Inner ear barotrauma

[Barney1]

Well, I went and got myself some suspected inner ear barrotrauma. Free diving/spear fishing, hood on in 10 meters of water. Pretty aggressive profile. Basically, dive down to 10 meters, stay for as long as possible then surface. Rinse and repeat. I was on a flat bottom reef, so no gradations to my profile. Very minimal rest time on the surface. I was out for about 1.30 hours.

I did feel some stuffiness in my ears that evening, but thought nothing of it as it has always cleared before from diving, free diving and surfing. 4 days later I woke up with death in my right ear. Phoned 111 told to go to A and E. Doc told me to go home as there was no indication of ruptured eardrum, said he would refer me to audiology. While driving home (9.30 that evening) I actually got a call from audiology telling me to go back to the hospital and pick up some steroids and start taking them immediately. Pretty great if you know anything about the mess the NHS is in at the mo.

40mg a day till I was booked to see the ENT 5 days later. He diagnosed me with SSHL and mentioned barrotrauma. The audiogram confirmed the SSHL. Horrible graph to look at. Profound to severe hearing loss across all frequencies. He upped my dosage to 60 mg and told me that I should have been on that amount the whole time. 60mg for three days and a then 30 mg for another 3 days. 10 days total steroid course.

Went home and spun out a bit. Had hellish tinnitus for two days and then seemed to recover some hearing back. Tinnitus has subsided, but still omnipresent. Feeling a little more hopeful. Pandoras fault.

This the where I am as I write this.

So my queries are these:
• my total dose of steroids is 470 mg over 10 days. Should I have been on more for longer. Especially seeing as they are seeming to work.
• Is it a good idea to have steroid injections direct in the ear after the oral meds have finished. Doc never mentioned this and I am not booked to see him for another 5 weeks.
• did I have inner ear DCS? I know it is unlikely as I was not breathing gas at depth but my profile was pretty wild. The doc did not seem to investigate this. I’m now getting what feels and sounds like tiny bubbles escaping from my ear. Could have implications for treatments. HBOT?
• should I push for and investigation of a tear in the fistula?
• Can anyone suggest any other treatments. I’m on high dose omeg 3 (cod liver oil) vitamins (zinc, magnesium. B12…). Fruit and veg, high strength turmeric tea, spirulina, CBD gummies, Sleep, Nature sound baths and non-linear prayer (seriously). I have have also been eating a lot.
• Lastly . Does anyone know of a diving or related specialist ENT in the South West of England?


I realise specific madical advice is beyond the remit of a of scuba forum, but any insights, background info might be useful when organising my continuity care.

Thanks for taking the time to read this.

I just wish I knew more about all this before.

Look after your ears!

B

 

[Duke Dive Medicine]

Well, I went and got myself some suspected inner ear barrotrauma. Free diving/spear fishing, hood on in 10 meters of water. Pretty aggressive profile. Basically, dive down to 10 meters, stay for as long as possible then surface. Rinse and repeat. I was on a flat bottom reef, so no gradations to my profile. Very minimal rest time on the surface. I was out for about 1.30 hours.

I did feel some stuffiness in my ears that evening, but thought nothing of it as it has always cleared before from diving, free diving and surfing. 4 days later I woke up with death in my right ear. Phoned 111 told to go to A and E. Doc told me to go home as there was no indication of ruptured eardrum, said he would refer me to audiology. While driving home (9.30 that evening) I actually got a call from audiology telling me to go back to the hospital and pick up some steroids and start taking them immediately. Pretty great if you know anything about the mess the NHS is in at the mo.

40mg a day till I was booked to see the ENT 5 days later. He diagnosed me with SSHL and mentioned barrotrauma. The audiogram confirmed the SSHL. Horrible graph to look at. Profound to severe hearing loss across all frequencies. He upped my dosage to 60 mg and told me that I should have been on that amount the whole time. 60mg for three days and a then 30 mg for another 3 days. 10 days total steroid course.

Went home and spun out a bit. Had hellish tinnitus for two days and then seemed to recover some hearing back. Tinnitus has subsided, but still omnipresent. Feeling a little more hopeful. Pandoras fault.

This the where I am as I write this.

