JOSR: Journal of Social Research

Desember 2022, 2 (1), 134-141

p-ISSN: 2827-9832 e-ISSN: 2828-335x

Available online at http:// https://ijsr.internationaljournallabs.com/index.php/ijsr

http://ijsr.internationaljournallabs.com/index.php/ijsr

INNER EAR DECOMPRESSION SICKNESS (IEDCS) IN DIVERS

Muhammad Aulia Hikmah Romadoni,

Dwi Rahmat,

Eka Arie Yuliyani

1 Faculty of Medicine, University of Mataram

2 Teaching Staff of the Otolaryngological Section of the Faculty of Medicine,

University of Mataram

muhammadauliahikmahromadoni@gmail.com

Abstract (English)

Received:

Revised:

Accepted:

November 26,

2022

November 29,

2022

December 01,

2022

Latar Belakang: Penyakit dekompresi telinga bagian dalam

(IEDCS) adalah penyakit umum pada penyelam. Di

Indonesia, IEDCS sering dialami oleh nelayan penyelam

dalam memenuhi kebutuhan hidupnya. Secara umum,

penyakit dekompresi (DCS) disebabkan oleh pembentukan

gelembung gas di dalam pembuluh darah dan jaringan organ.

Hal ini disebabkan oleh pengendapan gelembung gas di

ruang endolymphatic dan perilymphatic selama proses naik

ke permukaan dengan cepat.

Tujuan: Penelitian ini bertujuan untuk mengidentifikasi

penyakit IEDCS pada penyelam.

Metode: Penelitian ini meggunakan pendekatan kuallitatif

dengan model case study yang menganalisis dan

mengidentifikasi gejala-gejala yang muncul pada penyelam

yang menderita IEDCS.

Hasil: Gejala klasik IEDCS berkembang dalam waktu

sekitar 30 menit dan bersifat vestibular, ini termasuk vertigo,

ataksia, mual, dan muntah. Terapi pilihan yang dapat

diberikan pada penderita DCS dan IEDCS adalah terapi

oksigen hiperbarik (terapi rekompresi) dengan segera.

Komplikasi jarang terjadi setelah terapi oksigen hiperbarik.

Setelah terapi dan penderita DCS pulih, biasanya masih akan

ada defisit sisa dalam keseimbangan dan pendengaran.

Penyelaman yang sesuai protokol serta pemberian informasi

mengenai DCS melalui edukasi, penyuluhan, atau media lain

perlu dilakukan untuk kelompok beresiko agar tercipta

pengetahuan yang memedai dan dapat melakukan

pencegahan.

Kesimpulan: Penyakit dekompresi telinga bagian sering

terjadi pada penyelam gas terkompresi. Hal ini disebabkan

oleh pengendapan gelembung gas di ruang endolimfatik dan

perilimfatik selama proses naik ke permukaan dengan cepat.

Muhammad Aulia Hikmah Romadoni, Dwi Rahmat, Eka Arie Yuliyani / JOSR: Journal of Social

Research, 2(1), 134-141

Inner Ear Decompression Sickness (Iedcs) in Divers 135

Kata kunci: IEDCS, dekompresi, penyelam, telinga bagian

dalam

Abstract (English)

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.

Keywords: IEDCS, decompression, diver, inner ear

*Correspondent Author: Muhammad Aulia Hikmah Romadoni

Email: muhammadauliahikmahromadoni@gmail.com

INTRODUCTION

Scuba diving is an increasingly popular diving sport globally with around 1.2

million divers worldwide. At first, divers concentrated most of their dives only in warmer

Muhammad Aulia Hikmah Romadoni, Dwi Rahmat, Eka Arie Yuliyani / JOSR: Journal of Social

Research, 2(1), 134-141

Inner Ear Decompression Sickness (Iedcs) in Divers 136

coastal areas (Boyd KL WA, n.d.). But expansion in sports has expanded diving spots in

other waters, including temperate and even polar seas, lakes, mines, and many others

(Bove, 2014; Boyd KL WA, n.d.). This causes cases of diving-related disorders to appear

in any hospital, whether inland or coastal. All doctors and medical emergency personnel

should be aware of the signs and symptoms of decompression disease. In addition, all

persons working in or associated with the risk of decompression should also understand

this (Bove, 2014).

