Possible inner ear barotrauma/ possibly due to Valsalva maneuver

[Okidiver1369]

Hello, thanks for letting me join your chat, first let me say that I’m really impressed with how giving folks are with their time and expertise in answering and following along with questions. I’ve learned a lot through other’s experiences. We are in the middle of a pretty respectable Typhoon here in Okinawa Japan so I have a little bit of time to write this before my computer runs out of juice; sorry this is so long!

BLUF: Had a small ear issue scuba diving that turned into a bigger issue a couple of days later when spearfishing. The ear injury has reduced hearing in my right ear in the higher frequency’s and is the second ear issue I’ve had in that ear. This is after I’ve had a less impactful ear issue in the same a couple of years before. I am seeking diver informed opinions on what might have happened, those that have had similar experiences, and any other possible treatment options I should consider with the ENT.

Background: 41-year-old male with just shy of 50 scuba dives. In the military so decent health, scuba dive and spearfish at least every other weekend (I live in Okinawa Japan so why not?).

Diving medical history:

*Note: Sometimes have a hard time equalizing so Valsalva maneuver that sometime causes a squeal like a small animal getting murdered underwater. I frequently do it pretty hard without any previous issues (Didn’t realize you can get messed up doing, my mistake)

*2021, Apr-Initial ear injury while snorkeling in ’15 ft. Tried swallowing and popping ears to equalize w/o Valsalva maneuver. Sudden deflating feeling in ear followed by mild tinnitus and muffled hearing. No pain. Visited general medical doctor whom does not observe any visible damage inside the ear. Get appointment with ENT for 3 months later. The doctor theorizes sudden depressurizing of ear which causes impact to cochlear and subsequent damage to the ear nerves resulting in slight neurosensory hearing loss. Advised not to dive for 3 months, which I follow.

*2023

-20 July: Have chest congestion with productive cough but nothing in the sinuses (not smart to dive). Day dive (114’), Night Dive (69’), Slight trouble equalizing slight issues clearing, soft muffled hearing in right ear, don’t think much of it.

-22 July: Have chest congestion with productive cough. Spearfishing to ’18 ft, extreme forced Valsalva maneuver to right side to clear. No issues with dive until after returning to shore: 1) had a bit of what felt like lightheadedness’s and feeling slightly off, 2) Louder more erratic tinnitus, 3) Muffled hearing, frayed in higher frequencies noticeable when a baby crys or when I talk louder, muffled when sorting through ice or crinkling plastic bag

-25 July: Pure tone hearing test shows hearing loss in 3000 and up frequencies (results attached and below). General medical doctor refers me to a ENT. Notes that he sees fluid in the ear, tuning fork test heard in bad ear. *This is later contradicted by ENT whom does not see fluid in the ear the following day.

-26 July: ENT appointment: Dr. checks out ear and doesn’t observe fluid or trauma in ear, eustachian tubes functional. Theorizes that I have an enlarged vestibular aqueduct (EVA) worsened by mild barotrauma. Believes this because this is my second issue and mother had SSHL when she was a child so may be genetically predisposed for hearing issues. Prescribes 14-day prednisone taper. CT scan taken, awaiting results from radiology.

-28 July: Pure tone hearing test from administered by military audio technician show improvement in hearing in mid-level frequency’s and very slight improvement ~5 in higher frequencies (results below).

Date

Left​

​

Right

500

1000

2000

3000

4000

6000

500

1000

2000

3000

4000

6000

10 Apr 23

15M

15M

20M

35M

35M

35M

10M

15M

10M

20M

55M

55M

25 Jul 23

10M

10M

15M

30M

35M

20M

10M

5M

15M

55M

80M

85M

28 Jul 23

10M

5M

0M

25M

25M

35M

10M

0M

5M

30M

75M

80M

*First test taken with an audiologist. Second taken with audio tech, third taken with audio tech and while taking prednisone.



-2 Aug: Currently, taking prednisone and working out (run, bike, surface swim, crossfit type workouts). Slight feeling of being off in the morning with something like very minimal light headiness; balance is fine and no spinning or even dizziness.

