Am I foolish to dive?

[marineman]

Hi all,

I have been battling some symptoms for over three months now. A full thread can be found here:
http://www.scubaboard.com/forums/diving-medicine/395404-anyone-ever-had-these-symptoms.html

At this point, I have had a ton of tests. Blood is good, MRI/CT are fine, EKG is fine, barium swallow came back fine, etc. I have also seen two ENTs that have returned the same results. Audiogram and typanometry show that hearing is fine and my outer/middle ear is fine. No pain, pressure, fullness, etc in my ears. All docs believe I suffered something inner ear. At this point, I still have the tinnitus, vertigo and some leg tiredness that seems to be unrelated. Perhaps a back injury or some form of sciatica, though I cannot prove any of this as of yet. All symptoms are constant, and none seem to be improving despite numerous meds including predniSONE, meclizine, valium and several antihistamine/sinus meds. However, all docs (3 physicians, two ENTs and one ER staff) have cleared me to continue diving.

Note, I leave for vacation this Saturday! I am scheduled to go to the second (better) ENT on the 27th for an ENG and some other inner ear tests. Since my GP really sucks, I was delayed to where I couldn't get in before the trip.

1) Am I foolish to listen and dive anyways?
2) Am I really safe to fly? I'd REALLY hate to eat a $3,000 vacation though...
2) What are the chances these symptoms will ever go away?

On a side note, does anyone have any other ideas on what I may want to have the docs look for? My list includes perilymph fistula, inner ear barotrauma (seems unlikely at this point with no results, correct), and possibly cerebellar issues if nothing turns up with my ears. Stroke etc has been ruled out with imaging, blood has cleared thyroid, diabetes, etc. What else could this be?

 

[TSandM]

It sounds as though you've had a good workup for ENT matters, and basic neurologic issues.

When I can't for the life of me think what could possibly give a patient a constellation of weird and seemingly unrelated symptoms, there are two things that pop to the top of my list. One is MS, and the other is something autoimmune like lupus. Both illnesses can have protean manifestations, some of which can be extremely subtle at the outside. Neither is easy to diagnose. I do think, if you haven't seen a neurologist yet, it wouldn't be a bad next move.

As far as whether it's okay to fly and dive, without a diagnosis, there's no way I can advise you about that. But neither of the things I have listed would be affected by either, although both could affect your capacity to dive if they worsened (but so could anything else that got worse).

 

[marineman]

I certainly hope you're wrong on your thoughts, but you never know. Honestly, for now I just hope that the inner ear tests in a couple weeks show something in my ear. I like that option far more than things like what you mentioned. I have been known to have some back and leg issues up to and including torn muscles in both, so I'm hoping the leg thing is totally separate, especially since it come to be long after the vertigo. The swallowing issues were lingering around before the dive, so who knows what is going on there.

Thanks for your input, and I look forward to seeing what else may pop up. At this point, I have no idea.

 

[DocVikingo]

When I can't for the life of me think what could possibly give a patient a constellation of weird and seemingly unrelated symptoms, there are two things that pop to the top of my list. One is MS, and the other is something autoimmune like lupus.

I can think of a third.

All symptoms are constant, and none seem to be improving despite numerous meds including predniSONE, meclizine, valium and several antihistamine/sinus meds. (sic)

Hi marineman,

This most recent post primarily focuses on ear/vestibular symptoms that appear to have no determinable basis despite a rather through work up. There also are passing references to swallowing issues, back pain and leg weakness which seem to have been, at least in part, pre-existing conditions.

As I mentioned in a prior post, it would probably be a good move to see a neurologist, and if indicated a neuro-otologist.

In past posts you have indicated a wide variety of complaints, including but not limited to, chest tightness/breathing difficulty, GERD/bloating, lightheadedness, impaired coordination, "brain fog"/”not totally with it mentally”/"head in space", anxiety/stress/"a bit high strung", and fatigue/tiredness. What is the current status of these symptoms?

