(See also Overview of Diving Injuries Overview of Diving Injuries More than 1000 diving-related injuries occur annually in the US; > 10% are fatal. Similar injuries can befall workers in tunnels or caissons (watertight retaining structures used for construction)... read more and Overview of Barotrauma Overview of Barotrauma Barotrauma is tissue injury caused by a pressure-related change in body compartment gas volume in air-containing areas. During ascent, gas expansion affects the lungs and gastrointestinal (GI)... read more .)
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. When pressure within the middle ear remains elevated during or after ascent from a dive, the facial nerve can be compressed (facial baroparesis), resulting in ipsilateral upper and lower facial paresis. Weakness of both upper and lower face distinguishes facial baroparesis from stroke or arterial gas embolism.
Inner ear barotrauma (IEBT) occurs due to rupture of the labyrinthine window (round or oval window) or tears of the Reissner, basilar, or tectorial membranes. Symptoms, which include tinnitus, hearing loss, dizziness, disequilibrium, vertigo, nystagmus, ataxia, nausea, and vomiting, often worsen with activity and loud noise, and improve with rest. Symptoms usually start during descent when there is difficulty equalizing middle ear pressure, but can occur during ascent, possibly due to air expansion within the cochlea or vestibular apparatus. Symptoms can also occur days after a dive, often provoked by lifting or straining (1 Reference 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... read more ).
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. Sphenoid sinus barotrauma can cause optic nerve compression and blindness (2 Reference 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... read more ). Physical examination may detect tenderness in the sinuses or nasal hemorrhage.
1. Elliott EJ, Smart DR: The assessment and management of inner ear barotrauma in divers and recommendations for returning to diving. Diving Hyperb Med, 44(4):208-22, 2014. PMID: 25596834.
2. Schipke JD, Cleveland S, Drees M: Sphenoid sinus barotrauma in diving: case series and review of the literature. Res Sports Med, 26(1):124-137. Epub 2017 Aug 10. PMID: 28797173. doi: 10.1080/15438627.2017.1365292
Sometimes, audiometry and vestibular testing
Barotrauma causing only pain in the ear or sinuses is usually diagnosed clinically.
Patients with symptoms of inner ear barotrauma (eg, tinnitus, hearing loss, or vertigo) should be examined for signs of vestibular dysfunction and undergo urgent formal audiometry Testing Worldwide, about half a billion people (almost 8% of the world's population) have hearing loss (1). More than 10% of people in the US have some degree of hearing loss that compromises their... read more , vestibular testing Testing Dizziness is an imprecise term patients often use to describe various related sensations, including Faintness (a feeling of impending syncope) Light-headedness Feeling of imbalance or unsteadiness... read more , and possibly surgery. These patients should be referred to an otolaryngologist because prompt surgical treatment of labyrinthine window tears can reverse hearing loss.
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 twice a day for 3 to 5 days or pseudoephedrine 30 to 60 mg orally 2 to 4 times a day 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. Pain can be controlled with nonsteroidal anti-inflammatory drugs or opioids.
If bleeding or evidence of effusion is present, antibiotics are given (eg, amoxicillin 500 mg orally every 12 hours for 10 days, trimethoprim/sulfamethoxazole 1 double-strength tablet orally twice a day for 10 days).
For middle ear barotrauma, some physicians also advocate a short course of oral corticosteroids (eg, prednisone 60 mg orally once a day for 6 days, then tapered over 7 to 10 days).
Referral to an otorhinolaryngologist is indicated for severe or persistent symptoms. Urgent 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.
During a dive, ear barotrauma during descent 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 oxymetazoline 0.05% nasal spray, 2 sprays per nostril twice daily or pseudoephedrine 30 to 60 mg orally 2 or 4 times a day up to a maximum of 240 mg/day, beginning 12 to 24 hours before a dive, can reduce the incidence of ear and sinus barotrauma. Diving should not be done if congestion does not resolve or if an upper respiratory infection or uncontrolled allergic rhinitis is present.
If patients have tinnitus, hearing loss, or vertigo, arrange urgent 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 oxymetazoline or nasal pseudoephedrine.
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
Divers Alert Network: 24-hour emergency hotline, 919-684-9111