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Protect your ears as the pressure builds: Barotrauma and other ear problems



By: Gemma Smith

When you ask people who don’t dive what they think the most common type of diving injury is, the answer is usually ‘The Bends!’. If not this then at least an imagined tale of a Jaws-type marine monster attacking innocent divers one by one. The real answer is actually a lot simpler, and significantly less Hollywood. The most common injury you will encounter as a diver over a lifetime will be related to your ears.

The ears are an incredibly complex piece of our bodies. It is important we understand how to protect them. To do this, we need to first have a basic understanding of how they work. In very simple terms, the ear is actually formed from three areas: the outer ear, middle ear, and inner ear.

Outer Ear

The outer ear is what we see in ourselves and each other when we think of ‘ears’. It is made up of two parts, the pinna, and the ear canal.


The pinna is the cartilaginous, flesh-covered flap located on each side of our heads. While the ear is incredibly multifaceted and involved, most of the clever design features are located internally. The pinna is actually the only part of the ear which is externally visible to us. Its job is simple but vital: to collect sound waves and channel them down the external ear canal. It also channels water into and out of the ear. Its cleverly engineered shape is not for nothing. Sound waves that are approaching us from behind are partially shielded by this outer fleshy area. This helps us to better determine the location the sound has come from. This is what helps us judge whether the origin of the sound is from behind or in front of us.

Ear canal

The ear canal is just a few centimetres long in adults and has a slight S-curve to it. The outer portion of the ear canal is covered by a thin layer of skin containing glands. These glands are responsible for the production of earwax. Thin hairs are also found covering the skin near the ear canal. It is this dynamic duo of tiny hairs and ear wax that is crucial in catching airborne particles. Dirt and detritus are caught before they have a chance to reach the middle and inner ear.

The Middle Ear

Following the twisting ear canal inwards leads us to the eardrum, more technically known as the tympanic membrane. It is this membrane that separates the middle ear from the outer ear. Within this middle ear are located the body’s three smallest bones – the malleus, incus, and stapes. As divers, this is the area we are most concerned with. It is this air-filled chamber that is more likely to give us trouble than anything else over the course of our diving life. Connecting our middle ear to the back of the throat are the Eustachian tubes. These little tubes allow us to keep the pressure between the middle ear and the outside environment equalised. This prevents any pain or discomfort from occurring. The underwater swallowing or yawning we see divers do is to allow this equalisation to occur.

The Inner Ear

Last, but definitely not least, we come to the inner ear. This is the part of the ear deepest within our bodies. Within the inner ear is the cochlea. This is the part of the ear actually responsible for hearing. It converts the vibrations from sounds into what we eventually hear. The cochlea is also noteworthy as it contains fluid-filled chambers. This can cause serious issues if any rupturing were to occur. The seeping of fluid from the inner ear to the middle ear is not something any diver would ever want to risk happening. Aside from the obvious discomfort, anything that causes us to feel dizzy or disoriented underwater is downright dangerous. This is just one of several reasons why you should never ever force equalisation to occur.

So now we understand all the main different components that make up our ears. From here we can start to look at the best ways to protect them. Diving puts us in a physically very different environment than the land-based one we are used to. By being aware of the risks and differences in this new world, we can greatly limit any possible issues that may occur. Let’s look at a few of the most common ear problems we may encounter when submerging:


When we descend under the water, the most physically obvious difference to a diver is, of course, the pressure change. As we sink, the pressure of the water surrounding us increases. Any time the pressure around us changes, the chance of a barotrauma occurring rears its ugly head. Very simply, a barotrauma is any kind of pressure injury (baro comes from the Greek word for ‘pressure’, and trauma means ‘wound or injury’). If we don’t equalise as we go down then the pressure surrounding us increases while the pressure within our bodies stays the same. This causes an imbalance between the outer ear and the air filled chamber of the middle ear.

