Is the inner ear barotrauma DCI?

[Laurence Stein DDS]

Thanks I.G., I think that helped.

Nomaster, either pronunciation is correct...I say to-ma-to and you say to-maw-to.

LubaScuba...come on...you're holding back on us

Each time you reply to a previous post, you add more information. It seems you know something we don't. Come on, you can tell us. Your first question asked how to categorize the inner ear DCI. Your next post is more specific in asking about a special case of DCI in the inner ear pertaining to bubbles...which at first read I took to mean bubbles coming out of solution in the inner ear—a type of DCS. As I re-read it again, you could have been referring to gas from the middle ear entering the fistula into the inner ear...a DCI.

In your last post you are obviously referring to some, not previously stated use of HBOT to treat tinnitus/vertigo/hearing loss and any association with patients in Germany being treated for such loss. Were these patients divers who lost hearing or patients that were just being treated for hearing loss but never associated with diving.

If it is this last case, it might be the mechanism of the hearing loss that made the HBOT effective on those patients. Did any of these patients have DCI or DCS? I don't think you can extrapolate their successes to mean that recompression of divers displaying similar symptoms would have similar results. Comparing non-diving injuries to diving injuries may not be valid.

What research are you actually referring to in this last post? We should all see the data to help discuss this with you. The answer to your original question and this last revelation might be vastly different.

Regards,

Laurence Stein, DDS

 

[LubaScuba]

Thanks I.G., I think that helped.

Nomaster, either pronunciation is correct...I say to-ma-to and you say to-maw-to.

LubaScuba...come on...you're holding back on us

Each time you reply to a previous post, you add more information. It seems you know something we don't. Come on, you can tell us. Your first question asked how to categorize the inner ear DCI. Your next post is more specific in asking about a special case of DCI in the inner ear pertaining to bubbles...which at first read I took to mean bubbles coming out of solution in the inner ear—a type of DCS. As I re-read it again, you could have been referring to gas from the middle ear entering the fistula into the inner ear...a DCI.

In your last post you are obviously referring to some, not previously stated use of HBOT to treat tinnitus/vertigo/hearing loss and any association with patients in Germany being treated for such loss. Were these patients divers who lost hearing or patients that were just being treated for hearing loss but never associated with diving.

If it is this last case, it might be the mechanism of the hearing loss that made the HBOT effective on those patients. Did any of these patients have DCI or DCS? I don't think you can extrapolate their successes to mean that recompression of divers displaying similar symptoms would have similar results. Comparing non-diving injuries to diving injuries may not be valid.

What research are you actually referring to in this last post? We should all see the data to help discuss this with you. The answer to your original question and this last revelation might be vastly different.

Regards,

Laurence Stein, DDS

Dear Laurence,
Well i thought it could be more interesting to start from abstract concept of DCI and work towards the actual patient case. If we look at the CAGE case we have pressure treatment concerns coming from the lung injury (ie pneumothorax) but the bubble damage easily overweights those risks and justifies prompt recompression with special precautions either in mind or in the chest wall. That is not the case with inner ear barotrauma because we stop at the assumption that all the damage is from leaking perilymph and we baptise the condition exclusively as barotrauma and treat it at 1 ATA ignoring the possibility that compressed air might have entered from the middle ear (yes, that is what i meant) into the scala space. Expansion of such bubbles in the extremely fragile and confined environment of labyrinth might explain almost "exponential" worsening of symptoms on ascent in some PLF cases at depth as well as relief upon recompression. I mentioned German non-diving related HBO inner ear treatments not in ambition to extrapolate their results on diving cases (i agree that would not be valid) but to argue about ireversibility of vestibulo-cochlear damage. I am not too sure how "mere" HBO treatment would give so marked improvement in 20 minutes keeping in mind that such effects on injured tissues are rather of slow "grass growing" kind. The case i mentioned is the real one and it was decided to try with USN TT6 after previous reviews of some "inner ear DCI cases" where inner ear barotrauma was not excluded with certainity. Marked improvements with careful recompression in those border line cases encouraged the USNTT6 trial on what was found to be the pure case of inner ear barotrauma. It was maybe a bit advantureous decision pretty much in clash with my utilitarian views :11: but i did not regret it!
Of course, that is far from any serious randomised and blinded study but seeing the improvement myself i would dare to paraphrase here the humorous quote: "When you need statistics to confirm your conclusions you've done the wrong experiment."
I am actually not rushing into any conclusions here but simply want to have this case questioned as hardly as possible. The truth will survive.

