Ear Injuries & Diving: Everything You Need to Know

A Diver’s Guide: How to Equalise Your Ears

Your ears and sinuses are one of the most important organs when it comes to diving. Unfortunately, most divers only start to appreciate this fact after they incur an injury to this region. From minor ear infections to barotraumas, many a holiday or dive trip has been ruined due to preventable ear issues. That is why understanding the anatomy of your ear, and how diving affects this organ, is key to prevention. With this knowledge, and a few simple tips and tricks, divers can avoid annoying ear injuries and equalise like a pro.

Your Ear’s Anatomy

Your ear consists of three main parts: the outer, middle and inner ear. Below is a general overview of the anatomy and function of each. It is a basic overview, focusing on the critical knowledge needed for divers to understand equalisation. If you would like to learn more about your ears’ anatomy, check out the Divers Alert Network (DAN) article here. 

Outer Ear

The outer ear, or auris externa, is the external part of the ear. It is the starting point of your ear canal and is where earwax is produced. It is separated from the middle ear by your eardrum.

Middle Ear

The middle ear is the part of the ear between the eardrum and the oval window. This is the area that transmits sound from the outer ear to the inner ear. It is made up of three small bones, as well as the oval window, the round window and the Eustachian tube.

For divers, it is the most important area of the ear. This is due to the Eustachian tube, and its role in equalisation. These tubes, located in each ear, connect the middle ear with the back of the throat. Their function is to equalise the air pressure on both sides of the eardrum. Unfortunately, as they are surrounded by cartilaginous tissue, the tubes don’t allow for expansion. This means that a diver must equalise his or her ears by actively opening the tubes. We do this through various methods and techniques that introduce air through the tubes into the middle ear.

If a diver does not properly equalise during a dive, the pressure can build up on the eardrum. This can lead to a painful pressure-related injury called barotrauma.

Inner Ear

As the name suggests, this is the innermost part of your ear. It is a maze of tubes and passages often referred to as the labyrinth. The function of the inner ear is to transmit sound waves into electrical impulses for the brain. Additionally, it is home to the vestibular; the organ that controls equilibrium.

Diving Related Ear Injuries

There are many causes of ear pain when diving, but the two most common types encountered are ear infections and  pressure-related injuries.

Swimmers Ear (Otitis externa):

Otitis externa, or swimmers ear, is an infection of the outer ear. It is often caused by water remaining trapped in the ear canal. The moisture, coupled with the warmth of the body, creates the perfect breeding ground for bacteria. This usually leads to infection in the surrounding tissues. The main symptoms include inflammation, redness, swelling and/or itching.

Middle Ear Barotrauma:

Ear barotrauma is by far the most common injury reported among divers. As explained above, the injury is typically a result of poor equalisation. However, diving with a cold can also lead to the injury. As pressure builds up inside the ear, it can cause your eardrums to bulge. This overpressure will eventually cause fluid and blood to leak into the middle ear, partially or completely filling it.

A common symptom of a middle ear barotrauma is a feeling of fullness in the ear, as if it was filled with fluid. Muffled hearing or hearing loss can also be other indicators. On examination with an otoscope, fluid may appear behind the tympanic membrane, causing it to bulge and appear red. In other cases, the eardrum may be retracted or sunk in. Either condition warrants immediate medical attention.

Methods of Equalisation

No diver wants to go through the pain, or recovery time, associated with either of the above injuries. That is why it is so important to practice safe equalisation techniques. There are many different techniques available for divers to equalise. The most common method taught to open water divers is the Valsalva maneuver. However, there are other methods and tricks that you can utilise. The key is finding what works best for you as a diver.

Valsalva Maneuver - Pinch Your Nose and Blow

This is the method most divers learn. To execute it, you pinch your nostrils (or close them against your mask skirt) and blow through your nose. The resulting over-pressure in your throat forces air up your Eustachian tubes.

There are three major problems with this method, though. The first being that it does not activate the muscles of your ear. Instead, it forces air up the Eustachian tubes to open them. This means that it will not work if your tubes are already blocked, and could actually cause damage if they are. The second major issue is that blowing against a blocked nose increases your internal fluid pressure. This can result in a blowout of the round windows, and a lot of pain. So you should never blow too hard, nor maintain the pressure for more than five seconds. The last issue with the Valsalva is that it is very easy to use too much force in an attempt to equalise, and cause damage.  Remember, if you are using the Valsalva method, you want a gentle constant blow.

