Balkan Military Medical Review

Jan - Mar 2013; 16(1): 50 - 55

Review Article

Acute Barotitis Media in Flight: Pathophysiology, Symptoms, Prevention,

Treatment

Ourania FYNTANAKI1, George ALEVITSOVITIS2, Leonidas ANGELAKIS3, Vasileios

MOUTEVELIS4*

Affilation of Authors:
1. LT, MD, Aviation Medicine Office, 120 Flight Training Wing, Kalamata, Greece
2. CPT, MD, FS, Aviation Medicine Office, 120 Flight Training Wing, Kalamata, Greece
3. LT, MD, Sotiria General Hospital of Athens, Athens, Greece
4. LT, MD, FS, 251 AirForce General Hospital, Greece

Corresponding Author:
Lieutenant Fyntanaki Ourania
120 Flight Training Wing
Eirinis 6, 24100
Kalamata, Greece
Tel: 00306983525746
e-mail: raniafida@yahoo.gr
 Fyntanaki O. et al: Acute Barotitis Media in Flight
Abstract: Acute barotitis media or
aerotitis media is one of the most
prevalent medical issues caused during
flight. This is the reason that the
incidence of aerotitis media increases
not only among aviation crews but
among common travelers due to the
increasing airplane transportation. Its
pathophysiology is completely explained
by  Βoyle’s  law,  since the gas volumes in
our body and in the airplane cabin
change during the flight. In fact, the
problem is caused by the dysfunction of
equilibrium between the air in the
middle ear and the surrounding
environment. The main symptoms are
severe otic pain and partial hearing loss,
mainly during the descent. There are
many predisposing factors for this
medical condition such as a concomitant
upper respiratory infection. Many
preventive measures can be used to
avoid otic barotrauma, like the Valsalva
maneuver. The treatment is generally
symptomatic, but there are also ongoing
relevant research projects.
Key words: barotitis media, otic
barotrauma, aerotitis, eustachian tube
Introduction
In our days, acute aerotitis media
consists one of the most common problems
in flight. Taking into consideration the
progress of aviation and the increasing use
of airplane as a means of transportation,
the importance of the increasing incidence
of this condition is easily appreciated. It
occurs in conditions with severe rapid
changes of the surrounding atmospheric
pressure as in flights, in diving and in
hypobaric chambers [1, 2].
The first man who noted this
condition is Charles, a French physicist, in
51
1783, when -whilst in his first flight with a
hydrogen balloon- he experienced severe
pain in his right ear during descent [3, 4,
6].
Materials and methods
Our aim is to review the pathophy
siology, the mechanisms, symptoms, the
preventive measures and the treatment of
acute barotitis media. A literature search of
relevant published articles was performed.
Results
Pathophysiology
According   to   Boyle’s   law,   in   a  
constant temperature, the volume and the
pressure of a gas are inversely related [5].
The mathematical expression of this is the
following: P1/P2 = V2/V1, where P1 is
the initial pressure of the gas, P2 is the
final pressure, V1 is the initial volume and
V2 is the final volume [5, 6].
The pressure of the atmosphere is
760mmHg, according to the International
Civil Aviation Organization (ICAO) in sea
level and  at  15º  C.  Because  of Boyle’s  law  
as described above, this pressure decreases
gradually as we ascend above sea level. At
18,000 ft the atmospheric pressure is
380mmHg, half of that at sea level
(ICAO), while in 33,700 ft the pressure is
190mmHg [6, 7].
However, the airplane’s   cabin   is  
designed to pressurize the air in it about
three quarters of that of the atmospheric
pressure at sea level [3, 6].
During the ascent the pressure in
the airplane’s   cabin   reduces   at the above
levels and the air in the middle ear dilates.
If there are functional bilateral eustachian
tubes, there is a passive air escape through
the tubes and equalization of the ambient
