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Airplane Ear - Understanding treatment perspectives

Allergy, General, Infant and Children | August 27, 2015 | Author: The Super Pharmacist

Children, ENT, infant

Airplane Ear - Understanding treatment perspectives

Air travel–related ear pain results from unequal air pressure between the external atmospheric ambient air and the small volumes of air that exist within the structure of the human middle ear. Normally, the “eustachian tube,” which is a narrow passageway connecting the middle ear with the nose and throat, opens and allows the pressures to equalise. However, during air travel, the changes in cabin pressure can be quite rapid, and the eustachian tube may not open wide enough or frequently enough to normalise the pressure differential between the cabin air and the air in the middle ear. This results in “stretching” of the eardrum which causes ear pain. As the aircraft ascends and the atmospheric air pressure declines, the gas in the middle ear expands (in accordance with Boyle’s law) causing the eardrum to protrude outward which results in ear discomfort or pain. Likewise, as the aircraft descends, the atmospheric pressure rises and the air in the middle ear contracts causing the eardrum to be drawn inward producing ear pain. This condition is commonly known as “airplane ear,” also called ear barotrauma, barotitis media or aerotitis media. Actually, any situation in which rapid altitude or pressure changes occur can create the problem (see ‘Causes of Ear Barotrauma,’ below). It may be experienced when riding in elevators, diving to the bottom of a swimming pool or travelling in vehicles over mountainous regions.

How Common Is Airplane Ear?

A report found that 5% of adults and 25% of children experienced middle ear barotrauma during air flight, while another study found that 65% of children and 46% of adults experienced ear pain and discomfort. The latter study showed 31% of these passengers had ear discomfort or pain during takeoff and 85% during descent and landing.

What Are the Symptoms of Airplane Ear?

Airplane ear can occur in one or both ears. Common symptoms include:

  • Moderate discomfort or pain in one or both ears
  • Muffled hearing or slight to moderate hearing loss
  • Sensation of fullness or stuffiness in the ears
  • A need to "pop" the ears by swallowing, yawning or chewing gum

These symptoms are more likely to occur while a plane is descending and can persist after it lands. Symptoms may range in intensity from mildly uncomfortable to extremely painful, but often clear within 20 or 30 minutes after landing. Other symptoms may develop if the condition is severe or lasts more than a few hours:

  • Severe ear pain
  • Feeling of pressure in the ears (as if underwater)
  • Ringing in the ear (tinnitus)
  • Spinning sensation (vertigo)
  • Vomiting (normally resulting from vertigo)
  • Moderate to severe hearing loss
  • Bleeding or fluid coming from the ear (due to a ruptured eardrum)

What Causes Airplane Ear?

Children are generally more prone to aerotitis media due in part to anatomic differences of their eustachian tubes as well as to their increased susceptibility to upper respiratory tract infections. The eustachian tube is narrower and more horizontal in children than in adults. Children, especially those of pre-school age, have larger adenoids (small lymph glands behind the nose and above the throat) which can block the opening of the eustachian tube or act as a focus of infection causing it to swell and become narrowed.6 Airplane Ear - Understanding treatment perspectivesAny condition that blocks the eustachian tube or limits its function can increase the risk of airplane ear. Common risk factors include:

  • The common cold
  • Sinus infection
  • Hay fever (allergic rhinitis)
  • Middle ear infection (otitis media)
  • Sleeping on an airplane during ascent and descent

Occasionally, a condition known as eustachian tube dysfunction can cause dulled hearing and can worsen the symptoms of ear barotrauma. This occurs if the eustachian tube becomes blocked, if the lining of the tube swells, or if the tube does not open fully to allow air to travel to the middle ear. Colds and other nasal, sinus, ear or throat infections as well as allergies are common causes. Most people will have had one or more episodes in their life when they have a cold. The symptoms of eustachian tube dysfunction may persist for up to a week or so (sometimes longer) after the other symptoms of the infection have gone. This is because the trapped mucus and swelling may take a while to clear even when the germ causing the infection has gone. No particular treatment is needed and the symptoms will soon disappear.8 Lastly, it is important to note that any situation or activity in which rapid altitude or pressure changes occur can cause ear barotrauma. These include any of the following:

  • Scuba diving, especially with rapid ascent or breath-holding
  • Sky diving
  • High-altitude travel
  • High-impact sports: Boxing, soccer, water skiing
  • Exposure to blasting or explosions

How Is Airplane Ear prevented?

Most people recover quickly once air pressure has been equalised, and there are no long-lasting effects from airplane ears. However, for frequent air travelers, self-care measures include the following:10

Airplane Ear - Understanding treatment perspectivesPrepare for descent: Once the “fasten seatbelt” sign is turned on and the plane begins its descent, swallow several times. This helps keep the eustachian tube open and equalises ear pressure.

