Barotrauma: one of the most common injury in diving. Whether you are a scuba diver, free diver, or snorkeler (skindiver), you can experience Barotrauma because water pressure is denser. It is also easily preventable.
Barotrauma occurs when a part of the body experiences damage due to pressure differences between the inside and outside of an air space. That is why Equalization is one of the first skills we teach you before going underwater in confined open water or in the shallows near the shore.
Water Pressure causes injury in diving
According to DAN, Water pressure increases faster than air pressure because it has more weight packed into the same space. Even just a few meters below the surface, water exerts a lot of pressure on your body because you’re carrying the weight of all the water above you.
While this might sound technical, the concept is quite simple: as a diver descends or ascends in the water, the surrounding pressure changes. The body must adjust to this, particularly in air-filled spaces like the ears, sinuses, and lungs. When these adjustments fail or happen too slowly, tissue can become stretched, damaged, or even ruptured. That’s barotrauma.
Many new divers first encounter barotrauma injury in diving, as ear pain during descent. As you go deeper underwater, the pressure increases quickly—about one atmosphere for every 10 meters (33 feet). Your middle ears are air-filled cavities located behind your eardrums, and they don’t automatically equalize pressure.
Middle ear barotrauma,
The most frequent form of barotrauma in diving. The middle ear is the air-filled space behind the eardrum that includes the Eustachian tube and ossicles (tiny bones for hearing).If you forget to equalize or do it too late, the external pressure can force your eardrums inward, causing pain and possibly damaging the delicate ear tissues.
Very common and usually mild to moderate injury in diving. Most cases heal on their own with rest and no further diving until recovery.
Symptoms:
Usually no dizziness
Pain or pressure in the ear during descent
Muffled hearing or temporary hearing loss
A feeling of fullness
Fluid or blood in the ear canal (if severe)
🛡️ How to Prevent Middle Ear Barotrauma injury in diving
- Equalize early and often – Start equalizing before you even feel discomfort. Do it every few feet during descent.
- Descend slowly and feet-first – This helps the Eustachian tubes open more easily.
- Never dive with congestion – A blocked nose or sinuses makes equalization difficult or impossible.
- Use proper equalization techniques – The Valsalva (pinch-and-blow), Toynbee (pinch and swallow), or Frenzel methods can all work—find what suits you.
- Abort the dive if necessary – If you can’t equalize despite trying, it’s better to cancel the dive than risk injury.
🩺 What to Do If You Suspect Barotrauma
If you feel pain that lasts after diving, or experience muffled hearing, fullness, or dizziness, consult a doctor—preferably one with experience in diving medicine. Most mild cases resolve on their own, but more serious cases may need treatment like antibiotics or rest from diving. Never dive again until your ears are fully healed and cleared by a medical professional.
🌬️ Final Thoughts
Middle ear barotrauma is preventable with good habits and body awareness. Equalizing is a basic skill, but it’s one of the most important techniques you’ll ever learn as a diver. Take the time to master it, and you’ll avoid pain, injury, and missed dives in the future.
Inner ear barotrauma
The inner ear injury in diving includes the cochlea (hearing) and vestibular canals (balance). This part of the ear is filled with fluid and tiny hair cells and is very delicate.Usually happens when a diver equalizes too forcefully, especially with a blocked Eustachian tube. The pressure surge can rupture a membrane (round or oval window) between the middle and inner ear. It can also occur during a rapid descent or ascent with poor technique.
Rare but serious. May cause permanent hearing loss or balance issues if not treated promptly. Requires immediate medical attention, often from a dive medicine specialist or ENT.
Symptoms:
Often no outer or middle ear pain
Sudden vertigo (the world spins around you)
Hearing loss in one ear
Ringing (tinnitus)
Nausea and vomiting (due to balance disturbance)
🛡️ How to Prevent Inner Ear Barotrauma injury in diving
- Equalize early and often – Start equalizing before you even feel discomfort. Do it every few feet during descent.
- Be alert for Sudden Vertigo, Ringing in the ears, Muffled hearing, Feeling “off-balance” after equalization -If these occur, end the dive immediately and seek medical attention, preferably from a diving ENT specialist.
- Don’t Equalize When It’s Not Working– If your ears don’t clear easily within a few attempts, stop descending. Ascend slightly, try again gently. Forcing air against a blocked Eustachian tube increases the risk of round window rupture—a classic cause of inner ear barotrauma.
- Descend slowly and feet-first – This helps the Eustachian tubes open more easily.
- Never dive with congestion – A blocked nose or sinuses makes equalization difficult or impossible.
- Use proper equalization techniques – The Valsalva (pinch-and-blow), Toynbee (pinch and swallow), or Frenzel methods can all work—find what suits you.
