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Ear Nose and Throat Problems - Middle Ear

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - On a trip to Thailand last summer my buddy had a case of terrible dizziness which has put her off diving completely. She was just recovering from a cold when we dived, had a bit of trouble descending but got down to 20 m okay. The dive was fine but on the way up she looked like she suddenly panicked, thrashing about in the water. Luckily we were at about 5 m so she surfaced but missed her safety stop. She was choking and said she felt drunk, and vomited on the boat afterwards. It all went away quickly so we didn't think it was DCI (hope we were right!) Trouble is, I really want her to get back on the horse but she's frightened it might happen again. What do you think the problem was and could it recur?

A - This has all the hallmarks of alternobaric vertigo. The left and right middle ear spaces are never perfect mirror images of each other, so it’s usually the case that one ear equalises slightly out of sync with the other. If for some reason one side clears and the other doesn’t, then different signals from each side are sent to the brain, and the poor thing can’t work out which pressure is “right”. Vertigo is the end result: the whirling sensation of spinning and drunkenness is the classic consequence, and nausea and vomiting often follow. Once the pressures in the ears become equal, the stimulus stops and the condition resolves (so yes, I don’t think this was DCI either – more likely some residual snot from the cold caused one Eustachian tube to block). It’s impossible to guarantee it won’t happen again, but this is one very good reason not to dive with any hint of congestion. Best of luck convincing her to get wet soon.

Q - I've heard a lot about "reverse squeeze" but what does this term mean exactly? It sounds awful and I'd like to know how to avoid ever experiencing it if possible.

A - When we talk about “squeeze” we mean the contraction of gas in a confined space, as pressure increases on descent. This is most often felt in the middle ear, or the sinuses in the forehead and cheeks. But gas can also get trapped in these spaces on the ascent, where it expands (hence “reverse squeeze”), causing barotrauma which is often more serious: most divers can’t get past two or three metres with a squeeze on descent, but a reverse squeeze can occur at much deeper depths, risking a far greater pressure change on the ascent. The classic culprit for this used to be short-acting pseudoephedrine (Sudafed): it would widen up the Eustachian tube enough to allow descent, but as it wore off during the dive the congestion returned causing gas to become trapped at depth. Long-acting decongestants have largely eliminated this risk, but to be on the safe side you should avoid diving with any congestion, particularly if you’ve had a middle ear problem recently.

Q - I had to cut short a diving holiday to Mozambique recently because of an ear problem. I tried to push through a sticky ear situation and it got so painful I had to abort the dive and come up from about 4 metres. Luckily there was a trained ENT doctor on the same trip, who was also diving - she said she never goes anywhere without her trusty ear torch! Anyway she told me I had "grade 3 barotrauma" and I needed at least a month off diving. This happened a week ago and it all feels fine now. The problem is I've got a big weekend of diving planned… next weekend! Is there any chance I can get back in the water before the month is up? And what is grade 3 barotrauma anyway?!

A - The word “barotrauma” simply means damage to tissues resulting from pressure changes. Getting all scientific for a minute, Boyle’s Law states that at constant temperature, the pressure and volume of a gas are inversely proportional. The painful application of this to diving is that as you descend (and the pressure increases), the volume of air in the middle ear will shrink proportionally, sucking in blood, mucus and general gunk from the surrounding area until the pressure is “equalised” (as I described above). The grading system is basically a way of us docs describing to each other how bad the barotrauma is, by looking at the eardrum. The most common system has 6 grades, confusingly numbered 0-5. Grade 0 is the least serious – someone with symptoms but nothing abnormal when you peer into their lughole. A poor grade 6-er has a perforated eardrum. In between are various levels of bruising, bulging and blueness; your grade 3 would probably be a very red and engorged-looking eardrum, but no sign of a hole or blood sloshing about inside the middle ear. Recovery rate is very variable but barotraumas of grades 3-4 will take up to 2 weeks to get right. Be guided by how it feels and whether you can equalise, but be wary of pushing it too hard too soon, as you can easily perforate the drum in its weakened state and prolong your time out of the water massively (perforations can take up to 3 months to heal fully).

