Perilymphatic Fistula

[sundtzu]

I'm looking for a little guidance from one of the docs here...here goes:
5 August, after the second dive of the day I noticed diminished hearing in my left ear. (Last day of a 4 day boat trip out of Sharm el Sheikh). I don't recall having any particular problems clearing on that dive but my left ear is traditionally a little more reluctant to equalize than the right. Quit diving for the rest of the day and went to the local doctor as soon as the boat docked. Doctor noted blood/fluid behind the left eardrum and gave me Flixonase nasal spray and Terra-Cortril eardrops for 4 days. Didn't notice any improvement so I went to the Embassy doctor in Cairo who gave me Genasal spray for 4 days. Still no improvement so referred to Audiologist and ENT here in Cairo (now 13 days after initial problem). Audiologist says tympanic function normal on both sides but a moderate sensorineural hearing loss on the left. ENT suspects 'perilymphatic fistula' , has me taking 20mg prednisone 3x/day, 1g augmentin 2x/day and 30mg Lanzor 1x/day at bedtime and also wants me on total bed rest for 2 weeks (no flying/diving/driving/heavy lifting, etc.). Meanwhile, the Embassy doc has consulted with the military specialists in Germany (I'm an Army pilot) who want me to fly up there in 4 days to be seen. Finally, the question: Should I get on the plane as scheduled or ask to be treated locally for a couple weeks before flying up there? Local doc seems pretty adamantly opposed to it but the military doc's don't seem to think I can do any additional damage after what will be 17 days following the initial problem. I'd appreciate any input the experts here can give me with the full understanding that it does not constitute 'medical advice'. Thanks!

 

[pulpoloco]

Hi Sundtzu, I was searching for threads on PLFs and found yours. How has your recovery been over the past six months? How's your hearing? Did you require surgery? Have you been back diving?

I have been suffering a profound hearing loss in my right ear and currently mild vertigo for two weeks. After a peaceful shore dive with no NDL violations, a nice slow ascent and long safety stop, I was relaxing with my buddy. I took off my wetsuit, dried off, and started walking toward the car to put some stuff away when vertigo put me flat on the ground. I never had any pain during or after the dive. My ears equalized normally, and many tests since of middle ear, eustachian tube and tympanic membrane function have been perfectly normal. A Table 6 and two subsequent recompressions had no effect. I have had blood work, 2 fistula tests, EKG, CAT scan, MRI and three audiograms which have thus far not produced a definitive diagnosis. Perilymph fistula is the primary suspect, but the only way to be sure is to incise the ear drum and look inside. Even then there is only a 50% or so probability it will be seen.

All my research seems to say surgery for a PLF is quite controversial. When to do it is a big question. Success rates aren't real impressive. I'd like to hear from you as to how your recovery went. I would also hope to hear from others with PLFs as to what they did and what their results were.

Thanks, Pulpoloco


QUOTE=sundtzu]I'm looking for a little guidance from one of the docs here...here goes:
5 August, after the second dive of the day I noticed diminished hearing in my left ear. (Last day of a 4 day boat trip out of Sharm el Sheikh). I don't recall having any particular problems clearing on that dive but my left ear is traditionally a little more reluctant to equalize than the right. Quit diving for the rest of the day and went to the local doctor as soon as the boat docked. Doctor noted blood/fluid behind the left eardrum and gave me Flixonase nasal spray and Terra-Cortril eardrops for 4 days. Didn't notice any improvement so I went to the Embassy doctor in Cairo who gave me Genasal spray for 4 days. Still no improvement so referred to Audiologist and ENT here in Cairo (now 13 days after initial problem). Audiologist says tympanic function normal on both sides but a moderate sensorineural hearing loss on the left. ENT suspects 'perilymphatic fistula' , has me taking 20mg prednisone 3x/day, 1g augmentin 2x/day and 30mg Lanzor 1x/day at bedtime and also wants me on total bed rest for 2 weeks (no flying/diving/driving/heavy lifting, etc.). Meanwhile, the Embassy doc has consulted with the military specialists in Germany (I'm an Army pilot) who want me to fly up there in 4 days to be seen. Finally, the question: Should I get on the plane as scheduled or ask to be treated locally for a couple weeks before flying up there? Local doc seems pretty adamantly opposed to it but the military doc's don't seem to think I can do any additional damage after what will be 17 days following the initial problem. I'd appreciate any input the experts here can give me with the full understanding that it does not constitute 'medical advice'. Thanks![/QUOTE]

