Can't hear after diving

[doctormike]

I suffered a PLF in the early 80's while diving. It was repaired, but the ENT at the time advised that I should give up diving. I was left with a moderate hearing loss but no other symptoms. I stopped diving, but years later, my son got into diving and I wanted to dive with him. After a great deal of research of the scientific literature I could find no good reason not to dive. Some of the published rational not to dive suggested that it could happen to the other ear resulting in bilateral hearing loss. PLF is a rare diving related injury and I did not find any evidence based data to suggest that if it occurred in one ear it was more likely to affect the contralateral ear. Yes, if at the outside chance I sustain a PLF in the other ear it would affect hearing in both ears, but it won't kill me. How many divers with a PFO continue to dive a conservative profile thinking it would prevent them from getting a potentially fatal case of DCS. I am curious as to why an ENT would disqualify someone from diving just on the basis of a previous PLF but not a DCS hit. Diving is a sport that carries a lot of inherent risk. Divers accept that risk and do all they can to minimize it. Why then should a diver be prohibited from diving after a PLF just because it "may" happen in the other ear? IMHO, there is not scientific evidence to support this Draconian prohibition in a diver who gets great enjoyment from their sport.

No doctor can prohibit you from diving. But if you are asking an ENT doctor to tell you that you are at no risk for worsening hearing loss, or that you are "cleared" to dive, no one is going to do that either.

There is so little known about spontaneous and/or barotrauma induced PLFs that it's not possible to give you a percentage risk of further hearing loss, etc... There just aren't the numbers there to do real science.

So I'm not sure what you are expecting an ENT doctor to do besides tell you that you have a greater risk of further hearing loss than someone who has never had a diving injury to their inner ear. What you want to do with that information is up to you.

 

[Duke Dive Medicine]

I suffered a PLF in the early 80's while diving. It was repaired, but the ENT at the time advised that I should give up diving. I was left with a moderate hearing loss but no other symptoms. I stopped diving, but years later, my son got into diving and I wanted to dive with him. After a great deal of research of the scientific literature I could find no good reason not to dive. Some of the published rational not to dive suggested that it could happen to the other ear resulting in bilateral hearing loss. PLF is a rare diving related injury and I did not find any evidence based data to suggest that if it occurred in one ear it was more likely to affect the contralateral ear. Yes, if at the outside chance I sustain a PLF in the other ear it would affect hearing in both ears, but it won't kill me. How many divers with a PFO continue to dive a conservative profile thinking it would prevent them from getting a potentially fatal case of DCS. I am curious as to why an ENT would disqualify someone from diving just on the basis of a previous PLF but not a DCS hit. Diving is a sport that carries a lot of inherent risk. Divers accept that risk and do all they can to minimize it. Why then should a diver be prohibited from diving after a PLF just because it "may" happen in the other ear? IMHO, there is not scientific evidence to support this Draconian prohibition in a diver who gets great enjoyment from their sport.

What type of scientific evidence are you looking for? It would be unethical to conduct a controlled study on this, but there's pretty sound clinical rationale. If vertigo was one of your initial presenting symptoms, PLF/IEBT in the other ear could also affect your equilibrium and leave you with debilitating vertigo. That's the rationale we use when we advise divers not to dive any more. And it's just that, advice. Like doctormike said, what recreational divers do with that advice is entirely up to them. We would be very unlikely to sign a medical cert for a commercial/public safety/scientific diver in this situation, though.

Best regards,
DDM

 

[gkwalt]

Thanks Dr.Mike and DDM for your thoughtful comments. I certainly understand and recognize your rational. While vertigo was a presenting symptom, I have been over 20 years post injury without any further dizziness. Not signing off on a prospective commercial diver with a history of PLF has the affect of limiting someone livelihood without any concrete evidence. I am certainly aware that a RCT would be impractical, but there are observation data that would contradict such a conservative approach to limiting diving. Dr.Mike did reinforce this be stating the "numbers are just not there". As far as I know, PLF/IEBT, is a pressure related malady not an inherent structural defect. As such, the risk to the contralateral ear is the same as any virgin ear and therefore doesn't predispose a diver to further injury. I can't agree with DDM's assertion that there "pretty sound clinical rational" for their recommendations. "Just because it could happen" is not sufficient reasoning to make a generalized prohibition. Diving, whether it be it be recreational or commercial, has inherent risks. Medical evaluation of divers can weed out those conditions which can be life threatening to the diver or a buddy. But is just because my hearing can get worse a reasonable restriction to diving? I again would argue that a history of PLF is not an absolute "don't sign off" to diving. With every dive we make we are subject to undeserved hits, panic ascents, dysbaric osteonecrosis and various other risks. However, we still dive. Remember the days when seizures, asthma and diabetes would keep a potential diver out of the water? To fuither complicate the issue, where are the data on risk after repair of a PLF? I have utmost respect for DAN and their contribution to dive safety. I think that PLF/IEBT is an area that deserves a more critical review. If there is compelling evidence that there is a significant risk, so be it, but if not shouldn't recommendations be relaxed? As an aside, look at the thread in this forum regarding warfarin use while diving.

