Barotitis — Never dive with cold!

[rob1967]

I learned the hard way, never dive with a cold! Not even in a pool! I would like to share my story, to see what others might think about this, and also maybe learn from my mistake.

I am a relatively new diver, but really love this great new sport. I have OW, AOW and Nitrox certification, all done in the tropics this year without any serious incident. I am also a physician, but my specialty has nothing to do with diving or ENT.

I thought I would try out local diving, which supposedly is very good cold water diving. I thought I would start with a dry-suit course. Unfortunately, the day after I signed up for the course, I came down with a bit of a cold. Two days later, the day of the pool session, I still felt a bit sick and congested. I told the instructor that I wasn't sure if I should do the pool session because of my cold. He just kind of gave me a blank look, as if perhaps to imply that I didn't look sick, or that maybe I was a bit of a wimp. He did not suggest I do not dive, nor offer to re-schedule.

Needless to say, even though it was only 9' of water, I did have problems equalizing, but I just put up with it. I felt fine coming out of the water that evening, but the next morning, woke up with ear pain, which worsened during the day. I took a decongestant that afternoon, and the pain was relieved, but the pain recurred later that evening, to the point that it became very severe. Total Eustachian lock! Decongestants were no help, so I saw an ENT right away since the pain was so severe. I would describe the pain as being a 9/10, and when the ENT did the myringotomy (incision in the ear drum to relieve the pressure before the tympanic membrane ruptured), the pain went from a 9 to an 11/10. Seriously, more pain than I could ever have imagined. I also had a lot of tinnitus, dizziness and hearing loss right after. The pain was so bad the ENT had to take me from his office to the emergency room for a shot of morphine, which took the pain down to a 3.

By the next day, there was minimal to no pain, but I had
major hearing loss and tinnitus. The drainage stopped after about 6 days, and the dizziness seemed to gradually improve over a week. The hearing loss and tinnitus persisted.

Yesterday, day 12, I started doing some equalization exercises, which seems to have made a significant improvement in the hearing loss and tinnitus. However, I still have noticeable hearing loss and tinnitus. I hope it is not permanent! I will see the ENT in follow-up again.

I am kind of angry at the dive shop/instructor, for not encouraging me to re-schedule this silly course. Do I have a right to be upset at them? If my hearing loss is permanent, I will be seriously bummed out!

Also, in 3 weeks, I have a dream trip of a lifetime already booked for Sipidan Island. I don’t think I can cancel, since the travel insurance does not cover pre-existing conditions. One ENT says I should be fine to dive in 3 weeks, the other says it is dicey, but neither really has much experience with dive medicine.

I have been doing some research on the internet, and ordered some Docs Proplugs. I am also thinking of purchasing the ProEar mask (with ear cups to keep the ears dry, supposedly makes equalization easier). Can the Proplugs be used together with the ProEar Mask? Does anyone have any experience with these gizmos? I want to do everything I can so that I can safely try diving in 3 weeks while minimizing the risk of re-injuring my ear. Any advice, input, etc, is greatly appreciated.

 

[fisherdvm]

I am kind of angry at the dive shop/instructor, for not encouraging me to re-schedule this silly course. Do I have a right to be upset at them? If my hearing loss is permanent, I will be seriously bummed out!

I don't know if I would dare tell a physician when to dive and when not to dive. Afterall, you are a certified diver, and should be competent enough to call off a dive, when you need to. Going down 9 ft or even 14 ft is something that many folks have done with a cold.... You just call it off when it hurts.

I did my rescue class with a cold. I told the instructor that if I can not do the dive, it is because of my ear. I did fine, but we went down only about 30 ft. It is hard to tell how one respond to a cold, allergy, etc. And I don't think it is the instructor's call on the issue. He got to the pool, and deserve to get paid for the day. You are a certified diver, and a physician... You made the decision to sign up for the class... it is not the instructor's fault.

If you paid for a liveaboard, and blew your ear drum before the trip, they certainly will not refund your money. If you blew your ear drum during the trip, it is still your choice. No one made you dive.

My first dive in a cold fresh water lake resulted in a barotrauma on the ascend - and painful ear with a nasal bleed. It took about 2 weeks to clear up. Haven't had any problems since. I learn fast to keep warm in cold water, it decreases my congestion well.

