First presented at the 23rd Annual Undersea and Hyperbaric Medical Society, Pacific Chapter meeting (Seattle, WA 1995) by Edmond Kay, MD

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Middle ear barotrauma is the most frequent diving injury I see in my medical practice. It occurs much more commonly in the novice diver as a direct result of improper middle ear equalization technique. The following information is intended for the diving instructor, diving safety officer and any individual charged with the responsibility of managing novice divers. This information should also be of value for the advanced or commercial diver interested in rapid descent. The topic includes a discussion of nine different techniques of equalization, and offers tips on assessing the effectiveness of middle ear pressurization. Questions regarding "Techniques of Equalization" should be addressed to me via my Guest Book.


At the end of this topic, the reader should be able to:

  1. Define and recognize "Ear Fear".
  2. Recognize and assess the effectiveness of equalization efforts.
  3. Discuss the difference between middle ear pressurization and middle ear equalization.
  4. Describe and be able to teach nine different methods of middle ear equalization.
  5. Describe the medical conditions which might interfere with adequate middle ear equalization, and understand the appropriate use of decongestants.
  6. Describe the conditions or injuries which would preclude further diving until medical clearance is obtained.

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The Eustachian tube was first identified by Bartolomeo Eustachio (Latin: Eustachius), an Italian anatomist who died in the 1500's. In the United States the Eustachian tube is usually pronounced "yoo-sta-shan", but some pronounce it "yoo-sta-ke-an" in honor of the anatomist as it more closely approximates the original Latin pronunciation of the name. The tube is approximately 1.5" long and is located in the back of the nasopharynx at approximately nostril level. The tube is normally closed and has a highly variable patency. This means that some individuals will virtually never have problems with middle ear equalization while diving. Others with narrow or partially obstructed Eustachian Tubes may have trouble equalizing their middle ears in airplanes or elevators. These later individuals can dive safely, but for them middle ear pressurization requires meticulous attention to detail and much practice.

Thanks to the comments of Francisco Javier Orellana Ramos, a Diving Medical Officer from Spain, I am reminded that there are several factors which influence tubal patency and tolerance to pressure changes. The Eustachian Tube angle and the shape of the tube can affect ones ability to pressurize the middle ear. Individuals with a relatively large volume of air in the mastoid sinuses will be less tolerant to pressure changes as the actual volume change in the middle ear will be greater for a given amount of descent. Allergies, trauma, infection and Thyroid disorders are other possible causes of disruption in normal tubal function.

For individuals who have difficulty pressurizing ears, the position in the water column is extremely important. It is well known that the head-down position during descent can make middle ear equalization more difficult. Less well understood is the reason for this effect. Until recently I believed the effect to be caused by venous pooling and engorgement of Eustachian Tube tissues. Dr. Jolie Bookspan has eloquently pointed out that immersion reverses venous pooling, thus making redistribution of venous blood much less likely to be the cause of the problem. There are soft tissues in the nasopharynx which surround the membranous Eustachian Tube, and no doubt gravity plays a role in there normal functioning. The most likely candidate for positional obstruction to tubal patency are these tissues. A suboptimal position can compromise marginally patent Eustachian Tubes and for this reason, it is advisable for students to begin descent slowly, and always in the head up position. Divers with prior ear problems, timid divers and those who are not sure whether middle ears will equalize should also assume this position.

Half of the Eustachian Tube is surrounded by bone but the other half is open to the pressure changes of the respiratory system (ambient pressure). This membranous later half is partially surrounded by a "C" shaped cartilage and during swallowing, muscles of the soft palate pull on the Eustachian Tube. This traction opens the tube while closing the nasopharynx. The act of swallowing often causes a clicking or crackling sound to be heard and this sound is actually the noise made when the moist tissues of the Eustachian Tube pop open. You can hear this sound for yourself in a fellow diver or student by applying a stethoscope in the area around the ear. If the student swallows and the crackling sensation is heard, the listener can verify that the Eustachian tube has actually opened. This technique was first described by Joseph Toynbee in the 1800's, and will be described later.

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Ear Fear is a term I have coined to describe the apprehension associated with middle ear equalization. It tends to occur in individuals who have had prior middle ear trauma, a frequent childhood history of middle ear infections or those who just get queasy when they feel new bodily sensations. To some, this sensation of pressure in the middle ears and the crackling in one's head associated with the popping open of a Eustachian tube is uncomfortable. These are the individuals who do not like to "pop" their ears and many have been told all their life that this is "bad to do". For these individuals, middle ear pressurization effort is anxiety provoking and efforts tend to be very cautious and tentative. For many of these novice divers, middle ear trauma occurs at the first dive. Students can become confused about the actual pressure needed to achieve middle ear equalization when well meaning friends remind them not to blow too hard. This advice is certainly prudent when a student is under water and experiencing middle ear squeeze. Unfortunately, for the squeamish individual, and especially if a marginally patent Eustachian tube is present, this limits the ability of some to pressurize adequately at anytime during the dive. Pressurization of the middle ear can and should be vigorous on the surface, when no negative pressure gradient is present across the middle ear. This means that it is possible (and desirable) for an individual to pre-pressurize the middle ear and to inflate the Eustachian tube prior to descent. Pressurization of the middle ear provides a pillow of air behind the tympanic membrane, protecting the ear drum (TM) from barotrauma. As descent occurs, more air can easily enter an inflated Eustachian tube and pass into the middle ear, if pressurization begins early in the dive. If the Eustachian tube is allowed to collapse at any time during descent due to squeeze, the pressure to re-inflate it becomes greater. For this reason, I always recommend that individuals practice pressurization of their middle ears prior to diving in order to test their Eustachian tubes for patency, and to perform middle ear pressurization before beginning actual descent to cushion the ears against trauma.

