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Inner-ear decompression sickness in nine trimix recreational divers
Abstract
Introduction:
Recreational technical diving, including the use of helium-based mixes (trimix) and the experimentation of new decompression algorithms, has become increasingly popular. Inner-ear decompression sickness (DCS) can occur as an isolated clinical entity or as part of a multi-organ presentation in this population. Physiological characteristics of the inner ear make it selectively vulnerable to DCS. The inner ear has a slower gas washout than the brain thus potentially making it more vulnerable to deleterious effects of any bubbles that cross a persistent foramen ovale (PFO) and enter the basilar artery, whilst the inner ear remains supersaturated but the brain does not.
Methods:
A questionnaire was made widely available to divers to analyse the incidence of inner-ear DCS after technical dives. One-hundred-and-twenty-six divers submitted completed questionnaires, and we studied each incident in detail.
Results:
Nine (7.1%) of the 126 responders reported to have had at least one episode of inner-ear DCS, of which seven occurred without having omitted planned decompression stops. Of these seven, four suffered from DCS affecting just the inner ear, while three also had skin, joint and bladder involvement. Five of the nine divers affected were found to have a PFO. All affected divers suffered from vestibular symptoms, while two also reported cochlear symptoms. Three divers reported to have balance problems long after the accident.
Conclusions:
This small study is consistent with a high prevalence of PFO among divers suffering inner-ear DCS after trimix dives, and the pathophysiological characteristics of the inner ear could contribute to this pathology, as described previously. After an episode of DCS, vestibular and cochlear injury should always be examined for.
... This is due to the diver inhaling compressed gas when subjected to the high pressure during the dive. This process results in the supersaturation of nitrogen in the circulatory system because the increase in ambient pressure and compressed gas occurs simultaneously according to Boyle's law (Guenzani et al., 2016;Vann et al., 2011). These dissolved gases ventilate out of the body in a proper decompression process (slow ascent to gradually reduce the surrounding atmospheric pressure and release high concentrations of nitrogen through the lungs without significant incident). ...
... DCS is charged when excess dissolved gas undergoes rapid pressure changes and triggers the formation of gas bubbles in the blood and tissues, causing obstruction and inflammation. This occurs during the process of rising to the surface when the ambient pressure decreases too quickly to retain the gas solution and expel it through respiration (Guenzani et al., 2016). ...
... IEDCS is usually found on deep dives with the use of helium-oxygen mixtures, especially when breathing gases are diverted from nitrogen-containing decompression mixtures back to helium-containing mixtures (e.g., base mixtures on divers). This is most common in technical/professional divers but can also occur on dives within recreational divers (Guenzani et al., 2016;Vann et al., 2011). Although the actual mechanism is poorly understood, it is thought to occur because helium has a much higher diffusion rate than nitrogen, the diffusion of helium into endolymph-like tissues that are already close to supersaturation results in the formation of bubbles even at the time of the cessation of decompression where the ambient pressure remains constant. ...
Background: Inner ear decompression sickness (IEDCS) is a common disease in divers. In Indonesia, IEDCS is often experienced by diver fishermen in fulfilling their daily needs. In general, decompression sickness (DCS) is caused by the formation of gas bubbles in blood vessels and organ tissues. This is due to the deposition of gas bubbles in the endolymphatic and perilymphatic spaces during the process of their rapid rise to the surface. Objective: This study aims to identify IEDCS disease in divers. Method: This study used a qualitative approach with a case study model that analyzes and identifies the symptoms that appear in divers suffering from IEDCS. Result: Symptoms of classic IEDCS develop in about 30 minutes and are vestibular, these include vertigo, ataxia, nausea, and vomiting. The preferred therapy that can be given to people with DCS and IEDCS is hyperbaric oxygen therapy (recompression therapy) immediately. Complications are rare after hyperbaric oxygen therapy. After therapy and DCS sufferers recover, there will usually still be residual deficits in balance and hearing. Diving according to protocol and providing information about DCS through education, counseling, or other media needs to be done for at-risk groups to create knowledge that is relevant and can take precautions. Conclusion: The disease of decompression of the part ear is common in compressed gas divers. This is due to the deposition of gas bubbles in the endolymphatic and perilymphatic chambers during the process of rising to the surface quickly.
