Tinnitus/hydrops and diving

[bluebanded goby]

I've been diving for about 10 years and have done around 500 dives. For many years I've also had mild to moderate tinnitus (ear ringing), which I've learned to pretty much ignore.

A couple of months ago, I started having much stronger attacks of tinnitus -- piercing ringing intense enough to wake me up at night. After a couple of visits to an ENT, he concluded that I appear to have endolymphatic or cochlear hydrops -- excessive pressure in the fluid in some portion of my ear. Although this is often viewed as being a form of Meniere's disease, my ENT didn't think it would be appropriate to use that term in describing my condition, as I am not experiencing most of the symptoms of Meniere's. Specifically, I have no vertigo or dizziness at any time -- I've always had the most rock-solid stomach of anyone out on the dive boats -- and I also have no hearing loss. In addition, the ENT says Meniere's usually involves tinnitus at low frequencies, whereas mine is very high-pitched. I do have on-and-off feelings of ear fullness, which usually coincide with the tinnitus attacks. The tinnitus outbreaks seem to be strongly related to sleep position. Between watching my sleeping position very carefully and starting a low-sodium diet, the tinnitus has mostly returned to my historic (and mostly ignorable) mild to moderate level.

So here's my question. I've been taking a break from diving while getting this sorted out, but am thinking about resuming it sometime this summer. However, I wouldn't want to continue diving if there was a plausible chance that diving could worsen my ear issues. (The first week or so I had these piercing attacks, I literally could not sleep -- it was really horrible, and I thought I was losing my mind. Thankfully it's backed off, but the last thing I'd want to do is anything that could make it worse.)

From conducting some searches, the main concern that comes up about diving and Meniere's has to do with the vertigo/nausea that Meniere's patients experience. I haven't been able to find anything on whether diving could exacerbate a situation like mine. My ENT said he saw no reason I couldn't dive, as long as my eardrums were intact (and they are). Then again, he is not a diving specialist ENT. I called DAN for a referral, but they said there are no ENTs in my area listed with them.

Obviously, I would want to avoid any kind of barotrauma while diving. But is there any evidence that diving in and of itself can worsen ear problems like mine?

 

[doctormike]

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Obviously, I would want to avoid any kind of barotrauma while diving. But is there any evidence that diving in and of itself can worsen ear problems like mine?

While I really can't tell you that you are "fit to dive" over the Internet, maybe I can help a bit by explaining a few things..

Endolymphatic hydrops refers to elevated pressure in the inner ear (a fluid filled space deep in the skull, containing the sensory organs of hearing and balance), and Meniere's disease is a form of that. The usual pressure problems that come about from diving are related to poor ventilation of the middle ear (the space behind the eardrum). Sound is transmitted from the eardrum, through the chain of bones in the middle ear and into the inner ear across a plate of bone known as the stapes footplate, filling up a hole in the bony capsule of the inner ear known as the oval window.

Sometimes, middle ear disease can effect the inner ear, but this is pretty rare, and depends on there being a leak from one to the other (a perilymph fistula). This can cause dizziness or permanent hearing loss. The inner ear can be affected by diving directly (inner ear DCS, with bubbles in the inner ear fluid). Both of these are uncommon, and it sounds like you have been diving for a while without any such difficulty. Another thing that you have going for you is that the attacks didn't happen during diving, but spontaneously during sleep - making a fistula less likely.

SO, if you can ventilate well, that protects the middle ear from pressure related damage. I guess the thing to ask your ENT doctor is if there was any concern about a fistula causing the change in your tinnitus. In general, if tinnitus is caused by such a fistula, hearing loss is often present - the permanent, "nerve" type of hearing loss, as opposed to the temporary "conductive" hearing loss that usually comes from barotrauma.

Not a lot is known about the various causes of tinnitus, actually... it can be a very frustrating symptom..!

I hope that this helps...

Best,

Mike

 

[bluebanded goby]

Mike, thanks much for the explanation -- that's a big help. It does bring to mind another couple of questions, if I can prevail a little further on your time:

1) If I did have a fistula, what risk exactly would that pose for diving, if any? Would it just be a problem if barotrauma occurs, or could routine diving cause an issue with a fistula?