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Before teaching pressurization techniques, it is useful to learn a technique for assessing the adequacy of pressurization. A technique I use in my office is to "watch the nose inflate" (Watch the Schnazolla). Inflation can be observed if one pinches the nasal passages (nares) closed, with pinching fingers held low on the nose. With fingers occluding the nares, observe the fleshy portion of the nose immediately above the fingers. A good, strong pressurization effort will cause the tissues above the occluding fingertips to balloon outward. This nasal inflation is an indication of the inflation effort (nasopharyngeal pressure) which has been applied to the Eustachian tubes. This can be practiced in the mirror in order to optimize technique. Merely pressurizing the nose is not quite the same as inflating the middle ear, but if the diver reports no evidence of a popping or crackling sensation the instructor may check the pressure of the nose to evaluate inflation effort. Practicing on yourself allows some comparisons of effort (and pressure) to be made.

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Among the simplest and most basic techniques in diving are the yawn, swallow, jaw thrust and the head tilt. These techniques of equalizing middle ears are useful for individuals who have widely patent Eustachian tubes and NEVER have problems with equalization. These methods hardly ever work alone without the addition of pressurization in an individual with marginally patent tubes. I do not recommend these techniques for the novice diver as they offer little margin for error. The first dive in a swimming pool is often the cause of significant barotrauma due to a combination of poor technique, student distraction and other factors such as buoyancy control. Pressurization techniques (see below) should ALWAYS be used first, until a student is comfortable with a preferred technique which reliably prevents middle ear squeeze.

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THE VALSALVA MANEUVER (pressurization)

Antonio Valsalva lived in the 1700's and was the first to record a technique for pressurization of the middle ears. With the nostrils pinched closed, pressure is increased in the chest. An attempt is made to blow out the closed nostrils and cheek muscles are kept tight and retracted, not puffed out. With this technique, gradients of 6-10' of sea water can be achieved. This technique does have some disadvantages however as prolonged effort can cause venous engorgement of the tissues around the Eustachian tubes. It also causes a decrease in venous return to the heart and can lower blood pressure if the effort is prolonged. It does seem to be the easiest and most intuitive of the techniques and usually is what a student will perform on their own with no other training.

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THE FRENZEL MANEUVER (preferred pressurization)

Herman Frenzel was a Luftwaffe commander who taught this technique to dive bomber pilots during WW2. The pressure changes in commercial aviation are usually much more gentle and occur more slowly than in diving. A dive bomber pilot will experience pressure changes more rapidly however, much the same as in diving. The technique developed for flying is to close off the vocal cords, as though you are about to lift a heavy weight. The nostrils are pinched closed and an effort is made to make a "K" or guttural "guh" sound. By doing this you raise the back 1/3 of the tongue and the "Adams Apple" will elevate. For this reason I call the technique the "throat piston". A diver is actually making a piston out of the back of the tongue, pushing it upward. This maneuver compresses air in the back of the throat and the pressurization effort can be seen in the fleshy tissues of the nose. A student may practice the technique by watching the nose inflate and by watching the "Adams Apple" move up and down. Bobbing the "Adams Apple" is good practice for dive bomber pilots and scuba divers alike. This technique is actually my preferred pressurization maneuver as it can be done anytime during the respiratory cycle and it does not inhibit venous return to the heart. The effort is usually brief and can be repeated may times quickly.

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Joseph Toynbee lived in the 1800's and as you recall, he first identified the crackling sound present in ones head with the anatomical opening of the Eustachian tube during swallowing. His technique is to pinch nostrils shut while swallowing. The muscles in the back of the throat pull open the Eustachian tube and allow air to equalize if a gradient is present. Swallowing can be difficult for the novice diver, especially while breathing dry air. This technique is not recommended for rapid descent as there is no margin for error if the Eustachian tube does not equalize on first effort. If a middle ear squeeze is already occurring, it will be more difficult for the Eustachian tube to be pulled open.

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In the 1950's, the French Navy developed a technique for middle ear equalization called "Voluntary Tubal Opening". This technique is difficult to teach and in my hands, only approximately 30% of those taught can perform it reliably. Muscles of the soft palate are contracted while upper throat muscles are employed to pull the Eustachian tube open. This technique is similar to the events that happen in the back of your throat at the end of a yawn. It is also similar to wiggling your ears, and some people seem to be born with the talent, but many cannot master the technique reliably. For commercial divers and dive tenders in Hyperbaric chambers (people who spend many hours in decompression), there is an excellent opportunity to practice the technique while undergoing gradual and predictable pressure changes.

