When you ask people who don’t dive what they think the most common type of diving injury is, the answer is usually ‘The Bends!’. If not this then at least an imagined tale of a Jaws-type marine monster attacking innocent divers one by one. The real answer is actually a lot simpler, and significantly less Hollywood. The most common injury you will encounter as a diver over a lifetime will be related to your ears.

The ears are an incredibly complex piece of our bodies. It is important we understand how to protect them. To do this, we need to first have a basic understanding of how they work. In very simple terms, the ear is actually formed from three areas: the outer ear, middle ear, and inner ear.

Outer Ear

The outer ear is what we see in ourselves and each other when we think of ‘ears’. It is made up of two parts, the pinna, and the ear canal.

Pinna

The pinna is the cartilaginous, flesh-covered flap located on each side of our heads.  While the ear is incredibly multifaceted and involved, most of the clever design features are located internally. The pinna is actually the only part of the ear which is externally visible to us. Its job is simple but vital: to collect sound waves and channel them down the external ear canal. It also channels water into and out of the ear. Its cleverly engineered shape is not for nothing. Sound waves that are approaching us from behind are partially shielded by this outer fleshy area. This helps us to better determine the location the sound has come from. This is what helps us judge whether the origin of the sound is from behind or in front of us.

Ear canal

The ear canal is just a few centimeters long in adults and has a slight S-curve to it. The outer portion of the ear canal is covered by a thin layer of skin containing glands. These glands are responsible for the production of earwax. Thin hairs are also found covering the skin near the ear canal. It is this dynamic duo of tiny hairs and ear wax that is crucial in catching airborne particles. Dirt and detritus are caught before they have a chance to reach the middle and inner ear.

The Middle Ear

Following the twisting ear canal inwards leads us to the eardrum, more technically known as the tympanic membrane. It is this membrane that separates the middle ear from the outer ear. Within this middle ear are located the body’s three smallest bones – the malleus, incus, and stapes. As divers, this is the area we are most concerned with. It is this air-filled chamber that is more likely to give us trouble than anything else over the course of our diving life. Connecting our middle ear to the back of the throat are the Eustachian tubes. These little tubes allow us to keep the pressure between the middle ear and the outside environment equalized. This prevents any pain or discomfort from occurring. The underwater swallowing or yawning we see divers do is to allow this equalization to occur.

The Inner Ear

Last, but definitely not least, we come to the inner ear. This is the part of the ear deepest within our bodies. Within the inner ear is the cochlea. This is the part of the ear actually responsible for hearing. It converts the vibrations from sounds into what we eventually hear. The cochlea is also noteworthy as it contains fluid-filled chambers. This can cause serious issues if any rupturing were to occur. The seeping of fluid from the inner ear to the middle ear is not something any diver would ever want to risk happening. Aside from the obvious discomfort, anything that causes us to feel dizzy or disoriented underwater is downright dangerous. This is just one of several reasons why you should never ever force equalization to occur.

So now we understand all the main different components that make up our ears. From here we can start to look at the best ways to protect them. Diving puts us in a physically very different environment than the land-based one we are used to. By being aware of the risks and differences in this new world, we can greatly limit any possible issues that may occur. Let’s look at a few of the most common ear problems we may encounter when submerging:

Barotraumas

When we descend under the water, the most physically obvious difference to a diver is, of course, the pressure change. As we sink, the pressure of the water surrounding us increases. Any time the pressure around us changes, the chance of a barotrauma occurring rears its ugly head. Very simply, a barotrauma is any kind of pressure injury (baro comes from the Greek word for ‘pressure’, and trauma means ‘wound or injury’). If we don’t equalize as we go down then the pressure surrounding us increases while the pressure within our bodies stays the same. This causes an imbalance between the outer ear and the air filled chamber of the middle ear. By gently pinching our noses and blowing, wiggling our jaw from side to side, or even just swallowing, we open our Eustachian tubes. As mentioned earlier, these tubes provide a direct link from the back of our throats to our middle ears. They are what allows us an easy equalization of pressure. If we don’t do this, not only will it be painful, but we increase our chances of rupturing our middle ear with this pressure imbalance. Middle ear barotraumas are the most common injury in diving. They are also one of the easiest to prevent. Remember the golden rules:

1. Equalize carefully on the surface before you even start to descend. Continue gently equalizing every meter/few feet of your descent. This is especially important when shallow and the greatest pressure differences are occurring.
2. Although most people learn the Vasalva technique when they first learn to dive (where you gently exhale against your pinched nose), it isn’t the right fit for everyone. There are other equally valid methods out there to allow you to equalize. Look at the Toynbee Maneuver (where you pinch your nose and swallow) or Frenzel Maneuver (where you pinch your nose and make the sound of the letter ‘K’). Don’t be afraid to try them if the Vasalva is just not working for you.
3. If you are struggling to equalize as you descend try rising a little and trying again. This lessens the pressure slightly and may be all you need to allow you to continue a slow and controlled descent. Some people also find that descending in a more feet down position allows for an easier equalization.
4. Never ever force it.
5. If you have a cold of any kind give the dive a miss. Do not think decongestant will solve the problem. It is worth remembering that while most pressure injuries with ears occur on descent, there is also a pressure change when we ascend at the end of a dive. This is one reason to be very wary of taking any decongestants before submerging. The effects will most likely wear off before the end of your dive, and you will still need to ascend regardless. If the Eustachian tubes are now blocked then the expanding air in your middle ear, caused by the now lessening pressure on ascent, has nowhere to go. This is a reverse block, and can have painful consequences.
6. Without wanting to be the party-pooper in the room, smoking and alcohol are not good for you in any way as a diver. With regards to equalizing, both of these things can irritate your mucous membranes.  This can cause a blocking of your Eustachian tubes. Interestingly, for those of you having problems with your ears, consider cutting down on your dairy intake. Milk has been shown to increase the production of mucus. This may well be affecting your ability to comfortably equalize.
7. If you have any pain or discomfort in your ears after the first dive give any planned second dives a miss. There will always be more diving days in the future. Healthy ears are not so easily come by, nor damaged ears that easily fixed. If the pain or discomfort persists after the dive it is worth getting it checked out by a doctor. The peace of mind of knowing that everything is good with your ears is worth the time taken!

Infections

Ears are funny, twisty, labyrinthine parts of our bodies. As such they are sadly prone to detritus lodging in them. This is one cause of ear infections. While not always specifically a diving related problem, it is one that can be exacerbated by in-water time. Otitis Externa, for example, is an outer ear infection. This is generally caused by frequent time in the water. The water causes the cells which line your ears to swell slightly. This can create an opening for opportunistic bacteria to enter. Here they find a warm, damp, welcoming place to multiply. Left untreated this can cause pain and swelling all along the jawline. Realistically, infections are something you want to get sorted as soon as possible. As someone who has, sadly, had several ear infections over the years, I can attest to the extreme discomfort one feels with such an infection. Luckily it’s usually an easy fix, with ear drops prescribed by a doctor clearing up all but the worst cases. If not then antibiotics may be required. It does, unfortunately, mean it is more prudent to stay confined to dry land until it is all sorted.

All of us have ear problems from time to time. If you are finding that constant equalization or pain issues are regularly preventing you diving though, think about going to see a specialist. A doctor focusing on possible ear, nose, and throat (ENT) troubles may well be all you need to figure out what your body is not liking about your current regime. There are also various devices available now, such as masks which cover your ears as well as your eyes and nose. With tubes connecting all the air pockets so you can still equalize, this keeps water out of your ears and minimizes infection risks. Never risk your ears, but, as with most things in life, there is normally a way around most problems. Take the time to speak to experts and look at possible lifestyle changes.

Text By: Gemma Smith – TDI/SDI

Graphics By:  DAN AP