Ask the Doctors: Countering painful ear pressure when flying

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Q: Are some people just not meant to fly? I get severe ear pain when my plane is descending. I've tried chewing gum and repeated swallowing, and I never fly with a sinus condition. Unfortunately, I have clogged-up ears for several weeks afterward. Any suggestions?

A: First, let's look at the cause of ear pain when we fly. Initially, we experience a decrease in outside pressure as we ascend into the sky. This decrease causes less external pressure upon the eardrums. Thus, the air behind the eardrums (in the middle ear) pushes them outward.

Airplane cabins are pressurized to minimize this decrease in pressure, and the body does its part as well. For starters, the middle ear equilibrates some of the pressure difference within it by removing the air through the Eustachian tubes, where it is released into the back of the nose and expelled into the environment. Part of that excess air in the middle ear is absorbed by its mucous membranes.

But, as we descend, the external pressure on our ears begins to increase again to that of the landing altitude. This pressure pushes the eardrums inward. Again, the Eustachian tubes are important because they allow the external air to enter through the back of the nose and balance the pressure between both sides of the eardrums.

If a person has significant nasal congestion, the Eustachian tubes can be blocked, meaning the middle ear can't equilibrate on descent. Thus, the outside pressure pushes in on the eardrums, stretching them inward. As you know, this causes significant pain and, in some people, a swelling of the middle ear and a rupture of the eardrum. Infants and toddlers, whose Eustachian tubes are more susceptible to closure, will let you know how these changes in pressure affect them.

Chewing gum and swallowing can help some people by opening up the Eustachian tubes; so too can closing off the nose with the fingers and exhaling forcefully to help bring air into the middle ear. You can even purchase devices that help place air into the nose while swallowing, so as to open the Eustachian tubes.

This advice doesn't pertain to you, of course. It's possible you have chronic nasal congestion caused by allergies or environmental irritants. If that's the case, you have several straightforward options.

Nasal steroids, for starters, can decrease the nasal swelling and increase the ability of the Eustachian tubes to stay open. Because it may take five to six days before you notice an improvement in swelling, I would recommend that you take one of these drugs for three weeks prior to flying. The allergy and asthma drug Montelukast -- taken for a week before flying -- also may help reduce nasal congestion from allergies, benefitting the Eustachian tubes. Then there are over-the-counter nasal decongestants like Afrin, which also can be used to decrease nasal swelling and keep the Eustachian tubes open. There are no good studies on their use for this purpose, but I often recommend using them two hours prior to landing. You can also try -- and this is my recommendation -- a combination of all three.

Before you do, however, my suggestion is for you to ask your doctor why your Eustachian tubes become blocked with air travel. He or she can best guide your next steps. It's unlikely that you simply "weren't meant to fly."

Robert Ashley, M.D., is an internist and assistant professor of medicine at the University of California, Los Angeles. Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.

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