Diving ear pain: First Aid Treatment for Scuba Divers with Ear Pain
Chapter 2: Injuries – Divers Alert Network
Ear injuries are the leading cause of morbidity among scuba divers. The most common injury is middle-ear barotrauma (MEBT). Most cases of MEBT are mild, heal spontaneously and are never reported. In more serious cases, divers seek medical attention, and some call DAN. Various surveys indicate that more than 50 percent of all divers experience MEBT at least once. In contrast, only 4.4 percent of divers experience DCS in their lifetime.
Divers are affected by various other ear injuries, many of which are preventable, detailed in the chapter that follows.
In this chapter, you’ll learn about:
Middle-Ear Barotrauma (MEBT)
Middle-ear barotrauma is the accumulation of fluid and blood in the middle ear or rupture of the eardrum as a consequence of failed equalization of pressure in the air space of the middle ear during diving or flying.
The air pressure in the tympanic cavity — air-filled space in the middle ear — must be equalized with the pressure of the surrounding environment. The Eustachian tube connects the throat with the tympanic cavity and provides passage for gas when pressure equalization is needed. This equalization normally occurs with little or no effort. Various maneuvers, such as swallowing or yawning, can facilitate the process.
An obstruction in the Eustachian tube can lead to an inability to achieve equalization particularly during a descent when the pressure changes fast. If the pressure in the tympanic cavity is lower than the pressure of the surrounding tissue, this imbalance results in a relative vacuum in the middle ear space. It causes tissue to swell, the eardrum to bulge inward, leakage of fluid and bleeding of ruptured vessels. At a certain point an active attempt to equalize will be futile, and a forceful Valsalva maneuver may actually injure the inner ear. Eventually, the eardrum may rupture; this is likely to bring relief from the pain associated with MEBT, but it is an outcome to be avoided if possible.
Factors that can contribute to the development of MEBT include the common cold, allergies or inflammation — conditions that can cause swelling and may block the Eustachian tubes. Poor equalization techniques or too rapid descent may also contribute to development of MEBT.
Divers who cannot equalize middle-ear pressure during descent will first feel discomfort in their ears (clogged ears, stuffed ears) that may progress to severe pain. Further descent only intensifies the ear pain, which is soon followed by serous fluid buildup and bleeding in the middle ear. With further descent, the eardrum may rupture, providing pain relief; this rupture may cause vertigo, hearing loss and exposure to infection.
While diving: When feeling ear discomfort during descent, you should stop descending and attempt equalization. If needed, ascend a few feet to enable equalization. If equalization cannot be achieved, you should safely end the dive.
First aid: When feeling fullness in one’s ears after diving, abstain from further diving. Use a nasal decongestant spray or drops. This will reduce the swelling of nasal mucosa and Eustachian tube mucosa, which may help to open the Eustachian tube and drain the fluid from the middle ear. Do not put any drops in your ear.
Treatment: Seek a physician evaluation if fluid or blood discharge from the ear canal is present or if ear pain and fullness lasts more than a few hours. If vertigo and dizziness are present, which may be a symptom of inner-ear barotrauma, you should seek an urgent evaluation. Severe vertigo and nausea after diving require emergency medical care.
Fitness to Dive
Return to diving may be considered if a physician determines that the injury is healed and the Eustachian tube is functional.
- Do not dive with congestion or cold.
- Descend slowly. If unable to equalize after a few attempts, safely end the dive to avoid significant injury that may prevent you from diving the rest of the week.
Tympanic Membrane Rupture (Perforated Eardrum)
Tympanic membrane perforation is a tear of the eardrum, which can occur while scuba diving due to failed middle-ear pressure equalization.
The tympanic membrane (TM) is a tissue separating the external ear from the middle-ear space. It is attached to a chain of small bones (auditory ossicles) located in the middle ear. The TM also serves as a barrier between the sterile middle-ear space and the ambient environment.
Eardrum rupture may be caused by descending without equalizing the pressure in the middle ear, by a forceful Valsalva maneuver, explosion, a blow to the ear/head, or acoustic trauma. It is usually accompanied with pain; rupture relieves the pressure (and pain) in the middle ear and may be followed by vertigo. There may be some bleeding in the ear canal.
Contributing factors include congestion, inadequate training and excessive descent rates.
- Ear pain during descent that stops suddenly
- Clear or bloody drainage from ear
- Hearing loss
- Ringing in the ear (tinnitus)
- Spinning sensation (vertigo)
- Nausea or vomiting that can result from vertigo
Most perforated eardrums will heal spontaneously within a few weeks. It may be necessary to treat nasal and sinus congestion. If the tear or hole in your eardrum does not heal by itself, treatment will involve procedures to close the perforation. These may include:
- Eardrum patch: An ENT specialist may seal the tear or hole with a paper patch. This is an office procedure in which an ENT applies a chemical to the edges of the tear to stimulate growth and then applies a paper patch over the hole to provide a support structure for the growth of eardrum tissue.
- Surgery: Large eardrum defects may be fixed by surgery (tympanoplasty). An ENT surgeon takes a tiny patch of your own tissue and plants it over the hole in the eardrum. This procedure is done on an outpatient basis, meaning you can usually go home the same day unless medical conditions require a longer hospital stay.
For an ENT referral in your area, email *protected email* or call the DAN Medical Information Line at +1 (919) 684-2948.
Fitness to Dive
If your physician feels the healing is solid and there is no evidence of Eustachian tube problems, you can return to diving within several months. Chronic perforations that do not heal are a contraindication to diving.
Do not dive with congestion. Maintain a comfortable rate of descent, and equalize as needed.
O’Neill Grading System
The O’Neill grading system is a new way to grade the severity of middle-ear barotrauma. It is simplified and is expected to provide more consistent diagnosis with sufficient details to direct the treatment.
Eustachian Tube Dysfunction
- Baseline photo depicting anatomical appearance of the TM before exposure to pressure
- Symptoms with no anatomical change (no trauma) from baseline
- Erythema increased from baseline
- Fluid or air trapping (visible bubble) in the middle-ear space
- Any bleeding noted within the tympanic membrane or middle-ear space
Inner-ear barotrauma is damage to the inner ear due to pressure differences caused by incomplete or forceful equalization. A leak of inner-ear fluid may or may not occur.
Mechanisms of injury
The inner ear is separated from the external world by the middle ear. It is the organ for hearing and balance. When the pressure in the middle-ear space is properly equalized, the risk of inner-ear barotrauma is extremely low.
If the pressure in the middle ear is not equalized during descent, the water pressure on the eardrum transfers inward through the middle-ear ossicles to the oval windows, and the round window bulges outward. The pressure itself may damage sensitive inner-ear structures. If the pressure is excessive, either the oval window or, more commonly, the round window may tear, and the inner-ear fluid (perilymph) may leak into the middle ear (perilymph fistula).
The Valsalva maneuver increases the pressures in cranial tissues and circulation, which may transmit to the cochlear fluid, causing an outward movement of the round window. Pressure waves alone can cause damage to the inner ear without window rupture. If the rupture occurs, the loss of fluid from inner ear leads to damage of the hearing organ and sometimes of the balance organ. If the leak is not stopped soon by spontaneous healing or surgical repair, permanent hearing loss may occur.
Divers may experience:
- Severe vertigo
- Hearing loss
- Ears roaring/ringing (tinnitus)
- Involuntary eye movement (nystagmus)
- Fullness of the affected ear
Symptoms of middle-ear barotrauma are almost always present. Vertigo is usually severe and accompanied by nausea and vomiting. Hearing loss can be complete, instant and permanent, but divers usually lose just the higher frequencies. The loss becomes noticeable only after a few hours. You may not be aware of the loss until you have a hearing test.
In case of vertigo underwater, abort the dive, and obtain assistance to reach the surface safely. Begin surface oxygen if decompression illness is suspected. First aid providers should conduct a complete neurological exam and note any deficits.
Inner-Ear Barotrauma or Inner-Ear Decompression Sickness?
It is important to distinguish between these two conditons, because their treatments differ. The standard treatment for DCS of any kind is hyperbaric oxygen treatment in a recompression chamber; recompression or any pressure change is contraindicated when inner-ear barotrauma is likely. While the symptoms are similar in both conditions, barotrauma is preceded by failed equalization of middle-ear pressure and usually occurs at the beginning of dive, while DCS occurs due to failed decompression at the end of the dive.
Urgently seek an evaluation by a physician to rule out DCS. If your physician determines it is not DCS, consult an ENT specialist with experience treating divers. For a referral in your area, email *protected email*, or call the DAN Medical Information Line at +1 (919) 684-2948.
Avoid any exertion, middle-ear equalization, altitude or diving exposure, sneezing or nose blowing. Do not take aspirin, nicotinic acid (vitamins), other vasodilators or anticoagulants. Conservative treatment includes bed rest in a sitting position and avoiding any strains that can increase intracranial or middle-ear pressure. If symptoms do not improve, surgery may be necessary. Healing of the tear (fistula) usually occurs within a week or two. Hearing loss may become permanent.
Fitness to Dive
Evaluation of fitness to dive requires an expert diving physician and depends on the degree of permanent damage as well as the probability of repeated injury.
In many cases, complete healing occurs spontaneously. If fistula presents and does not heal soon spontaneously, surgery may be recommended. In some cases, the inner ear may be damaged permanently; the body may adapt to one side not working properly. If injury occurs to the other ear, the situation can be serious and may involve incapacitating balance problems.
Learn gentle but effective equalization techniques, and avoid aggressive employment of the Valsalva maneuver. Do not dive when congested.
A perilymph fistula is a tear in the round- and/or oval-window membranes through which inner-ear fluid (perilymph) is leaking.
Leakage of perilymph from the labyrinth may occur when the round or oval window is disrupted due to severe middle-ear barotrauma or forceful Valsalva maneuver.
The symptoms of perilymph fistula may include dizziness, vertigo, imbalance, nausea and vomiting. Some people experience ringing (tinnitus) and fullness in the ears, and many notice some hearing loss. Symptoms worsen with changes in altitude (elevators, airplanes or travel over mountains), weather changes and with physical exertion.
This condition can usually be managed conservatively with absolute bed rest in the sitting position. Straining, sneezing, nose blowing, sexual activity, loud noises and middle-ear equalizing should be avoided to prevent pressure waves in the inner ear.
The round-window fistula often heals spontaneously within a week or two with this regimen, but if hearing loss progresses or the other features persist, it may be necessary to resort to surgery to repair the round-window leak.
Fitness to Dive
Even after the acute symptoms of an oval- or round-window fistula have resolved, the diver’s future in diving is questionable. Flying should be completely avoided for several months to allow complete healing of the injury or the surgical repair.
For a referral in your area, email *protected email*, or call the DAN Medical Information Line at +1 (919) 684-2948.
Ensure the Eustachian tubes are functioning properly before diving by gently equalizing on the surface.
Alternobaric vertigo occurs during descent, ascent or immediately after surfacing from a dive and is caused by unequal pressure stimulation in each ear.
According to various sources, up to 25 percent of divers experience alternobaric vertigo at some time.
During ascent, air in the middle-ear space expands, relative pressure increases, the Eustachian tubes open passively, and gas escapes through the Eustachian tubes into the nasopharynx. Occasionally the Eustachian tube may obstruct this flow of air, with subsequent air distension and increased pressure sensation in the middle-ear cavity during ascent. If the obstruction is one-sided and the pressure difference is greater than 60 centimeters of water, vertigo may occur as the pressure increase stimulates the vestibular apparatus. Usually it is relieved by further ascent, because the increasing differential pressure in the middle-ear space forces open the Eustachian tube and vents the excess air. Contributing factors include middle-ear barotrauma during descent, allergies, upper respiratory infections (congestion) and smoking.
The symptoms of alternobaric vertigo may include disorientation, nausea and vomiting.
Note: The disorienting effects of vertigo while diving are extremely dangerous. The inability to discern up from down, follow safe ascent procedures, and the risks associated with vomiting pose a significant hazard to the diver as well as other divers in the water.
Advice provided by Dr. Carl Edmonds about how to manage alternobaric vertigo during a dive:
“If a diver encounters ear pain or vertigo during ascent, he should descend a little to minimize the pressure imbalance and attempt to open the Eustachian tube by holding the nose and swallowing (Toynbee or other equalization maneuver). If successful, this equalizes the middle ear by opening it up to the throat and relieves the distension in the affected middle ear.
