title: Inner-ear decompression sickness in nine trimix recreational divers.
abstract: BACKGROUND
  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.
authors.affiliation: Hyperbaric Center, Niguarda Hospital, Reparto di anestesia e rianimazione Bozza Blocco DEA primo piano, Niguarda Hospital, Piazza dell'ospedale maggiore, Milano, Italy, Phone: +39-(0)34-9868-3498, E-mail: silvia.guenzani@gmail.com.
authors.forename: Silvia
authors.initials: S
authors.lastname: Guenzani
authors.forename: Diego
authors.initials: D
authors.lastname: Mereu
authors.forename: Mark
authors.initials: M
authors.lastname: Messersmith
authors.forename: Diego
authors.initials: D
authors.lastname: Olivari
authors.forename: Mario
authors.initials: M
authors.lastname: Arena
authors.forename: Andrea
authors.initials: A
authors.lastname: Spanò
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D003664:Decompression; D003665:Decompression Sickness / Q000453:epidemiology* / Q000209:etiology; D004242:Diving / Q000009:adverse effects* / Q000706:statistics & numerical data; D007758:Ear, Inner; D005260:Female; D054092:Foramen Ovale, Patent / Q000175:diagnosis; D006371:Helium; D006801:Humans; D007759:Labyrinth Diseases / Q000453:epidemiology* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D009584:Nitrogen; D010100:Oxygen; D015995:Prevalence; D011998:Recreation; D011795:Surveys and Questionnaires
chemical_list: D006371:Helium; C045257:trimix; D009584:Nitrogen; D010100:Oxygen
keywords: Decompression illness; case reports; helium; persistent (patent) foramen ovale (PFO); rebreathers/closed circuit; rebreathers/semi-closed circuit; scuba/open circuit