TUBULAR AEROBICS

The exercises that are proposed in this section constitute a new approach to the activity of compensation. They are aimed at training all the structures of the nasalpharyngeal-tubular area that are directly or indirectly involved in the mechanics of the Eustachian tube, with the goal of creating a smooth and efficient system, ready to confront compensation at depth. We have divided these exercises into two categories: muscular exercises that reinforce and synchronise the structures of the nasal-pharyngeal-tubular area: and maneuvres of autoinsufflation that specifically train the Eustachian tubes. These exercises must be executed out of the water.

THE PURPOSES OF TUBULAR EXERCISES

The exercises that we propose in these pages are helpful to: 1. reinforce and synchronise the structures of the nasal-pharingeal-tubular area; 2. impart an awareness and competency aimed at obtaining an effective and appropriate compensation; 3. protect the auditory structures from lesions of any kind, safeguarding their auditory function; 4. allow anyone to discover, and be able to apply the best technique of compensation, tailored to suit personal capacity and objectives.

MUSCULAR EXERCISES
Each time you perform one of the proposed exercises try to achieve a better coordination, without forcing the structure.

WHAT, WHEN AND HOW MUCH TO EXERCISE

Tubular exercises, like all muscular training, should be executed daily for the first 20-30 days. During this period perform all the proposed exercises and manoeuvres for at least 10-15 minutes per day, sitting comfortably in front of the mirror and automating the proper movements without following them blindly, which won't bring the results desired. Subsequently, it is enough to maintain exercises once a week and to intensify the activity the day before diving, in order to prepare the structures.

Tongue exercises
Bring the tongue as far as possible out of the mouth, towards the chin, then retract it and force it all the way back, keeping the tip of the tongue on the floor of the mouth. Brush the roof of the mouth with the tongue, moving from front to back and trying to reach the soft palate. The correct execution of this exercise is often accompanied by a vomit reflex. Trace the perimeter of the lips with the tongue, rotating clockwise then anticlockwise.

Jaw exercises
Repeatedly open and close the mouth. Move the jaw latteraly, from right to left and back again, without contracting the lips. Rotate the jaw on the frontal plane, clockwise then anticlockwise. Repeatedly protrude and retract the jaw, keeping it on a transverse plane. During the execution of these exercises, if one or the other of the ears contains mucous in the middle ear cavity it is quite likely that the subject will hear noise like paper tearing. If the middle ear is free the only possible noise will be the sound of mandibular articulation.

Soft palate exercises

These exercises are very important, as the muscles of the soft palate play a primary role in the dynamics of the tubes. If possible watch and analyse the quality of movement of the soft palate in a mirror. Pronounce a series of three quich and powerful /ah/ sounds, then close the mouth for a few seconds and recommence. These vocalisations provoke a firm and complete contraction of the soft palate; if this does not occur then it is necessary to continue with this type of exercise until successful. The pause is recommended because a longer series can cause an uninterrupted contraction of the palate, making the movements imperceptible. In the same fashion pronounce successive series of /ee/, /eh/, /oh/, /oo/, /eek/, /ak/, /ok/, /ook/. Contract the soft palate without emmiting a sound (this corresponds to the enunciation of a silent /ah/ sound). Using a tongue depressor or a spoon, you can touch the soft palate and stimulate a reflex contraction. For some people this exercise is not appropriate, as it stimulates the vomit reflex.

Breathing exercises
Blow out a candle from an increasing distance, inflate baloons, and exhale through a straw into a container of water. Breathing exercises assume a perfect closure of the soft palate, so no air should escape from the nose at all. Emit vowel sounds with varying intensity and pitch. This exercise involves displacements of the larynx and soft palate.

Tongue-soft palate exercises

Slide the tongue over the palate from front to back, keeping it well in contact until it falls, producing a characteristic clicking sound. Usually we tend to produce this sound by striking the tip of the tongue quickly and repeatedly on the back of the bottom teeth; note that the correct exercise instead involves the top surface of the tongue, and the tip falls further backwards. Keeping the mouth open, move the tongue like a piston towards the soft palate, and at the same time contract the soft palate, without emmiting a sound. The tip of the tongue is kept in contact with the floor of the mouth.

