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Ear and Sinus Barotrauma

By Alfred A. Bove, MD, PhD, Professor (Emeritus) of Medicine, Lewis Katz School of Medicine, Temple University

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Barotrauma is tissue injury caused by a pressure-related change in body compartment gas volume. It can affect the ear (causing ear pain, hearing loss, and/or vestibular symptoms) or the sinuses (causing pain and congestion). Diagnosis sometimes requires audiometry and vestibular testing. Treatment, when required, may involve decongestants, analgesics, and sometimes oral corticosteroids or surgical repair of serious inner or middle ear or sinus injuries.

Diving can affect the external, middle, and inner ear. Typically, divers experience ear fullness and pain during descent; if pressure is not quickly equilibrated, middle ear hemorrhage or tympanic membrane rupture may occur. Inflow of cold water to the middle ear may result in vertigo, nausea, and disorientation while submerged. On examination of the ear canal, the tympanic membrane may show congestion, hemotympanum, perforation, or lack of mobility during air insufflation with a pneumatic otoscope; conductive hearing loss is usually present.

Inner ear barotrauma often involves rupture of the round or oval window, which causes tinnitus, sensorineural hearing loss, vertigo, nausea, and vomiting. The resulting labyrinthine fistula and perilymph leakage can permanently damage the inner ear.

Sinus barotrauma most often affects the frontal sinuses, followed by the ethmoid and maxillary sinuses. Divers experience mild pressure to severe pain, with a feeling of congestion in the involved sinus compartments during ascent or descent and sometimes epistaxis. Pain can be severe, sometimes accompanied by facial tenderness on palpation.

Rarely, the sinus may rupture and cause pneumocephalus with facial or oral pain, nausea, vertigo, or headache. Rupture of a maxillary sinus can cause retro-orbital air with diplopia due to oculomotor dysfunction. Compression of the trigeminal nerve in the maxillary sinus can cause facial paresthesias. Physical examination may detect tenderness in the sinuses or nasal hemorrhage.


  • Audiometry and vestibular testing

Patients with symptoms of inner ear trauma should be examined for signs of vestibular dysfunction and referred for formal audiometry and vestibular testing.

Imaging (eg, plain x-rays, CT) is not necessary for diagnosis of uncomplicated sinus barotrauma, but CT is useful if sinus rupture is suspected.


  • Decongestants and analgesics

  • Sometimes oral corticosteroids, surgical repair, or both

Most ear and sinus barotrauma injuries resolve spontaneously and require only symptomatic treatment and outpatient follow-up.

Drug treatment for sinus and middle ear barotrauma is identical. Decongestants (usually oxymetazoline 0.05%, 2 sprays each nostril bid for 3 to 5 days or pseudoephedrine 60 to 120 mg po bid to qid up to a maximum of 240 mg/day for 3 to 5 days) can help open occluded chambers. Severe cases can be treated with nasal corticosteroids. Doing the Valsalva maneuver immediately after nasal spray therapy may help distribute the decongestant into the occluded chamber. Pain can be controlled with NSAIDs or opioids.

If bleeding or evidence of effusion is present, antibiotics are given (eg, amoxicillin 500 mg po q 12 h for 10 days, trimethoprim/sulfamethoxazole 1 double-strength tablet po bid for 10 days).

For middle ear barotrauma, some physicians also advocate a short course of oral corticosteroids (eg, prednisone 60 mg po once/day for 6 days, then tapered over 7 to 10 days).

Referral to an otorhinolaryngologist is indicated for severe or persistent symptoms. Surgery (eg, tympanotomy for direct repair of a ruptured round or oval window, myringotomy to drain fluid from the middle ear, sinus decompression) may be necessary for serious inner or middle ear or sinus injuries.


Ear barotrauma may be avoided by frequently swallowing or exhaling against pinched nostrils to open the eustachian tubes and equalize pressure between the middle ear and the environment. Pressure behind ear plugs cannot be equalized, so they should not be used for diving.

Prophylaxis with pseudoephedrine 60 to 120 mg po bid or qid up to a maximum of 240 mg/day, beginning 12 to 24 h before a dive, can reduce the incidence of ear and sinus barotrauma. Diving should not be done if congestion does not resolve or if a URI or uncontrolled allergic rhinitis is present.

Key Points

  • If patients have tinnitus, hearing loss, or vertigo, arrange audiometry and vestibular testing.

  • Consider CT if sinus rupture is suspected.

  • If symptoms are severe, prescribe an analgesic and a decongestant.

  • Decrease risk of ear and sinus barotrauma by counseling against diving when the nose is congested and sometimes by prescribing prophylactic pseudoephedrine.

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