Recurrent Ear Problems

[mauisher]

I'm a retired scuba instructor and have had some recurrent problems with my right ear. A few years ago, I suffered a barotrauma to this ear after a couple of shallow dives with students. Upon surfacing at the end of the dive, I had vertigo, severe nausea, vomiting, and a "full" ear feeling that lasted days. I went to a physician who said I indeed had a barotrauma and sent me home with some decongestants and bed rest. The ear felt better in a few weeks and I resumed diving, but would experience bouts of tinnitus and an annoying full ear feeling after diving. These would resolve in a few days to a week after each occurrence.

I haven't been diving for awile. However, my ear has problems after flying (descent), with an onset of the full ear feeling that persists for a week or so and then goes away. This happened last summer during a trip. I haven't had any issues with diving, since I haven't been doing it.

A little over two weeks ago, I took a one night backpacking trip to a high elevation and had problems with my ears..that recurring stuffy, full feeling. I repeatedly did valsalva maneuvers, trying to clear them, while at altitude and upon my return to sea level. After my return to sea level (which is a short distance that here on Maui), my ear got noticably worse (full feeling and slight tinnitus). I went to my regular physician. Fluticasone Propionate nasal spray was prescribed. When nothing happened, I insisted to see an ENT specialist. First I had an audiology test, that showed a slight loss of both high and low frequencies of 20-30 dB (middle frequencies ok). A repeat audiology test two days later showed a slight improvement of my hearing. The ENT told me to quit the nasal spray and put me on oral prednisone (a high dosage that tapered off in 6 days) and has scheduled an MRI for December 21. He also prescribed blood tests (that were all normal)I am not to do any strenuous activities or heavy lifting for one month. So far, the full feeling has diminished, my hearing has slightly improved, but the tinnitus has persisted.

Sorry for this being so long-winded, but I have a couple of questions for you on this forum since you may have had this sort of thing happen. Have you heard of anyone having a repeating ear problem such as mine due to a barotrauma? In other words, could my original injury make me vulnerable to recurring injuries that begin with altitude/pressure changes? Would there be other tests or specialists you might recommend? I'm hoping to preserve my hearing and maybe (hopefully!) return to diving. Thanks!!

 

[doctormike]

I'm a retired scuba instructor and have had some recurrent problems with my right ear.

Sorry for this being so long-winded, but I have a couple of questions for you on this forum since you may have had this sort of thing happen. Have you heard of anyone having a repeating ear problem such as mine due to a barotrauma? In other words, could my original injury make me vulnerable to recurring injuries that begin with altitude/pressure changes? Would there be other tests or specialists you might recommend? I'm hoping to preserve my hearing and maybe (hopefully!) return to diving. Thanks!!

Hi, Mauisher... thanks for writing!

The key to your case is - as with most ear symptoms - knowing the site of the problem: middle vs. inner ear. Although these two are frequently confused and/or run together in casual discussions, they are completely different problems which, with a few exceptions such as perilymph fistula, do not cross over. So the most important piece of information (left out of your otherwise excellent description) is whether the hearing loss you have now is a conductive hearing loss (middle ear) or a sensorineural hearing loss (inner ear). This would be readily apparent from the results of the audiogram, but I am assuming that what you have now is a sensorineural hearing loss, since your doctor has recommended oral steroids (sometimes used for both problems, but more commonly for SNHL) and an MRI, which is primarily used to work up an unexplained SNHL, to rule out the presence of any sort of problem with the cochlea (inner ear) and/or the nerve of hearing that runs from the inner ear to the brain.

Problems in one ear on descent only do suggest a problem with the function of the right Eustachian tube in the past, leading to barotrauma and a conductive hearing loss. The dizziness can be seen with both, and if a SNHL with vertigo follows a diving injury, a perilymph fistula (PLF) is suspected - there are a lot of threads here about that if you want to read more. Just as with diving, barotrauma problems with flying are worse on descent because it is harder to get air into the middle ear than to let it escape. So if that right ET is your "Achilles heel", then you might well have recurrent problems like this, and make you more susceptible. However, it sounds as if right now you are being worked up for a SNHL. While it might be possible for you to get an acute SNHL with a new diving injury if a PLF was present, the pressure change simply by hiking to elevation would not typically result in such a rapid pressure swing to cause something like that.

