Alternobaric vertigo--really a hazard?

[The otolaryngologist's role in evaluating diving fitness]

Scuba diving and other modes of device-supported diving are popular activities that can be especially demanding and hazardous for people with preexisting physical conditions. Due to the high ambient pressure, the temperature differences, and potential unpredictable events, which have manifold effects on the organism, diving carries a high risk of life-threatening disease. A special risk is present if the body does not readily equalize air pressure changes. Therefore, prior to diving, all divers should undergo detailed education regarding the physical principles of the sport as well as specific physical examination. Consultation of an otolaryngologist is of exceptional relevance because many otorhinolaryngologic diseases can lead to (usually temporary) unfitness to dive. The role of the modern otorhinolaryngologist trained in diving medicine is to correctly advise the patient and restore fitness for diving via conservative or invasive methods.

Balloon dilation of the eustachian tube using endovascular balloon under local anesthesia-a case series and systematic literature review

Objective

To report a novel technique in Balloon Dilation of Eustachian Tube (BDET) using an endovascular balloon (EVB), in a prospective cohort. The results are compared with reported outcomes using standard balloons.

Methods

Demographic information and clinical parameters were collected prospectively fora series of patients with obstructive eustachian tube dysfunction (OETD). Balloon dilation Eustachian tuboplasty was performed under local anesthesia in a tertiary referral center, using the EVB. Systematic literature review was used for comparison, using Medline via "PubMed", "Embase", and "Web of Science".

Results

Eight OETD candidates (12 ears) were enrolled; 5 males and 3 females. Average age was 48 (range -23 to 63) years. The most common presenting symptom was aural fullness (9/12), followed by ear pressure (7/12), hearing loss (5/12) and tinnitus (4/12). Otoscopically, tympanic membrane retraction was evident in 10/12 ears, the majority of which was class II-Sade classification. Pre-operative tympanogram was type B and C in 7 and 5 ears, respectively. All BDETs were performed without complications. Post-operative tympanometry was A in 8/12 ears. Post-operatively, Eustachian Tube Dysfunction Questionnaire-7 results reduced to within normal limits (average score ≤3) in 11/12 ears (p = 0.0014). The systematic literature review included 6 papers (193 patients, 262 ETs) with comparable results, most also with little adverse effects.

Conclusion

BDET using an EVB is a safe and effective option for OETD. It is well tolerated under local anesthesia in properly selected individuals. The reduced procedural cost may be an important factor in certain healthcare jurisdictions.

Middle ear barotrauma in diving

INTRODUCTION

Middle ear barotrauma (MEBt) is the most common medical complication in diving, posing a serious risk to dive safety. Given this prevalence and the continuing growth of the diving industry, a comprehensive overview of the condition is warranted.

METHODS

This was a survey study. An anonymous, electronic questionnaire was distributed to 7,060 recipients: professional divers of the Finnish Border Guard, the Finnish Rescue Services, and the Finnish Heritage agency; and recreational divers registered as members of the Finnish Divers' Association reachable by e-mail (roughly two-thirds of all members and recreational divers in Finland). Primary outcomes were self-reported prevalence, clinical characteristics, and health effects of MEBt while diving. Secondary outcomes were adjusted odds ratios (OR) for frequency of MEBt with respect to possible risk factors.

RESULTS

A total of 1,881 respondents participated in the study (response rate 27%). In total, 81% of the respondents had experienced MEBt while diving. Of those affected, 38% had used medications and 1% had undergone otorhinolaryngology-related surgical procedures due to MEBt. Factors most associated with MEBt were poor subjective success in Valsalva ('occasionally' versus 'always' successful: OR 11.56; 95% CI 7.24-18.47) and Toynbee ('occasionally' versus 'always' successful: OR 3.51; 95% CI 1.95-6.30) manoeuvres.

CONCLUSIONS

MEBt is common in both recreational and professional divers, having affected 81% of the respondents. The main possible risk factors include poor success in pressure equalisation manoeuvres.

A Message from a Narrowed Internal Auditory Canal in a Patient with a Hyperpneumatized Petrous Bone

Hyperpneumatization of the temporal bone (HPTB) is a rare finding, and its clinical impact is poorly described in literature. We report the case of a 34-year-old woman with no previous otologic condition, complaining of paroxysmal vertigo and right pulsatile tinnitus shortly after a first scuba diving session. Clinical neurotologic assessment found a right vestibular impairment. Cranial tomodensitometry showed a bilateral hyperpneumatization of the petrosal air cell system. Brain magnetic resonance imaging to rule out any retrocochlear pathology was normal, although the cochleo-vestibular nerve (CVN) appeared to be over lengthened in a narrowed internal auditory canal (IAC), especially on the right-hand side. Pain was alleviated by administration of a low-dose anti-epileptic drug. The clinical, neurological, and radiological findings evoked a right vestibulopathy generated by a limited compression of the CVN; HPTB appeared to contribute to the narrowing of the IAC, especially on the right-hand side.

