Barotrauma of the Middle Ear, Sinuses and Lung – Causes, Symptoms, Diagnosis, Treatment and Ongoing care



  • Physical damage to tissue lining an enclosed body cavity resulting from an imbalance between ambient pressure and pressure within the cavity.
  • Cavities at greatest risk for barotrauma include the middle ear (otic barotrauma), paranasal sinuses (sinus barotrauma), and lungs (pulmonary barotrauma).
  • Otic and sinus barotrauma are associated with rapid or extreme changes in environmental pressure, as might result from air travel, mountain climbing, or scuba diving, especially in the presence of nasal congestion or eustachian tube dysfunction of any etiology:
    • Pressure changes with failure of eustachian tube to equilibrate pressure may distort the tympanic membrane (TM), causing discomfort and injury.
    • Rupture of round or oval membrane may cause inner ear barotrauma, vertigo, and sensorineural hearing loss.
  • Pulmonary barotrauma:
    • An iatrogenic complication of mechanical ventilation
    • Also a complication of scuba diving
  • Dental barotrauma is seen occasionally in scuba divers in whom small pockets of air trapped in dental work can cause rupture of teeth
  • System(s) affected: Ear/Nose/Throat (ENT); Pulmonary
  • Synonym(s): Dysbarism; aerotitis; otitic barotrauma; middle ear barotrauma


  • Dizziness and sensorineural hearing loss warrant immediate ENT referral for inner ear involvement.
  • Valsalva maneuver can spread nasopharyngeal infection into the middle ear.
  • Vertigo and hearing loss may cause disorientation.


  • Predominant age: All ages
  • Predominant sex: Male = Female


  • Pulmonary barotrauma is the 2nd leading cause of death among divers.
  • Otic barotrauma is common in air travel, especially among flight personnel.
  • Pulmonary barotrauma is noted in 3% of mechanically ventilated patients.

Pediatric Considerations

  • Children have difficulty opening the eustachian tube and have frequent upper respiratory infections. This combination results in higher risk for otic or sinus barotraumas at small pressure changes, as compared with adults.
  • Mechanical ventilation of neonates is associated with barotrauma contributing to bronchopulmonary dysplasia.

Pregnancy Considerations

Increased nasal congestion in pregnancy increases risk of barotitis media.

Risk Factors

  • Otic or sinus:
    • Participation in high-risk activities without adequate pressure equilibration:
      • Scuba diving, especially with rapid ascent or breath-holding
      • Airplane flight (especially high performance)
      • Sky diving
      • High-altitude travel or elevator rides
      • Underwater employment
      • High-impact sports: Boxing, soccer, water skiing
    • Upper respiratory infection: Sinusitis, rhinitis, tonsillitis, adenoiditis, otitis media
    • Nasal congestion or allergic rhinitis
    • Any cause of eustachian tube dysfunction
    • Exposure to blasting
    • Pregnancy (associated nasal congestion)
    • Anatomic obstruction in the nasopharynx:
      • Deviated nasal septum
      • Nasal polyps
      • Congenital anomalies, including cleft palate
    • Trauma to ear
  • Pulmonary:
    • Iatrogenic:
      • Mechanical ventilation, especially in the presence of asthma, chronic interstitial lung disease, acute respiratory distress syndrome
      • Hyperbaric oxygen therapy
    • Scuba diving or other underwater activities
    • Air travel in people with preexisting pulmonary pathology

General Prevention

  • Pulmonary barotrauma:
    • Judicious use of mechanical ventilation and hyperbaric oxygen therapy
    • In scuba diving, avoidance of breath-holding during ascent
  • Otic barotrauma:
    • Avoidance of altitude changes or scuba diving when at risk for eustachian tube dysfunction
    • Treatment of upper respiratory congestion
  • Equilibration of pressure by Valsalva, yawning, swallowing, drinking, chewing gum


  • For any gas at a constant temperature, the volume of the gas varies inversely with the pressure. When gas is trapped in a confined space such as the middle ear, paranasal sinus, or lungs, a sudden decrease in ambient pressure causes expansion of the gas within the cavity.
  • Otalgia and hearing loss occur as a result of stretching and deformation of the TM.
  • Sudden pressure differential between middle and inner ear may lead to rupture of round or oval window and consequent labyrinthine fistula and leakage of perilymph. Damage to inner ear may be permanent.
  • When transalveolar pressure disrupts the structural integrity of the alveolus, the alveolar wall ruptures, leading to interstitial emphysema, followed by pneumothorax, pneumomediastinum.

Eustachian tube, Otalgia, Scuba diving, Barotrauma, Eardrum, Nasal congestion, sinus barotrauma, pulmonary barotrauma,


  • Otic (middle ear) barotrauma:
    • Otalgia, sensation of fullness or pressure in ear
    • Conductive hearing loss
    • Vertigo secondary to cold water entering middle ear
    • Transient facial paralysis
    • With TM rupture, discharge of fluid from ear
    • Abnormality of TM
  • All patients with middle ear barotrauma should be evaluated for inner ear barotrauma:
    • Sensorineural hearing loss
    • Tinnitus
    • Vertigo
    • Disorientation
  • Sinus barotrauma: Facial pain, sensation of fullness or pressure
  • Pulmonary barotrauma:
    • Chest pain, dyspnea
    • Hypoxia, hypotension


  • Otic barotrauma: History of high-risk activity
  • Pulmonary barotrauma: Scuba diving, mechanical ventilation, air travel with preexisting lung disease

Physical Exam

  • Otic barotrauma:
    • Otoscopic exam
    • Assess patient’s balance and hearing.
    • Palpate eustachian tube for tenderness.
  • Pulmonary barotrauma:
    • Auscultation, percussion
  • Assessment of respiratory distress

Diagnostic Tests & Interpretation


Initial lab tests

Pulmonary: Arterial blood gas


Initial approach

  • Otic or sinus: Imaging to rule out nasopharyngeal tumor or sinusitis, if indicated
  • Pulmonary:
    • Chest radiograph
    • Chest computed tomography (CT) if chest x-ray (CXR) not informative
  • Ultrasound

Diagnostic Procedures/Surgery

  • Otic barotrauma:
    • Tympanometry
    • Audiometry: Conductive (middle ear) vs sensorineural (inner ear) hearing loss
    • Surgical exploration to rule out inner ear involvement if suspected
  • Pulmonary barotrauma: Chest tube insertion if indicated for pneumothorax.