Regards,

DocVikingo

 

[Duke Dive Medicine]

Marineman,

I'm not going to second-guess six separate physicians who have seen you and evaluated you in person, but going strictly by what you've posted, I do have concerns about you diving. Reviewing the original thread, there are a few general conclusions that I think we can make (Lynne, Doc V, can you give me a logic check here?):

1. You have a set of symptoms that all occurred after you dove, and you didn't have these symptoms before, so it's reasonable to conclude that these symptoms happened as a result of your dive.

2. Your symptoms involved several body systems. From our correspondence and what you've posted, the GI symptoms appear to have cleared up, as has the "foggy" feeling, but the vertigo and nystagmus have not. You also mention general fatigue and leg weakness.

3. There aren't too many things that can happen on a dive that cause persistent vertigo and nystagmus. Your profile was very benign, so as several of us said, DCS is at the bottom of the list. Quoting Doc V here: "Inner ear barotrauma, which can have signs and symptoms much like those of inner ear DCS, appears more likely given your report of equalization difficulty on one the dives, although the absence of “fast ascents, darts, rapid depth adjustments, etc” and onset delayed until 3-4 hours after the last dive does somewhat leave one pondering."

Inner ear barotrauma is essentially a diagnosis of exclusion, i.e. you rule everything else out first. It's generally not possible to identify it radiologically, but an electronystagmogram can be helpful. Classically there's a history of a forceful valsalva and/or difficulty equalizing. It can result in a tear (fistula) in the round or oval window (part of the vestibular apparatus) that allows the fluid inside to leak out, but it can also cause trauma to the vestibular apparatus without actually causing a fistula. It's possible to have a delay in symptom presentation, which would fit your scenario. This is NOT, repeat NOT a diagnosis, but it seems reasonable to conclude that you may have suffered inner ear barotrauma.

You have two sets of vestibular apparatus, one in each ear. If one set is injured, over time, the other set can take over and your symptoms may diminish or disappear altogether. Again, this fits with your current condition. The risk with returning to diving is that the other set may be injured. If that happens, you could end up with vertigo for the rest of your life.

I don't know what to say about the general fatigue and leg weakness. Having persistent vertigo would make most people tired; the leg weakness may be something else entirely. You've mentioned an anxiety component, which may also be contributing (possibly the "third" that Doc V mentioned).

I think that you need to take all of your medical information to a board-certified hyperbaric physician, preferably one who's also a diving medical examiner. I've sent you a PM about that.

Best regards,
DDM

-edit: Doc V posted while I was writing this, so apologies for any duplication of info.

 

[marineman]

Chest tightness/breathing difficulty and GERD/bloating seem to have been related. I've been on Nexium for nearly two months. All these symptoms came and went around the same time. None are much of a problem anymore, and when they do, antacids still do the trick. There also seems to be a link to stress/anxiety. I went weeks with no episodes, but now that I'm packing to leave in a couple days, punching through work deadlines, etc pre-vacation, I've had a bit of it over the course of the last few days. Of course I've been battling some sinus issues so I've been eating spicy food to clear it up, so that may also help...

As for the lightheadedness, impaired coordination, "brain fog"/”not totally with it mentally”/"head in space". While these may have been voiced differently, they are really one in the same to me. When one is bad, all are bad. There are two ways I can think to describe the two basic symptoms. 1) I feel drunk in terms of balance, coordination and vision. It almost feels like the world is moving, or like I'm on an unstable platform. 2) I feel sick mentally, as in the kind of "out of it" feeling you have when you have a sinus infections or the flu. I'm still mentally sharp, no speech issues, no issues with complex cognitive thought (I'm a computer programmer by trade, and my work efforts have not suffered). I just know something isn't quite right.

Anxiety/stress/"high strung". In many ways, this is just me and it always has been. I'm never still. I almost cannot force myself to sit still and I've always been highly energetic. It has always genuinely bordered on hyperactivity. This energy level and restlessness runs in my family. I wouldn't call myself a worry wort per se in terms of I don't think about death non-stop, but I do admit that being ill/injured for months has me much more anxious than normal. Sleep has been affected, there are days that border depression in terms of thinking the worst, etc. Other days, I'm able to keep myself more positive and upbeat. I have noticed ties with meds on this. For example, prednisone made me think I was literally going to die, and I discontinued taking the higher doses (60mg for one day, 40mg for four, 20mg for five days) after the fifth day because I had three days of really bad anxiety attacks, which was a relatively new experience for me! Not fun at all.

