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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 26  |  Issue : 4  |  Page : 254-257

A study to determine the incidence of otitic barotrauma during hyperbaric oxygen therapy


1 Department of ENT, Military Hospital, Meerut, Uttar Pradesh, India
2 Department of ENT, AFMC, Pune, Maharashtra, India

Date of Submission28-Nov-2019
Date of Decision06-Mar-2020
Date of Acceptance30-Mar-2020
Date of Web Publication23-Apr-2021

Correspondence Address:
Dr. Nirbhesh Saxena
Department of ENT, Military Hospital, Meerut - 250 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_131_19

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  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


How to cite this article:
Saxena N, Raghavan D. A study to determine the incidence of otitic barotrauma during hyperbaric oxygen therapy. Indian J Otol 2020;26:254-7

How to cite this URL:
Saxena N, Raghavan D. A study to determine the incidence of otitic barotrauma during hyperbaric oxygen therapy. Indian J Otol [serial online] 2020 [cited 2021 Jun 16];26:254-7. Available from: https://www.indianjotol.org/text.asp?2020/26/4/254/314336




  Introduction Top


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.

In this study, patients underwent otoscopic examination before 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:

  1. To assess changes in the tympanic membrane following HBOT
  2. To determine various factors predisposing to the development of otitic barotrauma.



  Materials and Methods Top


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 Top


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. We found no influence of age, sex, or comorbidities on the occurrence of barotrauma [Table 1].

Table 1: Association between otitic barotrauma and comorbidity of study population

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  Discussion Top


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.

In our study, all the patients always received explanations and education on HBOT and were taught how to perform a Valsalva maneuver. They were informed about the risks for otitic barotrauma and told to report to the chaperone in case of any symptoms of ear pain or discomfort. In cases of difficulties with pressure equalization, patients were assisted out of the chamber by the chaperone.[8] We believe that it contributed to reducing the incidence of otitis barotrauma. Difficulties with equalizing pressure were associated with otitic barotrauma.[9],[10]

This could be explained by a number of patients performing ineffective Valsalva, who would be at higher risk for otitic barotrauma; this is on par with previous findings on Eustachian tube function and higher risk of otitic barotrauma in patients unable to auto-inflate the middle ear.[11]

Various diseases for which HBOT was given did not influence the otitic barotrauma incidence.[12],[13]

In contrast to the other studies, we found no association between age or gender and otitic barotrauma.


  Conclusions Top


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. Middle ear barotrauma is the most common complication in HBOT,[14],[15] but it does not result in discontinuing HBOT for the patient altogether.[16] Proper screening of patients by pneumatic otoscopy for Eustachian tube dysfunction and proper practice of auto-inflation techniques[17] before the commencement of the first HBOT[18] session can go a long way in keeping the incidence of middle ear barotrauma low.[19],[20]

Limitations of this study

This was a study in which 100 patients were recruited. While a larger study population would have been preferred, we were constrained by the workload and availability of patients during a specific period of study.

While this study suggests that with appropriate training and guidance, the incidence of otitic barotrauma can be significantly reduced, larger studies will be required to confirm and validate the same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Blanshard J, Toma A, Bryson P, Williamson P. Middle ear barotrauma in patients undergoing hyperbaric oxygen therapy. Clin Otolaryngol Allied Sci 1996;21:400-3.  Back to cited text no. 2
    
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11.
Grim PS, Gottlieb LJ, Boddie A, Batson E. Hyperbaric oxygen therapy. JAMA 1990;263:2216-20.  Back to cited text no. 11
    
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Boykin VJ. Hyperbaric oxygen therapy: A physiological approach to selected problem wound healing. Wounds 1996;8:183-98.  Back to cited text no. 12
    
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Cohn GH. Hyperbaric oxygen therapy. Promoting healing in difficult cases. Postgrad Med 1986;79:89-92.  Back to cited text no. 13
    
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Lamm K, Lamm H, Arnold W. Effect of hyperbaric oxygen therapy in comparison to conventional or placebo therapy or no treatment in idiopathic sudden hearing loss, acoustic trauma, noise-induced hearing loss and tinnitus. A literature survey. Adv Otorhinolaryngol 1998;54:86-99.  Back to cited text no. 14
    
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Hampson NB, editor. Hyperbaric Oxygen Therapy: 1999 Committee Report. Kensington MD: Undersea and Hyperbaric Medical Society; 1999.  Back to cited text no. 15
    
16.
Sahni T, Singh P, John MJ. Hyperbaric oxygen therapy: Current trends and applications. J Assoc Physicians India 2003;51:280-4.  Back to cited text no. 16
    
17.
Lima MA, Farage L, Cristina M, Cury L. Middle ear barotrauma after HBOT- the role of insufflations maneuvers. Int Tinnitus J 2012;17:180-5. doi: 10.5935/0946-5448.20120032.  Back to cited text no. 17
    
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19.
Igarashi Y, Watanabe Y, Mizukoshi K. Middle ear barotrauma associated with hyperbaric oxygenation treatment. Acta Otolaryngol Suppl 1993;504:143-5.  Back to cited text no. 19
    
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Bessereau J, Tabah A, Genotelle N, Français A, Coulange M, Annane D. Middle-ear barotrauma after hyperbaric oxygen therapy. Undersea Hyperb Med 2010;37:203-8.  Back to cited text no. 20
    



 
 
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