Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
Q - I am a keen diver and my wife is interested in trying. However, she has for several years suffered from intermittent BPPV (benign paroxysmal positional vertigo) and is unsure if diving is likely to cause her problems. She is 45, otherwise in good health and has not had a problem with BPPV for 2-3 years now, but is hesitant to risk it recurring. Any advice would be much appreciated.
A - Despite being the subject of one of Alfred Hitchcock’s best films, vertigo has very little to do with a fear of heights. It’s actually defined as “an illusion of movement, either of the external world revolving around the individual or of the individual revolving in space”. BPPV is a particular form that is thought to be due to things called otoliths, or “ear rocks”, collecting in the canals of the inner ear that transmit the sensation of balance. Certain postural changes cause these otoliths to shift about and the brain interprets this as movement, rendering the hapless victim dizzy, sweaty and nauseous. Attacks are often brought on by changing position, for example rolling over in bed or stretching the neck (giving rise to BPPV’s seedy alternative title, “top shelf vertigo”). Luckily episodes are normally over within thirty seconds or so.
BPPV can be treated with something called the Epley manoeuvre, a neck mangling technique which is designed to dislodge the rocks once and for all. It’s usually quite successful, but occasionally surgery is needed for those with severe or recurrent episodes. There are also some drugs which aim to suppress the inner ear impulses, but these are often sedative, don’t work well and would not be suitable for divers.
So in your wife’s case, it would be important to check whether neck movement set off any symptoms, as the neck can be extended for prolonged periods during a dive. If she hasn’t had it done already, she ought to have the Epley manoeuvre performed. If successful, I think she would then be fine to give diving a go. As with many conditions, if she’s with a trusted buddy who knows about the problem (presumably yourself), she’s in safe hands.
Q - Hi Doc. I am at this moment recovering from a rather nasty bout of the flu. As is usual with the NHS, I couldn't get to see my GP until 3 weeks after my death. I was forced to call an emergency doc. When he examined me I told him that I had very bad headaches & felt as I though I had an inner ear infection. He said it was labyrinthitis, for which he gave me amoxicillin. As I still had the bad heads after 4 days I again went to see the emergency doc. Saw a different doc this time who said I didn't have labyrinthitis, to keep on doing as I was. It took about 8 days for the headaches to subside. All symptoms seem to have now gone, my question to you is: I shall be going on holiday in about 6 weeks, as a diver will I be okay to dive? J Daniels Esq. & Bar (mainly in the Bar).
A - Your first name wouldn’t be Jack, would it? If so, pleased to make your acquaintance again. I think the last time we met I was victim of a quadruple shot of your good self, after losing a bet at medical school… Labyrinthitis is an inflammation of the inner ear (the labyrinths are the areas that sense changes in head position). Your typical bout comes on a few days or weeks after a trivial cold, and presents with true vertigo (spinning dizziness), vomiting and a “generalised ill feeling”. Usually a virus is the culprit, but it can be precipitated by a head injury, allergic reaction or acute stress. Recovery takes anywhere from one to six weeks, but in some unfortunates, permanent damage to the inner ear leaves them with debilitating panic and depression for years. So, Jack, whether you had labyrinthitis or not, as you are now asymptomatic I would guess that you’ll be fine to dive in 6 weeks. Just remember to drink responsibly.
Q - I was doing my Open Water course last week. I had trouble equalising on my first dive and had to push really hard to pop my ears. At about three metres, I suddenly got dizzy. Everything was whirling around so I came up quickly. It seemed to settle on its own, so I did three more dives, all to about 7m, and had no problems on those. A day later though the vertigo came back, much worse than before, and I had loud roaring and ringing noises in both ears. Now every time I cough or get up or turn my head too quickly, I get very bad vertigo, I feel sick and very unsteady. Also, my hearing seems to be good some days, and bad on others. What should I do?
A - This sounds to me like a classic case of inner ear barotrauma. The key pointers are the persistence of your symptoms, their association with positional change, and the fluctuating hearing loss. I suspect that there’s been a rupture of the cochlea, what we call a “perilymph fistula”, and each time you strain or move, there’s fluid leaking out, causing your symptoms. You should see an ENT specialist as soon as you can, to get investigated properly, but I can make a few suggestions here. What you need to do is steer clear of any situations that increase the pressure in your head. This means avoiding sneezing, coughing, lifting, sexual activity, equalising… basically anything physically strenuous. Ideally bedrest is advised, in a quiet environment, to allow the fistula to heal. This can take several months. I’m sorry to report that in many cases there is permanent loss of some hearing, although the tinnitus tends to improve as the brain gets used to it. Quite often vertigo will persist too, and it would be difficult to sanction future diving in these circumstances.