Future:

-4 or 7 Aug: Plan to get another pure tone hearing exam with audio technician for in stride assessment, (If this typhoon lets up)

-8 Aug: Last day of 14-day prednisone taper

-14 Aug: Scheduled Audiogram with Audiologist (first appointment available) for audiometery, pure tone, speech test, etc.

~16 Aug: ENT follow up appointment to review audiogram eval and CT scan of effected ear for EVA.

Concerns:

• I understand that the first two weeks to a month is when most gains happen with hearing loss based on my informal research into treatment methods/timelines. Luckly, I was able to get prednisone within 4-6 days after the initial issues. Should I push harder to get to a closer follow-on visit with the ENT for a tympanic steroid injection? In my simple math, more is better.
• Given that I really yarded away at Valsalva maneuver against a possible already irritated inner ear could I possibly have something like perilymph fistula? Should I be concerned with the very slight off feeling in the morning? Should I lay off the working out? My thoughts were that it gives more blood flow to the effected area to aid in healing but that’s my best guess and not based on medical advice.
• What next step should I advocate for if no significant change?
• Anyone been a similar situation? I will of course weigh risks based on follow on assessments. I would imagine that if there is improvement and no genetic or structural issues then 3 months off if I do return to underwater life. It seems that spearfishing and free diving have been a bit tougher on the ear than just diving.

Thank ya’ll so much. Retrospectively a bit cringe worthy on some of the errors I made. I hope this helps other folks as well. Just out here in the far east trying to keep the trade routes open for the American empire and our allies while doing a little diving!



Charlie

 

[Angelo Farina]

I am not a medical doctor, so wait for answers from them.
There are a couple really good at these issues here on SB.
But I am an instructor, so I can comment on the equalising technique.
Valsalva is by far the worst, the most dangerous one, as you did learn.
When you are allowed to dive again, you should learn other methods of equalising.
There are at least half a dozen, just search for them on the Internet (but be aware that most pages are quite partial to just one of them): BTV, Frenzel, Fattah, Toynbee, Lowry, Marcante-Odaglia.
Free diving requires fast equalising, so some technique is more suited to free diving, such as Frenzel and Fattah, the latter specifical for deep free diving. These methods need to close the mouth, so they are unpractical for scuba diving, requiriing two free hands: one for removing the reg from your mouth and the other for pinching your nostrils.
A modified version of Frenzel is Marcante-Odaglia, which is basically a Frenzel with the reg in your mouth, closing it with the tongue.
Other methods suitable for scuba diving and still not involving your lungs are Toynbee and Lowry.
And then there is my favourite one, BTV, developed in France in the eighties. This works well both for free diving and scuba diving, does not create any overpressure or underpressure inside your nasal cavity, does not require to pinch your nose (in fact it is also called "hands free" equalisation) and incorporates automatically mask equalisation.
It is quite difficult to learn, as you must get voluntary and independent control of the small muscles which control epiglottis, soft palate, which open the Eustachian tubes and which control the motion of your pinnae. Often also tongue control is required (it appears that a number of people cannot control these muscles, and this is easily checked asking the student to curve up the tongue in an U-shape or to move their pinnas up and down).
Everyone is built different, so the optimal equalising technique can also be different.
But please, avoid to use Valsalva again.
And wathever technique you use, start opening your tubes at the surface and very often while descending, at least every meter in the first 10m.

 

[Okidiver1369]

Thank you so much for your reply. I had no idea that there were so many options. I’ve watched a couple of YouTube videos on different techniques but always thought the Valsalva method to be the standard. I’ll start doing a little more research into the other techniques.

 

[Duke Dive Medicine]

Concerns:

• I understand that the first two weeks to a month is when most gains happen with hearing loss based on my informal research into treatment methods/timelines. Luckly, I was able to get prednisone within 4-6 days after the initial issues. Should I push harder to get to a closer follow-on visit with the ENT for a tympanic steroid injection? In my simple math, more is better.
• Given that I really yarded away at Valsalva maneuver against a possible already irritated inner ear could I possibly have something like perilymph fistula? Should I be concerned with the very slight off feeling in the morning? Should I lay off the working out? My thoughts were that it gives more blood flow to the effected area to aid in healing but that’s my best guess and not based on medical advice.
• What next step should I advocate for if no significant change?
• Anyone been a similar situation? I will of course weigh risks based on follow on assessments. I would imagine that if there is improvement and no genetic or structural issues then 3 months off if I do return to underwater life. It seems that spearfishing and free diving have been a bit tougher on the ear than just diving.

