During flying (or high hill-walking) I experience pain that seems to be due to a pocket of air that is separate from the middle ear, and that has difficulty equalising with the decreased pressure of the middle ear region. The pain builds up over a few hours, but disperses as soon as I descend again. The pain is not accompanied by any loss of hearing or of balance.
This is not a Eustachian tube problem. Because that was such an obvious place to look first, I had a T-tube inserted - but the problem remains, exactly as before. So the question is: Where could there be an additional air-filled region?
Sometimes the problem clears itself during the time at high altitude - a process that involves a couple of minutes of a bubbling/seeping noise within the ear (bringing extra air into the middle ear, so I used to have to swallow before the T-tube was there). If this happens, the pain goes away. But we haven't yet found a way to make sure this does happen.
Any ideas? Is there even a way to scan the region to check it out?
University of Glasgow
Scotland, UK
Answer------
As I understand the problem, pain in the ear is experienced during ascent into higher altitude (eg lower ambient air pressure) and resolves during descent, occasionally being accompanied by an audible sound of air movement during resolution of the symptom. Furthermore the symptom occurs despite having a pressure equalizing tympanostomy tube in place.
The problem is unusual for 2 reasons:
1) Typically barotraumatic events occuring in the ear are felt during
descent rather than ascent into higher altitudes. This is because as one
travels from high ambient pressure at low altitude to low ambient pressure
at high altitude, it is easier for higher pressures in the middle ear to
exit the middle ear through the eustachian tube. In contrast, when the
ambient pressure is higher than the pressure in the middle ear, there is,in
essence, a vacuum effect in the middle ear keeping the eustachian tube
collapsed, if you will, until a certain opening pressure is reached thereby
forcing air through the tube into the middle ear. However there are some
individuals who experience middle ear pressure equalization difficulties on
both ascent and descent.
2) The placement of a tympanostomy tube provides continuous pressure
equalization between the middle ear and the atmosphere. The fact that
symptoms persist despite the presence of a tympanostomy tube certainly seems
to rule out the possibility of the middle ear as the location of the problem.
I suspect there are 2 main possibilities that might explain the phenomenon:
1) The pressure disturbance is occurring in the mastoid air cell system
behind the middle ear. The mastoid bone behind the auricle contains a
honeycomb like system of small air cells which communicates with the middle
ear through a small channel known as the aditus ad antrum. It is possible
that a partial anatomic obstruction to free air flow is occuring in the
channel interfering with pressure equalization between the mastoid and middle
ear. This would explain the persistence of the symptom despite the presence
of a tympanostomy tube.
2) The other possibility is that the pressure disturbance is occuring in the
sinus cavities of the skull rather than the ear, and the sensation is
referred to the ear. (ie referred otalgia) The sinuses, like the middle ear
and mastoid are merely air chambers in the bone of the skull which ultimately
communicate with the outside world through small channels in the bone.
Therefore, the sinuses, like the ear, are susceptible to pressure
equalization disturbances during rapid changes in ambient air pressures such
as those that occur during airplane flight.
I suspect that #1 is more likely than #2 as the location of the symptom described.
As to possible solutions, it should be understood that the placement of a tympanostomy tube is certainly the most appropriate initial step since it is a low risk procedure with a very high likelihood of alleviating this type of symptom. If the tympanostomy has failed, then the possible interventions become much more complex in nature and pose greater risk of complication. Then one must decide if the severity of the symptoms warrants the potential risk of intervention. I am assuming of course that more simple and conservative measures have been tried prior to the placement of the tympanostomy tube such as nasal vasoconstrictor sprays such as oxymetazoline (Afrin) or neo-synephrine prior to the activity triggering the symptom. Also, systemic decongestants such as pseudoephedrine might be useful.
Beyond these conservative measures, if the severity of the symptoms is high and the activity simply cannot be avoided, I would propose the following as possible further intervention:
A CT scan of the mastoid, and middle ear combined with a CT of the sinuses. An MRI scan is not useful for these structures in general, and in particular, when addressing bony detail. This type of study would likely allow a close and detailed view of the channels which I have previously described and might provide support for surgical exploration, again if symptoms warranted.
If radiographic support for a mastoid problem existed, a mastoid and middle ear surgical exploration (mastoidectomy) might alleviate an anatomic obstruction in the channel communicating the mastoid with the middle ear.
Similarly, if radiographic support for an obstructed sinus existed, a surgical procedure on the sinus to enlarge the involved ostium might be warranted.
--
Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
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