How to Equalize Your Ears When Diving, and What to Do If You Can't

Why do your ears hurt when you descend?

Your middle ear is a pocket of air behind the eardrum, and its only link to the outside is the Eustachian tube, which runs to the back of the throat. As you descend, water pressure rises, the air in that pocket shrinks, and the eardrum bows inward. The tube is normally closed and opens briefly when you swallow or yawn, so unless you open it and let air in, the pressure difference keeps growing and the stretched eardrum starts to hurt. DAN calls equalization a basic, required diver skill, and our training guides cover the others.

The change is fastest near the surface, which is why many people have felt it at the bottom of a deep pool. DAN's ear guide gives the numbers: at 1.2 m (4 ft) the difference is 0.12 bar (1.78 psi) and the eardrums bulge inward, and at 3 m (10 ft) it is 0.31 bar (4.45 psi), where a very fast descent may break the eardrums. Middle ear barotrauma, the pressure injury of the middle ear, can happen as shallow as 1.2 m, so staying shallow does not prevent it.

Wait too long and the tube can lock shut. A 2017 systematic review puts that point at about 1.4 m of descent without equalizing, where the pressure difference passes 90 mmHg. StatPearls gives a pressure equal to 3 m (10 ft) of seawater. Once the tube is locked, the usual techniques such as Valsalva seldom open it. You have to reduce the surrounding pressure by going up, and even that does not guarantee it reopens straight away.

How to equalize your ears: five techniques step by step

Each technique opens the Eustachian tubes so air can reach the middle ear. Learn them on land first (see the last section) and always use them gently.

• Valsalva. Pinch your nostrils, or seal them against the mask skirt, and blow gently through your nose. The overpressure in your throat usually pushes air up the tubes. It does not use the muscles that open the tubes, though, so it may fail once they are locked, and it is easy to blow too hard. DAN's rule: don't blow hard, and don't hold the pressure for more than five seconds.
• Toynbee. Pinch your nostrils and swallow. Swallowing pulls the tubes open while your tongue compresses air against them. DAN's ear guide notes that it also works when you need to equalize on the way up.
• Frenzel. Pinch your nostrils, close the back of your throat as if straining to lift a weight, then make the sound of the letter K. SSI describes the tongue working like a piston, with no push from the chest, and calls the technique ideal for freediving.
• Lowry. A Valsalva and a Toynbee together: with your nostrils pinched, blow gently and swallow at the same time.
• Voluntary tubal opening (BTV, from the French béance tubaire volontaire). Tense the muscles of the soft palate and throat while pushing your jaw forward and down, as if starting a yawn. Those muscles pull the tubes open with no pinching and no blowing. DAN says up to 30% of divers can master it, and some learn to hold the tubes open for continuous equalization.

Which equalization technique is best?

The best one is whichever opens your ears gently, and it helps to have a second one ready. StatPearls notes that equalizing early and often and using more than one technique can help divers who struggle. A sixth option, the Edmonds technique, adds the jaw thrust of tubal opening to a Valsalva or Frenzel.

A 2017 systematic review in Diving and Hyperbaric Medicine advises against a forced Valsalva because it can injure the inner ear, and names voluntary tubal opening as the least traumatic method. Both recommendations are graded level 5 on the Oxford scale the authors used, which is expert opinion rather than trial evidence.

How often should you equalize on descent?

Before you feel anything, and then almost constantly on the way down. DAN's guidance is to equalize about every 0.6 m (2 ft) of descent. At a slow 18 m (60 ft) per minute, that means every two seconds. DAN's ear guide says to equalize gently every metre or so ("every few feet") for the first 3-4.5 m (10-15 ft).

• On dive days, start gently equalizing every few minutes several hours before the dive.
• Equalize once at the surface before you go down. DAN calls this pre-pressurizing, and it helps get you past the critical first few feet.
• Descend feet first with your head up. The 2017 review says clearing works best head-up and advises against a head-down descent.
• Look up. Extending your neck tends to open the tubes.
• Use a descent or anchor line to control your speed.
• Stay ahead of the pressure: equalize often enough to keep a slight positive pressure in your middle ears.
• If equalizing is hard for you, descend slowly and try with every breath.
• Keep your mask clear, because water up your nose irritates its lining.

What to do when one ear won't clear

Stop descending, go up until the pressure eases, and try again gently. If it still won't clear after a few attempts, end the dive. Pushing on is how a mild squeeze becomes a burst eardrum or an inner ear injury.

