Assessment of Knowledge Regarding Airplane Ear Preventive Measures among Air Travelers of Najran University’s Staff

ABSTRACT


INTRODUCTION
A number of individuals fly both private and commercial flights on a regular basis, as the airlines are reportedly serving more than 100,000 passengers every day.These individuals are exposed to otic barotrauma (OBT) and seek help from an otolaryngologist.A practising otolaryngologist possesses knowledge of barometric changes essential for identifying ear infections (Mitchell-Innes et al., 2014;Wu & Kozin, 2024).OBT is a traumatic injury of the tympanic membrane and the middle ear resulting from an existing high-pressure differential between the external environment and the middle ear.This pressure is commonly experienced when slight changes in pressure are faced during air travel due to different elevations.The mild symptom is slight aural discomfort due to the increased adoption of air travel, with number of passengers increasing from 310 million to 3.7 billion every year for the last 50 years, with 1 million flying each moment (Naouri et al., 2016).Eustachian tube dysfunction is estimated to be around 30% in children and 10% in adults.It is experienced when cabin air pressure is at cruising altitude at sea level being lower than air pressure.This cabin air pressure at typical cruising altitudes (11 000-12 200 m) is equal to atmospheric air pressure (1800-2400 m) (Naouri et al., 2016;WHO, 2007).OBT is also referred to as the pathological change which results from poor eustachian tube function due to factors like increased likelihood of middle-ear barotrauma and degree of mastoid pneumatisation (Mitchell-Innes et al., 2014).Other symptoms include pain or loss of hearing (Naouri et al., 2016), vertigo and discharge in severe cases (Michael et al., 2021), long-term morbidity such as tympanic membrane perforation in rare cases (Ryan et al., 2018), sensorineural and conductive hearing loss 5 and perilymph fistula (Bhattacharya et al., 2019).Nevertheless, it is fortunate that a number of aeroplane ear preventive measures exist, such as swallowing and yawning for performing the Valsalva maneuver.However, it is evident with limited benefits in reducing ear discomfort linked with OBT in adults due to a lower level of awareness among the public.Past studies have highlighted the symptoms, causes and preventions of OBT, but limited research is available on public awareness for OBT causes and prevention in Saudi Arabia.Therefore, the current research was conducted to analyse the public perceptions of the knowledge of OBT, identifying symptoms' frequency and awareness levels for prevention measures among academic staff who are frequent air travellers of Najran University, Saudi Arabia.A cross-sectional survey-based approach was adopted to cater for the following objectives: 1. To assess the respondents' level of knowledge of preventive measures for aeroplane ear discomfort.
2. To investigate respondents' source of information on preventive measures for OBT.
3. To estimate the prevalence of OBT among the public in Saudi Arabia.

LITERATURE REVIEW
In a survey-based study, distributing an online questionnaire among commercial aircrew of three airlines in Finland, the researchers examined the most common symptoms of middle ear (ME) barotraumas, Am.J. Med. Sci. Innov. 3(1) 18-26, 2024 which may affect flight safety.Among 1789 respondents, 1516 reported experiencing ME barotraumas during flight, among which 5% had to undergo a surgical procedure due to an increasing number of upper respiratory tract infections.A common factor reported is poor performance subjected to Toynbee and Valsalva maneuvers (Lindfors et al., 2021).It is reported that OBT is one of the most reported medical complications of aviation caused by to middle ear's traumatic inflammation.The cross-sectional research was conducted to examine the quick response of travellers at the departure or arrival airport departments to identify their knowledge of the positive signs or symptoms of OBT.The suggestive preventive measures include chewing gum, the Valsalva maneuver, frequent swallowing and yawning to relieve ear tension (Almufarrej et al., 2023).The vaccine-preventable emergencies and tropical infectious diseases are the mainstay of pre-travel consultations.However, accidents and injuries, which are known as non-communicable diseases, also occur during travel, and therefore public should be aware of these as well.Results showed that 1 in 100,000 travellers die due to trauma (40%) and other diseases (60%), among which <3% are also associated with infectious diseases.These infections can be prevented with awareness of effective measures (Potin et al., 2023).A serious threat to flight safety is health incapacitation therefore a study a study was carried out examining the upper respiratory infection (URI) and ear-nose-throat (ENT) barotrauma among commercial pilots.Results were collected within one year from 463 pilots.These results reported that URI symptoms increased to 50.1% and ENT barotraumas to 55.5%.Consequently, pilots taking decongestant medicine increased to 59.5% (Boel & Klokker, 2017).
Another study highlighted that a common infection observed among air travellers is barotitis media (BM), which is the key cause of severe discomfort and sometimes permanent balance and hearing deficits.A questionnairebased survey was provided to 97 respondents identifying their travel history, advice-seeking behaviours before travelling and BM knowledge for effective air travel experience.Results showed that persistent ear pain and duration of the last flight are significantly associated with knowledge of participants of BM (Michael et al., 2021).In a systematic review, it is discussed that among flight attendants and physical health risk factors, the most prevalent physical risk factors include abnormal air pressure and ionising radiation.The most prevalent outcomes due to abnormal air pressure include barotrauma and cerebral blood flow.The change is characterised by low oxygen concentrations accompanied by an increase in altitude and a decrease in atmospheric pressure (Russo et al., 2023).

