Balloon Eustachian tuboplasty in a professional Navy SEAL diver: case report.

Middle ear barotrauma due to dilatory Eustachian tube dysfunction (ETD) is probably the most common medical disorder related to diving. Moreover, ETD makes divers prone to other diving-related accidents, including inner ear barotrauma and alternobaric vertigo. Until the development of Eustachian tube balloon dilation no diving-compatible surgical options existed to effectively and safely prevent recurrence. We present a case of an Israeli Navy SEAL diver who dives in extreme strenuous combat-related closed-circuit rebreather (CCR) dives. Due to repeated middle ear barotrauma, the patient underwent Eustachian tube balloon dilation of the affected side. Following surgery, the patient returned to both CCR and scuba dives but still suffered from middle ear symptoms and repeated barotrauma hence was eventually disqualified from further combat diving.

Navy diver with recurrent facial nerve baroparesis treated with eustachian tube balloon dilation.

Facial nerve baroparesis is a rare complication of middle ear barotrauma reported almost exclusively in overpressure events related to diving and flying. Until the development of Eustachian tube balloon dilation, no diving compatible options existed to effectively and safely prevent recurrence. We present a case of a U.S. Navy diver with a history of repeated ipsilateral facial nerve paresis that occurred during diving. The patient underwent Eustachian tube balloon dilation of the affected side. Following surgery, the patient completed a recompression chamber simulated dive that allowed the patient to return to diving. The patient has been symptom-free for 12 months following dilation. Laryngoscope, 129:E412-E414, 2019.

Inadvertent detection of massive Enterobius vermicularis infection in an asymptomatic adult with rectal blowout following barotrauma

Enterobius vermicularis (pin worm) is a common intestinal parasite infection which usually affects children and rarely causes significant illness. However, of the few reports of extra-intestinal E. vermicularis infection reported in the literature, patients can have significant morbidity and mortality, thus stressing the need for appropriate management of pin worm infection. We report a case of massive E. vermicularis infection in a 20-year-old male which was inadvertently discovered during an emergency abdominal surgery. The case emphasizes the need to perform routine ova-parasite screening at periodic intervals to detect intestinal parasitic infections, to promote adequate practices to improve sanitation facilities and to direct appropriate therapeutic measures to eliminate the worm burden in case of infections.

Surgical Outcomes on Hearing and Vestibular Symptoms in Barotraumatic Perilymphatic Fistula.

OBJECTIVE: To analyze surgical results on hearing and vestibular symptoms in patients with barotraumatic perilymphatic fistula (PLF) according to diagnostic criteria. METHODS: A total of 39 patients (41 ears) who underwent surgery on suspicion of barotraumatic PLF from January 2005 to December 2017 were included. Pure tone audiometry and videonystagmography (VNG) recording for spontaneous nystagmus and positional tests were performed preoperatively and postoperatively at 1 week and 1 month. Surgical outcomes were analyzed based on hearing results, subjective dizziness, and change of nystagmus. RESULTS: Preoperative hearing level was 75.5 ±â€Š28.7 dB for definite PLF and 88.5 ±â€Š22.8 dB for probable PLF, and levels were not significantly different between groups. Preoperatively, subjective dizziness was present in 18 (94.7%) and 19 (95%) in each group. Among 39 patients, 24 had VNG recordings. Positional nystagmus was recorded in 87.5% (7/8) and 87.5% (14/16) of the definite and probable PLF groups, respectively. Postoperatively, hearing was improved in 65% (13/20 ears) of definite PLF and 61.9% (13/21 ears) of probable PLF. There was no significant difference between the two groups. Hearing gain was significantly correlated with the time interval between symptom onset and surgical timing. Subjective dizziness was improved immediately after surgical repair in 97.4% (17/18) of definite PLF patients and 100% (19/19) of probable PLF patients. Even though dizziness was improved in most patients, some had persistent positional nystagmus and recurrent dizziness. CONCLUSIONS: Surgical sealing of both windows in suspected barotraumatic PLF is an effective treatment to improve hearing and subjective dizziness.

Barotrauma after liquid nitrogen ingestion: a case report and literature review.

