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We report the case of a healthy 21-year-old woman who performed iterative breath-hold dives in relatively cold water, not exceeding depths of 5 meters but with "empty lungs." At the end of a dive, after experiencing an intense involuntary diaphragmatic contraction underwater, she presented hemoptysis followed by chest pain and cough. Chest radiography and computed tomography were performed 24 hours later, confirming the diagnosis of pneumomediastinum. The clinical course was benign: However, chest pain and effort dyspnea lasted for a few weeks. The pathophysiology of this accident may be explained by a combination of mechanisms involved in several clinical entities, namely pulmonary edema of immersion, pulmonary barotrauma and spontaneous pneumomediastinum.

A previously healthy 20-year-old male trainee developed chest pain, shortness of breath, and neck pain after repeatedly shouting "Hooah!" during a motivational squad competition. He was found to have developed a pneumomediastinum with soft tissue crepitus of the neck. He had an uneventful recovery. Unique to the military training environment, vigorous shouting, including "Hooah!" as a motivational stimulus, can have barotraumatic consequences. The term "spontaneous" as applied to a pneumomediastinum diagnosis is examined and the auscultatory finding of "Hamman's sign" is reviewed.

Background: People suffer unique health problems in high altitude areas, due to such factors as elevation, aircraft ascent and descent, extreme cold, hypoxia, hypobaria, and low relative humidity. This study was conducted to evaluate ENT morbidity at high altitude., Methods: Serving soldiers introduced to a high altitude environment who presented with various ENT symptoms were examined to identify ENT disease. In addition, patients undergoing hyperbaric chamber therapy, tracheostomy and treatment of cold injuries were also examined for ENT problems., Results: The following were detected: 13 cases of otic barotrauma, 11 cases of sinus barotrauma, three cases of vertigo, six cases of pinna frostbite, three cases of barotrauma caused by hyperbaric chamber therapy, an unusually high incidence of epistaxis, and innumerable patients with high altitude pharyngitis., Conclusion: Diseases of the ear, nose and throat contribute significantly to high altitude morbidity. In a military context, health education of troops is necessary to avoid such problems.

History of underwater diving dates back to antiquity. Breath-hold technique in diving was known to the ancient nations. However, deep diving progressed only in the early decades of the 19th century as the result of advancements in efficient underwater technologies which subsequently led to invention of sophisticated sets of scuba diving in the 20th century. Currently, diving is performed for various purposes including commercial, recreational, military, underwater construction, oil industry, underwater archeology and scientific assessment of marine life. By increasing popularity of underwater diving, dive-related medical conditions gradually became more evident and created a new challenge for the health care professionals, so that eventually, a specialty the so-called "diving medicine" was established. Most of the diving-associated disorders appear in the head and neck. The most common of all occupational disorders associated with diving are otologic diseases. External otitis has been reported as the most common otolaryngologic problem in underwater divers. Exostosis of the external ear canal may be formed in divers as the result of prolonged diving in cold waters. Other disorders of the ear and paranasal sinuses in underwater divers are caused by barometric pressure change (i.e., barotraumas), and to a lesser extent by decompression sickness. Barotrauma of the middle ear is the most prevalent barotrauma in divers. The inner ear barotraumas, though important, is less common. The present paper is a brief overview of diving-related ear disorders particularly in scuba divers.

This retrospective study examined the etiology and treatment results for traumatic, conductive hearing loss in 22 patients who underwent surgery between 1998 and 2008 at Osaka Red Cross Hospital. All patients underwent computed tomography (CT) of the temporal bone preoperatively. The ear surgery comprised closure of the ruptured tympanic membranes and restoration of the sound-transmitting function of the ossicular chain. Their mean age was 30.3 years, and the average delay from injury until treatment was 6.0 years. Of the injuries due to foreign-body insertion, the most common cause was ear-pick injury. Incudostapedial disarticulation was the most common finding, which was diagnosed preoperatively using CT in seven cases and identified at surgery in 15 cases. Closure of the air-bone gap to within 10 and 20 dB was observed in 50.0 and 68.2% of the patients, respectively. The hearing threshold improved by 10 dB or more in 16 (72.7%) patients. If no improvement in hearing loss follows the absorption of hemotympanium or closure of an eardrum perforation, dislocation of the ossicular bones should be suspected. Ossicular reconstruction following trauma produces more stable and better hearing results, even after delayed treatment.

