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Persistent alternobaric vertigo at ground level
Abstract
We recently encountered a 15-year-old female with bilateral tympanostomy tubes who manifested persistent severe vertigo, at ground level, secondary to a unilateral middle-ear pressure of +200 mm H(2)O elicited by an obstructed tympanostomy tube in the presence of chronic nasal obstruction. We believe this is a previously unreported scenario in which closed-nose swallowing insufflated air into her middle ears, resulting in sustained positive middle-ear pressure in the ear with the obstructed tube. Swallowing, when the nose is obstructed, can result in abnormal negative or positive pressures in the middle ear, which has been termed the Toynbee phenomenon. In patients who have vertigo, the possibility that nasal obstruction and the Toynbee phenomenon are involved should be considered.
... Surrogate endpoint BMs can be used to assess disease progression or treatment efficacy (Aronson, 2005). Middle ear pressure (MEP) is a potential BM for ETD and can be measured by tympanometry or acoustic reflectometry (Shanks & Shelton, 1991;Teele & Teele, 1984) but requires additional research to establish its reliability and validity in ETD (Bluestone et al., 2012). PROMs and ePROMs are evaluation tools that measure patient-reported outcomes, such as symptoms, quality of life, and functional status (Fitzpatrick et al., 1998). ...
... MEP is the pressure in the middle ear (ME) space. Because MEP is linked to the Eustachian tube (ET) function, it has been implicated as a BM for ETD (Bluestone et al., 2012) (Figure 1). In persons who do not have ETD, the ET typically regulates MEP. ...
... A promising BM for ETD is MEP, which can be measured by tympanometry and acoustic reflectometry (Shanks & Shelton, 1991;Teele & Teele, 1984). MEP has been proposed as a surrogate endpoint BM of ET function and can be used to measure the efficacy of treatments for ETD (Aronson, 2005;Bluestone et al., 2012;Schilder et al., 2015). However, more research is needed to establish its reliability and validity as a BM for ETD (Bluestone et al., 2012). ...
Patients who suffer from Eustachian tube dysfunction (ETD) experience a significant decline in quality of life. To enhance patient outcomes, it is crucial to establish an accurate diagnosis, assess treatment effectiveness, and evaluate the severity of the condition. Substantial progress has recently been made in identifying biomarkers (BMs) and developing ETD clinical outcome assessments (COAs). This study examines the current state of BMs and COAs in ETD, including the methods evaluated historically and their potential clinical applications. The research in this area emphasizes the importance of using objective measures, such as middle ear pressure (MEP) and patient-reported outcome measures (PROMs), for diagnosing and evaluating ETD. Further, I discuss how electronic PROMs (ePROMs) and other digital health technologies can guide the development of innovative PROMs that ETD. Despite significant advances in COAs for ETD, much work remains to validate and improve them before their implementation in clinical practice. There has been less focus on vertigo as a symptom in recent assessments of ETD, suggesting that further examination of this aspect is needed. By validating BMs and COAs for ETD, we could enhance long-term patient outcomes and quality of life through improved diagnostic accuracy and evaluation of treatment efficacy.
... Eustachian tube dysfunction (ETD) occurs when the mucosal lining of the Eustachian tube (ET) swells or fails to open and close properly. Muffled hearing, pain, tinnitus, decreased hearing, a feeling of fullness in the ear, and balance problems may occur if the tube is damaged [1,2]. Long-term ETD has been linked to damage to the middle ear and eardrum. ...
... It is important to note that ETD can also cause alternobaric vertigo (ABV), a term coined by Lundgren in 1965 to describe vertigo in deep-sea divers [5], and later by Malm and Lundgren in pilots [1]. ABV can happen to pilots whose passive opening MEP during ascent is not the same at the same height in both ears [6]. ...
... ABV can happen to pilots whose passive opening MEP during ascent is not the same at the same height in both ears [6]. ABV is a type of vertigo caused by an asymmetric vestibular dysfunction resulting from an imbalance in the MEP [1,[7][8][9]. Because distinguishing between unilateral and bilateral ETD can be difficult [8,9], the practical definition of ABV is frequently used. ...
