Inner Ear Decompression Sickness on recreational dive

[CaveMD]

Kathryn,

I've emailed a colleague in Australia to try to get some insight into the policy on clearance to dive for people in your situation. Will get back to you.

Best regards,
DDM

I had actually just done the same.

 

[duke dive medicine]

I am finding the whole topic of PFO a very confusing one...

My dive doctor thinks it is likely that it will be found that I have one. But do I want to know?

Although recommending I have the test, she is also heeding caution that if found I will no longer be able to dive and it will NOT be recommended that I have a closure. I know this is the safe option, but I'm devastated at the thought of never diving again. BUT I have also been told that if I have a PFO it does not necessarily mean I will experience DCS again. I will be at higher risk but I also could do many more dives with no incident. So maybe I will be ok if I ignore it and do all future dives conservatively...

I spoke with DAN who told me I would still be able to dive if a PFO was found provided that I only dived within the restrictions they agreed safe for me (depth, number of dives and minimum surface interval). Something positive! He urged me to have the test for PFO done as I have had such a significant decompression event with unexplained cause. He warned that the blurred vision I had mean't that I had a bubble in my brain affecting my optic nerve which could have been very bad. After we spoke I was convinced I needed to have the PFO investigated, HOWEVER my local doctor then warned me that if a PFO is found no dive doctor would pass me fit to dive, which would mean I would not be able to provide DAN with a fitness to dive certificate - therefore back to square one - I'm not allowed to dive.

My dive doctor has told me that there are risks involved closing a PFO and it would not normally be considered for any reason other than diving. I couldn't justify having heart surgery if it was JUST to continue with my dive hobby. However, I also suffer from Aura Migraine's and struggle with excessive fatigue, and I believe you are at increased risk of stroke if you have a PFO. If it resolved those other symptoms then it would seem worth considering a closure. So why would a cardiologist only consider a closure for diving? Is it because 20-30% of the population have one and they would be doing too many procedures? Why do you have to wait until you have had a stroke to have closure considered?

There seems to be a lot of uncertainty over the issue, and I'm swinging back and forth trying to decide whether to have an investigation or not. I am unable to dive at the moment due to my residual inner ear symptoms so I guess I have time to work this out. A big thank you to everyone that has taken the time to offer feedback to me. I appreciate it so much.

Kath

Hi Kathryn,

If the whole topic of PFO seems to have a lot of uncertainty, it's because there IS a lot of uncertainty. I heard from my colleague, who is the medical director of a large chamber outfit based in Melbourne, and he confirmed what your diving physician told you. In Australia, unfortunately, if you're found to have a PFO after an incident of DCS you will be unable to dive until it's closed and you have a negative bubble contrast study. This isn't official SPUMS policy but is the general consensus among diving physicians there.

Dr. Alfred Bove has done a lot of work on the subject of diving with PFO. The gist of his conclusions is that though the risk of DCS when diving with a PFO is 3-5 times that of diving without, the risk of complications of PFO closure is still higher, so he does not recommend routine closure of PFO in divers.

Another side of this is, as you pointed out, about 30% of us are walking around with PFOs but the rate of DCS is orders of magnitude lower. There is not a direct 1:1 correlation between PFO and DCS, which is why many diving physicians are more liberal in their recommendations for divers in your situation.

Your decision as to whether to be tested for PFO is a difficult one. I'm not going to Monday-morning quarterback your treating physicians, but I'll reiterate that going by the information you provided, your DCS incident does raise the index of suspicion for PFO. Also, as I said in a previous post, your symptoms of dizziness after your other dives is concerning. If you haven't discussed this with your diving physician, you should; it may be an important factor in your decision.

Dr. Doug Ebersole (debersole here on Scubaboard) is a cardiologist in the U.S. who's currently doing some research with DAN on the subject of PFO. He has performed PFO closure on divers. He may be able to provide some more insights and he's great about answering private messages.

Best regards,
DDM

 

[Kathryn_Rob]

I will message Doug Ebersole and see if he can shed some more light on my situation.