pressure  with  the  middle’s ear pressure. [3,
4, 7-10]. This passive opening happens in
differential pressure of 15 mmHg and
about every 400-500 ft of ascent [3, 6, 12].
 52
During the descent, according to
Boyle’s   law,   the   ambient   pressure   rises   oedema of the mucosa of the middle ear,
while the pressure in the middle ear
decreases. Unfortunately, air cannot
passively re-enter the eustachian tube and
there is a need for an active muscular
movement for the equalization of these two
pressures on both sides of the tympanic
membrane [3, 6-10]. Such movements are
swallowing, yawning, jaw movements,
Valsalva’s   maneuver   and   Frenzel’s   any kind of eustachian tube obstruction or
maneuver [3-10]. If the above techniques
do not prove successful, because of an
eustachian tube dysfunction, the air
passenger feels severe ear discomfort at a
differential pressure of 60mmHg [3, 9].
When the differential pressure gets to
approximately 90mmHg, an irreversible
block of the eustachian tube occurs [4, 7,
13, 14] and beyond this level a rupture of
the tympanic membrane is possible. This
situation is rare and its incidence is
estimated about 4% [4].
Symptoms
The most prevalent and usually the
first symptom of a patient with barotitis is
the   ‘blockage’ of the ears. If this is not
reversed with techniques   like   Valsalva’s   air force flight maneuvers [15]. Aerotitis is
maneuver, it is usually followed by otic
pain. The pain may be severe and can be
accompanied with headache, nausea,
numbness, vomiting, vertigo, tinnitus and
conductive hearing loss [2-4, 8, 15, 16].
The hearing loss is usually acute and
transient, especially when it follows a
rupture of the tympanic membrane, which
mostly heals spontaneously without any
ear dysfunction [4, 11, 17]. More rare
complications are effusion and bleeding
into the middle ear cavity and
sensorineural hearing loss [1, 15-17].
Intracranial epidural hematoma,
perilymphic fistula, pneumocephalus and
parenchymal and extra-axial haemorrhage
have also been mentioned in the literature,
but these conditions are exceptionally rare
[12].
Balkan Military Medical Review
Vol. 16, No 1, Jan-Mar 2013
The otoscopic findings often include
capillary dilation, flushing of the tympanic
membrane and transudate fluid in the
middle ear cavity [18]. In more severe
cases, perforation of the drum with or
without hemorrhage can be seen [3, 4, 12].
Predisposing Factors
There is a clear association between
dysfunction and the incidence of aerotitis
media [13]. It is more often observed
when the passengers in the airplane are
sleeping during the descent. Medical
conditions like upper respiratory
infections, even subclinical, or any
abnormality of ear, nose or throat (ENT)
can be the underlying cause of barotrauma.
Enlarged adenoids, nasopharyngeal
carcinoma, nasal polyps, allergic or
vasomotor rhinitis, idiopathic dysfunction
of the eustachian tube predispose for
aerotitis [18, 19]. Some researchers found
an increasing incidence of otic barotrauma
in cases of higher differential pressure, i.e.
in higher altitudes [20] and in rapid
changes of ambient pressure, frequent in
particularly frequently observed in a speed
of descent more than 500 ft per min from
the level of 6000-8000 ft above the sea
level [6]. Moreover, there is higher
prevalence in women than in men and in
people less than 40 years old [20]. In
children, the frequency of aerotitis is
significantly higher than in adults at the
same travelling conditions [14]. However,
‘chronic   ears’, such as secretory otitis
media, atelelectasis and previously
operated cholosteatoma are not
predisposing factors for barotrauma [21].
Preventive Measures
Because of the pathophysiology as
explained above, it is recommended that
airplane passengers do not travel with an
 Fyntanaki O. et al: Acute Barotitis Media in Flight 53

