Inner ear barotrauma
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OP
In the hot, sunny S.W. of USA.
I don't know whether you guys are ENT and whether you see this problem often, but because you seem interested, I'll expand for the purpose of adding another "case."
I am a DM for fun and assist instructors. On day one I did two dives to only 35 ft in water with poor visibility. I noticed a bit more trouble equalizing than normal but was more focused on the students, keeping them together. After the two dives I felt a fullness in the left ear and figured it was mucous/blood in the middle ear. I dove the next day to 50 ft once and then to 30 ft. but with some ascending and descending. I had no trouble equalizing on day two.
Over the next two days I lost hearing in the left ear. No vertigo. It wasn't a sudden loss after the dives. I called DAN. The person I talked to didn't diagnose but was clearly sure it was middle ear barotrauma, mainly because I didn't have vertigo. I support DAN, but LESSON #1: you don't know who you are talking to there and whether they really know anything. DAN suggested I go somewhere and see if there was blood behind the T.M. I went to my doctor's office, where a nurse practitioner said there was blood, implying middle ear barotrauma. LESSON #2: Don't rely on people without much training or experience.
I have a tuning fork and determined there was likely sensory loss and luckily got into an ENT, who did the work up described above (no blood or fluid in the middle ear, by the way)
LESSON #3: If you have a medical issue related to diving (or anything else), get yourself to the highest authority. If you have to climb there through intermediaries, do it but get there.
The ENT doc put me on high dose prednisone. He felt that surgery would not be useful unless there was a fistula, and he didn't think there was for whatever reason (maybe lack of vertigo, he didn't say) After five days I started noticing some noise besides tinnitus in the ear, and every day there has been a bit more external sound. Not useful sound yet but maybe some hope. It was totally dead to start with. Will have another audiogram in a couple of weeks.
Don't usually put myself out there, but maybe someone will find the story useful
I don't know whether you guys are ENT and whether you see this problem often, but because you seem interested, I'll expand for the purpose of adding another "case."
I am a DM for fun and assist instructors. On day one I did two dives to only 35 ft in water with poor visibility. I noticed a bit more trouble equalizing than normal but was more focused on the students, keeping them together. After the two dives I felt a fullness in the left ear and figured it was mucous/blood in the middle ear. I dove the next day to 50 ft once and then to 30 ft. but with some ascending and descending. I had no trouble equalizing on day two.
Over the next two days I lost hearing in the left ear. No vertigo. It wasn't a sudden loss after the dives. I called DAN. The person I talked to didn't diagnose but was clearly sure it was middle ear barotrauma, mainly because I didn't have vertigo. I support DAN, but LESSON #1: you don't know who you are talking to there and whether they really know anything. DAN suggested I go somewhere and see if there was blood behind the T.M. I went to my doctor's office, where a nurse practitioner said there was blood, implying middle ear barotrauma. LESSON #2: Don't rely on people without much training or experience.
I have a tuning fork and determined there was likely sensory loss and luckily got into an ENT, who did the work up described above (no blood or fluid in the middle ear, by the way)
LESSON #3: If you have a medical issue related to diving (or anything else), get yourself to the highest authority. If you have to climb there through intermediaries, do it but get there.
The ENT doc put me on high dose prednisone. He felt that surgery would not be useful unless there was a fistula, and he didn't think there was for whatever reason (maybe lack of vertigo, he didn't say) After five days I started noticing some noise besides tinnitus in the ear, and every day there has been a bit more external sound. Not useful sound yet but maybe some hope. It was totally dead to start with. Will have another audiogram in a couple of weeks.
Don't usually put myself out there, but maybe someone will find the story useful
Thanks so much for the details! Yes, I'm an ENT doc (pediatric ENT, but I see a lot of divers just because I have a lot of diver friends).
Sounds like DCS is unlikely given the profile, but not impossible - there will probably be interesting data about this in the next few years. The inner ear seems to be more susceptible to decompression injury than other tissues.
