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Ear Nose and Throat Problems - Outer Ear

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - I've heard from some friends that earplugs can help stop infections and make equalising easier, but when I mentioned this to another friend who is a GP, she thought it sounded like a bad idea. What's your view?

A - “If the person you are talking to doesn’t appear to be listening, be patient. It may simply be that he has a small piece of fluff in his ear”. So spake Winnie the Pooh. Our favourite bear was obviously not an earplug-wearing diver. Earplugs and pressure don’t mix well in my opinion. The idea of vented earplugs is that a narrow passage through the plug allows air to move in and out, whilst stopping water entering the ear canal. In theory this reduces the risk of ear infections, and makes equalising easier. Much anecdotal evidence from divers seems to support these assertions, but there are potential problems: if the vent becomes blocked with wax or other debris, you suddenly have a closed off air space which could lead to barotrauma. If this occurs on a dive, the manufacturers recommend you take the plug out, but the sudden influx of cold water if you do this could then lead to vertigo, nausea and vomiting. I’d suggest it’s probably best to get to the root of the ear problem and sort that out, rather than relying on earplugs.

Q - Over the last year I've been working my way around the Pacific as a dive instructor. I thought I'd be immune to most waterborne diseases by now but I seem to get ear infections more than most. After a few days of diving my ears get itchy and painful and I have to stay out of the water, which is bad for business (and I'm sick of being sick all the time!) Do you have any tips on how to stop this happening?

A - Most certainly I do. If there was a 100% reliable cure for this I’d be happily retired (and probably working my way around the Pacific as a dive instructor too), but I can point you in the right direction. Prevention is always better than cure, and my preferred regime is to mess with the ears as little as possible. Earwax is naturally antibacterial, so doesn’t need to be dug out by dirty implements at all costs. A daily freshwater rinse of the ear canals will wash out any residual bug-infested seawater, but for even better effect this can be diluted with vinegar (proportions vary but a third vinegar to two thirds water is about right). Some use alcohol in there as well, but it can smart terribly if put on inflamed skin so I tend to avoid this. Plus you can’t put it on your chips afterwards.

If you do get an infection then treating early is key. Touching or pulling on the outer ear will cause pain in otitis externa, so if this happens start antibiotic drops as soon as possible. The best ones contain an antibiotic and a steroid, so it’s a good idea to carry a bottle with you on liveaboards or if diving in remote areas. The other tip I’d recommend is a trial of a mask with earpieces, which basically seal the lugholes off in (theoretically) watertight spaces, connected to the mask and nose space via two flexible tubes. Fitting them can be fiddly but many divers find them a boon, for equalising issues as well as for preventing recurrent ear infections.

Q - I've recently taken up diving and went to get myself checked over with a doc to be on the safe side. Lucky I did. She told me she couldn't see my eardrums with her telescope. I thought she was talking about wax (I've always been a waxy man) but she said there were "growths" in my ear that were blocking the canal. I've always surfed and skin dived but never had ear problems doing that. What are these growths and do they mean I can't dive?

A - I remember going to a museum in Brooklyn a few years ago and being somewhat startled to see the figure of a naked octogenarian slumped in the corner of one of the galleries. Normally I’m not one to risk approaching nude old folk (you never know what they might plant on your cheek) but in this instance I felt a compulsion. Nearing the body it became obvious it was a stunningly lifelike waxwork, and my finely honed emergency doctor’s response mode melted into sheepish embarrassment as my cheeks burned red. I don’t think anyone saw me… Anyway, from one waxy man to you (appalling link I know). I suspect these growths are exostoses, a fine, juicy term for bony growths that appear in the ear canals after long term exposure to water (or air, chemicals, fingers – anything, in fact, that causes prolonged irritation). They’re commonly spotted in surfer-type dudes or grizzled commercial divers, but only rarely enlarge to the point that they obstruct the ear canal. I’m surprised your hearing has not been impaired - but perhaps it has and you’ve put this down to too many gigs and all that bleached blonde hair in the way ;-) They are entirely benign (ie. non-cancerous), but if they grow too much they can predispose the sufferer to ear infections and in the worse case stop them equalising. Before you dive I’d suggest you’re reviewed by an ENT doc as they can be removed, which would make your diving a whole lot easier.

