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BMJ Clin Evid. 2007; 2007: 0501.
Published online 2007 September 1.
PMCID: PMC2943805

Middle-ear pain and trauma during air travel

Dr Arin Basu, MD MPH

Abstract

Introduction

Changes in air pressure during flying can cause ear-drum pain and perforation, vertigo, and hearing loss. It has been estimated that 10% of adults and 22% of children might have damage to the ear drum after a flight, although perforation is rare. Symptoms usually resolve spontaneously.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of interventions to prevent middle-ear pain during air travel? We searched: Medline, Embase, The Cochrane Library and other important databases up to April 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found four systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review we present information relating to the effectiveness and safety of the following interventions: nasal balloon inflation; oral pseudoephedrine; and topical nasal decongestants.

Key Points

Changes in air pressure during flying can cause ear-drum pain and perforation, vertigo, and hearing loss. Barotitis is inflammation of the ear drum as a consequence of air pressure changes.

  • It has been estimated that 10% of adults and 22% of children might have damage to the ear drum after a flight, although perforation is rare.
  • Symptoms usually resolve spontaneously.

Nasal balloon inflation may reduce symptoms of barotitis in people during air travel.

Oral pseudoephedrine may reduce symptoms in adults with previous ear pain during flights.

  • We don't know whether oral pseudoephedrine is also beneficial in children, but it can cause drowsiness.

We don't know whether topical nasal decongestants can prevent symptoms of barotrauma.

About this condition

Definition

The effects of air travel on the middle ear, as a result of changes in air pressure, can include ear-drum pain, vertigo, hearing loss, and ear-drum perforation.

Incidence/ Prevalence

The prevalence of symptoms depends on the altitude, type of aircraft, and characteristics of the passengers. One point prevalence study found that, in commercial passengers, 20% of adult and 40% of child passengers had negative pressure in the middle ear after flight, and that 10% of adults and 22% of children had otoscopic evidence of damage to the ear drum. We found no data on the incidence of perforation, which seems to be extremely rare in commercial passengers.

Aetiology/ Risk factors

During aircraft descent, the pressure in the middle ear drops relative to that in the ear canal. A narrow, inflamed, or poorly functioning Eustachian tube impedes the necessary influx of air. As the pressure difference between the middle and outer ear increases, the ear drum is pulled inwards.

Prognosis

In most people, symptoms resolve spontaneously. Experience in military aviation shows that most ear-drum perforations will heal spontaneously.

Aims of intervention

To prevent ear pain and trauma during air travel.

Outcomes

Barotrauma (includes incidence and severity of pain and hearing loss, and incidence of perforation of ear drum).

Methods

Clinical Evidence search and appraisal April 2007. The following databases were used to identify studies for this systematic review: Medline 1966 to April 2007, Embase 1980 to April 2007, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2007, Issue 1. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), Turning Research into Practice (TRIP), and NICE. We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the author for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language, at least single blinded, and containing more than 20 individuals of whom more than 80% were followed up (those studies with less than 80% follow-up but with intention-to-treat analysis were considered). There was no minimum length of follow-up required to include studies. We excluded all studies described as “open”, “open label”, or not blinded unless blinding was impossible. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).

Table
GRADE Evaluation of interventions for Middle-ear pain and trauma during air travel.

Glossary

Barotrauma
Symptoms caused by changes of atmospheric pressure are called barotrauma. In the ear, these include ear drum pain, vertigo, hearing loss, tinnitus, and ear drum perforation.
Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Very low-quality evidence
Any estimate of effect is very uncertain.

