If you have ever traveled in an airplane, you may have felt as if you needed to “pop” your ears during the ascent and descent. Oftentimes, ears will feel plugged and sound as if your hearing has gone muffled. This occurs because there is a discrepancy between the pressure in the environment and the pressure within the middle ear space behind the eardrum.
Attached to the eardrum are three bones within the middle ear space that make up the ossicular chain (malleus, incus, and stapes), which is then attached to the inner ear (the cochlea). When sound waves are present, they vibrate the eardrum, which then causes the ossicular chain to move, stimulating the inner ear. The middle ear space is filled with air. Attaching the middle ear to the back of the throat is a structure called the eustachian tube. At rest, the tube is closed, but when we “pop” our ears, swallow, or yawn, it opens and closes in an attempt to equalize the pressure behind the eardrum to the atmospheric pressure.
What Is Ear Barotrauma? What Causes It?
Ear barotrauma occurs as a result of the inability to equalize pressure behind the eardrum to the atmospheric pressure. There are two primary types of ear barotrauma: middle ear barotrauma and inner ear barotrauma. Both types of ear barotrauma can lead to ear pain, hearing loss, tinnitus (ringing in the ears), and dizziness/vertigo. Over 80% of cases of ear barotrauma occur unilaterally (impacting one ear rather than both).6
Middle ear barotrauma occurs when the atmospheric pressure changes rapidly and the eustachian tube fails to open and close properly, leading to a difference between the middle ear pressure and the environment. This difference in pressure causes damage to the eardrum. Using the TEED grading system, there are six degrees of severity regarding middle ear barotrauma, with the most mild being feelings of fullness in the ear(s), and the most severe being perforations of the eardrum(s).8 The most common first sign of middle ear barotrauma is ear pain or discomfort, followed by a decrease in hearing and sudden onset of tinnitus.
Inner ear barotrauma can be explosive or implosive. Explosive inner ear barotrauma occurs when the atmospheric pressure is increased, such as when a SCUBA diver descends. First, when the atmospheric pressure increases, the eardrum is pushed in towards the head. That increased pressure on the eardrum causes the stapes to be pressed into the inner ear, causing a ruptured cochlea. Implosive inner ear barotrauma is due to a decrease in atmospheric pressure, such as when a SCUBA diver ascends. When the pressure behind the eardrum is more than the atmospheric pressure, this causes the middle ear space to expand, pushing the eardrum away from the inner ear. When the eardrum moves outward, the ossicular chain can be pulled away and torn from the inner ear.4
What is ear barotrauma and how does it relate to ear fullness?
Ear barotrauma refers to the discomfort or pain experienced in the ears due to pressure changes, often encountered during activities like flying, diving, or driving through mountains. This pressure imbalance can lead to a sensation of ear fullness, where the ears feel blocked or clogged.
The condition occurs when the pressure in the middle ear and the environment’s pressure is not in sync, causing the eardrum to retract or bulge. Swallowing, yawning, or using the Valsalva maneuver (gently blowing while pinching the nose) can help equalize the pressure and relieve the sensation. If the feeling persists or is accompanied by severe pain, it’s recommended to consult an audiologist for proper evaluation and advice.
Who is at Risk for Ear Barotrauma?
Many individuals are at risk for ear barotrauma, but this article will focus on four populations: SCUBA divers, airline passengers, those undergoing hyperbaric oxygen therapy (HBOT), and patients with eustachian tube dysfunction.
