Physiological presentation of symptoms

[It'sNotLupus]

I'm going today for my 3rd visit to an ENT doc regarding some ear issues that arose in late March and haven't improved (and may have worsened). But I'm still stumped by the timing of my symptoms; that is, when they initially presented -- four days after a 107' dive and a 97' dive. What would delay the onset of symptoms for four days (tinnitus, minor hearing loss and now, a month later, some minor dizziness that is triggered by drops in barometric pressure)?

Does inner ear barotrauma take days to become apparent? (I experienced no pain and no difficulties clearing my ears during or after my dives.)

Or, could it be my problems are unrelated to diving? (ENT doc immediately ruled out all other causes when I said it was four days after a dive.)

Thanks -- trying to learn something here.

 

[TSandM]

I can't think of anything that would delay the onset of symptoms for four days, although changes in barometric pressure might take that long to occur . . .

But your symptoms could certainly be caused by a non-diving condition such as Meniere's disease.

You're looking for answers in the right place, with an ENT doc, but I think he's being a little short-sighted in not considering other diagnoses.

 

[DocVikingo]

Hi It'sNotLupus.

Given the facts that initial onset of the very first signs/symptoms of any sort was at least 4 days post-dive, a month later dizziness now results from changes in barometric pressure and the condition may have worsened over the interim, a diagnosis of DCI can almost certainly be ruled out.

As TSandM seems to suggest, a proper ENT evaluation probably has not yet been conducted. At a minimum, one would want to consider inner ear conditons such as Ménière's disease, perilymphatic fistula and even some types of infectious processes.

You well may wish to seek a second ENT opinion.

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice.

 

[It'sNotLupus]

Thanks, Doc and TSandM, for your insights and counsel. My visit today with the ENT doc was indeed a "second opinion visit." This doc doesn't see much connection to diving, but won't rule it out. He has ordered a CT scan and ENG test (tests not even mentioned during my first two visits with the initial ENT) and ordered no diving for another 6 weeks, until the dizziness issue is resolved. I'll report back on the test results if there's anything fruitful to share.

One thing I did learn today: in the ENT community, there are some who reject or disregard the notion of perilymph fistula. My first ENT is of this school (even terming it "hocus pocus," which led me to get a second opinion.) (Apparently, some surgeons were quick to diagnose -- and then perform surgeries to "patch" -- perilymph fistula, to make huge gobs of $$$. That lead to a backlash, with many folks saying, perhaps correctly, that the diagnosis was merely a ticket to a fast buck in the OR.) My "new" ENT won't dismiss out-of-hand that diagnosis, and is including PF as a possibility.

So, while a diagnosis still hasn't been made, at least some testing is being scheduled -- which is of some comfort. Not thrilled that I cannot dive, as I was hoping for a summer full of diving adventures, but there's always... yardwork.

 

[Lopaka]

One thing I did learn today: in the ENT community, there are some who reject or disregard the notion of perilymph fistula.

Interesting, isn't it? I am amazed at the differences in ENT's, having been to 4 of them over the last 6 years. Current ENT evaluating me (brain MRI on Monday) is middle of the road as far as I can tell. He is honest about PLF being extremely difficult to diagnose and said surgery for it is almost always not warranted for that reason.

 

[doctormike]

Important point of clarification (from an ENT doc) -

There is a condition called sudden sensorineural hearing loss (SSHL). It is, as the name implies, a sudden loss that is not related to fluid in the ear, etc... It is a "nerve" hearing loss which may be permanent. No one knows for sure what causes this, but many ENT doctors think that it might be a virus or the body's immune reaction to the virus. Because of this, the most common treatment is steroids, although even this has not been shown conclusively to work. This is actually a fairly common and terrifying condition.

Some docs have suggested that some cases of SSHL might be caused by a "spontaneous perilymph fistula", or SPLF.

It is well known that a leakage of inner ear fluid (a perilymph fistula, or PLF) can cause nerve hearing loss. PLF is usually seen after trauma, such as barotrauma (weight lifting, dive accidents other than DCI) or severe blunt trauma (e.g. auto accidents or assault). The proponents of SPLF say that maybe sometimes your ear just starts leaking inner ear fluid for no particular reason (or because of a pre-existing, undiagnosed weakness). They also feel that it can be fixed by surgery. The surgery involves opening up the middle ear and packing some material (fat or other stuff) around where a PLF occurs. Note that in most cases, you don't actually see the fluid leaking, you just put in the packing. There really is very little risk to the surgery itself.

SO, the proponents of SPLF surgery say that it helps, and that whatever your hearing level is afterwards, it would have been worse without the operation. The opponents of SPLF surgery say that it does nothing, and that these patients just have SSHL and that they don't need any operation.

Remember - PLF is real, and if it happens after trauma, surgery may save a patient's hearing. SPLF is controversial... A common question asked at ear surgery meetings is "do you believe in the fistula fairy?"

So In the context of SCUBA diving, I think that any sudden nerve hearing loss must be considered to possibly be caused by a traumatic PLF. This would NOT fall under the category of SPLF (if it's diving related, it is not "spontaneous")

Does that make sense..? I'm always happy to write more..!

 

[Lopaka]

So In the context of SCUBA diving, I think that any sudden nerve hearing loss must be considered to possibly be caused by a traumatic PLF. This would NOT fall under the category of SPLF (if it's diving related, it is not "spontaneous")

Does that make sense..? I'm always happy to write more..!

Good stuff Doc, thanks.