SSHL from Baro Trauma

[doctormike]

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.

The American Board of Medical Specialties recognizes ENT as a specialty, and there is an ENT board exam in that which we all take. All of the subspecialties of ENT (facial plastics, pediatric ENT, head and neck cancer surgery, otology/neurootology, sinus, etc..) have been maneuvering and discussing adopting further certifying examinations (Certificates of Added Qualifications, or CAQ) over the past decade or so. I know that there is none for pediatric ENT yet, but the otologists recently started giving one. So while many otologists right now are not "board certified", practicing otologists will be taking the test now that it is available...

However, most dedicated, academic otologists only do ears, so I'm not sure what to tell you about your doctor who also does plastic surgery. There are certainly many experienced general ENT doctors with a lot of experience in ear surgery, so he may be a fine person to see. Again, I can't advise you specifically, as you know...

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 ran this by a friend of mine who is an otologist, and she said that she would explore a patient with an acute sensorineural hearing loss after a diving injury even in the absence of vertigo. She didn't think that there was much risk of worsening the hearing with a simple exploration in experienced hands. On the other hand, if you are really recovering, then conservative management might also be appropriate - again, can't say specifically. And whichever approach you take, you will never know what would have happened with the other approach! Sorry, I know that this is a hard call...

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.

I wouldn't put too much emphasis on the endoscope, even with that technology, a leak can be pretty hard to see. There is much better visualization by exploring the ear with an operating microscope at surgery.

Also, I asked my otologist friend for a recommendation in Houston, and she gave me the name of Dr. Horwitz (here is his Web page).

 

[John S]

Thanks again for the advice DDN and doctormike. I've followed up on ALL the advice given.

Beside the general Otoronologist surgeon I'm seeing next week, I've added one appointment with an Otology specialist who works with the Baylor College of Medicine.

I've scheduled myself for new audiology testing on Monday to check for improvement, so I have current reports to take with me on my rounds.

Presently the tinnitus shows no change and I am concerned with my hearing ability with my good ear if it doesn't improve.

On the positive side, when scratching my skull just behind my left ear and I can hear the scratching sound now, this was not the case just two days ago. I also believe I can hear a voicemail better through my cellphone. (very unscientific)

I do seem to be getting some hearing back, it just remains to be seen how far it can go. Doctormike I've read some studies on direct injection of steroids into the ear giving some patients a 20db rise in hearing, anything you're familiar with, I need every db I can at this point.

Thanks,
John

 

[doctormike]

On the positive side, when scratching my skull just behind my left ear and I can hear the scratching sound now, this was not the case just two days ago. I also believe I can hear a voicemail better through my cellphone. (very unscientific)

Actually, that's not so unscientific... you may be recovering some function..!

Doctormike I've read some studies on direct injection of steroids into the ear giving some patients a 20db rise in hearing, anything you're familiar with, I need every db I can at this point.

Thanks,
John

As far as I know, that is not for traumatic perilymph fistula, but for sudden sensiorneural hearing loss (discussed above, thought to be an inflammatory, viral or autoimmune condition). It is a variation on giving oral steroids. The most recent meta-analysis (summary of a bunch of papers) that I saw didn't see much benefit of steroids, even for SSHL.

I have heard about a "blood patch" procedure which involves injecting some of your own blood into the middle ear, to form a clot and help seal the leak, but I don't know anyone who does that...

If you are interested, here is a video of the middle ear exploration and grafting procedure...

Happy Thanksgiving, everybody...

Good luck, John... keep us posted!

Mike

 

[John S]

Actually, that's not so unscientific... you may be recovering some function..!

If you are interested, here is a video of the middle ear exploration and grafting procedure...

Doctormike, quite the interesting video! The process of the surgery had been part of my online searches, but I never thought to look for a video.

Things are continuing to change. Yesterday the main tinnitus sound noticeable quieted down some. My gains in hearing aren't across the entire range of yet and I don't know how to explain it, except that it is really messing with my head dealing with the normal sounds from the right ear along with only the higher pitched portions of sound from the left. Most of the time I'm wearing an ear plug in the recovering ear. but YES, I'm using the word recovering now.

Tomorrow (Saturday) will be two weeks since the injury.

Will post more next week. I'm starting to have some hope that I will be piloting an 737 again in this life time.

SCUBA diving even momentarily crossed my mind for a moment, once today, but it would be years, if ever, and I have been warned and read that I'm a more likely canidate for damage again if I SCUBA in the future.

