Barotrauma:TheInsandOutsofthePopsandCracks ByEricHexdall,RN,CHRN Manyofusknowthefeeling.Wereondescentandrealizethatoneofourearshasnt equalized.WeperformtheValsalvamaneuver,andSQUEAK!Theairzipsin,wemayfeelsome momentarypain,andthepressureintheeargoesaway.Wecontinuethedivewiththeeargurglingand snapping,andsurfacewiththemostcommoninjuryindiving:middleearbarotrauma. BoylesLawstatesthataspressureincreases,thevolumeofanairfilledspacewilldecrease proportionally,andviceversa.Inpractice,thismeansthatalloftheairfilledspacesinandaroundour bodiescanbeaffectedinonewayoranotherbypressure.Whenwedive,thesespacesneedtobe equalizedasthepressurearounduschanges. ThemiddleearisMr.Boylesprimaryvictim.Thesinusesarealsofilledwithairasare,of course,ourlungs.Airtrappedbeneathfaultydentalworkcancauseextremediscomfort,and gastrointestinalaircanbeanissueforsomeofus.Ourdivinggearcanalsocreateairfilledspaces.Our maskstrapairagainstourfaces,andifweuseadrysuit,thereisanairfilledspacebetweenthesuitand ourbodies.

Typically,barotraumaofdescentiscalledasqueezeorblock,andbarotraumaofascentis calledareversesqueezeorreverseblock.Theairfilledspacesinandaroundourbodiesmaybe affectedbyoneorbothofthese.Letsexamineeachofthem. EarBarotrauma Thereareseveralareasintheearthatarevulnerabletobarotrauma.Beforewediscussthem, letstakeacloserlookattheanatomyoftheear.

Themiddleear,locatedjustbehindthetympanicmembrane,containsthethreebonesofthe ossicularchain:malleus,incus,andstapes.ItisfilledwithairandisequalizedviatheEustachiantube, whichconnectsthemiddleeartothenasopharynx(theareaofthethroatjustbehindthenose).In youngchildren,theEustachiantubetravelsthroughfleshandmucousmembraneandisorientedmore horizontally.Becauseofthis,theirearsdonotdrainorequalizeaseasilyasanadults.Anyonewhohas satnexttoacryingbabyonadescendingairplanehasbeenwitnesstothis.Aswegetolder,theendof theEustachiantubethatisclosesttothemiddleear(calledthedistalend)becomesencasedinbone andsobecomeslesspronetocollapse.Also,astheheadgrows,theorientationoftheEustachiantube changessothatfluidsdrainmoreeasilyfromthemiddleear.Theendofthetubethatisclosesttothe nasopharynx(theproximalend)remainssoftandtravelsthroughflesh,whichiswhyitismoredifficult toequalizetheearsondescentthanonascent.Ifadivergetsbehindonequalizing,itcancollapsethe proximalendoftheEustachiantubeandmakeitverydifficulttocleartheearwithoutascendingfirst.If thedivercontinueswithoutequalizing,theairinsidethemiddleearwillfollowBoylesLawandreduce itselfinvolume. Severalthingscanoccuratthispoint.Thetympanicmembranebeginstobowinwardandmay ruptureifthedivercontinues.Also,bloodand/orserousfluidcanbepulledfromthedelicatecapillaries thatlinethemiddleear.Thisfluidfillsthemiddleearandcanactuallyrelievesomeofthepainand/or pressurethatthediverisexperiencing.Also,asmentionedabove,thedistalendoftheEustachiantube collapses. IfadiverattemptstoforceaValsalvamaneuver,theairmayenterthemiddleearallatonce andoverpressurizeit.Theextrapressureintheearmakesthetympanicmembranesuddenlybow outward.Theossicularchainthenpullsontheovalwindowandmakesitbowoutwardaswell. Theovalwindowispartoftheinnerear.Theorgansoftheinnerear,thecochleaand semicircularcanals,arefilledwithfluidandareresponsibleforhearingandbalance,respectively.The roundwindowislocatedinferiorto(below)theovalwindow.Itactslikeadamperforthepressure wavesthataretransmittedtotheinnerearviatheossicularchainandovalwindow.Whentheoval windowpressesinward,theroundwindowbowsoutward,andviceversa.Thismechanismallowsthe pressureofthefluidintheinnereartoremainrelativelystableastheossicularchainvibratesin responsetosoundwaves.However,iftheovalwindowissuddenlyyankedoutwardbecauseofa forcefulValsalvamaneuverasexplainedabove,theroundwindowmaybedrawninwardsomuchthatit tears.Thisisknownasaperilymphfistula,anditisconsideredamedicalemergency.Symptomsofa perilymphfistulacanincludehearingloss,ringingintheear,vertigo,nausea,andvomiting.Ifnot treatedpromptly,itmayresultinpermanentdamagetothemiddleear. Adiverwithasuspectedperilymphfistulashouldstopdivingimmediatelyandbetransportedto thenearestemergencydepartmentassoonaspossible.Keepthediversheadup,andcautionhimto avoidstrainingorattemptingtoclearhisears,bothofwhichcanaggravatethecondition.Obtaina carefuldivehistory,includingpreviousdivesandtimeofonsetofthesymptoms.Perilymphfistulacan mimicinnereardecompressionsickness,soagoodhistorywillhelpthetreatingphysicianmakethe correctdiagnosis.Evenaftertreatment,adiverwithperilymphfistulamayhaveresidualsymptoms suchashighfrequencyhearinglossand/ortinnitus.

