American Journal of Otolaryngology–Head and Neck Medicine and Surgery 39 (2018) 14–19

Contents lists available at ScienceDirect

American Journal of Otolaryngology–Head and Neck

Medicine and Surgery
journal homepage: www.elsevier.com/locate/amjoto

Identifying eustachian tube dysfunction prior to hyperbaric oxygen

therapy: Who is at risk for intolerance?☆
Jason E. Cohn a,⁎, Michael Pfeiffer a, Niki Patel b, Robert T. Sataloff c, Brian J. McKinnon c
a
Department of Otolaryngology-Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, 4190 City Line Avenue, Philadelphia, PA 19131, USA
b
Department of Otolaryngology-Head and Neck Surgery, McLaren Macomb, 1000 Harrington Street, Mount Clemens, MI 48043, USA
c
Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, 219 North Broad Street, 10th Floor, Philadelphia, PA 19107, USA

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Determine whether specific risk factors, symptoms and clinical examination findings are associated with
Received 20 September 2017 hyperbaric oxygen therapy (HBOT) intolerance and subsequent tympanotomy tube placement.
Materials and methods: A retrospective case series with chart review was conducted from 2007 to 2016 of pa-
Keywords: tients undergoing HBOT clearance at a tertiary care university hospital in an urban city. Eighty-one (n = 81) pa-
Eustachian tube dysfunction
tient charts were reviewed for risk factors, symptoms and clinical examination findings related to HBOT
Middle ear barotrauma
eustachian tube dysfunction and middle ear barotrauma. Relative risk was calculated for each variable to deter-
Hyperbaric oxygen therapy
Hyperbaric oxygen intolerance
mine risk for HBOT intolerance and need for tympanotomy tube placement. Risk factor, symptom, physical exam-
Hyperbaric oxygen complications ination and HBOT complication-susceptibility scores were calculated for each patient.
Decongestant therapy Results: Mean risk factor, clinical and HBOT complication-susceptibility scores were significantly higher in pa-
Myringotomy tients who did not tolerate HBOT compared to patients who tolerated HBOT. Patients reporting a history of otitis
Tympanotomy tube placement media, tinnitus, and prior ear surgery were at a higher risk for HBOT intolerance. Patients reporting a history of
pressure intolerance and prior ear surgery were more likely to undergo tympanotomy tube placement. Patients
noted to have otologic findings prior to HBOT were at a higher risk for both HBOT intolerance and tympanotomy
tube placement.
Conclusions: A thorough otolaryngological evaluation can potentially predict and identify patients at risk for
HBOT intolerance and tympanotomy tube placement.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction HBOT, up to 69% of patients will redemonstrate signs of middle or

Hyperbaric oxygen therapy (HBOT) is a common treatment modali-
ty used for various medical conditions such as chronic infections, non-
healing wounds and ulcers, acute carbon monoxide poisoning, cystitis
and many other indications [1]. HBOT is safe and tolerated well, but it
is associated with side effects [2–3]. One commonly encountered side
effect is middle ear barotrauma (MEB) with an incidence ranging from
2 to 82% due to eustachian tube dysfunction (ETD) [2–8]. This develops
due to the patient's inability to equalize middle ear pressure, usually
during the compression phase of therapy [3,7–8]. It has been shown
that with continued therapy after development of intolerance to
Abbreviations: HBOT, hyperbaric oxygen therapy; MEB, middle ear barotrauma; ETD,
eustachian tube dysfunction; P, P-value.
☆ IRB approval: Drexel University College of Medicine.
⁎ Corresponding author at: Department of Otolaryngology-Head and Neck Surgery,
4190 City Line Avenue, Philadelphia, PA 19131, USA.
E-mail addresses: jasoncoh@pcom.edu (J.E. Cohn), michaelpf@pcom.edu (M. Pfeiffer),
nikipa@pcom.edu (N. Patel), rtsataloff@phillyent.com (R.T. Sataloff),
bmckinnon@phillyent.com (B.J. McKinnon).
inner ear barotrauma [6,8–9].
When these side effects develop during the course of treatment, oto-
laryngologists are often consulted. Normally, therapy has to be post-
poned or abandoned due to the side effects of HBOT until the
conditions are treated. Delays in HBOT caused by ETD occur in approx-
imately 10–40% of patients [6,10]. Topical and systemic decongestants
are a treatment option for patients with intolerance to HBOT [2,9,11].
Educating patients on auto-insufflation techniques such as Valsalva
and Toynbee maneuvers before the first session has also been shown
to reduce the risk of barotrauma during HBOT [13]. However,
myringotomy with tube placement is the standard treatment to prevent
MEB associated with ETD [11–12]. Myringotomy with tube placement
for patients with severe symptoms is required in 2–30% of patients un-
dergoing HBOT [5–6,11,14].
Current standard pre-HBOT assessment involves a baseline
otoscopic examination usually performed by hyperbaric staff. Otoscopy
is repeated for patients who have difficulty equalizing middle ear pres-
sure, intolerance to HBOT and subsequent development of MEB related
to ETD [15]. The results of these examinations are used to develop a
treatment plan for the patient which may include an otolaryngology

