Inner Ear Damage from Prolonged Valsalva - Prognosis?

[synewave]

On my third Open Water dive last Saturday, we started off with a CESA from seven metres (going down, equalisation seemed okay), then practiced inflating BCD manually, then removing weights at the surface. My instructor and I went back underwater to practice my buoyancy and trim skills (or lack of).

I was unable to equalise properly. Seemed to be okay down to about 5m but then going further caused discomfort in my left ear, so I went back up a bit, tried to equalise, then back down, pain, back up and repeat. This probably went on for about 10 minutes before I indicated to my instructor that I was ready to go back to the surface.

Completely my own fault. I knew at the time I was "performing an forced/extended equalisation" which the PADI video says not to do. I was however unaware of the consequences...

When we got to the shore, I could hardly stand up. Managed to get my gear off and out of my wetsuit and then spent the next few hours lying down or vomiting. The dizziness and nausea had decreased greatly by Sunday morning

After a visit to the local ENT on Tuesday, the doctor confirmed high frequency hearing loss and a some damage to my inner ear "window" (not sure of the exact term as my medical Japanese isn't fluent).

The doctor was frank and suggested my hearing might never return to what it was AND the ringing in my left ear might not go away AND I might not be able to dive again...I'm not sure which bothers me the most!

He gave me some steroids to take for a week and said at least, I should take the rest of the season off diving. Gutted as I was supposed to be going to Okinawa at the end of the month.

I'm just wondering how long other members have had to wait before getting back in the water after blowing out an inner ear?

Sent from my iPad using Tapatalk HD

 

[doctormike]

Hi,

So sorry that this happened to you. With ear stuff, specifics are VERY important, and in these threads people tend to weigh in with a lot of random ear stuff that may not be relevant to your situation. Here is my ear sticky, take a look at this for some background information: http://www.rothschilddesign.com/ear_scuba/

If you truly have an acute sensorineural hearing loss (as opposed to a conductive hearing loss, which should be obvious on a formal hearing test), especially with balance issues, then it is indeed possible that you have a perilymph fistula or even inner ear DCS (much less likely given your profile). So the first thing that you should do would be to see an ear specialist if possible. If you are still having symptoms and/or your hearing is continuing to drop, you might even be a candidate for surgery.

The bottom line is that an inner ear injury can indeed lead to permanent hearing loss and/or tinnitus (the noise in the ear), but the precise diagnosis is important. If you didn't have a formal audiogram in a booth with an audiologist, it might not be possible to make that distinction. There is no standard protocol for returning to diving after an inner ear injury, and you aren't likely to find an ENT doctor who will "clear" you for that (unlike after repair of an eardrum perforation). Finally, be VERY careful about following specific advice from these threads. Without an accurate diagnosis, some things can actually make your situation worse - like attempting valsalva maneuvers which would be appropriate for middle ear barotrauma but NOT for inner ear injuries.

There have been a few threads about this here that I have participated in:

http://www.scubaboard.com/forums/diving-medicine/271573-perilymph-fistula-surgery.html
http://www.scubaboard.com/forums/diving-medicine/239727-barotrauma-ugh.html
http://www.scubaboard.com/forums/diving-medicine/233882-physiological-presentation-symptoms.html

Good luck!

Mike

 

[Duke Dive Medicine]

Synewave,

Sorry to hear about this. Mike is an ENT physician and an expert in this field so I'm going to word this carefully as I know he'll be watching

I agree that you're not going to get inner ear DCS doing simple bounce dives to 5-7 meters. I would interpret "damage to inner ear window" as inner ear barotrauma, possibly a round or oval window rupture, which is the perilymph fistula mentioned by Mike above. A PLF can't be definitively diagnosed without surgery so the ENT physician's diagnosis is a presumptive one based on your symptoms.

If you don't recover within 12-24 hours it's possible that the damage is permanent, but there is no way to determine that for sure without further testing. Our counsel to divers with permanent inner ear damage, whether related to barotrauma or decompression illness, is to cease diving since damage to the opposite (presumably intact) vestibular apparatus could result in severe disability. Sorry the news isn't better, but inner ear damage is one of those things we don't like to take risks with.

Best regards,
DDM

 

[synewave]

Thanks for the responses.

I only have myself to blame! Unfortunately I was ignorant of the possible consequences of my actions.

When I visited the 'JiBiKa' (ENT in Japanese), I was given a hearing test while sitting in a booth trying to listen to faint sounds. The doctor confirmed high frequency hearing loss in my left ear.

He prescribed 10mg prednisolone daily for a week and told me to go back to see him next Tuesday.

Another hearing test next week so hopefully there'll be an improvement.

Oh, how I wish I'd spent more time learning how to clear my ears properly BEFORE going near the water...

Sent from my iPad using Tapatalk HD

 

[doctormike]

DDM speaks the truth, as always!

This has come up many times here (see the links above), and the unfortunate thing is that with a true inner ear injury, there just is no good data to reassure you about returning to diving. Only you can make that decision, but you should make it with as much information as you can. PLFs are notoriously difficult to confirm, even on surgical exploration...

Just to be clear about one thing - the vast majority of hearing loss after diving is due to middle ear barotrauma, which is reversible, usually related to middle ear blood or fluid, and causes a conductive hearing loss. Inner ear injury causes a sensorineural hearing loss. The distinction is crucial, and you only told us that you had a "high frequency hearing loss", which could be either. Did the doctor mention anything like that?

Keep us posted!

Mike

 

[synewave]

Hi Mike,

This is great information. Thanks! When I go back to see the ENT doctor I should be able to ask more knowledgable questions.

I'm now confused as to what type of hearing loss I have. The English terms aren't all that familiar, let alone the Japanese! I'll make sure I have them learned for next Tuesday.

During my consultation after hearing test and after the doctor had looked inside my ears, he got out a big picture of an ear. This is what I understood him to be meaning, perhaps my Japanese wasn't up to the task required.

"As you were blowing so hard, instead of clearing your ear as you hoped, You may have built up too much pressure and blown out one of the little windows in your inner ear. The cells at the entrance to the inner ear pick up high frequency sounds and this is where the damage occurred."

However, after reading DDM's message, my understanding is that diagnosing this kind of inner ear injury without surgery is impossible?

When I go back, I'll ensure I find out exactly what kind of hearing loss I sustained.

Many thanks for your advice.


Sent from my iPad using Tapatalk HD

 

[doctormike]

OK... if an ENT doctor used those terms, then it does sound like a sensorineural hearing loss. The devil is in the details... feel free to keep in touch, and if you are in the US at any point and want a local referral, feel free to PM me, I may be able to give you a name...

 

[gert7to3]

So it's not possible to pick out

a round or oval window rupture with MRI or CT?​

 

[doctormike]

So it's not possible to pick out

a round or oval window rupture with MRI or CT?​

Correct

---------- Post added October 18th, 2013 at 08:29 AM ----------

So it's not possible to pick out

a round or oval window rupture with MRI or CT?​

MRI is really not good for fine bony details at all, more for inner ear tumors like acoustic neuroma. CT can sometimes show a pre existing temporal bone abnormality, or a fracture from external trauma (eg assault with a heavy object or motor vehicle accident), but the rupture of the inner ear soft tissue membranes from barotrauma wouldn't show up on either.

PLF from diving is usually round window. Theoretically possible to get oval window leak but usually from displaced stapes, external eardrum trauma, or after surgery...