Essential DWS Knowledge
I created this section to share all the little things I've picked up along the way, to make your dive holiday more comfortable. You might notice that some tips are copied from my destination pages, and this is because a lot of the situations can be applicable in other places too.
Having suffered a nasty ear infection after (and yes only after) a series of dives (which thankfully didn't spoil the dive but didn't take MC either when I got back), I decided enough is enough.
I never thought it would happen to me (DENIAL), even though I had spoken personally to many experienced divers and dive guides who had an infection at one time or another.
It's very easy to tell when you have ear infection. PAIN in the ear. Pain on moving the jaw, pain on pulling the pinna of the ear, pain on touching the tragus (see diagram below). Pain on putting anything into the ear. AND PAIN when not doing anything at all. And for some poor others, impaired hearing, tinnitus and fullness of the ear.
So what causes it?
Know the normal to understand the abnormal.
In our ear, the important thing to know is that we have normal bacteria in the ear like Staphylococcus, Streptococcus and the one associated with acne (Propionibacterium acnes). These are usually living at low colonisation levels. In a study, 50% of individuals yielded no bacteria isolated from the ear canal. On top of that, the ear canal is coated by a protective layer of wax.
So a breakdown in this fine micro ecosystem in our ear will lead to chaos!
1. Loss of wax layer and the skin will be exposed
2. Increased fluid in the ear. More soup for the bacteria to grow. Also causes swelling, affects the skin permeability and allows penetration of bacteria.
3. Exogenous bacteria from the water. This is found to be a minor factor. In a study by I Brook, J C Coolbaugh, and R G Williscroft "Effect of diving and diving hoods on the bacterial flora of the external ear canal and skin" in the Journal of Clinical Microbiology (1982 May), it was found that divers picked up bacteria (gram negative rods) while swimming in harbour water and not in clear water. This might not be significant as they are not often the causative agent. Unless you dive in sewage this would be a factor. Hence this point is disputed by many people.
4. PH changes due to the moisture from the sea water.
5. Increased growth of ear flora
Types of Infection
Basically the EAR infection that we get in diving is Otitis Externa, infection of the external auditory canal (External Ear Infection). Glue Ear / serous otitis media and subsequent acute otitis media (Middle Ear Infection) is usually the result of barotrauma and pressure changes as a result of being unable to equalise the middle ear. The middle ear is sealed off from the external ear by an intact tympamic membrane (ear drum). You should not dive with a perforated(leaking) ear drum - let it heal or get it patched by an ENT surgeon.
Acute infections would be caused by bacteria rather then fungus, so let's leave Mr Fungus out of the equation.
How now that I have gotten an infection? The solution is very simple! See a Doctor and stop diving! This is because if you get a chronic infection it's going to be a pain. Or you can develop Necrotizing or Malignant Otitis Externa which is a life-threatening extension of external otitis into the mastoid or temporal bone and then to the brain.
So another holiday gone, another diving trip whiled away on the surface! SO HOW! LPPL? Prevention is the solution (hee hee don't mind the pun).
What we have found and summarised as what we would do is to target the causative factors!
1. Loss of wax layer- it is recommended by many not to clean the ear with Cotton Buds. So definitely no overzealous cleaning! The use of cotton buds in the ear should be restricted to just help soak up extra water. Cotton buds should not be used to korek and dig out all the gold! If you're not sure how to soak up the water, then don't risk putting anything in your ears. So leave the gold alone, as long as it's a normal layer of wax and NOT a big nugget. Some people are prone to getting a hard build up of wax which appears black and hard and dry. With exposure, these anhydrous black nuggets will work like a sponge - swell up and block the egress of water from your ear! So, do check your ears and clear the large hard black lumps of coal in your ear before you dive! Still not sure? See a doctor before diving.
Another recommendation which I don't practice but is cited in literature (Haider and Stanek "Otitis externa in tropical diving and swimming" Wien Klin Wochenschr. 1992) is to apply paraffin-oil before the dive. This was practiced by a dive instructor in Lembeh and dive guides from Shakti whom we met recently. They used Johnson's baby oil.
