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Otic Barotrauma

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Other Names

  • Otic Barotrauma
  • Ear Barotrauma
  • Ear Squeeze
  • External Ear Barotrauma (EEB)
  • Middle Ear Barotrauma (MEB)
  • Inner Ear Barotrauma (IEB)
  • Aural barotrauma


  • This page refers to Otic barotrauma, typically seen during scuba diving or air travel during descent



  • Middle Ear[1]
    • First time divers experience middle ear barotrauma 30% of the time
    • Experienced divers, 10% of the time


Anatomy of the outer, middle and inner ear.[2]
  • General
    • Barotrauma occur to external ear (EEB), middle ear (MEB) or inner ear (IEB); MEB is most common by far
    • Occurs during descent
    • Patients typically present with ear related complaints (pain, fullness, vertigo, disruption in hearing, tinnitus)
  • See: Dive Medicine Main
  • Terminology
    • FSW: Feet of Sea Water

External Ear

  • Etiology
    • Can occur during descent when external auditory canal is occluded
    • Vacuum-like force develops between occlusion, tympanic membrane
    • Subsequently, there is edema, hemorrhage in the canal[3]

Middle Ear

  • General
    • Most common injury related to diving[4]
  • Etiology
    • Occurs when middle ear pressure is not equalized with ambient pressure
    • For this reason, divers are taught to equalize their ears at surface and throughout the dive
    • The greatest changes occur in the first few feet of diving (1.78 PSI at 4 FSW, 2.67 PSI at 6 FSW)
    • At 2.67 PSI, the Eustachian tube is squeezed closed by the pressure gradient between the sinuses
  • Natural history
    • Without equalizing, pain will worsen during descent
    • Sudden relief of pain suggests TM has ruptured
    • Water may rush into the ear, causing a cold caloric stimulus (nausea, disorientation, balance dysfunction)[5]

Inner Ear

  • General
    • Most concerning form of otic barotrauma; can have permanent effects
  • Etiology
    • Results from forceful Valsalva against eustachian tube
    • Or rapid descent in diving or aviation
    • Pressure difference between middle ear, inner ear can rupture oval or round window

Associated Conditions

Risk Factors

  • Sports
    • Scuba Diving
    • Aviation

Differential Diagnosis

Differential Diagnosis Dive Medicine

Clinical Features

  • History
    • Generally, symptoms include ear pain, fullness, vertigo, hearing loss
    • Hearing loss
      • Middle ear: conductive
      • Inner ear: sensorineural
    • In inner ear lesions, vertigo is often more severe
    • Divers do not always know they have MEB, presence and degree to don't correlate with subjective symptoms
    • IEB: most common are sensorineural hearing loss, loud tinnitus, severe and persistent vertigo[6]
  • Physical Exam: Physical Exam HEENT
    • In external ear, edema and hemorrhage of the external auditory canal can be noted
    • Tympanic membrane may be ruptured, especially in middle ear
    • The remainder of the neurological exam should be normal to exclude infarction
  • Special Tests


  • Diagnosis is primarily clinical


TEED Grading System

  • General
    • Used to stage middle ear barotrauma
Grade Description
0 Symptoms without otologic findings
1 Erythema and mild retraction of the tympanic membrane
2 Erythema of the tympanic membrane with mild or spotty hemorrhage within the membrane
3 Gross hemorrhage throughout the tympanic membrane
4 Grade 3 changes pluse hemorrhage within the middle ear (hemotympanum)
5 Free blood in the middle ear plus perforation of the tympanic membrane



  • Equalize ears
    • Divers should know how to equalize their ears
    • If a diver experiences otalgia during descent, they should stop descent and ascend until pain is relieved
    • Once at a pain free depth, they should equalize and then resume depth

External Ear

  • Generally considered self limited
  • Can treat with topical analgesic drops or steroid drops[7]

Middle Ear

  • Medications to decrease inflammation
    • Decongestants
    • Topical nasal vasoconstrictors
  • Antibiotics
    • Consider if TM rupture
  • Audiology
    • Recommend seeing audiology if suspect sensorineural hearing loss
  • ENT Referral
    • Often not necessary
    • Consider if not improving or TM rupture not healing along anticipated timeframe

