Middle ear barotrauma several days after diving...PLEASE HELP!

[travisfull]

Hi guys,

I read all the different thread concerning ETD and middle ear barotrauma but I did not find anything similar to my case. Below the main points of my history, for which I ask for your kind help, especially because diving is really part of my happiness and life :

• dived always during summer (hot temperature) for several years, never had a problem;
• 2021, it was the first winter during which I started diving: November 2021, I experience middle ear barotrauma (probably related to a badly cured cold). However, I had NO PROBLEMS with compensation in that specific dive, and symptoms of barotrauma started only 48 HOURS AFTER THE DIVES;
• Visited ENT, gave me medicines and apparently everything was ok: no issues with flights, and no issue with a first 20mt dive.
• however, I started having problems especially after divings below 30mt, but, as above, NEVER EXPERIENCING DISCOMFORT DURING DIVES (no problem at all compensating) but only 48-72 hours after the dive. Sometimes it was diagnosed only tympanic thickening and others mild middle ear barotrauma, and never swimmer's ear due to bacteria. Except for the first time (november 2021), symptoms lasts always few days and included: mild ear pain only if I touched them, itching to the external ear and always ear fullness (sometimes only if I pull my lobes), sometimes in both eats or sometimes in right or left one (with no specific pattern);
• In all this time, I was followed by at least 2 ENT specialist, one of them was recommended by DAN. They prescribe me: politzer therapy with sulphur water, spray Avamys and Otovent. I also had a CT SCAN which was totally clean: no mastoiditis, no specific issues to flag up;
• the only period when I recorded a series of 5 different dives (all at different depth, from 18 to 35mt) without any issues at all was when I used Otovent 5 times a day and Avamys few days before any dive;
• The doctors diagnosed ETD due to either cold water or the first middle ear barotrauma of November 2021(which was weird anyway since I did not experience any problem at all during the dive), even if they can't explain why I don't experience any issue compensating and the symptoms arise ALWAYS and only a couple of days after the dive, which, theoretically, does not make any sense since the symptoms of barotrauma arise during or immediately after. One of them recommended to keep diving at least during the summer season so to have a clear picture, since cold water could have a major role to play, and after that he suggested to consider eustachian tube dilation.

I ask help to this big community of divers like me because I have anything left to do:

1. anyone like me? Any suggestions?
2. I kindly ask for any help for ENT specialist here in the blog, especially from @doctormike

I thank you in advance.

PS: If needed, I have all my diving and related issues recorded on paper so to have a full set of data to analyse: depth, any issue before or after diving, what symptoms and when came up and all my ENT examination.

 

[Akimbo]

These links may be helpful to readers interested in more information:

Resource by @doctormike
Ear Problems in Scuba Diving

ScubaBoard Knowledge Base article by @Duke Dive Medicine

Info - Barotrauma: The Ins and Outs of the Pops and Cracks

Barotrauma: The Ins and Outs of the Pops and Cracks By Eric Hexdall, RN, ACHRN @Duke Dive Medicine Article courtesy DiveAssure, originally published on Medical Articles – DiveAssure Many of us know the feeling. We’re on descent and realize that one of our ears hasn’t equalized. We perform the...

scubaboard.com

Both are information packed and have great illustrations.

 

[travisfull]

These links may be helpful to readers interested in more information:

Resource by @doctormike
Ear Problems in Scuba Diving

ScubaBoard Knowledge Base article by @Duke Dive Medicine

Info - Barotrauma: The Ins and Outs of the Pops and Cracks

Barotrauma: The Ins and Outs of the Pops and Cracks By Eric Hexdall, RN, ACHRN @Duke Dive Medicine Article courtesy DiveAssure, originally published on Medical Articles – DiveAssure Many of us know the feeling. We’re on descent and realize that one of our ears hasn’t equalized. We perform the...

scubaboard.com

Both are information packed and have great illustrations.

Thanks, I read that specific package of information and it is very interesting.

However, it does not include other specific cases like mine, unfortunately…

 

[Akimbo]

However, it does not include other specific cases like mine, unfortunately…

Understood. I posted these links more for other divers reading this since both of these authors have already addressed this case specifically. Hope you can get this sorted out.

