Ear-Popping Questions!

Eileen * comes to our ENT offices late on a winter afternoon complaining of ear pain and cold-like symptoms: headache, coughing, sneezing and congestion. She says her ears feel full and she feels like she is hearing everything underwater. She also reports intermittent dizziness and tinnitus. The ENT refers her to me, the audiologist, to assess the effects on her hearing. In his notes, he writes that his scope revealed signs of a bacterial sinus infection. Treatment will require antibiotics and a possible steroid taper if the infection does not clear.

Sitting in my office, the patient tells me that she has a cross-country flight for work tomorrow, with a return the following day. “Will it damage my hearing to fly if I already feel such fullness and pain?” she asks.

I get this question from patients at least once a day in our busy ENT practice on the Upper East Side of Manhattan. While most of my day is spent testing patients’ hearing and fitting hearing aids—on up to 30 patients per day—I am surprised at how often I address ear-pain and airplane-related issues.

When it comes to flying, patients can manage minor cold symptoms, such as a stuffy nose, with over-the-counter decongestants. Their symptoms usually resolve after a short time. However, a longer-term bacterial infection and inflammation of the sinuses may be more of a concern, especially if, as in Eileen’s case, there are accompanying ear pain and upcoming flights.

For many patients, it can be difficult to alter existing travel plans due to illness, so it is important that we educate patients about what to do if they experience trauma to the ear and symptoms persist after flying. We also need to recognize when patients’ symptoms require referral to a physician for more targeted treatment or advice. My goal here is to help audiologists make such determinations by describing how the eardrum changes in flight, how patients can minimize discomfort, and when and why flying while sick may be cause for concern.

Patients can manage minor cold symptoms with over-the-counter decongestants. However, a longer-term bacterial infection and inflammation of the sinuses may be more of a concern.

Air Pressure and Ear Popping:

Extreme air-pressure changes in the airplane cabin during ascent and descent affect functioning of the Eustachian tube—located within the middle ear, near the back of the nose. The tube is made of muscle, which regularly contracts to allow pressure to equalize in the nose and middle ear space (see sources). We can manually force this tube open by chewing, yawning, swallowing, or pinching our noses and gently blowing to “pop” the ears.

However, an adult with a head cold or sinus congestion may have tissue-swelling, which prevents normal opening of the tube and pressure equalization while flying. Sound is conducted from the outer ear, through the middle ear to be processed by the cochlea, located within the inner ear. If there’s a problem with sound conduction through the middle ear space and Eustachian tube, hearing ability is temporarily reduced.

As the plane climbs after taking off, air pressure in the cabin drops, which makes sense since we know that air gets thinner as altitude increases (see sources). As air pressure decreases, positive pressure increases behind the eardrum. The Eustachian tube then releases or “equalizes” this positive pressure via a natural opening process. As the plane reaches cruising altitude, our ears typically feel fine (see sources).

As the airplane descends, we are most likely to feel unpleasant effects in our ears: pressure or popping. This happens because as air pressure in the cabin increases again, negative pressure builds behind the eardrum. Negative pressure feels worse to us than positive pressure, as it essentially sucks and seals the Eustachian tube closed.

A patient who has ear pain going into a flight may afterwards experience bariotitis: feelings of fullness or pain, with possible reduction in hearing, but no physical alteration or damage to the eardrum. Barotrauma, on the other hand, includes the former symptoms, plus imbalance and possible hematoma or eardrum perforation (see sources).

As a hearing health care professional, I consider it my responsibility not only to advise the patients that I see, but also to respond appropriately when asked ear-related questions by friends and family. Clinicians need to ask appropriate history questions to assess symptom severity and advise patients whether to push through mild discomfort or seek professional attention.

An adult with a head cold or sinus congestion may have tissue-swelling, which prevents normal opening of the Eustachian tube and pressure equalization while flying.

Flying Questions:

After you describe the basics of Eustachian tube function and flying to patients, they will likely have some questions for you. Here are some examples of follow-up questions I typically get—and how I answer them:

How Can I Minimize Ear Pain or Discomfort if I Have to Fly?

You can try using EarPlanes. These small, blue-silicone, disposable pressure-regulating earplugs, made by Cirrus Healthcare Products LLC, attenuate up to 20 decibels and help equalize air pressure in the ear (you can purchase them in any drugstore). Insert EarPlanes 40 minutes before descent and right before ascent, if needed. Insert them properly by tugging your earlobe up and back.

You could also try taking a decongestant and nasal spray one hour before ascent, and 30 minutes before landing if the flight takes more than four hours. One negative to decongestant use, however, is that it may make the patient more prone to sleep during the flight, which means less swallowing. Swallowing manually opens the Eustachian tube, stimulating the natural process of air pressure equalization in the middle ear (see sources).

How Do I Know if I Have Eustachian Tube Dysfunction After Flying?

Symptoms of Eustachian tube dysfunction can manifest in many ways: ear pain, fullness or muffled (decreased) hearing. This dysfunction can give way to fluid build-up in the middle ear space, if left untreated. Build-up can cause conductive hearing loss: a temporary decrease in hearing, usually in the lower pitches, with no permanent damage to the cochlea or auditory nerve. When you have conductive hearing loss, sound needs to be louder than usual to conduct through the fluid-filled middle ear space, and hearing may feel muted. In most instances, a conductive hearing loss can be treated with antibiotics, steroids or insertion of a small pressure-equalizing tube to drain the fluid.

So, Should I Fly or Not When I’m Sick?

If you’re experiencing ear pain, try to reschedule your flight and wait a few days to see if the feeling resolves. If you have to fly with ear pain and you cannot manually equalize (or “pop”) the pressure in your ears 48 hours after flight descent, schedule an appointment with a primary care physician or ENT. Waiting and self-medicating with decongestants are not enough if there are signs of bariotitis or barotrauma to the eardrum.

Severe symptoms may include, but not be limited to, bleeding from the ear, pain, imbalance, vertigo, hearing loss and tinnitus (see sources). However, if you just have ear fullness, the risk of damaging your eardrums is minimal, and you can fly. Bon voyage!

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