Diving and ENT — Ear, Nose and Sinus Problems in Divers
Diving places the ear, nose, and sinuses under considerable physiological stress. The changes in ambient pressure that occur during descent and ascent can injure any air-filled space in the body that cannot equalise, and the ear and paranasal sinuses are among the most commonly affected structures. Understanding the mechanisms, presentations, and management of diving-related ENT disorders is important for divers, dive instructors, and the medical practitioners who assess them.
The Physics of Barotrauma
Barotrauma is injury caused by the compression or expansion of gas in body spaces that cannot equalise with the surrounding ambient pressure. Three physical laws govern the behaviour of gases under pressure and are directly relevant to understanding diving injuries.
Boyle’s Law — pressure multiplied by volume is constant. As a diver descends and ambient pressure increases, the volume of gas in any closed body space decreases proportionally. On ascent, as pressure drops, that gas expands. Any space that cannot equalise freely will be subjected to either a relative vacuum on descent or expanding gas on ascent.
Dalton’s Law — the total pressure of a gas mixture equals the sum of the partial pressures of its components. At depth, the partial pressure of each component gas in breathing air (oxygen, nitrogen) increases proportionally. This is relevant to nitrogen narcosis and oxygen toxicity at depth.
Henry’s Law — the amount of gas dissolved in a liquid is proportional to the partial pressure of that gas above the liquid. As ambient pressure increases at depth, more nitrogen dissolves into the bloodstream and tissues. Rapid ascent prevents adequate offgassing and can cause decompression sickness.
Barotrauma on Descent
Sinus Barotrauma
The paranasal sinuses communicate with the nasal cavity through a system of narrow ostia and clefts. If any sinus is unable to equalise air pressure during descent — because its ostium is blocked by mucosal swelling, polyps, or anatomical narrowing — a relative vacuum develops within that sinus. The mucosa becomes congested, oedematous, and may bleed into the sinus cavity. The diver experiences severe facial pain during descent, and on ascent the expanding gas may force mucus and blood out through the nose and into the dive mask.
The frontal and maxillary sinuses are most commonly affected. Complications include dental pain from involvement of the posterior superior branch of the maxillary nerve, tingling and numbness of the cheek and upper lip from the infraorbital nerve, secondary infection of collected fluid, and rarely periorbital emphysema if a breach in the lamina papyracea develops.
Conditions predisposing to sinus barotrauma include allergic rhinitis, chronic rhinosinusitis, nasal polyposis, and significant nasal septal deformity. Divers with any of these conditions require careful assessment before clearance to dive.
Treatment — topical vasoconstrictors (phenylephrine or oxymetazoline), systemic pseudoephedrine, analgesia, and abstinence from diving until fully resolved. Antibiotics are indicated if there is evidence of secondary sinusitis. A short course of corticosteroids may hasten recovery.
External Ear Canal Barotrauma
Air trapped in the external ear canal by an obstruction — ear wax, a tight wetsuit or drysuit hood, bony exostoses, otitis externa, ear plugs, or congenital canal stenosis — can cause pain during descent as the trapped air cannot equalise with the increasing ambient pressure. Management involves removing the obstruction; prevention requires that the ear canal be clear and patent before diving.
Middle Ear Barotrauma (Barotitis Media)
Middle ear barotrauma is the most common diving-related injury. On descent, if the Eustachian tube cannot open to equalise the increasing ambient pressure, a relative negative pressure develops in the middle ear. The tympanic membrane is drawn inward, the middle ear mucosa becomes congested, and transudate or blood may accumulate. The diver experiences increasing ear pain, fullness, and reduced hearing. Continued descent without equalisation can rupture the tympanic membrane.
Eustachian tube dysfunction — from upper respiratory infection, allergy, or anatomical narrowing — is the principal predisposing factor. Divers should never descend with a blocked nose or active upper respiratory infection. The Valsalva manoeuvre (gentle positive pressure against closed nostrils) and the Toynbee manoeuvre (pinch nostrils and swallow) are the standard equalisation techniques.
Inner Ear Barotrauma
Forceful Valsalva manoeuvring against a blocked Eustachian tube can transmit pressure to the inner ear via the round window, potentially causing rupture of the round or oval window membrane. This presents with sudden sensorineural hearing loss, tinnitus, and vertigo — a presentation that constitutes a medical emergency requiring same-day ENT assessment. Inner ear barotrauma is one of the most serious diving-related ENT injuries and can result in permanent hearing loss.