“Occluding the external ear by pressing in the tragus (the small fold of cartilage in front of the ear canal) and suddenly pressing the enclosed water inward may occasionally force open the Eustachian tube. If this fails, then try any of the other techniques of equalization described previously, and attempt a slow ascent. ”
Uncomplicated cases resolve quickly within minutes upon surfacing. If symptoms persist, see your primary care physician or an ENT specialist. Do not dive if you have equalization problems.
Associated injuries include middle-ear barotrauma and inner-ear barotrauma; alternobaric vertigo may occur during descent or ascent, but is commonly associated with a middle-ear barotrauma of ascent (reverse squeeze). Other conditions such as inner-ear DCS or caloric vertigo (when cold water suddenly enters one ear) should be ruled out.
Fitness to Dive
As soon as all symptoms and contributing factors have been resolved, a diver may return to diving.
Take measures for the prevention of ear barotraumas. Avoid the unequal pressurization of the ear by avoiding tight-fitting wetsuit hoods or earplugs. Maintain good aural hygiene. Do not dive when congested or unable to equalize.
A reverse squeeze is barotrauma due to an inability to release pressure from the middle ear on ascent.
Pressure must be released from the middle ear as the diver ascends, or the expanding air will bulge and even rupture the eardrum. Expanding air normally escapes down the Eustachian tubes, but if the tubes are blocked with mucus at depth (usually the result of poor equalization on descent, diving while congested or relying on decongestants that wear off at depth), barotrauma can result.
- Pressure, fullness in ear
- Ear pain
While diving: Sometimes one of the equalizing techniques used on descent will clear your ears on ascent. Pointing the affected ear toward the bottom may help, too. Ascend as slowly as your air supply allows. Increasing pressure usually opens the Eustachian tube and relieves overpressure. However, in rare cases it may persist all the way up. In that case, you will have to endure the pain to reach the surface. Notify your buddy, and stay in close proximity.
First aid: Nasal decongestant spray may help open the Eustachian tube. A physician evaluation is advised if you experience vertigo, protracted pain and fullness of the ears.
Fitness to Dive
Repeated episodes require an ENT evaluation. For an ENT referral in your area, email *protected email*, or call the DAN Medical Information Line at +1 (919) 684-2948.
Prior to diving, try equalizing on the surface to ensure Eustachian tube function is adequate.
Facial baroparesis is reversible paralysis of the facial nerve due to increased pressure in the middle ear when ascending in an airplane or from scuba diving.
Mans Bell’s Palsy
The facial nerve is a cranial nerve that controls the muscles of the face. On its way from the muscle to the brain it passes through the channel in the wall of the middle-ear space. Pressure changes in that space normally have little or no effect on the nerve.
In some people, the canal of facial nerve misses the bony wall and is separated from the middle-ear cavity by only a thin membrane. If such a person experiences an overpressure in the middle ear equal or greater to the capillary pressure, circulation to the facial nerve stops, the facial nerve loses its functionality and facial muscle is paralyzed (facial baroparesis). This can happen while flying or diving. Fortunately, the pressure in the middle ear returns to normal soon after the exposure, restoring the circulation to the nerve and enabling its functionality. Facial baroparesis tends to recur with flying or repeated diving.
Symptoms include numbness, paresthesia, weakness or even paralysis of the face. Decreased sensation and a facial droop can be seen, generally on one side of the face.
Facial baroparesis usually is discovered postdive. Even when its duration is brief and it resolves spontaneously, the patient should be evaluated by a physician to exclude other possible causes such as stroke, infection, trauma or decompression sickness.
In rare instances of protracted facial baroparesis, treatment may be necessary. There is experimental evidence that overpressure lasting more than 3.5 hours may cause permanent damage. Divers who continue to experience facial numbness and drooping should see a physician within three hours.
Fitness to Dive
This condition is self-limiting and resolves spontaneously within hours, but it can recur with diving or flying. Return to diving may be considered when symptoms have completely resolved and have been determined to be the result of facial barotrauma.
Learn gentle but effective equalization techniques. Do not dive with congestion.
Temporomandibular Joint Syndrome (TMJ)
Temporamandibular joint syndrome is pain in and around the temporomandibular joint caused by prolonged gripping of a mouthpiece from a snorkel or scuba regulator.
It has been reported that TMJ occurs in 15-20 percent of snorkelers and scuba divers.
TMJ is a chronic inflammation of the jaw joint just in front of the ear. The pain can be great enough to make holding the mouthpiece between the teeth difficult. The condition is exacerbated by local factors such as joint laxity, anatomical factors, capsular or muscular inflammation, or the type of mouthpiece used.
Diving-associated TMJ is thought to result from the forward posturing of the mandible by an ill-fitting mouthpiece and clenching of the mouthpiece, especially with heavy regulators. Diving may aggravate preexisting TMJ. The pain is sometimes severe enough to cause divers to abort the dive. It can occur in novice divers who clench their teeth, sometimes with such intensity that they occasionally bite through the mouthpiece.
- Pain in the TMJ and ears
- TMJ clicking or crepitus (cracking or popping sound)
- Trismus (inability to open mouth fully) and impaired TMJ mobility
- Dizzy spells (could be hazardous should it occur underwater)
- Masticatory muscle pain
- Stuffy sensation in the ears
- Eustachian tube dysfunction
- Headache and facial pain
While diving: Work to relax your bite while retaining the mouthpiece in place. If unsuccessful, safely end the dive, surface and consider alternative mouthpiece options.
Definitive treatment: If pain persists, a consultation with a specialist is suggested as solutions are highly individualized. Treatment includes bite adjustment, management of dental problems and the use of orthodontic mouthpieces. Heat and anti-inflammatory drugs are helpful.
Fitness to Dive
Return to diving is possible upon pain resolution. You must also be able to grip the mouthpiece without pain.
Use only a mouthpiece that fits properly. Consider a customized mouthpiece. Correct contributing conditions such as dental problems, anxiety and teeth grinding (bruxism).
Surfer’s ear is the narrowing of the outer ear canal due to an abnormal growth of bone caused by exposure to cold and wet conditions.
The external ear canal is a tubular structure that conducts sounds and protects the middle ear. Exostosis is a chronic condition characterized by narrowing of the inner half of the ear canal as a result of bone growth. The bony wall grows outward slowly over a period of years in response to local irritation by cold water. These growths are called swimmer’s nodes and are common in swimmers, surfers and divers. This condition is not related to infection nor is it caused by infection; however, the narrowing of the ear canal may prevent water from draining out, which increases susceptibility to outer-ear infections. The bony swellings continue to grow while there is a continued exposure to cold water (such as that found in seawater and outdoor swimming pools in temperate climates). Exostosis often occurs in outdoor enthusiasts in their mid- to late-30s, but individuals who experience significant cold-water exposure — such as surfers, swimmers and divers — can develop the condition earlier.
The narrowed ear canal is more prone to blockage by earwax or debris and more susceptible to swimmer’s ear (otitis externa). An exostosis on the floor of the ear canal can form a sump that retains moisture and is susceptible to infection. Exostosis is seen as a narrowing of the ear canal. The average ear canal is about 0.25 inches wide (7 milimeters). The bone growth may cause it to narrow to 0.04 inches (1 millimeter). Early signs include water trapping in the ear canal after swimming. Debris trapping and infections may make surgery necessary.
External ear infections and difficulty removing water from the external ear canal may be recurrent. Exostosis symptoms in advanced cases include a decreased hearing possibly combined with an increased prevalence of ear infections.
Other causes of external ear-canal obstruction could include infection or earwax (cerumen) impaction.
In case of decreased hearing or repeated infections, exostosis may be removed surgically.
Fitness to Dive
Exostoses do not affect fitness to dive unless they are occluding the ear canal or causing recurrent infection.
- Wear a hood in cold water.
- After diving, rinse both ears with freshwater to flush contaminated water and salt.
- If prone to ear infections, blow warm air into external canal using a hair dryer (take care to make sure the air is not too hot).
- If your ears have a natural tendency to build up a blockage of earwax, have them checked regularly, particularly before a prolonged diving trip.
Acute inflammation or infection of the outer ear (pinna and ear canal) caused by prolonged exposure to wet and warm conditions is known as swimmer’s ear.
Otitis externa affects one in 200 Americans every year and is present in chronic form in 3-5 percent of the population. Swimmers, surfers and other individuals who are exposed to wet and warm conditions are at an increased risk.
The external auditory canal is the tubular opening between the outside environment and the eardrum (tympanic membrane). It is covered by skin and secretes earwax (cerumen), which helps protect against infection.
Otitis externa, commonly referred to as swimmer’s ear, is the acute inflammation or infection of the external auditory canal, resulting in ear pain and pus discharge.
Breakdown of the external ear canal’s protective barrier leads to infection. Excessive moisture, mechanical trauma or underlying skin conditions are contributing factors. The bacteria normally found in the external ear canal often trigger the infection. With frequent immersion, water swells the cells lining the ear canal. Eventually, these cells separate far enough for the bacteria that are normally found on the surface of the ear canal to penetrate the skin, where they find a warm environment and start to multiply. Otitis externa is more likely to develop if the skin in the ear canal is already chafed and cracked by excessive moisture from showering or scratching. Bacteria or fungus from the water can easily invade damaged skin.
Seborrheic dermatitis, psoriasis and excessive cleaning of wax from the ears that injures the skin lining the external ear canal may increase susceptibility of the ear canal to infection. Excessive debris or cerumen may trap water in the canal.
The chief complaint is generally itching often accompanied by pain, tenderness and swelling of the ear canal. If left untreated, the swelling can increase to include nearby lymph nodes and produce enough pain that moving the jaw becomes uncomfortable.
- Avoid getting in the water until after the problem clears up.
- Use a hair dryer to carefully dry the ear after you shower (take care to ensure the air is not too hot).
- In case of pain, over-the-counter pain medications can be effective. Examples of such medications include acetaminophen (Tylenol), ibuprofen (Advil or Motrin) or naproxen (Aleve). Read and follow all instructions on the label.
Stop swimming and diving; schedule an appointment with your physician. Do not put anything in your ear unless instructed to do so. If you have diabetes or take medicine that suppresses your immune system, swimmer’s ear can cause severe problems that require immediate medical attention.
It is important for your physician to rule out external ear squeeze, otitis media and mastoiditis (infection of the bone just behind the ear).
Fitness to Dive
Return to diving is possible once your physician determines that the infection
Keep your ears clean and dry.
- Dry ears with a towel after swimming or showering by tilting your head and pulling your earlobe in different directions while your ear is facing down.
- Refrain from putting objects — such as cotton swabs or your finger — in the ear canal or removing ear wax yourself; both actions can damage the skin, potentially increasing the risk of infection.
- You can dry your ears with a blow dryer if you put it on the lowest setting and hold it at least a foot (about 0.3 meters) away from the ear.
- Talk to your doctor about whether you should use alcohol-based eardrops after swimming.
If you know you don’t have a punctured eardrum, you can use over-the-counter eardrops or homemade preventive eardrops before and after swimming. This mixture of one part white vinegar to one part rubbing alcohol may help promote drying and prevent the growth of bacteria and fungi that can cause swimmer’s ear. At the end of each day of diving, put five drops of the solution into each ear. Let it stay for five minutes before draining back out.
Next: Chapter 3 – Symptoms >
Diving and Ear Problems | Michael Rothschild, MD
As an avid scuba diver and a medical moderator for an online scuba forum, I answer more questions about ear problems than anything else in the context of diving. The ear is uniquely positioned to be vulnerable to both external and internal injury in this sport. Furthermore, there is a great deal of confusion about the nature of these problems – the relevant anatomy, the causes of symptoms and the best treatment.
To make things worse, even people who have obtained medical care may have no better understanding of the source of their pain, dizziness or hearing loss. This is because even for many brilliant and experienced general physicians, the ear can be difficult to examine. And while pediatricians generally have a lot of ear experience, they rarely treat scuba divers! I realize that this sounds arrogant on my part – believe me, I am humble about my own skills and deferential to GPs who must be able to manage a wide range of life threatening conditions. However, the fact remains that many doctors who are not otolaryngologists (ENTs) do not have the specialized equipment or experience necessary to clean the ear thoroughly, to examine the eardrum under high magnification, and to test hearing in a comprehensive manner.