By gently pinching our noses and blowing, wiggling our jaw from side to side, or even just swallowing, we open our Eustachian tubes. As mentioned earlier, these tubes provide a direct link from the back of our throats to our middle ears. They are what allows us an easy equalisation of pressure. If we don’t do this, not only will it be painful, but we increase our chances of rupturing our middle ear with this pressure imbalance. Middle ear barotraumas are the most common injury in diving. They are also one of the easiest to prevent. Remember the golden rules:

  • Equalise carefully on the surface before you even start to descend. Continue gently equalising every meter/few feet of your descent. This is especially important when shallow and the greatest pressure differences are occurring.
  • Although most people learn the Vasalva technique when they first learn to dive (where you gently exhale against your pinched nose), it isn’t the right fit for everyone. There are other equally valid methods out there to allow you to equalise. Look at the Toynbee Maneuver (where you pinch your nose and swallow) or Frenzel Maneuver (where you pinch your nose and make the sound of the letter ‘K’). Don’t be afraid to try them if the Vasalva is just not working for you.
  • If you are struggling to equalise as you descend try rising a little and trying again. This lessens the pressure slightly and may be all you need to allow you to continue a slow and controlled descent. Some people also find that descending in a more feet down position allows for an easier equalisation.
  • Never ever force it.
  • If you have a cold of any kind give the dive a miss. Do not think decongestant will solve the problem. It is worth remembering that while most pressure injuries with ears occur on descent, there is also a pressure change when we ascend at the end of a dive. This is one reason to be very wary of taking any decongestants before submerging. The effects will most likely wear off before the end of your dive, and you will still need to ascend regardless. If the Eustachian tubes are now blocked then the expanding air in your middle ear, caused by the now lessening pressure on ascent, has nowhere to go. This is a reverse block, and can have painful consequences.
  • Without wanting to be the party-pooper in the room, smoking and alcohol are not good for you in any way as a diver. With regards to equalising, both of these things can irritate your mucus membranes. This can cause a blocking of your Eustachian tubes. Interestingly, for those of you having problems with your ears, consider cutting down on your dairy intake. Milk has been shown to increase the production of mucus. This may well be affecting your ability to comfortably equalise.
  • If you have any pain or discomfort in your ears after the first dive give any planned second dives a miss. There will always be more diving days in the future. Healthy ears are not so easily come by, nor damaged ears that easily fixed. If the pain or discomfort persists after the dive it is worth getting it checked out by a doctor. The peace of mind of knowing that everything is good with your ears is worth the time taken!


Ears are funny, twisty, labyrinthine parts of our bodies. As such they are sadly prone to detritus lodging in them. This is one cause of ear infections. While not always specifically a diving related problem, it is one that can be exacerbated by in-water time. Otitis Externa, for example, is an outer ear infection. This is generally caused by frequent time in the water. The water causes the cells which line your ears to swell slightly. This can create an opening for opportunistic bacteria to enter. Here they find a warm, damp, welcoming place to multiply. Left untreated this can cause pain and swelling all along the jawline.

Realistically, infections are something you want to get sorted as soon as possible. As someone who has, sadly, had several ear infections over the years, I can attest to the extreme discomfort one feels with such an infection. Luckily it’s usually an easy fix, with ear drops prescribed by a doctor clearing up all but the worst cases. If not then antibiotics may be required. It does, unfortunately, mean it is more prudent to stay confined to dry land until it is all sorted.

All of us have ear problems from time to time. If you are finding that constant equalisation or pain issues are regularly preventing you diving though, think about going to see a specialist. A doctor focusing on possible ear, nose, and throat (ENT) troubles may well be all you need to figure out what your body is not liking about your current regime. There are also various devices available now, such as masks which cover your ears as well as your eyes and nose. With tubes connecting all the air pockets so you can still equalise, this keeps water out of your ears and minimises infection risks. Never risk your ears, but, as with most things in life, there is normally a way around most problems. Take the time to speak to experts and look at possible lifestyle changes.

To find out more about International Training, visit

From its humble beginning in 1994 to today, the group of training agencies Scuba Diving International (SDI), Technical Diving International (TDI), and Emergency Response Diving International (ERDI) form one of the largest diving certification agencies in the World – International Training. With 24 Regional Offices servicing more than 100 countries, the company today far exceeds the original vision the founders had when they conceived the idea on a napkin, sitting at a kitchen table in the early 1990’s.

