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Prevention of Otic Barotrauma in Aviation: a Systematic Review

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Prevention of Otic Barotrauma in Aviation: a Systematic Review Otology & Neurotology 39:539–549 ß 2018, Otology & Neurotology, Inc. Prevention of Otic Barotrauma in Aviation: A Systematic Review ÃPeter Ryan, ÃAlexander Treble, ÃyNirmal Patel, and ÃyNicholas Jufas ÃDepartment of Otolaryngology and Head and Neck Surgery, Royal North Shore Hospital, St Leonards; and yKolling Deafness Research Centre, Macquarie University and University of Sydney, NSW, Australia Objective: To conduct a systematic review of the published atic Reviews and Meta-Analyses and other international evidence relating to the prevention of otic barotrauma in guidelines. aviation. In particular, this review sought to identify Conclusions: This review highlights the lack of published procedures, techniques, devices, and medications for the evidence relating to what is a significant and increasingly prevention of otic barotrauma as well as evaluate the common problem in otology. There is level 1 evidence that evidence relating to their efficacy. supports the efficacy of oral pseudoephedrine (120 mg) in Data Sources: Ten databases including Embase, MEDLINE, preventing otic barotrauma in adults. However, oral pseudo- the Cochrane Database of Systematic Reviews, and the ephedrine (1 mg/kg) does not appear to be effective in Cochrane Central Register of Controlled Trials were children. There is insufficient evidence to support the searched using the full historical range. efficacy of either nasal balloon inflation or pressure-equaliz- Study Selection: English language articles including more than ing ear plugs for the prevention of otic barotrauma. A or equal to five participants or cases were included. Outcomes recently reported, novel technique for insertion of temporary of interest were reduced severity or the successful prevention of tympanostomy tubes is promising but requires further otic barotrauma in participants undergoing gradual changes in evaluation. Key Words: Aviation—Barotrauma—Middle pressure during air travel or its simulation. ear—Otic barotrauma—Tympanic membrane. Data Extraction: Articles and data were extracted and analyzed according to Preferred Reporting Items for System- Otol Neurotol 39:539–549, 2018. Otic barotrauma (also referred to as aerotitis media and factor in some aviation incidents (4,5). Recent studies barotitis media) is a traumatic process resulting from an have determined the incidence of subjective otalgia on a unrelieved pressure difference between the middle ear given flight to be up to 55% in children (4,6) and 20% in and the external environment. adults (4). Complications vary with severity, ranging As a clinical entity, otic barotrauma has been present from mild otalgia to more significant otologic disease for as long as people have taken flight. Jacques Charles, including rupture of the tympanic membrane and round the French physicist who made the first free ascent in a window (7,8). Awareness of the condition among air hydrogen balloon in 1783, described severe right ear pain travelers is somewhat lacking; Mitchell-Innes et al. (9) on rapid ascent to an altitude of 3,000 m (1), only relieved demonstrated that 30% of airline passengers were upon descent. unaware of any measures to prevent otic barotrauma. Otic barotrauma is an increasingly common problem The most widely accepted classification of otic baro- in otology. The number of passenger flights on commer- trauma has been proposed by Teed (10) and is based on cial aircraft is significantly increasing (Fig. 1), giving rise otoscopic findings (Table 1). to the phrase ‘‘the city in the sky,’’ with estimates putting To date, three reviews of the literature relating to otic approximately one million people in the air at any given barotrauma have been published (4,11,12). These time (2). In 2016, there were 3.7 billion passengers reviews are either non-systematic or limited in scope. carried worldwide, compared with only 310 million The aim of this systematic review is to present the passengers in 1970 (3). Otic barotrauma is the common- currently available evidence relating to the prevention est medical problem in aviation and has been a causative of otic barotrauma. Where the level of evidence in the included studies is low, we recognize these papers for providing a novel approach to the prevention of otic Address correspondence and reprint requests to Peter Ryan, BMed, barotrauma. c/o Dr Nicholas Jufas, Department of Otolaryngology and Head and Neck Surgery, Royal North Shore Hospital, St Leonards, NSW 2065, MATERIALS AND METHODS Australia; E-mail: [email protected] Financial disclosure: No funding or other support received. A systematic review, following the Preferred Reporting The authors disclose