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Mitchell SJ. Decompression illness: a comprehensive overview. Diving Hyperb Med 2024; 54:1-53. [PMID: 38537300 PMCID: PMC11098596 DOI: 10.28920/dhm54.1.suppl.1-53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/31/2024] [Indexed: 05/20/2024]
Abstract
Decompression illness is a collective term for two maladies (decompression sickness [DCS] and arterial gas embolism [AGE]) that may arise during or after surfacing from compressed gas diving. Bubbles are the presumed primary vector of injury in both disorders, but the respective sources of bubbles are distinct. In DCS bubbles form primarily from inert gas that becomes dissolved in tissues over the course of a compressed gas dive. During and after ascent ('decompression'), if the pressure of this dissolved gas exceeds ambient pressure small bubbles may form in the extravascular space or in tissue blood vessels, thereafter passing into the venous circulation. In AGE, if compressed gas is trapped in the lungs during ascent, pulmonary barotrauma may introduce bubbles directly into the pulmonary veins and thence to the systemic arterial circulation. In both settings, bubbles may provoke ischaemic, inflammatory, and mechanical injury to tissues and their associated microcirculation. While AGE typically presents with stroke-like manifestations referrable to cerebral involvement, DCS can affect many organs including the brain, spinal cord, inner ear, musculoskeletal tissue, cardiopulmonary system and skin, and potential symptoms are protean in both nature and severity. This comprehensive overview addresses the pathophysiology, manifestations, prevention and treatment of both disorders.
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Affiliation(s)
- Simon J Mitchell
- Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
- Slark Hyperbaric Medicine Unit, North Shore Hospital, Auckland, New Zealand
- Corresponding address: Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand, ORCiD: 0000-0002-5149-6371,
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Quatre R, Delafosse B, Schmerber S, Soriano E. Decompression sickness of the inner ear and relationship with a patent oval foramen: a study of 61 cases. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08544-w. [PMID: 38470517 DOI: 10.1007/s00405-024-08544-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVE To discuss the link between inner ear decompression sickness and patent foramen ovale. MATERIALS AND METHODS Monocentric and retrospective study on decompression sickness of the inner ear requiring hyperbaric chamber treatment, from 2014 to 2021. RESULTS Sixty-one patients of inner ear decompression sickness were included in this study. Twenty-four patients had vestibular injuries, 28 cochlear injuries and 9 cochleo-vestibular injuries. Compression chamber treatment was given, using an oxygen-helium mixture with oxygen partial pressure (PIO2) limited to 2.8 atmosphere absolute (ATA). All vestibular accidents completely recovered without clinical sequelae. For cochlear accident only 10 out of 37 patients (27%) recovered completely. A right-left shunt (patent foramen oval or intra-pulmonary shunt) was found in 31.1% of patients with inner ear decompression sickness (p > 0.05). CONCLUSION The presence of patent foramen oval in patients with inner ear decompression was not statistically significant in our study. Understanding of the pathophysiology of decompression illness and the physiology and anatomy of the labyrinth would suggest a mechanism of supersaturation with degassing in intra-labyrinthine liquids.
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Affiliation(s)
- Raphaële Quatre
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital Grenoble-Alpes, BP 217, 38043, Grenoble Cedex 09, France.
- GeodAIsics, Grenoble, France.
- BrainTech Lab INSERM UMR 2015, Grenoble, France.
