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Author: admin | 03.04.2015 | Category: Relieve Tinnitus

OBJECTIVE: To analyze the association of insuflation maneuvers status before hyperbaric oxygen therapy with middle ear barotrauma.
MATERIALS AND METHODS: Fouty-one patients (82 ears) admitted to the Department of Hyperbaric Medicine from May 2011 to July 2012.
RESULTS: Of the 82 ears included in the study, 32 (39%) had barotrauma after the first session.
CONCLUSION: Positive Valsalva and Toynbee maneuvers before the first session, alone or associated were protective factors for middle ear barotrauma by ear after the first session. The Hyperbaric Oxygen Therapy (HBOT) is an accepted treatment modality for primary and adjuvant treatment of various diseases1,2.
Symptoms range from discomfort, ear pain, ear fullness, hearing loss, tinnitus and even otorrhagia2,3,6. There are conflicting opinions regarding the role of the Eustachian tube (ET) in the occurrence of MEB7.
The role of self-insuflation maneuvers (Valsalva and Toynbee) status before HBOT is controversial and many authors have used tubal function tests instead, to try to predict MEB. This research was conducted to analyze the relevance of insuflation maneuvers status before hyperbaric oxygen therapy in order to stratify patients into similar categories of MEB risk.
The study group consisted of 41 patients (82 ears) admitted to the Hyperbaric Medicine Department at Brasilia Armed Force Hospital, from May 2011 to July 2012, for the treatment of various diseases.
Inclusion criteria: all patients undergoing HBOT evaluated by an otolaryngologist before and after the first session, with no history of ear disease. Were considered ear diseases for purposes of exclusion: chronic otitis media, history of previous otologic operations such as tympanostomy, tympanoplasty or mastoidectomy. The sample was selected by convenience respecting the free choice of the patient to participate (with signing of informed consent term). The equipment used for HBOT was a Seaway Diver multiplace chamber with eight places, model A-240. Videootoscopy was performed and recorded with the intent of reducing the interobserver difference in the degree of evaluated barotrauma. Tympanostomy with Ventilation tubes (VT) placement was heldin MEB grades 3 and 4 and in cases of severe pain in grade 2. To perform the Valsalva maneuver, patients were instructed to pinch the nostrils and inflate the cheeks through forced expiration with the mouth closed until a sensation of fullness was achieved in the ears. Besides the evaluation of each maneuver (Valsalva and Toynbee) separately, it was evaluated the result of the combined two maneuvers by ear.
In the analysis of the Valsalva maneuver by patient, the subjects were classified into Inflaters and Non-inflaters. After the first session of HBOT, there were 22 patients with MEB (53.65%), 12 unilateral and 10 bilateral.
In the present study, the refractory ulcers were the main indication for HBOT (29.3%) (Figure 3). There was no correlation of reported nasal obstruction before the first session with MEB after the first session.
Further analysis tested whether the insuflation categorized as symmetric or asymmetric had any association with MEB (Table 2). As in the present study, Diaz Caparros10 reported that the refractory ulcers constituted the major indication for HBOT in his sample (73.8%).
In the present study there was a correlation with both positive Valsalva or Toynbee maneuvers before the first session with the absence of MEB after the first session. Igarashi et al.11 evaluated the findings of the Valsalva maneuver prior to the beginning of HBOT (easy or difficult maneuver) and found no correlation with MEB. Beuerlein et al.1, in a prospective study, compared MEB incidence in auto-inflaters (which could lateralizate the TM during the Valsalva maneuver attested by otoscopy) and non-inflaters (comatose patients with artificial airways or patients who failed to perform Valsalva maneuver).
In this study patients were divided into auto-inflaters (by similar criterion used by Beuerlein et al.1) and non-inflaters (patients who could not perform the Valsalva maneuver). Although no association has been found between asymmetric tubal insufflation and increased MEB rate, there was a strong tendency in this direction that can be further investigated in future studies. 4 Specialist in Otology and Neurotology by Harvard Medical School, Boston, MA, USA, PhD in Medical Sciences from the University of Brasilia, Professor at Health Sciences School - University of Brasilia - Brasilia - DF - Brazil.
Paper submitted to the ITJ-SGP (Publishing Management System) on August 28, 2013; and accepted on September 28, 2013. HBOT is not without risks and the middle ear barotrauma (MEB) is its most common side effect3,4. Some authors advocate tube dysfunction as the primary risk factor for this condition1,8-10. Otoscopy persists as the most reliable method for detecting changes in the ME induced by HBOT2,7,12.
It was attempted to make an otolaryngological profile of patients undergoing HBOT, in order to establish more accurate protocols for the prevention and treatment of MEB.
During the evaluations were performed: otoscopy with Valsalva and Toynbee maneuvers, video otoscopy and specific questionnaire.

