Diving in Vietnam: ear and sinus barotrauma, and when to stay out of the water

Vietnam has a modest, pleasant diving scene. The islands off Nha Trang, the reefs around Phu Quoc, Hon Mun and Hon Mot on a calm morning, Cham Island out of Hoi An in the dry season, Con Dao for anyone who travels for it. The visibility is honest rather than spectacular. The depths are forgiving. So the injuries we are asked about are rarely the dramatic ones.

What we actually see is ears. Ears on the way down, ears on the way up, and ears two days later when warm water and a wet canal have turned into an infection that makes the pillow unbearable. Sinuses come second. This page sets out what goes wrong in the middle ear and the sinuses, what tropical ear is, and the conditions under which getting back in the water is the wrong decision. It is not a substitute for being examined. A dive injury is not something to settle by reading.

Symptoms after a dive that are an emergency

Decompression illness is uncommon at recreational depths. It is not impossible, and it can look deceptively mild at the start. If any of the following turns up during a dive, on surfacing, or within the day that follows, ring 115 or go to the nearest hospital emergency department now, and tell your dive operator so they can contact the chamber that covers them:

• Numbness, pins and needles, or weakness anywhere, however patchy it seems
• Difficulty walking straight, or a spinning sensation that will not settle
• Chest pain, a cough that came on after surfacing, or breathlessness
• Confusion, unusual behaviour, or a severe headache that is new
• Sudden deafness in one ear, especially with vertigo and vomiting
• Joint or limb pain that appeared after the dive with no injury to explain it
• A rash with a marbled, blotchy pattern on the trunk
• Any loss of consciousness, before or after surfacing

Breathing high-flow oxygen while being moved is standard first aid for suspected decompression illness. The definitive treatment is recompression in a hyperbaric chamber. Chambers exist in Vietnam. But not in every town with a dive shop. So the operator who put you in the water should know in advance which one covers them and how long the transfer takes. Ask that question before you book, not after.

Why equalising fails

The middle ear is a sealed box with one narrow door. That door is the Eustachian tube, opening into the back of the nose. On descent, the water pressure pushes the eardrum inwards, and the box has to be refilled with air through that door to keep the pressures matched. Anything that narrows the door makes the refilling late or impossible.

A head cold does it. Hay fever does it. Air conditioning in a hotel room that has you waking with a blocked nose does it. So does a long motorbike ride through roadside dust the afternoon before. The commonest sequence we hear starts with a mild cold. A traveller decides a dive they already paid for is worth trying, and gets to ten metres before the pain stops them.

• Equalise early and often, starting at the surface and continuing every metre or so, rather than waiting for discomfort
• If an ear will not clear, stop descending and go back up slightly. Descending through pain is how eardrums tear
• Do not force a hard Valsalva against a blocked nose. The pressure has to go somewhere. The inner ear is the thing it can damage
• Decongestant sprays that wear off mid-dive leave you worse than before, because the swelling rebounds while you are still deep
• A dive with a cold is a dive worth losing. The money is gone either way. The eardrum does not have to be

Middle ear barotrauma

This is the common one. The eardrum is stretched and bruised rather than torn. Pain during or after the dive, a blocked feeling, muffled hearing, sometimes a trace of blood in the nose from the same pressure problem. Most of it settles over days without anything being done to it. The sensible management is nasal decongestion, no diving, and no swimming until it has.

A torn eardrum is a different conversation. The pain often eases suddenly as the pressure equalises through the hole. There may be bleeding or discharge from the canal, and hearing drops. Water entering the middle ear through a perforation is what causes the infection that follows. So the canal stays dry — no swimming, no diving, and a shower with the ear turned away or plugged.

Inner ear trouble is the one to take seriously

Inner ear barotrauma is far less common and much more consequential. The pattern is hearing loss, tinnitus and a violent spinning sensation. It often follows a forceful attempt to clear a stubborn ear. It needs assessment urgently. Some of the damage is time-sensitive. And it can be difficult to separate from decompression illness affecting the inner ear.

Sinus squeeze and the reverse block

The sinuses are air spaces with the same requirement as the middle ear and the same narrow openings. Squeeze on descent produces pain across the forehead, behind the eye, or in the upper teeth when it is the maxillary sinus. Often a small amount of blood in the mask on surfacing, too. That blood looks alarming and is usually the least important part of it.

The reverse block is the ascent version. It is the scarier one. Air trapped in a sinus or the middle ear expands as you come up, with nowhere to go. Pain builds on ascent instead of easing. Slowing down and stopping, if your gas and your plan allow it, usually lets it clear. A reverse block in an ear can also present as sudden vertigo at the end of a dive.

Tropical ear: the water, not the dive

Otitis externa is the single most frequent reason divers and swimmers in Vietnam ask for help. Warm water, a canal that stays damp, hours in a wetsuit hood, and the same ear being flushed four times a day over a week-long course produce an infected outer canal. Itching first, then pain. Then a canal so tender that lying on it is impossible, with a discharge and sometimes a dramatically reduced hearing from swelling alone.

It responds well to proper treatment. And badly to the things people try first.

• Dry the canal after every immersion. Tilt the head and let it drain, then use a towel corner at the entrance
• Keep cotton buds out of the ear. They strip the protective wax and graze the skin, which is how most cases start
• Do not use drops left over from a previous trip without having the ear looked at. The choice depends on whether the eardrum is intact
• Stop diving and swimming while it is active. Each immersion restarts it
• Pain that spreads behind the ear, swelling of the bone there, fever, or a facial weakness means hospital today rather than another dose of drops

When not to get back in the water

There is a strong pull towards one more dive. The trip is short, the boat is booked, the certification is half finished. The conditions below are the ones where that is a bad trade. Any competent instructor will support the decision to sit out.

• An ear that still feels blocked, or hearing that has not returned to normal
• An eardrum known to be perforated, until it has been confirmed healed
• An active cold, sinus infection, or hay fever flare that stops you clearing on dry land
• Vertigo of any kind, however brief, since it recurs at depth
• Any symptom that raised the question of decompression illness, until a chamber doctor says otherwise
• Recent ear surgery, or a grommet in place

Flying afterwards

A cabin at altitude is a mild version of surfacing. That is why dive tables ask for a surface interval before a flight — longer after repetitive or deeper days than after a single shallow dive. Dive operators will give you the figure for the diving you did. Plan the last day of a trip around it rather than against it.

Separately, an ear or sinus that cannot equalise on a boat will not equalise in a descending aircraft either. If your last dive left you blocked, that is relevant to the flight home as well as to the next dive. Get looked at before you travel, not at the airport.

What a visit where you are staying covers

• An otoscope look at both canals and eardrums, which settles bruise against tear against infection
• Treatment chosen on what the drum looks like rather than on what the symptom sounds like
• An honest answer about diving again on this trip, in writing if a dive operator needs it
• A referral and a phone call if the picture is inner ear or decompression illness, because those belong elsewhere
• An itemised invoice and a report in English for a travel or dive insurance claim

In short

Equalise early, abandon the dive rather than push through pain, and keep the canal dry between dives. A cold is a reason not to dive. Not a reason to try harder. Hearing loss with vertigo, or anything neurological after surfacing, is the emergency department and a chamber conversation — not a problem to look at tomorrow.