Scubadoc's Diving Medicine Online Comprehensive information about diving and undersea medicine for the non-medical diver, the non-diving physician and the specialist.

ENT Problems

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This page is compiled and maintained by
Ernest S Campbell, MD, FACS

Table of Contents
ENT Anatomy
ENT Guidelines for the Medical Exam of the Diver
Symptoms of Ear Dysfunction
Temporary Ear Dysfunction in Diving
Chronic Ear Dysfunction in Diving
Tinnitus
Intracranial Difficulties due to Barotrauma

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Link to Ear Problems
Dr. Fred Bove's excellent web site

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Equalizing Techniques
An article by Allen Dekelboum, MD
Download zip

Download PDFFree Download

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Sensori-neural Hearing Loss and HBO2 Therapy
Allen M. Dekelboum, MD
Download PDFFree Download

ENT Anatomy

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The Ear

The external ear canal is a blind tube ending with the ear drum. The cerumen, or wax, is slightly acid and has a protective function. The ear drum has evolved to vibrate with sound waves in the air which is present on both sides. Herein lies the problem with diving --the air-filled space inside the ear drum has to have pressure equalized as a diver goes down and up in the water column. This can only be accomplished without pain and damage by air passing back and forth through the Eustachian tubes. These tubes are easily blocked by problems in the back of the nose.

Middle Ear

Inner ear
   The inner ear consists of fluid-filled bony channels in the temporal bone and has  nerve cells that are concerned with balance and hearing. These structures are separated from the middle ear by windows with very thin membranes, the round and oval windows, that are subject to rupture by excessive Valsalva maneuver with trying to clear the ears.

ENT Guidelines for the Medical Examination of Scuba Divers

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Ear
History

• Inability to equalize pressure in the middle ear by auto-inflation. This may be due to a correctable problem such as polyps, nasal septal deviation or coryza in which case the diver can be reevaluated after correction of the problem.
• Perforation of the tympanic membrane. Until fully healed or successfully repaired with good Eustachian tube function, diving is contraindicated.
• Open, nonhealed perforation of the TM.
• Monomeric TM
• Tympanoplasty, other than myringoplasty (Type I)
• History of stapedectomy. * Recent studies have shown that this is not necessarily true. See this article:

Otolaryngol Head Neck Surg 2001 Oct;125(4):356-60
Diving after stapedectomy: clinical experience and recommendations.
House JW, Toh EH, Perez A.
Clinical Studies Department, House Ear Clinic and Institute, 2100 West Third
Street, Los Angeles, CA 90057, USA.

CONCLUSIONS: Stapedectomy does not appear to increase the risk of inner ear
barotrauma in scuba and sky divers. These activities may be pursued with
relative safety after stapes surgery, provided adequate eustachian tube
function has been established.

• History of inner ear surgery
• Status post laryngectomy or partial laryngectomy
• History of vestibular decompression sickness
• Radical mastoidectomy (posterior) involving the external canal is disqualifying. (Closed childhood OK)
• Meniere's disease is disqualifying
• Labyrinthitis
• Perilymphatic fistula
• Cholesteatoma is disqualifying
• Cerumen impactions -remove before allowing to dive.
• Stenosis or atresia of the ear canal-disqualifying.
• Facial paralysis secondary to barotrauma
• Tracheostomy, tracheostoma
• Incompetent larynx due to surgery (Cannot close for valsalva maneuver)
• Laryngocoele  

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• Recurrent otitis externa or media
• Eustachian tube dysfunction
• History of Tympanic Membrane perforation
• Significant hearing loss in one ear
• Midface fracture
• Facial nerve paralysis
• Full mouth prosthetic devices
• Head and neck radiation
• Migraine, severe (scotomata, CNS symptoms and stroke after diving)

• Physical Exam (see above)

  An intact ear drum and the ability to easily autoinflate each ear by use of a gentle clearing technique. The ear drum should be visualized while this is done to ascertain movement. Tympanic perforation is a contraindication to diving, as is a thin, flaccid eardrum. A middle ear sac (cholesteatoma), stenosis or atresia of the ear canal, infection, and wax obstructions are contraindications to diving.


