Barotrauma

How barotrauma happens

Air spaces in the body (middle ear, sinuses, lungs, dental fillings with air pockets, and the space inside a diving mask) must equalize with outside pressure. The middle ear does this through the Eustachian tube, a narrow channel from the ear to the back of the nose that opens when you swallow or yawn.

During descent in a plane or dive, outside pressure rises. If the Eustachian tube does not open, lower pressure in the middle ear pulls the eardrum inward, causing pain, and fluid or blood may leak into the middle ear. In diving, pressure changes are much greater: at 10 meters (33 feet), pressure is double that at the surface.

Types of barotrauma

Middle ear barotrauma (airplane ear)

The most common type. Symptoms:

• ear pressure or fullness
• pain, which can be severe
• muffled hearing
• popping or crackling
• mild dizziness
• in severe cases, a ruptured eardrum with sudden relief of pain, then bleeding or discharge

Inner ear barotrauma

Less common but more serious. A tear in the membranes of the inner ear (perilymph fistula) causes sudden hearing loss, loud ringing (tinnitus) and vertigo. It is often linked to forceful equalizing. It needs urgent ENT assessment.

Sinus barotrauma

Blocked sinus openings cause sharp pain over the forehead, cheeks or around the eyes, and sometimes nosebleeds, usually during descent. It is more likely with a cold, sinusitis, allergies or nasal polyps.

Lung barotrauma (pulmonary)

In divers who hold their breath or ascend too fast, expanding air can rupture lung tissue, causing pneumothorax, air in the chest, or arterial gas embolism, where air bubbles reach the brain. This is a life-threatening emergency requiring recompression treatment in a hyperbaric chamber.

Other types

• Dental barotrauma: tooth pain from air trapped under fillings or in decay.
• Mask squeeze: bruising around the eyes and red eyes in divers who fail to exhale into their mask.

Risk factors

• colds, allergies, sinus infections or Eustachian tube dysfunction
• infants and young children, whose Eustachian tubes are small and more horizontal
• sleeping during descent (fewer swallows)
• rapid descent in diving
• nasal structural problems such as a deviated septum

Diagnosis

A clinician will look at the eardrum with an otoscope. Findings range from a retracted or red eardrum to fluid or blood behind it, or a perforation. Hearing tests check for conductive (middle ear) or sensorineural (inner ear) hearing loss. Divers with chest or neurological symptoms need emergency assessment and imaging.

Treatment

Middle ear barotrauma

• Equalize gently: swallow, yawn, chew gum, or perform a gentle Valsalva maneuver (pinch the nose, close the mouth and blow gently). Never blow forcefully.
• Decongestants: nasal spray such as oxymetazoline for up to 3 days, or oral pseudoephedrine if suitable. Not for people with high blood pressure, heart disease or glaucoma without medical advice.
• Pain relief: acetaminophen (paracetamol) or ibuprofen, following the label dose.
• Steroid nasal spray if allergies contribute.
• Avoid flying and diving until symptoms resolve and, if the eardrum was perforated, until it heals, usually 6 to 8 weeks.
• Keep water out of the ear if the eardrum is perforated.
• Antibiotics only if a secondary infection develops.

Most cases improve within a few days to 2 weeks. A perforated eardrum usually heals on its own. Persistent fluid or a non-healing perforation may need ear tubes or surgical repair.

Inner ear and lung barotrauma

Inner ear injury needs bed rest with the head raised, avoidance of straining, and sometimes surgery. Lung barotrauma and air embolism need emergency oxygen and hyperbaric recompression.

Prevention

When flying

• Stay awake during descent and swallow, yawn or chew gum.
• Use the Valsalva maneuver gently and often as the plane descends.
• Use a decongestant nasal spray about 30 minutes before descent if you have a cold, if your doctor agrees.
• Try filtered pressure-regulating earplugs.
• Give babies a bottle, breast or pacifier during takeoff and landing.
• Consider postponing travel if you have a severe cold or ear infection.

When diving

• Do not dive with a cold, congestion or sinus infection.
• Equalize early and often during descent, before you feel pressure.
• Descend feet first and slowly. Stop or ascend slightly if you cannot equalize.
• Never hold your breath while ascending, and follow safe ascent rates.

Frequently asked questions

What are the symptoms of ear barotrauma?

Typical symptoms are ear pain, pressure or fullness, muffled hearing and popping, usually during airplane descent or diving. Severe cases cause bleeding from the ear, ringing, dizziness or hearing loss, which need medical assessment.

How long does barotrauma last?

Mild ear barotrauma usually resolves within a few hours to a few days. Moderate cases with fluid behind the eardrum can take 1 to 2 weeks. A perforated eardrum usually heals within about 6 to 8 weeks. See a doctor if symptoms persist.

How do you get rid of airplane ear?

Swallow, yawn, chew gum or gently perform the Valsalva maneuver. A decongestant nasal spray can help open the Eustachian tubes. Pain relievers ease discomfort. If pain is severe or hearing does not return within a day or two, see a doctor.

Can barotrauma cause permanent hearing loss?

Middle ear barotrauma rarely causes permanent loss. Inner ear barotrauma can cause lasting hearing loss or tinnitus if not treated promptly. Sudden hearing loss, loud ringing or vertigo after flying or diving needs urgent assessment.

Can I fly with a cold?

You can, but you are more likely to get ear or sinus barotrauma. Use a decongestant before descent if suitable, stay awake to swallow during landing, and use pressure-regulating earplugs. If you have a severe cold or ear infection, consider postponing.