What’s the symptoms for a perforated ear?

[rlitt]

Hello,

I dove yesterday with a slight cold and had difficulty equalizing my right ears. During the dive, I experience some pressure/pain in my right ears; however, I didn't discontinue the dive because I managed to equalize by exerting greater force.

At the end of the dive, I had water in my right ear. Today, that right ear felt as though I had fired a gun without an ear muff - no ringing but it seems slightly muted.

Is there to determine if I had suffered a perforated ear?

 

[ScubaJorgen]

There is a way: go to the :doctor: doctor and have him to look with the otoscope. A perf ear is good visible.

Damn, you should have quited your dive instead of forcing your ear to be blown out! :whack: Remember: even without a cold, diving is an extreme violence excerted to a very delicate and sensitive instrument called the ear

Symptoms:
- Relief after (great) pain during dive (pressure is taken off the internal ear when the eardrum ruptures)
- Vertigo (cold water enters one ear, cooling the vestibular canals that play a role in keeping you upright)
- Liquid coming out of your ear after the dive.
- Inflamation/infection of the inner ear due to dirt getting into it with the water.

Occasionally (no perforation), your ears may feel 'stuffed' after diving a lot or equalizing to late. This vanishes (at least in my case).

Oh, and I am *NOT* a doctor, disclaim, blah blah, etc.

 

[DocVikingo]

Hi rlitt,

Sounds more like you've got a touch of serous otitis media than a ruptured tympanic membrane.

The signs & symptoms of a ruptured eardrum may include a momentary sharp pain in the affected ear (but not always), occasionally excruciating, followed by vertigo, possibly with nausea, vomiting & confusion. Later you may notice hearing impairment, earache & sinus pain. Some divers report hearing a "pop" or "pfffft" sound as the membrane tears, followed by a sensation of extreme coldness in the affected ear.

Serous otitis media is an accumulation of fluid within the middle ear space. Often this is due to blockage of the Eustachian tube or failure of the tube to open. This typically causes some hearing loss, often in the form of sounds seeming muffled, and there may be a sensation of fullness & pain. Diving with a cold is one way to bring on such a condition.

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to any particular individual, and should not be construed as such. See your doctor if you are concerned or if signs & symptoms continue.

Heal quickly.

DocVikingo

 

[rlitt]

ScubaJorgen:

I took your suggestion and went to see a physician today. An otoscope result came back negative; however, I was told a small perforation could have very well been flapped over, and thus may not be visible. I did have signs of inflammation and redness.

I'll certainly heed your warning by never to dive with a cold. I am new to the sport and didn't want to miss my first open water dive.


DocVikingo:

YOU ARE RIGHT ON THE MONEY! My ENT specialist diagnosed my condition as "Otitis Meida" (middle ear infection). The symptoms I am experiencing are exactly those you had mentioned - e.g. sounds seeming muffled & sensation of fullness. The doctor prescribed some antibiotic as a precautionary measure. I hoping to get well enough by next week to finish up my next two open water dives.

Thanks again to everyone who have responded to this message.

 

[devjr]

There was water in the ear and the drum was intact? I've warned about this before.

litt, ensure that you have no water in your mask, if water is present blow it out and shave your moustache. Do not tilt your head up when attempting to clear.

It could be argued that the incident was due to the cold. Perhaps so, as a proximate cause, and a direct cause could be excess pressure generated by attempts to clear the ear. Any water or fluid in the nose, or perhaps a sinus, can be driven into the upward slanting E tube.

 

[ScubaJorgen]

Devjr,

I wonder if water from the mask reaches the E tube during occasional diving. I once descended upside down :burnout: and tried to clear my ears. That definitely went wrong and I think I blew water into an ear. That hurted like hell.

Normally, when not clearing the ear, the pressure in the middle ear is lower than surrounding pressure. Fluid and blood from surrounding tissue is forced into the middle ear (effusion). This is called barotitis. The longer the ear stays non-equalized, the more fluid enters it. If the middle ear gets full, the pain reduces, since fluid is incompressible. More info on this on my homepage tag 'medicine', item ''pressure related problems - ear problems/barotrauma'.


When having a cold, it is more probable that mucus got blown into the middle ear. Mucus blocks the E-tube. When equalizing, this is blown into the ear. This gives rise to infection, our :ears: otitis media

Rlitt, I agree, missing a dive often seems the worst thing that can happen to you.....

 

[devjr]

I've seen blood get into the rigid sinus cavity but not the middle ear. However, I think it is safe to bet that some ENT who diagnoses "otitis", or ear infection, a thousand times a year has seen this, or diagnosed it. I suspect that if it does happen to divers, the sinuses are a source, not leakage of soft ear tissue. I don't think either is the majority problem for divers, however.

With divers the middle ear and inner ear problems stem from seawater, not mucus. A mucus flow and tissue swelling will make it hard to equalize followed by the pain and deafness which come when water accidentally enters the middle ear via the nose. Yes, this happens to divers who do not have congestion as well. Anytime the diver clears when the head is tilted up, either when vertical, or inverted while looking back up, and there is water in the mask, there is risk of flooding of the middle ear. This can happen if only a teaspoon of water enters the nose.

