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Listen to Your Ears: The Connection Between Eustachian Tube Dysfunction and Inner-Ear Barotrauma

Having ear problems? You’re not alone! According to DAN, eustachian tubes and their associated ear injuries represent the single largest cause of dive injuries bar none. Nearly 38% of diving injuries resulted from ear or sinus barotrauma with a prevalence 130% greater than all cases of DCS. Though middle-ear barotrauma is the most commonly associated with Eustachian tube (ET) dysfunction, the much more serious inner-ear barotrauma (IEBT) remains a close second. DAN’s risk mitigatory, Reilly Fogarty, reviews the latest research and what it may mean for your ears. Listen up people!

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by Reilly Fogarty

Eustachian tubes are your ear’s version of pushing a thumb loop through a wrist seal to equalize your dry glove, but maybe a bit less exciting. The narrow passage that connects the pharynx to the cavity of the middle ear allows equalization between the ears and the sinus passages, and that’s about it. 

In the same way that cardiovascular disease poses the single greatest risk of death to most adults in the U.S., Eustachian tubes and their associated ear injuries represent the single largest cause of dive injuries bar none. Nearly 38% injuries resulted from ear or sinus barotrauma (2018 DAN Annual Diving Report), with a prevalence of nearly 130% greater than all cases of DCS. 

In terms of ear injuries, middle-ear barotrauma is the most common associated with Eustachian tube (ET) dysfunction, but the more serious inner-ear barotrauma (IEBT) remains a close second. While trauma to the middle ear typically heals quickly and without lasting effect, IEBT can cause permanent damage if not recognized and treated in a timely matter. Because of the nature of the inner ear and the delicate structures connected to it, damage is more likely to be irreversible even with surgery. Given the prevalence of ear issues and the potential severity of IEBT, the key to preserving our ability to dive (and minimizing injuries) is prevention. A group of researchers (Kitajima N et al., 2016) recently worked to correlate the function of the Eustachian tube with an incidence of IEBT.  

Using replicable physical measurements and impedance tests, the researchers quantified ET function in 16 divers with a history of IEBT and 20 without. They measured the pressure required to open the ET, maximum volume of air in the middle ear and the speed at which equalization occurred. In an ideal situation, it should take 200-650 dekapascals (daPa) to open a healthy Eustachian tube, a pressure gradient equivalent to an 8—26-inch depth change. The paper categorizes ET function in these divers as one of three categories: 

  1. Patulous (open, or requiring less than 200 daPa to open)
  2. Normal (collapsed but requiring less than 650 daPa to open and filling or emptying instantaneously)
  3. Stenotic (collapsed and requiring up to 1200 daPa to open or filling and emptying very slowly)

The categories effectively categorize an ET that functions well, moderately, and poorly (respectively). Comparing these fitness measurements with the divers’ history of IEBT, they found the following:

  1. In healthy divers without a history of IEBT, 30% equalized slowly but the pressure required to do so was within the normal range.
  2. Among divers with IEBT, most had notably stenotic ET, either requiring significant time to empty or fill, or requiring increased pressure to open.
  3. Divers with IEBT and a perilymph fistula (a tear in the round or oval window of the ear often caused by forceful equalization) had significantly worse ET dysfunction. It is suspected that pressure caused by forceful equalization may be the cause of IEBT in these divers. The paper presents 11 cases of IEBT caused perilymphatic fistula.
  4. Some divers with IEBT did have normal ET function at the time of testing.

Like much frontline research, the results aren’t as clean or as groundbreaking as we’d like. The paper provides a strong argument for the correlation of ET dysfunction and IEBT, which seems reasonable, but then advocates a Eustachian tube function evaluation in divers to prevent these injuries. While IEBT can cause deafness and significant injury, it’s prevalence appears to be about 1.7% of dive injuries or 4.3% of ear injuries among divers. Whether the prevalence or severity of the injury warrants an additional test before divers get in the water is an entirely larger discussion about fitness to dive and risk-based analysis. 