... [1][2][3][4][5][6] A plethora of other ear pathologies have been identified affecting divers including exostoses, inner-ear barotrauma, hearing loss, vertigo, and inner ear decompression sickness (inner ear DCS). [7][8][9][10][11][12][13][14] Ear health as a component of diving medical guidelines is an important element of scuba training and good diving practice, but the training delivered to individuals new to the sport may not be optimal to develop ear-safe and symptom-free diving. 15 It is clear that symptoms frequently go unreported to medical practitioners and, for those symptoms which are reported to physicians, it is possible that unfamiliarity with the physiology and physics of scuba diving will be detrimental to the quality of the advice given. ...
... Although three technical divers reported inner ear DCS these data should be treated with caution as this fi nding is likely due to small numbers and/or reporting bias. 1,[12][13][14] Decongestants were successfully used in a quarter of all respondents with some using decongestants prophylactically for every dive. There was no statistical difference between decongestant use and the rate of inner and/or middle ear barotrauma, suggesting that decongestants were being selfadministered without negative outcomes. ...
Introduction:
Otological disorders, including Eustachian tube dysfunction (ETD), are commonly observed in divers. Data were gathered to observe the prevalence of ear disorders, and awareness of ear health recommendations for recreational divers in the United Kingdom.
Methods:
An anonymous online survey included: diver/diving demographics, the validated Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7) (a mean score of ≥ 2.1 indicating the presence of dysfunction), pre-existing ear health conditions, medications, decongestants and knowledge of diving and ear health guidance.
Results:
A total of 790 divers (64% males) responded (age range 16-80, median 47 years). An ETDQ-7 mean score of ≥ 2.1 was calculated in 315 of 790 respondents (40%), indicating varying degrees of ETD; 56/315 (18%) recorded a pre-existing ear condition. Ear disorders, (external, middle, and inner ear issues) since learning to dive were recorded by 628/790 (79%) of respondents; 291/628 (46%) did not seek medical advice. ETDQ-7 scores of ≥ 2.1 to 6.6 were reported by 293/628 (47%). Six reported inner ear decompression sickness. Decongestants were used by 183/790 (23%). Two hundred and seventy-seven of 790 divers (35%) had aborted a dive with ear problems. Only 214/790 (27%) of respondents were aware of the United Kingdom Diving Medical Committee guidance regarding ear health and diving.
Conclusions:
Ear problems and ETD since diving were widely reported in this cohort of divers, with not all divers in this study aware of ear health recommendations and advice.
... Multiple studies have demonstrated an increased incidence of major PFO in patients with IEDCS. 7,11,[33][34][35][36][37][38] Other theories include bubble formation within the otic capsule osteoclasts and gas supersaturation in the inner ear spaces, potentially leading to vascular injury. 11,30,39 Because the cochlea has a greater blood supply and smaller tissue volume, and thus a faster washout period, the vestibular system is believed to be more susceptible to IEDCS. ...
... 11,30,39 Because the cochlea has a greater blood supply and smaller tissue volume, and thus a faster washout period, the vestibular system is believed to be more susceptible to IEDCS. 33,36 A similar phenomena is suspected as the cause of IEDCS in the absence of stroke symptoms, as the half time of inert gas washout period is seven times greater in the inner ear than in the brain. 38 Primate models subjected to decompression injury are found to gradually develop fibro-osseus labyrinthitis, which consists of potentially obstructive osteoneogenesis in the tissue adjacent to the semicircular canals and can render a particular canal nonfunctional. ...
Objectives
Introduce pertinent self‐contained underwater breathing apparatus (SCUBA) physiology and corresponding terminology. Appreciate the scope of diving and related otolaryngological injury. Illustrate pathophysiologic mechanisms for diving injuries. Summarize strategies for ear, paranasal sinus, and lung barotrauma prevention, including medical optimization and autoinsufflation techniques.
Methods
We conducted a review of the available medical and diving literature in English, German, Spanish, Italian Turkish, and French to determine the degree of evidence or lack thereof behind recommendations for treating SCUBA divers. The databases of PubMed, Ovid Medline, and the Cochrane library, as well available textbooks, were queried for relevant data.
Results
Divers are subjected to large pressure gradients within the first few meters of descent. This can lead to gas embolism formation as well as barotrauma secondary to gas expansion/compression in potential closed spaces such as the middle ear, paranasal sinuses, and lungs. Physicians can minimize the risk of injury by counseling patients regarding proper equalization and descent/ascent techniques, and optimizing sinonasal and eustachian tube function. The use of decongestants is controversial.