However, the bottom line is that I can't give you specific advice over the Internet, and the devil is in the details. I wouldn't ask for specific tests, but if I were you I would see an otologist (an ENT doctor who only treats ears). I don't mean to disrespect your current ENT - I don't know if he/she is a generalist or an otologist, and many general ENT docs have a lot of experience with diving. But if there is a persistent and/or progressive SNHL, you might want to see someone specialized, especially if the MRI suggests inner ear problems.

Feel free to PM me at any time if you have specific questions that you don't want to raise in open forum..

Best,

Mike

 

[mauisher]

Hi Doctor Mike,
Thanks for the quick reply and clear explanations. Yes, you correctly surmised and I forgot to mention, I have SNHL, which has slightly improved. No hearing test was performed with my original barotrauma even though I had a 'stuffy/full' ear. I'll have another audiogram in a few weeks.

I also should clarify that the elevation gain/loss from where I hiked on top of the mountain to where I live at sea level is 10,000' and occurs over only 35 miles on one of the steepest roads in the world. In other words, the pressure change can occur rather quickly (unlike most other descents).

I'm fairly sure that my ENT is not an otologist. I'm not sure if one is here on Maui, but I'll check this out after I find out the results from the MRI.

Have you ever heard of someone who has a perilymph fistula that inadequately heals and gives them grief later?

Thanks and aloha

 

[doctormike]

Hi Doctor Mike,
Thanks for the quick reply and clear explanations.

Any time, always happy to help as best as I can...!

I also should clarify that the elevation gain/loss from where I hiked on top of the mountain to where I live at sea level is 10,000' and occurs over only 35 miles on one of the steepest roads in the world. In other words, the pressure change can occur rather quickly (unlike most other descents).

I guess so - I would think that if that was likely to happen, it would be more likely in a car with a quick descent, but I suppose that you could have some significant pressure swing in that setting.

I'm fairly sure that my ENT is not an otologist. I'm not sure if one is here on Maui, but I'll check this out after I find out the results from the MRI.

I looked at our academy Web site, and it lists two otologists in Hawaii:

Kevin S. Hadley, MD (Honolulu) and Mitchell J Ramsey, MD (Kaneohe). I don't know either of them, but if you want a second opinion, they might be worth a call..

Have you ever heard of someone who has a perilymph fistula that inadequately heals and gives them grief later?

Thanks and aloha

Well, without surgical exploration, the diagnosis of PLF is somewhat controversial... Usually, there is vertigo with a PLF as well (but not always). Conservative (non-surgical) treatment of a PLF can include bed rest, stool softeners, and other medical interventions, but it is always hard to make this diagnosis for sure. Did you get an audiogram back when you had your original barotrauma injury? That would have distinguished SNHL from a conductive hearing loss...

Keep us posted!

Mike

 

[Duke Dive Medicine]

Hi Mike and Mauisher,
Questions for both of you: first, for Mauisher, how quickly did your symptoms improve after your initial problem? Also, did the physician who treated you give you a more specific diagnosis that just "barotrauma"? Finally, did you notice any difficulty equalizing the right ear in the time leading up to the initial problem?

For Mike: What a great discussion/response. I had a conversation with our attending about this question this a.m. From the info that the OP gave about the initial treatment, it sounds to us like the original diagnosis was inner ear barotrauma with at least a rule-out for PLF. We haven't heard of someone experiencing residual middle-ear issues from this; have you? I wonder if it's a chicken-egg thing, like maybe the OP had equalizing difficulty with the right ear that led to the initial trauma, and the symptoms he's seeing (sorry if I got the gender wrong Maui, there wasn't one specified) are simply related to the same equalizing difficulty that likely contributed to the original problem. What do you think?
Cheers,
DDM

 

[doctormike]

For Mike: What a great discussion/response.

Thanks!