Q - I am going on a diving holiday in 3 weeks. Have dived previously (not for 8 years though) and always had problems with my ears/equalizing. Someone suggested I get my ears syringed by the nurse before I go to remove all the wax. Would this be wise? I do also get bad headaches, that sometimes can be daily for a week at a stretch. This has happened about 3 times this year. Would this suggest I have problems with my sinuses and would a nasal pump be recommended to try and clear them before I go?

A - Getting your ears unwaxed is a good idea, but it won't really affect equalizing. Wax is in the outer ear canal. Equalizing is all about the middle ear. If you have a lot of wax, it can affect the process of getting all the sea water out of the canal, as some can get trapped, but it seems that you don't really know if there's any there or not. Get the nurse to have a look in the ears and syringe as necessary.

These headaches are interesting. Here's a very basic rule of thumb. If they are frontal they could be sinus, which will be a problem diving, so see a dive doc before you go. If they are in your temples, think migraine. Anywhere else then its stress or neck problems radiating to your noggin.

It's never a good idea to dive if you do have a splitting headache though. So find the cause and try to stop them.

Q - US Navy Divers use Demeboro Otic(contains 2% acetic acid) drops before and after diving to prevent otitis externa. This product is not available in the UK. Do you know of an equivalent?

A - I do, I tend to use one called Swim Ear. It's not available in all pharmacies, but you can buy it at pools and dive shops, or try to buy online through its maker Co-pharma. I got an interesting reply to this.

"You may be interested in Otic Domeboro®."

US Navy instructors found that dripping an acidic drying solution intothe ear at the beginning and end of each day virtually eliminated swimmer's ear in their students. The US Navy now use Otic Domeboro®

Solution: 2 percent acetic acid, water, aluminum acetate, sodium acetate and boric acid. The acid retards bacterial growth, while the aluminum and sodium acetate act as astringents, drawing excess water out of the cells lining the ear canal. The use of Otic Domeboro® has eliminated the otitis externa problem for Navy saturation divers.

SwimEar certainly takes care of drawing excess water out of the cells, but its lack of acidity makes the solution less powerful at inhibiting bacterial growth. I have tried it when diving over several days, and it didn't prevent Otitis Externa for me.

The nearest solution I've found in the UK is Ear Calm. It has the 2 percent acetic acid but not the aluminum and sodium acetate astringents. Unfortunately Otic Domeboro® is not available in the UK, and I keep looking for an equivalent.

News to me. My final call on this is to let you know what I do. Swim Ear after every dive, and at the end of the day, I use an antibiotic ear drop, normally Gentisone-HC, just a couple of drops after a shower in each ear, as I think an astringent is all you need in the day, and good old antibiotics just once at the end of a long days diving.

Q - I am Rescue Diver qualified, I have been diving for about six years, if I do not dive for a few months, on return of my diving I develop an infection in my left ear, I have had an ear problem for five weeks, I have visited my own doctor four times and he has given me different antibiotics which at this stage has not helped much. My symptoms are:

Deafness
Severe pain in inner ear
Part numbness of my tongue
Pain in jaw and head

I generally feel fed up and I feel my doctor doesn't understand and tells me to give up diving if the ear infections are to stop. I do tend to suffer with blocked ears but I use swim ear to evaporate the water in my ears.

A - First things first, how to protect your ears when you are diving, if like me you suffer outer ear infections easily.

A simple 2 step programme.

Swim Ear after every dive.

Antibiotic ear drops after every days diving. These need a prescription and there are many to choose from. My current favourite is called Gentisone.

Now to your problem. This does not sound good at all. With severe pain and tongue numbness, there could be involvement with a nerve called the facial nerve. This is well dangerous, as we say in South London. Forget your GP and go to see an ENT surgeon. They need to see what's going on in your middle ear asap, and it may even involve an MRI scan. To effect this quickly go to casualty and jump the queue by feigning a heart attack. I always find a bit of defibrillation peps me up nicely!

Or more sensibly, ask your GP to call the hospital to get you seen at the next clinic.

