Ear Pain, Scuba Diving - Overview
Ear pain is the most common complaint from scuba divers. Some divers call it "ear squeeze." As a diver goes deeper under water and the outer environment pressure increases, the pressure in the middle ear (the part behind the ear drum) is "squeezed" by the increasing pressure of the water from outside.
The middle ear is an air-filled space formed by bone and the tympanic membrane or eardrum. It is connected to the back of the nose by a tunnel called the eustachian tube. Outside air passing through the eustachian tube keeps the pressure in the middle ear equal to that of the outside world. If the eustachian tube malfunctions and a pressure difference occurs across the eardrum, pain or ear squeeze occurs.
Diving Ear Pain - Causes
Ear pain occurs during the descent portion of a dive -- as the diver drops deeper underwater. The squeezing ear pain most often occurs near the surface where the relative pressure changes are greatest. Each foot below the surface places continuing pressure on the diver. For every 33 feet under water, atmospheric pressure increases in the amount of 1 atmosphere (this can be compared to the pressure of 1 atmosphere for anyone at sea level).
Normally, the eustachian tube will open and allow the pressure behind the eardrum to equalize with the outside pressure of the seawater in the ear canal. But, if the eustachian tube can't do its job, then as the seawater pressure in the ear canal increases, the eardrum is pushed inward, stretching and inflaming the eardrum and causing pain. If the pain is ignored and the diver drops deeper, the pressure will continue to increase and the eardrum may burst, allowing cold seawater to rush into the middle ear. Nausea, vomiting, dizziness, and confusion may follow.
Rapid ascents or descents in a car or commercial air flight may also cause pressure equalization problems in the ear, but not to the same degree as in a dive. You may get an ear pop but not an ear squeeze.
- There are many reasons for the eustachian tubes not to equalize the pressure:
- Upper respiratory infections
- Nasal polyps
- Previous facial trauma
- Overaggressive ear clearing
Diving Ear Pain Symptoms
Pressure against the eardrum is responsible for the symptoms of ear squeeze. At low pressure, the diver has a feeling of fullness. As the pressure increases, the eardrum bulges inward, swells, and becomes painful.
Continued high pressure can rupture the eardrum. If this occurs, air bubbles may be felt coming from the ear and the pain may lessen. Cold water then enters the middle ear through the hole in the eardrum, and the diver may become nauseated or vomit. The diver may also become disoriented or have a feeling of spinning, referred to as vertigo.
Upon returning to the surface, if the ear drum has ruptured, the diver may feel fluid draining out of the ear or notice hearing loss. Rarely, a one-sided facial paralysis resulting from too much pressure on a nerve in the inner ear may be associated with ear squeeze.
When to Seek Medical Care
The majority of cases of ear pain or ear squeeze force the diver to abort the dive before the eardrum ruptures. In these cases, symptoms often resolve shortly after the diver reaches the surface. If symptoms continue or the cause of the ear pain is not known, seek medical care. Disorientation, vomiting, and hearing loss are symptoms of a ruptured eardrum and require medical care.
If a ruptured eardrum is present or suspected, the diver should be evaluated in a hospital's emergency department. No further dives should be undertaken until the diver is medically cleared.
Exams and Tests
The doctor will evaluate the possibility of ear squeeze with a series of questions regarding the dive. These questions not only help diagnose the ear squeeze but also detect other potential dive injuries.
- Did the diver experience difficulty clearing the ear?
- Did the symptoms begin during descent or ascent?
- Were the symptoms present during the dive or after reaching the surface?
- How long did the symptoms last?
- Is there a history of ear or sinus infections?
The doctor will then examine the ear with an otoscope or ear scope. The exam may reveal a normal eardrum, swelling and redness of the eardrum, or a hole in the eardrum. Hearing loss or facial paralysis may also be present. X-rays and blood tests are not needed.
Diving Ear Pain Treatment - Self-Care at Home
The treatment of ear squeeze begins during the dive. If fullness or pain is experienced, do not continue to dive deeper. If ear clearing techniques fail, the dive must be ended. Always complete the decompression stops if necessary when returning to the surface.
If the eardrum ruptures, the diver may become disoriented or vomit, which may lead to panic. Panic may lead to ascending too rapidly. The dive partner should carefully observe and assist, if needed, during the ascent, making sure all decompression stops are made. On the surface, no objects or eardrops should be placed into the ear. Keep the ear dry.
The most important treatment was done by aborting the dive and ascending to the surface, making any necessary decompression stops.
- Initial treatment involves the use of oral decongestants and nasal spray to help open the eustachian tube. Antihistamines may also be prescribed if an allergy is a contributing factor.
- Pain medications are helpful, and eardrops to relieve pain may be used if the eardrum is not ruptured.
- A ruptured eardrum will require antibiotics by mouth to prevent infections.
- Hearing exams or audiograms may be needed if the eardrum is ruptured or hearing loss is present.
- If the person has a facial paralysis, oral steroids may be prescribed.
Next Steps - Follow-up
- Avoid eardrops unless prescribed by a doctor. Put nothing into the ear.
- The person may be referred to an ear, nose, and throat specialist (ENT) to monitor the eardrum healing.
- No further diving should be undertaken until 2 weeks after all symptoms are resolved and the eardrum is healed.
Prevention is the preferred treatment for ear pain involved with scuba diving.
- Divers who are unable to clear their ears or experience pain should stop their descent and abort the dive.
- Divers should equalize their ears frequently when descending.
- Diving should not be attempted if any sinus or upper respiratory symptoms are present.
Most ear pain with scuba diving will go away by itself -- usually within a week -- without long-term effects. Eardrum ruptures usually heal themselves over longer periods of time, but they sometimes require surgical repair. Facial paralysis, if present, most often is temporary. Mild hearing loss may continue.
Synonyms and Keywords
ear pain, scuba diving, middle ear barotrauma, MEBT, barotitis media, ear squeeze, scuba diving ear pain