 

[scubaozy]

Hi! Thanks a lot for your message. Below the response to your interesting points:
1. As mentioned previously, I’ve never had issues equalizing and never pain during or after diving; when I experienced pain it started ALWAYS 48 hours after diving.
2. No hearing loss, no tinnitus, no vertigo
3. As far as I know, both ENT - including the one suggested by DAN - agreed that it is a very particular form of ETD, and nothing to do with external ear…I’ve had several appointments with them, and I hope that at least one of them could have seen an external ear issue, right?

The one suggested by DAN advanced the hypothesis that cold water may cause my problem, especially because I’ve never had this problem during summer season.
He also said that delayed symptons for middle ear barotrauma are not unheard of.

Im sorry for the outburst but Im so frustrated: I’m in the middle of my DM course, I’ve done almost 100 dives without issues until this winter…lets hope that once the water ger hot in the coming weeks it will be solved, because at this point I have minor hopes for a medical solution.

Non allergic rhinitis can be triggered by cold or rapid temperature change, this is like, when you get to your warm home from cold and your nose starts running.
I find this video very comprehensive and informative with a lot of practical tips:

 

[doctormike]

Sorry if I'm having a bit of difficulty, @travisfull , but let me confirm. Have you seen an ENT doctor at the time that you are having symptoms? Or only later on...?

 

[travisfull]

Sorry if I'm having a bit of difficulty, @travisfull , but let me confirm. Have you seen an ENT doctor at the time that you are having symptoms? Or only later on...?

Sorry @doctormike, I may be confusing. Here the chronology of the events (sorry, its long I know):
- 21/11/2021: 40mt and 30mt dive in a day. No issue at all equalising. After 48 hours I started having symptoms: ears and jaw pain. Since I had a basic knowledge of symptoms concerning barotrauma (which normally arise during or immediately after) I thought it was something related to my jaw. However, the symptoms persisted and they increased in the following days, this is way I went to the ENT
-25/11/2021: 1st ENT visit (non diver specialist). Middle ear barotrauma was found, and it was prescribed Ceflixoral, Bentelan and biorinil spray plus 3 weeks of rest. You can see the tympanogram of 25/11/2021 in my previous posts;
- 09/012/2021: 2nd ENT visit (non diver specialist). I was recovering but not yet totally fine. Prescribed Brusonex spray and Bentelan for 6 days. The ENT authorised me to take a flight I had the following days;
- 11 and 19/12/2021: I took 4 flights, no issues at all, during or after.
- 20/12/2021: -23mt dive. No issues at all, during or after.
- 30/12/2021: -40mt dive. No issues at all equalising or immediately after. Ear pain arrived 48hours after the dive.
-03/01/2022: 3rd ENT visit, but he could not prescribed me anything because I had my COVID19 vaccination the following day. He advised to rest one week and to come back.
- 10/01/2022: 4th ENT visit. He diagnosed a catharral otitis media on my right ear. He prescribed Bentelan and Shedir flu. You can see the tympanogram dating 10/01/2022. He cleared to go diving after few days checking again my ears.
- 22 and 23/01/2022: -30mt dives. No issue at all equalising, or after diving. After 48hours I started having slight discomfort, mostly touching the ears, not real pain.
- 25/01/2022: 5th ENT visit. At that point he told about the ETD and he advised to try with Politzer and sulphurous water for 10 days in order to "train" the Eustachian tubes and he cleared for diving after that.
- 06/02/2022: -40mt dive. No issue at all equalising, or after diving. After 48hours I started having slight discomfort, mostly touching the ears, not real pain.
- 09/02/2022: CT scan that did not find anything expect for a slight tympanic thickening on my right ear: no ear glue, no mastoiditis or residual phlegm somewhere;
At that point I called DAN and I went to a ENT they suggested.
- 16/02/2022: the DAN ENT said my ears were still recovering and other 3 weeks of rest were advisable. You can see the tympanogram of 16/02/2022. He prescribed clenil+fluibron, Otovent 5 times a day.
I actually waited 1 full month before diving again for extra caution.
- 16, 19, 20, 26, 27, march and 23/04/2022: 5 dives (various depth, between 18 and 27mt), everything ok. No issues at all.
- 30/04/2022: -35mt dive.No issue at all equalising, or after diving. After 48hours I started having slight discomfort, mostly touching the ears, not real pain. I took an OKI and I was ok immediately.
- 10/05/2022: DM exercises in 2mt pool. No issue at all equalising, or after it. After 48hours I started having very slight discomfort, not real pain.
- 15 and 21/05/2022: took several flights, no issues at all.
- 28/05/2022: 31mt dive
- 29/05/2022: DM exercises, a lot of ups and downs in 5-10 mt depth. At the end of it I experienced some issues equalising, but I did not force it, I ascend, equalised and that's it. After 48hours slight discomfort, mostly touching the ears;
- 05/06/2022: 25mt dives. No issue at all equalising, or after it. After 48hours I started having very slight discomfort, not real pain, mostly touching only the left lobs;
- 09/06/2022: last ENT visit (not diving specialist, because the other one was not available). He saw nothing on my left ear, which is where the discomfort come from, while found a very mild middle ear barotrauma on my right which is TOTALLY FINE.