 

[scubadoc]

The nasopharyngeal ostium of the Eustachian tube is normally closed. It is opened by increased pressure in the middle ear or by the action of muscles when swallowing. During descent, an active effort must be made to open this ostium by contracting these muscles. On ascent this process is passive and unless there has been severe middle ear barotrauma on descent, there is little need to equalize. (Bove, 3rd Edit)

If equalization is delayed from predive nasopharyngeal dysfunction, a locking effect is caused and tubal mucosa is drawn into the middle ear, becoming congested and obstructing the tube (Edmonds, 4th Edit). If the diver continues descent without equalizing, mucosal congestion, edema and hemorrhage within the middle ear cavity occurs with inward bulging of the tympanic membrane, the ear drum itself becoming hemorrhagic. None of this is due to the presence of "sea water" in the middle ear. The only way water can enter the middle ear is for the tympanic membrane to rupture.

The NOAA Diving Manual, Bove's Diving Medicine Textbook, Carl Edmonds new textbook nor any other text that I have ever read states that the cause of fluid in the middle ear is due to the influx of seawater. They all specifically state that the middle ear damage from unrelieved pressure causes the fluid in the form of blood and serum.

Joe Farmer, MD, prominent ENT diving doctor at Duke and author of the section on the ear in Bove's Diving Medicine does not describe sea water in the middle ear as a problem at all. He does state that the Eustachian tubes are normally closed as stated above. It is conceivable that a diver could possibly attempt to clear his ears with a nasopharynx full of sea water and even possibly force some into the middle ear. However, this would be a rare event and would certainly not play any part in the many cases of MEB that occur.

It is not my intent to get into a debate about this issue - as the pathophysiology is well known and brought out in great detail in all of the texts that I have available. It is important for this medical board to provide information that is correct and not to present as fact some supposition that is not accepted by the mainstream medical community.

Best regards:

Ern Campbell, MD, FACS
Diving Medicine Online

 

[devjr]

Sea water does enter the middle ear under set circumstances. Your sources are wrong. BTW, do your sources still tell you that Vit E is of no benefit to humans, or that women who bear children must stay in bed for days, or that exercise is dangerous and causes enlarged heart? They did once. Do they still advise that freedivers' lungs will collapse and that the chest wall will be crushed when diving below 100 feet? The list is long.

 

[John Reinertson]

As with many controversies. both sides get polarized. I'm a middle child and often try to serve as the peacemaker.
Obviously, there are not a lot of studies where divers' ears have been inspected right after a dive, complete with tympanometry to detect subtle effusions. Probably I could write off a 14 day trip to Bonaire, with boat dives, if I did such a study ... Hmmm.


But until then, I'll have to rely on twenty years as a Family doc and many many thousands of ear infections, effusions, and not a few diving equalization ear injuries.

1. If sea water up the Eustachian tube were the primary problem, full masks or brass helmets with no water infiltration would solve it.
If you talk to Navy and Commercial divers, this is not the case. In the old days of dry brass helmets, barotrauma and effusions still occurred.

The source referred to (Bove and Davis) includes a veteran Navy diving Doc who has seen about anything that can happen in both everyday and exotic diving, and a pioneering doc in aerospace decompression science.
I never met Jeff Davis, but know Fred Bove, and the many episodes of effusion occurring in Caisson workers, helmet divers, and chamber attendants tell me that sea water is not the prime culprit.

I have also read the studies showing increased rates of middle ear effusion and otitis media in infants that are fed while lying down and know that under the right circumstances, fluids from the nasopharynx can enter the middle ear.

I have seen as a family doc an infant that had normal appearing eardrums in the afternoon. That night, after mom rushing the child to the ER after a choking episode on grape Kool-Ade, I saw purple fluid behind the TM. Therefore, fluid can enter the middle ear from the nasopharynx sometimes.
(This child had no further treatment, and two days later had normal eardrums.)

The thought of mucus being the plug in the middle ear doesn't hold up when you realize that mucus moves under suction or pressure. It moves more slowly than thin liquids, but it does move. Pressures in the middle ear with tympanometry are almost always way negative when effusion is present, and generally neutral to minus 100 when ears are healthy. (yes, I have an office tympanometer and a lot of curiosity.)

I can also valsalva and produce pressures that are +200 in my own ears. (Told you I was curious)

The cases of middle ear squeeze that I have experienced personally have occurred once when I had a cold, and once when I was descending head first in a swim through and couldn't equalize easily. I tried being macho and blew hard. I equalized, but had a tender ear for the rest of the trip, and a Grade I to Grade II squeeze that limited my participation somewhat.

That was several hundred dives ago, and I don't think I'd do that again. at least I like to think I would have learned from my mistake.

Can sea water get into the middle ear? probably.. I know grape koolaid can.

Is it the cause of most barotrauma or effusions? I don't think so, and the many circumstances that commonly produce effusion in the absence of sea water (and usually in the presence of mucous membrane swelling in the nasopharynx) would suggest that failed equalization is the problem in the vast majority of cases.

Blow bubbles in the water, not in your ears!

John