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Scuba Diving: Barotrauma Injuries

Divers who understand how pressure changes affect gas-filled cavities in the body, such as the ears and lungs, use different techniques to avoid tissue injury.

This section explains how to prevent barotrauma in scuba diving, with expert tips for treatment of the barotraumas that occur most often.

Most Common Barotraumas in Scuba Diving

Important: The information in this help guide focuses on 'pressure injuries'. Another section contains more about the way that scuba diving rules comply with the official health and safety guidelines in most countries.

Some changes in barometric pressure can create medical problems as divers descend below the surface due to the increased water pressure.

Water is more dense (heavier) than air. As a result, even a small change in depth may cause significant changes in pressure underwater.

In general, experienced divers will already be familiar with the techniques used for equalising air spaces, especially when descending.

Even so, middle ear barotrauma is the most common diving injury. Yet, other lesser known pressure injuries (also called squeezes) include subconjunctival haemorrhage and aerogastria.

Barodontalgia (Dental Barotrauma)

People who fly can get aerodontalgia, also called "flyer's toothache". It happens when changes in ambient pressure cause an expansion or contraction of the air cavity beneath a tooth filling.

Likewise, scuba divers with teeth problems can get barodontalgia (tooth squeeze). Hence, tooth pain from scuba diving occurs for the same reasons - pressure changes.

Causes of Barodontalgia

  • Air pocket following a cavity repair
  • Cariosity (tooth decay that extends into the dentin)
  • Faulty dental restorations
  • Loose or broken amalgam
  • Trapped air in tooth cavities (e.g. beneath a filling)

Dental Barotrauma Symptoms

  • Bleeding
  • Broken tooth
  • Facial pain (usually while descending)
  • Sensitivity
  • Toothache

Dental Barotrauma Treatment

  • Acetaminophen
  • Analgesics
  • Dental repair
  • Ibuprofen
  • Paracetamol

Pro Tip: Use any medication as directed by the manufacturer and visit a dentist without delay. You should avoid scuba diving (or flying) until you have completely recovered.

Decompression Sickness (DCS)

There are several terms used to describe decompression sickness, including the bends scuba diving hazard and generalised barotrauma.

Simply put, DCS is a pressure change injury caused by an uncontrolled decrease in the ambient pressure of air or water.

So, when scuba divers absorb an inert gas, usually nitrogen, it eventually reaches a pressure balance inside the tissues. But, ascending 'too quickly' can make dissolved nitrogen bubbles expand as the water pressure decreases.

DCS barotrauma can affect different body parts. Usually, it will depend on the exact location of the bubbles. In short, it happens because of (either):

  • An inability to equalise pressures.
  • The effect that increased pressure has on an enclosed volume.

Typical signs and symptoms of decompression sickness will be skin rash, bubbles under the skin, joint pain, fatigue, itching, chest pain, and localised swelling.

Decompression sickness (DCS) requires immediate medical attention and often results in hospitalisation or hyperbaric oxygen treatment.

Pro Tip: Check out another section that explains why decompression sickness is called the bends and how to prevent it.

Outer Ear Squeeze

A blocked auditory canal (tube running from the outer ear to the ear drum) is a common cause of external ear barotraumas.

This kind of 'ear squeeze' happens more often when you descend. The water pressure increases and the air pocket between the tympanic membrane (ear drum) and the blockage will shrink.

Barotrauma in Scuba Diving | Causes, Symptoms and TreatmentCauses of External Ear Barotrauma

Outer Ear squeeze Symptoms

  • Alternobaric vertigo (ABV)
  • Blood coming from the ear
  • Ear pain and swelling
  • Erythema (skin redness)
  • Tympanic membrane (eardrum) bulge
  • Vacuum effect (leading to tissue damage) inside the ear canal

Treatment for Outer Ear barotrauma

In most cases, ascending to a shallower depth will fix it. But, it is important that scuba divers are familiar with alternobaric vertigo symptoms and treatment in case the condition worsens.

Mask Squeeze Facial Barotrauma

Failing to equalise the pressure in the dive mask during the descent is one of the common mistakes novice divers make, as well as some entry-level freedivers.

In fact, facial barotrauma mask squeeze can injure blood vessels and nasal tissues, especially in periorbital regions (area covered by the orbicularis oculi), and the lower forehead.

Common Cause of Face Barotrauma

  • Failing to equalise mask pressure with ambient pressure

Symptoms of Mask Squeeze

  • Bruised eyes (or red face)
  • Feeling of tightness around the face
  • Vision changes (not common)

Facial Barotrauma Treatment

  • Cease diving until the injury heals
  • See a doctor to check for bleeding if eyesight changes occur

Pro Tip: Another section contains further information about scuba diving mask squeeze with expert tips for beginners about how to prevent facial barotrauma. Do you dive in cold water? If so, you should also learn how to avoid a suit squeeze (e.g. from a tight-fitting dry suit).

Aerogastria (Gastrointestinal Barotrauma)

Sometimes, the gas that divers 'swallow' during the dive will expand as they ascend. Despite it happening most often with learner divers, the pain is usually temporary and it is not considered as being one of the life-threatening scuba injuries.

