Diving with a history of eardrum ruptures.

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genericusername

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This is a long post. If you have experience diving with various earplug/ear-covering masks, and/or have discovered some secret workaround for eardrum perforation events, please read on. I really could use your advice. I'll underline the questions so it is easier to scan.

In the last 6 months, I perforated my left tympanic membrane (eardrum) twice. I'm looking for advice on how to best continue diving despite a high risk of having it happen again. All the authorities say that if your eardrum is actually blown, you need to stop diving until it heals completely. (That is certainly the conservative thing to do, though there may be options that will save your dive trip. I'll talk about these at the end.) However, it is less clear what to do if you have a history of blow outs.

Scuba-doc says that a history of tympanic membrane perforation is a "relative contraindication" for diving. In other words, a pretty good reason to quit. DAN is a tad less conservative. They have lots of advice on how to decrease risk of rupture; clear before you even get in the water, descend slowly & clear often and gently, when possible use a line to descend to help you go slowly, descend feet first, etc. All of these are good tips to try to avoid a blow out. But, is there a way to insure that no water gets into your middle ear if you do rupture during a dive? Given my history, I'm certain that, no matter how carefully I clear, it will happen again.

You might be asking, "What's the big deal if it ruptures?" That's what I used to think. The references say you might experience vertigo and have a chance of an ear infection. Let me tell you that this doesn't begin to capture the problem. The first time I had a blow out, it happened on surface after a night dive. Since it was at the end of the trip and there was only one more dive left, I simply did the conservative thing, and skipped the last dive. I had some muffled hearing, a little dizziness, and a some mild discomfort from a little water getting in my middle ear. The rupture healed over in a few days and the fluid eventually drained. I was all back to normal in a few weeks. The whole thing was not a big deal.

But this last time, just about a week ago in Hawaii, was much more dangerous. I was doing a shore dive at night. We swam a couple hundred yards at surface, then dropped. At only 10 or 15 feet, I cleared and felt air go out through my eardrum and then the water flood back in. I can only describe what I felt next as extreme vertigo. Like the last few seconds you're awake when going under general anesthesia, the world began to spin rapidly in three dimensions, everything went blurry, I lost track of up and down, and I was almost certainly going to vomit. I stayed calm. Inflating my b/c could rocket me upwards and I knew the bottom was sandy and only at about 10 feet away. Instead of trying to go up, I just waited until I hit the ground, which I did a few seconds later, shoulder first. I had a bunch of camera gear that I knew was slightly negative. I reached away from my body and dropped them. With my hands free, I tried to orient opposite the ground. Then I swam slowly, exhaling shallow breaths, until I hit surface. I inflated my b/c, pulled my mask, and called out for my buddy who I thought had not yet descended. There were a few other divers with us, and the top-side world was all swirling flashlights and darkness. Very off-putting and disorienting. I couldn't hear well but I could hear my buddy tell me he was coming. I lay on my back, keeping my head out of the water, and started blowing water out my ear by "clearing" with my nose pinched. I was certain that I was going to hurl. My buddy and I had a raft at surface for camera gear, which he took me to. I held on to that while he retrieved the cameras from the bottom and swam me, the gear, and the raft in. The whole time I worked on getting the water out of my middle ear. I blew water out, shook my head, blew again, tilted my head another way, blew again, etc. The dizziness started to subside. By the time we got back to shore, I could see straight, and walk my own gear out on the rocky shore. I never did hurl.

I tell this story because I hope it serves as a warning that this is not a minor injury. In many situations (e.g. on a wall or in blue water) this strategy wouldn't have worked. I couldn’t read my gages so I could easily have swum down for a while thinking it was up. Or, had I been at any appreciable depth, I could have gone horizontal a great distance from my buddy before surfacing. I've done a lot of thinking about how I'd handle this in the future, but have realized that if I'm to continue to dive, I need to find a way to keep my ears dry. That way, if I blow my drum again, I can avoid the vertigo. Also, I tell this story because, none of the references I've seen tell you what to do if you do flood your middle ear. I had one ENT tell me not to blow air out on purpose, but if I hadn't pushed to get the water out right away, I'd have been in the ER for sure.

If your eardrum is already blown and you really want to dive, you can try to keep it dry by completely plugging the ear water tight. So long as it doesn't leak, you should be fine. It's risky, but doable. I do wonder what that would feel like in your other ear when you try to clear, and if the air you're pushing out through your eardrum would eventually pop most plugs. Anyway, this won't help me most of the time because you can't put a water tight seal on an ear with an intact eardrum. If it isn't obvious why you can't, DAN has a pretty good description on this page.

