T H E AMERICAN JOURNAL OF CLINICAL PATHOLOGY
Vol. 40, No. 3, pp. 281-283
September, 1963
Copyright © 1963 by The Williams & Wilkins Co.
Printed in U.S.A.
HEMORRHAGE IN THE MIDDLE-EAR AND MASTOID IN DROWNING
N E L S O N R. N I L E S , M . D .
Department
of Pathology,
University
of Oregon Medical School, Portland,
The first observation at autopsy of acute
hemorrhage in middle-ear and mastoid cavities was recorded by Dr. V. D. Sneeden10 in
1951. The victim was a 20-year-old man
known to be a good swimmer, who had been
thrown into the water when his boat was
capsized by waves from a larger craft. His
actions in the water were described as wild
and ineffective until he submerged. No other
hemorrhages or significant abnormalities
were found.
MATERIAL
AND
FINDINGS
Subsequent examination of these structures in persons found dead in water yielded
the results listed in Table 1. Most of these
autopsies were performed for the Multnomah
County Coroner and a variety of circumstances was included. In all instances, however, the water was' fresh. The "drowning"
category includes the.case of a 15-year-old
boy with bilateral' hemorrhage, who had
been rescued from drowning only to die of
pneumonia in the hospital. In addition to the
examinations' mentioned here, many autopsies, particularly in-cases-of asphyxia and
the like, included"exploration of these structures,; but specific" records relative, to this
point'jwere not'kept. This lesion has been
found^ qrtly'Jn cSses of drowning, possible
drowning,' or near-drowning. The hemorrhage was' generally grossly visible, rilling
the air spaces' ('Figs. 1 and 2), but was variable in severity and sometimes obscured by
postmortem decomposition. It was accompanied by visceral petechial hemorrhage in
6 cases.
Depth of water in which death occurred
ranged upward from as little as a few inches
(bathtub) for persons with the lesion. Such
cases are in the "possible drowning" group,
but the lesion has also been found in cases
Received, October 30, 1962; revision received,
February 15,1903; accepted for publication May 1.
Dr. Niles is Associate Professor of Pathology,
University of Oregon Medical School.
281
*
Oregon
of witnessed drowning in as little as 6 ft. of
water. Information regarding swimming
ability was obtained for 8 persons who had
drowned and who had this lesion; 4 of these
were good swimmers.
DISCUSSION
Hemorrhage in the middle-ear (barotrauma) is a recognized result of underwater
swimming;3' 6 . 7 . 9 however, it has not previously received attention in postmortem investigations. The constancy of this finding in
this series of cases of drowning and the absence of it in other cases (except for the
1 example of near-drowning) imply that it
might eventually become a criterion for
that diagnosis, one which may be difficult to
establish on the basis of objective postmortem observations. Evidence that hemorrhage
occurred ante mortem is documented in the
case of the boy who was rescued but died
later. Otherwise it may have resulted when
the body sank after drowning.
The theory of pathogenesis most generally
acceptable is that the increased pressure,
transmitted from the surrounding water to
the body and tending to be uniformly distributed, more easily compresses air in
closed cavities than body tissues. The soft
tissue lining these cavities swells by virtue
of its ability to accept fluid from the rest of
the body. Vascular engorgement of this
TABLE 1
SUMMARIZED D A T A IN 51 C A S E S OP
SUSPECTED DROWNING
Number
of Cases
Middle-Ear-Mastoid
Hemorrhage
Drowning
24
22 bilateral
1 unilateral
Possible drowning
25
13 bilateral
5 unilateral
N o t drowning
2
0
7. £*;.•& T,V'
''
^-sc
M
MEC
•*»
EAM
^
' •
SI
JMM»
F I G . 1 (upper). Section through ear illustrating carotid a r t e r y (CA), 8th nerve (N8), semicircular
canals (SC), mastoid air cells (MAC), external auditory meatus (EAM), tympanic membrane (TM),
middle ear cavity (MEC). Hemorrhage may be observed throughout the mastoid cells.
F I G . 2 (lower). Microsection of mastoid area illustrating hemorrhage filling air cells. T h e magnification is not adequate for recognition of t h e epithelial lining. Hematoxylin and eosin. X 52.
