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Summary Table

Domain	Detail
Risk Factors	Recent upper respiratory infection, allergic rhinitis, nasal polyps, adenoid hypertrophy, craniofacial anomalies (e.g., cleft palate), frequent air travel or scuba diving, infant/young child (shorter, more horizontal Eustachian tube)
Etiology	Failure to equalize ambient pressure across the tympanic membrane due to Eustachian tube dysfunction, most commonly during descent (airplane landing, underwater diving descent)
Patient Presentation	Acute ear pain (otalgia) and sensation of ear fullness/pressure during or immediately after a rapid change in ambient pressure; hearing loss; occasionally tinnitus or vertigo
Classic Physical Exam	Retracted tympanic membrane (TM), TM injection and hyperemia, middle ear effusion, hemotympanum (blood behind the TM appearing dark blue or purple), or TM perforation in severe cases
Key Diagnostic Results	Clinical diagnosis based on history and otoscopy; tympanometry shows a negative middle ear pressure (type C tympanogram) or flat tracing (type B) if effusion is present; audiometry may show conductive hearing loss
Management	Nasal decongestants (topical oxymetazoline or oral pseudoephedrine), autoinflation techniques (Valsalva maneuver, Toynbee maneuver), analgesics, avoidance of further barotrauma until resolved; myringotomy for refractory or severe cases
Keywords	"Ear pain during airplane descent," "otalgia after scuba diving," "hemotympanum," "Eustachian tube dysfunction," "pressure equalization failure," "retracted tympanic membrane," "ear fullness after flying"

1. Pathophysiology

The middle ear is a closed, air-filled cavity that communicates with the nasopharynx through the Eustachian tube. Under normal conditions, the Eustachian tube opens intermittently during swallowing, yawning, or jaw movement to equalize the pressure between the middle ear and the external environment. The entire pathology of barotitis media hinges on the failure of this equalization mechanism.

During descent (whether in an aircraft or while diving), ambient pressure increases. If the Eustachian tube cannot open to allow air into the middle ear, a relative negative pressure develops within the middle ear space compared to the external auditory canal. This pressure differential causes the tympanic membrane to retract inward. As the gradient worsens, transudation of fluid from the mucosal capillaries occurs, leading to a serous middle ear effusion. If the pressure difference becomes large enough, submucosal hemorrhage develops, resulting in hemotympanum. In the most extreme scenario, the tympanic membrane ruptures.

This is why the vignette almost always places the patient in a context of descent rather than ascent. During ascent, expanding air in the middle ear can passively vent through the Eustachian tube. During descent, however, the tube must actively open against a positive external pressure gradient, which it cannot do if it is edematous, inflamed, or anatomically obstructed. This explains why patients with a concurrent upper respiratory infection or allergic rhinitis are at highest risk: mucosal swelling of the Eustachian tube orifice prevents active opening.

In children, the Eustachian tube is shorter, more horizontal, and less rigid, making it more prone to collapse under pressure differentials and less efficient at pressure equalization. This is the same anatomic basis that predisposes children to otitis media in general.

The grading of injury follows a predictable continuum (Teed classification), where each successive grade reflects a greater pressure differential and more tissue damage: from simple TM injection, to retraction with hemorrhage within the TM, to transudate/effusion, to hemotympanum, to frank perforation.

2. Classification and Clinical Manifestation

The Teed Classification (modified) is the standard grading system for middle ear barotrauma:

Grade	Otoscopic Findings	Symptoms
Grade 0	Normal TM, symptoms only	Mild ear fullness or discomfort; self-resolves quickly
Grade 1	Injection and erythema along the handle of malleus	Otalgia, ear fullness, mild conductive hearing loss
Grade 2	Diffuse TM injection and erythema; mild hemorrhage within the TM	Moderate otalgia, muffled hearing, tinnitus
Grade 3	Gross hemorrhage within the TM substance (appears dark red)	Pronounced pain, conductive hearing loss, possible tinnitus
Grade 4	Middle ear effusion visible; hemotympanum (dark blue/purple TM)	Severe otalgia, marked hearing loss, possible vertigo
Grade 5	Tympanic membrane perforation	Sudden pain relief at the moment of rupture, bloody otorrhea, hearing loss, vertigo if inner ear involvement

An important clinical nuance: patients with Grade 5 (perforation) often report a sudden decrease in pain at the moment of rupture because the pressure differential is immediately released. This paradoxical improvement in pain despite worsening injury is a testable point.