Thank you for your interesting replies. Feel free to be as critical as needed. I would like to have this issue moved from the middle vagueness either towards accepting that inner ear barotrauma might be the special form of DCI or towards the ridicule.

Best regards

Lubascuba

 

[Saturation]

Well you are right, recompressing could worsen it...because of equalization. Myringotomy is rather problematic as it implies the meningitis risk in these cases having a "nice" way to subarachnoidal space. How about slow descent rates (ie 2ft/min) together with passive equalizing, upright position during treatment, ear defenders during noisy vents, BIBS mask removal before resistance on exhaling starts...?
How can you explain marked improvement (almost full resolution) in hearing, tinnitus and vertigo during first O2 period at 60ft (USN table VI) in patient who had done forceful Valsalva at bottom, had sudden onset of tinnitus, severe sensoneural hearing loss and nasty vertigo?
"Post hoc ergo propter hoc" bias? It is true that PLF's improve spontaneously to a point but as far as i know not within couple of hours and not to such extent. What about all the successful HBO treatments of sudden hearing loss performed in Germany?

Hellow Ls:

In Medicine, all is possible, but is it probable? Quod erat demonstrandum.

In what Navy did you complete your Diving Medicine Officer training, and which continent is your chamber located in the world, Lubascuba ... no specifics necessary i.e., Europe, North America, Middle East, Asia etc., and if in the Pacific is it above or below the equator.

 

[Laurence Stein DDS]

Please, call me Larry...Laurence sounds so much like a shakespearian actor.

Hah! I knew there was more to this than meets the ears!

Could you enlighten us to the ACTUAL nature and circumstances of YOUR dive injury?

Maybe it goes without saying but your original question referred to a dive injury and would appropriately be called a DCI. However, when you included the HBOT treatements of non-diving (I assume) German patients, this is neither DCI or DCS because, by definition they would have had to have been either diving or exposed to increased ambient pressure, i.e., caisson workers and the like.

Had these patients received some sort of traumatic injury that either primarily or secondarily created a barotrauma to their ears resulting in a PLF it is neither a DCI or DCS. If their HBOT therapy was for non-barotrauma induced tinnitus, vertigo or hearing loss, then nothing speculated here really has any bearing on such treatment of barotrauma resulting in the same symptoms.

Another words, you got treated by HBOT for your problem and perhaps, got lucky. It worked or seemed to work and caused no known adverse side effects. Better evidence would be needed before such treatment would become mainstream.

Your experience is intriguing and further details would be welcome. I don't know if some ethical constraints apply to more widespread use of hyperbarics to treat conditions similar to yours. Certainly, nobody wants to "experiment" on patients to see if this treatment is effective...when the possibility of even greater hearing or vestibular damage is possible or, at least, might be anticipated.

Fill us in on the rest. Perhaps it would help others reading these posts if we would define our acronyms and abbreviations.

Laurence Stein, DDS

 

[liberato]

Could you enlighten us to the ACTUAL nature and circumstances of YOUR dive injury?

Interesting leap but I don't pick up on that. How did you conclude the case is self-referential?

 

[LubaScuba]

Hellow Ls:

In Medicine, all is possible, but is it probable? Quod erat demonstrandum.

In what Navy did you complete your Diving Medicine Officer training, and which continent is your chamber located in the world, Lubascuba ... no specifics necessary i.e., Europe, North America, Middle East, Asia etc., and if in the Pacific is it above or below the equator.

Dear Saturation,
Pacific, below equator, trained in South Australia....but that is all irrelevant to the subject, isn't it? As for "Quod erat demonstrandum." i doubt that fully applies for medicine where at best we end up with the hard evidence...and never with the proof. That is to say there is always a possibility for premises to be true and conclusion to be wrong which means that in medicine we don't deal with deductional logic to support the hypothesis. That is how medical science actually develops the data ...through the gap between the previous evidence and the ultimate truth which even if eventually found always remains logically unprovable. We might have the truth in our hands but can never be sure what it is as medicine is not mathematics. Disappointing isn't it :devil_smi Ok, ok enough philosophy.