• Laboratory Investigations
  Audiometric and electronystagmographic abnormalities indicating inner ear vestibular dysfunction should disqualify for future diving.
•    Nose and Paranasal Sinuses
  Patent nasal airways without acute or chronic nasal or sinus symptoms. Nasl polyps, septal deviations or anything blocking the Eustachian tubes need correction. Rhinitis medicamentosa and allergic rhinitis increase risks of barotrauma. Alpha blockers (Hytrin) causes increased mucosal congestion with increased danger of poor clearing.


•    Larynx
  A person with an incompetent larynx should not dive. This is evidenced by chronic symptoms od aspiration from regurgitation and reflux. See above for contraindications.

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Symptoms of Ear Dysfunction

• Ear Fullness and Pain

When the external ear canal is blocked with water and wax, or from increases or decreases in middle ear pressures, there will be a sensation of fullness, usually associated with some pain or discomfort. The diver feels that the ear has become blocked as there is an associated hearing loss from inability of the small bones in the ear to transmit sound. If the pressure differential gets high enough, the ear drum will rupture with extreme pain.

• Hearing Loss
 
Hearing loss can be conductive, that is, from physical blockage of passage of sound or transmission through the ear. It can be sensineural, or nerve hearing loss due to dysfunction in the inner ear, auditory nerve or brain. This can occur from blockage of blood vessels, trauma or bubbles in these structures, leakage of fluid, inflammation, or trauma induced degeneration as in excessive noise exposure. There can also be combinations of the above.It is widespread belief that old divers are deaf. Indeed, a number of audiometric studies have shown that a population of divers demonstrate hearing losses greater than in age-matched controls (Molvaer and Albrektsen, 1990, Susbielle and Jacquin, 1978).

Noise induced hearing loss is the most probable cause of hearing loss in professional divers. In professional divers these hazards include the rush of gas entering a chamber during compression, the circulation of gas in diving helmets, the use of noisy underwater tools and the occasional underwater explosion. There are other causes of hearing loss in divers and, even if obvious acute causes, such as decompression sickness and inner ear barotrauma, can be excluded, repetitive subclinical episodes of these same conditions must be considered.

•   Evaluation of hearing Loss
• Weber test
  Tuning fork test with sound heard transmitted into the affected ear from the forehead.


• Rinne test
  Tuning fork test comparing sound from the mastoid as opposed to the air. normally and with sensineural loss, bone conduction will be heard less loudly.


• Schwabach test
  Comparison of bone conduction between the diver and the examiner, testing the diver's mastoid tip first. If the examiner is longer, decreased nerve conduction is present.
• Tinnitus
  This is a spontaneous noise in the ear that can be from many sources; it can be a prominent symptom of middle ear disease, but is usually seen with inner ear or central auditory pathway disease. 

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Reference:

Scand Audiol 1999;28(2):91-6

Long-term effect of hyperbaric oxygenation treatment on
chronic distressing tinnitus.

Tan J, Tange RA, Dreschler WA, v d Kleij A, Tromp EC

Department of Otorhinolaryngology/Head and Neck Surgery, Academic Medical Center, University Hospital
of Amsterdam, The Netherlands. t.h.tan@amc.uva.nl

Tinnitus is still a phenomenon with an unknown pathophysiology with few therapeutic measures. During the last two decades, hyperbaric oxygenation therapy (HBO) has been used in the treatment of sudden deafness and chronic distressing tinnitus. In this study, we prescribed HBO to 20 patients who had had severe tinnitus for more than one year and who had already had other forms of tinnitus therapy with unsatisfactory results. Four
patients could not cope with the pressure gradient. The effect of HBO was assessed using subjective evaluation and VAS scores before and after HBO. Follow-up continued until one year after treatment. Six patients had a reduction of tinnitus and accompanying symptoms, eight patients did not notice any change and two patients experienced an adverse effect. Any outcome persisted with minor changes until one year after treatment. HBO may contribute to the treatment of severe tinnitus, but the negative effect on tinnitus should be weighed
carefully.


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• Vertigo
  Vertigo in Diving
Possible causes of vertigo in divers include hypoxia (low O2), hypercarbia (too much CO2), nitrogen narcosis, seasickness, decompression sickness, the effects of alcohol, sensory deprivation (spatial or blue orb syndrome), hyperventilation (a condition associated with anxiety causing rapid breathing blowing off too much CO2 with resultant lowered calcium blood levels), impure breathing gas, unequal caloric stimulation and middle ear pressure equalization problems. Dizziness can also occur with high pressure nervous syndrome, oxygen toxicity, unequal vestibular stimulation or response and decompression sickness of the inner ear.