https://doi.org/10.1016/j.amjoto.2017.10.005
0196-0709/© 2017 Elsevier Inc. All rights reserved.
 J.E. Cohn et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 39 (2018) 14–19
consult. Various classification methods have been used when
conducting an otoscopic examination. The initial TEED classification
has been modified over the years, and the other versions of the criteria
are used more commonly [15–16]. The modified TEED classification sys-
tem is graded in increasing severity from Grade 0 to 5, with 0 being a
normal appearing tympanic membrane and 5 being perforation of the
tympanic membrane [15,17]. The drawback of the TEED criteria is
inter-observer variability. The O'Neill grading system attempts to re-
move inter-observer variability. The O'Neill grading system uses photo-
graphic images of the tympanic membrane, which allow for more
consistent documentation from one examiner to the next. The O'Neill
grading system is graded in increasing severity from Grade 0 to 2.
Grade 0 is ETD while Grade 1 and 2 is varying barotrauma [15].
Prospective identification of patients at risk for otic barotrauma has
been discussed in the literature. The various physical examination
methods proposed for identification of barotrauma are otoscopic
inspection, ETD evaluation using the Bluestone method, and
tympanometry [11]. Each of these modalities has its own limitations.
Clinical ETD evaluation requires a patient who is awake and coopera-
tive. It also is not predictive prior to the patient's first session [6]. Risk
factors that have been reported for MEB due to HBOT are age N 60 or
b16, female gender, prior history of ETD, first HBOT session, radiation-
related injuries to the head and neck and presence of an artificial airway
[4–5,7,14,18–20]. Unconscious patients and infants are also susceptible
due to a compromised ability to equalize middle ear pressure [11]. Stud-
ies have shown that patients with an artificial airway are at a 94% risk
for middle ear complications, with 61% receiving tympanotomy tube
placement [14]. Allergic rhinitis, nasal congestion, inferior turbinate hy-
pertrophy, deviated nasal septum, otitis media and ear pain have also
been associated with middle ear barotrauma [21,22].
Currently there are no objective criteria which can effectively predict
and identify which patients scheduled to undergo HBOT will have MEB
due to ETD. In addition, there is no consensus on the use of various treat-
ment modalities (i.e. topical decongestants, systemic decongestants,
tympanotomy tubes). Studies have investigated the use of these treat-
ment modalities after patients have developed intolerance to HBOT.
However, data on the use of these treatments prior to the initiation of
HBOT have not been published. The primary goal of this study was to
identify patients at risk for developing HBOT intolerance using a thor-
ough otolaryngological history and physical examination with emphasis
on sinonasal and otologic processes.
2. Materials and methods
After institutional review board approval, a retrospective case series
with chart review was conducted at our institution. Charts were
reviewed of patients being evaluated by our otolaryngology service for
HBOT clearance from 2007 through 2016. A multidisciplinary team ap-
proach to HBOT had been created between the primary wound care
teams (either vascular surgery or podiatric surgery) and the consultants
needed for HBOT clearance (otolaryngology, ophthalmology and radia-
tion oncology). To our knowledge, an otolaryngology consultation was
not requested for every patient undergoing HBOT. However, of the pa-
tients who were evaluated by our department, the consultation was
completed prior to their first hyperbaric session. In our department,
consultation involved screening patients being considered for HBOT to
assess risk factors, symptoms, and clinical signs of ETD and subsequent
MEB. The only exclusion criteria were incomplete consultation in pa-
tients refusing evaluation, and patients who had tympanotomy tubes
at the time of evaluation. After exclusion criteria, a total of eighty-one
(n = 81) patients were identified.
Based on the existing literature as well as the clinical experiences of
the otolaryngology staff, a focused history and physical examination
was completed for each patient encounter. The patients were asked
about their past medical history including a history of pressure intoler-
ance (i.e. on an airplane or deep sea diving), rhinitis (i.e. history of nasal
15
obstruction or congestion treated with intranasal or oral therapy), ear
infections (as an adult or child), hearing loss, vertigo, tinnitus, ear trau-
ma and previous ear surgery (i.e. myringotomy, tympanoplasty with or
without mastoidectomy) as well as allergies, social history and family
history. A comprehensive review of otolaryngological symptoms prior
to HBOT included aural fullness, otalgia and nasal congestion, among
others. The physical examination included a head and neck examina-
tion, basic otoscopic examination (non-microscopic), anterior rhinosco-
py, and oropharyngeal examination. Specific pertinent physical
examination findings were noted, including monomeric tympanic
membrane, tympanosclerosis, tympanic membrane retraction and tur-
binate hypertrophy. The number of patients for each finding collected
was noted as a frequency and percentage of the total population.
Patients were cleared by our otolaryngology team for HBOT if they
were not having symptoms of ETD during the evaluation. Prior to
HBOT, no patients evaluated had symptoms of ETD and were therefore
cleared for therapy. For patients experiencing ETD after the institution
of HBOT, our team recommended 2 sprays of intranasal oxymetazoline
in each nasal cavity prior to their next hyperbaric treatment. When de-
congestant therapy was unsuccessful after one session, tympanotomy
tube placement was offered as definitive treatment. All patients requir-
ing decongestant therapy and/or tympanotomy tube placement were
classified as not tolerating HBOT. Intolerance to HBOT was defined by
a patient experiencing unrelenting otalgia and/or fullness with subjec-
tive hearing loss during or after a hyperbaric session. The session num-
ber during which the patients began not to tolerate HBOT was recorded.
Each aspect of the patient's history and physical examination was
noted to have or not have each specific finding (Fig. 1). The presence
of a particular finding was denoted as a score = 1, and its absence as a
score = 0 using a standard checklist for each item. A risk factor score
was calculated based upon the sum of having a history of pressure intol-
erance, rhinitis, ear infections, tinnitus, hearing loss, vertigo, ear trauma
and ear surgery (possible score range 0–8). A total symptom score was
calculated based upon the sum of having ear (otalgia or aural fullness)
and sinonasal (nasal congestion) symptoms prior to HBOT (possible
score range 0–3). A total physical examination score was calculated
based upon the sum of having ear (monomeric tympanic membrane,
tympanic membrane retraction and tympanosclerosis) and sinonasal
(turbinate hypertrophy) examination findings prior to HBOT (possible
score range 0–4). The risk factor, total symptom and total physical ex-
amination scores were added together to produce a HBOT complica-
tion-susceptibility score (possible score range 0–15). This novel
scoring system was developed by the author (J.C.).
Relative risk was used to determine whether each variable influ-
enced risk for HBOT intolerance and tympanotomy tube placement. Rel-
ative risk was not calculated for a history of vertigo and ear trauma due
to only one patient having a positive history of each. Independent t-test
was used to compare the mean risk factor, symptom, physical examina-
tion, and total HBOT complication-susceptibility scores in those who
tolerated and did not tolerate HBOT. Analysis of variance was conducted
to compare the mean risk factor, symptom, physical examination and
HBOT complication-susceptibility scores of those who tolerated HBOT
versus those who improved with oxymetazoline versus those who did
not improve with oxymetazoline and required tympanotomy tubes.
Chi-square test of independence was used to determine the relationship
between each variable and ETD improvement with oxymetazoline. A
multivariate analysis was performed to determine whether age, gender,
or race influenced risk of HBOT intolerance. The significance level was
set at a P-value (P) less than or equal to 0.05.
3. Results
Our total study population consisted of eighty-one (n = 81) pa-
tients who were evaluated by our department prior to starting HBOT
(Table 1). The mean age of our cohort was 59 years. Of the total study
population, 55 (67.9%) were male and 50 (61.7%) were African
16 J.E. Cohn et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 39 (2018) 14–19

