Short- and long-term outcomes of subtotal ear canal ablation and lateral bulla osteotomy in French bulldogs.

The objective of this retrospective study was to report the overall peri-operative complications and short- to long-term outcomes of subtotal ear canal ablation and lateral bulla osteotomy in French bulldogs with otitis media. Medical records from 2018 to 2021 were reviewed for preoperative neurological signs, surgical technique, postoperative complications, and long-term outcomes. Postoperative complications, such as a head tilt, nystagmus, ataxia, facial nerve dysfunction, as well as skin or wound infection, were recorded. Eighteen client-owned dogs (20 ears) were included in the study. Postoperative complications were observed in 5/18 dogs (6/20 ears) with 2 of them being considered major complications. Referring veterinarians and owner telephone follow-up (mean: 33 mo, range: 17 to 56 mo) were obtained for all patients. Total recovery was reported in 9/18 dogs (11/20 ears) with a postoperative improvement of the vestibular signs and facial nerve paresis within 8 wk. All dogs maintained the pinnas' natural, erect morphology, and movement.

L'objectif de cette étude rétrospective était de rapporter les complications peropératoires globales et les résultats à court et à long terme de l'ablation subtotale du conduit auditif et de l'ostéotomie de la bulle latérale chez les bouledogues français atteints d'otite moyenne. Les dossiers médicaux de 2018 à 2021 ont été examinés pour les signes neurologiques préopératoires, la technique chirurgicale, les complications postopératoires et les résultats à long terme. Les complications postopératoires, telles qu'une inclinaison de la tête, un nystagmus, une ataxie, un dysfonctionnement du nerf facial, ainsi qu'une infection de la peau ou des plaies, ont été enregistrées. Dix-huit chiens de propriétaires (20 oreilles) ont été inclus dans l'étude. Des complications postopératoires ont été observées chez 5/18 chiens (6/20 oreilles) dont 2 ont été considérées comme des complications majeures. Les vétérinaires référents et le suivi téléphonique des propriétaires (moyenne : 33 mois, intervalle : 17 à 56 mois) ont été obtenus pour tous les patients. Une récupération totale a été rapportée chez 9/18 chiens (11/20 oreilles) avec une amélioration postopératoire des signes vestibulaires et une parésie du nerf facial en 8 semaines. Tous les chiens ont conservé la morphologie et le mouvement naturels et dressés des pinnas.(Traduit par Docteur Serge Messier).

Fungal Infections of the External Auditory Canal and Emerging Pathogens.

Fungal infections of the external auditory canal can range from common (otomycosis) to life threatening (necrotizing otitis externa). Proper identification of fungal pathogens is necessary to guide appropriate therapy, and a high index of suspicion for fungal causes of ear canal disease is critical. Fungal pathogens may be an especially important cause of ear canal disease in certain populations, including patients with diabetes, patients recently treated with antibiotics, and immunosuppressed patients. Opportunistic fungal infections of the ear canal are an emerging concern.

Effect of an ear cleaner instillation containing lipacids in a model of re-acidification of the external auditory canal in dogs.

BACKGROUND: In humans, the acidic pH of the ear canal plays a protective role against infection and a change towards alkalinity of the external auditory canal (EAC) is a local factor in the progression of acute to chronic otitis externa (OE). The use of acidic preparations alone for treatment of OE without concurrent antibiotic use is well-documented in humans. In dogs, only one study has investigated the EAC pH in healthy dogs and in dogs with OE, and investigations to understand the role of EAC pH in the pathogenesis of canine OE are lacking. HYPOTHESIS/OBJECTIVES: To obtain physiological EAC pH values in beagle dogs. To develop a model of re-acidification of the EAC in dogs and to investigate how an acidic solution may accelerate the return to a physiological pH. ANIMALS: Ten healthy beagle dogs in a laboratory setting. MATERIALS AND METHODS: A model of re-acidification of the EAC was developed by instillation of a pH 10.1 phosphate-buffered saline (PBS) solution and the subsequent acidic effect of an ear cleaner containing lipacids was evaluated in this model. RESULTS: Mean physiological EAC pH was 6.12 (± 0.36). EAC re-acidification took up to 9 h in this model. Mean pH values dropped immediately to 6.38 (± 0.27) on ears treated with an acidic ear cleaner. No abrupt drop was observed of the mean pH values for the control ears. CONCLUSION AND CLINICAL IMPORTANCE: This study confirms that physiological EAC pH in dogs is acidic. This model of re-acidification of the EAC pH allows investigations on acidic properties of topical ear products in healthy ears.