Tongue-jaw-soft palate exercises

Try to induce a yawn by means of a deep oral inhalation, followed by a 2-3 second apnea, during which the mouth is kept open and the palate contracted without making a sound, then release the air with an oral exhalation. Yawning is an important physiological mechanism as it involves many muscles and causes an active opening of the Eustachian tubes. Execute the following succession of movements: Extend and lower the jaw. Push the tongue out of the mouth as far as possible towards the chin. Retract the tongue, brushing the palate from front to back, keeping the mouth open. Emit an /ah/ sound. Close the mouth and gently retract the jaw.

Swallowing exercise
Take a gulp of water into the mouth, pinch the nose closed and swallow, whils lowering the head. This position sends the air displaced by the liquid towards the tubes, and protects the airway, avoiding inhalation of water and coughing. The swallowing exercise can be peformed using any type of drink (fruit juice, milk, fruit shake etc). The greater the volume and density of the water in the mouth, the more air will be mobilised. The tubes are also opened by belching, so it is also possible to use fizzy drinks, closing the nose at the moment when air rises back up.

Single and double airway expiration exercise

This exercise favours nasal respiration, opening of the tubes (due to the pressure changes created during this type of respiration), aeration of the nasopharynx and nasal cavities and stimulation of movements of the soft palate. At first one nostril is used at a time the second is closed with the simple pressure of a finger but subsequently both nostrils are used together. Nasal inspiration and oral expiration Calm and comfortable inspiration and expiration Short and forced inspiration followed by a calm expiration Calm inspiration followed by a short and forced expiration Short and forced inspiration and expiration

AUTOINSUFFLATION
The term 'autoinsufflation manoeuvre' is used to identify an exercise useful for the training of the Eustachian tube. Optimal condition of the Eustachian tube critical for compensation is based on a continued and balanced muscular training. In this section we will examine in detail several exercises of autoinsufflation: these are basically compensatory manoeuvres performed 'dry'.

WARNING
The opening of the Eustachian tubes during autoinsufflation manoeuvres is evidenced in most people by a 'click' inside the ear. There may be a bothersome sensation during the initial session of autoinsufflation manoeuvres and in first exercises with the baloon and nosepiece, but this is not cause for concern. It is caused by the repeated introflexion and extroflexion (due to the movement of air) of a hypo-mobile eardrum, and will dissapear as soon as the condition of hyper-pressure is interrupted. However if the annoyance becomes painful it is advisable to discontinue autoinsufflation and receive an otoscopy exam in order to prevent the acute, light or initial phase of middle ear inflammation.

The tubular exercises must always be performed in the way indicated in the following pages; however during immersion they can be modified according to freedom of movement and requirements of the individual. Whether diving or training out of the water, it is necessary to remember that these manoeuvres should never be performed if the ear is inflamed or in cases of bad colds. This is to avoid pathogenic agents climbing the tube and the movement of air and liquid in the middle ear that could cause pain and damage to the structure. Instead, in these cases the muscular exercises are very helpful, as they favour the aeration and cleaning of an inflamed ear. Compensatory manoeuvres can protect ethe ear and make a dive more pleasurable, provided that they are perfectly understood and executed at the right time and place. Their success is based on a correct and constantly stimulated activity of the Eustachian tubes. As we have emphasised, these exercises are aimed at allowing anyone to obtain maximum mastery of the structures involved in compensation. In doing so it can happen that, possibly during training in a pool, and when the physical and surrounding conditions allow, the Valsava and Marcante-Odaglia manoeuvres can be substituted by movements targeted at single muscles, obtaining the same result, but with a lesser expense of air and energy.

Valsalva manoeuvre
1. Execute a moderately deep oral inspiration. 2. Close the mouth, lower the head, and gently pinch the nose with two fingers. 3. Breathe out powerfully into the closed nose, without inflating the cheeks or opening the mouth. 4. Maintain this condition for 3-4 seconds. 5. Free the nose, allowing the air to exit. The manoeuvre must be short and it is advisable to allow a moment's relaxation between one execution and the next, so as to avoid hyperventilation. The Valsalva manoeuvre is effective if the momentary state of hyperpressure created in the nasopharynx during the exercise is sufficient to cause the opening of the tubes. In fact, if a more elevated pressure is required then a possible sudden opening could cause great damage. To reduce the thoracic hyper-pressure that is created during the manoeuvre, it is a good idea to pronounce two vowel sounds in succession, after the oral inspiration and before proceeding to autoinsufflation.

