Can a person take decongestants (medications that relieve nasal congestion) for ear pressure during diving?

Decongestants for Diving and Ear Pressure

Yes, decongestants can be used to prevent and manage ear pressure problems during diving, with oral pseudoephedrine being the most evidence-based option for prophylaxis, though topical decongestants like oxymetazoline may be used cautiously for acute situations underwater. 1

Evidence for Decongestant Use in Diving

Oral Pseudoephedrine (Preferred for Pre-Dive Prophylaxis)

• A randomized controlled trial in 116 novice divers demonstrated that 60 mg pseudoephedrine taken 30 minutes before diving significantly reduced middle ear barotrauma (ear squeeze) compared to placebo—only 8% experienced ear discomfort versus 32% in the control group (P = 0.001). 1

• Pseudoephedrine works as an α-adrenergic agonist causing vasoconstriction, which reduces Eustachian tube mucosal edema and facilitates middle ear equalization during descent and ascent. 2, 3

• The British Thoracic Society guidelines recognize that Eustachian tube dysfunction is a legitimate indication for topical decongestants, and this principle extends to oral decongestants for diving prophylaxis. 4

Topical Nasal Decongestants (For Acute Underwater Use)

• A case report documented successful underwater administration of oxymetazoline nasal spray during a cave dive when a diver encountered equalization difficulty, allowing completion of the dive without middle ear barotrauma. 5

• Topical decongestants like oxymetazoline cause rapid local nasal vasoconstriction with minimal systemic absorption compared to oral agents. 2

• However, underwater administration carries significant risks including disorientation, loss of buoyancy control, coughing, sneezing, laryngospasm, and theoretically increased susceptibility to CNS oxygen toxicity. 5

Clinical Algorithm for Decongestant Use in Diving

Pre-Dive Planning (Recommended Approach)

• For divers with known congestion or history of equalization difficulty: Take pseudoephedrine 60 mg orally 30 minutes before diving. 1

• For divers with acute upper respiratory infection or allergic rhinitis: Consider postponing the dive, but if diving is necessary, use pseudoephedrine prophylaxis. 4, 1

• Screen for contraindications before recommending pseudoephedrine: cardiovascular disease, uncontrolled hypertension, arrhythmias, coronary artery disease, cerebrovascular disease, hyperthyroidism, closed-angle glaucoma, or bladder neck obstruction. 4, 2

Cardiovascular Considerations

• Pseudoephedrine causes modest systemic effects: increases systolic blood pressure by 0.99 mmHg and heart rate by 2.83 beats/min in normotensive individuals. 2

• Patients with controlled hypertension can generally use pseudoephedrine safely but require monitoring. 4

• The combination of diving-related physiological stress (cold water, increased work of breathing, intrathoracic blood volume shifts) with sympathomimetic effects warrants extra caution in those with cardiovascular disease. 4

Emergency Underwater Use (High-Risk Maneuver)

• Underwater administration of topical decongestants should only be considered in dire circumstances where inability to equalize during a multilevel dive (cave/wreck penetration) creates a life-threatening situation requiring further descent to exit safely. 5

• This maneuver requires removing the regulator underwater, administering the spray, and replacing the regulator—each step carries drowning risk. 5

• Divers should never rely on this as a planned strategy; proper pre-dive assessment and prophylaxis are essential. 5

Critical Diving-Specific Barotrauma Context

Why Ear Equalization Matters in Diving

• Middle ear barotrauma is the most common diving injury, occurring in over 50% of experienced divers at some point. 5

• During descent, increasing ambient pressure compresses air in the middle ear space, creating negative pressure that must be equalized via the Eustachian tube using techniques like Valsalva maneuver. 4

• Failure to equalize can progress from discomfort to tympanic membrane hemorrhage (graded by Teed scores 0-5) to rupture, with potential for cold water caloric stimulation causing severe vertigo underwater—a life-threatening situation. 4, 1

• During ascent, expanding gas in the middle ear must vent through the Eustachian tube; obstruction can cause reverse squeeze with similar complications. 4

Pulmonary Barotrauma Risk (Critical Safety Consideration)

• Decongestants do not increase pulmonary barotrauma risk, but divers must understand that any medication causing drowsiness, altered consciousness, or impaired judgment is dangerous. 4

• Pseudoephedrine's stimulant effects (insomnia, irritability) are generally not problematic for diving, unlike sedating antihistamines. 4

• The primary pulmonary barotrauma risk comes from breath-holding during ascent or localized airway obstruction—not from appropriate decongestant use. 4

Important Caveats and Contraindications

When NOT to Dive Despite Decongestants

• Active upper respiratory infection with significant congestion should prompt dive cancellation rather than relying on decongestants to enable diving, as medication may wear off at depth. 4, 6

• Decongestant rebound effect timing is unpredictable; if pseudoephedrine wears off during a long dive, sudden Eustachian tube obstruction during ascent creates dangerous reverse squeeze. 4

• Any condition causing localized airway narrowing, bullae, or parenchymal weakness increases pulmonary barotrauma risk and may contraindicate diving regardless of decongestant use. 4

Rhinitis Medicamentosa Risk

• Topical decongestants must be limited to ≤3 days of use to avoid rebound congestion (rhinitis medicamentosa), which would worsen equalization problems. 4, 2, 3

• Regular divers should not use topical decongestants chronically; oral pseudoephedrine or intranasal corticosteroids are better for ongoing management. 4, 7

Special Populations

• Oral decongestants should be used with extreme caution in children under 6 years due to risks of agitated psychosis, ataxia, and hallucinations. 4, 3

• Pregnant divers should use decongestants cautiously, especially in the first trimester, due to reports of fetal heart rate changes. 4, 7

• Elderly divers and those with cardiovascular disease require careful risk-benefit assessment before using any decongestant. 2

Practical Recommendations

• For recreational divers with occasional congestion: Pseudoephedrine 60 mg taken 30 minutes pre-dive is the evidence-based standard. 1

• For divers with chronic rhinitis: Intranasal corticosteroids started several days before diving provide better long-term management than repeated decongestant use. 7

• Phenylephrine is NOT recommended as it has poor oral bioavailability and unproven efficacy. 4, 3

• Divers should test their response to pseudoephedrine on land before using it for diving to identify any adverse effects. 4

• Carry topical oxymetazoline in a dive kit only for true emergencies, understanding the significant risks of underwater administration. 5