Also, do fistulas usually affect only one ear? I can't recall if my ENT mentioned anything about that. My recent "loud tinnitus" symptoms incline more toward the left ear, but have shifted to the right at times, and affected both ears equally at other times.

2) I'm still puzzled by the way my sleeping position leads to "loud tinnitus" eruptions. First, tinnitus is lessened if I sleep with my head as elevated as possible, which I understand is fairly common for many tinnitus patients. But there's an additional aspect that I don't understand. If I sleep on my left side, so that my right ear is elevated, it's the right ear that gets the strong tinnitus. Conversely, if I sleep on my right side, so that my left ear is elevated, it's the left ear that gets the strong tinnitus. Any idea why the ear that is elevated when the body is reclining would get this effect? The tinnitus seems to be minimized if I sleep on my back with head elevated, but this position gets tough to maintain all night long -- I'd love to find a way to deal with this that allowed me more latitude.

A few other random notes in response to your comments:

-- A new audiology test shows that I have moderate high-frequency hearing loss in both ears. But the audiologist and ENT said this is normal for my age (55), and a hearing aid was not recommended. When I had my last audiology test six years ago, I had about the same amount of high-frequency hearing loss but only in my left ear.

-- Equalizing has never been a particular issue for me. I always descend fairly slowly, and clear early and often. I gather I have adequate ventilation of the middle ear?

-- While I've known divers who have experienced inner-ear DCS, I have no reason to believe I've had this myself -- as noted I've never had vertigo or balance issues, either during or after diving or at any other time.

-- One side note on this that I haven't mentioned yet is that my mother (who is now 83) also experienced similar tinnitus for quite a few years as an adult. She said the tinnitus eventually disappeared fairly abruptly. Interestingly, the disappearance seems to have been around the time that she started permanently on a diuretic as treatment for congestive heart failure. Though I gather diuretics are among treatments for Meniere's, my ENT didn't want to use one at this point because of side effects. This might point to an inherited issue with circulation of the inner ear, I'm told.

-- Finally, one other aspect is that there may be a mild to moderate TMJ component to this. I'm told that I grind my teeth at night, and feel some amount of jaw soreness, which seems to be connected at times with the fullness in one or both ears. A TMJ specialist, however, said my case seems to be fairly mild. I had my dentist fit me for a night guard which I've been using for the past month. (It's a little difficult to sort out which part is helping the most -- the night guard, the attention to sleeping position or the low-sodium diet.)

Thanks again for the comments.

 

[doctormike]

Mike, thanks much for the explanation -- that's a big help. It does bring to mind another couple of questions, if I can prevail a little further on your time:

1) If I did have a fistula, what risk exactly would that pose for diving, if any? Would it just be a problem if barotrauma occurs, or could routine diving cause an issue with a fistula?

If you actually had a fistula, you would be at risk for a potentially permanent hearing loss with any big pressure swing in the middle ear (even if you were able to equalize).

Also, do fistulas usually affect only one ear? I can't recall if my ENT mentioned anything about that. My recent "loud tinnitus" symptoms incline more toward the left ear, but have shifted to the right at times, and affected both ears equally at other times.

There are a few threads about fistulas here, but basically there are two types of fistulas - spontaneous and acquired. Spontaneous fistulas are controversial, some ENT doctors don't believe that they exist at all, and it it probably more of a discussion that you want to get into here. But the bottom line is that there is not always a way of proving that such a thing exists. Sometimes, you don't even see the leak at surgery. An acquired fistula is generally the result of something that you would know about - such as a cholesteatoma (a type of chronic ear disease) or severe trauma.

2) I'm still puzzled by the way my sleeping position leads to "loud tinnitus" eruptions. First, tinnitus is lessened if I sleep with my head as elevated as possible, which I understand is fairly common for many tinnitus patients. But there's an additional aspect that I don't understand. If I sleep on my left side, so that my right ear is elevated, it's the right ear that gets the strong tinnitus. Conversely, if I sleep on my right side, so that my left ear is elevated, it's the left ear that gets the strong tinnitus. Any idea why the ear that is elevated when the body is reclining would get this effect? The tinnitus seems to be minimized if I sleep on my back with head elevated, but this position gets tough to maintain all night long -- I'd love to find a way to deal with this that allowed me more latitude.