Pathological Findings

  • TM retraction or bulging:
    • Teed 0: No visible damage
    • Teed 1: Congestion around umbo (2 psi)
    • Teed 2: Congestion of entire TM (2–3 psi)
    • Teed 3: Hemorrhage into middle ear
    • Teed 4: Extensive middle ear hemorrhage; TM may rupture
    • Teed 5: Entire middle ear filled with deoxygenated blood
  • Inner ear involvement with rupture of the round or oval windows, perilymphatic fistula, and leakage of perilymph into the middle ear
  • Pulmonary barotrauma:
    • Alveolar rupture may progress to interstitial emphysema, pneumoperitoneum, pneumothorax

Differential Diagnosis

  • Acute and chronic otitis media
  • Otitis externa
  • Temporomandibular joint syndrome
  • Pulmonary: Other causes of decompensation on mechanical ventilation


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  • Treatment of predisposing conditions, upper respiratory congestion prior to air travel:
    • Oral decongestants
    • Nasal decongestants
    • Antihistamines
  • Antibiotics are not indicated for middle ear effusion secondary to barotrauma.
  • Analgesics for pain control
  • Tinnitus can be treated with high-dose steroids if given within 3 weeks of onset (1)[C].

Additional Treatment

General Measures

  • Prevention/avoidance is best: Avoid flying or diving when risk factors are present.
  • Autoinflate the eustachian tube during pressure changes:
    • Valsalva method (2)[B] during ascent and descent in air travel
    • Infants: Breast-feeding or sucking on pacifier or bottle
    • ≥4 years: Chewing gum
    • ≥8 years: Blowing up a balloon
    • Adults: Chewing gum, sucking hard candy, swallowing, or yawning
  • Nasal balloon (2)[B]
  • For inner ear barotrauma:
    • Bed rest with head elevated to avoid leakage of perilymph
    • Tympanotomy and repair of round or oval window may be necessary.
  • Treatment of pneumothorax:
    • Removal of air from pleural space
  • Adjustment of iatrogenic cause (adjustment of mechanical ventilation)

Issues for Referral

  • Refer to otolaryngology if inner ear is exposed, perilymphatic fistula, or sensorineural hearing loss.
  • Chest tube placement

Surgery/Other Procedures

  • If necessary, myringotomy or tympanoplasty
  • Tympanotomy and repair of round or oval window may be necessary in inner ear barotrauma.
  • Tube thoracostomy for persistent pneumothorax

In-Patient Considerations

Admission Criteria

  • Patients with complicating emergencies (e.g., incapacitating pain requiring myringotomy, large tympanic perforation requiring tympanoplasty)
  • Inner ear barotrauma with hearing loss
  • Management of pneumothorax

Ongoing Care

Follow-Up Recommendations

  • No flying or diving until complete resolution of all signs and symptoms, and Valsalva succeeds in equalizing pressure.
  • Complete bed rest for inner ear barotrauma
  • No high-risk activities or air travel until pneumothorax is completely resolved.

Patient Monitoring

  • Otoscopic exams until symptoms clear
  • In severe cases, audiograms

Patient Education

  • Teach Valsalva maneuver.
  • Educate on how to create allergy-free environment.
  • American Academy of Pediatrics Travel Safety Tips:
  • Divers Alert Network of Duke University Medical Center information line: (919) 684-2948


  • Mild barotitis media may resolve spontaneously.
  • Tympanic rupture: Recovery within weeks–months
  • Hearing loss may be permanent in barotitis externa.
  • Prognosis of pulmonary barotrauma depends on underlying pathology.


  • Permanent hearing loss
  • Ruptured TM
  • Chronic tinnitus, vertigo
  • Fluid exudate in middle ear
  • Perilymphatic fistula
  • Sensorineural hearing loss


1. Duplessis C, Hoffer M. Tinnitus in an active duty navy diver: a review of inner ear barotrauma, tinnitus, and its treatment. Undersea Hyperbaric Med. 2006;33(4):223–30.

2. Stangerup SE, et al. Point prevalence of barotitis and its prevention and treatment with nasal balloon inflation: a prospective, controlled study. Otol Neurol. 2004;25(2):89–94.

Additional Reading

Mirza S, Richardson H. Otic barotrauma from air travel. J Laryngol Otol. 2005;119:366–70.

Plötz FB, Slutsky AS, van Vught AJ, et al. Ventilator-induced lung injury and multiple system organ failure: a critical review of facts and hypotheses. Intensive Care Med. 2004;30:1865–72.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Ear Pain



  • 993.0 Barotrauma, otitic
  • 993.1 Barotrauma, sinus


  • 49252004 Otitic barotrauma (disorder)
  • 88548007 Sinus barotrauma (disorder)

Clinical Pearls

  • Small children can equalize eustachian tube pressure by sucking on bottles or pacifiers. Crying also serves as autoinflation.
  • Pulmonary barotrauma is the 2nd leading cause of death among divers.
  • Otic barotrauma is common in air travel, especially among flight personnel.
  • Pulmonary barotrauma is noted in 3% of mechanically ventilated patients.

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