Case Report Open Access
Oxygen Toxicity Seizure During Hyperbaric Oxygen Therapy: A Case Report
Ibrahim Sarbay, Halil Dogan*, Bugra Ilhan
Department of Emergency Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
*Corresponding author: Halil Dogan, Department of Emergency Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey, Email: @
Received: August 14, 2018; Accepted: October 08, 2018; Published: October 09, 2018
Citation: Svensson T, Lorentzen AK, Penninga L (2018) Successful Treatment of Frostbite Lesions in Arctic Greenland. J Emerg Crit Care Diagn Manag 1(1): 1-2.
AbstractTop
Introduction: Several neurological and other side effects and complications from hyperbaric oxygen (HBO) therapy have been described in the literature. Possible complications during HBO therapy include barotraumatic lesions, oxygen toxicity, claustrophobia, and ocular effects.

Case Report: We presented a 29-year-old woman without any known history of neurological illness who had seizure during HBO therapy for Idiopathic Sudden Sensorineural Hearing Loss (ISSNHL).

Conclusion: There are several options for ISSNHL treatment which have been studied in the past with conflicting results. HBO is one of the treatment options. We presented a case with possible neurotoxic effects of HBO therapy. Clinicians should be aware of the complications of this procedure.

Keywords: Hyperbaric Oxigenation; Toxicity; Seizure;
Introduction
Idiopathic sudden sensorineural hearing loss (ISSNHL) is the clinical manifestation of diverse pathological processes. Because of the complex nature of the disease, many different options have been tried as therapy, including hyperbaric oxygen (HBO) [1]. While corticosteroids and HBO are supported by the clinical practice guidelines, other treatment options are not usually recommended.

HBO therapy is essentially breathing 100% oxygen at a pressure level higher than 1 atmosphere absolute in a special chamber. HBO therapy is thought to have complex effects on immunity, oxygen transport, and hemodynamics, reducing hypoxia and edema and potentiating normal host responses to infection and ischemia. It is used to treat several medical conditions in the past. Decompression sickness, arterial gas embolism, carbon monoxide poisoning, nonhealing wounds, hearing loss are among these conditions [2].

Vascular compromise and associated cochlear ischemia can contribute to SSNHL. HBO therapy allows for delivery of increased oxygen levels to cochlea, therefore it is believed to be an effective intervention for ISSNHL [2]. There is a time frame for HBO therapy in ISSNHL: It’s believed to be useful within 3 months of diagnosis [3].

HBO is a relatively safe treatment, but does carry some risks, due to the increased pressure and hyperoxia. HBO seems to have some neurological risks due to oxygen neurotoxicity such as seizures. The exact incidence of oxygen toxicity seizures varies in the literature. While a study reported the rate as low as 0.002% [4], a 1990 study reported a surprising rate of 4.7% [5]. A recent study published in 2014 showed that incidence of seizure is one in 2,121 treatments (0.05%) [6]. In a 2016 study, retrospective analysis of 62,614 HBO treatment sessions showed an overall seizure incidence of 0.011% [7]. Differences of patient selection, indications and protocols make it difficult to compare the studies. For example; most of the studies in the literature included patients with carbon monoxide poisoning, which is itself a cause of seizures [8]. To the best of our knowledge, there are no reports of seizures during HBO therapy for ISSNHL in the literature.

We have emphasized with our case that seizure is a rare complication of HBO therapy, and have benign outcome.
Case Report
A 29-year-old woman presented to the Emergency Department (ED) after losing consciousness, and having a series of tonic spasms for approximately 3 minutes during the second hour of HBO therapy (at 2.5 atmospheres absolute for 120 minutes). When paramedics arrived on the scene, the patient was conscious with a Glasgow Coma Score of 14 with confusion. Vital parameters were normal with a blood pressure of 125/73 mmHg, a heart rate of 69 beat/min., sPO2 of 99%, and a blood glucose level of 133 mg/dl.

Vital parameters at the time of admission to the ED were similar, and interpreted as normal. Full neurological examination showed no pathological findings other than the confusion.

The patient’s medical history and records indicated that she had sudden severe hearing loss three weeks ago with left ear affected, and diagnosed with ISSNHL. She had no known risk factors or family history for neurological disorders. She was currently using betahistine 24 mg twice a day (Vasoserc BID; Abdi İbrahim, Istanbul, Turkey), vitamin B12, 1 mg once a day (Benexol B12; Bayer Türk, İstanbul, Turkey), and proton-pump inhibitor 40 mg once a day (Lansor; Sanovel, İstanbul, Turkey) drugs at the time as prescribed by her physician for the tratment of ISSNHL. It is learned that the treatment started two weeks ago and the patient had no side affects. She also used corticosteroid therapy (Prednol; Mustafa Nevzat, Istanbul, Turkey) for a week but the treatment ended one week before her presentation to the ED. HBO therapy was added to the medical therapy from the beginning. The therapy was planned as a series of 20 sessions over three weeks, and the patient was having the 13th session during the incident. Previously she reported no side effects of HBO therapy.

Post-admission laboratory analysis and blood works showed elevated blood lactate level (4.8 mmol/L). All other conducted blood parameters were normal. Electrocardiography, cranial computerized tomography (CT), and diffusion-weighted magnetic resonance imaging (DW-MRI) were also normal. Inhospital consultation with Neurology confirmed the incident as a seizure, and an EEG test was planned.

The patient regained full consciousness after 30 minutes. She was monitored for another 6 hours in the ED, and had no seizures or new pathological findings throughout the observation period. A control arterial blood gas analysis showed that the lactate level returned to normal (1.6 mmol/L).

