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[ Position Statement]  DOI: 10.22462/01.03.2019.13

Middle ear barotrauma is common in diving. However, facial nerve baroparesis is a relatively rare complication. A dehiscent facial nerve canal may be a predisposing factor to developing this complication. Although there is an increasing number of facial baroparesis cases in the literature, they are likely still under-reported. In order to avoid unnecessary recompression treatments or detrimental effects to a professional diver’s career, it is important to consider this in the differential diagnosis while evaluating dive injuries. This case report describes recurrent facial baroparesis in a military diver, which manifested on contralateral sides of his face. His initial presentation was misdiagnosed as an arterial gas embolism, which led to recompression treatment and a cardiac procedure. Upon recurrence about one year later, a complete work-up was done, which included an ENT evaluation and a CT scan. Imaging demonstrated a predisposing anatomic variant bilaterally. His symptoms resolved quickly and spontaneously both times, and he has been able to return to diving. DOI: 10.22462/01.03.2019.11

Decompression sickness is a disease caused by abrupt pressure change and presents various symptoms. To date, acute kidney injury associated with decompression sickness has been reported frequently, but there is no report of hepatic infarction associated with decompression sickness. We report a case of acute kidney injury and acute hepatic infarction treated with hyperbaric oxygen (HBO2) therapy and dialysis in a patient with severe decompression sickness after work diving. 10.22462/01.03.2019.10

More blast injuries are encountered in the civilian setting in recent years as terrorist attacks have increased globally. A 17-year-old male patient with severe blast injury of the right lower extremity was admitted to our department on the fifth day after a terrorist bombing attack. Initially he had been admitted to an emergency department with segmental tibia fracture and arterial injury (Gustilo IIIC). An amputation had been foreseen due to ischemia that persisted even after orthopedic fixation and revascularization interventions, followed by fasciotomy incisions. After consultation with our department hyperbaric oxygen (HBO2) therapy was administered twice daily for the first week. Ischemia improved prominently after 10 HBO2 sessions. HBO2 therapy was continued together with antibiotherapy and wound care. The patient underwent a total of 40 HBO2 sessions and two reconstructive operations and healed without amputation. Vascular injuries with concomitant orthopedic trauma cause most of the delayed amputations in bombing attacks since ischemia can persist at the microvascular level even though adequate treatments are applied. HBO2 corrects hypoxia at tissue level and so provides oxygen for the critically ischemic cells in the injured area. HBO2 also enhances host defense and decreases the ischemia reperfusion injury. In this case, HBO2 was ..

Adjuvant radiation therapy for breast cancer treatment often involves high doses of radiation, making patients more susceptible to late radiation tissue injury (LRTI), severe complications of which involve necrosis and ulceration. Treatment of such wounds is challenging. One modality that can be utilized is hyperbaric oxygen (HBO2) therapy. However, an optimal dose and the objective evidence of its benefit in use as an adjunctive treatment modality is limited. Presented here is a case of a non-surgical candidate in which serial indocyanine green fluorescence angiography (ICGFA) was utilized to determine if it could detect changes in tissue perfusion over the course of treatment. Serial ICGFA allowed for visualization of the current phase of wound healing, angiogenesis and vasculogenesis. Future large studies should be employed to better determine the utility of serial ICGFA to improve HBO2 utilization in patients who are undergoing HBO2 as part of their course of treatment for LRTI. DOI: 10.22462/01.03.2019.8

Introduction: Carbon monoxide (CO) poisoning causes hypoxia and inflammation, which could adversely affect muscle. We could find no published information about CO poisoning causing myositis. Case report: A 53-year-old previously healthy female semi-truck driver had CO poisoning from a faulty diesel engine exhaust intermittently over three months, culminating in an episode of acute CO poisoning, with syncope after exiting the truck at the end of the three-month period. Neuropsychological symptoms immediately after the acute poisoning event were followed by the development of fatigue, weakness and myalgias within two months and a diagnosis of “polymyositis” within four months. C-reactive protein and creatine kinase were elevated. Electromyogram showed pure myopathy without sensory abnormalities. Occult malignancy was ruled out. Thigh muscle biopsy revealed severe inflammatory myopathy and myonecrosis. Muscle specialist pathologists interpreted the biopsy as toxic or viral inflammatory myopathy, not polymyositis, with CO poisoning as the likely etiology. She received steroids and mycophenolate. Nineteen months later, a repeat biopsy was negative for inflammation or myopathic process. Alternative diagnoses were ruled out by clinical investigation and her course over the next five years.  Conclusions: This patient’s presentation and clinical course support a diagnosis of myositis from CO poisoning, although it is possible that the ..

Introduction: Eustachian tube dysfunction (ETD) and middle ear barotrauma (MEB) are the most common adverse effects of hyperbaric oxygen (HBO2) treatments. Patients practice equalization maneuvers to prevent ETD and MEB prior to hyperbaric exposure. Some patients are still unable to equalize middle ear pressure. This ETD results in undesirable consequences, including barotrauma, treatment with medications or surgical myringotomy with tube placement and interruption of HBO2. When additional medications and myringotomy are employed, they are associated with additional complications.Methods: A device known as the Ear Popper® has been reported to reduce complications from serous otitis media and reduce the need for surgical interventions (myringotomy). Patients unable to equalize middle ear pressure during initial compression in the hyperbaric chamber were allowed to use the device for rescue. All hyperbaric treatments were compressed using a United States Navy TT9, or a 45-fsw hyperbaric treatment schedule. Patients with persistent ETD and the inability to equalize middle ear pressure were given the Ear Popper upon consideration of terminating their treatment.Results: The Ear Popper allowed all patients to successfully equalize middle ear pressure and complete their treatments.Conclusion: This study substantiates the use of this device to assist in allowing pressurization of the middle ear space ..