The best evidence in medical science comes from randomised and blinded human studies and as far as i know there is no such data available about recompression therapy of inner ear barotrauma. As physicians we sometimes make adventureous decisions not to experiment on our patients but in despair to help them. "Primum non nocere" must be still kept in mind and i did what i did (ie recompressed the obvious window rupture) after i believe to be reasonable estimation of treatment risks vs possible benefits and after meticulous precausions. I can still be questioned for the treatment decision but not for the outcome which was excellent, and i am aware that such causalistic exuses (here he comes again!) in medicine are usually unethical. Well, this is not about ethics but about the inner ear barotrauma treatment anyway. Like i said even if in possession of a medical truth one can not be sure, especially if there is limited amount of cases and questionable data. Thatswhy i posted this case which has, as far as my examination skills go, reliable but very controversial data hoping to be questioned with valid arguments and maybe some light could be found.

Take care

 

[LubaScuba]

Dear Larry,
Thanx for good points you made but i am afraid you misunderstood some little parts and that is most likely due to the fact that i learned my English watching Tarzan movies. I would try to put it other way for all to easier follow the logic that was used in this case and add some more little thoughts. I am even going to put numbers to make it more obvious for all:

1) patient (not me) had inner ear injury from diving
2)single dive, 26m, 5 minutes in total
3)onset of symptoms at bottom (26m) after forceful Valsalva manuever
4)sensorineural hearing loss, tinnitus, vertigo...got significantly worse during ascent
5)DCI excluded as there was no upward motion before symptom onset and keeping the history of forcefull equalizing followed by the sudden pop, hearing loss, tinnitus and vertigo in mind inner ear barotrauma (PLF) diagnosis was made.
6)despite that patient was recompressed with special precautions to 60ft (whatever the justifications) and USNTT6 followed
7)marked improvement after first O2 period (almost total resolution of severe hearing loss and significant decrease of tinnitus and vertigo)
8)question about possible special form of DCI from air penetration through fistula arised as so far nothing else could explain this rather controversial case
9)revision of some border line (inner ear barotrauma was not excluded) cases of "inner ear DCI" successfully treated in chamber further rises the question
10)standardizing and reevaluation of precaution measures is needed if any general recomendations to treat inner ear barotraumas in chamber ever arise
11) I believe that what we need to catch is a clear audiogram after chamber treatment of a 'pure' PLF case like i believe this was...unfortunately due to remote area location i am not in possession of such follow up possibilities. I am trying to convince the patient via mail to do audiometry at home but i am "afraid" the answer is going to be "Why?"


As for those German HBO treatments i mentioned them ( i regret because it just confused everything and as you pointed it is not relevant to this case) as an answer to your claim that cilial damage is definite.

Please, call me Larry...Laurence sounds so much like a shakespearian actor.

Hah! I knew there was more to this than meets the ears!

Could you enlighten us to the ACTUAL nature and circumstances of YOUR dive injury?

Maybe it goes without saying but your original question referred to a dive injury and would appropriately be called a DCI. However, when you included the HBOT treatements of non-diving (I assume) German patients, this is neither DCI or DCS because, by definition they would have had to have been either diving or exposed to increased ambient pressure, i.e., caisson workers and the like.

Had these patients received some sort of traumatic injury that either primarily or secondarily created a barotrauma to their ears resulting in a PLF it is neither a DCI or DCS. If their HBOT therapy was for non-barotrauma induced tinnitus, vertigo or hearing loss, then nothing speculated here really has any bearing on such treatment of barotrauma resulting in the same symptoms.

Another words, you got treated by HBOT for your problem and perhaps, got lucky. It worked or seemed to work and caused no known adverse side effects. Better evidence would be needed before such treatment would become mainstream.

Your experience is intriguing and further details would be welcome. I don't know if some ethical constraints apply to more widespread use of hyperbarics to treat conditions similar to yours. Certainly, nobody wants to "experiment" on patients to see if this treatment is effective...when the possibility of even greater hearing or vestibular damage is possible or, at least, might be anticipated.