Dive Training Blogs

Jeff chats to… Rich Somerset, Territory Director PADI EMEA (Watch Video)



In this exclusive Zoom interview, Jeff Goodman, Scubaverse Editor-at-Large, chats to Rich Somerset, Territory Director PADI EMEA Regional Support about Dive Project Cornwall and PADI’s conservation work.

Rich began diving as a teenager on the south coast of England. His university studies took him to the North of the UK and he developed a passion for cold water wreck diving in the frigid waters of Scotland. After finishing university, Rich became only the second person to be awarded the European Our World Underwater Rolex Scholarship. This experience allowed him to travel and develop training in a wide range of scuba related disciplines, including hyperbaric medicine, technical diving and marine conservation. Rich then worked as a PADI Instructor in Australia, Micronesia and the Caribbean before setting up and running dive centres in England.

A PADI Course Director and Instructor Examiner, Rich is now the Territory Director, leading a team of PADI staff supporting over 800 dive centres across the UK, Ireland, Maldives, France, Greece and Portugal.

Find out more at and

Rather listen to a podcast? Listen to the audio HERE on the new Scubaverse podcast channel at Anchor FM.

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Dive Training Blogs

Blog: Deptherapy go wreck diving in Malta



A Guest Blog from Deptherapy and Deptherapy Education Instructor Sharon El Shoura about the charity’s recent expedition to Malta…

Day one – Friday 3 September

Firstly just to explain what we do ….

We are a completely volunteer-led charity that seeks to rehabilitate injured troops, who have suffered life changing injuries, through the medium of scuba diving.

Our plan was to take eight beneficiaries to Malta to complete their RAID Advanced Wreck course.

So an early start for some to get to Heathrow for our previously agreed meeting time, with some of the beneficiaries travelling from various parts of the country starting out at 0100.

Thankfully we all made it in time, well most of us!  You know who you are!!

So Heathrow was very quiet and the transition through security was easy unless your name is Sean Martin, who had all the contents of his rucksack emptied and swabbed, including the inside of the dive log, obviously he is a bit dodgy looking 😉

So we loaded onto the very busy Air Malta flight, unable to book seats in advance we found ourselves scattered around the plane, service was very limited.

Arrival at Malta International Airport was a mixed experience for some. With the new requirements for COVID, our EU Passenger Locator forms were checked with the necessary COVID vaccination paperwork and we were sent through to a special screening area where it seemed that Sean’s look was still obviously a bit dodgy as he was taken into a separate room which ended being a case of mistaken identity!

So finally through to the warm, sticky atmosphere outside where we were met by drivers from the Dive Centre, Divewise and Tom Swarbrick who was already on the island.  We loaded up the equipment and the rest of us piled into the air-conditioned bus and off to the dive centre. About 20 minutes later we arrived at the dive centre in St Julian’s to a very warm welcome from Alan and Viv, who gave us a guided tour of the facilities, including the shore entry to the sea, just to wet our appetites for the morning dives! Then it was onto the paperwork and sorting out of kit, and then the bags returned to the truck and some chose to walk to our accommodation at Behotel, whilst others opted for the air conditioned bus again.

Check in was somewhat complicated due to a misunderstanding of the booking, but finally rooms allocated, we arranged to meet in the nearest hostelry to sample the night life.

Day two – Saturday 4 September

So after a very good night’s sleep and an excellent breakfast at the hotel, we headed for the dive centre, which was about a 15 minute walk away.  On arrival we decided to do some line tying skills and some academic refreshers whilst the other guests at the hotel got off to their days diving.


Thunderstorms and rain with drops the size of golf balls descended on us, sent us running for cover with little success. It was like we had all been in for our first dive without actually getting in the water!

Not to be deterred it seemed like a perfect moment to take a group picture!