Rarely,aircanbecometrappedinthemiddleearandfailtoventonascent.Ifoneearclears beforetheother,adivermayfeelalternobaricvertigorelatedtothedifferingpressuresontheinner ear.Itcanbefrighteninganddisorienting,especiallyifithappensinthewater.Ifadiverexperiences alternobaricvertigo,itishelpfultograbontosomethingstableuntilitpasses.Toreorientherself,a divercanobserveherbubbles.Oncetheearclears,thevertigoshouldabate.Inrarecases,reverse middleearsqueezecanresultinoutwardruptureofthetympanicmembraneorperilymphfistulaas describedabove.Adiverwhofeelssymptomsofreversemiddleearsqueezeshouldslowhisorher ascentandattempttoequalizetheearsbyswallowing.TheValsalvamaneuvershouldbeavoided,as thiscanincreasethepressureinthemiddleearandcauseinjury. Atightlyfittinghoodmaycauseairtobecometrappedintheexternalearcanal.Ifthisoccurs, theairbetweenthehoodandthetympanicmembranewillbecompressedondescent.Adivermay interpretthisasaneedtoaddmoreairtothemiddleearspace.However,addingairtoamiddleear thatisalreadyequalizedundertheseconditionsmayresultininjurytothetympanicmembraneand/or innerear.Hoodsshouldbesnugbutnotexcessivelytight.Whenwearingahood,itmaybebeneficial tomanuallyallowwatertoentertheexternalearbeforedescent. SinusBarotrauma Theearandsinusesarerelatedinthattheyarebothaffectedbycolds,allergies,andother irritants.Thesinusesarecavernousspacesintheskullthatservetowarm,humidify,andfilterincoming air.Therearefoursetsofsinuses,shownbelow:frontal,maxillary,ethmoidal,andsphenoidal.