John

 

[John S]

I promised I wouldn't ask for advice and disappear, so here we go.

I could tell my hearing was continuing to improve over the weekend, but I didn't know how much.
I just had an appointment with an audiologist this morning,

The difference between today and a week ago is staggering. A week ago I was characterized as "severe hearing loss" and today my hearing is measured as 100% normal in both ears!! My word recognition is at 96% at a very low decibel rating. My injured ear picks up some tones better than the good ear.

The audiologist remembered me, told me I was lucky and said in her experience, most of her patients with as severe loss as me don't recover full hearing.

I still have quite a bit of ringing in my injured ear, but it doesn't keep me from hearing sounds. I am still extremely sensitive to noise in the ear and a noisy environment will actually make me feel like I've just downed 3 beers real fast. I'm using an earplug right now.

I believe my brain is still adjusting to the changes in input and expect that some of the ringing may subside as the healing continues.

I meet ALL the FAA criteria for a hearing test and going back to work shouldn't be an issue!

Thanks for the support here on the board, you guys have been great and I had some low moments.
It's not over yet, but it seems to be just the clean up now.

Thanks,
John

 

[doctormike]

The difference between today and a week ago is staggering. A week ago I was characterized as "severe hearing loss" and today my hearing is measured as 100% normal in both ears!! My word recognition is at 96% at a very low decibel rating. My injured ear picks up some tones better than the good ear.

Hooray! Looks like watchful waiting did the trick this time..

 

[Duke Dive Medicine]

Good to hear, John. Thanks for the update.

 

[John S]

Update Two Years Later

Hi guys, I see the medical moderators that helped me out two years ago are still active on the board. I really appreciate your assistance back then.

I haven't been diving since my injury. I have all my hearing back in the injured ear. The tinnitus has not left and seems like I will live with it forever.

In the last two years I have been back to Guam and Palau, but only snorkled.

The ENT who originally examed me and diagnosed me with SSHL warned me, back then, that if I was lucky enough to fully recover my hearing that the odds of me experiencing SSNL loss again in the future was higher.

Since then my Aviation Medical Examiner has advised me to seek further advice if I really am interested in diving again. He likens the advice I received to a Doctor who doesn't jog telling a patient they shouldn't jog anymore. (As in If they don't do it they don't see the value in you doing it)

So... any advice or thoughts on the subject. Through the original experience, the common thing doctors told me was there really wasn't a good way to examine my inner ear and it was more about treating my symptoms and waiting to see if I had positive results.

I'm willing to travel and have good insurance if there is truly value in an exam by a diving specialized ENT. As a refresher I'm an airline pilot and require hearing with both ears. One audiologist recommended I not dive again until I'm ready to retire.

Appreciate any help or ideas.

 

[doctormike]

I'm willing to travel and have good insurance if there is truly value in an exam by a diving specialized ENT. As a refresher I'm an airline pilot and require hearing with both ears. One audiologist recommended I not dive again until I'm ready to retire.

Appreciate any help or ideas.

Hey, John....!

Glad to to hear that your hearing is back, sorry about the tinnitus.

I think that it is unlikely that you will get what you are looking for - that is, a doctor to "clear" you to dive. The very nature of SNHL after diving is not very well understood (whether related to inner ear barotrauma, inner ear hemorrhage, PLF, or inner ear DCS), and even at exploration, a fistula can be a subtle thing to visualize. So the bottom line is that it is always going to come down to you personally assuming an unknown increased risk of further ear injury, since you don't really know what caused your symptoms (i.e. any of those conditions might possibly have improved spontaneously and left you with tinnitus).

From a doctor's point of view, without a body of clinical data to support the theory that you are at no increased risk, he or she can't in good conscience tell you that it's fine for you to dive. I know that this sounds like defensive medicine, but it's just the reality of the situation. I did a pubmed search about diving and perilymph fistula, and in 27 years there were only five articles (feel free to see if any of those authors are accessible to you for consultation). One of the articles was a survey based study from the House group in Los Angeles - they are very well respected in this field, and it might be worth a call. If you haven't done this recently, you could also call DAN and see if they have someone on their lists who might have a better answer than mine.

Best,

Mike

 

[John S]

Mike,

Thanks again for your assistance.

Some interesting reading in the articles you provided links to. One specific regarding a small case study group with no problems seen in post-accident diving.
I am sure you're correct that I won't find the definitive answer I'm looking for. I think I will just have to see how great the pull to return to recreational diving becomes, possibly I won't go again until I retire from flying professionally.
Thanks,
John