Team Deptherapy in Malta – September 2021

As the rain’s slowed and the thunder and lightening stopped we took the opportunity to get into the water at the shore, to check weights and equipment, with plans to practice using the blacked out masks and tying skills in the water.  Unfortunately the storm had stirred up the water so much it was like diving in a blacked out mask permanently; the visibility was very poor and the surge was pretty uncomfortable, but certainly had everyone using their navigation skills.  Everyone ended up back on the shore safe and richer for the experience, although sea sickness did hit a few because of the surge.

Day three – 5 September

So a slightly later start to the day allowed the dive centre to clear its other guests to various locations and then we were onto the buses and trucks with resident instructor/ trainer Joe Phillips to go dive in the Bay of St Elmo, which lies on the south side of the entrance to Marsamxett Harbour. From the bay the bastion walls are an impressive site, and also the location of some films: World War Z, Assassins Creed and American Assassin to name a few!

The bay is also popular with divers due to HMS Maori, which was a destroyer in the British fleet that was sunk in WW2.  HMS Maori lies in 14 metres of water approximately 250 metres from the shore, so our plan was to enter from the shore and descend, do our safety checks in the water and swim across to the wreck, and use the wreck to start expanding the skills of primary and secondary tie offs on the outside of the wreck, and following the line, adding wraps on the line, which show the direction of travel into or out of a wreck.  Then, we planned to follow the lines with blacked out masks.

So we split into two groups of four students and each buddy pair were tying off on two places outside of the wreck, then following the line and following with masks covered up.  We also practiced deploying SMBs mid water.  Whilst in the water it is essential that the teams understand the air consumption at different depths so we all performed a 10 minute swim at an agreed depth of 10 metres, recording the air used during the exercise so the divers could work out their individual Surface Air Consumption also known as their SAC rates.

Once we had completed these drills it was time to head back to the shore and change the tanks and spend time on the surface before going back in for Dive 2.

Tom completing a tie-off with a blacked-out mask

During Dive 2 the teams were then simulating their lost line drills and entanglement drills. The teams worked extremely well together, and when you consider that the majority of the teams have suffered from mental health issues due to their service, they all performed the skills with professionalism and no panic attacks. It was wonderful to watch them successfully complete the skills.

So diving done, back to the dive centre, wash out the kit and store away and back to our hotel to again get ready to sample the night life of St Julian’s.

Day four – 6 September

Overnight, there had been very unusual weather and Malta had experienced winds that had a negative impact on the diving, limiting the locations and of course we have to risk assess all of the entry and exits because of the injuries that some of the beneficiaries are carrying.

So although today was planned to go out on the boat, this just was not possible because of the winds and sea conditions, so after discussions and suggestions being made we headed out to Marsaskala to try and dive the P33 which was a former patrol boat that was scuttled at the end of July 2021, close to already existing tug boat wrecks.

This wreck was built in Germany in 1971/2 and is around 23 metres long and has a beam of 5 metres.  It sits in approximately 20 metres of water making it a great wreck for training on.  Unfortunately on arriving at the site, it became obvious that due to the entry and exit being at the bottom of a long walk down to stone steps that were being bashed with quite strong waves it was not safe to dive.  As always we have to consider the safety of all the beneficiaries.  Again after consultation with resident Instructor Joe, and Viv back at the dive centre, we headed off to the X127 wreck located in the harbour at Marsamxett. The X127 was built in 1915 and sunk in 1942; she lies upright on a slope with her bow at 5 metres, and the stern at 22 metres. The access to this wreck was a lot easier and the bay itself was sheltered from the winds, so diving went ahead. As the wreck was not possible to penetrate safely due to the large numbers of divers and the high level of silt, it was dived by the beneficiaries as a recreational dive, but of course never one to let an opportunity pass, we did extra drills experimenting with weights and more exercises with the SMBs.

Due to the poor weather, we decided to do two dives on the wreck and then we headed back to the dive centre to wash down and pack away the kit.

Jon exiting a wreck

Day five – 7 September

Unfortunately this day was completely ruined by the expected thunderstorms and predicted high winds, so diving was cancelled and most of us took to the pool area and spent the day relaxing.

