Acta Oto-Laryngologica, 2007; 127: 843
846

ORIGINAL ARTICLE

Alternobaric vertigo: prevalence in Portuguese Air Force pilots

JOÃO SUBTIL, JORGE VARANDAS, FERNANDO GALRÃO & ALVES DOS SANTOS

Department of Otorhinolaryngology, Air Force Hospital, Lisbon, Portugal

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Abstract
Conclusion. Having found a prevalence rate of alternobaric vertigo in Portuguese Air Force pilots that is somewhat higher
than previously reported, we underline the importance of implementing education on the management of this condition as
part of routine Air Force pilot training programs. Objectives. Alternobaric vertigo is a condition in which transient vertigo
with spatial disorientation occurs suddenly during flying or diving activities, caused by bilateral asymmetrical changes in
middle ear pressure. Its prevalence is very likely underestimated and under-reported, with the 10
17% prevalence rate
mentioned in early literature not being challenged by recent data. Subjects and methods. To assess its actual prevalence, the
authors requested all high performance aircraft pilots presently on active duty in the Portuguese Air Force to anonymously
answer a questionnaire on alternobaric vertigo symptoms, after a short briefing on the subject. Results. A 29% prevalence
rate of in-flight episodes consistent with alternobaric vertigo was obtained.
For personal use only.

Keywords: Alternobaric vertigo, pressure vertigo, flight vertigo, Air Force pilots

Introduction and b). In consequence, the entrapped air expands,

Alternobaric vertigo is a frequently overlooked but
non-negligible mishap that should not be ignored
when investigating the causes of aircraft accidents. It
is characterized by transient vertigo appearing sud-
denly during flying or diving activities, typically
when ascending or when a Valsalva manoeuvre is
performed [1
4]. The subject initially experiences
difficulties in pressure equalizing in both ears, before
rapidly developing intense disabling vertigo, fre-
quently with nausea and vomiting [5]. If the ascent
or descent is immediately levelled or reversed,
vertigo rapidly subsides. Otherwise, sudden spatial
disorientation may ensue, with the risk of cata-
strophic consequences.
The term alternobaric was introduced by Lündg-
ren in 1965 to acknowledge the fact that the
pathogenesis of this form of vertigo possibly involves
a bilateral, yet asymmetrical (different stimuli in-
tensity experienced in each ear), change in ear
pressure [2]. When atmospheric pressure changes
occur in the course of flying or deep-sea diving,
middle ear pressure adjusts accordingly (Figure 1a
forcing the opening of the eustachian tube to allow
air out of the middle ear cleft. If the expanding
middle ear gas is allowed to build up rapidly it may
reach a point where an overbearing pressure that
affects the surrounding structures is created, the
internal ear being the most sensitive. Therefore,
whenever tubal opening pressure is asymmetrical,
pressure in the middle ear increases asymmetrically,
leading to different inner ear stimulation in the right
and left ear. Once the inner ear is stimulated in an
asymmetrical fashion an illusory motion sensation
occurs
hence alternobaric vertigo. A Valsalva
manoeuvre during flying or diving, while the eu-
stachian tube function is asymmetrical, may also
precipitate this process.
The mechanism leading to inner ear stimulation
is, in itself, still poorly understood [6
11]. Middle
ear relative pressure apparently must reach 50
60
mmHg or higher to initiate vestibular stimulation
[4]. Some authors admit that, in some subjects,
pre-existing anatomical abnormalities, such as a
unilateral thin bony wall [2] or variations of win-
dow anatomy [6,7], may render the inner ear

Correspondence: Dr João Subtil, Hospital da Força Aérea, ORL Dept, Az. Torre do Fato, Lumiar, 1600 Lisbon, Portugal. Tel: /351 964095965. Fax: /351
217958974. E-mail: subtil@netcabo.pt

(Received 29 August 2006; accepted 19 October 2006)