One of the greatest sources of confusion is the fact that the outer ear, middle ear and inner ear – which are completely different systems that have very little to do with each other – often can give rise to similar symptoms such as ear pain, vertigo or hearing problems. So let’s review each of the three main parts of the ear, and see how diving can affect them.
The outer ear refers to the part that sticks out of the head (the pinna) and the hole that leads to a tube (the ear canal) that ends at the eardrum. It is basically a pocket of skin, and it is where earwax (cerumen) is created and accumulates. Cerumen is a normal substance which protects the ear canal – it is generally just a thin layer coating the walls, but some people accumulate large amounts of it. It consists mostly of dead skin, mixed with various oily secretions from glands in the outer ear.
When water gets into the ear from swimming or diving, it gets into the ear canal. Unless there is a hole in the eardrum, the water from swimming or diving does not enter the middle ear.
Water from swimming or diving can get stuck in the external ear canal, especially if there is a lot of earwax. Furthermore, wet earwax takes a long time to dry out. Just like in cases of diaper rash or athlete’s foot, when an area of the body stays damp and dirty, it can lead to chronic inflammation and swelling, with skin breakdown and infection (usually with the pseudomonas bacteria that normally lives in this area). This inflammatory condition of the outer ear is called “swimmer’s ear” or otitis externa, and it can be extremely painful.
People who spend a lot of time in cold water can get bony growths in their ear canals (osteomas, or “surfer’s ear”). These can trap earwax and water if they get big enough. The growths occasionally require surgical removal.
Treatment of swimmer’s ear often requires carefully cleaning the wet debris from the ear canal to allow the ear to dry. This is best done by an ENT doctor using a microscope and small ear tools, under direct vision. This will also allow for a high magnification inspection of the eardrum, to rule out a perforation or other middle ear problems. Once the ear is clean, medicated ear drops are used, generally those containing an antibiotic to kill the bacteria, and a steroid to help with the swelling and pain.
Thorough disimpaction of large accumulations of cerumen (under direct vision, ideally with a microscope) will help avoid water trapping and prevent swimmer’s ear. But overly aggressive and frequent ear cleaning, especially with wax-dissolving drops, can actually make the situation worse by removing the protective layer of cerumen.
Drying the ear after swimming can help prevent this problem as well. A good way to do this is with a dedicated ear dryer, which blows a gentle stream of warm air into the ear canal. While a hair dryer can be used, an ear dryer is safer and directs the correct temperature air directly into the canal. Interchangeable tips can let family members share the device without sharing infections.
There are some ear drops that will help prevent the swelling and breakdown of the ear canal skin by lubricating the area and coating it lightly. I use something called EarShield myself when on dive trips with prolonged water exposure.
Another approach to prevention of swimmer’s ear is the use of 5-10 drops of a solution of rubbing alcohol and white vinegar after diving. Add three tablespoons of vinegar to a pint of alcohol. Unlike the 50-50 mixes which are sometimes recommended, this makes a mixture that does not have a lot of water in it. The alcohol dries the ear, and the vinegar makes the ear canal more acidic, which makes it harder for the pseudomonas bacteria to grow; you need very little vinegar for this purpose. A few drops of glycerine in the mix can help prevent overdrying. One easy way to make this is to add a small amount of white vinegar to commercially available solutions like “Swim-Ear”, which is 95% isopropyl alcohol and 5% glycerine. A half of a teaspoon in the one ounce bottle is enough.
Avoid overuse of this solution, as it can overdry the ear, breaking down the protective layer of earwax and causing irritation – no more than once or twice a day. Cotton tipped applicators should never be used – they tend to pack the wax into the ear canal, and can cause permanent injury if they touch the eardrum.
The middle ear is the space behind the eardrum. It is lined with mucosa, which is the same sort of “skin” that lines the mouth and nose. It also contains the three bones of hearing, known as “ossicles”, which carry sound vibrations from the eardrum to the inner ear (see below). The middle ear is basically an extension of the upper airway, and it is connected to the back of the nose by a tunnel called the Eustachian tube (ET). The walls of this tunnel are supported by cartilage, which tends to spring back into the normally closed position after being forced open (either by muscle action or by pressure changes in the airway from diving or from ear clearing maneuvers).
Diving injuries to the middle ear are the result of barotrauma, which is damage caused by pressure changes. As every certified diver knows, diving requires equalization of the pressure outside of the body with that inside, otherwise a big “gradient” occurs (a difference in pressure across a separating layer). This will cause pain and eventually damage. Since fluid is essentially not compressible, there are only significant pressure gradients in the air filled spaces of the body.
Most of the air in the body is in the airways – the lungs, the windpipe, the larynx (voicebox), the throat, mouth and nose. All of these spaces are connected by wide passages, so pressure changes occur everywhere at once in the airway, as a regulator delivers gas at ambient pressure (proportional to depth). It is possible to get a pressure gradient in the lungs – usually due to internal blockages of the air passages or holding the breath while ascending. While this is potentially serious, it is also quite rare.
There is also a small amount of air in other spaces in the body – the middle ear, the nasal sinuses, and sometimes the teeth (underneath dental work). These spaces are connected to the airways as well, but by small passages that may be blocked. Therefore, it is possible to build up a big pressure gradient in these spaces during descent and ascent, if a diver is not careful to equalize fully.
To equalize the ears, the diver must allow the ET to open against a pressure gradient. This can be done by a number of maneuvers taught in basic open water scuba instruction. Pinching the nose and blowing (Valsalva maneuver) and pinching and swallowing (Toynbee maneuver) are common methods for equalization, but many divers learn to open a blocked ET by other approaches, such as moving the jaw, tensing the roof of the mouth, etc…
A failure to equalize on descent can result in a block – a situation when the pressure gradient itself makes it harder for the ET to open, which results in a further gradient if descent is continued, leading to a vicious cycle and potential injury. The solution here is to stop the descent (or ascend a bit if necessary) until equalization is possible. A less common situation is a reverse block, which happens on ascent. The reason this is less common is that with a poorly functioning ET, the change in middle ear gas pressure with ascent or descent lags the change in ambient pressure. Therefore, with ascent you have higher pressure in the middle ear than in the airway. This pressure gradient tends to overcome a blocked ET – the air “forces” it’s way out. Think of how it is easier to squeeze toothpaste out of a tube than to put it back in.
A prolonged or significant pressure gradient in the middle ear can result in barotrauma. This can be a perforated eardrum (the eardrum acts like the burst disk in the scuba tank, and gives way when subjected to enough pressure). If the eardrum doesn’t perforate, fluid with or without blood can accumulate in the middle ear space. Unlike the middle ear infections that young children get, this fluid is clean with no bacteria. Clear fluid is called an “effusion”, and a bloody effusion is called a “hemotympanum”. The effusion is actually the result of fluid in the bloodstream (plasma) filtering into the middle ear when following the pressure gradient.
Fluid in the middle ear causes a temporary hearing loss by preventing the normal vibration of the eardrum with sound. It is a “conductive” hearing loss – the problem is that the mechanism that conducts sound into the inner ear is not working well. There is nothing wrong in this case with the sensory organ (the cochlea) or the nerves to the brain – if there were, it would result in a (usually permanent) “sensorineural” hearing loss, which we will discuss in the next section.
Some people have more trouble with this than others, due to dysfunction of the Eustachian tube (ETD). Many divers always need a long time to descend and ascend since their ETs don’t work very well at baseline. Other people may have no problem equalizing in general, but find it more difficult when a cold or other infection causes congestion of the lining of the ET. This is often oversimplified as the ET being “small” or “narrow” – the true problem is more of a functional issue than a structural one. Another common misconception is that fixing nasal obstruction, for example by straightening a deviated nasal septum, will help the function of the ET. While there is some overlap between nasal blockage due to an upper airway infection and ET function as mentioned above, most of the areas of the nose which require treatment to improve breathing are nowhere near the ET opening.
A single eardrum perforation related to barotrauma (without a history of ear disease) usually heals by itself over weeks to months, but no diving is allowed until the eardrum is once again intact. In some cases, surgery will be needed to seal the hole in the drum. Middle ear effusion typically resolves over time, and can be helped to resolve by the same sort of ET opening maneuvers described above. Antibiotics are generally not necessary.
Many divers swear by the use of decongestants and/or nasal steroid sprays to treat this problem or prevent its development. While these drugs can help prevent barotrauma of the nasal sinuses, there is not much data to suggest that they help middle ear disease any more than time and the ET maneuvers alone. Oral steroids can help the ears drain an effusion, but these drugs have side effects and are rarely needed in this situation. Motrin and other non-steroidal anti-inflammatory drugs may help with the pain, but have little effect on ET function. In some cases (when no more diving is planned in the near future) an ENT doctor can make a small hole in the eardrum to drain the effusion if it is causing severe symptoms (hearing loss, a blocked sensation in the ear, or dizziness).
There is not a lot that can be done directly to treat a poorly functioning ET, although there is a new procedure (balloon dilation) which may be helpful in selected cases. If the ETD is caused by a temporary problem (like a cold or other infection), then ear ventilation usually returns to baseline when the airway congestion resolves. Divers with longstanding baseline ETD usually address the problem by finding a maneuver that works to allow them to equalize.
The inner ear is deep inside the skull, and is an extension of the brain. It contains the cochlea, which is the organ of hearing (like the retina in the eye) that converts sound vibrations into electrical impulses that the brain can interpret as sound. It also contains the labyrinth, which is the organ of balance. The inner ear is behind a bony wall at the back of the middle ear, and connects with the middle ear through two small holes in the bone (the round and oval windows), which are normally sealed. Unlike outer and middle ear problems, inner ear injuries cannot be seen by looking into the ear canal, although patients with inner ear barotrauma often also have middle ear injury.
Diving related inner ear problems are very rare, but have the potential to cause permanent hearing loss. There are two main types that can result in serious injury- inner ear decompression sickness (IEDCS) and inner ear barotrauma (IEBT). These require immediate attention, and in the case of barotrauma, surgery may be necessary.
A thorough discussion of IEDCS is beyond the scope of this article, and the exact mechanism of this condition is still unclear. However, every certified diver has learned about the risk of bubble formation in the tissues with ascent, especially when inert gas (e.g. nitrogen) loading is high. IEDCS results in vertigo (and less commonly, hearing loss) when bubbles cause injury to the inner ear structures. It is not known for sure whether the injuring bubbles form in the inner ear tissue, or form elsewhere in the bloodstream and are carried to the inner ear through abnormal connections between the veins and the arteries (e.g. a patent foramen ovale or other blood vessel shunts in the lung).
IEBT can happen in a number of ways, involving a sudden pressure change in the inner ear fluid (known as perilymph). A rapid increase in middle ear pressure happens when a blocked ET suddenly opens during equalization on descent. This can cause the stapes (the bone between the middle and inner ear spaces) to be pushed sharply out of its normal position in the oval window, resulting in the inner ear fluid being pushed inward, potentially breaking the seal at the round window. A forceful Valsalva maneuver can cause an increase in inner ear pressure, pushing the round window membrane outwards, into the middle ear. Alternately, Valsalva with a blocked ET can result in pressure being transmitted the other way, as pressure in the brain rises while no corresponding rise in pressure happens in the middle ear.
This sort of trauma can result in a “perilymph fistula” (PLF) with leakage of inner ear fluid into the middle ear, potentially causing a progressive and often permanent sensorineural hearing loss, as well as vertigo and nausea. One other rare preexisting condition that can result in inner ear problems with diving is superior canal dehiscence, in which the bony covering of the inner ear is thin or missing. This can cause pressure changes to be transmitted directly to the balance organ of the inner ear.
Diagnosis of inner ear problems can be difficult, as the eardrum can normal on exam. Treatment for IEDCS and IEBT is very different, and recompression of a patient with IEBT can actually make the ear injury worse. Some authors have suggested that if the diagnosis is uncertain, holes should be made in the eardrums (myringotomy) before entering the chamber to prevent this complication. In actual practice, this is rarely necessary as the two conditions have different presenting features.
IEDCS may be suggested by the dive profile – excessive nitrogen loading, rapid or multiple ascents, aggressive decompression plans or skipped decompression stops. Also, there is usually a short symptom free interval after surfacing, with the vertigo generally starting within two hours. Symptoms of IEBT, on the other hand, usually develop during the dive, often following a forceful equalization. In both conditions, there may be nystagmus – rapid movements of the eye away from the injured inner ear.
