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Ear Nose and Throat Problems - Equalising

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 been training with a closed circuit rebreather for a few months now, having "graduated" from SCUBA to mixed gas diving. I've never been great at ear clearing, however I'm getting noticeably more frequent ear problems since I made the move. They feel stickier and more painful the morning after dives, sometimes to the point where I have to forgo the next days' diving because I just can't equalise. What is going on? I can't see why the equipment I'm using should have any effect on my ability to clear my ears!

A - This is a bit of an odd phenomenon, but there is an explanation. It comes down to oxygen again. With open circuit air diving, equalising occurs using air, ie. the same gas as is breathed at the surface. With mixed gas CCR, often the gas used to equalise is much richer in oxygen, so the middle ear fills with a higher percentage mix than it’s used to. This is not a problem in terms of volume contraction/expansion on descent/ascent, but after the dive it can be. The reason is this: the oxygen in the middle ear is gradually consumed by the tissues, and as it’s metabolised the gas volume shrinks. If the Eustachian tube doesn’t open (and why should it; after all, the diver is now at the surface), then the contracting gas will cause a barotrauma. This is called middle ear oxygen absorption syndrome, and although rarely troublesome, it can cause fluid to accumulate in the middle ear with consequent equalising difficulties. With your history I can only imagine that your Eustachian tubes are a little narrower than most and hence you have less leeway to play with. I’d recommend you equalise regularly for a few hours after each dive, to allow the middle ear gas to escape and equilibrate with normal air again. That should relieve the symptoms.

Q - Being honest, I'm one of those annoying on-off social smokers who's always scabbing cigarettes off people at parties and never buys their own. Normally I go out on Thursdays and don't smoke Friday so it clears my system before I dive on the weekend. This year though, I've been getting bunged up on Saturdays and Sundays and had loads of equalising problems and sinus squeeze. But last week we went out Friday, I smoked a pack and was fine diving: it's almost like it cleared everything out. What's all that about?

A - Being honest myself, it’s always difficult to give concrete explanations for quirky individual symptoms like this. I suspect though that after a day of withdrawal (your usual Friday off the fags), your lungs are beginning their recovery and consequently your respiratory tract produces more mucus, causing congestion in your ears, nose and sinuses. By smoking that pack last Friday you beat your poor cilia back down into submission, so rendering the system “clear”. Sadly this delaying tactic will only postpone inevitable (and bigger) problems. Social smokers run pretty much the same risks as full timers – they tend to take more drags, and inhale deeper and for longer, so their overall exposure is similar. The same goes for smokers of “light” cigarettes - research suggests they still get as much heart disease and lung cancer. Giving up totally is really the best option.

Q - My boyfriend wants me to do a dive course, but I've always been too scared of hurting my ears to try. Too many painful childhood ear infections I think. I've read about lots of different ways to equalise, but what is the best one for a frightened beginner like me?

A - The short answer is whichever one works. Be reassured that you’re not alone, most beginners are are anxious about equalising. It’s not a skill that comes naturally, but the key is practice. I’d suggest you start with the Valsalva: blowing against a pinched, blocked nose. How hard to blow? You might try a device called the Otovent: basically a nozzle with a balloon on the end, which you blow up with your nose. Very useful to teach novices about how much pressure to use, and you can buy it over the counter. I always suggest people go to a swimming pool to practice in the deep end, as you can try out other techniques in safety there. Good luck.

Q - I know you must get asked this a lot, but is there any reliable way to get my ears to equalise on every dive? Sometimes it works easily for me, but quite often (I'd say every 2 or 3 dives) I get a blocked ear and can't get it to clear. It's annoying being the one stuck at 2 metres while everyone else is waiting at 30 using up their air.

A - Another Holy Grail of Diving question… the fact is that because each individual’s anatomy is different, there’s no secret recipe for equalising that will suit everyone. We’re talking about a Eustachian tube that’s on average just 3mm wide, so it only takes a tiny amount of congestion to block it entirely. The key therefore is to try to widen the passage up as much as possible. This is often a question of addressing lots of different factors, in the hope that the cumulative effect will cure the problem. Simple things you should try include avoiding alcohol, tobacco and dairy products before you dive, as they all increase mucus production. Keep water out of your mask for the same reason. Never try to dive with a cold or any sinus blockage. Start to practise equalising a few days before the dive, so the eardrum is flexible and limbered up. On the dive itself, equalise at the surface, and then descend feet first, slowly, clearing with each breath, and most often in the first few metres of water, as this is where the biggest pressure changes occur. If you get stuck, ascend, wait and try again – trying to push through it and descending further will only cause more pain and barotrauma. If none of this helps, then you’ll need to visit the doc for a good probe, as sometimes medications or surgery can improve things.

