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Laryngoscope. 2012 Apr;122(4):868-72. doi: 10.1002/lary.22182. Epub 2012 Jan 31. 1. Persistent alternobaric vertigo at ground level. Bluestone CD1, Swarts JD, Furman JM, Yellon RF. Author information

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 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 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. Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.

PMID: 22294503 [PubMed - indexed for MEDLINE] PMCID: PMC3310321 Free PMC Article

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Aviat Space Environ Med. 2010 Sep;81(9):896-7. 2. You're the flight surgeon: alternobaric vertigo. Tran DA.

PMID: 20825001 [PubMed - indexed for MEDLINE]

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J Appl Physiol (1985). 2009 Jan;106(1):284-92. doi: 10.1152/japplphysiol.90991.2008. Epub 2008 Oct 30. 3. The physiology and pathophysiology of human breath-hold diving. Lindholm P1, Lundgren CE. Author information

Abstract This is a brief overview of physiological reactions, limitations, and pathophysiological mechanisms associated with human breath-hold diving. Breath-hold duration and ability to withstand compression at depth are the two main challenges that have been overcome to an amazing degree as evidenced by the world records in breath-hold duration at 10:12 min and depth of 214 m. The quest for even further performance enhancements continues among competitive breath-hold divers, even if absolute physiological limits are being approached as indicated by findings of pulmonary edema and alveolar hemorrhage postdive. However, a remarkable, and so far poorly understood, variation in individual disposition for such problems exists. Mortality connected with breath-hold diving is primarily concentrated to less well-trained recreational divers and competitive spearfishermen who fall victim to . Particularly vulnerable are probably also individuals with preexisting cardiac problems and possibly, essentially healthy divers who may have suffered severe alternobaric vertigo as a complication to inadequate pressure equilibration of the middle ears. The specific topics discussed include the diving response and its expression by the cardiovascular system, which exhibits hypertension, bradycardia, conservation, arrhythmias, and contraction of the spleen. The is challenged by compression of the lungs with of descent, intrapulmonary hemorrhage, edema, and the effects of glossopharyngeal insufflation and exsufflation. Various mechanisms associated with hypoxia and loss of consciousness are discussed, including hyperventilation, ascent blackout, fasting, and excessive postexercise O(2) consumption. The potential for high nitrogen pressure in the lungs to cause sickness and N(2) narcosis is also illuminated.

PMID: 18974367 [PubMed - indexed for MEDLINE] Free full text

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Acta Otolaryngol. 2007 Aug;127(8):843-6. 4. Alternobaric vertigo: prevalence in Portuguese Air pilots. Subtil J1, Varandas J, Galrão F, Dos Santos A. Author information

Abstract CONCLUSION: 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. OBJECTIVES: 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. SUBJECTS AND METHODS: 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. RESULTS: A 29% prevalence rate of in-flight episodes consistent with alternobaric vertigo was obtained.

PMID: 17762996 [PubMed - indexed for MEDLINE]

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Otol Neurotol. 2006 Dec;27(8):1120-5. 5. Alternobaric vertigo--really a ? Klingmann C1, Knauth M, Praetorius M, Plinkert PK. Author information

Abstract OBJECTIVE: 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. DESIGN: Retrospective cohort study. PARTICIPANTS: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

PMID: 17130801 [PubMed - indexed for MEDLINE]

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J Laryngol Otol. 2003 Nov;117(11):854-60. 6. Alternobaric vertigo in sport SCUBA divers and the risk factors. Uzun C1, Yagiz R, Tas A, Adali MK, Inan N, Koten M, Karasalihoglu AR. Author information

Abstract We investigated the function and the incidence of alternobaric vertigo (AV) in 29 sport self-contained underwater 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.

PMID: 14670144 [PubMed - indexed for MEDLINE]

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Undersea Hyperb Med. 2002 Winter;29(4):260-70. 7. Alternobaric in long-term treatment of Ménière's disease. Fattori B1, De Iaco G, Nacci A, Casani A, Ursino F. Author information Abstract Hyperbaric oxygen therapy (HBQ) has been used for several years as a treatment for Ménière's disease, particularly in Sweden. In this study continuous variations in pressure (from 1.7 to 2.2 ATA; alternobaric oxygen therapy: ABOT) were used to decrease endolymphatic hydrops, the typical histopathological substrate of Ménière's disease by increasing hydrostatic pressure and mechanical stimulation of the endolymphatic flow toward the duct and the endolymphatic sac, which produces a consequent increase in the dissolved O2 content in the labyrinth liquid, which should contribute to recovering cell and restoring cochlear electrophysiological function to normal. An experimental group of 20 patients suffering from unilateral Ménière's disease received a total of 15 ABOT treatment sessions during the acute episodes. Treatment foresaw two days without therapy every five days of application. Maintenance treatment consisted of one session per day for five consecutive days every month for one year. Thereafter, during the second, third, and fourth years of treatment, patients were submitted to one session per day for five consecutive days every three months. A control group of 18 patients suffering from Ménière's disease was treated with 10% glycerol i.v. (during the acute episodes) and with betahistine (8 mg x 3/day) in the periods in between. Mean pure tone average (PTA in dBHL) hearing thresholds at octave frequencies from 500 to 3,000Hz, and frequency of episodes of vertigo and tinnitus, both after 15 days of treatment and at the end of a four-year follow-up, were compared for both groups according to the 1995 Committee on Hearing and Equilibrium criteria. No statistically significant differences were found between the two groups at the end of the first 15 days of treatment. However, at the end of the follow-up period, patients treated with ABOT had significantly fewer vertiginous episodes and improved PTAs and tinnitus compared to the controls. The results support the use of ABOT as a valid alternative to drugs in the long-term treatment of Ménière's disease.

