Avoid the Valsalva Maneuver for Equalizing!

[scubaozy]

So facts are scaremongering? LOL.
Yes, of course we want beginners to equalize timely and correctly, but the problem is when we ASSUME all students can successfully do a proper Valsalva. That is demonstrably untrue. They need to understand the point is to equalize, not to do a Valsalva, and there are several ways to equalize, each with pros and cons. The cons of Valsalva are insufficiently mentioned, and the pros of other simple methods are rarely mentioned. There is a broad spectrum between Valsalva and something requiring being able to wiggle your ears; it is a false dichotomy to say that anything other than Valsalva is too hard to teach and too hard to do.

I am sure DAN, PADI etc. will issue warnings and reports and statistics once they find evidence that Valsalva is dangerous and responsible high portion of the barotraumas. That DAN documentation you shared is super basic, off course we have to inform the divers about the risks of overdoing it. Same way we tell them holding breath during diving might cause injuries.
I highly recommend you watch best to start 24:27, there are some tips to help teaching it.

 

[tursiops]

I am sure DAN, PADI etc. will issue warnings and reports and statistics once they find evidence that Valsalva is dangerous and responsible high portion of the barotraumas. That DAN documentation you shared is super basic, off course we have to inform the divers about the risks of overdoing it. Same way we tell them holding breath during diving might cause injuries.
I highly recommend you watch best to start 24:27, there are some tips to help teaching it.

Thanks for assuming I need this information.

 

[Angelo Farina]

Your priority list is different than mine, because this is all subjective based on biased personal opinions. I prioritize based on probability of success, if you rate BTV success rate as 1/5, I would not put it on top.
Anyone can pinch their noses and blow or swallow, there is no barrier for learning Valsalva and Toynbee like ability to control muscles that you did not know otherwise existed.
You can not verify how a student is able to equlize, you just depend on what they say. So, I assume they have no special talent or case and start from most simple to learn: Valsalva and Toynbee. If they can succeed, they can safely try other, more advanced techniques as well. If we start scaremongering Valsalva, we will create an environment where beginners will be worried to do most basic technique, this is potentially more dangerous as we want them to equilize timely and correctly and whichever technique they might be using.

Of course any instructor has different priorities, and I think it is normal that each instructor presents as the first equalization method his "favourite" one, the one he uses everyday.
And this makes sense, because the students will see it being used by their instructor, and it would look strange to them seeing the instructor using something different from what he did teach them...
So I understand that an instructor who uses Valsalva introduces this method as the first one (but followed by the other methods, always - because Valsalva is NOT for everyone, exactly as each of the other methods - we are all slightly different...)
Indeed, Valsalva is not so simple as it appears. Definitely much more complex than BTV.
BTV is the simplest one. You just ask to the student to open the tubes, and, if he can do that, he is done: no need to pinch the nose (which requires to have at least one hand free), nor to synchronise the noise-pinching action with some other voluntary action.
A number of my students had big problems learning Valsalva: this is a method which is really simple for free divers, as their mouth is closed, so blowing sends the air pressure to the nose. You pinch it, the pressure cannot escape, and it forces the tubes to open.
But for a scuba diver, with a reg in his mouth, the airway is usually open (and we insist a lot in keeping always the airways open).
So, when he blows, the air tends to escape form the mouth. For avoiding it, some voluntary control of the valves inside the head is required, raising the tongue and lowering the soft palate, so that they close the path to the mouth.
It is not so simple to control these valves, as you did correctly point out. A (small) number of students cannot do the Valsalva when breathing from a reg (they still can do it without a reg in their mouth, when freediving). Typically those are the students who also have some problems clearing their mask (again, they have no control of the valves, so they cannot force the air to go out form the nose, instead of the mouth).
In my career as no-profit instructor (5 years) plus the following career as a professional instructor (other 5 years) I certified more than 1500 students. My wife did almost the same number.
So, with a total around 2500 cases, we start to have some statistically significant numbers.
Only 1/5 of students can do the BTV, just asking them to do it, with no specific training; but there are at least 1/10 of students who cannot do Valsalva.
In my statistics, another 1/5 of students do the Marcante-Odaglia without any specific training and continuing breathing. It s definitely simpler than Valsalva for a scuba diver with a reg in his mouth.
Many experienced divers are actually using Marcante-Odaglia, but they do not know, and they think of being using Valsalva instead, or perhaps Frenzel.
And another 1/5 do easily the Toynbee.
So 3 over 5 students are better served by methods DIFFERENT than Valsalva. It is OK to teach ALSO Valsalva, but not to ignore the other valid, safe and easier methods, which are the preferred ones by the majority of divers.