Fill us in on the rest. Perhaps it would help others reading these posts if we would define our acronyms and abbreviations.

Laurence Stein, DDS

 

[Saturation]

Dear Saturation,

1. Pacific, below equator, trained in South Australia....but that is all irrelevant to the subject, isn't it?


2. As for "Quod erat demonstrandum." i doubt that fully applies for medicine where at best we end up with the hard evidence...and never with the proof. That is to say there is always a possibility for premises to be true and conclusion to be wrong which means that in medicine we don't deal with deductional logic to support the hypothesis.

2b. That is how medical science actually develops the data ...through the gap between the previous evidence and the ultimate truth which even if eventually found always remains logically unprovable. We might have the truth in our hands but can never be sure what it is as medicine is not mathematics. Disappointing isn't it :devil_smi Ok, ok enough philosophy.

3. The best evidence in medical science comes from randomised and blinded human studies and as far as i know there is no such data available about recompression therapy of inner ear barotrauma. As physicians we sometimes make adventureous decisions not to experiment on our patients but in despair to help them. "Primum non nocere" must be still kept in mind and i did what i did (ie recompressed the obvious window rupture) after i believe to be reasonable estimation of treatment risks vs possible benefits and after meticulous precausions.

4. I can still be questioned for the treatment decision but not for the outcome which was excellent, and i am aware that such causalistic exuses (here he comes again!) in medicine are usually unethical. Well, this is not about ethics but about the inner ear barotrauma treatment anyway.

5.Like i said even if in possession of a medical truth one can not be sure, especially if there is limited amount of cases and questionable data. Thatswhy i posted this case which has, as far as my examination skills go, reliable but very controversial data hoping to be questioned with valid arguments and maybe some light could be found.
Take care

Hello LS:

Answers and comments to your reply as numbered above mostly for discussion purposes. In the end, a qualified clinician-in-charge makes all the decisions in the field.

1. Its was need to insure what reply is given, potentially technical, does not go to waste, some folks post on this board to troll. Your questions are a mix of sometimes basic and high-end medical questions that are puzzling to me. So I'm take it on faith you are an MD, DO, BM or equivalent running a chamber maybe in Oceania.

2. Maybe your English looses something in the translation, but if its your second language your doing extremely well, and we should apologize to you.

For #2, that is why QED is Medicine operant, what works, works. The research in diving and hyperbarics is less atuned than for example, better funded diseases like heart disease, so in the end you answer your own question, the answer to #2, is 2b through to #5.

3. EBM is best statistical evidence, but it still must be applied to situations unique in individual cases and is up to the clinician in charge to make those determinations.

4. In medicine, outcome is preferred over all. If you cured the issue, then any a posteriori assumptions are immaterial until one gets a bad outcome; then the overall population issue of numbers-needed-to-treat and pathophysiologic models become operant, as suggest below.

If you needed to do a myringotomy, do so, there is risk but if the patient did not equalize you risk permanent deafness. Further, if gas was indeed trapped in there, the equalization resulting from a myringotomy could have cured the symptoms without recompression.

5. If indeed trapped gas under pressure may have formed inside the inner ear disrupted the entire area, ossicles, labyrinthine functions etc., and remained trapped, compression will improve the situation quickly ... if permanent damage was already caused to the inner ear, it may not have reversed and improved quickly. If you did not act soon, temporary deficit could have become perament damage also. However, trapped gas under pressure could dissipate on its own without recompression. So as you describe philosophically, we cannot be sure that by doing nothing, it would have improved spontaneously to justify exposing the patient to the risk of hyperbaric 02 instead: Post hoc ergo propter hoc.

If recompression caused quick and sudden relief of symptoms in the first 02 period? Maybe a TT5 alone would have sufficed. The dive profile did not suggest any DCS could be operant to warrant TT6, but TT6 is always, when in doubt, "TT6 is the fix". Again, that is the clinician in-charges decision.

A typanometry and audiometry is clearly needed for this patient as follow up. Even with relief of symptoms, subtle deficits can be caught by these simple ENT tests.