Prior to decompression, all patients with any sort of suspected decompression illness should be treated with 100% oxygen and hydration (if conscious and able to drink). Even if the diagnosis is actually IEBT, there is no harm of doing this, so this initial treatment should not be delayed because of any uncertainty.
A formal hearing test can distinguish between conductive and sensorineural hearing loss, and therefore should be a part of the evaluation of any diving related ear injury. Other tests include an assessment of the function of the balance mechanism, which can be measured in a special lab. A CT scan is rarely helpful, as an acquired PLF caused by barotrauma cannot be seen on an x-ray.
When there is enough of a suspicion of a PLF, an operation may be recommended; this condition can only be definitively diagnosed by surgical exploration of the ear (you can’t see the inner ear fluid by looking in the ear canal). The procedure involves lifting up the eardrum to visualize the middle ear directly. If what looks like inner ear fluid is seen leaking from the space around the round window (or anywhere else), fat grafts are used to seal the area. This leakage can be very subtle, as the volume of perilymph is small. However, early closure of a PLF can mean the difference between a recovery of hearing and a progression to complete deafness. Since the operation itself involves very little risk, it should be strongly considered in cases where PLF is a possibility.
Ear symptoms without the risk of permanent damage can be caused by other conditions that arise during diving. The one thing these have in common is a lack of normal inputs from the sensory organs to the brain. Either asymmetric signals from each ear, or inconsistent information from the ears and the eyes will result in nausea, vomiting or vertigo – this is the brain’s response to such confusing inputs.
The balance organ of the inner ear (the semicircular canals) can be cooled by exposure to water in the ear canal, which causes the fluid inside the canals to move – this is a cold caloric response. If one ear is exposed to more cold water than the other – because of a poor fitting hood or wax in one ear canal – the brain will get different signals from each ear. Similarly, if one ear equalizes before the other, there will be a pressure difference between the ears, with differential stimulation of the inner ear sensory mechanisms. This is known as altenobaric vertigo.
Both of these conditions are generally temporary, and resolve as the temperature stabilizes and the flow stops, or as equalization is completed in both ears. However, it can be very disconcerting to have sudden dizziness during a dive. Awareness of this phenomenon and taking any steps necessary to address it (such as careful and thorough equalization) can prevent a spiral into panic and bad decisions.
Another condition well known to boat divers is sea sickness. Here, the vertigo is caused by inconsistency between the inputs to the brain from the eyes and the ears. If you are on a moving boat, your ears are telling your brain that you are moving up and down in space. But if your eyes are looking at any part of the boat, they will send the signal that you are standing still. This is why staring at the horizon helps sea sickness – it coordinates the information received by the brain from the ears and the eyes.
Finally, there is the condition known as Mal de Debarquement (“the sickness of getting off a boat”). Some people are unsteady and have difficulty walking after reaching dry land. This is thought to be an issue with the brain’s adaptation to a new environment, and not an ear problem. In such cases, inner ear testing is normal, but the symptoms may last for a long time (months). Treatment with vestibular suppressants (like Bonine or Dramamine) rarely works, but sedatives and specialized physical therapy (vestibular rehabilitation) may be helpful.
The vast majority of ear pain after diving goes away by itself in a short time. However, without an examination, a diver may not be able to tell whether the problem is in the outer or middle ear, and treatment depends on accurate diagnosis. Hearing loss after diving should be evaluated soon, ideally with formal hearing testing. Thorough evaluation of persistent ear problems should be done by a doctor with the tools and experience necessary to distinguish outer, middle and inner ear disease.
How to Equalize Ear Pressure when Scuba Diving
Let’s review some basic dive physiology. Your middle ears are air spaces, sealed by the eardrum but connected to the outside by the eustachian tubes, which run to the back of your throat. As you descend, water pressure bends the eardrum inward as the air in the middle ear compresses. To restore volume lost to pressure, you send air into the middle ear via the eustachian tubes, equalizing or “popping” your ears. Failing to do this causes ears to hurt when diving, and potentially damages the delicate mechanisms of the ear. But you knew this already.
The key to safe equalizing is to get air to flow from the throat to the ears through the opening of the normally closed eustachian tubes. Most divers are taught to equalize by pinching their nose and blowing gently. This gentle pressure opens the eustachian tube and flows air gently to the middle ear.
You can blow by exhaling (called the Valsalva Maneuver) or by using your throat muscles (called the Frenzel Maneuver), the latter of which is preferred because it’s gentler and you control it more easily. You may do it already – at the surface, exhale fully as much as you can, squeezing out as much as you can, then pinch your nose and gently pop your ears. Since you can’t exhale anymore if you’re equalizing using your throat, not exhalation. Many divers can also equalize by swallowing, wiggling or stretching their jaws (not easy with a regulator though) or a combination of these. You can also swallow while pinching your nose.
Tips for Equalizing Ear Pressure
Whether you need help “clearing” or “popping” your ears, the best ways to equalize ear pressure when diving involves a few simple steps
Listen for the “Pop”
Before you even board the boat, make sure that when you swallow, stretch your jaw or gently pinch and blow you hear/feel the “pop” in both ears. This tells you both eustachian tubes are opening.
Several hours before the dive, begin gently equalizing your ears every few minutes. Chewing gum seems to help some people because it makes you swallow often.
Descend Head Higher Than Feet
Studies have shown that equalization can require more force when you’re in feet up than in a position than feet down position, but this is not an issue for many divers.
Tilt Your Head Up a Bit
Extending your neck tends to open your eustachian tubes, but this isn’t recommended for freedivers, BTW, because it may contribute to blackout.
Use a Descent Line
Following an anchor or mooring line can help you control your descent rate, which helps if your ears equalize slowly. A line also helps you stop your descent quickly if they’re not equalizing.
Equalize early and often, keeping up with the pressure as you descend. Don’t wait until you feel significant pressure, discomfort or any pain. Equalize as you feel slight pressure differences.
Stop if it Hurts
If you’re equalizing properly and often enough, you should not feel pain, period. Delaying equalization can block your eustachian tubes because the pressure differential. Ascend a few feet and try equalizing again.
If You Can’t Equalize your Ears, End the Dive
Continuing to descend with unequalized ears is painful and will lead to middle ear squeeze (blood and fluid forced into the middle ear) and/or ear drum rupture. Never continue descending with unequalized ears, and be sure to signal your buddy (or instructor if you’re taking a class). The only way another diver can know you can’t equalize is if you tell them.
Avoid Things that Produce Mucus
A common cause of equalization problems is congestion, so avoid things that cause mucus. Some foods, including milk, can increase your mucus production. Both tobacco smoke and alcohol irritate your mucus membranes, (not to mention all the many other reasons to avoid tobacco smoke, and to never dive under the influence of alcohol). A bit of water in your mask can make you a bit snotty, so keeping it dry may help..
Otologic Hazards Related to Scuba Diving
Sports Health. 2016 Mar; 8(2): 140–144.
Tiffany A. Glazer
†Department of Otolaryngology–Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan
Steven A. Telian
†Department of Otolaryngology–Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan
†Department of Otolaryngology–Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan
*Tiffany A. Glazer, MD, Department of Otolaryngology–Head and Neck Surgery, University of Michigan Health System, 1500 East Medical Center Drive, 1904 TC, SPC 5312, Ann Arbor, MI 48109-5312 (email: [email protected]).This article has been cited by other articles in PMC.
As of 2015, more than 23 million scuba diver certifications have been issued across the globe. Given the popularity of scuba diving, it is incumbent on every physician to know and understand the specific medical hazards and conditions associated with scuba diving.
Sources were obtained from PubMed, MEDLINE, and EBSCO databases from 1956 onward and ranged from diverse fields including otologic reviews and wilderness medicine book chapters.
Level of Evidence:
Otologic hazards can be categorized into barotrauma-related injuries or decompression sickness.
When combined with a high index of suspicion, the physician can recognize these disorders and promptly initiate proper treatment of the potentially hazardous and irreversible conditions related to scuba diving.
Keywords: scuba diving, barotrauma, decompression sickness
According to the Professional Association of Diving Instructors (PADI), as of February 2015, more than 23 million diver certifications have been issued across the globe, with a mean 900,000 certifications in more than 200 countries issued annually. Roughly two-thirds of these certified divers are men (mean age: men, 30 years; women, 27 years).16 Given the popularity of scuba diving, it is incumbent on every physician to know and understand the specific medical hazards and conditions associated with scuba diving.
Barometric pressure at sea level is 100 kPa and increases linearly underwater with every 10 meters of descent, adding 100 kPa. As depth increases, the diver breathes gas of increased density while the diving equipment provides oxygen and allows for elimination of carbon dioxide. Increased depth and pressure also leads to a decrease in gas volume and an increase in the amount of gas dissolved in body tissues. The otologic conditions of barotrauma and decompression sickness that can result from scuba diving are related to the behavior of gas changing under pressure as the diver descends. To understand this behavior more thoroughly, a brief overview of 2 gas laws is necessary. Boyle’s law explains pressure-related diving conditions like barotrauma, stating that at a constant temperature, the volume of gas inversely varies with pressure applied. Henry’s law explains decompression sickness and states that the amount of a given gas that is dissolved in a liquid at a given temperature is directly proportional to the partial pressure of that gas. These 2 laws are essential to understanding and treating pressure-related diving disorders that develop because of problems caused by the mechanical effects of pressure on closed air spaces (barotrauma) or problems caused by breathing gases at elevated partial pressure (decompression sickness). Both of these disorders will be discussed in detail in this review.
Barotrauma is the most common medical problem in scuba diving and can involve any structure that leads to entrapment of gas in a closed space. If a diver does not equalize pressure in gas-filled body spaces during descent, these spaces will decrease in volume in accordance with Boyle’s law. Gas-filled body spaces located within a bone space cannot collapse, so the space they take up is replaced by engorgement of the mucous membranes, often followed by hemorrhage.8 The risk of barotrauma is greater near the surface of the water as it is here that a small change in depth may lead to a large change in relative gas volume. Barotrauma can occur in any structure or combination of structures that leads to entrapment of gas in a closed space, including the ears (inner, middle, and/or outer ear spaces; ), paranasal sinuses, lungs, gastrointestinal tract, portion of the face under a face mask, and skin trapped under a fold in a drysuit.15
Basic anatomy of the external, middle, and inner ear. Reprinted with permission from Wenig.22
Middle Ear Barotrauma (Barotitis Media)
Middle ear barotrauma, also known as “middle ear squeeze,” is the most common diving-related medical disorder, affecting more than 40% of divers at some point.5,15 As the diver descends, hydrostatic water pressure forces the tympanic membrane inward and the volume within the middle ear space is reduced. The diver is taught to add air into the middle ear by ventilating through the eustachian tube. This is accomplished by performing a Valsalva maneuver, which equalizes the pressure in the middle ear cavity with the external ambient pressure. Middle ear barotrauma occurs when the eustachian tube cannot open to equilibrate pressure despite a Valsalva maneuver. A diver will begin to have otalgia with a 60 mm Hg pressure differential between the middle ear space and ambient water pressure. When a pressure differential of 90 mm Hg is reached between the middle ear space and the nasopharynx, the eustachian tube cannot be opened and Valsalva maneuvers will be unsuccessful. 2 The diver must ascend to equalize the middle ear pressure with ambient pressure. Middle ear edema, transudation, and hemotympanum may occur. The tympanic membrane becomes displaced medially (inward), and if the pressure is great enough and remains unaddressed by the diver, rupture of the membrane may occur. The failure of expanding gas to vent through the eustachian tube may occasionally lead to middle ear barotrauma during ascent as well, referred to as “reverse squeeze.”2
If a diver does not equalize pressure in the ear with a Valsalva maneuver, symptoms of middle ear barotrauma may occur. The main symptom is otalgia that increases with depth. Relief of pain without proper equalization of middle ear pressure usually indicates that the tympanic membrane has ruptured. Once above water, divers will typically complain of a sensation of pressure, fullness, and conductive hearing loss. If cold water enters an ear with a ruptured tympanic membrane, one may develop severe vertigo due to unilateral vestibular stimulation by the caloric effect. 15 Late complications include chronic tympanic membrane perforation and chronic otitis media. Rarely, the tympanic portion of the facial nerve is injured by increased middle ear pressure, and a temporary facial paralysis results. This occurs when middle ear pressure exceeds the capillary pressure of the facial nerve and causes an ischemic neuropraxia. The presence of middle ear barotrauma prohibits future diving until it has resolved.