A fracture of the orbital floor as a result of nose blowing is rare and we know of only three reported cases. We present a 40-year-old man who required repair of a blowout fracture of the orbital floor as a result of vigorous nose blowing. Patients who present with acute periorbital emphysema after nose blowing require careful assessment with potential blowout fractures in mind., (Crown Copyright 2010. Published by Elsevier Ltd. All rights reserved.)

An amateur scuba (Self Contained Underwater Breathing Apparatus) diver experienced an acute frontal headache following a low-depth dive. After 12 hours of worsening and unremitting headache, CT and MRI imaging were performed; these revealed gas and mucous in the frontal sinus and extradural space. This appears to be the first case of MRI-documented barotrauma of the frontal and ethmoidal sinuses resulting in extradural pneumo- and muco-cephalus.

Barotraumatic oesophageal perforation with bilateral tension pneumothorax is extremely rare and this is a first case reported in the literature. The possibility of the oesophageal perforation due to high-pressure gas flow should be kept in mind and the standard of diagnosis is oesophagography.

Introduction: It is known that exposure to severe hypobaric hypoxia induces changes of reactive oxygen species (ROS) and antioxidant systems. L-carnitine, a natural compound, has an antioxidant effect and decreases lipid peroxidation. The aim of this study was to investigate the protective effects of L-carnitine treatment on oxidative stress induced by exposure to hypobaric hypoxia., Material and Methods: 30 male Wistar rats were divided into 3 equal-size groups: 1st group - a control group, kept in normoxic conditions; 2nd group - rats exposed to hypobaric hypoxia in the barochamber (simulated high altitude equivalent to 5500 meters) for a 14-day placebo; 3rd group - rats exposed to hypobaric hypoxia for 14 days and treated with L-carnitine (L-carnitine, 100 mg/kg) every day. After 14 days, the serum levels of lipid peroxides expressed by the value of malondialdehyde (MDA), and the serum levels of carbonylated proteins (CP), glutathione (GSH) and donor hydrogen ability (DHA) were determined for all rats., Results: The results indicated an increase in MDA and CP levels, after the exposure to hypobaric hypoxia. L-carnitine significantly decreased (p <0.05) the levels of the MDA and CP and significantly increased (p <0.05) the serum antioxidant capacity: glutathione and DHA., Conclusion: This study suggests that the administration of L-carnitine can be beneficial in attenuating the oxidative stress associated with exposure to high altitude.

Ingestion of liquid nitrogen is rare but carries catastrophic complications related to barotrauma to the gastrointestinal tract. We describe a case of ingestion of liquid nitrogen followed by gastric perforation and respiratory insufficiency and discuss the mechanism of injury and management of this condition. Liquid nitrogen is widely available and is frequently used in classroom settings, in gastronomy, and for recreational purposes. Given the potentially lethal complications of ingestion, regulation of its use, acquisition, and storage may be appropriate.

Pneumomediastinum is an uncommon radiographic finding of potential clinical significance. Secondary pneumomediastinum (SPM) has a variety of etiologies that can lead to potentially morbid outcomes. There are limited data regarding the etiologies, diagnosis, and outcomes of this entity. A retrospective comparative study was conducted over an 11-year period of patients developing pneumomediastinum secondary to a specific pathologic or traumatic event. Forty-five patients were identified with an underlying condition resulting in SPM. Demographic data, radiologic findings, length of hospital stay, and mortality were recorded. Statistical comparison was conducted between patients with blunt thoracic trauma- and barotrauma-induced pneumomediastinum. Logistic and multiple linear regression analyses were performed to discover factors predictive of mortality and length of hospital stay. Median age of the patients was 40 years and 69% were men. Subcutaneous emphysema was identified in 44%, pneumothorax in 47%, and pleural effusion in 11%. Pneumomediastinum was identified by plain radiograph (CXR) in only 47% compared to 100% by computed tomogram (CT scan). Average length of hospital stay was 19 days and mortality was 38%. Patients with blunt thoracic trauma had a lower sensitivity for CXR to discover pneumomediastinum, were more likely to develop subcutaneous emphysema or pneumothorax, and had lower mortality and length of hospital stay compared with those with barotrauma-induced pneumomediastinum. Barotrauma was an independent predictor for hospital mortality. Secondary pneumomediastinum is a morbid condition with distinctive etiologies, radiologic findings, and outcomes. Barotrauma-induced pneumomediastinum is associated with a prolonged recovery and high mortality rate.