Sorry, forgot to welcome you to scubaboard. Hopefully your ear will clear soon. I do have to admit, I pop a claritin before my dives during the allergy season. Even if I forget, I am usually fine. I think practice, practice, and practice .... makes the ear problem much less an issue. I do think that the eustachian tube can be trained or hardened to handle clearing better. I do not have half the problems with clearing my ears now as I did with my first 8 dives.

 

[doctormike]

Hey, Rob... welcome to Scuba Board!

I have to say, that if we scrubbed every dive when we were feeling a bit under the weather, most of us would not see a lot of bottom time! I'm especially prone to "push the envelope" when I have spent thousands of dollars, arranged coverage, travelled for days, etc...

In Anguilla last year, I had a bit of a cold, got a nasty reverse sinus block, and dove knowing that every ascent would be agonizing until that amazing moment when my sinuses decompressed into my mask on the dive boat with a rush of blood and snot!

Sure, as an ENT doc, I'm willing to do that FOR MYSELF (and I'm NOT recommending it to any patients), because I made a judgement call based on my training and experience, my own symptoms, and the fact that it was sinus and not ear blockage, and that I was pretty sure that I wasn't going to decompress into my orbit or intracranial space, etc... Hey, I didn't want to miss any dives!

Ears are another story... I wouldn't risk permanent hearing loss for a dive. But the fact remains that reverse ear blocks are actually pretty rare, and inner ear stuff like DCS or traumatic inner ear fistulas are also not that common. The vast majority of diving related ear disease is middle ear barotrauma which presents on descent. And to paraphrase the pilots: "descents are optional, ascents are mandatory". Sometimes the only way to know if your Eustachian tubes are up for a dive is to try those first few feet of descent.

You don't give the most important piece of information, which is "what did your audiogram show?". If it showed a purely conductive hearing loss, then usually things return to normal once the middle ear mayhem (barotrauma, hemorrhage, infection, effusion, etc..) resolves with time (sometimes helped along by steroids). If you have a sensorineural hearing loss, that is a whole different diagnostic tree. Inner ear DCI, traumatic perilymph fistula, etc.. And if you do have a traumatic PLF, you need to get that attended to ASAP (usually by surgery). Similarly, DCI requires treatment in a chamber, which also should not be delayed - although this would be pretty unlikely in 9 feet of water! Still, something to remember for next time.

Proplugs are mainly for keeping out water and preventing swimmer's ear. They are great for this and I give them to my pediatric patients with ear tubes all the time. The Web site does suggest that they help with equalization, and gives some anecdotal evidence. Not sure about the science behind this, but they may work by slowing the rate of pressure change in the external ear (something like "Airplanes" ear plugs for flying). A lot of people on this board seem to like them. I don't know about the ProEar, but it seems less likely that that would be helpful.

Finally, to answer your question, I agree with fisherdvm that you really need to take responsibility for your own diving problems. There is such a wide range of physiology for people who state that they have "a cold", that it would not be reasonable for an instructor to have a firm policy that no one can dive if they say that they have a cold. Certainly having advanced certification (AOW, Nitrox) suggests that you should have even more self-reliance, and need to be making these judgements on your own.

Good luck, I hope that you are feeling better before your trip!

 

[wreckchick]

Just to take a slightly contradictory point of view... a few years ago I was working as a dive instructor and came down with a pretty foul sinus infection. I was very hesitant to call my dives because it was my livelihood. I managed to descend on one fateful dive with some trouble equalizing my sinuses and was looking forward to a very slow ascent to help it all work out on the way up. Well, funny thing about the body, it doesn't always understand the plan. On the ascent, I encountered significant reverse blocking in my sinuses and decided to descend a bit to relieve the pressure, except of course now my ears won't equalize at all. 7' was horrific sinus pain, 9' was unbearable ear pressure so I did what I had to do and I came up. The most fun part was actually feeling the crackling in my sinuses as the fine bones popped. On board I was still in terrible pain and barely made it back to the dock and home. The next day I had a black eye and my face was swollen. It took about two weeks for my face to look normal again and I didn't get in the water for close to a month. I don't dive at all congested anymore, lesson learned.