Treatment of middle ear barotrauma includes topical nasal and systemic decongestants to decrease middle ear edema and transudate. If purulent otorrhea is observed and infection has developed, topical antibiotic drops should be prescribed. The majority of tympanic membrane perforations heal spontaneously within 1 to 3 months if otorrhea is controlled, and normal eustachian tube function is restored.15 Prevention is key for barotitis media. Training must emphasize the importance of early and ideal pressure equalization of the middle ear space. Concomitant inner ear barotrauma is discussed next and should be ruled out in all cases of middle ear barotrauma.1
Inner Ear Barotrauma
Inner ear barotrauma is the most serious form of aural barotrauma because of the potential for lasting injury to the cochleovestibular system, which may lead to permanent deafness and/or vestibular dysfunction. Inner ear barotrauma may develop if a diver performs a forceful Valsalva maneuver in an attempt to equalize middle ear pressure with the eustachian tube blocked or if the descent occurs too quickly. During descent, the tympanic membrane is pressed inward, pushing the stapes against the oval window. Because perilymph and endolymph are not compressible, the resulting increased pressure may cause the round window membrane to bulge outward. The diver may attempt a forceful Valsalva maneuver to equalize the middle ear. This will raise intracranial pressure, which may be propagated through the internal auditory canal or the perilymphatic duct to the inner ear, causing the round or oval window to rupture. Rupture of either window can also occur by a sudden increase in middle ear pressure by a forceful Valsalva. This sudden pressure may cause any of several types of injury to the cochleovestibular apparatus, including hemorrhage within the inner ear, rupture of the Reissner membrane leading to mixing of endolymph and perilymph, fistulization of the oval or round window with development of a perilymph leak, or a mixed injury involving any number of these conditions.17 During ascent, the expanding middle ear gas may be forced through the perilymph fistula and enter either into the scala tympani or scala vestibule, which may damage cochlear or vestibular structures leading to permanent hearing loss. Although they typically occur concomitantly, inner ear barotrauma may occur independently of middle ear barotrauma.14,17 Vigorous isometric exercise such as yoga after a dive may complete an incipient or partial membrane rupture.
Severity may vary but divers suffering from inner ear barotrauma will classically complain of sensorineural hearing loss, loud roaring tinnitus, and persistent vertigo after diving. Treatment varies from observation and symptomatic treatment of vertigo and nausea with anti-emetics and benzodiazepines to surgical exploration for repair of the round or oval window. Tinnitus and reduced hearing may become chronic, particularly if a fistula is present and no treatment is provided. Divers who exhibit clinical evidence of inner ear barotrauma with intact round and oval windows may have suffered a pressure injury to the organ of Corti and/or the membranous labyrinth.18
There is no clinical basis for definitively distinguishing a perilymphatic fistula from inner ear barotrauma due to an internal membrane break. Traditional initial treatment is to recommend complete bed rest with the diver’s head elevated 30° and avoidance of any activities that can increase cerebrospinal fluid pressure as this may aggravate a perilymphatic leak.17 Vertigo and nausea can be managed symptomatically with anti-emetics and benzodiazepines. If inner ear function persists or continues to deteriorate despite conservative management, the patient may require an exploratory tympanotomy with patching of the round or oval window. Although no consensus exists as to how long to wait before surgical intervention, it has been recommended to explore the ear if the diver shows no improvement after 24 hours.15
External Auditory Canal Barotrauma
External auditory canal (EAC) barotrauma is less common but can occur if the diver wears a tight-fitting wetsuit hood or drysuit hood that can trap air in the EAC and lead to a painful “external ear squeeze” during descent. It may also occur if the EAC is blocked by cerumen, exostoses (bony growth in the outer ear canal), or a foreign object. Signs and symptoms of EAC barotrauma include pain, swelling, erythema, petechiae, or hemorrhagic blebs of the EAC wall. Blebs should not be incised. Antibiotic otic drops can be used to prevent infection due to contamination with seawater. EAC barotrauma can be prevented by breaking the seal of the wetsuit hood to allow water to fill the EAC before descent. Ear plugs should never be worn when scuba diving.
Alternobaric vertigo is a specific type of middle ear barotrauma that occurs if the reduction of middle ear pressure is not equivalent in the bilateral middle ear spaces. If the pressure differential exceeds a threshold of 45 mm Hg, asymmetric stimulation of the labyrinths will occur, resulting in what is called alternobaric vertigo.9 Symptoms include nausea, vomiting, disorientation, and generalized malaise. The sensation of vertigo may persist for 1 to 2 hours after ascent but gradually disappears without therapy. Divers may be particularly susceptible to alternobaric vertigo if they have had previous injury or infection of either labyrinth. In susceptible divers, use of moderate doses of antihistamines or decongestants prior to diving may prevent symptoms, although these medications are not recommended for routine use before diving as they may potentiate reverse squeeze. Although symptoms are usually mild, they may occur underwater, which is a serious problem that may lead to aspiration and drowning.11 The disorder must be differentiated from inner ear decompression sickness, which is described later and is usually associated with deeper, prolonged diving.
In accordance with Henry’s law, as a diver breathes under increased pressure, the tissues are loaded with increased quantities of oxygen and nitrogen. Increased oxygen can be used in tissue metabolism but nitrogen cannot as it is physiologically inert. Therefore, as a diver descends, the nitrogen content of tissue increases proportionally to ambient pressure and in relation to fat tissue content as nitrogen is 5 times more soluble in fat than in water.6 As a diver ascends, the ambient pressure decreases and a state of supersaturation is created. The sum of the gas tensions in the tissue may exceed the absolute ambient pressure and free gas is liberated from the tissues, leading to the onset of decompression sickness (DCS). The liberated gas can disturb organ function by blocking arteries, veins, and lymphatic vessels. In addition, its expansion can rupture or compress tissues. When the gas is liberated into a space with rigid boundaries, it may lead to compartment syndrome. Gas may also form within cells causing the rupture of the cell membrane. Finally, reactions at the interface of blood and gas bubbles can activate the clotting cascade.3,6 DCS can be avoided if rates of ascent are controlled with planned stops during the ascent, as specified in decompression tables such as those provided by the US Navy.20 However, severe DCS may occur despite adherence to decompression tables.
The chance of suffering DCS on any single dive is about 4 in 10,000 in warm water and 59 per 10,000 in cold water.21 Risk factors for DCS are those that enhance the accumulation of inert gases in tissues or slow their release. These include advanced age, female sex, obesity, elevated arterial carbon dioxide tension, low water temperature, poor physical fitness, and the level of physical activity during the dive. Repeated dives are also a major risk factor since a considerable quantity of nitrogen may remain in the tissues after a dive, increasing the risk of DCS during subsequent dives.7,20
Decompression sickness is classified into type I and type II based on clinical manifestations. Type I involves a mild insult, with the most common manifestation being localized joint pain, also known as “the bends.” Typically, it will develop within 1 hour of ascent, and symptoms may gradually become more severe during the following 24 to 36 hours. The joints most commonly affected are the elbow and shoulder. Pain is usually not exacerbated by motion, and tenderness and inflammation are very uncommon. Other symptoms of type I DCS include pruritus and skin rashes due to the presence of gas bubbles in subcutaneous fat. Typically, this will resolve on its own but if skin marbling or localized edema occurs, the diver would require recompression treatment.1
Type II is the more severe form of DCS and may lead to permanent neurologic injury and death. Symptoms start with a feeling of malaise and fatigue and occur 10 to 30 minutes after ascent. The mechanism of neurologic insult is related to paradoxical gas embolization. Gas bubbles may escape pulmonary filtration and enter the arterial circulation through a patent foramen ovale or an atrial-septal defect or they may be generated de novo as microemboli within the arterial circulation. The gas bubbles go on to occlude capillaries or damage the blood-brain barrier and result in a neurologic insult. Divers who have suffered from DCS have been reported to have a higher prevalence of patent foramen ovale.13 Poorly perfused areas of the nervous system or areas with high fat content are at a particularly high risk of DCS.6
When the spinal cord is involved, divers may complain of paresthesias that may progress to numbness, paraparesis, referred abdominal pain, fecal incontinence, or bladder paralysis. When the cerebrum is involved, divers may complain of severe headache, blurred vision, diplopia, tunnel vision, dysarthria, dizziness, sensorineural hearing loss, tinnitus, and/or vertigo, as well as mental status and personality changes. Severe cerebral involvement may lead to convulsions and death.3,6 Inner ear DCS is a type II manifestation and results from blockage of the microcirculation of the inner ear, hemorrhage, and transudation of protein within the cochlea. This irritates the endosteum within the bony semicircular canals, initiating osteoblastic differentiation and leading to fibroosseous labyrinthitis.4
Treatment for DCS involves urgent transfer to a recompression chamber for the administration of inhaled oxygen at the highest possible concentration. The time to administration of hyperbaric oxygen is one of the main determinants of outcome.12 Transportable single-person rescue chambers are commonly available and can be used as a diver is transferred to a recompression chamber.10 Hyperbaric oxygen is thought to work by eliminating gas bubbles and alleviating damage to hypoxic tissue. Treatment is given according to the US Navy treatment tables, and the recompression protocol is selected according to the severity of illness (type I or type II) and the patient’s response during therapy.20 Hydration with intravenous fluids is also of utmost importance as the hemodynamic changes that occur during severe DCS lead to hemoconcentration. High doses of steroids and mannitol can be given to reduce local edema in the nervous system and maintain an intact blood-brain barrier. Another therapeutic option first introduced by the US Navy in 1958 is administration of a mixture of helium and oxygen.19 Although the exact mechanism of action is unclear, it seems that when such mixtures are used in recompression, nitrogen is eliminated faster from the tissues as it is much more soluble than helium.
Given the millions of recreational, commercial, and military divers worldwide with nearly 1 million new divers trained each year, all physicians can benefit from a basic knowledge of barotrauma and decompression sickness. When combined with a high index of suspicion, the physician can recognize these disorders and promptly initiate proper treatment of the potentially hazardous and irreversible conditions related to scuba diving.
The authors report no potential conflicts of interest in the development and publication of this article.
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Ear Pain while Scuba Diving
How to deal with ear pain while diving?
Most divers really only start to appreciate how much of a hassle their ears can be once they start to have ear problems. From being a minor inconvenience to a major hassle, ear problems have ruined many a holiday. Understanding your ears and what are the most common problems you can have with them is key to avoiding them. By developing a few good habits, you are almost guaranteed to consign ear issue to history.
3 types of ear problems
Almost every common ear problem with diving will fall into one of three broad categories. Problems will either be related to the outer ear, which is not just the area on the side of your head, but also your ear canal and includes everything up to your eardrum (Tympanic Membrane). The second category of problems are related to the inner ear, and they include everything on the other side of your eardrum, including your middle ear, round window and oval window. The last category of ear-related problems concern your Eustachian tubes and your sinuses. The Eustachian tube supplies air to your inner ear and allows you to equalize. When they develop problems, equalization becomes difficult if not impossible.
Outer ear problems
The outer ear is particularly prone to two major types of issues: infections and wax build, both will result in pain when diving and difficulty equalizing. Wax build-up creates a plug in your ear, making it impossible to equalize properly. The only solution is to irrigate your ears with warm water! While there are some home kits you can buy to do this, it is not recommended, you should seek medical assistance with the procedure.
There are various types of infections that can affect the outer ear, most can be solved with a simple course of ear drops, that will treat the infection and reduce the inflammation. To be able to determine which drops to use, you will need to seek advice from a doctor. If you find that you are prone to outer ear infections, you will need to regularly rinse your ears out with clean, fresh water after every dive.
Inner ear problems
Inner ear problems fall into two distinct categories: infections and barotraumas. Infections can be caused by several things, and the only way you will be able to deal with them is by seeing a doctor and taking some medicine. A healthy strategy to avoid infections is to make sure that when you dive your ears are in great shape and you are not “pushing” them in any way.
Barotraumas are an injury to the inner ear caused by pressure. The main reason they happen is because you were not careful enough when descending and either equalized too hard, or failed to equalize sufficiently. The only way to avoid them is to make sure your sinuses and ears are in a good shape and unblocked, and to equalize regularly and gently when descending. Remember to be gentle with your ears to avoid barotraumas.
