Inner Ear Barotrauma - seeking opinions

[Duke Dive Medicine]

I submit for consideration that the 20' to 0' to 30' cycle with only seconds on the surface at 0' had a definite effect. The symptoms I felt on the descent (A "foggy dream-like thinking state" that I had to push through) certainly sound like descriptions I read elsewhere of nitrogen narcosis.

Whether it was nitrogen on the brain, or adrenaline, or just being 43-years-old - Whatever it was, that post-CESA descent was dramatically different from the other 4 descents I did that weekend. I suspect it had something to do with attempting to descend ALMOST IMMEDIATELY after the CESA ascent.

If I had a dive computer on my wrist, that would have helped. If I had drilled equalization to the point that it was a muscle memory skill, that would have helped. (It's one thing to answer a question correctly on a quiz, or to show your instructor that you can pinch your nose and exhale. It's another to do the right thing while descending from 10' to 15' in a matter of seconds while something else is going wrong. Hindsight being 20/20, I wish I had a prepared descent routine for equalization that I had actively practiced.)

I submit that a 2-3 minute rest on the surface after my CESA would have helped also. For instance, I knew that one should always ascend if there's an issue with equalization - but again, the "foggy dream-like state" interfered with my ability to conduct the descent correctly.

And that's been my main objective in posting here. A chain of unfortunate events lined up to result in a significant injury. I contend that a rest period on the surface after my CESA would have broken one of the links in the chain leading up to the injury.

@Ken Fischer , I concur with the other posters who have said that it is highly unlikely that you were suffering from nitrogen narcosis. There are a few potential explanations for the foggy feeling that do not involve that. Neurological symptoms immediately after a practice or actual CESA would be more concerning for arterial gas embolism, though if you were asymptomatic after surfacing the second time, that would be low on the differential. Way down the list, but a possibility, would be a bony dehiscence (area of missing or underdeveloped bone) between a sinus and the brain, which could lead to neurological symptoms if the sinus does not equalize properly.

It's also not unheard of to experience a mental "fogginess" during periods of vertigo, likely attributable to anxiety as you suggested in your first post; you could have had some momentary alternobaric vertigo that resolved on its own. You also could have become hypercapnic (too much CO2 in your body) on your second descent if you were having difficulty equalizing, felt anxious, and overbreathed your regulator. I would look at one of these two as the most likely explanation, though you didn't report a headache, which is one of the hallmarks of hypercapnia. You almost certainly were not narced though.

Best regards,
DDM

 

[Ken Fischer]

Didn't you need to equalize several times during your confined water sessions? How did that go?

Equalization was discussed, and I was shown the Valsalva maneuver, but there wasn't a *focus* on equalization. I did equalize in the pool, but that was much easier - and never reached the pressures I sustained on my open water dive. I remember asking a question about the conflicting guidance between "always breathe continuously - don't hold your breath" and the main equalization skill being the Valsalva maneuver.

I thought I was approaching diving with a healthy level of respect for the dangers involved. I did the coursework, studied the book material, memorized the BWRAF, etc. I wish I had practiced equalization, and just equalization, for 30-45 min in the pool - devoting as much time to the one danger present on every dive - as we did to all the other skills (mask clearing, breathing off a buddy's regulator, etc.) And during my open water certification, I was asked if I knew how to equalize, and I demonstrated the Valsalva maneuver in the dive shop, and that was the extent of the conversation about equalization.

 

[tursiops]

Equalization was discussed, and I was shown the Valsalva maneuver, but there wasn't a *focus* on equalization. I did equalize in the pool, but that was much easier - and never reached the pressures I sustained on my open water dive. I remember asking a question about the conflicting guidance between "always breathe continuously - don't hold your breath" and the main equalization skill being the Valsalva maneuver.

I thought I was approaching diving with a healthy level of respect for the dangers involved. I did the coursework, studied the book material, memorized the BWRAF, etc. I wish I had practiced equalization, and just equalization, for 30-45 min in the pool - devoting as much time to the one danger present on every dive - as we did to all the other skills (mask clearing, breathing off a buddy's regulator, etc.) And during my open water certification, I was asked if I knew how to equalize, and I demonstrated the Valsalva maneuver in the dive shop, and that was the extent of the conversation about equalization.