3. Diagnostic Workup

Test	Role	Expected Finding
Otoscopy	Best initial test and often sufficient	TM retraction, injection, effusion, hemotympanum, or perforation depending on grade
Tympanometry	Objective assessment of middle ear pressure and compliance	Type C curve (negative middle ear pressure) in mild cases; Type B curve (flat, no peak) if effusion or hemotympanum is present
Audiometry	Assess degree and type of hearing loss	Conductive hearing loss (air-bone gap); sensorineural component raises concern for inner ear barotrauma
CT temporal bone	Reserved for suspected complications	Evaluate for ossicular disruption, inner ear fistula (perilymph fistula), or mastoid involvement

Otoscopy is the cornerstone of diagnosis and is both the best initial test and the most clinically relevant one. The diagnosis is overwhelmingly clinical: a patient who develops ear pain during pressure change plus characteristic otoscopic findings requires no further workup in straightforward cases.

Tympanometry is useful when the diagnosis is uncertain or when objective documentation is needed (e.g., occupational health evaluation for a diver). A type C tympanogram (peak shifted to negative pressure) confirms Eustachian tube dysfunction with a pressure deficit. A type B tympanogram (flat tracing) indicates fluid in the middle ear space, consistent with effusion or hemotympanum.

Audiometry becomes important when the patient reports hearing loss. The expected finding is a conductive hearing loss (air-bone gap on the audiogram). If a sensorineural component is detected, this should raise concern for inner ear barotrauma (perilymph fistula at the round or oval window), which is a more serious condition requiring urgent ENT referral and possible surgical repair.

CT of the temporal bone is not part of the routine workup. It is reserved for cases where complications such as ossicular chain disruption or perilymph fistula are suspected, or when symptoms persist despite appropriate treatment.

4. Management and Treatment

Severity	Management
Mild (Grade 0-2)	Autoinflation (Valsalva or Toynbee maneuver), topical nasal decongestant (oxymetazoline 0.05% spray, 2 sprays per nostril BID for no more than 3 days), oral analgesics (ibuprofen 400 mg TID or acetaminophen 500-1000 mg Q6H PRN), avoidance of further barotrauma until resolution
Moderate (Grade 3-4)	Oral decongestant (pseudoephedrine 60 mg Q6H or 120 mg extended-release Q12H), topical nasal steroid spray (fluticasone 50 mcg, 2 sprays per nostril daily) for underlying allergic component, oral analgesics, consider short course of oral corticosteroids if mucosal edema is prominent, ENT referral if no improvement in 1-2 weeks
Severe (Grade 5 / Perforation)	Keep ear dry (no water entry), ototopical antibiotic drops if secondary infection develops (ofloxacin 0.3% otic, 5 drops BID for 7 days; avoid aminoglycoside-containing drops due to ototoxicity risk through the perforation), analgesics, ENT referral; most perforations heal spontaneously within 2-4 weeks
Refractory / Recurrent	Myringotomy with or without tympanostomy tube placement to provide a permanent pressure equalization route; treat underlying Eustachian tube dysfunction (adenoidectomy in children if adenoid hypertrophy is present)

For mild cases, the first-line approach is autoinflation combined with topical decongestants. The Valsalva maneuver (forced expiration against a closed glottis and pinched nose) forces air through the Eustachian tube into the middle ear, directly addressing the negative pressure deficit. Topical oxymetazoline reduces mucosal edema at the Eustachian tube orifice. It must be limited to 3 days to avoid rhinitis medicamentosa (rebound nasal congestion), which is itself a testable concept.