American. From the total population, 50 (61.7%) patients tolerated
HBOT. Seven (8.64%) patients indicated that they had tolerated HBOT
in the past, of which 5 of 7 (71.4%) tolerated HBOT again during our
evaluation period.
A total of 31 (38.3%) patients did not tolerate HBOT. Of those 31, 8
(25.8%) improved with oxymetazoline, while 23 (74.2%) eventually re-
quired tympanotomy tube placement. The average session number at
which patients' intolerance to HBOT developed was 1.80 sessions
(range 1–5). The average session number at which patients reported
HBOT intolerance for those who improved with oxymetazoline was
1.62 (range 1–5) sessions, versus 1.87 (range 1–5) sessions for patients
requiring tympanotomy tube placement (failed oxymetazoline
therapy). However, this difference was not statistically significant (t-
score = 0.43, P = 0.33) (data not shown).
Those who reported a history of otitis media, tinnitus and prior ear
surgery were at a higher risk for HBOT intolerance. Those who reported
a history of pressure intolerance and prior ear surgery were at a higher
risk for tympanotomy tube placement. Otologic and sinonasal symp-
toms were not significantly associated with HBOT intolerance nor
tympanotomy tube placement. Patients noted to have otologic findings
prior to HBOT were at a higher risk for both HBOT intolerance and
tympanotomy tube placement. Patients noted to have turbinate

