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Outcomes in the treatment of inner ear decompression sickness with hyperbaric oxygen therapy, a systematic review

Rosanna J Stokes^1,2, Jonathan Marsden¹, Doug Watts², Gary Smerdon², Stephen D Hall¹, Lisa Bunn¹

¹ Brain Research and Imaging Centre, University of Plymouth, Plymouth, UK
² DDRC Healthcare, Plymouth Science Park, Plymouth, UK

Corresponding author: Dr Rosanna J Stokes, DDRC Healthcare, Plymouth Science Park, Plymouth, UK
ORCiD: 0009-0006-4501-0634
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Keywords
Diving; Sharpened Romberg test; Review article; Vertigo; Vestibular

Abstract
(Stokes RJ, Marsden J, Watts D, Smerdon G, Hall SD, Bunn L. Outcomes in the treatment of inner ear decompression sickness with hyperbaric oxygen therapy, a systematic review. Diving and Hyperbaric Medicine. 2026 31 March;56(1):71−82. doi: 10.28920/dhm56.1.71-82. PMID: 41875444.)
Introduction: The primary objective of this review was to evaluate the effectiveness of hyperbaric oxygen therapy (HBOT) in the treatment of inner ear decompression sickness (IEDCS). Secondary objectives were to summarise the diver characteristics, HBOT parameters and outcome measures.
Methods: All descriptive observational study designs including case series and individual case reports involving divers suffering IEDCS treated with HBOT were included. PubMed, Scopus, CINAHL and EMBASE were used to search for texts reporting the outcome for divers treated with HBOT. Eligible studies were appraised by two independent reviewers and any disagreements resolved via the third reviewer. Data were extracted using standardised tools and narrative synthesis was undertaken.
Results: 3,683 records were identified with 24 included in the final review representing 539 cases of IEDCS. Mean age was 44, average (in-water) dive depth 29 metres of seawater and dive duration 38 minutes. Mean onset of symptoms was 32 minutes and 74% had a right sided lesion. Only 37% had residual symptoms on discharge despite 68% showing dysfunction on laboratory testing. Follow-up duration and assessment methods were variable. Vestibular rehabilitation was underutilised and only 46% of divers went on to have patent foramen ovale (PFO) screening despite the well-established link to IEDCS.
Conclusions: A standardised method of examination and assessment of symptoms should be considered along with vestibular rehabilitation (or referral to this service). All divers should be counselled on PFO screening. A standard 3-month follow-up is recommended to allow for assessment of residual dysfunction / symptoms and discussion regarding returning to diving. Further research should focus on assessment of vestibular deficit / symptoms over time to assess efficacy of HBOT including the effects of delay to recompression and number of treatments. Laboratory testing should be utilised to determine the mechanism of injury and recovery.

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