Ear Barotrauma Research Articles

Evaluation of Middle Ear Barotrauma during Hyperbaric Oxygenation

Evaluation of Middle Ear Barotrauma during Hyperbaric Oxygenation

Hearing loss in divers: a 6-year prospective study

Occupational diving is associated with hearing loss, but the cause is disputed. Our aim was to follow a cohort of divers through the first 6 years of their career in order to look for evidence of permanent threshold shift associated with diving activity, occupational noise exposure or acute injuries. Hearing was measured by pure tone audiometry in 67 participants at a basic course for working divers. Hearing thresholds were adjusted for age (ISO 7029). The subjects were examined and interviewed by an otologist. Additional medical and exposure data were recorded in questionnaires and personal logbooks. The procedure was repeated after 3 and 6 years. None of the subjects suffered inner ear barotrauma or inner ear decompression sickness during follow-up. Middle ear barotrauma was common. The prevalence of subjective hearing difficulties increased during follow-up, and there was a significant threshold shift at 4 kHz (mean 2.6 dB, 95% confidence interval 0.9-4.3 dB). Both subjective and objective hearing loss was associated with occupational noise exposure, but not with diving frequency or with a history of middle ear barotrauma. In the absence of manifest inner ear barotrauma or inner ear decompression sickness, noise seems to be the most important cause of long-term hearing loss in occupational divers. This study did not find evidence of long-term hearing loss caused by uneventful diving per se.

Protective Effect of Neurotrophic Agent T-817MA Against Inner Ear Barotrauma in the Guinea Pig

T-817MA (1-{3-[2-(1-benzothiophen-5-yl)ethoxy]propyl}azetidin-3-ol maleate), a neurotrophic compound newly synthesized for the treatment of Alzheimer's disease, has been found to reduce oxidative stress and exert neuroprotective effects. By assessing the auditory functioning and observing the cochlear sensory epithelia, we investigated whether T-817MA protects the cochlea from inner ear barotrauma in guinea pigs treated with rapidly intense pressure change. Sustained oral administration of T-817MA significantly reduced the extent of auditory threshold shifts and outer hair cell loss, indicating that T-817MA attenuates the intense pressure-induced cochlear damage that accompanies inner ear barotrauma via antioxidative activity.

Pressure Regulating Ear Plug Testing in a Pressure Chamber

Middle ear barotrauma is a condition frequently associated with flying. It is usually caused by Eustachian tube (ET) dysfunction. Pressure-regulating earplugs (PREP) should improve complaints due to pressure equalization problems. There were 21 patients with a history of pressure equalization problems while flying who were examined. ET function was measured with exploratory tests and in a pressure chamber. In a double-blind study, PREP were examined using continuous impedance measurement in the pressure chamber. Eardrum deflection and pressure-equalizing maneuvers were also examined. During pressure exposure the subjective state of patients with and without PREP was compared. Evidence of ET dysfunction was found in twice as many patients with the impedance method in a pressure chamber compared to tympanometry or the Valsalva test. Use of PREP reduced the rate of pressure changes in the external auditory canal. Maximum pressure was reached with a delay of about 7 min. The number of pressure-equalizing maneuvers did not differ significantly. Using PREP the patients reported a significantly better subjective state on the VAS scale of 2.19 +/- 1.50 compared to 3.38 +/- 2.33 without PREP. Continuous impedance measurements in the pressure chamber identified ET dysfunction more often than the exploratory ET function tests commonly used in routine diagnostics. This novel finding requires further validation. Although use of PREP showed no signs of improving ET function, it did significantly improve individual subjective state during sudden pressure changes.

