Middle Ear Barotrauma, was it delayed?

[parksb2]

So I have done pool dives only in the pool thus far, Scheduled to do the final certification dives July 5/6. On Wed Jun 18 ~ 7pm EST did a dozen shallow 12' dives equalized fine every time; or so I believed. I suffer no congestion or other health problems. On Friday morning I woke up with my right ear ringing, by noon i had definite pain in my right ear and booked a clinic for 5 pm. By the time I made the clinic @5pm I had an ear that was painful to touch and a feeling of fullness with some hearing loss. The doc said my right ear was very red, and evidence of a bulge in the drum, with my eustachian tube clear and the left ear was perfect? The doc put me on 500mg Amoxcillin 3x per day, recommended I take Ibuprofen, Naproxen Sulfate or Tylenol NSAID's were best, along with Benadryl. He also advised I may expect the eardrum to possibly rupture whereupon they would simply patch it up. So it's late Sunday afternoon and the feeling of "fullness" has greatly subsided, and my hearing is near normal with no bleeding having occurred.

Thought I would share this as I read that novices in the pool is the largest population of barotrauma sufferers are similar to myself nearly 25 to 30% of all newbies, and maybe someone else would benefit from this story. I wonder how many newbies won't admit they made a mistake or aren't even aware they have made one, getting off lucky... In the future I am going to be more careful and regular in equalizing!

Common Ear Injuries While Diving ? DAN | Divers Alert Network ? Medical Dive Article

I thought I was equalizing OK, but on reflection I may have been a bit forceful on one. I had NO immediate symptoms but do recall a slight "squeaking noise" on an equalization near the bottom. Sounds like <punny> I am headed back to normal hearing in short order which is good.

 

[parksb2]

So it's almost a full week now, On Mon/Tues I have some pretty bad dizziness and fairly severe hearing loss in the right ear. To compare I put a 30dB rated earplug in my left and the sound muffling was similar. The ringing in the left has been very constant. For today Thurs, I have felt mildly off kilter, I seem to want to lean left and the ringing is constant but there is some recovery in the "muffled" hearing. Since I'm in Canada and better still Ontario I get to see a GP tomorrow to check me out. I have caught up on all my paperwork for the foreseeable future and got a fair bit of planning in so with time on my hands I did a bit more googling on the topic and low and behold DAN has an excellent video which filled a lot of gaps in for me, wish I had found it first. Armchair doctors are suggesting failure to equalize to swimmers ear, either way I need to correct this ! Looking forward to a full recovery.

The link to the DAN video
[h=1]Ears and Sinuses: Barotrauma for the Dive Professional[/h]
https://www.youtube.com/watch?v=I6sB8K3sATg

 

[lowviz]

I'm on an overlong SI due to an ear problem. Same basic story, failure to listen to what your body is telling you, and most importantly, WHEN it is telling you.

I got exactly the same regimen, Amoxicillin 500 mg x3 for ten days. On day seven I got classic allergic symptoms, bigtime. Doc just said to stop the antibiotic and remember than I'm now allergic. All good now.

Bottom line, go slowly. No part of your dive should be a race. I used to only focus on the ascent. My diving has just become a lot more 'holistic'...

 

[TSandM]

I suspect your original presentation was pure barotrauma, and that the antibiotics were actually unnecessary. I was amazed, when I started learning about this, to realize that the appearance of the tympanic membrane (eardrum) in barotrauma is almost precisely the same as that of a bacterial infection, but bacterial infections of the middle ear are relatively rare in adults. Presenting as quickly as you did after diving, barotrauma is almost certainly the diagnosis, and antibiotics didn't help.

The balance issues and persistent hearing loss are quite worrisome, because, especially persisting more than a week after the dives, they may portend injury to the inner ear. This is more serious and more difficult to heal. I understand you are consulting with a GP, but you should ask quite firmly for a referral to an ENT doc, preferably one with some awareness of the issues of diving. You need hearing testing to evaluate conductive and sensorineural hearing loss, as well as an assessment of your balance. Dr. Mike, who is our resident ENT specialist here on ScubaBoard, may have some more advice for you -- I would suggest you PM him.

