What advice to give to a patient with a history of Acute Otitis Media (AOM) planning to travel by air?

Air Travel Advice for Patients with Prior Acute Otitis Media

For patients with a history of acute otitis media (AOM) who are planning air travel, the primary concern is preventing barotrauma during descent, which is best managed by staying awake during landing, actively swallowing frequently, and considering oral pseudoephedrine 120 mg taken 30 minutes before departure for adults with recurrent ear pain. 1

Risk Assessment Before Flight

The key to safe air travel is determining current middle ear status:

• Patients with partial middle ear fluid are at highest risk for pain during descent, while paradoxically, ears completely full of fluid typically cause no problems during flight 1
• A tympanogram can help determine middle ear fluid status and stratify risk before travel 1
• If the patient currently has active AOM or middle ear effusion, this should be identified before flight planning 2

Prevention Strategies During Flight

For All Patients with History of AOM:

Active pressure equalization techniques are essential:

• Keep the patient awake during landing and descent - this is specifically recommended by the American Academy of Otolaryngology-Head and Neck Surgery as sleeping prevents active pressure equalization 1
• Encourage frequent swallowing during descent - this is the most effective non-pharmacologic intervention 1
• Chewing gum, drinking water, or sucking on candy can facilitate swallowing 1

Pharmacologic Prevention:

• For adults with recurrent ear pain during flights: oral pseudoephedrine 120 mg taken 30 minutes before flight departure 1
• This recommendation comes from the American Academy of Otolaryngology-Head and Neck Surgery 1

What NOT to Do - Common Pitfalls

Do not prescribe antibiotics, antihistamines, intranasal steroids, or systemic steroids for prevention of ear symptoms during air travel - these have no proven benefit based on systematic reviews of randomized controlled trials and carry unnecessary risks 1

This is a critical point because many clinicians reflexively prescribe these medications, but evidence shows they are ineffective for this indication.

Special Considerations for Chronic Middle Ear Effusion

If the patient has chronic middle ear effusion (fluid persisting for months):

• The fluid may persist for months and requires monitoring every 3-6 months until resolution 1
• These patients should use the preventive strategies above (staying awake during landing, frequent swallowing, pseudoephedrine) for each flight until the effusion resolves 1
• Interestingly, research shows that ears completely filled with effusion are often asymptomatic during flight, while partially filled ears are most problematic 3

When to Delay Travel

While not explicitly contraindicated, consider delaying air travel if:

• The patient has active, acute AOM with severe symptoms 2
• There is concern for complications such as mastoiditis or intracranial extension 2
• The patient is within the first few days of antibiotic treatment for acute AOM and symptoms are not yet controlled 2

Practical In-Flight Recommendations

• Carry any pain medications (such as ibuprofen or acetaminophen) in hand luggage for immediate access if ear pain develops 4
• Avoid alcohol before and during the flight, as it can worsen eustachian tube dysfunction 4
• For children with history of AOM, parents should actively wake them during descent and encourage drinking from a bottle or sippy cup 1