Ear Pain After Breathing Oxygen at Altitude: Prevalence and Prevention of Delayed Barotrauma

Military pilots frequently report ear pain with onset several hours after altitude exposure while breathing pure oxygen, but the prevalence of this problem is unknown. A similar problem is described in divers after breathing hyperbaric oxygen and it is related to the oxygen contained in the middle ear. In order to assess the prevalence of delayed ear pain after altitude exposure and investigate the effectiveness of preventive use of a nasal balloon (NB), we studied 88 healthy military jet pilots who were asymptomatic after altitude chamber exposure which included 100% oxygen breathing. A group of 44 subjects received the NB shortly after the chamber and they were advised to use it every hour before going to sleep. A control group of 44 subjects was requested to perform the Valsalva maneuver alone over the same period. All subjects underwent clinical examination by an otolaryngologist and tympanometry just before the chamber exposure and again the day after. The day after the altitude exposure, 53.4% of subjects reported ear pain. In the treated group, 61.4% of subjects were free of symptoms, compared to 31.8% in the control group (P < 0.01). Tympanogram was abnormal in eight symptomatic subjects and in six asymptomatic. Our data suggest that in our subjects there is high prevalence of delayed ear barotrauma after altitude chamber exposure while breathing pure oxygen and the tympanogram may improve the accuracy of the diagnosis in asymptomatic subjects. The nasal balloon appears to be effective for prevention.

Vestibular effects of diving -- a 6-year prospective study

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

&lt;i&gt;Pneumolabyrinth&lt;/i&gt;: Radiologic Evidence of Labyrinthine Injury

A U.S. serviceman presented with a three month history of unsteadiness on ambulation and increasing episodes of vertigo whenever he turned his head rapidly to the right. He had previously been injured in a bomb blast while stationed in Iraq four months prior to consultation. Aside from multiple soft tissue and bone trauma, he had also experienced vertigo and nearly complete deafness in the right ear immediately after the blast. Medical records indicated the presence of a traumatic perforation of the right tympanic membrane and spontaneous nystagmus on initial emergency medical assessment after the incident. Physical examination on consultation revealed bilaterally intact eardrums, a positive right head impulse test, and a normal Romberg test. Audiometry showed a severe right SNHL. A presumptive diagnosis of a persistent perilymph fistula secondary to inner ear barotrauma was entertained, and supported by findings on temporal bone CT imaging. Figure 1 is the axial CT image of the patient's inner ear at the level of the basal turn of the cochlea. Two linear lucencies are visible within the cochlea (arrowheads). These have the same signal characteristics as the normal external auditory canal and middle ear space. As such, they indicate the presence of air within the cochlea – a condition termed pneumolabyrinth. Figure 2 shows a normal cochlea at the same level for comparison. Note the uniform soft tissue density within the cochlear lumen, representing the endocochlear fluids. The lucency in the round window niche (thin arrow) also represents air, but this is a normal finding. &nbsp; Barotrauma from blast injuries and traumatic tympanic membrane perforations may cause perilymph fistulas. This is probably due to a sudden pressure wave transmitted through the tympanic membrane that results in an inward rupture of the round window membrane or an inward displacement of the stapedial footplate.1 Pneumolabyrinth has been identified in patients suffering from perilymph fistulas due to barotraumas,2 and therefore can bolster the diagnosis when identified in the appropriate clinical setting. It has also been identified in patients with perilymph fistulas from other causes, including iatrogenic stapes fractures during mastoid surgery, temporal bone fractures, cholesteatoma, neoplasms of the temporal bone, stapedectomy, and after cochlear implantation.3

