One of the most serious diving-related conditions is caused by changes in pressure, which is known as It is called “barotrauma.” In divers, the middle ear is generally affected.

The main diving-related disorders can be classified as follows:

A) Barotrauma: It results from the expansion or contraction of gas-filled spaces in the body, such as the middle ear cavity and the paranasal sinuses.

B) Decompression Sickness (Caisson Disease, or as it is commonly known Diver’s Disease or (Decompression Sickness): It is caused by the rapid release of dissolved nitrogen gas into the bloodstream and tissues when ambient pressure drops suddenly; the condition is felt as body pain, particularly in the limbs and joints, but it can also affect the inner ear. In cases where the inner ear is affected, hearing loss and dizziness may occur.

Ear Problems Related to Diving

A significant number of divers may experience ear, nose, and throat (ENT) problems related to diving. Barotrauma and decompression sickness are considered the primary causes of hearing loss among diving groups.

External Ear Canal Inflammation (External Otitis): A study conducted on 429 active and experienced divers has shown that The most common condition is outer ear canal inflammation (43.6%). The factors influencing the development of external ear canal inflammation are as follows: local trauma, a decrease in the amount of sebum on the skin of the outer ear, high humidity, and fluctuating body temperatures, as well as Pseudomonas aeruginosa, the most common causative microorganism. The proliferation of bacteria in divers’ outer ear canals has been linked to helium diving conditions. The normal flora of the external auditory canal returns to normal only 48 hours after a return to normal atmospheric conditions.

Exostosis of the ear canal: Among divers, the frequency and severity of exostosis—a bony growth in the external auditory canal—are higher. Ear canal exostoses are found in 26% of divers, and the majority of these (70%) are clinically insignificant. Only 10–20% of cases are caused by a narrowing of the ear canal.

Middle ear barotrauma: A diver’s body, including the middle ear cavity and other gas-filled spaces, is exposed to high pressure underwater. Underwater barotrauma (commonly known as “ear popping”) can affect all parts of a diver’s ears. It occurs as a result of an inability to equalize the pressure on the eardrum while diving underwater. The pressure at sea level is 1 atmosphere (760 mm Hg). For every 10 meters, the underwater pressure increases by 1 atmosphere. Divers must be able to equalize the pressure in their middle ears by performing the Valsalva maneuver during a dive; otherwise, barotrauma may occur. In cases of mild to moderate middle ear barotrauma, the eardrum may become stretched due to vascular compression. Barotrauma can occur even at shallower depths—at depths of just 3–5 meters, or when the eardrum is thin or perforated. Negative pressure in the middle ear cavity can cause conductive hearing loss. This is caused by the buildup of fluid leaking from the capillaries in the middle ear wall. Middle ear barotrauma can occur during the descent and ascent phases of a dive, but it is more common during descent and may be accompanied by ear bleeding or a ruptured eardrum; it presents with symptoms of sudden-onset ear pain and hearing loss. In more severe cases—usually when ascending to the surface—increased pressure in the middle ear cavity can cause reversible facial nerve weakness; this condition It is known as “facial baroparesis.”

Temporary vestibular symptoms are common during diving. Barotrauma can cause prolonged dizziness and balance problems. In a study of divers, dizziness (28%), tinnitus (25%), lightheadedness (14%), and unsteady gait (25%) are common. Excessive exposure to underwater pressure is a major factor in the development of these symptoms. If inner ear barotrauma also causes a tear in the round window membrane of the inner ear, it can result in hearing loss.

After Ear Problems/Surgeries and Returning to Diving

The timing of when to dive again after inner ear barotrauma depends on the recovery of hearing in the affected ear. Following inner ear decompression sickness, the possibility of a right-to-left vascular shunt should be evaluated before diving is recommended. Diving may be resumed three months after middle ear surgery (particularly tympanoplasty), provided that normal middle ear ventilation has been restored. After sinus surgery, it is recommended to perform a test dive under supervision before being cleared to dive again. Diving is possible after ear surgery to correct hearing, the implantation of middle ear amplifiers or cochlear implants, paranasal sinus surgery, and even mastoidectomy performed through the canal wall, provided certain requirements are met. Whether scuba diving is permissible after stapes surgery in the middle ear is a matter of debate, as there is a risk of inner ear barotrauma.

Dr. Nuran Kalekoğlu Erkalp