Contexte - Chez l'homme, le pH acide du conduit auditif joue un rôle protecteur contre l'infection et l'évolution vers l'alcalinité du conduit auditif externe (CAE) et est un facteur local de progression de l'otite externe (OE) aiguë à chronique. L'utilisation de préparations acides seules pour le traitement de l'OE sans utilisation concomitante d'antibiotiques est bien documentée chez l'homme. Chez les chiens, une seule étude a étudié le pH du CAE chez les chiens en bonne santé et chez les chiens atteints d'OE, et les recherches pour comprendre le rôle du pH du CAE dans la pathogenèse de l'OE canine font défaut. Hypothèses/objectifs - Obtenir des valeurs physiologiques de pH du CAE chez des chiens beagle. Développer un modèle de réacidification du CAE chez le chien et étudier comment une solution acide peut accélérer le retour à un pH physiologique. Animaux - Dix chiens beagle de laboratoire en bonne santé. Matériels et méthodes - Un modèle de réacidification du CAE a été développé par instillation d'une solution saline tamponnée (PBS) à pH 10,1 et l'effet acide ultérieur d'un nettoyant pour oreilles contenant des lipacides a été évalué dans ce modèle. Résultats - Le pH physiologique moyen du CAE était de 6,12 (± 0,36). La réacidification du CAE a pris jusqu'à 9 h dans ce modèle. Les valeurs moyennes du pH chutent immédiatement à 6,38 (± 0,27) sur les oreilles traitées avec un nettoyant auriculaire acide. Aucune chute brutale n'a été observée des valeurs moyennes de pH pour les oreilles témoins. Conclusion et importance clinique - Cette étude confirme que le pH physiologique du CAE chez le chien est acide. Ce modèle de réacidification du pH du CAE permet des investigations sur les propriétés acides des produits topiques auriculaires dans des oreilles saines.

Introducción; en humanos, el pH ácido del canal auditivo juega un papel protector contra la infección y un cambio hacia la alcalinidad del canal auditivo externo (EAC) es un factor local en la progresión de la otitis externa (OE) aguda a crónica. El uso de preparaciones ácidas solas para el tratamiento de la OE sin el uso concomitante de antibióticos está bien documentado en humanos. En perros, solo un estudio ha investigado el pH de EAC en perros sanos y en perros con OE, y faltan investigaciones para comprender el papel del pH de EAC en la patogenia de la OE canina. Hipótesis/objetivos - Obtener valores de pH fisiológico de EAC en perros beagle. Desarrollar un modelo de reacidificación del EAC en perros e investigar cómo una solución ácida puede acelerar el retorno a un pH fisiológico. Animales- diez perros beagle sanos en un laboratorio. Materiales y métodos- se desarrolló un modelo de reacidificación del EAC mediante la instilación de una solución salina tamponada con fosfato (PBS) de pH 10,1 y se evaluó en este modelo el efecto ácido subsiguiente de un limpiador de oídos que contenía lípidos. Resultados - El pH fisiológico medio del EAC fue de 6,12 (± 0,36). La reacidificación de EAC tomó hasta 9 h en este modelo. Los valores medios de pH cayeron inmediatamente a 6,38 (± 0,27) en los oídos tratados con un limpiador de oídos ácido. No se observó una caída abrupta de los valores medios de pH para los oíds de control. Conclusión e importancia clínica- este estudio confirma que el pH fisiológico de EAC en perros es ácido. Este modelo de reacidificación del pH de EAC permite realizar investigaciones sobre las propiedades ácidas de los productos tópicos para el oído en oídos sanos.

