Otorhinolaryngologic disorders and diving accidents: an analysis of 306 divers

A review of 149 Divers Alert Network emergency call records involving diving minors

INTRODUCTION

Minors have been scuba diving for decades, and while the initial concerns about potential long-term complications related to bone development appear to be unfounded, the incidence of scuba diving injuries among them has been poorly studied.

METHODS

We reviewed 10,159 cases recorded in the DAN Medical Services call centre database from 2014 through 2016 and identified 149 cases of injured divers younger than 18 years. Records were analysed for case categorisation on the most common dive injuries. Information about demographics, level of training, risk factors, and relevant behavioural aspects were collected when available.

RESULTS

While the most common reason for the call was to rule out decompression sickness, the majority of cases pertained to ear and sinus issues. However, 15% of the dive-related injuries involving minors had a final diagnosis of pulmonary barotrauma (PBt). While no reliable data is available on the incidence of PBt in adult divers, the authors' impression based on personal experience suggests that the number of cases of PBt in minors trends higher than in the general diving population. The narratives on some relevant records describe unmanageable levels of anxiety leading to panic.

CONCLUSIONS

Based on the results and narratives on these cases, it is reasonable to infer that psychological immaturity, suboptimal management of adverse situations, and inadequate supervision might have led to severe injuries among these minor divers.

Diagnosis and Management of Barosinusitis: A Systematic Review

OBJECTIVE

To perform a systematic review to investigate the common presenting symptoms of barosinusitis, the incidence of those findings, the methods for diagnosis, as well as the medical and surgical treatment options.

METHODS

A review of PubMed/MEDLINE, EMBASE, and Cochrane Library for articles published between 1967 and 2020 was conducted with the following search term: aerosinusitis OR "sinus squeeze" OR barosinusitis OR (barotrauma AND sinusitis) OR (barotrauma AND rhinosinusitis). Twenty-seven articles encompassing 232 patients met inclusion criteria and were queried for demographics, etiology, presentation, and medical and surgical treatments.

RESULTS

Mean age of patients was 33.3 years, where 21.7% were females and 78.3% were males. Causes of barotrauma include diving (57.3%), airplane descent (26.7%), and general anesthesia (0.4%). The most common presentations were frontal pain (44.0%), epistaxis (25.4%), and maxillary pain (10.3%). Most patients received topical steroids (44.0%), oral steroids (28.4%), decongestants (20.7%), and antibiotics (15.5%). For surgical treatment, most patients received functional endoscopic sinus surgery (FESS) (49.6%). Adjunctive surgeries include middle meatal or maxillary antrostomy (20.7%), septoplasty (15.5%), and turbinate surgery (9.1%). The most efficacious medical treatments are as follows: 63.6% success rate with oral steroids (66 treated), 50.0% success rate with topical steroids (102 treated), and 50.0% success rate analgesics (10 treated). For surgical treatments received by greater than 10% of the sample, the most efficacious was FESS (91.5% success rate, 108 treated).

CONCLUSION

Oral and topical steroids should be first line therapies. If refractory, then functional endoscopic sinus surgery is an effective treatment.

A Case of Pott's Puffy Tumor Associated With Barosinusitis From Scuba Diving

ABSTRACT

Barosinusitis, or sinus barotrauma, is a well-described condition associated with changes in barometric pressure during flight and diving that can result in sinonasal mucosal injury. In this case report, we present an adolescent who experienced barosinusitis during scuba diving and subsequently developed Pott's puffy tumor (PPT), characterized by frontal sinusitis, frontal bone osteomyelitis, and overlying subperiosteal abscess. This unique case of PPT following scuba diving provides the opportunity to review the pathophysiology of both barotrauma-induced sinus disease and PPT, a rare and unreported serious complication of barosinusitis. Furthermore, we discuss how scuba diving and associated barosinusitis can be considered a risk factor in the development of PPT.

Effects of freediving on middle ear and eustachian tube function

INTRODUCTION

During descent in freediving there is exposure to rapidly increasing pressure. Inability to quickly equalise middle ear pressure may cause trauma to the ear. This study aimed to evaluate the occurrence of pressure-related damage to the middle ear and the Eustachian tube during freediving and to identify possible risk factors.