LINK
Dizziness by Charles Yanofsky


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Temporary Ear Dysfunction in Diving
• Middle Ear Barotrauma
• Clinical Presentation
  This usually starts as a fullness or pressure that gets worse as the diver descends and improves on rising in the water. Pain ensues as the pressure differential rises or unless the diver is able to equalize. Some conductive hearing loss is present and there may be tinnitus and vertigo.With ear drum rupture, the pain is severe and there is usually associated vertigo as the water runs into the middle ear.


• Physical signs
  Signs are noted on examination and include edema and hemorrhage of the ear drum, retraction of the drum and collections of fluid in the middle ear. Various grades of severity are described as Teed Grade 0 through 5.


• Treatment
• Type 1 Middle ear barotrauma (symptoms without signs)
  Avoid diving until asymptomatic, can autoinflate both ears at the surface, until preexisting nasal problems have cleared. Systemic and topical nasal decongestants.


• Type 2 Middle Ear Barotrauma
  Signs and symptoms without perforationAvoid diving until complete resolution. Systemic and topical nasal decongestants. Prophylactic antibiotics. Systemic analgesics for pain relief.


• Type 3 middle ear Barotrauma
  Avoid further diving until ear drum has healed. Cleanse external auditory canal. Do not use ototoxic eardrops. Systemic and topical nasal decongestants. Antibiotics and referral to a surgeon if the ear drum does not heal in 1 to 2 weeks.

•  Prevention of Middle Ear Barotrauma (Article by Ed Kay, MD)

  Good prediving exam. Avoid diving with nasal problems. Good clearing techniques.(See below)

Descend feet first. This not only prevents venous congestion and swelling around the openings to the Eustachian tubes but allows observation of the diving partner, an impossibility during a headfirst descent. A diving problem can occur at any depth, and in most cases a diving partner (qualified) may be able to observe a problem onset and those perhaps reduce the risk to both parties.

Descend on the anchor line. This allows for minute up and down control while clearing and descending.

Don't dive after taking medication that causes nasal congestion. Examples are certain blood pressure and prostate medications. (Hytrin).

Commercial airline passengers sometimes experience barotrauma of the middle ear that requires treatment by a physician. A recent article by Thomas P. Brown, a US Navy physician, explains how such trauma occurs, how it can be prevented, and how it should be treated. The information can be interpolated to apply to divers--just reverse the sequence.

During aircraft ascent, ambient pressure decreases slowly, causing the tympanic membrane to bulge outward. When the pressure differential reaches 15 mm Hg -- approximately every 122 m (400 ft) in increased altitude -- the properly functioning eustachian tube vents the positive pressure. On descent, the ambient pressure increases; the tympanic membrane bulges inward, and the eustachian tube resists the positive inward flow. Passengers experience discomfort when the differential reaches 60 mm Hg. At 90 mm Hg, the eustachian tube locks up, preventing the equalization of pressure by whatever means. A 100- to 500-mm Hg differential causes the tympanic membrane to rupture, relieving the pain but often resulting in vomiting, loss of hearing, dizziness, and vertigo.

During barotrauma, the tympanic membrane becomes distorted with respect to color, shape and integrity. As barotrauma progresses, the tympanic membrane mucosa becomes edematous, there is hemorrhaging, and a transudate forms in the middle ear. The tympanic membrane sometimes ruptures because of weakness of the tympanic membrane, inadequate transudate or hematoma formation, or too rapid a change in pressure.

The most effective means of combating middle ear block is to avoid flying while experiencing upper respiratory tract infection. Passengers should yawn, chew, or swallow -- activities that open the eustachian tube momentarily and allow for pressure equalization. Valsalva's maneuver, taking a small breath, holding the nose, and attempting to force air through the closed nostrils, is especially effective in equalizing pressure during descent. If flying in a small plane with few passengers, the pilot may be asked to reascend.