ISSN 0001-6489 print/ISSN 1651-2551 online # 2007 Taylor & Francis
DOI: 10.1080/00016480601075415
 844 J. Subtil et al.
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For personal use only.
Figure 1. Pathophysiology of alternobaric vertigo. (a) Ascending in
altitude leads to a decreasing environmental pressure, causing
middle ear air to expand and forcing air to escape through a patent
eustachian tube. (b) When expanding air is trapped inside the
middle ear due to unilateral tubal dysfunction, middle ear pressure
increases ( /p) ultimately producing inner ear stimulation ( /  /p).
asymmetrically vulnerable to middle ear pressure
stimuli. Ultimately, the vestibular stimulation in
alternobaric vertigo is characterized by different
(left and right) fluid shifts in the endolymphatic
and perilymphatic ducts [10,11].
The ensuing vertigo sensation is accompanied by
gradually increasing nystagmus (frequently horizon-
tal or torsional) [5] for the first 10
20 s, which stops
immediately once the inter-aural pressure difference
is no longer experienced, leaving no trace of histo-
pathological change [2].
As vertigo and nystagmus can be quickly reversed,
proper management depends essentially on the
subject’s prompt recognition of the condition and
on a rapid, panic-free, response, aimed at physiolo-
gically counteracting the precipitating circum-
stances. This depends essentially on the pilots’ and
divers’ awareness and knowledge of alternobaric
vertigo and its pathophysiology, acquired during
their training programs.
In order to underline the need for a more specific
education on this matter during flying and diving
basic training programs, and as it is the authors’
assumption that the prevalence of alternobaric
vertigo is very likely underestimated and most
certainly under-reported during routine flying, with
the 10
17% prevalence rate mentioned in early
literature [2] not being challenged by recent data,
the objective of this study was to report up-to-date
prevalence rates of alternobaric vertigo in Air Force
pilots flying high-performance jet aircrafts.
Subjects and methods
The entire population of currently on-duty pilots
flying high performance jet aircrafts in the Portu-
guese Air Force was enrolled (n /29). All had been
tested fit for combat flying at extensive routine
health check-ups carried out at least twice a year.
These pilots were individually briefed, in detail, on
alternobaric vertigo by one of the authors, detailing
symptoms and characteristics of its occurrence.
Afterwards they were requested to fill out a ques-
tionnaire anonymously. All questions had the pur-
pose of identifying past episodes of vertigo during
flight, and determining specific characteristics that
would allow for an unequivocal diagnosis of alter-
nobaric vertigo. A query about precipitant factors
was also included. Investigators were obligated to
keep any individual subject information that was
disclosed away from each pilot’s military medical
records. The study protocol required that the
investigators would rely solely on subjects’ ques-
tionnaire replies, present physical examination and
military clinical records. Access to further data, such
as vestibular testing results, which at the present
time are not part of the routine pilot medical check-
up, was not possible, inasmuch as a specific diag-
nostic suspicion would have to be forwarded and test
results could not be kept from the pilots’ military
medical records.
In all, 24 pilots agreed to participate in the study.
They were all male, ranging in age from 26 to
32 years (mean 28.5 years). Demographically the
participants were representative of the population of
Portuguese Air Force pilots on active duty flying
high-performance jet aircrafts.
Statistical analysis used the x2 test and Fisher’s
exact test. A p value of 0.05 was considered
statistically significant.
Results
Otolaryngological and neurological examinations
were normal in all subjects, with pure tone audio-
metry and tympanometry revealing normal hearing
and normal middle ear function. Sinus X-rays
showed no abnormality. None of the subjects had a