So my queries are these:
• my total dose of steroids is 470 mg over 10 days. Should I have been on more for longer. Especially seeing as they are seeming to work.
• Is it a good idea to have steroid injections direct in the ear after the oral meds have finished. Doc never mentioned this and I am not booked to see him for another 5 weeks.
• did I have inner ear DCS? I know it is unlikely as I was not breathing gas at depth but my profile was pretty wild. The doc did not seem to investigate this. I’m now getting what feels and sounds like tiny bubbles escaping from my ear. Could have implications for treatments. HBOT?
• should I push for and investigation of a tear in the fistula?
• Can anyone suggest any other treatments. I’m on high dose omeg 3 (cod liver oil) vitamins (zinc, magnesium. B12…). Fruit and veg, high strength turmeric tea, spirulina, CBD gummies, Sleep, Nature sound baths and non-linear prayer (seriously). I have have also been eating a lot.
• Lastly . Does anyone know of a diving or related specialist ENT in the South West of England?


I realise specific madical advice is beyond the remit of a of scuba forum, but any insights, background info might be useful when organising my continuity care.

Thanks for taking the time to read this.

I just wish I knew more about all this before.

Look after your ears!

B

Hi @Barney1 , sorry to hear this happened. To your questions on steroids, both the oral course and the injection, that's a question best discussed with your ENT consultant. If the tinnitus is subsiding and your hearing is coming back (subjectively) that would be an encouraging sign, but it would be helpful to have hard data like a follow-up audiogram. The time to investigate and treat a perilymph fistula would be immediately after the injury. If your ENT doesn't want to see you for five weeks one might conclude that he/she ruled that out, but that would be worth verifying with him/her immediately.

Unless you had been compressed-gas diving prior to free diving, the likelihood that this was inner ear DCS approaches zero.

For diving-related ENTs, you might consider contacting the UK Diving Medical Committee. Given the need for rapid intervention with fistulating inner ear barotrauma and your uncertainty about it, I'd recommend reaching out to them ASAP.

Did you have difficulty equalizing at any point?

Best regards,
DDM

 

[Barney1]

Thanks for the advice. It seems that the ENT has followed NICE guidance on steroid dose for SSHL. I’ve asked him if he thinks I should continue for a bit longer in them, especially as they seem to be working.

I’m not due for another audiogram for another 4 weeks or so.

I’ve asked the UKDMC for some advice , so will see what comes of that. As of today it seems as if my hearing has returned to near normal. Still not right. Like a radio trying to find a signal. And tinnitus.

It is highly likely I was forcing ear clearance. I certainly won’t be doing that again, if I ever do get back to diving that is. Bit of a depressing thought.

 

[Duke Dive Medicine]

Thanks for the advice. It seems that the ENT has followed NICE guidance on steroid dose for SSHL. I’ve asked him if he thinks I should continue for a bit longer in them, especially as they seem to be working.

I’m not due for another audiogram for another 4 weeks or so.

I’ve asked the UKDMC for some advice , so will see what comes of that. As of today it seems as if my hearing has returned to near normal. Still not right. Like a radio trying to find a signal. And tinnitus.

It is highly likely I was forcing ear clearance. I certainly won’t be doing that again, if I ever do get back to diving that is. Bit of a depressing thought.

SSHL and hearing loss related to inner ear barotrauma are not the same. I don't know that there are guidelines for steroids for IEBT. @doctormike ?

If your hearing is improving then that suggests that, if this was IEBT, it was non-fistulating and the damage may not be permanent. This does not automatically preclude diving in the future. I'd be interested to know what you hear from the UKDMC consultant.

You posted this early a.m. US East Coast time on Sunday, did it happen on Saturday?

Best regards,
DDM

 

[Barney1]

I guess from the point of view of the ENT the hearing loss is classed as sensorineural as opposed to conductive due to the the specifics of the audiogram. In sudden hearing loss the cause often unknown. In my case it is highly likely that it was due to Barotrauma given my recent diving. But the doc did say it was basically impossible to tell and that it was possible that my hearing loss was idiomatic and coincidental with the diving. In either case the first line response is steroids.
I checked the literature (medical journals) for treatments for both IEBt and SSHL and found that this was basically consistent with his approach. Although he did not suggest at all that I take it easy, rest up or take any time off work. He also did not seem to know about the possibility of a perilymph fistula. Or maybe he did and he was waiting to see what happened with the steroids. I don’t know. In any case my next appointment is not for another 4 weeks or so.
The steroid regime for both SSHL and IEBt seems to vary quite a bit and while it’s efficacy is inconclusive, a high dose taken as close to the onset of symptoms for at least a week seems to be the norm, with some indications that it can work.

The dive was on a Tuesday evening and the hearing loss was on the Saturday morning. This could give credence to the coincidence theory of SSHL.