Q - I have been having problems with what I think is Vertigo. Every time I dive in cold water I feel nauseous and last weekend I was violently sick during and after both of my dives. It didn't happen abroad (when the visibility was good and I was not wearing a hood) and it doesn't happen in the swimming pool. It seems to be worse when I am ascending up a slope. It has been suggested that I should flood my hood with water at about 1m on the descent and that this may help if it is an ear problem. Any suggestions?
A - Vertigo means many different things to different people. Depending on your tastes, a histrionic drone or a heartfelt chorus of Irish rock courtesy of U2; a serene cinematic exploration of obsession, courtesy of Alfred Hitchcock; or a genus of tiny land snails. Even in the medical sense the term is ripe for confusion. True “vertigo” is defined as “the sensation of spinning or rotating while the body is actually stationary with respect to the surroundings.” Not quite the same as the jelly-legged feeling as you peer over the railings of the Empire State Building; more the whirling dizziness experienced on the bathroom floor after an over-exuberant binge drinking session (so I’ve been told).
Numerous causes for vertigo exist; those specific to diving include narcosis, sea-sickness, hangovers, DCI, contaminated gas mixes, hyperventilation, and equalising problems (not necessarily in that order). I suspect in this case that the vertigo is due to the sudden exposure of the ear to cold water. This can occur in other situations such as having your ears syringed (in the medical world we call it “caloric stimulation”). If the ears are exposed unequally (for example if one ear is completely bunged up with wax), for a few seconds only, it can confuse the brain and cause vertigo and nausea. Once the water warms up the effect usually goes away. So you should get your ears checked out for any blockage such as wax, and if it persists, give your ears a good soak before you descend, to see if this will alleviate the effect.
Q - I am congenitally deaf in both ears and was lucky enough to be the recipient of a cochlear implant when I was 3 years old. I'm now 24 and have been wondering for the last few months whether there is any chance of ever going diving. My ears are fine when I fly on planes and I don't get infections or any other problems from them. Is there any information available on the safety of cochlear implants when diving?
A - Indeed there is. But first a little history, as some of this is great “eccentric scientist” stuff. Apparently the lengthily named Count Alessandro Giuseppe Antonio Anastasio Volta (from whom we get the well known electrical unit) was the first to discover that sound could be perceived by directly stimulating the auditory system. This he did by sticking a couple of metal rods in his own ears and connecting them to a 50 volt circuit. He experienced a “jolt” and a noise “like a thick boiling soup” (presumably his brain curdling). Nearly two centuries later some adventurous surgeons zapped an exposed acoustic nerve, whose owner heard sounds like “a roulette wheel” and “a cricket”.
These macabre experiments laid the groundwork for the cochlear implant, or “bionic ear”. Essentially it’s a surgically implanted electronic device which directly stimulates auditory nerves. External parts (including a microphone and speech processor) transmit sound signals to an internal receiver (implanted in bone behind the ear) and thence into the cochlea (the hearing bit of the inner ear) via electrodes. Not your average hearing aid, which is basically an amplifier. The results are pretty impressive, especially in those who have grown up with the implants, whose brains have presumably learned to “hear” in a different way. Older recipients are often not as enamoured with the devices; one described a human voice as sounding like “a croaking Dalek with laryngitis”.
Anyway, the deal with these and diving is that we need to be sure the various bits will not implode, explode, rust or generally become defective in water and under pressure. In this sense the situation is similar to the heart pacemaker. The implant manufacturer or surgeon who carried out the procedure should have some data on the safety of your particular device at depth, so you’d be well advised to consult them initially. If all is OK with them, and as long as your middle ears can equalize effectively, then there’ll be nothing stopping you.
Q - I was told to contact you by my local diving school before undertaking their PADI diving course. I have never dived before, but I would very much like to during my stay in the Maldives this April.
My issue is with vertigo, I developed this back in 2003 after being on a small boat in Barbados. I was never sick only slightly nauseous. However the feeling of swaying stayed with me for a few days after the boat trip. By the time I reached the UK, I was experiencing such severe spinning and dizziness that I was unable to drive etc. The vertigo persisted for nearly 6 weeks before I returned to normal.
