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Ears and Sinuses

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Although not the most serious of diving problems, those related to ear, nose and throat conditions are the most common and probably account for more time away from diving and for the majority of calls to DAN's emergency number than any other.

In your basic scuba course, you learned about diving physics and particularly the gas laws. You learned from Boyle's Law that there is an inverse relationship between pressure and the volume of gas in gas-filled spaces. Increasing pressure on descent reduces the gas volume and decreasing pressure on ascent increases the gas volume proportionately. Unless we equalize pressure on descent or allow the expanding gas on ascent to escape, problems related to barotrauma (pressure damage) can occur. Until the damaged areas heal, you need to stay out of the water. This is true for the ear and the sinuses, as well as other gas-filled spaces.

Sinus Congestion

Doc, I got sinus!

Sinus is a term used by lay people to categorize a wide spectrum of conditions, the chief characteristics of which are nasal congestion and nasal discharge, either from the front of the nose or the back. Actual sinus disease is uncommon, but the nasal congestion of allergic and non-allergic rhinitis is very prevalent. Certainly, if congestion is significant and affects the sinus openings and the eustachian tubes, sinus and/or ear squeezes can be a consequence.

The sinus ostea, or openings, are usually open. They are blocked only by severe congestion or mechanically by mucous or polyps. The eustachian tube is usually closed, and requires some effort to open.

To prevent congestion, you should treat allergies. This consists of using antihistamines, decongestants and nasal sprays, and allergy desensitization. Newer antihistamines do not cross the blood-brain barrier and do not produce drowsiness. They are only available by prescription.

Decongestants may have side effects such as speeding up your heart rate, keeping you awake and sometimes produce a rebound effect causing greater congestion. Over-the-counter nasal sprays can definitely produce this rebound congestion. They might also affect you if you have any cardiovascular diseases. Newer steroid nasal sprays do not have this side effect and are very useful. Again, these are only available by prescription.

Combinations of the same drugs are useful in non-allergic rhinitis. After discussion your condition with your physician, these medications can be very useful in controlling the "sinus" problem.

Tympanic Membrane Rupture

Is it safe to dive with a perforated tympanic membrane?

A perforated tympanic membrane (eardrum) can occur from diving as well as from non-diving causes. Most traumatic perforations heal spontaneously. Following an appropriate time after they have healed, you can return to diving if your physician feels the healing is solid and there is no evidence of eustachian tube problems. This usually takes about two months after it is healed.

If the perforation does not heal, then an ear surgeon can repair the damage. After healing has taken place, the same rules about returning to diving above apply. It is important to check for chronic nose and sinus problems if there is no healing.

Chronic perforations that do not heal are a contraindication to diving. Some have advocated the use of ear plugs for these individuals, but if there is any water leakage, it could cause a severe infection.

ENT Surgery

Is it safe to dive after ear or sinus surgery?

Obviously this is a broad question. The final decision on returning to diving depends on the nature of the problem and how well it heals. In general external canal surgery patients can return to diving as soon as the canal skin has completely healed. Middle ear surgery is more complicated. Middle ear problems are frequently caused by eustachian tube dysfunction, and this must be cleared up before the diver can go under pressure. If prostheses (artificial ear bones) are used, there is controversy between otologists about returning to diving. The diver should consult with his or her surgeon.

Inner ear surgery involving removal of the stapes bone or the placement of a stapes prosthesis (in otosclerosis) generally is a contraindication to diving. If you have had surgery for inner ear barotrauma, many diving physicians would advise against any further diving. Another group of diving physicians would allow returning to diving if there is no significant residual hearing loss, no balance problems, and you can easily equalize your middle ear. After sinus surgery, the surgical site should be completely healed, and there should be clearing of the sinus problem. Any residual sinus disease might lead to a worsening of the original problem or significant complications.

Ultimately, you should follow the advice of your surgeon.

Tinnitus (Ringing)

Will Tinnitus prevent me from diving?

Tinnitus or ringing in the ears can have many causes. Your doctor should investigate the underlying cause regardless is the condition is acute or chronic. Gradual progressive tinnitus can be due to noise exposure as well as advancing age. It is usually associated with a hearing loss. If the underlying problem is not serious, there is no reason to curtail diving.

Meniere's Disease

Can I dive with Meniere's disease?

Meniere's disease is a recurring group of symptoms, characterized by episodes of fullness in the ear, tinnitus (ringing), vertigo -- sometimes with nausea and vomiting -- and fluctuating hearing loss. The vertigo can occur without warning. If they occur underwater, it could lead to panic with possible uncontrolled ascent or drowning. Recurring episodes of vertigo from any cause should be a contraindication to diving.

Ear Plugs

Can I dive with ear plugs?

With an intact tympanic membrane (eardrum), the increasing water pressure against the ear plug and the decreasing volume of air between the plug and the tympanic membrane tend to drive the ear plug against the tympanic membrane. If the plug wedges within the ear canal, there is risk of external ear canal barotrauma.

Plugs that have a hole in them allow water to enter the canal and defeat the purpose of the plug. If there is a perforation of the tympanic membrane, this could cause middle ear infection. Advocates of the use of ear plugs have not presented enough evidence to recommend the use of plugs.