upper respiratory infection [22]. Jaw Unfortunately this technique is not

movements, swallowing and yawing are applicable in commercial flights.
simple techniques for the equalization of Another way for easier
the pressure [3, 4, 8-10].   Valsalva’s   and   equilibration are the Air Plugs, which are
Frenzel’s  maneuvers  are used for the same silicon ear plugs with ceramic insert, that
reason [2-4, 7, 12, 17]. The first one is decreases the rapid movement of the
performed with a forced expiration, while environment air in contact with the
keeping both nose and mouth closed. The tympanic membrane [11]. However, the
second one consists of the person common earplugs are not recommended
attempting to  say  the  letter  ‘k’  with  closed   during the flight because they can roll
nose   and   mouth.   Frenzel’s   maneuver   is   deeper into the auditory canal due to the
more  difficult  than  the  Valsalva’s,  but  it  is   increasing pressure and cause direct
more effective and it does not cause trauma in the tympanic membrane [9].
elevation of the intracranial pressure as the Another preventive measure is the
Valsalva’s   maneuver   does   [3, 4, 12, 23]. use of decongestants. Researchers suggest
Moreover, it is essential to mention that that the use of an oral decongestant, such
Valsalva’s   maneuver   can   cause   as pseudoephedrine, 30 minutes before the
alternobaric vertigo or convulsive syncope flight departure is a statistically important
in pilots with low ‘G’ tolerance, which can preventive mean for aerotitis media in
be seen, although extremely rarely, in air adults, but it is not effective in children
force pilots during demanding maneuvers [24, 25]. As far as topical decongestants
[8]. The above practices are recommended are concerned, the use of a nasal spray (eg
to be performed every few seconds, oxymetazoline) is recommended one hour
especially every time the feeling of ear before the departure and 30 minutes before
fullness returns. The opposite technique is the expected arrival with uncertain results
the Tonbee maneuver, which can be [2, 3, 24].
performed by swallowing with closed nose Systemic antihistamins could be
and it is used to force the air out of the used for the prevention of acute aerotitis
middle ear cavity and can be used in ascent media, mainly in virus infections of the
in case of a difficult equalization [3, 12, upper respiratory and in allergic rhinitis.
23]. When there is high risk of aerotitis
Another method that is selected media and air transport is unavoidable,
mostly in children and simulates there is the option of ventilation of the ear
Valsalva’s  maneuver  is  the  ‘Otovent’ [14]. by myringotomy, with or without
This is a balloon full of air that is applied grommets [3].
in each nostril, with the other nostril closed Finally, a new possible promising
with the hand, the inflation of which is technique for the prevention of acute
capable of opening the eustachian tube. It aerotitis media is laser eustachian
is important to mention the feeding tuboblasty, which can provide flights free
technique for young children and babies of otic pain in patients predisposed to otic
during the descent that eliminates the barotraumas [3].
incidence of barotitis media [3, 14].
When it is possible, especially in Treatment
aviation crews, in private flights and It is important for the patient not to
hypobaric chambers, it is suggested to stop fly, dive or have a challenge in a hypobaric
the descent and equalize the pressure in the pressure chamber until the symptoms
middle ear with the ambient in higher subside [9]. Treating the possible
altitude than that the otic pain started [12]. underlying condition, such as an infection,
 54
helps the prevention and the cure of
aerotitis. For the opening of the eustachian
tube in case of persistent otic pain because
of aerotitis media, middle ear inflation
with Politzer’s  bag  or  Valsalva’s  maneuver   air travel. The journal of laryngology
can be used [3, 12, 14]. Oral and topical
decongestants are recommended for the
treatment of otic barotrauma. The use of
antihistamins is not well established. In
constant transudate fluid in the middle ear,
needle aspiration is suggested, while in
more severe cases myringotomy is
preferred [10, 12]. The use of antibiotics is
