Comprehensive information about diving and undersea medicine for the non-medical diver, the non-diving physician and the specialist.
This page is compiled and maintained by
Ernest S Campbell, MD, FACS
Table of Contents
ENT Guidelines for the Medical Exam of the Diver
Symptoms of Ear Dysfunction
Temporary Ear Dysfunction in Diving
Chronic Ear Dysfunction in Diving
Intracranial Difficulties due to Barotrauma
Link to Ear Problems
Dr. Fred Bove's excellent web site
An article by Allen Dekelboum, MD
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Sensori-neural Hearing Loss and HBO2 Therapy
Allen M. Dekelboum, MD
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ENT AnatomyLink to ENT Anatomy
The external ear canal is a blind tube ending with the ear drum. The cerumen, or wax, is slightly acid and has a protective function. The ear drum has evolved to vibrate with sound waves in the air which is present on both sides. Herein lies the problem with diving --the air-filled space inside the ear drum has to have pressure equalized as a diver goes down and up in the water column. This can only be accomplished without pain and damage by air passing back and forth through the Eustachian tubes. These tubes are easily blocked by problems in the back of the nose.
The inner ear consists of fluid-filled bony channels in the temporal bone and has nerve cells that are concerned with balance and hearing. These structures are separated from the middle ear by windows with very thin membranes, the round and oval windows, that are subject to rupture by excessive Valsalva maneuver with trying to clear the ears.
Absolute ContraindicationsENT Guidelines for the Medical Examination of Scuba Divers
Head Neck Surg 2001 Oct;125(4):356-60
Diving after stapedectomy: clinical experience and recommendations.
House JW, Toh EH, Perez A.
Clinical Studies Department, House Ear Clinic and Institute, 2100 West Third
Street, Los Angeles, CA 90057, USA.
Stapedectomy does not appear to increase the risk of inner ear
barotrauma in scuba and sky divers. These activities may be pursued with
relative safety after stapes surgery, provided adequate eustachian tube
function has been established.
When the external ear canal is blocked with water and wax, or from increases or decreases in middle ear pressures, there will be a sensation of fullness, usually associated with some pain or discomfort. The diver feels that the ear has become blocked as there is an associated hearing loss from inability of the small bones in the ear to transmit sound. If the pressure differential gets high enough, the ear drum will rupture with extreme pain.
Noise induced hearing loss is the most probable cause of hearing loss in professional divers. In professional divers these hazards include the rush of gas entering a chamber during compression, the circulation of gas in diving helmets, the use of noisy underwater tools and the occasional underwater explosion. There are other causes of hearing loss in divers and, even if obvious acute causes, such as decompression sickness and inner ear barotrauma, can be excluded, repetitive subclinical episodes of these same conditions must be considered.
Scand Audiol 1999;28(2):91-6
Long-term effect of
oxygenation treatment on
chronic distressing tinnitus.
Tan J, Tange RA, Dreschler WA, v d Kleij A, Tromp EC
and Neck Surgery, Academic Medical Center, University Hospital
of Amsterdam, The Netherlands. email@example.com
Tinnitus is still a
with an unknown pathophysiology with few therapeutic measures. During
last two decades, hyperbaric oxygenation therapy (HBO) has been used in
the treatment of sudden deafness and chronic distressing tinnitus. In
study, we prescribed HBO to 20 patients who had had severe tinnitus for
more than one year and who had already had other forms of tinnitus
with unsatisfactory results. Four
patients could not cope with the pressure gradient. The effect of HBO was assessed using subjective evaluation and VAS scores before and after HBO. Follow-up continued until one year after treatment. Six patients had a reduction of tinnitus and accompanying symptoms, eight patients did not notice any change and two patients experienced an adverse effect. Any outcome persisted with minor changes until one year after treatment. HBO may contribute to the treatment of severe tinnitus, but the negative effect on tinnitus should be weighed
Dizziness by Charles Yanofsky
Descend feet first. This not only prevents venous congestion and swelling around the openings to the Eustachian tubes but allows observation of the diving partner, an impossibility during a headfirst descent. A diving problem can occur at any depth, and in most cases a diving partner (qualified) may be able to observe a problem onset and those perhaps reduce the risk to both parties.
Descend on the anchor line. This allows for minute up and down control while clearing and descending.
Don't dive after taking medication that causes nasal congestion. Examples are certain blood pressure and prostate medications. (Hytrin).
Commercial airline passengers sometimes experience barotrauma of the middle ear that requires treatment by a physician. A recent article by Thomas P. Brown, a US Navy physician, explains how such trauma occurs, how it can be prevented, and how it should be treated. The information can be interpolated to apply to divers--just reverse the sequence.