 

[tursiops]

So 3 over 5 students are better served by methods DIFFERENT than Valsalva. It is OK to teach ALSO Valsalva, but not to ignore the other valid, safe and easier methods, which are the preferred ones by the majority of divers.

I don't have the data than Angelo has, but I take no issue with his conclusions. I would say, however, "required" rather than "preferred" in his statement.

 

[doctormike]

@doctormike

Just saw this, sorry I don't have time to read all of the thread but:

1) The Valsalva maneuver is what the vast majority of people use safely and successfully to equalize their ears during descent. But it's not the only method, and there are a lot of other options.

2) There is a bell curve for everything, and some people have particularly poor Eustachian tube frunction due to congenital factors, anatomical issues or the result of previous ear disease. These people may have more problems diving, even though they may have normal middle ear ventilation at sea level..

3) While it is possible to cause ear damage (eardrum perforation or even inner ear injury) with overly aggressive attempts at equalization with a forced air technique like Valsalva, this should be a rare occurrence. It may be more likely if there is a history of a previous perforation, although a healed eardrum (spontaneously or after surgery) is usually just as strong as the original eardrum. Inner ear issues can also be related to excessive pressure changes if there is something like an underlying weakness in the otic capsule (e.g. perilymph fistula)

4) The main thing is that if you can't equalize equally, you stop your descent and try another method. You NEVER push through this, and if you can't equalize you need to thumb the dive. There are a lot of other options for people with theses issues, see this page for details. The main thing is to equalize gently, early, and continually, and to avoid diving with a significant upper respiratory tract infection or other acute ear issue (like unresolved barotrauma with middle ear disease).

5) Most equalization problems are due to technique and training, not to irreversible anatomic or functional issues with the Eustachian tube. So if a beginner can't do the Valsalva, it doesn't necessarily mean that they will never figure it out. On the other hand, if they realy can't do it, there is no reason to assume that it's Valsalva or nothing - as @tursiops mentioned and as I linked above, there are a lot of other options.

 

[Joneill]

Just saw this, sorry I don't have time to read all of the thread but:

1) The Valsalva maneuver is what the vast majority of people use safely and successfully to equalize their ears during descent. But it's not the only method, and there are a lot of other options.

2) There is a bell curve for everything, and some people have particularly poor Eustachian tube frunction due to congenital factors, anatomical issues or the result of previous ear disease. These people may have more problems diving, even though they may have normal middle ear ventilation at sea level..

3) While it is possible to cause ear damage (eardrum perforation or even inner ear injury) with overly aggressive attempts at equalization with a forced air technique like Valsalva, this should be a rare occurrence. It may be more likely if there is a history of a previous perforation, although a healed eardrum (spontaneously or after surgery) is usually just as strong as the original eardrum. Inner ear issues can also be related to excessive pressure changes if there is something like an underlying weakness in the otic capsule (e.g. perilymph fistula)

4) The main thing is that if you can't equalize equally, you stop your descent and try another method. You NEVER push through this, and if you can't equalize you need to thumb the dive. There are a lot of other options for people with theses issues, see this page for details. The main thing is to equalize gently, early, and continually, and to avoid diving with a significant upper respiratory tract infection or other acute ear issue (like unresolved barotrauma with middle ear disease).