Deviated Septum

Is a deviated nasal septum a reason not to dive?

If you don't have any problem with your sinuses or ears while diving, then a deviated nasal septum (history of a broken nose) is of no consequence. Straightening of the septum can often relieve chronic ear and sinus problems if they exist, and might also eliminate difficulty with ear and sinus equalization, preventing squeezes.

Temporal-Mandibular Joint Syndrome

What is TMJ? And can it occur in divers?

TMJ or temporo-mandubular joint syndrome is an inflammation of the jaw joint just in front of the ear. It can be caused by abnormalities of occlusion (the way your teeth come together). The chief symptom is pain in the ear when your ears appear normal upon examination. Tinnitus and vertigo can also occur. It usually occurs in novice divers who clench their teeth, occasionally biting through the mouthpiece. Treatment includes bite adjustment, management of dental problems and the use of orthodontic mouthpieces. Heat and anti-inflammatory drugs are helpful.

Hearing Loss/Deafness

I have a hearing loss in one ear. Is it safe for me to dive?

Although not common, it is possible for a diver to suffer a significant hearing loss in an ear from a diving accident. This is an individual decision for each diver to make, assisted by advice from your physician. Generally, if the original hearing loss is severe and loss of hearing in the remaining ear would make the person deaf, then my advice would be not to dive. This advice is particularly true if you tend to have difficulty equalizing regularly.

Most physicians are very conservative, even diving doctors. Severe hearing loss in both ears is a great handicap and should be avoided, if possible.

It takes me a long time to equalize my ears when descending in the water. How can I avoid this so my diving buddies will not have to wait for me?

On descent, the air in the middle ears is reduced in volume by the increasing surrounding (ambient) pressure. Some divers can equalize their middle ears easily, but on occasion every diver has had some trouble. Others always have difficulty.

The culprit is the inability of the eustachian tube to open. The tube extends from the middle ear to the back of the throat, above the palate. It is lined by the same kind of lining as the nose and sinuses and is subject to any inflammation that can occur in those areas. If there is enough swelling or mechanical obstruction, then equalizing can be difficult, if not impossible.

To avoid difficulty, you need to control all acute nasal and sinus problems. If cleared by your physician, using decongestant medications may be helpful. Equalize early and often. Use proper techniques.

Don't let your buddies rush you. If you do there may be permanent damage.

Instructions for Equalizing Ears and Sinuses

Middle ear and sinus barotrauma are the most common injuries associated with exposure to increasing and decreasing pressure. Descent in the water adds approximately one-half pound of pressure for each foot of descent and diminishes a similar amount on ascent. According to Boyle's Law, as the pressure increases on descent, the volume of a gas in an enclosed space decreases proportionately. As the pressure decreases on ascent, the volume of the gas increases proportionately. On descent it is imperative that all enclosed air filled spaces be equalized actively or passively. On ascent, the increasing volume usually vents itself naturally.

For equalization to be effective, you should be free of nasal or sinus infections or allergic reactions. The lining of the nose, throat and eustachian tubes should be as normal as possible. If this is true, the following techniques are effective in reducing middle ear and sinus squeeze.

  1. Prior to descent, neutrally buoyant, with no air in your buoyancy compensator, gently inflate your ears with one of the techniques listed below. This gives you a little extra air in the middle ear and sinuses as you descend.
  2. Descend feet first, if possible. This allows air to travel upward into the Eustachian tube and middle ear, a more natural direction. Use a descent line or the anchor line.
  3. Inflate gently every few feet for the first 10 to 15 feet.
  4. Pain is not acceptable. If there is pain, you have descended without adequately equalizing.
  5. If you do not feel your ears opening, stop, try again, perhaps ascending a few feet to diminish the pressure around you. Do not bounce up and down. Try to tilt the blocked ear upward.
  6. If you are unable to equalize, abort the dive. The consequences of descending without equalizing could ruin an entire dive trip or produce permanent damage and hearing loss.
  7. If your doctor agrees, you may use decongestants and nasal sprays prior to diving to reduce swelling in the nasal and ear passages. Take them one to two hours before descent. They should last from eight to 12 hours so you don't need to take a second dose before a repetitive dive. Nasal sprays should be taken thirty minutes before descent and usually last twelve hours. Take caution when using over-the-counter nasal sprays. Repeated use can cause a rebound reaction with worsening of congestion and possible reverse block on ascent.
  8. If at any time during the dive you feel pain, have vertigo (the whirlies) or note sudden hearing loss, abort the dive. If these symptoms persist, do not dive again and consult your physician.

  9. Equalizing Techniques
    • Passive - requires no effort
    • Valsalva - increase nasopharynx pressure by holding nose and breathing against a closed glottis (throat)
    • Toynbee - swallowing with mouth and nose closed - good for ascent!
    • Frenzel - Valsalva while contracting throat muscles with a closed glottis
    • Lowry - Valsalva plus Toynbee - holding nose, gently trying to blow air out of nose while swallowing - easiest and best method!
    • Edmonds - jutting jaw forward plus Valsalva and/or Frenzel (good method)
    • Miscellaneous - swallowing, wiggling jaws - good for ascent!

From the January 2001 issue of Alert Diver.