Therapeutic effect of edaravone on inner ear barotrauma in the guinea pig

Inner ear barotrauma (IEB) that is caused by acute pressure changes can often lead to permanent severe sensorineural hearing loss (SNHL). However, the mechanism that causes IEB is still unknown. In the current study, we assessed the involvement of reactive oxygen species (ROS) in IEB and the therapeutic effect of 3-methyl 1-phenyl-2-pyrazolin-5-one (edaravone), which is a free radical scavenger. To create the IEB model, guinea pigs were subjected to quick pressure changes that resulted in acute SNHL. The animals were then divided into two groups, an edaravone-treated IEB group and a non-treated IEB group that only received normal saline. Immunohistochemical analyses for 8-hydroxy-2-deoxyguanosine (8-OHdG) and 4-hydroxy-2-nonenal (4-HNE) were performed to examine the amount of oxidative DNA damage and lipid peroxidation that occurred in guinea pig cochlea. To assess the curative efficacy of edaravone, auditory brainstem response (ABR) testing was performed to evaluate auditory function. Strong immunoreactivities against 8-OHdG and 4-HNE were observed in the inner ear tissues of the non-treated IEB group. Lesser amounts of immunoreactivity were observed in the same region of the edaravone-treated IEB group as compared to the non-treated IEB group. Furthermore, ABR measurement revealed that there was a faster improvement in the threshold shift for the edaravone-treated IEB group as compared to that of the non-treated IEB group. At the final 7-week time point, the threshold shift for the edaravone-treated IEB group was significantly smaller as compared to the non-treated IEB group. These results strongly suggest that ROS is produced in the cochlea in response to acute pressure changes and that ROS plays an important role in the pathophysiology of IEB. Furthermore, edaravone treatment had a therapeutic effect on IEB-induced acute SNHL and thus, edaravone might possibly be able to be used as a therapeutic treatment for IEB.

Transient Facial Nerve Baroparesis: Case Report

We present a rare case of facial paralysis that was unusual not only in its causation but also in its rapidity of onset and recovery. We describe a rare case history of this accruing in 35 years old women traveling at the high altitude mountain road referred to ENT clinic with sudden symptoms of middle ear effusion and facial nerve paralysis. Patient had undergone medical systemic steroid treatment and after 3-4 weeks she had a good recovery of facial palsy with a minimum remnant of sensory neural hearing loss. Facial nerve paralysis resulting from a barotrauma of the middle ear is suggested. The correct diagnosis of this condition is important and unnecessary treatment should be avoided.

Powikłania tlenowej terapii hiperbarycznej w otolaryngologii

The epidemiological and clinical analysis of 238 patients treated in ENT Department of the Medical University of Gdansk using the hyperbaric oxygenation (HB) is reported. In all cases HBO therapy was applied in the Department of Hyperbaric Medicine and Sea Rescue. Clinical complications of the HBO therapy occurred in 19 cases (8% of all patients treated with HBO): middle ear barotrauma (6 patients), sinus pain (2 patients) and systemic disorders (11 patients). In 10 cases the occurrence of complications resulted in discontinuation of HBO therapy. Based on publications and own experience the authors present the methodology of medical treatment of the HBO complications.

Pneumolabyrinth: Radiologic Evidence of Labyrinthine Injury

A U.S. serviceman presented with a three month history of unsteadiness on ambulation and increasing episodes of vertigo whenever he turned his head rapidly to the right. He had previously been injured in a bomb blast while stationed in Iraq four months prior to consultation. Aside from multiple soft tissue and bone trauma, he had also experienced vertigo and nearly complete deafness in the right ear immediately after the blast. Medical records indicated the presence of a traumatic perforation of the right tympanic membrane and spontaneous nystagmus on initial emergency medical assessment after the incident. Physical examination on consultation revealed bilaterally intact eardrums, a positive right head impulse test, and a normal Romberg test. Audiometry showed a severe right SNHL. A presumptive diagnosis of a persistent perilymph fistula secondary to inner ear barotrauma was entertained, and supported by findings on temporal bone CT imaging.&#x0D; Figure 1 is the axial CT image of the patient's inner ear at the level of the basal turn of the cochlea. Two linear lucencies are visible within the cochlea (arrowheads). These have the same signal characteristics as the normal external auditory canal and middle ear space. As such, they indicate the presence of air within the cochlea – a condition termed pneumolabyrinth. Figure 2 shows a normal cochlea at the same level for comparison. Note the uniform soft tissue density within the cochlear lumen, representing the endocochlear fluids. The lucency in the round window niche (thin arrow) also represents air, but this is a normal finding.&#x0D; &#x0D; Barotrauma from blast injuries and traumatic tympanic membrane perforations may cause perilymph fistulas. This is probably due to a sudden pressure wave transmitted through the tympanic membrane that results in an inward rupture of the round window membrane or an inward displacement of the stapedial footplate.1 Pneumolabyrinth has been identified in patients suffering from perilymph fistulas due to barotraumas,2 and therefore can bolster the diagnosis when identified in the appropriate clinical setting. It has also been identified in patients with perilymph fistulas from other causes, including iatrogenic stapes fractures during mastoid surgery, temporal bone fractures, cholesteatoma, neoplasms of the temporal bone, stapedectomy, and after cochlear implantation.3