Background: The term "barotrauma" is used to describe a physical injury caused by a rapid or extreme change in air pressure. Enclosed areas within the body are particularly affected by barotrauma., Case Description: A 40-year-old man had complaints of restorations in three teeth fracturing and dislodging while he was scuba diving at a depth of 35 meters. The affected teeth contained carious dentin. The caries was removed, and the affected teeth underwent endodontic, restorative and prosthetic rehabilitation., Clinical Implications: Inadequate restorations and selection of dental materials in some cases predispose patients to barotrauma. To prevent barotrauma-related damages on the teeth, it is important to maintain good-quality restorations and avoid trapping air beneath them. Dentists and patients who are exposed to barometric stress as part of their jobs or hobbies should know the causes of barotrauma and be aware of the importance of routine dental checkups to avoid barotrauma-related dental problems.

Human lung development begins around day 26 postconception and continues throughout early childhood. Many crucial events can affect this delicate tissue as it develops, leading to altered and abnormal growth and development of the lungs, thereby yielding a variety of morbidities and sometimes even mortality. Understanding the pathophysiology of lung injury in the extremely low birth weight neonate is essential when caring for these infants, especially during the first hours of life. This article provides bedside clinicians with foundational information related to acute lung injury and the sequence of events that can ultimately lead to neonatal chronic lung disease and bronchopulmonary dysplasia.

Purpose: The aim of this study was to review the current knowledge regarding dental barotrauma., Methods: A search using the PubMed Bibliographic Index and Index-Medicus was performed to identify articles in English that were published between 1930 and 2007. The reference lists of the resulting articles were searched to find publications relating to dental barotrauma., Results: Only a few scientific publications reported this phenomenon. Moreover, a significant part of the relevant literature was from more than 60 years ago. There was no published study on the current incidence rate of this phenomenon., Conclusion: Besides other oral manifestations of barometric pressure changes, such as barodontalgia (barometric pressure-related oral pain), a clinician should be familiar with this entity and take preventive measures as well as periodically examine his or her patients who fly planes or scuba dive. The clinician should also search for occult pathologies such as leaking restorations or secondary caries lesions. In addition, the clinician should be aware of the possible influence of pressure changes on the retention of prosthetic devices and plan treatment accordingly.

Introduction: Complete sphenoethmoidectomy with a Draf IIA frontal dissection is the standard of care surgical management for medically resistant diffuse recurrent sinus barotrauma. Surgical failures still occur with this technique mainly due to the propensity of the frontal outflow tract to stenose. Endoscopic frontal revisions are notoriously prone to failure and historically represented the only option for aircrew afflicted by this career-ending complication of surgery. The frontal sinus drillout or endoscopic modified Lothrop procedure (EMLP) offers a highly successful salvage surgery for postoperative frontal ostium stenosis and is particularly suited to the physiologic requirements of the aviator., Case: A high-performance aircraft pilot developed frontal stenosis after extensive sinus surgery for recurrent sinus barotrauma. Multiple failed endoscopic attempts to rehabilitate his sinuses finally gave way to success using the EMLP. He was returned permanently to flight duty at 6 wk post-op., Discussion: This case report represents the first published successful application of the modified endoscopic Lothrop procedure to a pilot with recurrent frontal sinus barotrauma.

Although considered rare, dentists may encounter oral pain evoked by a change in barometric pressure, a condition known as barodontalgia (aerodontalgia). The article reviews the epidemiology, clinical presentation, pathogenesis, diagnostic process and differential diagnosis (including facial and dental barotrauma) of this phenomenon. Preventive measures are described as well.

We present a rare case of facial paralysis that was unusual not only in its causation but also in its rapidity of onset and recovery. We describe a rare case history of this accruing in 35 years old women traveling at the high altitude mountain road referred to ENT clinic with sudden symptoms of middle ear effusion and facial nerve paralysis. Patient had undergone medical systemic steroid treatment and after 3-4 weeks she had a good recovery of facial palsy with a minimum remnant of sensory neural hearing loss. Facial nerve paralysis resulting from a barotrauma of the middle ear is suggested. The correct diagnosis of this condition is important and unnecessary treatment should be avoided.

