| 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 forced inward, 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. Cold seawater rushes into the middle ear. Nausea, vomiting, dizziness, and confusion may follow. Rapid ascents or descents in a car or commercial air flight may 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. Smoking Allergies Upper respiratory infections Nasal polyps Previous facial trauma Overaggressive ear clearing SIGNS AND SYMPTOMS Section 4 of 13 Author Information Introduction Causes Signs And Symptoms Home Care When To Call The Doctor When To Go To The Hospital Physician Diagnosis Physician Treatment Prognosis Prevention Follow-up Bibliography 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. Upon returning to the surface, the diver may feel fluid draining out of the ear or notice hearing loss if the eardrum has ruptured. |
Middle Ear Squeeze
Middle ear squeeze. The external ear canal leads to the flexible
tympanic membrane or eardrum, which is exposed to the
ambient pressure.
Behind the eardrum is the middle ear air space, which will be
compressed at depth unless pressure is equalized, via the
Eustachian tube, with inhaled air.
If the Eustachian tube is blocked Ä as may happen without
equalization after descending just a few feet Ä fresh air cannot
enter the middle ear space and the ear drum will bulge inward,
causing pain. If the diver descends too quickly without
equalization, the tympanic membrane can rupture.
If the diver continues to descend slowly without equalization,
blood and fluid from surrounding tissue will be forced into the
middle ear space.
Thus the diver has to consciously work to keep the Eustachian
tube open on descent, or else it will seal shunt and prevent
compressed air from reaching the middle ear.
This is done by one of several maneuvers, including blowing
against a closed mouth and nose, swallowing, yawning, or the
Valsalva or Frenzel maneuvers. (The Valsalva is a forced
exhalation with nose pinched, lips closed against mouthpiece,
glottis open. The Frenzel is accomplished with nose pinched
and lips closed against the mouthpiece; the back of tongue is
thrust against soft palate, gently pushing air through the
Eustachian tubes.)
Whichever method is used, it must be done frequently on
descent because at some point no maneuver will work; this is
the situation when the pressure keeping the tube shut is too
great. If the pressure gradient across the tube (nasopharynx to
middle ear) exceeds 90 mm Hg - a gradient reached at only
about 4 feet depth - none of the maneuvers will open the
Eustachian tube and the diver must ascend to relieve the
pressure. Scuba divers are universally taught to prevent middle
ear squeeze by forcing air through the Eustachian tubes before
symptoms occur, just before or at the beginning of descent
and
then every few feet. "Equalize early and often" is the universal
advice.
WHAT IS THE TREATMENT OF MIDDLE EAR SQUEEZE?
Treatment of middle ear squeeze depends on its severity. Mild
cases often to respond to decongestants. Antibiotics may be
indicated if there is tympanic membrane rupture, but such a
problem should be referred to an otolaryngologist. In all cases
diving should be avoided until the ear has returned to normal.
WHAT OTHER FORMS OF BAROTRAUMA OCCUR ON
DESCENT?
The inner ear can also be affected, with rupture of the round
or
oval windows, cochlear damage and permanent hearing loss.
Tinnitus, vertigo, and deafness after a dive are the classic
symptoms of inner ear barotrauma. In such cases antibiotics
and bed rest are indicated, with surgical repair if there is no
improvement (Neblett 1985; Davis & Kizer 1989).
External ear squeeze may occur if the ear canal is blocked with
earwax or ear plugs; divers should never wear earplugs for this
reason. Another common cause of external ear squeeze is a
tight-fitting wetsuit hood.
The sinuses have no natural one-way valve by which to vent
expanding air, but as long as there is no sinus blockage the
diver can avoid "sinus squeeze." Sinus squeeze is accompanied
by a painful feeling behind the cheekbones, between the eyes,
in
the upper teeth area, or over the forehead.
A blockage from outside the sinuses (as from nasal polyps)
may
produce sinus squeeze on descent, as air cannot enter the
sinuses and equalize the pressures. In severe cases the diver can
experience sinus hemorrhage and a bloody nose. Decongestants
and analgesics are used for mild cases of sinus squeeze.
Antibiotics may be needed if there is evidence of fluid or
blood
in the sinus cavities. Diagnosis of this problem may require a
CT scan of the sinuses.
