"Thanks to my DAN Training I have been able to effectively assist many divers over the years with the provision of oxygen first aid following the onset of DCI-related symptoms post diving". - Xavier, Scuba Culture

Ear and Sinus Injuries

This is meant as a general overview and should not be used in place of a medical consultation

Learning to Adapt

As divers, we must adapt to an environment that exerts pressure on our bodies. The most common injuries reported to DAN each year involve pressure related injuries to divers’ ears and sinuses. A little education and common sense will go a long way to avoid these problems.

Sinus and Middle Ear Injuries

Barotrauma is a pressure related injury. Middle ear barotrauma, known as “ear squeeze”, is the most common diving injury. Sinus barotrauma also occurs but is less common. How does it happen? Barotrauma is caused by pressure changes when diving. During descent, air spaces in the sinuses and middle ear must be able to equalise to the surrounding water pressure, which increases with depth. When pressure in air spaces can’t equalise, the diver may sense pressure or pain from one of these areas. During ascent, if the expanding air can’t be vented, the cavity pressure increases, resulting in discomfort. This type of injury can range in severity - from mild to extreme. A sinus or middle ear injury may occur suddenly and lead to inner ear damage. For this reason, divers should know and use the “clearing” or equalising maneuver that works best for them.

How to Equalise

The Valsalva Maneuver is probably the most commonly taught means of equalising pressure where the diver closes the mouth, pinches the nose and blows gently. Avoid blowing too hard and over-inflating the middle ear space. The result could be injury to the middle or inner ear. The Frenzel Maneuver is similar to the Valsalva except that instead of blowing air into the sinuses, the diver closes the nose and mouth, and drives the tongue backwards on the roof of the mouth. The muscle contraction opens the nasal cavities and Eustachian tubes, which allows air into the middle ear. The Yawn & Swallow. Some divers can simply yawn, swallow or thrust the lower jaw forward and open the mouth while using the lips to maintain a seal with the regulator mouthpiece. This opens the Eustachian tube to the middle ear, which equalises pressure. As long as the sinuses also equalise easily, this maneuver is acceptable. For many divers, a combination of these methods - even switching back and forth during a single descent - works best.

Prevention is the Key

The most common reason divers suffer barotrauma is a failure to inflate the ears and sinuses with additional air during descent. Often divers mistakenly wait to equalise their ears or sinuses when they feel discomfort. Begin the equalising process by inflating your ears and sinuses with air before entering the water or beginning your descent - this ensures that the air passages are open and clearing is possible. A slow, steady descent with frequent inflation is then possible without barotrauma. If you feel discomfort, stop your descent and ascend about a metre until the discomfort is relieved. Attempt to clear but do not continue your descent unless your sinus and middle ear spaces have equalised.

Difficulty Equalising

What if you can’t equalise? First, don’t dive until the problem is resolved. If a diver has trouble equalising the sinuses and middle ear, there may be some pre-existing problem - the most common is diving with a cold or flu. Frequently the mucous membrane will retain fluid and swell, partially occluding the air passages to your sinuses and the Eustachian tube going from the back of your throat to the middle ear. This not only makes clearing difficult, but it may prevent diving altogether. Other recognisable factors in equalising problems are a history of childhood ear infections (or even one severe infection) that can damage the tubes, a history of a broken nose or a deviated septum that prevents one ear or a set of sinuses from clearing as fast as the opposite side, or hay fever which can produce swelling of the mucous membranes or cause nasal polyps that can partially or completely occlude a sinus cavity or airway. If you have a history that includes these conditions and want to dive successfully, it may require referral to an ear, nose and throat specialist or allergy specialist who is familiar with these conditions.

Symptoms of Barotrauma

The most common barotrauma symptom a diver experiences may be mild discomfort to intense pain in the sinus or middle ear - this is almost always the first indication of a problem in equalising. Middle ear barotrauma may also include symptoms of ringing or hearing loss. As blood or fluid accumulates in the middle ear a diver may experience a partial, complete or muffled hearing loss as well as damage to the inner ear. Roaring in the ear, nausea, vomiting, dizziness, a sensation of spinning and decreased hearing may also indicate inner ear barotrauma. Blood from the nose or in the sputum is also an indication of barotrauma and does not have to be associated with other symptoms. These are symptoms that should probably end the day’s - and possibly the week’s - diving. Continuing to dive with barotrauma may result in serious injury.

Treatment and Medication

If you experience any symptoms during or after a dive, then you should consult a doctor to determine if there has been any permanent damage, or if there is some treatable condition causing the problem. Your physician can determine the correct treatment and medication for sinus or middle ear barotrauma and refer you to an ear, nose and throat specialist if necessary. Proper care and medication under a doctor’s supervision can reduce the time divers experience barotrauma symptoms - and the sooner they can get back into the water to enjoy diving.