Common Causes of Aerogastria

  • Aerophagia (swallowing too much air)
  • Chewing gum during a dive
  • Consuming carbonated food and drinks
  • Distension (gas entering the stomach expands during an ascent)
  • Eating a heavy meal before diving
  • Performing the Valsalva manoeuvre in a head-down position

Gastrointestinal Barotrauma Symptoms

  • Breathing difficulties (rare)
  • Burping
  • Flatulence
  • Muscle cramps
  • Stomach pain

Treatment for Gastrointestinal Barotrauma

Inner Ear Barotrauma (Perilymph Fistula)

Significant pressure differences can damage the internal parts of the ear. It happens most often when the diver uses a poor technique for equalisation (e.g. incomplete or too forceful).

It is not uncommon for the diver to experience perilymph fistula (a leak of inner-ear fluid). Even so, recent statistics show that inner-ear trauma is less common than middle ear squeeze in diving (MEBT).

Cause of Inner-Ear Barotrauma

  • Overly forceful Valsalva manoeuvre
  • Sudden development of pressure differences between the middle and inner ear

Inner-Ear Barotrauma Symptoms

  • Deafness
  • Dizziness
  • Ear pain
  • Feeling of fullness in the ears
  • Hearing loss
  • Loss of spatial orientation
  • Nausea and vomiting
  • Nystagmus (involuntary repetitive eye twitching)
  • Tinnitus (ringing in the ears)
  • Vertigo (spinning sensation)

Treatment for Inner Ear Barotrauma

  • Avoid equalising the ears (even if you feel fullness)
  • Do not put drops in the ear canal
  • Nasal decongestant sprays may reduce mucous membrane swelling
  • To reduce vertigo, lay down, stay calm, and close your eyes

Pro Tip: Seek medical evaluation without delay. For example, an otolaryngologist will try to differentiate inner-ear barotrauma from inner-ear decompression sickness.

Middle Ear Squeeze

In fact, middle ear barotrauma (MEBT) is the most common injury in diving - according to DAN statistics.

Even though it happens most often during a descent, it can also happen while ascending, and sometimes while flying.

Cause of Middle-Ear Barotrauma

Symptoms of Middle-Ear Barotrauma

  • A feeling of discomfort in the ears
  • Buildup of fluid and bleeding in the middle ear
  • Pain (sometimes severe)
  • Ruptured eardrum

Middle-Ear Barotrauma Treatment

  • Avoid putting drops deep inside the ear canal
  • Medication to open blocked Eustachian tubes
  • Nasal decongestant sprays (e.g. anti-inflammatory drugs, mucolytic agents)
  • Refrain from diving until you get medical clearance from a specialist

As with many common scuba diving injuries, you should seek professional medical evaluation. In this case, an ENT specialist (ear, nose, and throat) may be the best choice for assessing the vestibular function.

Pro Tip: Divers with an upper respiratory infection (e.g. a cold) can also encounter a 'reverse squeeze' as they make their way back up to the surface.

Lung Squeeze (Pulmonary Barotrauma)

Pulmonary overpressurization syndrome (abbreviated to POPS) refers to a burst lung. Failing to expel some air from inside the lungs during an ascent is the common cause for this serious injury.

The gas volume expands. This can cause severe damage if divers do not exhale the excess gas. In addition, pulmonary barotrauma can also result in a pneumothorax (collapsed lung).

Even though aggressive free-divers can get a lung squeeze, very few humans can actually hold the breath long enough at depth to suffer this kind of 'air trapping' injury.

Cause of Pulmonary Barotrauma

Pulmonary barotrauma can occur if a diver holds their breath during an ascent, especially rapid or panicked uncontrolled ascents.

The gas pressure inside the lungs increases and so the likelihood of dysbarism squeeze also increases. This rise in pressure can result in a rupture, and air may also penetrate into the tissues around the lungs.

Lung Squeeze Symptoms

  • Air embolism (a sudden loss of consciousness shortly after surfacing)
  • Chest pain (e.g. after surfacing)
  • Fullness in the neck
  • Hoarseness
  • Loss of consciousness also may occur
  • Painful to swallow
  • Shortness of breath

Pulmonary Barotrauma Treatment

In most cases, the first aid treatment needed for pulmonary barotrauma results in hospitalisation. Patients will need fluid therapy and a constant supply of pure oxygen.

Paranasal Sinus Barotrauma

In fact, DAN considers a sinus squeeze as being the second most common diving condition. It can happen when divers are unable to equalise trapped inside an enclosed area as they descend.

Cause of a Sinus Squeeze

  • Anatomical deformity
  • Head cold
  • Nasal congestion
  • Nasal polyps
  • Sinusitis

Sinus Barotrauma Symptoms

  • Epistaxis (nosebleed)
  • Eye pain
  • Facial pain
  • Headache (especially in the forehead)
  • Mucus from the nose

Treatment for Sinus Barotrauma

  • Analgesics (use as directed)
  • Carotid Sinus Syndrome
  • Decongestants
  • Saline (e.g. 1.5ml of salt in 250ml of water at body temperature sniffed up the nose one nostril at a time and then spit it out)
  • Seek medical advice if the problem worsens

How to Avoid Pressure Injuries in Diving

The easiest way to avoid pressure injuries in scuba diving is to equalise the pressure in gas-filled cavities, especially the ears and the dive mask. So, to reduce the likelihood of barotrauma, you should:

Pro Tip: Avoid flying after scuba diving for the recommended periods. Check out our FAQs about in-water recompression and find out why the 'controversial' and risky technique still takes place in certain areas of the world.

Related Information and Help Guides

Important: The short tutorial video [4:55 seconds] presented by DAN contains safety tips for beginners about preventing barotraumas in the ears and sinuses.

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