Question to general practitioner Maarten: Ear pain after diving

Maarten Vasbinder lives in Isaan. His profession is general practitioner, a profession that he mainly practiced in Spain. On Thailandblog he answers questions from readers who live in Thailand and writes about medical facts.

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Dear Martin,

I just read M.'s story about ear pain after diving. I myself dived with SSI (scuba school international) and then switched to PADI, where I followed the rescue diver training 2 years ago and passed the tests. Neither dive school directly deals with the topic of “earache”.

In the basic “open water” training, the subject of “pression” is treated, but it is not associated with ear pain. It is said that you have to “clear” to eliminate the pressure difference between the inner ear and the outer ear. Most of them pinch their noses for a moment and then pretend to blow vigorously. I am one of the lucky ones who can equalize without pinching their nose.

To (largely) explain the earache, I want to return to the “pression”. When the diver has his head just above the water, the pressure on the inner ear and outer ear is equal, namely the atmospheric pressure of about 1 bar. At sea level, that pressure can vary slightly depending on the pressure area above the dive site, so low-pressure area or high-pressure area. In itself, however, this slight pressure variation is unimportant with regard to the earache.

What is much more important are the pressure variations as soon as your cup goes under. They initially only affect the outer ear. In his training, diver M. probably did not make the link between the ear pain and the pressure variations under water.

During diving, the pressure on the outer ear increases by 1 bar per 10 meters of diving depth. So at a depth of 10 meters you have 2 bar pressure, at 20 meters you have 3 bar and ... at 40 meters you have 5 bar pressure.

You can therefore see that the pressure variation is greatest during the first 10 meters of descent, where the pressure increases by 100%, namely from 1 bar to 2 bar. Those first 10 meters are just the diving area of ​​the novice diver. With a pressure increase of 100% on the outer ear and ..% on the inner ear, equalizing in this dive zone is super important. Once you are past the 10m depth, more is cleared only sporadically, because the pressure variation is then no longer so great.

To come back to diver M.'s ear pain: if you clear your ears and still get ear pain, then I think there are mainly 2 reasons for this:
1) you are among the unfortunate handful who need to pay more attention to equalizing or
2) as a beginner you went up and down too much in the 10 meter zone ( = did too much yo-yo)

The novice diver pays a lot of attention to the material until about the 50th dive, so that less attention is paid to the diving depth. The pressure differences that arise during the yo-yo in the 10-meter zone can indeed give rise to sharp stinging in the ear, because the novice diver does not think about equalizing again in time after the 1st clearance. During that yo-yo it is of course important to equalize again and again to eliminate those super large pressure differences. It is a pity that this is not stated in so many words in the SSI and PADI course books, for that you have to read between the lines.

We do not use nasal spray, because the earache is usually not related to a blocked Eustachian tube, but to the failure to equalize in time. By the way, you equalize before the outside pressure becomes too great. After all, as soon as you feel the pain it is already too late and it affects the rest of your dive.

We use ear drops that we make ourselves to make the eardrum a bit more flexible. It's a mixture of vinegar and rubbing alcohol. Dr Maarten may be able to say more about the correct mixing ratio.

Greetings,

Rene (BE)

*****

Dear Rene,

The auditory tube, or Eustachian tube, connects the nasopharynx to the middle ear and ensures equal pressure on both sides of the eardrum. The tube is shaped like a trumpet (tuba) and has a very narrow section in the middle. The entrance to the nasal cavity easily becomes clogged with a cold.

With the exception of broth, equalization is nothing more than increasing or decreasing pressure on the inside of the eardrum, so that the pressure difference inside and outside comes closer together. If the Eustachian tube is closed, you can equalize all you want, but without success. People who suffer from this a lot benefit from a nose drop, but others and beginners certainly do too.

The nasal drop dilates the tube by means of an adrenaline-like substance. Salt drops, which are widely used, do nothing. In an airplane it is the other way around. There is a negative pressure there, so that the eardrum is pushed outward. Swallowing often helps. Yawning and sniffing even better. Also a form of clearing.

The ear pain during diving and flying is caused by pressure differences. The eardrum is extremely sensitive and hurts when it is sucked in or bulged out. A nose drop can also be useful on the plane.

The vinegar plus alcohol prevents outer ear infections (otitis externa) and has nothing to do with making the eardrum flexible. Vinegar alone is sufficient. A drop before diving and after diving dry the ear with a cold hair dryer and then another drop of vinegar. Alcohol can even damage the eardrum. A nose drop of vinegar mixed with polyethylene glycol works well for otitis externa, but don't mess around yourself, as the drops must be sterile.

Otitis externa is very painful, but fortunately easy to treat. Antibiotics are very rarely necessary. However, the ear must be cleaned, which can hurt. Never do it yourself.

In my practice, I have seen about 25 cases of otitis externa in 20.000 years. An ENT doctor was only involved once, who could not do anything about it, and only a few dozen times antibiotics. Developed its own drop, which is still used.

Never go diving or swimming with so-called grommets (tubes in the eardrum), whatever the doctors say. No problem in cold water, but major problems can occur in water warmer than 25 degrees.

An inner ear infection caused by dirty water from the outside is very difficult to treat. Earplugs are also out of the question, because they give a false sense of security. Earplugs always leak and behind the cap a fantastic environment is created for everything that grows and blooms and so captivates the ear canal.

In scuba diving seems to me the best definition for equalizing. “Attempt to eliminate the pressure difference between the inside and outside of the tympanic membrane”. Of course the technique is important, but even more important is a well-functioning Eustachian tube. That tube doesn't work properly for me, one of the reasons I don't dive. Another reason is that I'm not going to try to be any better than a fish in water. My son, on the other hand, is a cave diving instructor, an occupation I have always followed with fear and trembling. Fortunately, he is now using his brain again.

In Spain I regularly inspected divers. A thorough ENT examination is especially important for beginners. If something is not right there, a good diving school will not accept them as a student.

A large nasal tonsil is in principle already a contraindication.

With regards

Dr. Maarten