It's now been 8 weeks since my incident and I am still struggling with fatigue, dizziness, nausea and brain fog. I have just seen an ENT specialist who has found that I have no inner ear damage (good news!) however, he believes the damage is to my brain instead. I have had a MRI which was all clear so at least the damage isn't major. I am now undergoing balance rehabilitation to retrain my balance. Given all this I have decided to go ahead with the test for PFO. Unfortunately I think there is too much at stake to ignore it and it's just not worth putting myself at risk of another incident of DCS like this.

Thank you so much for your recommendations and advice. If you are curious I can let you know how I go with the PFO test.

Cheers, Kath

 

[duke dive medicine]

Hi Kathryn, thanks for the update. I think it would be valuable for you to share the results of your test if you're willing.

Best,
DDM

 

[cmarz]

Hello,
I've just read this thread with great interest, because of a recent similar experience to Kathryn, but not nearly so severe. I wish her the best of luck in her continued search for answers and recovery.

I'm writing on this thread because a doctor with DAN Europe has suggested I might have inner ear decompression sickness. I contacted them because since returning from our trip to the Red Sea (Aug 3-10), I've been experiencing vertigo. My first few days home, I thought it was due to being on a liveaboard for several days, and that I was just adjusting to being back on land.

During my 16 dives in the Red Sea, I never experienced any problems clearing my ears. We dove 29-31% Nitrox the whole time. Some of my dives were deep (100 ft), but my computer never put me into decompression mode. I actually felt pretty great the whole trip and only felt the dizziness when we got off the boat the first night. Again, I attributed the feeling to my sea legs.

After a few days, my husband said his sea legs were gone, but I was still swaying, and still am, even three weeks out. I feel ok doing most tasks, but I have lost confidence in doing some things because I feel like I'm still on that boat and am highly distracted. So I finally contacted DAN in Europe, who is our dive insurance provider. After some interchange with the DAN Dr, he finally wrote this:

If it occurred 5 hours after your last dive then there is a good chance that it is decompression sickness of the inner ear.
Unfortunately after so much time, recompression therapy is useless and the only thing to do is ask your GP to refer you to your local GP who will be able to treat the sequelae of the injury
It is a pity you did not call our hotline there and then but no use crying over spilt milk and I am sure with proper care from your ENT and with time healing will occur as completely as possible
I would not advise you to dive again until you have obtained full recovery and allowed a few months after that as convalescence

Next week, I will be seeing a ENT specialist here in the UK. I am curious what others think of the DAN dr's advice, and what I should insist on with the ENT doctor, who I fear won't have much diving medicine experience. Also, is it really too late for hyperbaric treatment if indeed I do have ear DCS?

Thanks in advance!
Carol

 

[Kathryn_Rob]

Hi Carol

It is not true that it would only be Inner Ear Decompression Sickness if it occurred 5 hours after your last dive. Mine happened within 5 minutes of surfacing. I'm not sure, but I'm guessing they are saying it is too late for hyperbaric treatment as you have probably off gassed any residue nitrogen by now. It would be unusual to not have any of the other IEDCS symptoms so perhaps it was inner ear barotrauma? Damage to your inner ear can cause dizziness.

The ENT can send you off to do a range of audiology tests to look for any inner ear damage. I have been improving slowly with balance rehabilitation treatment from my physiotherapist. My ENT told me I had to stop taking the Stemetil I was on (drug for dizziness and nausea) as this would prevent the balance rehab exercises from being effective and would only prolong my recovery.

Good luck with your ENT appointment. I know how frustrating dizziness can be!!

---------- Post Merged at 10:46 PM ---------- Previous Post was at 10:32 PM ----------

I'm wondering if anyone has an opinion on if my residue symptoms from IEDCS (dizziness, nausea, brain fog) 10 weeks after the incident could be because I was not given oxygen at the onset of my symptoms?