Conclusions
Diving is an increasingly popular sport with predominantly otolaryngologic manifestations of injury and disease. Treating SCUBA divers requires a firm understanding of how physiology is altered underwater. This review presents the relevant background information using illustrations to understand the environmental forces acting on divers and how to prevent injury. Laryngoscope, 2019
... Celles-ci sont 31 présumées être le facteur déclenchant des mécanismes physiologiques à l'origine des accidents 32 de décompression (ADD) et l'oxygénothérapie hyperbare (OHB) en reste le traitement de 33 référence (8). Une étude récente a montré, chez des plongeurs Tek finlandais, que la majorité 34 des symptômes anormaux était soit négligés, soit pris en charge par les plongeurs eux-mêmes 35 sans recherche d'un avis médical ni d'OHB (9). Une sous-déclaration des accidents est probable 36 dans cette population comme cela a déjà été mis en évidence chez les plongeurs loisirs (10). ...
Objectives. — The democratization of deep technical diving beyond 50 meters was enabled by the development of rebreather and the use of helium-based breathing mixtures. Dives planification remains a widely debated topic in technical diving community. In addition, accident pattern could differ from what is classically observed in recreational scuba diving and must be largely under-reported. The aim of this investigation was to describe practices and accidentology in mixed-gas rebreather diving.
Methods. — An anonymous survey was conducted on social networks in destination to French residents certified trimix rebreather divers. Demographic data, planification habits and occurrence of post-dive abnormal symptoms were sought. Actions taken regarding onset of symptoms were also investigated.
Results. — In total, 194 questionnaires were analysed. Most of respondents were male (96.4%), mostly aged over 46 years with a high level of certification and for recreational purpose. The dive plans varied depending on the dive profiles with a very high inter-individual variability. Gas density at depth frequently exceeded the recommendations. Among the respondents, 9.8% declared having experienced symptoms suggestive of gas toxicity, mainly linked to nitrogen narcosis. Thirty-four percent reported experiencing evocative symptoms of decompression sickness (DCS) in their trimix dive history for an estimated incidence of 27/10,000 dives and 3.6% described persistent breathing difficulties, which could suggest immersion pulmonary oedema. In case of DCS evocative symptoms, only 42% received normobaric oxygen, 35% sought medical advice
and 29% got hyperbaric oxygen therapy. Three reported having long-term residual symptoms.
Conclusion. — The diversity of practices highlights the lack of strong scientific data supporting them. The accident rate in mixed-gas diving could be higher than in recreational diving, though mostly with mild severity. Treatment seems to be remained neglected despite the high level of knowledge of divers. However, the prognosis seems most often favourable. It appears essential
to continue research into decompression and physiological effects of these dives. Awareness and education efforts in diving first aid must be continued among this exposed community.
... Perforation of the tympanic membrane (TM) prevails as one of the common pathologies in otology practice. The most common cause of TM perforation is chronic suppurative otitis media (CSOM) followed by other causes of sudden perforation like direct trauma from diving and flying, blast injury, direct slap, self-cleaning of the ear using sharp articles and iatrogenic injury to TM. 1 Probable complications that can occur if perforations are not treated early includes mastoiditis, facial nerve paralysis, intracranial infections etc. 2,3 regardless of the placement technique. 6,7 Thus associated with increased failure rate in high-risk cases. ...
Background: Numerous grafting materials have been applied for repair of tympanic membrane (TM) in chronic otitis media patients. This study aimed to compare the anatomical and audiological results of temporalis fascia alone versus reinforced sliced cartilage in type 1 tympanoplasty. Methods: A prospective study was conducted on 50 patients of age group 15-55 years. Patients were randomly divided into two groups, each group having 25 patients. In group I patients under went type I tympanoplasty with temporalis muscle fascia alone and group II patients with sliced tragal cartilage reinforced to temporalis fascia. Post operatively all patients were followed on 30th, 60th and 90th day. In the last follow up, assessment of graft uptake was done and pure-tone audiometry was performed to evaluate air-bone gap closure. The data so obtained were collected and analysed using appropriate statistical tests. Results: Overall graft uptake rate in group I (TF alone) was 84%, whereas in group II (TF+ reinforced sliced cartilage) was 92% (p=0.5). The mean post op ABG improved to 16.17±6.26 dB and 16.56±5.25 dB respectively in group I and II. There was significant hearing improvement in each group but no statistical significant difference was observed in post-op ABG between the two groups. Conclusions: Reinforced sliced tragal cartilage technique is a good alternative to temporalis fascia alone in terms of graft uptake and prevention of disease recurrence, especially for large and subtotal perforations but additive effect of cartilage slicing in hearing gain still remains little controversial.
