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.

 

[doctormike]

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.

Here's my handout discussing all of that. Of course, ear beer / EarDryer has nothing to do with barotrauma...

 

[travisfull]

Here's my handout discussing all of that. Of course, ear beer / EarDryer has nothing to do with barotrauma...

Thanks a lot @doctormike

 

[travisfull]

Hi everyone and hi @doctormike

Here an update on my situation. During the last month I did 5 different dives all at different depth (between 18 and 35 metres), during or after which I did not experience any issues at all. So good news on that.

On thursday I had my 6th dive, a night dive at 18mt, no issue at all equalising (as always), but after 36hours - same timing of my past cases - I started experiencing mild discomfort on the right ear (nothing on my left) with the same symptoms experienced before and that I explained in my latest posts:
- itching in the ear canal
- discomfort pulling down my ear lob
- i don't have any problems, pain or discomfort equalising with both ears, and if it wasn't for the itching I would not notice it without touching the ear.

I can say that there was a difference between the first group of 5 dives and the last one: in the last one I used a standard mouthpiece and not my usual mares Jax customisable regulator. I did it on purpose so to systematically identify good habits that cause me no problems and apply them all the time. Next time I'll use the Jax regulator again and I'll apply ear beer right after the dive so to gather more data.

Any comment guys?
@doctormike my symptoms are compatible with a swimmer ear problem or it is more likely, considering the mouthpiece change, a jaw issue. As for the swimmer ear I've never understood if the symptoms are visible (like a rush) or the term "external" ear refers only to the section of the ear, and not to the fact the symptoms are external and visible.

thanks a lot and good dives guys!

 

[doctormike]

Hey, @travisfull ... thanks for the update. What you describe sure sounds like swimmer's ear. This is another name for otitis externa, it's an inflammatory condition of the outer ear canal, so it should be visible. Occasionally we will see someone with classic symptoms and the ear looks normal, and we treat with drops and they get better! Hard to know what to say about that...

TMJ issues (from the jaw joint) can mimic ear pain, but if your ear canal is itchy and pulling your earlobe causes pain, that's less likely to be the situation.

Here's a drawing of the different parts of the ear.

 

[travisfull]

Hey, @travisfull ... thanks for the update. What you describe sure sounds like swimmer's ear. This is another name for otitis externa, it's an inflammatory condition of the outer ear canal, so it should be visible. Occasionally we will see someone with classic symptoms and the ear looks normal, and we treat with drops and they get better! Hard to know what to say about that...

TMJ issues (from the jaw joint) can mimic ear pain, but if your ear canal is itchy and pulling your earlobe causes pain, that's less likely to be the situation.

Here's a drawing of the different parts of the ear.

Thanks @doctormike for your kind and rapid answer! I hope everything is fine in New Jersey! Let me know if you ever come to Italy, we are going to dive together

When you say "visible" you mean "naked eye" or only with a ENT tool?
What kind of drops if I may ask?
As for ear beer, I remember you don't like that much a 50/50 mix alcohol and vinegar. What do you recommend?

 

[doctormike]

Thanks @doctormike for your kind and rapid answer! I hope everything is fine in New Jersey! Let me know if you ever come to Italy, we are going to dive together

It's a deal! This is where I want to go:

JJ-CCR – Ponza Diving

When you say "visible" you mean "naked eye" or only with a ENT tool?

You would usually need an otoscope to see that. Sometimes, a swimmer's ear is so bad that there is crusting and inflammation on the far outside of the ear canal, but that's less common.

If you are careful, you can try one of these video otoscopes for less than $40 USD

What kind of drops if I may ask?

If you are treating an active otitis externa, we usually use antibiotic and steroid drops, something like cortisporin otic or Ciprodex.

As for ear beer, I remember you don't like that much a 50/50 mix alcohol and vinegar. What do you recommend?

Here's my recipe, and other advice for that problem:

Michael Rothschild: Ear Problems & DIving

 

[travisfull]

It's a deal! This is where I want to go:

JJ-CCR – Ponza Diving



You would usually need an otoscope to see that. Sometimes, a swimmer's ear is so bad that there is crusting and inflammation on the far outside of the ear canal, but that's less common.