5) Most equalization problems are due to technique and training, not to irreversible anatomic or functional issues with the Eustachian tube. So if a beginner can't do the Valsalva, it doesn't necessarily mean that they will never figure it out. On the other hand, if they realy can't do it, there is no reason to assume that it's Valsalva or nothing - as @tursiops mentioned and as I linked above, there are a lot of other options.

Good response - thanks!

So… no need “Avoid the Valsalva Maneuver for Equalizing” as the Op was trying to mandate. It’s a legitimate method and the most commonly used - perfectly safe and unlikely to cause issues if used with diligence (early and often) a bit of common sense (don’t keep descending or blow harder if you’re not equalized) - which is conceptually true for all of the various equalization techniques.

Different strokes for different folks - so use what works for you. Folks like the OP should focus on awareness of other techniques vs trying to tell us to stop using a valid and widely used technique.

I’ve use Valsava (and a bit of Toynbee). I have had had 1 barotrauma, but it was not because I was using Valsalva - it was a number of factors that resulted in a bad decision on my part: had a new full wetsuit, was underweighted and feeling rushed to keep up with the group descent so I pushed deeper before I had actually fully cleared both ears (though was not feeling strong ear pain so thought I was good). At 50 feet I paid the price in 1 ear.

I lost 3.5 days of diving on a week long trip while I healed up; which sucked, but learned a valuable lesson. I still mainly use Valsalva, but start early (on the boat and in the surface before descent) and equalize continuously as I descend and will not rush it or continue down if any question If I’m really equalized or not.

 

[tursiops]

Good response - thanks!

So… no need “Avoid the Valsalva Maneuver for Equalizing” as the Op was trying to mandate. It’s a legitimate method and the most commonly used - perfectly safe and unlikely to cause issues if used with diligence (early and often) a bit of common sense (don’t keep descending or blow harder if you’re not equalized) - which is conceptually true for all of the various equalization techniques.

Different strokes for different folks - so use what works for you. Folks like the OP should focus on awareness of other techniques vs trying to tell us to stop using a valid and widely used technique.

I’ve use Valsava (and a bit of Toynbee). I have had had 1 barotrauma, but it was not because I was using Valsalva - it was a number of factors that resulted in a bad decision on my part: had a new full wetsuit, was underweighted and feeling rushed to keep up with the group descent so I pushed deeper before I had actually fully cleared both ears (though was not feeling ear pain so thought I was good). At 50 feet I paid the price in 1 ear.

I lost 3.5 days of diving on a week long trip while I healed up; which sucked, but learned a valuable lesson. I still mainly use Valsalva, but start early (on the boat and in the surface before descent) and equalize continuously as I descend and will not rush it or continue down if any question If I’m really equalized or not.

I think if you reread the OP post -- instead of all the complaints about it -- you'll find that the major points are exactly what you say: if you do Valsalva right, there are no problems, there are alternate methods, and individuals should use what works best for them...which may not be Valsalva. The one additional point you do not say is that Valsalva is very easy to do incorrectly....as demonstrated by all the complaints people have about it being the only thing they learned and they hurt their ears.

 

[Joneill]

I think if you reread the OP post -- instead of all the complaints about it -- you'll find that the major points are exactly what you say: if you do Valsalva right, there are no problems, there are alternate methods, and individuals should use what works best for them...which may not be Valsalva. The one additional point you do not say is that Valsalva is very easy to do incorrectly....as demonstrated by all the complaints people have about it being the only thing they learned and they hurt their ears.

The problem is the title of your post: “Avoid the Valsalva Maneuver for Equalizing”! That’s bad advice as Valsalva may be a good technique for many people who may have far greater difficulty learning and being able to execute the other techniques.

Valsalva also appears to be the most commonly used technique so it’s no surprise that many people posting here with ear injuries may have stated they were using Valsalva.

However, as stated above by @doctormike, it’s likely rare that blowing hard via Valsalva will cause an ear issue/injury in itself. I believe it’s far more likely that folks are continuing descents before they’ve actually properly cleared - and that will happen regardless of technique used!

