“Ear Pain Management/Ear Equalizing Tips”
Descend a few feet, pinch your nose and breathe out through your nostrils, and you feel that satisfying pop as your ears equalize. Descend a bit further and repeat the process. Equalizing during a descent becomes second nature to many divers, but sometimes, it’s not that simple; congestion and poor execution of equalizing maneuvers can inhibit the process and may result in injury.
The most common diving injury is middle ear barotrauma. The middle ear is a gas-containing cavity that must maintain equal pressure across the tympanic membrane (which separates the outer ear from the middle ear). During descents, the increased pressure causes ear drums to bow inward, creating a negative pressure in the middle ear. You must use equalizing techniques to open the Eustachian tubes, which connect the middle ear to the back of the throat and allows the higher-pressure air from your throat to enter your middle ears and equalize.
In order to equalize your ears during descent, you must employ an equalizing maneuver to open the lower ends of the Eustachian tubes. Happily, there are several options available. As you descend, equalize often (approximately every two feet). Don’t force it; if you have trouble equalizing, ascend a few feet and try again. If this does not resolve the issue, discontinue the descent and safely end the dive. When you reach your maximum depth, remember to equalize again. While the pressure change may feel minimal at depth, it can still slowly cause barotrauma if air spaces aren’t equalized. Try out some of these maneuvers on land, in water or on airplanes; the more you practice, the easier it will be to employ on a dive.
Valsalva Maneuver: You probably learned the Valsalva maneuver in your first open water course. It is very simple: Pinch your nostrils and blow through your nose.
Toynbee Maneuver: Pinch your nostrils and swallow. This maneuver pulls the Eustachian tubes open and compresses air against them, helping to equalize with less force.
Lowry Technique: Pinch your nostrils, blow and swallow simultaneously (think Valsalva maneuver meets the Toynbee maneuver).
Edmonds Technique: Tense your soft palate and throat muscles, push your jaw forward and down and employ the Valsalva maneuver.
Frenzel Maneuver: Pinch your nostrils, close the back of your throat and make the sound of the letter "k."
Voluntary Tubal Opening: Tense your soft palate and the throat while pushing the jaw forward and down, similar to the first part of the Edmonds Technique. This maneuver takes a lot of practice to perfect, but eventually you may be able to hold your Eustachian tubes open during descent, allowing for continuous equalization.
Helpful Hints to Ease Equalizing
Leading up to a dive, avoid milk, tobacco and alcohol, all of which can increase mucus production and block the Eustachian tubes, making it very difficult to equalize. If you are on a dive boat, stay away from the boat exhaust as it can cause the same kind of swelling as smoking tobacco. Water in your mask may also irritate your mucus membranes, so keep your mask clear. As you prepare for your dive that day, start to practice your equalization. Test your Eustachian tubes by swallowing (if you hear the pop in both ears, the tubes are open and ready to equalize). Chewing gum and gently equalizing your ears every few minutes or so prior to a dive can make it easier to do as you dive (but get rid of the gum before you enter the water).
When you start to descend, it is easier to equalize if you descend feet first. Mucus in the Eustachian tubes tends to drain downwards; therefore, it takes less force to equalize if you are descending in a head-up position. If you look up as you try to equalize, it can help open your Eustachian tubes, thereby reducing the amount of force needed. If one ear is not cooperating, try tilting that ear upward as you attempt to equalize. If available, you can use a descent line to help control your rate of descent. Most importantly, stop if your ears start to hurt. Ascend a few feet to relieve some of the pressure, and try again. If this does not work, you may need to abort the dive to avoid injury.
Failure to Equalize: Ear Injuries & Pain Management
Failure to equalize properly may result in a variety of ear injuries, the most common of which is middle-ear barotrauma. Most divers are familiar with that one, but do you know the others?
Middle Ear Barotrauma
This injury may occur during descent, generally as a result of incomplete equalization of the middle ear, which may be due to allergies or congestion. But it can also occur on ascent if the Eustachian tubes are blocked by mucus and are unable to equalize; this is known as a reverse block. During descent, equalization is an active process, requiring specialized maneuvers to maintain pressure balance. Equalization on ascent is a passive process; the air in the middle ear is at a higher pressure and vents on its own via the Eustachian tubes. If you have congestion, it’s sometimes possible to equalize during descent by forcing air through mucus, but it may then act as a “one-way valve” during ascent, preventing proper venting and resulting in a reverse block. A feeling of fullness in the ear (like there is water or fluid trapped in it) and crackling sounds are characteristic signs of middle ear barotrauma. This injury may be painful and susceptible to infection. If you have these symptoms, discontinue diving and seek a medical evaluation.
Inner Ear Barotrauma
Improper equalization or forceful attempts can lead to inner ear injury. A diver with inner ear barotrauma may experience vertigo, tinnitus (ears ringing), hearing loss, nausea and vomiting. If this occurs, administer oxygen and seek emergency medical care. These symptoms also represent possible inner ear decompression sickness, which may require hyperbaric treatment.
Outer Ear Barotrauma
A tight hood, a blockage of ear wax or ear plugs may create a dead air space in your outer ear that cannot be equalized during descent. If this happens, the eardrum will bulge outwards and the pressure will cause the surrounding tissues to fill the ear canal with blood and fluid. As a result, your ear will have a feeling of fullness, similar to middle ear barotrauma. Keep your outer ears clear to prevent creating this dead air space.
Similar to middle ear barotrauma, this injury may result from impaired equalization of the sinuses and can occur on descent or as a reverse block. Symptoms include facial pain, and possible blood from the nose or mouth. Seek a medical evaluation if you experience these symptoms.
Alternobaric vertigo may occur during a dive as a result of differential equalization of your two middle ear spaces. This typically occurs during either ascent or descent and is resolved by the time you surface.
Caloric vertigo may happen if the ears are exposed to unequal water temperatures. For example, if you put one side of your head in the water before the other, the unequal water temperatures may make you feel dizzy. This form of vertigo resolves when the water in your ears is warmed to equal temperatures.
If vertigo happens underwater and you are unable to tell which direction is up, do not panic. Simply observe the water in your mask to judge your orientation and follow your bubbles to make a slow, controlled ascent. Vertigo may also be a symptom of a more serious ear injury, and if it is not resolved after surfacing should be evaluated by a doctor.
This injury is unrelated to equalization and the only condition for which ear drops should be used (to prevent it), because Swimmer’s ear is an external ear infection known as otitis externa. Do not use ear drops to treat ear injuries, they may cause unnecessary pain and will not successfully treat the injury.
In severe cases of barotraumas, the ear drum may be perforated, resulting in pain and possible infection. If you surface experiencing ear pain or tinnitus, you should discontinue diving and seek a medical evaluation. Do not dive until symptoms are gone. If you have any questions, contact the DAN Medical Information Line at +1-919-684-2948 or via email.
For more information about ears and ear injuries, you can read the DAN Diving Medicine FAQs on ear equalizing or Stop the Drops! Ear Pain Management. You can also download the “Divers Guide to Ears” or take DAN’s online seminar “Ears and Diving.”