Barotrauma... ugh.

[swinchen]

Well I think my diving career may have been cut drastically short...

I was on the steroids and the course ended before seeing the ENT. The day after ending the steroids I totally lost the hearing in my ear, but the ringing remained. The ENT did a fistula test (the blowing in your ear thing) and it was negative... I didn't get vertigo. So he put me on steroids again and said it probably wouldn't help at all... just something to try. Well... the steroids have made a huge difference. I am probably back up to 1/3 - 1/2 hearing in my left ear. He said that even though the fistula test was negative there still may be a small hole so it looks like I am going in for urgent surgery this week.

He mentioned I should probably never dive again. That makes me so sad I can't even begin to express it in words. I did this skin diving in a pool.... it isn't even like I was looking at a whale shark. But anyways.... that is the update.

 

[doctormike]

Wow... the ENT doesn't even want to see me for 6 weeks. Seeing that tympanic membrane wasn't ruptured...

Jumping in here late now, but why not..? So sorry to hear about your accident, but as with most things, "the devil is in the details". I'm not sure what to make about the above statement. Is this the same ENT doctor who you are seeing now? Did this doctor make that call, or did his office staff just put your appointment off because they were told that the eardrum wasn't ruptured.

An acute change in hearing after a dive is a ticket for an audiogram (hearing test) ASAP. No one is generally treated without an audiogram (you didn't mention if you had this, and what it showed). The audiogram will show one of three things:

1) Normal hearing (hooray!)

2) A conductive hearing loss with a normal "bone line" (from fluid or blood in the middle ear, or perhaps from a perforation). This may respond to some medications (like steroids), may require minor surgery, but usually a recoverable injury which should not preclude further diving once healed.

3) A sensorineural hearing loss (may co-exist with #2). This is the big problem. After diving, it is either from a fistula (leak of the inner ear fluid), or from an inner ear decompression injury. From what you described (free diving in the pool), we can pretty much rule out DCI. Surgical exploration of the ear with patching of the fistula is certainly appropriate and necessary.

Diving after operations that involve opening and closing the inner ear is controversial, and most ENT docs have in the past forbidden this. However, there is some evidence that people who have had stapedectomies (an operation in which the inner ear is opened and closed to improve hearing) have been able to dive without injury.

There isn't a lot of work in this field, as you might expect, but here is a paper from the famous House group in Los Angeles (one of the foremost ear surgery centers in the country) looking at 22 divers who had had stapedectomies. Note that I am not suggesting that you do or do not dive, but that you get all the information you can about your condition, and make an educated decision.

Good luck with the surgery, and keep us posted!

Best,

Mike

 

[swinchen]

Hi Dr. Mike.

Sorry about the confusion. My Doctor said the ENT wouldn't want to see me for 6 weeks because it looked (to him) to be simple middle ear barotrauma (fluid in the middle ear, not sure that this can even cause tinnitus?) but anyways... I called DAN and explained this to their medic and they were shocked and said I should be put on steroids and go to the ENT as soon as possible. So I called my doctor back up, he said ok... put me on a relatively low dose of steroids and after a couple days it was improving a little but nothing major, so he scheduled an ENT visit for me.

Before seeing the ENT my steroid course came to a end and my hearing dropped to nothing. I was literally totally deaf in my left ear.

I got to the see the ENT two weeks after the incident... he ran the fistula test (negative) and put the tunning fork on my forehead and I could only hear it in my right ear. Prognosis was not good. But he put on a higher dose of steroids anyway and my hearing is improving (greatly.. maybe 50% now).... when I told him this he jumped into action and is scheduling an emergency audiogram, follow-up and most likely surgery all this week. He seems to thing the fistula might still be open, so it can be patched.

So I have not had an audiogram yet... that will be tomorrow likely.

He wasn't too concerned about damaging my left (bad) ear with further diving, he was more concerned about doing damage to my right ear. As he put it... "If this happens in your right ear you might be taking sign language classes, not diving classes." That sort of scared me a lot.

So I will give it a few months and if I improve greatly I will continue... otherwise I will have to sell my brand new, top of the line gear, that I put myself into serious debt for at a huge cut I am REALLY hoping I can dive again.

 

[doctormike]

Hi Dr. Mike.

Sorry about the confusion. My Doctor said the ENT wouldn't want to see me for 6 weeks because it looked (to him) to be simple middle ear barotrauma (fluid in the middle ear, not sure that this can even cause tinnitus?) but anyways... I called DAN and explained this to their medic and they were shocked and said I should be put on steroids and go to the ENT as soon as possible. So I called my doctor back up, he said ok... put me on a relatively low dose of steroids and after a couple days it was improving a little but nothing major, so he scheduled an ENT visit for me.
So I have not had an audiogram yet... that will be tomorrow likely.