Alternatenobaric vertigo (ABV) develops when the middle ear pressure (MEP) is not equal at the same height in the sea or the air. This is possible when the altitude changes. Eustachian tube dysfunction (ETD) is a common cause of ABV. In this case report, we discuss a patient who experienced repeated bouts of ground-level alternobaric vertigo (GLABV) due to ETD. We also discuss how Conversational Generative Pre-trained Transformer (ChatGPT) might be used in the creation of this case report.
A 41-year-old male patient complained of vertigo at ground level on several occasions. His medical history included chronic sinusitis, nasal congestion, and laryngopharyngeal reflux (LPR). During the physical exam, his tympanic membranes were dull and moved less. Tympanometry showed that he had an asymmetric type A and that both of his middle ears had negative pressure. The results of the audiometry test were normal, and the laryngoscopy revealed LPR. The patient was found to have GLABV because of ETD, and different treatment options, such as Eustachian tube catheterization (ETC), were thought about.
This case study demonstrates how ChatGPT can be used to assist with medical documentation and the treatment of GLABV caused by ETD. Even though ChatGPT did not provide specific diagnostic or treatment recommendations for the patient's condition, it did assist the doctor in determining what was wrong and how to treat it while writing the case report. It also aided the doctor in writing the case report by allowing them to discuss it. The use of artificial intelligence (AI) tools such as ChatGPT has the potential to improve the accuracy and speed of medical documentation, thereby streamlining clinical workflows and improving patient care. Nonetheless, it is critical to consider the ethical implications of using AI in clinical practice
This case study emphasizes the importance of understanding that ETD is a common cause of GLABV and how ChatGPT can aid in the diagnosis and treatment of this condition. More research is needed to fully understand how long-term AI interventions in medicine work and how reliable they are.
... Possible symptoms include hearing loss, ear pain, tinnitus, and vertigo. [1][2][3][4][5][6][7][8][9][10][11] Allen also noticed that vertigo caused by ETD could be treated locally with an air douche and catheterization of the Eustachian tube as follows: "These are the uses of the catheter. It is, in essence, a device that allows access to the Eustachian tube and middle ear cavity. ...
... 13 ABV is a condition in which dizziness is caused by a change in pressure in one ear compared to the other. 3,4,8,9,11 This review looks at the complicated relationship between ETD, ABV, and LPR from both a historical and current perspective. We start by talking about the study's history and significance. ...
... The purpose of this research was to examine the complicated relationship between ETD, ABV, and LPR from both a historical and modern perspective. [1][2][3][4][5][6][7][8][9][10][11] The findings of this study demonstrated that ETD can contribute to LPR and that LPR can contribute to ETD. 6 They also demonstrated how these conditions can result in other related conditions, such as aternobaric vertigo. 3,4,[7][8][9]11 The use of both ancient and new material to demonstrate the evolution of these complex interactions over time is a strength of this study. ...
Decades of research have been devoted to understanding the complicated connections between the ears, nose, throat, and stomach. Pioneers in the discipline of otolaryngology/ear, nose, and throat (ENT), James Yearsley (1805–1869) and Peter Allen (1826–1844), produced theories and concepts that allowed us to determine the relationship between these items. The current study has contributed to clarifying the complex relationship between Eustachian tube dysfunction (ETD), alternobaric vertigo (ABV), gastroesophageal reflux disease (GERD), laryngopharyngeal reflux (LPR), and nasopharyngeal reflux (NPR). These
interrelationships are required for guiding otolaryngology research and improving patient care. This article investigates the historical and contemporary links between ETD, ABV, and LPR. James Yearsley developed the concept of “stomach deafness” in 1843, suggesting a relationship between stomach issues and hearing loss. Peter Allen thought that ETD might be related to vertigo, especially “alternobaric vertigo,” which happens when the air pressure changes in the labyrinth and affects the fluid in it. Recent investigations have shown that NPR or LPR can produce ETD and ABV by irritating and inflaming the Eustachian tube. For otolaryngology research to progress and patient care to improve, it is critical to understand both the historical and modern perspectives on these complex interactions.
