Triaging possible ENT or PFO issues

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Scuba-Lad

Contributor
Messages
126
Reaction score
46
Location
Indonesia
# of dives
200 - 499
Hey All,

I'm hoping there might be some ENT or cardio docs on here who also specialise in (or at least know about) diving medicine too, who might be able to help me triage and differentiate between possible sinus or ear issues (barotrauma related), versus inner ear dcs i.e bubbles being shunted to the inner ear. There are no ENT docs in my country that also specialise in diving medicine (that I've been able to find). I've been fighting this issue for some time, but it's getting too frequent to ignore now, however I'm not really getting any meaningful advice from local doctors on which path to go down for further investigation for the above reasons.

The issue:
Basically, a few hours after surfacing from a single salt water (open water) dive within recreational limits, I start to get a hissing / ringing that feels like it's coming from deep within my head, not quite the same as tinnitus, for the record. Sometimes it doesn't appear until the next day, and it's usually accompanied by mild nausea. It normally takes a week or two of abstinence from diving to get better. It doesn't necessarily happen on every dive, but I'd say it happens more often than not, and is causing me to not be able to dive. If I try to continue to dive the issue progresses over a week or so to include muscle twitching around my right eye / temple, which also causes a little vision wobble on that same side. I can also sometimes get what can be described as a "wet feeling" somewhere deep inside my ear, but when my ears are examined, there's no sign of blood or fluid behind my tympanic membrane.

On the dive:
No real issues to report, occasionally some minor frontal sinus equalisation issues on the way down, which a (gentle) Valsalva maneuver resolves. There's certainly no pain and my ears feel like they are equalising properly. On the slow ascent, my nose tends to feel a little "clogged" but other than that, nothing to report. My Surface GF is normally 50% or less, even as low as 0% after hanging around in the shallows to off gas, and I'm not conducting any saw tooth silly-ness on my profile. I'm already diving Nitrox 32% on all of my dives.

My physiology / tests:

1 - I do have a PFO, diagnosed by TTE, I ordered the test as a direct result of having issues from diving (so no stroke that I am aware of, and no migraines etc.). I've never had any skin bends, or signs of embolism etc. I have had type 1 DCS on at least one occasion, which was resolved by one table 5 session in the hyperbaric chamber.
Here are the findings of the TTE
1741251974823.png


2 - I have a moderately deviated septum, with some other issues such as chronic sinusitis. I've consulted with a couple of non diving ENTs, but I'm being warned away from correcting it due to the risk of Empty Nose Syndrome. ENTs have checked my middle ear / tympanic membrane numerous times, and I'm always told it's unremarkable / in excellent condition with no signs of middle ear barotrauma. Here are the findings from my latest (recent) Paranasal CT scan (of which I also have the images I can share if needed):
1741252151554.png


My question / discussion is, how do I approach this to try and differentiate which of these are causing my issues? On one hand I'm being told that PFO closure is only really considered if there is a risk of stroke (or already had a stroke?) or, if it's been proven to be the cause of DCS, but on the sinus side, I'm being told that since my sinuses are not giving me any obvious issues outside of diving (like sleep apnea or headaches etc.) that it's not worth the risk of causing Empty nose syndrome. I've already had a type II sleep study which was looked at in detail and confirmed no apnea. I'm unsure if either of those findings (either the bubble study, or the paranasal CT scan) are anything to raise eyebrows at when it comes to diving, in particular the CT scan?

Since this issue only occurs after diving, I cannot think of anything else that might causing the ringing / hissing with nausea, besides either the PFO shunting bubbles to my arterial network which then travels to the inner ear, or, some kind of barotrauma issue which I'm not aware of due to the lack of discomfort.

More than happy to have a more detailed discussion in PM regarding cardio or ENT, the specialist in that field, if that's helpful.

Note, this is not me asking for random peoples advice on an internet forum, however I do know that some specialists frequent this forum, who might be able to give some insight or advise on a direction, though I can't find the previous topics I was reading where they contributed, hence feel free to tag.

War & Peace novel writing finished :D

SL
 
Hey All,

I'm hoping there might be some ENT or cardio docs on here who also specialise in (or at least know about) diving medicine too, who might be able to help me triage and differentiate between possible sinus or ear issues (barotrauma related), versus inner ear dcs i.e bubbles being shunted to the inner ear. There are no ENT docs in my country that also specialise in diving medicine (that I've been able to find). I've been fighting this issue for some time, but it's getting too frequent to ignore now, however I'm not really getting any meaningful advice from local doctors on which path to go down for further investigation for the above reasons.

The issue:
Basically, a few hours after surfacing from a single salt water (open water) dive within recreational limits, I start to get a hissing / ringing that feels like it's coming from deep within my head, not quite the same as tinnitus, for the record. Sometimes it doesn't appear until the next day, and it's usually accompanied by mild nausea. It normally takes a week or two of abstinence from diving to get better. It doesn't necessarily happen on every dive, but I'd say it happens more often than not, and is causing me to not be able to dive. If I try to continue to dive the issue progresses over a week or so to include muscle twitching around my right eye / temple, which also causes a little vision wobble on that same side. I can also sometimes get what can be described as a "wet feeling" somewhere deep inside my ear, but when my ears are examined, there's no sign of blood or fluid behind my tympanic membrane.