The inner ear consists of vestibulocochlear organs that are involved in the hearing

and balance of a person. This organ is spiral in shape and is surrounded by an outer bone

and contains a fluid called endolymph that is responsible for the conduction of sounds as

well as perceiving changes in position (Scarpa et al., 2021; Whitfield, 2015). The cochlea

is the part responsible for the conversion of mechanical sound waves into the action

potential of the auditory nerve. The vestibular part consists of a utriculus, a sacculus, and

a semicircular canal to modulate position and balance signals (Rozycki et al., 2018; Scarpa

et al., 2021).

Inner ear decompression disease (IEDCS) is likely to occur as a result of the

deposition of gas bubbles in the endolymphatic and/or perilymphatic chambers during rapid

upward movement by divers (Mitchell & Doolette, 2015; Rozycki et al., 2018). Another

possible mechanism of IEDCS is that the patient may also have a right-to-left shunt,

showing arterial gas embolism (AGE) as a contributing factor if it enters the labyrinth

artery. The classic symptom of the DCS of the inner ear is a sudden attack of vertigo.

Tinnitus and acute sensorineural hearing loss can also appear alone or simultaneously

(Boyd KL WA, n.d.; Mitchell & Doolette, 2015; Rozycki et al., 2018).

RESEARCH METHOD

This study uses a qualitative approach with a case study model that analyzes and identifies

the symptoms that appear in divers suffering from IEDCS.

RESULTS AND DISCUSSION

IEDCS is a not fully understood condition that occurs in divers, likely caused by

the deposition of gas bubbles in the endolymphatic and perilymphatic chambers during the

rapid process of rising to the surface. The classic symptoms of IEDCS develop in about 30

minutes from the surface and are vestibular; These include vertigo, ataxia (or difficulties

with coordination), nausea, and vomiting (Tremolizzo et al., 2015).

Epidemiology

Decompression disease of the inner ear is extremely rare. Although the total

number and frequency of IEDCS in divers are unknown, one source reported the incidence

of IEDCS in recreational divers using compressed air accounted for nearly 3% of all treated

DCS cases (Smerz, 2007). Other sources reported incidents of 0.2 to 0.3% per recreational

dive (Lechner et al., 2018). The number of DCS occurrences depends on the dive

population (SATOH et al., 1992).

About a quarter of recreational divers who experience neurological decompression

disease will have vestibular-cochlear involvement (Arieli, 2019). Right-to-left shunts were

also found in 81% of patients diagnosed with inner ear DCS compared to 25% of patients

who had never experienced DCI. This may indicate an increased risk of DCS of the inner

ear in patients with venous-arterial shunts(Gempp & Louge, 2013).

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Inner Ear Decompression Sickness (Iedcs) in Divers 137

Etiology

In general, decompression disease (DCS) is thought to be caused by the formation

of gas bubbles inside blood vessels and organ tissues. 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. This phenomenon is known

as isobaric counter-diffusion. Changes in breathing gases should be carefully planned to

avoid such effects and avoid changes in diluents when the tissues approach supersaturation.

All dives must implement an appropriate decompression stop to minimize such risk

(Guenzani et al., 2016; Lindfors et al., 2021).

Risk Factors

In Indonesia, DCS is often experienced by diver fishermen in meeting their living

needs. But it does not rule out the possibility that this could happen to other divers,

including recreational divers. Lack of knowledge and dives that do not comply with safety

protocols will increase the risk of DCS occurring. Other factors that will affect the risk

level of DCS occurrence include diving frequency, diving duration, service life, how to rise

to the surface, and rest time (Rahmadayanti et al., 2017; Wijaya et al., 2018).

Pathophysiology

The pathophysiology of inner ear decompression disease (IEDCS) is still not fully

understood. As described above, the common causes of IEDCS are similar to the causes of

DCS in other organ systems (Boyd KL WA, n.d.). The mechanism thought to underlie this

is the occurrence of gas precipitation into the endolymphatic system when compared to that

into the joint space or more general circulation. Some of the factors that also influence this

include inadequate decompression, deep dives that would otherwise require a stop to

decompression, and insufficient surface time to rebalance nitrogen (Boyd KL WA, n.d.;

Mitchell & Doolette, 2015). Immersion, exercise, and warm temperatures are important

factors that can increase the risk of DCS by increasing the absorption of inert gases when

under pressure. On the contrary, it is also the same factor that can increase the elimination

of inert gases during decompression.