A 25-year-old man developed a gastric perforation after ingesting a homemade drink containing liquid nitrogen. Surgical repair had to be postponed to seek consultations with experts because the available practitioners in this case, including emergency physicians, surgeons, and anesthesiologists, had little experience and knowledge about the source of the patient's pneumothorax and subcutaneous emphysema. The patient ultimately underwent exploratory laparotomy with general anesthesia, considering that delaying the operation would lead to a longer duration of bacterial peritonitis and delay the standard treatment of postoperative systemic infectious complications. Our literature review revealed that barotrauma is the unique injury mechanism underlying liquid nitrogen ingestion. Injuries to the airway and esophagus are rare.

Global surgery in a postconflict setting--5-year results of implementation in the Russian North Caucasus.

BACKGROUND: Collaborations for global surgery face many challenges to achieve fair and safe patient care and to build sustainable capacity. The 2004 terrorist attack on a school in Beslan in North Ossetia in the Russian North Caucasus left many victims with complex otologic barotrauma. In response, we implemented a global surgery partnership between the Vladikavkaz Children's Hospital, international surgical teams, the North Ossetian Health Ministry, and civil society organizations. This study's aim was to describe the implementation and 5-year results of capacity building for complex surgery in a postconflict, mid-income setting. DESIGN: We conducted an observational study at the Children's Hospital in Vladikavkaz in the autonomous Republic of North Ossetia-Alania, part of the Russian Federation. We assessed the outcomes of 15 initial patients who received otologic surgeries for complex barotrauma resulting from the Beslan terrorism attack and for other indications, and report the incidence of intra- and postoperative complications. RESULTS: Patients were treated for trauma related to terrorism (53%) and for indications not related to violence (47%). None of the patients developed peri- or postoperative complications. Three patients (two victims of terrorism) who underwent repair of tympanic perforations presented with re-perforations. Four junior and senior surgeons were trained on-site and in Germany to perform and teach similar procedures autonomously. CONCLUSIONS: In mid-income, postconflict settings, complex surgery can be safely implemented and achieve patient outcomes comparable to global standards. Capacity building can build on existing resources, such as operation room management, nursing, and anesthesia services. In postconflict environments, substantial surgical burden is not directly attributable to conflict-related injury and disease, but to health systems weakened by conflicts. Extending training and safe surgical care to include specialized interventions such as microsurgery are integral components to strengthen local capacity and ownership. Our experience identified strategies for fair patient selection and might provide a model for potentially sustainable surgical system building in postconflict environments.

Grommets in HBOT patients: GA vs LA, unanswered questions.

We read with interest the article on grommet procedures for patients undergoing hyperbaric oxygen therapy (HBOT), and have a number of comments. It appears the authors may have missed a number of cases. In a previous paper from The Townsville Hospital Hyperbaric Unit (TTH HMU), Commons et al presented 14 of 106 patients (13%) who required grommets over the period between June 2009 and May 2010. These patients are included in the Lamprell et al data set. Figure 1 shows an apparent spike in their cases in 2010 (n = 13, part of the period covered in the previous paper) when compared to the remaining four years of their study (mean number of cases 4.5 per year, for an incidence of 3%). This difference in incidence is statistically significant (chi square = 8.336, df = 1, P = 0.004). We suspect the difference may be the result of missed cases rather than a true spike; however, it is not possible to determine this from the paper. Lamprell et al describe identifying cases using the TTH HMU patient database. Did the authors also consider using the operating theatre database and/or ENT clinic records to ensure all cases were captured? We also have concerns regarding Lamprell's primary outcome measure: time from ENT referral to date of re/commencement of HBOT. These data are presented as median values with the associated ranges, rather than an interquartile range (IQR), the traditional measure of dispersion in non-parametric data. We believe the data sets contain a number of outliers that should be excluded, e.g., 98 days. We ask to see the IQRs and box-and-whisker plots for both data sets, and suspect the statistically significant difference in medians might not remain with outliers excluded from the analysis. There is also no discussion about the clinical relevance of this difference of seven days. Based on the most common indications for HBOT listed, most patients would have received at least 30 daily sessions of HBOT. What impact does a delay of seven days have on their treatment? As doctors who have worked at this HMU, we know patients preferentially received their grommets under GA prior to 2012 at the request of the ENT surgeon, who believed that insertion under LA was poorly tolerated. The authors do not describe whether the insertion of grommets under LA was associated with patient discomfort; a limitation of this retrospective paper, but a clinically relevant factor in the decision-making process of which form of anaesthesia to use. The paper by Lamprell et al has shown us that patients may experience a more rapid insertion of grommets and return to HBOT, if inserted under LA versus GA, but this difference may not be important clinically. We believe the authors may have failed to collect all cases and exclude outliers and this, coupled with the lack of documentation about patient satisfaction with insertion under LA, leaves us with more questions than answers.

