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Barotrauma can affect the external, middle, or inner ear. Middle ear barotrauma (MEBT) is the most common being experienced by between 10% and 30% of divers and is due to insufficient equilibration of the middle ear. External ear barotrauma may occur on ascent if high pressure air is trapped in the external auditory canal either by tight fitting diving equipment or ear wax. Inner ear barotrauma (IEBT), though much less common than MEBT, shares a similar mechanism. Mechanical trauma to the inner ear can lead to varying degrees of conductive and sensorineural hearing loss as well as vertigo. It is also common for conditions affecting the inner ear to result in auditory hypersensitivity.
The sinuses similar to other air-filled cavities are susceptible to barotrauma if their openings become obstructed. This can result in pain as well as epistaxis (nosebleed).
Symptoms of arterial gas embolism include:
- Loss of consciousness
- Cessation of breathing
- Vertigo
- Convulsions
- Tremors
- Loss of coordination
- Loss of control of bodily functions
- Numbness
- Paralysis
- Extreme fatigue
- Weakness in the extremities
- Areas of abnormal sensation
- Visual abnormalities
- Hearing abnormalities
- Personality changes
- Cognitive impairment
- Nausea or vomiting
- Bloody sputum
- Symptoms of other consequences of lung overexpansion such as pneumothorax, subcutaneous or mediastinal emphysema may also be present.
Decompression sickness, also called caisson workers' disease and the bends, is the most well-known complication of scuba diving. It occurs as divers ascend, and often from ascending too fast or without doing decompression stops. Bubbles are large enough and numerous enough to cause physical injury. It is quite possible that all divers have microbubbles in their blood to some extent, but that most of the time these bubbles are so few and so small that they cause no harm. When DCS occurs, bubbles disrupt tissues in the joints, brain, spinal cord, lungs, and other organs. Symptoms vary enormously. DCS may be as subtle as unusual tiredness after a dive, or an aching elbow, or a mottled skin rash. Or, it may present dramatically, with unconsciousness, seizures, paralysis, shortness of breath, or death. Paraplegia is not uncommon.
Small amounts of air often get into the blood circulation accidentally during surgery and other medical procedures (for example, a bubble entering an intravenous fluid line), but most of these air emboli enter the veins and are stopped at the lungs, and thus a venous air embolism that shows any symptoms is very rare.
Arterial gas embolism (AGE) is a complication of lung barotrauma of ascent. It occurs when breathing gas is introduced to the circulation on the arterial side via lung over-pressure trauma. AGE can present in similar ways to arterial blockages seen in other medical situations. Affected people may suffer strokes, with paralysis or numbness down one side; they may suffer heart attacks; they may suffer pulmonary embolism with shortness of breath and chest pain. It is often impossible to distinguish AGE from DCS, but luckily it is rarely necessary for physicians to be able to distinguish between the two, as treatment is the same. Sometimes AGE and DCS are lumped into a single entity, Decompression Illness (DCI).
The main symptom is usually severe central chest pain. Other symptoms include laboured breathing, voice distortion (as with helium) and subcutaneous emphysema, specifically affecting the face, neck, and chest. Pneumomediastinum can also be characterized by the shortness of breath that is typical of a respiratory system problem. It is often recognized on auscultation by a "crunching" sound timed with the cardiac cycle (Hamman's crunch).
Pnemomediastinum may also present with symptoms mimicking cardiac tamponade as a result of the increased intrapulmonary pressure on venous flow to the heart.
Below is a summary comparison of the signs and symptoms of DCI arising from its two components: "Decompression Sickness" and "Arterial Gas Embolism". Many signs and symptoms are common to both maladies, and it may be difficult to diagnose the actual problem. The dive history can be useful to distinguish which is more probable, but it is possible for both components to manifest at the same time following some dive profiles.
A more detailed account of the signs and symptoms of Decompression Sickness can be found here.
This might have occurred due to barotrauma of descent, and/or the effects of nasal decongestants. It is due to unequal increase in middle ear pressures on ascent, is usually mild, and most often cleared by further ascent. When the pressures in both ears reach ambient levels, the stimulus for the dizziness stops. Although most often mild, the vertigo can persist until the diver reaches the surface continuing the unequal pressures, which can damage the inner ear or ear drum.
