I suffered an incident of inner ear barotrauma on Feb 16 during my 4th open water certification dive. I lost 100% of the hearing in my right ear, which was diagnosed by an ENT on Feb 20. I am specifically asking here about whether I should push my care team to consider a perilymph fistula, and treatment via a blood patch.
I've thrown the book at this injury with multiple treatments in parallel - I am an audiophile, with a sophisticated home theater that I have invested a significant amount of money in over the years for the enjoyment of both music and movies. I was the guy who wore ear plugs to concerts, and made my wife wear ear plugs too. I can't imagine having 40-50 years of life left with compromised hearing. Music sounds "tinny" and "scratchy" - and I really struggle to hear people's voices. If I can't get a miracle recovery at this point, I really hope I can get a little more sensitivity back to make hearing aids as successful as possible. In short, I am freaking out just a little bit...
For background - here is the dive incident:
I have a complete chronology of the entire weekend of 4 dives, but in trying to keep this as concise as possible, I'll only detail the 4th dive (which is where/when I believe the injury occurred.)
On the 4th dive, I demonstrated the use of a compass at approximately 30’. We then proceeded to ascend to 20’ where I executed a Controlled Emergency Swimming Ascent (CESA) from 20’ in approximately 20-30 seconds. Upon surfacing, my instructor congratulated me on completing the certification process. There were some ocean swells making bobbing on the surface unpleasant. We agreed to descend to 30’ and continue the dive. He cautioned me to take some time, as the 20’ to 0’ to 30’ cycle can sometimes mess with the “pressures in our heads.” We were on the surface for no more than 30 seconds.
With the adrenaline of the CESA, my equalization on the descent was certainly (evidently) sloppy. I recall feeling some pressure, but certainly never felt like I was consciously choosing to blow my ears out. I actually recall feeling euphoric and not having any concerns related to the pressure differential I was experiencing. The only equalization technique I knew was the Valsalva maneuver.
I heard 3 distinct tones that folded in on top of one another (similar to Close Encounters) in my right ear during the descent. I recall thinking “That doesn’t sound good” – but also assured myself it was likely nothing, just some bizarre underwater tinnitus or something.
I swam with my instructor for 5-10 minutes, but started to feel “off” – I realized I was simply focusing on following my instructor’s flippers and not enjoying the dive. I was starting to feel tired and out of breath, the gauge on my SPG had flipped upside down, things were starting to feel out of sorts. With the certification complete, and this being completely a “bonus portion” - I swam to catch up with my instructor, tapped him on the shoulder, and indicated to my instructor to end the dive prematurely.
We ascended to 20’ for a 3-min safety stop to decompress, and to stay at a safe depth while making contact with the boat. My instructor signaled the boat by vacating air from his secondary regulator to create bubbles on the surface.
Immediately after getting back onto the boat, I vomited violently and profusely several times. I had a significant nosebleed and blew a combination of blood and clear snot/liquid into my hand.
My instructor commented that our total time on the dive was approximately 30 minutes. I believe this included all portions (compass navigation, CESA, and the curtailed recreational portion of the dive.)
That evening, I was more tired than I have ever been. I did not feel like eating dinner. I felt some mild vertigo while laying in my bed, but it came and went in a matter of seconds.
The next day, I rode a bicycle. I had little concern for the "stuffiness" feeling in my ear. I perceived my hearing as being muffled - not gone.
Designating Sunday as "T+0" day - on Tuesday, "T+2" - I began to be concerned that I had something more serious going on that wouldn't be cleared up as a case of "swimmer's ear" With our air travel home designated for "T+3" [Wed], I paid a general care physician in Placencia, Belize to look at my ear drum. He saw some bruising and a small drop of blood, but no obvious perforation. He prescribed an antibiotic ear drop, but advised me that I should be ok to fly home.
Wednesday, T+3, I flew home with no incident.
Thursday, T+4, I met with my general care practitioner, who referred me to an ENT.