METHODS

Sixteen free divers performed diving sessions in an indoor pool 20 metres' freshwater (mfw) deep. During each session, each diver performed four own free dives and up to four safety dives. Naso- and oto-endoscopy and Eustachian tube function tests were performed on the right and left ears before diving, between each session and after the last session. The otoscopic findings were classified according to the Teed classification (0 = normal tympanic membrane to 4 = perforation). Additionally, ENT-related complaints were assessed using a questionnaire.

RESULTS

Participants performed 317 dives (on average 20 dives per diver, six per session). The average depth was 13.3 mfw. Pressure-related changes (Teed 1 and 2) were detected in 48 % of ears. Teed level increased significantly with an increasing number of completed sessions (P < 0.0001). Higher pressure-related damage (Teed 2) occurred in less experienced divers, was associated with significantly lower peak pressures in the middle ear and led to more ear-related symptoms. A preference for the Frenzel technique for middle ear pressure equalisation during freediving was shown.

CONCLUSIONS

Pressure exposure during freediving had a cumulative effect on the middle ear. Factors such as diving depth, diving experience and number of diving sessions correlated with the occurrence of higher Teed levels.

Children and diving, a guideline

Scuba diving is an increasingly popular recreational activity in children and adolescents. During the dive medical examination aspects of human physiology, anatomy, and psychology, that differ between adults and children, deserve our special attention. For example, lack of mental maturity, diminished Eustachian tube function and heat loss can pose problems during diving. It is important that children who wish to take up scuba diving are seen by a dive physician, with extra attention to Eustachian tube function. In children, asthma, bronchial hyperreactivity, pulmonary hypertension, and right-to-left shunts are contra-indications for scuba diving. Attention deficit hyperactivity disorder is a relative contra-indication. This article provides a review of the current literature and presents recommendations for recreational diving in children and adolescents. These recommendations are based solely on 'expert' opinion and were accepted by the Dutch Society of Diving and Hyperbaric Medicine in 2020.

Outcome of Balloon Eustachian Tuboplasty in SCUBA Divers

OBJECTIVES

Good Eustachian tube (ET) function is necessary in order to equalize middle ear (ME) pressure with ambient pressures and avoid barotrauma among divers. Since placement of ventilation tubes is not compatible with diving, balloon eustachian tuboplasty is a potential surgical solution for divers with ET dysfunction (ETD). This is the first report of the outcome of balloon tuboplasty for ETD among divers.

METHODS

A retrospective analysis of medical records and clinical examinations of adult divers treated in a single tertiary medical center.

RESULTS

Four male divers (age range 21-71 years, 5 ETs) underwent balloon tuboplasty for ETD. None had identifiable risk factors for ETD. Symptom duration ranged from 2 to 5 years and was restricted to diving in 3 patients. The most common symptom was difficulties in equalizing air pressure during descent and ascent, followed by aural fullness and hearing loss. The validated Hebrew version of ETD-7 questionnaire (ETDQ-7H) results were normal in 3 ears and pathological (2.9 and 3.3) in 2 ears. The averaged postoperative ETDQ-7H score was 1.2 points, significantly better than the preoperative score (P < .05). While diving, pressure-equalizing sensation improved in all ears.

CONCLUSION

Balloon eustachian tuboplasty is a safe method for treating diving-induced baro-challenge ETD. This procedure can improve symptoms and enable the patient to resume diving.

The surgical management of recurrent acute and chronic barosinusitis in sports self-contained underwater breathing apparatus (scuba) divers

PURPOSE

The aim of this retrospective study is to evaluate the feasibility of functional endoscopic sinus surgery (FESS) with supplementary surgical procedures in scuba divers with recurrent acute barosinusitis (RABS) and chronic barosinusitis (CBS).

METHODS

In this retrospective study, 25 divers were classified into RABS (n:11) and CBS (n:14) groups. The presentation of divers have been reviewed. The PNS CT images were scored according to Lund-Mackay (L-M) system. A score has been assigned to the extent of endoscopic procedures performed. The outcome of surgery and life quality were determined by SNOT-22 and dive-related questions (DRQ) tests.

RESULTS

The average L-M score was 3.8 ± 2 for RABS and 12.2 ± 3.4 for CBS groups. L-M score of CBS group was found to be statistically higher than RBS group (p < 0.05). The FESS score of CBS group (8.7 ± 2.4) was higher than RABS group (5.6 ± 2) which showed that the endoscopic sinus procedures were performed more extensively in CBS group (p < 0.05). The difference between the preoperative and postoperative SNOT-22 scores indicates that the degree of sinus symptoms improved better in RABS group than CBS group (p < 0.05). When DRQ test was evaluated, RABS group showed a better improvement in diving performance symptoms than the CBS group (p < 0.05).

