If
If one method of equalising doesnt work for you, there are plenty more from which to choose.

Over and over again, readers contact DIVERS Medical Q&A column about ear problems.  Dr Ian Sibley-Calder has been listening, and now he has pulled together the answers to all those frequently asked questions

EAR-CLEARING
THIS IS THE NUMBER ONE TOPIC.
There can hardly be a diver who has not had this problem at one time or another.
Understanding the anatomy of the ear helps in explaining problems. Youll find a diagram over the page, which shows that the ear canal goes down to the eardrum, which provides a seal to the middle ear. This very small space contains the ossicles (small bones) that transmit sound waves to the inner ear.
The only way pressure can be equalised between ear canal and middle ear is via the very small Eustachian tube that opens into the back of the throat.
When pressure increases as we dive, the pressure in the back of the throat and the ear canal are essentially the same, but the pressure in the middle ear is lower. If this pressure difference is not equalised, pain is felt over the ear drum as it is stretched. If still not corrected, bleeding into the eardrum can occur and the drum can even rupture.
Nature doesnt like vacuums, so fluid can also pour into the middle ear space, either as a viscous liquid or as blood.
This is one reason why so many divers complain of full feelings, deafness or hearing through cotton wool.
If the cause - the pressure difference - is removed, both problems will resolve on their own, although sometimes a short course of a decongestant can help speed things along.
Even so, the fluid can take weeks to go completely. Diving is not recommended until the symptoms are fully resolved.
We prevent the problem by equalising the pressure in the middle ear to the outside pressure. Here are common ways of helping:

  • Before descending, while neutrally buoyant with no air in the BC, gently inflate the ears (see Equalising Techniques panel, right). This gives you a little extra air in the middle ear and sinuses.
  • Descend feet first, if possible. This allows air to travel up into the Eustachian tube and middle ear, a more natural direction. Use a descent line or the anchor line. Looking upwards slightly also helps.
  • Inflate gently every half-metre for the first 5m; less frequently as you descend deeper.
  • Pain is not acceptable. If there is pain, you have descended without adequately equalising.
  • If you dont feel the ears opening, stop, try again, perhaps ascending a metre or two to diminish the surrounding pressure. Try to tilt the difficult ear upwards.

There are some soft-tissue cushions at the entrance to the Eustachian tube at the back of the throat.
These, and the fact that we rarely get practice in clearing our ears with the sort of pressures we get in diving, make ear-clearing difficult for a lot of divers, especially in their first 30 or so dives and after repetitive diving.
Lots of practice in gently clearing your ears helps, but a feet-first, slow controlled descent with lots of ear-clearing at the shallower depths is a good approach. Raising the head also seems to help.
Be patient - as your body learns what to do, things usually improve.

Equalising Techniques
  • Passive: Requires no effort and can usually be done only by experienced divers.
  • Valsalva: Increase pressure at back of throat by holding nose and breathing against closed throat.
  • Toynbee: Swallowing with mouth and nose closed good for ascents!
  • Lowry: Valsalva plus Toynbee holding nose closed, gently trying to blow air out of nose while swallowing.
  • Edmonds: Jutting jaw forward plus Valsalva often combined with wiggling jaws.
  • Miscellaneous: Swallowing, wiggling jaws.
REVERSE EAR
This is caused by a foreign body in the canal, such as wax or an ear plug that causes a pressure difference between the eardrum and the blockage. It can cause the eardrum to bulge out and potentially rupture. Tight-fitting hoods can also cause the problem. Wax often tends to move unless very impacted, and ear plugs should never be used.

MEDICATION
Lots of divers ask about this, and generally I dont like oral decongestants. They are stimulants, and I have seen several divers using them experience nasty anxiety/panic attacks under water. I have recommended long-acting topical decongestants, and unless you plan on being under water for several hours, cannot see the argument about them running out on a dive.
Divers with chronic nasal inflammation may benefit from long-term nasal steroids over the season.
It should go without saying (though many divers ignore this, with dire consequences) that you should not dive with a cold or excessive nasal catarrh or congestion.