Yes, not a lot is known about tinnitus, and different people respond to different things. If you haven't seen this, check it out: Home Page | American Tinnitus Association

-- A new audiology test shows that I have moderate high-frequency hearing loss in both ears. But the audiologist and ENT said this is normal for my age (55), and a hearing aid was not recommended. When I had my last audiology test six years ago, I had about the same amount of high-frequency hearing loss but only in my left ear.

Yes, that sounds like presbycusis, high frequency symmetric loss associated with age.

-- One side note on this that I haven't mentioned yet is that my mother (who is now 83) also experienced similar tinnitus for quite a few years as an adult. She said the tinnitus eventually disappeared fairly abruptly. Interestingly, the disappearance seems to have been around the time that she started permanently on a diuretic as treatment for congestive heart failure. Though I gather diuretics are among treatments for Meniere's, my ENT didn't want to use one at this point because of side effects. This might point to an inherited issue with circulation of the inner ear, I'm told.

Yes, that certainly is possible - a better answer as far as the question about diving is concerned!

-- Finally, one other aspect is that there may be a mild to moderate TMJ component to this. I'm told that I grind my teeth at night, and feel some amount of jaw soreness, which seems to be connected at times with the fullness in one or both ears. A TMJ specialist, however, said my case seems to be fairly mild. I had my dentist fit me for a night guard which I've been using for the past month. (It's a little difficult to sort out which part is helping the most -- the night guard, the attention to sleeping position or the low-sodium diet.)

Haven't heard of TMJ causing true tinnitus, but I guess some sort of jaw noise could be lumped together with this diagnosis!

Thanks again for the comments.

No problem, keep us posted...

 

[bluebanded goby]

Great, thanks again.

 

[bluebanded goby]

Just a follow-up: As suggested, I asked my ENT whether there was any concern about me possibly having a fistula. His response:

"I do not believe you have a perilymphatic fistula. Patient's with a fistula nearly always have significant vertigo (sensation of spinning) and associated hearing loss. If you had a fistula, I would expect to see some evidence of this on your physical exam or on your audiogram, but this is not the case.

"The only way to absolutely rule out a fistula would be a surgery to examine your middle ear space, but based on everything I have described, I strongly discourage you from undergoing any surgical procedures at this time."

So it sounds like I'd be reasonably safe diving again. Though I know I'd approach it very conservatively (reading some of the other threads here make more serious ear conditions not sound like fun).

I'll be flying Saturday (on a non-diving trip), so it will be interesting to see if my ears behave themselves during the pressure changes.

 

[doctormike]

Just a follow-up: As suggested, I asked my ENT whether there was any concern about me possibly having a fistula. His response:

"I do not believe you have a perilymphatic fistula. Patient's with a fistula nearly always have significant vertigo (sensation of spinning) and associated hearing loss. If you had a fistula, I would expect to see some evidence of this on your physical exam or on your audiogram, but this is not the case.

"The only way to absolutely rule out a fistula would be a surgery to examine your middle ear space, but based on everything I have described, I strongly discourage you from undergoing any surgical procedures at this time."

So it sounds like I'd be reasonably safe diving again. Though I know I'd approach it very conservatively (reading some of the other threads here make more serious ear conditions not sound like fun).

I'll be flying Saturday (on a non-diving trip), so it will be interesting to see if my ears behave themselves during the pressure changes.

It sounds like your doc knows what he is talking about, and that you are in good hands! Many docs just automatically say "no diving" without any basis, so it's good to hear that you have someone who has really thought this out.

And in fact, even at surgery, the question of a fistula may still be up in the air. As opposed to acquired fistulas (like with trauma, etc..), the spontaneous perilymph fistula is a controversial diagnosis, since the amount of fluid that would potentially be leaking is extremely tiny. Some doctors will operate on people with a fluctuating hearing loss, convince themselves that they see a little fluid pooling in the middle ear, and put some fat in to pack off the presumed leak. If the hearing doesn't get better, they can always say that it would have gotten worse without the operation! That is why otologists (ENT docs who specialize in the ear) will often ask each other "do you believe in the fistula fairy?"....

Feel free to keep us posted...

Mike