Am I crazy right?

 

[doctormike]

Sorry @doctormike, I may be confusing. Here the chronology of the events (sorry, its long I know):
- 21/11/2021: 40mt and 30mt dive in a day. No issue at all equalising. After 48 hours I started having symptoms: ears and jaw pain. Since I had a basic knowledge of symptoms concerning barotrauma (which normally arise during or immediately after) I thought it was something related to my jaw. However, the symptoms persisted and they increased in the following days, this is way I went to the ENT
-25/11/2021: 1st ENT visit (non diver specialist). Middle ear barotrauma was found, and it was prescribed Ceflixoral, Bentelan and biorinil spray plus 3 weeks of rest. You can see the tympanogram of 25/11/2021 in my previous posts;

I don't see your tympanograms any more in this thread for some reason. But I'm wondering what the doc actually saw? Blood in the middle ear? Retraction of the eardrum? Or middle ear fluid?

I don't know of good evidence for the use of antibiotics for middle ear barottrauma, or of any nasal spray. Systemic (oral) steroids can help (Bentelan)

- 09/012/2021: 2nd ENT visit (non diver specialist). I was recovering but not yet totally fine. Prescribed Brusonex spray and Bentelan for 6 days. The ENT authorised me to take a flight I had the following days;
- 11 and 19/12/2021: I took 4 flights, no issues at all, during or after.
- 20/12/2021: -23mt dive. No issues at all, during or after.
- 30/12/2021: -40mt dive. No issues at all equalising or immediately after. Ear pain arrived 48hours after the dive.
-03/01/2022: 3rd ENT visit, but he could not prescribed me anything because I had my COVID19 vaccination the following day. He advised to rest one week and to come back.

I don't understand this concern, but OK

- 10/01/2022: 4th ENT visit. He diagnosed a catharral otitis media on my right ear. He prescribed Bentelan and Shedir flu. You can see the tympanogram dating 10/01/2022. He cleared to go diving after few days checking again my ears.

I haven't heard that phrase used, but a google search gave me an article from 1944 (!) which sounds like this is a term for what is currently called OME, otitis media with effusion, implying a sterile fluid behind the eardrum. Again, oral steroids can be used in this situation (Bentelan), and no problems with a mucolytic like Shedirflu.

- 22 and 23/01/2022: -30mt dives. No issue at all equalising, or after diving. After 48hours I started having slight discomfort, mostly touching the ears, not real pain.
- 25/01/2022: 5th ENT visit. At that point he told about the ETD and he advised to try with Politzer and sulphurous water for 10 days in order to "train" the Eustachian tubes and he cleared for diving after that.

