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.

 

[travisfull]

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...

I understand well whats your point: the valsalva is technically easy (you just need to blow), so apparently easy that people blow too much.

In my personal case, I dont think Im blowing too much, may be, who knows, my blowing can be too much for my eustachian tube.

So, Im gonna take your advise and Im gonna do an equalisation course asap. In the meantime I keep looking for other possible causes.

 

[travisfull]

Hi everyone and Hi @doctormike ! I just wanted to give you a POSITIVE update on my situation:
- after the minor issue faced in august, I had 8 wonderful dives at different depth (between 15 an 36mt) and I did not experience any issue at all.
Following your suggestions I am currently under the following pre-dive routine:
1) Avamys spray - which was strongly recommended by my ENT - once a day for 4-5 days before any dive;
2) ear beer after each dive, thanks @uncfnp for your input.
3) careful compensation during the entire dive and I really try to be mindful of not "blowing" too hard. @Angelo Farina thanks a lot for your input, I took a short compensation free session with free divers from Y40 and "Eseafreediving" it was really really cool. If needed, they can also organise a 4hours workshop during which you learn new compensation method.

Next steps:
- I'll keep this routine in the coming winter months to see what happens with colder water;
- if I'll face other issues I plan to try other possible solutions: (i) Doc's pro plugs; (ii) taking a full compensation course with Eseafreediving in order to fully learn new compensation method.

Thanks again, and if someone in the community is having similar problems, Im more than happy to contribute to the discussion.

 

[Litos]

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 am also suffering the same symptoms as you: after several days diving, and once I take days off -usually by the end of a diving trip-, I experience first itchy ear, followed in 24 h by a serous otitis media. The onset if the first symptoms is usually 36/48 hours after the last dive. Usually starts on one ear and in 12 hours in the other.
Last year the process finished with a ruptured eardrum due to the infection; now I am having the same process after 5 days of diving (I stopped 3 days because a typhoon, but was feeling 100% ok before stopping). I am suspecting that the other eardrum will be rupturing (if it is not yet gone, as I think I can taste the eardrops on the back of my throat). I am under antibiotics by medical prescription, and the doctor diagnosed otitis media in both ears ('oh, my goodness' was the diagnostic, and said she could see liquid and blood in the middle ear), plus external infection in one of the ears.

It is true that my ETs are far from good: as a teenager I had a clinical intervention for pumping out mucus build up in the middle ear by piercing the eardrum. I have unresolved tinnitus, but nothing unbearable. Many times I have liquid in the middle ear for months when I am not diving.

I been diving for more than 10 years and have more than 400 dives. For the last 300+ dives I consider myself very smooth when compensating pressure (with Valsalva technique in a very delicate way and never forcing the ears). Before that i had many otitis following diving, and was prescribed the use of Dacortin and nasal sprays before diving.

For a few years, I had no problem.
Sometimes I have been able to do 40 dives in two weeks diving non stop without any problem afterwards. Notably I had 250 dives over a 4 year period without any remarkable ear problem. I wear hood and, from the last year, vented pro-plugs. I rinse my ears with fresh water after the dive -in the past also mixed with vinegar.

In the last year and a half situation has worsen: after few days of diving, if I stop for a couple of days, ears start to show the described symptoms. This seems to be the pattern in the last year and a half, following the 4 year period without any major problem.

As an analytical mind, the situation is troubling me since I don't know what's exactly happening and how to fix it. I think that there is combination of two problems, the first of them promoting the second:

1.- poor pressure compensation in the middle ear, causing lessions with limited effusion. In my first 50 dives compensating was always a problem; now I think I am doing it very well, but perhaps is just a perception. While diving I don't notice it since the effusion is limited, and going to depth and out forces the liquid out of the ear. It is interesting that i don't get the clogged ear sensation while diving or in the hours following the dive. I insist: if there is a middle ear barotrauma, I am just not able to notice it.
Once on land, the effusion is kept and, together with not-the-best-in-class ETs, this results on a serous otitis media.
An ENT also suggested the possibility of me pumping seawater on the middle ear when performing the frequent valsalva maneuver -I don't know if it is possible.

2.- I am prone to ear infection. Probably stressed eardrum is also helping the onset of the infection. As I am more experienced diver, dives tend now to be longer, which is not good for this issue.

Diving is my favourite hobby. And this includes going to remote places and spending hours and hours underwater photographing strange creatures. While being in the Philippines in a hammock has also some attractive points, the travel is just not the same if I cannot dive.

