Ears and diving

DAN Europe launched the ears and diving safety campaign in 2014.

Ear and Sinus Barotrauma can be caused by changes in ambient pressure. During descent, when pressure increases, divers must equalise air spaces in the sinuses and middle ears to the surrounding water pressure. Swollen, damaged tissues could restrict the passage of air through the opening that allows equalisation. When pressure in air spaces can’t equalise, the diver may experience pain and discomfort. During ascent, if the expanding air space can’t be vented, the volume of gas in the cavity increases, resulting in more pain and discomfort.
 

The most common injuries reported to DAN are pressure related injuries (Barotraumas) to ears and sinuses. Luckily, they are easy to avoid and a little education and common sense will go a long way to avoid these problems.The ears and diving safety campaign is mainly focused on correct education and an online “Ears and Diving” Seminar is made available free of charge to DAN members (also accessible for non-members with a small fee).

 

Ear and sinus barotrauma

Middle Ear Barotrauma

Middle ear barotrauma or “ear squeeze”, is the most common diving injury and can be caused by using a bad equalising technique or because of diving with a cold. The middle ear is a dead space, connected to the upper part of throat through the Eustachian tubes. These tubes are narrow and normally closed. When using one of the equalising techniques, these tubes open and allow the higher pressure air from your throat to enter the middle ears, equalising the dead space. These tubes however can easily get blocked with mucus, due to a cold, making it impossible to equalise the middle ear. During descent, when the pressure increases, there will be a lower pressure in the middle ear and when not equalised this will lead to discomfort and pain in the ear and can sometimes even result in a ruptured eardrum.


Sinus Barotrauma

Sinus barotraumas also occur, but are less common. Sinuses are air filled cavities within the bones surrounding the nasal cavity. Each sinus is connected to the nose through a narrow opening (Sinus Ostium) making it possible for the sinuses to be permanently open to the atmosphere. When these openings become obstructed (usually due to congestion resulting from allergies, smoking, infection or overuse of topical decongestants, sinus or nasal inflammation, polyps or plugs of mucus) the sinuses can no longer be equalised. As a result, pain will be felt above the eye, at the cheek bone or at the upper teeth and/ or deep in the skull, depending upon which sinus is involved. Small nose bleeds during or after ascent are frequently experienced. This can be because the sinuses might be filling up with blood to equalise the pressure difference during the dive.


Middle Ear or Sinus Barotrauma on ascent, or Reverse Block

During ascent, air in the middle ear will expand as the pressure decreases, if the Eustachian tubes become blocked; it makes it impossible for the expanding air in the middle ear to be released. It is possible vertigo can be experienced because of the pressure on the balance mechanism in the inner ear, if this continues the expanding air can cause severe pain and damage to the ear drum. Reverse Block is usually the result of diving whilst using decongestant drugs that wear off at depth, poor equalising on descent or diving with a cold. A similar case can occur with the sinuses when the Sinus Ostium gets blocked at depth. This will result in pain in the affected sinus with or without a nosebleed and could lead to a sinus rupture in severe cases.


Inner Ear Barotrauma

If the stress on the Middle Ear becomes too great (from not equalising or trying too hard with a Valsalva technique) it can cause damage to the Inner Ear (to the hearing and balance structure), which in some cases can be permanent. Deafness, ringing in the ears (tinnitus) and Vertigo can be experienced.


Outer Ear Barotrauma

Outer Ear Barotraumas can occur when the ear canal becomes blocked, trapping air between the blockage and the ear drum. This can create excess pressure or a vacuum in the air space as the diver changes depths. Blockages can be caused by excess wax, non-vented ear plugs or an extremely tight fitting hood. Due to the increasing pressure and squeeze in the outer-ear, the surrounding tissues can fill the canal with blood and fluid or the eardrum can rupture. Pain and discomfort will be noticed and after a release of pressure (due to the eardrum rupture), the cold water entering the middle ear may lead to vertigo.


External Ear infection – Otitis Externa

With frequent immersion, water swells the cells lining the ear canal. Eventually, these cells pull apart - far enough for the bacteria normally found on the surface of your ear canal to get underneath the skin, where they find a nice warm environment and start to multiply. Next thing you know, your ear canal itches, is sore and becomes inflamed. If left untreated, the swelling can spread to the nearby lymph nodes and cause enough pain that moving your jaw becomes uncomfortable. At this point, the only treatment is antibiotics, and diving is definitely out. In some cases a discharge coming out of the external ear can be noticed. Pain with ear tugging distinguishes external ear problems from middle ear infection, where this is painless.

