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Prevention of Infant's Otic Barotrauma

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Prevention of Infant's Otic Barotrauma International Journal of Neuroscience and Behavioral Science 1(2): 24-30, 2013 http://www.hrpub.org DOI: 10.13189/ijnbs.2013.010202 Prevention of Infant’S Otic Barotrauma – Observing the Infant Prior to Air Travel and Identifying Infants Less Likely At Risk Klaus Martin Beckmann School of Medicine, Griffith University, Logan Campus, Queensland *Corresponding Author: [email protected] Copyright © 2013 Horizon Research Publishing All rights reserved. Abstract Otic barotrauma is a potential risk for However to the author’s best knowledge and after review of travelers using commercial aircraft. A significant proportion the literature it appears that so far no infant specific advice of passengers are infants. No literature exists regarding how to prevent otic barotrauma is available. It appears that a pre-flight assessment for prevention of barotrauma in simple method to identify a subgroup of infants not at risk of infants due to air travel. Infants are preverbal in their barotrauma from Eustachian tube dysfunction has so far not development and cannot communicate their distress with been suggested. words, though will show age-typical distress and pain There is reference to a case example of one. Coincidental responses. Pain and concomitant trauma, where possible, pre-flight observation assessing Eustachian tube function are ideally prevented. This paper suggests that it may be can indicate patent Eustachian tube. The suggestion is to use possible for parents to detect prior to flight whether their a coincidental empirical observation on how the infant reacts infant is likely to suffer pain from Eustachian tube to small air pressure changes of around 15 mmHg (a height malfunction with in-flight cabin pressure changes. This may differential of over 100 meters). At an increase of 15 mmHg be achieved by co-incidental observation of infants and the Eustachian tube passively opens and vents of positive their subsequent distress with small rapid air pressure pressure; at a reduction by 15 mmHg diverse effects will change, such as in rapid elevator ascent/descent, which balance negative pressure. elicits “ear popping” in the parents. This may help predict a healthy infant’s response to change in air pressure during air travel. A case example is given. Barotrauma in the 2. Materials and Methods context of the infant’s neuropsychology is described and relevant literature to the topic is reviewed. A literature review was performed in May 2013 on PubMed, Informit, Uptodate, Google Scholar and National Keywords Infant, Ear, Air Travel, Barotrauma, Centre for Biotechnology Information using key words Prevention. “infant, ear, barotrauma, prevention, air travel”. A summary of relevant findings from this search and background information is provided. This draws on papers previously published on the subject across age-groups, not limited to infancy. 1. Introduction This paper reports the case of one infant subject to change Worldwide airlines transport over 1.25 billion passengers in air pressure in an every-day coincidental empirical per year [1]. A significant proportion of those passengers are observation and the subsequent response to air pressure infants. Infants for developmental reason cannot equalise ear changes in an aircraft and then refers to findings from pressure in the same way as older children and adults who for research relating to psychological trauma in infants. example can initiate a Valsalva maneuver. Hence infants may be at even greater risk of discomfort, ear pain and barotrauma. With repeated episodes of barotrauma infants 3. Results may be at risk of longer lasting sequelae of physical and psychological trauma. 3.1. Literature Review - barotrauma Numerous guidelines offer advice on how to prevent barotrauma and how to address air pressure changes in flight. A literature search with the key words “infant, ear, International Journal of Neuroscience and Behavioral Science 1(2): 24-30, 2013 25 barotrauma, prevention, air travel” did not yield any relevant and connects with the middle ear via the oval and the round papers regarding infants and barotrauma. References yielded window. papers relevant to the broader context of barotrauma in 3.1.3. Epidemiology of Barotrauma children and adults. This is likely the first paper that connects these keywords and specifically investigates air pressure There is no research data on ear problems associated with changes, pain and its psychological effects in the infant, and air travel in infants. However sufficient data are available use of an observation that identifies infants who have a confirming high prevalence of otalgia associated with air patent Eustachian tube. travel in children and adults. Stangerup et al [15] find that One paper on prevention, barotrauma and the middle ear 65% of children and 46% of adults report ear discomfort or in German language was found, provided by the publisher pain during