PMID: 12797667 [PubMed - indexed for MEDLINE]

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Rev Laryngol Otol Rhinol (Bord). 1997;118(5):301-5. 8. [Incidence of vertigo in diving]. [Article in French] Kossowski M1, Coulet O, Florentin JL, Bonete D, Gauvin Y, Bonne L, Cohat JP. Author information

Abstract Vertigo is relatively common after diving. Although it may be the result of the changes in pressure, it can also be a feature of decompression accidents, of clinical toxicity, simply be a manifestation of altered physiology resulting from immersion in a weightless environment in which all the organs involved in maintaining equilibrium (vestibular system, proprioception and vision) are affected. It seemed to us to be of interest to study the incidence of vertigo in naval divers by means of an anonymous questionnaire. The responses were elicited over a 3 month period from 333 divers. 45 divers reported clinical sensations of vertigo, an incidence of 13.5%. If this figure is related to the number of dives, the incidence falls to 0.06%. No decompression accidents were reported. The main aetiology was barotrauma, 42% being of alternobaric and 36% of pressure type. The remaining aetiologies were sensory illusions in 6% of cases, and other non-ENT causes in 16%. After a review of the physiopatholgy and study of the case hisotries, there is a discussion of the features which allow the aetiology to be determined and treatment planned.

PMID: 9687648 [PubMed - indexed for MEDLINE]

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Audiology. 1996 Nov-Dec;35(6):322-34. 9. Alternobaric and hyperbaric oxygen therapy in the immediate and long-term treatment of Menière's disease. Fattori B1, De Iaco G, Vannucci G, Casani A, Ghilardi PL. Author information

Abstract Forty-five patients suffering from Menière's disease were submitted to pressure chamber therapy: 20 with constant pressure (2.2 ATA, hyperbaric treatment) and 25 with continuous variations in pressure levels (from 1.7 to 2.2 ATA, alternobaric treatment). Oxygenation therapy consisted of one session per day lasting 90 minutes for 15 days during the acute attacks followed by five consecutive sessions per month during a follow-up of two years. For a control group we used 18 patients treated with 10 per cent intravenous glycerol during the acute episode and 8 mg tid of betahistine thereafter. We compared hearing loss, vertigo and tinnitus in the three groups 15 days after starting treatment and at the end of the follow-up, according to the criteria suggested by the 1995 Committee on Hearing and Equilibrium. We found no statistically significant differences in recovery from the cochlear- vestibular symptoms in the three groups at the end of the first 15 days of therapy, whereas hyperbaric and, in particular, alternobaric treatment permitted a significant control of the principal attacks of vertigo during the follow-up period. Hearing loss also showed a more significant and more persistent improvement in the patients treated with alternobaric oxygenation compared to the patients in the other two groups.

PMID: 9018366 [PubMed - indexed for MEDLINE]

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Aviat Space Environ Med. 1990 Jun;61(6):582-3. 10. From the Aerospace Medicine Residents' Teaching File. Case #36. Waack MW1, Bohnker BK. Author information

Abstract A designated naval aviator was evaluated after several episodes of vertigo related to a zoom climb flight profile. Workup led to the diagnosis of alternobaric vertigo. Contributing factors were concurrent upper respiratory infection and functioning left pressure equilibration (PE) tube for chronic otitis media.

PMID: 2369401 [PubMed - indexed for MEDLINE]

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Aviat Space Environ Med. 1989 Jan;60(1):67-72. 11. Alternobaric vertigo: an aeromedical review. Wicks RE. Author information

Abstract In this article a review of literature and clinical review of alternobaric vertigo is presented. The population of patients discharged from the USAF School of Aerospace Medicine with a diagnosis of alternobaric vertigo from 1 January 1970 to 31 December 1986 is described. The common characteristics of the seven cases are presented. Recommendations and considerations for the future are discussed.

