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Article F: Alternobaric Vertigo and Eustachian Tube Dysfunction. Charles D. Bluestone, MD; J. Douglas Swarts, PhD; Joseph M. Furman, MD, PhD; Robert F. Yellon, MD. Case Report: Persistent Alternobaric Vertigo at Ground Level due to Chronic Toynbee phenomenon. Laryngoscope 2012;122(4):868–72. The term “alternobaric vertigo” was coined by Lundgren in 1965 to describe vertigo in deep-sea divers, but also referred to aircraft pilots in 1966. It occurs during ascent and rarely descent and is a result of asymmetrical middle-ear pressures. Classically the vertigo due to this pathogenesis is transient but may last for several minutes. It is frequently associated with nausea and vomiting. It has been reproduced in pressure chamber experiments with some divers and fliers, but has not been reported spontaneously at ground level (Figure F–1). FIGURE F–1. Alternobaric vertigo can occur during ascent in an airplane or when scuba diving. We encountered a 15-year-old female with bilateral tympanostomy tubes who manifested persistent severe vertigo, at ground level, secondary to a unilateral middle-ear pressure of +200 mm H2O elicited by an obstructed tympanostomy tube in the presence of chronic nasal obstruction. She had had long-term tubes placed due to recurrent and chronic otitis media. Physical examination revealed achondroplasia, which is an autosomal dominate disorder characterized by abnormal bone growth, short arms and legs, short stature and a large head, which is associated with otitis media. The pathogenesis of otitis media in these individuals may be related to abnormal anatomy causing Eustachian tube dysfunction. Balance testing was abnormal, Eustachian tube function tests revealed dysfunction of tube. Surgery was performed to replace the obstructed tube with a patent one, and an adenoidectomy and bilateral inferior turbinate reduction to relieve the chronic nasal obstruction. Postoperatively balance testing was normal, Eustachian tube function remained dysfunctional, but she had complete resolution of her vertigo following the surgery. FIGURE F–2. Pathogenesis of alternobaric vertigo due to the “Toynbee phenomenon” One tympanostomy was obstructed and when swallowing, she developed high positive pressure in the middle ear, but in the ear with a patent tube, the pressure did not remain in the middle ear. We believed this was a previously unreported scenario in which closed-nose swallowing insufflated air into her middle ears, resulting in sustained positive middle-ear pressure in the ear with the obstructed tube. Swallowing, when the nose is obstructed, can result in abnormal negative or positive pressures in the middle ear, which has been termed the “Toynbee phenomenon.” We concluded that in patients who have vertigo, consideration should be given to the possibility that nasal obstruction and the “Toynbee phenomenon” are involved (Figure F–2). CHAPTER 7 PATHOLOGY The pathology of the ET may or may not be involved in the pathogenesis of otitis media, whereas the
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Charles D. Bluestone (Eustachian Tube: Structure, Function, and Role in Middle-Ear Disease, 2e)