VERTIGO
Vertigo is the sensation of the room spinning around. The sufferer can often tell you which way it is spinning, which helps to distinguish the condition from dizziness.
It is frequently associated with vomiting (often severe and prolonged) and incapacity due to the overwhelming sensations.
There are two usual origins for this problem - the ears and the brain.
I am going to concentrate on the ears.
In the inner ear, there are three canals at right angles to each other. These contain fluid and several calcium deposits that sit on some fine hairs.
When we move, these hairs are disturbed, and the brain can tell us our position from the set in each ear.
There are two small windows covered in a membrane called the oval and round windows. The oval window is next to the base of one of the ossicles and transmits sounds waves to the cochlea.
The round window acts as a safety valve, bulging slightly in response to the sounds waves. As the round window connects into the middle ear, it can be affected by the pressure changes there.
Anything that causes a problem in the inner ear, or imbalance between the two semi-circular canals, can cause vertigo:
  • Pressure (alternobaric vertigo): Probably the most common cause of vertigo, in which one ear clears but the other doesnt. This leads to a pressure imbalance in the semi-circular canals and confusing information going to the brain. It often occurs on descent with ear-clearing problems but can also occur on ascent for the same reason.
  • Round-window rupture: This serious pressure-induced vertigo is usually the result of excessive attempts to clear the ears with a Valsalva, or severe barotrauma caused by failure to equalise pressure. The round window ruptures, leading to severe vertigo, vomiting, hearing loss and incapacity. This is an emergency, as permanent damage to the hearing and balance can occur. Treatment, if it is diagnosed promptly, involves plugging the round-window rupture.
  • Temperature (caloric vertigo): If cold water gets into one ear canal but not the other, this can cause an imbalance between the ears. Some divers are sensitive to water against the eardrum and need hoods even in warm water.
  • Decompression illness: You can get bubbles in the semi-circular canals or in the blood vessels around them. Diagnosis can be difficult but dive profiles are often revealing. Even with hyperbaric treatment, this DCI can be difficult to treat.

Vertigo under water can be very serious. In severe forms, it can render the diver unable to function and require a buddy to help. Even in less severe cases it can cause nausea, vomiting
and be extremely unpleasant. Early and controlled exit from the water is recommended in all cases.

DEAFNESS/TINNITUS
Many divers complain of tinnitus, the name given to the condition of noises in the ears and/or in the head, with no external source.
These noises are described variously as ringing, whistling, buzzing and humming. The condition is often associated with deafness. The following problems often co-exist, are often temporary and resolve in weeks:
  • Noise: Diving can be noisy, especially hoodless and with bubbles streaming past the ears. Most deafness, however, results from noise at work or at home.
  • TMJ syndrome (Clenching of teeth on the regulator): This can be a problem for new divers who are tense, those on long dives and those with bite or denture problems. It causes a strain on the jaw joint (TMJ) and spasm in the muscle around the area. Prevent it by using a good mouthpiece, moving the jaw regularly and, for bite problems, visiting the dentist.
  • Middle-ear barotrauma (due to pressure/volume changes): Especially associated with colds and catarrh, this can last for several weeks.
  • Inner-ear barotrauma (due to pressure/volume changes).
  • Round-window rupture (see Vertigo above).
  • Inner-ear decompression accident (due to bubbles damaging the inner ear tissues).
Unfortunately there is no real treatment or cure for tinnitus or deafness associated with the more serious causes, and the constant noise can be very distressing to the sufferer long-term.
Judging fitness to dive in such circumstances is related more to the cause than to the severity.

