Mystery ear pain

[sonofzell]

Wow, I've been offline for a few days with the holiday and storm cleanup... I can't tell you all how grateful I am for the responses and information.

I intend to reach out to our pediatrician this week (apparently, my daughter's exam was performed by a physician that is new to the practice, and not one of the core providers we've been seeing for the past 20 years). I don't mean to imply any incompetence, rather that I feel one of our "regular" docs would have been much more elaborate on the indication and intended usage of the Cipordex. My presumption is that they are intended to be used prophylactically prior to diving, but I'm certainly not going to put her back in the water until I have more clarity on her condition and strategy.

The suggestions here are helpful, not to mention adding "earbeer" to my vocabulary lol. I think what I find most intriguing about this is the fact that, prior to our most recent dive outing, my daughter had never reported any issues or discomfort with her ears (during OR post-dive). Granted, 9 dives isn't exactly a lengthy experience base, but nonetheless, it just seems like there was some physiological change that occurred between her last successful dive (September 2020) and the recently failed one (July 2021).

For what it's worth, she flew again this past Saturday (without having used the Cipordex drops) and reported the same discomfort in her left ear. I advised her (prior to reading these replies) to use the drops as indicated (qd); she swam yesterday after using drops on Saturday & Sunday, and reported that her ears felt "better" in that there was no pain, but that she felt unusual "pressure". Keep in mind this was simply free-swimming to 8'. Her return flight is later this afternoon, so I'm curious to see if she notices any difference.

Rest assured, regardless of what she reports I will not have her attempt to dive again until I have a clear consent/strategy from a physician. If I'm unable to obtain that from our pediatrician I'll arrange for a more comprehensive consultation with an ENT specialist.

EDIT: "NOT have her attempt to dive again..."

 

[sonofzell]

Inflammation from middle ear barotrauma is notoriously slow to resolve. Unfortunately, her second attempt to descend in the quarry and her attempts to equalize in the swimming pool in Florida probably re-traumatized the area. I would recommend she wait several weeks before even attempting to clear her ears again.

Duly noted, and thank you! While I have no reason to doubt that she may have some barotrauma, I'm genuinely curious as to what potential etiology would be associated with it.

I know you can't comment about my daughter's case specifically, but in general, what type of events could cause barotrauma in a teenage girl that (prior to the failed dive) had not flown, dove, or experienced any other obvious rapid changes in atmospheric pressure? Would it be possible that such trauma could be caused by inflammation caused by allergies or infection for which other symptoms may not have been noticed?

 

[uncfnp]

This is our doctormike. Not surprisingly it is well written and covers many of the ear problems encountered by divers. The review of ear anatomy alone makes it worth reading and helps clarify the different issues and treatments needed for each part of the ear, outer, middle and inner ear.

Ear Problems in Scuba Diving

 

[Duke Dive Medicine]

Would it be possible that such trauma could be caused by inflammation caused by allergies or infection for which other symptoms may not have been noticed?

It absolutely could be possible. It's also possible that she got behind on her equalizing and by the time she got to 15 feet had suffered mild barotrauma, which then led to inflammation that cascaded with repeated trauma.

Best regards,
DDM

 

[dmaziuk]

It absolutely could be possible. It's also possible that she got behind on her equalizing and by the time she got to 15 feet had suffered mild barotrauma, which then led to inflammation that cascaded with repeated trauma.

FWIW more often than not my swimmers ear is the same feeling (of swollen/tender lymph node in the neck) that I sometimes get from toothache or flu.

 

[Duke Dive Medicine]

FWIW more often than not my swimmers ear is the same feeling (of swollen/tender lymph node in the neck) that I sometimes get from toothache or flu.

That sounds unpleasant. For the general readership, swimmer's ear is an infection of the lining of the external ear canal and is a different thing than middle ear barotrauma, which is an injury to the middle ear caused by pressure differential.

Best regards,
DDM

 

[doctormike]

The steroid will help with pain and inflammation from barotrauma, too, .

