A case of dizziness, headache, aural fullness, and concentration difficulty following scuba diving - Vestibulology Clinic

Ear, Nose & Throat Journal, May, 2003 by Kenneth H. Brookler

A 37-year-old woman, a financial analyst, came to the office with an 8-day history of dizziness. A certified diver, she had been scuba diving in the ocean 10 days earlier. She had no difficulty clearing her ears, even after several dives as deep as 60 feet. She had 4 undergone decompression in the approved manner.

The patient reported that she developed a headache soon after her last dive. She said the headache felt like it was "wrapped around my head." The day after her last dive, she flew home and did not feel well. The next day, she became lightheaded and dizzy. She sought treatment and was placed in a hyperbaric -- chamber for 10 hours. Afterward, she felt better for approximately 24 hours, but then her symptoms returned. She again underwent hyperbaric therapy, but she did not improve.

The patient said her dizziness took on different characteristics depending on the situation. When she was standing or walking, she felt as if she was about to fall down. When she was sitting or lying down, she felt "woozy." She felt best when she was lying down. She also complained of binaural fullness, more so on the right, but she was not sure how long it had been present. The sensation of fullness increased with rapid motion. She said she was not "thinking straight" and had difficulty focusing her eyes, and she also complained of photophobia. She had no hearing loss or tinnitus. Her bitemporal headache extended to the back of the neck.

Clinical examination yielded equivocal Vth cranial nerve findings and left nuchal tenderness. The patient exhibited marked difficulty performing the sharpened tandem Romberg's test. Findings on magnetic resonance imaging were negative. Audiology revealed normal hearing, and electronystagmography detected no spontaneous, positional, or neck-torsion nystagmus. The results of an alternate binaural bithermal caloric test were normal, with a reduced vestibular response right of 19% and a directional preponderance of 17%. Simultaneous binaural bithermal stimuli evoked a type 2 response, indicating that the patient had a reduced vestibular response on the right. A metabolic evaluation revealed a blood sugar level of 40 mg/dl and evidence of hyperinsulinemia. Ultrathinlayer, small-pixel computed tomography of the temporal bones yielded findings consistent with inner ear otosclerosis. The patient was placed on a diet to address her metabolic factors, and she was prescribed etidronate and calcium to treat the otoscler osis.

At the 2-month follow-up visit, the patient's dizziness, headache, aural fullness, focusing problem, and photophobia had completely resolved, and her concentration had improved. However, the pain in her neck and ears continued; she felt worse during her menstrual period, a finding commonly seen in women with otosclerosis. Sinusoidal vertical-axis rotation testing detected an abnormal symmetry, which is evidence of a continuing vestibular problem. A very low dose of desipramine was added to her regimen. As a tricyclic antidepressant, desipramine has sympathomimetic and anticholinergic effects, both of which are useful in suppressing vestibular symptoms.

The patient returned 3 months later and reported that her neck pain had disappeared and her ear pain was diminished. However, findings of abnormal symmetry on a follow-up sinusoidal vertical-axis rotation test continued to indicate that she had a peripheral vestibular disorder. She had also experienced palpitations as a result of the desipramine, so she was switched to Vertigoheel.

Six months later, the patient was almost symptom-free. Findings on a repeat sinusoidal vertical-axis rotation test were nearly normal. She was switched from etidronate to risedronate and continued on calcium. She returned 3 months later essentially symptom-free. Five months later, she had successfully discontinued the Vertigoheel. She remained symptom-free 6, 12, and 18 months later and was able to discontinue the remainder of her oral treatment regimen.

This case is an illustrative example of otoscierosis being triggered by a history of increased barometric pressure. Vestibular suppressants and other agents led to a resolution of her symptoms. A question still remains as to the possibility that her symptoms will return after she has been off the treatment regimen for a longer period of time.

From Neurotologic Associates, P.C., New York City.