Q - I was wondering if you could advise me as to whether I should have a dive medical.

I did a lot of diving about 2 and a half years ago and didn't have any probs. However, I've since had problems with my ears popping when flying (it took me an hour and a half of trying after one flight to try and pop them and it hurt when they did!). On that basis would it be worth me trying to have a dive medical before going on a diving holiday this summer?

A - I think it would be a good idea. The cabin pressure in a plane does not vary that enormously form the ground. As the plane is pressurised during the flight, you have to pop your ears to the equivalent of say ½ an atmosphere, or about 5 metres of water. If you are having problems with that, then you sure as hell will if you dive any deeper than that. So something way well have happened in the last couple of years that made it harder for you to equalize.

So rather than see me with middle ear barotrauma, or a perforation after the dive, best pop in to help the poppin’.

Q - Hi I am not sure you can help but reading your replies to other people I figure it is worth asking you. I am currently training to be a Navy Clearance diver in Australia. I am pretty sure the Royal Navy has similar teams. Anyway, I have huge issues with equalizing my left ear. I have seen one ENT who did not really do more of an examination than an underwater medic or GP. When I equalize on the surface using the old valsalva technique my ears are usually both rather slow according to medical specialists. My left ear in particular always comes second and usually needs a head tilt to get going. If I have any sort of cold etc then equalizing is usually impossible. I have this issue with different types of sets and I just recently had a grade four in both ears whilst coming close to actually rupturing one ear drum. I had my adenoids out when I was four due to serious and constant ear infections. I am not sure how these come into play and although other people seem to have asked this question of you I am yet to see any replies concerning them specifically. I have tried diving on a steady diet of sudafed, logicin, sinutab etc but this has other side effects as I am sure you know. I have seen you mention surgery and I am curious what this entails, how successful it is and the time frame involved etc? My course mates seem to be able to equalise by just wriggling their jaws, yawing etc which is something I cannot do. I also have trouble on airplanes but this has improved over the years with frequency. When I was younger I would actually lose hearing for hours after a flight. Not much fun. Any help you can provide would be most appreciated.

A - Even I can have sympathy for an Okker, even after the Ashes. Bad luck mate. This sounds like a classic case of Eustachian tube dysfunction {ETD}. From childhood where they whipped out your adenoids, through to inability to always pop your ears on a plane. The other telltale sign is just managing it normally, but add any cold or mucousness, you fail miserably.

Now for you, this is serious. A career is at stake. A naval diver responsible for getting rid of bombs etc.

So you must see the best. I assume there has to be a top Naval ENT with specialism in diving issues, not just a civvy ENT pretending to be one. So see if you can get referred to them for total assessment. This may involve MRI scans of the Eustachian tube, but it will give a clear picture of what is going on.

If it is that your tubes are so narrow or follow an odd course [thus preventing air from going in and out, hence problems equalizing] then there are 3 possibilities. Try diving on all the decongestants you can get, though this may impinge on Nitrox diving. Quit the job. Or I have heard of a Japanese doc who uses laser to widen the bore of the tube, but this is experimental at the moment. But it could be worth a try if that’s all that separates you from Naval Diving or a career topside.

Q - I got this email address from the magazine "Sport Diver". I'm actually Belgian, but dive in Tenerife (on vacations) via an English dive centre (they gave me this address). The problem is the following:

Last year in Tenerife I dove again after not diving at all for 9 years. However I had an issue with equalizing my right ear this time.I could not equalize it (at all) via blowing air in my nose, only with swallowing (even sipping sea water) I could equalize, and only when the dive was going gradually deeper, not when the depth was increasing at higher speed.

This was hampering the dives a lot and my buddies had to wait for me all the time, which was very frustrating.

I have to tell you that I have narrow sinuses (that's what the doctors tell me) and they get inflamed from time to time.

However, knowing this I came prepared. I took "Sinutab" the whole week I was diving to assure the sinuses were "open" as much as possible. So I don't think the problem is in that area, I could breath through my nose etc. without problems.

Also, 7 years ago or so, I broke the bone behind/below my right eye, I was very fortunate that my eye itself was not hurt. I got an operation and everything healed OK. I'm mentioning this, I don't know if (but fear) it is important.

Anyway, this year I went back to Tenerife to dive again, hoping that the equalize problem was a temporary thing. It was not. EXACTLY the same problem this year, only the right ear.

Before I went to Tenerife I went to see my doctor whom I explained the issue. He subscribed something (forgot the name) that basically does the same as Sinutab but also deals with allergies etc. Additionally he subscribed "Dexa-RhinoSpray" to puff in my nose. Anyway, like said, this didn't fix the issue.

