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Take the pressure off your ear

Uncomfortable pressure, pain in the ear and impaired hearing during a flight - especially when landing - are the typical symptoms of barotrauma. This pressure injury is usually harmless and reversible, but it can also have serious consequences for the ears and hearing. This article explains what these are and how the general practitioner can advise his patients on prevention.

A barotrauma (Greek: trauma: wound / injury, baros: heaviness / weight) is a health disorder caused by negative or positive pressure in body cavities containing air and caused by rapid pressure changes when diving or flying. The barotrauma can lead to diseases of the middle ear, in extreme cases to hearing loss or retraction of the eardrum up to hearing loss.

65% of children and 46% of adult flight passengers complain of ear complaints when flying - with temporarily impaired hearing and the occurrence of pain [1]. Most people are familiar with lighter forms from mountain railways, when driving in the mountains or when flying (take-off and landing). They can usually be remedied by swallowing or exhaling vigorously with the lips closed and the nose held shut (Valsalva maneuver). However, ear pain can also occur, which can lead to tearing of the eardrum, bleeding into the middle ear, impaired hearing and vertigo with nausea and vomiting. Small children are particularly often affected because of the anatomical nature of their tubes. Children also suffer more often from viral infections of the upper respiratory tract, which lead to a blocked nose and impaired pressure equalization via the Eustachian tube (Fig. 1).

Barotrauma - consequences for the hearing organ

When flying, strong air pressure fluctuations hit the eardrum during take-off and landing. This pressure fluctuation in turn can have a whole range of health consequences, such as tearing of the eardrum with subsequent conductive hearing loss in the injured ear. If the eardrum remains stable, however, the strong pressure pulse is transmitted to the chain of the ossicles. This can break the auditory bones or tear connective tissue connections.

Such damage is difficult to operate and entails an increased risk for the patient of permanent hearing loss. In the worst case, the ossicles withstand the load, but instead the oval window (fenestra vestibuli) to the inner ear tears (Fig. 1). A similar effect occurs when the pressure fluctuation ruptures the round window (snail window), which is supposed to balance the pressure between the inner and middle ear. In extreme cases, the pressure will shred both the oval and round window. The nerve endings in the organ of Corti then die within a few hours and the ability to hear disappears.

How do pilots do it?

Given these aspects, the question arises as to how commercial pilots deal with the problem of barotrauma. A current publication from 2017 describes that limitations in the health of pilots impair flight safety. 463 pilots with ear, nose and throat barotrauma and infections of the upper respiratory tract were surveyed at the Danish Aeromedical Center. The authors compared the answers with those that were given ten years later under the same framework conditions. Over the ten years, the number of pilots flying despite signs of an upper respiratory tract infection increased significantly (42.8% to 50.1%). The proportion of people who used decongestant nasal drops increased from 43.3 to 59.5%. Of the pilots who had suffered more than one barotrauma, the previous 37.4% were now 55.5%. Barosinusitis (inflammation of one or more paranasal sinuses caused by barotrauma after flying or diving) was affected by 27.9% instead of 19.5%. Half of the pilots flew despite the symptoms of barosinusitis. Also, more professional pilots did not classify this sinus infection as a reason for reporting sickness, contrary to international aeromedical recommendations to the contrary, according to the Danish authors [2].

Pressurized cabin against thin air

It is well known that the air becomes thinner and thinner with increasing altitude. Modern commercial aircraft are therefore equipped with a pressurized cabin so that the air pressure is approximately maintained. The aircraft is virtually inflated, which means that z. B. the circumference of an A340 expands by 26 centimeters, which is a heavy load on the airframe. However, the pressure in the cabin is slightly reduced with increasing altitude during flight. The passenger experiences an increase in altitude up to about 2,400 m.

So that the pressure does not keep increasing despite all the air supply into the cabin, a valve ensures permanent balance with the atmosphere and keeps the overpressure in the aircraft within limits. Controlled by a computer, the outlet valve monitors the pressure changes in the cabin and releases air into the environment as evenly as possible. The altitude and the external pressure are also taken into account, both of which are included in the calculation of the pressure equalization in the cabin.

Difference in pressure and health problems

At a height difference of 122 m, the air pressure changes by 15 mm of mercury. A functioning Eustachian tube can compensate for this pressure difference quite well. During the landing approach, the eardrum bulges inward as the air pressure increases. The eustachian tube as a mechanical obstacle still resists the outflow of air from the inner ear. With larger pressure differences there are health effects:

  • 60 mmHg: uncomfortable feeling of pressure
  • 90 mmHg: closure of the Eustachian tube, pressure equalization is no longer possible under any circumstances. Severe earache
  • 100 - 150 mmHg: torn eardrum with cessation of pain, but hearing loss, often also dizziness, vomiting

When descending from cruising altitude (approx. 10,000 m), the cabin pressure is increased in most line machines with a pressure gradient of 80 mmHg. The usual air pressure on the ground is 1,013 hPa, while in flight it is 750 hPa, which corresponds to an altitude of around 2,400 m. The rate of pressure change is around 18.3 hPa / min when climbing and 11.0 hPa / min when descending [5]. The severity of a barotrauma is closely related to this pressure gradient.

If the pressure compensation through the tube does not work sufficiently during the climb, the air in the middle ear expands, so that the eardrum bulges outwards. The conditions are more difficult when descending. This creates a negative pressure in the middle ear, and the eardrum bulges inward. The pressure equalization must take place actively through the lip valve of the tube.