Alternobaric vertigo is most pronounced when the diver is in the vertical position; the spinning is towards the ear with the higher pressure and tends to develop when the pressures differ by 60 cm of water or more. Ear clearing may be a remedy. A similar vertigo can also occur as a result of unequal heating stimulation of one inner ear labyrinth over the other due to diving in a prone position in cold water - the undermost ear being stimulated.
Signs and symptoms of spontaneous subcutaneous emphysema vary based on the cause, but it is often associated with swelling of the neck and chest pain, and may also involve sore throat, neck pain, difficulty swallowing, wheezing and difficulty breathing. Chest X-rays may show air in the mediastinum, the middle of the chest cavity. A significant case of subcutaneous emphysema is easy to detect by touching the overlying skin; it feels like tissue paper or Rice Krispies. Touching the bubbles causes them to move and sometimes make a crackling noise. The air bubbles, which are painless and feel like small nodules to the touch, may burst when the skin above them is palpated. The tissues surrounding SCE are usually swollen. When large amounts of air leak into the tissues, the face can swell considerably. In cases of subcutaneous emphysema around the neck, there may be a feeling of fullness in the neck, and the sound of the voice may change. If SCE is particularly extreme around the neck and chest, the swelling can interfere with breathing. The air can travel to many parts of the body, including the abdomen and limbs, because there are no separations in the fatty tissue in the skin to prevent the air from moving.
Ventilator-associated lung injury (VALI) is an acute lung injury that develops during mechanical ventilation and is termed ventilator-induced lung injury (VILI) if it can be proven that the mechanical ventilation caused the acute lung injury. In contrast, ventilator-associated lung injury (VALI) exists if the cause cannot be proven. VALI is the appropriate term in most situations because it is virtually impossible to prove what actually caused the lung injury in the hospital.
The Fédération dentaire internationale describes 4 classes of barodontalgia. The classes are based on signs and symptoms. They also provide specific and valuable recommendations for therapeutic intervention.
Barodontalgia, commonly known as tooth squeeze and previously known as aerodontalgia, is a pain in tooth caused by a change in ambient pressure. The pain usually ceases at ground level. Dental barotrauma is a condition in which such changes in barometric pressure changes cause damage to the dentition.
The most common victims are underwater divers because in deep dives pressures can increase by several atmospheres, and military pilots because of rapid changes.
In pilots, barodontalgia may be severe enough to cause premature cessation of flights.
Most of the available data regarding barodontalgia is derived from high-altitude chamber simulations rather than actual flights. Barodontalgia prevalence was between 0.7% and 2% in the 1940s, and 0.3% in the 1960s.
Similarly, cases of barodontalgia were reported in 0.3% of high altitude-chamber simulations in the Luftwaffe.
The rate of barodontalgia was about 1 case per 100 flight-years in the Israeli Air Force. During World War II, about one-tenth of American aircrews had one or more episodes of barodontalgia. In a recent study, 8.2% of 331 Israeli Air Force aircrews, reported at least one episode of barodontalgia.
Barodontalgia is a symptom of dental disease, for example inflammatory cyst in the mandible.
Indeed, most of the common oral pathologies have been reported as possible sources of barodontalgia: dental caries, defective tooth restoration, pulpitis, pulp necrosis, apical periodontitis, periodontal pockets, impacted teeth, and mucous retention cysts. One exception is barodontalgia manifested as referred pain from barosinusitis or barotitis-media. The latter two conditions are generated from pressure changes rather than pressure-related flare-up of pre-existing conditions.
A meta-analysis of studies conducted between 2001 and 2010 revealed a rate of 5 episodes/1,000 flight-years. Maxillary and mandibular dentitions were affected equally in flight, but in diving, maxillary dentition was affected more than the mandibular dentition, which can indicate a greater role for maxillary sinus pathology in diving barodontalgia. Surprisingly, despite cabin pressurization, the current in-flight barodontalgia incidence is similar to the incidence in the first half of the 20th century. Also, despite the greater fluctuation in divers' pressures, the weighted incidence of barodontalgia among aircrews is similar to the weighted incidence among divers. Furthermore, contrary to common belief, and in contrast to diving conditions, the role of facial barotrauma in the cause of in-flight barodontalgia is only minor (about one-tenth of cases).