Thank ya’ll so much. Retrospectively a bit cringe worthy on some of the errors I made. I hope this helps other folks as well. Just out here in the far east trying to keep the trade routes open for the American empire and our allies while doing a little diving!



Charlie

Charlie,

Ditto @Angelo Farina on the Valsalva maneuver - done improperly it can cause serious, permanent ear damage, and Angelo is a passionate crusader for safer equalization methods.

The mechanics of forcing a Valsalva are that once the middle ear forcefully equalizes, the tympanic membrane is forced outward rapidly and beyond its normal range of oscillation. That excessive, rapid outward bowing of the TM is translated directly to the vestibular apparatus (organ of hearing and balance aka the inner ear) via the ossicular chain (malleus, incus, and stapes aka hammer, anvil, and stirrup). This can cause a rupture of part of the vestibular apparatus, the perilymph fistula that you mentioned. Even absent a fistula, the inner ear can still be traumatized and result in the symptoms you described.

The only way to definitively diagnose perilymph fistula is via surgery; if it's seen, it's typically repaired during the same procedure. @doctormike can tell you more about how that's done if you're interested. The rub is that the surgery needs to be done very soon after the injury, i.e. within 24-48 hours, in order to maximize the chance of recovery. Without immediate treatment, the residual symptoms from perilymph fistula tend to be permanent.

The fact that your hearing loss seems to be resolving quickly, your tinnitus is mild, and you had minimal vertigo, is reassuring and suggests that if you did have inner ear barotrauma (which seems likely given your very detailed description), it was probably non-fistulating. There's no imaging (e.g. CT or MRI) that can confirm that though.

In the setting of a perilymph fistula, working out is absolutely contraindicated because it can increase the pressure in the vestibular apparatus. If we suspect PLF in a diver, we put them on strict bed rest with head elevated and start stool softeners so they don't have to strain to have a BM (it's that sensitive) prior to the surgery mentioned above. If PLF is anywhere in the differential diagnosis, I would strongly recommend that you avoid straining of any kind. Even absent a fistula, the "off" feeling that you're having may be mild vertigo brought on by irritation of the affected vestibular apparatus so you would probably be best advised to not work out. That is a conversation best had with your ENT right away, and I will defer to him/her for advice on working out.

I will defer to your ENT w/r to pharmacologic treatment (oral steroids vs intratympanic).

Re returning to diving, we recommend that someone who has experienced a perilymph fistula not dive again because of the risk of damage to the opposite, intact vestibular apparatus. If it's a non-fistulating inner ear barotrauma, the diver may be cleared to dive again provided that there's an identifiable, correctable cause. In your case it might be your equalization technique but with your history of difficulty equalizing and your vivid description of the squeaking sound, you may also have some sort of Eustachian tube dysfunction that would preclude diving if not correctable.

I don't know of any diving physicians in Okinawa though I would imagine that there is a Navy Diving Medical Officer (DMO, a physician trained in diving medicine) there who could be accessible via either a Navy or Marine unit with divers attached. I would strongly recommend that you track one down and follow up with him/her very soon in addition to your ENT.

If you do return to diving, it sounds like you've incorporated some learnings around avoiding diving in the setting of possible upper respiratory infection or other acute process that can affect your ability to clear, and equalizing early and often using a safe method like the Toynbee that Angelo mentioned.

Best regards,
DDM

 

[Okidiver1369]

Absolutely blown away by the efforts put into answering a strangers questions, thank you! As a precaution I’ll cut out the working out for a bit. I’m imagining it or medication but at points it still feels like something is slightly off so maybe a little more rest will help. Yes, I’ll reach out to some diving doctors once I get all my test results in then I’ll ask their advice. A big part will come down to the hearing. Not being able to hear that great these past couple weeks is a bit of a sobering thing so here’s hoping that it continues to improve and auditory discrimination is good. One of the many learning points to this thing is that time is critical to ear injuries and if you don’t advocate for yourself with frontline medical folks you might miss that window.