... Dr Charles Bluestones published a patient of AV at ground level due to chronic Toynbee phenomenon in 2012. [14] Bluestone documented the etiopathogenesis of the otitis media in such patient may be associate to abnormal anatomy of eustachian tube. That case was also showing abnormal vestibular function and dysfunction of eustachian tube. ...
... After surgery, function of eustachian tube became defective; however, vestibular functions come to normal and vertigo relieved. Hence, Bluestone [14] concluded, nose block and Toynbee phenomenon may be associated amongst patients those have vertiginous symptom. The assessment of function of the eustachian tube is an important part to make differential diagnosis in patients with normal tympanic membrane in the absence of middle ear infections but with presence of symptomatology related to eustachian tube dysfunctions such as otalgia, aural pooping, fluctuating hearing loss, tinnitus and vertigo. ...
Alternobaric vertigo (AV) is a type of barotrauma of the middle ear which occurs if the asymmetric middle ear pressure in both sides. If pressure differential exceeds a threshold, asymmetric stimulation of the labyrinth will occur, leading to vertigo, called as AV. The classical presentations is transient vertigo which appear sudden onset during the time of diving or flying, typically when ascends or when a Valsalva manoeuvre is performed. Other symptoms associated with AV are nausea, vomiting, disorientation and generalised malaise. If the descent or ascent is reversed immediately, vertigo suddenly disappears or may cause sudden spatial disorientation which may lead to catastrophic outcome. AV is often overlooked but this mishap should not be ignored as it may lead to fatal accident. The patient should be properly counselled for aetiology and nature of AV and its potential risks including aspiration and death. This review article focuses on the prevalence, etiopathology, clinical presentations and current management of the AV amongst underwater divers and aviators. This article will surely increase awareness amongst the clinicians and people those are practicing underwater diving or in aviation and help them to resolve this problem to a great extent.
... However, rapid and large pressure changes during diving or flight have occasionally been found to induce transient and reversible vertigo (alternobaric vertigo) [26,27]. Persistent alternobaric vertigo has also been reported in patients with nasal obstruction and obstructive sleep apnea at ground level [28,29]. We have previously reported that weather-sensitive patients suffering from pain show lowered thresholds for self-motion perception in response to galvanic vestibular stimulation [30]. ...
Weather changes accompanied by decreases in barometric pressure are suggested to trigger meteoropathy, i.e., weather-related pain. We previously reported that neuropathic pain-related behavior in rats is aggravated by lowering barometric pressure, and that this effect is abolished by inner ear lesions. These results suggest that mechanisms that increase vestibular neuronal activity may parallel those that contribute to meteoropathy generation. However, it remains unknown whether changes in barometric pressure activate vestibular neuronal activity. To address this issue, we used expression of c-Fos protein as a marker for neural activation. Male and female mice were placed in a climatic chamber, and the barometric pressure was lowered by 40 hPa, from 1013 hPa, for 50 min (LP stimulation). The total number of c-Fos-positive cells in the vestibular nuclei was counted bilaterally after LP stimulation. We also video-recorded mouse behaviors and calculated the total activity score during the LP stimulation. LP stimulation resulted in significant c-Fos expression in the superior vestibular nucleus (SuVe) of male and female mice. There was no effect of LP stimulation on the total activity score. These data show that distinct neurons in the SuVe respond to LP stimulation. Similar mechanisms may contribute to the generation of meteoropathy in humans.
Objective:
To explore the effect of obstructive sleep apnea (OSA) on the negative pressure and acoustic compliance of middle ear cavity in children.
Methods:
The clinical data of 258 children with suspected OSA, who complained of mouth breathing or snoring at night in the Department of Otolaryngology Head and neck surgery of the Second Affiliated Hospital of Xi'an Jiao Tong University from August 2020 to March 2022, were enrolled and analyzed retrospectively. The OSA and otitis media with effusion (OME) were determined by polysomnography (PSG) and acoustic immittance examination, respectively. Then, the parameters of tympanometry were compared between OSA and non-OSA children or among the children with various severity of OSA.
