Perilymph Fistula and FLYING on a commercial plane - I am stranded on an Island

[dowmartens]

Hey ScubaBoard.com folks - Long time listener, first time poster. I won't go into all the details, but I was recently diagnosed with a PLF directly related to diving. I do a lot of deeper bounce dives for work and upon surfacing after the 6th bounce dive (all done by computer, proper ascents, safety stops, etc), I had loss of hearing in tinnitus. At first, it was thought to be due to wax impaction, which was removed and I was cleared to go diving from a GP doc. Three days later - vertigo underwater and ringing again...etc.

The first visit to the ENT doc did not show any obvious signs of PLF other than my description of what happened, intermitent tinnitus, and minor decrease in high frequency from the hearing test in my affected ear. Originally, we decided to use the "wait and see" approach but three weeks later I started having dizzy spells at my desk accompanied by nausea, etc. These dizzy spells were often accompanied by headaches and more frequent headaches not associated with dizziness often appeared.

I returned to the ENT doc yesterday and he went to look in my ear and put a little puff of air and WHOA! I almost fell out of the chair. That ENT doc consulted with the only other ENT doc where I live (they work out of the same office). My new ENT is familiar with dive medicine and has a good amount of experience.

My question is this: I live on St. Thomas, USVI. Both doctors highly recommended having PLF surgery, but are also willing to do a barrage of tests before doing so to rule out other things, which I am already scheduled for. The ENT, because of my circumstances, description, and reaction to a puff of air, are VERY confident that I have a PLF. They also STRONGLY advised me not to get on a plane until at least 2 weeks after surgery due to potential serious and irreversible damage to my ear.

So- should I get a second opinion (or third in this case)? Can I fly with a PLF to go to the States to get the other opinion? Does anyone have experience with flying with a PLF?

I have perused the internet and found a lot of mixed results from "I've been flying with a PLF for years" to "you should NEVER fly with a PLF".

Any advice would be greatly appreciated. Or, if there is another thread on this specific subject of FLYING with a PLF, please redirect, as I could not find one.

Thanks in advance for any comments or advice.

 

[DocVikingo]

Hi dowmartens,

I'll open by saying that otology is not a specialty area of mine, but I do know a fair piece about diving medicine in general and it's my impression that PLF is a complicated & somewhat controversial issue and that one doesn't arrive at a "solid" diagnosis of PLF simply by otoscopic & tympanometric examination in the office. I believe that surgical exploration is the gold standard for establishing this condition. In any event, I personally would not allow any surgical procedure to be performed on my inner ear until a confident diagnosis was made and, if I decided to go ahead, I wouldn't have it done in the USVIs; I'd go to a recognized mainland specialty clinic.

I'm asking our resident diving ENT, “doctormike”, to respond to your inquiry. In the meantime, I strongly recommend holding off on any invasive repairs.

BTW, is return home by water a possibility?

Best of luck.

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

 

[flots am]

My question is this: I live on St. Thomas, USVI. Both doctors highly recommended having PLF surgery, but are also willing to do a barrage of tests before doing so to rule out other things, which I am already scheduled for. The ENT, because of my circumstances, description, and reaction to a puff of air, are VERY confident that I have a PLF. They also STRONGLY advised me not to get on a plane until at least 2 weeks after surgery due to potential serious and irreversible damage to my ear.

Pick up a cruise ship. They're run St. Thomas <-> Miami and FLL all the time.

You'll have to call the cruise line to setup the tickets, but it's a very civilized way to travel and I guarantee that you'll never be much more than ~100' above sea level.

flots.

 

[DocVikingo]

Pick up a cruise ship. They're run St. Thomas <-> Miami and FLL all the time.flots.

I don't know much about cruising, but trying to make a one-way booking could be a problem and, in any event I very much doubt that St. Thomas is a recognized port of embarkation.

If you try, please let us know how it works.

Regards,

DocVikingo

 

[dowmartens]

Thank you all for the information so far. I will let you know if jumping on a cruise ship is a viable option. I look forward to hearing from doctormike as I have already read most of the fistula posts that he has been involved in.

 

[Duke Dive Medicine]

Hi downmartens, what exactly led to your diagnosis? Your statement about recurrent vertigo and tinnitus underwater is suggestive of inner ear barotrauma, but given your immediate history of deep bounce dives I'm wondering how inner ear DCS was ruled out.

The treatment for suspected perilymph fistula is strict bed rest and stool softeners (to prevent straining) for the first 24-36 hours. If the symptoms haven't improved or resolved by then, we advise surgery. It's possible to have inner ear barotrauma without a fistula, but if you do indeed have a PLF, then flying would be highly inadvisable due to the potential for aggravating the injury during pressure changes.