CONCLUSION

Our study demonstrated that divers with RABS and CBS can be managed successfully with FESS and supplementary surgical procedures. The improvement in the RABS group was superior to the CBS group, a difference attributed to the severity of chronic inflammation in CBS.

Rhinologic and oral-maxillofacial complications from scuba diving: a systematic review with recommendations

Rhinologic and oral maxillofacial complications from scuba diving are common, representing approximately 35% of head and neck pathology related to diving. We performed a systematic and comprehensive literature review on the pathophysiology, diagnosis, and treatment of rhinologic and oral maxillofacial pathology related to diving. This included complications due to sinus barotrauma, barodontalgia, odontocrexis, temporomandibular joint dysfunction, partially dentulous patients, and considerations for patients following major head and neck surgery. Of 113 papers accessed, 32 were included in the final synthesis. We created a succinct summary on each topic that should inform clinical decision making by otolaryngologists, dive medicine specialists and primary care providers when faced with pathology of these anatomic sub-sites.

Hemorrhage within the tympanic membrane without perforation

Background

Hemotympanum refers to both the presence of blood in the middle ear cavity and to ecchymosis of the tympanic membrane (TM), and a systematic study of intra-TM (iTM) hemorrhage without bleeding in the middle ear cavity has not been conducted. The goals of our study were to analyze the causes of iTM hemorrhage without TM perforation or bleeding in the middle ear cavity, and to demonstrate the clinical characteristics of the disease.

Methods

This Case series study included five patients with iTM hemorrhage between August 2014 and August 2017. An iTM hemorrhage was diagnosed when otoendoscopic examination demonstrated minor bleeding behind the intact TM, a hemorrhage was observed between the TM annulus and the epidermal layer, and temporal bone computed tomography revealed thickening of the TM without soft tissue density within the tympanic cavity or temporal bone fracture. Initial symptoms, and serial findings of otoendoscopy and pure tone audiometry (PTA) were investigated.

Results

iTM hemorrhage developed due to blunt head trauma in two patients, descent barotrauma during scuba diving in two patients, and spontaneous epistaxis in one patient. Otalgia and ear fullness were the most common symptoms, but PTA showed no or minimal conductive hearing loss in all patients.

Conclusions

An iTM hemorrhage may develop after blunt head trauma, barotrauma due to scuba diving, or spontaneous epistaxis; otological symptoms included otalgia, tinnitus, and aural fullness. An iTM hemorrhage resolved spontaneously without specific treatment, usually within 1 month.

Influence of repetitive diving in freshwater on pressure equalization and Eustachian tube function in recreational scuba divers

INTRODUCTION

We investigated the effect of repetitive pressure exposure during freshwater dives on Eustachian tube function and the middle ear, assessed by the Eustachian tube function test (ETFT).

METHODS

This prospective observational cohort study included 23 divers over three consecutive days of diving in freshwater lakes in Nordhausen, Germany. Participants underwent otoscopy and ETFT before the first dive, between each dive and after the last dive. ETFT included regular tympanometry (R-tymp), tympanometry after Valsalva (V-tymp) and after swallowing (S-tymp). The peak pressure difference between the R-tymp and the V-tymp (R-V_dP) defined effectiveness of pressure equalization after Valsalva manoeuvres. We evaluated the change in compliance and peak pressure and correlated the results to the otoscopic findings and diving experience.

RESULTS

Twenty-three divers performed 144 dives. Middle ear barotrauma was assessed using the Edmonds modification of the TEED scoring system. In the ETFT, the R-tymp peak pressure displayed a negative shift from day one to three (P = 0.001) and differed significantly between the experience groups (P = 0.01). R-V_dP did not change significantly on any of the three days of diving (all P > 0.05). Participants without MEBt showed significantly lower R-tymp values than did those with barotrauma (P = 0.019).

CONCLUSION

Repetitive pressure exposure during three consecutive days of freshwater diving led to a negative shift of the peak pressure in the middle ear. Less experienced divers showed significantly higher middle ear peak pressure and higher pressure differences after equalization manoeuvres. Higher middle ear peak pressure was also associated with a higher prevalence of barotrauma.

