MARKAS BESAR ANGKATAN LAUT

DINAS KESEHATAN

LAPORAN PELAKSANAAN TUGAS BELAJAR

MIDDLE EAR BAROTRAUMA

DISUSUN OLEH :

UNIQUEAIN MALIU., dr NRP 23222/P

JAKARTA, 5 JANUARI 2020

 ABSTRACT

Barotrauma refers to injuries caused by increased air or water pressure,

such as during airplane flights or scuba diving. Generalized barotraumas,
also called decompression sickness, affects the entire body. Barotrauma
can occur on descent or ascent. Pressure underwater is directly
proportional to depth and pressure effects dominate the disorders
sustained by divers. If the pressure in these spaces does not equalize with
the ambient pressure, tissue injury results from the forces generated by
the pressure difference between the ambient pressure and the body
cavity. Divers who cannot equalize middle-ear pressure during descent will
first feel discomfort in their ears (clogged ears, stuffed ears) that may
progress to severe pain. Further descent only intensifies the ear pain,
which is soon followed by serous fluid build up and bleeding in the middle
ear. This is why prevention and recognition of ETD and MEB remain
important when evaluating and treating a pressure-related injury.
 CHAPTER I

PREFACE

Barotrauma refers to injuries caused by increased air or water

pressure, such as during airplane flights or scuba diving. Generalized
barotraumas, also called decompression sickness, affects the entire body
(Harvard, 2018). It is closely related to the effects of Boyle’s law result in
changes in volume of gas-containing spaces when exposed to the
increased pressure underwater (Bove, 2014). Parts of the body that are
directly affected by pressure are physiological air cavities in the body such
as the lungs, middle ear and paranasal sinuses. Barotrauma can occur
when divers go down (descent) or up (ascent). barotrauma when divers
descent is more common than when it ascent (Mahdi et all, 2018).

Barotrauma, in general terms documented as the most common

medical problem in divers. Like most other sports there are health risks
associated with diving that can be significantly reduced by ‘safe’ practice
(Mawle and Jackson, 2002). Eustachian tube dysfunction (ETD) and
middle ear barotrauma (MEB) remain the two most common complications
of SCUBA diving and commercial diving ( Neill and Frank, 2019).

An increase in atmospheric or hydrostatic pressure effects only the

air-containing spaces of the body. While most minor TM barotrauma heals
rapidly and uneventfully, major trauma, such as a perforation of the TM,
may take weeks or months to heal. Major TM barotrauma is likely
associated with permanent complications such as hearing loss. This is
why prevention and recognition of ETD and MEB remain important when
evaluating and treating a pressure-related injury ( Neill and Frank, 2019).
This review provides a basis for understanding the diving
environment and its accompanying disorders especially ear barotrauma
and provides prevention of ear barotrauma.
 CHAPTER II

COURSE OVERVIEW

Diving Environment

Common to underwater exposure and exposure in hyperbaric

chambers, caissons, and underwater habitats is an increase in ambient
pressure. Pressure underwater is directly proportional to depth (FIGURE
1), and pressure effects dominate the disorders sustained by divers.
Intrathoracic blood volume increases with water immersion. Hong and
colleagues estimated the blood volume shift related to head-out water
immersion to be about 700 ml, with a resulting increase in cardiac output
and central venous pressure. Diuresis results from an increase of
natriuretic hormones and suppression of antidiuretic hormone (Bove,

2014).

FIGURE 1 Pressure equivalents for altitude and depth (Bove, 2014)

Boyle’s Law : The Relationship between Pressure and Volume

As the pressure on a gas increases, the volume of the gas

decreases because the gas particles are forced closer together.
Conversely, as the pressure on a gas decreases, the gas volume
 increases because the gas particles can now move farther apart. Weather
balloons get larger as they rise through the atmosphere to regions of lower
pressure because the volume of the gas has increased; that is, the
atmospheric gas exerts less pressure on the surface of the balloon, so the
interior gas expands until the internal and external pressures are equal.
This relationship between the two quantities is described as follows
(Anonymous, 2019):

PV=constant

 Therefore, gas volume is reduced to one half of the original volume

when the absolute pressure is doubled. Based on Boyle’s law, a relative
volume change from 2 to 3 atmospheres absolute (ATA) (33–66 fsw) is
less than the change from 1 to 2 ATA (surface to 33 fsw); thus, for a given
change in depth the gas volume change is greater when closer to the
surface (Bove,2014).