This is not correct

 

[doctormike]

Wow! Missed the thread (I was diving!), but as usual, @Duke Dive Medicine will give you great advice.

Thanks, @uncfnp for posting my article!

Basically:

1) Outer ear infections and middle ear barotrauma are completely different things, that are treated differently. From the OP's description, this sounds more like barotrauma than swimmer's ear.

2) Drops have no effect on barotrauma, and should not be used to prevent problems with equalization.

3) The exam (by a primary care doc or even an ENT doc) almost never demonstrates a physical finding that can be fixed to improve equalization.

4) For the vast majority of people who have equalization problems in diving, it's a technique issue. This is what I give out to my patients: Prevention of Middle Ear Barotrauma

5) Diving with a significant upper respiratory tract infection can result in poor Eustachian tube function, and problems equalizing even if this was successful at other times. Allergies are less strongly associted with ET dysfunction.

5) In VERY rare cases, there may be functional problems with the ET that interfere with diving despite optimal technique. There is early evidence of the efficacy of ET dilation for adult divers, but it's hardly standard therapy, and I would be cautious about considering that...

 

[sonofzell]

Again, I'm beyond grateful for everyone's input. Based on everything I've learned, my takeaways from this experience are:

1. Even if aided by some pre-existing inflammation, the root cause of my daughter's [presumed] barotrauma was likely a delayed or improper equalization on her first dive.

2. Repeated attempts to return to depth, both in the quarry and subsequently in the pool were foolish and likely increased the severity of any barotrauma (as well as prolonged the necessary recovery time).

3. Based on the presentation of her injury & symptoms, as well as lack of any previous ear issues, there is no clear indication for the use of any otic drops or other medication.

4. There seems to be no recommended treatment for her injury other than the prevention of further pressure until it has healed.

Everything makes sense, however, one thing I'm still unclear about is how to assess her recovery. I understand that it may take a long time for her to completely heal, and I certainly won't rush her to get back in the water. That being said, when the time does come for the next attempted dive, what (if any) methods are recommended for ensuring that she will be safe/comfortable? How long of a hiatus is sufficient for us to begin planning for another dive without worrying if she'll experience the same pain (and to a lesser importance, wasting the time/money on preparing for dive only to abort it)?

Thanks again!

 

[Duke Dive Medicine]

Again, I'm beyond grateful for everyone's input. Based on everything I've learned, my takeaways from this experience are:

1. Even if aided by some pre-existing inflammation, the root cause of my daughter's [presumed] barotrauma was likely a delayed or improper equalization on her first dive.

2. Repeated attempts to return to depth, both in the quarry and subsequently in the pool were foolish and likely increased the severity of any barotrauma (as well as prolonged the necessary recovery time).

3. Based on the presentation of her injury & symptoms, as well as lack of any previous ear issues, there is no clear indication for the use of any otic drops or other medication.

4. There seems to be no recommended treatment for her injury other than the prevention of further pressure until it has healed.

Everything makes sense, however, one thing I'm still unclear about is how to assess her recovery. I understand that it may take a long time for her to completely heal, and I certainly won't rush her to get back in the water. That being said, when the time does come for the next attempted dive, what (if any) methods are recommended for ensuring that she will be safe/comfortable? How long of a hiatus is sufficient for us to begin planning for another dive without worrying if she'll experience the same pain (and to a lesser importance, wasting the time/money on preparing for dive only to abort it)?

Thanks again!

I would not use the word foolish. This is a sports injury just like any other. Self-flagellation is counterproductive. Learn instead

Re assessing recovery, I'd give it several weeks before even attempting to equalize again. After that, she can try a gentle Valsalva and see if she can get her ears to clear. Again, do not force it as that can result in serious injury. If her ears clear, it would be reasonable to try a slow descent in the water. It's harder to equalize on a breath-hold in a pool, but if she can manage to do that without forcing it and without pain, and provided she has no other medical contraindications, she could try diving again.

Best regards,
DDM