Ifadiverbeginsadescentwithblockedsinusopenings,theairintheaffectedsinuswillbe compressed.Thisexertsapullingforceonthemucousmembranes,andcanresultinruptureofthetiny

capillariesandsubsequententryofbloodintothesinus.Thisisusuallyarelativelypainlessoccurrence, sothediveroftenremainsunawareofwhatishappening.Onascent,astheremainingairinthesinus expands,thebloodandmucusmaybeexpelledintothemaskordraindownthenasopharynxandinto themouth.Asominousasitmayappear,sinussqueezeisusuallyarelativelybenignoccurrenceand healswithrestandavoidanceofpressurechanges. Ontheotherhand,theopeningtothesinusmaybecomesoirritatedastonotallowairto escapeonascent.Thisresultsinreversesinussqueeze,whichmaybepainfulenoughtopreventadiver fromfurtherascent.ThiscanbecomeproblematicinSCUBAasthediversgassupplyisdepleted.The divermayalsobeatadepthwhereheorshebeginstoincuradecompressionobligation,whichwillalso depletethediversairsupply.Adiverwithreversesinussqueezeshouldcontinuetoslowlyattemptto surface.Positioningtheheadsothattheopeningsofthesinusesareorientedupwardcanbehelpful, butisrecommendedonlyforimmediateclearingofthesinusesandnotfortheentireascent. Properearequalizationtechniques,moderationofthedescentrate,andavoidanceofdiving whilecongestedareallstrategiesthatcanhelpkeepadiversearsandsinuseshealthyandhappy.But, whatifyoureonthatdreamliveaboardvacation?Youvesavedfortwoyears,shelledoutthousandsof dollars,flownhalfwayacrosstheworldandnowyourestuffedupbecausethehackingfellowinthe windowseatwassharinghisgermswithyou.Dontdespair,thereareafewstrategiesthatcanhelpget youinthewater. 1. Decongestants.Overthecounterdecongestantslikepseudoephedrine(Sudafed,others) canbehelpful.Overthecounterantihistamineslikediphenhydramine(Bendadryl,others) andloratadine(Claritin,others)canbebeneficialifthecongestionisduetoallergies.Many ofthesemedicationsmaycausedrowsiness,sousethemwithcautionanddonotdiveifyou experiencesleepinessorsedation.Alwaysfollowalldosinginstructions,andbewareof medicationinteractions,especiallywithprescriptiondrugs.Consultyourphysicianifyou haveanyquestionsaboutyourmedications. 2. Nonsteroidalantiinflammatorymedications(NSAIDs).NSAIDslikeibuprofen(Motrin, others)andacetaminophen(Tylenol,others)canhelpreducetheinflammationandswelling ofthemucousmembranes.Again,followdosinginstructions,bewareofmedication interactions,andconsultyourphysicianifyoureunsureaboutmedications. 3. Sinusrinsesandsalinenasalspray.Severaloverthecountersinusrinsesareavailable. Theytypicallycomewithpremixedpacketsofsaltandsodiumbicarbonatetomakean isotonic(compatiblewithbodyelectrolytesandpH)liquidthatwillnotirritateyoursinuses. Salinenasalspraysaregentleenoughtousefrequentlyandcanhelpkeepsecretionsclear. 4. Goslowly.Donttrytopushitonyourdescentsandascents.Whenequalizing,stayahead ofthedescent.Thatis,activelyequalizeyourearseventhoughitdoesntfeellikeyouhave to.Trydifferentequalizationmethodstoseewhichworksbestforyou.Onascent,donot addanyairtoyourmiddleear.Goslowlyenoughtoallowyourearstoequalizethemselves.