Best regards,
DDM

 

[flots am]

Thank you all for the information so far. I will let you know if jumping on a cruise ship is a viable option. I look forward to hearing from doctormike as I have already read most of the fistula posts that he has been involved in.

The last time I checked, they would do it, but you had to pay for the whole cruise.

flots

 

[doctormike]

I'll open by saying that otology is not a specialty area of mine, but I do know a fair piece about diving medicine in general and it's my impression that PLF is a complicated & somewhat controversial issue and that one doesn't arrive at a "solid" diagnosis of PLF simply by otoscopic & tympanometric examination in the office. I believe that surgical exploration is the gold standard for establishing this condition.

I totally agree &#8230; !

If you have read my previous posts about this, you will probably recall that there are two types of PLFs - spontaneous and traumatic. The traumatic type are associated with external head trauma or barotrauma (as might be seen with a diving injury, with acute symptoms on ascent or descent), and there may or may not be a pre-existing anomaly in the temporal bone to make one more susceptible to this problem. The spontaneous type are fairly controversial (i.e. "do you believe in the fistula fairy?"). In either case, the diagnosis is made at surgery, and treated by packing the area off where inner ear fluid is leaking into the middle ear. The fact that the OP noted symptoms acutely after a dive suggests barotrauma.

On the other hand, the fact that it was the sixth deep bounce dive of the day means that inner ear DCS is also a possibility, as DDM pointed out. Going against that theory is that the symptoms recurred when you went diving again after they had improved (you would think that the reverse would be true with DCS, is that correct?).

How far out are you from this injury? DDM, would a chamber ride or evaluation by a hyperbaric doc at this point make any sense?

I really don't know who is available in the USVI to do ear surgery, but I wouldn't necessarily rule that out ahead of time - there are some good, well trained docs there (I actually spoke with one recently about a patient of mine who lives there). You might ask them how many of these they have done, where they trained in otology, etc&#8230; The operation is not a very technically demanding procedure, but it should be done by someone with good ear surgery training.

It's very hard to assess results - if the hearing doesn't improve, you can always say that it would have been worse without the repair. If it gets worse, you can say that it would have been lost completely! It's hard to do real science about these, since you would need a lot of PLFs and patients willing to be randomized to different treatment arms - not gonna happen.

dowmartens, I'm assuming that the audiogram showed a sensorineural hearing loss (as opposed to conductive) and that the tympanogram was normal (i.e. no fluid in the middle ear)&#8230;? What tests are you scheduled for? CT scan? Balance testing?

As far as travel, there is not a huge pressure swing in modern commercial aircraft, but if you truly had a PLF or inner ear DCS, surface transportation would probably be preferable (again, not much hard data here). The main medical tradeoff there would be the spike in your serum cholesterol due to the midnight buffet&#8230;





Keep us posted, and feel free to let me know more about the docs that you have seen, by PM if you prefer.

Best,

Mike

 

[Duke Dive Medicine]

How far out are you from this injury? DDM, would a chamber ride or evaluation by a hyperbaric doc at this point make any sense?

He may have already been evaluated for DCS... there isn't much detail in his initial post. It sounds more like barotrauma but I wanted to ask the question to make sure. At any rate, if it is actually DCS (unlikely though it appears to be) recompression at this point would probably be of little benefit.

 

[dowmartens]

Here is the story (long one) The last time I went diving was on August 7th.
I was diving on August 3rd doing some bounce dives for work (see profiles below). I did dives (in succession) or 62', 56', and 45' on Nitrox 29%. All three dives were 5-7 minutes long (total dive time). I then had a one hour surface interval and did three more dives to 60', 116', and 102'. Dives were 6mins, 12mins, and 11mins long. All diving is done off of VR3 computers.

We did a safety stop on each of the last three dives (3mins 15'). No problems were present underwater. When I returned to the boat, I immediately noticed that my right ear had extremely reduced hearing, not much pain, but there was ringing.

I did not dive again that day, but had reduced hearing and ringing all day. No headache or other problems. The next morning after not sleeping because of the ringing I called DAN and they advised me to go see a doctor. I saw a general doc and he noted there was a very large chunk of impacted wax in my right ear. He flushed the ear with warm water and my hearing was immediately restored, but the ringing persisted. He looked in my ears and said I was fine and the ringing should go away either immediately or soon. If not, I should return. I was also supposed to do more diving the following day, and he cleared me to dive.