During aircraft ascent, ambient pressure decreases slowly, causing the tympanic membrane to bulge outward. When the pressure differential reaches 15 mm Hg -- approximately every 122 m (400 ft) in increased altitude -- the properly functioning eustachian tube vents the positive pressure. On descent, the ambient pressure increases; the tympanic membrane bulges inward, and the eustachian tube resists the positive inward flow. Passengers experience discomfort when the differential reaches 60 mm Hg. At 90 mm Hg, the eustachian tube locks up, preventing the equalization of pressure by whatever means. A 100- to 500-mm Hg differential causes the tympanic membrane to rupture, relieving the pain but often resulting in vomiting, loss of hearing, dizziness, and vertigo.
During barotrauma, the tympanic membrane becomes distorted with respect to color, shape and integrity. As barotrauma progresses, the tympanic membrane mucosa becomes edematous, there is hemorrhaging, and a transudate forms in the middle ear. The tympanic membrane sometimes ruptures because of weakness of the tympanic membrane, inadequate transudate or hematoma formation, or too rapid a change in pressure.
The most effective means of combating middle ear block is to avoid flying while experiencing upper respiratory tract infection. Passengers should yawn, chew, or swallow -- activities that open the eustachian tube momentarily and allow for pressure equalization. Valsalva's maneuver, taking a small breath, holding the nose, and attempting to force air through the closed nostrils, is especially effective in equalizing pressure during descent. If flying in a small plane with few passengers, the pilot may be asked to reascend.
One hour before takeoff and again 30 minutes before, two puffs of oxymetazoline hydrochloride will constrict the arterioles of the nasal mucosa, permitting the eustachian tube to function efficiently. Oral decongestants (e.g., pseudoephedrine and phenylpropanolamine), which affect areas that sprays don't reach, may be initiated 1 or 2 days before a flight. Newer antihistamines without sedating effects may also be effective. Severe or unremitting earblock may be treated by a physician using a Politzer bag. With the patient seated, one nostril is occluded and the flange of the bag is inserted into the other nostril. While the patient rapidly repeats the letter K or takes small sips of water, the bulb is compressed. The Politzer bag is effective in clearing ear block in 50% of cases. If the patient has excruciating pain or still has earblock after one week of the treatments described, myringotomy may be required.
Med. 1994; 96: 135-142.)
This is a blockage of the inner portion of the ear canal by a bony growth called exostosis. This is more commonly seen in surfers, but occasionally can be seen in cold water divers. It is thought to be due to the cooling effect of evaporating water on surfers - and on the effect of cold water on divers. It can cause problems in divers by blocking the egress of cerumen and thus the canal, producing the possibility of an external ear squeeze, decreased ability to ewqualize, alternobaric vertigo and caloric vertigo.
Prevention is by
of ear plugs in surfers and hoods or vented ear plugs in divers.
Definitive treatment is by an operative procedure called canalectomy - or the excision of the bony area of the ear canal that is blocking the canal.
See also http://www.earaces.com/surfear.htm
This is important in that the
is entirely different. Recompression is necessary for inner ear DCS
it is contra indicated for inner ear barotrauma.
Factors helpful in the differential:
1. Time of onset--symptoms occurring during compression (Descent) indicate possible barotrauma. Those symptoms occurring shortly after decompression (ascent) are more likely related to DCS.
2. History of the dive profile--- shallow, air dives more likely barotrauma. Deeper, mixed gas diving--more likely DCS.
3. Associated symptoms of barotrauma, such as pain, fullness, blockage with barotrauma; joint, skin or neurological problems with DCS.
4. Physical findings associated with barotrauma,ear drum findings: skin and neurological findings with DCS.
Investigations have failed to definitely incriminate high background noise as the cause of sensorineural deafness seen in the usual diving population. Conflicting reports fail to provide enough information to allow for recommendations to be made one way or the other. (Farmer, JC in Diving Medicine, Bove, (ed.)
Tinnitus is the perception of sound when no external sound is present; and is often referred to as "ringing in the ears." It can also take the form of hissing, roaring, whistling, chirping or clicking. The noise can be intermittent or constant, with single or multiple tones; it can be subtle or at a life-shattering level. It can strike people of all ages and, for most, it is difficult to treat.
It is estimated that over 50 million Americans are affected by tinnitus to some degree. Of these, about 12 million suffer severely enough to seek medical attention. And, about one million sufferers are so seriously debilitated that they cannot function on a "normal," day-to-day basis. In diving, it is a symptom of serious changes that have occurred because of the effects of pressure, either barotrauma, excessive attempts to equalize or to a decompression accident.