One hour before takeoff and again 30 minutes before, two puffs of oxymetazoline hydrochloride will constrict the arterioles of the nasal mucosa, permitting the eustachian tube to function efficiently. Oral decongestants (e.g., pseudoephedrine and phenylpropanolamine), which affect areas that sprays don't reach, may be initiated 1 or 2 days before a flight. Newer antihistamines without sedating effects may also be effective. Severe or unremitting earblock may be treated by a physician using a Politzer bag. With the patient seated, one nostril is occluded and the flange of the bag is inserted into the other nostril. While the patient rapidly repeats the letter K or takes small sips of water, the bulb is compressed. The Politzer bag is effective in clearing ear block in 50% of cases. If the patient has excruciating pain or still has earblock after one week of the treatments described, myringotomy may be required.

 (Brown T. Postgrad Med. 1994; 96: 135-142.)


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• Ear Squeeze
  Link 
• External Ear Canal Barotrauma (External Ear Squeeze)
• Surfer's Ear (Bony exostosis)

This is a blockage of the inner portion of the ear canal by a bony growth called exostosis. This is more commonly seen in surfers, but occasionally can be seen in cold water divers. It is thought to be due to the cooling effect of evaporating water on surfers - and on the effect of cold water on divers. It can cause problems in divers by blocking the egress of cerumen and thus the canal, producing the possibility of an external ear squeeze, decreased ability to ewqualize, alternobaric vertigo and caloric vertigo.

Prevention is by the use of ear plugs in surfers and hoods or vented ear plugs in divers.
http://www.proplugs.com/scuba.html
Definitive treatment is by an operative procedure called canalectomy - or the excision of the bony area of the ear canal that is blocking the canal.
See also http://www.earaces.com/surfear.htm


• Otitis Externa


• Prevention of Otitis Externa
  Cleanse external canals of occluding wax and avoid trauma from Q-tips, bobby pins, etc. Use a good ear solution to maintain a slightly acid environment. A 2% acetic acid and aluminum acetate solution is a good choice. (The pharmacist either can make this up or provide a generic solution; 'Domeboro Otic Solution is not made or sold by Bayer any more.)


• Treatment of Otitis Externa
  Irrigate with lukewarm tapwater or 1.5% peroxide. Eardrops that are slightly acid or contain antibiotics.



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• Vertigo
• Transient Vertigo Resulting from Unequal Middle Ear Pressure Equilibration (Alternobaric Vertigo)
  This is dizziness resulting from unequal pressures. It is due to unequal increase in middle ear pressures on ascent.
• Transient Vertigo Resulting from Caloric Stimulation
  A similar vertigo can also occur as a result of unequal caloric stimulation of one labyrinth over the other due to diving in a prone position in cold water--the undermost ear being stimulated.
• Transient Dizziness Resulting from HPNS High Pressure Nervous Syndrome
  
• Link to Medline article (Incidence of Vertigo in Diving)
• Alternobaric Facial Paralysis
  The facial nerve traverses a canal very close to the middle ear. Middle ear over-pressure can cause damage to this nerve resulting in a one-sided facial paralysis. It is often associated with alternobaric vertigo. The paralysis is temporary.



Chronic Ear Dysfunction In Diving


• Inner Ear Injuries Related to Middle Ear Barotrauma During Descent or  Compression Inner  Ear Barotrauma
• Pathophysiology of Inner Ear Barotrauma
  This is thought to be due to implosive or explosive rupture of the round or oval windows in relation to diving stresses. Straining or valsalva maneuvers in attempts to clear the ears increases the pressure differential between the middle ear and the labyrinth to the point of rupture.


• Diagnosis and Management of Inner Ear Barotrauma
• Surgery for Inner Ear Barotrauma
  There is a debate as to the proper management of the perilymph fistula. Some feel that it should be operated upon immediately (Pullen). Some feel that watchful waiting should be done with operative closure of the perilymph fistuls done only when there is no improvement after 48-72 hours of bedrest with head elevated. Most authors advise an initial trial of medical management and that surgery should be undertaken on those who don't improve after 5 to 10 days or if inner ear function worsens in the meantime.


• Otologic Problems Occurring at Stable Depth
  Three divers experienced this in a chamber dive after changing from helox to a gas containing neon or nitrogen at depth. Vertigo, nausea, nystagmus were experienced and permanent end-organ damage was demonstrated in two of these divers.