Eustachian tubes and sinuses
The Eustachian tubes are key to proper equalization. Most problems with them are due to congestion and inflammation. To avoid problems caused by inflamed or congested Eustachian tubes, make sure to only dive when you are completely healthy. The most common issue divers have is trying to dive slightly congested, or just after a cold, where the mucus build-up will interfere with proper equalization and could even cause more problems as you try to force your body to do something difficult. It is not recommended that you use decongestants or sprays to clear your tubes to go diving.
The Eustachian tube is the main guilty party when it comes to reverse blocks affecting the ears or sinuses. A reverse block is similar to a squeeze but occurs on ascent. As you go up and the pressure is reduced, normally the air in your ears and sinuses would just escape automatically and equalize with the water pressure. However occasionally mucus will block the Eustachian tube or sinuses, making it impossible for the air to escape. This leads to a pressure imbalance causing pain. The only solution to dealing with a reverse block is to re-descend until the pain stops. Then recommence your ascent as slowly as possible to give the trapped air a chance to work its way out.
If you love diving then keeping your ears in good shape should be one of your top priorities, since if they are damaged you will not be able to dive. It is much better to suffer one or two days on the shore letting your ears recover from any ailment, than to force yourself to dive and potentially risk losing he ability to dive ever again!
Which is the best equalization technique?
Basically, there isn’t one. The most commonly used techniques are the Valsalva and the Frenzel, which are ancient techniques. There are multiple other techniques that have been developed over the years. Most of the more modern techniques were developed by dive bomber pilots during the second world war. The best technique for equalization is the one that works for you, small differences in our anatomy can make one technique more difficult or even impossible, search around and practice the various techniques until you find the perfect one for you.
I keep getting outer ear infections, how do I protect myself?
Persistent ear infection can be a real hassle, if you search online you will find many a recipe to treat your ears after a dive. These can be somewhat strange, and can involve everything from pouring olive oil in your ear, to other weird and wonderful mixtures. By far the safest and one of the best and least controversial method, is to just use some clean fresh water to rinse your ears out with after every dive. Using water is the simplest, most hygienic and readily available way to rinse out your ears after diving!
What about decongestants, I hear many divers take them?
While a lot of divers will swear that they use one or the other types of decongestants, it is generally absolutely not recommended without proper medical clearance. Decongestants and nasal sprays, can cause you significant problems in the water. This is because as the spray takes effect at the beginning of the dive you can equalize easily, however near the end of the dive after an hour or so, when the effects of the spray have worn off problems can develop. Blockage can in return lead to reverse blocks in your sinuses or ears or possibly even both.
Can I still dive if I perforated my eardrum?
No you cannot dive, do not even consider diving until you have had a full check-up from your doctor, or even better a physician who specializes in diving medicine. Going diving with a perforated eardrum can lead to some very nasty consequences, including infection which can lead to the perforation becoming permanent and could ultimately damage your hearing.
Ear Barotrauma • Scuba Diver Life
Dive instructors always explain the relationship between pressure and volume to new divers, describing the need to descend slowly and steadily, and to equalize air-spaces early and often. New divers learn this information within the first few minutes of every scuba class, but why? Simply put, because ear barotrauma is the most common dive-related injury. It often relegates divers to land or, sadly, deters potential divers from pursuing the sport at all.
Ear barotrauma is incredibly common, hitting approximately 30 percent of first-time divers. Additionally, around 10 percent of experienced divers have suffered an incident as well. Symptoms can vary from mild to excruciating, with permanent hearing loss in extreme examples.
What is ear barotrauma?
The human ear consists of three main parts: the external, middle and inner ear. The word “barotrauma” stems from the Greek baros, meaning pressure, and trauma, meaning injury. If the ear cannot cope with abrupt pressure changes, a key area of the ear will likely rupture. Diving with a cold or congestion can also cause ear barotrauma.
The outer ear
The auricle, or pinna, of the outer ear — the funnel visible on the outside — is what most of us think of as our “ear.” From here, sound waves funnel down a canal and arrive at the tympanic membrane — the eardrum. The average adult’s ear canal is around one inch long (2.4 cm), and on the other side of the eardrum is the middle ear. Here, three tiny bones conduct the sound into a format that our brains can interpret.
The Eustachian tube
The Eustachian Tube connects the middle ear to the throat. Therefore, its function is crucial to scuba divers. Introducing air into this contracting air space is what equalizes the pressure on the inside of the tympanic membrane with the ambient pressure external to the diver descending through the water column.
The inner ear
Finally, the oval and round windows are within the inner ear. These sensitive membranes are key to the ear’s health. Overzealous equalizing can rupture either, or both, of these tiny areas, leaving the diver with anything from vertigo and vomiting to hearing loss. Consequently, instructors advise students to equalize early and often, gently blowing against pinched nostrils, wiggling the jaw or swallowing.
What causes ear barotrauma?
Cast your mind back to the first section of your Open Water Diver manual. According to Boyle’s Law, as the ambient pressure increases, the volume of the air spaces within your body in contact with that pressure will — if left unattended — decrease. This basic lesson in physics is the core of understanding ear barotrauma, which occurs when increasing ambient pressure during your descent causes the volume of the gas-filled spaces in your ear to shrink. The sensitive membranes and tissue that make up the ear’s key areas become distorted, eventually becoming damaged. This is the most common type of ear barotrauma. Attempting to ascend while diving with a cold, congestion or fading decongestants can cause a “reverse block,” which means gas is unable to escape. This can also cause ear barotrauma.
Types of ear barotrauma
There are various types of ear barotrauma. Each has its own causes and symptoms.
- External ear canal superficial vessel rupture: A rupture of the blood vessels in the external ear. Often a scuba diver may experience small amounts of bleeding from the ear canal.
- Tympanic Membrane (TM) rupture: Perforation of the eardrum. Pain, dizziness and vertigo are common symptoms.
- Inner ear barotrauma: Damage to the round or oval window. A distressing condition that can cause tinnitus, dizziness and vomiting.
- Otitis media: While not strictly a barotrauma, divers can confuse the pain and fluid-loss from a middle-ear infection with a barotrauma.
- Otitis externa: Commonly called “swimmer’s ear,” this is a common condition among scuba divers, especially those who neglect post-dive ear care. Inflammation, pain and swelling of the ear canal are common symptoms.
Crucially, if you experience any of these symptoms, you must stop diving. Diving again will — at best — cause further discomfort and exacerbate the injury or infection. At worst, diving with ear pain may endanger both your health and the rest of your dive team’s safety. Unfortunately, there is no quick fix for most of these issues. Thusly, it’s best to consult a qualified medical professional with knowledge of diving medicine. Alternately, you can access additional resources on ear health at the Divers Alert Network (DAN).
Only your doctor can determine how long you must stay out of the water. However, don’t expect to be in the water again for several days for even minor injuries or infection. For more serious injuries, dry weeks lie ahead.
Avoiding ear barotrauma
No matter what your qualification, experience level, or number of dives, you can’t change the laws of physics. You must go back to basics on every dive.
- Practice on land. Relax before your dive and practice equalizing before getting in the water. While practicing, you should hear a pop, clunk or click indicating your Eustachian tubes are open. If you’re struggling to equalize, tell your buddy and the dive leader because you may need to descend very slowly. If you cannot descend slowly, such as in an area with strong current where you need to get to depth quickly, consider skipping the dive. Don’t force your ears.
- Avoid accessories. Don’t wear earbuds or any accessory that will block the flow of air in the body’s air spaces.
- Don’t dive with a cold or congestion. Mucus in the body’s air spaces can make equalizing a long, protracted and painful affair. Don’t compromise your safety and your buddies’ dive by forcing the issue.
- Avoid decongestants. To avoid missing a dive, some divers with colds or congestion divers pop medications to ease equalization. This is unwise, since these drugs can often wear off mid-dive. Then, as the diver ascends, expanding gas cannot escape. This often leads to a reverse block and injury.
- Avoid milk, tobacco and alcohol. These may irritate your mucus membranes, making equalizing difficult if you are already prone to equalization problems.
- Chew gum. There is some anecdotal evidence that chewing gum between dives may help your ears.
- Equalize early and often. Memorize the mantra of scuba-diving instructors. Begin equalizing before you feel any pain or discomfort. Leave the surface with one hand on your nose, beginning to equalize early in the descent.
- Use the tools at your disposal. If there is a descent line available, use it. And if you have any problems, pause your descent. Take the line for control. Only move deeper in the water column when you have successfully cleared your ears.
- Help your body. Make the initial few feet/meters of your descent feet first. The biggest proportional pressure change occurs during the first 30 feet (10 m). If you’re still struggling to equalize, look up to the surface. Doing so may help extend your Eustachian tubes and help you equalize.
- Learn what works. Everybody has differing physiology, so learn which method of equalization works best for you. Techniques include swallowing, wiggling the jaw, Valsalva, Toynbee, Lowry, Edmonds and Frenzel. Each of these differs slightly in technique, but there is no right or wrong — only what works for you.
- Don’t force it. Sometimes it’s not your day to dive. If you feel pain or discomfort, don’t force your ears and potentially hurt yourself or compromise everybody’s dive.
Ear barotrauma is surprisingly common. So remember to take care of your ears and dive safe and equalize early and often to avoid potential problems. If you do suffer an ear-related problem, abort the dive and seek professional medical advice.
Marcus Knight / About Author
Marcus Knight (aka “The Scuba Monkey”) first dived during the ‘90s and was bitten by the scuba bug. During the years that followed, Marcus became absorbed in diving and, today, is a Master Instructor for both PADI and SSI.
With over a decade as a professional diver, Marcus has lived and taught
scuba around the world, including Australia, Asia, the Mediterranean Sea and the wreck heaven of Scapa Flow in the Orkney Islands. Check out his website here.
More posts by Marcus Knight
Treatment for Ear Barotrauma
Ear barotrauma is a type of ear damage. It’s caused by a difference in pressure between the inside of the ear and the air around you. It can cause pain and may lead to lasting hearing loss. It can harm the eardrum. The eardrum is between the outer and middle ear. Harm to the eardrum can cause bleeding or other damage to the outer, middle, or inner ear.
Flying is the most common cause of barotrauma. It can also occur with diving in the mountains, decompression, a blast injury or explosion, or treatment in a hyperbaric oxygen chamber.
Types of treatment
You may be referred to an ear, nose, and throat doctor (ENT or otolaryngologist). Or you may not need any treatment. Most barotrauma injuries heal on their own with time, and your symptoms will go away. But your eardrum may not heal as normal if a blast caused the injury.
Your healthcare provider may tell you to rest in bed with your head raised on a pillow. Keep your ear dry. Ask your provider how to prevent your affected ear from getting wet when taking a bath or shower.
You may also need to take medicine, such as:
You may need surgery if your ear barotrauma is severe. A surgeon may rebuild the eardrum or the opening into the inner ear. A tiny cut may be made in the eardrum. In rare cases, a ventilation tube in the eardrum may be needed to equalize pressure between the middle ear and outside air.
What happens if you don’t get treated?
In some cases ear barotrauma can cause symptoms that don’t go away, such as:
Follow your healthcare provider’s advice about bed rest or surgery. This may help cut your risk for these problems.
Preventing ear barotrauma
You can take steps to help prevent ear barotrauma. If you are congested from a cold or allergies, you may want to delay flying, driving in the mountains, or scuba diving. Or you can take medicines such as a decongestant or antihistamine. These may help your ears equalize more easily and prevent ear barotrauma.
You can do some things to open the eustachian tube during pressure changes, such as:
Pinching your nose, closing your mouth, and then acting as if you were going to breathe out through your nose
Chewing gum or candy
Using special ear plugs when flying
The eustachian tube links the middle ear to the throat to equalize pressure and drain fluid as needed. Using a ventilation tube is a choice for some people whose eustachian tubes don’t work well or for those who need to fly often. These may help you if you need high pressure oxygen therapy for wound healing. A surgeon places these tubes in the eardrum. They then help even out pressure differences. Ventilation tubes can’t prevent ear barotrauma caused by diving.
Coping with ear barotrauma
If you’re a diver, don’t dive again until your injury has fully healed. Diving again too soon can cause injury again. Your healthcare provider will tell you when it’s safe for you to dive again. You should also not fly until your healthcare provider says it’s OK.
When to call your healthcare provider
Call your healthcare provider right away if:
Your symptoms don’t get better or they get worse
You have any new symptoms, such as dizziness, fever, or hearing loss
90,000 Diseases of vacationers – diffuse otitis media, otitis media
3.67 (Voted: 3)
The long-awaited vacation has come, and we are going on vacation. Of course, at sea! But it happens that our rest is overshadowed by diseases, and often this is manifested by pain in the ears.