In divers, it also can be related to TM joint pressure from clamping down on the mouthpiece, wax buildup in the ear canal with tympanic membrane irritation, barotrauma to the middle and inner ear, decompression illness involving the inner ear, or rupture of the round window with perilymph fistula. With the latter, it most often found in association with vertigo and there is usually some deafness.
It may also be caused by physical trauma, infections of the ears, long standing exposure to very noisy environments, scarring and rigidity of the small bones in the middle ear (otosclerosis), toxic damage by medications (e.g. Streptomycin), and tumors of the brain or the auditory (hearing) nerve.
Tinnitus is still a phenomenon about which we know little and which has few effective treatments. During the last two decades, hyperbaric oxygenation therapy (HBO) has been used in the treatment of sudden deafness and chronic distressing tinnitus, with mixed results. Other therapies include non specific prescription medicines, non-traditional medical treatments, such as acupuncture, stress reduction and relaxation therapy, hearing aids and biofeedback therapy.
It should be emphasized that the newer methods of treatment are still under evaluation and that at this time there is no universal, symptomatic or specific treatment for tinnitus.
Things that divers
1. Get a good examination by a diving oriented ENT doctor. The tinnitus may not be from diving at all!
2. Check out your regulator mouthpiece for fit. Consciously avoid clamping down on the mouthpiece. (Try this yourself--clamp down on your teeth and hear the high-pitched whine!)
3. Avoid the use of nerve stimulants, i.e, excessive amounts of coffee (caffeine) and smoking (nicotine).
4. Learn as quickly as possible to accept the existence of the head noise as an annoying reality and them promptly and completely ignore it as much as possible.
5. Tinnitus is usually more marked at bedtime, when one's surroundings become quiet. Use any kind of masking sound-maker.
How to Treat Tinnitus: There is not a cure for tinnitus. However, a variety of treatment options exist that offer varying levels of relief to many sufferers. Treatment options include:
• hearing aids
• Tinnitus Retraining Therapy
• TMJ treatment
More About Tinnitus Related to Diving
This information is
only as a background for becoming an informed diver. It should never
for the expertise of a diving physician or ENT specialist. Tinnitus can
be described as "ringing" ears and other head noises that are perceived
in the absence of any external noise source. It is estimated that 1 out
of every 5 people experience some degree of tinnitus. Tinnitus is
into two types: objective (what can be heard by someone else) and
(what can be felt).
audible or observable )
The rarer form,
of head noises audible to other people in addition to the sufferer. The
noises are usually caused by vascular anomalies, repetitive muscle
or inner ear structural defects. The sounds are heard by the sufferer
are generally external to the auditory system. This form of tinnitus
that an examiner can hear the sound heard by the sufferer by using a
Benign causes, such as noise from TMJ, openings of the eustachian
or repetitive muscle contractions may be the cause of objective
The sufferer might hear the pulsatile flow of the carotid artery or the
continuous hum of normal venous outflow through the jugular vein when
a quiet setting. It can also be an early sign of increased intracranial
pressure and is often overshadowed by other neurologic abnormalities.
sounds may arise from a turbulant flow through compressed venous
at the base of the brain.
Subjective Tinnitus(Inaudible to an observer)
This form of tinnitus may occur anywhere in the auditory system and is much less understood, with the causes being many and open to debate. Anything from the ear canal to the brain may be involved. The sounds can range from a metallic ringing, buzzing, blowing, roaring, or sometimes similar to a clanging, popping, or nonrhythmic beating. It can be accompanied by audiometric evidence of deafness which occurs in association with both conductive and sensorineural hearing loss. Other conditions and syndromes which may have tinnitus in conjunction with the condition or syndrome, are otosclerosis, Meniere's syndrome, and cochlear or auditory neve lesions.
Hearing loss, hyperacusis (excessive loudness), recruitment, and balance problems may or may not be present in conjunction with tinnitus.
Many sufferers report that their tinnitus sounds like the high-pitched background squeal emitted by some computer monitors or television sets. Others report noises like hissing steam, rushing water, chirping crickets, bells, breaking glass, or even chainsaws. Some report that their tinnitus temporarily spikes in volume with sudden head motions during aerobic exercise, or with each footfall while jogging.
Objective tinnitus sufferers may hear a rhythmic rushing noise caused by their own pulse. This form is known as pulsatile tinnitus.
In a database of 1544 tinnitus patients, 79% characterized the sound as "tonal" with an average loudness of 7.5 (on a subjective scale of 1-10). The other 21% characterized the sound as "noise" with an average loudness of 5.5. When compared to an externally generated noise source, the average loudness was 7.5dB above threshold. 68% of patients were able to have their tinnitus masked by sounds 14dB or less above threshold. The internal origination of the tinnitus sounds was perceived by 56% of the patients to be in both ears, 24% from somewhere inside the head, 11% from the left ear, and 9% from the right ear.