 

[Laurence Stein DDS]

I'm looking for a little guidance from one of the docs here...here goes:
5 August, after the second dive of the day I noticed diminished hearing in my left ear. (Last day of a 4 day boat trip out of Sharm el Sheikh). I don't recall having any particular problems clearing on that dive but my left ear is traditionally a little more reluctant to equalize than the right. Quit diving for the rest of the day and went to the local doctor as soon as the boat docked. Doctor noted blood/fluid behind the left eardrum and gave me Flixonase nasal spray and Terra-Cortril eardrops for 4 days. Didn't notice any improvement so I went to the Embassy doctor in Cairo who gave me Genasal spray for 4 days. Still no improvement so referred to Audiologist and ENT here in Cairo (now 13 days after initial problem). Audiologist says tympanic function normal on both sides but a moderate sensorineural hearing loss on the left. ENT suspects 'perilymphatic fistula' , has me taking 20mg prednisone 3x/day, 1g augmentin 2x/day and 30mg Lanzor 1x/day at bedtime and also wants me on total bed rest for 2 weeks (no flying/diving/driving/heavy lifting, etc.). Meanwhile, the Embassy doc has consulted with the military specialists in Germany (I'm an Army pilot) who want me to fly up there in 4 days to be seen. Finally, the question: Should I get on the plane as scheduled or ask to be treated locally for a couple weeks before flying up there? Local doc seems pretty adamantly opposed to it but the military doc's don't seem to think I can do any additional damage after what will be 17 days following the initial problem. I'd appreciate any input the experts here can give me with the full understanding that it does not constitute 'medical advice'. Thanks!

Hi Sundtzu,

I'm not one of the Docs you might want to hear from but here goes.

For those reading this thread, a perilymphatic fistula is the leakage of perilymph (the fluid that fills the inner ear) into the middle ear through a tear in either the round or oval window. The contents of the inner ear are encased in bone. Sounds are directed through the external ear canal to the ear drum. Here, the ear drum vibrates and mechanically moves a series of bones which transmits and amplify the sound vibrations. The final bone, the stapes rests on the oval window and transmits these vibrations into the inner ear to be received by the nerve endings within the cochlea.

As the oval window is depressed or lifted by the movement of the stapes, the round window moves in and out sympathetically with the movement of the round window.

Generally, a perilymph fistula is the result of improper equilization technique. If a fistula developes, there is usually sudden vertigo, variable loss of hearing and tinnitus (ringing in the ears). You don't necessarily have to use "too much pressure" like you are having difficulty clearing your ears.

When a fistula occurs, there is a sudden movement of perilymph fluid. The fluid movement is sufficient to break some of the little hairs responsible for sensing particular sound frequencies. Hearing loss for any given frequency of sound is associated with the breakage to the hair(s) that are responsible for sensing that frequency.

These hairs do not regenerate so hearing loss is permanent.

The vertigo is usually temporary since no physical damage has to occur to the semicircular canals. Once the loss of perilymph stops, the vertigo will usually subside.

There is no guarantee that the fistula will spontaneously heal so it is imperative that you see an ENT for evaluation and treatment.

Since we are born with only two ears and damage to the hearing apparatus is usually permanent, the general advice will be to discontinue diving permanently. If you continue diving and another injury occurs to the "good" ear, then you really have some sensory problems.

Hopefully, some of the other Docs will chime in on this.

Good luck.

Laurence Stein, DDS

 

[sundtzu]

I had the surgery last Sept...got a small amount of hearing back. The doc said he didn't see anything overt but patched the oval and round windows anyway. One issue I had that I wasn't warned about was that half of my tongue was numb for about 3 months afterward; I guess the nerve that supplies half of the tongue is routed right around the eardrum and is easily bruised or damaged during the procedure. Still have some tinnitus that comes and goes. It's hard to say if I got any real benefit from having the surgery but if I had to do it over again I'd probably do the same thing. I'm done with diving though...don't want to risk the good ear!

Good luck,
Sundtzu

Hi Sundtzu, I was searching for threads on PLFs and found yours. How has your recovery been over the past six months? How's your hearing? Did you require surgery? Have you been back diving?

