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Scuba Diving–Related Disorders


Disorders related to scuba diving include those caused by environmental exposure (see Chapters 3 and 50 ), dysbarism, nitrogen narcosis, contaminated breathing gas, decompression sickness (DCS), and hazardous marine life (see Chapters 52 and 53 ; Box 51.1 ).

Box 51.1
Medical Problems of Scuba Divers

Problems Related to Environmental Exposure

  • Motion sickness

  • Drowning

  • Hypothermia

  • Heat illness

  • Sunburn

  • Phototoxic and photoallergic reactions

  • Irritant and other dermatitis

  • Infectious diseases

  • Mechanical trauma

Disorders Related to Diving

  • Barotrauma

  • Arterial gas embolism

  • Decompression sickness

  • Dysbaric osteonecrosis

  • Dysbaric retinopathy

  • Immersion pulmonary edema

  • Shallow water blackout

Problems Related to Breathing Gas

  • Inert gas narcosis

  • Hypoxia

  • Oxygen toxicity

  • Hypercapnia

  • Carbon monoxide poisoning

  • Lipoid pneumonitis

Problems Related to Hazardous Marine Life (See Chapters 52 and 53 )

Miscellaneous Problems

  • Hyperventilation

  • Hearing loss

  • Carotid sinus-related blackout

  • Panic and other psychological problems

Dysbarism

Dysbarism encompasses all the pathologic changes caused by altered environmental pressure. At sea level, atmospheric pressure is 760 mm Hg (14.7 psi), or 1 atmosphere (atm). Each 10-m (32.8-ft) descent under water increases the pressure by 1 atm. Gas in enclosed spaces obeys Boyle's law, which states that the pressure of a given quantity of gas when its temperature remains unchanged varies inversely with its volume.

Barotrauma of Descent

Mask Barotrauma

An air space is present between the face and the glass of a scuba (self-contained underwater breathing apparatus) diving mask. If nasal exhalations do not maintain air pressure within this space during descent, the volume of air contracts, creating negative pressure. This leads to capillary rupture, which is potentially dangerous after keratotomy because of the slow healing rate of corneal incisions.

Signs and Symptoms

  • Skin ecchymoses in mask pattern

  • Subconjunctival hemorrhage similar to strangulation injury

  • Hyphema (rare)

Treatment

  • 1.

    No treatment is necessary (unless hyphema is present) because the manifestations are self-limited.

  • 2.

    Cold compresses can be used for analgesia.

  • 3.

    Orbital hemorrhage is a rare complication and associated with diplopia, proptosis, and visual loss. Prompt referral should be made for magnetic resonance imaging and ophthalmologic care. Recompression therapy is not indicated.

Sinus Barotrauma

Sinus barotrauma, or “sinus squeeze,” results from inability to inflate a paranasal sinus during descent, at which time contraction of the trapped air creates a relative vacuum. This damages the sinus wall mucosa, which ultimately hemorrhages. Less often, a “reverse sinus squeeze” can occur on ascent in the water because the expanding air cannot be vented from the sinus. The frontal sinus, followed by the maxillary sinus, is most commonly affected by barotrauma. With maxillary sinus involvement, the diver often experiences pain in the maxillary teeth caused by compression of the posterior superior branch of the fifth cranial nerve, which runs along the base of the maxillary sinus

Signs and Symptoms

  • Pain in and over the affected sinus, with radiation like that seen with sinusitis (e.g., into the upper teeth with maxillary involvement)

  • May be accompanied by epistaxis

  • May develop bacterial sinusitis

Treatment

  • 1.

    Give oral and topical decongestants (mucosal vasoconstrictors), such as pseudoephedrine and oxymetazoline.

  • 2.

    Administer an analgesic as appropriate.

  • 3.

    If an episode of sinus squeeze has occurred, particularly with epistaxis, and the patient subsequently develops symptoms of sinusitis (pain, fever, tenderness over the affected sinus, nasal discharge), administer an antibiotic, such as amoxicillin/clavulanate or azithromycin.

External Auditory Canal Barotrauma

A tight-fitting wet suit hood, earplugs, exostoses, or cerumen impaction can trap air in the external auditory canal. On descent, this air contracts in the enclosed space between the tympanic membrane and the (occluded) external opening of the ear.

Signs and Symptoms

  • Pain, swelling, erythema, and petechiae or hemorrhagic blebs (bullae) of external ear canal wall

  • Hemorrhage

  • In severe cases, tympanic membrane rupturing outward

Treatment

  • 1.

    If a remediable occlusion exists, correct it.

  • 2.

    If inflammation of the external canal occurs without tympanic membrane rupture, instill eardrops suitable for the treatment of otitis externa (a fluoroquinolone combined with steroid) for 2 to 3 days.

  • 3.

    If the tympanic membrane is perforated, seek otolaryngologic evaluation. Do not allow further diving until the membrane has healed. Instill fluoroquinolone otic drops for 2 to 3 days.

  • 4.

    Do not incise bullae.

Middle Ear Barotrauma

If air cannot enter the middle ear via the (contracted or blocked) eustachian tube during an underwater descent, the existing air in the middle ear space contracts, creating a relative vacuum and pulling the tympanic membrane inward ( Fig. 51.1 ).

FIGURE 51.1, Middle Ear Trauma.

Signs and Symptoms

  • Initially, slight pain that progresses to severe pain with further underwater descent

  • Hemorrhage in the tympanic membrane; ranges from erythema over the malleus to gross blood throughout the tympanic membrane; blood around the mouth and nose and hearing loss also possible

  • If the tympanic membrane ruptures:

    • Sudden severe pain, accompanied by vertigo as water rushes into the middle ear

    • Total hearing loss in the affected ear

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