In aother database
tinnitus patients, no known cause was identified for 43% of the cases,
and noise exposure was the cause for 24% of the cases.
Diving Causes of Tinnitus
TMJ syndrome (Clenching of teeth on the regulator)
Middle ear barotrauma (Due to pressure/volume changes)
Inner ear barotrauma. (Due to pressure/volume changes)
Round window rupture (Due to elevated pressure blowing this window out into the middle ear0
Inner ear decompression accident (Due to bubbles damaging the inner ear tissues)
from an otolaryngologist
familiar with the damage that can occur from diving should be obtained.
Self -diagnosis and treatment has no place in the management of
from diving injuries.
Long-term effect of hyperbaric oxygenation treatment on
chronic distressing tinnitus.
Tan J, Tange RA, Dreschler WA, v d Kleij A, Tromp EC
Department of Otorhinolaryngology/Head and Neck Surgery, Academic Medical Center, University Hospital of Amsterdam, The Netherlands. firstname.lastname@example.org
Lamm K, et al.
Effect of hyperbaric oxygen therapy in comparison to conventional or placebo therapy or no treatment in idiopathic sudden hearing loss, acoustic trauma, noise-induced hearing loss and tinnitus. A literature survey.
Adv Otorhinolaryngol. 1998;54:86-99. Review.
Bohm F, et al.
[Round window membrane defect in divers].
Laryngorhinootologie. 1999 Apr;78(4):169-75. Review. German
Schumann K, et al.
[Effect and effectiveness of hyperbaric oxygen therapy in chronic hearing disorders. Report of 557 cases 1989].
HNO. 1990 Nov;38(11):408-11. German.
Peifer KJ, et
Tinnitus: etiology and management.
Clin Geriatr Med. 1999 Feb;15(1):193-204, viii. Review.
Long-term effects of psychological treatment of tinnitus.
Scand Audiol. 1987;16(3):167-72.
Kau RJ, et al.
Effectiveness of hyperbaric oxygen therapy in patients with acute and chronic cochlear disorders.
ORL J Otorhinolaryngol Relat Spec. 1997 Mar-Apr;59(2):79-83.
Roeser RJ, et al.
Clinical experience with tinnitus maskers.
Ear Hear. 1980 Mar-Apr;1(2):63-8.
Treatment of severe tinnitus with biofeedback training.
Laryngoscope. 1978 Mar;88(3):406-12.
AJ, et al.
Evaluation of a tinnitus masking program: a follow-up study of 598 patients.
Ear Hear. 1980 Mar-Apr;1(2):71-4.
Marion MS, et al.
Mayo Clin Proc. 1991 Jun;66(6):614-20. Review.
This most often involves the frontal or maxillary sinuses and the pressure differential usually causes the lining of the sinuses to become swollen and bleeding can ensue.
is a common event with diving and can be caused by negative pressure
the mask or from pressure change after ascent. Dull aching is present
treatment is directed at the use of nasal decingestants and symptomatic
pain relief. Antibiotics are also used to treat infection.
Goldmann reported a case of sinus barotrauma presenting as air in the subdural space. (JAMA. 255:3154-3156, 1986.) There is really no difference between the damage and pain with descent or ascent. It occurs in both flyers and divers and the pathophysiology is the same--the inability to equilibrate the air pressure as it changes, up and down.
All of this depends mainly on the function of the mucosa of the nose and sinuses. Some people secrete large quantities of mucus in response to allergy. Others have a definite correctible problem, such as nasal septal deviation, polyps or tumors, resulting in blockage of the ostia (openings) of the sinuses.
The frontal sinuses are the most frequently involved, probably because the nasofrontal duct is longer and more tortuous. The damage that is done by the pressure change leads to a series of changes within the sinuses consisting of air absorption, decreased pressure in the sinus; swelling, engorgement, inflammation and fluid collection in the sinus cavity. This decrease becomes greater with descent (as with flying) the changes become greater, more painful and often associated with bleeding into the sinus cavity. On ascent, there is one-way valve blockage of the ostia, resulting in more barotrauma. The next step after all this is usually infection, which increases the blockage by causing it's own swelling and purulent discharge.
Common causes of all this include, allergy; chronic irritation, such as smoking, diesel fumes, chemicals, prolonged use of nose drops or nasal sprays; mechanical blockage; vasomotor problems from chronic tension, stress or anxiety.
It should be
what should be a very simple problem can be stubbornly difficult to
Ernest Campbell, MD, FACS All Rights Reserved.