Influence of repetitive diving in saltwater on pressure equalization and Eustachian tube function in recreational scuba divers

INTRODUCTION

We investigated in a prospective, observational trial the feasibility of using the Eustachian tube function test (ETFT) to measure the effect of repetitive pressure exposure during open seawater dives on Eustachian tube function.

METHODS

The study included 28 adult divers during six consecutive days of diving in the Red Sea. Participants underwent otoscopy and ETFT before the first dive, between each dive and after the last dive. ETFT included regular tympanometry (R-tymp), tympanometry after Valsalva (V-tymp) and after swallowing (S-tymp). The R-tymp was obtained as 'baseline' peak pressure. After a Valsalva, the peak pressure should shift (positively), revealing a positive shift of the tympanic membrane. This pressure shift is defined here as R-VdP. The changes in compliance and peak pressure were recorded and correlated with otoscopic findings and diving experience. Middle ear barotrauma was scored using the Edmonds modified TEED scale.

RESULTS

The 28 participants performed 437 dives. Positive shift of pressure in the middle ear was evident with significant changes from day one to day three (P < 0.0001). Divers with barotrauma showed significantly lower values of R-tymp peak pressure and significantly higher negative R-VdP, compared to divers with normal otoscopic findings (P < 0.05). Diving experience significantly correlated with R-tymp peak pressure and prevalence of middle ear barotrauma.

CONCLUSION

Significant changes in middle ear pressure and pressure equalization from repeated pressure exposure in saltwater were seen using ETFT. Repetitive, multi-day diving led to significantly decreased compliance and increased R-tymp peak pressure (overpressure) in the middle ear. Most profound changes were observed in less and intermediate experienced divers.

Barosinusitis: Comprehensive review and proposed new classification system

Background:

Barosinusitis, or sinus barotrauma, may arise from changes in ambient pressure that are not compensated by force equalization mechanisms within the paranasal sinuses. Barosinusitis is most commonly seen with barometric changes during flight or diving. Understanding and better classifying the pathophysiology, clinical presentation, and management of barosinusitis are essential to improve patient care.

Objectives:

To perform a comprehensive review of the available literature regarding sinus barotrauma.

Methods:

A comprehensive literature search that used the terms “barosinusitis,” “sinus barotrauma,” and “aerosinusitis” was conducted, and all identified titles were reviewed for relevance to the upper airway and paranasal sinuses. All case reports, series, and review articles that were identified from this search were included. Selected cases of sinus barotrauma from our institution were included to illustrate classic signs and symptoms.

Results:

Fifty-one articles were identified as specifically relevant to, or referencing, barosinusitis and were incorporated into this review. The majority of articles focused on barosinusitis in the context of a single specific etiology rather than independent of etiology. From analysis of all the publications combined with clinical experience, we proposed that barosinusitis seemed to fall within three distinct subtypes: (1) acute, isolated barosinusitis; (2) recurrent acute barosinusitis; and (3) chronic barosinusitis. We introduced this terminology and suggested independent treatment recommendations for each subtype.

Conclusion:

Barosinusitis is a common but potentially overlooked condition that is primed by shifts in the ambient pressure within the paranasal sinuses. The pathophysiology of barosinusitis has disparate causes, which likely contribute to its misdiagnosis and underdiagnosis. Available literature compelled our proposed modifications to existing classification schemes, which may allow for improved awareness and management strategies for barosinusitis.

Prevalence of Barotrauma in Recreational Scuba Divers After Repetitive Saltwater Dives

INTRODUCTION

The aim was to investigate the prevalence of middle ear barotrauma (MEB) and to establish risk factors of MEB after repeated saltwater dives.

METHODS

In this prospective observational cohort study 28 divers were examined over 6 consecutive days of diving in the Red Sea, Egypt. Participants underwent an otoscopic examination before the first dive, between each dive and after the last dive. In addition, they performed Valsalva maneuver (VM) and were questioned about dive-related complaints. Otoscopic findings were classified according to TEED classification for MEB (0 = normal otoscopy to 4 = perforation) separately for each ear. First examination was conducted before the first dive. Final examination, including a questionnaire, was conducted at least 12 h after the last dive.

