How can ear symptoms be managed during air travel?

Management of Ear Symptoms During Air Travel

The most effective strategy is encouraging active swallowing during descent, particularly keeping passengers awake during landing, combined with oral pseudoephedrine 120 mg taken 30 minutes before flight departure for adults with recurrent ear pain. 1, 2

Understanding the Problem

Ear symptoms during air travel result from pressure differences between the middle ear and cabin atmosphere, occurring when the eustachian tube fails to equalize pressures during descent. 3 This affects approximately 10% of adults and 22% of children, though severe complications like tympanic membrane perforation are rare. 4

Risk Assessment Before Travel

Patients with partial middle ear fluid (mixed with air) are at highest risk for pain during descent, while ears completely full of fluid typically cause no problems. 1 A tympanogram can determine fluid status—a flat reading indicates the ear is full and safe for travel. 1

High-Risk Conditions Requiring Caution:

• Active upper respiratory infections with eustachian tube dysfunction 5
• Resolving colds with mildly blocked eustachian tubes 5
• History of recurrent ear pain during previous flights 2
• Partial middle ear effusion 1

Preventive Strategies

Pharmacological Prevention

For adults with recurrent ear pain history, oral pseudoephedrine 120 mg taken 30 minutes before departure significantly reduces ear discomfort (32% vs 62% in placebo). 2 This represents a strong evidence-based intervention with minimal adverse effects (primarily drowsiness in 7% of patients). 2

Topical nasal decongestants (oxymetazoline) taken 30 minutes before descent do NOT provide statistically significant benefit and should not be routinely recommended. 3, 4

Oral pseudoephedrine does NOT reduce ear pain in children and should not be used in this population. 3

Non-Pharmacological Maneuvers

Keep passengers awake during landing and actively encourage swallowing to equalize pressure—this is the single most important behavioral intervention. 1 The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends this approach for children with middle ear effusion. 1

Additional helpful techniques include:

• Frequent swallowing during descent 1
• Chewing gum or sucking candy 3
• Valsalva maneuver (though this may be less effective during descent) 5
• Nasal balloon inflation (limited evidence) 4

What NOT to Do

Do not prescribe antibiotics, antihistamines, intranasal steroids, or systemic steroids for middle ear effusion or prevention of ear symptoms—these have no proven benefit and carry unnecessary risks. 1 This represents a strong recommendation against these interventions based on systematic reviews of randomized controlled trials. 1

Management of Acute Symptoms

If severe ear pain develops during flight:

• Encourage repeated swallowing and yawning 3
• Attempt gentle Valsalva maneuvers 5
• Apply warm compresses if available 3

Post-Flight Complications

Severe cases can result in:

• Tympanic membrane perforation 5, 3
• Round window membrane rupture (rare) 3
• Permanent sensorineural hearing loss (very rare but documented) 5
• Vertigo and vestibular symptoms lasting months 5

Any patient with persistent severe pain, hearing loss, vertigo, or suspected perforation requires urgent otolaryngology evaluation. 5

Common Pitfalls to Avoid

• Flying with active upper respiratory infections significantly increases risk—consider postponing travel if possible. 5
• Assuming all ear fluid is problematic—completely fluid-filled ears are usually safe, while partial fluid is high-risk. 1
• Using decongestants in children—evidence shows no benefit. 3
• Relying on topical nasal decongestants—these lack proven efficacy for barotrauma prevention. 3, 4
• Prescribing antibiotics prophylactically—no evidence supports this and it contributes to resistance. 1

Special Populations

For patients with chronic middle ear effusion requiring frequent follow-up, the fluid may persist for months and requires monitoring every 3-6 months until resolution to prevent long-term complications. 1 These patients should use the preventive strategies above for each flight until the effusion resolves. 1