Contexto - Em humanos, o pH ácido do conduto auditivo exerce uma grande função protetora contra infecções e a alcalinização do conduto auditivo externo (CAE) é um fator local de progressão de otite externa (OE) aguda para crônica. A utilização unicamente de formulações ácidas para o tratamento de OE sem a utilização concomitante de antibióticos é bem documentada em humanos. Em cães, apenas um estudo investigou o pH do CAE em cães saudáveis com OE, e são escassas as pesquisas investigando o papel do pH do CAE na patogênese da OE. Hipótese/objetivos - Se obter os valores fisiológicos do pH dos CAEs de cães Beagle. Desenvolver um modelo de re-acidificação do CAE em cães e investigar como uma solução ácida pode acelerar o retorno ao pH fisiológico original. Animais - Dez cães Beagle saudáveis de laboratório. Materiais e Métodos - Um modelo de re-acidificação do CAE foi desenvolvido por instilação de solução salina tamponada com fosfato (PBS) com um pH 10,1 e o efeito acidificante subsequente de um limpador de ouvido contendo ácidos lipídicos foi avaliado neste modelo. Resultados - O pH fisiológico médio do CAE foi de 6,12 (± 0,36). A re-acidificação do CAE levou até 9h neste modelo. Os valores médios de pH caíram imediatamente para 6,38 (± 0,27) nas orelhas tratadas com um limpador otológico ácido. Não foi observada queda abrupta dos valores médios de pH para as orelhas controle. Conclusão e importância clínica - Este estudo confirmou que o pH fisiológico do CAE de cães é ácido. Este modelo de re-acidificação do pH do CAE permite investigações sobre as propriedades acidificantes de produtos otológicos tópicos para orelhas saudáveis.

Chronic Otitis Externa Secondary to Tympanic Membrane Electrode Placement in Rhesus Macaques (Macaca mulatta).

Otitis externa (OE) is a condition that involves inflammation of the external ear canal. OE is a commonly reported condition in humans and some veterinary species (for example, dogs, cats), but has not been reported in the literature in macaques. Here, we present a case series of acute and chronic OE likely precipitated by abrasion of the ear canal with a tympanic membrane electrode in 7 adult male rhesus macaques (Macaca mulatta). All animals displayed purulent, mucinous discharge from 1 or both ears with 3 macaques also displaying signs of an upper respiratory tract (URT) infection during the same period. A variety of diagnostic and treatment options were pursued including consultation with an otolaryngologist necessitated by the differences in response to treatment in macaques as compared with other common veterinary species. Due to the nature of the studies in which these macaques were enrolled, standard audiological testing was performed before and after OE, including tympanometry, auditory brainstem responses (ABRs), and distortion product otoacoustic emissions (DPOAEs). After completion of study procedures, relevant tissues were collected for necropsy and histopathology. Impaired hearing was found in all macaques even after apparent resolution of OE signs. Necropsy findings included abnormalities in the tympanic membrane, ossicular chain, and middle ear cavity, suggesting that the hearing impairment was at least partly conductive in nature. We concluded that OE likely resulted from mechanical disruption of the epithelial lining of the ear canal by the ABR electrode, thereby allowing the development of opportunistic infections. OE, while uncommon in macaques, can affect them and should be included as a differential diagnosis of any macaque presenting with otic discharge and/or auricular discomfort.

[Peripheral facial palsy in children: an unusual manifestation of foreign body in the ear]. / Paralysie faciale périphérique de l´enfant: une manifestation inhabituelle d´un corps étranger de l´oreille.

Foreign bodies in the ear are common in children but they rarely lead to complications. We here report a rare case of homolateral facial palsy in a 4-year old female child that occurred 15 days after introduction of toxic foreign body (Abrus precatorius seed) in her ear. The patients had signs of local necrosis associated with external otitis, without systemic involvement. Foreign body extraction was performed using micro-hook. Local and general treatments as well as corticosteroid therapy and physiotherapy were started with good outcome after three weeks. Prolonged stay of the foreign body in the ear can cause local infection resulting in potential functional complications. Early extraction and local treatment are the basis for treatment.

Meta-analysis does not support routine traditional nuclear medicine studies for malignant otitis.