In-office balloon dilation of the Eustachian tube under local anesthesia: A retrospective review

Objective

To study the effectiveness and feasibility of in office balloon dilation of the Eustachian tube (BDET) utilizing a novel anesthetic protocol. Study design: retrospective review.

Methods

Retrospective chart review looking at the tolerability and effectiveness of stand-alone BDET in an office setting utilizing a novel topical anesthesia protocol in 33 patients with Eustachian tube dysfunction as defined by an ETDQ-7 score greater than 2.2 and type B or C tympanograms for greater than 3 months despite maximal medical management, including at least 4 weeks of nasal steroids.

Results

BDET in the office was well tolerated with 94% (31/33) of patients completing the procedure as planned. No adverse effects or complications were reported; however, the planned dilation time was cut short in one case due to significant discomfort and aborted prior to dilation in another due significant coughing. Tympanograms normalized at six weeks in 87.1% (27/31) of patients who underwent dilation.

Conclusion

This study demonstrates that performing BDET in an office setting utilizing a local anesthesia protocol is feasible and effective when the unique barometric considerations of BDET are addressed.

SCUBA Medicine for otolaryngologists: Part I. Diving into SCUBA physiology and injury prevention

OBJECTIVES

Introduce pertinent self-contained underwater breathing apparatus (SCUBA) physiology and corresponding terminology. Appreciate the scope of diving and related otolaryngological injury. Illustrate pathophysiologic mechanisms for diving injuries. Summarize strategies for ear, paranasal sinus, and lung barotrauma prevention, including medical optimization and autoinsufflation techniques.

METHODS

We conducted a review of the available medical and diving literature in English, German, Spanish, Italian Turkish, and French to determine the degree of evidence or lack thereof behind recommendations for treating SCUBA divers. The databases of PubMed, Ovid Medline, and the Cochrane library, as well available textbooks, were queried for relevant data.

RESULTS

Divers are subjected to large pressure gradients within the first few meters of descent. This can lead to gas embolism formation as well as barotrauma secondary to gas expansion/compression in potential closed spaces such as the middle ear, paranasal sinuses, and lungs. Physicians can minimize the risk of injury by counseling patients regarding proper equalization and descent/ascent techniques, and optimizing sinonasal and eustachian tube function. The use of decongestants is controversial.

CONCLUSIONS

Diving is an increasingly popular sport with predominantly otolaryngologic manifestations of injury and disease. Treating SCUBA divers requires a firm understanding of how physiology is altered underwater. This review presents the relevant background information using illustrations to understand the environmental forces acting on divers and how to prevent injury. Laryngoscope, 130:52-58, 2020.

Scuba diving and otology: a systematic review with recommendations on diagnosis, treatment and post-operative care

Scuba diving is a popular recreational and professional activity with inherent risks. Complications related to barotrauma and decompression illness can pose significant morbidity to a diver's hearing and balance systems. The majority of dive-related injuries affect the head and neck, particularly the outer, middle and inner ear. Given the high incidence of otologic complications from diving, an evidence-based approach to the diagnosis and treatment of otic pathology is a necessity. We performed a systematic and comprehensive literature review including the pathophysiology, diagnosis, and treatment of otologic pathology related to diving. This included inner, middle, and outer ear anatomic subsites, as well as facial nerve complications, mal de debarquement syndrome, sea sickness and fitness to dive recommendations following otologic surgery. Sixty-two papers on diving and otologic pathology were included in the final analysis. We created a set of succinct evidence-based recommendations on each topic that should inform clinical decisions by otolaryngologists, dive medicine specialists and primary care providers when faced with diving-related patient pathology.

Auditory complaints in scuba divers: an overview

Pre-1970s, diving was seen as a predominantly male working occupation. Since then it has become a popular hobby, with increasing access to SCUBA diving while on holiday. For a leisure activity, diving puts the auditory system at the risk of a wide variety of complaints. However, there is still insufficient consensus on the frequency of these conditions, which ultimately would require more attention from hearing-healthcare professionals. A literature search of epidemiology studies of eight auditory complaints was conducted, using both individual and large-scale diving studies, with some reference to large-scale non-diving populations . A higher incidence was found for middle ear barotrauma, eustachian tube dysfunction, and alternobaric vertigo with a high correlation among females. Comparing these findings with a non-diving population found no statistically significant difference for hearing loss or tinnitus. Increased awareness of health professionals is required, training, and implementation of the Frenzel technique would help resolve the ambiguities of the Valsalva technique underwater.