So what I appear to have is an issue just beyond the sinuses, in the inner ear perhaps? I greatly appreciate any information you can share to help me. A wonder drug that opens everything up would be nice ;-)

A - A wonder ENT surgeon is what you need. Forget the sinuses, they seem to equalize OK as you say, it's the ear that's the problem. If you have dived on Sudafed and steroid nasal sprays, and still had a problem popping the right ear, then this leans towards Eustachian problems. But, not insurmountable, as you did get there in the end. The basic potions haven't helped so to Plan B. You must practice popping 20 times a day before you go. Feet first descent. Slow as possible and pop little and frequently. Swallow if that works, but not sea water. It'll make you sick. Then try a Pro-ear mask made by Oceanic. If all that has failed, you need to see an ENT to ascertain whether an op will fix it. This is where some divers pull out and go paragliding instead. Scalpels and anaesthetics can scare a man. However there is hope over that shimmering horizon. I recently came across a paper about laser Eustachian surgery. Quick and easy, out in a few minutes, but that was only in Japan at the time of writing.

Watch this space.

Q - I have just come back from a dive holiday in Thailand where between the 15th and the 19th of Jan I was on a live-aboard Boat trip around the Similan islands, we did 13 dives in 4 days, 4 dives per day for 3 days, then 1 dive on the morning of the last day.

On the 12th dive , a night dive I was keeping an eye on my partner and buddy Natasha who was having trouble equalizing, unfortunately I was too busy looking at her and not paying enough attention to my own decent rate as relation to equalizing my ears, so before I knew it I had quite a painful squeeze, I ceased my decent and equalized and when my ears finally popped there was quite a painful feeling.

Once my mind was on other things whilst diving I forgot about the pain. Once on the surface the pain started to come back so I took some Ibuprofen and went to bed, and this was where the problem started, because when I woke in the morning I felt fine and should not of completed the last dive of the trip, but I stupidly did. I was very careful whilst descending , but after the dive I had excruciating pain in my ear, and down my jaw. When I got to shore I went to see an ear, nose & throat doctor who diagnosed me with barotrauma, bleeding of the inner ear, he prescribed me pain killers and decongestants (pseudoephedrine).

When we got back to London I went straight to see my GP, he examined me and said that there was nothing he could do & suggested I keep taking the Sudafed. Maybe I naively expected to come back to London and get given some, one pill wonder, miracle cure, so this news hit me pretty hard.

I have taken 60mg of Sudafed 4 times a day for the past 15 days with absolutely zero effects, I still have a lot of pain and pressure in the ear not to mention the deafening ringing that sometimes keeps me awake, all I can hear in my right ear at the moment is my heart beating. The major problem I have at the moment is that I am a sound engineer by trade so when involved in a test and the customer asks if the system is sounding ok I have to say "Yes, yes wonderful". I can't carry on doing that for too long or I will lose all my customers! Some one mentioned that there was a procedure that involved cutting the ear drum to release the pressure and drain the fluid, but this does sound a bit drastic and possible dangerous! I know you must be very busy but any advice or council you could offer at this time would be greatly appreciated.

A - This is one of those problems where you need a good ENT assessment and fast. Barotrauma sounds a reasonable diagnosis for your case and it can take quite a while for things to get back to normal. But in your case your job and livelihood depends on good hearing and I think the wait and see attitude is not best for you.

On top of this there is a chance that you could have a "perilymph fistula". This is where the unequalised descent has caused a rupture of one of the windows between your inner ear and middle ear. Tinnitus or ringing in the ear is a consequence of this and it can only be corrected by ENT surgery. You need a referral from your GP for this and quite frankly with the appauling wait times in the NHS I would bite the bullet and go privately.

Good luck.

Q - I am concerned about diving again after my most recent diving experience. I experienced a lot of trouble with equalising and had to descend very, very slowly forcing equalising all the time. On ascending I had terrible reverse blocks, I was in pain for several days after but I don't think I have suffered any permanent damage.

I spoke to my GP about it but all he could suggest was taking anti-histamines before diving. I am concerned that this may not solve the problem and I am worried about diving again and experiencing such discomfort and spoiling what should be an enjoyable activity and holiday or causing myself permanent damage.

I did the PADI Scuba diver program in 1999. I completed the PADI open water program in January 2001 and I went diving two weeks ago. The problems have occurred on all my dives but never as bad as on my last holiday.

Please could you offer advice to me about diving again.

A - It sounds like you really have a problem there if as you say you were descending really slowly and you still had to force equalisation on the way down.