I have no idea what this means. Politzerization usually implies using a bulb to blow air into someone's nose to ventilate the Eustachian tube, but of course you can do this yourself by a valsalva maneuver. There is also a procedure where a doctor actually puts a tube into the ET orifice in the back of the nose, I doubt that this is what he was recommending. What were you doing with the sulphurous water?

- 06/02/2022: -40mt dive. No issue at all equalising, or after diving. After 48hours I started having slight discomfort, mostly touching the ears, not real pain.
- 09/02/2022: CT scan that did not find anything expect for a slight tympanic thickening on my right ear: no ear glue, no mastoiditis or residual phlegm somewhere;
At that point I called DAN and I went to a ENT they suggested.
- 16/02/2022: the DAN ENT said my ears were still recovering and other 3 weeks of rest were advisable. You can see the tympanogram of 16/02/2022. He prescribed clenil+fluibron, Otovent 5 times a day.
I actually waited 1 full month before diving again for extra caution.

I use the Otovent a lot, but mostly for children who can't do a regular Valsalva maneuver. For most adults, alternating Valsalva and Toynbee maneuvers seems to do the trick for barotrauma.

- 16, 19, 20, 26, 27, march and 23/04/2022: 5 dives (various depth, between 18 and 27mt), everything ok. No issues at all.
- 30/04/2022: -35mt dive.No issue at all equalising, or after diving. After 48hours I started having slight discomfort, mostly touching the ears, not real pain. I took an OKI and I was ok immediately.
- 10/05/2022: DM exercises in 2mt pool. No issue at all equalising, or after it. After 48hours I started having very slight discomfort, not real pain.
- 15 and 21/05/2022: took several flights, no issues at all.
- 28/05/2022: 31mt dive
- 29/05/2022: DM exercises, a lot of ups and downs in 5-10 mt depth. At the end of it I experienced some issues equalising, but I did not force it, I ascend, equalised and that's it. After 48hours slight discomfort, mostly touching the ears;
- 05/06/2022: 25mt dives. No issue at all equalising, or after it. After 48hours I started having very slight discomfort, not real pain, mostly touching only the left lobs;
- 09/06/2022: last ENT visit (not diving specialist, because the other one was not available). He saw nothing on my left ear, which is where the discomfort come from, while found a very mild middle ear barotrauma on my right which is TOTALLY FINE.

It seems that a lot of your symptoms involve touching the ears, 48 hours later, which sounds a lot more like an outer ear problem. But I guess the ENTs would have seen that!

Am I crazy right?

Hah! I'm DEFINITELY not qualified to make THAT diagnosis. But it does sound frustrating...

 

[Akimbo]

Am I crazy right?

Hah! I'm DEFINITELY not qualified to make THAT diagnosis. But it does sound frustrating...

Crazy was unofficially a prerequisite of the Navy medical exam for divers. Needless to say, I passed with flying colors. Welcome to the club.

 

[travisfull]

I don't see your tympanograms any more in this thread for some reason. But I'm wondering what the doc actually saw? Blood in the middle ear? Retraction of the eardrum? Or middle ear fluid?

I don't know of good evidence for the use of antibiotics for middle ear barottrauma, or of any nasal spray. Systemic (oral) steroids can help (Bentelan)




I don't understand this concern, but OK



I haven't heard that phrase used, but a google search gave me an article from 1944 (!) which sounds like this is a term for what is currently called OME, otitis media with effusion, implying a sterile fluid behind the eardrum. Again, oral steroids can be used in this situation (Bentelan), and no problems with a mucolytic like Shedirflu.



I have no idea what this means. Politzerization usually implies using a bulb to blow air into someone's nose to ventilate the Eustachian tube, but of course you can do this yourself by a valsalva maneuver. There is also a procedure where a doctor actually puts a tube into the ET orifice in the back of the nose, I doubt that this is what he was recommending. What were you doing with the sulphurous water?



I use the Otovent a lot, but mostly for children who can't do a regular Valsalva maneuver. For most adults, alternating Valsalva and Toynbee maneuvers seems to do the trick for barotrauma.



It seems that a lot of your symptoms involve touching the ears, 48 hours later, which sounds a lot more like an outer ear problem. But I guess the ENTs would have seen that!