Subcutaneous emphysema is when gas or air is in the layer under the skin. "Subcutaneous" refers to the tissue beneath the skin, and "emphysema" refers to trapped air. It is sometimes abbreviated SCE or SE and also called tissue emphysema, or Sub Q air. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs on the chest, neck and face, where it is able to travel from the chest cavity along the fascia. Subcutaneous emphysema has a characteristic crackling feel to the touch, a sensation that has been described as similar to touching Rice Krispies; this sensation of air under the skin is known as "subcutaneous crepitation".
Numerous etiologies of subcutaneous emphysema have been described. Pneumomediastinum was first recognized as a medical entity by Laennec, who reported it as a consequence of trauma in 1819. Later, in 1939, at The Johns Hopkins Hospital, Dr. Louis Hamman described it in postpartum woman; indeed, subcutaneous emphysema is sometimes known as Hamman's syndrome. However, in some medical circles, it can instead be more commonly known as Macklin's Syndrome after L. Macklin, in 1939, and M.T. and C.C. Macklin, in 1944, who cumulatively went on to describe the pathophysiology in more detail.
Subcutaneous emphysema can result from puncture of parts of the respiratory or gastrointestinal systems. Particularly in the chest and neck, air may become trapped as a result of penetrating trauma (e.g., gunshot wounds or stab wounds) or blunt trauma. Infection (e.g., gas gangrene) can cause gas to be trapped in the subcutaneous tissues. Subcutaneous emphysema can be caused by medical procedures and medical conditions that cause the pressure in the alveoli of the lung to be higher than that in the tissues outside of them. Its most common causes are pneumothorax and a chest tube that has become occluded by a blood clot or fibrinous material. It can also occur spontaneously due to rupture of the alveoli with dramatic presentation. When the condition is caused by surgery it is called "surgical emphysema". The term "spontaneous subcutaneous emphysema" is used when the cause is not clear.
Subcutaneous emphysema is not typically dangerous in and of itself, however it can be a symptom of very dangerous underlying conditions, such as pneumothorax. Although the underlying conditions require treatment, subcutaneous emphysema usually does not; small amounts of air are reabsorbed by the body. However, subcutaneous emphysema can be uncomfortable and may interfere with breathing, and is often treated by removing air from the tissues, for example by using large bore needles, skin incisions or subcutaneous catheterization.
Pneumomediastinum (from Greek "pneuma" – "air", also known as mediastinal emphysema) is (abnormal presence of air or other gas) in the mediastinum. First described in 1819 by René Laennec, the condition can result from physical trauma or other situations that lead to air escaping from the lungs, airways, or bowel into the chest cavity.
In aviation and underwater diving, alternobaric vertigo is dizziness resulting from unequal pressures being exerted between the ears due to one Eustachian tube being less patent than the other.
Diving disorders, or diving related medical conditions, are conditions associated with underwater diving, and include both conditions unique to underwater diving, and those that also occur during other activities. This second group further divides into conditions caused by exposure to ambient pressures significantly different from surface atmospheric pressure, and a range of conditions caused by general environment and equipment associated with diving activities.
Decompression Illness (DCI) describes a range of symptoms arising from decompression of the body.
DCI can be caused by two different mechanisms, which result in overlapping sets of symptoms. The two mechanisms are:
- Decompression sickness (DCS), which results from metabolically inert gas dissolved in body tissue under pressure precipitating out of solution and forming bubbles during decompression. It typically afflicts underwater divers on poorly managed ascent from depth or aviators flying in inadequately pressurised aircraft.