I have been suffering a profound hearing loss in my right ear and currently mild vertigo for two weeks. After a peaceful shore dive with no NDL violations, a nice slow ascent and long safety stop, I was relaxing with my buddy. I took off my wetsuit, dried off, and started walking toward the car to put some stuff away when vertigo put me flat on the ground. I never had any pain during or after the dive. My ears equalized normally, and many tests since of middle ear, eustachian tube and tympanic membrane function have been perfectly normal. A Table 6 and two subsequent recompressions had no effect. I have had blood work, 2 fistula tests, EKG, CAT scan, MRI and three audiograms which have thus far not produced a definitive diagnosis. Perilymph fistula is the primary suspect, but the only way to be sure is to incise the ear drum and look inside. Even then there is only a 50% or so probability it will be seen.

All my research seems to say surgery for a PLF is quite controversial. When to do it is a big question. Success rates aren't real impressive. I'd like to hear from you as to how your recovery went. I would also hope to hear from others with PLFs as to what they did and what their results were.

Thanks, Pulpoloco

 

[Laurence Stein DDS]

I had the surgery last Sept...got a small amount of hearing back. The doc said he didn't see anything overt but patched the oval and round windows anyway. One issue I had that I wasn't warned about was that half of my tongue was numb for about 3 months afterward; I guess the nerve that supplies half of the tongue is routed right around the eardrum and is easily bruised or damaged during the procedure. Still have some tinnitus that comes and goes. It's hard to say if I got any real benefit from having the surgery but if I had to do it over again I'd probably do the same thing. I'm done with diving though...don't want to risk the good ear!

Ain't nature mysterious!? A portion of the 7 cranial nerve (Facial Nerve) crosses the face of the tympanic membrane (eardrum). This is called the corda tympani and supplies a portion of the tongue. Most of the tongue is innervated by branches of the 5th cranial nerve (Trigeminal Nerve). The Facial Nerve is the one we associate with Bell's Palsy...drooping of the face. Why it take two different, seemingly unrelated nerves to innervate the tongue and to have that specific branch actually cross the eardrum is mysterious.

Larry Stein, DDS

 

[pulpoloco]

I had the surgery last Sept...got a small amount of hearing back. The doc said he didn't see anything overt but patched the oval and round windows anyway. One issue I had that I wasn't warned about was that half of my tongue was numb for about 3 months afterward; I guess the nerve that supplies half of the tongue is routed right around the eardrum and is easily bruised or damaged during the procedure. Still have some tinnitus that comes and goes. It's hard to say if I got any real benefit from having the surgery but if I had to do it over again I'd probably do the same thing. I'm done with diving though...don't want to risk the good ear!

Good luck,
Sundtzu

Hi Sundtzu, I was searching for threads on PLFs and found yours. How has your recovery been over the past six months? How's your hearing? Did you require surgery? Have you been back diving?

I have been suffering a profound hearing loss in my right ear and currently mild vertigo for two weeks. After a peaceful shore dive with no NDL violations, a nice slow ascent and long safety stop, I was relaxing with my buddy. I took off my wetsuit, dried off, and started walking toward the car to put some stuff away when vertigo put me flat on the ground. I never had any pain during or after the dive. My ears equalized normally, and many tests since of middle ear, eustachian tube and tympanic membrane function have been perfectly normal. A Table 6 and two subsequent recompressions had no effect. I have had blood work, 2 fistula tests, EKG, CAT scan, MRI and three audiograms which have thus far not produced a definitive diagnosis. Perilymph fistula is the primary suspect, but the only way to be sure is to incise the ear drum and look inside. Even then there is only a 50% or so probability it will be seen.

All my research seems to say surgery for a PLF is quite controversial. When to do it is a big question. Success rates aren't real impressive. I'd like to hear from you as to how your recovery went. I would also hope to hear from others with PLFs as to what they did and what their results were.

Thanks, Pulpoloco

Thanks Sundtzu and Larry,

Sundtzu, From your post it implies your numbness went away. Is that the case? Also, did you initially have any disequilibrium problems? I'm very hesitant to give up diving because of this, and am committed to teaching an OW class Mar 12-13 (pool) and first OW dives would be the 2nd of April. Assuming no problems , I would then quit teaching OW, thereby elliminating the many ascents and descents, and thereby greatly reduing my risk to further injury. I still have not been convinced that potential gain from surgery is greater than the risk. Hope others will respond. Thanks, Pulpoloco

 

[sundtzu]

Numbness is almost completely gone...now I have a sensation of residual 'flavor' on that side, kind of like i've just finished a breath mint or something. I never had any equilibrium problems either at the time of the injury or following the surgery.