PMID: 2647073 [PubMed - indexed for MEDLINE]

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Undersea Biomed Res. 1988 Jul;15(4):271-82. 12. Alternobaric vertigo in professional divers. Molvaer OI1, Albrektsen G. Author information

Abstract 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.

PMID: 3212844 [PubMed - indexed for MEDLINE]

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Undersea Biomed Res. 1987 May;14(3):277-95. 13. Facial baroparesis: a review. Molvaer OI, Eidsvik S.

Abstract If impaired eustachian tube function causes an overpressure to remain in the middle ear after ascent in diving or aviation in a subject with a defect in the wall of the facial canal, an ischemic neurapraxia of the seventh cranial nerve may occur. This type of facial palsy is designated facial baroparesis, baroparesis facialis, or alternobaric facial palsy. If the middle ear pressure is asymmetric the subject may also have alternobaric vertigo. A causative relationship between middle ear overpressure and facial palsy is supported by the palsy's rapid onset following a reduction in and by its quick disappearance after either an increase in ambient pressure or release of the middle ear overpressure. Transient compression-induced ischemic neurapraxia of the facial nerve is also demonstrated in animal experiments. A similar palsy, ischemic neurapraxia of the fifth cranial nerve due to compression in the maxillary sinus, has been reported in divers. Although it is under-reported, facial baroparesis occurs infrequently, with 23 subjects mentioned in the available literature. Nevertheless, it is important to be aware of its existence, because misdiagnosis as type II DCS or results in unnecessarily long recompression treatments and pointless delay of resumption of diving. In the worst case, a misdiagnosis might cause a diving license to be revoked.

PMID: 3307083 [PubMed - indexed for MEDLINE]

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ORL J Otorhinolaryngol Relat Spec. 1984;46(5):264-9. 14. Pressure chamber tests for selection of aircrew. Groth P, Tjernström O.

Abstract The Eustachian tube function requested from flying personnel today is generally regarded as acceptable if hearing and otoscopic findings are normal and there is no history of ear disease. Since increasing performance of modern aircrafts place more rigorous demands on the equilibrating capacity of the Eustachian tube and difficulty to clear the ears already is the most common cause of temporary grounding among flying personnel, the present requirements for tubal function might gradually get more and more inefficient. Inability to equilibrate in flight may lead to temporarily reduced hearing, acute ear pain and alternobaric vertigo that will affect the pilot's capacity and thus constitute a problem of flight safety. A testing procedure that makes it possible to continuously measure the middle ear pressure in subjects with intact eardrums during simulated flights in a pressure chamber would introduce a possibility to find basic medical standards of Eustachian tube function to be used in the selection of flying personnel. Student pilots, accepted for primary flight training, were examined in the present study by such a method. A comparison is made with the results of other tests of the Eustachian tube function in order to find out the relevance of the latter tests in the selection of flying personnel. The results are presented and discussed.

PMID: 6483385 [PubMed - indexed for MEDLINE]

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Audiology. 1977 Mar-Apr;16(2):89-93. 15. Alternobaric effects on the endolymph. Holmquist J, Lindeman P.

Abstract Hearing loss and vertigo experienced as a result of environmental pressure change has been the subject of many superficial inquiries. The mechanism of these conditions remains obscure. In human volunteers and a rhesus monkey, the effects of intratympanic as well as ear canal pressure changes on the endolymphatic system were measured using electronystagmography (ENG). For the monkey histological evaluation of the pressure effects on auditory structures was performed. We were unable to cause any ENG effects on the monkey neither did we produce intracochlear pathology. The data obtained in humans using a similar approach are presented and explanations for the mechanism related to hearing loss and vertigo in barotrauma are discussed.

PMID: 403903 [PubMed - indexed for MEDLINE]

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Ann Otol Rhinol Laryngol Suppl. 1977 Jan-Feb;86(1 Pt 3 Suppl 36):1-20. 16. Diving injuries to the inner ear. Farmer JC Jr.