Results:
There was no significant difference in the incidence of OME between children with OSA and those with non-OSA (15.80% vs 11.80%, P = 0.422). Compared with non-OSA children, OSA children had lower negative pressure (-56.42 vs -12.38, P < 0.001) and higher acoustic compliance (0.45 vs 0.38, P = 0.030) in middle ear cavity. There were also significant differences in negative pressure and acoustic compliance among children with mild, moderate and severe OSA (P < 0.001; P = 0.001). However, only the absolute value of negative pressure was markedly decreased after surgical therapy accompanied with transformation from OSA to non-OSA (-156.67 vs -45.67, P < 0.05), while this was not observed for acoustic compliance (0.48 vs 0.40, P > 0.05).
Conclusion:
OSA may have an adverse influence on the negative pressure and acoustic compliance of middle ear cavity in children.
The number of people participating in sport self-contained underwater breathing apparatus (SCUBA) diving has increased tremendously, bringing with it a rise in diving accidents. Alternobaric vertigo (AV) is a common problem in SCUBA divers. We investigated the relationship between Eustachian tube function and incidence of AV in sport SCUBA divers. We also followed the progress of these divers after Eustachian tube function improved.
Forty-four patients who experienced a SCUBA diving accident affecting the middle ear (11 men and 33 women; mean ± SD: 37.5 ± 11.5 yr) and 20 healthy volunteer divers who did not experience an accident (6 men and 14 women; mean ± SD: 33.5 ± 13.9 yr) were compared. We divided the divers with an accident into two groups (those with AV vs. those without) and then compared the two groups. All patients regularly underwent Eustachian tube function tests (sonotubometry and impedance test).
In sonotubometry and impedance testing, the mean duration (p < 0.001), amplitude (p < 0.002), and maximum air content (p < 0.05) of divers who experienced a diving accident were significantly different from those of healthy volunteers. However, these parameters in divers with AV did not differ significantly from those in divers without AV. In 7 of 15 divers, vestibular symptoms disappeared immediately after ascent. In the remaining eight divers, however, vertigo/dizziness persisted and even was observed at their first clinic visit.
To prevent AV or barotraumas in SCUBA divers, we recommend a thorough Eustachian tube function evaluation. Any dysfunction should be treated before engaging in SCUBA diving.
Achondroplasia is the most prevalent chondrodysplasia and numerous authors have documented the varied social and medical complications that may compromise a full and productive life. Complications include cervicomedullary compression, spinal stenosis, restrictive and obstructive lung disease, otitis media, and tibial bowing, among others. These known complications have led to recommendations for the anticipatory management of such patients. There are relatively few data on the actual rates and timing of these problems. This paper reports data on the rates and age of occurrence of several of these complications based on a review of recorded chart information of 193 patients ascertained from several well established genetic centres with a known interest in the chondrodysplasias. The length of follow up varied and the rates of occurrence at specific age intervals were used to estimate the cumulative percentage affected for each complication. The report includes information on otitis media, ventilation tubes, hearing loss, tonsillectomy, speech problems, tibial bowing and osteotomy, ventricular shunting, apnoea, cervicomedullary decompression, and neurological signs attributable to spinal stenosis.
To evaluate the relationship between nasal obstruction and otitis media, 10 ferrets were studied before and after either unilateral (E = 5) or bilateral (n = 5) nasal obstruction. Observations included otomicroscopic assessments of middle ear status, tympanometric recordings of middle ear pressure and forced-response, inflation-deflation and continuous monitoring tests of Eustachian tube function. During the 6 8 week post-obstruction follow-up period no animal developed evidence of otitis media. Abnormal positive middle ear pressures lasting for the period of follow-up occurred only in the animals with bilateral nasal obstruction. Eustachian tube function test results showed these pressures to be generated during swallowing. No changes in the passive function of the tube were documented in either group, but changes in active function consistent with alterations in the pressure gradient between the middle ear and the nasopharynx were observed in both groups.
