perilymph fistula

[Agent 52]

Hello from the beautiful state of Washington~

For the past couple of months I have been having issues with my right ear. When diving I have no problems clearing my ears and my dives are just fine, but a day or so after a dive my ear becomes completely plugged up, hearing loss, ringing in my head and just total discomfort. I went to EN&T doctor and he has advised I have perilymph fistula and have injured my right inner ear. I am taking a Steroid treatment now for a 14 day course, once done will have another hearing test and go from there. My BIG concern and worry is that I am going to be told I can no longer dive. Diving is my passion and I just can't imagine no longer doing it. I have only been out of the water for one week now and am already going crazy. So can anyone advise if they have had this before, what kind of treatment did they have, surgery? and the most important question to me were you able to continue diving?

 

[DocVikingo]

This should get you started --> ScubaBoard - Search Results

Regards,

DocVikingo

 

[doctormike]

Hello from the beautiful state of Washington~

For the past couple of months I have been having issues with my right ear. When diving I have no problems clearing my ears and my dives are just fine, but a day or so after a dive my ear becomes completely plugged up, hearing loss, ringing in my head and just total discomfort. I went to EN&T doctor and he has advised I have perilymph fistula and have injured my right inner ear. I am taking a Steroid treatment now for a 14 day course, once done will have another hearing test and go from there. My BIG concern and worry is that I am going to be told I can no longer dive. Diving is my passion and I just can't imagine no longer doing it. I have only been out of the water for one week now and am already going crazy. So can anyone advise if they have had this before, what kind of treatment did they have, surgery? and the most important question to me were you able to continue diving?

Hi, Agent 52...!

Perilymph fistula is a rare and somewhat controversial diagnosis. Often, the diagnosis cannot be made without surgical exploration of the ear, and even then there is sometimes uncertainty.

There have been a number of threads about this question, you could read this, this, or this to start.

While I can't make a specific recommendation over the Internet, if you want a second opinion and if you PM me with your location, I may be able to give you a local referral.

Best,

Mike

 

[Cruisin Home]

Did your ENT prescribe and perform a CT scan? Particularly while you are symptomatic? Should be done in my opinion.

Piece of advice, it's coming on winter, take a break from diving and give your ear a real chance to heal and membrane damage whter t omiddle or inner ear. Then see how it goes in spring with very conservative equalization techniques.

 

[doctormike]

Did your ENT prescribe and perform a CT scan? Particularly while you are symptomatic? Should be done in my opinion.

While it is true that a relatively large bony defect in the otic capsule will show up on a CT scan, this is a rare cause of perilymph fistula. These are occasionally congenital or related to the presence of cholesteatoma.

Perilymph fistula is either spontaneous or related to significant barotrauma (usually something like weightlifting which causes a spike in cerebrospinal fluid and inner ear fluid pressure). Spontaneous perilymph fistula is, as mentioned above, a controversial diagnosis even at surgery, since the actual leak is often too small to be seen even under the operating microscope.

While CT scan is not typically helpful in the case of PLF, I do agree with Crusin Home that a scan would be useful in the setting of a new onset nerve (AKA sensorineural, as opposed to conductive) hearing loss. I'm assuming that is what is being discussed here, if the diagnosis of PLF was given. The choice of CT vs. MRI would depend on what diagnosis was suspected - there are some new onset types of nerve hearing loss which are better evaluated by MRI (not to get into that whole field!).

However, if you get a CT to look for an abnormality in the bony capsule of the inner ear, it would not be necessary to get it while you were symptomatic, as the CT appearance would not change during active leakage of inner ear fluid (assuming that you were not using contrast injected directly into the cerebrospinal fluid, which is not typically done for PLF).

Piece of advice, it's coming on winter, take a break from diving and give your ear a real chance to heal and membrane damage whter t omiddle or inner ear. Then see how it goes in spring with very conservative equalization techniques.