 

[doctormike]

But you see, PLF is not like PFO. PFO is something that a quarter of the population has, is easily measurable by echo or more invasive techniques, and you can do some real science (like with asthma, diabetes, and other extremely common diseases). You can see if people with these conditions actually have a higher rate of complications.

PLF is extremely controversial, often times even when the surgeon makes a diagnosis at surgery, it's sort of vague, they see a little fluid welling up near the oval or round window and put some fat there. Then if the hearing gets better, it's a success. If it stays the same, it's a success because it would have gotten worse. If it gets worse it's a success because it would have gone completely without the surgery..!

I know that doesn't sound reassuring, but there is a common question in otology circles - "do you believe in the fistula fairy?". Also, there are congenital abnormalities of the temporal bone that can be seen on imaging, but then there are barotrauma PLFs where you would see nothing. So is it fair to say that if you get a pressure induced tear in your round window membrane, that there is something weak about your round window membranes and the other side is at risk? Or was it just the particular dive accident that you had? I don't know, and no one else does either, because you just can't do good science on such a rare and ill defined entity.

So as far as relaxing recommendations, I think that for someone to publish a study saying that there is no risk of diving after PLF would be pretty hard to do, and not possible to get past the IRB on ethical grounds (randomizing people with PLFs into diving and no diving cohorts?).

But the larger issue here is I'm not sure what you are looking for. Your argument is that you personally feel that your risk is minimal, and that you personally want to take that minimal and/or unknown risk because you want to dive and accept the possibility. So what is stopping you? Why are you telling a doctor about your PLF if you have already decided that the risk is not an issue for you, and you have decided ahead of time that his or her reluctance to clear you is irrelevant? I guess you are planning on doing some training, so you need a new physical? Or do you just want to find a doctor who will tell you that it's OK for you to dive? The other risks you mention are present for all divers, so "clearance" doesn't enter into the discussion...

I hope this doesn't sound snarky, I realize what you are saying, and many divers in your situation would just dive. But you asked about why ENT docs don't clear people in this situation, and that question is a bit more complicated...

Dive safe!

Mike

 

[TSandM]

There is a huge difference between what a diver may decide is reasonable for himself, and what a doctor will give approval to do.

If I say it is safe for you to dive with a PLF, and you lose your hearing in the other ear, and you sue me . . . if I have no literature or textbooks to use to support my decision, I may very well lose.

The warfarin thread is a great example. It's almost certain that someone who incurs an injury while therapeutic on Coumadin will lose more blood than someone who isn't taking the drug. In the majority of cases that won't be a game-changer. In some cases, it could make the difference between a relatively minor injury and major disability or death. There aren't any literature guidelines for what a physician should do in such a case -- probably the closest to an authoritative reference is the DAN FAQ, and that's a pretty poor leg to stand on. At that point, the recommendation comes down to individual risk tolerance. I'd be comfortable documenting the stink out of the discussion I had with the patient, and signing someone off to dive; Duke Dive Medicine would not be, and that's just who we are.

The biggest goal of every physician in the United States is to stay out of trouble (and if it isn't, it should be. I speak from experience.) Most of us will make every decision with a weather eye to our own safety in any foreseeable consequence. Most of us are therefore VERY conservative in what we will say a patient is "safe" to do. Life ain't safe . . .