Objective: To sum up the experiences of diagnosis, treatment and medical evaluation of sinusitis and nasal polyp in aircrew., Method: Ninety three aircrew with sinusitis and nasal polyp were included in the study., Result: There were 11 cases with acute sinusitis and 82 cases with chronic sinusitis and nasal polyp. Of the 82 cases, there were 46 cases in class I (including 39 cases with symptoms and signs on ground in Ia, 7 cases only with signs in Ib), 36 cases in class II (no symptoms on ground but with symptoms of secondary barotraumas in flight, including 14 cases with secondary barosinusitis in IIa, 13 cases with secondary barotrauma in IIb, 9 cases with secondary barosinusitis and barotrauma in IIc ). Of the 82 cases, there were 24 cases in 1 stage of type I, 38 cases in 2 stage of type I, 7 cases in 3 stage of type I, 2 cases in 1 stage of type II, 6 cases in 2 stage of type II, 3 cases in 3 stage of type II, 2 cases in type III. Eighty four cases continued their flying jobs and 9 cases were permanently grounded., Conclusion: Flying safe can be endangered by sinusitis and nasal polyp alone or with its secondary barotraumas. Chronic sinusitis and nasal polyp complicated with barotraumas are important causation for medical grounding. The aircrew with sinusitis and nasal polyp will be allowed to continue their flying jobs only after getting well curative effect and normal gas pressures of ear and nasal sinus.

Purpose of Review: Provide a comprehensive overview of the pathophysiology and surgical management strategies of sinus barotrauma with attention to recent advancements in endoscopic surgical technique., Recent Findings: New endoscopic frontal sinus surgery techniques have been shown to be highly effective with rhinosinusitis management, but these techniques have not been evaluated with sinus barotrauma management., Summary: We discuss the surgical goals and expectations with sinus barotrauma and contrast these to those with chronic rhinosinusitis (CRS). Sinus barotrauma surgery requires anatomic patency of involved sinuses whereas CRS patients are satisfied with a lack of symptoms from any residual mucosal disease.

Background: With the growing number of air passengers, flight attendants, leisure pilots as well as military and airline pilots, dentists may increasingly encounter flight-related oral conditions requiring treatment. Moreover, dentists should prevent the creation of in-flight hazards when treating aircrew members. The aim of this article is to introduce the concepts of aviation (aerospace) medicine and dentistry., Methods: Data were gathered to cover the following issues: head and facial barotraumas (barotrauma-related headache, external otitic barotrauma, barosinusitis and barotitis-media), dental barotrauma (barometric pressure-related tooth injury), barodontalgia (barometric pressure-related oro-dental pain), and dental care for aircrews., Results and Conclusions: Special considerations have to be made when planning restorative, endodontic, prosthodontic and surgical treatment to an aircrew patient. This article supplies the dental practitioner with some diagnostic tools as well as treatment guidelines. Principles of prevention, periodic examination, dental-related flight restriction (grounding) and dental documentation (for forensic purposes) are described as well.

Introduction: Cerebral air embolism is a rare cause of stroke, but may occur in patients undergoing invasive cardiac and pulmonary procedures, as well as in divers suffering pulmonary barotrauma from rapid ascent. Cerebral air embolism during air travel, however, is particularly rare., Case: We present a case of a previously healthy gentleman who presented with an acute stroke after a commercial flight; the stroke was initially felt to be of cardioembolic origin. A large intrapulmonary cyst was noted on his imaging studies, but thought to be an incidental finding. During a return flight, he suffered another stroke and was found to have cerebral air emboli., Conclusion: This case suggests the importance of considering cerebral air embolism in patients with stroke associated with air travel; restricting air travel in patients with intrapulmonary cysts may be prudent.