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• Permanent Otologic Injuries Occurring During Ascent or Decompression (Inner Ear Decompression Sickness)
  This is related to nitrogen bubble formation in the labyrinthine vasculature.


• Human Reports of Inner Ear Decompression Sickness
  Buhlmann, A, Waldvogel W: The treatment of decompression sickness. Helv Med Acta 33:487-491.1967Rubenstein CJ, Summitt Jk:Vestibular Derangement in decompression. In Lambertsen CJ (ed):Underwater Physiology. Proceedings of the Fourth Symposium on Underwater Physiology. New York. Academic press. 1971, pp. 287-292.


• Management of Inner Ear Decompression Sickness

• Differential Diagnosis of Inner Ear Barotrauma and Inner Ear Decompression Sickness

This is important in that the treatment is entirely different. Recompression is necessary for inner ear DCS while it is contra indicated for inner ear barotrauma.
Factors helpful in the differential:
1. Time of onset--symptoms occurring during compression (Descent) indicate possible barotrauma. Those symptoms occurring shortly after decompression (ascent) are more likely related to DCS.
2. History of the dive profile--- shallow, air dives more likely barotrauma. Deeper, mixed gas diving--more likely DCS.
3. Associated symptoms of barotrauma, such as  pain, fullness, blockage with barotrauma; joint, skin or neurological problems with DCS.
4. Physical findings associated with barotrauma,ear drum findings: skin and neurological findings with DCS.


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Otologic Injuries Related to High Background Noise During Diving Conditions

Investigations have failed to definitely incriminate high background noise as the cause of sensorineural deafness seen in the usual diving population. Conflicting reports fail to provide enough information to allow for recommendations to be made one way or the other. (Farmer, JC in Diving Medicine, Bove, (ed.)

 


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Tinnitus and Diving
Ringing in the ears or 'tinnitus' (pronounced with the accent on the 'tin') is one of the most prevalent and bothersome of symptoms related to diving. Tinnitus may be caused by damage or disease, anywhere along the path of the auditory system.

Tinnitus is the perception of sound when no external sound is present; and is often referred to as "ringing in the ears." It can also take the form of hissing, roaring, whistling, chirping or clicking. The noise can be intermittent or constant, with single or multiple tones; it can be subtle or at a life-shattering level. It can strike people of all ages and, for most, it is difficult to treat.

It is estimated that over 50 million Americans are affected by tinnitus to some degree. Of these, about 12 million suffer severely enough to seek medical attention. And, about one million sufferers are so seriously debilitated that they cannot function on a "normal," day-to-day basis. In diving, it is a symptom of serious changes that have occurred because of the effects of pressure, either barotrauma, excessive attempts to equalize or to a decompression accident.

In divers, it also can be related to TM joint pressure from clamping down on the mouthpiece, wax buildup in the ear canal with tympanic membrane irritation, barotrauma to the middle and inner ear, decompression illness involving the inner ear, or rupture of the round window with perilymph fistula. With the latter, it most often found in association with vertigo and there is usually some deafness.

It may also be caused by physical trauma, infections of the ears, long standing exposure to very noisy environments, scarring and rigidity of the small bones in the middle ear (otosclerosis), toxic damage by medications (e.g. Streptomycin), and tumors of the brain or the auditory (hearing) nerve.

Tinnitus is still a phenomenon about which we know little and which has few effective treatments. During the last two decades, hyperbaric oxygenation therapy (HBO) has been used in the treatment of sudden deafness and chronic distressing tinnitus, with mixed results. Other therapies include non specific prescription  medicines,  non-traditional medical treatments, such as acupuncture, stress reduction and relaxation therapy, hearing aids and biofeedback therapy.

It should be emphasized that the newer methods of treatment are still under evaluation and that at this time there is no universal, symptomatic or specific treatment for tinnitus.

Things that divers can do:
1. Get a good examination by a diving oriented ENT doctor. The tinnitus may not be from diving at all!
2. Check out your regulator mouthpiece for fit. Consciously avoid clamping down on the mouthpiece. (Try this yourself--clamp down on your teeth and hear the high-pitched whine!)
3. Avoid the use of nerve stimulants, i.e, excessive amounts of coffee (caffeine) and smoking (nicotine).
4. Learn as quickly as possible to accept the existence of the head noise as an annoying reality and them promptly and completely ignore it as much as possible.
5. Tinnitus is usually more marked at bedtime, when one's surroundings become quiet. Use any kind of masking sound-maker.

