SSHL from Baro Trauma

[John S]

Hello all, hate to come on board like this, but I've got a BIG problem.

Although I am a SCUBA diver I was out on Maui last week and was snorkeling from a boat instead. I wasn't happy with just floating around on the surface and was free diving over and over and over to 25+ft to look at the turtles in caves etc. I was doing maxiimum breath holds and got lazy with my equalization, I was doing the valsava a LOT, but also putting up with some of the pain, knowing I would turn and be headed up in seconds. I very well over did a valsava or two after waiting too long.

Back at the boat I had ringing in my left ear that was noticeable (tinnintus) enough that I mentioned it to my wife and brother. I also noticed a slight loss of hearing that I was putting off to having water in my ear that I couldn't get out.
There was NO vertigo!

Noticeable ringing continued the following day.

Possibly unrelated, two days later we're at a beach and I'm playing in the surf with a Boggie Board and I get rolled so bad in a wave that I get beat to the botom and even hear my head hit the sand. I stood up dazed, had a headache that lasted 15 minutes and a sore neck.
That evening I noticed the ringing in my left ear was getting louder and I could tell my hearing was almost gone now in my left ear. Figured it must be blocked with wax and made an appointment.

One of two ENT's on Maui saw me, after a tuning fork and audiometry, diagnosed SSHL (sudden sensorieaural hearing loss), prescribed steroids (prednisone) and said good luck, prognosis is 50% on regaining hearing. Told me to follow up in Houston, TX.

EVERYTHING I read online says barotrauma induced SSHL normally requires surgery.

I've seen two ENT's today and both say surgery was kind of the old way and I should just see if it heals.

My research was CURRRENT medical papers and diving manuals.

I read that waiting to operate may cause even more damage.

I called DAN and they said any good ENT in Houston should be able to work through this, they had no one specific to recommend.

I called the Hyberbaric and Undersea department at Memorial Herman Hospital and they were interested until they found out I didn't have a SCUBA tank on my back when I did the damage, no special recommendation for a Dr.

The docs I've seen seem to cover everything ENT related and barotrauma certainly isn't anything normal to them.

The lack of vertigo really throws them off a PLF and they say they don't see any fluid in my middle ear.

ANY ADVICE appreciated. I need a Dr who understands barotrauma.

I'm an airline pilot and this could be career ending!
doctormike you there?

 

[doctormike]

I'm an airline pilot and this could be career ending!
doctormike you there?

Hey, John...! I read you five by five...



I will make a few general comments, and then send you some local referrals by PM. Also, I wouldn't go to a general ENT doctor, but to an otologist (an ENT doc who only does ear disease).

As you might recall from my other posts, it is very hard to diagnose anyone specifically over the Internet, and I usually discourage that. However, if you had an acute, new onset sensorineural hearing loss immediately after diving, it would have to be an extreme coincidence for that to be called an SSHL. Yes, technically it is "sudden" and it sounds like you have been determined to have a sensorineural hearing loss (as opposed to the typical conductive hearing loss that you would get from middle ear fluid or blood). However, SSHL really refers to a poorly understood entity of sudden hearing loss that is possibly related to an autoimmune process. And although people often give steroids for this - since it really doesn't hurt and there is some anecdotal evidence of it helping - a recent large analysis of multiple studies found that even with true SSHL steroids are not that useful.

Although I am not an otologist, and I haven't had the chance to see you, in the case of a sudden onset sensorineural hearing loss immediately after diving, I would assume that was a traumatic (barotrauma related) perilymph fistula (PLF) until proven otherwise. Unfortunately, the only way to "prove" that would be surgical exploration. The operation involves opening up the middle ear (by lifting the eardrum) and looking for a leakage of inner ear fluid. If this is found, it can sometimes be repaired. There are other things that may be done as well (such as preventing sudden increases in inner ear pressure by avoiding heavy lifting, straining etc…).

The bottom line is that if I were you I would see an otologist ASAP. He or she might agree that surgery is not indicated in your particular case, but it is at least worth checking out. I don't mean to imply that the doctors that you saw were wrong, since I'm not there and haven't been able to examine you myself, but from what you told me it is probably worth looking a bit further… You are correct that typically PLFs involve vertigo, but I don't believe that the lack of vertigo 100% rules out a fistula.

Feel free to keep us posted!

Best,

Mike

 

[John S]

Doctor Mike, thanks for your quick response, I am seeing an Otologist this morning and after making a phone call last night to a Unviversity of Washington Diving medicine Dr I was able to get a referral to an undersea doc in Houston, who called me at home first thing this morning and is opening the doors for me to the University of Texas inner ear specialists.

It seems to have taken me some work to get to the right people.

Persistance has been important in this matter and I'm now talking to people that I had been blocked from talking with when I originally called from Hawaii with my problem.

I will commit to keeping the board updated to the outcome of this matter. Reading through the threads it's tough when someone makes a post like this and then disappears without leaving the "rest of the story"

Thanks,
John

 

[doctormike]

Doctor Mike, thanks for your quick response, I am seeing an Otologist this morning and after making a phone call last night to a Unviversity of Washington Diving medicine Dr I was able to get a referral to an undersea doc in Houston, who called me at home first thing this morning and is opening the doors for me to the University of Texas inner ear specialists.

It seems to have taken me some work to get to the right people.

Persistance has been important in this matter and I'm now talking to people that I had been blocked from talking with when I originally called from Hawaii with my problem.

I will commit to keeping the board updated to the outcome of this matter. Reading through the threads it's tough when someone makes a post like this and then disappears without leaving the "rest of the story"

Thanks,
John

Excellent..! Keep us posted, and good luck!

