Tympanic membrane (TM) perforation is a tear of the eardrum, which can occur while diving due to failed middle-ear equalization.
Mechanisms of Eardrum Injury
The eardrum is a tissue separating the external ear from the middle-ear space. It is attached to a chain of small bones (auditory ossicles) located in the middle ear. The eardrum also serves as a barrier between the sterile middle-ear space and the ambient environment. The pars tensa is the tightly stretched portion of the eardrum. It consists of three layers and is the main structure of the membrane. The pars flaccida is a small triangular portion of the eardrum that consists of two layers and is quite fragile. Although the pars tensa is more robust than the pars flaccida, the pars tensa is more commonly associated with perforations.
Eardrum rupture can be caused by descending without equalizing the pressure in the middle ear, a forceful Valsalva maneuver, an explosion, a blow to the ear or head, or acoustic trauma. It is usually painful; rupture relieves the pressure (and pain) in the middle ear and may result in vertigo. There may be some bleeding in the ear canal. Contributing factors include congestion, inadequate training and excessive descent rates.
Signs and Symptoms
- Ear pain during the descent that stops suddenly, sometimes with a loud pop (this pop usually relieves the pressure and can cause pain)
- Bubbles coming out of your ear while equalizing
- Clear or bloody drainage from the ear
- Hearing loss
- Ringing in the ear (tinnitus)
- Lightheadedness or dizziness
- Vertigo (spinning sensation)
- Nausea or vomiting (usually as a result of vertigo)
- Do not dive when congested.
- Refrain from diving when feeling popping or crackling in your ears, or if you have a feeling of fullness in your ears after diving.
- Learn and use proper equalization techniques.
- Do not use any ear drops. If ear drops reach the middle ear, they could make things worse.
- Lie down and rest. Keep movements and physical activity to a minimum.
- Lying down and closing your eyes may help with vertigo, which might be significant and will likely make you feel miserable. Try to remain calm. Vertigo is usually accompanied by nausea and vomiting.
- Seek professional medical evaluation ASAP. Any doctor should be able to help, regardless of any dive medicine knowledge or training.
Implications for Diving
For the Diver
- If you suspect you have had a tympanic membrane rupture you should stop diving immediately.
- If you dive with a rupture, water could pass through your ear canal into the middle ear. This could cause a sudden onset of vertigo. Never attempt to continue diving with earplugs.
- Avoid any Valsalva-like maneuvers for middle-ear equalization, sneezing and nose blowing.
- If you are having vertigo, your inner ear might be compromised as well. Valsalva-like maneuvers might exacerbate vertigo. Do not lift heavy weights.
For the Dive Operator
- Provide first aid treatment, as described above. As the expedition’s leader, you have a duty of care for a diver injured during your trip.
- Be skeptical of folkloric first aid treatments. Use common sense, and don’t attempt magic solutions. Remember that you might be liable.
- Have the diver sit down, and reassure them during the process.
- Help them deal with vertigo, which can be a very uncomfortable feeling that will likely make the diver — and you — feel uneasy about the situation. Rapid movements of the head and Valsalva-like maneuvers (such as lifting heavy things) might exacerbate vertigo. People with vertigo usually have:
- A spinning sensation: They feel they are spinning or that the environment is spinning around them.
- Repetitive nystagmus: Involuntary eye movement that can occur from side to side, up and down, or in a circular motion.
- Nausea and vomiting: Make sure the diver does not aspirate vomit.
- Have the diver evaluated by a medical professional in a timely fashion.
- Don’t worry about finding a doctor with dive medicine experience. An ear, nose and throat (ENT) specialist would be ideal, but any doctor should be able to help with the initial evaluation.
For the Physician
- Most perforated eardrums will heal spontaneously within a few weeks. It may be necessary to treat nasal and sinus congestion. If the tear or hole does not heal by itself, further treatment may involve procedures to close the perforation.
- Eardrum patch: This is an office procedure in which an ENT applies a chemical to the edges of the tear to stimulate growth and then applies a paper patch over the hole to provide a support structure for the growth of eardrum tissue.
- Surgery: Large eardrum defects may be fixed with surgery (tympanoplasty). An ENT surgeon takes a tiny patch of your own tissue and plants it over the hole in the eardrum. This procedure is done on an outpatient basis unless medical conditions require a longer hospital stay.
- For assessing the severity of an ear barotrauma, use the O’Neill grading system.
Fitness to Dive
If your physician feels the healing is adequate, and there is no evidence of Eustachian tube problems, you can return to diving within several months. Chronic perforations that do not heal are a contraindication to diving.