I did more diving from Aug 5 - Aug 7, without incident until the last dive on August 7. I descended to 58' and when I cleared the final time, I immediately got vertigo underwater. My buddy was working and did not notice that I kneeled on the bottom to get my bearings. Shortly after, my buddy noticed I signaled something was wrong and we ascended. The whole dive took 4 minutes. We did an abbreviated safety stop (1 minute) because we had only done 3 other bounce dives, all to shallower depths (24', 44', 47') previously. I could not look around underwater because I would get vertigo, so I simply focused on my computer which seemed to help.

Upon exiting the water, I noticed ringing in my ears again (it had been intermittant and decreasing over the past two days). I have not had my head in the water since.

I saw another GP doctor who looked in my ear, said my ear canal was abnormally small and that there appeared to be more fluid than normal behind by ear drum. She referred me to an ENT, as she mentioned she was not a specialist.
After relating all of this to ENT, he said I had given him the textbook definition and situation of a perilymphatic fistula. The audiologist at that time did a nystagmus test while pressurizing each ear and did not observe any nystagmus. I also had a hearing test and only in my damaged ear (right) was a slight decrease at the 8K frequency range.

ENT told me that fistulas may heal by itself, sometimes it requires surgery. At that time, from Aug 7-Aug 20th (when I saw first saw the ENT) I did not have any vertigo. We decided to wait 4-6 weeks and see how I felt.
Over the last week and a half of so, I started having fairly minor symptoms of vertigo sitting at my desk. Sometimes lasting 20 minutes, other times it is 2 minutes. I have felt nausea and close to vomiting a few times, but that hasn't happened yet. Most of the time, these onsets are accompanied by headache. I have had some dull headaches and some more severe ones but nothing like the "worst of my life". But they have seemed more frequent.

Over the last few days, my episodes of vertigo have seemed more severe but not necessarily longer in duration. I also experienced occasional tinnitus in the opposite ear from the damaged one. I have also noticed a bit of soreness in my ear, but not like an outer ear infection, more like "inside". I notice it more when I move my jaw, but it is not all the time.

So I went back to the ENT yesterday because I was supposed to fly next Thursday to go home and I didn't know if I should. ENT put the ear scope in my ear and before he could even puff some air, I had a monster vertigo attack and told him to stop because I thought I was going to pass out. I also became flush and felt sick to my stomach.

At this time, he consulted with the other ENT who came in, listened to my story and suggested that under no circumstances should I fly, and that he advised exploratory surgery to patch my round and oval window with ear fat. He advised it would be 2 weeks at least before I could fly and 2 months or more before I dive again.

I am just trying to get some other opinions as to whether or not I should get the surgery, can fly, or dive again.

If you stuck it through all of this I really appreciate any thoughts you can give and I will go from there.

I am supposed to undergo a Videonystagmography on Tuesday on my own request. ENT was fairly comfortable with the fistula diagnosis and said I don't need to do these tests, but I don't want a surgery that I don't need if there is something else going on.

Last bit on info that may be important. I have always Valsalva cleared early and often, but ENT told me that this procedure is not a good idea any more. I have never had a problem clearing and I still don't right now and I do not get dizzy if I do, however, I am refraining from this from now on.

Dive Profiles and INFO
	Date	Depth (ft)	Time IN	Dive Time	Time OUT	Surface Interval	GAS
	8/3/2012	62'	10:02	00:05	10:07	00:13	29%
	8/3/2012	56'	10:20	00:06	10:26	00:09	29%
	8/3/2012	45'	10:35	00:06	10:41	00:57	29%
	8/3/2012	60'	11:38	00:06	11:44	00:16	29%
	8/3/2012	116'	12:00	00:12	12:12	00:09	29%
	8/3/2012	102'	12:21	00:11	12:32		29%
						12:47
	8/5/2012	57'	12:47	00:11	12:58	00:22	AIR
	8/5/2012	12'	13:20	00:30	13:50	01:27	AIR
	8/5/2012	27'	15:17	00:30	15:47		AIR
						08:44
	8/6/2012	45'	08:44	00:16	09:00	05:08	AIR
	8/6/2012	30'	14:08	00:27	14:35	00:03	AIR
	8/6/2012	30'	14:38	00:06	14:44		AIR
						11:00
	8/7/2012	30'	11:00	00:01	11:01	00:06	AIR
	8/7/2012	26'	11:07	00:02	11:09	00:13	AIR
	8/7/2012	33'	11:22	00:03	11:25	00:15	AIR
	8/7/2012	58'	11:40	00:24	12:04	03:02	AIR
	8/7/2012	24'	15:06	00:01	15:07	00:02	AIR
	8/7/2012	44'	15:09	00:02	15:11	00:06	AIR
	8/7/2012	47'	15:17	00:03	15:20	00:10	AIR
	8/7/2012	58'	15:30	00:04	15:34		AIR

As before, any friendly thoughts or advice are appreciated.