Barotrauma of the middle ear the diver consultation

Ear diseaseMiddle ear barotrauma is a very common condition that can occur while diving. But not only for scuba divers but especially for apnoea divers or non-divers who dive in the swimming pool, a middle ear damage can occur.

The cause is always an insufficiently performed prere equalization.


Barotrauma of the middle ear during descent

During the descent, there is an increase in prere in the middle ear. According to Boyle-Mariotte's law, this increase in prere leads to a reduction in volume in the middle ear. The eardrum closes the middle ear tightly to the outside, so that the prere equalization can only take place via the eustachian tube. Since the Eustachian tube does not open passively during descent, prere equalization must be actively initiated. There are different methods for this, which are explained in the anatomy of the middle ear. If prere equalization is omitted or if prere equalization cannot be performed to a sufficient degree (d.h. nothing else than descending too fast for the momentary tube function) the volume in the middle ear decreases. Since the middle ear is a rigid cavity, this reduction in volume can only be compensated for in the following ways:

1. The tympanic membrane bulges inward 2. there is a "sweating out" of tie fluid to reduce the volume of the tympanic membrane 3. there is hemorrhage into the tympanic membrane 4. If the expansion of the eardrum exceeds a certain level, the eardrum can rupture: this allows water to flow into the middle ear and a sudden prere equalization takes place.

Mechanism of middle ear barotrauma. With kind permission of Prof. Timothy C. Grove, Northwestern University, Chigago, USA

Barotrauma of the middle ear the diver's consultation

The picture shows the typical bleeding into the eardrum after a barotrauma of the middle ear. The hemorrhage extends along the hammer handle. From there on to 6 o'clock. Cause was prere equalization problems during descent.© Dr. med. Christoph Klingmann

Barotrauma of the middle ear during ascent

During ascent, the ambient prere decreases relative to the prere in the middle ear. According to Boyle-Mariotte's law, this leads to an increase in volume in the middle ear. When the Eustachian tube is fully functional, air flows passively through the Eustachian tube into the nasopharynx. However, if the eustachian tube is displaced (see under tube ventilation disorders), the air in the middle ear expands. This increase in volume can be compensated by:

1. a protrusion of the eardrum into the auditory canal 2. Opening of the Eustachian tube and outflow of air through the Eustachian tube

If the necessary opening prere of the eustachian tube is greater than the stability of the tympanic membrane, a rupture of the tympanic membrane will result. Again, there is not necessarily a rupture of the tympanic membrane, but the tympanic membrane and the tympanic membrane may just be irritated.

Barotrauma of the middle ear the diver consultation

Mechanism of middle ear barotrauma.© Dr. Ch. Klingmann

Nasal drops

Particularly at risk for barotrauma of the middle ear during ascent are divers who have used nasal drops before diving. Usually there is a tube ventilation disorder, which leads to the use of nasal drops. The descent succeeds without problems thanks to the nasal drops, but the effect of nasal drops wears off after a while. Since the air must passively flow out of the ear during descent, but the eustachian tube is displaced due to the lessening of the effect of the nasal drops, the resulting volume expansion in the middle ear leads to a rupture of the tympanic membrane. For this reason, nasal drops should not be used until 12 hours before diving.


The diver first notices a feeling of prere in the area of the ear. If the prere compensation does not succeed one feels pain. Sometimes a "smacking" sound can be heard in the ear, which is caused by the fluid behind the eardrum. If these warning symptoms are ignored, a rupture of the eardrum will occur. The affected diver usually notices a significant decrease in pain. As water enters the middle ear, which is usually colder than 37 degrees Celsius, a spinning sensation may occur, as this caloric stimulus stimulates the horizontal arcuate duct (part of the organ of equilibrium). The danger is that the rotational vertigo can cause a loss of orientation, which could lead to a panic-like ascent. If the diver does not exhale during such a panic ascent, a barotrauma of the lungs results, which can be life-threatening. If dizziness occurs, it usually subsides after about a week. minute after.

On the surface, the diver may notice air hissing out of the ear when prere equalization is performed. This is the sign of a rupture of the eardrum. Other symptoms include pain, sometimes bleeding from the ear canal and hearing loss with possible tinnitus (a ringing in the ears). After a while, throbbing pain can be added, if there is an accompanying middle ear infection due to contamination of the water.

– pain – rotational vertigo – air from the ear canal during prere equalization – bleeding from the ear canal – hearing loss, if applicable. Tinnitus – In the interval: throbbing pain and fever (infection)

These symptoms do not have to occur together. Some divers report only a brief pain in the ear, although there is a rupture of the eardrum. Beginners are particularly at risk, as they are so busy with the technique that they often do not feel the first symptoms at all, or feel them too late, and perform prere equalization too late.

Classification of middle ear barotrauma

Not every middle ear barotrauma is caused by a hole in the eardrum! Barotrauma only means that it is a prere-related injury. There are v.a. in the Anglo-American area different classifications of the tympanic membrane findings, which however have not become generally accepted in the German area. It is better to stick to the description of the eardrum findings, which also apply to other diseases in the middle ear area. The eardrum and the tympanic membrane can be affected to varying degrees:

– redness in the area of the hammer grip – bleeding into the eardrum – serous or bloody fluid in the tympanic membrane – rupture of the eardrum


Initially, there is an absolute ban on diving. In any case, one should be examined by a doctor, preferably under the microscope. On the spot, the ear should be cleaned if necessary. be covered sterilely. Please do not put ear drops into the ear, because they are often ototoxic and can damage the inner ear in case of a ruptured eardrum. If pain develops, a painkiller should be taken, but be sure to avoid aspirin! If an effusion is present, decongestant nasal drops should be administered, as the secretion can then flow off better.

If the ear is not infected, a tympanic membrane splinting can be performed depending on the severity of the findings. In this case, a silicone foil inlaid with antibiotic drops is applied to the defect after it has been refreshed and, if necessary, repaired. was rolled out. The eardrum is supported by a tamponade of the auditory canal. The defect can be closed along the foil. In the case of very large defects, a tympanoplasty (eardrum closure surgery) must be performed directly. Sometimes the incoming water causes an infection of the middle ear, so antibiotics must be administered.

As you can read, a safe evaluation of a middle ear barotrauma is only possible by an otolaryngologist, who would have to perform an operation if it seems to be necessary. One should always keep in mind that it is important to splint a tympanic membrane defect as early as possible and not to present to the doctor only after a couple of days. Finally, further fitness for diving depends on the function of the eardrum.

– Diving ban – cover ear sterilely – if necessary. Nasal drops – if necessary. painkillers – if necessary. Antibiotics – ENT medical control – if necessary. eardrum splinting \ if necessary. Ear drum surgery – do not put water in the ear – do not put ear drops in the ear before the ENT doctor's check-up

Fitness for diving

It is very difficult to give a general answer as to how long a diving ban will last. It can be said that with a slight reddening of the tympanic membrane, diving is possible again directly. In case of bleeding into the middle ear, min. wait 1-2 weeks before diving. A ruptured eardrum should not be stressed for at least 6 weeks after spontaneous or surgical closure. Again, I recommend seeing an otolaryngologist here, preferably one with training in diving medicine.

The question of what to do on vacation always comes up when problems arise at the beginning of a vacation. After all, you don't want to miss out on the beautiful dives of your expensive vacation. This is a question everyone must answer for themselves. However, it must be remembered that it is possible to suffer permanent eardrum damage and end one's diving career.

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