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

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OP
T

travisfull

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



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!

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

You are doing GREAT!






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?
Hi @doctormike thanks a lot.
1. Yes, it basically means breathing spa gas through your nose, forcing it into your eustachian tube, closing your mouth and swallowing your saliva. Apparently, it should help loosing the mucus and at the same time producing the same effect of a valsalva maneuver.
2. What do you mean by “some of those tympanograms look more like artifact than actual ETD”?
3. As for possible tempomandibular problems, the DAN ENT suggested the dental evaluation and I subsequently bought the jax regulator from mares to adapt it to my mouth.
 
Hi @doctormike thanks a lot.
1. Yes, it basically means breathing spa gas through your nose, forcing it into your eustachian tube, closing your mouth and swallowing your saliva. Apparently, it should help loosing the mucus and at the same time producing the same effect of a valsalva maneuver.
2. What do you mean by “some of those tympanograms look more like artifact than actual ETD”?

A tympanogram is a plot of the degree to which a small probe tone is reflected by the eardrum. The Y axis is the amount reflected, the X axis is the pressure in the outer ear, which is varied along a range by the tympanometer. There are basically four types of tympanograms that correlate with actual middle ear conditions:

Type A - there is a peak in the curve, which can only happen if there is gas in the middle ear. The peak corresponds to the point when the ear canal pressure matches the middle ear pressure, making the "reflectance" of the test signal at the maximum. In a normally ventilated middle ear, that peak is between -100 and +100 mm H20 (approximately the same as daPa).

Type C - same as type A, but the middle ear pressure is lower than ambient. That means that the peak is shifted to the left, below -100. Theoretically you would think that there should be a corresponding type of typmanogram with a peak above +100, but there is no medical condition where that occurs. Negative pressure comes from chronic underventilation of the ear, with the lining of the ear resorbing gas. If you took a tympanometer with you while diving, you could theoretically get this type of positive pressure (right shifted) curve if you ascended with a reverse block and didn't clear. The eardrum would bulge out with expanding gas.

Type B - this is just a flat curve, meaning that the reflectance of the signal doesn't change with changing external ear pressure. There are two situations where that can happen.

Type B with a large canal volume - a hole in the eardrum. With a hole, there is no change in reflectance with changing ear canal pressure because you are basically just measuring one big space. There is no eardrum dividing the system into two separate spaces from a gas physics viewpoint (ear canal and middle ear).

Type B with amall canal volume - fluid in the middle ear. Fluid is non-compressible, so no matter what you set the ear canal pressure to, the eardrum doesn't change and neither does the reflectance.

Some of your tymps just looked like the machine might not have been working properly or making a good seal, like the one with the wiggly line. Hard to telll..

3. As for possible tempomandibular problems, the DAN ENT suggested the dental evaluation and I subsequently bought the jax regulator from mares to adapt it to my mouth.

Maybe that will help!
 
A tympanogram is a plot of the degree to which a small probe tone is reflected by the eardrum. The Y axis is the amount reflected, the X axis is the pressure in the outer ear, which is varied along a range by the tympanometer. There are basically four types of tympanograms that correlate with actual middle ear conditions:

Type A - there is a peak in the curve, which can only happen if there is gas in the middle ear. The peak corresponds to the point when the ear canal pressure matches the middle ear pressure, making the "reflectance" of the test signal at the maximum. In a normally ventilated middle ear, that peak is between -100 and +100 mm H20 (approximately the same as daPa).

Type C - same as type A, but the middle ear pressure is lower than ambient. That means that the peak is shifted to the left, below -100. Theoretically you would think that there should be a corresponding type of typmanogram with a peak above +100, but there is no medical condition where that occurs. Negative pressure comes from chronic underventilation of the ear, with the lining of the ear resorbing gas. If you took a tympanometer with you while diving, you could theoretically get this type of positive pressure (right shifted) curve if you ascended with a reverse block and didn't clear. The eardrum would bulge out with expanding gas.

Type B - this is just a flat curve, meaning that the reflectance of the signal doesn't change with changing external ear pressure. There are two situations where that can happen.

Type B with a large canal volume - a hole in the eardrum. With a hole, there is no change in reflectance with changing ear canal pressure because you are basically just measuring one big space. There is no eardrum dividing the system into two separate spaces from a gas physics viewpoint (ear canal and middle ear).