LungSqueezeandPulmonarybarotrauma Lungsqueezeofdescentisnottypicallyencounteredincompressedgasdiving.However,free diversmaysufferfromlungsqueezeifthelungsarecompressedbeyondtheirresidualvolume,orthe amountofgasthatremainsinthelungsafterafullexpiration.Typically,residualvolumeinanadultis about1liter.Ifthesametypicaladulttookasdeepabreathaspossible,thetotalvolumeofthelungs wouldbeabout5liters.IfweworkalittleBoylesLawmagiconthesenumbers,wecanpredictthe depthatwhichthelungswillbecompressedtotheirresidualvolume: P1xV1=P2xV2 P1=atmosphericpressure,1ATA V1=beginninglungvolume,5liters P2=unknown V2=residualvolume,1liter 1ATAx6liters=P2x1liter P2=1ATAx5liters 1liter P2=5ATA,or132feetofseawater So,theoretically,beyondadepthof132feet,anaveragepersonwouldbeatriskoflungsqueezeduring afreedive.However,freediverswhocanattainadepthof132feetandgreaterprobablywouldnotbe describedasaverage.Asofthiswriting,thecurrentunlimitedfreedivingdepthrecordisheldby AustrianHerbertNitsch,whoplungedtoanastoundingdepthof214meters(702.10feetofseawater, or22.27atmospheresabsolute)inJune2007(source:www.aidainternational.org).Atthatdepth,his lungswerecompressedtoabout4.7%oftheiroriginalvolume.So,whydontcompetitivefreedivers likeHerbertsufferfromfatallungsqueeze?Inbrief,theimmersionrelatedshiftofbloodintothe organsofthechestcavity(sometimesuptoaliterormore)protectsthechestitselffromtrauma.Also, trainedfreediversuseavarietyoftechniquesandexercisesdesignedtomaximizelungcapacityand minimizepotentialdamagetothelungswhentheydescendbeyondthetheoreticalmaximum(Ferrigno andLundgren2003).Theemphasisisonthewordtrained.Formalinstructionishighlyrecommended forthosewantingtoexplorethisareaofdiving. Reverselungsqueezeisbetterknownaspulmonaryoverinflation.Asalldiverslearn,holding thebreathonascentcanresultinruptureofthedelicatealveoliandcapillariesinthelungs.Thismay leadtopneumothorax(airbetweenthelungsandchestcavity),mediastinalemphysema(airinthespace betweenthelungsandaroundtheheart),subcutaneousemphysema(airbeneaththeskin),and/or arterialgasembolism.Aircanalsobetrappedbybullae(airfilledcystsinthelungs)orbyrestrictedair passagesrelatedtoreactiveairwaydiseaseslikeasthma.

Pulmonaryoverinflationisamedicalemergency.Diverswithsuspectedpulmonaryoverinflation shouldbeplacedonoxygenbyqualifiedpersonnelandmonitoredcarefullyforbreathingand circulation,thenevacuatedtothenearestemergencydepartmentbythequickestmeanspossible. Preventionstrategiesincludeawarenessofbreathing,divingwithinonesownlimits,andscreeningof divecandidatesforphysicalconditionsthatmaypredisposethemtoairtrapping. Gastrointestinalbarotrauma Sincethegutisdesignedtocontractinordertomovefoodalongthedigestivetract,airtrapped inthegutthatiscompressedondescentwillnotaffectadiver.However,thereverseisnottrue. Expandingairinthegutonascentcancausedistentionandpain.Ifadiverfeelsgastricdistentionon ascent,theascentshouldbehaltedandanattemptmadetoexpeltheoffendinggas.TheU.S.Navy DivingManualaddressesthisinafrankandsuccinctmanner:Thedivershouldattempttogently burporreleasethegasanally.Overzealousattemptstobelchshouldbeavoidedastheymayresultin swallowingmoreair.(NAVSEA2008)Gastricdistentiononascentcannormallybepreventedby avoidingfoodsknowntoproducegas,especiallyifthediverisparticularlypronetosuchproblems. Toothbarotrauma Alsoknownasbarodontalgia,toothbarotraumacanbeanextremelypainfuloccurrence.Air maybetrappedunderafillingduetodecayorimproperplacement.Inadiver,thisairwillbe compressedondescent.Thiscanexertapullingforceonthepulpofthetooth,resultinginpain. Ifafillingisnotproperlysealed,itmaybecomepressurizedatdepth.Whenthediverascends,theair willexpandandmaycrackthetoothorexpelthefilling. Preventionofbarodontalgiainvolvesensuringthatfillingsarefreeofair.Dentiststypicallydo notleaveairbeneathfillings,butitisadvisableforadivertoinformhisorherdentistthatheorshe dives,andaskforextracautioninplacingafilling.Ifadiverexperiencesbarodontalgiaondescent,the diveshouldbeimmediatelyaborted.Ifbarodontalgiaoccursonascent,thedivershouldascendas slowlyaspossiblegivenhisorherdecompressionstatusandremaininggassupply.Thiswillbest facilitateairventingaroundthefillingandthuspossiblyallowthedivertoavoidcrackingthetoothor expellingthefilling. Facemasksqueeze Masksqueezeresultsfromfailuretoaddairtothemaskviathenoseondescent.Theairinthe maskwillbecompressedandmaycausethedelicatecapillariesaroundtheeyestorupture.Thiscan resultinreddeningofthescleraandecchymosis(bruising)aroundtheeyes,alongwithswellingofthe eyelidsandconjunctiva(liningoftheeyelid).Surprisingly,thediveroftendoesnotfeelpainwhenthis happens.Theresultsaredramaticbutarenormallyrelativelybenignandshouldresolveinacoupleof weeks.Painorchangesinvisionshouldbeaddressedimmediatelyinthenearestemergencyroom.