If you are careful, you can try one of these video otoscopes for less than $40 USD





If you are treating an active otitis externa, we usually use antibiotic and steroid drops, something like cortisporin otic or Ciprodex.



Here's my recipe, and other advice for that problem:

Michael Rothschild: Ear Problems & DIving

Thanks a lot!

Ponza is one of the best place in Italy for diving addicted like us. Plus, the Ponza Diving you chose they are specialised in CCR diving and they are really really good!

https://ponzadiving.com/relitto-lst/

This is one of the best dive in Ponza for sure!

 

[Angelo Farina]

As I reported already some times, my wife at the beginning of her career had severe equalization problems.
Albeit these were usually evident already during the dive, or just after, in at least a couple of cases she had delayed symptoms. The first time after roughly 18 hours, the second after almost 3 days. No pain, nor reported equalization problems during the dives.
In both cases she was visited by an ENT, who did found some external problems, probably originated by minor damage to the tympanic membrane, which evolved into external otitis later on.
She was prescribed with external drops, something containing antibiotics and inflammatory drugs (Tobradex, if I remember correctly).
As the visual inspection of the external ear did already show the origin of the problem, she was not prescribed further exams, and the pathology was solved in a few days in both cases.
It must also be said that in the case of my wife there was nothing pathological causing her equalization problem, simply she was trained to ONLY use Valsalva, which for her revealed to be a poor technique (it works for many others, but not for everyone).
She solved entirely her eq problems only when following the Instructor course at Nervi, taught by Duilio Marcante, in 1982. There she did learn how to practice several other equalization techniques, including the (not so) famous Marcante-Odaglia method, which solved entirely her problems.
As you are in Italy, I warmly suggest that you spend one day and 100 euros in the DAN course about equalization:

DAN Europe - EqualEasy - course - DAN Europe - EqualEasy - course

nome:EqualEasy - Equalisation Awarenessabstract:At present, this content is only available in Italian language. The DAN Equalisation Awareness course is the training course focusing on...

www.daneurope.org

Just a couple of years ago one of my young research assistants had systematic problems, and he went to this Equaleasy course at Y-40 pool near Padova. This solved entirely his problems, exactly as it happened to my wife 40 years ago.
Please note that it was not "just" a course, the day included medical examinations and consultancy with a diving ENT, something usually costing twice the cost of the "course"...

 

[travisfull]

As I reported already some times, my wife at the beginning of her career had severe equalization problems.
Albeit these were usually evident already during the dive, or just after, in at least a couple of cases she had delayed symptoms. The first time after roughly 18 hours, the second after almost 3 days. No pain, nor reported equalization problems during the dives.
In both cases she was visited by an ENT, who did found some external problems, probably originated by minor damage to the tympanic membrane, which evolved into external otitis later on.
She was prescribed with external drops, something containing antibiotics and inflammatory drugs (Tobradex, if I remember correctly).
As the visual inspection of the external ear did already show the origin of the problem, she was not prescribed further exams, and the pathology was solved in a few days in both cases.
It must also be said that in the case of my wife there was nothing pathological causing her equalization problem, simply she was trained to ONLY use Valsalva, which for her revealed to be a poor technique (it works for many others, but not for everyone).
She solved entirely her eq problems only when following the Instructor course at Nervi, taught by Duilio Marcante, in 1982. There she did learn how to practice several other equalization techniques, including the (not so) famous Marcante-Odaglia method, which solved entirely her problems.
As you are in Italy, I warmly suggest that you spend one day and 100 euros in the DAN course about equalization:

DAN Europe - EqualEasy - course - DAN Europe - EqualEasy - course

nome:EqualEasy - Equalisation Awarenessabstract:At present, this content is only available in Italian language. The DAN Equalisation Awareness course is the training course focusing on...

www.daneurope.org

Just a couple of years ago one of my young research assistants had systematic problems, and he went to this Equaleasy course at Y-40 pool near Padova. This solved entirely his problems, exactly as it happened to my wife 40 years ago.
Please note that it was not "just" a course, the day included medical examinations and consultancy with a diving ENT, something usually costing twice the cost of the "course"...