What’s going on?
External diffuse otitis media
is an inflammation of the skin of the external auditory canal as a result of water entering the ear and hypothermia.
Sea water is not always useful and not as clean as it is commonly thought. When you are in water for a long time, it does not matter, in sea or fresh water, in a pond or a chlorinated pool, the humid environment in the external auditory canal promotes the development of bacterial and fungal flora.
This is compounded:
- subsequent hypothermia under air conditioning or when traveling in a car with an open window,
- an independent attempt to clean the “stuffy ear” with cotton swabs.
At the same time, a mixture of earwax with water, sometimes sand, is rubbed into the skin of the ear. passage, and the skin loosened due to water is easily injured and infected.
Rapidly emerge and intensify
congestion, hearing loss due to increasing edema,
- with further development of the disease – an increase in temperature to 38-39C.
How to avoid illnesses of vacationers:
If water gets into your ear, do not use cotton swabs!
Try to shake out the water by pulling the auricle,
blot with a cotton swab or towel,
Dry a little with a hair dryer (warm air jet).
In case of persisting congestion, the appearance of pain in the ear, it is better to immediately consult a doctor. At the initial stage, inflammation can be stopped with drops, with the development of otitis media, combined (antibacterial or antifungal) therapy is necessary.
External diffuse otitis media is often recurrent. In this case, you need to constantly protect your ears from the ingress of water, use special earplugs when bathing.
Exudative otitis media (EMC)
is an inflammation of the middle ear, in which exudate accumulates in the tympanic cavity – a fluid that impedes the movement of the tympanic membrane, which manifests itself: ear congestion, hearing loss, a feeling of “gurgling” in the ear, with further development – pain.
ESO can develop with frequent diving, with water entering the nose, and then through the auditory tube into the middle ear.
This is compounded:
if you have a runny nose, nasal congestion, and you cannot normally blow your nose and blow out your ears after diving
flight by plane due to atmospheric pressure drops, especially during takeoff and landing.
How to avoid illness of vacationers
: if you go on vacation not quite healthy, with a runny nose, avoid diving, especially to the depth, do not dive! Before flying on an airplane, contact your ENT doctor in advance, you will be prescribed treatment to avoid complications.
Remember, you can get sick in 1 day, it takes much longer to be treated.
Barotrauma of the tympanic membrane
– occurs with a sharp and rapid increase in pressure in the external auditory canal. Usually occurs when diving from a height. This can result in rupture of the tympanic membrane, hemorrhage into the tympanic cavity, or membrane. It is manifested by a sharp pain in the ear, a sharp decrease in hearing, noise in the ear.
What not to do: drip any drops into your ear on your own!
If there is a rupture of the tympanic membrane, it is important to prevent infection and the development of purulent otitis media.The ingress of water into the tympanic cavity is categorically excluded. More often than not, just a dry turunda is enough so that nothing gets into the ear. As a rule, perforations heal on their own, within about a month, and a scar remains on the membrane. Perforation may remain with significant trauma. Contact your ENT doctor immediately.
If you have the above complaints, do not self-medicate, but contact qualified specialists.
When applying for medical help at “ENT clinic number 1” , otorhinolaryngologists will carry out diagnostics using video endoscopy of ENT organs, will provide the necessary assistance: relieve pain, prescribe effective drug treatment, wash the external auditory canal, conduct the necessary hardware treatment.
Take care of yourself! Relax with pleasure!
90,000 Water ingress into the ear – first aid for adults and children – Dobrobut clinic
What to do if water gets into your ear
Getting water into your ear is an unpleasant situation that needs to be corrected. If not treated promptly, water in the ear can cause serious inflammatory and infectious diseases (with damage to the eardrum). In any case, everyone needs to know what to do if water gets into the ear.
Providing first aid
The recommendations below can be used to get rid of water in the ear for both an adult and a child. And it doesn’t matter where exactly the trouble happened – at home after swimming in the bathroom or on the beach near the reservoir. What you can do as first aid:
- Jump on one or two legs, tilting the head to the side corresponding to the stuffed ear. Usually one minute of active jumping is enough to get rid of the problem.
- How to remove water from a child’s ear if he does not yet know how to jump or does not understand how to do it? The parent should place his or her hand on the child’s obstructed ear, press firmly and then abruptly remove. Under the influence of the air flow, the existing water block is destroyed.
- The method of professional divers and swimmers can be used. To get rid of the unpleasant sensation, you need to draw more air into the lungs, then, holding your nose with your fingers, blow with force, simulating a deep and powerful exhalation.This is how the water plug comes out of the ears.
What to do if the ear is blocked from water and hurts
It often happens that the sensation of water in the ear is painful, and the above first aid methods do not help. The best option in this case is to seek qualified medical help. But if the ear is blocked from water and hurts, and there is no opportunity to visit a doctor, then you can do the following:
- Make a flagellum out of cotton wool and clean the ear with it.A cotton swab (ear) is not suitable for this procedure, since it cannot absorb water, which is the first priority.
- You can simply lie on a flat surface (without a pillow) on the side where the ear is. Under the weight of the head, the water will come out on its own and relief will come.
- If seawater enters the ear and does not come out, then you can drip 1-2 drops of alcohol and wait 3-5 minutes. The alcohol mixes with water and evaporates. This method can be used to solve the problem not only in adults, but also in children.
- If water gets into the ear after bathing, use hydrogen peroxide. This solution is injected into the problem area in the amount of 1-2 drops, then the earlobe is pulled slightly down and back to the back of the head. In this case, the water will penetrate a little further along the ear canal (this is usually felt), but you should not worry, because in a mixture with hydrogen peroxide it will evaporate quickly enough.
If water gets into the newborn’s ear while bathing, it can only be removed with a cotton flag! It is not worth taking the above methods, it is more advisable to seek help from a doctor.Many parents simply cannot understand which ear the water got into and whether there is a problem at all. To get rid of doubts after bathing, the baby must first be put on one side, then (after a few seconds) on the other – the water should flow out on its own.
What to do if the ear hurts after taking out the water
Often, ENT patients complain that after getting water in the ear there is an obsessive aching pain. The reason for its appearance is swollen sulfur, which has turned into a dense plug and pressing on the nerve endings.It is unlikely that it will be possible to remove the sulfur plug on your own, but it is quite easy to push it deeper or damage the eardrum. In this case, a specialist will help.
If there is pain, but there is no feeling of ear congestion, then you can do the following:
- Apply dry heat to the ear. This means heated salt or sand, poured into a sock or any textile napkin.
- Put a drop of propolis tincture into the ear. It is imperative to make sure that there is no allergy to this product.
- Apply a vodka compress to the site of pain at night. Vodka is preliminarily diluted with water in a 1: 1 ratio. Failure to do so may result in burns.
For more information on how to get rid of the sensation of water in the ear, visit Dobrobut.com.
Sunstroke and heatstroke
Water has entered the ear. Otolaryngologists recommend!
The simplest problem after bathing is water got into the ear .More difficult is partial hearing loss. Even more serious – the ear hurts and shoots. ENT doctors combine all these diseases with a common name – “bather’s ear”. They are treated in different ways. But almost always, if you behave correctly, you can avoid negative developments.
WATER DOES NOT HURRY TO SPILL
Water remains in the ear, does not pour out, causes discomfort, noise, a feeling of overflow. What to do?
You need to lie down so that your ear with water is at the bottom.And if you lie for a long time, it will still leak out. But the process can be accelerated, make a few such movements as if you are swallowing.
Or jump on one leg, tilting your head and slapping your ear at the same time.
Or take a deep breath and, holding your nose with your hand, try to exhale.
WATER IN THE MIDDLE EAR
Water enters the middle ear only if it has filled the nasal cavity. This happens when diving or if you have swallowed water. The main symptom – the sensation of water deep into the nose and throat – is hard to miss.In this case, you need to contact an otolaryngologist.
Water that has entered the middle ear usually causes lumbago and a feeling of ear congestion.
Swimming in the sea with a child may result in complaints of ear pain. It is not always possible to explain their occurrence. Perhaps just discomfort due to water ingress. There may be more serious reasons. For example, infected water can cause ear inflammation.
Otitis media, apart from pain in the ears, is manifested by a decrease in hearing, an increase in body temperature.The danger is represented by the complications and consequences of improper treatment in the form of subsequent hearing loss.
Normally, the protective mechanisms of the external auditory canal prevent the spread of harmful microorganisms.
- traumatic injuries of the outer ear,
- long exposure to humid environment,
- chronic diseases of the child.
The anatomical features of the structure of the outer ear in children, impaired immunity, water ingress into the ears also have an impact.
The nature of the process in the ears will be determined by the otolaryngologist. Will conduct an examination and additional examinations. According to the indications, he will prescribe treatment.
To prevent the development of ear diseases: ⠀
- After bathing, dry your ears thoroughly.
- Be sure to shake out all water from your ears and rinse them with clean water. To do this, tilt your head to the side towards the ear, into which the water has entered. If it does not work out, then you need a specialist consultation.
- Observe ear hygiene.
- Temper, maintain a balanced diet for the child.
- Treat runny nose and colds in a timely manner.
Do not self-medicate. If you suspect an ear problem, see your doctor.
Medakom Medical Center. We are trusted with invaluable children!
90,000 Lays in ears: what to do?
22 July 2016
One of the most common causes is the pressure drop that occurs both at high altitude and at depth.The ear in such conditions cannot readjust so quickly, and the eardrum begins to press into the Eustachian tube, which balances the pressure inside the auricle, and your ears start to block. After a while, the congestion goes away, but the phenomenon itself may be accompanied by pain in some cases.
Less commonly, problems with some internal organs can be the causes of ear blockages. For example, an inflammatory process in the auditory tube of the ear (eustachitis) occurs as a result of a cold or a simple runny nose.Therefore, if your ears are blocked during a cold, it is best to consult an ENT. Eustachitis can also develop due to polyps in the nose, sinusitis, overgrown adenoids or curvature of the septum. Most often, these causes of Eustachitis cause ear congestion in children.
If you do not climb to a height or depth, and you do not have a cold, but your ears still stick, the reasons may lie in hearing impairment – deafness. It occurs due to damage to the auditory nerve, to which blood does not flow well.Many do not pay attention to the problem, although the main signs are quite noticeable – hearing impairment and ear congestion.
Heart problems, hypertension, coronary artery disease and a number of traumatic brain injuries can also cause ear congestion.
Ears can still be blocked due to otitis media suffered in childhood. Adhesions could form in the eardrums, which led to a deterioration in their mobility. In this case, the problem of ear congestion constantly worries, and you need to see a doctor.
What to do?
• Open your mouth several times in a row as if you were yawning;
• If problem persists, close your mouth and pinch your nose and hold your breath;
• Take a lollipop or candy and start sucking it, while actively swallowing saliva;
• Drink water in small sips;
• If your ears get stuck due to deep swimming, pinch your nose with your fingers and try to blow water out of your ear – this will reduce pain, but if this happens again, you need to see a doctor urgently.
Anyone can get an ear, but the reasons are not always harmless. Treat yourself and your health responsibly and attentively, so you can save yourself from many problems.
About Polyclinic No. 2 named after Semashko
Quite often, people are worried about hearing loss: they heard well, but suddenly after swimming in the sea, or washing their hair, or swimming in the pool, they “lost their hearing.” What could it be? Otitis media, sulfur plug, water that has not been evacuated. In any case, a doctor’s examination is necessary, i.e.because self-medication often leads to a worsening of the situation. A man, hoping that he has a sulfur plug, is trying to “pull out” it on his own. Sometimes it works, but it happens that it pushes it deeper, and then suffers for a long time, tk. hearing loss worries him. We must not wait, but go to the doctor for an examination. After all, how long can you walk with a sulfur plug or with otitis media ?!
Sulfur plug is formed due to the accumulation of sulfur with increased secretion of sulfuric glands. In a normal state, the sulfur is removed on its own.The retention of sulfur is facilitated by the narrowness and tortuosity of the ear canal, as well as the increased viscosity of sulfur. Sulfur plug may not cause any sensations, but it is enough for a small amount of water to enter the ear (when washing the head, diving, bathing), as the plug swells, hearing suddenly decreases sharply, there is a feeling of congestion and noise in the ear. The plug can put pressure on the eardrum, causing pain and dizziness. All these symptoms disappear after the removal of the sulfur plug by an otolaryngologist.
