Ear problems are the most common reported Public Safety Diving injury. Public Safety Divers as a rule don’t often dive as deep as their commercial and recreational counterparts, so most don’t ever consider just how dangerous it can be.
I would also venture to say that many do not even realize that they have injured their ears. This month we will look at some of the more common ear problems and hopefully how you can avoid them.
Basic Ear Anatomy
The ear is broken up into three main segments, the outer ear, the middle ear and the inner ear.
The outer ear is everything from the eardrum (tympanic membrane) out. The biggest concerns of the outer ear involve actual injuries to the TM and infections to the ear canal.
The middle ear falls between the TM and the windows of the inner ear. Primarily this includes the malleus (hammer), Incus (anvil), the stapes (stirrup) and the ET (Eustachian Tube). The three smallest bones in the body are here and can be involved in some significant injuries to the ear. The malleus rests on the TM and picks up vibrations from it and passes it on to the incus. The incus transmits vibrations to the stapes which passes it on to the oval window in the inner ear. The ET is a passageway from the middle ear to the back of the throat allowing pressures to be regulated back and forth so that the diver can change depths. The majority of the injuries to the ear occur in this area due to infection, allergies and pressure injuries.
The inner ear contains the balance and auditory controls for your body. It consists of the oval and round windows which help to transmit vibrations to the vestibule to allow you to hear and the semi-circular canals which help you to keep your balance. These fluid-filled chambers are also at risk to pressure injuries and can drain into the middle ear causing vertigo, nausea, and loss of hearing and balance.
The most important skill for a new diver to learn is to equalize their ears. Unfortunately, not a lot of time is spent on proper equalizing and how pressures affect your body in open water diving.
Equalizing is the method of increasing or decreasing the air pressure in your mouth and nose to inflate and open your ET to your middle ear. This allows the air pressure to push on the TM to help move it against the increase of water pressure. Proper equalizing begins long before you enter the water. You should begin exercising your ears while on the surface. There are many ways to equalize and most divers know what works best for them. Some can stretch their jaw or make a chewing motion, while others have to squeeze their nose and gently blow air into the oropharynx and nasopharynx. The process of equalizing as you descend is an active process, meaning that you must intentionally do it. As a diver ascends back to the surface, the process becomes passive, meaning that it should occur naturally without the diver thinking about it. Look at visually with the graphics in this article:
Common Ear Injuries and Problems from Diving
There are quite a few injuries and medical problems that can occur during a dive. An important part of the assessment for medical personnel is to ask the diver what the symptoms are and when did they start. Ear injuries can be identified easier if you can determine if they occurred while descending, at depth or on ascent.
The tympanic membrane is a very thin layer of tissue that picks up vibrations to pass to the inner ear. This tissue can rupture due to pressure injuries from loud noise, water pressure, or air pressure changes such as an explosion. In diving the TM starts to feel pressure in as little as three to four feet of water and if not equalized, it will continue to cause pressure and pain until either equalization occurs, the TM ruptures, or the pressure is balanced in the middle ear with something other than air. A TM rupture needs to be evaluated by a medical professional and will usually heal itself with time. In severe cases it can cause permanent hearing loss.
Middle Ear Barotrauma
As the diver descends in the water, external pressure starts to push against the TM. If the diver is unable to equalize by pushing air through the ET, then the lower pressure created in the middle ear will cause an injury. It may cause a rupture of the TM, or it can create a tearing of the mucosa, or vessels in the middle ear causing it to fill with blood. The filling of the middle ear with blood will make it feel better, although hearing will be affected. These injuries all can heal with time, but they need to be assessed by a medical professional and the diver must stop all diving.
Inner Ear Barotrauma
If the pressure of the dive is passed along through to the inner ear, the round and oval windows can also rupture. Much like the TM, the windows are a very thin layer of cells which when put under pressure can tear, filling the middle ear with fluid. Inner ear barotrauma is usually associated with dizziness, vertigo and inability to stand or walk. These injuries are more severe and must also be assessed by a medical professional as soon as possible.
Ear infections are one of the most common problems seen by dive medical personnel. Public Safety divers will enter some very dirty and polluted water during their missions and need to pay special attention to cleaning them after every dive. There are a number of solutions that divers use to keep their ears clean, both homemade and commercially available. A simple solution of a 50/50 combination of white vinegar and isopropol alcohol or “Ear Beer” as its affectionately known, will keep your ears clean and dry. Mix up your solution into a small baby bottle and keep it in your dive bag.
All of these injuries are difficult to assess on a dive site and many get missed when they aren’t looked at early on. Dive Medics can undergo ear assessment training using a device called an Otoscope. Everyone has had an otoscope placed into their ear at the doctor and with some training and practice, any Public Safety Diver, or Medic can perform a basic ear exam. Otoscopes on amazon are available from about $10 to $1000. You can get a decent LED otoscope with disposable inserts for about $35. I recently purchased a small digital otoscope that plugs into my ipad or iphone for $40. While it seems a little fragile for firefighter use, it provides a decent picture and video for the classroom. My more durable digital otoscope, made by Firefly is available in wired or wireless and runs about $300. It records HD video through my laptop and takes pictures to store for medical records. While having an otoscope at a dive site should never replace sending someone out for a proper evaluation, they work great to get an idea of why a diver suddenly has ear pain or loss of hearing.
I wanted to share an actual scenario that occurred during our basic dive school only two weeks ago. This is a three-week school that starts with classroom and practice in a 10 feet deep end pool. On the fourth day of school, one of the divers came to me with a sudden loss of hearing in their right ear. So, let’s do our assessment:
“25ish yo male c/o loss of hearing in (R) ear, (L) ear normal. Occurred today after numerous skill sessions in the deep end. Denies any pain or discomfort, just sounds like he is in a tunnel.”
BP – 124/78, HR- 86, RR- 18, SP02 – 97 percent
Any recent illnesses
Been sick with some congestion during the last two weeks, been taking decongestants on and off, but none in the last 24 hours.
Left ear – very red with lots of irritation. (ALWAYS LOOK AT THE NON-AFFECTED EAR FIRST)
Diagnosis – Middle Ear Barotrauma
I had him start taking decongestants that afternoon after pulling him from diving. I also had him take ibuprofen for the swelling and nasal spray if he had any. The next morning, I reassessed the ear and it looked like diagram A:
A much clearer picture, with the blood gone, but if you look closely you can now see the air bubbles trapped behind the TM. He was sent out and confirmed with MEB. No diving for two weeks.
This just shows that a diver does not have to be doing anything major to sustain a significant injury.
Public Safety Diving continues to be one of the most dangerous occupations that we as firefighters, police officers and EMS providers can do. It’s important that we have medical supervision at all of our training and missions to look out for our overall health. New inexperienced divers always place me on high alert, because of all the things that can and do go wrong. Proper training, pre-dive briefings and medical oversight can help keep injuries to a minimum. If you have any questions about any Public Safety Dive Medicine topics, please feel free to call me or email any time. Remember to hydrate and keep those divers safe!