Evidence-informed decision aid for fitness-to-dive assessment after otologic surgery

Clinical Snapshot

Key Findings

• P Value: Not reported; no inferential statistics conducted

• Effect Size: Not applicable (scoping review with descriptive charting; no pooled effect size calculated). Key finding: canal wall down mastoidectomy consistently described as incompatible with diving; selected middle ear reconstructions and stapes surgery described as potentially compatible in appropriately selected individuals; cochlear implantation guidance conditional on hyperbaric testing and manufacturer depth limits

• Primary Outcome: Characterisation of available evidence and development of a procedure-specific, function-based clinical decision aid for fitness-to-dive assessment after otologic surgery

• Nnt Or Sensitivity: Not applicable. Procedure-specific depth/pressure limits from manufacturer specifications and experimental chamber studies are the closest analogue to quantitative thresholds, but specific values are not extractable from the abstract alone

• Confidence Interval: Not reported; quantitative synthesis not performed

Clinical Application

The decision aid framework is feasible to implement in specialist ENT and hyperbaric medicine outpatient settings. Implementation requires clinical assessment of postoperative stability and pressure equalisation function rather than additional investigations in most cases. For cochlear implant recipients, device-specific manufacturer documentation review is required. The framework does not require expensive or specialised equipment beyond standard otoscopy and tympanometry In Australia, fitness-to-dive assessments are conducted by designated medical examiners under frameworks informed by the Diving and Hyperbaric Medical Association (DHMA) and South Pacific Underwater Medicine Society (SPUMS). Cochlear implants listed on the Australian Register of Therapeutic Goods (ARTG) via TGA approval include device-specific depth restrictions that align with the manufacturer guidance approach described in this review. The RACGP does not provide specific guidance on post-otologic surgery diving clearance, making this decision aid potentially valuable for GP-level referral decision-making. PBS-listed hearing devices and implants are subject to TGA-approved indications that do not currently address diving-specific use conditions. Australian dive medical examiners should note that the individualised, function-based approach advocated aligns with SPUMS guidance principles favouring clinical assessment over blanket procedural prohibition. The high prevalence of recreational diving in Australia (particularly Queensland, Western Australia, and the Northern Territory) makes this a clinically relevant population consideration. Adults who have undergone otologic surgery (mastoidectomy, tympanoplasty, stapedectomy/stapedotomy, cochlear implantation) and wish to return to recreational or occupational scuba or breath-hold diving. Applicable to ENT surgeons, hyperbaric medicine physicians, dive medical examiners, and general practitioners conducting fitness-to-dive assessments

Abstract

INTRODUCTION: Fitness-to-dive after otologic surgery is often approached conservatively, with some procedures historically labelled as absolute contraindications despite limited empirical evidence. The available literature is heterogeneous and includes clinical reports, experimental pressure studies, guidance documents, and manufacturer specifications, leading to uncertainty in clinical counseling. We aimed to characterise the available evidence regarding fitness-to-dive after otologic surgery and to develop an evidence-informed clinical decision aid. METHODS: A scoping review was conducted in accordance with PRISMA-ScR guidance. PubMed/MEDLINE, Embase, Scopus, and relevant non-indexed sources were searched. Eligible sources included clinical reports and series, experimental or hyperbaric chamber studies, guidance or consensus documents, and manufacturer statements providing explicit pressure- or depth-related information. Data were charted descriptively by procedure type and evidence stream. RESULTS: The search identified 324 records; after removal of duplicates and screening, 40 sources were included. The evidence base was predominantly non-comparative. Across procedures, recommendations emphasised postoperative stability and reliable pressure equalisation rather than surgical history alone. Canal wall down mastoidectomy was consistently portrayed as incompatible with diving, whereas selected middle ear reconstructions and stapes surgery were commonly described as potentially compatible in appropriately selected individuals. For cochlear implantation, guidance was mainly conditional and based on hyperbaric testing, limited clinical diving reports, and manufacturer-specified pressure or depth limits. Communication emerged as an additional practical consideration in cases of significant hearing loss. CONCLUSIONS: Relevant evidence is limited and heterogeneous, and does not consistently support blanket prohibitions for all otologic procedures. A function-based, individualised approach is supported, while specific higher-risk scenarios warrant restriction. Prospective registries and standardised outcome reporting are needed to refine procedure-specific recommendations.

References

1. 1.Riestra-Ayora, J., Fernández-Navarro, C., Martín-Sanz, E., & Salvador-Marín, M. F. (2026). Evidence-informed decision aid for fitness-to-dive assessment after otologic surgery. Diving and Hyperbaric Medicine, 56(2), 177–184. https://doi.org/10.28920/dhm56.2.177-184