Q - I have problems equalising on descent - and it is always the same ear. But when it does equalise it pops and then sort of whistles and crackles. I can tell whether I am ascending or descending purely by the feel of the pressure (and noise) on my ear - is this normal? Or is it something I should get looked at more seriously? It is particular evident on successive dives.Sometimes equalising can be very painful and I have to wait a little while before continuing with the dive. Any advice on how I can equalise easier or whether I should be concerned about this problem?

A - You should not be too concerned. As long as you can equalize then that's cool. It seems your Eustachian function is not as good on one side as the other. It worsens with successive dives as the tube might be getting inflammed slowly after each dive. If you had a toot of a nasal spray called Beconase an hour before subsequent dives, that would help. You can buy it over the counter at any pharmacy.

For more info on the vagaries of the middle ear, and hlpful tips on popping your ears, please look at "easy equalization" on the dive pages of e-med.

Q - I went on a dive and when I came up after an hour I had a hissing in my ear and have about 10% hearing. I have seen two specialists here in Oman but nobody seems to know what the problem is.

A - I assume these were ENT specialists, not gynaecologists. Odd they can't find the cause, as I would have put money on either perforation of the ear drum, or middle ear barotrauma.

If you can hear hissing still, especially if you try to equalize, then think perforation. If the ear is hissing and painful, and feels full think of barotrauma.

But I assume they have had a look and can't see redness of the drum or a hole, in which case is it really hissing or tinnitus instead? As this combined with deafness could indicate a whole new level of problems. I think the best way ahead is to see an ENT surgeon with diving experience. I have had this before where divers end up seeing the "expert" who happens to be the King of Tonsillectomy, but has never seen a diver with an ear problem before. They're both ENT surgeons, but of course vary in expertise.

Q - Dear doctor, could you be so kind and tell me what is maximal allowed hearing loss to pass HSE diver exam. I am commercial diver, and I work and live in Croatia. I am thinking to take enroll HSE diving school and obtain HSE certification. After the war I got some hearing loss (from noise)and want to check can I pass medical according HSE. I been diving for 13 years and got logged more 2500 diving hours.

A - The HSE rules are that your hearing should be good enough to permit no loss greater than that of the normal spoken voice. There is a range there of course. From the shouty bloke on the train with a mobile, to the softly spoken priest at confessional in a quiet church. My rule of thumb is a 30 to 40 decibel loss is OK. Make sure you get an audiogram each year at your HSE renewal, as you don’t want diving over a period of time to tend you towards full deafness. If it were you may have to pull out of commercial diving. That wouldn’t be so bad though, as from what I read over here, the best thing you could do in Croatia right now is open up an estate agency. We’ve already bought most of France, its you lot next.

Q - For the past 9 months I have had problems with pressure in my ears (popping/squeaking/squelching), tinnitus and difficulties with my balance. I have visited an ENT specialist on 3 occasions and recently had an MRI scan (which was clear). He has diagnosed me with labyrinthtis and says there is nothing more he can do.

Three months before having these problems I had done a large number of dives (30-40) some of which were deep (40-55 meters) and had no problems at all after. I have been told that there is no way it is connected but can't help but think it must have something to do with it.

It is possible to experience such problems so long after diving or is it in no way connected?

A - I think I've gotta go with the ENT team here.

3 months after diving is too long a gap for any ear problems, be they middle ear barotraumas, or even inner ear DCS to appear if they were diving related.

If the problem you describe had been either immediate, or even up to a week after, then I would have suspected diving as the cause. The only other explanation would be that you didn't realise until 3 months after the diving that you had a problem. But a popping squeaking squelching sound in your ears is pretty recognisable from day 1, unless you were the sound engineer on a porno shoot!