 

[parksb2]

I suspect your original presentation was pure barotrauma, and that the antibiotics were actually unnecessary. I was amazed, when I started learning about this, to realize that the appearance of the tympanic membrane (eardrum) in barotrauma is almost precisely the same as that of a bacterial infection, but bacterial infections of the middle ear are relatively rare in adults. Presenting as quickly as you did after diving, barotrauma is almost certainly the diagnosis, and antibiotics didn't help.

The balance issues and persistent hearing loss are quite worrisome, because, especially persisting more than a week after the dives, they may portend injury to the inner ear. This is more serious and more difficult to heal. I understand you are consulting with a GP, but you should ask quite firmly for a referral to an ENT doc, preferably one with some awareness of the issues of diving. You need hearing testing to evaluate conductive and sensorineural hearing loss, as well as an assessment of your balance. Dr. Mike, who is our resident ENT specialist here on ScubaBoard, may have some more advice for you -- I would suggest you PM him.

Thanks for your response, I have no idea if it was initially barotrauma or not, but wonder why it would take ~ 36 hrs to present any symptoms? Maybe it was a mild/moderate barotrauma and I didn't notice till I caught a swimmers ear infection? I don't know if there is anyway to tell.

On the advice of the nurse practitioner at the GP clinic I double dosed all remaining 500mg Amoxocillin prior to an appt at 11:30 today. So overnight I developed a "crusty" right eye lots of little yellow/gold nuggets and it was very "scratchy", I had a mild sense of imbalance and the hearing loss was still slightly in excess of 30dB earplug with plenty of ringing, my right lower rear skull was in headache overdrive and I had a mild headache isolated behind my right eye. This is Ontario where Dr's typically are trained to affix toe tags and fill out death certificates...

but my local GP has a great rep, she examined both ears and said, eardrum is intact and you definitely have fluid trapped behind the eardrum. Take Cefprozil 500mg 3x per day because you're a big lad (~220lbs) and an ENT would do just the same, keep me in the loop if it gets worse/stays static we'll get you to an ENT....

I left with a scrip and mixed thoughts. Popped the first cefprozil at about 1pm with lunch and the second at about 7:30 with dinner... As of right now I have mild ringing in the right ear, and the hearing is MUCH better not quiet normal I would guess 50% better than it was at noon, my sense of balance is normal, the right eye however is still "scratchy" but much less so. I'll post again when I have more/less clarity on what exactly happened.

The real takeaway is equalize, if you dont' it can wreck your week or more.

 

[doctormike]

It's really hard to say this without sounding arrogant, and I don't mean to come off that way. However, in 20 years of practice I have come to realize that the ear is a black box, with VERY few non-ENT doctors really able to accurately diagnose middle ear pathology. The few who can are usually pediatricians. I am NOT saying that your GP or NP aren't terrific clinicians, but I really can't comment specifically on what your injury is without an exam, etc... Please read my article, it will help you understand some of the following points better.

1) The most common ear diving injury is barotrauma, due to poor equalization. I have not heard of symptoms presenting after 36 hours, so not sure if this was just a coincidental ear problem that happened afterwards. Hard to say over the Internet. I guess that would depend on the sequence of events.

2) Barotrauma involves the accumulation of blood or fluid in the middle ear, and a "conductive" hearing loss. The ear should not appear red, and there is no role for antibiotics in the treatment of middle ear barotrauma. In fact, if someone tells me that the ear looks red, then I assume that they don't have an accurate diagnosis. Barotrauma should look dull or dark, acute otitis media (very rare in adults) should be yellow and bulging.