Barotrauma on Ascent (Reverse Squeeze)
The sinuses and ears are subject to barotrauma during ascent as well as descent. As ambient pressure drops on ascent, gas in the sinuses and middle ear expands and must be able to escape. Where this is prevented — by mucosal oedema, a polyp acting as a one-way valve, or Eustachian tube inflammation from multiple short dives — trapped expanding gas causes pain and tissue damage.
A polyp or cyst in a sinus can allow air to enter on descent but prevent its escape on ascent, causing pressure to build to levels that may exceed intravascular pressure in adjacent tissue, causing local ischaemia. Fainting underwater from frontal sinus pain has been reported.
Reverse middle ear squeeze occurs when expanding middle ear gas cannot escape through a blocked Eustachian tube. Multiple short dives can cause cumulative Eustachian tube inflammation that worsens with successive dives. Trapped air causes pain, tinnitus, vertigo, and outward rupture of the tympanic membrane.
Alternobaric Vertigo
Unequal middle ear pressures on ascent — where one ear equalises and the other does not — causes asymmetric vestibular stimulation and pronounced vertigo, nausea, and vomiting. Disorientation underwater is potentially dangerous and can precipitate panic and further injury. The Toynbee manoeuvre can help release middle ear overpressure on ascent.
Alternobaric Facial Nerve Palsy
The facial nerve passes through the middle ear, and in some individuals part of its bony covering (the fallopian canal) is dehiscent — absent or thinned — leaving the nerve directly exposed to middle ear pressure changes. Significant pressure differential can cause an ischaemic neuropraxia of the facial nerve, presenting with ear pain, facial tingling, and varying degrees of facial weakness including inability to close the eye or move the corner of the mouth. Management includes oral and topical decongestants; recompression may restore capillary circulation in severe cases, and myringotomy may be necessary to equalise middle ear pressure urgently.
Ear Wax and Diving
Ear wax impaction is a common and underappreciated contributor to diving ear problems. Impacted wax can trap air in the external ear canal and cause external canal barotrauma on descent. It can also prevent adequate assessment of the ear canal and tympanic membrane before diving. Divers who use ear plugs, hearing aids, or cotton buds are at increased risk of impaction.
Wax removal options include softening drops (olive oil, hydrogen peroxide, sodium bicarbonate), microsuction under direct vision, curette removal, and irrigation. Irrigation should be avoided in any diver with a history of tympanic membrane perforation, ventilation tube, or active otitis externa. Microsuction is the safest and most controlled technique.
Fitness to Dive — ENT Considerations
A number of ENT conditions are relevant to dive fitness assessment. Absolute or relative contraindications to diving from an ENT perspective include active upper respiratory infection, significant nasal polyposis, uncontrolled allergic rhinitis causing nasal obstruction, chronic Eustachian tube dysfunction, history of inner ear surgery, active otitis media or otitis externa, significant tympanic membrane perforation, and bony exostoses causing canal stenosis of greater than 75%.
Divers with a history of ENT surgery — tympanoplasty, stapedectomy, sinus surgery, septoplasty — require individual assessment before returning to diving. The stability of any reconstruction and the adequacy of pressure equalisation need to be confirmed.
Dr Roth’s Clinical Perspective
The ENT structures are disproportionately affected by diving because they contain the air-filled spaces most vulnerable to pressure change — and because equalisation depends on anatomy and technique that vary significantly between individuals. The most important message for divers is that descent with any degree of nasal obstruction from a cold, allergy, or sinusitis is the single most preventable cause of serious diving ENT injury. A blocked nose before a dive is a reason not to dive that day, not a reason to try harder to equalise.
Inner ear barotrauma deserves particular emphasis because it is both underrecognised and potentially permanent. A diver who surfaces with sudden hearing loss, tinnitus, or vertigo — particularly after a difficult equalisation — should be assessed by an ENT surgeon the same day. The window for intervention is narrow and the consequences of delay can be irreversible hearing loss.
I worked at the Hyperbaric Unit at Prince of Wales Hospital earlier in my career and developed a specific interest in diving medicine through that experience. The combination of ENT pathology and hyperbaric physiology is a genuinely interesting area, and the clinical presentations are often dramatic.
— Dr Jason Roth, MBBS, FRACS (ORL-HNS), IBCFPRS
Hearing Loss → | Sinus Problems → | Contact Us →
Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
View full profile