2. Increased fluid in the ear - It is important to dry the ears. I read a post on scubaboard of one's personal remedy of hairdrying the ear. However, this is not an evidence-based suggestion. The best way is to apply drops with isopropyl alcohol to help dry the ear (more on the solution later). Moisture from perspiration, high humidity and high environmental temperatures in a non-diving setting can also trigger an ear infection. The time I had an infection was a multiple dive day, which was hot and humid. It was also during the rainy season and the room was by the beach without much seabreeze and no air con! So air conditioning in the room is important to help dry the ears! Super important for live aboards too!
3. Exogenous bacteria - Debatable point. But a good practice which we follow is to rinse our ears with clean water immediately after the dive.
4. PH Changes- Normal ear PH is 4.5. The acidic environment is important for the normal balance of flora. PH of sea water is more or less constant at 8-8.2. So the dilution by an alkaline medium will affect the growth of bacteria and the normal protective mechanism of the ear. This is why Acetic Acid is an important ingredient in your ear drops.
5. Increase in growth of ear flora - controlled by controlling the PH and moisture. The Acetic acid also functions as an astringent as the low PH is bactericidal (though some sources regard it more as a growth retarder and hence aluminum and sodium acetate may be added). As noted earlier the ear is normally relatively free of bacteria.
After endless sifting through mulitple papers, websites and forums, two main ingredients are needed.
1. Acidifying agent - Acetic Acid 2.5% (White Vinegar which is approximately 5% Acetic acid)
2. Drying agent - Isopropyl Alcohol. Not Ethyl Alcohol.
The DiveWithSus formulation is 50 % White Vinegar (which brings the acid concentration to 2.5%). Any stronger will be too irritating. The other 50% comprises 40% isopropyl alcohol and 10% sterile water (available in vials of 10 or 20 mls). Although the most common recommendation is 50% vinegar and 50% isopropyl alcohol, I find 50% alcohol a bit too drying. Do measure out the solution properly.
The proper way to use the solution is to use it twice a day before and after diving. Some also recommend paraffin oil/ baby oil pre dive, and eardrops post exposure. It is important to tilt the head, gently fill the ear canal with the solution and leave in place for not more than five minutes (just lie down). Then let the solution run out (just roll over). Then repeat for the other side. Personally, I don't fill the entire ear canal as I found it too strong and biting, but I do observe the duration closely. It just depends how susceptible you are to infections and how sensitive you are to the solution.
As with all medicinal solutions, it is best to discard your brew a month after preparation.
Water in the ear
The above points are based on the assumption that your ear canal gets exposed to the sea water and its associated contents. So to make all the abovementioned points less relevant is to keep your ears dry while diving. A system which allows for this is the ProEar mask. We at Dive with Sus have not used such as product but a fellow diver whom we have dived with swears by it. The ProEar mask basically includes ear muffs / cups which goes over the ears, and have vents attached to the mask to allow equalisation of the ear drum. It's a simple and effective concept, but will probably take some getting used to, not just in terms of wearing it but also to the differences in sounds underwater. It comes in multiple colours... including pink! The price (as quoted in the ProEar website in April 2009) ranges from USD169 to USD219.
1. Don't dig your ears
2. Apply oil before dive (the way I've seen people do this is to put a drop onto one finger and gently swipe the ear openings)
3. Air conditioning in rooms
4. Rinse ear with clean water after dive
5. Ear Drops
7. ProEar 2000... if you aren't too hesistant about the looks, price and getting used to it. Might be a good idea but it could be hard to come by for divers in Asia.
1. Edward Thalmann, M.D, Can You Prevent Otitis Externa, or Swimmers Ear? DAN revisits and expands on the preventive measures for otitis externa.
2. I Brook, J C Coolbaugh, and R G Williscroft,Effect of diving and diving hoods on the bacterial flora of the external ear canal and skin. J Clin Microbiol. 1982 May; 15(5): 855-859.
3. DAN Europe Faq
4.T Haider, G Stanek, Otitis externa in tropical diving and swimming,Wien Klin Wochenschr,1992;104(2):39-41
5.Ernest Campbell, MD, FACS, Ear Drops, Scuba Doc,
6.Sea Quest Dive Center, Cebu Bohol, Fears for Ears
7.Robert Sander, M.D, Otitis Externa: A Practical Guide to Treatment and Prevention, American Academy of Family Physicians, 1st March 2001
8.Richard Stockton college of New Jersery,The pH of seawater -Seawater properties and trends
9. Stroman, Roland, Dohar, Burt,Microbiology of normal external auditory canal.,Laryngoscope,2001 Nov;111(11 Pt 1):2054-9