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Guide to Avoiding Ear & Sinus Injuries in Scuba Diving

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Learning to Adapt

As divers, we must adapt to an environment that exerts pressure on our bodies. The most common injuries reported to DAN each year involve pressure-related injuries to divers' ears and sinuses. A little education and common sense will go a long way to avoid these problems. Take a minute to read this page. DAN, your dive store and your instructor want your scuba adventures to be enjoyable and safe.

Sinus and Middle Ear Injuries

Barotrauma is a pressure-related injury. Middle ear barotrauma, known as "ear squeeze," is the most common diving injury. Sinus barotrauma also occurs, but is less common. How does it happen? Pressure changes when diving cause barotrauma. During descent, air spaces in the sinuses and middle ear must be able to equalize to the surrounding water pressure, which increases with depth. When pressure in air spaces can't equalize, the diver may sense pressure or pain from one of these areas. During ascent, if the expanding air can't be vented, the cavity pressure increases, resulting in discomfort. This type of injury can range in severity - from mild to extreme. A sinus or middle ear injury may occur suddenly and lead to inner ear damage. For this reason, divers should know and use the "clearing," or equalizing, maneuver that works best for them.

How to Equalize

The Valsalva Maneuver.

In what is probably the most commonly taught means of equalizing pressure during diving, divers close their mouths, pinches their noses and blow gently. Avoid blowing too hard and over-inflating the middle ear space. This can occur if divers are overly excited or having a difficult time equalizing during descent - and especially if they have waited too long before attempting to equalize. The result could be injury to the middle or inner ear.

The Frenzel Maneuver.

This method is similar to the Valsalva maneuver, except that instead of blowing air into the sinuses, the diver closes the nose and mouth, and drives the tongue backwards on the roof of the mouth. The muscle contraction opens the nasal cavities and eustachian tubes, which allows air into the middle ear.

The Yawn & Swallow.

Some divers can simply swallow, yawn or thrust their lower jaw forward and open their mouths while using their lips to maintain a seal with the regulator mouthpiece. This opens the eustachian tube to the middle ear, which equalizes pressure. As long as the sinuses also equalize easily, this maneuver is acceptable.

For many divers, a combination of these methods - even switching back and forth during a single descent - works best.

Prevention is the Key

The most common reason divers suffer barotrauma is a failure to inflate their ears and sinuses with additional air during descent. Often divers mistakenly wait to equalize their ears or sinuses when they feel discomfort. Begin the equalizing process by inflating your ears and sinuses with air before entering the water or beginning your descent - this ensures that the air passages are open and clearing is possible. A slow, steady descent with frequent inflation (every 1 to 2 feet) is then possible without barotrauma.

If you feel discomfort, stop your descent and ascend a few feet until the discomfort is relieved. Attempt to clear but do not continue your descent unless your sinuses and middle ear spaces have equalized.

Some divers may use topical nasal vasoconstrictors such as Afrin®, which may help with the process of equalizing when used before a dive. Regardless of the technique you use to equalize your ears and sinuses, remember to descend slowly until you can easily clear these air spaces.

To avoid barotrauma, remember:

  • Test your ears and sinuses by equalizing prior to entering the water or prior to your descent;
  • Descend at a slow, steady pace and keep up with your clearing maneuvers;
  • Do not continue to descend and forcefully clear if you're having difficulty - stop your descent before you experience ear or sinus pain (waiting until you feel discomfort to begin clearing means you've waited too long);
  • Descend and equalize in a feet-first position; it is easier than head-first;
  • If you do experience pain or discomfort, ascend until it is relieved;
  • Equalize early and often to stay "ahead" of barotrauma.
Difficulty Equalizing

What if you can't equalize? First, don't dive until the problem is resolved. If a diver has trouble equalizing the sinuses and middle ear, there may be some pre-existing problem - the most common is diving with a cold or flu. Frequently the mucous membrane will retain fluid and swell, partially occluding the air passages to your sinuses and the Eustachian tube going from the back of your throat to the middle ear. This not only makes clearing difficult, but it may prevent it altogether.

Other recognizable factors in equalizing problems are:

  • a history of childhood ear infections or even one severe infection that may leave the eustachian tube scarred and partially occluded;

  • a history of a broken nose or a deviated septum that prevents one ear or set of sinuses from clearing as fast as the opposite side;

  • hay fever, which may produce swelling of the mucous membranes or cause nasal polyps that can partially or completely occlude a sinus cavity or airway.

If you have a history that includes these conditions and want to dive successfully, it may require referral to an ear, nose and throat physician or allergy specialist who is familiar with these conditions.

Symptoms of Barotrauma

The most common barotrauma symptom a diver experiences may be mild discomfort to intense pain in the sinus or middle ear - this is usually the first indication of a problem in equalizing. Middle ear barotrauma may also include symptoms of ringing or hearing loss. As blood or fluid accumulates in the middle ear a diver may experience a partial, complete or muffled hearing loss as well as damage to the inner ear. Roaring in the ear, nausea, vomiting, dizziness, a sensation of spinning and decreased hearing may also indicate inner ear barotrauma, which requires urgent specialized treatment. Blood from the nose or in the sputum is also an indication of barotrauma and does not have to be associated with other symptoms. These are symptoms that should probably end the day's - and possibly the week's - diving. Continuing to dive with barotrauma may result in serious injury.

Treatment and Medication

If you experience any symptoms during or after a dive, then you should consult a physician to determine the extent of the injury, or if there is some treatable condition causing the problem. Your physician can determine the correct treatment and medication for sinus or middle ear barotrauma and refer you to an ear, nose and throat specialist if necessary. Proper care and medication under a physician's supervision can reduce the time divers experience barotrauma symptoms - and the sooner they can get back into the water to enjoy diving.

Additional Resources
DiversGuidetoEars.pdf