At the ENT, on initial presentation, my ENT speculated that I had some blood in the middle ear and would simply need to be monitored. However, after the audiogram, my entire world turned upside down at 4:45pm on Thursday, Feb 20. My right ear had almost 0 detection of any frequency, across-the-board, both air and bone conduction.
My ENT prescribed oral steroids [PrednisONE] on a tapered dose, and commented on intratympanic steroids and hyperbaric oxygen as additional available therapies.
Friday, Feb 21 [T+5] - I had a tube installed in my right ear, had the blood vacuumed out of my middle ear, and had my first dose of intratympanic steroids administered. I consulted another ENT for a 2nd opinion.
I began hyperbaric oxygen therapy on Monday, Feb 24 [T+8]. I was prescribed 20 sessions at 2.5 atmospheres (253 kpa) for 110 minutes - including 2 "air breaks" to prevent oxygen toxicity. I had a tube installed in my good ear also - on the 2nd hyperbaric session, I bled from my left [good] ear. (I also felt no pain or perceived any issues with equalizing when this happened in the chamber.) In the first week of hyperbaric O2, I had some amazing experiences - literally feeling my hearing returning while in the tube. Not being able to hear a dialtone on my kitchen phone at 7:15am, and then hearing it when I got home at 10:30am, etc.
I have received 7 intratympanic steroid injections on T+5, T+8, T+12, T+15, T+18, T+22, T+25. I plan on receiving 2 more next week [my last week of hyperbaric oxygen therapy.]
By Feb 28 (T+8), For freq. <= 1 kHz, I recovered normal hearing [20-30 dB down, equal to my left ear.] 2 kHz has 60 dB suppression. I was still deaf for f=4 KHz and f=8 kHz.
I test my hearing daily with a phone-based app [Mimi - free on the app store.] The test showed I was able to hear 4 KHz on Sunday, March 8 (T+21) 2 kHz remains stubbornly at 60 dB down. 8 kHz is 90+ dB down.
In addition to digital tests, I also purchased a cheap set of tuning forks. I periodically gauge my ability to hear the 2 kHz and 4 kHz tuning forks. I am able to hold the forks farther from my right ear as time progresses - although these gains are not showing up in my app.
I will have another professional audiogram taken on March 16 (T+29). I am having an MRI taken today, March 13 (T+26) My ENT advised against the MRI, saying it would not reveal anything - but wasn't opposed to having it done - essentially for "peace of mind."
The two ENTs I consulted with discounted the possibility of a perilymph fistula - since I showed no signs of balance issues, vertigo, passed the various tests. I have to wonder, though, if I have a slow leak of fluid, which is compromising/stalling my progress in the higher frequencies.
I understand that the only way to definitively diagnose a perilymph fistula is via direct visual inspection, which involves surgically lifting the ear drum out of the way to inspect the perilymph fistula. I wonder, however, if there would be much downside to administering a "blood patch" in the middle ear, without lifting the ear drum. [Could the blood be injected via the tube I already have installed?]
If you made it this far, thank you for reading my post! Even if this post doesn't help me, I hope this information is helpful to someone. I wish my training had truly PRACTICED equalization for the same amount of time we spent practicing mask clearing, breathing off a free-flowing regulator, etc. Equalization was not a "muscle memory skill" for me - it's one thing to answer a test question correctly. It's another to do the correct thing in a matter of seconds while descending from 15' to 20', still hyped up on adrenaline from having completed a CESA. I also speculate if I didn't have some mild form of nitrogen narcosis from the ascent/descent cycle? I recall my thinking on the descent not being clear - perhaps that was just the adrenaline. In any event, my other "lesson learned" to any instructors/students is to give students the opportunity to perform the CESA at the END of dives 2 and 3. Doing the CESA at the front-end of dive 4 was the root cause for the sloppy circumstances that lead to my poor equalization, which lead to this really unfortunate injury.
