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

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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.
 

doctormike

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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?

Well, the first one seems unlikely if you actually had symptoms when you saw them. And of course I'm not going to tell you that doctors who have seen you are wrong when I haven't seen you myself. I'm just trying to help you understand the basic anatomy and physiology.

I'm just saying that if you show up in an ENT office with complaints of ear pain after diving with no evidence of an outer ear process, you may get the diagnosis of ETD/barotrauma even if you have a relatively normal tympanogram at the time. Pain is subjective, and of course there is no way of objectively measuring that. I have plenty of patients like that, and I always assume that it's either something unrelated (like TMJ), or it IS a manifestation of ETD, in which they are just very sensitive to changes in middle ear pressure that might not be enough to progress to OME, hemotympanum (blood in the middle ear), collapse, etc...

FWIW, I see a lot of teenagers (with normal appearing ears) who just are hyper-aware of their ET function to the point of it causing discomfort or even habitual compulsive clearing of the ears, like a tic.

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?

Again, I suppose that's possible, if that's what these other docs are saying. I'm just saying that I haven't seen delayed symptoms like that myself. There are a lot of approaches to equalization. Dr. Kay used to have a good list of them on his website, the text list has since been removed, but there is a lecture about that still on his site.


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

Yes, I remember participating in that thread...

Thanks to all guys, a very cool community of scuba divers!
 
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travisfull

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Well, the first one seems unlikely if you actually had symptoms when you saw them. And of course I'm not going to tell you that doctors who have seen you are wrong when I haven't seen you myself. I'm just trying to help you understand the basic anatomy and physiology.

I'm just saying that if you show up in an ENT office with complaints of ear pain after diving with no evidence of an outer ear process, you may get the diagnosis of ETD/barotrauma even if you have a relatively normal tympanogram at the time. Pain is subjective, and of course there is no way of objectively measuring that. I have plenty of patients like that, and I always assume that it's either something unrelated (like TMJ), or it IS a manifestation of ETD, in which they are just very sensitive to changes in middle ear pressure that might not be enough to progress to OME, hemotympanum (blood in the middle ear), collapse, etc...

FWIW, I see a lot of teenagers (with normal appearing ears) who just are hyper-aware of their ET function to the point of it causing discomfort or even habitual compulsive clearing of the ears, like a tic.



Again, I suppose that's possible, if that's what these other docs are saying. I'm just saying that I haven't seen delayed symptoms like that myself. There are a lot of approaches to equalization. Dr. Kay used to have a good list of them on his website, the text list has since been removed, but there is a lecture about that still on his site.




Yes, I remember participating in that thread...
Thanks again @doctormike
I'll keep you posted on my progress, it may be helpful for others I guess! :)
 

uncfnp

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Hi travisfull! Sorry about all the problems you have had and I hesitate to post since others in this thread are much more qualified to give advice and suggestions. I mostly just want to clarify exactly what you are experiencing.

Excluding the first episode when you were diagnosed with barotrauma, exactly what symptoms are you experiencing post dive since? Is it just pain when you move the earlobe and itch?

Do you ever get the same symptoms when you have not been diving?

When you are having symptoms can you still equalize easily?

Have you ever had this discomfort and not sought out medical care? If so how long did it last?

Edit. Like doctormike I wonder if your original episode of trauma has perhaps made you more aware of ear sensation. From your posts it seems that there are minimal findings during your ENT exams and wanting to help they are going after the possibilities, including ETD and TMJ.

I might suggest switching gears and if cold water seems to be the problem and assuming you already wear a hood, have you tried diving ear plugs? Have you tried any of the post dive ear washes like the ear beers or earshield?
 
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travisfull

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Hi travisfull! Sorry about all the problems you have had and I hesitate to post since others in this thread are much more qualified to give advice and suggestions. I mostly just want to clarify exactly what you are experiencing.

Excluding the first episode when you were diagnosed with barotrauma, exactly what symptoms are you experiencing post dive since? Is it just pain when you move the earlobe and itch?

Do you ever get the same symptoms when you have not been diving?

When you are having symptoms can you still equalize easily?

Have you ever had this discomfort and not sought out medical care? If so how long did it last?

Edit. Like doctormike I wonder if your original episode of trauma has perhaps made you more aware of ear sensation. From your posts it seems that there are minimal findings during your ENT exams and wanting to help they are going after the possibilities, including ETD and TMJ.

I might suggest switching gears and if cold water seems to be the problem and assuming you already wear a hood, have you tried diving ear plugs? Have you tried any of the post dive ear washes like the ear beers or earshield?
Thanks a lot for your interest @uncfnp and for your interesting suggestions.

