Middle ear squeeze (barotitis media) results from a decrease in pressure within the middle ear as an individual descends through water or is exposed to an increase in atmospheric pressure that can be seen in descending aircraft or while driving in mountainous terrain. According to Boyle’s law, as pressure increases, volume decreases proportionately. At a depth of approximately 1.2 m (4 ft), the pressure difference is great enough to collapse the eustachian tube and cause obstruction. If attempts to equalize the pressure such as a Valsalva or Frenzel maneuver fail, ascent is necessary or injury may ensue. If a diver continues to descend, hemorrhage and edema occur within the middle ear and rupture of the TM may occur. The influx of water into the middle ear may cause extreme vertigo and lead to a diving disaster.
Barotitis media may present with pain only (grade 0), TM erythema (grade 1), erythema and mild TM hemorrhage (grade 2), gross TM hemorrhage (grade 3), free middle ear blood (grade 4), or free blood with TM perforation (grade 5).
Management and Disposition
Treatment includes decongestants and appropriate analgesia. Antihistamines may be of use for allergy-related eustachian tube dysfunction. Antibiotics are recommended for preexisting infections or for TM rupture. Most cases resolve spontaneously within hours to days. The patient should not resume diving until the condition has resolved or the TM is completely healed.
Barotitis Media. Tympanic membrane erythema and mild hemorrhage consistent with barotitis media. (Photo contributor: Richard A. Chole, MD, PhD.)
Barotitis media is the most common medical problem associated with diving.
Associated barotraumatic injuries should be considered when the diagnosis of barotitis media is made.