Equalizing Made Easy

Pain-proof your ears with this natural and chemical guide to descents and ascents.

By Samuel Shelanski, M.D.

If you're a diver, rest assured that you will have trouble equalizing your ears at some point. Blame poor planning on evolution's part. When we evolved from sea dwellers to land dwellers, somebody forgot to take into account that we might want to go back on vacation. The result is that we have pressure-sensitive spaces in our ears that have important implications for every descent and ascent we make.

What Happens When You Equalize?

As you descend, the air filling your ear's internal spaces is compressed and its pressure reduced. But outside your ears the pressure applied by water against your ears increases. To bring these two pressures into balance, and to prevent damage to your ear's tissues and organs, you must add air via your eustachian tubes to these internal spaces.

Illustration by Ann Geisinger.

What Happens When You Don't?

A squeeze, defined as ear pain on descent, is the most common medical complaint from divers. The sharp pain occurs when water pressure forces the eardrum inward toward the unequalized air space in your middle ear. Continuing down despite the pain results in blood and other fluids filling the air space, eventually reducing the pain and producing a "full" feeling in the ear. Failure to equalize properly on descent, especially a fast one, can also rupture the eardrum or the round window leading to the inner ear.

Equalization Techniques

Most divers use the Valsalva maneuver - blowing gently against a pinched nose. The key word here is "gently." Blowing too hard can shut the eustachian tube's opening and damage the middle and inner ears. If you have to blow hard, ascend a few feet and try again - gently.

The Frenzel maneuver is similar in that you also compress air against a pinched nose, but you do so by swallowing or otherwise contracting your throat muscles, instead of using your diaphragm.

Other methods include yawning (with mouth closed) or pressing your tongue against the roof of your mouth. Which method will work for you is a matter of experimentation. Most divers gradually evolve away from sole use of the Valsalva and toward more gentle methods like the Frenzel.

Why You Must Equalize Early and Often

The opening of the eustachian tube is called the ostium. It functions like a pressure-sensitive valve. Very sensitive. Even small pressure changes equivalent to a change in depth of 2.5 feet is enough to cause the ostium to close. After about four feet, the ostium is essentially locked shut. Swallowing won't open it and a hard Valsalva maneuver will actually shut it even tighter. At this point the ear's membranes will be getting inflamed, with possible leakage of fluid into the middle ear. Most divers will experience a significant degree of pain at this point.

Why Do I Have Trouble Equalizing?

There are several factors that can lead to difficulty in clearing your ears and increase your risk of injury. These include the usual suspects: mucus from nasal congestion due to a cold or allergies; swelling from a sore or irritated throat; and narrowed eustachian tubes, often the result of scarring in people with a history of ear infections. Temperomandibular joint problems can contribute to difficulty equalizing by causing irritation that can occlude the eustachian tubes.

But even healthy divers may occasionally experience difficulty equalizing. After repeated and rapid depth changes, the throat muscles can tire. Absence from diving for a long period can leave a diver with rusty equalizing techniques. Equipment can be the culprit, too: tight neck seals on dry suits and cold-water hoods can constrict the throat and the eustachian tubes.

What Is a Reverse Squeeze?

A reverse squeeze, or ear pain on ascent, occurs when expanding air in your ear's inner spaces can't escape via the eustachian tubes. It happens most frequently to divers with nasal congestion who manage to equalize adequately on descent, but whose eustachian tubes become blocked during the dive. If you rely on a decongestant to clear your eustachian tubes and the decongestant wears off during a dive, you can also experience a reverse squeeze.

The pain is similar to that of a squeeze, but is caused by the pressure inside the middle ear spaces being greater than the ambient pressure, forcing the eardrum outward instead of in. Techniques for handling a reverse squeeze are also similar: descend slightly until the pain is relieved and gradually attempt to ascend again. You can also attempt a reverse equalization technique: inhaling against a pinched nose. Attempting to surface despite the pain can also result in rupture of the eardrum.

My Ears Hurt After Diving - Should I Dive Again?

Not until the ear is pain-free. If you have pain, then it is a pretty sure bet that the membranes in the ear and eustachian tube are swollen and inflamed, which will make equalizing that much more difficult on subsequent dives. You may need to skip a day or two of diving, but that sure beats the alternative: risking more severe damage. If the eardrum or round window is ruptured, then there should be no further diving until the damage is completely healed, which may require surgical intervention.

It may be difficult to give up a day or two of diving due to ear pain, especially when you've just shelled out a couple of thousand dollars and taken a week of precious vacation time. But it is important to use good judgment and keep things in perspective. Taking a day or two to relax, snorkel and off-gas may not be why you went on a dive vacation, but it sure beats permanent hearing loss.

Will Ear Drops Help or Hurt?

Possibly both. Many divers use ear drops to reduce the irritation, inflammation and potential infection that can accompany frequent immersion of the ears in water. The ear canal is protected by a thin layer of cerumen, or wax, which has a slightly acidic pH. Water can dissolve some of the fatty acids that make up cerumen and make the ear canal more alkaline and therefore susceptible to bacterial infection.

Drops that contain 2 to 3 percent acetic acid seem to work best for drying out the ear canal and as a prophylactic against infection. For proper and effective prophylaxis, drops should be used after each dive. Drops that contain alcohol will help eliminate water in the ear, but can irritate the skin of the canal, especially if it is already inflamed.

If you suspect that your external ear is already infected, then these drops will generally not help. It is important to seek medical attention to determine whether it is the external or middle ear which is infected, and receive the proper antibiotic therapy. This is especially true if you have drainage from your ear or think that you may have ruptured your eardrum. If the drum is ruptured, then drops can actually make the situation worse by washing bacteria from the outer ear into the middle ear space.

The 5 Golden Rules of Equalizing

1. Equalize immediately upon beginning a descent and continue to do so every few feet to avoid discomfort.

2. Never wait until discomfort is felt before equalizing.

3. If you have trouble equalizing, ascend slightly and try again. If after repeated attempts you still can't equalize, abort the dive.

4. If you have trouble equalizing, use a line to help control your descent and maintain a feet-down position.

5. Never attempt a lengthy or forceful Valsalva maneuver. You may rupture your eardrum or round window.

Questions for Dr. Shelanski should be addressed to RSD, Dive Medicine, 6600 Abercorn St., Suite 208, Savannah, GA 31405; e-mail: RSDmgzn@aol.com.