In addition to these factors, the report also indicates the existence of an IEDCS

relationship with persistent oval foramen (PFO), a type of right-to-left shunt (RLS) (Hartig

et al., 2020; Mitchell & Doolette, 2015). RLS allows blood to pass through the pulmonary

system. In other words, the gas bubbles that form in the venous circulation are not excreted

by the lungs and can enter the arterial circulation or rather referred to as arterial gas

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Inner Ear Decompression Sickness (Iedcs) in Divers 138

embolism (AGE) (Gempp & Louge, 2013a; Hartig et al., 2020). One study found in 77%

of IEDCS cases, large RLS was detected with greater right-side lateralization (80%). But

this is also not fully understood. If IEDCS is caused by AGE, it is necessary to carefully

observe this phenomenon. IEDCS is also often found in the absence of other brain

symptoms (Gempp & Louge, 2013a).

Management

Understanding the metabolism of aspirin in patients with DCS and IEDCS should

be carried out immediately with hyperbaric oxygen therapy (recompression therapy) which

is the treatment of choice. This action will increase the ambient pressure to push the gas

back into the solution and improve oxygen delivery to the ischemic tissue. Controlled

decompression will support the process of regulating dissolved gases to prevent the re-

formation of air bubbles. After the patient improves clinically, the patient is slowly

decompressed to the pressure of the atmospheric surface. Several sessions of

recompression therapy may be required if symptoms return (Bove, 2014; Boyd KL WA,

n.d.). If recompression therapy cannot be administered immediately, the patient should be

given 100% oxygen for several hours (even if there is a resolution of symptoms or not) or

until recompression can be carried out. This will trigger an oxygen washout, which is when

there is a maximum inert gas gradient between the lungs and dissolved gas which results

in rapid discharge (Boyd KL WA, n.d.; Vann et al., 2011).

Another early intervention for IEDCS that must be carried out is the resuscitation

of adequate liquids with crystalloid solutions. The formation of free gas in the bloodstream

can also induce platelet activation, so it can be considered the administration of antiplatelet

therapy (aspirin) if needed (Bove, 2014; Klingmann, 2004). In patients with suspected

suffering from IEDCS, inner ear barotrauma cannot be easily eliminated. Therefore,

bilateral myringotomy should be considered before starting hyperbaric oxygen therapy

(Livingstone et al., 2017; Rozycki et al., 2018). But empirically, recompression therapy

does not harm if the diagnosis of barotrauma or IEDCS has not been enforceable (Boyd KL

WA, n.d.).

Complications and Prognosis

In general, a thorough recovery of a temporary nature from DCS is quite high,

especially with proper treatment. A full recovery, however, is still rare. Studies have

reported residual deficits in between 32 and 91% of patients, with 3 out of 5 studies

reporting residual deficits in more than 85% of patients (Gempp & Louge, 2013a; Rozycki

et al., 2018). Vestibular deficits are more common than cochlear deficits. One of the sources

states even with adequate recompression therapy, it is common to have residual deficits in

balance and hearing. Complications that can occur after hyperbaric oxygen therapy are rare

(Mitchell & Doolette, 2015; Rozycki et al., 2018).

Education and Prevention

With the development of technology today and with the implementation of diving

safety protocols, any form of DCS can be prevented and the number of cases can also be

reduced. Divers, workers in high-pressure areas, and airmen should know and follow

appropriate safety measures. Following the decompression schedule is very important for

divers, as the majority of patients experiencing IEDCS are found to violate this schedule.

Providing information about DCS through education, counseling, or other media needs to

be done for at-risk groups in order knowledge that is relevant and can take precautions

(Boyd KL WA, n.d.; IRA T, n.d.).

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Inner Ear Decompression Sickness (Iedcs) in Divers 139

Collaboration Between Teams

Distinguishing between IEDCS and barotrauma is quite difficult. Accurate reports

on dive sites, including dive profiles, the onset of symptoms, unwanted events, or sudden

changes in depth or gas mixtures, can all provide clues to distinguish DCS from

barotrauma. Therefore input from a fellow divemaster, an EMS personnel, and others in

contact with the patient is essential. This patient care may include an interprofessional team

including an autologist, audiologist, neurologist, hyperbaric physician, and specially

trained (Schwerzmann & Seiler, 2001).

CONCLUSION

Part ear decompression disease often occurs 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. 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.

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