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A Most Common Ear Injury Most Divers Have Never Heard Of

Freediving instructor trainer and coach Ted Harty discusses the ear injury that most scuba and freedivers have likely suffered and didn’t even know what to call it. Just say, Klaatu Barada…err, Barotitis Media?

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by Ted Harty

Header image by Lorenzo Mittiga

Photo courtesy of Ted Harty

I’m going to share with you what is, in my opinion, the most common ear injury in diving; it’s so common that many people, myself included, didn’t even realize it was a diving injury.

By way of background, my name is Ted Harty and I’m the founder of Immersion Freediving, my pride and joy Freediving Safety, and my new podcast Freedive Live. I’m a Performance Freediving International (PFI) Instructor Trainer, PADI Staff Instructor, and competitive freediver. I’m also a past USA Freediving Record Holder, and I’ve been involved as a freediving and scuba instructor since 2005.

When I give a presentation to a group of divers (scuba or freedivers) I often start with the following prompts:

  • Raise your hand if you have ever felt like there was water in your ear that will not come out after a dive.
  • Raise your hand if you have ever noticed your hearing in one or both ears feels muffled after a dive.
  • Raise your hand if you have ever noticed that if you go diving 2-3 days in a row it gets harder and harder to equalize.

    If I have a hundred people in the audience I expect to see at least ninety hands raised.

As a dive instructor this used to happen to me all the time. I’d get back on the boat and feel like there was water in my ear.  I’d start banging my head to try to get the water out. The captain would tell me, “no, no, you have to jump up and down and hit on the other side of the head and then knock it out.” My captains were always so helpful!

It wouldn’t work, and I couldn’t get the water out, so I go buy some Swim-EAR; it says it gets the water out right on the bottle.  I’d use it but that wouldn’t work either. 

Photo by Andrei Voinigescu.

I’d often notice on the boat trip back to the dive shop my hearing was muffled in the same ear. When I would get home and go to bed, I’d think, I’m gonna get this water out, I’m going to sleep with that ear down so the water can drain out. What I didn’t know is the reason none of this worked was because it wasn’t water in my ear.

Photo courtesy of Ted Harty

The Most Common Ear Injury in Diving: Barotitis Media.

I was regularly getting barotitis media, but I had no idea what it was, or that it was an ear injury. Had I gone to an Ears, Nose & Throat (ENT) doctor, they would have scoped my ear and said the blood vessels in my eardrum were enlarged, and told me I have barotitis media.

The Swim-EAR wouldn’t work because there was blood in my eardrum, not water in my ear. It was actually blood in my tympanic membrane (eardrum). In fact, instead of putting the bad ear down when I was sleeping, I should have placed my bad ear pointing up so the blood could drain down the eustachian tube.

As a busy dive instructor in the Florida Keys, I regularly dive 10-14 days straight.  I frequently get the water-in-my-ear feeling, or feel my hearing muffled after diving; it  happens to me all the time. In fact, if my students came to me complaining of water in their ears, I’d just tell them it was part of diving and not to worry.

I had no idea that this was an actual injury to my ears.

Photo by Andrei Voinigescu.

Why is This Happening?

Let’s go back to that same room of 100 divers.  If I asked that same group “when do you equalize your ears?” I would expect most of them to say, “When I feel pain or pressure in my ears.”

Most people wait until they feel pain or pressure in their ears and use that as the cue to equalize. Let’s talk about what happens when you do this.

As you dive underwater, the water pressure pushes in on your ear drum. This causes it to bend in. This is what causes the feeling or pain or pressure.  You then equalize (hopefully via the Frenzel Method of Equalization ) and then the ear drum goes back to normal.  Then, as you keep descending, this happens again and again throughout your dive.

At some point your body says, “Hey, you are terrible at this; you shouldn’t be letting your eardrum bend in like that.” Then the body decides since you won’t take care of it, it will. Then the body fills the eardrum with fluid so that the eardrum is less flexible and won’t bend in as much. That fluid is, of course, blood. 

That’s why the ENT will see the blood vessels inflamed when they scope your ear.


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How to Stop This From Happening

The solution to stop this from happening is extremely simple. In fact, it’s so simple I’m sure you have heard it so many times it probably ceases to have any meaning.

Equalize BEFORE you feel pain or pressure in your ears. Equalize early and often.

Photo by Lorenzo Mittiga.

My deepest freedive is 85 m/279 ft, and when I dive that deep I feel zero pain or pressure in my ears, which people find hard to believe. Considering that I equalize every other kick, how could I feel any pressure or pain at all?

