Author: Keith Spain, MD
Co Author #1: Michele Pescasio, MD
Co Author #2: Edwin Prevatte, MD

Patient Presentation:
22 year old male football player presents to athletic training room physician clinic complaining of trouble hearing and bilateral subconjunctival hemorrhages.

History:
Patient reports a history of going SCUBA diving 3 days prior. Patient states he completed one dive in salt water which was to 55 feet for 30 minutes. He reports the dive as uneventful, except for some difficulty and pain with equalizing pressure in his ears during descent.

Although not a certified diver, and having only been diving once before, he says his friends that took him diving were careful with slow ascent rates. Upon surfacing from his dive, he had a brief episode of epistaxis. He says the bleeding stopped without difficulty within approximately 15 minutes. Patient's friends then noticed he had bilateral subconjunctival hemorrhages (see photo). Case Photo #1

Over the hours following his dive he developed bilateral difficulty hearing. He describes a sensation of listening to everything through ear muffs. He denies any vertigo, visual changes, otorrhea, joint pains, shortness of breath, or other systemic symptoms. Over the past couple days this hearing deficit had not improved and he therefore presented for evaluation.

Physical Exam:
VITALS: Stable and WNL
WDWD, NAD, A&OX4
HEENT: ATNC, EOMI, PERRL. + bilateral subconjunctival hemorrhage. Bilateral visual acuity WNL. Case Photo #2
Left otoscopic exam: + mild erythema to external canal. + obvious hemotympanum with loss of normal anatomic landmarks. No TM perforation.
Right otoscopic exam: mild erythema to external ear canal. + hemotympanum with visible landmarks. No TM perforation. Case Photo #3
Pt has decreased hearing for whisper and unable to hear finger-rub on left, decreased hearing on right.
Nose: WNL. Normal turbinates. No bleeding.
CV: RRR. No M/R/G. S1S2
PULM: CTAB. No W/R/R. No increased respiratory effort.
ABD: Soft. NT/ND. + normal bowel sounds
EXT: No visible defects. No C/C/E. 2+ pulses X4. No joint tenderness.
NEURO: No focal deficits

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