The Eustachian tube: Eustachian tube ventilates the middle ear

The Eustachian tube is about 3.75 cm long in the adult and sits on the back of the throat, about level with the nostrils. The tube is normally closed but has a high, variable permeability. Some people with a narrow or partially blocked tube have problems equalizing the pressure in the middle ear.

Due to its bending angle and shape, the tube has the ability to put the middle ear under increased pressure. Individuals with relatively large paranasal sinuses are less tolerant of changes in pressure, since the actual change in volume in the middle ear is greater for a given decrease in altitude associated with an increase in pressure. Half of the Eustachian tube is surrounded by bones, the other, membranous half, can absorb changes in pressure in the respiratory system. Muscles of the soft palate also pull on the tube when swallowing, causing it to open.

Maneuver to equalize pressure

Since the pressure equalization in the inner ear mainly takes place via the Eustachian tube, it makes sense to establish this equalization by yawning, chewing or swallowing. If that is not enough, as mentioned, the Valsalva maneuver is a suitable measure. As the nostrils are closed with the fingers, pressure builds up in the chest. Exhale through the closed nostrils. Cardiac arrhythmias can be provoked by "venous blood pooling" or cardiac arrhythmias [1].

With the Frenzel maneuver, these effects - particularly important for pilots - can be avoided. Hermann Frenzel was a German air force commander who developed this technique during the Second World War, especially for diving flights. The vocal cords were actively closed (as if you were lifting a heavy weight) and the nostrils were blocked. Now you try to form a "K" or a "Guh" with your tongue. The back third of the tongue and the Adam's apple rise. In the upper airways, air is compressed and pressure built up, which allows the middle ear to be ventilated through the tube.

Drug prevention

In the case of nasal congestion as a result of viral infections or allergies, systemic or topical drugs that decongest the nasal mucous membrane seem to be useful, such as pseudoephedrine or imidazoles (e.g. xylometazoline or oxymetazoline) to open a Eustachian tube closed by mucus and for to make the pressure equalization free. If it is not possible to pass the tubes passively due to the high viscosity of the mucus in the lumen, pressure compensation via the ear trumpet cannot take place. As described in the Danish study, pilots often use decongestants (59.5%) [2].

Some airlines, e.g. B. Lufthansa, recommend decongestant nasal sprays to prevent barotrauma. A study with 36 patients between 12 and 75 years of age who had a dry central perforation of the eardrum came to the conclusion that the topical application of a decongestant drug - but with unphysiologically high pressure (according to the Valsalva maneuver) - the function of the Eustachian tube can improve. After an unsuccessful Valsalva maneuver, 18 patients received nasal drops containing 0.1% xylometazoline directly into the pharyngeal opening of the Eustachian tube. A control group of 17 patients received a placebo (0.9% saline solution). Only one patient in this group subsequently demonstrated a successful Valsalva maneuver. In the verum group, however, ten patients felt a clearly positive effect.

Other methods without pressure development (aspiration test / deflation test) were ineffective [3]. A study with children came to the conclusion that the administration of topical decongestants (0.05% xylometazoline HCl) had no positive effect on the function of the Eustachian tube [4].

Physical methods of prevention

In the case of many passengers, the function of the Eustachian tube is impaired due to an acute (viral) infection of the upper airways and cannot be adequately opened by active measures such as chewing or swallowing. The pressure equalization does not take place, with a corresponding displacement of the eardrum and clinical symptoms. Children in whom the ear trumpet is not yet fully developed are particularly affected.

With a filter specially developed for air travel that is integrated in earplugs, continuous pressure equalization between the environment (aircraft cabin) and the middle ear is possible. Better adaptation of the pressure differences can be achieved, especially when descending [1]. The soft fins of the Sanohra fly earplugs are comfortable to wear and should be used especially when the aircraft is landing. In the start phase, on the other hand, the internal cabin pressure decreases rapidly. Such a pressure drop is usually problem-free for a healthy ear, because the Eustachian tube only has to passively release the relative overpressure in the middle ear.

The anatomical peculiarities of the Eustachian tube and infections in the upper airways cause a particular sensitivity to pressure differences during flight, especially during landing. A preventive, effective measure can be the administration of decongestant nasal drops in the case of infections, although controversial data is available here. Physical measures and chewing movements (chewing gum), swallowing (can be reached in babies by breastfeeding) and pressure build-up (Valsalva maneuver) are helpful. Earplugs have proven to be effective as they regulate pressure changes better and thereby optimize the function of the Eustachian tube.

1. Hero K .: Barotrauma on the plane. Flight and
Upper respiratory infections and barotrauma among commercial pilots.
Aerosp Med Hum Perform 2017; Jan 1, 88 (1): 17-22
3. Jensen, J. H .; Leth, N .; Bonding, P .: Topical
application of decongestant in dysfunction of
the Eustachyan tube: A randomized, doubleblind,
placebo-controlled trial. Clin Otolaryngology
4. van Herbeek, N .; Koen, J .; Ingels, O; Zielhuis,
A. No effect of a nasal decongestant on
Eustachian Tube function in children with ventilation
Tubes. Laryngoscope 2002; 112:
5. Schmitz, G .: Air conditioning of aircraft cabins
January 15, 2004. Technical University

Conflicts of Interest: The author received an author's horn from the Sanohra company.

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