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236 Correspondence

At teaching institutions, the use of ultrasound can anamnesis, all of them referred transient episodes of aural
enhance the resident physician’s understanding of anatomy fullness and hearing loss during their life, which was
and facilitate mastery of new skills. Often, ultrasound- compatible with a diagnosis of eustachian tube dysfunction
guided vascular access and nerve blockade serve as a bridge (ETD). No significant relation between the incidence of
to performing such procedures bblindlyQ as the resident middle ear barotrauma and other parameters, such as age,
physician’s skills grow. sex, surgical procedure, medical therapy, and anesthesia
It is foreseeable that such technology can also assist in duration, was noted. Nineteen (90.5%) of 21 patients
epidural placement, not only as a prepuncture diagnostic experiencing GA-related middle ear barotrauma had spon-
tool but also to guide epidural placement in real time. taneous resolution of their symptoms within 1 month.
As technology improves and our acceptance of it in- Hearing symptoms following anesthesia in nonotolog-
creases, ultrasound-guided epidural placement could become ical procedures are more often associated with cardiac and
a valuable tool both for resident and experienced physician. orthopedic surgery [6]. The pathogenesis of such symp-
toms may be related to several events. In cardiopulmonary
bypass procedures, the most likely etiology is emboli of
References particulate matter generated by the cardiopulmonary
bypass pump [3], whereas in orthopedic surgery, it is
[1] Chan VW, Perlas A, Rawson R, Odukoya O. Ultrasound-guided
probably related to fat embolism [4]. In case of nitrous
supraclavicular brachial plexus block. Anesth Analg 2003;97:
1514 - 7. oxide (N2O) anesthesia, changes in middle ear pressure
[2] Grau T, Leipold RW, Delorme S, Martin E, Motsch J. Ultrasound may take place: during induction, N2O enters the air-filled
imaging of the thoracic epidural space. Reg Anesth Pain Med 2002;27: cavity of the middle ear and produces an increased
200 - 6. pressure. When the N2O supply is stopped, the reverse
[3] Grau T, Leipold RW, Horter J, Conradi R, Martin E, Motsch J. The
process takes place, producing a considerable subatmo-
lumbar epidural space in pregnancy: visualization by ultrasonography.
Br J Anaesth 2001;86:798 - 804. spheric pressure. Pressure changes can be overcome by
[4] Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of either active tubal opening, such as swallowing or
ultrasound imaging in obstetric epidural anesthesia. J Clin Anesth yawning, or passive venting by forcing opening. These
2002;14:169 - 75. physiological mechanisms of middle ear pressure regula-
[5] Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for
tion are not active during GA, while they progressively
presumed difficult epidural puncture. Acta Anaesthesiol Scand
2001;45:766 - 71. recover as long as the patient’s consciousness level
[6] Yeo ST, French R. Combined spinal-epidural in the obstetric patient improves. However, some patients may suffer from ETD,
with Harrington rods assisted by ultrasonography. Br J Anaesth which interferes with venting of the tube [2,6]. In these
1999;83:670 - 2. cases, obstruction of the eustachian tube generates a
[7] Grau T, Leipold RW, Horter J, Conradi R, Martin EO, Motsch J.
negative pressure during recovery from anesthesia, causing
Paramedian access to the epidural space: the optimum window for
ultrasound imaging. J Clin Anesth 2001;13:213 - 7. ear fullness, autophony, transient conductive hearing loss,
and traction on the round window membrane with
consequent irritation of the vestibular system and possible
Mir E. Ali, MD
rupture of the membrane [2,5,6,8]. Furthermore, resuscita-
Charles E. Laurito, MD
tive procedures with positive pressure mask ventilation
Department of Anesthesiology
may cause injury to the tympano-ossicular system by
University of Illinois at Chicago
excessive pressure transmitted rapidly through the eusta-
Chicago, IL 60612, USA
chian tube, with a consequent rapid increase in middle ear
doi:10.1016/j.jclinane.2005.02.002 pressure [1]. During anesthesia, manual positive pressure
ventilation is performed, and patients with ETD might be
Middle ear barotrauma in general anesthesia: particularly vulnerable [6].
special care Although GA-related hearing symptoms secondary to
middle ear pressure changes are not common (0.4%, in our
To the Editor: experience) and often resolve spontaneously within a few
Hearing loss, tinnitus, and vertigo are rarely considered days, extremely rapid variations may be responsible for
as potential complications of general anesthesia (GA), rupture of the round window membrane, with severe
despite several cases of postoperative hearing and/or consequences such as perilymph fistula [5]. Because
vestibular impairment that have been reported [1 -7]. patients with ETD are at higher risk for middle ear
We reviewed 4988 adults (mean age 47 years) submitted barotrauma [6], we suggest estimating tube function in all
to GA in the last year at Campus Bio-Medico University for patients candidates to GA through an easy evaluation of
both major and minor surgery. Among them, 21 (0.4%) aural fullness and Valsalva maneuver before hospitalization.
experienced tinnitus, conductive hearing loss, and aural If ETD is suspected, an otolaryngological assessment is
fullness immediately after recovery from GA, which was recommended, and in cases of deferrable surgery, we
suggestive of middle ear barotrauma. At a more accurate suggest resolving the ETD with an adequate ENT therapy
Correspondence 237

before the procedure. Finally, we suggest introducing [7] O’Neill G. Prediction of post-operative middle ear pressure changes
the augmented risk of hearing disorders in the informed after general anaesthesia with nitrous oxide. Acta Otolaryngol 1985;
100:51 - 7.
consent of all patients with ETD who will be submitted to [8] Iwano T, Kinoshita T, Hamada E, Ushiro K, Yamashita T, Kumazawa
general anesthesia. T. Sensation of ear fullness caused by eustachian tube dysfunctions.
Auris Nasus Larynx 1991;18:343 - 9.

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Felice Agrò, MD (Professor, Director)
open heart surgery: a detailed study of seven cases. Laryngoscope Department of Anesthesia
1981;91:101 - 9. Campus Bio-Medico University –School of Medicine
[4] Millen SJ, Toohill RJ, Lehman RH. Sudden sensorineural hearing loss: 00155 Rome, Italy
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[5] Segal S, Man A, Winerman I. Labyrinthine membrane rupture caused
Luca D’Ascanio, MD
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Otolaryngol 1984;5:308 - 10. Campus Bio-Medico University –School of Medicine
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