Fig. 1. HBOT scoring system.

 J.E. Cohn et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 39 (2018) 14–19
Fig. 1 (continued).
hypertrophy prior to HBOT were not at a higher risk for HBOT intoler-
ance nor tympanostomy tube placement (Table 2). No single variable
was shown to relate to ETD improvement with oxymetazoline (data
not shown).
Each calculated score was compared between patients who did and
did not tolerate HBOT (Table 3). Mean risk factor score was significantly
higher in patients who did not tolerate HBOT compared to patients who
tolerated HBOT [0.90 vs. 0.50, P = 0.04]. Mean symptom score was not
significantly higher in patients who did not tolerate HBOT compared to
patients who tolerated HBOT [0.19 vs. 0.12, P = 0.23]. Mean physical ex-
amination score was significantly higher in patients who did not toler-
ate HBOT compared to patients who tolerated HBOT [0.48 vs. 0.22, P
= 0.03]. Mean HBOT complication-susceptibility score was significantly
higher in patients who did not tolerate HBOT compared to patients who
tolerated HBOT [1.58 vs. 0.84, P = 0.02].
Furthermore, these scores were compared between those who toler-
ated HBOT, improved with oxymetazoline and those who did not im-
prove with oxymetazoline and required tympanotomy tubes. Between
these three groups, there were no significant differences in risk factor,
symptom, physical examination and HBOT complication-susceptibility
score (data not shown). However, among the patients who did improve
17
with oxymetazoline (n = 8), 3 had turbinate hypertrophy on examina-
tion, 2 had a history of tinnitus and hearing loss, 1 had a history of ear
infections and vertigo, 1 had aural fullness on examination, 1 had
nasal congestion on examination, and 1 had monomeric tympanic
membranes on examination. In the multivariate analysis, there was no
association between age, gender, or race and developing HBOT intoler-
ance (data not shown).
4. Discussion
Although there are systems in place for identifying patients with ETD
and MEB after undergoing HBOT sessions, no effort has been made pre-
viously to clearly and systematically identify those at risk prior to HBOT.
In our study, we approached the evaluation of HBOT patients in a multi-
dimensional manner which included a thorough otolaryngological his-
tory, review of systems and physical examination. Additionally, we ad-
dressed HBOT intolerance both with medical and surgical treatment.
A thorough history was determined to be an important evalua-
tion tool. Those who reported a history of otitis media (n = 4), tinni-
tus (n = 8) and/or prior ear surgery (n = 2) were at a higher risk for
HBOT intolerance. Patients who had a history of pressure intolerance
18 J.E. Cohn et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 39 (2018) 14–19

Table 1 Table 3
Baseline characteristics of patient cohort (N = 81). Score results: HBOT intolerance vs. Tolerance.