Vented earplugs like Doc's Proplugs say they can help. Reviews on this site and others suggest they may reduce the chance of a blow out by easing clearing, but they don't keep the ear dry. The vent lets water in your ear canal, right? Therefore, if you do blow a drum, your middle ear will still get wet with these plugs? They say the water will be warmer due to the reduced flow, therefore, the vertigo should be decreased. That simply doesn't comfort me very much. If you are a user of these plugs, am I correct in my understanding of how they work, and their limitations?

The only other option seems to be the ProEar masks. These silly contraptions keep your ears dry by enclosing them in little "masks" of their own. These spaces are connected to your mask so air can flow freely. Despite how silly they look, they seem like the solution. I've read reviews on this site and it seems the mask works, that you need to practice with it, that you can have some troubles creating too much pressure yourself, and that most people with trouble clearing seem to think it helps. But has anyone ever used a ProEar mask with a ruptured eardrum? How does that effect the system? Can you clear your good ear OK? Do you end up drizzling air from the bad ear's cup when you clear?

Then, has anyone every tried combining the vented Proplugs, with the ProEar mask? Would that provide more protection, or just screw both gadgets up? Are there any other options? Can I get a replacement eardrum?

If you've read all this, thanks for your interest. If you can offer informed advice, thanks even more.
 
I had an ear drum blown out do to over pressureization (SP?) from a 9 mm fired at point blank range.

It took over a year before I could equalize. I didnt go back into the water until it was completely healed.
 
First, have you had your ear checked by an ear doctor? Your eustachian tube may not work very well on the side which blew out. Your medical history, bad strep throat, scarlet fever, allergies, etc. may be part of the problem.

The first instance you describe is a reverse squeeze. The symptoms of the second occurance are a very compelling cautionary tale.

I have had two tympanoplasties, the first one didn't take, 30 years later I tried again. Then I went diving. I suffered a reverse squeeze in my right ear, in cooler water, on my 35th dive. I didn't perceive a perforation immediately, but on my second dive that day I noticed I had a pin hole at 60 feet. I didn't flood my middle ear, so no vertigo. Since I had a hood on, I just kept pushing air into my ear canal, sort of kept my right ear down and maintained a bubble to keep the ear dry. Finished the dive, then contacted my ear doctor. Things healed quickly without complication.

I decided to use a Pro Plug in my right ear. Things worked ok for more than 20 dives, but during a dive week in Bonaire that damn pin hole reformed. Since the Pro Plug was in my ear, I could maintain a bubble in my outer ear canal, thus keeping my middle ear dry and not sufferring infection or vertigo. This is not the best medical practice, but we all know how alluring diving is.

For the last third of the trip I used the Pro Plug and kept diving, though just once a day. I did a little modification to it. I put a thin bead of silicone ear plug material around the perimeter of the Pro Plug, so I could really seal it to my ear and maintain the bubble. It is very important not to get the hole in the Pro Plug clogged in any way, no wax, dirt or silicone. Blocking the hole would almost guarantee a ruptured eardrum.

My conclusion is that the Pro Plug would be a possible solution for you. By permitting you to control the outer ear canal, it can help minimize the effects of a ruptured eardrum at depth. My modification with the silicone sealer around the perimeter is a possible risk factor for clogging the hole in the Pro Ear plug, but it really let me control my ear.

I am also thinking very strongly about the Pro Ear mask myself, though I would combine it with Pro Ear plugs.

Finally, I use Sudafed tablets to help make sure my sinuses are clear. The four to six hour version is easier on your system. Sudafed can raise your blood pressure and could possibly interact with other medications. Affrin nasal spray also works, but it starts to clog you up with more than a couple of days use. Taking an antibiotic along on a diving trip, if you have ear issues could help prevent infection if you rupture your eardrum.

A final caveat, most of what I just related should not be construed in any way, shape, or form as proper medical advice. I had a perforated ear drum for over 20 years, so I am familiar with being able to move air through my ear. The perforation I suffered from diving was a very small one, a pin hole. I already have a hearing loss on my right ear and am willing to screw around with that ear.......a little bit.
 
That is very helpful advice. Thank you. I had time to react but didn't think in terms of maintaining a bubble of air. At the very least, that could have put me back on surface more safely. I do think I had time to react, if I had known better what to do.

Your experience with the ProPlug, and interest in the ProEar, are extremely helpful as well. I will probably just get both and just start experimenting in the pool. I've got a trip coming up in 5 weeks, so I have to move quickly.