Q - About 3 weeks ago I had a problem with my right ear, went to the doc and he put me on otosporin ear-drops and all was well in 3-4 days. I have now just experienced the same problem, not as serve in my other ear, again went on the drops. The doc has said I have ear eczema. Will this affect me diving.

A - Yes it well might. If you have a condition that inflames your outer ear canal, i.e. the bit you put your pen in whilst you think, then this can make you more prone to outer ear infections if you dive in mucky water.

So here's what you do.

There's no point seeing the doc before every dive to see the state of the canal, as that is too logistically difficult. So you have to assume you have it each dive. Before each dive I would suggest you use a barrier cram with a bit of steroid in it to protect your ear from contact with potential water borne bugs. Try betnovate ointment. And I mean ointment and not the cream as the latter is too flimsy.

At the end of every diving day after your shower or bath use a couple of drops of gentisone ear drops. This is good stuff and will beat any bug that's slipped through the cordon.

If you try this combo then you should stay clear of otitis externa, that can ruin a dive trip.

Both meds are prescription only so get your GP to do this for you.

Q - I am shortly going to the Maldives for a dive holiday.
I have been there before together with diving previously in Indonesia and the Caribbean.

Every time I dive in plankton rich water I end up with an ear infection, despite using fresh water to rinse my ears on surfacing, trying "Swim Ear" and using other treatments. The infection in the outer ear is always painful and keeps me out of the water for a few days, which is unpleasant and inconvenient.

It has been suggested by an instructor friend that I use a mixture of 5% acetic acid in propylene Glycol to "oil" the ears and prevent infection.

The question is where do I get this stuff from and do you think it would work?

A - This is an all to frequent problem for those on extended diving holidays and one which happens to me each time I go away, so I will give you a few tips on how to avoid what we call "otitis externa" or "OE" next time you dive.

Firstly though, you cant blame the poor old plankton all the time as this is far more frequently caused by water borne bacteria that are plentiful the closer you dive to major coastal conurbations and areas where the tidal flow is poor. So as a consequence you have to be really on your guard in the Mediterranean especially around Southern Spain and Italy. Likewise in some developing countries the sewage outfall from a hotel or resort is often to only yards off the shore and onto the reef where people dive.

The key to outer ear infection is in the prevention, and your Instructors cocktail of vinegar and propylene glycol acts in very much the same way as Swim Ear, in that it breaks down the surface tension of the water that is left in your ear canal after a dive so it can run out more easily when you shake your head. As well as this the alcohol component helps in evaporating any water left there too. This would mean that any bacteria are expelled so the infection can't take a hold.

But the consequences of OE are that although its not going to cause you any long term harm, the fact that you are off diving is enough to make this minor problem a major irritation. I always take antibiotic ear drops with me as well to use after a days diving and I've showered off. These can give the peace of mind that if there are any bacteria that have managed to hang on in the ear canal then they will be killed off by the antibiotic before they can cause OE. My preferred drops are called Gentisone as there is a small amount of steroid in the drops, so if OE has taken a hold the steroid can reduce the inflammation which is the main cause of the pain in this condition.

These are prescription only drops so ask your GP for a scrip, which will have to be a private one as you are taking them " just in case" but expect to pay around £4 to £5 at the chemist.

So my suggestion is Swim Ear after each dive and a couple of the antibiotic drops at the end of the day and that should see you well on your next trip.

A final point here is that if OE has set in then only drops will work for it and I have seen a lot of people treated with oral antibiotic tablets for this problem which don't work as they are not concentrated in the tissues of the ear canal in high enough doses to be of any real use.

If OE does not clear up quickly then insist that your GP does an ear swab to culture any bacteria as there are some rarer bacterial causes such as Pseudomonas which may need a far stronger antibiotic to treat it.

Q - I have just returned from a diving trip to the Red Sea. I have noticed that whenever I undertake an intensive dive program (2-3 times a day for 6 days) I experience problems equalising. It seems that after a couple of days the ear canal becomes inflamed and equalising becomes increasingly difficult. I believe that this could be due to "trapped" water providing a "comfy" environment for bacteria to thrive. I tried "Swim Ear" last week but this did not seem to make any difference.