A Pilot Study Evaluating Surfactant on Eustachian Tube Function in Divers

Middle ear barotrauma (MEBT) is the most common medical complication in diving, aviation, and hyperbaric medicine. Eustachian tube dysfunction (ETD) quantifies the inability to open the eustachian tube (ET), risking MEBT. Surfactant administration improved ET function and efficaciously treated otitis media in a host of animal models. We performed a pilot study evaluating the efficacy of intranasal surfactant administration in reducing MEBT in repetitive diving. Eight divers participated in a subject-blinded, placebo-controlled, random order, multiarm (air and O2)-repeated measures trial investigating the relative efficacy of intranasally administered surfactant, acetylcysteine and oxymetazoline, and orally administered pseudoephedrine versus saline-placebo in middle ear equilibration during repetitive, multiday diving. Subjects were tested with the Nine-Step Inflation/Deflation Tympanometry Test (NSI/DT) and sonotubometry (testing eustachian tube opening pressure [ETOP]) before and immediately after each dive. Significant interaction effects were found for drug-by-test (F8,668 = 4.05; p < 0.001) and the three-way interaction of drug-by-dive-by-test (F16,668 = 2.47; p = 0.001) in sonotubometry testing. The ETOP revealed trends toward lowered (improved) values post-versus predive in all treatment arms, which was significant for oxymetazoline (p = 0.04). Only four of the eight subjects experienced any holds during diving. Statistical analysis of the NSI/DT data showed that none of the drug interventions resulted in improvements in ET function over that expected by chance. There is large intra- and intersubject variability in daily functioning of the ET as measured using the NSI/DT and sonotubomtery (ETOP). Sonotubometry engendered trends toward lowered (improved) values post-versus predive in all treatment arms. The repetitive dives did not result in a significant decrease in ET function as evidenced in the saline-placebo trials, circumventing an ability to detect superiority among the various treatment arms in our subject population. Additionally, since our study was underpowered to detect significant effects, we can only assert that various inhalational agents may improve middle ear ventilation in repetitive diving warranting further study. A larger subject population including subjects diagnosed with ET dysfunction may provide more statistical power to discern the benefit of inhaled agents as a useful prophylactic for preventing or reducing ET dysfunction during diving and/or hyperbaric/hypobaric pressure changes.

Middle Ear Barotrauma with Hyperbaric Oxygen Therapy: Incidence and the Predictive Value of the Nine-step Inflation/Deflation Test and Otoscopy

We conducted a prospective study to determine the incidence of middle ear barotrauma in patients who were undergoing hyperbaric oxygen therapy (HBOT). We also investigated the value of the nine-step inflation/deflation test and otoscopic findings before and immediately after the initial HBOT session in predicting barotrauma in an attempt to establish some criteria for prophylaxis. The study was conducted on 36 ears of 18 adults who had no history of eustachian tube dysfunction. Patients were being treated with HBOT for sudden hearing loss, wound-healing complications, or complications of diabetes. After 7 days of HBOT, barotrauma was seen in 12 of the 18 patients (66.7%) and in 18 of the 36 ears (50.0%). The nine-step inflation/deflation tests, which were performed before and immediately after the initial HBOT session, were not predictive of barotrauma (p = 0.095 before and p = 0.099 after). However, otoscopic findings obtained immediately after the first session of HBOT were predictive of barotrauma, with a sensitivity and specificity of 83 and 100%, respectively. We conclude that patients with even minor positive pathologic findings on otoscopy immediately following HBOT are at increased risk of middle ear barotrauma if HBOT is to be continued without prophylaxis.