RESULTS

In total, 436 dives were performed and 1161 otoscopic findings were analyzed. All participants showed a normal eardrum and a positive VM during initial exam. MEB prevalence (TEED >0) was 36.5% at final examination. Prevalence increased significantly with number of dives per day (p < 0.001) as with number of diving days (p = 0.032). Neither depth nor duration of dives significantly influenced MEB prevalence (all p > 0.05). More experienced divers (>200 dives lifetime) showed significantly less barotrauma (p < 0.0001). Despite the high prevalence of MEB, 81.7% (316 of 387) of all dives were reported asymptomatic.

CONCLUSIONS

After 6 days of repetitive diving, MEB prevalence was high (36.5%). It was the most often cause of otalgia in divers. Cumulative pressure exposure during repetitive dives resulted in significant increase of MEB. Diving experience significantly reduced the MEB prevalence. Interestingly, the severity of MEB did not correlate with subjective complaints.

Hazards and Health Risks Encountered by Manual Sand Dredgers from Udupi, India: A Cross-sectional Study

INTRODUCTION

Globalization and urbanization have resulted in an increased demand on sand dredging. Legal and environmental restrictions on automated dredging have led to a rise in manual technique. The working techniques and environment involved in manual sand dredging may expose the workers to multiple work related disorders.

AIM

To determine the health risks and occupational hazards involved in manual sand dredging.

MATERIALS AND METHODS

An assessment schedule was developed and content was validated by five experts for the study. A cross-sectional study was then conducted using this assessment schedule. Thirty manual sand dredgers were recruited from three randomly selected docks on Swarna riverbed in Udupi district, Karnataka, India. A detailed work and worksite assessments were conducted using systematic observation and close-ended questions. Work-related health risk evaluation included onsite-evaluation and self-reported health complains.

RESULTS

The prevalence of musculoskeletal pain and discomfort was 93.34% with lower back (70%), shoulder (56.7%) and neck (46.7%) involvements being most common regions. Prevalence of sensory deficits at multiple site and ear pain was 66.6% and 76.6% respectively. All the workers recruited, complained of dermatological and ophthalmic involvements. Also, lack of health and safety measures like personal protective devices and security schemes were identified.

CONCLUSION

This study shows a high prevalence of multiple work-related disorders and hazards involved in manual sand dredging, a highly demanding job in coastal Karnataka. Lack of health and safety measures were also identified.

Ruptured tympanic membrane from underwater impact with an Atlantic salmon, Salmo salar

An unusual case of tympanic membrane rupture in a diver due to impact from an Atlantic salmon, Salmo salar is described. The diver was treated conservatively and the injury fully healed by eight weeks after which the diver successfully returned to diving. The author contends that the appearances of such traumatic perforations differ from barotrauma in divers secondary to ear clearing problems on descent.

Sphenoid sinus barotrauma in diving: case series and review of the literature

About 50% of scuba divers have suffered from barotrauma of the ears and about one-third from barotrauma of paranasal sinuses. The sphenoid sinuses are rarely involved. Vital structures, as internal carotid artery and optic nerve, adjoin the sphenoid sinus. Thus, barotrauma could lead to serious neurologic disorders, including blindness. After searching the literature (Medline) and other sources (Internet), we present some cases of sphenoid sinus barotrauma, because these injuries may be underreported and misdiagnosed due to the lack of awareness and knowledge. Therefore, information is provided, e.g. on anatomical and pathophysiological features. Divers and physicians should have in mind that occasional headache during or after diving sometimes signals serious neurological disorders like vision loss. We show that injuries can develop from both negative and positive pressures in the sinuses. Because visual recovery depends on prompt diagnosis and proper therapy, physicians like otolaryngologists, ophthalmologists and neurologists need to closely collaborate.

Scuba diving and otology: a systematic review with recommendations on diagnosis, treatment and post-operative care

Scuba diving is a popular recreational and professional activity with inherent risks. Complications related to barotrauma and decompression illness can pose significant morbidity to a diver's hearing and balance systems. The majority of dive-related injuries affect the head and neck, particularly the outer, middle and inner ear. Given the high incidence of otologic complications from diving, an evidence-based approach to the diagnosis and treatment of otic pathology is a necessity. We performed a systematic and comprehensive literature review including the pathophysiology, diagnosis, and treatment of otologic pathology related to diving. This included inner, middle, and outer ear anatomic subsites, as well as facial nerve complications, mal de debarquement syndrome, sea sickness and fitness to dive recommendations following otologic surgery. Sixty-two papers on diving and otologic pathology were included in the final analysis. We created a set of succinct evidence-based recommendations on each topic that should inform clinical decisions by otolaryngologists, dive medicine specialists and primary care providers when faced with diving-related patient pathology.