Correction and response to: Grommets in HBOT patients: GA vs. LA, unanswered questions.

We thank Gibbs and Commons for their interest in our paper. There is a key difference between the datasets for Commons et al and our study. Our data set, has grouped five years of data according to the calendar year. This is different from Commons et al's study population recruited between 01 June 2009 and 31 May 2010. We feel this may explain the difference of one case between the two papers in 2010. Our data collection used the standard clinic and operating theatre databases, and we were advised that there was no searchable clinical code for grommet procedures undertaken with local anaesthetic (LA) in the outpatient clinic. The alternative, to review many hundreds of patients, was considered beyond the study's scope. Instead, the TTH Hyperbaric Medicine Unit (HMU) database was used to recruit cases and cross checked with operating theatre data. We have since re-investigated the operating theatre database to identify any additional bilateral grommet procedures during 2008 to 2012 and cross checked these with the HMU database. This has identified one to four additional patients per year in the general anaesthesia (GA) group and one additional LA patient that meet the criteria for recruitment into the study. There was one further unconfirmed patient from each of 2008 and 2010, whose charts were unavailable for this response, and have not been included in this amendment. The corrected Figure 1 reflects these changes. Despite the additional cases, the frequency spike during 2010 remains. A published audit of the number of middle ear barotrauma (MEBT) cases between 2007-2010 also reports an increased incidence of MEBT in 2009-2010 compared with previous years at our unit. Possible reasons for this may be the introduction of new technology at the unit, in the form of the digital Macro View™ otoscope during this period, leading to a possible change in clinical practice and an increased detection of MEBT, or a lower threshold for ENT referral for grommet placement. Alternatively, a 'Hawthorne effect' from the conduct of a prospective study within the TTH HMU, during 2009-2010 may be considered. With the outliers removed using ROUT's test, the significant difference in the delay time to surgery remains (LA median 1, IQR 2, range 0-5 days; GA median 7.5, IQR 6, range 0-24 days; P < 0.0001; Figure 2). The data values of 98 days and 86 days from the GA group published in our paper are corrected to six days and 12 days respectively. On review, the first individual was found to have had two HBOT courses, and it was only in the second round of HBOT that an ENT referral for grommets was made. The second individual was found to have been offered two ENT referrals after experiencing MEBT, the first was followed by the patient declining further HBOT until representing to TTH HMU four months later and receiving prophylactic grommets before recommencing HBOT; this second ENT referral date has been used in the amended data. These corrections have not been found to change the primary outcome of statistical significance between the LA and GA groups. A delay of seven days may not be considered clinically relevant in the most common cases requiring HBOT, aside from affecting patient convenience and logistics as well as hospital efficiency and resources. In emergency cases, knowledge of factors able to reduce the delay for grommet insertion is clinically relevant. In centres where a long wait for GA is the norm, LA may convey a clinically important lesser waiting time. As a retrospective study, only data documented in the patient records could be studied, and patient discomfort was not consistently recorded in the charts. We would liken this to undertaking other surgical procedures, where clinicians often do not routinely document pain scores for the benefit of retrospective research. Several studies have examined patients' tolerance of grommets under LA, finding the technique tolerable.

Retrospective review of grommet procedures under general versus local anaesthesia among patients undergoing hyperbaric oxygen therapy.

INTRODUCTION: One significant side effect of hyperbaric oxygen treatment (HBOT) is middle ear barotrauma (MEBT) may require tympanostomy tube (grommet) insertion by the Ear, Nose and Throat service. Where timely HBOT is needed, routine insertion of grommets under local anaesthesia (LA) is becoming common. AIMS: To investigate the differences between patients receiving HBOT and concurrent grommets under LA versus general anesthesia (GA) at The Townsville Hospital (TTH). METHODS: A retrospective chart analysis of patients receiving HBOT between 2008 and 2012 and requiring grommets was undertaken. RESULTS: Thirty-one (5%) out of 685 patients treated with HBOT from 2008 to 2012 received grommets. Twelve cases received grommets under LA, and 19 under GA. Twenty out of the 31 cases had grommets following MEBT and the remainder prophylactically. Complications of grommet insertion comprised two cases with blocked grommets. There was a significant difference (P = 0.005) in the time in days from ENT referral to HBOT between the LA group (median 1 day, range 0-13 days) and the GA group (median 8 days, range 0-98 days). CONCLUSION: A greater number of hyperbaric patients received grommets under GA than LA at the TTH. Insertion of grommets under LA was safe, offering advantages to both the patient and the treating team in the setting of HBOT-associated otic barotrauma.