Characteristics Frequency (%) Score type Score, mean ± SDa t-Score P value

Patients HBOT HBOT

Age (years) 59 ± 13.7 [31–87]a intolerance tolerance
Gender
Risk factor 0.90 ± 1.14 0.50 ± 0.79 1.73 0.04b
Male 55 (67.9)
Symptom 0.19 ± 0.48 0.12 ± 0.33 0.75 0.23
Female 26 (32.1)
Physical examination 0.48 ± 0.68 0.22 ± 0.51 1.87 0.03b
Race
HBOT complication-susceptibility 1.58 ± 1.78 0.84 ± 1.31 2.00 0.02b
Caucasian 22 (27.2)
African American 50 (61.7) Abbreviations: HBOT, hyperbaric oxygen therapy; SD, standard deviation.
a
Hispanic 8 (9.9) Degrees of freedom = 79.
b
Other 1 (1.2) Statistically significant value (P value ≤ 0.05).
HBOT indication
Chronic wound 79 (97.5)
Cystitis 2 (2.5)
Past medical history Physical examination was also determined to be a very important
History of pressure change intolerance 9 (11.1) component of screening HBOT patients for ETD. Patients noted to have
History of rhinitis 11 (13.6)
otologic findings (n = 12) such as tympanosclerosis (n = 1), monomer-
History of ear infections 4 (4.9)
History of tinnitus 8 (9.9)
ic tympanic membrane (n = 6), and tympanic membrane retraction (n
History of hearing loss 17 (21.0) = 5) prior to HBOT were at a higher risk for both HBOT intolerance and
History of vertigo 1 (1.2) need for tympanotomy tube placement. However, turbinate hypertro-
History of ear trauma 1 (1.2) phy was not a key indicator for HBOT intolerance or the need for
History of ear surgery 2 (2.5)
tympanotomy tube placement.
Review of symptoms
Ear symptoms prior to HBOT Our results also showed that the majority of patients (71.4%) who
Otalgia 2 (2.5) had tolerated HBOT previously continued to tolerate it. Therefore, that
Aural fullness 4 (4.9) can be an important screening tool, since many HBOT patients have
Sinonasal symptoms prior to HBOT
chronic conditions requiring repeated therapy. In our total cohort, 31
Nasal congestion 6 (7.4)
Physical examination
(38.3%) patients did not tolerate HBOT. Most patients who develop in-
Monomeric tympanic membrane 6 (7.4) tolerance to HBOT do so during either their first or second treatment
Retracted tympanic membrane 5 (6.2) session (the average time to intolerance was 1.80 sessions in our co-
Tympanosclerosis 1 (1.2) hort). However, there was no significant difference in the timing of
Turbinate hypertrophy 14 (17.3)
HBOT intolerance between the patients who improved with
Previous HBOT
Tolerated in past 7 (8.6) oxymetazoline versus those who required tympanotomy tube place-
Continued tolerance 5 (71.4%) ment. The reason why certain patients were at a higher risk for HBOT in-
Current HBOT tolerance but not tympanotomy tubes was because a proportion of the
Tolerance 50 (61.7) population improved with oxymetazoline, a decongestant. Deconges-
Intolerance 31 (38.3)
Improved with conservative therapy 8 (9.9)
tants are thought to improve eustachian tube patency and facilitate
Required TTP 23 (28.4) equalization of pressure [2,9,11]. Studies have demonstrated that sys-
Improved after TTP 21 (91.3) temic decongestants are effective at treating ETD. However, in previous
Abbreviations: HBOT, hyperbaric oxygen therapy; TTP, tympanotomy tube placement. studies, the use of topical decongestants has been shown to be ineffec-
a
Values expressed as mean ± SD [min-max]. tive at treating the side effects of HBOT. Despite these findings, decon-
gestants still are used anecdotally by 80.6% of HBOT centers in the
(n = 9) and prior ear surgery (n = 2) were more likely to undergo United States [9,11]. In our cohort of patients who did not tolerate
tympanotomy tube placement. Although elucidating certain symptoms HBOT, 25.8% improved with oxymetazoline. Therefore, conservative
is an important part of evaluating patients prior to HBOT, no particular therapy with a topical decongestant had a 74.2% failure rate. Although
symptoms alone predicted significant risk of HBOT intolerance or need we expected specific patient variables to be associated with clinical im-
for tympanotomy tube placement. provement after oxymetazoline treatment (i.e. nasal congestion,

Table 2
Relative risks of factors associated with HBOT intolerance and tympanotomy tube placement.

HBOT intolerance Tympanotomy tube placement

Relative risk 95% CI P value Relative risk 95% CI P value

Past medical history

Pressure intolerance 1.54 0.80–2.98 0.20 2.22 1.09–4.51 0.03b
Rhinitis 0.44 0.12–1.59 0.21 0.61 0.16–2.23 0.45
Ear infections 2.06 1.09–3.90 0.03a 1.83 0.64–5.21 0.26
Tinnitus 2.19 1.31–3.65 0.003a 1.92 0.87–4.25 0.11
Hearing loss 1.54 0.88–2.70 0.13 1.65 0.81–3.35 0.17
Ear surgery 2.72 2.04–3.64 b0.0001a 3.76 2.61–5.43 b0.0001b
Review of systems
Otologic symptoms 1.85 0.98–3.52 0.06 1.88 0.77–4.54 0.16
Sinonasal symptoms 0.86 0.27–2.77 0.80 0.57 0.09–3.52 0.54
Physical examination
Positive otologic exam 1.86 1.07–3.22 0.03a 2.25 1.14–4.43 0.02b
Positive sinonasal exam 1.40 0.76–2.58 0.29 1.01 0.40–2.51 0.99

