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The Middle Ear refers to a collection of bones (ossicles) and muscles contained within a chamber (tympanic cavity) that sit between the Outer Ear and the Inner Ear, bounded by the tympanic membrane (eardrum) and the oval window respectively. Efficient hearing requires an intact tympanic membrane (eardrum), a normal ossicular chain, and a well-ventilated tympanic cavity.
Normally the walls of the Eustachian tube are collapsed, and jaw-moving actions such as swallowing, talking, yawning and chewing open the tube to allow air in or out as needed for equalisation. Sinuses are cavities within a bone or other tissue, and humans have many around their bodies. The paranasal sinuses are lined with respiratory epithelium; which is a moist tissue whose purpose is protection from potential damage caused by mucous movement, and also to act as a barrier to pathogens and particles. The paranasal sinuses are joined to the nasal cavity via small orifices called ostia; these are normally clear and allow pressure to equalise between the sinus cavities and the external environment. There are several competing hypotheses regarding the biological function and purpose of the paranasal sinuses, but it is possible that they serve no biological function at all.
Whether flying in an unpressurised or pressurised aircraft, passengers and crew will experience a decrease in ambient (environmental) pressure whilst climbing, and an increase in pressure during descents.
In most people, the ability of the middle ear to equalise pressure via the Eustachian tubes is adequate to prevent discomfort and retain good hearing during all stages and profiles of flight. Similarly, the ostia usually remain clear enough to allow equalisation between the paranasal sinus cavities and the external air pressure.
In the case of the eardrum, the tympanic membrane will be distorted inward or outward, depending on the direction of the pressure differential. Apart from physiological reasons, the anatomic causes of blocked Eustachian tubes and ostia are practically identical and often the two events will occur together.
Most commonly, these causes are both bacterial and viral infections such as colds and flu; however, blockages can also occur as a reaction to allergies and various diseases. Pain - Even moderate amounts of pain will distract an aircrew member from being able to conduct their tasks – they can become, effectively, incapacitated.
Vertigo - If one ear equalises, but the other doesn’t, then a form of pressure vertigo can be experienced as dizziness, which is not helpful for aircrew, especially pilots.
Disorientation - Blocked Eustachian tubes may also give rise to infection in the inner ear and therefore lead to risk of dizziness and spatial disorientation – both very serious flight hazards. Headache - Sinusitis may develop giving rise to a constant throbbing headache felt in the face (often under the eyes or in the upper teeth). Hearing - Unequalised ears result in distortions of the eardrum and therefore, hearing will be impaired, in terms of attenuation and also clarity. Workload - Finally, but by no means least, it can be quite traumatic (and a distraction) having a colleague or passenger on-board suffering from blocked Eustachian tubes while descending. If symptoms of otic or sinus barotrauma, or discomfort, occur in-flight then action is required, depending on the stage of the flight profile (climb, cruise, or descent), the severity of the trauma, and also depending on whether the patient is a crew member or passenger.
All cabin and flight crew are regularly trained in first aid and the use of the first aid equipment on-board.

The simplest measure to take is to never fly with a cold, flu, or any other similar illness and infection.
The common causes of blocked ostia and Eustachian tubes usually clear up within a period of a few weeks, and usually no long-term damage occurs.
Blockages resulting from allergic reactions may be relieved through decongestants and antihistamine, but ultimately the source of the allergy will need to be addressed. Sinusitis is an inflammation of the nasal sinuses that accompanies upper respiratory infection. Special techniques for facial massage can be used to encourage the drainage of mucus from the nose and sinuses. Garlic is a valuable immune stimulant and natural antibiotic that keeps infections in check. Bee pollen increases immunity and speeds healing so a small daily supplement of bee pollen is recommended, if you’re not allergic to it.
Acupuncture and acupressure are very effective therapies for sinusitis and can be used alongside aromatherapy. Mucus is a normal protective layering around the airway, eye, nasal turbinate, and urogenital tract. Until the late 1970s, there were few tools to help pinpoint sinusitis, and treatment was difficult. The eardrum transforms air pressure waves into physical vibrations – the middle ear amplifies these vibrations – the oval window allows the amplified vibrations to “flow” into the fluid-filled cochlea. This amplification is variable, depending on the frequencies; higher frequencies need less amplification for transmission to the cochlea. This is mostly achieved automatically, and any “lag” between the middle ear cavity and the aircraft cabin can usually be eliminated by gentle yawning or chewing. There is no natural mechanism we can employ to hasten the equalisation of the sinuses as there is for the middle ear.
Because, in both the middle ear and the sinuses, a blockage means that mucous cannot be removed, it is possible for bacteria to grow in this mucous, causing further infection, such as sinusitis, and therefore prolonging the problem. In severe cases of barotrauma an aircrew member can be grounded for a long period, and may suffer a burst eardrum. The inner ear contains semi-circular canals which automatically detect accelerations in three dimensions and give us our “sense” of balance – where is up, down, left and right, and which way are we moving. The pain gets worse when you move your head, strain or bend down, and when you experience extreme changes in temperature. Pilots will need to balance the desire to get the patient to a medical facility as soon as possible against the need for a slow descent. There can be some leeway if one of only two pilots is affected, depending on the severity of pain; but discussions will need to cover the potential symptoms of degraded hearing, performance and possible dizziness and imbalance. This will include the use of nasal decongestants to assist in freeing up the Eustachian tubes and ostia, usually in connection with the Valsalva method of ear “popping”.

Similarly, do not fly if you cannot equalise the pressure in your middle ears using the Valsalva method; perhaps making it a habit to check this before every flight is a good habit to adopt?
Symptoms, including sinusitis headaches, can be alleviated by an array of different prescribed and over the counter drugs and products. The throat may be affected by problems originating in the lungs, the nose, or the sinuses. Mucus is an adhesive viscoelastic gel produced in the airway by submucosal glands and goblet cells and is principally water. Medications were limited, and surgery involved major incisions and a lengthy recovery time.
Such changes in pressure, and the speed of change, are not normally experienced “on the ground”; a rare example concerns travelling on a train as it enters or exits a tunnel at great speed. Sometimes, if pressure is felt within the ear, it is possible to force the issue by clasping the nose and blowing into a closed mouth (Valsalva method); what may be known as “popping” the ears. Your face will also feel tender to the touch, and you may have other general symptoms such as a runny nose and sore throat. Most critical for severe cases will be the need to control the descent in stages, allowing the patient time to equalise their ears frequently.
They will also be familiar with the use of analgesics to relieve some of the associated pain. However, flight and cabin crew should not self-medicate and should consult their Company surgeon or private Doctor.
Without the middle ear 99.9% of the sound energy entering the outer ear, and vibrating the eardrum, would be reflected by the fluid-filled inner ear. This means the air pressure within the middle ear must equal that of the external environment.
Even when the Eustachian tubes are infected (see below) it can be relatively easy to equalise the ears when adjusting to lower cabin pressure (i.e. The symptoms of a sinus headache can easily be confused with both migraine and tension headaches. All of these are additional to the pilots’ normal workload and concerns, and can potentially introduce hazards. For some persistent bacterial infections antibiotics may need to be prescribed, which may preclude any flying for the duration of the course (often 10-days). The course of sinusitis is better understood, and advances such as CT scans, minimally invasive procedures, and more powerful antibiotics are making even the balkiest cases more manageable.’*^. This is because fluid has a much higher impedance to sound waves than air, which in contrast is a very efficient medium.

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