How to Treat Tinnitus: There is not a cure for tinnitus. However, a variety of treatment options exist that offer varying levels of relief to many sufferers. Treatment options include:

• biofeedback
• hearing aids
• medication
• masking
• Tinnitus Retraining Therapy
• TMJ treatment


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More About Tinnitus Related to Diving

This information is provided only as a background for becoming an informed diver. It should never substitute for the expertise of a diving physician or ENT specialist. Tinnitus can be described as "ringing" ears and other head noises that are perceived in the absence of any external noise source. It is estimated that 1 out of every 5 people experience some degree of tinnitus. Tinnitus is classified into two types: objective (what can be heard by someone else) and subjective (what can be felt).
 

Objective Tinnitus (Actually audible or observable )
 

The rarer form, consists of head noises audible to other people in addition to the sufferer. The noises are usually caused by vascular anomalies, repetitive muscle contractions, or inner ear structural defects. The sounds are heard by the sufferer and are generally external to the auditory system. This form of tinnitus means that an examiner can hear the sound heard by the sufferer by using a stethoscope. Benign causes, such as noise from TMJ, openings of the eustachian tubes, or repetitive muscle contractions may be the cause of objective tinnitus. The sufferer might hear the pulsatile flow of the carotid artery or the continuous hum of normal venous outflow through the jugular vein when in a quiet setting. It can also be an early sign of increased intracranial pressure and is often overshadowed by other neurologic abnormalities. The sounds may arise from a turbulant flow through compressed venous structures at the base of the brain.
 

Subjective Tinnitus(Inaudible to an observer)

This form of tinnitus may occur anywhere in the auditory system and is much less understood, with the causes being many and open to debate. Anything from the ear canal to the brain may be involved. The sounds can range from a metallic ringing, buzzing, blowing, roaring, or sometimes similar to a clanging, popping, or nonrhythmic beating. It can be accompanied by audiometric evidence of deafness which occurs in association with both conductive and sensorineural hearing loss. Other conditions and syndromes which may have tinnitus in conjunction with the condition or syndrome, are otosclerosis, Meniere's syndrome, and cochlear or auditory neve lesions.

Hearing loss, hyperacusis (excessive loudness), recruitment, and balance problems may or may not be present in conjunction with tinnitus.

Many sufferers report that their tinnitus sounds like the high-pitched background squeal emitted by some computer monitors or television sets. Others report noises like hissing steam, rushing water, chirping crickets, bells, breaking glass, or even chainsaws. Some report that their tinnitus temporarily spikes in volume with sudden head motions during aerobic exercise, or with each footfall while jogging.

Objective tinnitus sufferers may hear a rhythmic rushing noise caused by their own pulse. This form is known as pulsatile tinnitus.

In a database of 1544 tinnitus patients, 79% characterized the sound as "tonal" with an average loudness of 7.5 (on a subjective scale of 1-10). The other 21% characterized the sound as "noise" with an average loudness of 5.5. When compared to an externally generated noise source, the average loudness was 7.5dB above threshold. 68% of patients were able to have their tinnitus masked by sounds 14dB or less above threshold. The internal origination of the tinnitus sounds was perceived by 56% of the patients to be in both ears, 24% from somewhere inside the head, 11% from the left ear, and 9% from the right ear.

In aother database of 1687 tinnitus patients, no known cause was identified for 43% of the cases, and noise exposure was the cause for 24% of the cases.


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Diving Causes of Tinnitus

Noise
TMJ syndrome (Clenching of teeth on the regulator)
Middle ear barotrauma (Due to pressure/volume changes)
Inner ear barotrauma. (Due to pressure/volume changes)
Round window rupture (Due to elevated pressure blowing this window out into the middle ear0
Inner ear decompression accident (Due to bubbles damaging the inner ear tissues)

Finally, advice from an otolaryngologist familiar with the damage that can occur from diving should be obtained. Self -diagnosis and treatment has no place in the management of tinnitus from diving injuries.


