Alternobaric vertigo and facial baroparesis caused by scuba diving and relieved by chewing pineapple: a case report

Facial and trigeminal nerves neuropathy induced by atmospheric pressure changes: A meta-analysis

BACKGROUND

Barometric pressure changes during flight or diving may cause facial barotrauma. Neuropathy of the fifth (CN5) or the seventh (CN7) cranial nerves is a rare manifestation of this condition. The aim of this study was to analyze risk factors for baroneuropathies of CN5 and CN7.

METHODS

A search of PubMed and Cochrane Library databases was conducted to identify all published cases of CN5 and CN7 neuropathies. Only original case reports and series that documented events of neuropathies associated with the trigeminal nerve or facial nerve while flying, diving, or mountain climbing were included. Assessed variables included sex, medical history, age, setting (flight or diving), atmospheric pressure changes, number of episodes, symptoms, treatment, and recovery.

RESULTS

We identified a total of 48 articles described >125 episodes in 67 patients. Mean age was 33.5 ± 12.1 years with a male predominance (76.1 %). Cases were equally distributed between flight and diving (50.7 %, 46.3 %, respectively). CN5 involvement was observed in 77.6 % of patients, with ear pain and facial numbness as the most common symptoms. The latter was correlated with positive otolaryngology medical history. CN7 was involved in 88.1 % of patients. Flying, as opposed to diving was correlated with spontaneous resolution of symptoms (86.7 % vs. 42.3 % of cases resolved spontaneously, respectively, p = 0.001).

CONCLUSIONS

Flight is an equal risk factor to diving with respect to CN5 and CN7 barotrauma. Involvement of CN7 was observed in most cases, but possibly due to report-bias. Positive medical history is a risk factor for facial numbness.

Imaging of Alternobaric Facial Palsy: An Etiologic Hypothesis

OBJECTIVE

To report a case of alternobaric facial palsy (AFP) with a hyperpneumatized temporal bone and to review the relevant literature in order to propose a new facet of AFP pathogenesis.

METHODS

A patient with a hyperpneumatized temporal bone was found to have recurrent episodes of facial palsy associated with air travel. Systematic review of PubMed, Cochrane Library, and Embase characterized all articles related to transient facial palsy associated with altitude changes or diving with a focus on demographics and imaging findings.

RESULTS

A 25 year-old male was referred for recurrent facial palsy associated with commercial air travel. Imaging demonstrated a hyperpneumatized and well-aerated temporal bone. Total air cell volume was calculated to be 8.59 cc on the affected side. A systematic review of the literature identified 49 cases of AFP. Mean age was 34 years old and 80% were male. Twelve cases had imaging of the temporal bone for evaluation, of which 85% demonstrated at least 1 area of hyperpneumatization. Hyperpneumatization was most frequently encountered in the mastoid, zygomatic root, and inferior petrous apex.

CONCLUSION

Hyperpneumatization of the temporal bone is critical to AFP etiology as it predicts higher middle ear pressure, if atmospheric pressure changes cannot be equilibrated, via reduced efficacy of normal tympanic membrane pressure buffering. This hypothesis helps to better account for the rarity of the condition and male preponderance.

Middle ear barotrauma in diving

INTRODUCTION

Middle ear barotrauma (MEBt) is the most common medical complication in diving, posing a serious risk to dive safety. Given this prevalence and the continuing growth of the diving industry, a comprehensive overview of the condition is warranted.

METHODS

This was a survey study. An anonymous, electronic questionnaire was distributed to 7,060 recipients: professional divers of the Finnish Border Guard, the Finnish Rescue Services, and the Finnish Heritage agency; and recreational divers registered as members of the Finnish Divers' Association reachable by e-mail (roughly two-thirds of all members and recreational divers in Finland). Primary outcomes were self-reported prevalence, clinical characteristics, and health effects of MEBt while diving. Secondary outcomes were adjusted odds ratios (OR) for frequency of MEBt with respect to possible risk factors.

RESULTS

A total of 1,881 respondents participated in the study (response rate 27%). In total, 81% of the respondents had experienced MEBt while diving. Of those affected, 38% had used medications and 1% had undergone otorhinolaryngology-related surgical procedures due to MEBt. Factors most associated with MEBt were poor subjective success in Valsalva ('occasionally' versus 'always' successful: OR 11.56; 95% CI 7.24-18.47) and Toynbee ('occasionally' versus 'always' successful: OR 3.51; 95% CI 1.95-6.30) manoeuvres.

CONCLUSIONS

MEBt is common in both recreational and professional divers, having affected 81% of the respondents. The main possible risk factors include poor success in pressure equalisation manoeuvres.

