DAN Incident Insights: Quiet Rupture

A “mild” barotrauma leaves a diver with potentially permanent hearing loss. By John Lippmann, DAN AP Founder, Chairman, Director of Research

Diver’s Background. “James” (not his real name) is a 62 year-old Australian male. He is an experienced diver, logging more than 1500 dives over 33 years, mainly in the cooler waters of southern Australia. However, he has also done at least one overseas diving trip each year, mainly to tropical locations.

He is taking medication to lower his cholesterol, as well as Vitamin D to offset a related deficiency. He had what appears to have been a relatively mild middle ear barotrauma two years earlier, involving his right ear. This cleared up with saline rinses and decongestant spray.

Case Report

The Diving.
James was on a diving holiday in Papua New Guinea and had done three dives per day for the past three days. He was breathing EANx32 and using a Mares Icon dive computer with the relevant Nitrox setting.  He had not dialled up any extra conservatism into the computer.

His profiles for the last day were:

  • Dive 1: 25m/65 min; SI = 1:13
  • Dive 2: 15m/61 m; SI = 1:34
  • Dive 3: 16m/61 min.

James indicated that he had gone to the maximum depth early in each dive and then worked his way shallower, spending a lot of the time in shallow water on the top of the reef. Safety stops were done on all dives and there were no reported problems in or under the water. However, he noticed ringing in his left ear (tinnitus) after the second dive. Believing this to be from water trapped in his ear, James unsuccessfully used ear drops to try to clear the water and decided to do the next dive.

When the tinnitus persisted for the next two days, along with some hearing loss, James became concerned and went to a local clinic. The doctor found that James had ruptured his right ear drum and she could see swelling in the left ear and prescribed antibiotics.

The Call to DAN Asia-Pacific
James then called the DAN Diving Emergency Service (DES) Hotline and spoke to the on-call doctor, Dr David Wilkinson, who was concerned about James having a possible Inner Ear Barotrauma (IEBT) in the left ear. Being the DAN AP staff on-call that day, I received a call from Dr Wilkinson to give me a “heads-up”, and we decided that it would be advisable to bring James back to Australia and arrange a consultation with an Ear, Nose and Throat (ENT) specialist. Such appointments are often difficult to arrange at short notice and, as this was a weekend, we were aware that it could be hard to have James seen quickly.

James wasn’t due to fly home for another 10 days but his travel agent, Diversion Dive Travel (DAN AP Super Supporters), worked hard to rearrange flights so he could fly back the next day. I asked James to call me after landing on each leg of the journey so I could intervene and change plans if his symptoms worsened. This was done religiously and, happily James reported no deterioration with flying.

Medical Treatment and Outcome
The following morning James presented at the Emergency Department (ED) at the major local hospital, as advised. He was examined by an ED doctor and sent home after being told that an ENT specialist would be in contact within 7 days. James then called me to provide an update, as requested. In frustration, I called several of the hyperbaric doctors based at that hospital and asked them to intervene, which they did successfully. James was examined by an ENT that same day and tests were scheduled. The hearing test (audiometry) revealed substantial hearing loss in James’ left ear and he was prescribed medication (steroids) to facilitate healing.

It is now nearly five months later and James is still suffering from substantial hearing loss in his left ear. Despite some slight improvement, it is likely to be permanent. Fortunately, his tinnitus has abated.

The Future?
As a very keen diver, James is now trying to weigh up whether or not he is prepared to continue with diving. The main concern is the ramifications of an injury to his good ear. If he suffered a severe barotrauma in that ear, he could be potentially left with hearing loss in both ears, which would be disabling.

Comments
In the event of a suspected inner ear injury, it is important to stop diving and any straining activity immediately, rest, and get appropriate specialist medical advice as soon as possible. Unfortunately, James failed to realise the potential severity of his injury and dived again, probably exacerbating the problem. By the time DAN AP was called several days later, most of the damage was likely already done.

DAN AP deals with many cases of inner ear injury and, unfortunately, continued diving and delay to reporting is not uncommon. This can lead to permanent hearing loss, tinnitus or problems with balance.

One important aspect of this incident is that James has been unable to really identify how the initial problem was caused. He did not notice any problem when equalising and there was no uncontrolled ascent or descent to explain the barotrauma. In addition, the ENT specialists who have examined him have not noted any particular anatomical deformity that might have put James at an increased risk. This makes the decision about future diving more difficult.

Safety Tip:
Enter DAN as a contact in your phone. Make sure you have your lifeline when you need it. Visit “Emergency” at danap.org. Whilst all divers can call DAN for advice, DAN can only arrange an Emergency Evacuation and pay for associated treatment costs for current Members (within the limits of their coverage option).

Not Yet a DAN AP Member? Join at danap.org. If you are not yet a DAN AP Member, we look forward to welcoming you.

Images by Stephen Frink

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