Millions of people around the world participate in Self-Contained Underwater Breathing Apparatus diving, more commonly known as SCUBA diving. While this activity is enjoyed by many, there are health risk factors that come with it. 80% of SCUBA diving-related complications involve the ears, nose, and throat (collectively called “otolaryngology“).5 SCUBA divers are at risk for both middle ear barotrauma and inner ear barotrauma. Despite the fact that we are exposed to atmospheric pressure changes in daily life, the human ear did not evolve to be functional during descents and ascents while diving. During a descent, the atmospheric pressure doubles within the first 10 meters.2 Similarly, airline passengers are at risk for ear barotrauma, with the middle ear being significantly more impacted than the inner ear. One study suggests that up to 10% of adults and 22% of children experience ear barotrauma following air travel.7
Next, patients undergoing hyperbaric oxygen therapy (HBOT) may be at risk for developing ear barotrauma. This treatment allows for a patient to breathe 100% oxygen while inside of a chamber at a pressure that is above sea level. HBOT is a medical treatment that may be recommended to patients with severe infections, carbon monoxide poisoning, burns, idiopathic sudden sensorineural hearing loss, air embolisms (bubbles) in the blood vessels, and many other conditions. In a sample size of 1115 patients undergoing HBOT, 165 (14.8%) had complications of the ears. Of those patients, 95% reported ear pain, 7.3% reported hearing loss, and 1.8% reported tinnitus. Only one patient in the study suffered from inner ear barotrauma, while the other 164 suffered from middle ear barotrauma.8
Lastly, patients with chronic eustachian tube dysfunction may be at risk for ear barotrauma. Eustachian tube dysfunction can be caused by infection, scarring, and other physiological and functional conditions. A person may be born with smaller or narrower eustachian tubes, or with eustachian tubes that do not open and close as they should. Eustachian tube dysfunction can be exacerbated by allergies, sinus conditions, and upper respiratory infections.3
What are the Symptoms of Ear Barotrauma?
The first symptom of ear barotrauma that a person may experience is a sudden onset of sharp pain in the impacted ear. After conducting a survey with experienced divers spanning over 436 dives, 18% experienced ear-related problems, and 75% of those individuals reported ear pain.2 Following ear pain and discomfort, the second most common symptom of ear barotrauma is decreased hearing.
After a person experiences inner ear barotrauma, vestibular symptoms are commonly experienced within two hours of the incident. When the vestibular portion of the inner ear is damaged, a patient may experience dizziness, vertigo, nausea, and/or vomiting.6
One very rare complication of middle ear barotrauma is facial nerve paralysis. A case study of a patient who experienced facial nerve paralysis following a dive was published in Diving and Hyperbaric Medicine. This patient reported a sudden onset of ear pain, tinnitus, hearing loss, and a right-sided facial droop after diving more than 5 meters below sea level. In order for middle ear barotrauma to cause facial nerve paralysis, the portion of the facial nerve that runs under the middle ear space must be compromised. Oftentimes the symptoms of facial nerve paralysis resolve on their own after the middle ear space is able to equalize its pressure to the atmospheric pressure.1
How is Ear Barotrauma Diagnosed?
Ear barotrauma is often first evaluated by a patient‘s report of any of the above symptoms. A physician may look into the ear canals to observe any visual trauma to the eardrum. The eardrum may appear retracted or swollen and irritated. There might be blood in the ear canal caused by a perforated eardrum.
In order to determine if the ear barotrauma impacted hearing, it is recommended that the patient undergo a comprehensive audiologic evaluation. Patients experiencing vestibular symptoms might be referred to a vestibular audiologist to evaluate what aspect of the inner ear has been affected by the barotrauma.
How is ear Barotrauma Treated?
In an attempt to avoid permanent hearing loss after experiencing inner ear barotrauma, a patient may be prescribed high doses of steroids for up to 20 days.5 If a fistula (a hole or tunnel) is observed, surgical corrections may be required.
Depending on the severity of middle ear barotrauma, recommendations may differ. If symptoms are mild, a patient may be advised to seize activities that contributed to the cause of the ear barotrauma (i.e. SCUBA diving) until the symptoms have resolved. If a perforation develops in the eardrum following middle ear barotrauma, a physician will determine if it is appropriate to wait and see if it heals on its own or if surgical intervention is required.
What are the Possible Complications of Ear Barotrauma?