Day six – 8 September

So today brought about slightly better weather, although still not able to dive on a boat, it was thought that maybe we could return to the P33 at Marsaskalla, but when we arrived the conditions were worse than when we first visited and again with the welfare of the group in mind, it was decided to move to a different location! So having Alan Whitehead owner of Divewise with us, off to Cirkewwa we went!

Cirkewwa is very popular with divers and has a couple of wrecks, swimthroughs and a patch of reef to explore.  Unfortunately due to the weather, many other dive centres had the same idea, and also as it was a public holiday in Malta, the queue to the ferry terminal which takes day trippers to Gozo was very, very long!  Once we arrived at the dive site, we carried out a risk assessment and decided it would be possible to dive the first wreck which was laying at 34 metres.  So continuing with the RAID Advanced Wreck course, we would be tying primary and secondary lines within the wreck and the students would be following in, and then simulating out of air scenarios and swimming out on long hoses, finding guidelines and following out of the wreck to the primary tie-offs.

Off we went out to the wreck P29 which appeared out of the gloom, and was actually very well preserved. She was a 52 metre patrol boat that was scuttled in 2007 and sits at 34 metres at the deepest point and approximately 12 metres at the highest point.  Covered in life, the P29 was a perfect wreck for the skills.

So after returning back to the shore, tanks changed and a good surface interval, the students were given the opportunity to explore the reef system themselves as qualified divers. So off they went and came back with different stories of their findings; two of them actually found the second wreck – the Rozi – further along the reef, and with some pretty impressive video to prove its existence.  The Rozi was a former tugboat of approximately 30 metres in length, laying upright with the bottom around 30 metres and the top around 20 metres.

All in all, despite the issues with the weather and the lack of boat diving, everyone was close to finishing their courses and had enjoyed their diving.

Practising diving with blacked-out masks

Day seven – 9 September

So our day started with the required visit to a COVID testing centre prior to our departure from Malta back to the UK. So off to the centre, everyone swabbed and then back to the dive centre. Due to our later flight time on Friday, it was possible to get in a couple of dives.  So it was organised that in our groups we would enter the water at the shore of the dive centre and swim out past the sea wall to meet the boat that would then take us out to Tug 2 in Sliema. She is around 30 metres and was sunk in June 2013 to form an artificial reef.  Tug 2 lies upright and has a variety of marine life on it with a maximum depth of 22 metres.  So it was time to finish up on the skills that needed to be checked off or repeated and then we headed back to the boat that took us back to the shore.  Then it was back up to the dive centre to rinse off and dry the equipment ready for packing.

We then all started to receive the COVID test results ready for our return journey back to the UK.

Day eight – 10 September

Our final day and after breakfast and checking out of the hotel, we made our way to the dive centre to pack the dive kit and head off to the airport. What an amazing week with an awesome group of beneficiaries, who certainly took up the mantra, Adapt and Overcome.  All of the students had the Ambition to succeed and certainly had the sense of Adventure and definitely the mental stimulus to Achieve their set goals for the week.

Thank you to Richard  Cullen who did an incredible job of organising the trip, Martin Weddell who as always provides the calm in the storm and guides the students to success, and finally thank you to all of the students / beneficiaries who gave their best to succeed and achieved.

Sharon El Shoura

For more information about the work of Deptherapy and Deptherapy Education visit

Photos: Deptherapy / Martin Weddell

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Egypt | Simply the Best Itinerary | 04 – 11 November 2021 | Emperor Echo

Jump on board the latest addition to the Emperor fleet and enjoy diving the famous sites of the Red Sea with this fantastic special offer. Great value for money and perfect for small groups of buddies with a ‘Book 5 and 1 dives for FREE’ offer all year round.

Price NOW from just £1275 per person based on sharing a twin cabin/room including:

  • Flights from Gatwick to Hurghada with 23kgs baggage
  • 7 nights in shared cabin
  • 3 meals a day, soft drinks, red wine with dinner
  • 6 days’ diving, guide, 12ltr tank & weights, Marine Park fees and port departure fees
  • Free Nitrox

Subject to availability.
Alternative departure airports available at supplement.

Call Diverse Travel on 01473 852002 or email

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