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References

Inner ear Problems
References to Perilymph fistulas, inner ear barotrauma

Scand Audiol 1999;28(2):91-6
Long-term effect of hyperbaric oxygenation treatment on
chronic distressing tinnitus.
Tan J, Tange RA, Dreschler WA, v d Kleij A, Tromp EC
Department of Otorhinolaryngology/Head and Neck Surgery, Academic Medical Center, University Hospital of Amsterdam, The Netherlands. t.h.tan@amc.uva.nl

Lamm K, et al.
Effect of hyperbaric oxygen therapy in comparison to conventional or placebo therapy or no treatment in idiopathic sudden hearing loss, acoustic trauma, noise-induced hearing loss and tinnitus. A literature survey.
Adv Otorhinolaryngol. 1998;54:86-99. Review.

Bohm F, et al.
[Round window membrane defect in divers].
Laryngorhinootologie. 1999 Apr;78(4):169-75. Review. German

Schumann K, et al.
[Effect and effectiveness of hyperbaric oxygen therapy in chronic hearing disorders. Report of 557 cases 1989].
HNO. 1990 Nov;38(11):408-11. German.

 Peifer KJ, et al.
Tinnitus: etiology and management.
Clin Geriatr Med. 1999 Feb;15(1):193-204, viii. Review.

 Lindberg P, et al.
Long-term effects of psychological treatment of tinnitus.
Scand Audiol. 1987;16(3):167-72.

 Kau RJ, et al.
Effectiveness of hyperbaric oxygen therapy in patients with acute and chronic cochlear disorders.
ORL J Otorhinolaryngol Relat Spec. 1997 Mar-Apr;59(2):79-83.

Roeser RJ, et al.
Clinical experience with tinnitus maskers.
Ear Hear. 1980 Mar-Apr;1(2):63-8.

House JW.
Treatment of severe tinnitus with biofeedback training.
Laryngoscope. 1978 Mar;88(3):406-12.

 Schleuning AJ, et al.
Evaluation of a tinnitus masking program: a follow-up study of 598 patients.
Ear Hear. 1980 Mar-Apr;1(2):71-4.

Marion MS, et al.
Tinnitus.
Mayo Clin Proc. 1991 Jun;66(6):614-20. Review.

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Intracranial Difficulties from Ear Barotrauma


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•    Paranasal Sinus Barotrauma

      This most often involves the frontal or maxillary sinuses and the pressure differential usually causes the lining of the sinuses to become swollen and bleeding can ensue.

Paranasal sinuses

Nosebleed is a common event with diving and can be caused by negative pressure within the mask or from pressure change after ascent. Dull aching is present and treatment is directed at the use of nasal decingestants and symptomatic pain relief. Antibiotics are also used to treat infection.
 

• Pneumocephalus.

Goldmann  reported a case of sinus barotrauma presenting as air in the subdural space. (JAMA. 255:3154-3156, 1986.)  There is really no difference between the damage and pain with descent or ascent. It occurs in both flyers and divers and the pathophysiology is the same--the inability to equilibrate the air pressure as it changes, up and down.

All of this depends mainly on the function of the mucosa of the nose and sinuses. Some people secrete large quantities of mucus in response to allergy. Others have a definite correctible problem, such as nasal septal deviation, polyps or tumors, resulting in blockage of the ostia (openings) of the sinuses.

The frontal sinuses are the most frequently involved, probably because the nasofrontal duct is longer and more tortuous. The damage that is done by the pressure change leads to a series of changes within the sinuses consisting of air absorption, decreased pressure in the sinus; swelling, engorgement, inflammation and fluid collection in the sinus cavity. This decrease becomes greater with descent (as with flying) the changes become greater, more painful and often associated with bleeding into the sinus cavity. On ascent, there is one-way valve blockage of the ostia, resulting in more barotrauma. The next step after all this is usually infection, which increases the blockage by causing it's own swelling and purulent discharge.

Common causes of all this include, allergy; chronic irritation, such as smoking, diesel fumes, chemicals, prolonged use of nose drops or nasal sprays; mechanical blockage; vasomotor problems from chronic tension, stress or anxiety.

It should be obvious that what should be a very simple problem can be stubbornly difficult to diagnose and manage.