Photo courtesy of Ted Harty

This is even more important if you are a freediver. Consider how fast a freediver descends compared to a scuba diver and how many more descents a freediver makes compared to their scuba counterpart. I believe freediving is harder on the ears than scuba due to the number of fast ascents and descents.

If you notice it gets harder and harder to equalize after diving for multiple days, this is often why.

The bottom line is this: if you regularly feel like there is water in your ears, or if your hearing is muffled, or if you notice it gets harder to equalize after multiple days of diving, this is likely due to, in my opinion, the most common ear injury in diving:  barotitis media. As always, I would suggest getting an ENT to look at the ear and follow their advice.

By the way, it is possible to just have water in your ears. But when divers tell me they have these symptoms and nothing fixes it, in my experience, it’s more than likely barotitis media.  I’ve had water trapped behind some ear wax before and that, of course, actually is just water in the ear.  Ear wax removal drops can fix that up if you suspect that.

Prevention is as simple as equalizing before you feel pain or pressure in your ears.  Stop using pain or pressure as the cue to equalize. Equalize BEFORE you feel the need to equalize.

I’ve had hundreds of students say this one simple tip made a big difference in their diving. I hope you find that this helps!

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Dive Deeper:

InDepth: Should Tech Divers Be Thinking More About Equalization —Like Freedivers Do? by Charly Stringer

InDepth: Is Freediving Safe by Ted Harty

Podcast: Freedive Live (or find it wherever you get your podcasts)

Immersion Freediving: Online Freediving Classes


Ted Harty began his professional underwater career as a Scuba Instructor for PADI, NAUI, and SSI in 2005. In 2008 he took his first freediving class with Performance Freediving International. After that course, he wanted to go freediving instead of scuba diving on his days off, and realized his passion was freediving. In 2009, Ted took PFI’s first official Instructor program, and immediately started working for PFI helping Kirk Krack and Mandy Rae-Kruckshank teach courses all across the USA.

Ted went to his first freediving competition in 2009 as an overweight, out of shape scuba instructor and progressed from 24-27 m/80-90 ft freediver to 54 m/177 ft in three weeks. After the experience he wondered what he could do if he actually started training. Since that time, he’s broken a USA Freediving record in 2011, won three freediving competitions, and was selected to be the captain of the USA Freediving team in 2012; his deepest dive is 85 m/279 ft.

Lately, Ted has been focusing on spreading his message of safe freediving through www.FreedivingSafety.com, which offers a free online course sharing ches in his in-person classes. He can be reached via Facebook, Instagram, Youtube, and Twitter, @ ImmersionFD. Email: tedharty@ImmersionFreediving.com

Education

Don’t Hold Your Breath: The Movement to Ban Breath-holding in Pools

There’s a movement afoot to ban breath-holding in pools in an effort to prevent hypoxic fatalities—Sorry, no freediving or scuba training for you! Unfortunately, as dive educator Tec Clark reports, they’re throwing the breath-holder out with the pool water. Wouldn’t the water tribe be better served if aquatic directors followed the education model of scuba and swimming and properly trained and educated people to manage the risks versus banning the activity outright? Tec’s got the deets.

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By Tec Clark

Timing a static apnea.
Timing a static apnea. Photo courtesy of Tec Clark

I became the National Director of the YMCA Scuba Program in the summer of 1998, where, while at the USA YMCA headquarters in Chicago, my attendance was requested at an urgent meeting with the top legal counsel of the Y. Once there, I was asked, “Can you tell us what freediving is?” 

With enthusiasm, I described the sport in detail since I was a freediving judge and co-founder of the U.S. Freediving Team. After my passionate pitch the attorney said, “Well, we just had a fatality at a Y. A member told the lifeguard to ‘leave him alone’ while he practiced freediving. The guards pulled him up after a long time underwater and could not resuscitate him.” I interjected and told our legal counsel that the deceased had violated some major safety rules of freediving and that is why we were going to promote a nationwide safety campaign for freediving in YMCA pools, she immediately said, “No. I want to ensure freediving does not take place in any YMCA. We need to condemn and disallow this activity.”

Similar conversations have taken place by aquatic directors, attorneys, and insurance managers in dozens of municipal, not-for-profit and private aquatic facilities nationwide. And, instead of fixing the problem with education and proper safety protocols, a much simpler approach has taken place, and that is to ban breath hold diving in aquatic facilities.

“No breath holding” policies are now seen in almost every aquatic facility and on pool rules signs throughout the U.S., which means that many aquatic facilities are completely shutting down freediving training. There are numerous reports of freediving instructors being turned away by aquatic directors who disallow freediving in their pools—even under supervision and with instruction by qualified instructors.