Tinnitus has also remained in both ears through the duration of the complications. It is worse the days and times the vertigo is worse.


Fatigue and tiredness remain. Some days are better than others, but I sleep better and feel slightly better some days than others.

Though I have not seen a neuro, I have had a couple different neuro workups. My balance is slightly off, but I show no signs of loss of feeling to sharp vs dull, hot vs cold, no numbness or tingling (other than the tiredness I feel in my legs/stiffness in my lower back, but I think chiropractic and exercise is helping that symptom).

The last two months, there haven't been any new surprises good or bad. Things have remained pretty steady.

Thanks again!

 

[marineman]

No problem, DDM. I responded to your PM. Thank you very much, to you and the others.

I also assume the "third" is anxiety. I have that thought myself, and rightfully so given the fact that I know how I'm feeling, and it does run in my family. I view it as secondary since it clearly didn't cause the problems, but certainly a notable player to consider now. All along I figured it was ear-related, especially since I know I made a mistake. Also, I did try to force the Valsalva to clear on that dive. I'd give anything to go back to that day knowing what I do now, but we all know there are no mulligans in life.

I've done months of research on inner ear stuff and I have some questions you guys may be able to answer. I have tinnitus in both ears. Does that mean both vestibular systems are shot? If this is the case, is there anything that can be done to help the symptoms? It is very difficult to find information on what happens when both systems are affected.

 

[Doppler]

Marineman: Let me start off by saying I really feel for you and the difficulties you are experiencing with your health and decision-making.

Let me also suggest something to you, and please understand this is a totally hypothetical scenario which I am using to point out some risk management issues that your situation seems to highlight. Necessary to add that although I have a little background in diving and things related, I am not a physician of any sort.


Let's suppose a diver complaining of similar aliments to yours -- and who has asked the same question you have -- goes diving, and gods-forbid, during her ascent she suffers a bout of severe vertigo... I can assure you this is not a pleasant experience at all. The effects are marked enough for her to temporarily lose her bearings and control of her buoyancy. She begins to sink and partly because of her condition and perhaps in part because of the medications she has been prescribed, she is unable to regain control. She is not seen again.

Her family is obviously heartbroken, but at some point it is suggested to them that their loved one dived whether in part or wholly because of advice received from some well-meaning folks on a scuba-related web forum. Investigations are made and their council names several people who offered advice in a law suit. The suit may or may not have foundation, but it will be troublesome.

I am not suggesting any of this will happen in your case. However, it is an interesting scenario don't you think?


P.S. For what it's worth and in answer to your question, I believe you would be ill-advised to scuba dive until your condition is identified and resolved. Sorry, mate.

 

[marineman]

Thanks to some good consultation from this board, I will definitely not be diving. I'm now far more concerned with my last group of questions. It almost sounds as though my vertigo and symptoms over the last three months may be a permanent thing (REALLY hope this isn't the case). I'll enjoy the ocean from the beach, or maybe from the surface with a snorkel, then try to figure out future options after the trip to try to minimize these symptoms for the rest of my life.

 

[marineman]

I guess I left out one important part. Am I safe to fly? I drive a rather hilly route to and from work, and I do know I can equalize my ears. I've had no ear pain or pressure over the last three months. I can even test with a VERY carefully performed Valsalva or Frenzel to ensure that I can clear easily, but I'm well aware this is far from what my ears will go through in flight. The ENT I saw a week ago cleared me to fly, but keep in mind he also said I can dive. That said, I'd like some more input/advice.

I fly out in 18 hours, so time is of the essence. My thoughts were to load up on antihistamines and pick up a pair of Ear Planes (ear plugs). Either way, should I be OK? Any other advice?