He wasn't too concerned about damaging my left (bad) ear with further diving, he was more concerned about doing damage to my right ear. As he put it... "If this happens in your right ear you might be taking sign language classes, not diving classes." That sort of scared me a lot.

So I will give it a few months and if I improve greatly I will continue... otherwise I will have to sell my brand new, top of the line gear, that I put myself into serious debt for at a huge cut I am REALLY hoping I can dive again.

OK, makes a bit more sense... I usually try to steer clear from commenting on treatment when I only have bits and pieces of the story, so forgive me for jumping in, it was just that some of the details didn't quite hang together...

Of course, the most conservative thing to do is to forbid further diving, and that may be appropriate... it depends on a lot of technical details such as the presence or absence of a fistula (not always obvious, even at surgery), the incidence of bilateral fistulas in patients with a single fistula, the results of imaging studies, the exact nature of the hearing loss, etc...

Again, I really can't tell you what is appropriate in your situation, but I would encourage you to educate yourself as best as you can, and make sure that there are reasonable answers for everything. Still not clear on why you are so far out without an audiogram...

Mike

 

[Lopaka]

when I told him this he jumped into action and is scheduling an emergency audiogram, follow-up and most likely surgery all this week. He seems to thing the fistula might still be open, so it can be patched.

Since I went (still in process) through much of this over the last few months, I am curious why the ENT is so eager to do surgery. If the fistula testing is negative, why open the ear? What is the reasoning here?

 

[doctormike]

Since I went (still in process) through much of this over the last few months, I am curious why the ENT is so eager to do surgery. If the fistula testing is negative, why open the ear? What is the reasoning here?

The fistula test is a very basic test, which will show if you have a big hole in your otic capsule (the bone surrounding the inner ear. If it is positive, great. If it is negative, that doesn't mean that much. Hearing loss can occur even with a small fistula which might not cause vertigo.

Furthermore, the operation is very quick and safe, so if there is any chance of saving the hearing, most people wouldn't hesitate to do it. You basically just peel up the eardrum, look in the middle ear, and if you see or suspect a small leak of clear fluid from the inner ear, you put some fat or other packing material in the area. The eardrum heals easily after this type of exploration.

I am certainly a conservative surgeon, but to avoid surgery when there is a possibility of a fistula just because you can't prove it would be totally inappropriate. You have a very short window of opportunity to save someone's hearing...

In reality, there is often no way of proving the presence of a fistula preoperatively (unless it is huge, big enough to show up on a CT, which would be very unusual in this situaton).

If you are interested, I posted something about SPONTANEOUS perilymph fistulas a while back (which is not what we are discussing here). Click here...

Mike

 

[Lopaka]

Informative Doc. I am now curious why my ENT did not even discuss this after my vertigo and SHL. Did do fistula tests and said negative, so I assumed this was SOP. Still getting little noises in the ear, with little to no improvement in hearing after 3 months. Did multiple audiograms, steroids, and MRI though............

 

[swinchen]

For your enjoyment, fresh off the press.... audiogram! The doctor is going to hold off surgery seeing I am doing well on steroids and just monitor me very very closely... as the steroids taper off if the hearing drops he will bump them back up and cut me open.

My Audiogram

 

[doctormike]

Informative Doc. I am now curious why my ENT did not even discuss this after my vertigo and SHL. Did do fistula tests and said negative, so I assumed this was SOP. Still getting little noises in the ear, with little to no improvement in hearing after 3 months. Did multiple audiograms, steroids, and MRI though............

Yes, well... I'm pretty careful not to suggest management in any one case, I just give my general approach and background.

I guess he felt that looking at everything (history, exam, response to steroids, fistula test, etc..), the likelihood of a surgically reparable fistula was low. I was only pointing out that a negative fistula test does not rule out the presence of a fistula the way a positive fistula test strongly suggests the diagnosis. It is really important to have the whole picture, and I hope that you don't think that I was suggesting one approach or another over the Internet..!

I just like to give context here so people have some background to discuss things with their own docs...!



Mike

 

[doctormike]

For your enjoyment, fresh off the press.... audiogram! The doctor is going to hold off surgery seeing I am doing well on steroids and just monitor me very very closely... as the steroids taper off if the hearing drops he will bump them back up and cut me open.

My Audiogram

Great, thanks for posting that... looks like this is all inner ear, and that there is no perforation, ear fluid, congestion, etc... Remember, not every case of inner ear hearing loss (sensorineural hearing loss) is caused by a fistula.

It is good that you are getting a response to the steroids, an it is also good that he is ready to operate based on your clinical progress if it looks like it would be helpful...

Keep us posted... good luck!

Mike