The author commences by alluding to the opinion generally held by anatomists, viz. that the guttural orifice of the Eustachian tube is always open, and that the air in the tympanum is constantly continuous with that in the cavity of the fauces. An examination of the guttural orifice of the tube in man and other animals has led the author to conclude, that, except during muscular action, this orifice is always closed, and that the tympanum forms a cavity distinct and isolated from the outer air. The muscles which open the Eustachian tube in man are the tensor and levator palati, and it is by their action during the process of deglutition that the tubes are ordinarily opened. That the act of swallowing is the means whereby the Eustachian tubes are opened, is shown by some experiments of which the following may be cited.
Eustachian tube function studies were carried out in patients with concurrent or recent middle ear effusions. Radiographic techniques were employed in assessing tubal response to liquid flow. Studies of air flow and air pressure were carried out using a Madsen bridge, and depended on the presence of either a perforation or a tympanostomy tube.
Most of the Eustachian tubes studied showed varying degrees of obstruction or abnormal distensibility or both, often depending on the direction of flow, or on whether pressures were increased or reduced.
Quite apart from other factors which may contribute to intrinsic oxextrinsic obstruction of the Eustachian tube, its compliance appears to play an important role in determining its function. In particular, compli. ance appears to be an important factor in the response of the Eustachian tube to increased positive or to negative pressures.
Elimination of the causes of both nasal obstruction and abnormal nasopharyngeal secretions may alleviate problems in the function of the Eustachian tube which seem attributable to increased tubal compliance.
In an attempt to determine the effect of an upper respiratory tract infection on the ventilatory function of the Eustachian tube, 20 children who had recurrent acute or chronic middle ear effusions were studied. Baseline Eustachian tube function testing was obtained when there were no signs or symptoms of upper respiratory infection. These tests were repeated at six-week intervals and whenever an upper respiratory tract infection supervened.
The results of this study were the following:
The basic problem in all of the children was functional obstruction of the Eustachian tube that could result in a middle ear effusion; however, in the absence of an effusion, their poor Eustachian tube function would place them at particularly high risk for developing one, especially during periods of upper respiratory infection. Since management of the functional Eustachian tube obstruction remains obscure at present, therapy should be directed toward alleviating the transient or persistent middle ear negative pressure or the intrinsic mechanical Eustachian tube obstruction when an upper respiratory infection is present
In an attempt to better define the changes affecting the temporal bone that might predispose achondroplastic dwarfs to otitis media, nine achondroplastic subjects who were evaluated for hearing loss underwent high-resolution CT scanning of the temporal bone. Comparisons were made with 10 nonachondroplastic subjects. A number of morphologic changes were seen, including (1) poor development of mastoid air cells, (2) foreshortening of the carotid canals, (3) narrowing of the skull base, (4) "towering" petrous ridges, and (5) relative "rotation" of the cochlea and other temporal bone structures. The most significant change was the rotational effect, which was more pronounced medially, resulting in an abnormal orientation of inner ear structures relative to middle ear structures and of middle ear structures relative to the external auditory canal. There was a notable lack of evidence for otitis media or its sequelae in any of the achondroplastic subjects. Audiograms were obtained in six of the nine achondroplastic subjects (two adults and four children). There was evidence of mixed hearing loss in the four children, but only of sensorineural hearing loss in the adults. We believe that the persistent hearing loss in achondroplasia is not due to sequelae of otitis media as some authors have suggested. Intrinsic vestibulocochlear changes below the limits of resolution of high-resolution CT scanning may be responsible.