Inner Ear

  • General
    • Head elevation at 45°, especially when resting, sleeping
    • Do not blow nose
  • Medications
    • Meclizine
    • Oral Corticosteroid taper
      • Klingmann et al proposed 250 mg prednisolone for 3 days, tapering down for a total of 18 d[8]
    • Stool softeners to avoid straining
  • ENT Consultation
    • Indicated in all cases of suspected IEB
  • CT Scan
    • Consider in consultation with ENT

Rehab and Return to Play


Return to Play/ Work

  • Middle ear
    • Patient should refrain from all diving until symptoms have completely resolved
    • If TM rupture, no diving until complete resolution/ healing
    • Should be evaluated by a physician prior to returning
  • Inner ear
    • Historically, IEB patients were counseled to stop diving entirely
    • This may be viewed as an extreme recommendation
    • One study of 20 divers with IEB resumed diving without complication over 12 years of follow up[9]
    • 5 return to diving criteria (2014 paper)[10]
      • Hearing loss is stable and not severe
      • No vertigo
      • Reduction of risk factors for MEB
      • No anatomical risk factors present
      • No further surgical intervention needed

Complications and Prognosis


  • Duration
    • Resolution usually occurs in about 5-7 days
    • Can take up to 2 weeks
  • Middle Ear
    • Most tympanic membrane ruptures will heal spontaneously in 1 to 3 months[11]


See Also


  1. Bayliss GJ. Aural barotrauma in naval divers. Arch. Otolaryngol. 1968; 88:141Y7. doi:10.1001/archotol.1968.00770010143005.
  2. Occupational Safety & Health Administration (1999). Section III: Health Hazards. Chapter 5: Noise.
  3. Becker GD, Parell GJ. Barotrauma of the ears and sinuses after SCUBA diving. Eur. Arch. Otorhinolaryngol. 2001; 258:159Y63. PMID: 11407445.
  4. Buzzacott P. DAN Annual Diving Report 2017 edition. A report on 2015 diving fatalities, injuries, and incidents. Divers Alert Network. 2018. Available from: https://www.diversalertnetwork.org/medical/report/AnnualDivingReport- 2017Edition.pdf.
  5. Asmul K, Irgens A, Grønning M, Møllerløkken A. Diving and long-term cardiovascular health. Occup. Med. (Lond.). 2017; 67:371Y6. doi:10.1093/ occmed/kqx049.
  6. Glazer TA, Telian SA. Otologic hazards related to SCUBA diving. Sports. Health. 2016; 8:140Y4. doi:10.1177/1941738116631524.
  7. Lacey JP, Amedee RG. The otologic manifestations of barotrauma. J. La State Med. Soc. 2000; 152:107Y11. PubMed PMID: 10851823.
  8. Klingmann C, Praetorius M, Baumann I, Plinkert PK. Barotrauma and decompression illness of the inner ear: 46 cases during treatment and follow-up. Otol. Neurotol. 2007; 28:447Y54. doi:10.1097/mao.0b013e318030d356.
  9. Parell GJ, Becker GD. Inner ear barotrauma in SCUBA divers. A long-term follow-up after continued diving. Arch. Otolaryngol. Head Neck Surg. 1993; 119:455Y7. doi:10.1001/archotol.1993.01880160103016.
  10. Elliott EJ, Smart DR. The assessment and management of inner ear barotrauma in divers and recommendations for returning to diving. Diving Hyperb. Med. 2014; 44:208Y22. PubMed PMID 25596834.
  11. Neblett LM. Otolaryngology and sport SCUBA diving. Update and guidelines. Ann. Otol. Rhinol. Laryngol. Suppl. 1985; 94(Suppl1):2Y12. doi:10.1177/ 00034894850940s101
Created by:
John Kiel on 12 May 2022 18:19:22
Last edited:
25 July 2022 19:18:00