What we do know now is that healthy divers and those with ET dysfunction can both experience IEBT and significant associated ear injuries from failed, too rapid, or too forceful equalization, but divers who have trouble equalizing due to stenotic Eustachian tubes are likely at significantly greater risk. These divers (like those with slow equalization in the group of divers without a history of IEBT) can minimize their risks and likely dive without much worry by equalizing slowly and often and listening to their ears during their dives. 

Additional resources:

  1. Kitajima N, Sugita-Kitajima A, Kitajima S. Quantitative analysis of inner ear barotrauma using a Eustachian tube function analyzer. Diving Hyperb Med. 2016;46(2):76-81. (can be found at: https://www.ncbi.nlm.nih.gov/pubmed/27334994)
  1. May I Bend Your Ear? by Michael Menduno

Reilly Fogarty is a team leader for its risk mitigation initiatives at Divers Alert Network (DAN). When not working on safety programs for DAN, he can be found running technical charters and teaching rebreather diving in Gloucester, MA. Reilly is a USCG licensed captain whose professional background also includes surgical and wilderness emergency medicine as well as dive shop management.

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Evolution of Dive Planning

Unbeknown to many tekkies, sophisticated dive computers like Shearwater’s offer divers real-time dive planning tools that enable them to adjust their dive plan on the fly. This summary of erudite tech educator Mark Powell’s latest blog outlines some of the specifics. Be sure to check out his blog.

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Header image courtesy of Trisha Stovel

Find the full story in the Shearwater Blog

Photo by Trisha Stovel.

Mark Powell discusses decompression planning for technical dives with diving computers and PC planning tools. More time is spent planning technical dives than recreational dives. This is due to increased risks, greater depths, high gas usage at depth, increased decompression obligations, increased oxygen toxicity loading, and a host of other reasons. He describes how in the early days of technical diving, there were no PC planning tools or dive computers suitable for technical dive planning. Now computers are much more available and reliable. Also, the costs have reduced so much that many people have backup computers. The flexibility offered by the computer is in contrast to the rigid nature of tables. Unfortunately, when your backup is based on written tables, you can’t make full use of this flexibility. When you have a backup computer, suddenly this flexibility comes into its own and this is where significant changes to planning styles started to be adopted. 

In reality, a dive computer gives a much more flexible tool for managing the dive. However, many divers keep the tables mindset even when using a very reliable and flexible planning tool. It is important to understand the features incorporated in your dive computer as they can provide additional information that can be used to manage the situation. On the Shearwater computer range, the NDL is shown on the display and counts down the time available until it reaches 0. Once the diver goes into deco, this field can be configured to show several other pieces of information. Any one of these can be selected to be shown in the NDL space once the NDL reaches zero. Alternatively, all of the following options can be viewed together by stepping through the display options: TTS, @+5, Δ +5, CEIL, GF99 setting, and SurfGF display. This article is intended to show that, far from removing the need to plan a dive, the sophisticated dive computers available today can help to improve the planning process. They can be used to provide a more realistic and more flexible planning tool. They can also be used to adapt the plan when the situation changes. This is only possible if the diver understands the tools they have at their disposal and practices using them. 

After reading and digesting the information contained in this article, I would encourage you to make sure you know where to find the various display options on your computer. On your next dive look at the SurfGF value during the dive and watch the relationship between it and the NDL value. During the NDL ascent, look at the GF99 and SurfGF values. Then on a decompression dive, compare the CEIL and Stop Depth values as well as comparing the CEIL, GF99, and SurfGF values. It is essential that you understand all of the information in this article and practice it before using it to plan your dive or modify your dive plan. Like any tool, you must practice before using them for real. However, a bit of investment in time and practice will give you the ability to manage your ascent in a much more intelligent way than blindly following your computer or a fixed set of deco tables.


Read the full article on Shearwater’s Blog.

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