... 22 The vestibular portion of the inner ear is the most affected because it has higher tissue volume and smaller blood supply and thus a slow washout period. 23,24 All this promotes supersaturation of the vestibular apparatus and consequently vascular bubble overload. 17 Although the exact pathogenetic mechanism is still unclear; it has been speculated that gas bubbles can interact with the endothelium of blood vessels in the labyrinth and trigger an inflammatory reaction with the activation of the coagulation cascade and subsequent hypoxic injury can occur. ...
Self-Contained Underwater Breathing Apparatus (SCUBA) diving is a popular sport. However, improper diving may injure different organs. The majority of dive-related disorders concern otolaryngology, and may include hearing loss, tinnitus, aural fullness, disequilibrium, and vertigo. Three main inner ear pathological conditions can occur underwater: inner ear barotrauma (IEB), inner ear decompression sickness (IEDS), and alternobaric vertigo (AV). IEB results from inappropriate equalization of middle ear pressure and consequent inner ear injury produced by pressure changes within the middle ear; IEDS is characterized by the formation of gas bubbles within the vessels of the inner ear during rapid ascent; AV typically develops while ascending or performing the Valsalva maneuver and can follow asymmetrical equalization of middle ear pressure transmitted via the oval and round window membranes. The clinical pictures of these pathological conditions are partly superimposable, even if they have specific peculiarities. Before starting SCUBA diving, a fit-to-dive assessment is recommended. It should include an otolaryngologic examination with audiological assessment to evaluate nasal, middle ear, and tubal patency and to minimize the risk of IEB, IEDS, and AV. It is of utmost importance to identify individual risk factors and predisposing pathological conditions that favor inner ear injury before diving, to prevent acute events and preserve auditory and vestibular functions in SCUBA divers. This review aims to provide an overview of the pathological conditions characterized by inner ear injury in SCUBA divers, discussing their pathogenetic mechanisms, diagnostic work-up, and prevention.
... 41 Patients with severe or recurrent neurologic DCS are sometimes referred for echocardiogram to assess for patent foramen ovale (PFO). Despite the connection between large PFO and neurologic DCS, 30,[42][43][44][45][46] PFOs are common in the general population, and many patients with DCS do not have a PFO, suggesting that closure may not prevent future incidents. PFO closure has been performed successfully to allow full return to diving 47 ; however, closure carries a serious adverse event risk of 1%, which is an order of magnitude larger than the risk of DCS. ...
... The tympanic membrane injury can predispose to middle ear infection which has grave consequences including facial nerve paralysis, formation of cholesteatoma, perilymph fistula, and intracranial infections and may require ear and intracranial exploration. 1 The incidence of perforations of the tympanic membrane due to trauma is on the increase consequent to trauma, and increased violence and accidents seen in present-day life. 2 Ear buzzing, earache, and hearing loss are the major symptoms of tympanic membrane perforation. In addition, tympanic membrane perforation can increase the risk for middle ear infection or otitis media. ...
p class="abstract"> Background: The aim of the study was to evaluate various etiological factors, clinical presentation in patients presenting with Traumatic ear perforations.
Methods: 27 patients were taken in our study who reported within two weeks of history of trauma with no previous history of middle ear pathology. Data was collected and patients were treated.
Results: 27 patients were studied (11 males and 16 females); age ranging from 15 years to 56 years. Laterality of trauma was found to be more in left ear. Aural Fullness & pain in ear were the most common presenting complaints. Most common etiology was found to be assault and poster inferior quadrant was found to be most commonly involved.
Conclusions: Traumatic perforations have a very good prognosis if they are treated at the right time. We would also like to stress on the fact that domestic violence is still prevalent in our society leading to patients of traumatic perforation.
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... Generally, helium is known to be non-narcotic, but only in a few articles mood and behavior changes have been reported at high pressures, not high concentrations. Thus, helium narcosis is more of a theoretical entity and attributing a narcotic effect to helium in relation to concentration may be misleading [5]. Furthermore, "less bubble formation with helium" is arguable. ...