I collapsed 5 minutes after surfacing with extreme dizziness and blurred vision. The boat crew told me I was probably just tired and to go to bed. The following day my symptoms were still there but had lessened a little in severity. 18 hours later they finally gave me oxygen for only 2 hours. It was another 21 hours again before the boat got back and I could get to hospital. The hospital then put me on continuous high flow oxygen until I could get to the hyperbaric chamber. I then had to be re compressed 12 times.

I have since read that a delay in oxygen treatment can prolong recovery and cause permanent damage. I have also read that being given oxygen immediately can often resolve decompression sickness without the need for hyperbaric treatment. If this is right, I'm at a loss as to why I was not given oxygen. Shouldn't a healthy and well diver presenting unwell immediately after a dive be an immediate concern for decompression sickness?

 

[duke dive medicine]

Hello,
I'm writing on this thread because a doctor with DAN Europe has suggested I might have inner ear decompression sickness. I contacted them because since returning from our trip to the Red Sea (Aug 3-10), I've been experiencing vertigo. My first few days home, I thought it was due to being on a liveaboard for several days, and that I was just adjusting to being back on land.

During my 16 dives in the Red Sea, I never experienced any problems clearing my ears. We dove 29-31% Nitrox the whole time. Some of my dives were deep (100 ft), but my computer never put me into decompression mode. I actually felt pretty great the whole trip and only felt the dizziness when we got off the boat the first night. Again, I attributed the feeling to my sea legs.

After a few days, my husband said his sea legs were gone, but I was still swaying, and still am, even three weeks out. I feel ok doing most tasks, but I have lost confidence in doing some things because I feel like I'm still on that boat and am highly distracted. So I finally contacted DAN in Europe, who is our dive insurance provider. After some interchange with the DAN Dr, he finally wrote this:

If it occurred 5 hours after your last dive then there is a good chance that it is decompression sickness of the inner ear.
Unfortunately after so much time, recompression therapy is useless and the only thing to do is ask your GP to refer you to your local GP who will be able to treat the sequelae of the injury
It is a pity you did not call our hotline there and then but no use crying over spilt milk and I am sure with proper care from your ENT and with time healing will occur as completely as possible
I would not advise you to dive again until you have obtained full recovery and allowed a few months after that as convalescence

Next week, I will be seeing a ENT specialist here in the UK. I am curious what others think of the DAN dr's advice, and what I should insist on with the ENT doctor, who I fear won't have much diving medicine experience. Also, is it really too late for hyperbaric treatment if indeed I do have ear DCS?

Thanks in advance!
Carol

Carol,

To confirm, you felt great the entire trip and only noticed the vertigo after you got off the boat? Absent any details about dive profiles it's difficult to comment, but it's possible that you got hit after your last set of dives and the symptom onset just happened to coincide with getting off the boat. It's also possible that you have a more severe form of the sort of post-motion vertigo that most people get after being on a boat. It's called mal de debarquement. See the following link: https://vestibular.org/mal-de-debarquement?gclid=CI60lfL4lrICFQoFnQodfy0A9g

I'm not sure where the 5 hour figure comes from. DCS onset times can vary widely, as Kathryn pointed out above. The rest I'd agree with... if you did indeed have DCS, then hyperbaric treatment this far out would be of little benefit.

Hi Carol
I'm wondering if anyone has an opinion on if my residue symptoms from IEDCS (dizziness, nausea, brain fog) 10 weeks after the incident could be because I was not given oxygen at the onset of my symptoms?

I collapsed 5 minutes after surfacing with extreme dizziness and blurred vision. The boat crew told me I was probably just tired and to go to bed. The following day my symptoms were still there but had lessened a little in severity. 18 hours later they finally gave me oxygen for only 2 hours. It was another 21 hours again before the boat got back and I could get to hospital. The hospital then put me on continuous high flow oxygen until I could get to the hyperbaric chamber. I then had to be re compressed 12 times.