The second episode was in the Maldives 2006 after I again went on a boat trip (thankfully it was very mild and lasted no more than 3 days). It probably helped that I refrained from snorkelling and generally tried to rest. However in August 2006 whilst in Egypt I again returned to the UK with severe vertigo that lasted around 5-6 weeks in total. I was signed off for 2 of those weeks because I couldn't even sit at my VDU or drive.
I'm a 27 year old female who leads a normal active life, since the first episode I have cut out unnecessary salts and high fatty foods from my diet and I barely drink alcohol and never fizzy drinks or coffee and tea. I train 4 times a week (I'm currently training for the Edinburgh marathon this year), so in general my fitness is good.
The doctor examined ears thoroughly the first + second time I had the vertigo, and could find no perforated ear drum or obvious reason for the symptoms. I was never prescribed medication or given anything apart from eye exercises to follow.
In August ‘06 the doctor prescribed me 4 different types of medication… there was little or no improvement in the vertigo and as with the first episode in ‘03 it seemed to eventually dissipate by itself.
I'm at a loss, I don't think the diving would actually cause me to have vertigo again… but I'm positive being on the boat and the motion of being on top of the water will… the same as when I'm snorkelling.
I really didn't want to bore you with my life history but I thought it better to try and give you all the facts surrounding the vertigo etc. I have searched the internet and read loads of articles re. vertigo and preventing it. I even read about an injection you can take to help prevent the nerves sending the message to brain that you're moving - thus stopping the vertigo kicking in (apparently) but I need professional advice.
Any feedback or info would be gratefully received and I would gladly pay for a cure/prevention if there is such a thing to enable me to undertake a diving course prior to going away this year.
A - That’s a long tale indeed. I assume that you have never dived before, but just being on a boat causes this intense spinning and dizziness. It sounds motion related - do you ever get the same effect in cars or on planes? You’ve been through most of the normal measures used to relieve vertigo and motion sickness without any luck. The next step would be vestibular exercises and quirky ENT manoeuvres involving twisting your head and neck into awkward positions. These can sometimes help but you would probably need to see an expert ENT doctor for these. I would say go for the pool dives on the open water course and see what effect that has on the vertigo. If you’re OK then progress to some nice calm shallow shore diving and again see what happens. You might make it to some boat diving in ultra-flat seas but if at any stage the vertigo returns you will sadly have to forget diving and choose a safer leisure pursuit that doesn’t involve big swells and brain operations.
Q - I'm waiting for a Cochlear Implant. Will I still be able to go diving with the implant? If this is possible is there a time scale once I've had the operation to begin diving again, and is there a depth limit? Currently I don't dive beyond 30 metres. I have no problem equalising or have any other problem with my ears.
Hope to hear from you soon.
A - And I hope you can hear from me soon too. There are a few issues here: Firstly, there are some docs that don't let divers with deafness on one side dive, as if you were to frag your other ear, then that becomes totally deaf, a terrible situation. However it seems you have been given the OK, and are diving merrily, so it would be a cold heart that stopped you now.
So, can you dive with this little gizmo that cures nerve deafness? Well, it all depends on the manufacturer. Its rather like pacemakers, you can use them but only those that churn them out, know the mechanical limitations with depth. You have to ask your ENT surgeon to find that out for you. Once fitted, they sit in your inner ear, and interface with the middle ear. Oh, and they cost a fortune too. So you must make sure that if there were a dive problem, that you did not burst your ear drum, letting water flood in, and potentially affecting it in the inner ear, that it did not stop working. Again, this is a worst case scenario, and as you can pop your ears fine, it should not happen, but it might be an idea to wear the Pro-Ear mask, as this could build in a safety factor.
Finally, I would leave this a couple of months before diving, if all the above is OK.
Q - I became partially deaf as a result of the german measles at the age of eleven. I have been diving for the last two years and as yet had no effect on my hearing. Is it possible if I continue to dive my hearing may worsen?
I intend doing my diving instructors course but is it possible that my G.P. will not give me a clear medical.
A - I don't see a problem here. The only way you could worsen your hearing is by blowing your middle ear on a dive, but as you know divers do not suffer a serial decrease in hearing just because they dive.
It may be wise to get an audiogram before you do the IDC for medico-legal reasons, just in case your employers in the future send you down with a bunch of muppets who somehow cause you to blow said ear. At least you would have a baseline measurement in case of future litigation. Mind you it is part of the HSE medical you should be having to pass your IDC, but this is in the UK and not necessarily in other parts if the world.