Hi Angelo, thanks a lot for your precious contribution.
I read before your discussion about equalisation technique and I was quite interested in having your contribution on my issue. I'll certainly do the course you recommended: I'm already looking for the next slot available.

Before experiencing this problem at the end of 2021, I had already almost 100 recreational dives without any issue at all (different depth, max 35mt) and I had always used Valsalva and NEVER had systemic issues equalising.
Even now, after my issue came up, originally probably due to a badly cured cold, I still never have any issue equalising (I do it frequently, I do it long before experiencing any pain or discomfort): my symptoms arise always after 36 hours minimum after the dive and that's what makes me frustrated. I mean, having pain during the dive is a concrete and real signal that something is off (my technique, a cold, a mouthpiece, whatever) and I can work on it...but with these symptoms is something I can't really work on, its like a random thing, unless I don't identify the issue, which, according to my ENT (DAN recommended) is EDT...but apparently all over the internet no-one had similar symptoms (and this is odd).

 

[Angelo Farina]

Hi Angelo, thanks a lot for your precious contribution.
I read before your discussion about equalisation technique and I was quite interested in having your contribution on my issue. I'll certainly do the course you recommended: I'm already looking for the next slot available.

Before experiencing this problem at the end of 2021, I had already almost 100 recreational dives without any issue at all (different depth, max 35mt) and I had always used Valsalva and NEVER had systemic issues equalising.
Even now, after my issue came up, originally probably due to a badly cured cold, I still never have any issue equalising (I do it frequently, I do it long before experiencing any pain or discomfort): my symptoms arise always after 36 hours minimum after the dive and that's what makes me frustrated. I mean, having pain during the dive is a concrete and real signal that something is off (my technique, a cold, a mouthpiece, whatever) and I can work on it...but with these symptoms is something I can't really work on, its like a random thing, unless I don't identify the issue, which, according to my ENT (DAN recommended) is EDT...but apparently all over the internet no-one had similar symptoms (and this is odd).

In case of my wife, the ORIGIN of the problem was her difficulty to equalise (narrow tubes).
So she did perform a very powerful Valsalva; she was an athlet, with chest muscles far more powerful than mine, and using Valsalva she did equalize succesfully, but often over-extruding her tympanic membranes.
She did never get any mid-ear barothrauma, as she was very concerned of equalising, as you. She did equalise early, often, but TOO MUCH, with excessive pressure.
The result was stretching the external surface of the tympanic membrane. In a couple of cases, this resulted in inflammation and bacterial infection...
Which takes some time to develop.
So the initial difficulties in equalising indirectly caused an external ear problem.
When she finally got rid of the crap Valsalva technique all problems magically disappeared.

I have another episode to report.
In 1983 both I and my wife were following the course for upgrading our national Fipsas instructor certification to international Cmas.
The course was in open water at Lago Maggiore, Arona.
During it, a number of tests were to be passed.
One was swimming down to 15 meters free diving, with the help of a weight of 15 kg during descent.
It was basically a test of quick equalisation of ears and mask.
We both passed the test easily at the first attempt (I was using my native BTV, my wife the recently-learned Marcante-Odaglia, which actually becomes a pure Frenzel while free diving).
Another candidate, coming from Genoa, did fail at the first attempt, as he was not equalising one ear.
At the second attempt he did use Valsalva, forcing very hard for equalising that ear. This worked, he reached the bottom and surfaced without apparent problem and reporting no pain.
After half an hour we had to make another test using the ARO (CC rebreather). When he did descend a couple of meters he had a severe vertigo and was forced to surface.
He was unable to stand up properly, the vertigo did take a lot of time to attenuate.
Suspecting some damage to his ears he was landed and sent to local emergency health facility. There they found that the tympanic membrane of the other ear, the one with no equalisation problem, was ruptured.
It appears that the powerful Valsalva manouvre was performed at such high pressure to open the occluded tube on one side, but exerting too large pressure in the other side.
During the free dive no water entered, as the internal pressure was larger. Instead during the subsequent dive with the ARO some cold water entered the medium ear, causing the vertigo.
Conclusion: the problem caused by Valsalva both to my wife and to this fellow instructor was not being ineffective. Actually, it was very effective. Too much effective...