I would really like to know what happened. As it stands my hearing is back but I am a bit worried that when I stop the steroids it will return.

I hope I can return to diving in the future, but I feel that my spearo days are up. I wasn’t any good at it anyway.

Will post an update on any outcome with the UKDMC if you like.

Cheers

B

 

[lowflyer]

I can't diagnose your problem, but I had inner ear barotrauma, as did a friend. In the words of an ENT, my ear was "dead". I will say that if you have inner ear barortrauma, you are very lucky if it is truly improving in this very short time frame. I was treated with steroids, and it took months for improvement to start. It was fully 6 months before it got almost back to normal. Same with the friend.

 

[Duke Dive Medicine]

The dive was on a Tuesday evening and the hearing loss was on the Saturday morning. This could give credence to the coincidence theory of SSHL.

Was Saturday morning when the hearing loss actually occurred, or when you first noticed it? That may sound like a silly question but the post-dive stuffiness you mentioned could have been a distractor. The time span may lend more credence to the sudden sensorieneural hearing loss as you said, but the close proximity in time to diving with symptoms of barotrauma and a reported forceful Valsalva maneuver is suspicious for barotrauma.

Best regards,
DDM

 

[doctormike]

The dive was on a Tuesday evening and the hearing loss was on the Saturday morning. This could give credence to the coincidence theory of SSHL.

If this is accurate (symptoms 4 days after diving), it's SSHL, and not IEBT. In which case, steroids is the standard treatment, with intratympanic injection being recommended for severe cases or those that do not respond to oral steroids. Note that steroids may be used in iEBT as well, although there the question of something like a fistula and surgical management is considered.

Just to be clear, IEBT and SSHL are both types of sensorineural hearing loss, different from the much more common conductive hearing loss that comes from fluid or blood behind the tympanic membrane associated with middle ear barotrauma.

I go over this all in some detail here: Michael Rothschild: Ear Problems & DIving

And here: Michael Rothschild: Ears & Diving part 3

And to silt things up even further, there was at least one large meta-analysis that showed no benefit to steroids in SSHL! But if I had it, I would definitely take them. Sometimes there are undettected subgroups that may benefit even if the larger group doesn't.

 

[Barney1]

‘If this is accurate (symptoms 4 days after diving), it's SSHL, and not IEBT.’

Hello Dr Mike, it’s tricky because as Duke mentioned it is possible that my stuffy ears were masking the onset of the hearing loss before waking on Sat morning. I didn’t have complete hearing loss upon waking but it progressed pretty rapidly throughout the morning.

From my understanding IEBt is mostly felt pretty rapidly after the actual trauma takes place, often during an accent. But that it has been ‘diagnosed’ as occurring up to 72 hours after an event. Plus, there will always be outliers.

I don’t know. The ENT doc said SNHL due to barotrauma. I haven’t seen my record yet but it will interesting to see exactly what he has written. And it would be a wicked coincidence. Perhaps some kind of link between the two?

Have you come across the review article by Elliot, E and Smart, D (2014) The assessment and management of inner ear barotrauma in divers and recommendations for returning to diving.

I found this pretty informative. Plus others. Your own article was also really useful.

Cheers

B

 

[doctormike]

‘If this is accurate (symptoms 4 days after diving), it's SSHL, and not IEBT.’

Hello Dr Mike, it’s tricky because as Duke mentioned it is possible that my stuffy ears were masking the onset of the hearing loss before waking on Sat morning. I didn’t have complete hearing loss upon waking but it progressed pretty rapidly throughout the morning.

From my understanding IEBt is mostly felt pretty rapidly after the actual trauma takes place, often during an accent. But that it has been ‘diagnosed’ as occurring up to 72 hours after an event. Plus, there will always be outliers.

The most important sentence in medicine is "there is a bell curve for everything"

I don’t know. The ENT doc said SNHL due to barotrauma. I haven’t seen my record yet but it will interesting to see exactly what he has written. And it would be a wicked coincidence. Perhaps some kind of link between the two?

Have you come across the review article by Elliot, E and Smart, D (2014) The assessment and management of inner ear barotrauma in divers and recommendations for returning to diving.

I found this pretty informative. Plus others. Your own article was also really useful.

Cheers

B

Yup. Hang in there, hopefully things will improve soon. You may never get a real "answer" about what happened. Imaging almost never shows a bony capsule defect associated with IEBT, and even at surgery, the diagnosis of PLF is often questionable. So we do what we can...