I have since read that a delay in oxygen treatment can prolong recovery and cause permanent damage. I have also read that being given oxygen immediately can often resolve decompression sickness without the need for hyperbaric treatment. If this is right, I'm at a loss as to why I was not given oxygen. Shouldn't a healthy and well diver presenting unwell immediately after a dive be an immediate concern for decompression sickness?

Kathryn,

Going by your narrative of the events, I think it's likely that your delay in treatment (both surface O2 and recompression treatment) influenced your outcome. You'd have had a better chance of a faster and more comlete recovery had you been placed on O2 and evacuated straightaway.

The bold in your quote above is mine because I think that part deserves special attention. We've run into numerous cases where divers have been given surface O2 for suspected DCS and recovered completely, only to have their symptoms reoccur after they're sent home. ALL divers with suspected DCS need to be evacuated to the nearest medical facility, even if their symptoms disappear on surface O2.

Best regards,
DDM

 

[cmarz]

Thank you both for your replies.

The 5-hour mark is the time between our last dive (see info below) and when we got off the boat -- the DAN Europe doctor just took that as the time frame when I started having symptoms, since that's when I really first noticed the vertigo. I have been on boats for extended periods of time before, and it always takes me a while to adjust to being back on land. I really thought that is what I was experiencing and in no way suspected an ear trauma or decompression sickness at the time.

Now having read your link about mal de debarquement, it's possible that's what it is. However, the last couple of days, I'm now hearing a ringing/low roar in my ears. (It is all very maddening to me.)

So, my concern is now is whether the ENT specialist will be able to diagnose the problem. If it is indeed IEDCS, should he be able to detect any trauma or damage? What tests should he do, and what should I ask for? What is the followup treatment? If the ENT rules out inner ear problems, I suppose I can assume it is Mal de Dembarquement and wait for the symptoms to fade away?

Another concern is I have to fly across the pond on September 11 and don't want to do any more damage. It would be great to just speak to someone knowledgeable with the subject and not have to communicate all in writing.

Here's the info on my last two dives (and I have the rest downloaded).
Dive 2: 1104am, Max depth: 29 m, Bottom time: 33 min, Avg depth: 20 m, Nitrox= 31.2%
Dive 1: 0637am, Max depth: 31 m Bottom time: 49 min Avg depth: 16 m Nitrox= 31%

 

[tracydr]

I am also struggling to understand why the crew did not recognise my symptoms and give me treatment earlier. They kept telling me I was probably just tired and my middle ear was inflamed from equalising. I think they were inexperienced with recognising the symptoms of IEDCS and did not want to concern the other divers...

I have an appointment with an ENT today, so hopefully that will shed some light on what is going on with my balance.

I am a bit confused with whether to investigate a PFO or not. My Hyperbaric doctors did not feel it was necessary as the decompression sickness was "deserved" (multiple dives on consecutive days). However, my local dive doctor has concerns, especially as I also suffer from Aura Migraines and unexplained mild Sleep Apnoea (I am very active, fit and of good weight) She feels I should be tested.

My concern with having the test for PFO is that if found, I can no longer dive. BUT... approx 30% of people have a PFO, which I guess would mean approx 30% of divers are diving with one. The rate of DCS is much much lower than that so the odds are that I could continue diving and probably not ever have an issue again. It's really hard to decide whether to take the risk or not.

Thanks so much for your advise. I am missing diving so much, but I won't be returning to it at least until my dizziness is resolved.

