Hear, Hear … Or, Don’t

Eugene R. Worth, M.D.

At one time or another, every diver has had some type of difficulty with ears. Ear problems in diving don’t usually affect hearing, but they certainly can. This installment about diving health will deal with common diving abnormalities in the ears and sinuses. There are two basic mechanisms of ear injury in SCUBA: moisture and pressure. Not only are ear problems common, they are the most likely problems that will keep you out of the water. In general, when surrounded by water, our ears are less able to distinguish where a particular sound originates. This does affect our ability to hear and becomes more problematic at greater depths and pressures. To some extent, the sounds we hear are distorted by breathing gases – divers breathing helium are much more difficult to understand, sometimes requiring speech descramblers. The most common moisture problem involving the ears is infection. Modified sweat glands in the ear canal produce ear wax, called cerumen. Cerumen is a natural barrier to water and bacteria, but continuous soaking dissolves the protective earwax. When the ear loses its protective wax and is waterlogged, any minor trauma (Q-tip, fingernail, etc.) can lead to infection called swimmer’s ear. Swimmer’s ear usually has a rapid onset of intense ear pain, made worse by chewing or touching the parts of the outer ear. In fact, this exquisite pain when touching or tugging on the ear sets it apart from a middle ear infection. In order to prevent swimmer’s ear (external otitis), you should chemically dry your ears when leaving the water. My favorite drying solution consists of equal parts of household vinegar and rubbing alcohol. Several drops of this solution in the ear canal, followed by a gentle tug on the outside of the ear will displace the water, quickly evaporate (alcohol), and make an acidic pH (vinegar) in the ear canal. These actions help prevent infection. Commercial agents such as Swimmers Ear or Auro Dry are available at Dive Addicts as well. Should you have an ear infection, this solution alone may help clear it. More severe infections require antibiotic ear drops. And, if your ear canal is swollen and inflamed, a cotton wick down the canal may be needed in order to get the antibiotic drops to the eardrum. If you do use antibiotic drops, it is important to finish the ten-day course, even when your ear feels better. Pressure problems in the ear are more complicated. We will discuss the common pressure problems and only mention the more uncommon, but substantially more serious, problems. The most common of the pressure problem is ear barotrauma. The ear consists of an external canal, the middle ear space, and the inner ear. The tympanic membrane separates the external canal from the middle ear space. A very thin layer of bone and a movable window on which the bones of the middle ear rest separate the middle ear from the inner ear. The middle ear space, behind the tympanic membrane and outside the inner ear, becomes a problem when we don’t clear our ears correctly. The middle ear space is always absorbing oxygen, and always has a negative pressure when you are out of the water. You don’t realize that you naturally clear your ears every 5 minutes during waking hours. A yawn, a swallow, or wiggling your jaws equalizes the pressure naturally. When we SCUBA, we must be more active about clearing. Most divers get into trouble by not clearing frequently enough. I clear at the surface before getting into the water, then clear immediately before starting to descend then every foot or so during descent. A rapid descent means that you need to clear with every breath. You remember Boyle’s law don’t you? I didn’t think so. The air space in the middle ear decreases as the ambient pressure around it increases. Now you remember? Great! The largest differential change in pressure occurs very close to the surface. Simply summarizing the physics, you can descend as little as 3 feet seawater and collapse the Eustachian tube then not be able to equalize regardless of how much effort you put into the process. If you continue to descend, the feeling of pressure becomes pain and the eardrum ruptures. Oopppsss … That becomes a bad day. Rupturing the eardrum leads to a brief but intense dizziness as cold water rushes into the middle ear space. Later the pain returns as infection sets in, but you didn’t want to know about that. How do we equalize? The most common method is the Valsalva maneuver, where you pinch both nostrils, close your mouth and try to blow the air out of your ears. While this works well, most novice divers are either too gentle or too vigorous with the activity, making it less effective. If you are too vigorous, you can over-correct and cause the eardrum to tent outward, still feeling pressure in the ears. If you blow vigorously enough, for long enough, you can actually rupture the movable membrane on the inner ear and cause inner ear barotrauma. This is now a really, really bad day! So, if Valsalva doesn’t equalize within five seconds … stop doing it. Halt your descent immediately, in fact ascend several feet and try another equalizing maneuver. Remember no other maneuver will work until you diminish the pressure collapsing the Eustachian tubes, so you must ascend a few feet. It is almost always easier to equalize when descending feet first rather than head first. Other maneuvers include the Toynbee, which is pinching the nose and swallowing while your nose is pinched. A combination maneuver is pinching the nose, gently blowing, and swallowing at the same time. Yes, it can be done even with a regulator in your mouth. You can also look up, keeping your shoulders level, then tilt the head to one side while gently blowing and repeat for the other side. Finally, another favorite of mine is jutting your lower jaw forward as far and you can. This puts the back of the throat (where the Eustachian tubes enter) stretched. Now, Valsalva gently and listen for a pop or squeak as air fills the middle ear. Once the pressure is equalized continue your descent. Remember that ear or mask squeezes are the primary limiters for a rapid descent. With practice at the surface, you will clear easily and recognize when you must clear. What happens after you have an equalization issue and then surface? Frequently, you end up with one ear (or both) that feel stuffy at the surface. You have removed the water from the external canal, but you hear gurgling when you bend over and the stuffiness will not go away. Welcome to the world of ear barotrauma. If you didn’t rupture your eardrum, the fluid in the middle ear usually goes away over several days. I have some helpful hints that you can try. While you can continue to SCUBA with fluid filled middle ears, why compound the problem? Stop diving for the day. Using a nasal steroid spray (like Nasalcort or Flonase) will help decrease the swelling of the Eustachian tubes. A more rapid-acting nasal spray is Afrin, however using it frequently or for more than 3 or 4 days can actually make the swelling worse from a rebound phenomenon. Equally effective is to gently clear your ears every hour or so while awake, encouraging the fluid to escape the middle ear through the Eustachian tube. Be gentle. Fluid issues usually resolve after 2 to 4 days. Sinus problems when diving are more troublesome. You can practice ear equalizing and become efficient at doing it. When you have a sinus squeeze, you can do very little under the water to relieve this problem. If you get a sinus squeeze, you will likely need to surface and call it a day. Having a nasal steroid and/or Afrin in your dive bag can help. The openings to the sinus are very small, and any swelling around that tissue makes it impossible for the pressure in the sinus to equalize with the nose. So, use the nasal sprays in order to reduce the swelling. Once you feel the pressure in the sinus diminish, you can try diving again. Dizziness (you are whirling) or vertigo (the room is whirling) should never be ignored. These symptoms may mean that your eardrum is ruptured or that you have an inner ear barotrauma or inner ear decompression illness. If you have these problems, you need to see a diving medicine or ear, nose, and throat doctor as soon as possible. In summary, ear problems are common among divers. You can control external ear infections by making sure that your ears are dry and the pH is acidic whenever you finish diving for the day. You can avoid ear barotrauma by practicing different equalization techniques on the surface. Find a method that works well for you and adapt it to having a regulator in your mouth. Remember that equalizing with every breath while descending is an excellent idea! Finally, never … never … never hold your breath and equalize your ears during ascent. This can result in an air gas embolism. If you feel pressure on the ears, just move your jaws around. The increased middle ear pressure will almost always find its way out of the Eustachian tube without your help. Until next time, keep those bubbles rising!