So, to reply to your questions:
1. Yes, expect for 5 straight dives between march and april after which I did not have any kind of issue, I usually experience mild pain when I move the earlobe (without specific pattern in terms of right or left lobe, may be both or just one) and a sense of ear fullness ONLY if I pull my earlobes downward, and also hitching;
2. When I don't dive, I don't have any issue at all, never experienced particular problems with my ears in the past.
3. When I have those symptoms I can still easily equalised, no issues at all and without any kind of discomfort.
4. "Have you ever had this discomfort and not sought out medical care?" I'm trying this week. After last sunday same symptoms emerged after 48 hours, I went to my ENT but he did not prescribe me anything expect for Neuridase which, as far as I understand, it is just a dietary supplement. Im just taking OKI and symptoms are fading away now, I guess in the coming days it will be ok.
5. It is actually part of the next steps: I bought the "DOC's pro plugs" and I'll try them next time. As for the hood, I usually wear it, but Im thinking of trying without it, just to mix things up and see how it goes.
5. As for the ear washing, I usually try clean water after dive, but not in a consistent manner if I have to be honest.
 

uncfnp

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Thanks a lot for your interest @uncfnp and for your interesting suggestions.

So, to reply to your questions:
1. Yes, expect for 5 straight dives between march and april after which I did not have any kind of issue, I usually experience mild pain when I move the earlobe (without specific pattern in terms of right or left lobe, may be both or just one) and a sense of ear fullness ONLY if I pull my earlobes downward, and also hitching;
2. When I don't dive, I don't have any issue at all, never experienced particular problems with my ears in the past.
3. When I have those symptoms I can still easily equalised, no issues at all and without any kind of discomfort.
4. "Have you ever had this discomfort and not sought out medical care?" I'm trying this week. After last sunday same symptoms emerged after 48 hours, I went to my ENT but he did not prescribe me anything expect for Neuridase which, as far as I understand, it is just a dietary supplement. Im just taking OKI and symptoms are fading away now, I guess in the coming days it will be ok.
5. It is actually part of the next steps: I bought the "DOC's pro plugs" and I'll try them next time. As for the hood, I usually wear it, but Im thinking of trying without it, just to mix things up and see how it goes.
5. As for the ear washing, I usually try clean water after dive, but in a consistent manner if I have to be honest.
So. As a fellow diver here is my personal routine. Take it for what it’s worth.

I do have trouble equalizing so I take pseudophedrine (12 hour version) before a day of diving. (Middle ear)

After a day of diving I use my version of ear beer (there are several formulas offered on SB or EarShield brand). (Outer Ear)

I have a Seacure mouthpiece to limit TMJ and I use an NSAID (Ibu) liberally (jaw and many other aches and pains). (Joints)
 
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travisfull

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So. As a fellow diver here is my personal routine. Take it for what it’s worth.

I do have trouble equalizing so I take pseudophedrine (12 hour version) before a day of diving. (Middle ear)

After a day of diving I use my version of ear beer (there are several formulas offered on SB or EarShield brand). (Outer Ear)

I have a Seacure mouthpiece to limit TMJ and I use an NSAID (Ibu) liberally (jaw and many other aches and pains). (Joints)
@uncfnp
Thanks a lot, this is very interesting routine.
As for pseudoephedrine, we don't have sudafed in Italy, do you recommend something else similar?

As for your formulas for ear beer, can you share it?
 

uncfnp

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@uncfnp
Thanks a lot, this is very interesting routine.
As for pseudoephedrine, we don't have sudafed in Italy, do you recommend something else similar?

As for your formulas for ear beer, can you share it?
A google search shows it might be one of the active ingreditents in Actifed in Italy. I know of no alternatives that has shown to be as effective.

As for formulas I believe that @doctormike can be more help here. I recall he uses the brand EarShield but also advocates a home mix of mostly alcohol with some vinegar with the addition of glycerin to prevent excessive drying if you use it frequently. With your itch and frequency of diving the glycerin is probably a good idea.

Another possibility » Ear Dryer

I keep it simple with a 50/50 alcohol and white vinegar mix but doctormike doesn’t like this version :). Too much water from the vinegar.
 
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travisfull

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A google search shows it might be one of the active ingreditents in Actifed in Italy. I know of no alternatives that has shown to be as effective.

As for formulas I believe that @doctormike can be more help here. I recall he uses the brand EarShield but also advocates a home mix of mostly alcohol with some vinegar with the addition of glycerin to prevent excessive drying if you use it frequently. With your itch and frequency of diving the glycerin is probably a good idea.

Another possibility » Ear Dryer

I keep it simple with a 50/50 alcohol and white vinegar mix but doctoemike doesn’t like this version :). Too much water from the vinegar.
Thank you very much @uncfnp , very much appreciated. Its good to have a big community to help each other with the same passion for diving.
I'll keep you all posted, hopefully I'll be finishing my DM course so I still have other course dives to do...
 
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