Cheers, Kathryn

We had a case of DCS on our liveaboard that I ended up being involved in providing first aid and ongoing care to for a few days, since we were far away from help, in the Galapegos. At first, the patient didn't provide a complete and accurate description of his symptoms and we didn't recognize what we were seeing as DCS. ( actually, he never gave us a complete history, until after we returned from the trip, that made any sense and when he did it all made sense)
With two physicians and crew, we provided oxygen and pain relief. However, we were very far away from help with no helicopter for pickup so the only option if somebody is hit by DCS is to turn the boat around and end the trip,at the best part of the entire trip.
The crew, before allowing the boat around, actually went to all passengers, and asked them if they wanted to turn around and asked for a show of hands!
I was appalled! More appalled that the other physician voted no and that nearly half the passengers voted not to turn around!
BTW, getting the oxygen from the crew for an injured passenger was a big deal as well. I understand not wasting the oxygen on a long trip as resources can be very scarce but when a physician orders oxygen for a possible DCS hit, the oxygen needs to be given!
my point to this? On liveaboards, you are in a remote area. The crew is balancing the life of one passenger with a possibility of DCS to the loss of a bunch of tips that they depend on for they're livelihood if they have to end the trip early. Thus, the possible delay in treatment and evacuation, unless a DCS hit is very obvious.

---------- Post Merged at 07:46 AM ---------- Previous Post was at 07:38 AM ----------

I am also struggling to understand why the crew did not recognise my symptoms and give me treatment earlier. They kept telling me I was probably just tired and my middle ear was inflamed from equalising. I think they were inexperienced with recognising the symptoms of IEDCS and did not want to concern the other divers...

I have an appointment with an ENT today, so hopefully that will shed some light on what is going on with my balance.

I am a bit confused with whether to investigate a PFO or not. My Hyperbaric doctors did not feel it was necessary as the decompression sickness was "deserved" (multiple dives on consecutive days). However, my local dive doctor has concerns, especially as I also suffer from Aura Migraines and unexplained mild Sleep Apnoea (I am very active, fit and of good weight) She feels I should be tested.

My concern with having the test for PFO is that if found, I can no longer dive. BUT... approx 30% of people have a PFO, which I guess would mean approx 30% of divers are diving with one. The rate of DCS is much much lower than that so the odds are that I could continue diving and probably not ever have an issue again. It's really hard to decide whether to take the risk or not.

Thanks so much for your advise. I am missing diving so much, but I won't be returning to it at least until my dizziness is resolved.

Cheers, Kathryn

Repairing a PFO is not a terribly difficult operation. The fact that you have migraines and sleep apnea will help to establish a case for insurance to pay, if it's a problem, otherwise.

 

[duke dive medicine]

Thank you both for your replies.

The 5-hour mark is the time between our last dive (see info below) and when we got off the boat -- the DAN Europe doctor just took that as the time frame when I started having symptoms, since that's when I really first noticed the vertigo. I have been on boats for extended periods of time before, and it always takes me a while to adjust to being back on land. I really thought that is what I was experiencing and in no way suspected an ear trauma or decompression sickness at the time.

Now having read your link about mal de debarquement, it's possible that's what it is. However, the last couple of days, I'm now hearing a ringing/low roar in my ears. (It is all very maddening to me.)

So, my concern is now is whether the ENT specialist will be able to diagnose the problem. If it is indeed IEDCS, should he be able to detect any trauma or damage? What tests should he do, and what should I ask for? What is the followup treatment? If the ENT rules out inner ear problems, I suppose I can assume it is Mal de Dembarquement and wait for the symptoms to fade away?

Another concern is I have to fly across the pond on September 11 and don't want to do any more damage. It would be great to just speak to someone knowledgeable with the subject and not have to communicate all in writing.

Here's the info on my last two dives (and I have the rest downloaded).
Dive 2: 1104am, Max depth: 29 m, Bottom time: 33 min, Avg depth: 20 m, Nitrox= 31.2%
Dive 1: 0637am, Max depth: 31 m Bottom time: 49 min Avg depth: 16 m Nitrox= 31%

Carol,

Looking at your dives, I don't think that inner ear DCS can be ruled out, but as has been previously stated, recompression at this stage wouldn't be much help. Had you received O2 and recompression treatment at the time, your response to treatment would have been helpful in making a diagnosis.

Beyond that, you're probably best off seeking advice from an ENT over there. The London Diving Chamber may be helpful in locating one who is familiar with diving injuries, and they have an advice number. Flying shouldn't be a problem, but the diving chamber may have some additional recommendations after speaking with you.

Best regards,
DDM