The present investigation was part of a project performed to detect possible effects of diving on the cochleovestibular system. A group of 194 professional divers were interviewed, examined otologically, and their hearing was tested audiometrically. Caloric vestibular tests were performed in 48 subjects. The interview reviewed age, diving experience, previous ear disease or injury, head trauma, noise exposure during diving and during spare-time activities, eye color, tobacco habits, and the occurrence of vertigo during diving. Useful information regarding vertigo was obtained from 193. Of the 76 (39%) who had experienced vertigo, 64 (33%) were classified as alternobaric vertigo (AV), a type of vertigo caused by asymmetric middle ear pressure. A stepwise multiple logistic regression analysis was performed to detect variables contributing to the presence of AV. Variables having a statistically significant association with AV were previous barotrauma of the ear (P less than 0.05) and noise exposure during diving (less than 0.05). AV was most frequently encountered when diving during a common cold. In this sample of divers, AV did not lead to any serious or critical situations.
The Toynbee maneuver, swallowing when the nose is obstructed, leads in most cases to pressure changes in one or both middle ears, resulting in a sensation of fullness. Since first described, many varying and contradictory comments have been reported in the literature concerning the type and amount of pressure changes both in the nasopharynx and in the middle ear. In our study, the pressure changes were determined by catheters placed into the nasopharynx and repeated tympanometric measurements. New information concerning the rapid pressure variations in the nasopharynx and middle ear during deglutition with an obstructed nose was obtained. Typical individual nasopharyngeal pressure change patterns were recorded, ranging from a maximal positive pressure of +450 to a negative pressure as low as -320 mm H2O.
The ability to equilibrate middle ear pressure was studied in 2 groups of divers. One group consisted of 12 divers who had experience of vertigo which, based on the history, was considered to be alternobaric vertigo (i.e. to have been caused by middle ear overpressure). The other group consisted of 6 divers without vertigo experience. When exposed to simulated ascents and passive clearing of the ears in a pressure chamber, the 12 divers with vertigo experience required significantly higher middle ear pressures for passive opening of the eustachian tubes than the 6 divers without experience of vertigo during diving. Furthermore, 6 of the 12 divers with vertigo experience reported vertigo in the laboratory; nystagmus simultaneous with the vertigo episodes indicated that the latter were of vestibular origin.
A method permitting quantitative tubal function tests across an intact tympanic membrane has been worked out. The method permits a continuous recording of the volume deviation of the drum in relation to the neutral position both at changes of the ambient pressure and changes of the pressure in the middle ear. Repeated testings have been performed on 102 cases with normal ears which all had normal hearing, i.e. a normal audiogram, and normal ear findings. 64 % could equilibrate under dynamic pressure conditions, i.e. simulated descent, 84 % could propagate a square wave pressure from the rhinopharynx to the ear and 79 % had a positive Toynbee's test. 12 % could equilibrate negative ear pressures completely while the rest have a reduced capacity to equilibrate or none at all, though the ears were regarded as normal. The findings are discussed.
Characteristic temporal bone changes have recently been defined by high resolution CT in nine patients with achondroplasia (Cobb et al., Am J Neuroradiol 9:1195, 1988). These included narrowing of the skull base and "towering" petrous ridges resulting in abnormal orientation of the inner and middle ear structures. In order to determine whether these morphologic changes are the cause of the hearing deficit in achondroplasia, audiometric studies and ENT evaluation were performed in eight of the nine patients. All had a history of frequent otitis media and four had experienced tympanic membrane tube insertion. Three patients had significant sensorineural hearing loss, two had conductive hearing loss and one patient had combined hearing loss. None of the temporal bone morphologic changes were found to be correlated with the degree of either sensorineural or conductive hearing loss. Fusion of the ossicular chain was not present in any of our cases. Appropriate treatment of frequent acute otitis media and early awareness of middle ear effusions and conductive hearing loss in children with achondroplasia may be of great importance in preventing permanent hearing loss.