3) Swimmer's ear (otitis externa) is a skin infection of the outer ear canal. It has absolutely nothing to do with middle ear barotrauma, apart from the fact that they both cause ear pain. They are distinguished by an accurate diagnosis by looking in the ear. Also, middle ear barotrauma shouldn't cause the ear to be painful to the touch, that's more common in swimmer's ear.

4) An audiogram (hearing test) is the best way of distinguishing a conductive from a sensorineural hearing loss (SNHL). SNHL is much less common in dive injuries, generally from inner ear DCI or a leak in the inner ear fluids (perilymph fistula). This is a critical difference. Dizziness and ringing can be associated with either barotrauma or an inner ear injury, again, you need an audiogram to sort this out.

5) I agree, don't forget to equalize early and often..!

Good luck, glad to hear that you are feeling better... Feel free to PM with specifics as they develop..



Mike

 

[parksb2]

Dr. Mike, wish you were closer to Ontario.. The 5 points are particularly enlightening to me.

So in the wonderful world of Ontario.. I warpped up the Cefprozil last Sunday and my hearing improved dramatically, I saw my GP on Monday July 7 and said I had some hearing loss in the right ear, was advised to see an audiologist and if the ear show hearing loss, perhaps an ENT would be in order..... and told to clean my ears with .25% vinegar solution every couple days. I went for an audiogram on Wed July 9 and my right ear has 5-10dB loss in the mid/low range frequencies and 20dB loss in higher frequencies. The right ear has a constant mild ringing/tinnitus which seems to vary in intensity and may explain the loss in higher frequency(?). My left ear unknowing to me has 40-50dB loss in High frequencies, something that was likely preexisting and I was unaware of..

My enthusiasm for Ontario free health care is dwindling as my GP has gone on vacay now and I can't get her covering to see me...

Any suggestions on internet diagnosis? I am tempted to grab my wallet and try to see someone in Michigan as it would be closest?

 

[doctormike]

Dr. Mike, wish you were closer to Ontario.. The 5 points are particularly enlightening to me.

So in the wonderful world of Ontario.. I warpped up the Cefprozil last Sunday and my hearing improved dramatically, I saw my GP on Monday July 7 and said I had some hearing loss in the right ear, was advised to see an audiologist and if the ear show hearing loss, perhaps an ENT would be in order..... and told to clean my ears with .25% vinegar solution every couple days. I went for an audiogram on Wed July 9 and my right ear has 5-10dB loss in the mid/low range frequencies and 20dB loss in higher frequencies. The right ear has a constant mild ringing/tinnitus which seems to vary in intensity and may explain the loss in higher frequency(?). My left ear unknowing to me has 40-50dB loss in High frequencies, something that was likely preexisting and I was unaware of..

My enthusiasm for Ontario free health care is dwindling as my GP has gone on vacay now and I can't get her covering to see me...

Any suggestions on internet diagnosis? I am tempted to grab my wallet and try to see someone in Michigan as it would be closest?

The devil is in the details. Conductive or sensorineural hearing loss? What did the tympanometry show? Do you have your audiogram? If you want to scan it and post it, I may be able to help you read it (but of course, I can't really give you management advice over the Internet).

Mike

 

[parksb2]

The devil is in the details. Conductive or sensorineural hearing loss? What did the tympanometry show? Do you have your audiogram? If you want to scan it and post it, I may be able to help you read it (but of course, I can't really give you management advice over the Internet).

Mike

Thanks Dr Mike, attached.

 

[doctormike]

Interesting - the mixed loss is uncommon (conductive and sensorineural), but I guess if you had a pre-existing hearing loss that might explain it! Do you have a report of the tympanometry and canal volumes (that is usually done as part of the hearing test).

Hopefully, the conductive component will improves as your middle ear ventilation returns to normal. Can't tell about the presence or absence of a perforation by the audiogram alone without temps and canal volumes, but I suppose if they are advising you to rinse your ear with vinegar the eardrum must be intact!

Good luck,

Mike