Question Advice dealing with suspected inner ear barotrauma / PLF

[Polynikes]

Hey everyone (and in particular hoping for a reply from Dr. Mike or others),

I'm a doctor from Dallas. My wife and I did some diving in Cozumel last week and upon surfacing from the 2nd of a 2 tank dive my wife started vomiting. At first we thought it was due to sea sickness as it was choppy, but she continued to have pressure in her ear, dizziness/vertigo, and tinnitus throughout the remainder of the day and into the evening. It was slowly improving throughout the day. The next day she skipped diving and continued to have somewhat milder symptoms. The third day she decided she felt well enough to dive again (in retrospect this was clearly a mistake, but we thought she just had acute sea sickness). She did OK during the 2 dives but again developed the same symptoms (although somewhat milder this time, no vomiting) which progressed into the evening and persisted the 4th day, we flew home the 5th day without any significant issues, and it has continued being relatively stable or maybe slightly improved with today being day 8. I didn't really know much about these conditions until I read up on it today, and now I'm very concerned that we didn't treat this seriously enough. I pulled some strings to get her into an ENT two days from now, but I'm unsure how knowledgeable they are about this, and I'm also wondering if two days is too long and we should take her into the ED. Further complicating this is that I'm on call all week and our daughter's daycare shut down to a gas leak and she's supposed to fly out this weekend for her sister's 40th so its a hectic week and she's not getting any rest.

I guess my main question is how you recommend we proceed from here. Is it OK to wait two more days for an office visit? Should she hurry to the ED? Should we insist on a quick procedure such as blood patch if the ENT doesn't seem well versed in this?

Thanks for any advice, I just want to optimize her recovery going forward.

 

[Capt Jim Wyatt]

Wow. I doubt many of us would take on second guessing you. I presume you are a Medical Doctor? I ask because we have a guy who is a "Dr" who wrote rebreather books, he is a Dr. A Ph.D. in English literature.

Have you called DAN?

 

[Polynikes]

Wow. I doubt many of us would take on second guessing you. I presume you are a Medical Doctor? I ask because we have a guy who is a "Dr" who wrote rebreather books, he is a Dr. A Ph.D. in English literature.

Have you called DAN?

Yes I'm a radiologist. My wife is a medical doctor as well. But neither of us specializes in this area and I've basically just had to read up quickly. I haven't called DAN but I'll look into that. I managed to get her ENT appointment moved up to tomorrow so we will see what he says. He's not specifically trained in scuba-related injuries but otherwise seems knowledgeable. His initial thought (doctor to doctor on the phone) was that its probably perilymph fistula and he anticipates doing a tissue flap surgery this week. I inquired about a blood patch as a less invasive first option as I've read it's a newer treatment with promising results but he hasn't done that before. Just curious if anyone here has experience/recommendations navigating this somewhat rare condition.

 

[DanBMW]

CALL DAN now ! It sounds like a reverse squeeze. Not unusual with a cold or clogged estuation tube. I had one with no discomfort surfacing. See and ENT familiar with diving.

 

[h2o_hamilton]

Yes I'm a radiologist. My wife is a medical doctor as well. But neither of us specializes in this area and I've basically just had to read up quickly. I haven't called DAN but I'll look into that. I managed to get her ENT appointment moved up to tomorrow so we will see what he says. He's not specifically trained in scuba-related injuries but otherwise seems knowledgeable. His initial thought (doctor to doctor on the phone) was that its probably perilymph fistula and he anticipates doing a tissue flap surgery this week. I inquired about a blood patch as a less invasive first option as I've read it's a newer treatment with promising results but he hasn't done that before. Just curious if anyone here has experience/recommendations navigating this somewhat rare condition.

Does she have ear fullness, ear pressure, hearing loss and/or continuing tinnitus?

 

[Polynikes]

Does she have ear fullness, ear pressure, hearing loss and/or continuing tinnitus?

Yes to all of those.

 

[rsingler]

@doctormike

 

[Duke Dive Medicine]

Hey everyone (and in particular hoping for a reply from Dr. Mike or others),

I'm a doctor from Dallas. My wife and I did some diving in Cozumel last week and upon surfacing from the 2nd of a 2 tank dive my wife started vomiting. At first we thought it was due to sea sickness as it was choppy, but she continued to have pressure in her ear, dizziness/vertigo, and tinnitus throughout the remainder of the day and into the evening. It was slowly improving throughout the day. The next day she skipped diving and continued to have somewhat milder symptoms. The third day she decided she felt well enough to dive again (in retrospect this was clearly a mistake, but we thought she just had acute sea sickness). She did OK during the 2 dives but again developed the same symptoms (although somewhat milder this time, no vomiting) which progressed into the evening and persisted the 4th day, we flew home the 5th day without any significant issues, and it has continued being relatively stable or maybe slightly improved with today being day 8. I didn't really know much about these conditions until I read up on it today, and now I'm very concerned that we didn't treat this seriously enough. I pulled some strings to get her into an ENT two days from now, but I'm unsure how knowledgeable they are about this, and I'm also wondering if two days is too long and we should take her into the ED. Further complicating this is that I'm on call all week and our daughter's daycare shut down to a gas leak and she's supposed to fly out this weekend for her sister's 40th so its a hectic week and she's not getting any rest.

I guess my main question is how you recommend we proceed from here. Is it OK to wait two more days for an office visit? Should she hurry to the ED? Should we insist on a quick procedure such as blood patch if the ENT doesn't seem well versed in this?

Thanks for any advice, I just want to optimize her recovery going forward.

Highest on the differential here are alternobaric vertigo, inner ear barotrauma, and inner ear DCS. DCS can't be ruled out, especially without a detailed dive history. Alternobaric vertigo happens when one ear clears before the other, usually happens on ascent, and is typically transient. Inner ear barotrauma is almost always preceded by difficulty equalizing; some divers report a forceful Valsalva maneuver beforehand. The symptoms with IEBT are more persistent than with ABV. IEBT can be accompanied by perilymph fistula. Both PLF and DCS are medical emergencies. DM sent.

Best regards,
DDM

 

[doctormike]

The devil is in the details, as VERY different ear pathologies present in a similar fashion, so to figure out what is going on, you really need an audiogram to start with, and a good exam. You didn't say anything about the profile, can you let us know if she would have been at risk for DCS or barotrauma, etc...

 

[apnea diver]

I would say go to the ENT doctor asap, do audiogram and all tests related to IEBT and SSHL. Don't wait, as there is a window of time to do the therapy procedures, especially for PLF. It is a medical emergency.
I am not a doctor but recently suffered IEBT and had to go through a course of steroids, and hyperbaric oxygen. After a month I have recovered greatly.