Background: Middle ear barotrauma (MEBT) is the most common medical complication in diving, aviation, and hyperbaric medicine. Eustachian tube dysfunction (ETD) quantifies the inability to open the eustachian tube (ET), risking MEBT. Surfactant administration improved ET function and efficaciously treated otitis media in a host of animal models. We performed a pilot study evaluating the efficacy of intranasal surfactant administration in reducing MEBT in repetitive diving., Methods: Eight divers participated in a subject-blinded, placebo-controlled, random order, multiarm (air and O2)-repeated measures trial investigating the relative efficacy of intranasally administered surfactant, acetylcysteine and oxymetazoline, and orally administered pseudoephedrine versus saline-placebo in middle ear equilibration during repetitive, multiday diving. Subjects were tested with the Nine-Step Inflation/Deflation Tympanometry Test (NSI/DT) and sonotubometry (testing eustachian tube opening pressure [ETOP]) before and immediately after each dive., Results: Significant interaction effects were found for drug-by-test (F8,668 = 4.05; p < 0.001) and the three-way interaction of drug-by-dive-by-test (F16,668 = 2.47; p = 0.001) in sonotubometry testing. The ETOP revealed trends toward lowered (improved) values post-versus predive in all treatment arms, which was significant for oxymetazoline (p = 0.04). Only four of the eight subjects experienced any holds during diving. Statistical analysis of the NSI/DT data showed that none of the drug interventions resulted in improvements in ET function over that expected by chance., Conclusions: There is large intra- and intersubject variability in daily functioning of the ET as measured using the NSI/DT and sonotubomtery (ETOP). Sonotubometry engendered trends toward lowered (improved) values post-versus predive in all treatment arms. The repetitive dives did not result in a significant decrease in ET function as evidenced in the saline-placebo trials, circumventing an ability to detect superiority among the various treatment arms in our subject population. Additionally, since our study was underpowered to detect significant effects, we can only assert that various inhalational agents may improve middle ear ventilation in repetitive diving warranting further study. A larger subject population including subjects diagnosed with ET dysfunction may provide more statistical power to discern the benefit of inhaled agents as a useful prophylactic for preventing or reducing ET dysfunction during diving and/or hyperbaric/hypobaric pressure changes.

Introduction: Orbital floor fractures are usually the result of mechanical trauma. Orbital emphysema tends to develop in fractures affecting the paranasal sinuses and walls of the orbit., Clinical Case: We report the case of a 35-year-old male who suffered an orbital floor fracture with associated orbital emphysema as a result of nose blowing., Discussion: Only one other similar case has been found in the literature.

Pneumolabyrinth is a rare clinical manifestation seen in the practice of otology. It occurs usually after head trauma with temporal bone fracture. However, pneumolabyrinth without temporal bone fracture is a very rare occurrence. When it occurs, it is usually diagnosed by high-resolution computed tomography of the temporal bone. Therapy for pneumolabyrinth is conservative treatment or an exploratory tympanotomy. Recently, we saw two cases of pneumolabyrinth after trauma without temporal bone fracture. The patients were treated with conservative management for the pneumolabyrinth. However, the degree of recovery from hearing loss was different for each patient.

We present two new cases of airplane headache and compare them with 13 cases described so far. The two new cases refer to a man and a woman, one each. The woman suffered from headache during the take off and throughout the flight, which is rarely encountered. The man had a typical airplane headache with accompanying symptoms, with the feeling of pressure in the left side of the head. Diagnostic treatment revealed no pathomorphological substrate of the condition. The etiology and pathophysiology of this type of headache have not yet been fully clarified. We presume that this type of headache may be connected with changes in the nasal mucous membrane with deviation of the nasal septum, as well as in ethmoidal sinuses and other paranasal cavities. The rise of atmospheric pressure in the airplane and barotrauma from activation of the trigeminovascular system certainly play a major role in the occurrence of this headache.

Orbital emphysema is a well-recognized complication of fractures involving the orbit. Commonly, it occurs when high pressure develops in nasal cavity as during nose blowing, coughing or Valsalva's maneuver and usually occurs in the subcutaneous tissues. We report the case of a young breath-hold diver who developed spontaneous, non compressive orbital emphysema during underwater fishing, with a maximal depth of 25-30 meters in the Sardinian sea. He was otherwise healthy, without previous cranio-facial trauma and nasosinusal diseases or surgery were not present in the history. When he was referred to our attention the patient presented right eyelid ptosis but diplopia and vision impairment were absent. Computer tomography scans showed subcutaneous air in the right upper eyelid and around the eyeball, particularly near the orbit's roof but optic nerve area, intraconal, was free of air. A dehiscence in lamina papyracea was evident. In our opinion, this has been the point of air entry into the orbit. A supportive therapy was advised and two weeks later the emphysema was recovered completely and the subject was symptoms free. The literature has been revised and to our knowledge no previous cases of barotraumatic orbital emphysema, in a breath-hold diver, are referred.