The chamber in Oceania is lucky to have one so introspective and philosophical.

Best of luck to future endeavors. If you haven't yet, consider joing SPUMS to share notes with your colleagues in that region.

 

[LubaScuba]

Dear Saturation,
I believe that good medical issues should always have, as you pointed, "basic" and "high end" questions mixed to ensure both that issue is up to date and ethical...respectively, of course. That is always puzzling but without both ends, i am convinced, medicine goes blind either way.
Having some letters behind the name should make no difference in evaluation of one's arguments and i believe i provided enough premises to reasonably support my arguments even if never went to any school. I am physician but i don't find that category 'ignorance-proof' at all and adding any significance to one's arguments just because of the mere memberhip in that category is "Ad verucundiam" bias and should be avoided as it has disastrous effect on critical thinking. Blind faith killed more in medicine than in all religions together. :1poke: Just as bad would be denying the right to someone to participate in arguing just because of mere lack of some letters around the name.
Why TT6 if first O2 did the job? Job was done but as i said not completely so i agree: six is a fix. As you recall the thread was started wandering about abstract concept of DCI and mainly so because it might greatly influenze one's treatment decisions. If one does not think only "barotrauma" but "special form of DCI" while facing this case it is clear why TT5 was not really an option for initial treatment.

Thanx for your critical yet kind reply, i shall consider joining SPUMS.

Hello LS:

Answers and comments to your reply as numbered above mostly for discussion purposes. In the end, a qualified clinician-in-charge makes all the decisions in the field.

1. Its was need to insure what reply is given, potentially technical, does not go to waste, some folks post on this board to troll. Your questions are a mix of sometimes basic and high-end medical questions that are puzzling to me. So I'm take it on faith you are an MD, DO, BM or equivalent running a chamber maybe in Oceania.

2. Maybe your English looses something in the translation, but if its your second language your doing extremely well, and we should apologize to you.

For #2, that is why QED is Medicine operant, what works, works. The research in diving and hyperbarics is less atuned than for example, better funded diseases like heart disease, so in the end you answer your own question, the answer to #2, is 2b through to #5.

3. EBM is best statistical evidence, but it still must be applied to situations unique in individual cases and is up to the clinician in charge to make those determinations.

4. In medicine, outcome is preferred over all. If you cured the issue, then any a posteriori assumptions are immaterial until one gets a bad outcome; then the overall population issue of numbers-needed-to-treat and pathophysiologic models become operant, as suggest below.

If you needed to do a myringotomy, do so, there is risk but if the patient did not equalize you risk permanent deafness. Further, if gas was indeed trapped in there, the equalization resulting from a myringotomy could have cured the symptoms without recompression.

5. If indeed trapped gas under pressure may have formed inside the inner ear disrupted the entire area, ossicles, labyrinthine functions etc., and remained trapped, compression will improve the situation quickly ... if permanent damage was already caused to the inner ear, it may not have reversed and improved quickly. If you did not act soon, temporary deficit could have become perament damage also. However, trapped gas under pressure could dissipate on its own without recompression. So as you describe philosophically, we cannot be sure that by doing nothing, it would have improved spontaneously to justify exposing the patient to the risk of hyperbaric 02 instead: Post hoc ergo propter hoc.

If recompression caused quick and sudden relief of symptoms in the first 02 period? Maybe a TT5 alone would have sufficed. The dive profile did not suggest any DCS could be operant to warrant TT6, but TT6 is always, when in doubt, "TT6 is the fix". Again, that is the clinician in-charges decision.

A typanometry and audiometry is clearly needed for this patient as follow up. Even with relief of symptoms, subtle deficits can be caught by these simple ENT tests.

The chamber in Oceania is lucky to have one so introspective and philosophical.

Best of luck to future endeavors. If you haven't yet, consider joing SPUMS to share notes with your colleagues in that region.

 

[Laurence Stein DDS]

Interesting leap but I don't pick up on that. How did you conclude the case is self-referential?

Hi Liberato,

You're right...donno why I thought LubaScuba was the patient...there is no reference in the posts...perhaps it was the close personal knowledge of the events that made it seem like he was the patient.

Larry