Hah! I'm DEFINITELY not qualified to make THAT diagnosis. But it does sound frustrating...

Hello @doctormike, thanks a lot for your answer.

Here my post with the different tympanogram posted in the previous page:

Middle ear barotrauma several days after diving...PLEASE HELP!

Hi guys, I read all the different thread concerning ETD and middle ear barotrauma but I did not find anything similar to my case. Below the main points of my history, for which I ask for your kind help, especially because diving is really part of my happiness and life : dived always during...

scubaboard.com

Below some clarifications, and Im sorry for some wrong medical definitions I posted before:

1. yes, it was a OME. After the first middle ear barotrauma there was ear fluid (phlegm).
2. as for the Politzerization, I link you here an article that talk about it: The role of spa therapy with politzer method in dysfunction of the eustachian tube - Gazzetta Medica Italiana Archivio per le Scienze Mediche 2010 August;169(4):131-6
It is basically a SPA therapy to loosen the mucus. Im really sorry for not being that clear from a medical standpoint, but Im not a specialist and english is not my mother tongue
3. As for the COVID19 vaccination, the ENT wanted to prescribe me Bentelan but he could not because he said there may be some incompatibility issue between the vaccination and those medications.
4. Yes, it involves a lot the lobes touching, at least all my symptoms that emerged after the first real middle ear barotrauma which was.

I still don't understand the following issues:
A. Can barotrauma be without symptoms during or immediately after and emerge only 48 hours?
B. Can my problems be related to a mechanical issue in my jaw? I saw a dentist and he gave a dental guard to wear at night.

 

[doctormike]

Hello @doctormike, thanks a lot for your answer.

Here my post with the different tympanogram posted in the previous page:

Middle ear barotrauma several days after diving...PLEASE HELP!

Hi guys, I read all the different thread concerning ETD and middle ear barotrauma but I did not find anything similar to my case. Below the main points of my history, for which I ask for your kind help, especially because diving is really part of my happiness and life : dived always during...

scubaboard.com

Below some clarifications, and Im sorry for some wrong medical definitions I posted before:

1. yes, it was a OME. After the first middle ear barotrauma there was ear fluid (phlegm).

I think that a lot of my confusion here stems from different terminology used in Italy vs the US.

2. as for the Politzerization, I link you here an article that talk about it: The role of spa therapy with politzer method in dysfunction of the eustachian tube - Gazzetta Medica Italiana Archivio per le Scienze Mediche 2010 August;169(4):131-6

Still can't tell what they mean by politzerization. That implies forcing gas into the nose from an external device, in my experience, and the abstract doesn't describe the actual method. Sounds like the kids were breathing spa gas or something?

The problem with studying a disease with such a high spontaneous cure rate is that virtually everything "works". So improvement in middle ear function in 67% of cases isn't that impressive when you consider that if you take 100 kids with OME after an ear infection and sing "Happy Birthday" to them every day, 90% of them will be better in 3 months!

https://www.minervamedica.it/en/journals/gazzetta-medica-italiana/article.php?cod=R22Y2010N04A0131

It is basically a SPA therapy to loosen the mucus. Im really sorry for not being that clear from a medical standpoint, but Im not a specialist and english is not my mother tongue

You are doing GREAT!

3. As for the COVID19 vaccination, the ENT wanted to prescribe me Bentelan but he could not because he said there may be some incompatibility issue between the vaccination and those medications

4. Yes, it involves a lot the lobes touching, at least all my symptoms that emerged after the first real middle ear barotrauma which was.

I still don't understand the following issues:
A. Can barotrauma be without symptoms during or immediately after and emerge only 48 hours?
B. Can my problems be related to a mechanical issue in my jaw? I saw a dentist and he gave a dental guard to wear at night.

I mean, some of those tympanograms look more like artifact than actual ETD. The one from January of this year looks normal. I would think that if you had clinically significant barotrauma (OME), you would notice it. Tempormandibular joint problems can absolutely mimic ear disease, but the timing relationship to the diving makes that less likely, unless it's an issue with your regulator mouthpiece?