Meanwhile, freediving is becoming more popular, and more and more dive centers are offering freediver training. When a dive center that teaches scuba classes at a pool now wants to teach freediving classes, they are being told they cannot. When questioned, most aquatic directors point to their pool rules of “no extended underwater swimming” or “no breath holding allowed”. Interestingly, it is true that during an Open Water Diver course there is a skin diving component in which people hold their breath and swim underwater. And some scuba training agencies require an underwater swim during the prerequisite swim test. Also happening are underwater breath hold swims for American Red Cross Lifeguard tests. In addition to these activities, would synchronized swimmers also fall into the breath holding activity category?

In fact, as Tom Griffiths with the Aquatic Safety Group says, “Whatever we do in aquatics requires breath holding at some point.” He’s right, for even when we go swimming we are breathing in between strokes. That means we are breath holding at varying intervals. And, don’t get me started on swim lessons.

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If there are such strict rules against breath holding, then why are the American Red Cross and YMCA swim lesson programs teaching kids how to hold their breath? Of course, we answer this rhetorical question with, “because it is how we get along in the water—sometimes we breathe and sometimes we hold our breath.”

Photo by Laura M. Hamel / U.S. Masters Swimming.
Photo by Laura M. Hamel / U.S. Masters Swimming.

The Incident Data

Some will argue that I’m taking it to the extreme and that what is really being prevented with these policies are “prolonged” or “extended” times of breath holding underwater. This could be in the form of distance underwater, time underwater, or both. This is because of the shocking number of fatalities that have taken place in pools with people engaged in pushing those two limits while holding their breath underwater. Dozens of drownings and non-fatal drownings take place each year with these actions either individually, as a person tries to break their own records, or in a group setting, as individuals compete with others to see who can hold their breath longer and/or go farther on one breath of air.

The root malady causing harm is termed shallow water blackout, but it is more accurately named hypoxic blackout. This is when unconsciousness results from hypoxia (low oxygen) to the brain. Our bodies’ cue to breathe comes primarily from rising CO2 levels. As CO2 levels increase, so does the urge to breathe. However, if an individual pushes through the urge to breathe and/or hyperventilates prior to a breath hold dive, then hypoxic blackout can occur easily. Once a blackout takes place and the respiratory tracts are submerged, the chances are high that water will enter the lungs at some point and the person will drown. If the victim survives, then the condition is non-fatal drowning—the old term for this was near drowning.

Scuba training. Photo by Steve Millington
Scuba training. Photo by Steve Millington

Since 2004, Divers Alert Network, DAN, has collected and analyzed breath-hold incidents. Between 2004 and 2017, 995 incidents were reported with 73% being fatal. However, the DAN reports often do not capture swimming related blackout events such as with swim teams. The swimming community is becoming increasingly aware of the dangers of shallow water blackout (hypoxic blackout). Olympic gold medalist Michael Phelps recently recorded a PSA with his coach Bob Bowman to warn swimmers and athletes about the dangers of shallow water blackouts. This video is located on SHALLOWWATERBLACKOUTPREVENTION.ORG—a website dedicated to hypoxic blackout prevention.

Preventing hypoxic blackouts is precisely the reason for aquatic facilities’ restrictions of breath holding, which is also the proverbial throwing away the baby with the bathwater. In scuba diving we have risks. and we use technology and techniques to mitigate those risks. Technology is our gear to stay underwater safely and our techniques are our skills and standards brought about through education. But there is still risk. The only way to eliminate all risk is to not scuba dive. Since that is not an option, we educate.

The same holds true in aquatics. Swimming has risks, and there are plenty of programs to teach people how to swim. Yet, even when people have their skills and education, there is still risk. The only way to completely eliminate the risks of drowning or non-fatal drowning is to not swim at all. That, too, is not an option.

Photo by Laura M. Hamel / U.S. Masters Swimming.
Photo by Laura M. Hamel / U.S. Masters Swimming.

But here with freediving, the risk is being eliminated by shutting down the activity completely. Wait a minute, what happened to the education model as seen in scuba diving and swimming lessons? Wouldn’t it be better to properly train and educate people on the risks than to completely prevent the activity? The answer is a resounding yes!

“What happened to the education model as seen in scuba diving and swimming lessons? Wouldn’t it be better to properly train and educate people on the risks than to completely prevent the activity? The answer is a resounding yes!”

College-aged males are the number one demographic of fatalities due to extended breath holding events. This includes trying to push their own limits in a pool or freediving in an open body of water. And the overwhelming majority of these men were never trained in proper breath-holding methods and protocols as offered in a formal freediving course.

