Why does air travel often end in ear trouble?

Combine an aeroplane trip with a blocked nose and you may have the makings of an unpleasant travel experience.

Barotrauma is the most common medical disorder with air travel. A report (Kanick 2005) found 5% of adults and 25% of children experienced middle ear barotraumas, while another study found 65% of children and 46% of adults experienced ear pain and discomfort (Mirza, 2005). This latter study showed 31% of these passengers had ear discomfort or pain during takeoff and 85% during descent and landing (Mirza, 2005).

The major aetiological factor for barotrauma is the reduction of air pressure at high altitude. There are two types of barotraumas based on their clinical signs and pathophysiology: barotitis media and baromyringitis.

Barotitis media is defined as middle ear mucosal inflammation, haemorrhage and leakage of transudate into the middle ear. This is precipitated by moderate middle ear pressures relative to the surrounding middle ear mucosa. Symptoms include a sensation of ear blockage, followed by pain and a conductive hearing loss.

Baromyringitis is caused by large pressure differences between the middle ear and the cabin, resulting in the perforation of the tympanic membrane and causing severe pain.

There have been many cases of round window rupture occurring during air travel. A history of barotrauma presenting with vomiting, tinnitus, vertigo and imbalance, and the presence of a sensorineural hearing loss may suggest a rupture leading to a perilymph fistula¹.

A perilymph fistula is a condition where there is an abnormal communication between the inner and middle ear with resultant leakage of perilymph.

Ascent & descent

As aircraft ascend, the atmospheric pressure decreases and the gas of the middle ear expands. The Eustachian tube (if working normally) opens passively and equalizes the ambient and middle ear pressures. If the Eustachian tube does not open, then the middle ear gas will continue to expand the tympanic membrane.

This is not common during ascent but ear pain or discomfort may occur if there is Eustachian tube dysfunction. During descent, the Eustachian tube behaves differently, as air does not enter the middle ear passively. Muscular activity must open the Eustachian tube. This may be achieved by swallowing, yawning or performing the Valsalva manoeuvre².

Are children more prone to barotraumas?

Children may be more prone to otic barotraumas due to anatomic differences in the Eustachian tubes, and their increased frequency of viral upper respiratory tract infections. Some younger children will not be able to do the Valsalva manoeuvre, which will put them at risk of barotraumas.

Prevention: Infants and Children

• Sucking helps equalise the pressure in infant ears. Drinking milk from a bottle with a rubber teat, or sucking a lollipop during ascent and descent may aid in middle ear pressure regulation.
• Children may fly safely with pressure equalization tubes (grommets) because the pressure equalization in the middle ear takes place without relying on the Eustachian tube.
• Staying awake especially during descent to allow swallowing and yawning.
• Administering two sprays to each nostril of paediatric xylometazoline nasal spray every 20 minutes for one hour starting two hours prior to aircraft descent.

Prevention: Adults

• Repeated swallowing and chewing sweets or gum. Swallowing and yawning activates the muscle that opens the Eustachian tube.
• If swallowing and yawning are not successful, try the Valsalva manoeuvre, which may be used repeatedly during descent. This technique involves forced nasal expiration with the lips and nose closed.
• Patients with allergic rhinitis can take corticosteroid nasal sprays and antihistamines.
• Staying well-hydrated with non-alcoholic beverages is also important to maintain a clear ear and throat.
• Cirrus ear plugs may also be considered, and sometimes a grommet is considered.
• Staying awake especially during descent to allow swallowing and yawning.
• Administering two sprays to each nostril of adult xylometazoline nasal spray every 20 minutes for one hour starting two hours prior to aircraft descent.

1. Kanick, S.C. Doyle, W.J. Barotrauma during air travel: predictions of a mathematical model. Journal Applied Physiology 2005. 98: pp1592-1602.
2. Mirza, S. Richardson, H. Otic barotraumas from air travel. The Journal of Laryngology of Otology. May 2005. Vol 119, pp 366-370 Schumacher, M. Air travel can be a pain in the ear. Vibrations Magazine. National Foundation for the Deaf Inc. Summer 2007.