Returning to diving after middle ear barotrauma?

[doctormike]

This was very helpful! From what I can tell this was a middle ear barotrauma with effusion, no eardrum rupture. I did have some sensorineural and conductive hearing loss. No other symptoms of inner ear injury though.

I was treated with steroids. Here is the audiologist report on 6/27 and then on 7/12. We don't have a baseline, but can assume the right ear is a good baseline for the left.
View attachment 533161 View attachment 533162

Thanks! So it looks like you had a mixed hearing loss (conductive AND sensironeural) which improved on steroids. Likely the biggest improvement was in the conductive component with some improvement in the bone line (sensorneural) in the high frequencies (hard to say 100% from the audio scan, having a bit of a problem reading all of it).

That does suggest some degree of inner ear injury, possibly transmitted injury from the middle ear barotrauma. There is no tympanogram on the affected ear on the first scan (the doctor told the audiologist not to do it?), but presumably it would have showed middle ear fluid causing the conductive hearing loss.

A CT scan might be helpful in determining if there was a bony abnormality making the inner ear more vulnerable, but a negative scan can't rule that out.

The bottom line is that this story does suggest some increased risk of further (possibly permanent) hearing loss with future injury. No doctor is going to be able to really "clear" you, ultimately you will need to make this decision by juggling unquanitifiable risks. I can't really tell you much one way or the other, but I certainly would be concerned about your diving with this history.

 

[freedc]

Does this just mean that I should dive extra-conservatively, like be ready to turn any dive where I can't equalize easily?

I'm trying to understand if I am at greater risk of injury, or if I am at greater risk of permanent hearing loss *if* I am injured.

Relatedly, I'm trying to understand if the problem is trying to push too hard to force equalization or if somehow I am at risk of barotrauma in situtations where I don't have a warning sign, like noticeable pressure buildup that is not equalizing upon descent. In one case, it's a matter of being extra careful and not letting the pressure build. In the other case, my ear is a bomb waiting to go off and I shouldn't dive at all.

I also wonder if it would affect the profiles I should dive, or whether any dive has the same risk. This is where the non-scuba-knowing ear docs I went to are useless. (I emailed DAN and they gave me some referrals. Not sure if those docs are in my network so I haven't seen them yet).

 

[doctormike]

I wouldn't say that your ear is a "bomb", but the bottom line is that you had a significant injury during diving (and I wouldn't consider isolated middle ear barotrauma a significant injury).

There is no way of "clearing" you and saying that if you dive conservatively and equalize often you won't get another worse inner ear problem. And there is no way of giving you accurate statistics to help you make the decision to dive or not. I'm not being evasive or thinking medicolegally, I'm just being honest with you. We don't know what happened, but it sure sounds like you somehow beat up your inner ear, which normally doesn't happen with diving. Even with a diagnosis, it's very hard to give you an accurate prognosis with future diving. Without a diagnosis, it's even harder.

Sorry...

 

[freedc]

I wouldn't say that your ear is a "bomb", but the bottom line is that you had a significant injury during diving (and I wouldn't consider isolated middle ear barotrauma a significant injury).

I was confused by this. Is middle ear barotrauma, which was my diagnosis, significant or not?

Or should I infer that you are saying you are convinced there was inner ear injury involved? The examining doctor did not say that, but he did say something about possible cochlear nerve injury, so maybe he said it in other words.

 

[freedc]

There is no tympanogram on the affected ear on the first scan (the doctor told the audiologist not to do it?), but presumably it would have showed middle ear fluid causing the conductive hearing loss.

FWIW, I don't know if it was the tympanogram, but the audiologist did say that she didn't want to do "the test that blows something into my ear" on the first exam because she worried that it could damage the ear drum (or something like that, I don't remember exactly), whereas for the followup exam she said it was healed enough that she wasn't worried.

 

[freedc]

By the way, thanks so much @doctormike for your helpful and thoughtful comments here. I asked DAN for some local referrals and they gave me two names, one an ENT who advertises himself as primarily a plastic surgeon, the other a hyperbaric/emergency medicine specialist. I might try to see the latter, as I think she treats commercial divers. Thanks to you, I'll be more informed when I go in to see someone.

 

[doctormike]

I was confused by this. Is middle ear barotrauma, which was my diagnosis, significant or not?

Or should I infer that you are saying you are convinced there was inner ear injury involved? The examining doctor did not say that, but he did say something about possible cochlear nerve injury, so maybe he said it in other words.

Hard to be specific over the Internet, but middle ear barotrauma rarely causes any permanent injury, while inner ear injury can result in a permanent hearing loss. As far as your diagnosis goes, you had a mixed hearing loss. That means conductive AND sensorineural hearing loss. So it sounds like middle ear barotrauma alone would be an incomplete diagnosis.

Conductive is almost always middle ear disease. While it's true that you can have sensorineural hearing loss that is not caused by inner ear trauma, the fact that your symptoms happened while diving makes that less likely.

It's a bit confusing. It's called "sensorineural" because from a hearing point of view, the two causes are managed similarly in most cases. But "sensory" means the organ of hearing sensation (cochlea, which is part of the inner ear). "Sensory" hearing loss would come from an inner ear pressure injury, inner ear DCS, perilymph fistula, etc... "Neural" means the nerve of hearing (cochlear nerve), and that would imply a something beyond the cochlea (like a tumor of the cochlear nerve, multiple sclerosis, viral cranial nerve inflammation, etc..).

So I'm not sure if he meant by "cochlear nerve injury" that he thought that you had a non-diving related cause of the sensorineural component of your hearing loss that just happened to coincide with your middle ear injury. Seems unlikely.