Facial Barotrauma Can Mimic Acute Ischemic Stroke

By Will Boggs MD

January 29, 2020

NEW YORK (Reuters Health) - Unilateral facial paralysis resulting from increased middle ear pressure transmitted to the facial nerve can mimic acute ischemic stroke, according to a case report from a physician who treated the patient during an airplane flight.

"My principal aim in submitting this was to share my experience with audiences (primarily clinicians) who may not have encountered this phenomenon before, in order to better enhance awareness of the syndrome," Dr. Alan J. Hunter from Oregon Health and Science University in Portland told Reuters Health by email. "I was struck how quickly I found descriptions upon landing, but also how none of my peers (high-frequency travelers) had experienced this."

During the flight, Dr. Hunter responded to a request for a doctor on board to care for a passenger who "was probably having a stroke."

He found a young, fit looking man who had a complete right-sided facial droop and had lost his forehead wrinkles and could not close his right eye. The episode had begun several minutes earlier with an abrupt-onset, right-sided headache with ear pain and fullness that progressed to slurred speech and drooling.

His medical history was uneventful and he was taking no medications, but he had recovered from a head cold the day before the flight. He had no changes in vision, swallowing, or taste, and his neurological examination was otherwise unremarkable.

Dr. Hunter felt the presentation was consistent with acute Bell's palsy and informed the attendant that the pilots need not divert the plane.

Based on the timing of symptoms (shortly after reaching cruising altitude), he wondered whether declining atmospheric pressure in the cabin might have led to a relative increase in middle ear pressure from a blocked eustachian tube that was transmitted to the branches of the seventh cranial nerve as they ran through the individual's middle ear. He asked the man to breathe oxygen-enriched air and to perform various maneuvers aimed at relieving any excess pressure in his ears (e.g., swallowing and yawning).

Fifteen minutes later, the man reported that his ear had popped and he was feeling better and, a few minutes later, his signs and symptoms had resolved completely, according to the report in Annals of Internal Medicine.

After landing, Dr. Hunter found few descriptions of this condition in the general medical journals but identified several cases described as facial barotrauma in medical specialty and undersea research journals.

According to that literature, the diagnosis of facial barotrauma is supported if facial paralysis consistent with a peripheral seventh nerve palsy occurs during ascent to altitude and reverses with maneuvers that reduce inner air pressure.

"Would the syndrome have lasted longer, not been as clear-cut with respect to physical examination findings, or any other alarm history or exam features had been present, I would most certainly have at least involved the ground physicians in consultation and likely recommended diversion," Dr. Hunter said.

He added, "The phenomenon is much better recognized in professional and amateur scuba divers, where it is still difficult to estimate prevalence or frequency (but the case numbers are much higher), but also related to other high altitude travel, post-operative, and/or congenital/structural processes involving the middle ear."

SOURCE: http://bit.ly/37BpxHq Annals of Internal Medicine, online January 27, 2020.