Upper Respiratory Infections and Barotraumas in Commercial Pilots: A Retrospective Survey

One of the most common causes of acute incapacitation among aircrew is barotrauma induced by pressure changes during descent in aviation. However, the incidence of ENT barotrauma during flight among commercial pilots with or without upper respiratory infections (URI) has not been described in detail. There were 948 commercial pilots--equivalent to one-third of all commercial pilots in Denmark--visiting the Danish Aero Medical Centre during a 6-mo period who answered a questionnaire regarding signs and symptoms of URI and barotrauma incidence in relation to flying with a common cold. On average, every commercial pilot experienced one to two URI per year. About two-thirds of the pilots (57.2%) reported themselves unfit, while 42.8% continued with their flying duties despite signs and symptoms of a URI. Of the latter group the 78.0% reported taking decongestant medication. More than one-third of all pilots (37.6%) reported having experienced one or more episodes of ear barotrauma, mainly during descent (90%), whereas 19.5% reported one or more sinus barotrauma incidents during their flying career. Less than 2% of these had felt incapacitated prior to the flight. The results suggest that not all pilots and airline companies consider URI a valid reason for unfitness to fly despite the risk for acute incapacitation. Urgent attention to this fact and to the risk factors caused by URI are strongly recommended.

Tauchtauglichkeit im HNO-Bereich

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.

鼻かみ後に発症した水疱性鼓膜炎の検討

The etiology of bullous myringitis (BM) is unknown. We speculated that BM involves middle ear barotrauma because of frequent bleeding in the tympanic membrane, including a patient with BM who strongly blew the nose.We investigated 186 patients with BM aged one to 80 years old (average age; 8.83), including 16 patients with recurrent BM.In six patients, BM was associated with blowing their nose. Patient ages ranged from 6 to 58 years old (average age; 32.7). None of the patients showed recurrent BM. Two patients had multiple bulla formations and 5 patients showed bleeding in the tympanic membrane. Among all 186 patients examined, 36 patients had multiple bulla formations and 78 of 181 patients demonstrated bleeding in the tympanic membrane.These findings suggest that a sudden reflex of secretions and air from the nasopharynx into the middle ear could cause bulla formation on tympanic membrane.

Hals-Nasen-Ohren ärztliche Erkrankungen im Zusammenhang mit dem Sporttauchen

Due to the increasing number of scuba divers in Germany, the otorhinolaryngologist has to face rising numbers of diving-associated ENT disorders. However, data about the lifetime prevalence of these disorders are insufficient. The aim of this study was to determine the frequency of ENT disorders in scuba divers correlated with their diving history. The study design was a non-randomized, retrospective, cross-sectional study based on questionnaires. The study population included 429 active divers attending three medical diving symposia. The study population consisted of highly experienced divers (mean of logged dives m= 670.0) with a high diving certification level. Otitis externa was the most frequent disorder (43.6%). Barotrauma of the sinuses (10.9%), alternobaric vertigo (9.0%) and barotrauma of the middle ear (8.7%) played an important role as well. In contrast, inner ear barotrauma and decompression illness of the inner ear were less frequent but not rare (1.7 % each). A substantial number of scuba divers suffered diving-related ENT disorders.

