Permanent ETD following Reverse Block

[alfkristian]

Hey!

TL;DR:
Lasting ETD after reverse block. Air won't escape eustachian tube on ASCENT. Descent works fine. Problems arises on all flights, dives (which I've stopped) and trips to above ~1000m above water. Have experienced ruptured air drum, and facial baroparesis one time each. Now I'm functionally grounded at water levels, and depressed.

I have a lasting problem that occurred after a reverse block on a very shallow free dive about 5 years ago. I was cruising a 6 meter deep beach area for about 30 min. After ascending the last time, air did not escape, and the pain forced me to descend again. I tried a couple of times with no resolution, and gave up. Medium amounts of pain and muffled hearing in right ear stayed with me for several days.

Fast forward to today. Problem still exists, albeit only on ascent in an air plane. After a few more test dives the year after, I gave up diving all together. Now, every time I fly, I get increasing pressure and pain in right ear on ascent. Sometimes the air finally releases/pops (most long flights). Sometimes it persists during the whole flight (short flights), only to relieve itself on descent.

On two occasions it became horrible. Once, my eardrum ruptured. Sounded like a gun was fired in my head, but the relief overshadowed the pain. Last time i flew, I got facial baroparesis on the right side. My gf thought I was having a stroke. Now I don't dare to fly anymore.

I've visited 4 ear specialist doctors (ENT?) over the years. All but the last of them claim that air escapes automatically on ascent, and that I'm misunderstanding anatomy (seriously). One invited me to remove water from the middle ear through the airdrum, but changed his mind on the operation day due to not seing enough "water mirror" (translated from norwegian).

The last one is now actually taking me seriously. He is sending me to a CT, and considering a balloon-inflation treatment for the eustachian tube. We've tried a nasal spray daily for 6 months, but it doesn't help. I still have to insist every time I talk to him, that the problem is ON ASCENT. Descent is fine, swallowing or valsalva "refills" the middle ear.

I've read that one can have nasal polyps on the entrance to the eustachian tube middle ear side. I'm also a bit worried about tumors...

Anyone here have experience or knowledge or could help?

I can't fly, I can't go over 1000m to the cabin or a mountain trip, I can't dive, and ENTs are not impressing me

Sincerely,
AK

 

[Duke Dive Medicine]

Hi alfkristian,

It sounds like you're doing everything that anyone here would recommend you do. I hope the balloon tuboplasty works for you.

Best regards,
DDM

 

[alfkristian]

Thanks, Duke, glad to hear. I wish there were more answers out there, as my experience of the problem is that it occured after one incident, and then predictably persisted ever since. I only have some medical/biological training, but to me that describes the etiology of a distinct issue.

However the issue of being able to increase pressure/"fill up" the middle ear with air with i.e. valsalva, while having problems with excess air/pressure not releasing by itself seems kind of rare. My reasoning is that the problem then subsides somewhere around the opening to the Eustachian tube on the middle ear side, not the mouth-side. None of the doctors have examined the middle ear-opening to the Eustachian tube, as that demands an incision or imaging. They all look through the nose, and state that nothing is wrong. However, mechanically, if there is something acting as a "lid" on the opening, it should be in the middle ear.

I read one old article last year about a medical group treating ETD with professionals (divers/pilots/astronauts), which found that one of the few who had a similar issue as me, actually had a polyp on the middle ear opening to the Eustachian tube. Sadly, I can't seem to find the article again before my next follow up.

If anyone else know anything about this, please reach out.

alfkristian

 

[Duke Dive Medicine]

Hi Alfkristian,

Persistent reverse block of the middle ear is unusual. The Eustachian tube goes through bone at the point closest to the middle ear and through soft tissue at the point closest to the nasopharynx, so anatomically speaking it's much easier for air to exit the middle ear than to enter. @doctormike would be the guy to answer questions about polyps but yes, there's almost certainly something acting as a one-way valve. I hope they're able to find a cause.

Best regards,
DDM

 

[alfkristian]

Thanks again, I'm really glad to hear that you think it's reasonably to assume that something is acting as a one-way valve. I'm very curious as to what this may be, but the most frustrating thing is how hard it has been to convince ENT-specialists about this.

I would assume it's also possible that the "valve" could be inside the Eustachian tube too. I understand it makes an angle, at least in adults? Also, there couldve been some kind of collapse in the structure following the initial incident? In case it's due to some sort of change inside the Eustachian tube, I'm guessing balloon dilatation might help, but if it's a polyp somewhere else, it probably wouldn't.

Let's hope @doctormike maybe has the opportunity to share of his wisdom

-alfkristian

 

[Duke Dive Medicine]

Thanks again, I'm really glad to hear that you think it's reasonably to assume that something is acting as a one-way valve. I'm very curious as to what this may be, but the most frustrating thing is how hard it has been to convince ENT-specialists about this.

I would assume it's also possible that the "valve" could be inside the Eustachian tube too. I understand it makes an angle, at least in adults? Also, there couldve been some kind of collapse in the structure following the initial incident? In case it's due to some sort of change inside the Eustachian tube, I'm guessing balloon dilatation might help, but if it's a polyp somewhere else, it probably wouldn't.

Let's hope @doctormike maybe has the opportunity to share of his wisdom

-alfkristian

The Eustachian tube is pretty straight. In children the bones are less developed and it's more fleshy toward the middle ear, which is why kids typically have more middle ear issues than adults. I'm square in @doctormike's territory now so he may have additional information.

Best regards,
DDM

 

[doctormike]

I think that people in general have unrealistic expectations about the utility of an examination in terms of diagnosing the specific problem with ET function. In the vast majority of cases (with a few exceptions, like the one you mentioned), there is no physical thing that you would find, but rather the ET is just "dysfunctional" meaning that it isn't functioning well to either let air in or out of the middle ear cleft. That is why the term is ETD and not ETO (for "obstruction").

At this point, it sounds like imaging (CT scan) would be helpful to rule out the remote possibility of a physical anomaly causing the reverse block. It is unlikely that even by doing a middle ear exploration (surgery to peel up the eardrum and look at the region leading to the ET) would reveal anything, if the ears are otherwise clear.

Assuming that the CT is normal, and if the symptoms are still very troublesome to you, and not addressable by these different equalization techniques, then the option of tuboplasty remains. I don't do this (not really a pediatric thing), but remember that (1) this is still something in the experimental stages, (2) there are risks of serious complications (the internal carotid artery runs right next to the ET), and (3) there is no guarantee that this will help. From what I understand, it is primarily done for patients with chronic ET obstruction from conditions like radiation therapy to the skull base with scarring and stenosis.

 

[Duke Dive Medicine]

That's good info about tuboplasty, thanks Mike!

 

[alfkristian]

Thank you very much, that was very helpful information.

I just did the CT, and am waiting for the result. It's sad, cause it's effortless to gently push air into the middle air, but everytime I go to a place with lower pressure (mountain, plane), air does not release. After having half my face paralyzed, I'm a bit apprehensive about flying :/

Fingers crossed!

 

[doctormike]

Keep us posted! Good luck...