Recreational self-contained underwater breathing apparatus (SCUBA) diving continues to grow in popularity. Medical requirements to be ‘fit to dive’ vary throughout the world, from self-certification to a full medical examination prior to training. This review discusses the relative merits of the most commonly used guidelines for recreational SCUBA diving, with reference to common diving-related otorhinolaryngological conditions. Areas of controversy, such as fitness to dive after rhinological and otological surgery, are discussed. The authors suggest that a unified approach from the various recreational SCUBA diving organizations involved would aid in clarification for divers and physicians alike. The difficulties in achieving such a unified approach, however, should not be underestimated.