Mediastinal and subcutaneous emphysema may occur after dental and oral surgery as a result of iatrogenic introduction of air or injury to the tracheobronchial tree. We report a patient who developed emphysema and pneumothorax after dentoalveolar surgery, which made diagnosis and management difficult. We suggest that persistent postoperative vomiting caused inhalation of mediastinal and intrathoracic air.

Background and Objectives: Acute respiratory distress syndrome (ARDS) is a frequent form of hypoxiemic respiratory failure caused by the acute development of diffuse lung inflammation. Dysregulated systemic inflammation with persistent elevation of circulating inflammatory cytokines is the pathogenetic mechanism for pulmonary and extrapulmonary organ dysfunction in patients with ARDS. Glucocorticoids (GCs) have a broad range of inhibitory inflammatory effects, including inhibition of cytokines transcription, cellular activation and growth factor production. They inhibit the inflammatory pathways through two specific intracellular glucocorticoid receptors (GRs), named GR alpha and GR beta. The aim of our study was to evaluate the histologic evidence of inflammatory injury and the GR alpha uptake of resident and inflammatory cells in different experimental models of acute lung injury (ALI)., Methods: We studied four groups of rats: three different experimental rat models of lung injury and a control group. The ALI was caused by barotrauma (due to an overventilation), oleic acid injection and mechanical ventilation. Results were compared to nonventilated rat control group. The duration of mechanical ventilation was of 2.5h. At the end of each experiment, rats were sacrificed. Lung biopsies were evaluated for morphologic changes. The immunohistochemistry was performed to study GR alpha expression., Results: Histologic evidence of lung injury (alveolar and interstitial edema, vascular congestion, alveolar haemorrhage, emphysema, number of interstitial cells and neutrophils, and destruction of alveolar attachments) were present in all ventilated groups. Barotrauma lead to an additional inflammatory response. GR alpha expression significantly increased in the three ventilated groups compared with nonventilated groups. GR alpha expression was highest in barotrauma group., Conclusions: These data indicate that ALI is associated with diffuse alveolar damage, up-regulation of the inflammatory response and GR alpha overexpression. Barotrauma is the most effective mechanism inducing acute lung inflammation and GR alpha overexpression.

We present a case of accidental low-pressure inflation injury to the hand sustained while inflating a football with a foot-operated bellows pump when the nozzle slipped and punctured the first web space. The patient made a full recovery after ecacuation of a haematoma, elevation, antibiotics, and physiotherapy.

Introduction: Aeromedical evacuation of patients with posttraumatic and/or post-surgical pneumocephalus has often been regarded with great concern. The expansion of intracranial air with increasing altitude can theoretically result in tension pneumocephalus, with potentially fatal results. This concern is primarily based on extremely rare case reports and theoretical models rather than any significant clinical experience. We report the outcomes of a series of 21 patients with posttraumatic and/or post-craniotomy pneumocephalus who underwent long-range air evacuation from a combat theater in military aircraft., Methods: The estimated volume for each patient was calculated with a simplified method, purposely intended to err toward overestimation, based on computerized tomography scans performed within 24 h prior to air travel., Results: The volumes of pneumocephalus ranged from 0.6 to 42.7 ml, with mean volume of 9.3 ml and median volume of 4.2 ml. No patient sustained a temporary or permanent neurologic decline as a result of air transportation. Three patients with continuous monitoring of intracranial pressure (ICP) were not observed to have any sustained pressure elevations during flight., Discussion: We conclude that pneumocephalus in the head-injured and/or craniotomy patient is not likely by itself to be an absolute contraindication to air evacuation. The mechanism causing pneumocephalus, its time course, progression, and the rate of altitude change are likely more important factors in determining its clinical significance. More clinical experience is required to better assess the safety of aeromedical evacuation of these patients, but this small series suggests that it is not as dangerous as previously thought.

