Ears can be problematic in divers. Like swimmers, they are prone to otitis externa. They are also at risk of middle and inner ear barotrauma because of the pressure changes they are exposed to.

Basic Science and Pathophysiology

The middle ear is an enclosed gas-filled space. It is therefore exposed to Boyle’s law and so vulnerable to barotrauma if it is not equalised correctly. This can affect the round window and the oval window, causing subsequent inner ear barotrauma.

Clinical Presentation

Otitis externa: Infection presents with pain, discharge and sometimes fever.


  • Middle ear barotrauma presents with pain and loss of hearing. The tympanic membrane is usually injected and there may be fluid behind the tympanic membrane. The worst cases present with ruptured tympanic membrane. The TEED score can be helpful in classifying severity.
  • Inner ear barotrauma usually presents with vertigo, tinnitus, co-ordination and balance problems. It is often confused with audio-vestibular DCI.


To determine the difference between infection, DCI or barotrauma it is imperative that an ear examination is undertaken.


Otitis externa: Most cases will resolve within a few weeks without treatment. However antibiotic ear drops can be useful in resolving the condition quickly. Oral antibiotics are not more effective due to limited absorption. Pain can be an issue so simple analgesia advice should be given. If there is a cartilage involvement an ENT review is advised as these patients may require admission for IV antibiotics. It is important that the ear is kept dry until treatment is complete.


  • Middle ear barotrauma mild cases will usually heal with conservative management in a few days to weeks. Perforations may require antibiotic drops and surgery if not healing. ENT opinion is advised in cases of perforation.
  • Inner ear barotrauma ENT review in ED is advised