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Ear perforation after scuba diving

Tympanic membrane rupture from middle-ear barotrauma - the diver who surfaces with a sudden pop, pain and a blocked, blood-streaked ear. Most heal with nothing more than dry-ear care; vertigo changes everything.

Last updated 7 Sep 2026 · ENTdiving medicinepresented same-day

GP consultation - history

The typical story: pain on descent that built despite equalising ("ear squeeze"), then a sudden pop or tear with relief of pressure - followed by reduced hearing, tinnitus and sometimes a little blood-stained discharge. Failure to equalise on descent is the mechanism: about 1.4 m down without equalising, a pressure differential over ~90 mmHg locks the eustachian tube shut, and the drum can implode at depths as shallow as 1.2 m.

Establish the mechanism and dive profile:

• Descent or ascent? Descent squeeze is the classic cause; pain on ascent (reverse squeeze) points to a blocked middle ear that usually injures without rupture.
• Depth, dive number in the series, and whether they were congested (URTI, hay fever) or using decongestants that wore off mid-dive.
• Equalisation technique and how hard they were forcing a Valsalva.
• Any cold-water caloric vertigo at the time of the pop - water flooding the middle ear through a fresh perforation causes immediate vertigo and tells you the drum breached early.

Symptoms that sort simple from sinister:

• Expected: conductive hearing loss (muffled, blocked ear), tinnitus, mild unsteadiness, small amount of blood.
• Red flags - inner ear barotrauma / perilymph fistula until proven otherwise: true rotational vertigo, sensorineural hearing loss (or fluctuating loss), sound-induced vertigo (Tullio phenomenon), nystagmus on pneumatic otoscopy (positive fistula test - but a negative test does not exclude it).
• Facial weakness suggests temporal bone injury - look for other head or neck trauma if the story includes a blow, not just pressure.

Background: previous perforations, grommets or ear surgery, chronic ear disease, and how the ear has behaved on flights. Also ask what they plan to do next - many divers intend to dive again tomorrow, and that conversation starts now.

Examination

• Otoscopy - confirm the perforation. Document location (posterior and superior perforations are more likely to involve ossicular or inner-ear injury) and size by the rule of quadrants (grade 1 = one quadrant, through to grade 4 = total loss). Note clot, blood or discharge in the canal. Do not syringe the ear.
• Tuning forks (Weber and Rinne) - the bedside discriminator. Conductive loss fits a simple perforation; anything suggesting sensorineural loss is an urgent ENT conversation. Repeat if equivocal.
• Vestibular screen if any dizziness - nystagmus, Romberg, gait. A fistula test (pneumatic otoscopy inducing vertigo or nystagmus) supports perilymph fistula but has low sensitivity.
• Cranial nerves, facial nerve in particular.
• Brief general survey for other barotrauma or decompression illness if they are unwell beyond the ear - chest, sinuses, skin, neurology.

Investigations

• Most patients need nothing acutely - this is a clinical diagnosis.
• Audiogram: urgent if tuning forks suggest SNHL, the tests are equivocal, there is any suspicion of perilymph fistula, a single hearing ear, or a posterior-superior perforation. For a simple, small central perforation, arrange one within about a week as a baseline and to document recovery.
• Imaging: confirmed SNHL on audiogram plus clinical suspicion of fistula warrants an urgent thin-slice CT temporal bones - after discussion with ENT, and that decision belongs to them.
• Microscopy, culture and sensitivity of any discharge before antibiotics, where practical.

Treatment plan

Keep the ear dry - the single most important instruction. No swimming and no diving. Shower with a cotton-wool plug coated in petroleum jelly. Nothing goes in the ear canal unless prescribed.

Analgesia: paracetamol or an NSAID is usually enough; the worst pain resolves at the moment of rupture.

Antibiotics - most need none:

• Simple, clean central perforation: no antibiotic, no drops. Most traumatic perforations heal spontaneously over weeks.
• Dirty or contaminated-water injury - and seawater that entered the middle ear through the perforation counts as contaminated: ciprofloxacin 0.3% ear drops, 5 drops twice daily, until the middle ear has been discharge-free for 3 days. Quinolone drops are non-ototoxic and safe with an open drum.
• Discharge suggesting middle-ear infection: MCS plus micro-suction where available, ciprofloxacin drops as above and amoxicillin 500 mg orally three times daily for 5 days. No response in 48-72 hours (think Haemophilus influenzae or Moraxella catarrhalis): switch to amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days. Penicillin allergy: cefuroxime 500 mg twice daily (delayed, non-severe) or trimethoprim-sulfamethoxazole 160/800 mg twice daily (immediate or severe), each for 5 days.
• Avoid aminoglycoside drops (neomycin, framycetin, gentamicin combinations such as Sofradex/Otocomb) in any ear with a perforation - ototoxic with an open middle ear.

While it heals: no forceful nose blowing and no Valsalva; treat nasal congestion (saline, short-course topical decongestant) if it contributed. Most perforations close within 1-2 months.

Refer and escalate:

• Same day, to ED/ENT: vertigo, sensorineural or fluctuating hearing loss, positive fistula test, facial weakness - perilymph fistula is a surgical emergency (admission, possible exploratory tympanotomy). Confirmed SNHL with a perforation is managed with a high-dose weaning prednisolone regimen under specialist direction.
• Routine ENT / otology clinic: perforation persisting beyond about 4 months in an adult (surgery - myringoplasty - is then indicated), or persisting conductive loss at around 2 months (suggests ossicular chain disruption). Posterior perforation or equivocal fistula features with reassuring forks: admit for observation and audiogram rather than send home.
• GP follow-up: review with audiogram at about one week, then recheck the drum until closure is documented.

Return to diving: not until the drum is fully healed and the eustachian tube demonstrably equalises - typically around three months for a healed perforation, and at least three months after tympanoplasty, which is an ENT decision with formal testing of equalisation. Point the keen diver to a diving-medicine assessment (Divers Alert Network or a SPUMS-trained doctor) before they get back in the water, and use the consult to coach equalisation: never dive congested, equalise early and often, and abort the dive at the first ear squeeze rather than forcing through it.

References and guidelines

• RACGP AJGP: Diving-related otological injuries: initial assessment and management (August 2020) - fistula testing, inner-ear barotrauma vs DCS, return-to-diving intervals
• Royal Victorian Eye and Ear Hospital: Traumatic Tympanic Membrane Perforation - Clinical Practice Guideline (CPG v2.0, approved 2019, published 2021 - dated, but still the current posted version; source of the antibiotic regimens, red flags, grading, audiogram/CT criteria and follow-up intervals)
• Divers Alert Network: Tympanic Membrane Rupture (Perforated Eardrum) and Ears and Diving - Injuries (2020 - first aid, fitness-to-dive guidance)
• MSD Manual Professional: Traumatic Perforation of the Tympanic Membrane (reviewed 2026 - contaminated-injury drop prophylaxis, aminoglycoside-drop ototoxicity warning)
• Livingstone and Smith: Scuba diving and otology: a systematic review (Diving Hyperb Med, 2017 - pressure-differential and shallow-depth rupture figures)
• All sources above reviewed 7 Sep 2026.
• Therapeutic Guidelines (eTG): Otolaryngology - perforated tympanic membrane; confirm current antibiotic recommendations before prescribing
• Local: Gold Coast HealthPathways (ENT referral criteria); SPUMS diving-medicine doctors for fitness-to-dive assessment