Type B with amall canal volume - fluid in the middle ear. Fluid is non-compressible, so no matter what you set the ear canal pressure to, the eardrum doesn't change and neither does the reflectance.

Some of your tymps just looked like the machine might not have been working properly or making a good seal, like the one with the wiggly line. Hard to telll..



Maybe that will help!
@doctormike thanks a lot for the explanation.
So, to sum up:
1. A middle ear barotrauma caused by ETD cannot provoke symptoms delayed of 48hours without experiencing any issue during or right after dive?
2. Is there any form of ETD that could reflect my symptoms?
3. In case I like to do some other exams to analyse the tempomandibular situation, what do you recommend? A dentist with a certain specialist or another kind of specialist?

Thanks again!
 
@doctormike thanks a lot for the explanation.
So, to sum up:
1. A middle ear barotrauma caused by ETD cannot provoke symptoms delayed of 48hours without experiencing any issue during or right after dive?

I mean, I wouldn't swear that couldn't happen. I guess there could be some sort of pressure trauma that caused a progressive swelling in the ET and the symptoms might be delayed. I just have never heard of that, but I don't see a lot of adults. The whole scenario doesn't sound that typical.

2. Is there any form of ETD that could reflect my symptoms?

I mean, if you are having symptoms of ETD/barotrauma 48 hours after surfacing, especially if that's backed up by the physical exam or tympanometry, then I would believe that your symptoms are ETD symptoms. To be more accurate, I would have to examine you when you were symptomatic.

3. In case I like to do some other exams to analyse the tempomandibular situation, what do you recommend? A dentist with a certain specialist or another kind of specialist?

Usually that's done by an oral surgeon who specializes in TMJ stuff, but I guess general dentists could make you a night guard, if it looks like you are grinding your teeth during sleep...
 
I mean, I wouldn't swear that couldn't happen. I guess there could be some sort of pressure trauma that caused a progressive swelling in the ET and the symptoms might be delayed. I just have never heard of that, but I don't see a lot of adults. The whole scenario doesn't sound that typical.



I mean, if you are having symptoms of ETD/barotrauma 48 hours after surfacing, especially if that's backed up by the physical exam or tympanometry, then I would believe that your symptoms are ETD symptoms. To be more accurate, I would have to examine you when you were symptomatic.



Usually that's done by an oral surgeon who specializes in TMJ stuff, but I guess general dentists could make you a night guard, if it looks like you are grinding your teeth during sleep...
Thanks a lot @doctormike , very much appreciated and clear and very useful.

So, not all the ETD are related to a difficulty of equalising If I understand correctly?
Normally it is like that, but sometimes, like in my case, the ET may function properly underwater, but for some unclear reasons (the DAN ENT said that being cold water a vasoconstrictor, that can be the primary cause, even if he can't explain the delay in symptoms), the ET "did not like the pressure" and they react gradually, provoking symptoms after a couple of days?

Sorry for all those questions, Im trying to collect all the possible feedbacks for something that apparently does not have a clear scientific explanation :)
 
Thanks a lot @doctormike , very much appreciated and clear and very useful.

So, not all the ETD are related to a difficulty of equalising If I understand correctly?
Normally it is like that, but sometimes, like in my case, the ET may function properly underwater, but for some unclear reasons (the DAN ENT said that being cold water a vasoconstrictor, that can be the primary cause, even if he can't explain the delay in symptoms), the ET "did not like the pressure" and they react gradually, provoking symptoms after a couple of days?

Sorry for all those questions, Im trying to collect all the possible feedbacks for something that apparently does not have a clear scientific explanation :)

Sure, always happy to help as best as I can.

The ET (Eustachian tube) is the pathway that connects the upper airway to the middle ear space. It's not just a static tube, but a dynamic structure that opens with muscular activity. And in some cases, it just doesn't work. That's the D (dysfunction). So ETD is a term that describes patients in which the ET doesn't do its job and the middle ear is poorly ventilated. Even without ambient pressure changes, ETD can lead to chronic negative middle ear pressure or middle ear effusion - this is what happens in small children who need ear tubes. Other people can have ETs that normally work fine but aren't up to the challenge of dealing with changes in ambient pressure, like with diving. Some people can deal with ambient pressure changes fine normally, but not after a cold or other things that cause congestion of the lining of the ET. And some adults have chronic ETD from anatomic issues like radiation therapy.

