Diving after perilymph fistula surgery

[hevene]

Hi,

My partner has been diagonoised with round window rupture 2 weeks ago and we are wondering if it's possible to go diving again. There has been a number of threads about perilymph fistula, however I would like start a new one to gather some opinion or experiences of people going back to diving after having perilymph fistula surgery done.

My questions are:
1. Did you let it heal by itself or performed the surgery to patch it up?
2. How long was the recovery (natural healing or surgery)
3. Did you go back diving again and have you experienced any complications?

Thank you

 

[Duke Dive Medicine]

Hevene,

There are a lot of variables, so what worked for one person with perilymph fistula might not work for your partner. Some things for your partner to consider:

- What caused the fistula? Was it related to diving? If so, did it result from improper ear equalization technique or an anatomic abnormality that affected ear clearing?
- What were the initial symptoms?
- How long after the injury was the surgery done?
- Have the symptoms subsided, or are they still there?

Perilymph fistula is a tear in the round or oval window. The round and oval windows are part of the vestibular apparatus, the organ of hearing and balance in the inner ear. When a perilymph fistula occurs, one or both of these functions can be affected.

Hearing loss and/or tinnitus in the affected ear is likely to be permanent. Damage to the semicircular canals (the organs of balance) may also be permanent; however, the brain has an amazing capacity to compensate for injury to one set of semicircular canals. In other words, your partner's semicircular canals may be permanently damaged, but the vertigo may eventually improve or subside altogether as the brain compensates. This does not mean that he/she has healed, it means that the injury has been compensated for.

When we work with divers who've had a PLF, we typically wait until the healing plateaus (i.e. the symptoms don't get any better), then have them undergo both a hearing test and electronystagmogram (ENG). This determines if the vestibular apparatus in the affected ear is permanently damaged.

A diver with permanent damage to one vestibular apparatus only has one left to work with. If the undamaged vestibular apparatus is subsequently injured, the compensatory mechanism mentioned above will cease to work and any vertigo will likely be permanent. Hearing may also be adversely affected. Because the potential consequences are drastic and life-altering, we typically recommend that divers with permanent damage to one vestibular apparatus stop diving altogether.

It's best for your partner to work closely with his/her ENT surgeon in making any determination about returning to diving.

Best regards,
DDM

 

[hevene]

DDM,

It is definitely a diving related incident, didn't equalize properly and he immediately experienced the symptoms of hearing loss and tinnitus. He does not have dizziness or vertigo. The E&T specialist said he has a round window rupture. I suspect his semicircular canals are intact due to the lack of dizziness or vertigo.

It would be devastating if he cannot dive again, we would like to know if there are people out there that experienced this and went back to diving successfully.

Thanks

 

[Duke Dive Medicine]

DDM,

It is definitely a diving related incident, didn't equalize properly and he immediately experienced the symptoms of hearing loss and tinnitus. He does not have dizziness or vertigo. The E&T specialist said he has a round window rupture. I suspect his semicircular canals are intact due to the lack of dizziness or vertigo.

It would be devastating if he cannot dive again, we would like to know if there are people out there that experienced this and went back to diving successfully.

Thanks

The fact that there was no vertigo is definitely in his favor. It still may be appropriate to have an ENG done to rule out subclinical damage, and he should have a hearing test once he's healed from surgery and his hearing loss and tinnitus have stabilized.

It is possible return to diving after perilymph fistula that heals without complications. The best source of advice will be your partner's ENT surgeon. If the ENT clears him from a surgical perspective, he'll have to decide what degree of disability he's willing to accept should the other vestublar apparatus become injured. He'll also have to exercise extreme caution when changing depth and be willing to scrub a dive if he's unable to equalize easily.

It would be interesting to hear from other SB members who've experienced this firsthand.

 

[DocVikingo]

Hi hevene,

The following recent thread contains an extensive discussion of this issue, including responses by our resident diving ENT, "doctormike." You might find it informative.

http://www.scubaboard.com/forums/di...returning-diving-after-perilymph-fistula.html

Regards,

DocVikingo

 

[hevene]

Updated info:

My partner has been reviewed by the ENT specialist who has conducted another audiogram and related tests to measure damage. Hearing loss was originally significant in higher frequency range after the event and has since improved (2 weeks after event). ENT specialist has stated that any rupture of the window (if there was a rupture) has probably already healed and hearing will continue to improve. He also stated that the repaired window shouldnt be significantly weaker than before.