Q - I wonder if you would be kind enough to advise on what to me is an apparently simple question, but may very well not be. Recently from an acquaintance I understood the following: a young woman, very good swimmer, qualified lifeguard at municipal swimming pool, would very much like to learn dive with scuba, but has been advised, by whom I do not know, that because of deafness, which causes her to have to wear a hearing aid, presumably only while not swimming, she would not be able to descend more than a very few (two or three?) metres. The question is therefore: is it generally true, or entirely false, that deafness prevents diving, or only that certain conditions involving deafness may do so?
A - You are right there. It very much depends on the condition that causes the lack of hearing. In a nutshell any cause that also has tinnitus and vertigo as a problem such as Menieres disease may be a problem. Likewise an auditorty nerve tumour that is untreated could also be an issue.
However if it is also a problem that has destruction of the ear drum or middle ear then there would be a situation where the inflow of water or inability to equalise would prevent diving. Some deafness, though is a simple affair present from birth and in these situations she may well be fine to dive.
There are issues of communication underwater that should be addressed. She should always stay close to her buddy and even thing of an alternative way of being attracted in case of emergencies. Also think about situations on ascent where a boat is coming in, she has to always come up under a hearing buddy so she can be protected from not hearing the props on ascent.
So don't worry about underwater hearing aids and depths, but get advice on the exact nature of her deafness, but she could well be fine to dive.
Q - For some time now I have been trying to pluck up the courage to learn to dive. In October last year my partner (an experienced SAA dive leader) and myself went to the Red Sea for two weeks and, whilst there, I finally managed to do a PADI "Discover Scuba Diving" course which entailed basic theory and pool work plus two dives. This whetted my appetite and, since then, I have been gearing myself up to do my open water certificate. However, I have some concerns about my ears and am wondering whether I should dive or not?
Firstly, about 12 years ago I woke in the middle of the night with the feeling that the bedroom was spinning violently. After this incident I experienced a lot of dizzy spells and, after several visits to various doctors I was told that I had probably had a bad ear infection. The dizzy spells subsided but ever since I have had problems with my balance if I go on a reasonably long boat journey. Basically, when I get off the boat I still feel as if I am on it (i.e the floor and objects around me seem to be moving up and down like the swell on the water!) for a number of hours afterwards (usually until I have had a good nights sleep). When I mentioned this to my GP he said I have a "delicate" balancing mechanism, which is easily unbalanced! I have also spoken to friends and have been told (rightly or wrongly) that there is a "pea-shaped" lump behind your ear, which is what affects our balance. I can feel one behind my right ear but not behind my left, which is the ear that I had the infection in. Could the infection have damaged this balancing mechanism and if so will it affect me when I am diving?
Secondly, for some time now I have been experiencing pain in my left ear. It is not like an earache as it is not totally inside my ear. When I experience the pain it hurts to touch around the entrance to my ear and also around the back of my ear. Sometimes the pain is also accompanied by a slight sore throat! I have spoken to my GP but he said he couldn't see anything wrong. However, on the occasion that I did go diving, and also in the swimming pool, I experienced some discomfort in my ear. I have put it down to the coldness of the water against my eardrum but am wondering if it is anything more serious?
A - That's a long old ear question there that probably deserves a far fuller answer than I can give you right now.
But to take your points individually, the coming off the boat problem first of all. This is completely normal. In your balance part of the ears are the organs responsible for you feeling steady. They're called the "semi-circular canals" and this stuff called perilymph whooshes around inside them to tell you at which angle you are. After a boat trip the nerves that this liquid is connected to continue to think they should be getting messages of movement. You aren't of course, but the brain hasn't figured that yet so you still feel you are moving up and down. So don't let that stop you diving. As for the pea sized lump that controls your balance your friends tell you about. You are rubbing the wrong pea sized thing. The mastoid has little to do with balance and a lot to do with where a muscled attatches to your skull, so no worries there.
As for the penultimate about the ear pain, if your doc says all looks fine but you have this nagging pain around your ear it could well be a neuralgia. Get to see an ENT surgeon if your GP is offering you little help.
And finally, your dive in the pool pain was probably due to not equalising properly, and for tips of how to do this look at the archived answers I have on the e-med site as I have my pointers of how to do this properly on the "Dive Medicals" pages. All in all you will probably be fit to dive, just get seen first by your local dive doctor.