Background: Perianal fistulizing Crohn’s disease (pCD) has a significant impact on patients’ health and quality of life. Current treatment options have a relatively low success rate and a high recurrence risk. Positive effects of hyperbaric oxygen (HBO2) therapy have been indicated in animal studies as well as in small case series. Methods/Design: This is a non-randomized, controlled pilot study. A total of 20 patients with pCD who have been refractory to standard therapy for at least six months will be included. Patients with a seton and stable treatment regimen will be included. Patients with anal strictures, rectovaginal fistulas, stoma or deep ulceration of the rectum will be excluded. Patients who are eligible but refuse HBO2 will be asked to serve as controls. Patients in the HBO2 group will be treated with 40 sessions of HBO2 therapy at 243-253 kPa, with the seton being removed after 30 sessions. Co-primary endpoints are changes in the perianal disease activity index and MRI-scores. Secondary outcomes are fistula drainage assessment, laboratory findings and patient-reported outcomes. Assessment will be done at baseline, 16 weeks, 34 weeks and 60 weeks after finishing HBO2. Discussion: The aim of this study is to investigate the feasibility and therapeutic effect of ..

Introduction: Diabetic foot ulcers are a frequent complication of diabetes and the first cause of non-traumatic lower limb amputation. They affect quality of life, restrict social productivity and generate a high economic burden for health care systems. Hyperbaric oxygen (HBO2) therapy is an adjunctive treatment option because it improves wound healing in the short term. However, its ability to modulate the pro- and anti-inflammatory balance and the hypoxic cell response in the clinical setting has not been fully described. Objective: To determine modifications in HIF-1α, NF-κB, IGFBP-3, and VEGF expression in wounds as well as circulating inflammatory cytokines in patients with diabetic foot ulcers subjected to HBO2. Materials and methods: We studied 17 ambulatory patients and one hospitalized patient with diabetic foot ulcers classified as Grade 3 or 4 according to the Wagner scale. All underwent HBO2 therapy. Tissue expression of HIF-1α, NF-κB, IGFBP-3 and VEGF was determined by immunohistochemistry. Plasma levels of adiponectin, IL-6, IFN-γ, IL-10 and IL-4 were measured by ELISA and chemiluminescence. Fibrosis and angiogenesis were determined by Masson’s trichrome staining. Results: Ulcers in all patients healed after one month of HBO2, and none presented relapses at the one-year follow-up. At the beginning of treatment, HIF-1α and NF-κB expression ..

Crew survival in a distressed submarine (DISSUB) scenario may be enhanced by the knowledge of the risks of different types of decompression sickness (DCS) should the crew attempt tower escape. Four models were generated through calibration against DCS outcome data from 3,919 pressure exposures, each for the prediction of one of four categories of DCS: neurological, limb pain, respiratory and cutaneous. The calibration data contained details of human, goat, sheep and pig exposures to raised pressure while breathing air or oxygen/nitrogen mixtures. No exposures had substantial staged decompression or cases of suspected pulmonary barotrauma. DCS risk was scaled between species and with body mass. A parameter was introduced to account for the possibility of the occurrence of some symptom types masking others. The calibrated models were used to estimate likelihood of DCS occurrence for each symptom category following submarine tower escape. Escape depth was found to have a marked effect only on predicted rates of neurological DCS. Saturation at raised internal DISSUB pressure prior to escape was found to affect predicted rates of all symptom types. The iso-risk curves presented are offered as guidance to submarine crews and rescue forces in preparation for, or in the event of, a ..

Purpose: This study examined the independent effects of cold-water submersion and a rehydration strategy on an aerobic endurance performance and orthostatic tolerance following a four-hour dive in cold water (10°C).Methods: Nine male subjects completed a control (CON) performance and lower-body negative pressure test (LBNP) and two water immersion visits with either no rehydration (NR) or a post-immersion rehydration (RH) with 1 L of water. Following submersion, subjects ran to exhaustion and submitted to LBNP.Results: Core body temperature declined during submersion and remained reduced from baseline until the run (P <0.001) and was not different between NR and RH (P = 0.13). Total urine output during submersion was not different between groups (1.69 ± 0.49 (NR), 1.75 ± 0.52 (RH) L; P = 0.74) eliciting a body mass reduction of -2.2 ± 0.3 and -0.8 ± 0.3% (P < 0.01), respectively. Run duration was not different (547 ± 141 (NR), 566 ± 152 (RH) s; P = 0.79); however, both NR and RH run duration was shorter compared to CON (722 ± 170 s; P = 0.04). Cumulative stress index was suppressed in NR (534 ± 163 mmHg*min) and RH (591 ± 129 mmHg*min) compared to CON (707 ± 170 ..

Hypoxia is one of the main problems an underwater diver may have to face. The probability of experiencing hypoxia is related to the type of dive and the equipment used. Hypoxia in diving is a potentially fatal event for the diver, as it can lead to the loss of brain functions and consequently to the loss of breathing control, all in the absence of specific premonitory symptoms. It is a risk that may be encountered more frequently by divers who use a closed-circuit rebreather (CCR). For those who use this type of equipment, hypoxia is usually the most frequent cause of death [1]. Our study was aimed at the detection of peripheral oxygen saturation in order to identify, in the future, a preclinical hypoxic condition. We combined the use of pulse oximetry with two forehead sensors on an underwater diver subject who was using an electronic closed-circuit rebreather (ECCR). Despite the known limits of this method and the preliminary status of these findings [2], the recorded data show a clear validity in the use of pulse oximetry in immersion for the detection of peripheral oxygen saturation. In the future, the pulse oximeter could become part of the instrumentation of the diver who uses CCR gear. The device could easily be implemented in these rebreathers. The possibility of being able to perform a basic ..