During air flight, ambient pressure alterations in the air-filled middle ear space are controlled by opening and closing of the Eustachian tube. When the Eustachian tube isn’t functioning effectively, it’s unable to equalize the pressure difference on either side of the tympanic membrane, and barotrauma or barotitis can ensue. One might assume that patients with an effusion would be particularly sensitive to this phenomenon due to the underlying Eustachian tube dysfunction, but the opposite is actually true. When the middle ear is filled with fluid, the middle ear space does not undergo pressure alterations because the Eustachian tube is functionally closed at all times. Moreover, fluid is less compressible than air and doesn’t obey the laws of gas filled spaces. So airflight with an effusion is actually the safest time to fly.

Barotrauma, or barotitis, are more likely to occur in a flyer who’s at the beginning or end of an upper respiratory tract infection, or who has chronic eustachian tube dysfunction. For those patients requiring preventative measures to prevent barotrauma, the first is repeated equalization of middle ear pressure by jaw motion, swallowing or a Valsalva’s manoeuvre. In infants, nursing (or bottle feeding) is recommended, in young children chewing gum can be used. Second-line prevention involves medical therapy. Systemic pseudoephedrine has been shown in randomized controlled trials to reduce otalgia in adults with chronic Eustachian tube dysfunction, however, results weren’t replicated in kids. This is felt to be due to a lower dosing schedule in children. Topical nasal application of oxymetazoline hydrochloride 30 minutes before ascent and descent has also been shown to reduce otalgia in adults with chronic ETD, however the differences were not significant.

Finally, several earplug devices have recently been marketed to regulate the air pressure change in the ear canal, theoretically allowing a more gradual change in air pressure, but no randomized controlled trials exist testing their efficacy.

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