no conflicts of interest. Items for Systematic Reviews and Meta-Analyses (PRISMA) DOI: 10.1097/MAO.0000000000001779 2009 guidelines (13) was performed and the review protocol 539 Copyright © 2018 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited. 540 P. RYAN ET AL. 4.0 3.5 3.0 2.5 2.0 1.5 1.0 Passengers (billions) carried 0.5 0.0 1972 1994 2004 1970 1974 1976 1980 1982 1984 1986 1990 1992 1996 1998 2000 2002 2006 2008 2010 2012 2014 2016 1978 1988 Year FIG. 1. Total number of passengers carried on aircraft by year (1970–2016). registered in the PROSPERO database (14) (registration num- ‘‘barotrauma,’’ ‘‘barotitis,’’ and ‘‘aerotitis,’’ expanding the ber CRD42017079924). Inclusion criteria for eligible studies search using the MeSH term ‘‘Barotrauma.’’ Duplicate results are shown in Table 2. were removed from the search and the search was limited to A literature search of 10 databases was performed on Octo- papers published in the English language. Papers that were ber 21, 2017 using the full historical range. Articles relating to exclusively concerned with non-aviation causes of barotrauma the tympanic membrane, middle ear, and eustachian tube were (scuba diving and/or hyperbaric oxygen therapy) were excluded identified by searching abstracts, titles, and key words for the from the study. Table 3 lists the databases searched. terms ‘‘otic,’’ ‘‘otologic,’’ ‘‘ear,’’ ‘‘otitic,’’ ‘‘middle ear,’’ Abstracts were assessed for potential eligibility against the ‘‘tympanic membrane’’ and expanding the search using the inclusion and exclusion criteria by two authors. Any disagree- MeSH terms ‘‘Middle Ear’’ and ‘‘Tympanic Membrane.’’ ment between reviewers was resolved through discussion with Articles relating to the clinical entity of otic barotrauma were the input of the senior authors. Full-text articles of all poten- identified by searching the same fields for the terms tially eligible studies were retrieved and reviewed collabora- tively by all four authors to determine final eligibility for TABLE 1. Teed’s classification (13) of otic barotrauma inclusion. The reference list of each full-text article was manu- ally searched for additional eligible studies. The process of Grade 0 Normal article selection is illustrated as a PRISMA flow diagram in Figure 2. Level of evidence was classified according to the Grade 1 Retraction with redness in Schrapnell’s membrane Oxford Centre for Evidence-Based Medicine’s 2011 Levels of Grade 2 Retraction with redness of the entire tympanic membrane Evidence (15). Statistical results are reported as described in the Grade 3 Grade 2 þ evidence of middle ear fluid/haemotympanum included studies including measures of effect and statistical Grade 4 Rupture of the tympanic membrane significance. The risk of bias in included studies was assessed using the Cochrane Risk of Bias Tool (16). Where the included TABLE 2. Inclusion and exclusion criteria TABLE 3. Databases searched Participants All persons undergoing gradual or incremental Database Matching Articles changes in pressure during air travel or its simulation Embase 558 Intervention Inclusion: Any intervention administered before or MEDLINE 439 during flight aimed at reducing the incidence or PREMEDLINE 13 severity of otic barotrauma MEDLINE Epub Ahead of Print 3 Comparators Any intervention or none Cochrane Database of Systematic Reviews 19 Outcomes Successful prevention or decreased severity of otic Cochrane Central Register of Controlled Trials 18 barotrauma Health Technology Assessment Database 1 Study design Inclusion: All study types published in peer- reviewed journals Joanna Briggs Institute EBP Database 0 Exclusion: Case series or trials including less than NHS Economic Evaluation Database 0 five participants, and Reviews, systematic or ACP Journal Club 0 otherwise Language English language only ACP indicates American College of Physicians; EBP, evidence-based practice; NHS, National Health Service. Otology & Neurotology, Vol. 39, No. 5, 2018 Copyright © 2018 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited. PREVENTION OF OTIC BAROTRAUMA 541 Records identified through database searching (n = 1051) Records after duplicates removed (n = 696) Records screened Records excluded (n = 666) (n = 696) Records excluded (n=20) Full-text articles assessed for eligibility - Intervention post-flight (n=5) (n = 30) - No intervention (n=6) - Opinion/editorial (n=6) - Review (n=3) Articles included after manual search of reference lists (n = 1) Articles meeting eligibility criteria (n = 11) FIG. 2. Results of literature search presented as a PRISMA flow diagram. studies were found to have broader population (e.g., inclusive of Inclusion and exclusion criteria were generally con- patients undergoing hyperbaric oxygen therapy), only the pop- sistent across all studies. Five of the eight studies
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