Barotrauma and tinnitus

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Two days ago I failed to properly equalize my ears while snorkeling, and a few minutes after getting out of the water my left ear started ringing. There was no pain or sensation of fullness, maybe some numbness of the ear lobe. I only did a few dives and the deepest dive was only to 8mfw but all along my left ear felt suspiciously easy to equalize, there was no discomfort at all. On the other hand, a few weeks earlier on a scuba dive I had equalized like a boss, so I thought that maybe my right ear was the problem after all, getting it to equalize took some trying. I did not specifically let water inside my hood because the water was so cold, but I don't think this was contributing factor.

By that evening I was quite worried since the distracting sound had not stopped and by the next morning it had not even noticeably gone down in volume. Today I had an appointment with an ear doctor, and the doctor discovered irritation and a small amount of blood of behind the ear drum. An audiogram showed a "depression towards" (?) 6000Hz, 45dB, consistent with barotrauma. I received a prescription of betahistin (improves circulation) and cortisone (which to my surprise is a category of steroids). The doctor believed there was no fluid trapped under pressure, but said that the cortisone will open up the tubes anyway.

Several years earlier, I had had a fairly bad ear infection (unrelated to diving) , which I recall was worse in the bad ear, and earlier than that on a scuba dive the same ear had suffered minor reverse blockage that did not clear until the drive home, and it did so with a loud pop. Other than that I'm not sure if there's much of a difference in behaviour, the bad ear might be slightly more difficult to equalize.

Three factors contributed to the incident:

1) I was careless because I was "only" freediving: in the absence of jellyfish, sharks and boat traffic, the only real risk is drowning. But equalization techniques do in fact differ, and equalization must be taken seriously. The dive was actually my deepest on breathhold!

2) I had always thought that there would be a clear warning before ear-related damage occurred: first there would be moderate pain, then severe pain and only then would something break. That is, I believed that the dangereous area begins only after some pain is already being experienced. But apparently the level of risk increases much more rapidly.

3) My second false belief was that even in the worst case, the damage would be limited to a burst ear drum, likely causing vertigo and probably an infection. While freediving, catastrophic vertigo can be overcome by dropping the weight belt and ear infections can be cured. Had I known that eternal loud ringing was even a possibility, I would have been much more cautious! Tinnitus is a horrible condition, and although the one I'm suffering from is fairly mild and less noticeable already, only 48 hours after the incident, and even though the doctor was quite relaxed about it and said that conditions like this are usually transient, I remain worried.

I'm due for another audiogram in a month, and I certainly hope the ailment will go away completely well before then. The doctor also saw no reason why the issue would reoccur or that it would reoccur in a worse form, even mentioning how the prescriptions can be refreshed easily. But will this have an effect on what kind of diving I can do? Should I get my ears inspected by a specialist? I really like scuba diving and it is one of the extremely few topics on which I display athletic ability and physical courage above that of the general population. Although it does not take up much of my time, it is pretty much the only activity that reliably gets me out of the house and socializing with people.

If I were to ever suffer debilitating tinnitus, I would be liable to self-medicate with a 9mm hollowpoint, I can't imagine living the iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii life for very long.
 
Although I cannot give you actual medical advice, I would have to mostly agree with the physician you visited. Blood in the middle ear can sound like a bad thing, but in fact it's likely that a good deal of people who dive regularly experience this condition one of more times in their life. It is the first thing that happens when your middle ear can't equalize and the pressure gradient rises too high, the space is filled with liquid leaking through the tissues surrounding the middle ear cavity, in most cases blood. The degree of symptoms one experiences before this happens varies, but there may be little to almost no pain to warn you. Most people feel some discomfort or pain, but slowly continue to descend (using SCUBA) and at some point the pain passes. This in fact often means that a vein has burst and your middle ear has filled with blood, not that you suddenly managed to equalize it (you can suspect this if your hearing is weaker or you hear sloshing in the affected ear after the dive). A burst ear drum is actually quite rare and usually only happens under sudden and extreme stress, unless there is a structural weakness in the membrane. Tinnitus on the other hand is a bit more problematic as a symptom. It is very common and most of the time benign. 6000Hz is at the high frequency range, although 45dB sound like a rather marked depression to me. There's a caveat that tinnitus is more difficult to explain with a middle ear problem alone and does likely indicate that the inner ear was affected too. If the doctor you saw really was an ear specialist (not to mention if they had expertise in diving medicine), I would probably take their word for it. Then again, we all have our personal tolerance to risk and uncertainty, and your temperament might very well be on the more cautious side, so I'm afraid no one can make that decision for you. That being said, I would personally not consider diving before a middle ear effusion or bleeding has completely resolved, as this can in the worst case prevent gas from escaping the middle ear and cause increasing pain and risk of further damage when ascending (and it's never a good thing to have something complicating your ascent).

