Vertigo occurrs when Ascending (Seen by ENT & Audiologist)

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DanV1317

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I've started diving regularly since moving to the Seattle area, have done about 100 dives in 2016.

I cant remember the exact time frame of when the symptoms started, but it's something new this year. I would guess maybe 6 months ago that it started.

What happens: Within the first 30-40 seconds of ascending from depth (usually 50 feet or deeper), i can feel and episode of vertigo come on. It lasts less about 10 seconds or so and then goes away. My head feels woozy and i feel as if i'm spinning. The rest of my ascent after that is usually vertigo free and I have no issues. I never feel nauseated, never vomit, never passed out. Now, I almost know it's coming and i just hang tight for a bit until it passes and then continue my ascent. It may have got slightly worse since i first noticing it, but very little.

I've gone to seen an ENT recently who did a physical exam and found no obvious signs of damage to my ear. I initially told him i thought maybe i had problems with my left ear, as sometimes i have a stuffy feeling in my left ear after i finish the dive and also because i felt my ears were equalizing at different rates therefor causing unequal pressures. (alternobaric vertigo)

He sent me for a VNG and hearing test today. During the test, when pressure was applied to my left ear, i felt fine, when pressure was applied to my right ear, i did get a quick head rush of dizziness. (Weird, since i thought my left ear was the issue).

Moving along to the goggles. The audiologist had me put a set of goggles, which are cameras to watch my eyes. All tests were good until she started to watch for nystagmus with the goggles and began pushing air into my ears.

First my left ear, i did get a small amount of vertigo which she said would be expected since she WAS trying to create some of that. I did fine with it, and it only lasted a few seconds. When she started doing it on my right ear, it was the same exact feeling i got when i am under water. It was a full body rush of vertigo. She stated that she didnt see anything abnormal with my eyes during this test, even when i told her that i was experiencing the same issues as underwater when i start to ascend. It happened with the cool air that she blew into my ear and also with the warm air. It took a few seconds of the air blowing for the vertigo to kick in and then lasted about the same length of time as underwater. When the vertigo started to hit, she blew air another few seconds and then stopped but the vertigo continued (10-15 seconds).

She told me there's a possibility i may have:

Left Vestibulopathy, a Right perilymphatic fistula or an ossicular issue.

She said to me there were no issues with my eustachian tubes during testing.

Aside from diving, i'm disgustingly healthy, no medical problems and no medications. I occasionally get 2 second bouts of vertigo when i move to quickly or i turn my head fast while on land at work or at home. They happen maybe once a week or twice a week. I dont have any ringing in my ears, no hearing loss, no pain in my ears at any time. I rarely have difficulty equalizing while descending underwater and never have ear pain when i surface. I've never had ear infections, and never had any drainage from my ears.

I'm going to be making a follow up appointment with my ENT to interpret the results of the VNG. I wanted to reach out to the dive community to see if anybody has had these types of issues and if any ENTs that are more versed in scuba diving may have input. Thanks
 
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It's called alternobaric vertigo. Not uncommon in varying degrees.

Call DAN. They will have plenty of info for you.
 
There may be a component of alternobaric vertigo but that would probably not explain your symptoms when you aren't diving. I say probably because I've seen persistent alternobaric vertigo in a non-diver (my oldest child). DAN is a good source for general diving medical info, but I don't know that they can help you any more than your ENT physician already is. I recommend you continue the track that you're on until your ENT comes up with a diagnosis. DoctorMike is a medical moderator here; he is an ENT specialist and a rebreather diver as well so he may have more to offer.

Best regards,
DDM
 
I think it's in the differential... likely it's on the ENT's radar.
 
Fritz, during my audiologist testing, they did the testing for crystals as you suggested. They had me quickly move left and right onto the table to check for such symptoms. didn't have any issues with that test.
 
Yes, sounds more like a vestibular (inner ear) issue than classic altenobaric vertigo. The test that reproduced the underwater symptoms is a caloric test, in which cool air (or water) introduced into the ear canal causes motion of the fluid in the horizontal semicircular canal (which is the part of the inner ear closest to the ear canal, covered by a thin plate of bone). The motion is caused by a convection current.

Symptoms of vertigo commonly occur when the two inner ears are transmitting different inputs to the brain. In this case, the test sounds like it showed that the left vestibular apparatus (the part of the inner ear that detects positioning in space and motion) wasn't working as well as the right one. That is consistent with the history - if the right ear is normal and the left ear has reduced function, something that stimulates both ears will produce a different signal, and thus, vertigo.

Altenobaric vertigo classically refers to unequal ventilation of the MIDDLE ears, which then stimulate the inner ears differentially. In this case, it doesn't sound like there was a problem with middle ear ventilation, so possibly the differential causing symptoms was from something related to the inner ears themselves. That thing could be a problem on the right side (PLF, causing excessive stimulation of the right inner ear), or on the left side (vestibulopathy, causing reduced response to stimulation).

BBPV seems less likely, as the symptoms don't sound positional as reported. What's a bit odd is that it happens on ascent from depth in the first few feet, when the pressure change is less. I'm assuming that the inner ear stimulation gets extinguished after symptoms are present for a short time, and then further stimulation during the rest of the ascent isn't enough to cause them again.

The symptoms sound more pressure related than temperature related, assuming that there isn't the same thermocline every time this happens! So while this isn't typical altenobaric vertigo (i.e. not a middle ear thing), if the stimulating factor is a pressure change then even if it's due to a vestibulopathy, it would be "altenobaric" in a more general sense. That's really just semantics...

Interesting case! Please let us know what the ENT says about these results.

Here's my sticky on ear disease and diving, if anyone want's some background info.
 
Hey Mike, thanks for the response. I did read through your website and went through article on ear issues and diving. Great information. The more i spoke with the ENT and the audiologist, it seems this problem is going to be very difficulty to diagnose properly and then fix. it seems like they are more wishy washy on what exactly it could be. Even based on the audiology, it still isn't clear. When i get a copy of the audiology results, I will post them up here for you to see.
 
https://www.shearwater.com/products/teric/

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