• Stop descending as soon as you feel discomfort. DAN is blunt about it: pain is not acceptable, and it means you have already descended without equalizing enough.
• Signal your buddy and ascend about a metre (a few feet) until the pain stops.
• Tilt the blocked ear toward the surface and try again gently. A different technique may work where the first one failed.
• Don't bounce up and down to force it.
• Don't blow harder. Blowing against a blocked nose raises the fluid pressure in the inner ear and may rupture the round window, a membrane between the middle and inner ear.
• If the ear still won't open, end the dive. DAN warns that descending without equalizing can ruin a whole dive trip or cause permanent damage and hearing loss.

Signs of ear barotrauma and when to see a doctor

Ear barotrauma usually starts as fullness or a clogged feeling and moves on to pain. Fluid or blood from the ear, pain lasting more than a few hours, hearing loss and any vertigo need a doctor. It is the most common diving injury: DAN says surveys show more than half of all divers get middle ear barotrauma at least once, and at least 40% of the medical calls and emails DAN receives are about ears.

• Fullness, muffled hearing or pain that began on descent points to middle ear barotrauma. Stop diving, and see a doctor if fluid or blood comes from the ear canal or if pain and fullness last more than a few hours.
• Pain on descent that stops suddenly, followed by clear or bloody drainage, hearing loss, ringing or a spinning sensation, suggests a perforated eardrum. Water entering the middle ear through the tear can cause vertigo underwater.
• Severe vertigo, nausea or vomiting, involuntary eye movements, ringing or hearing loss can mean inner ear barotrauma. DAN advises an urgent evaluation, and emergency care for severe vertigo and nausea after diving. Hearing loss may only become noticeable hours later.

Barotrauma or decompression sickness, and when to dive again

They can look alike, and a doctor has to tell them apart because the treatments conflict. Decompression sickness is treated with recompression in a chamber, while further pressure changes are contraindicated when inner ear barotrauma is likely. Barotrauma usually follows a failed equalization early in the dive, and decompression sickness follows the ascent at the end. If there is any doubt, call local emergency services and then the DAN Emergency Hotline on +1-919-684-9111, which is staffed 24 hours a day.

Go back in the water only after a doctor confirms the injury has healed and the Eustachian tube works. StatPearls adds that a patient with ear barotrauma should not be exposed to pressure again until symptoms are gone and the eardrum looks normal on examination. Some injuries are silent: in one study of freshwater divers, 74.4% of those with ear barotrauma had no symptoms. See our safety guides for other diving injuries.

Congestion, colds and decongestants

Don't dive congested. Colds, hay fever and other allergies, smoking and a deviated septum can all make equalizing harder, and DAN's advice is not to dive with congestion or a cold. StatPearls says the congestion should be treated and pressure changes avoided until you can equalize successfully.

Decongestants reduce swelling, and one trial found they help. A 1992 randomised trial gave 116 first-time divers either 60 mg of pseudoephedrine or a placebo 30 minutes before diving. Ear discomfort or blockage occurred in 8% of the pseudoephedrine group and 32% of the placebo group, and two subjects had dizziness and nausea. StatPearls still calls taking medication before diving controversial, because of side effects and the chance that the drug wears off before the dive ends.

The diving-specific worry is a decongestant wearing off at depth. The tubes can block while you are down, and the expanding air cannot escape on the way up: a reverse block. DAN's ear guide says to use decongestants only if your doctor agrees and never for the first time before a dive. It gives one to two hours before descent for decongestants (which last 8-12 hours) and about 30 minutes for nasal sprays (usually 12 hours), and warns that repeated use of over-the-counter sprays can cause rebound congestion and a reverse block on ascent.

How to practise equalizing on land

Practise until you know which technique opens your ears with the least effort. DAN calls middle ear equalization the most important skill for divers and says it is worth the time to master.

• Check the basics: when you swallow, you should hear a pop or click in both ears.
• Try each pinched-nose technique and note which one gives the click most easily. Keep any blowing gentle and under five seconds.
• For Frenzel, practise in front of a mirror so you can see and feel the throat and tongue movement.
• For voluntary tubal opening, practise the start of a yawn with the jaw pushed forward and down, without pinching your nose. The French diving federation (FFESSM) has published exercises for learning it.
• Before each dive, equalize gently at the surface to confirm both tubes open. If one ear never clears, don't dive until it has been checked. The 2017 review notes that formal testing of Eustachian tube function can be considered.