The big combination studies (meta-analysis) of steroids in sudden sensorineural hearing loss (SSNHL) show no clear benefit. However, (1) that doesn't mean that there might be subsets of people who do respond, and (2) diving related injuries are clearly not the types of injuries that most of these studies look at. If I had a SSNHL, for any reason, I would absolutely take steroids - very little downside.
Exploration for a PLF is controversial for a lot of reasons beyond the scope of this discussion, but there are probably very few people who really have that without vertigo. Again, not a lot of downside to a middle ear exploration, but not routinely done.
This is an incredibly important insight. I think that general docs and NPs usually know a lot more than I do about most things. HOWEVER (and it's hard to say this without sounding arrogant), my experience after 25 years of practice is that any ear exam by someone who is not an ENT or a pediatrician is rarely accurate. The average doc just doesn't see enough normal and abnormal ears to get proficient with this exam. If I ever hear that another doc thought that the ear looked "a little red", I know that the patient didn't get a real exam.
Good luck wth your recovery. If you want a second opinion, PM me your zip code and I'll see if I know anyone in your area.
Sounds like DCS is unlikely given the profile, but not impossible - there will probably be interesting data about this in the next few years. The inner ear seems to be more susceptible to decompression injury than other tissues.
The big combination studies (meta-analysis) of steroids in sudden sensorineural hearing loss (SSNHL) show no clear benefit. However, (1) that doesn't mean that there might be subsets of people who do respond, and (2) diving related injuries are clearly not the types of injuries that most of these studies look at. If I had a SSNHL, for any reason, I would absolutely take steroids - very little downside.
Exploration for a PLF is controversial for a lot of reasons beyond the scope of this discussion, but there are probably very few people who really have that without vertigo. Again, not a lot of downside to a middle ear exploration, but not routinely done.
This is an incredibly important insight. I think that general docs and NPs usually know a lot more than I do about most things. HOWEVER (and it's hard to say this without sounding arrogant), my experience after 25 years of practice is that any ear exam by someone who is not an ENT or a pediatrician is rarely accurate. The average doc just doesn't see enough normal and abnormal ears to get proficient with this exam. If I ever hear that another doc thought that the ear looked "a little red", I know that the patient didn't get a real exam.
Good luck wth your recovery. If you want a second opinion, PM me your zip code and I'll see if I know anyone in your area.
OP
Dr.Mike, I don't think that is arrogance. I'm a retired rheumatologist and know what I was good at and what I wasn't good at. Maybe back in Osler's time a smart doc could know just about all that was then known.
Do you see any significance in the fact that the hearing loss didn't occur immediately during or after the dive, but one to two days later?
Thank you for your interest and insight!
Do you see any significance in the fact that the hearing loss didn't occur immediately during or after the dive, but one to two days later?
Thank you for your interest and insight!
Sure!
Obviously you are best equipped to know the exact course of the symptoms. However, I will say this - when I have audiometric data I rely on it more than on subjective symptoms. I have always been impressed at how the symptoms and actual pathology don't always track perfectly. I have people who swear that they have a new onset of a hearing loss who have a flat normal audiogram, and other people who are surprised when they see how much their audiogram has changed. You did say that you felt fullness in the left ear right after the dive as well, so it's possible that the onset of whatever injury you had was earlier than you thought.
IEDCS more commonly involves vertigo than hearing loss, while the reverse is true for IEBT, so your symptoms do favor the latter. Delayed onset could be the case if there was poor middle ear ventilation with the pressure transmission to the IE happening later as you attempted reventilation on the surface (although the doc you eventually saw didn't see effusion or blood at the time).
However, I wouldn't totally discount the idea of inner ear DCS. This is an area of research that I am watching closely, and it seems that the inner ear isn't necessarily subject to the same "rules" that we assume for clinical DCS in other tissues. Specifically, profiles that might seem "benign" could put a diver - especially one with a PFO - at risk for IEDCS. Here is an article that discusses theories of pathophysiology:
Inner-ear decompression sickness: 'hubble-bubble' without brain trouble? - PubMed - NCBI
It may be a moot point in your case, but recompression has been shown to help SSNHL in divers without a specific diagnosis of IEBT vs IEDCS. This maybe be because it improves tissue oxygenation which is helpful for ischemic or traumatic injury independent of a history of DCS, or it could be because a lot of what we diagnoses as IEBT is actually IEDCS, because the inner ear is uniquely susceptible to this.