Anatomy of The Ear

The parts of the ear include:

 External or outer ear, consisting of:

 Pinna or auricle. This is the outside part of the ear.

 External auditory canal or tube. This is the tube that connects the
outer ear to the inside or middle ear.
 Tympanic membrane (eardrum). The tympanic membrane divides
the external ear from the middle ear.

 Middle ear (tympanic cavity), consisting of:

 Ossicles. Three small bones that are connected and transmit the
sound waves to the inner ear. The bones are called Malleus, Incus,
Stapes
 Eustachian tube. A canal that links the middle ear with the back of
the nose. The eustachian tube helps to equalize the pressure in the
 middle ear. Equalized pressure is needed for the proper transfer of
sound waves. The eustachian tube is lined with mucous, just like
the inside of the nose and throat.

 Inner ear, consisting of:

 Cochlea. This contains the nerves for hearing.

 Vestibule. This contains receptors for balance.
 Semicircular canals. This contains receptors for balance (Stanford,
2019).

FIGURE 2 Anatomy of the ear (Fairview, 2019)

Barotrauma

Barotrauma can occur on descent or ascent. With increased

pressure during descent, gas volume in air-containing body cavities, such
as the lungs, middle ear, paranasal sinuses, and gastrointestinal tract, is
diminished. If the pressure in these spaces does not equalize with the
ambient pressure, tissue injury results from the forces generated by the
pressure difference between the ambient pressure and the body cavity
(Mahdi et all, 2018). 

Middle Ear Barotrauma

 Barotrauma can occur on descent or ascent. With increased
pressure during descent, gas volume in air-containing body cavities, such
as the lungs, middle ear, paranasal sinuses, and gastrointestinal tract, is
diminished. If the pressure in these spaces does not equalize with the
ambient pressure, tissue injury results from the forces generated by the
pressure difference between the ambient pressure and the body cavity
(Bove, 2014). 

Mechanism

The air pressure in the tympanic cavity, air-filled space in the

middle ear must be equalized with the pressure of the surrounding
environment. The Eustachian tube connects the throat with the tympanic
cavity and provides passage for gas when pressure equalization is
needed. This equalization normally occurs with little or no effort. Various
maneuvers, such as swallowing or yawning, can facilitate the process
(Dan, 2015).

An obstruction in the Eustachian tube can lead to an inability to

achieve equalization particularly during a descent when the pressure
changes fast. If the pressure in the tympanic cavity is lower than the
pressure of the surrounding tissue, this imbalance results in a relative
vacuum in the middle ear space. It causes tissue to swell, the eardrum to
bulge inward, leakage of fluid and bleeding of ruptured vessels. At a
certain point an active attempt to equalize will be futile, and a forceful
Valsalva maneuver may actually injure the inner ear. Eventually, the
eardrum may rupture; this is likely to bring relief from the pain associated
with MEBT, but it is an outcome to be avoided if possible (Dan, 2015).

Factors that can contribute to the development of MEBT include the

common cold, allergies or inflammation conditions that can cause swelling
and may block the Eustachian tubes. Poor equalization techniques or too
rapid descent may also contribute to development of MEBT (Dan, 2015).
Manifestation

Divers who cannot equalize middle-ear pressure during descent

will first feel discomfort in their ears (clogged ears, stuffed ears) that may
progress to severe pain. Further descent only intensifies the ear pain,
which is soon followed by serous fluid build up and bleeding in the middle
ear. With further descent, the eardrum may rupture, providing pain relief;
this rupture may cause vertigo, hearing loss and exposure to infection
(Dan, 2015).

