November 2002

By Ernest Campbell

The Ins and Outs of the Ear

Help! I love to dive, but I have a hard time equalizing my ears. It hurts like hell and it takes me forever to get to the bottom. Got any tips?
--Adam Laramie
Atlanta, Ga.

You want tips? How about 11 of 'em, Adam? You're not alone in having trouble clearing the old ears. In fact, it's one of the most common problems divers have.

Let's review some basic dive physiology. Your middle ears are dead air spaces, connected to the outer world by the eustachian tubes running to the back of your throat (see illustration). When you fail to increase the pressure in your middle ears to match the building pressure around you, the result is pain and potential damage to the delicate mechanisms of the ear. But you knew that already.

The key to safe equalizing is opening the normally closed eustachian tubes, allowing higher-pressure air from your throat to enter your middle ears. Most divers are taught to equalize by pinching their nose and blowing gently. Called the Valsalva Maneuver, it essentially forces the tubes open with air pressure.

The better way is to use the throat muscles to pull your eustachian tubes open the way nature intended--by swallowing. You already do this hundreds of times a day--just listen for that faint "pop" you hear about every other gulp. The rapid pressure changes of scuba diving, however, are more challenging. You need to help this process along.

• Listen for the "pop." Before you even board the boat, make sure that when you swallow you hear a "pop" in both ears. This tells you both eustachian tubes are opening.

• Start early. Several hours before the dive, begin gently equalizing your ears every few minutes. Chewing gum seems to help because it makes you swallow often.

• Equalize at the surface. "Prepressurizing" at the surface helps most divers get past the critical first few feet of descent. It may also inflate your eustachian tubes so they are slightly bigger. Not all medical authorities recommend this, however. The lesson here is to pre-pressurize only if it seems to help you, and to pressurize gently.

• Descend feet first. Studies have shown a Valsalva Maneuver requires 50 percent more force when you're in a head-down position than head-up.

• Look up. Extending your neck tends to open your eustachian tubes.

• Use a descent line. Pulling yourself down an anchor or mooring line helps control your descent rate more accurately. A line also helps you stop your descent quickly if you feel pressure.

• Stay ahead. Equalize often, trying to maintain a slight positive pressure in your middle ears. Don't wait until you feel pressure or pain.

• Stop if it hurts. Your eustachian tubes are probably locked shut by pressure differential. Ascend a few feet and try equalizing again.

• Avoid milk. Some foods, including milk, can increase your mucus production.

• Avoid tobacco and alcohol. Both tobacco smoke and alcohol irritate your mucus membranes, promoting more mucus that can block your eustachian tubes.

• Keep your mask clear. Water up your nose can irritate your mucus membranes, which then produce more of the stuff that clogs.

Better Clearing Techniques

There are two other problems with the Valsalva Maneuver: It may not work if the tubes are already locked by a pressure differential, and it's all too easy to blow hard enough to damage something. Divers who experience difficulty equalizing may find it helpful to master some alternative techniques.

• Toynbee Maneuver. With your nostrils pinched or blocked against your mask skirt, swallow. Swallowing pulls open your eustachian tubes while the movement of your tongue, with your nose closed, compresses air against them.

• Lowry Technique. A combination of Valsalva and Toynbee: while closing your nostrils, blow and swallow at the same time.

• Edmonds Technique. While tensing the soft palate and throat muscles and pushing the jaw forward and down, do a Valsalva Maneuver.

• Frenzel Maneuver. Close your nostrils, and close the back of your throat as if straining to lift a weight. Then make the sound of the letter "K." This forces the back of your tongue upwards, compressing air against the openings of your eustachian tubes.

• Voluntary Tubal Opening. Tense the muscles of the soft palate and the throat while pushing the jaw forward and down as if starting to yawn. These muscles pull the eustachian tubes open. This requires a lot of practice, but some divers can learn to control those muscles and hold their tubes open for continuous equalization.

No Bull: Energy Drinks and Diving

Is it safe to drink energy drinks like Red Bull and then dive?
--via e-mail

I've heard of people mixing Red Bull and vodka in nightclubs (sometimes with disastrous effects--the combination has been linked to three deaths in Sweden), but this is the first time I've heard of mixing Red Bull and diving.

For readers who aren't plugged into the club scene, Red Bull is the leading brand among a new breed of "energy drinks" that claim a host of groovy effects, including increased mental concentration and physical stamina, improved reaction speed and an "overall feeling of well-being."

Typically, these drinks are lightly carbonated blends of caffeine (one 7.5-oz. can of Red Bull has about the same caffeine as a cup of regular coffee), B vitamins and carbohydrates in the form of sugar, along with concentrated amounts of some exotic-sounding nutritional or herbal supplements. In the case of Red Bull, it's the amino acid taurine and a glucose byproduct called glucuronolactone.

Any lift you get from these drinks probably comes from the sugar-and-caffeine jolt, not the supplements. Red Bull's taurine and glucuronolactone are naturally found in the body, prompting some doctors to downplay their effects and others to worry about the results of drinking concentrated doses. Of course, no studies have evaluated the effectiveness of the drinks and no one knows the effects depth, pressure and nitrogen might have on those more exotic ingredients. Just to be on the safe side, I'd skip energy drinks before diving until we know for sure.

Your question prompts me to ask one of my own. Why are you drinking an energy drink before diving? I only ask because some people use Red Bull as a hangover helper. If you're so hung over that you need an energy drink to be "up" for the dive, you might want to consider sitting this one out. A hangover also means you're dehydrated (a risk factor for DCS), so you're probably better off rehydrating with water than chugging a can of Red Bull.

--Ern Campbell

Questions and responses have been edited by Ernest S. Campbell, M.D., FACS, a retired surgeon, avid diver and webmaster of "Diving Medicine Online" (www.scubadoc.com).

Ed.'s note: Answers to questions are offered as information only and not as medical diagnosis or advice and should always be used in conjunction with advice from your personal diving physician. Please send your dive medicine questions to [email protected].