I will say though, in my experience that labyrinthitis is normally associated with dizziness and vertigo. Its an inner ear problem you see, inflammation in the balance centre, often caused by a virus. Popping and squeaking is more likely middle ear. So this could be one of those chuck away diagnoses when they can think of nothing else. I reckon you ought to get your scan results and go get a second opinion from a middle ear specialising ENT surgeon.

Q - Has there been any research into the long term effects of scuba diving on hearing? As a sound engineer by trade, this is something that concerns me when I go diving. Apart from a couple of cases of Otitis Externa after diving holidays I've never had any ear problems whilst diving and am always very careful about keeping descents slow and equalising effectively. What I have noticed, however, is that it always takes some time for my hearing to return to normal after a diving trip and in my line of work this is worrying. Am I doing myself permanent damage by continuing to dive? Is there anything I can do to protect my ears even more?

I would greatly appreciate any thoughts you may have on this subject.

A - I have not come across any real significant research on this. I suppose it all depends on how easy you find it to equalize. Remember it only takes one dive with a bad blow out to give permanent ear problems, and you have dived many times with no problem.

If you do find you are a bit hard of hearing after a dive trip then have a look at my piece "Easy Equalizing" on the e-med dive pages for various tips as to how to improve your chances of no ear problems diving.

Q - I recently started an open water PADI course and have completed two pool sessions. Upon filling in my medical form it was apparent that I had to tell the dive master that I had a mastoidectomy thirteen years ago. He suggested I consult a G.P. who referred me to an ENT specialist. The specialist looked at my ear and was doubtful as to whether I could dive because he was unsure what the operation entailed. He had an incling that there was a cavity around where my mastoid had been removed and was concerned that a bony bridge had been built between an organ around my middle ear and inner ear to enhance my hearing although the name of the organ evades me. I am very keen to take up diving even if it means having to be restricted to limited depths or having to have some sort of surgery. Could you please advise.

A - This is a tough one. It depends really on why you had the mastoidectomy and what has been left by the ENT surgeon.

If there is now a bony hollow which contains air then this space has to be able to be equalised. And for this to happen there must be a connection to your middle ear or and nose so the Eustachian tube can pop some air into it as you descend. On top of this if pressure were to increase on a dive you also want to be sure its not going to damage and of your hearing and balance mechanisms in the middle and inner ear.

My advice is to see an ENT doctor who specialises in diving. They are thin on the ground though, but I know a couple of good ones in London. Let them have a poke around your ears, and if they can’t make the call they may order a CT scan to see what’s going on.

It may be worthwhile also taking along your hospital notes and any X-rays from the op, so get the wheels in motion now to get this from your old hospital. And don’t let them say you can’t, just quote the freedom of information act. Good luck.

Q - 3 weeks ago I was diving out of Weymouth and had a fast decent to 34m, during the decent I failed to equalise properly. After 4mins at 34m we made a very slow ascent (19mins) and respected all stops. At the surface I had a nose bleed. I continued diving the rest of the week end, experiencing only slight discomfort in my ears. They felt better under pressure but I experienced no pain on the ascents.

Since the weekend I have had pain in both ears and the feeling that I need to equalise permanently- my ears have still not cleared. Having thought I had an ear infection my GP prescribed antibiotics, ear drops and recently a nose spray-Flixonase. These have made no difference to my current condition.

I would like to thank you for taking the time to read me email and would very much appreciate any advice that you could give me.

A - You are a lucky diver. A rapid descent to 34 metres without equalising properly can only mean one thing. Barotrauma. And often this one dive could affect your ears so much that you wouldn't be able to dive again for a while, so the fact that you were able to equalise for the rest of your dives means you goy away lightly. The reason you feel like your ears have yet to clear is that as you descend, if you cannot blow the necessary air up your Eustachian tube into your middle ear then what happens next is the process by which the barotraumas results. The increasing negative pressure or vacuum in your middle ear as you get deeper will pull inwards your ear drum and also the vessels lining the middle ear. Some thick exudate from these vessels will fill up your middle ear as well as your Eustachian tube so that after the dive you feel bunged up like after a cold.

