As a professional diver, people ask me all the time “Doesn't scuba diving hurt your ears?” Many people have experienced deep ear pain when diving down in a swimming pool because they did know how to properly equalize the pressure in their ears. And they imagine that they will experience similar pain—or much worse—when scuba diving at even greater depths.  But relax: most people can equalize their ears quite easily with the techniques outlined in this article.

Try this: pinch your nose closed and gently breath out against your pinched nostrils. You should feel something happen in your ears as they equalize. Interior ear pressure equalization is usually accompanied by a popping/clicking/“poof” sound and a sensation of fullness in the ears. It is the same method that perhaps you've used to equalize your ear pressure when descending from high altitude in a commercial airliner. If this technique did not work for you, alternate methods used to equalize the ears when diving are listed below.

Understanding Ear Pressure Issues

To understand how ear equalization works, divers must first learn some basic ear anatomy.

• The outer ear is open to the environment and is filled with air (or water, when you are diving) from the surroundings. The outer ear experiences the same pressure as the outside environment.
• The middle ear is not open to the environment. In fact, the middle ear is almost completely air-tight. The only way air can move in and out of the middle ear is through a thin tube called the Eustachian tube.
•  The eustachian tube connects your ears to your nose and throat. When the Eustachian tube is open, air can flow from your nose and throat into your ears. However, the Eustachian tube is normally closed, trapping air in the middle ear.
•  The eardrum is a thin tissue that separates the outer ear and the middle ear.

Water pressure increases the deeper a diver goes. Since the outer ear is affected by the pressure of the surrounding environment, the pressure in the outer ear increases as a diver descends. However, the middle ear is sealed so that the pressure in the middle ear does not change. If a diver descends without equalizing his ears, the increased pressure in the outer ear relative to the middle ear flexes the eardrum inwards, creating obvious pain.  The discomfort felt as the eardrum bends inwards is called a squeeze.

A diver must equalize the air pressure in his middle ear with the pressure in his outer ear or he risks an ear barotrauma (pressure-related injury) or even rupturing his eardrum.

Equalizing Ear Pressure During a Dive

To equalize the air pressure in his middle ear during descent, a diver must manually open his eustachian tube to allow higher pressure air to fill the middle ear. This is easier than it sounds. Divers can equalize their ears using any of the following techniques.

• Valsalva maneuver: Pinch your nostrils closed and blow gently through your nose.
• Frenzel maneuver: Perform a very gentle Valsalva maneuver by breathing against pinched nostrils and swallowing at the same time.
• Swallow, or wiggle your jaw. While keeping the regulator in your mouth, swallow or wiggle your jaw.

How Often Should Divers Equalize Their Ears on Descent?

The answer varies from diver to diver. The general rule is that a diver should equalize his ears before he feels pain or discomfort. Most divers equalize their ears every few feet while descending. Keep in mind if a diver ascends a little bit during the dive, he will have to re-equalize his ears as he descends again. A diver cannot over-equalize his ears, so when in doubt--equalize!

Do Divers Have to Equalize Their Ears on Ascent?

Usually, divers do not have to manually equalize their ears as they ascend. As the water pressure decreases on ascent, the pressure in the middle ear becomes greater than the pressure in the outer ear. The extra air pressure usually leaks out the Eustachian tube automatically.

But if a diver's ears do not equalize automatically as he is ascending, he may experience discomfort in his ears as the eardrum bends outwards, called a reverse block. A diver experiencing a reverse block may feel discomfort, sometimes accompanied by a feeling of dizziness called alternobaric vertigo. Alternobaric vertigo occurs when one ear equalizes automatically on ascent while the other does not.

Reverse blocks are common when one or both eustachian tubes are inflamed or when a diver is congested. Keep in mind that a reverse block is caused by too much air pressure in the middle ear, so attempting a Valsalva Maneuver (or similar equalization technique for descents) will only make the problem worse, since it adds more air pressure to the already over-full middle ear. The Toynbee maneuver may help: 

• Toynbee Maneuver (Equalizes Ear Pressure on Ascent): If you must manually equalize your ears on ascent, try the Toynbee Maneuver. Pinch your nose closed and swallow. This creates a negative pressure and will help to suck extra air pressure out of the middle ear.

What Should a Diver Do If He Has Equalization Problems?:

If a diver has equalization problems, either on ascent or descent, he should immediately establish neutral buoyancy so that he does not descend or ascend inadvertently. Any further depth (and therefore pressure) change could exacerbate the problem. The diver should signal to his buddy that he has a problem with his ears, and attempt one of the following techniques. Remember never to equalize forcefully.

• For Equalization Problems on Descent:

1.  Take a few seconds to relax and focus on your breathing.
2.  Gently try a different equalization technique, such as swallowing.
3.  Look up to stretch open your eustachian tubes and gently try to equalize.
4.  Ascend a few feet and try to equalize again.
5.  If nothing works, slowly ascend to the surface, relax for a few minutes, blow your nose and clear your throat, and then try again.

• For Equalization Problems on Ascent:

1.  Open your Eustachian tubes by swallowing or wiggling your jaw.
2.  Try the Toynbee Maneuver: pinch your nose closed and swallow.
3.  Descend a few feet and wait for the pressure to equalize on its own.

Some Medical Conditions Make it Difficult to Equalize

• Age: Children have small, flat eustachian tubes that gradually open as they mature. Kids may find it difficult or impossible to equalize until their eustachian tubes open fully. Read more about kids and diving.
•  Illness: Congestion and inflammation associated with upper respiratory tract infections may block the eustachian tubes and prevent equalization. Ear infections may make equalization impossible, but can often be prevented with ear beer. 
•  Deviated septum: A deviated septum can inhibit proper air flow to the Eustachian tubes.
• Uncontrolled nasal allergies: Any allergy that causes congestion can make equalization difficult.

Can Divers Take Decongestants to Aid Equalization?

No. Decongestants will clear out your airways and make it easy to equalize your ears, but they are a bad idea for several reasons.

•  Decongestants wear off: Decongestants and other medicines may be metabolized more quickly while diving. If a decongestant wears off while you are underwater, it is likely you will experience reverse block. While you don't have to go down, you eventually have to go up as your air runs out, and ascending with a reverse block can lead to an ear injury.
• You are sick: If a diver is sick, his body is in a weakened state and may more likely to get decompression illness.
• Your chest may also be congested: If your chest is congested, you run the risk of lung-expansion, which occurs when air can not effectively escape the lungs on ascent. This can happen on a molecular scale and it can kill you.
• Impaired reflexes: if you shouldn't be operating heavy machinery on a medication, it is generally a bad idea to be diving on it.