to the editor: The article by Drs. Bettes and McKenas¹ was a useful overview of air travel preparation. However, the section on ear conditions did not address what is probably the most common scenario encountered by primary care physicians. I am not aware of any study that has shown what to recommend to patients who are planning to travel and who present with acute otitis media. Generally, I have been taught to recommend a delay of commercial air travel for two weeks. Are the authors aware of any evidence-based recommendations in this case?

in reply: The letter from Dr. Hyman highlights two areas that can be addressed. The first is the small number of good evidence-based studies on which to make recommendations for patients who travel by air. Studies by Kramer¹ and Cox² referenced in our article³ are good examples of the type of research that would be useful but is generally lacking for most conditions commonly encountered when physicians are answering specific questions from patients.

The second point we hoped to make in the article was the need to individually assess each patient whenever possible. Recent disability legislation (i.e., the Air Carrier Access Act of 1986⁴) discourages making blanket assessments involving passenger acceptance unless good evidence is available to back it up. In the case of a patient with acute otitis media, it may be useful to perform follow-up tympanometry or simply a repeat examination documenting resolution of symptoms and having the patient demonstrate the ability to perform an adequate Valsalva maneuver before providing the clearance to fly. This, of course, is not always possible with managed care and reimbursement constraints.

I agree with Dr. Hyman that a general recommendation of waiting two weeks after a patient presents with acute otitis media to give the condition time to resolve would be reasonable, notwithstanding the above two caveats.