Persistent alternobaric vertigo at ground level

We recently encountered a 15-year-old female with bilateral tympanostomy tubes who manifested persistent severe vertigo, at ground level, secondary to a unilateral middle-ear pressure of +200 mm H(2)O elicited by an obstructed tympanostomy tube in the presence of chronic nasal obstruction. We believe this is a previously unreported scenario in which closed-nose swallowing insufflated air into her middle ears, resulting in sustained positive middle-ear pressure in the ear with the obstructed tube. Swallowing, when the nose is obstructed, can result in abnormal negative or positive pressures in the middle ear, which has been termed the Toynbee phenomenon. In patients who have vertigo, the possibility that nasal obstruction and the Toynbee phenomenon are involved should be considered.

Vestibular effects of diving - a 6-year prospective study

BACKGROUND

Permanent injuries to the vestibular end organs may occur in diving due to decompression illness (DCI) or barotraumas. This may lead to distressing long-term symptoms, including dizziness and disequilibrium.

AIMS

To look for evidence of vestibular disorders in working divers and to relate this to diving exposure or injuries.

METHODS

A cohort of 67 men aged 28 +/- 5 years (mean +/- SD) completing a basic course for working divers answered a questionnaire and underwent clinical otoneurological examination, electronystagmography (ENG), including alternate bithermal caloric tests and platform posturography. The procedure was repeated after 3 and 6 years.

RESULTS

At follow-up, none of the divers had experienced inner ear barotraumas or inner ear DCI. Two cases of untreated probable DCI were diagnosed retrospectively in 27 232 dives. Middle ear barotrauma was reported by 36%. There was no correlation between diving frequency and postural sway at follow-up. Transient dizziness during or shortly after a dive was reported by 63 and 15%, respectively. The prevalence of dizziness on land and ENG abnormalities did not change during follow-up. No vestibular disorders were diagnosed.

CONCLUSIONS

Transient vestibular symptoms and middle ear barotraumas are common in diving. This study found no evidence of long-term vestibular effects. Vestibular disorders in divers are probably related to singular events, like inner ear barotraumas or inner ear DCI, rather than frequent diving per se.

[Fitness to dive in the otorhinolaryngological field]

In line with the rising number of recreational divers, the otorhinolaryngologist has to deal with growing numbers of diving-associated disorders of the ear, nose and throat (ENT). Nevertheless, the majority of divers present to their ENT doctor for assessment of their fitness to dive. On the basis of long-term follow-up examinations and increasing experience in diving medicine, even divers with a history of ENT problems can be considered fit to dive. Therefore, diving is possible after tympanoplasty, surgery to improve hearing including stapesplasty, after implantation of middle ear amplifiers or cochlear implants, after sinus or scull base surgery and even after canal wall down mastoidectomy, provided that certain requirements are fulfilled. Assessing fitness to dive after inner ear barotrauma as well as after inner ear decompression illness requires meticulous consideration of residual damage and possible underlying conditions like vascular right-to-left shunts. This article is based on the new recommendations of the German Undersea and Hyperbaric Medical Society for the assessment of fitness to dive in the otorhinolaryngological field.

Otorhinolaryngologic disorders and diving accidents: an analysis of 306 divers

Diving is a very popular leisure activity with an increasing number of participants. As more than 80% of the diving related problems involve the head and neck region, every otorhinolaryngologist should be familiar with diving medical standards. We here present an analysis of more than 300 patients we have treated in the past four years. Between January 2002 and October 2005, 306 patients presented in our department with otorhinological disorders after diving, or after diving accidents. We collected the following data: name, sex, age, date of treatment, date of accident, diagnosis, special aspects of the diagnosis, number of dives, diving certification, whether and which surgery had been performed, history of acute diving accidents or follow up treatment, assessment of fitness to dive and special remarks. The study setting was a retrospective cohort study. The distribution of the disorders was as follows: 24 divers (8%) with external ear disorders, 140 divers (46%) with middle ear disorders, 56 divers (18%) with inner ear disorders, 53 divers (17%) with disorders of the nose and sinuses, 24 divers (8%) with decompression illness (DCI) and 9 divers (3%) who complained of various symptoms. Only 18% of the divers presented with acute disorders. The most common disorder (24%) was Eustachian tube dysfunction. Female divers were significantly more often affected. Chronic sinusitis was found to be associated with a significantly higher number of performed dives. Conservative treatment failed in 30% of the patients but sinus surgery relieved symptoms in all patients of this group. The middle ear is the main problem area for divers. Middle ear ventilation problems due to Eustachian tube dysfunction can be treated conservatively with excellent results whereas pathology of the tympanic membrane and ossicular chain often require surgery. More than four out of five patients visited our department to re-establish their fitness to dive. Although the treatment of acute diving-related disorders is an important field for the treatment of divers, the main need of divers seems to be assessment and recovery of their fitness to dive.