Could the aquatics industry be exacerbating this phenomenon by shutting down the ability to teach proper breath-hold-diving safety techniques as taught in supervised freediving courses vetted by diving training agencies? I believe so.

Photo by Ted Harty, Immersion Freediving
Blow, tap, talk to revive an unconscious diver. Photo by Ted Harty, Immersion Freediving

What’s To be Done?

If you look at SHALLOW WATER BLACKOUT PREVENTION.ORG, one of their stated goals is, “To ban prolonged breath-holding in pools for the general public.*” However, note the asterisk. Here is the associated footnote that accompanies this statement: “We believe qualified breath-hold freedive training agencies need access to public pools during non-general public usage with lifeguards on duty. Using the buddy system, proper supervision, and training protocols with continuous monitoring, along with waivers by participants to protect the facility and staff, freediving may be practiced safely.”

As a Performance Freediving International (PFI) Freediver Instructor, I teach people how to breath-hold dive responsibly. Not only are there multiple courses for multiple levels of proficiency but, in these courses, about 70% of the education and skills developed are dedicated to safety principles. These safety principles are practiced over and over, drilled into the minds and motor memory so that individuals who walk away from the course with their freediving certification would be extremely unlikely to break the safety protocols taught in the course.

Photo by Ted Harty, Immersion Freediving

Scuba training agencies are reporting that freediving is the fastest rising certifications in the industry. Just over twenty years ago freediving was such a specialty niche that only one agency, PFI, was in place. Today, most scuba training agencies have freediving courses and issue freediving certifications.

With this rise in popularity of freediving, there is a problem. If aquatic facilities shut freediving down entirely, these interested parties are going to do it somewhere—untrained, unsupervised, and by violating numerous safety protocols. They are in danger of becoming an unfortunate and preventable statistic. Primarily because they were not allowed to learn correctly in the first place. It is extremely important for aquatic directors to embrace freediving training at their facilities with as much care as they would swimming lessons so that freedive training is a public safety initiative rather than a “dangerous program.”

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As diving professionals, we have the ability to help educate aquatic directors and managers as to why they should allow proper freediving training and proper freediving practices to take place at their facilities. It all boils down to supervision and standards. First, as noted by SHALLOW WATER BLACKOUT PREVENTION.ORG qualified freediving instructors need access to public pools. Freediving training teaches the proper supervision, safety and training protocols of breath hold diving. This can help save lives.

Breath Hold Safety

Freediving or breath holding in an aquatic facility can take place properly under specific guidelines. For an aquatic facility to open up breath holding to its patrons, here are some sample guidelines to put in place with patrons:
  1. Participation is limited to individuals who are either students in a freediving class or those with valid freediving certifications.
  2. A certified and insured freediving supervisor (Safety Freediver, Freediver Supervisor or Freediver Instructor) must be present during training.
  3. Weight yourself correctly (positively buoyant at surface) even after exhalation.
  4. Do not hyperventilate to excess.
  5. One up/ One down—diving with constant visual contact.
  6. Maintain close, direct supervision of any freediver for no less than 30 seconds after they surface.
  7. Make your minimum surface interval twice the duration of your dive time.
  8. Do not take every dive to its limit. Maintain a reserve.
  9. Review, practice and discuss how to recognize and handle blackouts and near blackouts.

3 responses to “Don’t Hold Your Breath: The Movement to Ban Breath-holding in Pools”

  1. Anthony

    If this is enforced, it’ll be the death of synchronized swimming as a competitive sport.

  2. Armando

    ““No breath holding” policies are now seen in almost every aquatic facility and on pool rules signs throughout the U.S., which means that many aquatic facilities are completely shutting down freediving training”

    I would gently ask for the source of this statement, just to match the total number of aquatic facilities and pool in the US and that “almost every one” has no breath holding policies.

    Thanks for your answer!

  3. Oliver Christen-Drew

    Great article, very complete, and apparently very necessary!!

    Oli Christen-Drew
    AIDA IT
    Molchanovs ITD

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Tec Clark is a diving industry expert who has held elite positions in the dive industry including Managing Director of the University of Florida’s Academic Diving Program and National Director of the YMCA Scuba Program. He holds over 40 professional certifications with over 15 diving agencies. Tec has also been a police officer, dive rescue team member, and forensic dive accident investigator. He also appeared as a diving expert on A&E, The Learning Channel, and Outdoor Life Network. Tec was Captain of the US Freediving Team, founder of Reef Ministries, and curates ScubaGuru.com and ScubaGuru Academy. He is also the host of two podcasts: The League of Extraordinary Divers and The Dive Locker. Tec is the Associate Director for Aquatics and Scuba Diving at Nova Southeastern University in Fort Lauderdale, Florida.


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