Successful treatment of highly recurrent facial baroparesis in a frequent high-altitude traveler: a case report

Background

Facial baroparesis is a palsy of the seventh cranial nerve resulting from increased pressure compressing the nerve along its course through the middle ear cavity. It is a rare condition, most commonly reported in barotraumatic environments, in particular scuba diving and high-altitude air travel. We report here an unusual case of highly frequent baroparesis, workup, and successful treatment.

Case presentation

A 57-year-old Caucasian male frequent commercial airline traveler presented with a 4-year history of recurrent episodes of right-sided facial paralysis and otalgia, increasing in both frequency and severity. Incidents occurred almost exclusively during rapid altitude changes in aircraft, mostly ascent, but also during rapid altitude change in an automobile. Self-treatment included nasal and oral decongestants, nasal corticosteroids, and warm packs. Temporal bone computed tomography (CT) scan revealed possible right-sided dehiscence of the tympanic bone segment; audiogram and magnetic resonance imaging of the internal auditory canals were unremarkable. After a diagnosis of facial nerve baroparesis was made, the patient underwent myringotomy with insertion of a pressure equalization tube (PET) into the right tympanic membrane. Despite re-exposure to altitude change multiple times weekly post-treatment, the patient reported being symptom-free for more than 6 months following intervention.

Conclusions

Prompt PET insertion may represent the preferred treatment for individuals who suffer recurrent episodes of facial baroparesis. Education regarding this rare condition may prevent unnecessary testing and treatment of affected patients. Future studies should explore the pathophysiology and risk factors, compare therapeutic options, and provide follow-up data to optimize the management of affected patients.

Simultaneous Determination of Schisandrin and Promethazine with Its Metabolite in Rat Plasma by HPLC-MS/MS and Its Application to a Pharmacokinetic Study

This study aimed to develop a selective, simple, and sensitive HPLC-MS/MS method for the simultaneous determination of schisandrin and promethazine (PMZ) with its metabolite in rat plasma, which was further used for a pharmacokinetic herb-drug interaction study. HPLC-MS/MS analyses were performed on an Agilent Technologies 1290 LC and a 6410 triple quadrupole mass spectrometer. The following parameters, the lower limit of quantification (LLOQ), calibration curve, accuracy, precision, stability, matrix effect, and recovery, were validated. The linear range of the developed method for PMZ, its metabolite promethazine sulfoxide (PMZSO), and schisandrin in rat plasma was 0.5–200 ng/mL (R² > 0.995), with an LLOQ of 0.5 ng/mL, which completely met the determination requirements of biosamples. The intra- and interday precision (RSD, %) was below 13.31% (below 16.67% for the LLOQ) in various plasma, whose accuracy (bias, %) was from −8.52% to 11.40%, which were both within an acceptable range. This method was successfully applied to a pharmacokinetic herb-drug interaction study after oral administration of PMZ with or without S. chinensis water extract. The results demonstrated that coadministration with the S. chinensis water extract might affect the pharmacokinetic behaviors of PMZ. In turn, when taken together with PMZ, the pharmacokinetic parameters of schisandrin, the main active component of S. chinensis, were also affected. The method established in the current study was selective, simple, sensitive, and widely available with good linearity, high accuracy and precision, and a stable sample preparation process. Moreover, this analytical method provides a significant approach for the investigation of herb-drug interaction between S. chinensis and PMZ. The potential pharmacokinetic herb-drug interaction of PMZ- and schisandrin-containing preparations should be noted.

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.

Recurrent and Progressive Facial Baroparesis on Flying Relieved by Eustachian Tube Dilation

Objectives:

Facial baroparesis is a rare phenomenon of seventh cranial nerve palsy traditionally reported in divers, with only 11 cases reported in aviation so far. It is important to correctly diagnose facial baroparesis given the differential diagnosis of stroke and decompression disease and offer appropriate treatment for recurrent cases.

Methods:

The authors present the case of a patient with recurrent and progressive facial baroparesis treated with Eustachian tube balloon dilation. Institutional medical records were reviewed, and analysis of the current literature was performed.

Results:

A 37-year-old woman experienced recurrent and progressive left facial paralysis on descent from altitude on commercial airline flights, with resolution between flights. The patient flew frequently for work-related trips and for the past 7 years had noted facial paralysis that began with mild asymmetry of the face and progressed to an inability to close her left eye. She denied any otologic symptoms other than ear fullness and pressure causing left otalgia. The right side was not involved. After treatment with Eustachian tube dilation, the patient has been on numerous flights with complete resolution of symptoms.

Conclusions:

This study presents a rare case of facial baroparesis on commercial flight descent that resolved after left Eustachian tube dilation. Although unilateral facial palsy can be concerning for stroke, a history of ear fullness and pressure may suggest facial baroparesis instead. For recurrent and progressive cases, Eustachian tube dilation should be considered for treatment.