Ear Health Tips for Scuba Diving and Free Diving
Scuba diving is an incredible activity that lets people submerge into and explore an entirely different watery world. But to breathe air, special equipment and precautions are necessary when going underwater. Remember that diving carries some inherent risks and recreational divers should always do everything possible to minimize their risks, optimize safety, and keep your ears safe and comfortable while scuba diving.
What's Important to Know about Ear Anatomy?
The ear consists of three parts: the outer ear (including the ear canal), the middle ear (the air-filled space behind the eardrum), and the inner ear (the fluid-filled portion that contains hearing and balance nerves and mechanisms). The eardrum picks up sound from outside and passes it into the middle ear where three tiny hearing bones transmit the sound to the inner ear. The eardrum is a watertight, elastic membrane but it’s also very thin and extremely sensitive to changes in pressure. The middle ear is full of air and the pressure needs to be equalized with the outside environment or it will stretch the eardrum, potentially becoming painful. The air vent to the middle ear is known as the Eustachian tube, which contains a valve that is normally closed to prevent material, germs, and internal sounds from entering the ear. It normally opens every few minutes when you swallow, yawn, or move your jaw.
Why and How Should Divers Clear (or "Pop") Their Ears?
When divers move deeper underwater, the surrounding water pressure increases rapidly, but the air pressure in the middle ear will not change unless the Eustachian tube opens to clear the difference in pressure. That’s why it’s important that divers learn to clear their ears frequently as soon as they feel any “squeeze” or change in pressure (also when returning to the surface). Most divers find that it is more challenging to clear their ears when descending because the middle ear pressure becomes less than the surrounding water pressure and this squeezes the valve of the Eustachian tube, making it harder to open. When ascending, the middle ear pressure is greater than the outside pressure and it tends to push the air out through the valve on its own. The same effects occur in air travel, but the rate of pressure changes is greater with diving.
There are several techniques to clear the ears, including:
Valsalva Maneuver—A person holds their nose and mouth closed and gently tries to blow their nose without letting the air out. This is the most common technique. The nose blowing should never be forceful or abrupt as the excess pressure suddenly popping into the ear could damage the eardrum, middle ear structures, or even cause permanent nerve damage to hearing and balance.
Lowry Technique—A person performs the Valsalva maneuver while swallowing at the same time. This may take some practice.
Edmonds Technique—A person tenses the soft palate (the soft tissue flap in the back of the roof of the mouth) and throat muscles, pushing the jaw forward and downward, then performing the Valsalva maneuver. An exercise that can help you to learn this technique is to hold the mouth open halfway, place the tip of the tongue against your upper two front teeth, then try to swallow.
When diving, it’s easiest to clear your ears when your body is vertical with your head upward and fins pointing downward. You can also tilt your head back, looking up toward the surface, which brings the Eustachian tube into a horizontal position, making it easier to open. You should clear your ears frequently and as soon as you begin to feel any ear squeeze before continuing. Most people will feel pain if they go below two meters (6.6 feet) without ear clearing, and the eardrum can even rupture by three meters (9.8 feet) depth without clearing.
What If I Cannot Clear My Ears?
Difficulty clearing the ears with pressure changes is called “barochallenge” and failure to clear the ears can cause pain and injury to your ears, known as “barotrauma,” including eardrum rupture and hearing loss. If you cannot clear your ears, stop, grab a descent line if available to stabilize your depth, and ascend a bit to try to make it easier to clear. If you still cannot clear, give “Not OK/Problem” hand signals to your diving buddy (i.e., hand outstretched, palm down, fingers splayed out, rotate wrist/hand so thumb and little fingers rock up and down) followed by pointing to your ear. Ultimately, it’s best to return to the surface and try again later or another day. Do not try to “push through” the pain.
Also, a respiratory illness or allergies causing nasal congestion may make it more difficult to clear your ears. If you cannot clear your ears using the techniques above, then you will likely not be able to clear your ears underwater, which is more challenging.