OBJECTIVES: The role of traditional nuclear medicine studies in the management of malignant otitis externa (MOE) is unclear and there are ongoing debates regarding their diagnostic value. The authors perform a systematic review and meta-analysis to assess the sensitivity and specificity of traditional nuclear medicine studies in the diagnosis of MOE. METHODS: In accordance with PRISMA guidelines, a query of the Medline, Embase, Web of Science, and Cochrane databases was undertaken. The primary outcomes of interest were the sensitivity and specificity of traditional nuclear medicine studies to detect MOE. RESULTS: Of the initial 1317 hits from the four databases, 20 articles with a combined 608 patients were ultimately included in the review. The pooled sensitivities for Technetium-99 and Gallium-67 were 85.1% (95% CI, 72.0-98.1%) and 71.2% (95% CI, 55.1-87.3%) respectively. The available evidence suggested poor specificity of these modalities, but was insufficient for meta-analysis. Neither modality was shown to be effective in the assessment of disease resolution. CONCLUSION: The sensitivities of Technetium-99 and Gallium-67 to detect MOE are less favorable than was initially thought. Given this finding and their poor specificity, lack of anatomic resolution, unproven ability to detect disease resolution and variable availability, this review does not support the routine use of these studies in the management of MOE. LEVEL OF EVIDENCE: N/A Laryngoscope, 130:1812-1816, 2020.

Central Diabetes Insipidus Associated with Orbital Apex Syndrome.

Orbital apex syndrome (OAS) manifests as multiple cranial nerve palsies caused by an abnormal nerve response to inflammation or other processes. Central diabetes insipidus (CDI) is characterized by deficient synthesis or secretion of antidiuretic hormone. A 62-year-old woman underwent myringotomy for otitis media with effusion. Two months after the procedure, symptoms of hearing loss had not improved, and she underwent left tympanoplasty and mastoidectomy. After surgery, she presented with left ocular pain and visual loss. Neurologic examination revealed ptosis, total ophthalmoplegia, and a relative afferent pupillary defect on the left eye. Magnetic resonance imaging showed an asymmetric contrast-enhancing lesion in the left orbital apex and left cavernous sinus, with adjacent dural thickening and enhancement. OAS was diagnosed, and steroid treatment was started. During the regular follow-up period, she reported polyuria, and CDI was diagnosed. Treatment with intranasal desmopressin 10 µg twice daily was started, and symptoms greatly improved. The mechanism underlying the association of CDI with OAS is unclear, and further research is needed. The present case suggests that polyuria in OAS should alert neurologists and ophthalmologists to possible CDI.

Myeloid sarcoma presenting as bilateral acute otitis externa in newly diagnosed acute myeloid leukemia.

Myeloid sarcoma (MS) is an extramedullary collection of immature myeloid cells that can commonly occur with acute myeloid leukemia (AML). While head and neck presentations are not unheard of, there have been few published pediatric cases of external auditory canal MS. Here, we report a case of a 14-year-old male who presented with MS masquerading as bilateral acute otitis externa. To the best of our knowledge, this is the first reported case of a bilateral presentation leading to a new diagnosis of AML. A literature review of head and neck presentations of MS is included.

Fungal Malignant Otitis Externa Involves a Cascade of Complications Culminating in Pseudoaneurysm of Internal Maxillary Artery: A Case Report.

BACKGROUND Pseudomonal infection is the most common cause of malignant otitis externa (MOE), which typically affects elderly diabetic patients. Fungi are a rare cause of MOE. MOE can be life-threatening if not recognized and treated promptly. It can result in a wide spectrum of complications, including skull-base osteomyelitis, cranial nerve palsy, cerebral venous thrombosis, and brain abscess. Pseudoaneurysm formation of the intracranial vessels is a life-threatening complication of MOE that is seldom reported in the literature. CASE REPORT We report the case of a 66-year-old diabetic man with MOE who was initially treated with antipseudomonal antibiotics after negative initial culture results. His MOE resulted in a cascade of complications, including facial nerve palsy, skull base osteomyelitis, and sigmoid sinus thrombosis, and culminated in left maxillary artery pseudoaneurysm formation resulting in massive epistaxis and hemodynamic instability. Endovascular embolization resulted in a successful obliteration of the pseudoaneurysm. A subsequent functional endoscopic sinus surgical (FESS) tissue biopsy confirmed Candida glabrata as the etiological agent. The patient was successfully treated with antibiotics and antifungal and anticoagulation therapy, and was discharged home in good condition. CONCLUSIONS A high index of suspicion for the diagnosis of fungal MOE, particularly in intractable cases of MOE with negative initial cultures, should be maintained. Pseudoaneurysm formation is a life-threatening complication of MOE that is seldom reported in the literature and should be suspected in any patient with MOE who presents with epistaxis or intracranial bleeding.

Clinical analysis and nonsurgical management of 11 dogs with aural cholesteatoma.

