What is the diagnosis?

Tympanic membrane (TM) perforation with sensorineural hearing loss secondary to barotrauma 

• Pearl: Barotrauma can present as tinnitus, pressure, pain and hearing loss. Hemotympanum can occur from stretching of tissues and vessels due to the unequal pressures in the external and middle/inner ear. Bleeding into the inner ear and rupture of the round or oval window will cause vertigo and sensorineural hearing loss [2].

What is the mechanism of injury?

With descent, air pressure has to increase in the middle ear to balance the increase in external atmospheric pressure. If the eustachian tube is unable to aid in this due to congestion or high pressures, the TM is forcibly stretched and can lead to bleeding in the middle ear and/or rupture the TM if the pressure is great enough [1,6].  

What physical exam findings are expected?

On otoscopic examination, you can see bruising and blood behind the tympanic membrane or in the external auditory canal with a defect in the tympanic membrane. Weber test will lateralize to the unaffected ear and Rinne test will show a difference between bone conduction and air conduction in the affected ear [2].

What is the management in the ED?

Most injuries, including TM perforation due to barotrauma, heal spontaneously with time. Antibiotics are not indicated in the absence of infection such as otitis externa. Analgesics can be given for pain as indicated. When barotrauma creates a perilymphatic fistula between the middle and inner ear, causing loss of fluid from the inner ear, this can lead to vertigo and sensorineural hearing loss which requires an urgent referral to ENT [3,4]. 

• Pearl: If there is a need for antibiotics with TM perforations, avoid aminoglycoside drops as these are ototoxic to the middle and inner ear. Fluoroquinolone drops are an appropriate alternative. 

When do you consult a specialist?

Urgent referral to an otolaryngologist is indicated in cases where there is significant hearing loss, large eardrum perforation, or vertigo, particularly when nystagmus is present [5].

What prophylactic measures could have been taken to reduce his risk of injury?

Optimizing eustachian tube function prior to diving and flying can reduce the risk of barotrauma. He should avoid multiple dives in a short time period, diving and flying in the same day, and diving or flying with an upper respiratory infection. Antihistamines, decongestants, yawning, chewing, and valsalva maneuvers may help to optimize eustachian tube function during descent [1].

What counseling would you provide this patient about future dives?

Patients with severe barotrauma including; perilymph fistula, intralabyrinthine membrane tear, inner ear hemorrhage and severe sensorineural hearing loss are conservatively recommended to permanently refrain from diving. However, there is inconsistent data to support this and it may be unnecessarily restrictive [6, 7]. Risk stratification and informed decision making before returning to diving is recommended.

• Pearl: It is important to council your patients to avoid submerging their head in water for at least 4-6 weeks or until cleared by an ENT surgeon to minimize the risk of subsequent infection