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Noel Roydhouse is a Sports Medicine Physician from New Zealand. He has written an excellent book on the subject, referenced at the end of this article. Some of the most interesting tidbits of information in this section come from his book and I highly recommend it for the reader who just cannot get enough information about the ears. His technique is similar to the Voluntary Tubal Opening except that Dr. Roydhouse has provided an additional clue for contracting the muscles in their proper order in the back of the throat. The instructions are to contract the palate lifters (the levator palatini) and to contract the palate tensor muscles, (tensor palatini). This raises up and tilts forward the uvula. The uvula is the small, fleshy protuberance hanging down from the soft palate in the back of your throat and it can be seen in the mirror. If an individual watches the soft palate and trains the uvula to raise up and tilt forward, half of the technique is mastered. The second part is to tense the muscles of the tongue in such a way as to cause the crackling sensation of Eustachian tube opening to occur. Often a jaw thrust can help make this maneuver more effective, and if the technique for "blowing smoke rings" was ever mastered, this is another good training maneuver which teaches you to recognize the muscles necessary to pull open the Eustachian tube.

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THE EDMONDS TECHNIQUE (pressurization)

Carl Edmonds is a contemporary Australian author and lecturer who described a technique where pressurization such as that accomplished by either the Valsalva or the Frenzel maneuver can be combined with jaw thrust or head tilt to more effectively open the Eustachian tube. His book (see below) is a must for anyone interested in Diving Medicine.

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THE LOWRY TECHNIQUE (pressurization)

Another combination technique has been described, whereby a pressurization maneuver is combined with a swallow. Coordination and practice is required to pinch nostrils, build up pressure and swallow at the same time but the technique is very effective once it is mastered. Carl Edmonds knows how this technique came about and as soon as he tells me the story I'll update this section. While I have not had that much luck teaching the technique, one of the most respected ENT Physicians in diving medicine, Dr. Alan Decklebaum of San Francisco prefers it.

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THE TWITCH (pressurization)

This combination technique is effective for some, and involves pinching nostrils with a moderate pressure in the back of the throat. Generation of pressure is again by either Valsalva or Frenzel Technique. Instead of swallowing as in the Toynbee Maneuver, the head is suddenly "twitched" sideways. Tension in the throat muscles helps to make this a more effective maneuver.

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Most new divers have trouble with technique, not anatomy. In a very few individuals allergies, acute or chronic infection or nasal polyps may play a role. By far the most common reason however is inadequate pressurization of the middle ears due to a lack of basic understanding of the mechanisms involved. "Ear Fear" must always be considered as a possible complicating factor and an instructor must be sensitive to the issues surrounding the reluctance of a diver to fully and aggressively pressurize the middle ears. Occasionally a "dragooned diver" will be quite reluctant to learn the techniques of equalization as this may provide a legitimate reason to drop out of the diving. Other phobias may be present such as the fear of water, or confinement fear (claustrophobia). Problems with nasal anatomy such as a deviated nasal septum, intranasal polyps, or obstructed sinuses must be addressed by a medical practitioner and occasionally these will require surgery. Recent advances in endoscopic surgery offer vast improvements over older techniques. There is much that a professional diving safety officer or a good friend can do to help an individual learn safe middle ear equalization practices, but don't forget to look for the obvious. A person with cold symptoms should not dive until the cold has cleared and the Eustachian tube clearly pops with a swallow.

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Eustachian tube awareness should be taught to all divers. Learning to listen for the crackle and pop of the Eustachian tube opening (during swallowing) will help train the ears for advanced techniques. Watch the tissues of the nose balloon out as inflation pressures increase during pressurization maneuvers. Assess the adequacy of inflation effort to help identify the causes of equalization problems. Practice bobbing the "Adams Apple" to perfect the Frenzel Maneuver and once middle ear barotrauma has occurred, discontinue diving immediately. If symptoms are mild, they should subside within 1-2 weeks. When equalization ability is back to normal, no abnormal sounds or crackles are present in the middle ears and hearing is normal, a diver can return safely to the water. Decongestants never help when cold or trauma symptoms are bad, but at the very end of a cold, when just a little stuffiness remains, the occasional use of an inhaled decongestants like Afrin (oxymetazalone) spray will do no harm. Never use a spray more than three consecutive days whether diving or not, and if symptoms are severe or prolonged, medical evaluation is advisable.

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  1. Questions can be addressed directly to me via my Guest Book.
  2. "Underwater Ear And Nose Care", Noel Roydhouse: Best, 1993.
  3. "Diving And Subaquatic Medicine", Carl Edmonds: (Third Edition) Butterworth 1992.
  4. "Diving Physiology in Plain English", Jolie Bookspan, Ph.D: UHMS 1995
  5. Divers Alert Network.
Copyright © 1997, 1998 Edmond Kay, M.D.
13030 Military Rd. S., Suite 210
Seattle WA 98168
Phone -- 206-242-6500 ... Fax -- 206-246-7946
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Last modified September 12, 1998