As an interesting detail, patient described that she felt she gained full recovery of hearing after the seizure.

The patient was discharged after the observation period in ED, and decided to discontinue the HBO therapy. EEG test results of the patient was normal. Follow-up for 1-month showed that the patient had no seizures or other neurological symptoms during this period.
Discussion
Sudden hearing loss is defined as a rapid onset of a subjective sensation of hearing impairment in one or both ears. ISSNHL is defined as sudden sensorineural hearing loss with no identifiable cause despite adequate investigation. It is common and often results in permanent hearing loss. HBO therapy is one of the various treatment options.

There are a number of studies in the literature supporting HBO therapy for ISSNHL, especially within 2 weeks to 3 months of diagnosis. Young age, starting the therapy early, and severity of the hearing loss seems to be the related factors for the efficacy of HBO therapy [3]. A 2012 Cochrane Review on this topic reported that there is no evidence of any functionally important improvement, and the routine use of HBO therapy in ISSNHL patients cannot be justified. The review doesn’t give any information regarding the safety [3,9].

HBO is a relatively safe treatment, but carries some risks. Possible complications can be divided into four categories: 1) Barotraumatic lesions, 2) Oxygen toxicity, 3) Confinement anxiety and 4) Ocular effects. Oxygen toxicity can have effects on Central Nervous System (Paul Bert effect), and lungs (Lorraine Smith Effect). Central Nervous System oxygen toxicity presents itself with seizures. Seizure incidence seems to be correlated by treatment pressure, as there is significant increased risk of seizure with increasing treatment pressure [6]. Yildiz et al. presented a case of a 22-year-old man who developed tonicclonic convulsions in the last HBO session, and eventually died in status epilepticus after four days. A case report published in 2017 presented a patient who had hyperbaric oxygen-associated seizure leading to stroke. But underlying cause of the seizures in these two patients could not be definitively diagnosed [4,10]. There has been no other report on sequelae in patients with seizures due to oxygen toxicity presented in the literature. Sanders et al.’s literature review of oxygen toxicity seizures showed 112 cases presented in the literature until 2012, and most of the time seizures were self-limited, without any adverse effects [11]. A review of the literature regarding HBO therapy related seizures was performed (Table 1) [12-21]. The literature review showed that there are only 18 articles published relative to the issue. Nine of them included the HBO treatments for all indications, while 5 of them included only CO toxicity cases, and 4 of them included non-emergent cases (excluding CO, arterial gas embolism, decompression sickness). There were 1,973,333 HBO treatments, and 419 seizures (0.021%) in total. Number of total treatments, and number of seizures were also calculated for each indication group. Seizure rates were 0.027% for “All” indications, 0.018% for “Non-emergent” indications, and 2.246% for “CO toxicity”. These rates may indicate that patients with CO toxicity are more prone to seizures.

While most of the seizing patients received no treatments for seizures, some of them received anti-convulsants [4,22]. Suspected risk factors for oxygen toxicity include family history [23], conditions reducing the seizure threshold (like epilepsy, hypoglycemia, hyperthyroidism), and spesific risk factors like hypercarbia, acetazolamide or disulfiram medication [24,25]. Our case had none of these risk factors and did not need any additional treatment. (Table 1)
Table 1: Literature review of seizure incidence during hyperbaric oxygen therapy

Source

Number of Total Treatments

Number of (Seizures %)

Indications

Hart, 1987(16)

Unknown

44 (0.008)

All

Davis, 1989(17)

52,758

5 (0.009)

All

Sloan et al., 1990

297

14 (4.714)

CO

Welslau, 1996(18)

107,264

16 (0.015)

All

Hampson et al., 1996

900

16 (1.777)

CO

Plafki, 2000

11,376

4 (0.035)

Non

Weaver, 2002(19)

152

0 (0)

CO

Hampson and Atik, 2003(20)

20,328

6 (0.030)

Non

Yildiz et al., 2004

80,679

2 (0.002)

All

Yildiz et al., 2004(21)

36,500

3 (0.008)

All

Hampson et al., 2006(22)

30

0 (0)

CO

Sanders et al., 2008

5,972

2 (0.033)

All

Banham, 2011(23)

41,273

25 (0.061)

All

Heyboer et al., 2014

23,328

11 (0.047)

All

Hadanny et al., 2016

62,614

1 (0.002)

All

Marziali et al., 2016(24)

1

1 (100)

CO

Warchol et al., 2017

1

1 (100)

Non

Jokinen-Gordon et al., 2017(25)

1,529,859

267 (0.017)

Non

Present Case

1

1 (100)

Non

TOTAL of All Indications

410,388**

109 (0.027)

 

TOTAL of Non Indications

1,561,565

279 (0.018)

 

TOTAL of CO Indication

1,380

31 (2.246)

 

TOTAL

1,973,333**

419 (0.021)

 

* Indications included in study: All: all indications; CO: CO toxicity only; Non: non-emergent cases, excludes CO, arterial gas embolism, decompression sickness. OT: Oxygen toxicity; CO: carbon monoxide.

** Incomplete due to Hart, 1987’s unknown total treatments number.
Conclusıon
HBO therapy is a treatment option for ISSNHL, which can be used in some cases especially in the early period. We presented a case with oxygen neurotoxicity that occurred during the HBO therapy. Although these seizures are self limited, clinicians should be aware of this risk, and further studies are necessary to understand the nature of oxygen toxicity.
ReferencesTop
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