Best Wishes,
Sundtzu

I had the surgery last Sept...got a small amount of hearing back. The doc said he didn't see anything overt but patched the oval and round windows anyway. One issue I had that I wasn't warned about was that half of my tongue was numb for about 3 months afterward; I guess the nerve that supplies half of the tongue is routed right around the eardrum and is easily bruised or damaged during the procedure. Still have some tinnitus that comes and goes. It's hard to say if I got any real benefit from having the surgery but if I had to do it over again I'd probably do the same thing. I'm done with diving though...don't want to risk the good ear!

Good luck,
Sundtzu



Thanks Sundtzu and Larry,

Sundtzu, From your post it implies your numbness went away. Is that the case? Also, did you initially have any disequilibrium problems? I'm very hesitant to give up diving because of this, and am committed to teaching an OW class Mar 12-13 (pool) and first OW dives would be the 2nd of April. Assuming no problems , I would then quit teaching OW, thereby elliminating the many ascents and descents, and thereby greatly reduing my risk to further injury. I still have not been convinced that potential gain from surgery is greater than the risk. Hope others will respond. Thanks, Pulpoloco

 

[djfirelt]

Hi,
I read your post, I had the same situation Dec 13, I did three dives to 60 ft No problem clearing, Woke up the next day tried to get out of bed and fell on my face. Dizzyness continued for several weekes even after having every test in the book done. I suffered a 90% hearing loss in the left ear. I got about 70% back after prednisone and antibiotics, But was still dizzy. My Ent refered me to an Out of town Neurotoligist in Tampa florida. After several test he suspected a plf and scheduled me for inner ear surgery. He repaired my oval window and patched my round window. Two weeks after surgery my dizzyness was finally gone. As of today I still have a 20% hearing loss and tinnitus this is five weeks post surgey. My Doc says I will have to learn to live with the tinnitus and will not get any more hearing back. He has cleared me to finally return to work as a fireman on April 10th and says I can return to diving with minimal risk after that.

Would love to hear What your results are
Good luck
Robert

Hi Sundtzu, I was searching for threads on PLFs and found yours. How has your recovery been over the past six months? How's your hearing? Did you require surgery? Have you been back diving?

I have been suffering a profound hearing loss in my right ear and currently mild vertigo for two weeks. After a peaceful shore dive with no NDL violations, a nice slow ascent and long safety stop, I was relaxing with my buddy. I took off my wetsuit, dried off, and started walking toward the car to put some stuff away when vertigo put me flat on the ground. I never had any pain during or after the dive. My ears equalized normally, and many tests since of middle ear, eustachian tube and tympanic membrane function have been perfectly normal. A Table 6 and two subsequent recompressions had no effect. I have had blood work, 2 fistula tests, EKG, CAT scan, MRI and three audiograms which have thus far not produced a definitive diagnosis. Perilymph fistula is the primary suspect, but the only way to be sure is to incise the ear drum and look inside. Even then there is only a 50% or so probability it will be seen.

All my research seems to say surgery for a PLF is quite controversial. When to do it is a big question. Success rates aren't real impressive. I'd like to hear from you as to how your recovery went. I would also hope to hear from others with PLFs as to what they did and what their results were.

Thanks, Pulpoloco


QUOTE=sundtzu]I'm looking for a little guidance from one of the docs here...here goes:
5 August, after the second dive of the day I noticed diminished hearing in my left ear. (Last day of a 4 day boat trip out of Sharm el Sheikh). I don't recall having any particular problems clearing on that dive but my left ear is traditionally a little more reluctant to equalize than the right. Quit diving for the rest of the day and went to the local doctor as soon as the boat docked. Doctor noted blood/fluid behind the left eardrum and gave me Flixonase nasal spray and Terra-Cortril eardrops for 4 days. Didn't notice any improvement so I went to the Embassy doctor in Cairo who gave me Genasal spray for 4 days. Still no improvement so referred to Audiologist and ENT here in Cairo (now 13 days after initial problem). Audiologist says tympanic function normal on both sides but a moderate sensorineural hearing loss on the left. ENT suspects 'perilymphatic fistula' , has me taking 20mg prednisone 3x/day, 1g augmentin 2x/day and 30mg Lanzor 1x/day at bedtime and also wants me on total bed rest for 2 weeks (no flying/diving/driving/heavy lifting, etc.). Meanwhile, the Embassy doc has consulted with the military specialists in Germany (I'm an Army pilot) who want me to fly up there in 4 days to be seen. Finally, the question: Should I get on the plane as scheduled or ask to be treated locally for a couple weeks before flying up there? Local doc seems pretty adamantly opposed to it but the military doc's don't seem to think I can do any additional damage after what will be 17 days following the initial problem. I'd appreciate any input the experts here can give me with the full understanding that it does not constitute 'medical advice'. Thanks!

