Inner ear barotrauma

[J.Angulo]

Hi @J.Angulo ,

Sorry to hear about this injury. From my own non-ENT perspective, a forceful Valsalva maneuver is definitely a precursor to inner ear barotrauma (IEBT). Anatomically, the three bones in the middle ear: malleus, incus, and stapes, aka the ossicular chain, are all connected end to end. The malleus lies against the tympanic membrane (eardrum), and the far ends of the stapes connect to a part of the vestibular apparatus (the inner ear) called the oval window. A forceful valsalva can cause the tympanic membrane to bow outward; the force is then transmitted to the oval window via the ossicular chain. The oval window can then rupture, producing a fistula (tear). The force can also be transmitted through the vestibular apparatus to the round window, which basically compensates for the motion of the oval window and keeps the pressure in the vestibular apparatus relatively stable. If that happens, the round window could rupture as well. Mild IEBT may not produce a rupture of the round or oval windows (aka perilymph fistula) but could still damage the delicate vestibular apparatus and result in inflammation.

What you're describing is consistent with a relatively mild case of IEBT - no hearing loss or vertigo, but you do have some lingering tinnitus and hyperacuisis (the noise sensitivity you mentioned). So, if you did suffer IEBT, it's likely either non-fistulating or the fistula was not clinically significant. The only way to definitively diagnose a fistulating IEBT is via surgery, and if your medical team thought that was indicated in your case, it probably would have already happened.

Ear injuries like this are notoriously slow to heal. Your ENT would be the best person to address specifics about recovery time, having evaluated you personally. If he/she lacks experience in this area, DM me your location in FL and I'll see if I can point you toward some resources.

I'll tag @doctormike , our resident ENT, for his perspective as well.

Best regards,
DDM

Hello my location is south Florida, but I will literally drive anywhere in the USA if there is a specialized doctor in barotrauma

 

[J.Angulo]

Sure... who are you seeing as an

Sure... who are you seeing as an ENT doc?

Michael Ellis Hoffer, MD​

 

[doctormike]

No such thing as a specialist in barotrauma, but it looks like Dr. Hoffer is an experienced neurootologist, which is what you want. I would defer to him.

 

[BlakeB]

I have an appointment with Hoffer in November. Id be interested to know how your experience was with him and if you have resolution of symptoms. we have a similar sounding injury.

 

[Johnboy70_99]

I have an injury that sounds very similar as well. I have a follow up in 4 weeks with an ent near me. Following this thread for updates.

 

[BlakeB]

I have an injury that sounds very similar as well. I have a follow up in 4 weeks with an ent near me. Following this thread for updates.

Hi John, had my Appt with neuro-otologist. I suggest you talk to one as well. These guys are a sub specialty of ENT that have specific training / focus on the ear/ nerves etc.

I saw Hoffer at UMiami. He has been the first to suggest surgery could help. He also helps DAN write protocol for IEBT. The surgery is both exploratory and corrective. The only way to know id you have a tear in the membrane in oval or round window is by visualization. (They put a scope in your ear and look). If a tear is found they take a fat graft and repair the defect. Hoffer said 30-40% chance I have a tear, I’d I have one 80-90% chance the surgery will help/ resolve my issues. Biggest complaint now is constant high pitch tinnitus & hearing loss. It’s a value proposition in the end, take the risk or hope it heals and resolves on its own.

 

[Johnboy70_99]

Hi John, had my Appt with neuro-otologist. I suggest you talk to one as well. These guys are a sub specialty of ENT that have specific training / focus on the ear/ nerves etc.

I saw Hoffer at UMiami. He has been the first to suggest surgery could help. He also helps DAN write protocol for IEBT. The surgery is both exploratory and corrective. The only way to know id you have a tear in the membrane in oval or round window is by visualization. (They put a scope in your ear and look). If a tear is found they take a fat graft and repair the defect. Hoffer said 30-40% chance I have a tear, I’d I have one 80-90% chance the surgery will help/ resolve my issues. Biggest complaint now is constant high pitch tinnitus & hearing loss. It’s a value proposition in the end, take the risk or hope it heals and resolves on its own.

Thanks for your response. At the moment the tinnitus and hearing loss above 7k are my only symptoms. The tinnitus isn't constant, if I walk around for a while it goes away. If I lay or sit down it comes back most of the time although I have had days that are mostly free of the ringing. I saw an ent yesterday. They said I am stable. They think I may have a minor fistula, and if the ringing persists they want me to come back in 3 months for an MRI. They said I am ok to start lifting weights again but not to dive until I see an ent who specializes in diving to see what my options are. I have an appointment with Mass eye and ear in about 3 weeks to see what they say, but I would like to find an ent knowledgeable in diving in my area.

