Diving-related ear, nose, and throat disorders: a structured review using a phase-of-dive framework

The aim of this review was to synthesise evidence on ear, nose, and throat (ENT) and related head and neck complications in scuba divers, with emphasis on mechanisms of injury, dive phase-specific risk patterns, and implications for clinical management and fitness-to-dive decision-making.

A structured literature search of PubMed, Embase (Ovid), and the Cochrane Library identified systematic reviews, clinical trials, cohort studies, and case series reporting clinically relevant ENT outcomes in scuba divers. Animal studies, freediving studies, and papers focused solely on non-ENT complications were excluded. Forty analytic studies met inclusion criteria, including large cross-sectional surveys and multiple case series of inner ear decompression sickness. Study characteristics and levels of evidence were summarised, and findings were integrated into a phase-of-dive framework (descent, bottom time, ascent).

Across included studies, middle-ear barotrauma was the most prevalent diving-related ENT injury, particularly during descent. Inner ear barotrauma and inner ear decompression sickness were less common but carried a substantially higher risk of persistent auditory or vestibular deficit. Additional reported conditions included sinus barotrauma, otitis externa and external auditory canal exostoses, temporomandibular joint symptoms, odontobarotrauma, and marine-exposure injuries. Evidence concerning postoperative states, following operations such as stapedectomy, tympanoplasty, mastoidectomy, and cochlear implantation, was limited, heterogeneous, and often contradictory, with few data to guide return-to-dive clearance.

Scuba diving-related ENT complications appear to be diverse, influenced by dive phase, and shaped by individual anatomical and physiological factors. A phase-aware framework offers clinicians a useful way to contextualise symptom onset and guide prevention and counselling, particularly for divers with prior ear or nasal surgery or implanted devices. Prospective studies are needed to refine screening practices and establish evidence-based return-to-dive recommendations.