When there were signs of MEB on otoscopy, self-inflating maneuvers were not realized after the sessions, to prevent pain or discomfort.
Were excluded 3 patients who required bilateral VT placement before the beginning of sessions and a patient who already had bilateral VT, totaling 4 exclusions. It was adopted a standardized treatment protocol which consisted of one session per day (5 days per week) (Figure 1).Were included both inpatients and outpatients.
To accomplish the Toynbee maneuver, the patients were asked to swallow while pinching the nostrils. The following groups of ears were obtained: those with positive Valsalva and Toynbee maneuvers, those with only one positive maneuver (Valsalva or Toynbee), those with negative Valsalva and Toynbee maneuvers. To be considered Inflater the patient should perform the Valsalva maneuver successfully in both ears.
Patients were divided into three groups: those patients who could perform the maneuver Toynbee in both ears, those who could not perform the Toynbee maneuver in both ears, and those who could do it unilaterally. It was obtained 4 maneuvers per subject that were categorized as: 4 positive maneuvers (Valsalva and Toynbee maneuvers positive bilaterally), 3 positive maneuvers and 1 negative, 2 positive and 2 negative maneuvers, 1 positive and 3 negative maneuvers, 4 negative maneuvers (Valsalva and Toynbee maneuvers negative bilaterally).
The number of sessions per patient ranged from 1 to 100 sessions, with an average of 28.46 sessions. Unlike this study, these authors found no influence of history of allergic rhinitis in MEB. Bessereau et al.5 reported the same incidence of MEB in patients who did or didn't perform the Valsalva maneuver.
But the finding was not statistically significant given the small number of non-inflaters (n = 3, 2 intubated patients and 1 with tracheostomy). Counteracting the opinion of several authors, it is believed that the capacity of self-insuflation (by Valsalva and Toynbee maneuvers) is relevant and should be evaluated before HBOT. In both cases, the patient underwent maneuvers during otoscopy, allowing the examiner to assess the movement of the TM. Using these categories, the insuflation of each ear was rated respectively as: Good, Medium and Bad. The group of Non-inflaters was then constituted by two subgroups: those who could not perform the Valsalva maneuver in both ears, and those who could do it unilaterally.
Using these categories the insuflation of each patient was rated respectively as: Good, Medium (for 3 intermediate categories) and Bad.
As the diagnosis of allergic rhinitis was based on patients self-reporting, it is subject to bias, which may have result in this unexpected finding of inverse correlation with MEB. By grouping the results of the two tests, the correlation was even better (P = 0.013) with good differentiation of MEB rates by ear between the three categories of tubal insuflation. They attribute this finding to patients who perform ineffective Valsalva maneuvers, which would be under increased risk of MEB. The authors conclude that the non-inflaters have increased risk for MEB and therefore recommends prophylactic VT placement in patients with artificial airways and in patients with tubal dysfunction who do not respond to medical therapy. There are insufficient studies to evaluate the risk of MEB in non-inflaters without airway alterations or altered state of consciousness. Does the slow compression technique of hyperbaric oxygen therapy decrease the incidence of middle-ear barotrauma? Eustachian tube function and middle ear barotrauma associated with extremes in atmospheric pressure. Estudio del barotraumas de oido medio en pacientes sometidos a tratamiento con oxigenoterapia hiperbarica.
Evaluation of predive parameters related to eustachian tube dysfunction for symptomatic middle ear barotrauma in divers. Its incidence ranges from 8 to 68.7% and achieves up to 91% in patients unable to auto-inflate their middle ear (ME)5.
During the Valsalva maneuver was expected lateralization of TM and during the Toynbee maneuver, its medialization. In the studies evaluated it hasn't been described if the auto-inflator can perform the Valsalva maneuver successfully in both ears or in just one. Tubal insuflation was classified in Good, Median and Bad according to combined results of Valsalva and Toynbee maneuvers. When these outcomes occurred maneuvers were classified as positive and otherwise as negative. In this study, to be considered auto-inflater, the patient should perform the Valsalva maneuver successfully in both ears. Inclusion criteria: patients evaluated by an otolaryngologist before and after the first session, with no history of ear disease, who agreed to participate in the research (convenience sample).

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