A scuba diver has hearing loss, tinnitus, vertigo, and a positive fistula test. What is the diagnosis and initial management?

• A. Middle Ear Squeeze Barotrauma — Decongestant; Analgesics; Bed rest with head upright
• B. Inner ear barotrauma — Antibiotics; Steroids; Bed rest
• C. Eustachian tube dysfunction — Nasal sprays; Analgesics; Bed rest
• D. Hearing loss due to noise — Analgesics; Rest

Answer: (A)

Pressure changes from diving can injure the ear when the air that a diver swallows or the air in the middle ear cannot equalize properly. If the force tears membranes at the boundary between the middle and inner ear, a perilymph fistula forms. Hearing loss, tinnitus, and vertigo after a scuba dive, combined with a positive fistula test, point to inner ear barotrauma with a perilymph fistula. The fistula test is a clinical clue that abnormal perilymph leakage is present, confirming this inner-ear involvement.

Initial management focuses on preventing further injury and alleviating symptoms. A decongestant helps reduce mucosal swelling and improves Eustachian tube function, making it easier to equalize pressure. Analgesics control pain, and bed rest with the head in a position that minimizes fluctuations in inner-ear pressure limits additional stress on the delicate structures. This conservative approach is appropriate while monitoring for improvement; if symptoms persist or worsen, urgent ENT evaluation is needed for further assessment and potential surgical repair of the fistula.