I do have a history of ear surgeries. Tubes in both ears 7 or 8 times as a young child. So I have a lot of scar tissue on my eardrums. Before I started diving as a teenager in the 1980's I went to a diving ENT (evidence of his diving in the form of his own underwater photographs all over the walls of his waiting and examining rooms) who told me I was more at risk for a blowout, but that so long as I knew the risks, I should just be careful. He advised Sudafed and tons of Affrin before each dive.

I dove a bunch in the 80's and early 90's and never had a problem. Then I took about 10 years off and came back to diving in a big way just this last year. Both of my blowouts are since my return to the sport. Since DAN and PADI both now advise not to use Sudafed, I skipped it. Also, I probably haven't been spraying the gallons of Affrin that I used to into my head. I probably should just go back to using both like I used to. (I have started to dive Nitrox, and you definitely don't want to take Sudafed on Nitrox since it increases the risk of O2 toxicity. But the Affrin isn't a problem and I rarely dive Nitrox.) After the first rupture, I saw two ENTs (neither a diving specialist) who gave me the same diagnosis. My Eustachian tubes are small and my eardrums are scarred. Now I've got prescription Nasocort or Rhinocort, one of those local steroidal sprays I use each day. But I still use Affrin before each dive.

I think that through a combination of more concerted decongesting, knowing better what to do if it happens again, and some protective equipment, I can make it work. And of course, I promise not to blame you or anyone else if it doesn't. I know the risks.

Thanks for taking the time to give such a thoughtful reply.
 
Wow, you sure had a lot of tubes installed. A brief bit about the anatomy of the the eardrum. It has a relatively strong fibrous center layer sandwiched between two vascular layers. Your tubes probably weakened the fibrous layer, making your eardrums more prone to ruptures.

A person with tympanoplasty has probably lost much of the total structure of their eardrum. The reconstruction will create an eardrum of sorts, but with a significantly weaker structure overall. This is because the fibrous center layer is missing. I have asked, but there is no way to create a stronger tympanoplasty.

Be safe, go slow with those descents and ascents.
 
Hi gert7to3,

Thank you for the lesson in tympanum anatomy.

I'd like to follow up on your concluding remark, "Be safe, go slow with those descents and ascents."

The inquirer provides a history of 7-8 myringotomies as a child with the expected surgical scarring and weakening of structure. In addition, it would not be unreasonable to assume possible harm to the middle ear from many bouts of apparently severe otitis media. Two ENTs have diagnosed "small" Eustachian tubes.

She goes on to indicate a history of ruptures of the left tympanum, with two perforations while diving within the past 6 months. The most recent incident, about two weeks ago in HI, resulted in vertigo of life-threatening severity.

She uses a nasal steroid daily, Afrin when diving and also would be taking Sudafed except for cautions she's read from PADI and DAN, and is considering going to the extreme of simultaneously wearing both Proplugs and a ProEar mask.

She states, "Given my history, I'm certain that, no matter how carefully I clear, it [rupture] will happen again." I think this probably is accurate.

Considering the above in total, do you believe that persisting with scuba when there is a substantial likelihood of a serious diving accident with possible loss of life and a permanent reduction in hearing is a wise idea? Is it fair to her dive buddies and those who care about her?

Thanks,

DocVikingo
 
genericusername:
Then, has anyone every tried combining the vented Proplugs, with the ProEar mask? Would that provide more protection, or just screw both gadgets up? Are there any other options? Can I get a replacement eardrum?

Yes. The wife of a major authority in diving medicine dives with either a permanent hole or an easy ruptured ED and dives with both devices.

I also have several patients with ED issues who dive with either the proplug or the ProEar.

However, to dive reasonably safe with these devices you MUST see a diving doctor to insure the fitting and counseling for its use is well understood.
 
Hard hat diving? Not that I've ever seen it in a recreational context, but that would certainly keep the middle ear dry in the event of a ruptured eardrum.
 
To DocVikingo, I would have to agree with your conclusion.

My use (and abuse) of Pro Plugs was not meant to be gonzo cheerleading.

I still regard the Pro Plug as a means to control a potentially problematic ear.

Your counsul is well taken.
 
Doc Vikingo certainly offers an important perspective. But I think it is a bit extreme. I prefer "Saturation," the medical moderator's, perspective. I don't think I'll stop diving. I will however take a number of additional precautions and add some equipment to my rig. I'll always inform my buddy so they know what's happening if something looks wrong. And I'll probably temper my interest in more extreme technical diving and any overhead diving where self rescue is much more difficult. I am trying to find a good diving ENT in New York (upstate if possible) and follow Saturation's advice to get a professional opinion and fitting of new equipment as well.

So Doc Vickingo thanks for the stern warning and advice, but I'm not going to follow it.

Now the hard hat idea... That one sounds interesting.
 

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