| | - Bertrand Delafosse
- Service de Médecine Hyperbare, CHU de Lyon, University of Lyon, Lyon, France
| | - Sébastien Schmerber
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital Grenoble-Alpes, BP 217, 38043, Grenoble Cedex 09, France
- BrainTech Lab INSERM UMR 2015, Grenoble, France
| | - Edouard Soriano
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital Grenoble-Alpes, BP 217, 38043, Grenoble Cedex 09, France
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Vargas-Figueroa VM, Cáceres-Chacón M, Labat EJ. Scuba Diving-Induced Inner-Ear Pathology: Imaging Findings of Superior Semicircular Canal and Tegmen Tympani Dehiscence. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e941558. [PMID: 38163945 PMCID: PMC10773621 DOI: 10.12659/ajcr.941558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/30/2023] [Accepted: 10/10/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Superior semicircular canal dehiscence is an inner-ear pathology which presents with vertigo, disequilibrium, and hearing loss. Although the exact etiology of superior semicircular canal dehiscence is unknown, it is thought that an increase in middle-ear pressure disrupts a thin overlying temporal bone. Superior semicircular canal dehiscence is frequently seen in association with dehiscence of the tegmen tympani, which overlies the middle ear. Here, we present a case report of a 52-year-old Puerto Rican man with vertigo, dizziness, vomiting, and mild hearing loss associated with superior semicircular canal and tegmen tympani dehiscence after performing improper scuba diving techniques. CASE REPORT A 52-year-old Puerto Rican man presented to the emergency department with vertigo, dizziness, vomiting, and mild hearing loss in the right ear. The symptoms began shortly after scuba diving with inadequate decompression techniques on ascent. He was treated with recompression therapy with mild but incomplete improvement in symptoms. Bilateral temporal magnetic resonance imaging was suggestive of segmental dehiscence of the right superior semicircular canal and tegmen tympani. High-resolution computed tomography of the temporal bone confirmed right superior semicircular canal and tegmen tympani dehiscence with an intact left inner ear. CONCLUSIONS The increased inner-ear pressure that occurs during scuba diving can lead to dehiscence of the superior semicircular canal and tegmen tympani, causing vertigo and hearing loss. Performance of improper diving techniques can further increase the risk of dehiscence. Therefore, appropriate radiologic evaluation of the inner ear should be performed in such patients.
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Affiliation(s)
| | - Mauricio Cáceres-Chacón
- Department of Anatomy & Neurobiology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - Eduardo J. Labat
- Department of Diagnostic Radiology, University of Puerto Rico School ofMedicine, San Juan, Puerto Rico
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Mason JS, Buzzacott P, Gawthrope IC, Banham ND. A retrospective review of divers treated for inner ear decompression sickness at Fiona Stanley Hospital hyperbaric medicine unit 2014-2020. Diving Hyperb Med 2023; 53:243-250. [PMID: 37718299 PMCID: PMC10735645 DOI: 10.28920/dhm53.3.243-250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 05/21/2023] [Indexed: 09/19/2023]
Abstract
Introduction Inner ear decompression sickness (IEDCS) is increasingly recognised in recreational diving, with the inner ear particularly vulnerable to decompression sickness in divers with a right-to-left shunt, such as is possible through a persistent (patent) foramen ovale (PFO). A review of patients treated for IEDCS at Fiona Stanley Hospital Hyperbaric Medicine Unit (FSH HMU) in Western Australia was performed to examine the epidemiology, risk factors for developing this condition, the treatment administered and the outcomes of this patient population. Methods A retrospective review of all divers treated for IEDCS from the opening of the FSH HMU on 17 November 2014 to 31 December 2020 was performed. Patients were included if presenting with vestibular or cochlear dysfunction within 24 hours of surfacing from a dive, and excluded if demonstrating features of inner ear barotrauma. Results There were a total of 23 IEDCS patients and 24 cases of IEDCS included for analysis, with 88% experiencing vestibular manifestations and 38% cochlear. Median dive time was 40 minutes and median maximum depth was 24.5 metres. The median time from surfacing to hyperbaric oxygen treatment (HBOT) was 22 hours. Vestibulocochlear symptoms fully resolved in 67% and complete symptom recovery was achieved in 58%. A PFO was found in 6 of 10 patients who subsequently underwent investigation with bubble contrast echocardiography upon follow-up. Conclusions IEDCS occurred predominantly after non-technical repetitive air dives and ongoing symptoms and signs were often observed after HBOT. Appropriate follow-up is required given the high prevalence of PFO in these patients.