I had a conversation with our attending about this question this a.m. From the info that the OP gave about the initial treatment, it sounds to us like the original diagnosis was inner ear barotrauma with at least a rule-out for PLF. We haven't heard of someone experiencing residual middle-ear issues from this; have you? I wonder if it's a chicken-egg thing, like maybe the OP had equalizing difficulty with the right ear that led to the initial trauma, and the symptoms he's seeing (sorry if I got the gender wrong Maui, there wasn't one specified) are simply related to the same equalizing difficulty that likely contributed to the original problem. What do you think?
Cheers,
DDM

Well, true inner ear problems are really very rare - although it can be hard to disprove a fistula if there is a SNHL, the vast majority of barotrauma is middle ear disease with a conductive hearing loss. Even vertigo can come from middle ear problems with significant pressure shifts affecting the stapes footplate, without the need for a true fistula. The only way to sort that out would be to have audiometric data from the original "barotrauma" from a few years ago, which is not provided. However, he was treated with decongestants, so if the doc at the time had done an audiogram, that would suggest a CHL and not an SNHL.

When you say "inner ear barotrauma", that really refers to either PLF or inner ear DCS. Did you mean "middle ear barotrauma"...? Perilymph and endolymph (inner ear fluids) are not compressible, and there is normally no gas in the inner ear. Although perhaps you are referring to transmitted pressure changes in the inner ear without a fistula, as mentioned above...

You can definitely get chronic and/or recurrent middle ear problems from significant and/or ongoing barotrauma or other middle ear pathololgy. Some kids who have lots of middle ear infections (especially untreated, from underserved areas) will end up with a persistent CHL from middle ear scar tissue, etc...

I suspect that you are right about the chronic ET problems on the right...

Mike

 

[Duke Dive Medicine]

Thanks!

No problem. I always read your posts closely. It's great to have an ENT who's also a hard-core diver as a resource - nice combination of skill sets.

Well, true inner ear problems are really very rare - although it can be hard to disprove a fistula if there is a SNHL, the vast majority of barotrauma is middle ear disease with a conductive hearing loss. Even vertigo can come from middle ear problems with significant pressure shifts affecting the stapes footplate, without the need for a true fistula. The only way to sort that out would be to have audiometric data from the original "barotrauma" from a few years ago, which is not provided. However, he was treated with decongestants, so if the doc at the time had done an audiogram, that would suggest a CHL and not an SNHL.

Rgr. I didn't think that alternobaric vertigo was in the differential since it took so long to clear up per the OP; or, are you talking about pressure-related trauma to the vestibular apparatus that doesn't result in fistula? I was also going by his response where he reported SNHL on audiogram. I know that that was from a followup exam and it assumes that he didn't have it before the injury... I guess we need more info from him to really answer that. If it is new-onset though, would it be more indicative of a history of inner ear vs. middle ear barotrauma?

When you say "inner ear barotrauma", that really refers to either PLF or inner ear DCS. Did you mean "middle ear barotrauma"...? Perilymph and endolymph (inner ear fluids) are not compressible, and there is normally no gas in the inner ear.

We differentiate between inner ear barotrauma and inner ear DCS - different etiologies and treatments.

Although perhaps you are referring to transmitted pressure changes in the inner ear without a fistula, as mentioned above...

That's what I was talking about (in the above answer as well)... we've seen this described in divers.

You can definitely get chronic and/or recurrent middle ear problems from significant and/or ongoing barotrauma or other middle ear pathololgy. Some kids who have lots of middle ear infections (especially untreated, from underserved areas) will end up with a persistent CHL from middle ear scar tissue, etc...

Have you ever seen or heard of this related to diving? We were just talking about this the other day in another thread - a couple of guys were reporting increasing incidence of reverse block as they got older. One had equalization issues probably related to a tight-fitting hood, but the other didn't report any history of consistent difficulty clearing. Can't remember if you were there for that one or not - we ended up researching age-related degenerative changes in the middle ear but didn't come up with anything.

Anyway, back to the OP... guess we'll wait and see!
Cheers,
DDM

 

[doctormike]

No problem. I always read your posts closely.

As I do yours!

Rgr. I didn't think that alternobaric vertigo was in the differential since it took so long to clear up per the OP; or, are you talking about pressure-related trauma to the vestibular apparatus that doesn't result in fistula? I was also going by his response where he reported SNHL on audiogram. I know that that was from a followup exam and it assumes that he didn't have it before the injury...