Abstract We have read the case report about a decompression sickness that was unresponsive to hyperbaric oxygen treatment in your journal. Presented case is intriguing; however, we think there are some contradictive issues in the discussion of the case. In this letter, we aim to comment on these issues that may raise further question. Bubble formation plays a very important role for decompression sickness, but proposed mechanism is incorrect as nitrogen does not change state during decompression. Use of terminology for diving-related diseases and comments on properties of helium may cause misunderstandings. Also importance of history of the dive in evaluating an accident should be emphasized.
Objective:
The aim of this study was to assess the association between the presence of a right-to-left shunt (RLS) and neurological decompression sickness (NDCS) and asymptomatic brain lesions among otherwise healthy divers.
Background:
Next to drowning, NDCS is the most severe phenotype of diving-related disease and may cause permanent damage to the brain and spinal cord. Several observational reports have described the presence of an RLS as a significant risk factor for neurological complications in divers, ranging from asymptomatic brain lesions to NDCS.
Methods:
We systematically reviewed the MEDLINE, Embase, and CENTRAL databases from inception until November 2021. A random-effects model was used to compute odds ratios.
Results:
Nine observational studies consisting of 1830 divers (neurological DCS: 954; healthy divers: 876) were included. RLS was significantly more prevalent in divers with NDCS compared to those without (62.6% vs. 27.3%; odds ratio (OR): 3.83; 95% CI: 2.79-5.27). Regarding RLS size, high-grade RLS was more prevalent in the NDCS group than the no NDCS group (57.8% versus 18.4%; OR: 4.98; 95% CI: 2.86-8.67). Further subgroup analysis revealed a stronger association with the inner ear (OR: 12.13; 95% CI: 8.10-18.17) compared to cerebral (OR: 4.96; 95% CI: 2.43-10.12) and spinal cord (OR: 2.47; 95% CI: 2.74-7.42) DCS. RLS was more prevalent in divers with asymptomatic ischemic brain lesions than those without any lesions (46.0% vs. 38.0%); however, this was not statistically significant (OR: 1.53; 95% CI: 0.80-2.91).
Conclusions:
RLS, particularly high-grade RLS, is associated with greater risk of NDCS. No statistically significant association between RLS and asymptomatic brain lesions was found.
INTRODUCTION Traumatic tympanic membrane perforation is the most common type of trauma – induced otologic dysfunction. The study is aimed to evaluate factors affecting healing of truamatic tympanic membrane perforation after 12 weeks. MATERIAL AND METHODS A prospective observational study conducted at UCMS, Bhairahawa, Nepal. Sixty patients with traumatic tympanic membrane perforation were evaluated on the basis of causes of trauma, symptoms, otoscopic examination, size of perforation and other factors affecting the outcome of perforation. Healing status of tympanic membrane was assessed 12-week post injury. RESULTS The age of the patients ranged from 4-79 years with mean age (years) of 27.84 ± 13.16. Otalgia was seen in 36 (60%) followed by hearing loss 21 (35%) and least common was vertigo 2 (3%). Most common etiology for injury was ‘Slap’(30%) followed by fall injury and physical assault excluding slap with each comprising 16%. Number of patients with small, medium and large perforations were 27 (45%), 21 (35%) and 12 (20%) respectively. After 12 weeks, 46 (77%) cases had healed perforation with best healing seen in younger patients having age group 11-40 years (26.28±13.5) and least in age group >60 years (52±25.11 ) with p value of 0.01. 97% cases of smaller perforation had healed tympanic membrane whereas in larger perforation healing was observed in only 42 % cases. CONCLUSION Age, size of perforation, types of traumas have significant effect on outcomes of spontaneous healing. With cautious care and strong aural precautions, the prognosis of tympanic membrane perforation spontaneous healing is favourable.
Introduction: Inner ear barotrauma (IEBt) and inner ear decompression sickness (IEDCS) are the two dysbaric inner ear injuries associated with diving. Both conditions manifest as cochleovestibular symptoms, causing difficulties in differential diagnosis and possibly delaying (or leading to inappropriate) treatment.