Rachel

 

[rob1967]

Thanks everyone for your input. I certainly would have scrubbed the dive if I had severe pain during the dive. Maybe it is a bit unusual that the severe pain, etc, occured almost 24 hours later? Also, would this be termed a reverse block?

I actually saw my ENT friend in the afternoon during those few hours when I was pain free, (a few hours before the pain returned severely resulting in the myringotomy) and he did an audiogram which showed "your hearing is pretty good". I had a conductive loss then.

Another ENT briefly examined me yesterday just with Weber's etc, and my loss seems mainly conductive. But I do worry if there is some component of sensori-neural hearing loss given the symptoms I had. I will try to see the ENT again soon for reevaluation and another formal audiogram.

I am a bit confused. Although I have managed to amass 3 c-cards already, I would still consider myself an inexperienced diver. After all, I have only done 17 dives over two trips of one week each. I still would look to the instructor for guidance and advice since I really have no experience. My instructor for my OW and AOW course (Huw, in PG, Philippines) was fantastic. He was cautious and really looked out for you. I remember him looking worried and asking if I had a cold when I happened to sniffle in his presence! The guy here, though, had an indifferent attitude, so I don’t know which of these two attitudes is “normal” for an instructor.

Also, my attitude prior to this incident is perhaps similar to docotormike, ie., I am not going to let a little cold get in the way of diving. And then I was burned with a potentially permanent hearing loss. So I guess the real question is, what is the likelihood of a nasty barotrauma with possible permanent effects occurring if one chooses to dive with a cold?

 

[doctormike]

Just to take a slightly contradictory point of view... The next day I had a black eye and my face was swollen. It took about two weeks for my face to look normal again and I didn't get in the water for close to a month. I don't dive at all congested anymore, lesson learned.

Rachel

Yes, Rachel is exactly right, which is why I would NEVER suggest that a patient (or dive buddy) make any kind of dive on my say so only. The only reason that I did it has less to do with my ENT knowledge and more to do with my knowledge of my own body and my dive experience...

The bottom line is that there is a bell curve for everything. Many people have worse Eustachian tube function and sinus ventilation function at baseline than others have with a cold. That is why statements like "never dive with a cold" have to be guidelines and not strict rules.

There are some conditions which are black and white, definite diagnoses. "Never dive with a pneumothorax" would be an example of a rule that is not subject to a judgement call - a pneumothorax is either there or not, and if it is, you may well die during a dive. A cold is, as I implied above, a description that means very different things to different people, which is why it will always be a judgement call.

Your Eustachian tube function may be suboptimal for weeks or months after you are feeling better after an upper respiratory tract infection - should you dive then? On the other hand, some people with terrible colds can equalized just fine.

And of course, there are always secondary factors which push us to push the envelope. Is this my only hard-earned, long anticipated dive trip of the year? If I'm an instructor, and I cancel my classes too frequently for marginal symptoms, will I lose my job? It's not just divers who have to make these calls... no easy answer!

 

[doctormike]

Thanks everyone for your input. I certainly would have scrubbed the dive if I had severe pain during the dive. Maybe it is a bit unusual that the severe pain, etc, occured almost 24 hours later? Also, would this be termed a reverse block?

Well, a reverse block is inability to vent excess pressure from the middle ear on ascent. This is less common than the regular block, which is an inability to pressurize the middle ear on descent. I agree that yours is not as typical a presentation, so it may be that you had congestion of your Eustachian tube due to the dive, which then resulted in a delayed accumulation of effusion... however, if you were feeling fine until the next day, then you probably didn't have too much of a pressure gradient right after the dive..

he did an audiogram which showed "your hearing is pretty good". I had a conductive loss then.

Good - as long as the "bone line" (the function of the inner ear and the nerve of hearing) was normal, you have a good prognosis.

Another ENT briefly examined me yesterday just with Weber's etc, and my loss seems mainly conductive. But I do worry if there is some component of sensori-neural hearing loss given the symptoms I had. I will try to see the ENT again soon for reevaluation and another formal audiogram.

Weber alone is not sufficient. If you feel that there is any change, you need a follow up audiogram. If there was a perilymph fistula on top of the barotrauma, you could have a delayed sensorineural hearing loss.

I am a bit confused. Although I have managed to amass 3 c-cards already, I would still consider myself an inexperienced diver. After all, I have only done 17 dives over two trips of one week each. I still would look to the instructor for guidance and advice since I really have no experience.