A special diving mask (Pro-Ear) with special air cuffs connected to the mask is commercially available and reduces the possibility of external ear infections. Also available are ear drops or sprays containing Tea Tree Oil which forms a coating on the auditory canal creating a water resistant barrier. When using these drops, the emphasis is on prevention: Once an injury has taken place these drops do not have any medicinal value and can actually cause unnecessary pain.

Symptoms and medication

Symptoms of barotraumas of the ears and sinuses

  • Presence of mild discomfort to severe pain in the sinuses or ear
  • Ringing or roaring in the ear
  • Muffled hearing, partial or complete hearing loss
  • Nausea, vomiting, dizziness (especially after experiencing ear pain)
  • Blood coming from the nose or present in sputum (even if not associated with other symptoms)
  • Pain felt above the eye, at the cheek bone or at the upper teeth and/ or deep in the skull

Divers with these symptoms should probably end the days, and possibly the week’s diving as continuing to dive might result in severe injury.

 


Treatment and medication

If you experience any symptoms during or after a dive, consult a physician (preferably an Ear, Nose & Throat specialist) to determine the extent of any injury. There may be some treatable condition causing the problem. The physician can determine the correct treatment and medication. If medication is prescribed, then check with your physician if it will interfere with safe diving. Proper care and treatment under the supervision of a physician can reduce the recovery time from symptoms of barotraumas, allowing you to return to diving sooner.

Prevention and equalising techniques

How to prevent ear and sinus barotrauma

  • Equalise before you enter the water or descend and make sure you hear the “pop” or “click” in both ears. This means the Eustachian tubes are open.
  • Descend slowly and equalise in a feet-first position and if needed extend your neck (looking up) as this tends to open the Eustachian tubes.
  • Equalise early and often (every 0.3-0.5m, especially in the beginning of the dive) until you reach the deepest point. If you feel discomfort, you may have waited too long to equalise.
  • If you can’t equalise or experience pain and discomfort during descent, then ascend slightly until the discomfort is relieved and attempt to clear again; do not forcefully clear or attempt to descend unless your ears and sinuses have equalised.
  • Don’t dive with a cold or whilst congested.
  • Do not use not-vented earplugs or a hood that is too tight as it does not allow water /air to enter the external ear.
  • If you experience pain and discomfort during ascent, you should stop or descend slightly (or point the affected ear towards the bottom) and use of one the equalising techniques to open the Eustachian tubes; ascend as slowly as possible. If you still can’t equalise you will have to endure the pain in order to reach the surface.
If you could not equalise during a previous dive then you should not be diving until the problem is resolved. It may indicate a pre-existing problem, most commonly from infection or allergies. The mucus membrane will retain fluid and swell, narrowing the pathways to the sinuses and the Eustachian tubes. This not only makes clearing difficult, but it may prevent it altogether. Some divers use nasal sprays or oral medications to temporary shrink swollen mucus membranes and aid sinus and middle ear equalisation. These medications however can wear off at depth, possibly leading to complications on ascent.


Equalising techniques

Although ear problems might be caused by a cold, it is also possible that the diver is not using the correct equalising technique. Divers should know, practice and use the “clearing” or equalising manoeuvre that works best for them:

  • Valsalva: hold nose and breathe against a closed throat
  • Toynbee: Swallow with mouth and nose closed (good for ascent)
  • Frenzel: Valsalva while contracting throat muscles with a closed throat
  • Lowry: Valsalva plus Toynbee – holding nose, gently trying to blow air out of the nose while swallowing
  • Edmonds: jutting jaw forward plus Valsalva/Frenzel
  • Miscellaneous: Swallowing, wiggling jaws (good for ascent)
Equalisation becomes more difficult as the pressure gradient between middle ear and the environment increases. Frequent gentle equalisations are more effective and less likely to cause injury than forceful equalisation, especially after significant pain has occurred. For many divers a combination of techniques works best. Since the pathway to the sinuses is normally open, sinus equalisation typically does not require any special manoeuvres.

 


Possible reasons for difficulties in equalising

  • Recent cold or congestion
  • History of ear infections or even one severe infection
  • History of a deviated septum or a broken nose, preventing one ear or set of sinuses from clearing as fast as the opposite side
  • Allergies, which may produce swelling of the mucus membranes or cause nasal polyps that can partially or completely close a sinus airway
A diver with a medical history may require referral to an Ear, Nose and Throat (ENT) Physician or Allergy Specialist.
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