Airplane ear

The typical symptoms of airplane ear include:

• Discomfort in the ears
• Pain in the ears
• Fullness in the ears
• Mild to moderate hearing loss

In severe cases, an individual may experience:

• Severe pain in the ears
• Moderate to severe hearing loss
• Tinnitus (ringing sound in the ear)
• Vertigo
• Hemotympanum (presence of blood in the middle ear cavity)

To understand the cause of airplane ear, it is important to know the normal structure of the ear and how the ear works at ground level.

Structure of the Ear

The structure of the ear is divided into three parts:

• Outer ear: The part of the ear visible from the outside. The external auditory canal connects it to the middle ear, separated by the eardrum.
• Middle ear: A tube-like structure called the eustachian tube connects the middle ear to the back of the nose, playing a crucial role in maintaining air pressure on either side of the eardrum.
• Inner ear: The inner ear contains several compartments that perform specific functions for hearing and maintaining balance.

How Does the Ear Work at Ground Level?

At normal levels, the air pressure is equal in the middle ear cavity and external ear canal. This equalization of pressure is essential for the normal functioning of the ear.

What Happens to the Ears During Flight?

• During take-offs and landings, the air pressure inside the middle ear decreases rapidly compared to the external cabin air pressure.
• This pressure difference causes the eardrum to be pulled inward.
• The eustachian tube may not react quickly enough and can become flattened.
• This stretching of the eardrum and eustachian tube leads to symptoms of ear barotrauma.

Other Conditions That Can Cause Ear Barotrauma Include:

• Scuba diving without proper gear
• Exposure to loud explosions, such as in and around a war zone
• Hyperbaric oxygen chambers
• Riding in an elevator in a tall building
• Driving in the mountains

Why Doesn't Everyone on the Flight Experience the Same Degree of Airplane Ear?

Not everyone suffers from the same intensity of airplane ear symptoms while flying. This variation is due to differences in the opening and closing of the eustachian tube. In most cases, the eustachian tube opens periodically during swallowing, yawning, and chewing, attempting to maintain equal pressure between the outside and inside of the ear.

However, individuals with a narrow eustachian tube or blockages associated with colds, throat infections, etc., are more prone to develop airplane ear or ear barotrauma.

Everybody on the flight experiences the effects of pressure changes. However, some individuals experience more severe ear pain than others. The following risk factors that block the eustachian tube or hinder its function are associated with airplane ear:

• Age: Infants and toddlers are more susceptible to airplane ear due to their small eustachian tubes.
• Medical conditions: Certain medical conditions make it difficult for the ears to adapt to rapid pressure changes, increasing the likelihood of airplane ear. These include:
  • Common cold
  • Sinusitis
  • Allergic rhinitis (hay fever)
  • Otitis media (middle ear infection)
  • Certain hormonal changes (for instance, during pregnancy)
• Sleeping or napping during air travel: Activities such as swallowing and yawning help to equalize ear pressure. These activities are reduced during sleep, increasing the chances of airplane ear if individuals take a nap during the flight.

The diagnosis of airplane ear is confirmed based on air travel history and symptoms experienced by the patient. In cases of uncertainty regarding the symptoms, confirmation is achieved through the following methods:

• Otoscopy: This involves examination of the inner ear using an instrument called an otoscope. The signs assessed with an otoscope include:
  • Bulging in the eardrum
  • Tear in the eardrum
  • Blood or fluid in the eardrum
• Audiometry: This test is performed when a person complains of hearing loss.

Airplane ear is a preventable condition. The prevention strategies can be divided into three categories:

A. Primary prevention

It involves measures that can be taken before or during any discomfort in the ears.

• Practice self-care measures: Activities such as yawning, chewing, and swallowing, especially during takeoff and landing, should be performed while flying. These activities help keep the eustachian tubes open and prevent airplane ear. Sucking on lozenges and chewing gum during ascent and descent is also helpful.
• Stay awake: Individuals should avoid sleeping or napping during ascent and descent to practice activities such as yawning, chewing, and swallowing. They can also request flight attendants to wake them up before landing.
• Use of air pressure regulating earplugs: Specialized earplugs, often sold at airports, pharmacies, or hearing clinics, help equalize pressure against the eardrum and prevent airplane ear.
• Take medications: Individuals suffering from a cold can prevent airplane ear by taking decongestants an hour before takeoff. Note: It is important to obtain consent from your healthcare provider before taking a decongestant if you have high blood pressure, a heart ailment, a heart rhythm disorder, or are pregnant.
• Use over-the-counter (OTC) nasal sprays: Nasal congestion increases the chances of airplane ear, so it is recommended to use a nasal spray about 30 minutes before takeoff.
• Blow a special autoinflation balloon: These balloons are inflated through the nose by blocking one nostril at a time and blowing through the other. They can be purchased at pharmacies and help manage pain during flying or unblock ears afterward.
• Reschedule air travel plans: If possible, try to reschedule travel plans if you are suffering from a common cold, sinusitis, nasal congestion, or have had recent ear surgery or infection, especially if you have experienced significant airplane ear symptoms during prior flights.

B. Secondary prevention

It involves strategies to prevent severe ear pain in case of ear discomfort.

• Valsalva manoeuvre: This technique helps equalize pressure in the middle ear and prevent airplane ear. It involves the following steps:
  • Take a breath.
  • Push that breath out against the closed mouth and nose.
  • Hold for 15 to 20 seconds.
  • Open the nose and mouth.
  • Breathe out.
• Ear packing: In case of bleeding, immediate ear packing should be done to prevent further damage.

C. Tertiary prevention

It involves long-term preventive techniques. A tube is surgically placed in the eardrum to aid fluid drainage and equalize pressure between the outer and middle ear. This is used for frequent fliers who are prone to severe airplane ear.

Special tips to prevent airplane ear in infants and toddlers

Infants and toddlers are more prone to airplane ear due to their small eustachian tubes. As a parent or guardian flying with kids, the following measures may help minimize symptoms of airplane ear:

• Breastfeeding
• Feeding with a bottle
• Sucking on a pacifier
• Drinking fluids through a sipper or straw

Children over 4 years of age can try the following:

• Chewing gum
• Drinking fluids through a straw
• Blowing bubbles through a straw

Note: Decongestants are usually not recommended for children under 6 years of age. Always consult the child’s pediatrician before administering them.

Preventive instructions should be provided by airplane authorities regarding this phenomenon to enhance awareness and combat the condition. Airplane ear is managed through simple techniques.

• Yawning or swallowing is recommended as it opens the eustachian tube and reduces the pressure difference, helping to ease symptoms.
• In cases of prolonged cold or allergies, medications such as antihistamines (e.g., cetirizine, fexofenadine, loratadine) and decongestants (e.g., oxymetazoline, phenylephrine, pseudoephedrine) can be taken.
• For severe pain, pain relief medications such as paracetamol may be used.
• A minor surgery known as myringotomy is performed in rare cases, where a surgical cut is made in the eardrum to drain accumulated fluids and allow equalization of pressure.

The symptoms of airplane ear are mostly self-limiting, respond well to preventive measures, and usually do not pose any complications. In very rare instances, when the eardrum is subjected to excessive pressure causing it to burst, it can lead to:

• Acute ear infections
• Hearing loss
• Chronic tinnitus (ringing in ears)
• Vertigo
• Perforation of the eardrum