(Written from a hammock in Romblon, enjoying my three week diving trip transformed into 5 day diving trip)

 

[travisfull]

I am also suffering the same symptoms as you: after several days diving, and once I take days off -usually by the end of a diving trip-, I experience first itchy ear, followed in 24 h by a serous otitis media. The onset if the first symptoms is usually 36/48 hours after the last dive. Usually starts on one ear and in 12 hours in the other.
Last year the process finished with a ruptured eardrum due to the infection; now I am having the same process after 5 days of diving (I stopped 3 days because a typhoon, but was feeling 100% ok before stopping). I am suspecting that the other eardrum will be rupturing (if it is not yet gone, as I think I can taste the eardrops on the back of my throat). I am under antibiotics by medical prescription, and the doctor diagnosed otitis media in both ears ('oh, my goodness' was the diagnostic, and said she could see liquid and blood in the middle ear), plus external infection in one of the ears.

It is true that my ETs are far from good: as a teenager I had a clinical intervention for pumping out mucus build up in the middle ear by piercing the eardrum. I have unresolved tinnitus, but nothing unbearable. Many times I have liquid in the middle ear for months when I am not diving.

I been diving for more than 10 years and have more than 400 dives. For the last 300+ dives I consider myself very smooth when compensating pressure (with Valsalva technique in a very delicate way and never forcing the ears). Before that i had many otitis following diving, and was prescribed the use of Dacortin and nasal sprays before diving.

For a few years, I had no problem.
Sometimes I have been able to do 40 dives in two weeks diving non stop without any problem afterwards. Notably I had 250 dives over a 4 year period without any remarkable ear problem. I wear hood and, from the last year, vented pro-plugs. I rinse my ears with fresh water after the dive -in the past also mixed with vinegar.

In the last year and a half situation has worsen: after few days of diving, if I stop for a couple of days, ears start to show the described symptoms. This seems to be the pattern in the last year and a half, following the 4 year period without any major problem.

As an analytical mind, the situation is troubling me since I don't know what's exactly happening and how to fix it. I think that there is combination of two problems, the first of them promoting the second:

1.- poor pressure compensation in the middle ear, causing lessions with limited effusion. In my first 50 dives compensating was always a problem; now I think I am doing it very well, but perhaps is just a perception. While diving I don't notice it since the effusion is limited, and going to depth and out forces the liquid out of the ear. It is interesting that i don't get the clogged ear sensation while diving or in the hours following the dive. I insist: if there is a middle ear barotrauma, I am just not able to notice it.
Once on land, the effusion is kept and, together with not-the-best-in-class ETs, this results on a serous otitis media.
An ENT also suggested the possibility of me pumping seawater on the middle ear when performing the frequent valsalva maneuver -I don't know if it is possible.

2.- I am prone to ear infection. Probably stressed eardrum is also helping the onset of the infection. As I am more experienced diver, dives tend now to be longer, which is not good for this issue.

Diving is my favourite hobby. And this includes going to remote places and spending hours and hours underwater photographing strange creatures. While being in the Philippines in a hammock has also some attractive points, the travel is just not the same if I cannot dive.

(Written from a hammock in Romblon, enjoying my three week diving trip transformed into 5 day diving trip)

thanks a lot for your message, and very sorry for the delay. I did not have the notification ON.

I totally understand what are you saying. From what I read, it is probably something either related to external ear infections and also some ETD problems since you have issues compensating.
I don't know if you ever tried the procedures I listed before, but it is working for me, or at least it worked for the last 5 months:
- avamys spray 3-4 days before every dive
- ear beer after each dive
- the first 2-3 metres are KEY for the process: go slowly, compensate very gently and very frequently, don't push it, we don't get paid to go forward.

 

[Litos]

I don't know if you ever tried the procedures I listed before, but it is working for me, or at least it worked for the last 5 months:
- avamys spray 3-4 days before every dive
- ear beer after each dive
- the first 2-3 metres are KEY for the process: go slowly, compensate very gently and very frequently, don't push it, we don't get paid to go forward.

Thanks. That is exactly what I used with success for some years and that I will reinstate. My ENT also agrees (well, I'll be using Nasonex instead of Avamys, but i think they are similar).

 

[travisfull]

Thanks. That is exactly what I used with success for some years and that I will reinstate. My ENT also agrees (well, I'll be using Nasonex instead of Avamys, but i think they are similar).

Yes…not everyone was born with highly performing ear system so some of us need a little help and unfortunately as soon as we stop with it the problem comes back…
I know divers who goes straight down as soon as they get in the water with no compensation issue ever and no barotrauma…

So, my non medical advice: just come back to do what you uses to do when you had no issues…and enjoy diving since its basically our real passion in life!

Last advice: I also use Tonimer spray (hypertonic version) which is basically a sterile hypertonic solution of sea water (so no medication) very useful in winter time to prevent middle ear otitis and to loosen the mucus in the eustachian tube.
You can use it on a daily basis