6-2
Assessment:
Differential Diagnosis
External ear barotrauma - swimmer’s ear
Middle ear barotrauma - viral/bacterial ear infection, URI
Inner ear barotrauma - tertiary syphilis, Meniere’s disease, Arterial Gas Embolism, inner ear decompression
sickness.
Plan:
Treatment
External ear barotrauma: Avoid plugs and hoods while diving. Remove from dive status until ear is healed.
Keep ear dry. Clean ear of any obstructions. If infection sets in, treat as external otitis (swimmer’s ear)
with Cortisporin otic drops.
Middle ear barotrauma: Remove from dive status until asymptomatic. Use nasal decongestants (i.e., Afrin)
for no more than 5 days or systemic decongestants. Do not use any eardrops if TM is ruptured. Avoid exertion
and all swimming while TM is healing.
Inner ear barotrauma: Remove patient from water and continuously monitor until evaluated by Diving
Medical Officer (DMO) or ENT physician (within 72 hrs). Maintain strict bed rest with head slightly elevated.
Avoid straining or Valsalva. Do not allow flying until injury is fully healed. Obtain immediate consult with
ENT if diver has persistent vertigo and ataxia. A round window or oval window rupture causes permanent
disqualification from military diving.
Patient Education
General: Pressure can greatly affect the sensitive tissues in the ear. Time away from pressure is usually
enough to allow the ears to heal.
Diet: Normal
Medications: Topical decongestants like Afrin should be not taken for more than 5 days continuously due to
rebound effect. Do not use topical eardrops when there is a chance the TM is ruptured.
Prevention and Hygiene: Avoid diving hoods, equalize ears often, avoid forceful Valsalva.
No Improvement/Deterioration: Consult ENT or DMO.
Follow-up Actions
Return evaluation: Weekly until healed.
Consultation Criteria: Patients with persistent vertigo, loss or significant decrease in hearing, non-healing TM
rupture, large TM rupture, or foreign body stuck in EAC should be referred to ENT.
TEED CLASSIFICATION
Grade Clinical description Expected Healing Time
TEED 0 Symptoms without otoscopic signs May dive same day
TEED 1 Diffuse redness and retractions of the tympanic membrane 1-2 days
TEED 2 Grade 1 plus slight hemorrhage within the tympanic membrane 1-4 days
TEED 3 Grade 1 plus gross hemorrhage within the tympanic membrane 3-7 days
TEED 4 Dark and slightly bulging tympanic membrane due to free blood in the
middle ear; a fluid level may be visualized behind the tympanic membrane 5-12 days
TEED 5 Free hemorrhage into the middle ear with tympanic membrane perforation 7-15 days. Perforation
must be totally healed
before diving again.
References: Bove, Alfred A., Bove and Davis’ Diving Medicine, 3rd Edition, WB Sauders Company, Philadel-
phia, 1997, pp. 241.