 

[Duke Dive Medicine]

Gkwalt, this is a low-risk/high-consequence situation. Your risk of injuring the other ear may be very low, and if you're comfortable with that, well, nobody here is the diving police. However, the consequences of injuring this ear could be life-altering, especially given the fact that you verified that you did indeed have vertigo when it first happened. That needs to be part of the thought process as well, not just for yourself but for anyone in this situation, including medical professionals who evaluate divers who've had IEBT/PLF.

Best regards,
DDM

 

[TSandM]

Low risk/high consequence . . . good way to describe it.

Low risk/low consequence -- no problem signing someone off.

High risk/low consequence -- document, but I'm okay with it.

High risk/high consequence -- No.

Low risk/high consequence . . . that's a judgment call and really involves the patient's understanding of what the risks ARE and what, if anything, can be done to deal with them.

 

[gkwalt]

I don't mean to be a throne in any bodies' flesh, but I think you all of your comments supported my argument. There is NO evidence that PLF is related to an inherent weakness in the round window! Additionally, there is NO evidence that a previous PLF disposes any diver to a subsequent PLF. Can any of the experts given any numbers regarding the risk involved? You and I both know that is impossible. What is the risk of dying while scuba diving? Ask DAN, they have those data but not the risk of PLF. I don't want anything from the experts on this thread. I don't need a sign off. Regardless, I'm going to keep on diving. Not because I'm willing to accept the risk, but because there is no risk! Evidence based medicine regarding PLF and diving is no where to be found. So why, based on your "maybe's" are you so steadfast? Keep one thing in focus, a commercial diver that is not signed off loses their ability to support their family, a recreational diver that is not signed off loses a sport that brings them great pleasure. It is common knowledge, psychiatrists suffer the highest rate of suicide among physicians. Based on that knowledge would you deny a medical student from becoming a psychiatrist? Maybe that's a weak analogy, but you get my point. I'm not going to stop diving because of a "who knows what may happen", maybe the experts should look at the ramifications too. There is absolutely no evidence that diving after a PLF, especially one that is repaired is "high risk" as stated. But if you are a commercial diver that relies on that paycheck to support your family or a recreational diver that gets an unbelievable peace and satisfaction from being underwater the "consequences" are high. My analysis would be: risk of diving with a history of repaired PLF- low; consequences of being denied commercial or recreational diving- high.

 

[doctormike]

I think you all of your comments supported my argument. There is NO evidence that PLF is related to an inherent weakness in the round window! Additionally, there is NO evidence that a previous PLF disposes any diver to a subsequent PLF.

I think that I can sum up the concept that you are grappling with in one sentence:

"The absence of evidence does not imply the evidence of absence"

Look, I'm not sure why your tone has become a bit adversarial, we really are trying to help. No one is denying you anything. You asked for medical advice, and you got it. It is imperfect advice, based on what we do know, not only about PLFs but about the anatomy of the temporal bone and barotrauma. Do with it what you like...

Your analogies really don't make sense to me. If you are planning to engage in an activity that has a high inherent risk, then it is up to you to make a decision whether or not to assume that risk. But if you have a specific condition, which while not proven but suspected to put YOU at SPECIFIC additional risk, then any honest doctor is going to tell you about that.

The main reason why we are responding (for me, and I suspect for my colleagues as well), is that we hope that someone else doesn't read this thread and assume that because you feel that there is no risk, that represents some sort of proven opinion.

In any case, it sounds like you are pretty convinced that there is no risk, so be safe!

Mike

 

[sprklep]

Good stuff. I am still following. I go back to Dr. Admire on Monday. I think the steroids gave me some hearing back but just some. Still quite a bit of loss there. Doc was to get all my old ear medical records and since I have weird ears, try and piece this all together and try and figure out what happened. Never any vertigo, never anything else weird at all. Felt fine the entire trip. Only time I felt weird was when they put me on that crazy prednisone when I got back. Call me crazy but if they never figure this out, I prob keep diving. Been diving 20 years and 744 dives...maybe I go another w/o incident?? Hate to give up diving for a bunch of what ifs??? Just be more cautious with my ears and clearing. I don't remember any pain this trip but other trips, yeah, prob went down too fast. I remember a trip, prob last July, it popped so hard it hurt.

---------- Post added January 16th, 2014 at 11:10 PM ----------

Oh yeah...and Dr. Andy Chung...the ENT doc that is a diver that DAN suggested. I plan to see him for yet another opinion. Dr Admire is my doc, I like her but since he is a diver, I will go see him just for advice, etc.