Barotrauma and the Ear
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Direct answer
Barotrauma injures the ear through Boyle's law: as ambient pressure rises during descent in flight or diving, gas in the middle-ear cleft shrinks, and if the eustachian tube cannot equalise, the tympanic membrane retracts, vessels transude and the drum can rupture. Ascent reverses the gradient and can force vertigo — alternobaric vertigo — or, in divers, inner-ear barotrauma with round window perilymph leak presenting as sudden hearing loss, tinnitus and vertigo. Equalisation by swallowing, the Valsalva or Frenzel manoeuvre during descent prevents nearly all of it, and the pilot or diver who cannot equalise must stop the descent, ascend to relieve the gradient, and only then retry.
What you must remember
- Physics in one line: pressure changes with depth or altitude while middle-ear gas volume changes inversely — a failure of active equalisation, not of pressure itself, causes the injury; the greatest volume change per metre occurs near the surface.
- Middle-ear barotrauma spectrum: retraction with injection, then haemorrhagic blebs or a haemotympanum, then tympanic membrane perforation with pain that paradoxically eases at the moment of rupture — the clinical picture is graded on otoscopic findings (Teed's grades).
- Inner-ear barotrauma: forceful Valsalva against a blocked tube or unequalised descent ruptures the round or oval window — sudden sensorineural hearing loss, tinnitus and vertigo in a diver demand strict bed rest, head elevation, and surgical exploration with patching if perilymph leak persists.
- Alternobaric vertigo: asymmetric middle-ear pressure during ascent or descent, classically in divers and aviators, causes transient vertigo and nystagmus — it resolves with equalisation but is dangerous mid-flight or mid-dive.
- Immediate management: decongestant nasal drops and oral pseudoephedrine-type decongestants, analgesia, no further pressure exposure until the drum and hearing normalise; keep the ear dry and treat the effusion or haemotympanum conservatively for weeks before considering myringotomy.
- Return-to-fly and return-to-dive rules: no flying or diving with an active upper respiratory infection, uncontrolled allergy or an unrecovered drum; divers with barotrauma need audiological and otoscopic clearance before re-exposure.
- Prevention techniques: swallowing, yawning, gentle Valsalva and Frenzel manoeuvre during descent only — never a forceful Valsalva at depth; infants feed during descent for the same reason.
Case walk-through: the diver who equalised too hard
A 30-year-old recreational diver reports ear fullness and muffled hearing after a descent during which he "had to force equalisation". Otoscopy shows a retracted, haemorrhagic right drum — middle-ear barotrauma — treated with decongestants, analgesia and strict no-diving advice while the haemotympanum resolves over two to three weeks.
Now change one detail: alongside the fullness he noticed abrupt vertigo, nausea and a high-pitched tinnitus in the same ear, and hearing feels dead, not muffled. That is the inner-ear barotrauma scenario — suspected perilymph fistula at the round window. Management changes character entirely: strict bed rest with head elevated, avoidance of straining and nose-blowing, urgent audiometry documenting the sensorineural loss, and surgical exploration with fascia or fat grafting of the window if the leak and loss persist. Sending that patient home with decongestants alone can cost the ear. The examiner's discriminating question is exactly this pair of scenarios, and the hinge is conductive versus sensorineural loss — one tuned fork pair at the bedside sorts them.
How the exam frames it
Physiology questions come first: why is the greatest risk near the surface? Because Boyle's law operates on proportional volume change, the first ten metres of seawater halve gas volume — more change than all the deeper metres combined. Clinical questions follow: pain relieved suddenly during descent means the drum has perforated, and continuing the dive risks water flooding the middle ear. Viva examiners also pair barotrauma with eustachian tube function — any tubal obstruction from adenoids, allergy or upper respiratory infection converts an ordinary flight into an otological event, which is why decongestants before descent in blocked-nose passengers is standard advice. Finally, the term "mask squeeze" and sinus barotrauma belong to the same family: facial petechiae and frontal pain from the same pressure-volume law.
Frequently asked questions
Why does barotrauma mainly occur during descent rather than ascent?
Descent raises ambient pressure and shrinks middle-ear gas volume, requiring active eustachian equalisation; ascent passively vents gas through the tube, so obstruction injures chiefly on the way down.
What is inner-ear barotrauma and how does it present?
Rupture of the round or oval window from unequalised or forceful descent, presenting with sudden sensorineural hearing loss, tinnitus and vertigo in a diver or aviator, sometimes needing surgical repair.
What is alternobaric vertigo?
Transient vertigo from asymmetric pressure differences between the two middle ears during ascent or descent, resolving with equalisation; significant because it strikes at moments demanding full orientation.
How is middle-ear barotrauma managed?
Decongestants, analgesia, keeping the ear dry, and abstaining from flying and diving until the drum and hearing recover; persistent effusion or haemotympanum may need myringotomy.
Which manoeuvres prevent ear barotrauma?
Swallowing, yawning and gentle Valsalva or Frenzel manoeuvres performed proactively during descent, alongside avoiding diving or flying with a blocked nose or upper respiratory infection.