Mysuria manoeuvre
1. Execute a moderately deep oral inspiration. 2. inflate the cheeks with the inspired air and pinch the nose closed with two fingers of a hand. 3. Place the thumb of the second hand on one cheek, the palm on the mouth and the fingers on the other cheek. 4. Place the base of the tongue against the soft palate, and push lightly bacwards. 5. Squash the cheeks with a light pressure of the fingers, without allowing the air to escape from the mouth, and at the same time lower the head and swallow. The Mysuria manoeuvre combines the hyper-pressure of the nasopharynx with a contraction of the entire pharyngeal zone, caused by the act of swallowing. There is a reduced amount of pressure required to open the tubes with respect to that required by the Valsalva manoeuvre.

Marcante-Odaglia manoeuvre, or Frenzel

The nasopharynx is turned into a closed cavity full of pressurised air that is easily forced towards the middle ear through the Eustachian tube. We have discussed this at length in the preceeding section, but it will help to be reminded that this manoeuvre requires the most coordination. 1. Draw air up into the oral cavity by a pumping action of the base of the tongue. 2. Maintain both the nostrils closed and epiglottis closed for the entire duration of the exercise. 3. During the exercise the soft palate must be repeatedly contracted.

Using an instrument of autoinsufflation

There are instruments available that, if used correctly, allow for the compensation of the middle ear, guaranteeing proper function of the transmission system of the eardrum and ossicles and a suitable ventilation of the cavity behind the eardrum. With these instruments, air may be injected through the nostrils towards the cavity of the nasopharynx, where the orifices of the Eustachian tubes are located. The success of the exercise is only guaranteed under normal anatomic and physiological conditions of the tube, on the basis of which the instruments were designed. If these conditions are not present, and the pressure alterations and functional problems of the middle ear derived from a prolonged state of insufficient activity or inactivity of the tubes, then for a complete and specific treatment it is necessary to precede the exercise with a program of 'tubular aerobics'. These are then continued while the autoinsufflation exercises are gradually introduced. Most autoinsufflation instruments consist of a plastic toggle that is inserted into nostril and connected to balloon. They are used as follows: 1. Place the round part of the toggle in contact with a nostril, and close the other nostril with a finger. 2. Perform a deep oral inspiration and close the mouth. 3. Breathe air out through the nose to inflate the balloon. We now suggest seceral exercises with this instrument. Don't forget that for a complete execution the exercises should be performed through both nostrils!

Exercise A
1. Inflate the balloon to the required dimensions. 2. Breathe the air from the balloon into the nose. 3. Swallow. The swallowing exercise associates the active opening of the tubes caused by the swallowing to a passive mechanism of opening created by the air from the balloon. Coupled with the constant airflow, this combination allows an optimal aeration of the middle ear and an effective tubular cleansing.

Exercise B
1. Inflate the balloon to the required dimensions. 2. Pronounce the following phrases with sustained intensity, articulating and stressing each phoneme. "The geese with golden galoshes" "This gelato is gustatory" "Alana bred a jaguar and a llama" "A pyjama rotter" "Frodo's dodo got in a grotto" "A duo of rude two-timing ghouls" "Catch the cadet" "Two teens guard an apartment" "Claire ate an iguana" "Tomcat, tomcat, tomcat..." "The gang joked with a go-go girl"

3. With the jaw lightly protruded, pronounce: "Aug, aug, aug..." (like an Indian) "Ghi, ghi, ga/goh/geh/ghi/goo" "Kee, kee, ka/koh/ke/kee/koo" "Glug, glug, glug! When air rises into the nasopharynx cavity and the trunk of the Eustachian tube the voice acquires a distinctive tone. It can be defined as intermittent, monotonous, 'course', and resonant. At the same time as the vocal emission you may have a sensation of open ears, of air moving or rising towards the ears, of confusion or feeling dazed, or of cleanness and freshness. The phonation exercise has the same aim as those preceding: to open the Eustachian tube by means of the production of precise phonic sequences. Generally, the phenomena that cause the tubes to open are those in which correct articulation requires distinct movements of the soft palate, but eceryone should find the most effective phrases for themselves.