One complication of inner ear barotrauma can be permanent sensorineural hearing loss. If a person does not seek treatment for inner ear barotrauma immediately following the onset of symptoms, hearing loss can be irreversible.
When an eardrum is perforated, it can put patients at a higher risk of developing infections due to the open wound. Unmanaged middle ear barotrauma may result in long-term conductive hearing loss and difficulty of the eardrum to heal itself.
What can I do to Prevent Ear Barotrauma?
If a person has chronic eustachian tube dysfunction, it is recommended to avoid activities that result in rapidly changing pressure in the atmosphere, such as SCUBA diving or flying. One may also be advised to avoid these activities when experiencing severe allergies or upper respiratory infections, as they can contribute to the onset and severity of ear barotrauma.
Prior to participating in the above-mentioned activities, a person should practice “popping“ their ears or equalizing pressure behind the middle ear space. If an individual is new to SCUBA diving, they might want to approach the activity slowly and test personal limits of the descents and ascents in a controlled environment prior to advancing to deeper dives. Additionally, it is often recommended for airline passengers to chew gum or swallow frequently during ascents and descents to alleviate the pressure discrepancies.
What is the significance of a frequency hearing test for ear barotrauma?
A frequency hearing test is essential for individuals who have experienced ear barotrauma. This specialized hearing assessment helps audiologists determine the extent of damage caused by changes in pressure, such as during air travel or scuba diving. By examining your hearing across different frequencies, audiologists can pinpoint specific areas of hearing loss or damage, allowing for tailored treatment and rehabilitation plans to address the effects of ear barotrauma effectively. If you’ve encountered pressure-related ear issues, consulting with an audiologist and undergoing a frequency hearing test can provide valuable insights into your ear health and guide appropriate interventions.
To conclude, there are several contributing factors to ear barotrauma, including SCUBA diving, air travel, and undergoing hyperbaric oxygen therapy. Others with Eustachian tube dysfunction may be at a higher risk for developing ear barotrauma. The type of ear barotrauma (inner ear and middle ear) can result in different symptoms with varying degrees of severity. If a person experiences pain, discomfort, hearing loss, tinnitus, or dizziness following suspected ear barotrauma, they should seek out medical evaluation and treatment when necessary.
1. Carmichael, M. L. & Boyev, K. P. (2016). Middle ear barotrauma causing transient facial paralysis after scuba diving. Diving and Hyperbaric Medicine, 46.
2. Jansen, S., Meyer, M. F., Boor, M., Felsch, M., Kluenter, H., Pracht, E., Huttenbrink, K., Beutner, D., & Grosheva, M. (2016). Prevalence of barotrauma in recreational scuba divers after repetitive saltwater dives. Otology & Neurotology, 37.
3. Monard Boel, N. & Klokker, M. (2017). Upper respiratory infections and barotrauma among commercial pilots. Aerospace Medicine and Human Performance, 88.
4. Rozycki, S. T., Brown, M. J., & Camacho, M. (2018). Inner ear barotrauma in divers: An evidence-based tool for evaluation and treatment. Diving and Hyperbaric Medicine, 48.
5. Scarpa, A., Ralli, M., De Luca, P., Gioacchini, F., Cavaliere, M., Re, M., Cassandro, E., & Cassandro, C. (2021). Inner ear disorders in SCUBA divers: A review. The Journal of International Advanced Otology, 17.
6. Sohn, J. H. & Cho, K. R. (2017). Middle ear barotrauma in student pilots. Aerospace Medicine and Human Performance, 88.
7. Wright, T. (2015). Middle-ear pain and trauma during air travel. The British Medical Journal Publishing Group: Clinical Evidence.
8. Yamamoto, Y., Noguchi, Y., Enomoto, M., Yagishita, K., & Kitamura, K. (2016). Otological complications associated with hyperbaric oxygen therapy. European Archives of Otorhinolaryngology, 273.