Changes in ambient pressure can elicit the vertigo and bodily disequilibrium known clinically as alternobaric vertigo. Our previous studies showed that changes in middle ear pressure altered the activity of the primary vestibular neuron, and the finding suggests that the pressure-induced vestibular response causes alternobaric vertigo. To investigate the roles played by the round window (RW) and the oval window (OW) in the vestibular response induced by pressure, we measured the change in perilymphatic pressure and the firing rates of primary vestibular neurons after the application of positive or negative pressure to the middle ear. We found an increase in the pressure-induced vestibular response in the group with a closed OW, and a decrease in the group with a closed RW. Measurements showed that the amplitude of the change in perilymphatic pressure in the group with a closed OW did not differ from that in the control group, whereas the amplitude of the perilymphatic pressure change in the group with a closed RW was significantly reduced. A discrepancy between the number of neurons responding and the amplitude of the perilymphatic pressure change in the closed OW group suggests that the vestibular response induced by the change in middle ear pressure was not related solely to the magnitude of the pressure change in the inner ear, but also involved the oval and round windows.
Otitis media (OM) is most common in infants and young children. Despite a dramatic reduction in its incidence after the age of six, the disease still occurs in older children, adolescents, and may even persist into adulthood. The goal of this study was to identify characteristics of eustachian tube (ET) function in an older population which may underlie their persistent OM.
Following a medical history and a head and neck examination, 38 subjects over 6 years of age (64 ears) had their ET function assessed with the forced-response test (FRT). Parameters derived from this test included opening and closing pressures as well as steady-state and active resistances.
Adenoidectomy had previously been performed in 71% of the sample. Clinically, 5% of these subjects had evidence of nasopharyngeal inflammation. The distributions of closing pressure and steady-state resistance were very similar to the distributions of the historic normal controls. The distributions of opening pressure and active resistance were highly skewed relative to the control sample. All study subjects had either abnormal opening pressures or high active resistance, with 79% having both abnormalities.
If nasopharyngeal inflammation and hypertrophied adenoids are significantly correlated to ET dysfunction and persistent OM, this sample should be free of middle-ear (ME) disease. However, these individuals suffer persistent OM due to ET dysfunction characterized by high opening pressures and high active resistances. The abnormalities underlying these skewed forced-response parameters must be identified and corrected if we are going to alleviate the ME disease in these and similar patients.
We investigated the eustachian tube function and the incidence of alternobaric vertigo (AV) in 29 sport self-contained underwater breathing apparatus (SCUBA) divers with, or without, some possible risk factors for AV. The divers had normal audiological and otoscopic findings at the pre-dive examination. We used the nine-step inflation/deflation tympanometric test and Toynbee test for evaluation of eustachian tube function, and the Valsalva manoeuvre for patency. Information on divers, their history, and their otolaryngologic examination were obtained in the pre-dive examination. Divers performed 1086 dives (mean 37, range: 3-100) during the observation period. Four divers (14 per cent) experienced AV during five dives (0.46 per cent), (one diver experienced AV two times). It was found that having an otitis media history or eustachian tube dysfunction determined with the nine-step inflation/deflation tympanometric test before diving, or difficulty in clearing ears during diving could be important risk factors for AV in sport SCUBA divers (p <.05). Divers with such findings seem to be more prone to AV and should pay rigorous attention to the precautions for prevention of AV.
INFORMATION regarding the physiological movements of the eustachian tube in man and the particular muscles involved in these movements has been obtained through anatomical dissection, observations on living animals and observations on living human subjects either by means of a nasopharyngoscope or directly through large pathological defects of the face and palate. These observations have not resulted in any general agreement about the action of the muscles in this region or the sequence and time relations of the movements that take place in man. Some representative studies and conflicting ideas are described below.
Cleland,1 a contemporary of Toynbee, had a patient with an ulceration of the palate through which the mouth of the tube could be visualized. He taught the patient to swallow with his mouth open so that he could observe the tube at this time. He called attention to Toynbee's observations on the tube and Toynbee's conclusion
To determine the prevalence of alternobaric vertigo (AV) in sport divers and to find out whether AV led to dangerous situations underwater. Furthermore, to examine whether objective neurootologic tests are associated with the manifestation of AV.
Retrospective cohort study.
Sixty-three sport divers with an average diving experience of 10 years and 650 dives were questioned regarding their medical and diving history and the manifestation of vertigo during diving.