282
Sept. 196S
OTIC H E M O R R H A G E
tissue is followed by hemorrhage into the
chambers.3 • 6 • 8 Disturbances of vestibular
function are common in severe aero-otitis
and have been recorded in connection with
caisson disease6 and skin diving.5 The
mechanism of this function is presumably
the same as that involved in caloric tests of
equilibrium. But if the pressures within and
without the chambers are equated, these
events do not occur. Therefore, patent
eustachian tubes and sinus ostia are important safeguards, and upper respiratory infections are wisely regarded as contraindications to scuba diving. 6 ' 9 In regard to the
depth of water needed to produce the lesion,
Lanphier lias observed hemorrhage in the
middle-ear and rupture of the tympanic
membrane with violent vertigo and nausea
with as little as 10 ft. of unequalized descent.8 It is thought that 6 ft. may be sufficient.4 Behnke reported striking changes in
the tympanum resulting from slight differences in pressure such as 1 to 2 p.s.i.;2 this is
equivalent to 2.3 to 4.6 ft. of water. There
is no explanation, however, for hemorrhage
in the cases of death in shallower water
unless mechanisms other than external
pressure were active.
In terms of its effect on the swimmer, this
hemorrhage may be very significant in that
the consequent vestibular dysfunction could
induce him to go in a wrong direction.
Literally he might not know which way is
up. Such an event might be disastrous, as
noted by Alvis.1 This is possibly the reason
for the actions of 2 of the victims and for the
otherwise unexplained drowning of good
swimmers.
SUMMARY
Acute hemorrhage in middle-ear cavities
and mastoid air cells was demonstrated at
autopsy in 23 of 24 cases of drowning, and
in 18 of 25 cases of possible drowning. It
has not been seen in cases in which drowning
is excluded. One person with the lesion was
rescued from drowning only to die later of
pneumonia.
Although depth of water in which drowning occurred was not found to be significant
in the production of the lesion, the most
important factor is presumed to be the
IN
DROWNING
283
pressure differential across the cavity
lining.
Swimming ability is known for 8 of the
above 23 persons; 4 were good swimmers.
This finding may be an explanation for their
unusual behavior in the water and for the
resulting death.
SUMMAItIO I.V INTERLTNGUA
Acute hemorrhagia in le cavitates del aure
niedie e le cellulas aeree del osso mastoide
esseva demonstrate al necropsia in 23 de 24
casos de necamento e in 18 de 25 casos
possibile de necamento. Illo ha non essite
notate in casos in que necamento esseva
excludite. Un subjecto con le lesion esseva
salvate ab necamento sed moriva subsequentemente ab pneumonia.
Ben que le profundor del aqua in que le
necamento occurreva non pareva esser significative in le production del lesion, il es
supponite que le factor le plus importante
es le gradiente de pression cis-trans le revestimento del cavitate.
Le capabilitate de natar esseva cognoscitemente possedite per 8 del supra-mentionate
23 personas; 4 esseva bon natatores. Isto
explica possibilemente lor inusual comportamento in le aqua e le resultante morte.
REFERENCES
1. ALVIS, H . J . : Hazards of diving with selfcontained underwater breathing a p p a r a t u s .
Tndust. Med., 27: 389-392, 1958.
2. B E H N K E , A. R.: Physiologic effect of pressure
changes with reference to otolaryngology.
T r . Am. Acad. Ophth., 49: 63-71, 1944.
3. D U F F N E R , J . : Medical problems involved in
underwater compression and decompression. Ciba Clinical Symposia, 10: 99-114,
1958.
4. D U F F N E R , J . : Personal communication (April,
1959).
5. F I E L D S , J. A.: Skin diving: its physiological
otolarvngological aspects. A. M. A. Arch.
Otolaryng., 68: 531-541, 195S.
C. H I L L , L . : Caisson Sickness, and the Physiology of Work in Compressed Air on the
H u m a n E a r . New York: Longmans, Green
and Company, 1912.
7. LAMBERTSEN, C. J . : Problems of shallow water
diving. Occup. Med., 3 : 230-245, 1947.
8. L A N P H I E R , H . : Diving medicine. New England J. Med., 256: 120-131, 1957.
9. M A R T I N S , J. K . : What's new in diving medicine. G P , 14: 91-96, 1956.
10. SNEEDEN, V. D.: University of Oregon Medical
School, D e p a r t m e n t of Pathology. Report
of autopsy no. 393-A-51; July 15, 1951.