Spontaneous otogenic pneumocephalus caused by barotrauma is extremely rare. We surveyed the literature and describe a case report of otogenic pneumocephalus from barotrauma managed with a middle fossa craniotomy. The neurotologic literature review revealed three similar cases. We conclude that anatomic defects in the floor of the middle cranial fossa contribute to the development of spontaneous otogenic pneumocephalus. Neurotologic consultation should be obtained. In selected instances, middle fossa craniotomy may be required for repair.

Objectives: The aim of this prospective study was to investigate the hearing levels and transient evoked otoacoustic emissions (TEOAEs) of scuba divers., Methods: The study group consisted of 15 scuba divers (9 males, 6 females) and 30 ears. The control group consisted of 15 healthy nondiver patients (9 males, 6 females) and 30 ears. For the study group, total diving duration (TDD), total diving score (TDS), duration after the last dive (DALD), and maximum diving depth (MDD) were obtained by questionnaire. All subjects were evaluated by an otolaryngologic examination, pure-tone and high-frequency audiometry, and transient evoked otoacoustic emissions (TEOAEs)., Results: There was no significant difference between the hearing thresholds and TEOAEs of the study and control groups. For divers, age, higher TDDs and TDSs, and a higher MDD caused an increase in hearing thresholds and a decrease in TEOAEs. When the DALD increased, cochlear functions again achieved nearly normal levels., Conclusion: We recommend that divers' hearing levels and cochlear functions be evaluated before diving. Noninfected status and differences in the volume of the mastoid cell system may explain the results of our study.

Introduction: Diving accidents affecting the inner ear are much more common than was once thought. Among the 319 patients treated in our clinic between January 2002 and November 2005, 46 cases involved 44 divers with symptoms of acute inner ear disorders. The objective of the present article is to investigate the symptoms of the acute disorders and assess any residual damage., Study Design: Retrospective case analysis., Materials and Methods: The medical records were used to study the cases of 18 divers treated for inner ear decompression illness on 20 occasions and 26 divers who had inner ear barotrauma. The symptoms of the disorder at the beginning of treatment, latency period before the first therapeutic measures, kind of initial therapy, symptoms after the accident, and hearing and balance functions at the last examination in our clinic were assessed. Divers with inner ear decompression illness were examined via means of transcranial or carotid Doppler ultrasonography for the presence of a vascular right-to-left (R/L) shunt., Results: Of 18 divers with inner ear decompression illness, 17 reported vertigo as the main symptom. In one diver, the inner ear decompression illness was manifested bilaterally. The divers with inner ear decompression illness had been treated with hyperbaric oxygen therapy in 14 of 20 cases; the average latency period before the start of therapy was 40 hours (median, 10 h). In 15 (83%) of 18 patients, a large R/L shunt was detected, and in 14 (78%) of 18 patients, residual cochleovestibular damage was detected. Only 9 of 26 patients with inner ear barotrauma mentioned feeling dizzy, and in no patient was vertigo the main symptom. Twenty-one patients complained of tinnitus, whereas 20 complained of hearing loss. The hearing loss ranged from an unobtrusive difference of 10 dB between the ears up to complete deafness. Three patients were subjected to tympanoscopy because of suspected rupture of the round window membrane. Of patients with inner ear barotrauma, 78% had residual cochleovestibular damage., Conclusion: We describe for the first time a patient with bilateral manifestation of inner ear decompression illness. Inner ear decompression illness is frequently associated with a R/L shunt; therefore, after a diving accident, the patient's fitness to dive should be assessed via a specialist in diving medicine. Both decompression illness and barotrauma of the inner ear result in residual cochleovestibular damage in more than three of four patients.

Objectives: To report a rare presentation of dehiscent infraorbital canal associated with a maxillary antral cyst., Case Report: A 26-year-old woman presented with symptoms of right infraorbital nerve dysfunction experienced while travelling by aeroplane. She was subsequently diagnosed with dehiscent infraorbital canal and large maxillary antral cyst on computed tomography scanning. The cyst was removed by endoscopic sinus surgery, and the patient's symptoms resolved., Discussion: The effects of barotrauma on the ears and paranasal sinuses are reviewed. This is the first report of infraorbital nerve dysfunction caused by altered atmospheric pressure in the presence of dehiscent infraorbital canal and maxillary antral cyst. Endoscopic sinus surgery was successful in relieving the symptoms in this case.