Abbreviations: HBOT, hyperbaric oxygen therapy; 95% CI, 95% confidence interval.
a
Statistically significant risk in developing HBOT (P value ≤ 0.05).
b
Statistically significant risk in requiring tympanotomy tube placement (P value ≤ 0.05).
 J.E. Cohn et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 39 (2018) 14–19
turbinate hypertrophy), this was not shown to be significantly true in
our study.
The majority (74.2%) of patients who did not tolerate HBOT
eventually required tympanotomy tube placement. Out of the total pa-
tients (n = 23) who ultimately underwent tympanotomy tube place-
ment for HBOT intolerance, 21 (91.3%) had resolution of their
symptoms (otalgia or fullness with hearing loss). The remaining 2 pa-
tients (8.7%) did not improve due to otorrhea. This is not unusual
given that 5–49% of patients experience early post-tympanotomy tube
otorrhea, which occurs b 2 weeks postoperatively [23]. However, no dis-
tinction is made between the pediatric and adult population.
We developed a scoring system to assist providers in risk-stratifying
patients about to undergo HBOT. Patients with higher mean risk factor,
physical examination and HBOT complication-susceptibility scores are
susceptible to HBOT intolerance. However, they do not have significant-
ly higher symptom scores. When comparing these scores between pa-
tients who tolerated HBOT, improved with oxymetazoline and those
requiring tympanotomy tubes there was no statistical significance.
Therefore, it can be concluded that our scoring may assist providers in
predicting who will not tolerate HBOT and need prophylactic
oxymetazoline.
The results of this study should be interpreted within the context of
certain limitations. Although a universal consultation form was utilized
for patient evaluations, it was not standardized. For example, several in-
dividuals interviewed and examined the patients in this study. As a re-
sult, the history intake and physical examination was documented in
several ways, making the findings unstandardized. The otoscopic exam-
inations in this study involved basic, visual examination of the auricle,
external auditory canal, and tympanic membrane. Pneumatic otoscopy
was not performed in all cases, and there were no attempts made to ex-
amine the eustachian tube directly. Additionally, formal audiometry
and tympanometry were not performed on these patients. Turbinate
hypertrophy was generally noted without a severity as well. Certain re-
sults in this study were calculated with small sample sizes. For example,
a history of ear surgery was present in only 2 patients, and a history of
vertigo and ear trauma was observed in only 1 patient. Additionally,
our scoring system yielded low total scores in our cohort. For risk factor,
symptom, physical examination and HBOT complication-susceptibility
scores the possible total scores were 8, 3, 4 and 15, respectively. The av-
erage scores in our analysis ranged from 0.12 to 1.58. Although these
scores were statistically different between these two groups for risk fac-
tor, physical examination and HBOT complication-susceptibility scores,
the clinical significance remains uncertain. In future prospective studies,
this scoring system might need to be re-scaled, and audiometry and
tympanometry might be added, to optimize clinical application of the
scoring system introduced in this report.
5. Conclusions
In conclusion, evaluation of patients being considered for HBOT in-
volves a multi-disciplinary approach. A thorough otolaryngological
evaluation that includes collecting information about risk factors, symp-
toms and physical examination findings can help to identify patients at
risk for HBOT intolerance. Although we are unable to predict patients
that will need decongestant therapy or tympanotomy tube placement,
it appears that we are able to properly identify those who will not toler-
ate HBOT. Based off of our results, tympanotomy tube placement should
be considered in a patient not tolerating their first or second session
who requires long-term HBOT. This will allow for better management
of these patients prior to HBOT, which in turn, will prevent interruptions
19
and delays in therapy for these patients. Additionally, the utilization of a
pre-treatment scoring system taking into account these risk factors,
symptoms and physical examination findings can potentially help to
predict those at risk for HBOT intolerance and to offer them treatment
prophylactically. The results of the study should serve as a supplement
to, rather than a replacement of, established systems such as the TEED
classification and O'Neill grading system. However, our findings indicate
that further research should be encouraged.
Conflicts of interest
None.
Funding statement
This research did not receive any specific grant from funding agen-
cies in the public, commercial, or not-for-profit sectors.
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