[/QUOTE]

 

[sundtzu]

Well, I'm about 5 months post-surgery and about 6 months post-incident. Still no dizziness but about 50 Db hearing loss in the lower frequencies remains in the affected ear. Tinnitus comes and goes, seems to be worse if I'm exposed to higher ambient noise levels for an extended period. The tongue thing has mostly resolved itself but seems to be more noticeable when the tinnitus is acting up (go figure). I suspect I would have had a better outcome if I had been referred to a specialist much earlier, as it was I didn't see one until about two weeks after the injury so didn't start appropriate treatment until then. About the only thing I could have done at the time may have been to get on oxygen as soon as I noticed a problem...some of the literature recommends Carbogen (95% Oxygen/5% CO2) therapy early on (first 24-48 hours) and the 02 couldn't have hurt.
Still can't get out of the habit of putting the phone up to the bad side though. Just enough left to hear the hollering and remember to switch to the good side!

Good luck,
Sundtzu

Hi,
I read your post, I had the same situation Dec 13, I did three dives to 60 ft No problem clearing, Woke up the next day tried to get out of bed and fell on my face. Dizzyness continued for several weekes even after having every test in the book done. I suffered a 90% hearing loss in the left ear. I got about 70% back after prednisone and antibiotics, But was still dizzy. My Ent refered me to an Out of town Neurotoligist in Tampa florida. After several test he suspected a plf and scheduled me for inner ear surgery. He repaired my oval window and patched my round window. Two weeks after surgery my dizzyness was finally gone. As of today I still have a 20% hearing loss and tinnitus this is five weeks post surgey. My Doc says I will have to learn to live with the tinnitus and will not get any more hearing back. He has cleared me to finally return to work as a fireman on April 10th and says I can return to diving with minimal risk after that.

Would love to hear What your results are
Good luck
Robert

[/QUOTE]

 

[pulpoloco]

Thanks Robert,
Did they do an ENG (elctronystagmography)? If so, were the results positive for the fistula? Or, as I suspect, were all the tests "ambiguous?" That's a term I have come to hate! Did they just go ahead with exploratory surgery to see if you had a plf? When they opened up your ear, did they actually see the plf, or did they not see it and assume it was there and patch it? It looks like your results were about as good as one could hope for. I'm glad the surgery was so successful. My ENG (2/14/05) apparently did not show a plf, but I can't get in to see the neurotologist (whose clinic did the ENG) until 3/11. The waiting is killin' me! Although the dizziness has improved to the point where I feel safe driving again, there is no change in the hearing and tinnitus. Since none of the tests have shown a plf, I've decided to go ahead with OW pool sessions I had scheduled for 3/5-6 and 3/12-13. Equalizing isn't now, nor has it ever been, a problem. It would be nice to have a clear diagnosis though. Thanks, again for your input. Pulpoloco

Hi,
I read your post, I had the same situation Dec 13, I did three dives to 60 ft No problem clearing, Woke up the next day tried to get out of bed and fell on my face. Dizzyness continued for several weekes even after having every test in the book done. I suffered a 90% hearing loss in the left ear. I got about 70% back after prednisone and antibiotics, But was still dizzy. My Ent refered me to an Out of town Neurotoligist in Tampa florida. After several test he suspected a plf and scheduled me for inner ear surgery. He repaired my oval window and patched my round window. Two weeks after surgery my dizzyness was finally gone. As of today I still have a 20% hearing loss and tinnitus this is five weeks post surgey. My Doc says I will have to learn to live with the tinnitus and will not get any more hearing back. He has cleared me to finally return to work as a fireman on April 10th and says I can return to diving with minimal risk after that.

Would love to hear What your results are
Good luck
Robert

[/QUOTE]