Well, this is really another topic... and I hesitate to mention my own prejudices. Certainly, the dive agencies push training as much as possible, and more/better training is generally a good thing. However, I personally feel that you are better in the beginning putting your limited time and money into doing a bunch of dives, rather than just taking more classes. There is no substitute for a lot of dive experience. Even doing "routine" dives makes us all more aware of every aspect of our underwater surroundings, and makes us better equipped to deal with all sorts of emergencies.

I have seen divemaster courses offered to people who have a minimum of 20 logged dives. I feel that this is totally wrong. No amount of book study alone can qualify you to deal with the kind of problems that you will encounter taking a student on a dive.

There is a pejorative term used, I believe, in the book "Fatal Depth" about one of the people who died diving the Andrea Doria. The term "Patch Diver" refers to someone who quickly runs through a bunch of courses (i.e. gets the patches to sew on his dry suit) without much diving experience.

So while I am not knocking training, more dives will make your overall experience better than getting a Nitrox card. Are you really already hitting your non-deco limits on air?

Sorry if this comes off as sounding condescending - nothing could be further from the truth. It sounds as if you love diving and have a lot of great experiences to look forward to!

 

[Ber Rabbit]

I learned the hard way, never dive with a cold! Not even in a pool! I would like to share my story, to see what others might think about this, and also maybe learn from my mistake.

I am a relatively new diver, but really love this great new sport. I have OW, AOW and Nitrox certification, all done in the tropics this year without any serious incident. I am also a physician, but my specialty has nothing to do with diving or ENT.

I thought I would try out local diving, which supposedly is very good cold water diving. I thought I would start with a dry-suit course. Unfortunately, the day after I signed up for the course, I came down with a bit of a cold. Two days later, the day of the pool session, I still felt a bit sick and congested. I told the instructor that I wasn't sure if I should do the pool session because of my cold. He just kind of gave me a blank look, as if perhaps to imply that I didn't look sick, or that maybe I was a bit of a wimp. He did not suggest I do not dive, nor offer to re-schedule.

Needless to say, even though it was only 9' of water, I did have problems equalizing, but I just put up with it.
Any advice, input, etc, is greatly appreciated.

I don't know if I would dare tell a physician when to dive and when not to dive. Afterall, you are a certified diver, and should be competent enough to call off a dive, when you need to. Going down 9 ft or even 14 ft is something that many folks have done with a cold.... You just call it off when it hurts.

I did my rescue class with a cold. I told the instructor that if I can not do the dive, it is because of my ear. I did fine, but we went down only about 30 ft. It is hard to tell how one respond to a cold, allergy, etc. And I don't think it is the instructor's call on the issue. He got to the pool, and deserve to get paid for the day. You are a certified diver, and a physician... You made the decision to sign up for the class... it is not the instructor's fault.

Hey, Rob... welcome to Scuba Board!

I have to say, that if we scrubbed every dive when we were feeling a bit under the weather, most of us would not see a lot of bottom time! I'm especially prone to "push the envelope" when I have spent thousands of dollars, arranged coverage, travelled for days, etc...

Sure, as an ENT doc, I'm willing to do that FOR MYSELF (and I'm NOT recommending it to any patients), because I made a judgement call based on my training and experience, my own symptoms, and the fact that it was sinus and not ear blockage, and that I was pretty sure that I wasn't going to decompress into my orbit or intracranial space, etc... Hey, I didn't want to miss any dives!

Finally, to answer your question, I agree with fisherdvm that you really need to take responsibility for your own diving problems. There is such a wide range of physiology for people who state that they have "a cold", that it would not be reasonable for an instructor to have a firm policy that no one can dive if they say that they have a cold. Certainly having advanced certification (AOW, Nitrox) suggests that you should have even more self-reliance, and need to be making these judgements on your own.

Thanks everyone for your input. I certainly would have scrubbed the dive if I had severe pain during the dive.