BACKGROUND: Aural cholesteatomas, also called tympanokeratomas, are destructive and expansile growths of keratinizing epithelium that develop in the middle ear. They have been reported sporadically in dogs, and surgery is usually the recommended treatment. OBJECTIVES: To describe the common clinical, radiological and histological findings of cholesteatoma; to report on the outcome of conservative management. ANIMALS: Eleven dogs (13 ears) with cholesteatomas. METHODS AND MATERIALS: Medical records were reviewed for dogs diagnosed with cholesteatoma between 2012 and 2018. All dogs had computed tomography (CT) and/or magnetic resonance imaging (MRI) followed by trans-canal endoscopic procedure (TEP) for removal and biopsy of middle ear lesions. Dogs were then treated with in-clinic flushing initially weekly tapered to monthly, as well as at-home ear cleaning and application of topical otic steroid medication, initially daily then tapered to once or twice weekly. RESULTS: Nine dogs had a history of chronic otitis externa; head tilt or facial paralysis was present in seven and four cases, respectively. Otic examination identified a protruding nodule in seven ears. CT demonstrated soft tissue-like material in 12 bullae and expansion in seven bullae. MRI revealed minimally contrast-enhancing bulla contents in 12 ears. Post-TEP and with maintenance medical treatment, nine ears had no further signs of middle ear disease during a mean follow-up of 27.9 months. CONCLUSIONS AND CLINICAL IMPORTANCE: The results suggest that otitis externa may not necessarily precede cholesteatoma in all dogs. MRI appears to be more sensitive than CT for identifying cholesteatomas. Conservative treatment of cholesteatomas could be useful before or as an alternative to surgery.

Acute otitis externa because of negative pressure wound therapy applied over the head and ear canal for scalping treatment.

Scalping is considered a complex wound with difficult treatment, requiring early surgical intervention, reconstructive plastic surgery, and a multidisciplinary team. The reconstruction of the scalp frequently requires a combination of therapies, including temporary coverage, such as negative pressure wound therapy (NPWT). Complications of NPWT, such as bleeding, infection, and pain, have been described. However, there is no report of acute otitis externa (AOE) because of NPWT. In this article, we present an unprecedented clinical case - a female patient who developed AOE after scalping treatment with NPWT applied over the head and ear canal. We consider that it may be a result of the direct physical action of subatmospheric pressure, the presence of dressing covering the external meatus, and alteration of the bacterial population.

A Lateral Neck Myeloid Sarcoma Presenting as Acute Otitis Externa.

Myeloid sarcoma (MS) is a solid extra-medullary tumor of immature myeloid cells which could occur before, during or after remission of acute leukemia at any site on the body. Owing to variation in differential diagnosis, pathologic evaluation and immunohistochemical staining are essential for definitive diagnosis. Rarely, MS has been shown as an isolated extramedullary relapse (iEMR) after allogeneic stem cell transplantation (allo-SCT), which often does not necessarily result in bone marrow involvement. It seems that despite chemotherapy and graft-versus-leukemia (GVL) effects on bone marrow, leukemic cells could remain alive in the extra-medullary region. However, in order to achieve longer survival, timely diagnosis as well as combined systemic, local, and cellular therapeutic modalities should be considered in any patient with iEMR after allo-SCT. We report a left lateral neck isolated MS presented as acute otitis externa in a patient with prior allo-SCT due to acute myeloid leukemia (AML). Therefore, MS should be considered in patients with any history of acute leukemia even if the patient presents with signs and symptoms of an infectious disease.

Malignant Otitis Externa Outcomes: A Study of the University HealthSystem Consortium Database.

OBJECTIVE: To characterize factors that affect outcomes for patients with malignant otitis externa (MOE). METHODS: Retrospective review of inpatients with MOE was performed. Patient demographics, comorbid conditions, complications, procedures, and mortalities were analyzed. RESULTS: A total of 786 patients with MOE were identified. The mean hospitalization length of stay (LOS) was 18.6 days (SD = 19.7). The overall mortality rate was 2.5% (n = 20), and complication rate was 4.3% (n = 34). Increasing age significantly and positively correlated with the incidence of MOE (r = 0.979, P < .0001). Factors that were associated with an increased rate of mortality were sepsis (odds ratio [OR] = 18.5; ES = 0.94; 95% CI, 0.47-1.42), congestive heart failure (OR = 3.1; ES = 0.42; 95% CI, 0.02-0.82), weight loss (OR = 10.2; ES = 1.23; 95% CI, 0.61-1.85), and coagulopathy (OR = 8.8; ES = 1.84; 95% CI, 0.91-2.77). Surgical intervention was performed in 19.2% (n = 151) of patients. Facial nerve involvement was present in 15.5% (n = 122) of patients and was associated with a significantly longer LOS of 12.9 days (SD = 19.6; ES = 0.21; 95% CI, 0.03-0.41). CONCLUSIONS: This large multi-institutional database study of MOE demonstrates that several patient factors impact the LOS and mortality. Patients at risk for unfavorable outcomes include the elderly, male gender, comorbidities, or cranial nerve involvement.