Are There Treatment Options to Help Clear My Ears?
Allergies can be treated with antihistamine medications, nasal steroid sprays, and nasal saline irrigations. Antihistamines come as oral or nasal spray medications that are available over the counter. Some common oral medications include cetirizine (Zyrtec®), loratadine (Claritin®), and fexofenadine (Allegra®). These medications are usually non-sedating. Diphenhydramine (Benadryl®) is sedating and therefore not a good choice for diving. There are many different nasal steroid sprays, and they are generally similar. They will work best if taken regularly for five or more days prior to diving. Decongestant sprays should only be used when necessary. Talk to your doctor to see which medication is best for you.
A decongestant spray such as oxymetazoline (Afrin®) can be taken 30 minutes before a dive and the maximum benefit will usually last about two hours. Although it is labeled as effective for eight hours, the amount of benefit is unreliable after two hours. Some divers will repeat the spray if there are to be repetitive dives on a single day. Caution should be exercised with this medication as it can raise your blood pressure and heart rate as well as increase your oxygen consumption from your tank. Additionally, it can only be used for no more than two to three days as the nasal mucosa can become highly dependent on the spray, causing severe nasal congestion when attempting to stop the medication. Decongestant spray should only be used when necessary.
An oral decongestant such as pseudoephedrine (Sudafed®) can be taken to supplement the nasal decongestant spray. Only the short-acting, four-hour tablets should be used as the long-acting tablets may release the drug at an unpredictable rate. Like the decongestant spray, it will also raise blood pressure, pulse, and oxygen consumption, and it will be an additive effect if taken together with nasal decongestant.
What If My Ear Continues to Feel Blocked after Surfacing?
If your ear feels blocked after surfacing, it may not have fully cleared and you can continue using the techniques and medications listed above. You may have a retained vacuum, or even fluid, in the middle ear and you may have decreased hearing. You should still hear your own voice normally (not muffled or distorted), indicating that your nerve hearing (i.e., sensorineural hearing) is still fine. If you have pain, you should seek medical attention, and your dive master/instructor should know who to contact nearby.
If you experience blood coming from your ear, indicating a ruptured eardrum, you should see an ENT (ear, nose, and throat) specialist. If you have dizziness, vertigo, or sensorineural hearing loss (i.e., your own voice sounds muffled or distorted, and you cannot hear yourself scratch the skin in front of your ear), then you should be seen immediately in a local emergency room. If the emergency room is unfamiliar with diving injuries, they should call a medical center who does treat such injuries or contact the Diver’s Alert Network (DAN) for advice.
What Other Precautions Should I Take?
It is not recommended to dive with a perforated eardrum. The pressure can cause water to pass through the perforation and may cause dizziness or vertigo. Severe dizziness can be disorienting and may result in nausea and vomiting, which could be extremely dangerous. It is also not recommended to wear earplugs as they trap air within the ear canal and cause pressure changes that could injure your ear.
For patients who are chronically unable to clear their ears, there is a new procedure, if appropriate, called Eustachian Tube Balloon Dilation (ETBD) that may be offered by your ENT specialist. If your doctor determines that your Eustachian tubes are chronically congested with inflammation despite treating any known existing related medical conditions (such as sinusitis, allergies, or gastroesophageal reflux disease), then the ETBD procedure might be recommended. This minimally invasive outpatient procedure can be done in the office with local or general anesthesia.
References
Divers Alert Network (DAN) (https://dan.org)
Bove AA. Diving medicine. Am J Respir Crit Care Med. 2014 Jun 15;189(12):1479-86
Lambert D, Binkley M, Gaskill Z. Underwater and Scuba Diving Accidents. Emerg Med Clin North Am. 2024 Aug;42(3):551-563.
Mallen JR, Roberts DS. SCUBA Medicine for otolaryngologists: Part I. Diving into SCUBA physiology and injury prevention. Laryngoscope. 2020 Jan;130(1):52-58.
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