Methods: This was a systematic review of IEBt and IEDCS cases aiming to define diving and clinical variables that help differentiate these conditions. The search strategy consisted of a preliminary search, followed by a systematic search covering three databases (PubMed, Medline, Scopus). Studies were included when published in English and adequately reporting one or more IEBt or IEDCS patients in diving. Concerns regarding missing and duplicate data were minimised by contacting original authors when necessary.
Results: In total, 25 studies with IEBt patients (n = 183) and 18 studies with IEDCS patients (n = 397) were included. Variables most useful in differentiating between IEBt and IEDCS were dive type (free diving versus scuba diving), dive gas (compressed air versus mixed gas), dive profile (mean depth 13 versus 43 metres of seawater), symptom onset (when descending versus when ascending or surfacing), distribution of cochleovestibular symptoms (vestibular versus cochlear) and absence or presence of other DCS symptoms. Symptoms of difficult middle ear equalisation or findings consistent with middle ear barotrauma could not be reliably assessed in this context, being insufficiently reported in the IEDCS literature.
Conclusions: There are multiple useful variables to help distinguish IEBt from IEDCS. Symptoms of difficult middle ear equalisation or findings consistent with middle ear barotrauma require further study as means of distinguishing IEBt and IEDCS.
Introduction: Inner ear decompression sickness (IEDCS) is a condition from which only a minority of patients recover completely, the majority ending up with mild to moderate residual symptoms. IEDCS has been reported after deep technical dives using mixed breathing gases, and moderate recreational dives with compressed air as the breathing gas. Considering this and the high proportion of technical diving in Finland, a comparison between IEDCS cases resulting from technical and recreational dives is warranted.
Methods: This is a retrospective examination of IEDCS patients treated at Hyperbaric Center Medioxygen or National Hyperbaric Centre of Turku University Hospital from 1999 to 2018. Patients were included if presenting with hearing loss, tinnitus, or vertigo and excluded if presenting only with symptoms of middle ear or cerebellar involvement. Patients were divided into technical and recreational divers, based on incident dive.
Results: A total of 89 (15.6%) of all DCS patients presented with IEDCS, two-thirds treated during the latter decade. The most common predisposing factors were consecutive days of diving (47.2%), multiple dives per day (53.9%), and factors related to an increase in intrathoracic pressure (27.0%). The symptoms were cochlear in 19.1% and vestibular in 93.3% of cases, symptoms being more common and severe in technical divers. Complete recovery was achieved in 64.5% of technical and 71.4% of recreational divers.
Conclusion: The incidence of IEDCS in Finland is increasing, most likely due to changing diving practices. A comprehensive examination should be carried out after an incident of IEDCS in all cases, irrespective of clinical recovery.
Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed , including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recog-nising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics.
Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recognising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics.
Objective:
To characterize traumatic tympanic membrane perforation (TTMP) in terms of distribution, mechanisms, and outcome of treatment. To assess the factors influencing such outcome.
Study design:
Prospective analytical study, assessing outcomes post-injuries.
Setting:
Clinical department of a tertiary referral hospital.
Participants:
Patients with TTMP based on history of trauma to the ear, and otoscopic examination confirming tympanic membrane (TM) perforation.
Interventions:
Conservative, inactive treatment.
Main outcome measures:
Distribution and healing of perforations.
Results:
There were 53 patients, Male: Female ratio =1.5:1, age 8-71years (Mean ±SD= 33.8 ±12.9). Median duration of injury before presentation was 3 days. 11 patients had both ears traumatized. 46.9% of perforations were in the antero-inferior part of the TM. Median size of perforations was 33.0%; Patients main complaints were blockage of the ears/ hearing loss and tinnitus. Common causes of perforations were domestic assault (28.3%), self-inflicted/ accidental injuries (20.8%), and road traffic accidents (18.9%). There was a significant difference in the mechanism/cause of injuries between the sexes (X2 =15.607, p=0.005). Traumatic perforation was caused by penetrating injuries in 22 (34.4%) ears. The outcome of TTMP was poor in 18.7%. Big sized perforations (t=2.630; p=0.011), penetrating injuries (X2 =9.263; p=0.005), and postero-superior location (X2=6.326;p=0.009) had negative impacts on the healing.
Conclusions:
TTMP was common in young adult males, caused often by assaults, presented with ear hearing loss and tinnitus, perforations were located in antero-inferior part of TM and most healed well. Factors associated with poor healing were postero-superior location, large size and penetrating injuries to the TM.
Funding:
Not indicated.
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