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Original Article

A Study to Determine the Incidence of Otitic Barotrauma during

Hyperbaric Oxygen Therapy
Nirbhesh Saxena, Dilip Raghavan1
Department of ENT, Military Hospital, Meerut, Uttar Pradesh, 1Department of ENT, AFMC, Pune, Maharashtra, India

Abstract
Context: Barotrauma is caused by the difference in pressure between the air‑containing spaces of the ear and the outside environment. Aim: The aim
of the study was to determine the incidence of otitic barotrauma during hyperbaric oxygen therapy (HBOT). Setting and Design: A prospective
study was conducted in a tertiary care hospital setting. Materials and Methods: All patients planned for HBOT were clinically assessed for
Eustachian tube function by pneumatic otoscopy. Patients undergoing HBOT were subjected to otoscopy, and the tympanic membrane of
these patients was evaluated before and immediately following the session of HBOT. These changes were correlated with other variables of
the patient such as age, underlying illness, comorbidities, and general condition. Analysis: Data collected were analyzed using appropriate
statistical means to determine the level of correlation. Results: Of the 100 conscious patients, 19 (19%) had otitic barotrauma. Of those,
31.6% had Grade I otitic barotrauma, 47.4% had Grade II otitic barotrauma, and 21.0% had Grade III otitic barotrauma. Risk factors for
otitic barotrauma were pressure equalization problems. We found no influence of age, sex, or comorbidities on the occurrence of barotrauma.
Conclusions: Difficulties in pressure equalization were the only risk factors for middle ear barotrauma. Age, sex, or other comorbidities did
not affect the incidence of otitic barotrauma.

Keywords: Hyperbaric oxygen therapy, incidence, otitic barotrauma

Introduction In this study, patients underwent otoscopic examination before

Barotrauma is caused by the difference in pressure between the
air‑containing spaces of the ear and the outside environment.
Since fluids do not compress under pressure, the fluid‑containing
cavities of the ear do not alter their volume under the pressure
changes of hyperbaric oxygen therapy  (HBOT). However,
the air‑containing spaces of the ear do compress, resulting
in damage to the ear if the alteration in ambient pressure
cannot be equalized. These changes are dependent on speed
of pressurization as well as underlying conditions of the ear.
Otitic barotrauma can cause various symptoms and signs,
such as tinnitus, hearing loss, pain, fullness of ear, and even
tympanic membrane perforation. It is one of the leading causes
for discontinuation of HBOT therapy. The treatment depends
on the severity of barotrauma and ranges from temporary
cessation of therapy, nasal decongestants, and occasionally
middle ear surgery. Early diagnosis is important to relieve
symptoms and prevent disease progression.
Submitted: 28-Nov-2019 Revised: 06-Mar-2020 Accepted: 30-Mar-2020
Published: 23-Apr-2021
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and immediately following the session of HBOT. Patients
with positive findings underwent suitable treatment and were
graded according to the standard grading system. Their other
variables such as age, underlying illness, comorbidities, and
general condition were analyzed. The data were statistically
analyzed to ascertain any predisposing factors for developing
barotrauma.
Aims
The aim of the study was to determine the incidence of otitic
barotrauma during HBOT.
Objectives
The objectives of this study were as follows:
Address for correspondence: Dr. Nirbhesh Saxena,
Department of ENT, Military Hospital, Meerut ‑ 250 001, Uttar Pradesh,
India.
E‑mail: drnirbhesh@gmail.com
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DOI: How to cite this article: Saxena N, Raghavan D. A study to determine the
10.4103/indianjotol.INDIANJOTOL_131_19 incidence of otitic barotrauma during hyperbaric oxygen therapy. Indian J
Otol 2020;26:254-7.