WHAT BAROTRAUMA PROBLEMS CAN OCCUR ON
ASCENT?
Closed air spaces pose a serious threat on ascent from a dive.
Boyle's law predicts that closed air spaces will expand as the
ambient pressure decreases on ascent. As long as the
Eustachian
tube and sinus passages are not blocked, the middle ears and
sinuses will vent expanding air into the nose, from where it
will
be exhaled along with expanding air from the lungs.
"Reverse squeeze" can occur if the Eustachian tube and nasal
passages are blocked on ascent. This is much less common
than
squeeze on descent, for if compressed air can get into these
spaces it usually can get out. However, sometimes with an
infection divers can get air into the spaces but then the air is
blocked coming out.
The sinus and/or middle ear spaces attempt to expand as the
air
in their spaces expands; the result is pain on ascent. In a
worst-case scenario, middle ear expansion without adequate
venting could lead to rupture of the tympanic membrane
outward, resulting in severe pain, vertigo, and drowning. For
these reasons people with upper respiratory infection, sinus or
nasal congestion, or middle ear infection should not dive until
the problem is resolved.
Alternobaric or "pressure" vertigo is a feeling of disorientation
and spinning caused by a sudden, and unilateral, pressure
difference between the middle and inner ear (Farmer 1990). It
usually occurs during or immediately after an attempt to
equalize middle ear pressure by the Valsalva maneuver.
Alternobaric vertigo has been described on both ascent and
descent, but is more common on ascent. If symptoms persist
on
the surface treatment is with decongestants, although surgery
(a myringotomy Ä placing an opening in the tympanic
membrane) may be necessary.
Any unvented space can cause discomfort or pain on ascent.
Gastric discomfort is rare because of the ease of venting the
stomach and intestines but does occur (Weeth 1965; Edmonds
1976). Barodontalgia (tooth pain), usually from an improperly
or incompletely filled tooth, can occur on ascent when air in
the cavity expands.
Figure 3. Ambient pressure and percentage change in lung
volume with equivalent depth change (33 feet). In each
instance the diver is breathing compressed air at the point of
breath-hold.
Pulmonary barotrauma usually manifests immediately after
ascent but may be delayed for several hours. It may also recur
after an initial period of improvement (Krzyzak 1987). People
suffering pulmonary barotrauma should be treated with a
high-inspired oxygen concentration, 100% if available. Oxygen
"denitrogenates" the blood and hastens absorption of bubbles.
Middle ear squeeze. The external ear canal leads to the flexible
tympanic membrane or eardrum, which is exposed to the
ambient pressure.
Behind the eardrum is the middle ear air space, which will be
compressed at depth unless pressure is equalized, via the
Eustachian tube, with inhaled air.
If the Eustachian tube is blocked Ä as may happen without
equalization after descending just a few feet Ä fresh air cannot
enter the middle ear space and the ear drum will bulge inward,
causing pain. If the diver descends too quickly without
equalization, the tympanic membrane can rupture.
If the diver continues to descend slowly without equalization,
blood and fluid from surrounding tissue will be forced into the
middle ear space.
Thus the diver has to consciously work to keep the Eustachian
tube open on descent, or else it will seal shunt and prevent
compressed air from reaching the middle ear.
This is done by one of several maneuvers, including blowing
against a closed mouth and nose, swallowing, yawning, or the
Valsalva or Frenzel maneuvers. (The Valsalva is a forced
exhalation with nose pinched, lips closed against mouthpiece,
glottis open. The Frenzel is accomplished with nose pinched
and lips closed against the mouthpiece; the back of tongue is
thrust against soft palate, gently pushing air through the
Eustachian tubes.)
Whichever method is used, it must be done frequently on
descent because at some point no maneuver will work; this is
the situation when the pressure keeping the tube shut is too
great. If the pressure gradient across the tube (nasopharynx to
middle ear) exceeds 90 mm Hg - a gradient reached at only
about 4 feet depth - none of the maneuvers will open the
Eustachian tube and the diver must ascend to relieve the
pressure. Scuba divers are universally taught to prevent middle
ear squeeze by forcing air through the Eustachian tubes before
symptoms occur, just before or at the beginning of descent
and
then every few feet. "Equalize early and often" is the universal
advice.