Microscopic otoscopy, tympanometry, stapedius reflexes, hearing threshold for air and bone conduction, caloric video-oculography including analysis of the slow-phase velocity of the nystagmus, acoustic brain stem responses, and magnetic resonance imaging were performed to find possible differences between divers with and without AV.
We found 17 divers with AV (27%). There was no significant difference in all measured parameters apart from sex and history of middle ear equalization difficulty in divers with AV. Ten (59%) of 17 female divers and 7 (15%) of 46 male divers experienced AV, representing a significant sex difference (p < 0.001). Correlation with our divers' outpatient clinic revealed that female divers had a significantly higher incidence of middle ear equalization disorders which could be an explanation for the predominance of female divers with symptoms of AV. None of the divers reported any dangerous or life-threatening situations following AV. Whether AV leads to dangerous situations underwater remains unclear, but this hypothesis is not supported by our data.
Alternobaric vertigo is a common finding in divers. In our study group, female divers had a four-time higher risk to suffer AV. Our data do not support the thesis that AV is a life-threatening condition.
To describe the common otolaryngologic manifestations in patients with achondroplasia.
Retrospective review.
Tertiary care children's hospital.
Twenty-two patients with achondroplasia, who were treated from 1994 to 2005, with a focus on otolaryngologic diagnoses.
Descriptive statistics of common otolaryngologic diagnoses in patients with achondroplasia.
Of the 22 patients, 15 (68%) received an otologic diagnosis, including 6 with recurrent otitis media and 5 with otitis media with effusion, and 11 patients (50%) underwent an otologic procedure, with 10 undergoing tympanostomy tube insertion. Nine patients (41%) had adenotonsillar hypertrophy, 6 of whom had polysomnogram-documented obstructive sleep apnea. Seven patients underwent adenotonsillectomy (TA). Two patients had significant residual postoperative obstructive sleep apnea, and 1 patient died from acute respiratory distress syndrome following TA. All patients had preoperative neurosurgical evaluation for foramen magnum stenosis, with 11 (50%) requiring decompression. No other airway or laryngeal diagnoses were seen.
Patients with achondroplasia often present with common diagnoses such as otitis media and adenotonsillar hypertrophy, and familiarity with the condition and its common otolaryngologic manifestations improves the likelihood of successful patient care.
Having found a prevalence rate of alternobaric vertigo in Portuguese Air Force pilots that is somewhat higher than previously reported, we underline the importance of implementing education on the management of this condition as part of routine Air Force pilot training programs.
Alternobaric vertigo is a condition in which transient vertigo with spatial disorientation occurs suddenly during flying or diving activities, caused by bilateral asymmetrical changes in middle ear pressure. Its prevalence is very likely underestimated and under-reported, with the 10-17% prevalence rate mentioned in early literature not being challenged by recent data.
To assess its actual prevalence, the authors requested all high performance aircraft pilots presently on active duty in the Portuguese Air Force to anonymously answer a questionnaire on alternobaric vertigo symptoms, after a short briefing on the subject.
A 29% prevalence rate of in-flight episodes consistent with alternobaric vertigo was obtained.
CT of the temporal bone structure in achondroplasia [PubMed: 3143244] Bluestone et al. Page 5 Laryngoscope Author manuscript; available in PMC 2013 April 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript 6 Alternobaric vertigo—really a hazard
- Sr Cobb
- M Shohat
- Cm Mehringer
- Lachman
Cobb SR, Shohat M, Mehringer CM, Lachman R. CT of the temporal bone structure in achondroplasia. Am J Neuroradiol. 1988; 9:1195–1199. [PubMed: 3143244] Bluestone et al. Page 5 Laryngoscope. Author manuscript; available in PMC 2013 April 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript 6. Klingman C, Knauth M, Praetorius M, Plinkert PK. Alternobaric vertigo—really a hazard. Otol Neurotol. 2006; 27:1120–1125. [PubMed: 17130801]
Textbook of Audiological Medicine: Clinical Aspects of Hearing and Balance
- A Martini
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