254 © 2021 Indian Journal of Otology | Published by Wolters Kluwer - Medknow

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Saxena and Raghavan: Incidence of otitic barotrauma during HBOT
i. To assess changes in the tympanic membrane following
HBOT
ii. To determine various factors predisposing to the
development of otitic barotrauma.
Materials and Methods
General setting
The study was conducted in a tertiary care hospital setting.
Study design
A prospective study was undertaken.
Sample size
A total of 100 patients were evaluated.
Inclusion criteria
The study comprised individuals undergoing HBOT for various
indications who consented/  Next of Kin (NOK) consented (if
an individual was unable to give consent) were recruited into
the study.
Exclusion criteria
The exclusion criteria of this study were as follows:
1. Patients where consent was not forthcoming to participate
in the study
2. Preexisting middle ear pathology as diagnosed by
pneumatic otoscopy
3. Diagnosed nasal allergy/sinonasal polyps/growths.
Methodology
All patients planned for HBOT were clinically assessed for
Eustachian tube function by pneumatic otoscopy. This method
has been found to be as good as a predictor of Eustachian tube
function as tympanometry. Patients undergoing HBOT were
subjected to otoscopy, and the tympanic membrane of these
patients was evaluated before and immediately following the
session of HBOT. A standard grading system was used to grade
the changes when noticed. These changes were correlated with
other variables of the patient such as age, underlying illness,
comorbidities, and general condition.
Analysis
Data collected were analyzed using appropriate statistical
means to determine the level of correlation.
Results
The study included 100 patients, of whom 46 (46%) were male
and 54 (54%) were female, with a mean age of 47.1 years.
HBOT was performed for radiation cystitis/prostatitis in 45%
of patients, sensorineural hearing loss in 17%, nonhealing
ulcer in 10%, dental causes in 8%, amputation healing in
5%, avascular necrosis in 2%, and other causes. Of the 100
conscious patients, 19  (19%) had otitic barotrauma [Graph
1]. Of the patients with otitic barotrauma, 31.6% had Grade I
otitic barotrauma, 47.4% had Grade II otitic barotrauma, and
21.0% had Grade III otitic barotrauma [Graph 2]. Risk factors
for otitic barotrauma were pressure equalization problems.
Indian Journal of Otology  ¦  Volume 26  ¦  Issue 4  ¦  October-December 2020
We found no influence of age, sex, or comorbidities on the
occurrence of barotrauma [Table 1].
Discussion
Middle ear barotrauma is one of the most common side effects
of HBOT;[1,2] reported incidences range from 8% to 68.7%
and up to 91% in patients who are unable to auto‑inflate their
middle ear. Known risk factors for otitic barotrauma include
older age, artificial airways, and history of Eustachian tube
dysfunction or the inability to auto‑inflate the middle ear.
Slower compression is a known protective factor for otitic
barotrauma.[3]
The incidence of otitic barotrauma is important for patients
undergoing HBOT because it can lead to interruption of
treatment or delay in commencement of treatment. In our
study, grades of middle ear barotrauma ranged from Grade I
to Grade III, and therefore, treatment sessions were interrupted
due to the same.[4,5]
The overall incidence of middle ear barotrauma in our
study (19%) was found to be lower as compared to other studies
conducted worldwide. This may be attributable to highly
trained staff working at the HBOT center who themselves
knew about the barometric changes during HBOT and were,
therefore, able to guide the patients better both before and
during the sessions of HBOT.
The incidence of middle ear barotrauma is also related to the
rate of compression of HBOT chamber. Sanders mentioned in
his study on middle ear barotrauma that a rate of compression
of 2 psi/min was adequate in preventing the occurrence of
middle ear barotrauma, and compression at any slower rate
did not add to the reduction in number of cases of middle ear
barotrauma. In our center too, we compressed the chamber
at a rate of 2 psi/min and is, therefore, consistent with other
literature.
Another important aspect in the development of middle ear
barotrauma is the understanding and practice of auto‑inflation
techniques inside the HBOT chamber. We noted in our study
that a vast majority of the patients (58 of 100) were in the age
group of 45 years and above. In these patients, it was imperative
for us that more time should be devoted toward explaining
and making them practice auto‑inflation techniques before
subjecting them to HBOT.[6]
This emphasizes the clinical importance of otitic barotrauma
and confirms the need for proper treatment of middle
ear barotrauma with active prevention and precautionary
measures.[7]
In our study, HBOT was performed in a multiplace chamber, and
patients were accompanied by a chaperone who explained the
potential complications of HBOT. This is reported to reduce the
risk of otitic barotrauma. The successful equalization of pressure
by inflating the middle ear has been reported to be protective,
whereas the prophylactic use of nasal decongestants has not.
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Saxena and Raghavan: Incidence of otitic barotrauma during HBOT

Graph 1: Distribution of study population according to otitic barotrauma

Table 1: Association between otitic barotrauma and

Graph 2: Distribution of study population according to grades of otitic
comorbidity of study population
barotrauma
Otitic barotrauma Comorbidity Total
Present Absent the first HBOT[18] session can go a long way in keeping the
Grade 1 3 (4.5) 3 (8.8) 6 (6.0) incidence of middle ear barotrauma low.[19,20]
Grade 2 6 (9.1) 3 (8.8) 9 (9.0)
Grade 3 3 (4.5) 1 (2.9) 4 (4.0) Limitations of this study
No otitic barotrauma 54 (81.8) 27 (79.4) 81 (81.0) This was a study in which 100 patients were recruited. While
Total 66 (100.0) 34 (100.0) 100 (100.0) a larger study population would have been preferred, we were
χ2, P 0.847, 0.838 (NS) constrained by the workload and availability of patients during
NS: Not significant a specific period of study.
While this study suggests that with appropriate training
In our study, all the patients always received explanations and guidance, the incidence of otitic barotrauma can be
and education on HBOT and were taught how to perform significantly reduced, larger studies will be required to confirm
a Valsalva maneuver. They were informed about the risks and validate the same.
for otitic barotrauma and told to report to the chaperone in
case of any symptoms of ear pain or discomfort. In cases of Financial support and sponsorship
difficulties with pressure equalization, patients were assisted Nil.
out of the chamber by the chaperone.[8] We believe that it
Conflicts of interest
contributed to reducing the incidence of otitis barotrauma.
There are no conflicts of interest.
Difficulties with equalizing pressure were associated with
otitic barotrauma.[9,10]
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