Pneumopericardium and pneumomediastinum are rare presentations seen most commonly in the context of chest trauma or mechanical ventilation. Here we present a case of a spontaneous pneumopericardium and pneumomediastinum, which occurred in a young man with a recent coryzal illness and multiple Valsalva maneuvers in flight. Although the etiology of pneumopericardium and pneumomediastinum are well described in the literature, possible acute risks to flight personnel have not been previously documented.

We report the case of a 84-year-old patient who came to the emergency department for vomiting and epigastralgia which had occurred during an air flight. These symptoms were related to the intraabdominal perforation of a massive hiatal hernia on barotrauma due to high altitude.

A diving fatality at the extreme depth of 264 m fresh water is described. The diver was equipped with an underwater video camera which recorded events leading to his death. These events corroborated predictions about respiratory complications at extreme pressure made by early researchers. Review of the video and relevant literature resulted in the following physiological interpretation: an increase in respired gas density during descent caused a progressive increase in resistance to flow in both the airways and the breathing circuit. Initially, this was associated with a shift to ventilation at higher lung volumes, a relative degree of hypoventilation, and mild permissive hypercapnia. The promotion of turbulent airway flow by increasing gas density resulted in effort-independent expiratory flow at lower flow rates than usual. The consequent inability to match ventilation to the demands of physical work at the bottom precipitated a spiraling crisis of dyspnea, increasing PaCO2, and wasted respiratory effort, thus producing more CO2. Extreme hypercapnia eventually led to unconsciousness. This tragic case provides a timely and salient lesson to a growing population of deep "technical" divers that there are physiological limitations that must be understood and considered when planning extreme dives.

We report a case of a 60-year-old woman who reported a popping sound in her left ear, induced by changes in pressure, since she pulled her index finger out of her ear canal after accidentally inserting it while washing her hair. Otoscopic examination revealed a wrinkled tympanic membrane and irregular malleus handle. An isolated malleus-handle fracture resulting from barotrauma was suspected. The fracture was repaired surgically using calcium phosphate bone cement. Postoperatively, the problem disappeared and her hearing recovered. This case is the first to demonstrate the efficacy of calcium phosphate bone cement for repairing a malleus-handle fracture.

Since its introduction in 1985 by Ciaglia et al, percutaneous dilational tracheostomy (PDT) has gradually become the procedure of choice in establishing a long-term airway in many intensive care units (ICU). However, the safety of performing PDT in patients with barotrauma is still unknown and has never been reported. We present the case of a 35-year-old man with AIDS, who was admitted to our medical ICU for pneumonia and acute respiratory distress syndrome. He developed subcutaneous emphysema and pneumomediastinum as complications of mechanical ventilation. After stabilization of the barotrauma, he underwent PDT with the standard Ciaglia Blue Rhino technique. However, rapid and extensive progression of preexisting barotraumas occurred shortly after PDT. This severe complication was nearly fatal. The prolonged procedure during which the susceptible lung was exposed to longer duration of high airway pressure was thought to be the mechanism of rapid deterioration of the preexisting barotrauma. With aggressive supportive care, the patient survived. To prevent further deterioration of preexisting barotraumas during and after PDT in future cases, we propose some principles that should be strictly followed. Under administration of these principles, we safely performed PDT in another case with preexisting barotrauma 1 month later.

Although it is estimated that > 1 billion passengers travel by air worldwide each year, the incidence of in-flight emergencies is low. However, due to nonstandardized reporting requirements for in-flight medical emergencies, the true incidence of pulmonary barotrauma in airplane passengers is unknown. We describe the case of a passenger with an asymptomatic intrapulmonary cyst in whom a severe case of cerebral gas embolism developed during an aircraft flight. The decrease in ambient pressure during the aircraft climb resulted in expansion of the cyst volume based on Boyle's law (pressure x volume = constant). Due to the cyst expansion, we believe tears in the wall led to the leakage of air into the surrounding vessels followed by brain gas emboli. Adult patients with intrapulmonary cysts should be strongly considered for cyst resection or should at least be advised to abstain from activities leading to considerable changes in ambient pressure.