A 55 year old female diver, had difficulty to equalize the pressure in her left middle ear during a diving descent, she had to make a forceful valsalva maneuver a few times to be able to equalize the pressure. She complained from some pain after the dive and decided not to dive the second dive that day
She was found by examination to have moderate middle ear barotrauma, with intact ear drum.
Over the next few days, she noticed that hearing over this side was getting progressively less, she attributed this to the barotrauma, but as she was taking her medication, and the pain was getting better, the deafness got worse, and she started having tinnitus as well.
On Examination, her deafness was found to be senosoneural deafness, meaning that the deafness was due to the inner ear injury or nerve injury.
How did this happen?
The explanation built on the studies of Harker and co-workers (1974) is that the inadequate middle ear pressure equalization during descent results in the pressure of middle ear to become negative relative to the intralabrynthine pressure of the inner ear, the forceful valsalva maneuver in an attempt to equalize the middle ear pressure, increases further the pressure difference by increasing the intralabrynthine pressure as a result of increase in the cerebrospinal fluid (csf )pressure, with resulting oval or round window rupture.
This case was diagnosed as inner ear barotrauma due to oval window rupture.
Management of this case is first conservative with bed rest and avoidance of any measures that lead to an increase in the pressure of csf such as coughing, straining, nose blowing, carrying heavy objects, or any physical exertion.
With improvement of this case, it meant healing of the oval window tear.
Neglected or unimproved cases might need surgical intervention.
What to avoid in such a case?
Flying is not recommended in the first few weeks following the injury unless in a one bar pressurized aircraft.
Recompression Treatment should be avoided unless it is essential for another injury as it worsens the condition.
Medication without consulting a physician could be dangerous, as aspirin that is considered a bench medication could precipitate hemorrhage in the swollen traumatized tissues of the inner ear.
Conclusion
Hearing loss, tinnitus, or attacks of vertigo following a dive during which the diver had conducted forceful valsalva maneuver, should be promptly investigated and managed before progressing to permanent hearing loss.
