Ear pain is the most common complaint from scuba divers and is experienced by almost every diver at some point. Some divers call it ear squeeze. The pain occurs because of differences in pressure between the middle ear and the outside environment.
The middle ear is an air-filled space formed by bone and the tympanic membrane or eardrum. It is connected to the throat by a tube called the eustachian tube. Air passing through the eustachian tube keeps the pressure in the middle ear equal to that of the outside world. If the eustachian tube malfunctions and a pressure difference occurs across the eardrum, pain or ear squeeze occurs.
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.
Upper respiratory infections
Previous facial trauma
Overaggressive ear clearing
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. Rarely, a one-sided facial paralysis may be associated with ear squeeze.
The treatment of ear squeeze begins during the dive. If fullness or pain is experienced, do not continue to dive deeper. If ear clearing techniques fail, the dive must be ended. Always complete the decompression stops if necessary when returning to the surface.
If the eardrum ruptures, the diver may become disoriented or vomit, which may lead to panic. Panic may lead to ascending too rapidly. The dive partner should carefully observe and assist, if needed, during the ascent, making sure all decompression stops are made. On the surface, no objects or eardrops should be placed into the ear.
The most important treatment was done by aborting the dive and ascending to the surface, making any necessary decompression stops.
Initial treatment involves the use of oral decongestants and nasal spray to help open the eustachian tube. Antihistamines may also be prescribed if an allergy is a contributing factor.
Pain medications are helpful, and eardrops to relieve pain may be used if the eardrum is not ruptured.
A ruptured eardrum will require antibiotics by mouth to prevent infections.
Hearing exams or audiograms may be needed if the eardrum is ruptured or hearing loss is present.
If the person has a facial paralysis, oral steroids may be prescribed.
Prevention is the preferred treatment for ear pain involved with scuba diving.
Divers who are unable to clear their ears or experience pain should stop their descent and abort the dive.
Divers clear their ears by several methods. The most common is plugging the nose, closing the mouth, and blowing. This increases the pressure in the mouth and throat and pushes the eustachian tubes open.
Divers should equalize their ears frequently when descending.
Diving should not be attempted if any sinus or upper respiratory symptoms are present.