Mike

 

[Duke Dive Medicine]

Hi John,
Concur with Dr. Mike. Sudden sensorineural hearing loss is a pretty generic diagnosis. To add a little info, only about 60% of divers who have a perilymph fistula experience vertigo. The most common symptom is a feeling of fullness in the ear. Tinnitus and high-frequency hearing loss are also common. Going by what you've written, PLF is certainly a possibility. If that's what it is, it may heal on its own or it may require surgery. If your symptoms are steadily improving, that's a good sign. Way to be your own advocate, and please keep us posted.
Kindest regards,
DDM

 

[doctormike]

Thanks, DDM!

One of the reasons why there is such a lack of good research data about PLF is that it is inherently a difficult thing to study. The gold standard would be to get a big series of patients with suspected traumatic PLFs, and randomize half of them into conservative management (e.g. avoiding heavy lifting and straining, bed rest, etc..) and the other half of them to surgical exploration. But this would not pass the ethical standards of a review board, so you can't really get that data.

If you just look at patients who underwent surgery (and PLFs are relatively rare, so it's hard to get too big a study group), you will find that some get better, some get worse and some stay the same. You find the same thing for people treated without surgery. But for any one given person, there theoretically must be a "right" choice - the problem is figuring that out.

You can always say that people who get better with surgery improved because of the operation, and you can say that people who did not improve would have gotten worse without the surgery. On the other hand, you can see improvement in some people who don't have surgery, so maybe those patients did actually heal on their own and improve.

So my understanding is (and remember, I'm not an otologist) that since there isn't much of a downside to the operation in skilled hands, surgical exploration of the ear is frequently recommended when the history strongly suggests a traumatic PLF (e.g. barotrauma).

Your mileage may vary!

Mike

 

[Duke Dive Medicine]

Hi Mike,
I think we both agree that in this case, PLF has to be assumed until ruled out. Between our clinic and the ENT clinic here, we recommend surgery when symptoms either worsen or don't improve within 24 hours of the event, as measured subjectively and/or by audiology. Like you said, your mileage may vary and I'm sure there are other opinions out there. At any rate, it sounds like John's in some good hands, so hopefully they can maximize his chances for a positive outcome.
Cheers,
DDM

 

[John S]

Hi guys,

Thanks for the interest. I wish I felt as sure of my current care as you guys. Today I saw an ENT surgeon who specializes in Neurootology, although not board certified in that area. (He does plastic surgery also) He is one of the senior Dr's in one of our multiple-location ENT groups here in Houston. Older gentlemen with undoubtedly lots of experience. He has been an ENT for 35 years.

He told me he could lay my eardrum aside and go exploring around but... his opinion was to avoid surgery because of my lack of vertigo, that I still have some hearing and because I can recognize words at 64%, so far. He thought surgery could worsen any of the above. His opinion was to wait to see if it heals further on its own, then start working toward a hearing aid.

I believe my profession as a pilot is possibly swaying a Dr from surgery, as he believes maybe I can get by with what hearing I have.

I still don't think I'm finding the right otologist with an endoscope. Someone with an understanding of the processes specifically involved with baro trauma. I really want / need a Neuro-otologist who also specializes or at least has a special interest in diving medicine/undersea. I haven't found that person and I'm frustrated.

Since the call I received this morning from the doc that formerly was over the Hyperbaric and Undersea program here in Houston I am now going to see a University of Texas surgeon (assistant professor) that I've been put in touch with. He will be back from vacation and see me for a consultation on Dec. 2. He's doing some interesting surgery, including with his endoscope (featured on Dr. Oz) but it is all types of ENT surgery and not just otology.

The lack of vertigo seems to throw the ENT people away from this being a fistula.

If it helps anyone understand my situation, my hearing loss, is interpreted in the Audiology assessment as "moderately severe rising to mild SNSL - conductive component @2K & 4KHZ" Threre was no "speech audiometry" done during the initial testing in HI, only my own "testing" by listening to voicemails on a cell phone. Originally nothing but squeaks, now I can make out most words with a clear talking person. Presently I test at 64% in a booth.

I'm really frustrated here. I still can't believe I did this to myself. It's a shame most divers won't take the time to see a post like this and realize how a little laziness can turn your life and your diving upside down. The saying if it hurts, DON'T DO IT! applies here.
This was totally preventable.
Gotta go, I think the jet engine idling in my ear is warmed up and ready for takeoff!

John

 

[Duke Dive Medicine]

The lack of vertigo seems to throw the ENT people away from this being a fistula.

A lot of divers we see here with perilymph fistula do not have vertigo. This isn't necessarily a symptom. You can feel free to ask your ENT to consult us, we're happy to speak with him directly and/or put him in touch with our ENT attending that works with us.

If it helps anyone understand my situation, my hearing loss, is interpreted in the Audiology assessment as "moderately severe rising to mild SNSL - conductive component @2K & 4KHZ" Threre was no "speech audiometry" done during the initial testing in HI, only my own "testing" by listening to voicemails on a cell phone. Originally nothing but squeaks, now I can make out most words with a clear talking person. Presently I test at 64% in a booth.

It sounds as if your symptoms are improving, which is a good sign. This also may be the reason they're advising conservative management. Is the tinnitus getting any better?

Hang tight for a while, I'll call Hermann when they open, see which ENT they use and pass you his/her contact info.

DDM

 

[Duke Dive Medicine]

John, updated info. The hyperbaric center at Memorial Hermann uses the ENT department in-house but did not have a recommendation for a specific physician. Not sure who you're seeing, but the number for the ENT clinic there is (713) 704-2384. Good luck, and thanks for keeping us posted.
DDM