Aviation Fuel Exposure Resulting in Otitis Externa with Vertigo.

BACKGROUND: Otitis externa secondary to irritant or chemical exposure is well documented; however, specifically secondary to jet fuel exposure and its associated toxicology is not. Over 2 million military and civilian personnel per year are occupationally exposed to aviation fuels. CASE REPORT: An aircraft maintainer presented with noninfectious acute otitis externa secondary to external ear canal exposure to JP-5 jet fuel. Proper exposure guidelines were followed, but it was not realized that the external ear canal was involved. The first symptoms to emerge were vertigo, dizziness, and disequilibrium; however, on physical exam it appeared that there was no middle ear involvement. DISCUSSION: Otitis externa normally does not present with vestibular symptoms as the pathology affects the external ear canal dermal tissue. Upon review of JP-5's toxicology profile, dermal absorption is a route of entry and can cause general neurological symptoms, including loss of coordination. This case highlights potential deficiencies in the standardized safety data sheets that are used after exposure. Without mention of possible auricular exposure one may focus on the logical protection of the eyes, mouth, and visible skin. This is concerning due to potential delayed exposure symptoms, dermal absorption, high level of dermal destruction, and the close proximity to the sensory system. The goal of this case report is to improve the knowledge of providers caring for personnel who may be exposed and to suggest possible revisions to the Safety Data Sheets for jet fuel.Long RJ, Charles RA. Aviation fuel exposure resulting in otitis externa with vertigo. Aerosp Med Hum Perform. 2018; 89(7):661-663.

Acute external otitis as debut of acute myeloid leukemia - A case and review of the literature.

Acute leukemia is a well known childhood cancer. The relation between leukemia and otological symptoms has long been established but is highly rare as a debut symptom of leukemia. External otitis is a common condition affecting many children, and most cases are successively treated with topical medicine. Here we present a child with acute external otitis later shown to be the debut symptom of acute myeloid leukemia, to our knowledge the first specific case described. We have reviewed the literature to find red flags for suspicion of severe disease in case of acute external otitis.

Lyric hearing aid: a rare cause of benign necrotising otitis externa/external ear canal cholesteatoma.

An 80-year-old Caucasian man presented with an incidental and asymptomatic lesion in his right ear thought to be secondary to his use of hearing aids for presbycusis. He used Lyric hearing aids, designed for 24 hours-a-day use for 4 months at a time and had no other previous otological problems. He underwent a bony meatoplasty and vascular flap reconstruction via a retroauricular approach to remove the lesion for histological analysis and regrafting of the area. The lesion was confirmed on histopathology as an ear canal cholesteatoma.

Scuba diving and otology: a systematic review with recommendations on diagnosis, treatment and post-operative care.

Scuba diving is a popular recreational and professional activity with inherent risks. Complications related to barotrauma and decompression illness can pose significant morbidity to a diver's hearing and balance systems. The majority of dive-related injuries affect the head and neck, particularly the outer, middle and inner ear. Given the high incidence of otologic complications from diving, an evidence-based approach to the diagnosis and treatment of otic pathology is a necessity. We performed a systematic and comprehensive literature review including the pathophysiology, diagnosis, and treatment of otologic pathology related to diving. This included inner, middle, and outer ear anatomic subsites, as well as facial nerve complications, mal de debarquement syndrome, sea sickness and fitness to dive recommendations following otologic surgery. Sixty-two papers on diving and otologic pathology were included in the final analysis. We created a set of succinct evidence-based recommendations on each topic that should inform clinical decisions by otolaryngologists, dive medicine specialists and primary care providers when faced with diving-related patient pathology.