Modified Tedd Classification

The original Teed classification was modified to include another TM

grade totalling 6 possible Teed results: 

 Grade 0: Symptoms with no ontological signs of trauma

 Grade 1: diffuse redness and retraction of the TM

 Grade 2:  Grade 1 plus slight hemorrhage within the tympanic

membrane

 Grade 3: Grade 1 plus gross hemorrhage within the TM,

 Grade 4: Dark and slightly bulging TM due to free blood in the

middle ear (a fluid level may also be present)

 Grade 5: Free hemorrhage into the middle ear, TM perforation with

blood visible in the external auditory canal (Neil and Frank, 2019).
 FIGURE 3 Middle ear barotrauma grade 0-5 (Ronson)

Management

While diving: When feeling ear discomfort during descent, you

should stop descending and attempt equalization. If needed, ascend a few
feet to enable equalization. If equalization cannot be achieved, you should
safely end the dive (Dan, 2015).

First aid: When feeling fullness in one's ears after diving, abstain

from further diving. Use a nasal decongestant spray or drops. This will
reduce the swelling of nasal mucosa and Eustachian tube mucosa, which
may help to open the Eustachian tube and drain the fluid from the middle
ear. Do not put any drops in your ear (Dan, 2015).

Treatment: Seek a physician evaluation if fluid or blood discharge

from the ear canal is present or if ear pain and fullness lasts more than a
few hours. If vertigo and dizziness are present, which may be a symptom
of inner-ear barotrauma, you should seek an urgent evaluation. Severe
vertigo and nausea after diving require emergency medical care (Dan,
2015).
 Treatment recommendation that is :

a. Rest, no diving or maneuvering Valsalva

b. Use decongestants or antihistamines per oral or through the nose

c. Antibiotics for bleeding and perforation of membrane tympani cases

Divers can dive back when their ears have healed completely. For
degrees 0-4 healing varies between 2-7 days. For grade 5 if there is no
complications can recover between 1-3 months (Mahdi, 2018).

Prevention

 Examination of the tympanic membrane before diving, otoscopy is

performing while diver do valsalva maneuver. The apparent
movement of the tympanic membrane compared to the strength
needed to perform the valsalva maneuver, it can be estimated tuba
patency. When the result doubt, we can use nasal drop or nasal
spray decongestants for improve tuba patency (Mahdi, 2015).
 Do not dive with congestion or cold.
 Descend slowly. If unable to equalize after a few attempts, safely
end the dive to avoid significant injury that may prevent you from
diving the rest of the week (Dan, 2015).

Prognosis

Most cases of barotrauma get better quickly without complications

(Harvard, 2018). Complications associated with MEB have been
discussed but can be summarized as perforation of the TM with
associated hearing loss, vertigo, middle, and external auditory canal
infection, especially post perforation and disruption of the skin of the
external ear canal. Recurring chronic pain has been reported (Neil and
Frank, 2019). 
 CHAPTER III

DISCUSSION

The parts of the body that will be directly affected by pressure are
the physiological cavities in the body and the parts of the body that form
artificial air cavities with diving equipment used. Parts of the body that are
directly affected by pressure are physiological air cavities in the body such
as the lungs, middle ear and paranasal sinuses. (Mahdi et all, 2018).

The middle ear space is situated directly behind the TM and is

covered by mucosa. It is connected to the throat via the Eustachian tube
(ET), also referred to as the auditory tube. It is responsible for the
drainage of fluid produced in the middle ear space, allowing it to enter the
throat. The ET opens and drains just beyond the nasal openings in the
posterior nasopharynx. This tube is also responsible for allowing the
exchange of air between the external environment and the middle ear
space, thereby maintaining an equal pressure between the middle ear
space and the external auditory canal. This is known as the equalization of
middle ear pressure. Another less described air exchange takes place via
the middle ear mucosa and mixed venous circulation. This transmucosal
gas exchange is less important during rapid and large changes in ambient
pressure occurring during diving and flying or when being treated in a
hyperbaric chamber (Neil and Frank, 2019). Therefor accumulation of fluid
and blood in the middle ear or rupture of the eardrum as a consequence of
failed equalization of pressure in the air space of the middle ear during
diving or flying (Dan, 2015).
 Pressure underwater is directly proportional to depth and pressure
effects dominate the disorders sustained by divers. It is closely related to
the effects of Boyle’s law (Bove, 2014). The reason that some people and
not others can equilibrate ET and middle ear high-pressure changes is
unknown. Anatomic or physiologic differences have not explained the
susceptibility of certain individuals to extreme ambient pressure changes
and barotrauma. Hence, ETD and MEB cannot be successfully predicted
or prevented in any individual, unless an anatomical opening and
connection between the external ear canal and middle ear space is
created. This is accomplished by performing a myringotomy with or
without placement of ventilation tubes. The procedure is classically
performed in the anterior and inferior portion of the TM to avoid potential
damage to middle ear structures, especially when performed emergently
in extreme cases. This surgically created connection through the TM
makes the need for equalization of middle ear pressure unnecessary and
passive. However, placing these tubes increases the likelihood of well-
known complications associated with the procedure such as infection,
bleeding, migration of the tubes into the middle ear space, hearing loss,
and chronic perforation requiring surgical repair (Neil and Frank, 2019).
 CHAPTER IV