WHAT IS THE TREATMENT OF MIDDLE EAR SQUEEZE?
Treatment of middle ear squeeze depends on its severity. Mild
cases often to respond to decongestants. Antibiotics may be
indicated if there is tympanic membrane rupture, but such a
problem should be referred to an otolaryngologist. In all cases
diving should be avoided until the ear has returned to normal.
WHAT OTHER FORMS OF BAROTRAUMA OCCUR ON
DESCENT?
The inner ear can also be affected, with rupture of the round
or
oval windows, cochlear damage and permanent hearing loss.
Tinnitus, vertigo, and deafness after a dive are the classic
symptoms of inner ear barotrauma. In such cases antibiotics
and bed rest are indicated, with surgical repair if there is no
improvement (Neblett 1985; Davis & Kizer 1989).
External ear squeeze may occur if the ear canal is blocked with
earwax or ear plugs; divers should never wear earplugs for this
reason. Another common cause of external ear squeeze is a
tight-fitting wetsuit hood.
The sinuses have no natural one-way valve by which to vent
expanding air, but as long as there is no sinus blockage the
diver can avoid "sinus squeeze." Sinus squeeze is accompanied
by a painful feeling behind the cheekbones, between the eyes,
in
the upper teeth area, or over the forehead.
A blockage from outside the sinuses (as from nasal polyps)
may
produce sinus squeeze on descent, as air cannot enter the
sinuses and equalize the pressures. In severe cases the diver can
experience sinus hemorrhage and a bloody nose. Decongestants
and analgesics are used for mild cases of sinus squeeze.
Antibiotics may be needed if there is evidence of fluid or
blood
in the sinus cavities. Diagnosis of this problem may require a
CT scan of the sinuses.
WHAT BAROTRAUMA PROBLEMS CAN OCCUR ON
ASCENT?
Closed air spaces pose a serious threat on ascent from a dive.
Boyle's law predicts that closed air spaces will expand as the
ambient pressure decreases on ascent. As long as the
Eustachian
tube and sinus passages are not blocked, the middle ears and
sinuses will vent expanding air into the nose, from where it
will
be exhaled along with expanding air from the lungs.
"Reverse squeeze" can occur if the Eustachian tube and nasal
passages are blocked on ascent. This is much less common
than
squeeze on descent, for if compressed air can get into these
spaces it usually can get out. However, sometimes with an
infection divers can get air into the spaces but then the air is
blocked coming out.
The sinus and/or middle ear spaces attempt to expand as the
air
in their spaces expands; the result is pain on ascent. In a
worst-case scenario, middle ear expansion without adequate
venting could lead to rupture of the tympanic membrane
outward, resulting in severe pain, vertigo, and drowning. For
these reasons people with upper respiratory infection, sinus or
nasal congestion, or middle ear infection should not dive until
the problem is resolved.
Alternobaric or "pressure" vertigo is a feeling of disorientation
and spinning caused by a sudden, and unilateral, pressure
difference between the middle and inner ear (Farmer 1990). It
usually occurs during or immediately after an attempt to
equalize middle ear pressure by the Valsalva maneuver.
Alternobaric vertigo has been described on both ascent and
descent, but is more common on ascent. If symptoms persist
on
the surface treatment is with decongestants, although surgery
(a myringotomy Ä placing an opening in the tympanic
membrane) may be necessary.
Any unvented space can cause discomfort or pain on ascent.
Gastric discomfort is rare because of the ease of venting the
stomach and intestines but does occur (Weeth 1965; Edmonds
1976). Barodontalgia (tooth pain), usually from an improperly
or incompletely filled tooth, can occur on ascent when air in
the cavity expands.
Figure 3. Ambient pressure and percentage change in lung
volume with equivalent depth change (33 feet). In each
instance the diver is breathing compressed air at the point of
breath-hold.
Pulmonary barotrauma usually manifests immediately after
ascent but may be delayed for several hours. It may also recur
after an initial period of improvement (Krzyzak 1987). People
suffering pulmonary barotrauma should be treated with a
high-inspired oxygen concentration, 100% if available. Oxygen
"denitrogenates" the blood and hastens absorption of bubbles.
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