On top of this anyone having a look down your ear canal will see a bloody red ear drum as all the vessels have expanded and burst as they get sucked in with the negative pressure inside your ear. This redness is often mistaken for infection and the doc hands out some antibiotics thinking it will help. Well it wont as here time is the great healer. The flixonase is a good call as anything that can help make the Eustachian tube wider will help, and as this is an anti-inflammatory it will. I also suggest Sudafed tablets too as they have a small amount of adrenaline like substance which helps constrict the inflammed lining of your nasal and ear passages. However be warned as we all know this is what got poor old Maradonna sent home from Italia 90, so if you are a professional athlete tell the judges that your performance enhancement is on my orders!

So stay on the flixonase, add Sudafed and give it about a month or so to get better.

Q - This March after a dive to 14m for 40 minutes, I carried out a 1minute stop at 6m & then suffered a reverse block (I did have a very slight cold at the time) upon ascending (which hurt a lot until I reached the surface), since then I've had continual tinnitus in the afflicted ear. This is in the form of very faint 'interference' rather than ringing. My afflicted ear, and strangely, to a lesser extent, my 'good' ear were both initially sensitive to sudden changes of pressure caused by such things as car doors slamming, but this has now diminished greatly.

My GP referred me to a specialist, who tested my hearing. The test showed I had a slight loss of hearing in the high frequency range. The specialist decided that I must have ruptured my round window (despite the fact that I have not experienced any dizziness), and warned me against diving again. I asked him why I hadn't experienced any dizziness as a result of this & he couldn't explain this, nor could he explain why my 'good' ear was sensitive to sudden pressure changes.

I've carried out 30 dives since March, including several to 40m involving decompression stops of up to half an hour - & my ears have not given me any problems.

My question is do you think I really have ruptured my round window (I understood that subsequent loss of perilymph fluid resulted in vertigo), & if not, could the tinnitus be caused by something else such as a stretched ear drum, or damaged acoustic nerve?

I would really appreciate a reply on this!

Many thanks,

A - This is a tricky one to deal with and one that probably needs referring on to an ENT diving doc. From my intro to this column you can now see why it is best to deal with someone who understands diving as it is the easiest thing to just say to a patient "you can never dive again" when in reality they probably could if they had someone who understood hyperbarics better.

Anyway, his automatic assumption that it is a round window problem is not strictly accurate as tinnitus can result from other damage during a reverse block. Generally round window and cochlea (part of the inner ear) damage would give you a loud tinnitus whereas middle ear damage, to the drum and the ossicles could cause a tinnitus of a lower volume like you seem to be experiencing. Also it is the oval window that connects to the balance part of your inner ear and so damage to this would cause dizziness and vertigo. So before you think that you will never put on a BC again, get a second opinion from another ENT Consultant.

Finally if there is any vertigo or dizziness after a dive, a diagnosis of inner ear DCS should also be considered, and prompt advice from your local Hyperbaric Chamber sought.

Q - I have been Diving for 4 years and my son wants to take up the sport, he had a mastoidectomy about nine years ago would there be any problems with him diving?

The ENT Specialist told us there could be a risk of the occasional infection.

A - Thanks for your interesting question.

The good news is that a previous mastoidectomy is not a bar to diving or learning to dive. As you probably know, the mastoid is a bony outgrowth from the skull that only really serves as a muscle attachment for the sternomastoid muscle that stabilises the head and neck. They have to be removed for chronic infective reasons.

Now as there is no communication with the middle or outer ear , removal of the mastoid should not affect equalising.

However as there can be some proximity to the middle ear outlet... the Eustachian tube, you should check that he can equalise normally.