EAR INFECTIONS
There are essentially three areas of infection that can affect divers:
  • Pinna (outer ear)
  • Middle ear (otitis media)
  • Ear canal (otitis externa)
Infections of the pinna can cause marked swelling and pain in the outer ear, which becomes hot. Although painful and requiring antibiotics, it is not serious and produces no long-lasting problems.
Middle-ear infections are often associated with young children, due to their short Eustachian tubes and inability to blow noses well. Divers get them following episodes of barotrauma, especially when serous fluid fills the ear and becomes secondarily infected.
Ear pain is often accompanied by a temperature, deafness and a full feeling in the head/ear.
The doctor sees a bulging inflamed eardrum and prescribes antibiotics and occasionally decongestants.
The pain settles quickly but the deafness and full feeling can last for weeks. Ear-clearing may be difficult for some time, and diving should not be attempted during this time.
Ear-canal infections are by far the most common and problematic. The canal going down to the eardrum is a thin-walled, skin-covered tube that gets warm and sweaty. These are ideal conditions in which infections can take hold, especially on immersion in infected water.
Symptoms are mainly pain and swelling of the skin in the canal, often with discharge. Treatment can be prolonged and difficult, involving antibiotics by mouth, antibiotic/steroid ear drops and occasionally suction clearance of the debris.
To make life interesting, over-treatment by antibiotics can increase the risk of secondary infection by fungus, which is even harder to treat. Diving can be stopped for weeks and even months. The canal remains vulnerable for a long time, with increased risk of future infections.
Prevention is better than cure.
I recommend rinsing the canal with clean water after each dive and a few drops of olive oil to moisturise it before bed.
This should keep the skin in good condition and prevent any dry skin or cracks that could let in an infection.
Mild and fungal infections can be treated with Ear Calm (acetic acid), which can be bought over the counter. More severe or non-responsive infections should be seen by a doctor.
Some divers recommend the integral mask and ear protector system that is supposed to keep water out of the ears.

EAR OPERATIONS
Many operations affect the ear - this list reflects some of the more common ones that I have been asked about:
  • Grommets: Small tubes placed through the eardrum to allow drainage of fluid and equalisation of pressure, mainly to treat children with glue ear. The tubes fall out after about six months and the drum heals itself. Some children have more permanent grommets fitted that have to be removed. Complications include infection and permanent perforation of, or a weakness in, the eardrum. Diving is not permitted while grommets are in place and for several months after they fall out, to allow healing of the drum. The grommet could allow liquid into the middle ear while diving which, if the ear became infected, would be serious.
  • Eardrum repair: Permanent holes in the eardrum can follow surgery or rupture after infection or barotrauma. Normally the eardrum is excellent at healing itself, but if infection occurs a more permanent hole can result. Repairs usually involve a small piece of fibrous tissue (fascia) placed over the hole. Once healed it can be very strong and diving may be possible, though Eustachian tube or nose problems that may have led to the perforation should be considered.
  • Stapedectomy: This is delicate and complex surgery to the small stapes bone, the last in the chain of ossicles that vibrates against the oval window to transmit sound to the cochlea. In otosclerosis this bone fuses against the oval window and deafness occurs - a stapedectomy can restore some hearing. Unfortunately this operation is a permanent bar to diving, due to the risk of damage to the surgery.
  • Mastoidectomy: This operation, rarely undertaken nowadays, follows an infection of the mastoid bone (behind the ear) which then gets an abscess that needs drainage. This is sometimes associated with a cholesteotoma - debris that collects in the ear that can produce deep infection and has to be cleared out. Depending on the surgery involved, the canal and ear can be left disrupted and damaged, leading to increased risk of infection and caloric vertigo (see above). Scuba diving will not normally be possible after these problems.
  • Cochlea implant: A small, complex electronic device that can help to provide a sense of sound to someone profoundly deaf or severely hard of hearing. One portion sits behind the ear and a second is surgically placed under the skin. The manufacturers have tested this device to 4 atmospheres and, surprisingly, say that scuba diving is not necessarily banned. Full assessment of the device, mask straps, hoods and so on is required, with balance or vertigo problems considered. A diving doc should liaise with the centre fitting the implant to assess fitness to dive.


All
All advice given here is general - more specific guidance is often needed in certain situations.