Chew gum: The act of chewing (like swallowing) activates the muscle that opens the eustachian tube. Once opened, a little droplet of air can pass from the nose and throat to the middle ear, thereby relieving pressure.

Yawn: This is a more powerful way to activate the muscle that opens the eustachian tube.

Try a gentle blowing maneuver (Valsalva maneuver): Another method to unblock the ears is to squeeze the nostrils shut with the thumb and forefinger, inhale through the mouth, and then attempt to force the air back into the nose. If successful, this maneuver is associated with a “popping” sensation. This popping sensation is often accompanied by mild pain, but it usually disappears quickly. This technique may have to be repeated several times.

Applying a warm, wet towel over the external ear to decrease “ambient” pressure during descent.

For infants, breast/bottle-feeding during descent, commenced when adults perceive the need to clear their ears is a useful strategy to prevent infants from crying, presumably due to barotitis.

Airplane Ear Treatment Options?

The most important preventive measure is to avoid flying when symptoms of upper respiratory tract infection are present. Recent surgical procedures involving structures of the inner or middle ear may be affected by pressure changes and are a contraindication to air travel.

Systemic decongestants

Numerous sources recommend prophylactic and therapeutic use of oral or topical nasal decongestants to prevent and treat middle-ear barotrauma. Pseudoephedrine causes adrenergic vasoconstriction which results in reduction of tissue hyperaemia and oedema, and shrinkage of swollen mucosal membranes. These effects are well documented for the nasal passages and presumably occur in other areas of the respiratory tract, including the eustachian tube. Therefore, pseudoephedrine should improve or maintain eustachian tube patency and allow equilibration of middle-ear pressures. According to the most recent review, only 2 randomised controlled studies were identified in the scientific literature that compared the efficacy of oral pseudoephedrine to placebo. In the first study,18 only 34% of subjects who received 120 mg oral pseudoephedrine at least 30 minutes before flight departure reported symptoms of ear barotrauma versus 71% of the placebo group. The second study included 190 adults, and each subject received 120mg pseudoephedrine or placebo 30 minutes before flight departure. Ear discomfort was present in 32% of those receiving pseudoephedrine versus 62% of the control group. Authors concluded that use of an oral decongestant before flying decreased the incidence of middle ear barotrauma. On the other hand, in a trial involving children, pseudoephedrine was not found to decrease in-flight ear pain and was associated with drowsiness. This may be related to the 1 mg/kg dose of pseudoephedrine given, which is a smaller dose per kilogram than the 120mg administered to the adult subjects in the above studies.

Topical nasal decongestants

Quick-acting sympathomimetic agents such as oxymetazoline hydrochloride, in the form of a nasal spray, decongest the nasal passages and may also reach the post-nasal space to allow the orifice of the eustachian tube to function more efficiently for pressure equalisation. In the study mentioned above,18 using adult volunteers with a history of ear pain during air travel, symptoms of barotrauma were reported in 64% of those receiving topical oxymetazoline nasal spray in comparison to 71% of those receiving a placebo, but this effect of oxymetazoline did not reach statistical significance. The study involved dosage just 30 minutes before descent, which may not provide the optimal effect. and the delivery to the eustachian tube orifice may not have been adequate. Perhaps two puffs inhaled one hour before take-off and two puffs 30 minutes before descent may have been more effective.

Antihistamines

Passengers with allergies may benefit from the use of an antihistamine. The ability of antihistamines to dry and reduce mucosal oedema may be sufficient to reduce swelling and clear tenacious exudates from the eustachian tube orifice.21 However, there is no scientific data at present to support their efficacy in preventing barotrauma.

Ear plugs

Small silicone rubber ear plugs marketed under the name EarPlanes have a filter that equalises the effects of cabin air-pressure changes. These may be especially helpful if a cold or sinus congestion makes it hard to relieve ear discomfort by swallowing air. EarPlanes, which are safe for children, are available in pharmacies and airport shops.

Steroid nasal spray

A steroid nasal spray may be advised if an allergy or other cause of persistent inflammation in the nose is suspected. It works by reducing inflammation in the nose. It takes several days for a steroid spray to build up to its full effect, and as such is best commenced at least 2 days prior to travel (but optimally 7 days prior).

Myringotomy

If a high-risk person finds it essential to fly, a myringotomy can be performed to help avoid the problems associated with recurrent barotrauma.15 Myringotomy involves creating a small incision or hole in the eardrum. Fluid that has accumulated behind the eardrum from the infection drains out through the incision. A small plastic or metal tube called a pressure equalizing tube is inserted through the incision and is left in place. The tube provides a ventilation hole in the eardrum, which allows the ear to heal.

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