Vestibular rehabilitation and recovery in divers with inner ear decompression sickness: a case series

Introduction: The mechanism of injury and recovery of divers with inner ear decompression sickness (IEDCS) is not well understood and there is no consensus regarding management following recompression treatment. Given the rare occurrence, divers are not routinely offered the standard therapies that patients with other acute vestibular disorders may be offered such as vestibular rehabilitation. Methods: This is an observational case series of 13 divers presenting acutely with IEDCS to DDRC Healthcare in Plymouth, UK between July 2021 and January 2024. Vestibular and balance tests were undertaken to aid the treating dive physician in the diagnosis and management of the divers with both hyperbaric oxygen therapy and customised vestibular rehabilitation. Results: Average values for vertical perception, posturography, dynamic gait index and patient-reported outcomes measures improved by discharge and at the three month follow up despite 67% showing an ongoing positive head impulse test or nystagmus in the dark on videonystagmography at follow up. Conclusions: Divers should be warned that despite symptom resolution or minimal residual symptoms post-IEDCS there is a high rate of deficit evident on vestibular testing, and this, alongside investigation for a right to left cardiac shunt, should be a major consideration when considering returning to diving. For the clinician, a stopwatch timed Sharpened Romberg’s test appears to be a reasonable method for monitoring progress of balance stabilisation during the treatment period. Early initiation of vestibular rehabilitation exercises should be considered for all divers with IEDCS.