What treatment options are available for a patient experiencing ear congestion after a flight?

Management of Ear Congestion After Flight

For ear congestion after a flight, start with NSAIDs (ibuprofen) or acetaminophen at fixed intervals combined with repeated Valsalva maneuvers, chewing, yawning, or earlobe extension, and if these fail within 24-48 hours, use nasal balloon autoinflation (Otovent device) to equalize middle ear pressure. 1

Immediate Treatment Approach

First-Line Pain and Inflammation Management

• Administer NSAIDs (ibuprofen) or acetaminophen at scheduled intervals rather than as-needed dosing, as pain is easier to prevent than treat once established 1
• NSAIDs are superior to acetaminophen alone because they address both pain and the underlying inflammation from barotrauma, which is the primary pathophysiology 1
• Pain should improve within 24-48 hours; lack of improvement requires reassessment for complications 1

Pressure Equalization Techniques

• Perform the Valsalva maneuver repeatedly during the first 24-48 hours to open the Eustachian tube and equalize middle ear pressure 2, 1
• Additional maneuvers include chewing, yawning, and earlobe extension, which can provide immediate symptomatic relief 2, 1
• These techniques work by mechanically opening the Eustachian tube and should be attempted multiple times 1

When Simple Maneuvers Fail

• If the Valsalva maneuver is unsuccessful (fails to equalize pressure in approximately 54% of adults and 67% of children), use nasal balloon autoinflation with an Otovent device 3, 4
• Nasal balloon inflation successfully normalizes middle ear pressure in 69-73% of patients who failed Valsalva maneuvers 3, 5
• This device can be used by patients themselves and is particularly effective in children who have difficulty performing Valsalva maneuvers 4

What NOT to Do

Avoid Unnecessary Medications

• Do not prescribe systemic antibiotics unless there is evidence of acute otitis media with purulent otorrhea or systemic infection, as barotrauma is a mechanical injury, not an infection 1
• Do not prescribe antihistamines, intranasal steroids, or systemic steroids for ear congestion after flight, as they have no proven benefit and carry unnecessary risks 6
• Avoid benzocaine otic solutions, as they are not FDA-approved for this indication and may mask progression of underlying disease 1

Important Contraindication

• Do not use oral decongestants (pseudoephedrine/ephedrine) in patients with glaucoma, narrow angles, or increased intraocular pressure, as these sympathomimetic agents can precipitate acute angle-closure glaucoma through pupillary dilation 7

When to Reassess

Red Flags Requiring Further Evaluation

• If pain persists beyond 48-72 hours or worsens, perform otoscopy to rule out tympanic membrane perforation, middle ear effusion, or secondary acute otitis media 1
• Severe cases can result in tympanic membrane rupture, permanent sensorineural hearing loss, and prolonged vestibular symptoms lasting months 8
• Persistent Eustachian tube dysfunction may last months to years in some patients and requires specialized otolaryngologic evaluation 9

Prevention for Future Flights

For Patients with Recurrent Problems

• The American Academy of Otolaryngology-Head and Neck Surgery recommends keeping passengers awake during landing and actively encouraging swallowing, combined with oral pseudoephedrine 120 mg taken 30 minutes before flight departure for adults with recurrent ear pain 6
• Nasal balloon inflation during descent reduces the incidence of barotitis from 15% to 6% in prospective controlled studies 5
• Frequent swallowing during descent is helpful for pressure equalization 6

Risk Assessment

• Patients with partial middle ear fluid are at highest risk for pain during descent, while ears completely full of fluid typically cause no problems 6
• For patients with chronic middle ear effusion, use preventive strategies for each flight until the effusion resolves, which may take months 6