Barotrauma and Decompression Illness of the Inner Ear

Diving accidents affecting the inner ear are much more common than was once thought. Among the 319 patients treated in our clinic between January 2002 and November 2005, 46 cases involved 44 divers with symptoms of acute inner ear disorders. The objective of the present article is to investigate the symptoms of the acute disorders and assess any residual damage. Retrospective case analysis. The medical records were used to study the cases of 18 divers treated for inner ear decompression illness on 20 occasions and 26 divers who had inner ear barotrauma. The symptoms of the disorder at the beginning of treatment, latency period before the first therapeutic measures, kind of initial therapy, symptoms after the accident, and hearing and balance functions at the last examination in our clinic were assessed. Divers with inner ear decompression illness were examined via means of transcranial or carotid Doppler ultrasonography for the presence of a vascular right-to-left (R/L) shunt. Of 18 divers with inner ear decompression illness, 17 reported vertigo as the main symptom. In one diver, the inner ear decompression illness was manifested bilaterally. The divers with inner ear decompression illness had been treated with hyperbaric oxygen therapy in 14 of 20 cases; the average latency period before the start of therapy was 40 hours (median, 10 h). In 15 (83%) of 18 patients, a large R/L shunt was detected, and in 14 (78%) of 18 patients, residual cochleovestibular damage was detected. Only 9 of 26 patients with inner ear barotrauma mentioned feeling dizzy, and in no patient was vertigo the main symptom. Twenty-one patients complained of tinnitus, whereas 20 complained of hearing loss. The hearing loss ranged from an unobtrusive difference of 10 dB between the ears up to complete deafness. Three patients were subjected to tympanoscopy because of suspected rupture of the round window membrane. Of patients with inner ear barotrauma, 78% had residual cochleovestibular damage. We describe for the first time a patient with bilateral manifestation of inner ear decompression illness. Inner ear decompression illness is frequently associated with a R/L shunt; therefore, after a diving accident, the patient's fitness to dive should be assessed via a specialist in diving medicine. Both decompression illness and barotrauma of the inner ear result in residual cochleovestibular damage in more than three of four patients.

水疱性鼓膜炎症例の検討―水疱性鼓膜炎は急性中耳炎なのだろうか？―

Bullous myringitis (BM) is an acutely painful condition of the ear characterized by bulla formation on the tympanic membrane. The etiology is unknown despite its recognition over a hundred years ago by Lowenberg (1892). BM was described in early articles as occurring in association with acute otitis media; however, BM has different features from AOM: usually unilateral, more often in school age children and frequently in adults, and almost always with a self-limited clinical course.We studied 74 patients with BM aged 0 to 83 years (average age: 8.53), of which 65 patients had allergic rhinitis and others nasal disorders. Most patients had a sudden onset of very severe otalgia, but rarely had a high temperature. In all cases, bulla formations on the tympanic membrane were unilateral, and 54 of 69 patients had significant bulging of the pars tensa, whereas only 44 of 69 patients had significant middle ear fluid. As other findings of the tympanic membrane, including a patient who strongly blew the nose, 24 of 72 patients had bleeding and 32 of 36 patients with analysis of recorded photography had significant bulging of the pars flaccida.Merifield (1966) considered that BM is a mechanical injury, which follows upper-respiratory infection of any sort (eg, Eustachian tube insufficiency, fever etc). We thought that BM might be a middle ear barotrauma: abnormal nasopharynx pressure due to allergic rhinitis and others nasal disorders caused a sudden reflux of secretions and air from the nasopharynx into the middle ear such that a vibration and positive pressure suddenly struck the tympanic membrane.

Recurrent Diving-Related Inner Ear Barotrauma

To present two cases of recurrent diving-related inner ear barotrauma (IEB) and to discuss the possible cause and pathogenesis of the increased inner ear vulnerability. Case series. Tertiary referral center. Two scuba divers suffering from repeated cochleovestibular barotrauma. Neurotological evaluation, perilymphatic fistulae repair, and conservative treatment. The increasing popularity of scuba diving expose the individuals involved in this sport to unique pathologies that are not common under terrestrial conditions. The otolaryngologist who is involved in the care of these patients is required to diagnose and treat diving-related ear injuries and to consider the risk for recurrent inner ear injury when diving is resumed. IEB carries a risk for permanent hearing loss and chronic vestibulopathy. We recommend complete neurotological evaluation including high-resolution CT of the temporal bones as a routine workup for IEB. The presence of a significant residual sensorineural hearing loss, evidence for noncompensated vestibular damage, and CT findings of possible enhanced cerebrospinal fluid-perilymph connection should be considered when a return to diving activity is considered.