Ear Barotrauma vs Swimmer's Ear: Symptoms, Urgency, Diving Again

Barotrauma or swimmer's ear: how to tell them apart

Barotrauma is a pressure injury and swimmer's ear is an infection, so timing gives most of it away. Barotrauma follows a pressure change your ears could not match, usually on descent, and you feel it during the dive or soon after. Swimmer's ear (acute otitis externa) is a bacterial infection of the skin lining the ear canal. It develops when the canal stays wet for long periods, which is why DAN links it to repetitive, multi-day diving.

The most useful clue for swimmer's ear is pain when you tug the outer ear or press the small flap in front of the canal (the tragus). CDC and StatPearls both list it. Middle ear barotrauma starts differently, as fullness or a clogged feeling on descent that can progress to pain. Inner ear barotrauma adds vertigo, ringing and hearing loss.

This page summarises what DAN and the medical literature say. It is not medical advice. Several of these conditions look alike from the outside, and an ear problem after diving needs a doctor to look inside the ear. More on staying safe in the water is in our safety guides.

Middle ear barotrauma: what to do after the dive

Stop diving and keep everything out of the ear. DAN's first aid for ear fullness after a dive is to abstain from further diving and use a nasal decongestant spray or drops, which can shrink the swelling around the Eustachian tube and help the middle ear drain. Nothing goes into the ear canal itself. See a doctor if fluid or blood comes out of the ear, or if the pain and fullness last more than a few hours.

This is the injury most divers will meet. StatPearls calls Eustachian tube dysfunction and middle ear barotrauma the most common complications of diving, with reported rates between 4.1% and 82% depending on the study. Most minor cases heal quickly and without fuss. A perforated eardrum or an inner ear injury can take weeks or months.

It can also happen on the way up. Fluid and swelling left by a squeeze on descent can block the tube, so the expanding air cannot get out: a reverse block. If one ear vents and the other does not, the imbalance can spin the room for a moment. DAN calls this alternobaric vertigo, says up to 25% of divers experience it at some time, and notes that uncomplicated cases clear within minutes of surfacing.

Preventing the squeeze comes down to technique and timing, covered step by step in our guide to equalizing your ears.

Inner ear barotrauma and why vertigo changes the picture

Inner ear barotrauma is the one that can cost you hearing or balance for good, and it looks almost the same as inner ear decompression sickness, which needs the opposite treatment. That combination is why vertigo after a dive always goes to a doctor.

The inner ear is fluid-filled and sits behind two thin membranes, the oval and round windows. A forceful Valsalva against a blocked tube raises the pressure of the fluid around the brain, and that pressure reaches the inner ear. The round window can tear and inner ear fluid leaks out, a perilymph fistula. DAN notes that when the middle ear is properly equalized, the risk of inner ear barotrauma is extremely low.

DAN lists severe vertigo, involuntary eye movements (nystagmus), ringing, a full ear and hearing loss, usually with the signs of a middle ear squeeze as well. The vertigo tends to bring nausea and vomiting. Hearing loss often affects only the high frequencies and may only be noticed hours later, or on a hearing test. The 2017 otology review adds that the eardrum can look normal and that a delay between the dive and the symptoms does not rule the diagnosis out.

The treatments conflict. Decompression sickness is treated in a recompression chamber, while DAN says recompression or any pressure change is contraindicated when inner ear barotrauma is likely. Barotrauma usually follows a failed equalization early in the dive. Inner ear DCS follows the ascent: the 2017 review gives vertigo within about two hours of surfacing, a higher risk on deep heliox and trimix dives, and a stark number on delay. When treatment of inner ear DCS starts more than 5 hours late, about 90% of divers can expect some permanent inner ear damage.

Until a doctor has seen you, DAN advises avoiding exertion, equalizing, altitude, diving, sneezing and nose blowing, and not taking aspirin or other drugs that widen blood vessels or thin the blood. If decompression sickness is possible, start oxygen and follow the steps in our DCS first aid guide.

Warning signs that need urgent care

Get medical help the same day, or call emergency services, for any of the signs below. DAN calls vertigo, ringing and sudden deafness the most alarming ear symptoms after diving, because they can mean inner ear barotrauma or decompression sickness. DAN's emergency line is +1-919-684-9111.

