Ears and diving

Otitis External

Question:
Last year I for the first time started having troubles with my ear and around easter time ended up with a very bad middle and outer ear infection (external otitis). After seeing several specialists the problems was solved with several antibiotic cures and creams. After going back to Norway I did another check up and was told everything was fine. Did several dives in Norway with no complications.
Went back to Asia in October and after four dives in Malaysia the infection came back, went to see another specialist who gave me penicillin. It felt fine and I went diving again in Thailand but after five dives the infection came back very strong. So went to two more specialists where the last one took swaptests and told me I have a cronic external otitis. The name of the bacteria(culture) is Pseudomonas and it is resistent to many of the antibiotics I have already been treated with. Got many different advice from "never dive again" to "you will just have to try it out and see" Started working six weeks after the last infection and managed two weeks of diving before it hit me again. This time also bad and with the development of many "bumps" behind my ear. A doctor told me this was the bodys antidotes who was working to fight the infection.
My question is, is there any records on this matter and is there anything to be done about this?

Answer:
I am very sorry for your continuing problems with external otitis. However this is not at all an uncommon problem, even if not always reaching the levels of moderately severe infection like it happened in your case.
The occurrence of Pseudomonas as the infecting bacterium is also the norm, and very often this is accompanied by a Candida infection, a fungus. Both microorganisms normally live in the ear canal, but are, so to speak, "kept under control" by the other, more normal, bacterial guests of the human ear. When teh environment changes, however, such as it can happen with prolonged swimming or diving, expecially so in tropical waters, the protective ear wax is often washed away and the pH (acidity) of the ear canal's skin changes and turns basic. The health of the ear canal and the normal predominance of "good" bacteria is strongly linked to an acid environment. Hence the most important preventive measure for diving otitis externa: keeping the ear canal acid, by means of acidic solutions, such as the ones described below.
When the situation develops to the level of a clear infection, ear canal acidification is not any longer effective and antibiotic treatment is requiered.
This condition is also frequent in commercial saturation divers ( such as the ones working in the North Sea) and an effective antibiotic combination, when Pseudomonsa is the infecting agent, is often a combination of an oral antibiotic which is effectively working against Pseudomonas, as determined by the laboratory antibiogram, with a local externa treatment with a mixture of gentamycin and polymixin B or another equivalent anti-fungal active against candida albicans.
Diving should be interrupted during the course of therapy, until all signs and synptoms disappear.
Another very effective solution may be the Pro-Ear Mask, a specially designed mask including pressure-equalized ear cups, that keep the ear dry when diving. This mask has been the solution of the problem for some divers who had found all other measures ineffective. You can learn more about the mask by visiting the website www.proear2000.com

COMMON INJURIES TO THE EAR ASSOCIATED WITH SCUBA DIVING

Otitis Externa (swimmer's ear): This is an inflammation of the external ear canal caused by infection. If the ear remains moist from immersion in the water, this moisture, coupled with the warmth of the body, creates an inviting growth area for many microorganisms, especially opportunistic bacteria.
Signs & Symptoms: The external ear canal is red and swollen and may itch. Pulling or touching the outer ear may cause intense pain.
Treatment: Prevention is key, especially in those persons who have previously shown they are susceptible to this malady. Otic Domeboror Solution and other similar preparations, may function as a prophylactic and treatment for otitis externa when it's used as directed.

From Alert Diver
Can You Prevent Otitis Externa, or Swimmer's Ear?
BY EDWARD THALMANN, M.D.,
The US Navy Protocol: Otic Domeboro Solution: 2 percent acetic acid, water, aluminum acetate, sodium acetate and boric acid. The acid retards bacterial growth, while the aluminum and sodium acetate act as astringents, drawing excess water out of the cells lining the ear canal. The divers put this solution in each ear canal twice a day and hold the solutions for at least five minutes at a time.

There are other preparations available over the counter (Auro-Dri, Swim-Ear) that are less expensive and consist of 95 percent isopropyl alcohol, with anhydrous glycerine. These preparations, however, lack acidity and are less powerful at inhibiting bacterial growth. Application: before your first dive in the morning and after your last dive each night, here's what to do: the head is tilted to one side and the external ear canal gently filled with the solution, which must remain in the canal for five minutes. The head is then tilted to the other side, the solution allowed to run out, and the procedure repeated for the other ear. The five-minute duration must be timed with a watch. If the solution does not remain in the ear a full five minutes, the effectiveness of the procedure is greatly reduced. Remember, this is a prophylactic procedure that should be started before the ear becomes infected - beginning it only after an infection occurs will not help much. Do not put drops in your ear if you have any reason to suspect you may have a ruptured eardrum from a squeeze. If you do, you may wash bacteria into the middle ear, where an infection can be really bad news.