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Affiliation(s)
- Jeremy S Mason
- Department of Hyperbaric Medicine, Fiona Stanley Hospital, Murdoch, WA, Australia
- Corresponding author: Dr Jeremy Mason, Department of Hyperbaric Medicine, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA, 6150, Australia,
| | - Peter Buzzacott
- Prehospital, Resuscitation and Emergency Care Research Unit, Curtin School of Nursing, Curtin University, WA, Australia
| | - Ian C Gawthrope
- Department of Hyperbaric Medicine, Fiona Stanley Hospital, Murdoch, WA, Australia
- University of Notre Dame, Fremantle, WA, Australia
| | - Neil D Banham
- Department of Hyperbaric Medicine, Fiona Stanley Hospital, Murdoch, WA, Australia
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Doolette DJ, Mitchell SJ. Extended lifetimes of bubbles at hyperbaric pressure may contribute to inner ear decompression sickness during saturation diving. J Appl Physiol (1985) 2022; 133:517-523. [PMID: 35834629 DOI: 10.1152/japplphysiol.00121.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Inner ear decompression sickness (IEDCS) may occur after upward or downward excursions in saturation diving. Previous studies in non-saturation diving strongly suggest IEDCS is caused by arterialization of small venous bubbles across intracardiac or intrapulmonary right-to-left shunts, and bubble growth through inward diffusion of supersaturated gas when they arrive in the inner ear. The present study used published saturation diving data, and models of inner ear inert gas kinetics and bubble dynamics in arterial conditions to assess whether IEDCS after saturation excursions could also be explained by arterialization of venous bubbles, and whether such bubbles might survive longer and be more likely to reach the inner ear under deep saturation diving conditions. Previous data show that saturation excursions produce venous bubbles. Modelling shows gas supersaturation in the inner ear persists longer than in the brain after such excursions, explaining why the inner ear would be more vulnerable to injury by arriving bubbles. Estimated survival of arterialized bubbles is significantly prolonged at high ambient pressure such that bubbles large enough to be filtered by pulmonary capillaries but able to cross right-to-left shunts are more likely to survive transit to the inner ear than at the surface. IEDCS after saturation excursions is plausibly caused by arterialization of venous bubbles whose prolonged arterial survival at deep depths suggests larger bubbles in greater numbers reach the inner ear.
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Affiliation(s)
- David J Doolette
- Department of Anaesthesiology, The University of Auckland, Auckland, New Zealand
| | - Simon J Mitchell
- Department of Anaesthesiology, The University of Auckland, Auckland, New Zealand
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Affiliation(s)
- Simon J Mitchell
- From the School of Medicine, University of Auckland, and the Department of Anaesthesia, Auckland City Hospital - both in Auckland, New Zealand (S.J.M.); Prince of Wales Clinical School, University of New South Wales, and Wales Anaesthesia, Prince of Wales Hospital - both in Sydney (M.H.B.); and the Departments of Anesthesiology and Medicine, Duke University Medical Center, and the Center for Hyperbaric Medicine and Environmental Physiology, Duke University - both in Durham, North Carolina (R.E.M.)
| | - Michael H Bennett
- From the School of Medicine, University of Auckland, and the Department of Anaesthesia, Auckland City Hospital - both in Auckland, New Zealand (S.J.M.); Prince of Wales Clinical School, University of New South Wales, and Wales Anaesthesia, Prince of Wales Hospital - both in Sydney (M.H.B.); and the Departments of Anesthesiology and Medicine, Duke University Medical Center, and the Center for Hyperbaric Medicine and Environmental Physiology, Duke University - both in Durham, North Carolina (R.E.M.)
| | - Richard E Moon
- From the School of Medicine, University of Auckland, and the Department of Anaesthesia, Auckland City Hospital - both in Auckland, New Zealand (S.J.M.); Prince of Wales Clinical School, University of New South Wales, and Wales Anaesthesia, Prince of Wales Hospital - both in Sydney (M.H.B.); and the Departments of Anesthesiology and Medicine, Duke University Medical Center, and the Center for Hyperbaric Medicine and Environmental Physiology, Duke University - both in Durham, North Carolina (R.E.M.)
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