Sinus Barotrauma on Descent After a Upper Respiratory Infection
Captain A is a 44-year-old pilot scheduled for a 2 h 15 min sector in a pressurized twin turboprop, cruising at FL300 with a cabin altitude of 7,500 ft. He is on day 3 of a viral upper respiratory infection. Nasal congestion is improving but his right ear still feels full. One hour before departure he takes a single 60 mg dose of oral pseudoephedrine, which he has used before without drowsiness. The flight is uneventful until descent. Passing cabin altitude 4,000 ft he develops sharp right ear pain rated 6/10 and muffled hearing. He performs a Valsalva maneuver twice without relief, but continues because the approach is busy and the weather is at minima. After landing, the pain persists and he notices dried blood on a tissue. He is rostered for another flight in 12 hours and still feels congested.
1. Explain the physiological mechanism that produced the ear pain and bleeding during descent, and why continuing the approach increased the risk.
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During descent, cabin pressure rises while gas trapped in the middle ear must contract in volume. If the Eustachian tube is blocked by mucosal swelling, the pressure cannot equalize. A pressure differential develops across the tympanic membrane, pulling it inward and stretching it. The pain is the warning signal. If descent continues, the mucosa can hemorrhage, serous fluid can accumulate, and the drum can rupture. The bleed after landing is consistent with mucosal or tympanic injury, not simply wax or external ear trauma. Continuing was risky because the pressure gradient increases with further descent, equalization becomes harder, and the pilot may develop severe pain, hearing loss, vertigo, or sudden incapacitation close to the ground. The busy approach and weather minima do not remove the need to level off, slow the descent, or hand control to the other pilot. A blocked ear on descent is an operational problem, not just discomfort.
2. Decide whether he is fit for the flight in 12 hours and state the operational and medical actions you would take.
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He should not operate the flight in 12 hours. The unresolved congestion, persistent pain, muffled hearing, and evidence of bleeding indicate barotrauma with a high chance that the Eustachian tube is still dysfunctional. The oral decongestant may reduce symptoms but does not guarantee equalization and can mask deterioration; it is not a substitute for fitness. A further pressurized flight or a descent could worsen the injury, cause severe pain, produce vertigo, or impair radio and cockpit communication. The correct actions are to remove him from the roster, arrange alternate crew, and refer him for aeromedical assessment. He should not fly until symptoms have resolved, hearing is normal, and he can equalize reliably. He also needs advice about flying with a cold: early equalization attempts on descent, yawning, swallowing, and avoiding flight with active congestion. If a similar block occurs in flight, level off, reduce descent rate, and do not force a Valsalva until the ear clears.