It is always tempting to give advice in these forums, and I know that Cruisin is trying to be helpful here. However, I am careful to limit my comments to general discussions of these conditions and local specialists referrals only. We should not advise someone to dive when we really do not know what is going on. If Agent 52 actually has a PLF, then diving would be contraindicated. While I can't tell (and wouldn't try to guess) what the actual diagnosis is over the Internet, I would leave any recommendations to dive or not up to Agent's local doc...

 

[Cruisin Home]

While it is true that a relatively large bony defect in the otic capsule will show up on a CT scan, this is a rare cause of perilymph fistula. These are occasionally congenital or related to the presence of cholesteatoma.

Perilymph fistula is either spontaneous or related to significant barotrauma (usually something like weightlifting which causes a spike in cerebrospinal fluid and inner ear fluid pressure). Spontaneous perilymph fistula is, as mentioned above, a controversial diagnosis even at surgery, since the actual leak is often too small to be seen even under the operating microscope.

While CT scan is not typically helpful in the case of PLF, I do agree with Crusin Home that a scan would be useful in the setting of a new onset nerve (AKA sensorineural, as opposed to conductive) hearing loss. I'm assuming that is what is being discussed here, if the diagnosis of PLF was given. The choice of CT vs. MRI would depend on what diagnosis was suspected - there are some new onset types of nerve hearing loss which are better evaluated by MRI (not to get into that whole field!).

However, if you get a CT to look for an abnormality in the bony capsule of the inner ear, it would not be necessary to get it while you were symptomatic, as the CT appearance would not change during active leakage of inner ear fluid (assuming that you were not using contrast injected directly into the cerebrospinal fluid, which is not typically done for PLF).




It is always tempting to give advice in these forums, and I know that Cruisin is trying to be helpful here. However, I am careful to limit my comments to general discussions of these conditions and local specialists referrals only. We should not advise someone to dive when we really do not know what is going on. If Agent 52 actually has a PLF, then diving would be contraindicated. While I can't tell (and wouldn't try to guess) what the actual diagnosis is over the Internet, I would leave any recommendations to dive or not up to Agent's local doc...

Thanks Doc Mike but I do feel people need advice , its why they are reaching out and their clinicians are most cases not giving them the answers and they dont know what to ask for. I am not advocating self treatment, I am just trying to eduucate them on what to ask. For the type of snsoneural hearing loss and vertigo that this man suggests I do think it is very wise to perform CT . cholelsteomas are seen and diag with CT. As far as a PLF, well that is wat a lot of diagnosticians would call a Zebra. Best to look for horses before you go chasing zebras. I am always surprised sometimes that some people take this course without first checking obvious.

I would save MRI as a second option. But also a PLF would suggest a wait and heal, or surgical intervention. One would always want to suggest the first course before one tried the latter. However this course of treatment is not always practiced by all, evidence being spine patients that go to instrumented surgeries because they pay large $$$$.

I always fling out the imaging question because I am surprised at how many people don't recieve it.

I did recommend while he was symptomatic.

 

[doctormike]

Thanks Doc Mike but I do feel people need advice , its why they are reaching out and their clinicians are most cases not giving them the answers and they dont know what to ask for. I am not advocating self treatment, I am just trying to eduucate them on what to ask.

Well, that's true... that's why I'm here as well. And it is good of you to share your experience and expertise! Thanks...

However, I will point out that you did suggest that Agent return to diving, unless I read that wrong. I think that is not something that we should be doing over an Internet forum in someone who potentially has a PLF, since there is the possibility of irreversible damage.

For the type of snsoneural hearing loss and vertigo that this man suggests I do think it is very wise to perform CT . cholelsteomas are seen and diag with CT. As far as a PLF, well that is wat a lot of diagnosticians would call a Zebra. Best to look for horses before you go chasing zebras. I am always surprised sometimes that some people take this course without first checking obvious.