Notes

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

References

1. Stangerup S-E, Tjernstrom O, Klokke M, et al. Point prevalence of barotitis in children and adults after flight, and the effect of autoinflation. Aviat Space Environ Med 1998;69:45–49. [PubMed]
2. O'Reilly BJ. Otorhinolaryngology. In: Ernsting J, Nicholson AN, Rainford DJ, eds. Aviation medicine. 3rd ed. Oxford: Butterworth-Heinemann, 1999:319–336.
3. Stangerup SE, Klokker M, Vesterhauge S, et al. Point prevalence of barotitis and its prevention and treatment with nasal balloon inflation: a prospective, controlled study. Otol Neurotol 2004;25:89–94. [PubMed]
4. Jones JS, Sheffield W, White LJ, et al. A double-blind comparison between oral pseudoephedrine and topical oxymetazoline in the prevention of barotrauma during air travel. Am J Emerg Med 1998;16:262–264. [PubMed]
5. Csortan E, Jones J, Haan M, et al. Efficacy of pseudoephedrine for the prevention of barotrauma during air travel. Ann Emerg Med 1994;23:1324–1327. [PubMed]
6. Buchanan BJ, Hoagland J, Fischer PR. Pseudoephedrine and air travel-associated ear pain in children. Arch Pediatr Adolesc Med 1999;153:466–468. [PubMed]
2007; 2007: 0501.
Published online 2007 September 1.

Nasal balloon inflation

Summary

Nasal balloon inflation may reduce symptoms of barotitis in people during air travel.

Benefits and harms

Nasal balloon inflation versus control:

We found one controlled trial comparing nasal balloon inflation during flight versus no nasal balloon inflation.

Barotrauma

Nasal balloon inflation compared with no nasal balloon inflation Nasal balloon inflation during flights may be more effective at reducing barotitis compared with controls (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Barotitis
120 people Barotitis
2/36 (6%) with nasal balloon inflation
10/69 (15%) with control

P <0.05
See further information on studies for methodological details
Effect size not calculatednasal balloon inflation

Adverse effects

No data from the following reference on this outcome.

Further information on studies

The intervention and control groups took different flights — which may lead to bias. The trial was of sufficient sample size and power to detect the efficacy of nasal balloon inflation in reducing the symptoms of barotrauma during flight among adults. 105 people who had negative middle-ear pressure after the flight performed a valsalva manoeuvre (forceful blowing of air while keeping the mouth and nose closed), after which 48/105 (46%) had equalised their middle-ear pressure. The remaining 57 underwent nasal balloon inflation. The study found that 36/52 (69%) were able to equalise their middle-ear pressure after nasal balloon inflation.

Comment

None.

Substantive changes

No new evidence

2007; 2007: 0501.
Published online 2007 September 1.

Pseudoephedrine (oral) in adults

Summary

Oral pseudoephedrine may reduce symptoms in adults with previous ear pain during flights.

Benefits and harms

Oral pseudoephedrine versus placebo:

We found no systematic review. We found two RCTs in adult passengers with a history of ear pain during air travel.

Barotrauma

Oral pseudoephedrine compared with placebo Oral pseudoephedrine is more effective than placebo at reducing the symptoms of barotrauma during air travel — such as ear pain and hearing loss — in adults with a history of ear pain (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Symptoms of barotrauma

RCT
3-armed trial
150 adults Proportion of people with symptoms of barotrauma (ear pain, blockage, hearing loss, dizziness/vertigo, and tinnitus; assessed by post-flight questionnaire)
14/41 (34%) with pseudoephedrine 120 mg
29/41 (71%) with placebo

RR 0.48
95% CI 0.29 to 0.67
Moderate effect sizepseudoephedrine

RCT
190 adults Proportion of people reporting ear pain (assessed by post-flight questionnaire)
25/96 (26%) with pseudoephedrine 120 mg
43/94 (46%) with placebo

P = 0.007
Effect size not calculatedpseudoephedrine

RCT
190 adults Proportion of people reporting hearing loss (assessed by post-flight questionnaire)
20/96 (21%) with pseudoephedrine 120 mg
38/94 (40%) with placebo

P = 0.006
Effect size not calculatedpseudoephedrine

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Drowsiness

RCT
3-armed trial
150 adults Drowsiness
4/41 (10%) with pseudoephedrine 120 mg
2/41 (5%) with placebo

Significance not assessed

RCT
190 adults Drowsiness
7/96 (7%) with pseudoephedrine 120 mg
2/94 (2%) with placebo

Significance not assessed
Dry mouth

RCT
3-armed trial
150 adults Dry mouth
4/41 (10%) with pseudoephedrine 120 mg
1/41 (2%) with placebo

Significance not assessed

RCT
190 adults Dry mouth and nausea
4.2% with pseudoephedrine 120 mg
4.3% with placebo
Absolute numbers not reported

