Eustachian Tube Dysfunction: Preventative measures when travelling

Patients often ask what they can do to prevent that awful ear discomfort during travel, during air flights or driving though mountain passes of varying altitudes. 

You might have experienced this conundrum: pressure, plugging or horrible ear pain when descending in an airplane or you driving down from the mountains.  Or you’ve got a cold AND your folks insist you fly out, in a small single-prop, puddle-jumper (the double whammy—a harbinger for ear problems to come) since they live out in the boonies of Alaska and you absolutely must see the cute, lost grizzly cub they’re keeping as a pet. 

The problem arises from eustachian tube dysfunction (aptly shortened to ETD).  The eustachian tube (likewise abbreviated as ET) is the collapsible tunnel that travels from your middle ear space behind the eardrum (tympanic membrane, abbreviated TM) to the back of your nose (nasopharynx).

The problem arises from lack of pressure-equalization between the middle ear space and the outside environmental pressure, what we call ETD.  As one gains altitude and travels farther above sea level, atmospheric pressure gradually decreases.  There’s less air molecules as one ascends away from the earth, and air pressure is directly related to the density of air molecules (for the more technical folks: air is a combination of oxygen, nitrogen, carbon dioxide, etc., with varying degrees of carbon monoxide which is greater the closer you are to car-infested urban areas).  As one descends from higher to lower altitudes, the reverse happens and atmospheric pressure increases.  The same holds true for scuba divers or those descending into deeper water; water pressure increases on the outside of the ear relative to the middle ear as one goes deeper, but on the ascent the reverse occurs.  

The eustachian tube usually is closed or collapsed at rest, then opens and closes to equalize middle ear pressure, such that the air pressure is the same inside and outside the ear.  But during more rapid changes in altitude, more often with descending from lower to higher pressure levels, the ET may not be able to overcome the pressure difference, remaining collapsed instead.  As one continues to descend and the pressure outside the ear increases, the middle ear then has a relative negative pressure, meaning the pressure is lower behind the ear drum relative to the pressure outside it.  This causes the drum to retract inward which causes the discomfort or pain.  If the pressure difference continues, fluid from the mucosal normally lining the middle ear is sucked into the air space which causes hearing loss and more discomfort.  If fluid is not eventually drained when the ET opens, bacteria can multiply and thrive, creating pus and causing an ear infection (otitis media).  If there is excessive fluid or pus buildup, rupture through the TM can occur.

Below is a handout I give to patients who are about to travel:

Measures to Prevent ETD When Travelling

* You may do a Toynbee maneuver, especially when descending during an airflight or travel by car.  This is accomplished by squeezing the nostrils closed with your fingers and blowing your nose against this.  This brings air up from the lungs into the throat and into the back of your nose (nasopharynx). Automatically, the soft palate drops down and the tongue raises up, both to prevent air escaping through your mouth.  Air pressure then increases in the nose and nasopharynx.  Air will flow through areas of least resistance, in this case through the eustachian tubes to open them and equalize the pressure in the middle ear.  You can do this several times to help clear the ears.  However, don’t do this too forcefully to the point of discomfort—you don’t want to blow a hole through your TM.  Scuba divers are taught to do the same when gradually diving deeper below the water’s surface.

* Chew gum, especially when descending or ascending, also can help. This stimulates swallowing which helps open the eustachian tube.  When swallowing, the soft palate moves along with muscles around the throat (pharynx) which in turn pulls on tissue bands around the ET which opens the tube.  Stop the gum-chewing when no longer travelling or flying; i.e., don’t make a habit of chewing gum frequently which can lead to jaw pain and TMJ (temporal mandibular joint) problems.

* Oxymetazalone nasal spray (i.e., Afrin spray):  Use 1-2 sprays each side of the nose about 10-15 minutes before taking-off for an air-flight or driving through higher altitudes.  This takes should decongest (shrink) the tissues around the eustachian tubes and takes effect in a few minutes.  The decongestion should last 12 hours.   Do NOT use for more than three days in a row; otherwise you may experience prevent rebound nasal congestion/stuffiness or rhinitis medicamentosa.

These instructions, along with remedies for a number of other ENT problems, are found in a patient guidebook I’ve written, developed from written hand-outs provided to patients in the office.

In rare instances, a few patients begged to have ear tubes (aka, pressure-equalizing tubes or PE tubes) placed when about to take a trip by air. None of the above measures helped in the past, and flying is torture.  In these cases, we’ll do myringotomy and tubes a few weeks prior to their planned trip.  The ears will automatically equalize as air easily travels through the PE tube into-and-from the middle ear with changing altitudes, and none of the above measures are needed.  I had one patient whose spouse was a private pilot, and they flew nearly every week in their small plane, which for her was a killer for one of her ears.  She wanted ta PE tube to fly pain-free.  The PE tubes typically stay in place for 8-12 months or longer, so this worked well for her.  At one point she had a tiny hole where the tube had extruded, and she followed ever few months to make sure it was present (the hole acts as a ventilating port in lieu of a tube) or we made it larger to prevent it from healing up completely.  This is one example where an extra “hole in the head,” so to speak, is beneficial.

©Randall S. Fong, M.D.


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