I am a bit confused. Although I have managed to amass 3 c-cards already, I would still consider myself an inexperienced diver. After all, I have only done 17 dives over two trips of one week each. I still would look to the instructor for guidance and advice since I really have no experience. My instructor for my OW and AOW course (Huw, in PG, Philippines) was fantastic. He was cautious and really looked out for you. I remember him looking worried and asking if I had a cold when I happened to sniffle in his presence! The guy here, though, had an indifferent attitude, so I don’t know which of these two attitudes is “normal” for an instructor.

Also, my attitude prior to this incident is perhaps similar to docotormike, ie., I am not going to let a little cold get in the way of diving. And then I was burned with a potentially permanent hearing loss. So I guess the real question is, what is the likelihood of a nasty barotrauma with possible permanent effects occurring if one chooses to dive with a cold?

I have to disagree with fisher et al. When I'm training a student they are under my care and are my responsibility no matter what they do for a living. It's my responsibility to make sure they understand the implications of decisions they are getting ready to make whether it's deciding they want to dive without a hood in 50 degree water or deciding they can dive with a cold. How they process and apply my advice is up to the individual but if they waiver on the dive/don't dive decision I push them in the "don't dive" direction because I don't want them risking personal injury to avoid inconveniencing ME. I try to teach my students that if they are unsure about any aspect of a dive it's because their little voice is trying to tell them something and the little voice is usually right. Rob your little voice was talking to you when you weren't sure if you should do the pool session and you found out the hard way that the voice was right.

Doctormike is right about a wide range of physiology to deal with when someone tells me "I have a cold" and there really isn't a way to have a policy that's etched in stone for every case. Personally I emphasize the squeeze/barotrauma material from the class, explain that they are the only one who knows how they feel and let them know that aborting a dive if they don't feel it can be done safely is in their best interest. If they decide to try getting in the water I tell them that if they feel pressure or have ANY problems equalizing they need to let me know and we will either stay in the shallows if they have no symptoms there or abort completely.

Many years ago a student in a class I was DM'ing for insisted he was ok to do the pool session with a sinus issue. He ruptured a sinus in 5 feet of water and turned the pool into a bloody mess after failing to pay attention to the pressure/pain he was feeling at shallower depths.

Learning to dive is about learning how to make decisions. Newer divers just don't have the experience base to make decisions involving physiology. They are still learning what "normal" feels like underwater so their ability to make a good decision with abnormal physiology once they are underwater is hampered. The "don't dive with a cold" policy is a good one for newbies, they will suffer no injury following that advice. "Suck it up and dive" should not be part of an inexperienced diver's repertoire because there is no way for them to know when to stop sucking it up. Over time divers learn what can be pushed in the "suck it up" category but even experienced divers get burned on that sometimes.
Ber :lilbunny:

 

[doctormike]

IIt's my responsibility to make sure they understand the implications of decisions they are getting ready to make whether it's deciding they want to dive without a hood in 50 degree water or deciding they can dive with a cold. How they process and apply my advice is up to the individual but if they waiver on the dive/don't dive decision I push them in the "don't dive" direction

Right... this is a good balance. Provide the advice and background information, and let people make a decision based on that along with their own internal symptoms and sensations. And erring on the side of safety is always a good thing..

Sometimes, new divers may feel anxious about a given dive, and they might just want to call it off at some point. Many people are hesitant to do this because they don't want to appear scared or not as macho as they would like to be. One thing that they can do in this situation is to claim problems with equalization! No one knows but you....

 

[TSandM]

If you haven't watched it already, I'm going to recommend Dr. Kay's video on equalization. A lot of the anatomy will be review for you, but I learned some things about equalization techniques, and a LOT about the appearance of barotrauma on examination, from watching the video.

It seems as though equalization is given rather short shrift in the majority of OW classes. People are told to do it, but not given much information on how, and nobody seems to watch or talk to students to see how easily it is going. It's pretty clear that some people find equalization very easy (I'm one of them) and others find it difficult even at baseline. How much a given amount of congestion is going to impact your ability to clear is obviously going to vary with how easy it is for you to do it when you aren't ill.

I think the majority of us tend to equalize when we're uncomfortable, and how much discomfort it takes before you notice and do something about it is an individual variation as well. In fact, it's preferable to equalize BEFORE the discomfort is noticeable, but I doubt many people actually achieve this. And new divers, whose bandwidth is being heavily taxed by the mechanics of diving, are often distracted enough not to pick up the need to equalize before some barotrauma has occurred.