Well, altenobaric vertigo refers to a differential stimulation of the two labyrinths, and is classically a phenomenon associated with an acute change in ventilation. However many people have chronic underventilation of one middle ear as compared to the other. The thing is that there is usually accommodation with time, that is why kids with one ear full of fluid or negative pressure aren't usually dizzy.

You can get vertigo from middle ear disease in the absence of a fistula. Although there is no good animal model for this that I know if, again the presumption is stimulation of the inner ear (the labyrinth) from a middle ear process (e.g. pressure transmitted through the footplate of the stapes). That would actually be the mechanism for alterobaric vertigo, since vertigo by definition is the result of inner ear mis-stimulation, or stimulation that does not "match" with the other two balance inputs (the sensors in the spinal cord and visual input). That is why you can get dizzy trying to read in a moving car - your eyes are telling you that you are still, while your inner ears don't agree! Also, there is the possibility of a caloric response, with cold water chilling one of the semicircular canals from the outer ear to the inner ear, completely bypassing the middle ear, but let's leave that one for now…

I guess we need more info from him to really answer that. If it is new-onset though, would it be more indicative of a history of inner ear vs. middle ear barotrauma?

If we are talking about his recent symptoms, I don't think that the new-onset aspect would suggest one over the other. Since there is a SNHL, though, I have to assume some sort of inner ear process. I'm still a little surprised to hear that a hike to the mountains would result in enough of a pressure swing to cause this sort of problem...

We differentiate between inner ear barotrauma and inner ear DCS - different etiologies and treatments.

Oh, of course, completely different. I was just saying that both DCS and PLF would technically be considered types of barotrauma in the broadest sense of the word, since they are pressure related injuries, but I agree that the way that barotrauma is used in the dive community does not typically include DCS. The reason that I lumped them together in that sentence was to distinguish inner ear processes related to pressure changes from middle ear processes. I agree, the terminology is inconsistent between fields…

Have you ever seen or heard of this related to diving? We were just talking about this the other day in another thread - a couple of guys were reporting increasing incidence of reverse block as they got older. One had equalization issues probably related to a tight-fitting hood, but the other didn't report any history of consistent difficulty clearing. Can't remember if you were there for that one or not - we ended up researching age-related degenerative changes in the middle ear but didn't come up with anything.

Absolutely, but not in the sort of diving that is usually discussed here. The age related thing is usually presbycusis, a common high frequency SNHL that most of us will get at some point. As far as chronic middle ear disease in divers, this is unfortunately very common in working freedivers and SCUBA divers in the third world (sponge divers, abalone divers, etc..) who are under tremendous economic pressure to dive deeper and longer as shallow beds get depleted. They will often have chronic eardrum perforations, and have to dive anyway, so you can imagine how bad their hearing can be.

A bit off topic, but I just saw a heartbreaking documentary about lobster divers in Central America, who have a phenomenally high rate of serious permanent DCS injuries (paralysis, etc..). These guys don't have pressure gauges, they have to go deeper and deeper to keep up with demand. Very little in the way of company support for the divers' health problems, and they only recently got a chamber. And if they refuse, there will always be someone else willing to do it for the (fairly good) money…

 

[mauisher]

Hi Dr. Mike and DDM,
Thank you both for your informative discussion. In answer to your questions, no audiogram was conducted with the original barotrauma, so it's impossible to say if hearing loss occurred then. I remember staying mostly in bed for a day or so and the symptoms improved after a while...can't remember exactly how long. The physicians records state only ear barotrauma. And, yes, I've had more trouble equalizing the right ear than the left. I am a woman with smaller eustachian tubes, I guess.

It may be that what's happening is unrelated to the barotrauma, but with recurrent symptoms of fullness/tinnitus that resolve, hearing loss, and a seeming link to pressure changes, it makes me wonder.

Also, thanks for the names of two Hawaii otologists on Oahu. My plan of 'attack' will be to continue to avoid strenuous activities as requested by my ENT, see the results of the MRI and proceed from there to an otologist. Thanks, again!

 

[doctormike]

My plan of 'attack' will be to continue to avoid strenuous activities as requested by my ENT, see the results of the MRI and proceed from there to an otologist. Thanks, again!

Sounds good... hang in there, and keep us posted..!

Best,

Mike