If he can then he is free to learn to dive.

Because he has had this op. he will need to get clearance from a medical referee before learning.

Q - I have been diving for over 10 years now and do suffer from sea sickness. 18 months ago I went on a live aboard and was taking Sturgeron. I had to seek medical advice in Egypt after a reverse block on ascent ruptured my L tympanic membrane. I was told that it was the medication that contributed to block and so to the rupture. I am now diving again with no problems (other than sea sickness) but am going on holiday and need some advice about what medication I can take, as it can be misery without it but obviously do not want to scupper the holiday or my ear again.

A - This is a very interesting point you have brought up here, and one which I have been asked a lot. Exactly what is the best treatment for seasickness when you're diving and what other preventative measures you can take.

Stugeron, or cinnarizine as it is known medically is an antihistamine. It stops seasickness by stabilising the inner ear's balance centres, however as an antihistamine it also decreases any mucous production too. What could have happened to cause your eardrum to blow is an increased mucous production if the drugs effects wore off.

This could have blocked your Eustachian tube thus stopping the air from escaping down it as you ascended. Result .blown eardrum.

The other thing about cinnarizine is that it's antihistamine properties are sedating. The makers don't recommend you drive on them, so I don't think you should dive on them either. Doziness underwater can only lead to errors of judgement so best leave them alone.

So where does this leave the seasick diver?

Well I would recommend you try one of the homeopathic alternatives, such as Nelsons Travella which don't sedate, or even those acupressure wristbands to start with, as at least there are none of the side effects of antihistamines.

If someone does need something a little stronger then I've found prochlorperazine a good non-sedating medication. Its prescription only though and you need to see a doc to get it.

Q - Any hints on how to clear a blocked ear which is hanging around a week after diving? Will it eventually clear or should I be worried?

Any advice would be greatly appreciated!

A - Yes, you need to widen the diameter of your Eustachian tube. This can be achieved by using nasal sprays like Beconase or Otrivine which constrict the cell lining of the tube and so increases the bore.

Or you can take Sudafed tablets orally which have the same effect. On a more non druggy way, try inhaling steam with Eucalyptus as this can dislodge the blockage.

Q - My husband has just had a 'modified radical mastoidectomy', and he has not yet completed PADI Open Water qualification - will he be able to dive?

A - The short answer to this is no, I’m afraid. I’ll explain. Orientation first: everyone know where the mastoid is? Put your fingers behind your earlobe and the hard bone you can feel is our culprit. The mastoid contains air cells which are connected indirectly to our friend the middle ear. This means that infections in one can often spread to the other. Lots of gooey middle ear infections can lead to an overgrowth of the skin of the eardrum, which goes by the lovely name of a cholesteatoma, and if this growth is left unchecked it can increase in size and destroy the surrounding delicate hearing bones of the middle ear.

The “modified radical mastoidectomy” is a very long complicated name for what is, in essence, removal of infected mastoid bone. The theory goes thus: a cavity is created in the ear which is open to the outside world, this therefore makes ear diseases such as cholesteatoma safer by allowing an easy passage of disease out of the body. Now the “radical” mastoidectomy is not some politically extremist form of surgery – it refers to removal of the eardrum and 2 of the tiny bones in the middle ear that conduct sound, in addition to removal of the infected mastoid. This is only done in the most severe cases as it often leaves the poor patient with damaged hearing. In the “modified” version, the bones and the eardrum are saved, which preserves hearing as much as possible. But the issue with both these procedures and diving is this: because the mastoid is now connected to the outside world, it is much more susceptible to infection and water can flood straight in, hugely increasing the risk of vertigo. As you would imagine, a sudden unheralded attack of dizziness is not ideal underwater, so the view of most doctors is that diving is unsafe in these circumstances. Vented earplugs theoretically can stop water entering the ear, but these can be unreliable and any leakage could be disastrous. I think your husband would be best off sticking to above water pursuits from now on.

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