I'm sorry about your instruction. It was sub-par.
Valsava is probably the worst way to equalize for many folks....but it so easy for some -- like some instructors -- that it never occurs to them that it might not as effective for everyone. See, for example, Beat the Squeeze: Equalize Like a Pro. Toynbee and Lowry are usually more effective that Valsalva, for many folks, in my experience.

 

[Steve_C]

If you are equalizing at the start AND you are going down slow enough that you can keep equalizing then depth does not matter. Depth only matters if you get behind the curve. Problem is that as a student most do not have the confidence to stop and go up a bit and equalize and then continue their descent.

 

[Ken Fischer]

@Ken Fischer , I concur with the other posters who have said that it is highly unlikely that you were suffering from nitrogen narcosis. There are a few potential explanations for the foggy feeling that do not involve that. Neurological symptoms immediately after a practice or actual CESA would be more concerning for arterial gas embolism, though if you were asymptomatic after surfacing the second time, that would be low on the differential. Way down the list, but a possibility, would be a bony dehiscence (area of missing or underdeveloped bone) between a sinus and the brain, which could lead to neurological symptoms if the sinus does not equalize properly.

It's also not unheard of to experience a mental "fogginess" during periods of vertigo, likely attributable to anxiety as you suggested in your first post; you could have had some momentary alternobaric vertigo that resolved on its own. You also could have become hypercapnic (too much CO2 in your body) on your second descent if you were having difficulty equalizing, felt anxious, and overbreathed your regulator. I would look at one of these two as the most likely explanation, though you didn't report a headache, which is one of the hallmarks of hypercapnia. You almost certainly were not narced though.

Best regards,
DDM

Regardless of the exact physiological mechanism, I'd boil my incident statement down to this:

"Student performed a CESA in the middle of Open Water dive #4. After resting on the surface for a very brief time (< 30 sec), on subsequent descent, the student reported experiencing a mental fogginess and dreamlike/euphoric state, and hearing "tones" in his right ear. The "mental fogginess" lead to the student botching equalization on the descent, with a forced Valsalva maneuver, and subsequently suffering inner ear barotrauma (as diagnosed by an ENT 4 days post-incident.) The student lost nearly 100% of his hearing in the right ear; ~2 months post-incident, the student has recovered ~50% of his hearing, with some persistent hearing loss and tinnitus. Treatment consisted of prednisone (oral steroids), 9 intratympanic steroids, and hyperbaric oxygen treatments."

I hope that is of some benefit to other divers. (I've reported this to both PADI and DAN.)

 

[Steve_C]

I remember asking a question about the conflicting guidance between "always breathe continuously - don't hold your breath" and the main equalization skill being the Valsalva maneuver..

The don't hold you breath rule is kept simple and repeated many times to reduce injuries in an ascent..

However, like many such rules it is nuanced. Holding your breath for 5 or 10 seconds while holding a constant depth is harmless.

 

[Steve_C]

(I've reported this to both PADI and DAN.)

If they are going by the rules the instructor should have reported it to PADI also. Not saying they did, but they were supposed to.

 

[saxman242]

If they are going by the rules the instructor should have reported it to PADI also. Not saying they did, but they were supposed to.

Assuming that with a diagnose 4 days after the dive, the instructor is even aware there was an issue.

 

[Ken Fischer]

Assuming that with a diagnose 4 days after the dive, the instructor is even aware there was an issue.

I reported the hearing loss the day of the dive (Sunday) and every day after the dive, until our departure from the resort on Wednesday. I was continuously advised by the resort dive shop that it was "nothing, just a routine injury" and that it would clear up on its own. It was out of my own abundance of caution (and my wife's concern) that I scheduled an appointment with an ENT immediately upon my return to the US.

The resort followed up with me a week later, and I informed them about the seriousness of my injury at that time. I also reported the incident to PADI at that time as well (mid-February.)

 

[saxman242]

I reported the hearing loss the day of the dive (Sunday) and every day after the dive, until our departure from the resort on Wednesday. I was continuously advised by the resort dive shop that it was "nothing, just a routine injury" and that it would clear up on its own. It was out of my own abundance of caution (and my wife's concern) that I scheduled an appointment with an ENT immediately upon my return to the US.

The resort followed up with me a week later, and I informed them about the seriousness of my injury at that time. I also reported the incident to PADI at that time as well (mid-February.)

Then yes, the instructor should have reported it as well.