Page 69 - Journal of Special Operations Medicine - Summer 2016

Figure 3 US Navy double-lock hyperbaric chamber: internal. The Marine underwent MRI of the brain with internal
auditory canal (IAC) protocol to assess for possible inner
ear pathology. The MRI was significant only for inflam-
matory sinus disease. No IAC pathology was found. The
patient’s vertigo and hearing symptoms subsequently
resolved 3 weeks after initial neurology evaluation. It
was determined that his sensory deficit was probably
congenital, and not likely due to a brain or spinal patho-
logic process. Therefore, no further workup for this
finding was warranted. The vestibular symptoms, on
the other hand, were attributed to a left-sided vestibular
pathology that had since resolved. The Marine was sent
to an ENT specialist to rule out permanent vestibulo-
cochlear impairment. There, he was diagnosed with a
single episode of otic barotrauma leading to temporary
vestibular instability, hearing loss, and tinnitus, which
had since resolved. It was determined that there was no
to further hyperbaric pressure. If operational necessity middle ear or eustachian tube pathology and normal in-
dictates the patient undergo repeated hyperbaric expo- ner ear function was present.
sure after injury (as in the case of a required covert exfil-
tration after injury during insertion), the patient and the Conclusion
chain of command should be informed of the medical
risks the patient will face with this repeated exposure. IEDCS was ruled out as the cause of symptoms in
These may include further pain, hearing impairment, this case because the patient was not breathing com-
and, most significantly, vertigo symptoms during the pressed air. A waiver of physical standards for Naval
dive, which could lead to drowning. Special Warfare/Special Operations and Dive duty was
requested for this Marine because of his history of in-
Military medical practitioners have a duty to educate ner ear injury. Unfortunately, the waiver was ultimately
both the patient and their chain of command of all pos- denied. This case serves as a cautionary reminder that
sible risks so commanders may make informed tactical relatively benign and routine activities practiced within
decisions. Still, the most important treatment of IEB is the Special Operations community, such as transiting
prevention. Divers experiencing ear, upper respiratory a pool bottom or knot tying on a breath hold without
or sinus infections, or congestion may be at increased breathing compressed air, at relatively shallow depths,
risk for certain barotraumas. These conditions should have the potential to cause substantial injury. Every ef-
be effectively treated and managed with decongestants fort should be made to ensure those who participate in
and/or antibiotics, as indicated. These ailments should these activities are free from injuries or ailments that in-
be thoroughly addressed prior to the diver proceeding terfere with the effective pressure equalization processes
with dive operations. Medical personnel should ensure of the body.
divers can adequately perform the Valsalva maneuver
without straining after illness to minimize risk of sus- Disclaimer
taining injury.
The view(s) expressed herein are those of the authors
Case Presentation, Continued and do not reflect the official policy or position of the
Subsequent neurologic examinations of the patient per- US Navy Bureau of Medicine and Surgery, US Marine
formed at the BAS showed continued balance instability Corps, Department of the Navy, Department of De-
toward the right side and persistent sensory deficit over fense, or the US Government.
the left antecubital fossa. The patient also endorsed on-
set of tinnitus and perceived decreased hearing in the left Disclosures
ear. Accordingly, the Marine was referred to a neurolo-
gist at the on-base naval hospital for further evaluation. The authors have no conflicts of interest or financial
Examination by the staff neurologist showed dimin- considerations to disclose.
ished pinprick and temperature sensation in the left an-
tecubital region only, in a nondermatomal distribution. References
Romberg testing oscillated in multiple directions and 1. Hunter SE, Farmer JC Jr. (2004). Ear and sinus problems in
the Dix-Hallpike maneuver was symptomatic on the left diving. In: Bove AA (ed), Bove and Davis’ Diving medicine. 4th
side without significant nystagmus. ed. Philadelphia, PA: Saunders; 2004:446–452.

Inner Ear Barotrauma 55