Middle Ear Barotrauma Question

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Chris Ross

Contributor
Messages
695
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Location
Sydney Australia
# of dives
200 - 499
Had an ear issue on my last dive, we got a little lost in lowish vis and came up to get bearings and it was a little rough compared to entry point, conferred with buddy and decided to descend and follow wall back to exit. Descent was a little fast and I just started to feel the need to equalise when I heard a pop in right ear then instant vertigo. Normally equalising is not a problem for me and just swallowing on the way down is all that's needed. My buddy dragged me away from the wall and in a minute or so the vertigo settled. we swam back UW for a while then finished with a surface swim. I felt wiped out from the whole vertigo thing and vertigo was sort of hovering in the background. Dive time was about 40-45 minutes at this time maximum depth 17m, mostly around 15m.

I thought I must have damaged an eardrum as the sudden rush of cold water would explain the vertigo. I called DAN and they suggested I go see a GP to check the ear with no special requirements on who I saw. The doctor examined the eardrum and said it looked intact, gave me antibiotics as he said it looked like I had an ear infection as the canal of both ears looked a little red and to see my own GP the next day for follow up.

I had a bit of wax in my my ear canal and my GP had trouble examining the ear drum so he sent me to an ENT who cleared out the wax - he confirmed eardrum intact - said it looked "wet" due to the wax possibly holding fluid against the ear drum, I had some clear fluid drain that night. Ear was feeling full. No more fluid after that night.

ENT examined, had audiology done a couple of days later including bone conduction. which indicated no significant loss compared to other ear on bone conduction, but loss from the headphone test. Eardrum looked good he said and he could see there was fluid behind drum . Ear still feels a little full but improving and there is slight tinnitus. ENT said he hoped that would fade once fluid build up goes and indeed it seems improved when ear feels less full. Prednisone not used as bone conduction showed no significant loss of hearing and reluctant to give it in the current COVID situation as therapeutic dose will suppress immune system.

So a couple of questions.

If eardrum was/is intact - what caused the vertigo? ENT did not have a good answer but said sudden contact with cold water in one ear could do it. Connected with wax in ear canal? Is this something to explore further?

What criteria to use to return to diving? ENT suggested 1 month after ear feels good and try it in a pool first in case of any issues. ENT is not dive specialist but knew of the various issues surrounding diving and ears.
 
Hey @doctormike , how likely is it that an ENT could have missed a small perforation?
@Chris Ross, I see Australia. Were you diving without a hood? Asymmetric ear exposure to cold water can indeed cause vertigo (Google "cold water caloric") but it's uncommon without a hood. When vertigo does occur, its usually when trapped air inside the hood is suddenly replaced with sea water, but only on one side.

Diving Doc
 
Hi @rsingler thanks for the reply - No hood on this dive water temperature was 21°C (70 F) and there was definitely a pop preceding the vertigo. I was wondering is there was wax shielding the ear which suddenly moved to get cold water on the eardrum - but seems unlikely after being down about 40 minutes??

The severe vertigo was short lived I then had a few short episodes for about 2-3 hours after surfacing when I suddenly moved my head or stood up quickly, but it then settled down. The severe vertigo felt like I was rolling around at random back and forth like I was in a washing machine - the later episodes were more general dizziness.

I was also wondering about missing a small perforation The ENT saw the ear 4 days after the incident. Could a small perforation have healed by then? He only saw the full eardrum after removing wax - he commented the eardrum looked wet like skin that had been wet for some time. I saw him again 1 week later and he said it looked much better.

I'm basically interested to know if I should explore the issue further in relation to diving again once the ear settles down.
 
Doctormike can tell you how long you need to be cautious, in case there actually was an unrecognized perforation.
Without a hood, it sure sounds like a perf to me...
 
Hey, Chris...

It's usually hard to be specific about ear stuff over the Internet, nothing replaces a good microscopic exam. Can you post your audiogram? Do you know what tympanometry showed (type of curve and canal volumes)?

It's certainly possible for a small perforation to heal or to be missed with a handheld otoscope, especially if there is debris in the ear canal. There are a number of things that can cause vertigo when diving that could be applicable to you - the caloric response that @rsingler mentioned, altenobaric vertigo, or any sort of middle ear pressure spike that was transmitted to the inner ear. This can happen without a perforation or a perilymph fistula. I would certainly try diving in a pool before going in open water again, to make sure that you can equalize, etc...
 
Hi @doctormike, thanks for response. I don't have the audiogram, I do recall the tympanometry was said to be normal for left ear and curve almost completely flat for right ear.

To be clear the GP who examined used a handheld otoscope and ENT used a microscope arrangement on a support arm with a grommet in my ear to look through. (assume that's the right terminology), he then used that to suck out the wax and get a clear view. He first looked at the eardrum 4 days after the incident. Wondering is that was time enough to heal over?

I'm not trying for a diagnosis - more an indication if it's worthwhile digging deeper with another specialist with more diving background perhaps. It'd be nice to know the cause as well.
 
Hey, Chris....

If you have access to the actual audiogram and tympanogram, the crucial number is the "canal volume". There are two things which will give a flat curve on a tympanogram. Middle ear fluid of any type, OR an eardrum perforation. So you need the canal volume to distinguish between them.

Yes, a traumatic perforation can heal pretty quickly. On the other hand, I have seen patients where I examine the ear with a microscope, don't see a perforation, and I still get a flat (type B) tympanogram with a large canal volume, suggesting that there may be a pinhole perforation that is simply not visible.
 
https://www.shearwater.com/products/perdix-ai/

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