Magnetic resonance imaging in a guinea pig model of inner ear decompression sickness and barotrauma

OBJECTIVES/HYPOTHESIS

Scuba diving may cause severe hearing loss and vertigo due to inner ear barotrauma and decompression sickness. These may be difficult to differentiate clinically. Decompression sickness requires costly and potentially dangerous hyperbaric therapy, whereas such treatment may worsen barotrauma. The objective of this study was to assess the potential utility of magnetic resonance imaging to identify and distinguish blood from air in the inner ear, manifestations of barotrauma and decompression sickness, using a guinea pig model.

STUDY DESIGN

Prospective animal trial.

METHODS

Magnetic resonance of the head was performed at 3 Tesla, pre- and postinjection of 2, 4, or 10 μL of air or blood through the round window into the perilymph. With this model, 2 μL has been shown to cause hearing loss. Images were reviewed by a neuroradiologist blinded to the treatment.

RESULTS

All 14 normal ears, five of seven blood- and five of seven air-injected ears, were correctly interpreted. Two blood- and one air-injected ear were interpreted as indeterminate. One air-injected ear was incorrectly interpreted as blood.

CONCLUSIONS

Magnetic resonance reliably distinguishes small volumes of air and blood in the guinea pig inner ear. Magnetic resonance should be evaluated for its utility in the diagnosis of inner ear barotrauma and decompression sickness in scuba divers.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:2106-2109, 2016.

Occupational and environmental risk factors for chronic rhinosinusitis: a systematic review

BACKGROUND

Chronic rhinosinusitis (CRS) is a prevalent and disabling paranasal sinus disease, with a likely multifactorial etiology potentially including hazardous occupational and environmental exposures. We completed a systematic review of the occupational and environmental literature to evaluate the quality of evidence of the role that hazardous exposures might play in CRS.

METHODS

We searched PubMed for studies of CRS and following exposure categories: occupation, employment, work, industry, air pollution, agriculture, farming, environment, chemicals, roadways, disaster, and traffic. We abstracted information from the final set of articles across 6 primary domains: study design; population; exposures evaluated; exposure assessment; CRS definition; and results.

RESULTS

We identified 41 articles from 1080 manuscripts: 37 occupational risk papers, 1 environmental risk paper, and 3 papers studying both categories of exposures. None of the 41 studies used a CRS definition consistent with current diagnostic guidelines. Exposure assessment was generally dependent on self-report or binary measurements of exposure based on industry of employment. Only grain, dairy, and swine operations among farmers were evaluated by more than 1 study using a common approach to defining CRS, but employment in these settings was not consistently associated with CRS. The multiple other exposures did not meet quality standards for reporting associations or were not evaluated by more than 1 study.

CONCLUSION

The current state of the literature allows us to make very few conclusions about the role of hazardous occupational or environmental exposures in CRS, leaving a critical knowledge gap regarding potentially modifiable risk factors for disease onset and progression.

[Scuba diving in children: Physiology, risks and recommendations]

INTRODUCTION

The increase in recreational scuba diving in recent years, including children, involves risks and the possibility of accidents. While legislation, conditions and risks of scuba diving are well documented in adults, scientific evidence in scuba diving by children and adolescents is sparse and isolated. Furthermore, existing guidelines and recommendations for adults cannot be transferred directly to children.

METHODS

These circumstances have led to the Group on Techniques of the Spanish Society of Pediatric Pulmonology (SENP) to perform a literature search to review and update the knowledge about scuba diving in children.

RESULTS

Physiological adaptations of the body are examined during the dive, as well as the anatomical and physiological characteristics of children that should be taken into account in scuba diving. The most common types of accidents and its causes, as well as the risks of scuba diving practice in children with previous diseases are discussed, along with details of the medical and psychological requirements for scuba diving to be considered in the assessment of child and adolescent.

CONCLUSIONS

A list of recommendations for scuba diving with compressed air in children is presented by a group of experts.