Facemasksqueezecanbepreventedbyaddingairtothemaskondescent.Onascent,theairinthe maskwillsimplyexpandandeitherenterthediversrespiratorysystemorventitselfthroughtheseal.

Facemasksqueeze.ImagecourtesyLesterQuayleandRitaBarton. Suitsqueeze Sincetheytrapair,drysuitsalsopresentanopportunityforbarotrauma.Astheairinthesuitis compressedondescent,foldsofskinmaybetrappedinthecreasesonthesuit.Thisiseasilyprevented bygraduallyaddingairtothesuitondescent.

Drysuitsqueeze.ImagecourtesyOakvilleDivers.

Onascent,adrysuitdiverneedstoventairfromthesuittopreventoverinflationandblowup,or uncontrolledascent.Whilenottechnicallybarotrauma,ablowupcanresultindecompressionillnessor pulmonaryoverinflation. WholeBodySqueeze Therearecasereportsofsurfacesuppliedhardhatdiverssufferingfromsevere,sometimes fatalbarotraumawhentheirgassupplyumbilicalwassuddenlydepressurized,eitherbyseveringthe umbilicalatthesurfaceorthroughmechanicalfailure(e.g.threadfailureonatopsideairfitting).If thereisnotaworkingcheckvalveattachedtothedivinghelmet,theairinthehelmet(andattached suit,ifthediverisinafullyencloseddrydivingdress)willrushuptheumbilicalduetothepressure differencebetweenatmosphericpressureandthepressureonthebottom.Sincethegassupply umbilicalisflexiblebutrigid,theeffectofthisistoproducealargenegativepressureintheumbilical, whichactslikeaverypowerfulvacuum.Ifthediverisdeepenough,diversbodymaybeliterallysucked intothehelmet. Toavoidthis,partofthesafetychecklistformilitaryandcommercialdivinginvolvestestingthe checkvalveforfunctionalitypriortoattachingthehelmettotheumbilical. Thelawsofphysicscantbecircumvented,onlycompensatedfor.Barotraumaismuchbetter preventedthantreated,andbyapplyingyourknowledgeofBoylesLawalongwithappropriatediving training,youcanavoidsqueeze. Ericcanbecontactedateric.hexdall@duke.edu References Ferrigno,M.andC.E.Lundgren(2003).BreathHoldDiving.BennettandElliott'sPhysiologyand MedicineofDiving.A.O.BrubakkandT.S.Neuman,ElsevierScience:153180. NAVSEA(2008).U.S.NavyDivingManualRevision6.D.o.t.Navy.Washington,DC,NavalSeaSystems Command.