MORE ON SWIMMERS EAR

DAN revisits and expands on the preventive measures for otitis externa
By Edward D. Thalmann, M.D.,
Making Your Own "Home brew" to prevent ear infection, as many of our member wrote in to share with us.
White wine vinegar is 4-6 percent acetic acid, and if it's mixed with an equal amount of isopropyl alcohol, it would probably work fine. Using undiluted vinegar may make the solution too acidic and cause irritation. Using less alcohol may be wise if you find that the 50:50 mix provides too much drying Ä this can make your ear canal sore after several days of use.
In principle, just diluting the acetic acid 50:50 with water might work since it appears that the acidic pH is more important than the drying effect of the alcohol. Adding propylene glycol or other moisturizers would seem either to be a waste of time in a home-brew, or it might produce undesirable effects according to Dr. Jones' observations.
Could lemon juice, which contains citric acid instead of acetic acid, be used instead if vinegar, as some members advised? In principle, if a solution was mixed to a pH of 3.0 it might, but whether other substances in lemon juice might promote bacterial growth I cannot say. For home brew I'd stick to what works Ä vinegar and isopropyl alcohol.
No matter what solution you use, remember its effectiveness is drastically reduced unless it remains in the ear canal a full five minutes. Another caution: the above solutions are for use in the otherwise normal ear with an intact eardrum. If there is any hint that the eardrum may be torn, do not use these solutions as they may cause damage to middle ear structures. And if any solution causes irritation, stop using it.

Otitis and perforated eardrum

Question:
I have been diagnosed with having a hole in my right eardrum and this has become infected. It happened 2 days ago (29/05/2000) and is, I suspect a resurgance of an old infection I had from about a month before. I believe I have a "reverse block" and the pain has been quite intense.
What I need to know is - how serious is this?, should I go to a hospital or back home (to the UK)?.
The medications I have been prescribed are listed below:
Augmentin (amoxycillin and clavulanate potassium) 375mg - 4x/day.
Taravid (otic solution - 3mg of loxacin per 1ml - 4 drops/day.
and then Oticin (500mg of chloramphenicol per 10c.c. - 2 drops every 4 hours.
Actifed (triprolidine HCI 2.5mg & pseudoephedrine HCI 60mg – 4 tablets per day.
and! ibrupofen 400mg capsules as and when for pain.
I also have "Swim Ear" (isopropyl alcohol 95% anhydrous glycerin 5% - which I have been using occasionally. Are these drugs OK?

Answer:
The treatment you have been prescribed is, generally speaking, appropriate for a case of otitis media and external. However if there is a certain or suspected perforation of the eardrum, the use of external medications to be instilled in the external ear canal is not advisable, unless made under direct supervision by a qualified ENT specialist. Likewise, I do not recommend the use of the "Swim Ear" preparation until the current ear infection and eardrum perforation are satisfactorily healed.
The situation is not very serious, but it does require specialits attention and we do recommend that you see an ENT specialist, or go to a hospital with an adequate ENT department.

Ear infections

Question:
I have been diving for over 2 years, with occasional difficulty equalising. On a few occasions i have been a little impatient and forced them. Following this I took "Ibruprofen" and they where fine the following day with no lasting symptoms. During December i completed a few dives at Stoney cove and my ears didnt feel quite right. I thought they just needed a rest. It was cold and I thought I may have been a little congested. Subsequently I stopped diving over Christmas and New year. I visited my GP in January on the 15th. She was shocked when looking down my ears she saw they where full of pus and my ear drums where ruptured. She started me on Amoxycilin for seven days and Locorten-Vioform ear drops three times a day. I have also been experiencing pain in my sinuses and i took Sudofed which helped but kept me awake all night. Following this I commenced Otomize four times a day. My left ear was still infected with pus and the right was clearing up nicely. At present I still get occasional "twinges" in both ears. Currently I am still using Otomize in my left ear and await the ENT consultant appointment.
The question is can you advise me regarding this.

Answer:
The ear infections you have picked up during your diving have to clear up completely before you can consider diving again. The perforations in your ear drums are likely to be due to the severity of the ear infections and not following an in water rupture as this is consistent with the history you describe. These perforations normally close spontaneously within a few weeks once the infection is cleared and you would then be able to resume diving after 1-2 months when the ear drum should be strong enough to resist re-perforation. If closure does not occur spontaneously this may need surgery and return to diving is subject to an assessment by an ENT specialist with diving medical knowledge.