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Bilateral Hemotympanum in a Pair of Scuba Divers

Esala, Nicolai DO; Busey, Sharon L. MD

doi: 10.1249/JSR.0b013e3182a4b960
Sport-Specific Illness and Injury: Case Report

1Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI; 2Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI; and 3Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI

Address for correspondence: Nicolai Esala, DO, Medical College of Wisconsin, Milwaukee, WI; E-mail:

Two divers with mostly warm water experience took a dive vacation in Baja, CA, as part of a diving group. Both divers had well over 100 dives of experience. There was no significant medical history in diver A, whereas diver B had a history of breast cancer. There was no prescription or over-the-counter medication use in either. The water conditions at the dive sites included significant surge and current, poor visibility, and water temperatures (°F) in the mid 60s to lower 70s. This was a once a year boat diving trip for the two, so they underwent the dive despite the conditions. The colder water resulted in the divers wearing 7-mm full neoprene wetsuits over their usual 3-mm wetsuits to stay warm. Because of the increased buoyancy from their wetsuits, the divers were forced to wear more lead on their weight belts than they were accustomed to (20 lb of lead instead of her typical 12 lb for diver A and 18 lb instead of his typical 8 lb for diver B). Air was used as their gas mix. The divers found that the descents were challenging due to the surge, current, and poor visibility, which essentially prohibited a slow descent. Diver A opted to turn head down and kick several feet to overcome the surge and current. During her descent, she experienced an abrupt onset of bilateral ear pain (7 on a 10-point pain scale). She continued the dive for 41 min, reaching a maximum depth of 100 ft. Upon ascent, she experienced some relief (but not full resolution) of the pain. She continued to dive over the next three consecutive days and experienced an increase in the pain during each dive, but overall, of a lesser acuity than on the day of injury (approximately 5 of 10). Symptoms between dives were approximately 2 out of 10 on the pain scale, with a sensation of fullness. She experienced mild discomfort on the flight home 3 d after the injury. Four days after the injury, her examination showed bilateral tympanic membranes (TM) bulging with blood-tinged serous effusions. The pain diminished quickly, although the sensation of fullness lasted approximately 1 wk. An examination 13 d after the injury revealed essentially normal TM.

The day after diver A developed symptoms, diver B experienced the onset of pain in his left ear during a descent on a dive under similarly difficult conditions. He experienced difficulty equalizing his ears and subsequently descended slower than most of the divers. He completed the 40-min dive with a maximum depth of 51 ft. The left ear pain continued (approximately 4 out of 10) throughout the dive; upon ascent, he experienced moderate relief. The following day, he attempted a descent but aborted the dive due to being unable to equalize his left ear. Two days later, he flew home and he experienced ear pain and pressure in both ears and crackling sensation in his left > right ear. Upon examination the following day (7 d after the injury), his left TM was bulging with serosanguineous fluid (Fig.); his right TM appeared to have a slightly blood-tinged effusion behind it. Ten days after the injury, his symptoms were diminished significantly and his left TM was no longer bulging; both TM still had effusions, which appeared to be resolving. Fourteen days after the injury, his TM appeared normal and he was asymptomatic. Neither diver experienced any long-term problems.

Figure. Dive

Figure. Dive

The recent growth and popularity of scuba diving have led to an increase in diving-related injuries. Common dive injuries include injuries related to the equipment or environment such as injuries from hazardous marine life, breathing gas-related problems, and barotrauma. Barotrauma is defined as tissue damage resulting from the direct effects of pressure. It may occur with altitude changes, such as occurs while flying, scuba diving, or travelling in the mountains. Barotrauma affects air-containing areas, including lungs, ears, sinuses, and gastrointestinal tract. It occurs in scuba divers due to the differences between internal physiologic pressure levels and pressure levels in the water surrounding the diver. For a diver to avoid barotrauma, the pressure in these air-filled spaces must be equalized to ambient pressure; otherwise, as the diver descends, the surrounding hyperbaric pressure forces blood and tissue fluids into the air-filled spaces until ambient pressure is equalized. Equalizing pressure early and often is an important preventive safety measure as a person dives.