I equalise little and often on descent. I do not strain or "push" too hard. I have also noticed that by the end of the week I'm sometimes getting a reverse block on ascent - I can hear the air fizzing out with a final pop as I reach close to the surface.

Is there any action I can take to reduce the problem?

A - Any infection in the outer ear canal will not affect equalising, as it's the middle ear and Eustachian tube axis that controls this.

If you are, though , getting outer ear problems with discharge and pain it is worth getting them checked before you go to have any excess wax removed as this can trap water in the canal and allow infection to occur.

If your ears are clear inside then try Swimear after each dive as this helps any remaining sea water evaporate from the canal.

But you need to do this before an infection gets established, if there is pain in your outer ear then you need antibiotic ear drops.

My preferred ones are called Gentisone-HC, which have a little steroid with the antibiotic to reduce any inflammation.

The other problem of difficulty equalising later on on your trip is a different matter. After exposing your Eustachian tubes to the marine environment and the constant process of equalising and unblocking the tubes get a bit enflamed after a while making equalising more difficult.

What I tend to do is take a steroid nasal spray with me to use regularly on these trips to prevent any inflammation in the Eustachian tubes.

OTC stuff like beconase nasal spray will do, take 1 puff up each nostril 2x a day on these longer trips, but if its just the odd dive here and there you don't need to bother.

Q - My last dive was in the Maldives in January - magnificent; I did not have any problems, but about a month after I was back home, my ear felt uncomfortable. My GP said there was an infection, so I took Gentison-HC and a later course of antibiotics as it didn't clear. The ear felt blocked.

I went to a specialist who couldn't see anything the first time, but after six weeks saw something pulsating in my ear; I have now had a CT scan and MRI scan and there is some soft tissue in the middle ear and mastoid. No one thinks it's a tumour or anything recognisable. I am having a tympanoplasty soon, to see what it is - and hopefully remove it.

I am concerned about the longer term impact of this operation - also the short term (I was told I couldn't a)fly or b) swim for six weeks, which is hard for a) work, and b) training. My consultant didn't seem to think there would be a problem with diving and the whole operations sounds a bit gruesome, too.

Any helpful comments?

A - Yes I agree the op is worthwhile .There are some things more important than diving... so go with the ENT docs on this one and have the op. Now as regards a return to the deep, it depends very much on what they find.

If there is anything that will affect your balance or cause permanent dizziness after the op then you may have to give up the sport as it will cause disorientation underwater.

However if all is well post op then all you have to worry about is the eardrum healing.

Once it has healed fully you should be OK to return to diving. How long this takes depends on how much they have to open it. Ask the ENT team afterwards.

I agree with no flying or swimming for 6 weeks, that's worth following. Bottom line.... if your Eustachian tube remains in full function and your drum is healed , and there's no residual balance dysfunction ...then you will be fine to dive afterwards.

Q - I have been diving for a number of years, but in the last twelve months I have suffered from recurring infections of the outer ear. My GP has prescribed antibiotic tablets and ear drops, which temporarily cure the problem, only for it to return a couple of months later. I suspect that my diving in UK waters and teaching in the swimming pool, is aggravating the condition.
Do you know of any earplugs on the market, which still allow one to clear one's ears whilst diving? Are there any other measures, which you know of, which could prevent this condition coming back?

Any suggestions, which you have would be much appreciated.

A - It's a big no to ear plugs whilst diving. They block air into the ear canal that can't be equalized, this can then pull on the ear drum causing a paradoxical squeeze, so forget them.

My tips for treating recurring outer ear problems whilst diving are as follows.

Swimear after every dive, and antibiotic ear drops after every days diving.

This works for me as I get gammy ear canals on day 3 of a dive trip as the bacterial load builds up.

If this doesn't work then try the Proear mask made by Oceanic. This seals around the outer ear preventing water from getting into the ear. It is equalized by tubes running to the ear cups from the mask itself. Just make sure you don't dive behind a muppet who kicks it off your face.

Finally if you or anyone does ever get a resistant outer ear infection, ask your GP to swab it and send it of for lab analysis. There's some weird bacteria out there, resistant to a lot of frontline antibiotics so the sooner you find out what they are the sooner you can get the correct treatment.

(other dive medical questions)



   


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