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Ear Infections and Scuba Diving

Thursday, January 16th, 2014

Can You Prevent Otitis Externa, or Swimmers Ear?

The Answer is in the Solution

ear infections while swimming and scuba divingBy Edward Thalmann, M.D., DAN Associate Medical Director

The diving has been great all week. Now, while sitting in your room, you notice that one of your ears itches and feels wet. You look in the mirror and don’t see any problem, so you go to bed. Next morning when you wake up, you feel a fullness in your ear and a twinge of pain. What a time for an earache! You wonder if you should cancel the day’s diving.

Your problem is probably otitis externa, a fancy name for an external ear infection sometimes called swimmers ear. As the name implies, it’s usually associated with someone who swims a lot – and divers certainly fit that bill on dive-intensive scuba holidays.

The Cause
Despite what most people believe, otitis externa is not caused by bacteria in the water: instead, it’s triggered by the bacteria normally found in your external ear canal. Here’s how these normally innocuous bacteria can become troublesome.

With frequent immersion, water swells the cells lining the ear canal. Eventually, these cells pull apart – far enough for the bacteria normally found on the surface of your ear canal to get underneath the skin, where they find a nice warm environment and start to multiply.

Next thing you know, your ear canal itches, is sore and becomes inflamed. If left untreated, the swelling can spread to the nearby lymph nodes and cause enough pain that moving your jaw becomes uncomfortable. At this point, the only treatment is antibiotics, and diving is definitely out.

Some History
When I first entered the Navy in 1972, I was asked to look into the problem of ear infections in saturation divers. These divers spend up to a month in diving chambers aboard ships, where they are kept at the same depth as the job they are performing in the sea, whether it’s salvaging a sunken vessel or performing a research project.

Each day these divers are transferred from the chamber to the work site in a diving bell. The divers spend a great deal of their time immersed. Both the chamber and the bell provide a hot, humid environment, perfect for breaking down the cellular lining of the ear canal; and the result is often otitis externa.

Otitis externa was so prevalent at the time I entered the Navy that up to 20 percent of all saturation divers were expected to get it. I searched the medical literature and found an article that had the answer: instructors at a summer camp found that dripping an acidic drying solution into the ear at the beginning and end of each day virtually eliminated swimmer’s ear in their young charges. The trick, however, was that the solution had to remain in each canal a full five minutes. If this part of the treatment was ignored, ear infections soon reappeared.

To treat the Navy divers I decided to use Otic Domeboro®* Solution: 2 percent acetic acid, water, aluminum acetate, sodium acetate and boric acid. The acid retards bacterial growth, while the aluminum and sodium acetate act as astringents, drawing excess water out of the cells lining the ear canal. We had the divers put this solution in each ear canal twice a day and hold the solutions for at least five minutes at a time, timing them from outside the chamber.

The result? Otitis externa is no longer a problem in Navy saturation divers, and the above external ear prophylaxis remains a standard part of U.S. Navy Saturation diving procedure to this day. It’s useful for sport diving, too, when there are frequent dives over several days.

Using the Solution
The only problem for sport divers is that Otic Domeboro Solution is a prescription drug, so you’ll need to get it through a doctor. (Note: Bausch & Lomb and Qualtest make similar products.) And it’s not cheap: a 2-ounce bottle costs in the neighborhood of $25. But that bottle should easily be enough for 60 or more days of use.

There are other preparations available over the counter (Auro-Dri, Swim-Ear) that are less expensive and consist of 95 percent isopropyl alcohol, with anhydrous glycerine. These preparations will certainly take care of drawing excess water out of the cells, but their lack of acidity makes them less powerful at inhibiting bacterial growth. Unfortunately, none of these over-the-counter preparations has been tested in the diving environment, so whether they will work as well as Otic Domeboro Solution is unknown.

Whatever preparation you choose to use, the trick is in the application. Before your first dive in the morning and after your last dive each night, here’s what to do:

The head is tilted to one side and the external ear canal gently filled with the solution, which must remain in the canal for five minutes. The head is then tilted to the other side, the solution allowed to run out, and the procedure repeated for the other ear. The five-minute duration must be timed with a watch. If the solution does not remain in the ear a full five minutes, the effectiveness of the procedure is greatly reduced.
– From the U.S. Navy Diving Manual

Remember, this is a prophylactic procedure that should be started before the ear becomes infected – beginning it only after an infection occurs will not help much. One word of warning: Do not put drops in your ear if you have any reason to suspect you may have a ruptured eardrum from a squeeze. If you do, you may wash bacteria into the middle ear, where an infection can be really bad news.

Clearing That Waxy Buildup
If you’re diving for an extended period of time, the cerumen in your ear may build up and cause the external ear canal to become blocked off. Once this happens, it greatly reduces the effectiveness of the external ear prophylaxis and makes an infection much more likely.

If you think your ear canal is blocked, the best way to find out is to have someone who is trained to use an otoscope use one to look in your ear. If the eardrum isn’t visible, the excess cerumen should be removed. Don’t use swabs or other instruments to remove cerumen. Gently flushing the canal with water while in the shower, with hydrogen peroxide, or by using commercial over-the-counter solutions designed to remove earwax are the best bet. If that doesn’t work, see a doctor to have the wax removed. Any intrusion into the ear canal should be done by trained medical personnel only.