Significance not assessed
Nasal irritation

RCT
3-armed trial
150 adults Nasal irritation
1/41 (2%) with pseudoephedrine 120 mg
0/41 (0%) with placebo

Significance not assessed
Gastrointestinal symptoms

RCT
3-armed trial
150 adults Stomach upset
1/41 (2%) with pseudoephedrine 120 mg
0/41 (0%) with placebo

Significance not assessed
Headache

RCT
3-armed trial
150 adults Headache
0/41 (0%) with pseudoephedrine 120 mg
1/41 (2%) with placebo

Significance not assessed

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

2007; 2007: 0501.
Published online 2007 September 1.

Pseudoephedrine (oral) in children

Summary

We don't know whether oral pseudoephedrine is beneficial in children, but it can cause drowsiness.

We found no clinically important results from RCTs about the effects of oral decongestants compared with topical decongestants in children with ear pain during air travel.

Benefits and harms

Pseudoephedrine (oral) in children versus placebo:

We found no systematic review. We found one RCT. We found no RCTs comparing oral versus topical decongestants in children.

Barotrauma

Oral pseudoephedrine compared with placebo Oral pseudoephedrine may be no more effective at reducing ear pain at take-off or landing compared with placebo (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Ear pain

RCT
50 children aged 6 months to 6 years, total of 91 flights assessed Proportion of children reporting ear pain take off
2/50 (4%) with pseudoephedrine
2/41 (5%) with placebo

P = 1.0
Not significant

RCT
50 children aged 6 months to 6 years, total of 91 flights assessed Proportion of children reporting ear pain landing
6/49 (12%) with pseudoephedrine
5/39 (13%) with placebo

P = 1.0
Not significant

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Drowsiness

RCT
50 children aged 6 months to 6 years, total of 91 flights assessed Proportion of children reporting drowsiness take off
30/50 (60%) with pseudoephedrine
11/41 (27%) with placebo

P = 0.003
Effect size not calculatedplacebo

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

2007; 2007: 0501.
Published online 2007 September 1.

Nasal decongestants (topical)

Summary

We don't know whether topical nasal decongestants can prevent symptoms of barotrauma.

We found no clinically important results about the effects of topical decongestants compared with other topical nasal decongestants or oral decongestants in adults with ear pain during air travel.

Benefits and harms

Topical decongestants versus placebo:

We found no systematic review. We found one RCT. The RCT did not directly compare topical versus oral decongestants. We found no RCTs comparing other topical nasal decongestants versus oral decongestants or versus placebo or during air travel.

Barotrauma

Nasal decongestant compared with placebo Nasal decongestant (oxymetazoline nasal spray) is no more effective than placebo at reducing symptoms of barotrauma in adults with a history of ear pain during air travel (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Barotrauma

RCT
3-armed trial
150 people with a history of ear pain during air travel Proportion of people with symptoms of barotrauma (ear pain, blockage, hearing loss, dizziness/vertigo, and tinnitus; assessed by post-flight questionnaire)
27/42 (64%) with oxymetazoline 0.05%
29/41 (71%) with placebo

P = 0.695
Not significant

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Nasal irritation

RCT
3-armed trial
150 people Nasal irritation
6/42 (14%) with oxymetazoline 0.05%
0/41 (0%) with placebo

Significance not assessed
Drowsiness

RCT
3-armed trial
150 people Drowsiness
1/42 (2%) with oxymetazoline 0.05%
2/41 (5%) with placebo

Significance not assessed
Dry mouth

RCT
3-armed trial
150 people Dry mouth
1/42 (2%) with oxymetazoline 0.05%
1/41 (2%) with placebo

Significance not assessed
Gastrointestinal symptoms

RCT
3-armed trial
150 people Stomach upset
1/42 (2%) with oxymetazoline 0.05%
0/41 (0%) with placebo

Significance not assessed
Headache

RCT
3-armed trial
150 people Headache
1/42 (2%) with oxymetazoline 0.05%
1/42 (2%) with placebo

Significance not assessed

Further information on studies

The RCT may have been too small to detect an effect of topical decongestants.

Comment

None.

Substantive changes

No new evidence


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