A novel technique of otic barotrauma management using modified intravenous cannulae.

This article provides the first detailed description and systematic evaluation of the management of otic barotrauma using modified intravenous cannulae. A 24-gauge IC cannula was modified as a tool for tympanostomy tube placement and middle ear ventilation. The medical records of 271 ears of 156 adult patients (median age 49 years) who underwent this procedure were reviewed retrospectively. Hundred and ninty-one tubes were placed for otalgia because of hyperbaric oxygen therapy, 58 tubes were inserted for air travel prophylaxis and 22 tubes were placed for management of otic barotrauma post-flight. All the patients who had this procedure for prophylaxis experienced regular otic barotrauma symptoms during air travel prior to tube placement. All patients were reviewed 6 weeks (range 2-9 weeks) post-procedure. This technique of otic barotrauma management worked effectively in 99 % of treated patients. On follow-up, 88 % of tubes were found to be extruded and non-extruded tubes were removed in clinic without any anaesthesia. 99.6 % of tympanic membrane had healed completely and spontaneously without sequelae. Given the safety, effectiveness, low risk of complications associated with this novel tympanostomy technique, it provided a simple yet effective therapeutic option for the management of otic barotrauma. Finally, this technique can be easily applied in all health settings as it only requires medical supplies readily available in hospitals, therefore there is no additional cost.

Abdominal compartment syndrome caused by tension pneumoperitoneum in a scuba diver.

Abdominal compartment syndrome is a surgical emergency caused by a raised intra-abdominal pressure, which may lead to respiratory, cardiovascular and renal compromise. It is most commonly seen in post-operative and trauma patients and it has a variety of causes. Tension pneumoperitoneum (TP) is a rare cause of abdominal compartment syndrome most often seen after gastrointestinal endoscopy with perforation. We present the case of a fit 52-year-old experienced female diver who developed TP and shock following a routine training dive to 27m. Following accidental inhalation of water, she had an unstaged ascent and, on reaching the surface, developed severe acute abdominal pain and distension. She was brought to our emergency department by air ambulance for assessment. Clinical and radiological examination revealed a shocked patient with dramatic free intra-abdominal gas and signs of abdominal compartment syndrome, which was treated with needle decompression. Symptoms and signs resolved quickly with no need for further surgical intervention. TP is a surgical emergency where surgery can be avoided with prompt diagnosis and treatment.

[Middle ear barotraumas due to rhinopharyngeal scar tissue: tubomanometry diagnostic and therapeutic contribution]. / Barotraumatismes de l'oreille moyenne par brides rhinopharyngées: intérêt diagnostique et thérapeutique de la tubomanométrie.

OBJECTIVE: Evaluation of tubomanometry contribution to diagnosis middle ear barotraumas in relation with rhinopharyngeal scar tissue, and contribution to check postoperative effectiveness of scar tissue surgical resection. METHODS: Clinical cases study of two stewardesses who have lost their flight fitness consecutively to barotraumatic otitis during landing, engendered by rhinopharyngeal scar tissue. RESULTS: Pre-operative tubomanometric parameters were abnormal in both cases: decrease of intratympanic pressure in one case, variability of tube opening latency index and lengthening of intratympanic pressure rising time in the other case. Surgical section during endonasal endoscopy results in initially abnormal tubomanometric parameters normalization, allowing resumption of flight fitness without any barotrauma. CONCLUSION: Some abnormal tubomanometric parameters help to establish causality link between middle ear barotrauma and rhinopharyngeal scar tissue for which surgical section is thus indicated. Post-operative tubomanometric parameters normalization prove surgical effectiveness. Then, flight fitness could then be restored.

Sphenoid sinus barotrauma after scuba diving.