Edit: Didn't notice you mentioned (s)he was an ear doctor on the first read-through, edited accordingly. Then again, what did you mean with a specialist later in your post, a diving medicine specialist?
 
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Good information, thanks. I went to a general ENT doctor, not one specialized in diving medicine. My local diving season is over for this year and I won't be travelling any time soon, so any transient effects will be resolved before the next dive. I don't know if the medication will do anything to inner ear damage but then again is there any cure at all for tinnitus?

One thing I would like to see is an online self-diagnosis tool that tells you if the problem is urgent enough to start calling hyperbaric chambers: I reasoned that DCI was 100% out of the question due to short, shallow dives without compressed gases but some extra certainty would have been nice.
 
I burst my round window back in 1999, no idea how as I never had a problem with equalising that day or the previous days. Since then I have had tinnitus. I have gotten used to it and only really notice when I am not doing anything or it is very quiet. I hope yours gets better.
 
One thing I would like to see is an online self-diagnosis tool that tells you if the problem is urgent enough to start calling hyperbaric chambers: I reasoned that DCI was 100% out of the question due to short, shallow dives without compressed gases but some extra certainty would have been nice.

If you are in doubt about the nature and urgency of a diving related injury, you could try calling DAN (Divers Alert Network). I believe they have a diving physician on call for urgent consultations even if you don't have their insurance.

See this page for more info: Scuba Diving Medical Services — Decompression Illness — DAN | Divers Alert Network
 
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Throwaway,

It's possible that you suffered from inner ear barotrauma, as previous posters alluded to. Tinnitus and high-frequency hearing loss are both symptomatic. IEBT is a serious condition and it's not one that is often considered by ENTs who are unfamiliar with diving-related injuries. In compressed gas divers inner ear DCS may also be in the differential, but as you pointed out, this is not likely in your case (unless you were snorkeling after a SCUBA dive and shunted bubbles through your pulmonary capillary bed to your inner ear vasculature).

The treatment for inner ear barotrauma is complete bed rest with the head of the bed elevated, stool softeners to prevent straining and possible further injury to the vestibular apparatus, and finally surgery if the symptoms do not resolve within 24 hours or so. Unfortunately, surgery is the only way to definitively diagnose IEBT; in the absence of that, it's a presumptive diagnosis based on history and symptom presentation.

I recommend you contact the ENT physician you saw immediately with this information.

Best regards,
DDM
 
I had a (regrettably brief) phone call with a specialist in diving medicine, and he agreed with the earlier diagnosis and treatment. If the only symptom is a "mild" tinnitus, without vertigo, inner ear damage such as a rupture (fistula) of the oval/round window is unlikely. Cortisone is the only worthwhile treatment. (Betahistin is unlikely to have an effect but won't hurt.) Antibiotics and surgery could be used in a severe case.

However, we agreed that the routine control in a month is a bit far away, and if the situation does not improve over the weekend, I should go and have the ear looked at again, just to make sure the situation has not worsened.
 
Throwaway,

I don't want to armchair QB another practitioner, especially online, but the absence of vertigo does not mean that inner ear barotrauma can be ruled out, especially given the dive history that you reported. The treatment may not change but it may have a bearing on deciding fitness to dive in the future.

Best regards,
DDM
 
A month after the incident, the tinnitus is thankfully largely gone, although still often detectable. The cause was apparently inner ear barotrauma of some kind. A second audiogram showed normal hearing and the original doctor said that I'm good to dive, but I need to exercise caution with equalizing. That is advice I am sure to obey.
 

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