METHODOLOGY Study Design
This study is a cross-sectional online survey-based research conducted between March 2023 to May 2023 among academic staff of Najran University to explore their knowledge on awareness and symptoms of OBT during air travel.A quantitative research design was adopted in the current study since knowledge patterns among targeted respondents were observed from numerical data.Quantitative research is essential for seeking data from a broader population, providing findings with higher generalisability and objective answers (Taherdoost, 2022).Therefore, to draw a statistical pattern on the awareness of respondents regarding OBT and the symptoms identified most commonly during air travel, a quantitative research design was used.

Sample Size and Population
The targeted population of the research included air travellers to observe their OBT awareness and symptoms.For this purpose, the academic staff of Najran University who have travelled at least once by air were considered eligible for the research.Purposive sampling is a sampling technique used to target the respondents who are selected "on purpose" to provide specific outcomes in the research (Mweshi & Sakyi, 2020).Therefore, a total of 206 respondents who agreed to participate in the research were sampled using a purposive sampling technique to assess the knowledge regarding aeroplane ear preventive measures among air travellers of Najran University's staff.

Data Collection and Analysis
In this research, data was collected through a primary source such that close-ended surveys were conducted to get the first-hand opinion of respondents on knowledge of aeroplane ear preventive measures.Google formbased questionnaires containing 10 questions with multiple choices to investigate research objectives were distributed among the sampled respondents with messages containing informed consent to participate or not and details about research aims and data security.SPSS 26.0 was used for data analysis, applying frequency analysis to the gathered data and highlighting the most frequent symptoms and preventions during air travel among the public in Saudi Arabia.

Demographics
The respondents were asked a few questions relevant to their gender and age demographics and their job designation in their organisation to limit any biases in results.Table 1 depicts the gender demographics of the respondents.It shows that the majority of respondents, i.e., 54.9%, were male, whereas 45.1% were female out of the 206 academic staff who participated in the study.(35) were aged between 26 and 30 years; however, only 2.9% (6) respondents were aged between 20 and 25 years.
The research respondents were also asked about their job roles at the Najran University.As shown in Table 3, 26.2% (54) respondents were assistant professors, 10.7% (22) respondents were associate professors, and 11.2% (23) respondents were in Masters at the time of data collection.However, 51.5% (106) of respondents marked 'other' when asked about their job role.

How Often Do You Fly?
It was essential to ask respondents about how often they fly to make sure results reflect their true flight experiences in terms of symptoms observed and prevention taken for OBT.
Table 4 shows that the majority of the respondents, i.e., 51.9% (107), mentioned that they at least fly once a year, 23.8% (49) mentioned they travel up to 3 times per year, 14.6% (30) up to 6 times per year, and 8.3% (17) stated they travel up to 12 times per year.However, only 3 respondents claimed they have never air travelled yet.The research respondents were asked to mark all that apply in terms of the prevention measures they have known or used during air travel for OBT.As shown in Table 5, it was observed that 23.8% (49) respondents marked 'none of the above', reflecting that they have not heard of any prevention before.However, 23.8% (49) respondents mentioned that they are aware of 'Chewing gum or sweets', reflecting that it is the most common measure the general public is aware of for treating OBT during air travel.Furthermore, 15.5% (32) were aware of both 'Chewing gum or sweets' and 'Yawning or swallowing' as prevention measures, 12.1% (25) respondents have heard of 'Chewing gum or sweets', 'Yawning or swallowing', and 'Blowing against a pinched nose (Valsalva maneuver)' depicting these 3 as the most common known preventions.However, the results also showed that the least heard prevention measures by the respondents include 'Otrivin' and 'Decongestant, i.e. lorinase' reported along with any other reported prevention as well including 'Chewing gum or sweets', 'Yawning or swallowing', 'Otrivin', 'Decongestant, i.e. lorinase', 'Blowing against a pinched nose (Valsalva maneuver)'. in airports' (6.8%), and 'Social Media' (5.8%).However, 1.9% also reported 'Posters/Leaflets in GP practices/ hospitals' as their source of information for prevention measures during air travel.

Do You Agree Getting More Information will be Useful?
Table 8 below presents that upon asking respondents whether the providing more information will be useful or A few respondents marked more than one symptom to be suffered from during air travel.For example, 3.9% (8) respondents mentioned 'Ear pain, Dizziness' and 'Ear pain, Popping noises' together as the symptoms they suffered while flying.Lastly, respondents were also asked to mention if they have had any previous ear surgery due to OBT suffered during air travel.Table 10 shows that the majority of them responded 'No', i.e., 98.5%; however, 1.5% (3) respondents said 'Yes', depicting that knowledge regarding ear preventive measures is essential since it may limit even the small chance of suffering from OBT such that an individual had any recent ear surgery should delay air travel.(Naouri et al., 2016;Sannigrahi et al., 2018).Similarly, Bhattacharya et al. (2019) highlighted chewing, swallowing and yawning as helpful measures which should be taken during landing and taking-off since they activate eustachian tubes' muscles bi-laterally.Nonetheless, it is recommended not to sleep during the descent and ascent of flights as it is the period which may create sudden pressure change.Earplugs also assist in equalising the pressure slowly when ear discomfort is felt against the eardrum (Bhattacharya et al., 2019).Valsalva maneuver is one such effective prevention which is beneficial for crucial ear discomfort conditions such as the prevalence of aerotitis media (Sharma et al., 2020).However, another research highlighted that if yawning, jaw movements, and swallowing do not prevent ear discomfort, then the air should be forced into the cavities of the middle ear by raising nose and mouth pressure to occlude the nostrils (Bagshaw & Illig, 2019).(Naouri et al., 2016).