• Vertigo, meaning the room spins, that persists after the dive. DAN says severe persistent vertigo after diving is an emergency.
• Vertigo with nausea, vomiting or jerky eye movements.
• Sudden hearing loss or new ringing in one ear. StatPearls advises referral to an ear, nose and throat (ENT) specialist for any sensorineural hearing loss or new vertigo after a pressure change.
• Ear symptoms together with any other possible sign of decompression sickness. Give oxygen and call for help rather than waiting to see.
• Fluid or blood draining from the ear, or pain and fullness lasting more than a few hours. DAN's advice here is a physician evaluation rather than emergency care.
• Swimmer's ear with fever, swelling that spreads to the glands around the ear, or pain when you move your jaw.
• Any swimmer's ear if you have diabetes or take drugs that suppress the immune system. DAN says it can cause severe problems that need immediate attention, and StatPearls describes a life-threatening spreading form, necrotizing otitis externa, seen mostly in older people with diabetes.

Swimmer's ear on dive trips: causes and treatment

Divers get swimmer's ear a lot. The 2017 systematic review in Diving and Hyperbaric Medicine calls otitis externa the most common ear disorder among divers, affecting nearly half of active divers at least once. StatPearls says swimming alone makes it five times more likely.

The canal protects itself with earwax, which keeps the skin slightly acidic. DAN describes what repeated immersion does: water swells the cells lining the canal until bacteria that normally live on the surface can get into the skin, where they find a warm place to multiply. Scratched skin, cotton swabs, over-cleaning of wax, eczema and a narrow canal all make it easier. Pseudomonas aeruginosa is the most common culprit in divers.

It starts with itching, then pain that gets worse when the outer ear is moved, sometimes with discharge, a full feeling and muffled hearing. In a severe case the canal swells shut and the pain is intense.

Treatment is prescription antibiotic ear drops, often combined with a steroid, plus pain relief. StatPearls expects an uncomplicated case to improve within 48 hours of starting drops and advises a recheck if the pain has not improved in 48-72 hours. With any drop, 65-90% of cases clear within 7-10 days. Antibiotic tablets are kept for specific situations. If the eardrum might be perforated, some common drops are avoided because they can harm the inner ear, one more reason to let a doctor look first.

How to prevent swimmer's ear while diving

Keep the canal clean, dry and undamaged between dives. These are the steps DAN, CDC and the 2017 review describe. DAN also says that most divers do not need ear drops after diving; they make most sense for divers who keep getting infections.

• Rinse both ears gently with fresh water after each dive to flush out salt and contaminated water.
• Drain and dry: tilt your head so each ear faces down, pull the earlobe in different directions, then towel dry.
• If water stays trapped, use a hair dryer on its lowest setting. DAN says to hold it at least 0.3 m (1 ft) away; CDC says several inches. Either way, the air must not be hot.
• Use drying drops only if you know your eardrum is intact, and ask your doctor about alcohol-based drops first. DAN's homemade mix is one part white vinegar to one part rubbing alcohol: five drops in each ear at the end of each dive day, left for five minutes, then drained. Over-the-counter drops use similar ingredients, such as acetic acid and isopropyl alcohol.
• Leave earwax alone and keep cotton swabs and fingertips out of the canal. Wax protects the skin, and scratches let bacteria in. DAN's medics put it as "don't put anything smaller than your elbow in your ear."
• Don't dive in standard earplugs. CDC suggests earplugs for swimmers, but DAN says solid plugs trap an air space that cannot be equalized and can be pushed into the canal, and that vented diving plugs have not been independently tested.
• Wear a hood in cold water. Years of cold exposure make the bony canal wall grow (exostoses, or surfer's ear), and the narrowed canal holds water and gets infected more easily.
• If you have had swimmer's ear before and are heading somewhere remote, ask your doctor whether to carry prescription drops. The 2017 review suggests it.

When can you dive again after an ear injury?

When a doctor has examined the ear and says it has healed. None of these sources gives a fixed number of days for middle ear barotrauma. They tie the return to a normal examination and working Eustachian tubes, and StatPearls puts the rule plainly: no further pressure exposure until the symptoms are gone and the eardrum looks normal.

For inner ear barotrauma, the advice has softened a little. Divers were often told to stop for good, and the 2017 review calls that possibly unnecessarily restrictive. It cites 21 divers who kept diving after inner ear barotrauma, against medical advice, with no further loss of inner ear function over 1-12 years. Its conditions for a return include hearing loss that is stable and limited to a narrow band of frequencies, no vertigo or imbalance, and dealing with whatever made equalizing hard in the first place.

On a trip the real cost is counted in days. DAN's advice when an ear won't clear after a few attempts is to end the dive, because pushing on can cause an injury that stops you diving for the rest of the week.