Other Techniques for Equalisation

If the Valsalva method isn't working for you, don't worry. There are a number of alternative techniques available to help you equalise. Many of them will feel unnatural at first, so practice will make perfect here. Your ears will thank you for it.

Voluntary Tubal Opening

Tense the muscles of the soft palate and the throat while pushing the jaw forward and down as if you are starting to yawn. The activation of these muscles helps pull the Eustachian tubes open.

Toynbee Maneuver

With your nostrils pinched or blocked against your mask skirt, swallow. Swallowing pulls open your Eustachian tubes, while the movement of your tongue, with your nose closed, compresses air against them.

Frenzel Maneuver

Close your nostrils, and close the back of your throat as if you are straining to lift a weight. Then make the sound of the letter "K." This forces the back of your tongue upward, compressing air against the openings of your Eustachian tubes.

Lowry Technique

A combination of Valsalva and Toynbee: while closing your nostrils, blow and swallow at the same time.

Edmonds Technique

While tensing the soft palate (the soft tissue at the back of the roof of your mouth) and throat muscles and pushing the jaw forward and down, do a Valsalva maneuver.

Additional Tricks

Below are a few other common tricks that can be utilised alongside the above techniques.

• Wiggle your jaw back and forth
• Tilt your head from side to side
• Massage your ears/Eustachian tubes
• Blow out of each nostril independently
• Take off your mask, clear your nose and equalise. Then place mask back on and try and clear again.

With all the above techniques, the most important rule is to stop and slowly ascend a few metres if you encounter any pain. Usually adjusting the depth by a few metres is all a diver will need to achieve that “pop” or “click” and equalisation. If this doesn’t work, slowly go up another metre or two and try again. Do not try to push through the pain. You will likely only regret it later.

10 Tips to Help You Equalise

Here are some other tips that divers can use to help with equalisation as well as general ear health. Used in conjunction with the above techniques, they can help you beat the squeeze, and avoid that vacation-crushing ear pain.

1. Equalise Early and Often.Several hours before your dive, begin gently equalizing your ears every few minutes. Continue this all the way until you are at the surface. This process of “pre-pressuring” will help you get past the first few critical feet of descent.
2. Slow and Feet First. Take your time when making your descent. You should never feel pressured or obligated to rush. If you tend to have equalisation issues, let your dive instructor know beforehand so they can assist. When making your descent, always go feet first. Air rises up your Eustachian tubes, and fluid-like mucus tends to drain downward. Studies have shown a Valsalva maneuver requires 50% more force when you're in a head-down position than head-up.
   
   
3. Use Rubbing Alcohol or Vinegar. Drops Many divers swear by the use of these drops before and after a dive. A common mixture to use is 50/50 of alcohol to vinegar. The alcohol works against the growth of bacteria and helps dry out the ear canal. The vinegar counters the alcohol and ensures your ear will not dry out too much.
   
   
4. Use Oil.A few drops of oil in each ear before the dive is said to prevent bacteria from entering or staying in the ear. Recommended oils are - baby oil, olive oil, tea tree oil (diluted) and almond.
   
   
5. Mask That Covers Ears/Vented Ear Plugs.Ear masks and vented ear plugs are designed to keep water out of the ear while allowing you to equalise. These products are ideal for divers who often struggle with ear issues.
   
   
6. Keep it Clear.Water in your nose can irritate the mucus membranes . Agitated membranes mean increased mucus production which leads to further congestion. Keep the mask free of water to keep yourself snot free.
   
   
7. Use a Descent Line.Pulling yourself down an anchor or mooring line helps control your descent rate more accurately.
   
   
8. Avoid Irritants.Certain foods or products can lead to increased mucus production. Milk, cigarettes and alcohol are all considered irritants so it is best to avoid them before a dive.
   
   
9. Look Up.When you look upwards you are extending the neck, which can help to open your Eustachian tubes.
   
   
10. Don’t Worry.It is quite normal to struggle with equalisation in the beginning. Even experienced divers will have ear issues now and then. The more you stress, the more tense you will become and this will in turn make it harder for your body to equalise. So relax and stop worrying about other people in your group waiting for you. It is better to be safe and slow than to injure your ears.

The Bottom Line

Ear issues may be the most common type of injury in scuba diving, but they are 100% preventable. With a little practice, and the adoption of some of the techniques and tricks mentioned above, you can say goodbye to annoying, holiday ruining ear pain.

We as dive professionals are here to ensure you have a safe and memorable experience. So, if you are ever nervous about equalisation prior to a dive, let us know!  Our instructors will work to find the best techniques for you. Ensuring a safe, enjoyable dive - for you and your ears.