We report the case of an 18-year-old male patient operated on for sphenoid sinus barotrauma after scuba diving. The patient attended our emergency department because of intractable headache but did not improve with conservative treatment. After computed tomography and magnetic resonance imaging examination, he was diagnosed with sphenoid sinusitis that extended to the nasal septum. He therefore underwent surgery for sinus ventilation and abscess drainage.

Barotraumatic esophageal perforation by explosion of a carbonated drink bottle.

We report a case of barotraumatic esophageal perforation caused by the explosion of a carbonated beverage containing plastic bottle into the mouth. A 6-year-old girl presented with sudden sharp pain in her mouth and upper abdomen after outburst of the plastic bottle. A computed tomography scan showed massive pneumomediastinum with diffuse edematous esophageal wall thickening and subcutaneous emphysema primarily in the neck. An esophagogram revealed a perforation of the middle portion of the esophagus with extravasation of contrast on left side. Surgical repair was performed successfully. The patient was discharged on postoperative day 15 after an uneventful postoperative course.

Unsuccessful frontal balloon sinuplasty for recurrent sinus barotrauma.

The standard of care treatment for diffuse recurrent sinus barotrauma (RSB) is an endoscopic sphenoethmoidectomy with a complete frontal dissection. Successful healing leaves the RSB patient with no ethmoid sinuses and endoscopically patent frontal, sphenoid, and maxillary ostia. In persistent cases, patients with small frontal ostia will go on to require a frontal drillout. Patients presenting for surgical management of RSB generally have minimal sinus disease despite significant symptoms during flight and the prospect of extensive surgical management can be unappealing. With the advent of balloon sinuplasty, military otolaryngologists anticipated this technology would permit therapeutic dilation of sinus ostia without the extensive surgical dissection and prolonged recovery typical for standard of care management. This case report is a cautionary note to the wider flight community to recognize a mechanism for recurrence of the underlying pathology when balloon sinuplasty is used that is not possible after properly performed standard of care sinus surgery for RSB.

[Application of pedicled muscular flaps of brachioradialis in repairing wounds at proximal forearm resulted].

OBJECTIVE: To explore the clinical effects of pedicled muscular flaps of brachioradialis in repairing wounds at proximal forearm resulted from hot crush injury. METHODS: From February 2003 to December 2008, 5 wounds at proximal forearm resulted from hot crush injury were repaired with pedicled muscular flaps of brachioradialis. The size of muscular flaps ranged from 6 cm x 4 cm - 9 cm x 5 cm. The wounds at donor sites were closed directly or by free skin grafts. RESULTS: All the muscular flaps of brachioradialis were survived completely. 4 patients were followed up for 3 to 36 months. The cosmetic and functional results were satisfactory both in recipient areas and in donor sites. CONCLUSIONS: Pedicled muscular flap of brachioradialis can not only repair wounds at proximal forearm resulted from hot crush injury, but also repair extensor muscle defects. It is an ideal method and is very practical.

Analysis of 60 patients after tympanotomy and sealing of the round window membrane after acute unilateral sensorineural hearing loss.

OBJECTIVE: This retrospective study was performed to evaluate the effectiveness of tympanotomy and sealing of the round window membrane after unilateral acute hearing loss. DESIGN: All patients presenting idiopathic sudden hearing loss, acoustic, or barotrauma were treated with prednisolone and caroverine. Thirty-six patients had a mean pure tone hearing level worse than 70 dB. Recovery was defined as improvement of hearing threshold for 5 frequencies (250, 500, 1000, 2000, and 4000 Hz). If hearing did not improve after conservative treatment, an exploratory tympanotomy and sealing of the round window membrane were suggested. In the last 8 years, 60 patients with idiopathic sudden hearing loss, acoustic, or barotrauma underwent tympanotomy. RESULTS: In 40 patients, we observed improvement of hearing level up to complete remission. In 20 patients, no change could be detected. In the group of patients with documented barotrauma, 12 patients showed improved hearing levels. Of 37 patients with idiopathic sudden hearing loss, 26 had an improved hearing after surgery. Most patients were operated on within 14 days (range, 1-60 days), but time of surgery had no influence on outcome in patients with idiopathic hearing loss. In contrast, in patients with barotrauma, time of surgery seems to have an influence on outcome. CONCLUSIONS: Tympanotomy and sealing of the round window membrane can be recommended in cases of acute hearing loss after failure of conservative treatment.