The human body is well adapted to dealing with small variations in atmospheric pressure. However when our pursuit of sport and recreation takes us to extreme altitudes or ocean depths, the change in surrounding pressure has the potential to cause significant morbidity. Sports with more extreme changes in atmospheric pressure such as skydiving and scuba diving commonly place the athlete at risk for barotrauma injuries, especially in the middle ear and sinuses. Middle ear barotrauma occurs when a pressure differential develops between the middle ear and the pressure outside of the tympanic membrane. Early symptoms include ear pain, dizziness, and muffled hearing. When extreme pressure gradients are not relieved, middle ear effusions and rupture of the tympanic membrane can occur. A similar mechanism and injury pattern occurs in the sinuses as well. With proper training and prevention strategies, athletes in these sports can protect themselves from most barotrauma injuries.