Auditory complaints in scuba divers: an overview

Pre-1970s, diving was seen as a predominantly male working occupation. Since then it has become a popular hobby, with increasing access to SCUBA diving while on holiday. For a leisure activity, diving puts the auditory system at the risk of a wide variety of complaints. However, there is still insufficient consensus on the frequency of these conditions, which ultimately would require more attention from hearing-healthcare professionals. A literature search of epidemiology studies of eight auditory complaints was conducted, using both individual and large-scale diving studies, with some reference to large-scale non-diving populations . A higher incidence was found for middle ear barotrauma, eustachian tube dysfunction, and alternobaric vertigo with a high correlation among females. Comparing these findings with a non-diving population found no statistically significant difference for hearing loss or tinnitus. Increased awareness of health professionals is required, training, and implementation of the Frenzel technique would help resolve the ambiguities of the Valsalva technique underwater.

Sphenoid sinus barotrauma after scuba diving

We report the case of an 18-year-old male patient operated on for sphenoid sinus barotrauma after scuba diving. The patient attended our emergency department because of intractable headache but did not improve with conservative treatment. After computed tomography and magnetic resonance imaging examination, he was diagnosed with sphenoid sinusitis that extended to the nasal septum. He therefore underwent surgery for sinus ventilation and abscess drainage.

[Differential diagnosis of headaches in otorhinolaryngology]

Facial pain and headaches are heterogeneous, therefore, a differential diagnosis, interdisciplinary survey and mapping of the pain symptoms are essential for determination of treatment concepts. This requires an otorhinolaryngology (ENT) adapted zoning of the various pains in the head and neck in line with the classification of the International Headache Society (IHS). In this review, idiopathic, symptomatic and neuralgic facial pain and headaches will be differentiated and classified according to their location from the ENT medical point of view. This provides otolaryngologists with a simplified, targeted diagnosis and subsequent indication for therapy.

[Infraorbital lesion after scuba diving with chronic sinusitis: diagnosis and treatment of reverse block]

A 32-year-old diver repeatedly reported pain in the right side of the face after diving. He felt strong pain on pressure over the right face combined with hypaesthesia of the infraorbital nerve. In addition, he reported nasal breathing obstruction and problems regulating pressure in the middle ear. ENT consultation revealed a septal deviation to the right side of the nasal cavity. CT diagnosis showed the typical picture of chronic pansinusitis with total transfer of the right frontal sinus, subtotal transfer of the right ethmoid and subtotal transfer of the right maxillary sinus. Following successful functional sinus surgery (FESS), combined with septal surgery, the patient was able to dive again symptom-free.

Functional effects of repeated pressure loads upon the tympanic membrane: mechanical stiffness measurements after simulated habitual sniffing

In experimental studies it was found that otitis media causes stiffness loss in the tympanic membrane, possible precursors to retraction pockets and cholesteatoma. Besides otitis media habitual sniffing behaviour is associated with the development of retractions. The present study aims to test the hypothesis that repeated sniffing manoeuvre may cause not only structural, epithelial tympanic membrane changes presumed to be possible precursors to retractions, but also tympanic membrane stiffness loss, another possible mediator for the development of retractions. An experimental model with a pressure chamber was used to mimic the pressure conditions for the tympanic membrane in habitual sniffers' ears. The stiffness properties of twelve Mongolian gerbil tympanic membranes were measured with moiré interferometry after varying time up to 12 days with repeated pressure loading. Three days later, lower overall displacement were obtained in two ears; after 7-12 days the displacement readings were normal. This study with maximum of 12 days of pressure loading did not verify the hypothesis that habitual "sniffing" impairs the stiffness of the tympanic membrane.

[Fitness to dive in the otorhinolaryngological field]

In line with the rising number of recreational divers, the otorhinolaryngologist has to deal with growing numbers of diving-associated disorders of the ear, nose and throat (ENT). Nevertheless, the majority of divers present to their ENT doctor for assessment of their fitness to dive. On the basis of long-term follow-up examinations and increasing experience in diving medicine, even divers with a history of ENT problems can be considered fit to dive. Therefore, diving is possible after tympanoplasty, surgery to improve hearing including stapesplasty, after implantation of middle ear amplifiers or cochlear implants, after sinus or scull base surgery and even after canal wall down mastoidectomy, provided that certain requirements are fulfilled. Assessing fitness to dive after inner ear barotrauma as well as after inner ear decompression illness requires meticulous consideration of residual damage and possible underlying conditions like vascular right-to-left shunts. This article is based on the new recommendations of the German Undersea and Hyperbaric Medical Society for the assessment of fitness to dive in the otorhinolaryngological field.