The best way to avoid equalization problems underwater is to prevent them, rather than hoping to cure them.
Use proper equalization techniques 'before' pain and discomfort and not ‘after’ it is has started.
Non-divers ask; does scuba diving hurt your ears?
If you continue to descend without equalizing your air spaces, especially your ears, you are likely to feel pain and suffer one of the barotraumas in diving.
If you fail to equalize during your descent, to avoid a squeeze you should discontinue the dive and never attempt a forceful or extended equalization.
Divers should equalize early and often when descending below the surface. Avoid problems by equalizing air spaces with the ambient (surrounding) water pressure, at least every meter.
The change is at its greatest in the first few meters of the descent. Pressure injuries occur - most often in the ears - if equilibrium does not happen during the descent. Omitted equalization, forceful or ineffective equalization, and congestion, are the cause of most ear barotraumas.
Excessive gradients - more than 2 psi - distort the eardrum and the diver feels pain and discomfort. Surprisingly, a rupture can occur just two or three meters down, if the difference in middle and outer ear pressure increases to 5 or more psi.
There are three different types of ear barotraumas:
OUTER EAR EQUALIZING PROBLEMS and BAROTRAUMAS
The outer ear is the visible part on the side of the head. It also includes the ear canal, which is the part normally filled with wax. The tympanic membrane separates the outer canal with the inner ear.
Trapped air in the outer canal creates a pressure gradient or a vacuum, causing outer ear damage as the diver changes his or her depth. This is one reason why you cannot use earplugs when scuba diving.
Though rare, excessive ear wax and tight-fitting dive hoods cause blockages. Divers should also be aware that bony growths or cysts (exostoses) produce passage-blocking lumps or infection.
Symptoms of an outer ear barotraumas include pain and further difficulty equalizing. The vacuum inside the canal distends and distorts the blood vessels. Burst vessels lead to minor bleeding in the ear canal and extreme cases can deteriorate to problems in the middle ear.
Treatment for outer ear barotraumas is generally self-healing. However, middle ear problems are more serious and the divers can prevent future problems by keeping the canals free of anything that blocks the airway.
MIDDLE EAR EQUALIZING PROBLEMS and BAROTRAUMAS
Middle ear barotraumas are the most common ear injuries experienced by sport divers. The middle ear is a chamber filled with air.
The round and oval windows – thin tissue-covered openings - separate it from the inner ear, and the outer ear is kept separate by the eardrum. Divers equalize by adding air through the Eustachian tube, which joins the throat to the inner ear.
Middle ear injuries can occur during the descent and ascent. A descending diver’s inability to equalize the middle ear causes a vacuum. The imbalance sucks the soft tissues, Eustachian tubes, and eardrum, inwards. If equilibrium is not achieved during the ascent, excessive pressure flexes the delicate ear parts outwards.
Congestion and swellings block the airways inside the Eustachian tubes. This is why diving should not be attempted if you are feeling sick. Tight or narrow Eustachian tubes also cause middle ear barotraumas because they restrict the airflow through the vessels. However, the most common cause is ineffective or over-forceful equalization.
This is particularly pertinent to new divers who have not yet perfected the correct technique.
ENT Doctors Use TEED Classification for Middle Ear Barotrauma
Divers will experience a pressure build-up, causing pain, soreness, and an inability for further equalization. Negative pressure causes the Eustachian tubes to collapse.
A continued descent without equalizing may cause the eardrum to burst, which results in a build-up of pressure, sharply followed by relief as the drum bursts. You will feel cool sensations as water enters the middle ear. Further complications may lead to inner ear barotraumas, which are more serious.
After the dive, the victim feels a sensation of ‘watery fullness’ in the ears. This is blood and fluids settling in the middle ear.
Other symptoms include unclear hearing and crackling sounds, dizziness, soreness, and fluid leaking through the Eustachian tubes to the throat. Medical attention is required for all middle ear injuries and involves antibiotic treatment for infection.
INNER EAR EQUALIZING PROBLEMS and BAROTRAUMAS
The round window and the oval window separate the inner ear from the middle chamber. Delicate tissues cover these window openings. They are some of the most delicate tissues in the body. The inner ears control our balance and the way that we hear.
Deep inside the ear, the oval window and the round window connect directly to the eardrum by the ossicles - a chain of tiny bones. These help to transfer motion into sound. They are both affected by changes in fluid pressure.
Not equalizing is a regular cause of inner ear barotraumas. Divers use the Valsalva maneuver to equalize their ears. Blowing with too much force can cause a rupture to the round window. Continuing the descent without equalizing, increases inner ear fluid pressure – endolymph – and blows out the membrane resulting in a bulging rupture.
Inner ear barotraumas cause tissue perforations, vertigo, vomiting, and disorientation. Symptoms such as these are potentially life threatening while underwater.
Other common signs include hearing loss and buzzing sounds in the ears – tinnitus. Inner ear injuries need immediate medical attention and may require surgery.
EQUALIZING PROBLEMS WHILE ASCENDING
Equalizing the air space in the ears during ascent is not normally necessary. The ascending diver experiences a drop in ambient pressure outside of the ears. The higher pressure in the middle ear is therefore greater than the surrounding pressure.
The gradient usually balances itself automatically, and air escapes outwards through the Eustachian tubes.
A reverse block is rare. It happens while ascending, if the diver's ears do not equalize. The bending of the eardrum causes pain, discomfort and dizziness - alternobaric vertigo.
A diver suffers this form of underwater vertigo when only one of the ears equalizes on ascent. Inflamed Eustachian tubes are the most likely causes of reverse blocks. Another contributing factor is congestion.
A reverse squeeze happens when the middle ear has too much pressure inside. Attempting normal equalization techniques for descending - such as the Valsalva maneuver - will increase the problem.
Further build-up stretches the middle ear too much worsening the condition. One technique used to equalize a diver's ears while ascending is the Toynbee maneuver. Block your nose with your fingers, and swallow. Negative pressure created in the middle ear helps to relieve the problem by sucking out air.
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