So people with ETD can have problems equalizing during diving, but this is usually a technique issue and not an anatomic issue.

Yes, technically cold water can act as a "vasoconstictor", but that has nothing to do with the ET. First of all, cold water doesn't get anywhere near the ET, it's in the center of the skull. If that area becomes cold, it means that you are dead! The only cold related ear issue that comes to mind is the cold caloric response in which the semicircular canals are stimulated by cold water causing vertigo, but they are much more superficial and can be exposed to cold water.

Also, vasoconstriction means that blood vessels close down, which is what happens in frostbite of the fingers, etc... Not really relevant to ET function.

I really don't know what anyone meant by your ETs "not liking the pressure" and then causing symptoms 2-3 days after that barotrauma. But maybe that's a thing that does happen and I just don't know about it.
 
Usually that's done by an oral surgeon who specializes in TMJ stuff, but I guess general dentists could make you a night guard, if it looks like you are grinding your teeth during sleep...

I clench my teeth at night and it was diagnosed by my normal dentist and he could make a night guard, or there are several types over the counter in the US, hopefully in other countries as well. I honestly prefer one of my over the counter ones to my fancy dentist custom one, but I don’t have brand info handy to mention the specific type. I can look it up tomorrow.
 
Sure, always happy to help as best as I can.

The ET (Eustachian tube) is the pathway that connects the upper airway to the middle ear space. It's not just a static tube, but a dynamic structure that opens with muscular activity. And in some cases, it just doesn't work. That's the D (dysfunction). So ETD is a term that describes patients in which the ET doesn't do its job and the middle ear is poorly ventilated. Even without ambient pressure changes, ETD can lead to chronic negative middle ear pressure or middle ear effusion - this is what happens in small children who need ear tubes. Other people can have ETs that normally work fine but aren't up to the challenge of dealing with changes in ambient pressure, like with diving. Some people can deal with ambient pressure changes fine normally, but not after a cold or other things that cause congestion of the lining of the ET. And some adults have chronic ETD from anatomic issues like radiation therapy.

So people with ETD can have problems equalizing during diving, but this is usually a technique issue and not an anatomic issue.

Yes, technically cold water can act as a "vasoconstictor", but that has nothing to do with the ET. First of all, cold water doesn't get anywhere near the ET, it's in the center of the skull. If that area becomes cold, it means that you are dead! The only cold related ear issue that comes to mind is the cold caloric response in which the semicircular canals are stimulated by cold water causing vertigo, but they are much more superficial and can be exposed to cold water.

Also, vasoconstriction means that blood vessels close down, which is what happens in frostbite of the fingers, etc... Not really relevant to ET function.

I really don't know what anyone meant by your ETs "not liking the pressure" and then causing symptoms 2-3 days after that barotrauma. But maybe that's a thing that does happen and I just don't know about it.
Thanks a lot @doctormike

So, as far as you know, there may be 2 options: either two different ENT (and one of them suggested by DAN) have not recognised for several times that its an outer ear problem, or it is something totally new and they say it is ETD because they have excluded all the other possible problems?

What do you think about different equalising technique? I use the classic valsalva, but as I said I’ve never experienced any discomfort (for almost 100 dives) and I equalise frequently and early in the dive.
Is there any chance that valsalva - being less gentle than others methods - during winter time may cause some kind of trauma with delayed symptoms of 48hours?

I know @Angelo Farina is very vocal about the bad consequences of valsalva and the benefits or other technique.

Thanks to all guys, a very cool community of scuba divers!
 
I clench my teeth at night and it was diagnosed by my normal dentist and he could make a night guard, or there are several types over the counter in the US, hopefully in other countries as well. I honestly prefer one of my over the counter ones to my fancy dentist custom one, but I don’t have brand info handy to mention the specific type. I can look it up tomorrow.
Yes indeed, I went to my normal dentist to get a custom night guard. However, being scuba diving a very specific domain with specific physiological consequences, there may be some specialist who can advise better on tempomandibular issues related to scuba diving, like a surgeon or other specialist.
 

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