Abstract Most of the previous literature concerning otologic problems in compressed gas environments has emphasized middle ear barotrauma. With recent increases in commercial, military, and to deeper depths, inner ear disturbances during these exposures have been noted more frequently. Studies of inner ear physiology and pathology during diving indicate that the causes and treatment of these problems differ depending upon the phase and type of diving. Humans exposed to simulated depths of up to 305 meters without barotrauma or develop transient, conductive hearing losses with no audiometric evidence of cochlear dysfunction. Transient vertigo and nystagmus during diving have been noted with caloric stimulation, resulting from the unequal entry of cold water into the external auditory canals, and with asymmetric middle ear pressure equilibration during ascent and descent (alternobaric vertigo). Equilibrium disturbances noted with , , hypercarbia, or hypoxia appear primarily related to the effects of these conditions upon the central nervous system and not to specific vestibular end-organ dysfunction. Compression of humans in helium-oxygen at depths greater than 152.4 meters results in transient symptoms of tremor, dizziness, and nausea plus decrements in postural equilibrium and psychomotor performance, the high pressure nervous syndrome. Vestibular function studies during these conditions indicate that these problems are due to central dysfunction and not to vestibular end-organ dysfunction. Persistent inner ear injuries have been noted during several phases of diving: 1) Such injuries during compression (inner ear barotrauma) have been related to round window ruptures occurring with straining, or a Valsalva's maneuver during inadequate middle ear pressure equilibration. Divers who develop cochlear and/or vestibular symptoms during shallow diving in which decompression sickness is unlikely or during compression in deeper diving, should be placed on bed rest with head elevation and avoidance of maneuvers which result in increased cerebrospinal fluid and intralabyrinthine pressure. With no improvement in symptoms after 48 hours, exploratory tympanotomy and repair of a possible labyrinthine window fistula should be considered. Recompression therapy is contraindicated in these cases...

PMID: 402882 [PubMed - indexed for MEDLINE]

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Undersea Biomed Res. 1976 Dec;3(4):403-10. 17. The direction of apparent movement during transient pressure vertigo. Ross HE. Author information

Abstract Pressure vertigo or alternobaric vertigo is the type of vertigo normally associated with relative overpressure in the middle ear. As with other types of vertigo, it should occur only if there is unequal stimulation of the left and right vestibular systems: there should be a lawful relation between the orientation of the head, the side of the overpressured ear, and the direction of apparent movement. Few published accounts give information on all these aspects. This paper reports some old and new cases which suggests that, when the head is upright during the ascent, overpressure in the right ear causes apparent bodily and visual movement to the right (clockwise), while overpressure in the left ear has the opposite effect. Horizontal orientation of the head probably reduces the vertigo. There are no detailed and unequivocal reports of pressure vertigo during descent, or with the head inverted. Some reports exist of tumbling sensations and of tilting of the visual scene, but the exact circumstances are unclear.

PMID: 10897867 [PubMed - indexed for MEDLINE]

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Audiology. 1976 Jul-Aug;15(4):273-8. 18. Cochleo-vestibular disturbances in diving. Coles RR.

Abstract Insidious development of high-tone sensorineural hearing loss may be associated with diving, but the evidence is not certain and further research is needed. 'Internal ear barotrauma' can cause an acute or relatively acute onset of hearing loss and/or vertigo, and it may be that 'alternobaric vertigo' provides a link between the insidious and acute forms of labyrinthine injury in diving. With , decompression sickness and other syndromes can also affect the cochleo-vestibular system. These aetiologies and effects will be discussed, together with evidence from an audiometric survey of naval divers and of 5 experimental deep divers.

PMID: 1084150 [PubMed - indexed for MEDLINE]

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Undersea Biomed Res. 1974 Dec;1(4):343-51. 19. Function of the eustachian tubes in divers with a history of alternobaric vertigo. Tjernström O.

PMID: 4469100 [PubMed - indexed for MEDLINE]

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Acta Otolaryngol. 1974 Nov-Dec;78(5-6):376-84. 20. Middle ear mechanics and alternobaric vertigo. Tjetnström O.

PMID: 4451087 [PubMed - indexed for MEDLINE]

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Undersea Biomed Res. 1974 Sep;1(3):251-8. 21. Alternobaric vertigo and hearing disturbances in connection with diving: an epidemiologic study. Lundgren CE, Tjernström O, Ornhagen H.

PMID: 4469094 [PubMed - indexed for MEDLINE]

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Acta Otolaryngol. 1974 Sep-Oct;78(3-4):221-31. 22. Further studies on alternobaric vertigo. Posture and passive equilibration of middle ear pressure. Tjernström O.

PMID: 4432745 [PubMed - indexed for MEDLINE]

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ORL J Otorhinolaryngol Relat Spec. 1973;35(3):184-8. 23. Alternobaric or pressure vertigo and the pseudo-positive fistula symptom as a reflex phenomenon. Reflexogenic vertigo and nystagmus. Lansberg MP.

PMID: 4795591 [PubMed - indexed for MEDLINE]

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Mil Med. 1970 Mar;135(3):182-5. 24. Alternobaric vertigo in military divers. Vorosmarti J, Bradley ME.

PMID: 4991688 [PubMed - indexed for MEDLINE]

MeSH Terms Aerosp Med. 1970 Feb;41(2):200-2. 25. Aeromedical consultation service case report: alternobaric vertigo. Enders LJ, Rodriguez-Lopez E.

PMID: 5418848 [PubMed - indexed for MEDLINE]

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Aerosp Med. 1966 Feb;37(2):178-80. 26. Alternobaric vertigo among pilots. Lundgren CE, Malm LU.

PMID: 5906039 [PubMed - indexed for MEDLINE]

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