For preventive measures, one way to prevent the buildup of cerumen (earwax) is to gently flush the ear canal when showering: Cup your hand next to your ear, and let your hand fill with water, which will overflow into the ear canal. Don’t let the shower stream enter your ear directly, though; it could damage your eardrum or hearing.

For more details, see More on Swimmers Ear.

(c) Jan/Feb 1999 Alert Diver

* Note: Bayer ceased manufacture of Otic Domeboro in December 2000.

Safe Diver Training – Why Divers Die

Tuesday, December 31st, 2013


Posted by Jeffrey Bozanic on 08/12/2012

Technical diving is considered more hazardous than standard recreational diving. Why? Because many divers, including some exceptionally experienced divers, have died while participating in advanced diving activities. What caused these accidents, and how can we prevent them?

There are many types of technical diving. The best studied is cave diving, with over 650 fatalities in the most recent review of the data. Early pioneers of the activity took an active interest in systematically examining incidents, and tried to develop general causes of those accidents. This became known as “Accident Analysis,” and it formed the basis of cave diving instructional programs in the United States.


Image4cs Why Divers Die

Continued review of fatalities and near misses has added knowledge, and has further defined contributory causes to accident analysis. While these studies looked primarily at cave diving, and some of those factors are specific to cave diving, reviews of fatalities in other environments are applicable in other types of technical diving, as well.

Takeaways from this research:

  • Be trained in the type of diving you are doing: The primary cause of fatalities is exceeding the level of training. In cave diving, this often means entering overhead environments without any specialized training. In fact, about two-thirds of all cave diving accidents involved people who had no training at all. Another 25% were exceeding their level of training at the time they perished.In all types of diving, it is common for divers to “try” a type of diving before seeking training. As an example, think of someone you might know who “tried” a decompression dive or set a personal “deepest” dive before receiving specialized training in these activities. Training levels were exceeded in more than 90% of all fatalities, pointing to the importance of receiving adequate training beforestarting technical diving activities.Environmental conditions often contribute to accidents. In cave diving, lack of direct access to the surface and darkness are obvious considerations. Others include silting, depth, and currents. In cave diving, environmental issues led to the development of the next four rules of accident analysis in cave diving: guideline use, Third’s Rule, deep diving, and lights.D2714 Image14cs Why Divers Die
  • Utilize a continuous guideline to where an uninterrupted ascent to the surface may be made:Cave and wreck divers must be able to exit from either the cave or wreck before they can return to the surface. To do this, they must be able to find their way out, despite branching passages, sediment obscuring visibility, loss of lights, or other issues. Persons working from fixed anchor or up lines whose safety are dependent on reaching those locations, and saturation divers working from fixed habitats on the bottom face similar navigational challenges.Guidelines are mandatory in cave diving, and in my opinion, most wreck diving as well. While wreck diving-enthusiasts utilize a “progressive penetration” rule for their penetrations, I feel the use of guidelines is essential for all but the most limited penetrations. Guidelines can assist in many types of technical diving, both with navigational issues, as well as with reducing stress.
  • Reserve a minimum of two-thirds of your initial gas supply for exiting: This is called the “Rule of thirds,” and is the basis for gas management for many technical- diving activities. The general concept is you use one-third of your gas entering, one-third exiting, and save one-third to cope with any unexpected emergencies or contingencies. Setting penetration distances based on air consumption is the primary way cave divers meter out their air and the duration of their dives.Utilizing air rules is a common practice for limiting dive distances or times in other technical-diving activities as well. A future column will be devoted to examining these gas-management rules.
  • Avoid deep diving on air:Depth was the primary reason experienced cave divers died. Before Trimix was readily available, air was used to explore even very deep caves. Dives on air to depths exceeding 250 feet were not uncommon, and fatalities often resulted from situations exacerbated by nitrogen narcosis. The rule was once stated as “Do not dive deeper than 150 feet,” but even that depth limit has resulted in hazardous situations.Similar problems have been seen in open water. One of the most common ways for divers to compare their “experience” or “competence” with other divers was to see who had been the deepest. “How deep have you been?” was the first question often asked upon meeting a new diver. This pressure to go deep led to many incidents. It still does. Deep diving can be pursued with a reasonable degree of risk, but only if the participants have proper training and equipment.
  • Carry at least three lights per person:Caves are almost 100% pitch black. Wrecks, too, can contain areas with no natural light at all. But we need light to swim or move efficiently through passageways, to communicate, and to efficiently handle equipment. It makes no difference if we are cave diving, wreck diving, deep diving, or night diving. Redundant lights allow us to safely terminate a dive if we lose our primary light. Numerous fatalities in caves stemmed from divers who could not see when their only light failed.These rules constitute the “classical” rules of accident analysis. They were identified in the 1970-80s. In the next issue, we will look at additional contributing causes to cave diving fatalities that have been identified in the last decade. We will find that these apply even more strongly to other modes of technical diving. Until then, safe diving!


Words and Photos by Jeff Bozanic. This article appeared in the May/June 2012 issue of California Diver Magazine.

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