Hyperbaric oxygen therapy for sudden sensorineural hearing loss in divers. - PubMed - NCBI
Good luck!
Mike
Mike, great post. I might add that unless the OP is a profound bubbler, it's highly unlikely that there would be clinically significant VGE after such benign dives (though the article you linked does question this mechanism of injury). You mentioned hyperbaric oxygen for idiopathic sudden sensorineural hearing loss. This (for the benefit of others) is the newest indication for HBO approved by the Undersea and Hyperbaric Medical Society. For clarification (again for others reading), if inner ear barotrauma is the suspected cause of the SSHL, hyperbaric exposure would be contraindicated due to the risk of aggravating the injury. However, if the diagnosis of IEBT vs IEDCS is unclear, recompression, with great care taken during ambient pressure changes, would be indicated.
Best regards,
DDM
Best regards,
DDM
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Yup, and thank to you for putting this into context! DDM is the real hyperbaric medicine expert here, I just dig out earwax to pay for my sorb.
This discussion is probably a bit beyond the scope of this forum, but I think that in the next few years we will see some clarification on this point. SSNHL that is diving related presumably has SOME relation to either barotrauma or decompression. Unfortunately, neither of these diagnoses are typically made with certainty, so I'll bet that the threshold for recompression goes down in the future. Yes, you could aggravate IEBT with recompression if it was quick and if the patient couldn't equalize well, but for people with a significant hearing loss going in, balancing the risks and the benefits would probably favor recompression anyway. Even when exploring an ear for a PLF, you often have to convince yourself that you see a little bit of perilymph pooling in the middle ear. So you pack in a fat graft, and then if the patient doesn't end up with a dead ear, you congratulate yourself for stabilizing the process!
I think that there is a lot of underdiagnosed DCS out there. We all bubble, and not every bubble causes a spinal cord hit. Bubbles cause tissue inflammation, and we may all get a little bit of this on every dive. There are so many vague complaints of tiredness, muscle aches, ill defined and transient neurological symptoms, etc... If we really had a good marker for DCS, we would probably make that diagnosis more often.
Also, there are real psychological disincentives to make that diagnosis. Active divers don't want to be told that the thing that they love is more dangerous for them than they think. 25% of the divers reading this thread have a PFO - many don't want to know if they have it because of the implications.
While it's true that most experienced divers looking at the OPs profile would dismiss the idea of DCS, once again the inner ear seems to be different than other tissues. Time will tell!
This discussion is probably a bit beyond the scope of this forum, but I think that in the next few years we will see some clarification on this point. SSNHL that is diving related presumably has SOME relation to either barotrauma or decompression. Unfortunately, neither of these diagnoses are typically made with certainty, so I'll bet that the threshold for recompression goes down in the future. Yes, you could aggravate IEBT with recompression if it was quick and if the patient couldn't equalize well, but for people with a significant hearing loss going in, balancing the risks and the benefits would probably favor recompression anyway. Even when exploring an ear for a PLF, you often have to convince yourself that you see a little bit of perilymph pooling in the middle ear. So you pack in a fat graft, and then if the patient doesn't end up with a dead ear, you congratulate yourself for stabilizing the process!
I think that there is a lot of underdiagnosed DCS out there. We all bubble, and not every bubble causes a spinal cord hit. Bubbles cause tissue inflammation, and we may all get a little bit of this on every dive. There are so many vague complaints of tiredness, muscle aches, ill defined and transient neurological symptoms, etc... If we really had a good marker for DCS, we would probably make that diagnosis more often.
Also, there are real psychological disincentives to make that diagnosis. Active divers don't want to be told that the thing that they love is more dangerous for them than they think. 25% of the divers reading this thread have a PFO - many don't want to know if they have it because of the implications.
While it's true that most experienced divers looking at the OPs profile would dismiss the idea of DCS, once again the inner ear seems to be different than other tissues. Time will tell!