- Abort the dive if necessary – If you can’t equalize despite trying, it’s better to cancel the dive than risk injury.
🩺 What to Do If You Suspect Barotrauma
This is a serious injury that requires medical attention and rest from diving. In extreme cases, especially if you descend too fast or try to equalize forcefully, the inner ear may be affected. This can lead to, which impacts your balance and hearing. Signs include ringing in the ears (tinnitus), dizziness, and even temporary or permanent hearing loss.
🌬️ Final Thoughts
The key to preventing inner ear barotrauma is being gentle, patient, and attentive with your equalization. Respect your limits, prioritize safety, and never force it—your hearing and balance depend on it.
Sinus barotrauma
Another common barotrauma issue, particularly for divers who dive with a cold or allergies. Your sinuses are air-filled cavities in your skull, connected to your nasal passages. If the passages are swollen or blocked, the air can’t move freely to equalize pressure during descent. As pressure builds, tissues inside the sinuses can become inflamed or damaged. Divers often describe this as a sharp pain in the forehead, cheeks, or around the eyes. Sometimes, blood-tinged mucus may come out of the nose after a dive. Although less dramatic than ear injuries, sinus barotrauma can be painful and should not be ignored.
Symptoms
- Sharp or stabbing facial pain during descent or ascent (often around the cheeks, eyes, forehead, or nose)
- Persistent headache after a dive
- Nosebleeds during or after diving
- A feeling of fullness or pressure in the face
- Bloody or discolored mucus when blowing the nose
- In some cases, pain radiates to the upper teeth or jaw
Symptoms usually affect one side more than the other and often appear suddenly during descent.
🛡️ How to Prevent Sinus Barotrauma
✅ 1. Never Dive Congested
If you’re feeling even mildly stuffy or have sinus issues, skip the dive. Even mild congestion can block sinus openings and put you at risk.
✅ 2. Use a Saline Spray or Rinse Before Diving
A gentle saline spray or rinse (like a neti pot) before your dive can help clear mucus and reduce inflammation naturally.
✅ 3. Equalize Early and Often
While you can’t actively equalize your sinuses like your ears, descending slowly and equalizing your ears helps maintain overall pressure balance in your head.
✅ 4. Stay Hydrated and Breathe Gently
Dry sinuses are more prone to irritation. Staying hydrated helps keep the mucus membranes functioning. Avoid aggressive nose-blowing or forceful breathing through the mask.
✅ 5. Avoid Smoking and Polluted Environments
Smoke, dust, and pollutants irritate the sinus lining and narrow the passages, increasing your risk of blockage and barotrauma.
🩺 What To Do If You Suspect Sinus Barotrauma
- Stop diving for the day and rest.
- Avoid diving again until symptoms fully resolve.
- Use over-the-counter pain relief if needed.
- Mild cases heal on their own, but if symptoms (especially facial pain, nosebleeds, or sinus pressure) persist for more than a few days, consult a doctor—preferably one with experience in dive medicine.
In some cases, sinus infections can follow barotrauma if blood or fluid becomes trapped inside the sinus cavity. This may require antibiotics or further treatment.
🌬️ Final Thoughts
Sinus barotrauma is uncomfortable and entirely avoidable. By diving only when you’re healthy, descending slowly, and taking care of your airways, you can protect your sinuses and enjoy a much more comfortable and safe dive. When in doubt, remember: if you can’t breathe clearly through both sides of your nose, you probably shouldn’t be diving that day.
Pulmonary Barotrauma
The most serious and potentially life-threatening type of barotrauma. Scuba Divers call it Lung overexpansion injury. This typically occurs during ascent, especially if a scuba diver holds their breath.
According to Boyle’s Law, the volume of gas increases as pressure decreases. So, as a diver ascends and the pressure drops, the air in the lungs expands. If the diver doesn’t exhale, this expanding air can overinflate and rupture the delicate alveoli (air sacs) in the lungs. This can lead to pneumothorax (collapsed lung), mediastinal emphysema (air trapped in the chest), or worse, arterial gas embolism (AGE)—where air bubbles enter the bloodstream and block blood flow to the brain or heart. Symptoms of pulmonary barotrauma or AGE include chest pain, difficulty breathing, coughing up blood, numbness, confusion, or even unconsciousness shortly after surfacing. These are medical emergencies that require immediate treatment in a hyperbaric chamber.
In freediving, this type of barotrauma is rare but can occur in extreme situations, like if a diver traps air in the lungs (e.g., during aggressive reverse packing) and forcefully exhales at depth or near the surface, disrupting lung tissue. Unlike scuba divers, freedivers don’t breathe underwater—but their lungs still compress and re-expand during the dive. The maximum depth a person can reach safely depends on lung flexibility and how well they adapt to increasing pressure.