previous flights and for a single flight 26-55% of upon request [2] and not available online. children and 20% of adults report ear pain. Buchanan et al Numerous papers were found that address ear problems [16] find that on a single flight 31% of children experience associated with scuba and Deep Sea diving, blast injuries, pain or discomfort during ascent and 85% during descent. physical trauma, hyperbaric oxygen therapy, space medicine Lewis [17] finds in healthy air crews the incidence of and sky diving and are not referred to in this article. barotrauma ranges between 1.9 and 9 %. Morgagni et al [18] find that amongst 314 individuals there were 7 men who had 3.1.1. Barotrauma - the Historical Context acute barotitis (incidence of 2.3%) and 28 men who had Anatomist Eustachio [6] described the Eustachian tube in delayed ear pain (incidence of 9.2%). This research was done the 15th century. In adults this tube, which reaches from the in hypobaric chambers using 2 altitude training profiles of middle ear to the nasopharynx, is around 3.75 cm long. around 35,000 feet (10,668 meters) and 25,000 feet (7620 Boyle [7] in 1662 and Marriotte [8] in 1676 confirmed meters). Moore et al [19] report 222 pre-flight and in-flight independently from each other by experiment the emergencies, representing 9.2% from amongst their database. relationship between pressure and volume. Valsalva [9] They estimate 1 paediatric emergency call in 20775 flights. described the eponymous maneuver in 1704: this involves The most common and 27% (45 calls) of all emergencies forced expiration with lips and nostrils closed, hence were due to infectious diseases, fever and otitis media. increasing air pressure in the nasopharynx, forcing air along Aerospace Medical Association [20] reports that 62% of the Eustachian tubes and thereby increasing pressure in the in-flight emergencies were associated with pre-flight middle ear. The first description of barotrauma was given by morbidities. Charles [10] in 1783. He was the first person to make a free 3.1.4. Pathophysiology of Otic Barotrauma ascent in a hydrogen balloon and complained of severe pain in his right ear during descent. Corti [11] described the Rapid or significant changes of air pressure can lead to eponymous organ in 1851. In 1860 Toynbee[12] described middle ear discomfort, pain and barotrauma. Failure to how pinching the nose and swallowing can relieve ear facilitate balanced air pressure may distort and stretch the discomfort due to pressure differential. Politzer [13] in 1861 tympanic membrane, causing bleeding into the membrane, developed a method to inflate the middle ear by increasing fluid exudates in the middle ear and possible tympanic pressure in the nasopharynx with the assistance of a rubber membrane rupture. Magnified pressure may be exerted onto balloon and asking the patient to swallow. In 1938 Frenzel the auditory ossicles with resultant damage. Pressure [14] described a maneuver used by pilots: saying the letter “k” magnified by a factor of 20-30 may also be conducted onto whilst closing nose, mouth and glottis as if lifting heavy the oval window, due to the hydraulic effect of the tympanic weights. The advantage of Frenzel maneuver in flight is that membrane being much larger than the oval window. This it can be performed both during expiration and inspiration, pressure can damage the Reissner’s membrane of the cochlea. although requires some training to learn the technique. Occasionally with severe pressure changes the round window is ruptured. With open round and oval windows 3.1.2. Anatomy and Physiology Associated with Eustachian lymph fluid may leave the Organ of Corti with resultant Tube neural cell loss and likely inner ear hearing loss. The middle ear is filled with air. It is separated from the 3.1.5. Aetiology of Otic Barotrauma outside world, on the one side by the tympanic membrane and on the other side by the Eustachian tube. Middle ear Failure of the Eustachian tube can occur for a variety of pressure ideally is similar to the pressure of the outside world. reasons. There are some conditions that make barotrauma, If conditions are right the tympanic membrane can vibrate due to Eustachian tube failure, more likely. Oedematous and sounds are clear. Any air in the middle ear can get mucosa due to upper respiratory tract infection or allergy in absorbed albeit slowly. If healthy the Eustachian tube is the nasopharynx will obstruct the lumen of the Eustachian mostly closed, to prevent motion of the tympanic membrane, tube. Appropriate middle ear ventilation may also be and opens only briefly and allows movement of air. During impaired by enlarged adenoids or nasopharyngeal tumours. swallowing, crying, yawning, it opens briefly. Muscles Nakashima et al [21] found in 3 out of 8 patients with which lift and tense the palate are responsible for opening the barotrauma had no jugular fossa and postulated a link. Eustachian tube. The inner ear is filled with lymphatic fluid Flying is the most frequent cause of barotrauma [22, 23].
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