Hyperactive Gag Reflex

Opinions as to the proper management of the gag reflex
Questions come up fairly frequently concerning vomiting underwater and an overactive gag reflex.

Dr. Murray Grossan writes:
I have had some success with hyperactive gag reflex by using mirror biofeedback.Similar to my treatment for TMJ at http://www.ent-consult.com you use the mirror as a visual biofeedback device. Start with the snorkel, breathe in count of 4 and out at count of 6, relax as you exhale. See the face relax. If you see the face, jaw, eyes, neck shoulders relax, then you are doing it right. Then we try tongue blades and then the mouthpiece itself. Haven’t had that many patients but several did work out ok.
Murray Grossan, M.D. http://www.ent-consult.com

Dr. Tom O’Connor, a diving dentist writes the following:
“Looking toward the causes of the hyperactive gag reflex is interesting. It may be that the mouthpiece simply needs to be trimmed. Removal of some of the silicone that extends back on the back teeth and trimming the extent which hits the roof of the mouth and the tongue may help. But doing this still negates the benefit of being able to use your buddy’s regulator. Stimulus desentization worked for our diver. We just had him suck on that regulator mouthpiece all day long while we were working on gear configuration and filling tanks. There are many factors which can lead to this problem. Some are obvious and can be eliminated. Use of alcohol or medication can heighten the gag reflex. Obesity, smoking, or tobacco use are also factors that can be eliminated. Dental problems, systemic illness, and psychological factors including fear can be contributors. In my opinion, as an open water instructor of ten years, a trimix cave diver, and a dentist, I would not recommend diving until such time that this reflex is under control. It could be catastrophic. This is dangerous for the diver and an unfair burden on his buddies. Another option would be to put this fellow in the pool with a snorkel and have him swim laps forever until the gag reflex goes away.
If he only feels it with scuba and not with a snorkel (having a vitally identical
mouthpiece) I would suggest that the gagging is anxiety related, and not anatomical or physiological in nature.”

Dr. Pat Haley, of Selma, Alabama states:

‘I agree with Dr. O’Connor regarding the trimming of the mouthpiece, especially in the soft palate area. We sometimes sprinkle sugar or salt on the tongue or palate before impressions to inhibit the gag reflex. A topical anesthetic works well especially Dyclone which is longer acting. For barfing I suggest a return to the surface !!’

Dr. Kimberly Loos, DDS has the following advice:

“I cannot recommend a drug to relieve a hypersensitive gag reflex. If the regulator mouthpiece is truly the cause of the gagging, I would suggest using an orthodontically correct regulator mouthpiece. There are over-the-counter mouthpieces that can be made by softening them in hot water. However, the best way to get an orthodontically correct mouthpiece is to have the dentist design one based on an impression of the diver’s teeth. Unfortunately, there are not many dentists that make custom regulator mouthpieces. My other
suggestion is that the diver use a full face mask. Caveat: these masks cost between 1-3 thousand dollars each! (One consultant feels this cost estimate to be way too high!) If the salt water causes the gag reflex, perhaps the diver should dive only in fresh water. If water seeping into the mouth between the mouthpiece and the lips causes the gag reflex, perhaps the diver should try a new mouthpiece with a different silicon seal.”

Vomiting while at depth

I was unable to locate any studies regarding vomiting during scuba diving.
The Divers Alert Network (DAN) acknowledges that divers do occasionally vomit while underwater but they do not have a protocol for this event. They also do not advise vomiting during a dive because of the risk of choking. Choking may cause a diver to rush to the surface for air. We are well aware of the dangers associated with this scenario.

If a diver must suddenly vomit during a dive, a common-sense approach might be to:
1) remove the regulator from the mouth and hold it in the hand;
2) vomit;
3) clear the regulator using the purge valve;
4) place the regulator back into the mouth;
5) contact the dive buddy and signal to
abort the dive; and
6) if safe, begin an immediate, controlled ascent to the surface.

*Another point of view is that it’s better to go ahead and vomit through the regulator. It is felt that anything would be better than the diver removing the regulator, vomiting and then reflexively gasping a lungful of salt water. The regulator can then be purged and cleared of any stomach content that might be lodged in the valves. A compromise between leaving it in and taking it out would be to leave one side of the regulator in the corner of the mouth, vomiting out the other side and immediately replacing the regulator for the next breath. This presupposes an aware, highly competent and experienced diver, however.

Recreational scuba diving is supposed to be a fun sport. If this diver is gagging and vomiting, I doubt he is having fun! If the gag reflex persists, the diver should discontinue scuba diving.


Ernest S. Campbell, M.D., FACS

5/5 - (14 votes)

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