Again, the devil is in the details. Cholesteatoma is not diagnosed with a CT, it is diagnosed by examining the ear. A CT is usually obtained to determine the extent of the lesion before surgery. And while a PLF is rare, you can't really say if it is a "zebra" without knowing the details of the case. If Agent had a new onset of a unilateral (one sided) sensorineural hearing loss immediately after diving with no suspicion of inner ear DCI by the dive profile, then I would say that a PLF would be pretty high on my list of diagnoses. The other thing that might cause a new onset one sided sensorineural hearing loss in an adult - an acoustic neuroma - would be a fairly slow presentation compared to a sudden change during or after a dive.

I would save MRI as a second option. But also a PLF would suggest a wait and heal, or surgical intervention. One would always want to suggest the first course before one tried the latter. However this course of treatment is not always practiced by all, evidence being spine patients that go to instrumented surgeries because they pay large $$$$.

Oh, Cruisin..! So cynical... (although you may be right)

While I can't speak for everyone, and while I am not an otologist, in the face of deteriorating hearing (again, with a sensorneural hearing loss), many surgeons would not wait to operate. With a true acquired PLF and a leakage of perilymph, time could be of the essence, and your final results might be much better with early surgery.

MRI and CT in otology are usually for different things. MRI is for soft tissue lesions like an acoustic neuroma, CT is better when you need fine bony detail (e.g. looking at the middle ear bones, PLF, cholesteatoma).

 

[Cruisin Home]

Hi, Agent 52...!

Perilymph fistula is a rare and somewhat controversial diagnosis.
Mike

To quote you Doc Mike, PLF is a rare and controversial. I call that a Zebra. maybe you call it a horse i dont know. I think we both know that each other knows the ins/outs of what CT and MRI can and cannot do in ENT imaging.

I think we are almost in violent agreement. But also we have both drifted from the Poster's question. I go back, he is very concerned on the course of treatment, and also whether he will ever dive again. Given the "rare and controversial" nature I think our advice is that he is on somewhat unknown ground. One cannot even be certain of his diagnosis, nevermind his future prognosis. Seems like only time will tell.

I'm am often surprised (getting to be not surprised) at how many people are given improper DX without proper workup. Just this week scanned a friend of mine that has been suffering sinus/headache issues for several years. His doctor had put him on numerous courses of medicine and treatment for all this time assuming that it is sinusitis. Never got a CT. What did I find? A very large and serious benign Osteoma, occupying almost his entire frontal sinus and soon to invade orbit and brain. No other evidence of sinus disease. And this is Boston, not the sticks.

So thats why i always ask.

 

[doctormike]

I think we are almost in violent agreement. But also we have both drifted from the Poster's question. I go back, he is very concerned on the course of treatment, and also whether he will ever dive again. Given the "rare and controversial" nature I think our advice is that he is on somewhat unknown ground. One cannot even be certain of his diagnosis, nevermind his future prognosis. Seems like only time will tell.

Yup, I have been doing these sorts of online "consults" for a long time...!

I'm always wary of being too specific over the Internet, too many unknowns. But I think that our comments here can be helpful by giving people good background information, and an understanding of what to ask their doctor (as you pointed out regarding imaging).

I'm am often surprised (getting to be not surprised) at how many people are given improper DX without proper workup. Just this week scanned a friend of mine that has been suffering sinus/headache issues for several years. His doctor had put him on numerous courses of medicine and treatment for all this time assuming that it is sinusitis. Never got a CT. What did I find? A very large and serious benign Osteoma, occupying almost his entire frontal sinus and soon to invade orbit and brain. No other evidence of sinus disease. And this is Boston, not the sticks.

So thats why i always ask.

Wow, good pickup...!

Yup, I agree... sometimes there is no substitute for imaging! Although lately I have been substituting sonogram for CT in evaluating inflammatory and/or presumed cystic neck masses in infants and small children (try to avoid radiation when possible). And modern CT scans are so quick that we often don't need anesthesia for kids who are a bit squirmy.

Thanks!

Mike

 

[Agent 52]

Thanks for sharing your thoughts.

Do you think I should request some kind of imaging to be done?

oh and by the way I am a women not a man.....