SUMMARY

MEB to occur, there must be a history of being exposed to

increased atmospheric pressure with a dysfunction of the Eustachian tube.
This could be in the form of wet scuba diving or dry hyperbaric exposure in
a hyperbaric chamber. Most patients will complain of pain or pressure in
the affected ear. It may also be associated with varying degrees of hearing
loss. Physical examination may demonstrate blood in the external ear
canal, especially if the tympanic membrane has ruptured. Most commonly,
there will be varying degrees of erythema or bleeding into the tissues (Neil
and Frank, 2019).

If you are a diver, don’t dive again until your injury has fully healed.
Diving again too soon can cause reinjury. Your healthcare provider will tell
you when it's safe for you to dive again. You should also not fly until your
healthcare provider says it's OK.

Key points about ear barotrauma :

 Ear barotrauma is a type of ear damage caused by pressure

differences between the middle ear and the outer ear.

 Scuba diving and air travel are common causes of ear barotrauma.

 This condition occurs when there is also a problem with your

eustachian tubes.
 Symptoms can include ear pain, ringing in the ears, dizziness, ear
bleeding, and hearing loss.

 Symptoms are often short-term (temporary). But some don't go

away.

 Treatment may include medicines or surgery.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

 Know the reason for your visit and what you want to happen.

 Before your visit, write down questions you want answered.

 Bring someone with you to help you ask questions and remember
what your provider tells you.

 At the visit, write down the name of a new diagnosis, and any new
medicines, treatments, or tests. Also write down any new instructions
your provider gives you.

 Know why a new medicine or treatment is prescribed, and how it

will help you. Also know what the side effects are.

 Ask if your condition can be treated in other ways.

 Know why a test or procedure is recommended and what the

results could mean.

 Know what to expect if you do not take the medicine or have the
test or procedure.
 If you have a follow-up appointment, write down the date, time, and
purpose for that visit.

 Know how you can contact your provider if you have questions
(Sinai, 2019).

CHAPTER V

CONCLUSION

Diving is an ancient skill that was first limited to commercial and

military interests, but over the last 60 years diving has become an
increasingly popular sport. Because of the unique environment and the
well-defined disorders related to this environment, physicians are likely to
encounter an occasional patient with a diving-related disorder. Some
knowledge of this area of medicine is essential for recognizing these
disorders. In addition, evaluations for diving fitness have become an issue
for physicians. Knowledge of the underwater environment and the diving
disorders provides a basis for assessment of fitness for diving (Bove,
2014).
 Requirements for fitness depend on operational needs, with tactical
military divers requiring the highest levels of fitness among various
communities of divers. Standards have been created for commercial
divers, tunnel and caisson workers, and support staff for clinical hyperbaric
chambers. Disorders that lower exercise capacity, such as compromised
cardiopulmonary function, poor physical condition, and physical
disabilities, can increase the risk for diving-related injury (Bove, 2014).

Recreational diving is not usually associated with high workloads,

but with the possibility of unpredicted adverse diving conditions, a steady-
state oxygen consumption of about 20 ml/kg/min allows the diver to
manage adverse diving exposures. Divers who cannot sustain this level of
aerobic activity should plan diving exposures that are not likely to create
this demand (Bove, 2014).

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