Sources of Information on
Another study pointed out that for the public, education leaflets should be posted on the official website as a significant source for informing about ear discomfort.However, social media is also a useful resource (Ho et al., 2017).

Prevalence of OBT
Ear discomfort during flight or aeroplane air is common whether the travellers are flying in business class or getting leg space; the problem is often faced.The current research highlighted the prevalent symptoms of ear discomfort during air travel, highlighting symptoms Am.J. Med.Sci.Innov.3(1) 18-26, 2024 which are most commonly observed such as ear pain, popping noises, reduced hearing, dizziness, and ringing noises in the ear.Similarly, past research highlighted that air travel symptoms include fullness, pain, discomfort, and moderate to mild loss of hearing.However, severe hearing loss, severe pain, vertigo, tinnitus, and hemotympanum are the symptoms affected individuals face in severe cases (Bhattacharya et al., 2019).Nevertheless, another painful ear disorder experienced during air travel due to external pressure's rapid change is called aerotitis media, which leads to pain, vertigo, tinnitus and hearing loss (Sharma et al., 2020).Besides, some of the risk factors for tinnitus and hearing loss other exposure to high noise and low pressure in aircraft include hypertension, acoustic trauma, flying time, smoking and diabetes mellitus causing hearing loss (Muyassaroh et al., 2021).Respondents were also asked if they have had any previous ear surgery and few of them responded 'Yes'.Consequently, Bhattacharya et al. (2019) highlighted in their research that individuals suffering from sinusitis, recent ear surgery, common cold, ear infection or nasal congestion should reschedule travel plans or use decongestants an hour or 30 minutes before travel to limit the change of ear discomfort.

CONCLUSION
The pressure changes during air travel is one of the most common challenge which causes barotrauma or OBT.Considerably, equilibration is achieved normally by jaw movements, swallowing, chewing or yawning.Also, prior to the flight the use of an oral decongestant limits the incidence of OBT which is generally recommended to passengers.The research highlighted that it is important to increase the awareness on the prevention measures during air travel to limit ear discomfort among passengers.The common symptoms are often mild but they can get worse like trouble hearing, feeling that eat is blocked, dizziness, severe ear pain and ear discharge.These can cause severe issues and an ear surgery is required therefore taking early measures is important to secure the eardrum.Therefore, education leaflets should be posted on the official website of airlines as a significant source for informing about ear discomfort.

Limitations and Future Implications
The research sample size was limited to the academic staff of Najran University however for generalisability for broader Saudi population, the future research can be enhanced by considering diverse demographics to limit any bias.Additionally, the recent study was limited to survey-based research however in the future it ca be improved using open-ended interviews to support survey findings with in-depth perceptions.The current research highlights the most common symptoms observed during air travel and the commonly known preventive measures among public.It will be beneficial for the healthcare sector, aeroplane industry and researchers to increase the general awareness on measures which prevent OBT and other challenges pertinent to ear discomfort during air travel.

Table 2
below shows the age demographics of the respondents.It can be viewed in the table that the majority of the respondents, i.e., 30.1% (62), each belonged to the age group of 36-40 years and greater than 40 years.Besides, 19.9% (41) lied in the age group 31-35, 17.0%

Objective 1: To Assess the Respondents' Level of Knowledge of Preventive Measures for Aeroplane Ear Discomfort
A few questions were asked relevant to research objective 1, investigating the respondents' level of knowledge on preventive measures for aeroplane ear discomfort.

Table 4 :
Respondents' Frequency of Air Travel

Table 5 :
Prevention Measures Respondents Have Heard

Table 6 :
Measures Considered by Respondents

To Investigate Respondents' Source of Information on Preventive Measures for OBT
The respondents were asked questions relevant to sources of information for them regarding the preventive measures for OBT.

Which of the Following Sources of Information are You Aware of for Air Travel? Mark All that Apply Table
7 depicts that the most common sources of information for air travellers include 'Internet' (11.2%), 'Posters/Leaflets in aeroplanes' (7.8%), 'Posters/Leaflets

Table 8 :
Usefulness of Provision of More Information

Mark All those Apply from the Symptoms Following You have Faced During Air Travel?
Table 9 below presents the responses of students identified when they were asked about the symptoms they have ever observed while flying.It is observed that

Table 9 :
Most Common Symptoms of OBT Suffered During Air Travel

Table 10 :
Respondents with Previous Ear Surgery