Now for some back story. He is a regular diver and in this particular occasion did not equalize while snorkelling to a depth of ~7 metres. He has more than learnt from this experience and will take the following steps to ensure that this situation does not arise again.

1. Duck diving while snorkelling will be minimised and when done will be equalised gently using the Toynbee technique while descending.
2. Descending while diving will be done at slow speed and once again only while using the Toynbee technique (as opposed to Valsalva technique which while it never caused harm previously is a more forceful technique). If equalisation cannot be completed at any depth the dive will be aborted and divers will surface.

An interesting question is he did not notice any particular pain while duck diving to ~7 metres and only noticed the tinnitus/ringing once surfaced from duck dive, what would be the future signs to watch for that something was not going correct with the equalising?

Also is it true that forced equalizing such as using the Valsalva technique may cause round/oval window rupture, but not equalizing may only cause the ear drum to rupture?

Thanks

 

[Duke Dive Medicine]

I'm inferring from this that he didn't have surgery, and that the diagnosis of perilymph fistula was a presumptive one. PLF is hard to definitively diagnose, and it sounds as if the ENT isn't sure whether a fistula actually occurred. It is possible to have inner ear barotrauma without having a PLF.

Updated info:
Now for some back story. He is a regular diver and in this particular occasion did not equalize while snorkelling to a depth of ~7 metres. He has more than learnt from this experience and will take the following steps to ensure that this situation does not arise again....

...Also is it true that forced equalizing such as using the Valsalva technique may cause round/oval window rupture, but not equalizing may only cause the ear drum to rupture?

He didn't equalize on the dive to 7 meters and ended up with inner ear barotrauma (with our without fistula). I don't know if this particular question has ever been studied, but I wouldn't volunteer to be a test subject The best way to avoid inner ear barotrauma is to equalize early and often, avoid a forceful Valsalva maneuver as you've already pointed out, and thumb a dive if you're unable to equalize.

An interesting question is he did not notice any particular pain while duck diving to ~7 metres and only noticed the tinnitus/ringing once surfaced from duck dive, what would be the future signs to watch for that something was not going correct with the equalising?

Usually with snorkelling you descend head down, which makes equalization more difficult. It could be that he was concentrating more on holding his breath than equalizing. I'd think that he'd have felt some pain if he hadn't equalized by 7 meters. Does he have any type of peripharal neuropathy that might decrease pain sensitivity?

 

[hevene]

I'm inferring from this that he didn't have surgery, and that the diagnosis of perilymph fistula was a presumptive one. PLF is hard to definitively diagnose, and it sounds as if the ENT isn't sure whether a fistula actually occurred. It is possible to have inner ear barotrauma without having a PLF.

Yup, the ENT said it was possible there was no fistula but the hearing loss at the higher frequencies was typical of one.

He didn't equalize on the dive to 7 meters and ended up with inner ear barotrauma (with our without fistula). I don't know if this particular question has ever been studied, but I wouldn't volunteer to be a test subject The best way to avoid inner ear barotrauma is to equalize early and often, avoid a forceful Valsalva maneuver as you've already pointed out, and thumb a dive if you're unable to equalize.

He intends to only equalise very gently and early from now on. It just a slightly confusing topic as the pressure should’ve been on the tympanic membrane not the round window and am confused as to how it could’ve been damaged.

Usually with snorkelling you descend head down, which makes equalization more difficult. It could be that he was concentrating more on holding his breath than equalizing. I'd think that he'd have felt some pain if he hadn't equalized by 7 meters. Does he have any type of peripharal neuropathy that might decrease pain sensitivity?

No he has no decreased pain sensitivity and I think you are right he was concentrating more on holding his breath than equalizing.

 

[Duke Dive Medicine]

He intends to only equalise very gently and early from now on. It just a slightly confusing topic as the pressure should’ve been on the tympanic membrane not the round window and am confused as to how it could’ve been damaged.

The tympanic membrane's on one side of the middle ear, and the vestibular apparatus with the round and oval windows is on the other side. The TM is connected to the oval window via the ossicular chain (malleus, incus and stapes bones). Of course it's impossible to tell exactly what happened without cracking him open and looking, but significant negative pressure in the middle ear could affect either the TM or the vestibular apparatus. Usually you hear of the TM rupturing before the vestibular apparatus is damaged, but at 7 meters it's not unreasonable to assume that he damaged the vestibular apparatus as well.