Sulfur plug can occur in any person; in ENT practice, it occurs in 10-15% of all patients, or even more. Sulfur plug can form at any age, more often in the elderly, but it is not uncommon for a young person to have a sulfur plug.
Attempts to remove the sulfur plug on their own with “improvised” means (sharp objects, hairpins, the tip of a rolled towel, a cotton swab) usually leads to pushing the sulfur into the depths of the ear canal and even injuries to the ear canal and eardrum.
You can use anti-inflammatory drugs for pain in the ears, but they can even more “block” the ear canal, respectively, increased congestion in the ear. And long-term presence of the drug in the ear will cause reactive edema of the skin of the ear canal and tympanic membrane, which, in turn, will require extended therapy.
With hearing loss, preparations that soften sulfur are still used (they soften it, and do not remove or dissolve). Therefore, such drops can be used according to the doctor’s prescription for the subsequent removal of the sulfur plug by rinsing.Patients need to warn the doctor before washing the ear canal about the presence of a chronic ear disease, perforation of the tympanic membrane in order to avoid complications during the procedure.
That is why it is necessary in any case to consult a specialist. If it is a sulfur plug, then it is easily removed from the ear (it is very rare when the sulfur plug is removed with difficulty), and its independent removal can lead to an unfavorable course of the process; if there is inflammation in the ear, then adequate therapy prescribed by the doctor will relieve the symptoms quickly and effectively.
Which doctor should I contact:
For diseases of the ear, throat or nose, you should consult an otorhinolaryngologist (ENT).
The length and depth of diving depend on the duration of the breath hold. The breath holding time is on average about 1 min. Trained athletes are able to hold their breath for a few minutes. After preliminary inhalation of oxygen, the breath holding can reach 13 minutes or more. For the first time, the Frenchman J.Mayol and is equal to 3 min 40 s. The time for a high-speed dive to 50 m with fins is about 15 s.
To increase the time for holding the breath, it is recommended:
– before diving, perform 6-8 deep exhalations and breaths;
– dive after the usual full inhalation, and during diving in depth (before surfacing) do not exhale;
– when diving in length, swim under water at a depth of 1-1.5 m;
– while diving, the swimmer should not have any negative emotions, as they drastically reduce the duration of holding the breath;
– at the end of diving to increase breath holding, it is necessary to make a swallowing movement;
– at the end of diving, take 3 quick breaths: 1st at 20%, 2nd at 40%, 3rd at 60% of the maximum breath.After the third breath, calm deep breathing.
Underwater orientation is difficult, so dive should only be done with eyes open; in poor visibility under water, you must stretch your arms forward.
Ear pain often occurs during diving. This occurs when the eustachian tubes are poorly patented and due to water pressure on the eardrum. To prevent rupture of the eardrum, you need to pinch the nostrils, try to exhale lightly through the nose or, without opening your mouth, make an energetic swallowing movement.If this does not help, diving should be stopped and surfaced. For colds, diseases of the nasopharynx or tympanic membranes, diving is unacceptable.
Methods of diving when diving in length and depth
Diving from the surface of the water. Can be performed upside down or upside down.
To dive from the surface of the water with your feet down, you must make a vigorous stroke with both hands and feet, rise as high as possible out of the water and inhale. The higher the swimmer rises out of the water, the faster he will dive.So that the dive does not slow down under water, the rowing movements with the hands must be performed from the bottom up. When the swimmer reaches the required depth or bottom, he can group and, turning, swim in the desired direction.
To dive from the surface of the water upside down, the swimmer groups up, takes a breath and lowers his head under the water with a sharp movement.
Then he straightens up, raising his legs above the water (i.e. takes a vertical position upside down), and plunges into the water. When fully submerged, he can speed up the dive by starting with his legs and guiding himself with his arms in the right direction.
Walking dive with long diving. It is performed by a sharp one-handed stroke with vigorous crawl leg movements; while the other arm remains extended forward. After the stroke, while carrying the hand through the air, the head turns towards this hand and inhalation is made. At the moment of joining the arms, the swimmer bends the legs at the hip joints, immersing the arms and the front of the body to the desired depth. Continuing to move his legs, he straightens up under water in a horizontal position.
Push-off dive from a support (pool wall, side of a boat or cutter). The swimmer is grouped, lowers his head down, and puts his legs on a support above the level of the head. Pushing off from the support, the swimmer straightens up and, in a sliding position, goes to depth.
For a long dive, the swimmer flexes while continuing to move his legs. To ascend from a great depth, a push with the legs from the bottom and rowing movements with the hands down to the hips are performed.
Methods of diving
The technique of diving underwater during diving is the same in length and depth.When diving in conditions of good visibility, the most effective methods are used: breaststroke and combined swimming methods, in which the arms work with the breaststroke, and the legs – with the crawl or dolphin.
When diving at night or in poor visibility under water, the arms must be stretched forward. Legs work as a crawl, which is especially effective when diving with fins, or breaststroke.
For breaststroke diving, use a long arm stroke to the hips.
From the starting position, a hand stroke is performed, after which the sliding phase begins. Then, as the glide slows down, the arms and legs simultaneously perform preparatory movements. When the arms return to their original position, a leg stroke is performed, after which the swimmer again performs a slide in the initial position. After sliding deceleration, the entire cycle of movements is repeated.
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90,000 Treatment of chronic otitis media
Otitis media is an inflammatory process in the ear, accompanied by a whole range of symptoms.Depending on the place of localization, clinical manifestations and the presence of exudate, several types of this disease are distinguished.
Human ear: structure
The human ear consists of auricle and external auditory canal , which passes into the tympanic membrane of the middle and inner ear. In comparison with other parts, this part of the hearing aid carries a conditional functional load. The task of the auricle is to capture sound waves and direct them into the auditory canal.
Middle ear – the tympanic cavity, in which there are three bones – the malleus, incus and stapes. The function of the cavity is to transform and amplify the audio signal.
The base of the stapes separates the middle from the inner ear. Most of the inflammatory processes we know as otitis media develop right here, in the middle ear.
Inner ear looks like a snail.It is located in the temporal bone and is filled with fluid and hair cells. The functional load of the inner ear is the transformation of sound waves into nerve impulses, which instantly go to the corresponding parts of the brain.
Allocate otitis media of the outer , of the middle and of the inner of the ear.
Outer ear is usually very unaffected by inflammatory diseases. Basically, acne and boils appear here.The greatest difficulty is the aseptic processing of the boil, especially if it is located deep enough: there is a risk of damaging the eardrum.
If the focus of inflammation grows, then the patient’s hearing may decrease, however, this is due to purely physical factors. After elimination of the rash, hearing returns in full.
Middle ear inflammation is most common . This is due to the anatomical features of the cavity.For the transmission of a sound wave, the density of the medium in which it propagates plays an important role. The corresponding pressure is provided by Eustachian tube , which connects the tympanic cavity to the pharynx. By equalizing the pressure in the cavity with each sip, it also creates conditions for the penetration of infection into the hearing aid from the mouth and nasal passages. This is how otitis media develops.
Pay attention! Inflammation of the inner ear is an extremely dangerous condition that is a complication of otitis media of the middle ear.Inflammation of the labyrinth of the snail develops quickly and is fraught with emergency conditions that pose a threat to life – sepsis or meningitis. The likelihood of permanent hearing loss in this case is much higher than with inflammation of other parts.
Depending on the clinical manifestations, otitis media are divided into acute and chronic.
Acute otitis media is characterized by severe pain and rapid onset of symptoms.
Chronic otitis media develops as a result of untreated acute and is an alternation of periods of exacerbation of the disease with periods of remission.
Another classification of otitis media is based on the presence or absence of purulent discharge. Thus, purulent otitis media and catarrhal are isolated.
Types of otitis media
Otitis media is of two types – infectious and traumatic.
Traumatic otitis media is quite rare. The most common type of injury that doctors have to deal with is the consequences of hygiene procedures performed with a cotton swab.It must be remembered that it is necessary to get rid of sulfur only in the area of the external auditory canal. When trying to push the stick deeper, there is a high risk of damaging both the villi located in the thickness and the eardrum itself.
If a sulfur plug has formed in the ear, which significantly reduces hearing, then this is a reason for a visit to the otolaryngologist.
Otitis media of an infectious nature develop as a result of acute respiratory infections of a viral or bacterial nature.
With significant contamination of the nasal mucosa, a runny nose develops, which is a constant secretion of mucus. Such mucus can penetrate the eustachian tube into the tympanic cavity and cause inflammation. The thickening and drying of mucus is especially dangerous, since its natural outflow is hampered.
An additional factor that contributes to the entry of phlegm into the ear is improper or excessive blowing of the nose. Inflammation in the eustachian tube – eustachitis – provokes the formation of pus, which in large quantities can cause perforation (rupture) of the tympanic membrane .After such a spontaneous drainage, the patient’s condition gradually improves, the membrane is scarred, and the pain subsides.
For reference. Acute otitis media develops less frequently in adults than in children. This is due to the fact that with age, the diameter of the Eustachian tube increases, which facilitates drainage of the cavity. In addition, adults are less active in sniffing and clearing their sinuses more gently by blowing their nose. With age, adenoids, which are found in every second child, atrophy and stop squeezing the Eustachian tube.
Symptoms of otitis media in adults
Symptoms of the disease depend on the localization of the inflammatory process.
Otitis externa :
- Moderate hyperemia of the skin, redness of the auricle;
- pain radiates to the temple or jaw, especially when chewing food or talking.
With timely sanitation of foci of inflammation – boils and acne – the process quickly stops and the pain disappears.
Otitis media :
- Severe pain can be sharp, shooting, or aching.
- symptoms of general malaise are noted – increased body temperature, drowsiness, fever with chills.
These signs are characteristic in general for acute respiratory infections, the complication of which is often otitis media.
With purulent otitis media , there may be discharge from the ear canal. This indicates a perforation of the tympanic membrane.
Permanent ear congestion or the constant presence of background noises, decreased hearing acuity are symptoms characteristic of chronic otitis media .
There are two forms of chronic otitis media – tubo-tympanic , when only the mucous membrane is affected, and epithympan-antral , in which bone tissue is also involved in the inflammatory process.
Pay attention! It is impossible to independently determine the form of the disease, and treatment at home can lead to irreversible consequences – the development of hearing loss and complete deafness.
Otitis media of the inner ear – develops against the background of the above symptoms, which are joined by:
- severe dizziness;
Deterioration of health occurs rapidly, and in the absence of qualified medical care, the prognosis for the patient is unfavorable.
Diagnosis of otitis media
Diagnosis of otitis media in adults is carried out in several steps: collecting anamnesis – patient complaints, examination – otoscopy, which is carried out using a special device inserted into the auditory canal.
If otitis media has become chronic, the doctor prescribes a bacterial culture of mucus from the nasopharynx for sensitivity to antibiotics.
The otolaryngology department of the Medline Surgut clinic uses the following diagnostic methods:
- video metering;
The most accurate assessment of the condition of the middle ear and the degree of development of the inflammatory process is possible using a video endoscope – a special video camera that allows a significant increase in the image during examination.
To determine the degree and find out the cause of hearing loss, you can use a method such as audiometry . During the examination, the otolaryngologist, using an audiometer, determines the sensitivity to sounds of different frequencies and assesses the degree of hearing damage.
Another method of modern diagnostics is tympanometry . It is performed using a tympanometer, which allows you to examine the functions of the middle ear, determine the degree of mobility of the tympanic membrane and the conduction of the auditory ossicles.The data obtained in the process of tympanometry, the doctor compares with the results of audiometry and makes an accurate diagnosis.
Otitis media of the middle ear is often fraught with complications. If an additional study of the state of the temporal bone is necessary for the presence or absence of destruction, radiography or computed tomography is used.
Treatment of chronic otitis media
Only an otolaryngologist should diagnose and choose a course of treatment for chronic otitis media, therefore, the appearance of tinnitus, sharp pain, hearing loss, congestion, a feeling of pressure should be a serious signal for you to visit a doctor!
A full course of therapy for chronic otitis media in adults at the Medline Surgut medical center is 5-7 days and is carried out in accordance with the causes of this disease.
Therapy of the inflammatory process occurring in the middle ear cavity consists in the use of drugs of the following groups:
- pain relievers;