I have chronic sinusitis, just finished a short course of azithromycin (Zithromax) and am using intranasal fluticasone (Flonase), saline irrigations, and a non‑sedating antihistamine; I stopped oxymetazoline (Afrin) due to rebound congestion and now have decreased hearing likely from eustachian‑tube dysfunction. I will be flying on Friday—should I obtain an ENT referral before travel and what measures can prevent worsening of my ear symptoms?

Management of Eustachian Tube Dysfunction and Air Travel with Chronic Sinusitis

You should obtain an ENT referral now, before your Friday flight, given your persistent eustachian tube dysfunction with hearing loss after completing antibiotics—this suggests either treatment failure requiring alternative management or an underlying structural issue that warrants specialist evaluation. 1

Immediate Pre-Flight Management

Continue Current Effective Therapies

• Maintain daily intranasal fluticasone (Flonase) twice daily to reduce mucosal inflammation and improve eustachian tube function 1, 2
• Continue high-volume saline irrigations (ideally 150ml per nostril) to mechanically clear secretions and reduce edema 1, 2
• Keep using your non-sedating antihistamine only if you have documented allergic rhinitis—otherwise discontinue it, as antihistamines can worsen congestion by drying nasal mucosa in non-allergic sinusitis 1

Add Short-Term Oral Decongestant for Air Travel

• Start oral pseudoephedrine 30-60mg, taken 30 minutes before flight and every 4-6 hours during travel to improve eustachian tube patency 1
• This is preferable to topical decongestants since you've already experienced rebound congestion from Afrin 3
• Oral decongestants theoretically widen the eustachian tube opening and reduce turbinate swelling 1

Consider Short-Course Oral Corticosteroids

• A 5-7 day course of oral prednisone (e.g., 40-60mg daily for 3 days, then taper) may rapidly reduce mucosal edema and improve eustachian tube function before your flight 1, 4
• This is particularly indicated given your marked symptoms (hearing loss) and the time-sensitive nature of your travel 1, 4

Why ENT Referral is Warranted Now

Treatment Failure Indicators

• You completed azithromycin but still have decreased hearing and ongoing symptoms—this represents either inadequate antibiotic coverage or non-infectious pathology 1, 5
• Chronic sinusitis that fails to improve after 21-28 days of treatment may be caused by resistant pathogens, nasal polyps, structural abnormalities, or non-compliance 1

Evaluation Needed Before Travel

• ENT can perform nasal endoscopy to directly visualize the middle meatus, eustachian tube opening, and assess for polyps or purulent drainage 1
• Tympanometry or audiometry can objectively document middle ear effusion and hearing loss 1
• CT scan may be indicated if not already done to evaluate for osteomeatal complex obstruction, which commonly causes recurrent infections and eustachian tube dysfunction 1, 6

Structural Concerns

• Persistent eustachian tube dysfunction after appropriate medical therapy suggests possible anatomic obstruction (septal deviation compressing middle turbinate, concha bullosa, or polyps) 1
• These structural issues will not resolve with medical therapy alone and may require surgical correction 1, 6

In-Flight Techniques to Minimize Barotrauma

Active Pressure Equalization

• Perform Valsalva maneuver (pinch nose, close mouth, gently blow) every 10-15 minutes during descent—this is more effective than passive yawning or gum chewing when eustachian tubes are inflamed 1
• Swallow frequently during descent while performing jaw-thrust movements 1
• Use oral decongestant 30 minutes before descent to maximize eustachian tube patency during the critical pressure-change period 1

Avoid Flying If Possible

• The safest recommendation is to postpone air travel until eustachian tube function normalizes—flying with existing middle ear effusion and hearing loss significantly increases risk of severe barotrauma, tympanic membrane rupture, and worsening hearing loss 1
• If travel cannot be postponed, the measures above minimize but do not eliminate risk 1

Addressing Your Antibiotic Course

Azithromycin May Have Been Inadequate

• Azithromycin is not first-line for acute bacterial sinusitis due to increasing pneumococcal resistance 1, 5
• High-dose amoxicillin-clavulanate (1.5-4g/day in divided doses) for 10-14 days is the preferred first-line antibiotic for chronic or recurrent sinusitis 1, 5, 6
• Your persistent symptoms suggest you may need a switch to broader-spectrum coverage 1, 5

ENT Can Culture and Guide Antibiotic Selection

• Endoscopic-guided culture from the middle meatus can identify resistant organisms (including anaerobes) and guide targeted antibiotic therapy 1, 6
• This is particularly important in chronic sinusitis where polymicrobial infection is common 6, 7

Common Pitfalls to Avoid

• Do not restart Afrin or any topical decongestant—you correctly stopped it, and restarting will worsen rebound congestion 3, 8
• Do not rely on antihistamines alone for congestion unless you have confirmed allergic rhinitis—they may paradoxically worsen symptoms 1
• Do not assume your hearing will spontaneously improve—persistent eustachian tube dysfunction after completing antibiotics requires evaluation for middle ear effusion, which can become chronic 1
• Do not delay ENT referral until after your trip—the specialist can provide interventions (such as oral steroids or myringotomy if severe effusion is present) that may prevent serious complications during flight 1

Long-Term Management After Travel

Evaluate Underlying Risk Factors

• Allergy testing is indicated if not already done, as allergic rhinitis is present in a significant proportion of patients with recurrent sinusitis 1, 5
• Consider immunologic assessment (quantitative immunoglobulins, functional antibody responses) if you have recurrent infections despite appropriate treatment 1, 5
• CT scan to evaluate for anatomic abnormalities (if ENT hasn't already ordered) is necessary for recurrent or chronic symptoms 1, 5, 6

Prevention Strategy

• Daily intranasal corticosteroids long-term are the most important preventive intervention for chronic sinusitis 5, 2
• Daily high-volume saline irrigation (150ml per nostril) combined with intranasal steroids is more effective than either alone 5, 2