I have seen a lot of cases like yours and always recommend you see a diving doctor before you go in again. In most cases with a good ear examination and my "how to equalise properly" talk things seem to sort out, but on a few occasions a trip to the ENT surgeon is needed to assess your Eustachian tubes.

The most common problem I see with novice divers or those doing their 4 open water dives to get their first PADI Cert is a simple one.

In the pool its fine, you can probably get down to a couple of metres without having to equalise properly so you never really learn how until it's the 4 dives time at the end of your course. But then what happens is that for your first dive into the blue, excitement levels build, you are descending down making sure all the air is out of your BCD, checking your depth and air gauges, and guess what? Yup, you have forgotten to equalise until its at least 5 or 6 metres deep. And the deeper it is the harder it is to get the air into your middle ear as the Eustachian tube begins to collapse upon itself. If you get to 8 or 9 metres without any air going in, forget it as you will damage your drums and middle ears too much. I know it can be embarrassing for a first timer to still be at 3 or 4 metres, when the rest of the group are down at the bottom, but you really can't risk your long term ear well being just to please your Instructor who is looking up at you.

So it's a little and often, straight from under the surface, and don't worry about all those dials and gauges, they'll work, as you should have checked them properly at the surface.

Q - I'm sure my problem is far from new but I have found it hard to get any good advice. I am keen to do a PADI course but on the couple of "try it out" dives I went on, I found it very difficult to equalise my ears with the result that my enjoyment was seriously marred by the considerable pain, even though I certainly wasn't down very deep.

I have a similar problem on planes and have been told that having my adenoids out as a child may have something to do it.

I would be very grateful for advice on two questions;

Is there anything I can do to alleviate this problem and, if I decide to ignore the pain, am I likely to suffer any damage to my ears from doing a diving course?

A - This problem is a frequent occurrence in those who are just taking up diving. You are getting the ear pain because you are not equalizing your middle ears adequately and as most qualified divers know, if the air in your middle ear contracts, it pulls in the ear drum and causes the pain you describe. The reason it occurs most frequently on your first pool dives is that the tube that links the middle ear up to the nasopharynx through which the air is pushed up, the Eustachian tube, has been lying underused and dormant for a while.

On normal day to day functioning this tube is rarely used as we do not experience pressure differences of any significant degree. Unless you are a pilot or a miner, the tube lies closed and dormant. So when you suddenly don a BC and leap into a pool and blow hard onto your closed nose you cant really expect instant trouble free equalization. I always tell divers to "exercise" their Eustachian tube if they have not been diving for a while or it is the first time. Just blow gently onto your closed nose up to 10 times a day for 5 or 6 days before you dive.

What you should never do, though, is dive deeper through the pain. This could cause permanent problems, such as a ruptured round or oval window, which is the interface between the middle and inner ear and this will cause tinnitus and deafness, and even long lasting balance problems.

What you also say about not even being able to equalize on aeroplanes worries me a bit though. There are conditions where you may have an abnormal Eustachian tube called "tube dysfunction" where you will always find trouble equalizing, this is only really diagnosable by an ENT consultant by CT scanning , but if it is the cause then it can be corrected surgically allowing you to dive again.

So try practising equalizing and see if that helps you get down to the bottom of the pool without any pain, but if not, stop where you are , surface and get a referral to a consultant ENT surgeon.

Q - My fiancee and I dive twice are year (normally for a period of two weeks at a time). We normally dive three times per day and during the first week of our holiday I have real trouble equalising - quite often it can take me up to 3 minutes to reach bottom depth. My buddy is very patient but when diving with a group, especially drift diving, it can cause a problem.

At the beginning of the 2nd week, all of a sudden, equalising becomes extremely easy, much like the other divers and I have no problems at all.

A - It's the good old Eustachian tube again in your case.

I think what is probably happening here is that when you haven't dived for a while your Eustachian tube gets under-used as you don't really need it to help equalise on a day to day basis if you are just going into work, home and then to bed. The tube doesn't close up but it becomes harder to get it to allow air in when you start diving again. Like a muscle in the body, it becomes more easy to use you more you have to use it.

What I suggest is that you "exercise" your Eustachian tubes before you go and you can do this by blowing gently onto your pinched nose several times a day. Do this for a week before you go and it should work. If it doesn't, make sure you have some Sudafed tablets with you, as this will help widen the tubes diameter in the first week of your trip.

Take it easy on the way down too on the first couple of dives and make sure you tell your buddy and DM that you may be a bit slower going down. This shouldn't be a problem in good visibility though, as you can gently drift down to the group equalising slowly.

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