Typically divers experience ear fullness and pressure exclusively during their descent. This is due to the failure to open actively the normally closed eustachian tube. To equalize, most divers mechanically open their eustachian tubes by using a Valsalva maneuver, jaw thrust, or swallowing. In contrast, during ascent, expansion of the air in the middle ear in response to dropping external pressure opens the eustachian tube, which results in passive equalization of the middle ear. Inexperienced divers may increase their risk of experiencing barotrauma when they continue to descend despite ear pressure and pain. Attempts to equalize pressure in the ears at this time are often ineffective because the eustachian tubes irreversibly block with a pressure differential of 90 mm Hg, which is equivalent to the pressure at a depth of 4.5 ft. Descending too quickly because of overweighting or to escape strong surface currents also places divers at increased risk. Avoiding barotrauma by diving at a shallow depth is not helpful, because the greatest change in volume — and therefore the most difficult time to equalize pressures — occurs near the water’s surface. Indeed the TM may rupture in as little as 4 ft of water if pressure is not equalized (4).

Middle ear barotrauma is the most common barotraumatic otologic injury and has been experienced by virtually all divers to some extent. If pressure is not equilibrated, middle ear hemorrhage or TM rupture may occur. Inflow of cold water to the inner ear may result in vertigo, nausea, and disorientation while submerged, with potentially fatal consequences. Injury to the middle ear may be as mild as minimal edema of the middle ear mucosa (manifested as “stuffy ears” after the dive) or hemorrhagic streaking along the manubrium of the malleus. At the other extreme, the middle ear may fill with blood or the TM may rupture. Teed’s classification of middle ear barotrauma (5) is as follows:

Grade 0: no visible damage, normal ear

Grade 1: congestion around the umbo

Grade 2: congestion of the entire TM

Grade 3: hemorrhage in the middle ear

Grade 4: extensive middle ear hemorrhage with blood bubbles visible behind the TM

Grade 5: entire middle ear is filled with dark blood

Hemotympanum is defined as the presence of blood in the middle ear canal. It can have many causes, including temporal bone fractures, barotrauma, hematologic disorders, and/or use of anticoagulants. On examination of the ear, the TM may show congestion, hemotympanum, and lack of mobility during air insufflation with a pneumatic otoscope; conductive hearing loss is usually present as well (3).

Treatment is generally conservative for hemotympanum resulting from barotrauma. Routine use of antibiotic agents and oral or topical nasal decongestants has not shown to be useful (1). Most ear perforations heal spontaneously, and diving may be resumed after the middle ear contusion or TM perforation has healed. Pain can be controlled with nonsteroidal anti-inflammatory drugs or opioids. For middle ear barotrauma, some physicians also advocate a short course of oral corticosteroids. Referral to an otolaryngologist is indicated for severe or persistent symptoms. Surgery (e.g., tympanotomy for direct repair of a ruptured round or oval window, myringotomy to drain fluid from the middle ear, and sinus decompression) may be necessary for serious inner ear, middle ear, or sinus injuries. Some studies have shown that the use of an oral decongestant before diving can decrease the incidence and severity of middle ear squeeze in novice divers (2).

Physicians need to be aware of problems that divers may present with, because no matter where they practice, many scuba divers will present with problems after they return home. In fact, some problems may be triggered actually by the flight home since airplanes are typically pressured only equal to 8000 ft. Some problems such as the hemotympanum that occurred in these divers may be self-resolving and only a mild irritation. Other more serious problems such as decompression illness may lead to serious chronic problems and, in some cases, be life threatening.

The authors declare no conflicts of interest and do not have any financial disclosures.

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Copyright © 2013 by the American College of Sports Medicine.