On the dive:
No real issues to report, occasionally some minor frontal sinus equalisation issues on the way down, which a (gentle) Valsalva maneuver resolves. There's certainly no pain and my ears feel like they are equalising properly. On the slow ascent, my nose tends to feel a little "clogged" but other than that, nothing to report. My Surface GF is normally 50% or less, even as low as 0% after hanging around in the shallows to off gas, and I'm not conducting any saw tooth silly-ness on my profile. I'm already diving Nitrox 32% on all of my dives.

My physiology / tests:

1 - I do have a PFO, diagnosed by TTE, I ordered the test as a direct result of having issues from diving (so no stroke that I am aware of, and no migraines etc.). I've never had any skin bends, or signs of embolism etc. I have had type 1 DCS on at least one occasion, which was resolved by one table 5 session in the hyperbaric chamber.
Here are the findings of the TTE
View attachment 886880

2 - I have a moderately deviated septum, with some other issues such as chronic sinusitis. I've consulted with a couple of non diving ENTs, but I'm being warned away from correcting it due to the risk of Empty Nose Syndrome. ENTs have checked my middle ear / tympanic membrane numerous times, and I'm always told it's unremarkable / in excellent condition with no signs of middle ear barotrauma. Here are the findings from my latest (recent) Paranasal CT scan (of which I also have the images I can share if needed):
View attachment 886881

My question / discussion is, how do I approach this to try and differentiate which of these are causing my issues? On one hand I'm being told that PFO closure is only really considered if there is a risk of stroke (or already had a stroke?) or, if it's been proven to be the cause of DCS, but on the sinus side, I'm being told that since my sinuses are not giving me any obvious issues outside of diving (like sleep apnea or headaches etc.) that it's not worth the risk of causing Empty nose syndrome. I've already had a type II sleep study which was looked at in detail and confirmed no apnea. I'm unsure if either of those findings (either the bubble study, or the paranasal CT scan) are anything to raise eyebrows at when it comes to diving, in particular the CT scan?

Since this issue only occurs after diving, I cannot think of anything else that might causing the ringing / hissing with nausea, besides either the PFO shunting bubbles to my arterial network which then travels to the inner ear, or, some kind of barotrauma issue which I'm not aware of due to the lack of discomfort.

More than happy to have a more detailed discussion in PM regarding cardio or ENT, the specialist in that field, if that's helpful.

Note, this is not me asking for random peoples advice on an internet forum, however I do know that some specialists frequent this forum, who might be able to give some insight or advise on a direction, though I can't find the previous topics I was reading where they contributed, hence feel free to tag.

War & Peace novel writing finished :D

SL
Hi @Scuba-Lad ,

From your detailed description, I would lean more toward this being related to barotrauma, especially given the CT results. It seems likely that you have some sort of chronic inflammation in the mucous membranes. Of course DCS can't be ruled out via the internet, but given the information you've provided, it sounds more like barotrauma.

Best regards,
DDM
 
Intersting case, and really hard to say. 25% of the population has a PFO, and while there is possibly a link between that and clinical DCS, it doesn't sound like your N2 loading was severe, you were well offgassed before surfacing and you didn't do quick or sawtooth ascents.

None of that 100% rules out IEDCS out (I had an "undeserved" hit last year!). And the onset an hour after diving certainly is more suggestive of DCS than barotrauma, unless you were doing forceful clearing after surfacing. Furthermore, the inner ear does seem to be particularly succeptible to DCS - I have seen that in relatively minor cases of decompression stress. On the other hand, symptoms the DAY after diving are LESS sugggestive of IEDCS. I'm definitely not an expert in hyperbaric medicine, though. Overall, I agree with @Duke Dive Medicine

The twitching is interesting, since the facial nerve runs through the middle ear, and it's possible to get issues with that. More commonly a paralysis associated with middle ear infection if there is dehiscience of the nerve, but again, sort of an edge case. Presumably the CT would have showed any major anatomic issue in the middle ear, but this was a sinus CT and not a temporal bone CT - while there is some overlap, it doesn't completely image the ear. If your scan didn't adequately image the ear, you might consider getting a TB scan done.

Did you get an audiogram while you were having ear symptoms?

Finally, the sinus stuff doesn't necessarily have any impact on ear ventilation. And if you are having nasal symptoms, I wouldn't rule out treating them because of "empty nose syndrome". That's an uncommon complication of an aggressive turbinate reduction procedure, but there are a lot of other things to be done with the nose besides that operation. That might help with the frontal pain, but probably not with the ear equalization.

I wish I could be more helpful. Feel free to DM me if you want to explore this further.
 

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