I’m all for ensuring divers know and try the different techniques that they can use to equalize and find what works best for them - but, in my opinion, the actual technique used is secondary to the other aspects of a safe descent that include: equalize early/often/continuously, don’t dive with congestion of any level, if not clearing go back up 5-10 feet to try again, and absolutely don’t continue a descent if not sure you are clear or sense any pain/fullness.

 

[tursiops]

The problem is the title of your post: “Avoid the Valsalva Maneuver for Equalizing”! That’s bad advice as Valsalva may be a good technique for many people who may have far greater difficulty learning and being able to execute the other techniques.

Valsalva also appears to be the most commonly used technique so it’s no surprise that many people posting here with ear injuries may have stated they were using Valsalva.

However, as stated above by @doctormike, it’s likely rare that blowing hard via Valsalva will cause an ear issue/injury in itself. I believe it’s far more likely that folks are continuing descents before they’ve actually properly cleared - and that will happen regardless of technique used!

I’m all for ensuring divers know and try the different techniques that they can use to equalize and find what works best for them - but, in my opinion, the actual technique used is secondary to the other aspects of a safe descent that include: equalize early/often/continuously, don’t dive with congestion of any level, if not clearing go back up 5-10 feet to try again, and absolutely don’t continue a descent if not sure you are clear or sense any pain/fullness.

How many OW students have you taught? I do NOT find they all can comfortably use Valsalva, sitting in a classroom. Nothing to do with descents. They just blow harder, which is my point. It is too easy to just blow harder. Yes yes Yes, equalize early and often...but first you've got to equalize correctly.

 

[AfterDark]

Another post appeared on ScubaBoard today about someone who hurt their ears while learning/trying to equalize. This should not be happening!
A common method taught to do this is the Valsalva maneuver, which consists of closing your mouth, holding your nose, and blowing.
IT IS TOO COMMON TO BLOW TOO HARD! A result can be physical and hearing damage to your ears.
There are much better equalizing techniques than Valsalva. Divers Alert Network (DAN) lists 6 of them, which DAN mostly describes aa "safer." They are, quoting:

PASSIVE | Requires No Effort​

Typically occurs during ascent.​

​

VOLUNTARY TUBAL OPENING | Tense Your Throat and Push Your Jaw Forward​

Tense the muscles of the soft palate and the throat while pushing the jaw forward and down as if starting to yawn. These muscles pull the Eustachian tubes open. This requires a lot of practice, but some divers can learn to control those muscles and hold their tubes open for continuous equalization.​

​

TOYNBEE MANEUVER | Pinch Your Nose and Swallow​

With your nostrils pinched or blocked against your mask skirt, swallow. Swallowing pulls open your Eustachian tubes while the movement of your tongue, with your nose closed, compresses air against them.​

​

FRENZEL MANEUVER | Pinch Your Nose and Make the Sound of the Letter “K”​

Close your nostrils, and close the back of your throat as if straining to lift a weight. Then make the sound of the letter “K.” This forces the back of your tongue upward, compressing air against the openings of your Eustachian tubes.​

​

LOWRY TECHNIQUE | Pinch Your Nose, Blow and Swallow​

A combination of Valsalva and Toynbee: while closing your nostrils, blow and swallow at the same time.​

​

EDMONDS TECHNIQUE | Pinch Your Nose and Blow and Push Your Jaw Forward​

While tensing the soft palate (the soft tissue at the back of the roof of your mouth) and throat muscles and pushing the jaw forward and down, do a Valsalva maneuver.​

Try the Toynbee technique; it is really simple, really effective, and not dangerous.

Lastly; equalize early (BEFORE you feel the pressure in your ears) and often (every few seconds during initial descent.

See also: https://dan.org/wp-content/uploads/2020/06/smartguide_ears_2017_lores.pdf

I have done all of those and combos of 2 or more at one time or another. After not diving for a few months I find it very hard to equalize. The more I dive the easier it happens, before the summer is over I need only to swallow and my ears equalize.

Having varied options is always better.