Are you going to proceed with the surgery? Did they say there is a chance it will heal on its own eventually?

 

[Kimela]

Hoping @Duke Dive Medicine and @doctormike see this. Roger (husband) and I got a nasty virus back in November (actually, I got it in October and R became symptomatic in November) - one feature was a lot of sinus and chest involvement, but the sinus was the worst. Both of us had absolutely unclearable ears for at least a week. Mine eventually cleared up, very slowly. Here we are on December 27th and R went to an ENT (NP) who said he has fluid behind one ear and the gold standard is Flonase (he's been on it for 2 weeks) and prescribed a stronger steroid. We are going to Cozumel on January 20th and the NP he saw was dubious about flying or diving that soon. She wants him to see the doctor (January 15th) to determine if he might need to have the ear drained. I don't know if that means tubes or just putting a hole in his ear for it to drain? Also don't know the recovery time. I'm ok with missing a Cozumel trip, but we've got a PI trip on the books for the end of March. Wondering what the normal medical course is for something like that - I guess 'bad case scenario' if not 'worst case scenario'. We can miss trips - won't be the end of the world (bought trip insurance). But I really was looking forward to PI.

Any info appreciated. Now I'll go over to DAN to see if they have any articles too, so take your time. Thanks so much!

 

[doctormike]

Hi,

I can't give you specific advice, since I haven't seen him myself, but I can make some general comments.

1) I don't feel that there is good evidence of Flonase having any effect on middle ear fluid. Since this is a condition that almost always resolves spontaneously, there are a lot of anecdotal reports of people taking nasal steroids and their ears getting better. Same goes for systemic or topical decongestants.

2) Oral steroids are the only medical therapy that I know that hastens the resolution of middle ear fluid, for patients who don't want to wait for spontaneous improvement.

3) GENTLE Valsalva and Toynbee maneuvers can also help middle ear fluid resolve faster.

4) Office myringotomy (draining the fluid from the middle ear) is generally done for adults who are very symptomatic with middle ear fluid and really want it fixed right away, not wanting to wait for natural resolution, steroids or Valsalva/Toynbee to work. If you do that, you can't dive until the ear is healed.

5) It would be unusual to recommend tubes for an adult with short term middle ear fluid related to an upper respiratory tract infection - those are for people with long term ET dysfunction (i.e. young children).

6) Commercial air travel (as opposed to military or cargo aircraft) really don't have enough of a pressure swing to make flying dangerous in most cases of barotrauma (this would be an issue with inner ear DCS). In fact, if the ear is completely filled with fluid, that's actually protective against ear pain on descent or ascent, since what hurts is expanding gas.

7) If you can't equalize (ears or sinuses), you can't dive. So it might make sense to take a mask and try it in a pool before making any decisions.

Good luck!

 

[Kimela]

Hi,

I can't give you specific advice, since I haven't seen him myself, but I can make some general comments.

1) I don't feel that there is good evidence of Flonase having any effect on middle ear fluid. Since this is a condition that almost always resolves spontaneously, there are a lot of anecdotal reports of people taking nasal steroids and their ears getting better. Same goes for systemic or topical decongestants.

2) Oral steroids are the only medical therapy that I know that hastens the resolution of middle ear fluid, for patients who don't want to wait for spontaneous improvement.

3) GENTLE Valsalva and Toynbee maneuvers can also help middle ear fluid resolve faster.

4) Office myringotomy (draining the fluid from the middle ear) is generally done for adults who are very symptomatic with middle ear fluid and really want it fixed right away, not wanting to wait for natural resolution, steroids or Valsalva/Toynbee to work. If you do that, you can't dive until the ear is healed.

5) It would be unusual to recommend tubes for an adult with short term middle ear fluid related to an upper respiratory tract infection - those are for people with long term ET dysfunction (i.e. young children).

6) Commercial air travel (as opposed to military or cargo aircraft) really don't have enough of a pressure swing to make flying dangerous in most cases of barotrauma (this would be an issue with inner ear DCS). In fact, if the ear is completely filled with fluid, that's actually protective against ear pain on descent or ascent, since what hurts is expanding gas.

7) If you can't equalize (ears or sinuses), you can't dive. So it might make sense to take a mask and try it in a pool before making any decisions.

Good luck!

Thank you! I think walking around feeling the fullness in his ear for two weeks is also driving him nuts - and the directionality of where sounds is coming from it all cock-eared for him. He's not in pain - he was for a couple of days but no longer. Poor guy. I'm passing along all the info. Thanks again.