For moderate cases with effusion or hemotympanum, oral pseudoephedrine provides systemic decongestion. Nasal corticosteroid sprays are added when an allergic component is contributing to chronic Eustachian tube dysfunction. The effusion typically resolves over 1-3 weeks with conservative management. Patients should be counseled to avoid flying or diving until symptoms fully resolve and otoscopy normalizes.

For perforation, the priority is preventing secondary infection and allowing spontaneous healing. Aminoglycoside-containing otic drops (neomycin, gentamicin) are contraindicated with a perforated TM because they can enter the middle ear and cause ototoxicity. Fluoroquinolone otic drops (ofloxacin, ciprofloxacin) are safe to use through a perforation. This contraindication is frequently tested.

Myringotomy is reserved for cases that fail conservative management or for patients with recurrent barotrauma who must continue exposure (e.g., military divers, aircrew). Tympanostomy tubes bypass the dysfunctional Eustachian tube entirely by providing an alternate route for pressure equalization through the TM itself.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Acute otitis media (AOM)	Both present with ear pain, TM erythema, and possible effusion	AOM occurs in the setting of infection (fever, preceding URI with purulent rhinorrhea), not temporally linked to pressure changes; TM in AOM is typically bulging rather than retracted; no history of recent flying or diving
Otitis media with effusion (OME)	Both show middle ear effusion and conductive hearing loss	OME is painless, chronic, and not associated with an acute pressure change event; no hemotympanum; TM appears amber or dull rather than hemorrhagic
Otitis externa	Both cause otalgia	Otitis externa produces pain with tragal pressure and pinna traction; the TM itself appears normal; canal edema and discharge are present; no association with pressure changes
Inner ear barotrauma (perilymph fistula)	Both occur in the context of pressure change (diving/flying)	Inner ear barotrauma produces sensorineural hearing loss (not conductive), vertigo, nystagmus, and tinnitus that is disproportionate to the middle ear findings; audiometry shows bone conduction loss; requires urgent surgical referral
Temporomandibular joint (TMJ) dysfunction	Can cause referred otalgia	TMJ pain is exacerbated by jaw movement and mastication, not by ambient pressure changes; otoscopy is normal; tenderness over the TMJ on palpation
Cholesteatoma	Can present with conductive hearing loss and TM abnormality	Cholesteatoma is chronic, progressive, associated with a retraction pocket with keratin debris or a marginal perforation, often with foul-smelling discharge; no temporal link to pressure changes

6. Traps and High-Yield Pearls

The most common way students get this topic wrong is by confusing barotitis media with acute otitis media. Both can present with ear pain, a red tympanic membrane, and middle ear effusion. The critical discriminator is the temporal relationship to pressure change: a vignette that mentions airplane descent, scuba diving, or hyperbaric chamber use is pointing you toward barotrauma, not infection. The absence of fever and the presence of hemotympanum further distinguish the two.

A second common trap involves the direction of pressure change. Students often assume barotrauma occurs during ascent (because "pressure drops and things expand"). In reality, the middle ear is most vulnerable during descent because the Eustachian tube must actively open against a rising external pressure. During ascent, passive venting occurs more easily. A vignette that says "shortly after landing" or "during descent to 30 meters" is giving you the diagnosis.

Another frequently tested point is the contraindication of aminoglycoside otic drops in the presence of a TM perforation. If the vignette describes a perforation and then asks you to choose an otic antibiotic, the answer is a fluoroquinolone (ofloxacin), never neomycin or gentamicin.

Finally, students must distinguish between middle ear and inner ear barotrauma. If the vignette includes sensorineural hearing loss (no air-bone gap, or bone conduction is also reduced), prominent vertigo, and nystagmus following a diving incident, the answer shifts to perilymph fistula, which demands urgent ENT referral rather than conservative decongestant therapy. The core competency being tested is the ability to identify the anatomic level of injury based on audiometric pattern and symptom severity, and to match the correct management to the correct diagnosis.

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