- Arterial gas embolism (AGE), which is gas bubbles in the bloodstream. In the context of DCI these may form either as a result of bubble nucleation and growth by dissolved gas into the blood on depressurisation, which is a subset of DCS above, or by gas entering the blood mechanically as a result of pulmonary barotrauma. Pulmonary barotrauma is a rupturing of lung tissue by expansion of breathing gas held in the lungs during depressurisation. This may typically be caused by an underwater diver ascending while holding the breath after breathing at ambient pressure, ambient pressure escape from a submerged submarine without adequate exhalation during the ascent, or the explosive decompression of an aircraft cabin or other pressurised environment.
In any situation which could cause decompression sickness, there is also potentially a risk of arterial gas embolism, and as many of the symptoms are common to both conditions, it may be difficult to distinguish between the two in the field, and first aid treatment is the same for both mechanisms.
Although the term has occasionally been used in other ways, in medical literature biotrauma is usually defined as a severe inflammatory response produced in the lungs of patients who breathe by means of a mechanical ventilator for a long period of time. The term was coined in a 1998 paper by L. N. Tremblay and A. S. Slutsky, titled "Ventilator-induced injury: from barotrauma to biotrauma". The message of that paper was that barotrauma caused by pressure differentials is only one of several types of lung damage that a ventilator can produce.
A variety of disorders may be caused by ergonomic problems due to poorly fitting equipment.
- Temporomandibular joint dysfunction is pain or tenderness in the jaw, headache or facial ache caused by gripping the regulator mouthpiece between the teeth of the upper and lower jaws. This action is required to retain the mouthpice in place for the duration of the dive, and may strain the masticatory muscles or the temporomandibular joint, which is where the lower jawbone (mandible) hinges on the skull at the temporal bone. This problem van be aggravated by cold water, stress, and strong water movement, and can be reduced by use of custom mouthpieces with longer and more rigid bite grip surfaces, which allow better support of the second stage with less effort.
- Leg and foot cramps may be caused by unaccustomed exercise, cold, or ill-fitting fins.
- Lower back pain may be caused by a heavy weightbelt hanging from the small of the back, counteracting the buoyancy of the diving suit which is distributed over the full length of the diver. This effect can be reduced by use of integrated weight systems which support the weights over the length of the back on the diving harness backplate.
- Restricted circulation to the hands may be caused by excessively tight dry suit cuff seals.
VALI does not need to be distinguished from progressive ALI/ARDS because management is the same in both. Additionally, definitive diagnosis of VALI may not be possible because of lack of sign or symptoms.
Loss of attachment:
- By far the most common cause is periodontal disease (gum disease). This is painless, slowly progressing loss of bony support around teeth. It is made worse by smoking and the treatment is by improving the oral hygiene above and below the gumline.
- Dental abscesses can cause resorption of bone and consequent loss of attachment. Depending on the type of abscess, this loss of attachment may be restored once the abscess is treated, or it may be permanent.
- Many other conditions can cause permanent or temporary loss of attachment and increased tooth mobility. Examples include: Langerhans cell histiocytosis.
Increased forces on the tooth:
- Bruxism (abnormal clenching and grinding of teeth) can aggravate attachment loss and tooth mobility if periodontal disease is already present. The tooth mobility is typically reversible and the tooth returns to normal level of mobility once the bruxism is controlled.
- Dental trauma. Luxations, and root fractures of teeth can cause sudden mobility after a blow. Dental trauma may be isolated or associated with other facial trauma.
- Increased biting force on one tooth can cause temporary increased mobility until corrected. A common scenario is a new filling or crown which is a fraction of a millimeter too prominent in the bite, which after a few days causes periodontal pain in that tooth and/or the opposing tooth.
Dental subluxation is a traumatic injury in which the tooth has increased mobility (i.e., is loosened) but has not been displaced from its original site in the jawbone.
Dental trauma refers to trauma (injury) to the teeth and/or periodontium (gums, periodontal ligament, alveolar bone), and nearby soft tissues such as the lips, tongue, etc. The study of dental trauma is called dental traumatology.
This is quite a common condition and one of the most common traumatic dental disorders. However, the exact prevalence is difficult to be assessed because dental subluxations are often asymptomatic or only mildly symptomatic, and even overlooked by caregivers when treating more serious dental traumas in adjacent teeth.