At extreme depths, the lungs compress to a very small volume. If that volume goes below the body’s residual lung volume (the air left in your lungs after exhaling fully), soft tissue can be pulled into the lungs, leading to bleeding or other injuries.
Here’s a side-by-side comparison of lung overexpansion injuries in scuba vs. freediving, showing how and why they differ. These injuries are rare but very serious—and often misunderstood because the mechanics of breathing in each activity are so different.
⚖️ Key Differences: Lung Overexpansion in Scuba vs. Freediving
| Aspect | Scuba Diving | Freediving |
|---|---|---|
| Air Source | High if the diver holds their their breath during ascent | Single breath at surface (no air intake underwater) |
| Risk of Overexpansion | Overexpansion is possible if diver traps extra air (e.g., reverse packing) and exhales forcefully or ascends too rapidly | Very rare, but possible in extreme cases (e.g., reverse packing) |
| Cause | Lung overexpands due to air expansion during ascent when breath is held | Lungs compress during descent, and re-expand naturally during ascent |
| Main Risk Scenario | Holding breath during ascent | Aggressive reverse packing, poor technique, or extreme depths |
| Pressure Behavior | Air at depth is compressed; as you ascend, it expands | Coughing blood, chest tightness, fatigue, possibly after a deep dive |
| Common Injury Result | Pulmonary barotrauma: alveolar rupture, pneumothorax, arterial gas embolism | Rare cases of lung squeeze or capillary rupture, sometimes misinterpreted |
| Warning Signs | Chest pain, shortness of breath, coughing blood, dizziness, unconsciousness | Rare, but it can lead to serious complications if lung trauma occurs |
| Fatal Risk | Yes—air embolism can lead to stroke, unconsciousness, or death | Rare, but can lead to serious complications if lung trauma occurs |
| Prevention | Never hold your breath while ascending; ascend slowly and continuously breathe | Avoid reverse packing unless well-trained; progress slowly in depth |
| Training Emphasis | Breathing continuously during ascent is a core safety rule | Flexibility, diaphragm conditioning, and avoiding advanced techniques too early |
🔵 Summary:
- In scuba diving, lung overexpansion is a top cause of fatal accidents and is entirely preventable by breathing continuously and ascending slowly.
- In freediving, the risk is very low because divers are not inhaling compressed air at depth. But extreme breath manipulation techniques (like reverse packing) or poor lung flexibility at depth can potentially lead to lung injury or minor overexpansion effects.
🛡️ Prevention Tips
For Scuba Divers:
- Never hold your breath while ascending.
- Ascend slowly (no faster than 18 meters/60 feet per minute).
- Always exhale gently if you feel overinflated.
For Freedivers:
- Avoid advanced techniques like reverse packing unless professionally trained.
- Train flexibility in your diaphragm and intercostal muscles.
- Progress to deeper dives slowly and with supervision.
THE GOOD NEWS
Fortunately, barotrauma is almost always preventable. The most effective way to avoid ear and sinus barotrauma is to equalize early and often during descent. Start equalizing as soon as your head is underwater—before you even feel pressure. Continue equalizing every few feet. Never wait until your ears hurt to equalize, because by that point, your Eustachian tubes may be swollen shut, making it even harder to balance the pressure. Descend slowly and feet-first when possible, as this position supports natural drainage and makes equalization easier.
For sinus health, never dive with a cold, allergy congestion, or sinus infection. These conditions block the tiny openings that help equalize sinus pressure. Over-the-counter decongestants might help temporarily, but they wear off quickly and can even rebound during a dive. It’s always best to skip the dive if your sinuses aren’t clear.
When ascending, remember the most important rule in diving: never hold your breath. Always breathe continuously and ascend slowly—no faster than 18 meters (60 feet) per minute, or according to your dive computer. This gives your lungs time to release expanding air naturally and reduces the risk of embolism. Practicing buoyancy control and proper ascent techniques during training helps build habits that protect you from lung barotrauma. I recommend taking the Peak Performance Buoyancy course to learn more about buoyancy control.
Also, stay hydrated and avoid alcohol or smoking before diving, as these can affect your sinus and respiratory function. Good overall health, regular dive training, and respect for depth limits and no-decompression limits all contribute to preventing barotrauma.
In summary, barotrauma is a pressure-related injury that every diver must understand. While it can be painful or dangerous, it’s entirely avoidable with the right knowledge and habits. Equalize early, never dive congested, ascend slowly, and always breathe—these simple actions can protect your ears, sinuses, and lungs for a lifetime of enjoyable and safe diving. If you ever experience symptoms like pain, dizziness, hearing loss, or trouble breathing after a dive, don’t ignore them—seek medical help, preferably from a dive medicine specialist. Your safety and your next dive depend on it.