not necessary unless signs of infection are
obvious. Although in most cases of
tympanic rupture spontaneous healing
occurs, sometimes the healing is slow and
difficult. For these cases tympanoplasty is
recommended [10]. Moreover, there is an
interesting perspective for the use of
artificial eustachian tube surfactant in the
treatment of acute aerotitis media but this
therapeutic option is still at research level
[26].
Discussion
Acute barotrauma of the middle ear
is a common health problem in our days,
and anyone may experience associated
severe pain. Nevertheless, it is almost
always a condition that can be prevented
with simple measures that anyone can
perform. Informing the air-passengers
about this condition is important, as well as
their education about the preventive
measures. Treatment is mainly
symptomatic, while more research has to
be done at this domain.
References
1. Daniel Jethanamest, MD et al:
Audiologic and Vestibular
Manifestations of Free Diving Inner
Ear Barotrauma, Triological Society
Posters, 115th Annual Meeting, Apr
2012
Balkan Military Medical Review
Vol. 16, No 1, Jan-Mar 2013
2. Saski Arora, Aerotitis media, Eds: Self
Assesment and Review ENT, Jaepee,
2009 pp 90
3. S. Mirza et al, Otic barotraumas from
and otology 119: 366-370, May 2005
4. P.F. King, Otic barotraumas. Audiology
15: 279-286, 1976
5. Jonh B. West: The original presentation
of Boyle's law. J Appl Physiol 87:
1543-1545, 1999
6. R.M. Harding, The atmosphere of
earth,Eds: Aviation Medicine, John
Ernsting et al, 2003, Bita medical arts,
pp 6-16.
7. PD Hodkinson: Acute Exposure to
Altitude. J R Army Med Corps
157(1):85-91
8. Subhabrata Ghosh et al: Study of
middle ear pressure in relation to
eustachian tube patency. Ind J
Aerospace Med 46(2), 2002
9. Antony Jarrett: Reversed-Ear Syndrome
and the Mechanism of Barotrauma.
British Medical Journal, pp 483-486,
Aug 1961
10. P.F. King et al: Otic barotrauma and
related conditions, Eds: Stuart
Mawson, Section of otology, Volume
68, 1975, pp 817-820
11. Gary D. Becker, Barotrauma of the
ears and sinuses after scuba diving,
Eur Arch Otorhinolaryngol 258:159-
163, 2001
12. Barotrauma, Otorhinolaryngology,
Seabee Operational medical and dental
guide
13. Miyazawa T et al: Eustachian tube
function and middle ear barotraumas
associated with extremes in
atmospheric pressure, Ann Otol Rhinol
Laryngol., 105(11):887-892, Nov 1996
14. Stangerup S.E. et al: Barotrauma in
children and adults after flying.
Prevalence and treatment with
Otovent, Ugeskr Laeger 16(12):1794-
6, Mar 1998
 Fyntanaki O. et al: Acute Barotitis Media in Flight
15. Maria D. P. Cortes: Barotrauma
Presenting as Temporal Lobe Injury
Secondary to Temporal Bone Rupture.
AJNR 26: 1218-1219, 2005
16. Westerman ST, Aerotitis: cause,
prevention, and treatment., J Am
Osteopath Assoc. 90(10):926-8, Oct
1990
17. MH Azizi: Ear Disorders in Scuba
Divers, www.theijoem.com 2(1); Jan
2011
18. Stephen Chad Kanick and William J.
Doyle: Barotrauma during air travel:
predictions of a mathematical model. J
Appl Physiol 98:1592-1602, 2005
19. Morgagni F: Predictors of ear
barotrauma in aircrews exposed to
simulated high altitude. Aviat Space
Environ Med. 83(6):594-7, Jun 2012
20. Fitzpatrick DT, Risk factors for
symptomatic otic and sinus barotrau
mas in a multiplace hyperbaric
chamber, Undersea Hyperb
Med. 26(4):243-7, 1999
21. Sadé   J et al: Barotrauma vis-a-vis the
"chronic otitis media syndrome": two
55
conditions with middle ear gas
deficiency, Is secretory otitis media a
contraindication to air travel?, Ann
Otol Rhinol Laryngol. 112(3):230-5,
Mar 2003
22. Harold Ludman, Pain in the ear, ABC
of ENT. British Medical Journal 281:
1538-1541, Dec 1980
23. Hans Ornhagen et al, Ear nose and
throat problems in diving, UHMS
workshop, Medical aspects of diving
safety, Atami, Japan, 2004
24. Cuneyt M et al: Eustachian tube,
middle ear and mastoid: anatomy,
physiology, pathophysiology and
pathogenesis, Eds: Lim, Recent
Advances in Otitis Media
25. Csortan E et al: Efficacy of
pseudoephedrine for the prevention of
barotrauma during air travel. Annals
of Emergency Medicine 23(6):1324-
1327, 1994
26. Feng L et al: An experimental study on
the therapeutic effects of eustachian
tube surfactant in barotitis media
16(11):613-5, Nov 2002