previous history of ear and/or vestibular disorder in
their official medical records.
Seven pilots (29.2%) reported having had vertigo
episodes compatible with the diagnosis of alterno-
baric vertigo, at some time during flight. Of these,
five admitted that this occurrence had happened
on more than one occasion, although no more than
10 times. All episodes were described either during
ascending flight maneuvers or after a forceful Val-
salva manoeuvre, and usually preceded by a full ear
sensation. Angular or linear accelerating manoeuvres
were not indicated as precipitating factors. All
vertigo episodes were uneventful, ceasing after only
a few seconds, the time the pilots took to stabilize the
plane or reverse the flight manoeuvre.
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None of the pilots admitted reporting the incident
on their flight report sheets once on the ground
(despite being obligated to do so), and none
considered asking for medical advice.
Table I shows potentially relevant data in both
vertigo sufferers and non-vertigo sufferers.
As breathing 100% oxygen is a known upper
respiratory tract irritant, and thus may act as a
precipitating factor for alternobaric vertigo, subjects
were specifically asked if any flight vertigo spell was
For personal use only.
preceded by breathing 100% oxygen. This was
denied by all participants.
Concomitant upper respiratory tract infection was
reported by five pilots as a precipitant factor for their
alternobaric vertigo episodes. Nevertheless, it was
not found to be statistically significant.
Tobacco smoking, a proven upper respiratory
pathogen, also did not reach statistical significance
as a precipitant factor (p / 0.653). The statistical
relationship to the previous diagnosis of rhinosinu-
sitis or allergy was also non-significant (p / 0.315
and p / 0.111, respectively). This also applied to
previous history of infancy/early adulthood adenoid
surgery, an eventual risk for direct tubal damage
(p/ 0.605).
Table I. Comparison of data obtained in the two populations of
Air Force pilots, with and without alternobaric vertigo.
Vertigo Non-vertigo
Parameter sufferers (n/7) sufferers (n /17)
More than 1000 h flying 5 13
experience
Smoking history 4 7
Allergy history 1 0
Rhinosinusitis history 2 2
Adenoid surgery history 3 8
Use of 100% O2 in flight 0 0
Concomitant upper 5 0
respiratory tract infection
Alternobaric vertigo in pilots 845
Flight experience, as assessed by the total flight
hours, was not found to be of statistical significance
(p / 0.58) as an influential factor.
Subjects who had experienced in-flight alternoba-
ric vertigo more than once did not statistically relate
to any particular influential factor.
The intake of alcohol while on duty was strongly
denied by all participants.
Discussion
The 29.2% prevalence rate found in this study
population is somewhat higher than reported in
earlier studies. As the latter studies date back a few
decades, the higher prevalence figures we obtained
may be explained by the higher performance cap-
abilities of modern aircraft, enabling increasingly
rapid pressure variations inside the pilot’s cabin. On
the other hand, the figure still surprises us, as
nowadays high performance pilot selection, particu-
larly in the Air Force, is ruled by strict, increasingly
demanding, health concerns. Subjects suffering from
mild to moderate upper respiratory tract pathology
that would eventually be accepted for flight training
programs some years ago are presently being denied
access to high performance flight training, particu-
larly in the military. We can speculate that health
evaluation procedures may still have fallen short of
desirable levels, failing to diagnose, for instance, the
minor inner ear anatomic variations that would
predispose to in-flight vertigo. On the other hand,
we admit that the methodology employed may have
somehow encouraged false positive over-reporting.
Since the pilots did not feel the incidents important
enough to report them on their flight sheets at the
time they happened, it is admissible to believe that
they may now admit to any in-flight malaise,
including the common ‘righting’ reflex symptoms
to sudden vestibular stimulation, happening inside a
high speed airplane undergoing combined linear and
angular acceleration. However, from our present
knowledge of the pathogenesis of this condition, it
is realistic to consider that all healthy subjects are
potentially susceptible, and the investigators made
themselves quite clear on the characteristics and
circumstances of the specific vertigo spells they
wanted reported.
Certainly the small number of subjects in our
study group precludes a definitive conclusion re-
garding the identification of predisposing factors;
larger series or meta-analyses are needed. But,
perhaps, subject selection based on health issues
(essential for other aspects of flight safety) is not so
critical in specifically reducing the prevalence of
alternobaric vertigo, implying that this eventuality
 846 J. Subtil et al.
still occurs in perfectly healthy subjects if parti-
cular circumstances converge. This emphasizes the
critical importance of the pilots’ education during
their training programs on how, why and when
alternobaric vertigo happens, and how to deal with
it promptly in an effective way. That all our subjects
intuitively responded to immediately counteract,
uneventfully, the in-flight symptoms they were
suddenly experiencing, may lead us to reason that
they are already well prepared to adapt to a number
of in-flight physical challenges. This adaptive re-
sponse does not seem to require a ‘learning’ curve
type of process to develop, as all symptomatic pilots
successfully reacted to the events, regardless of their
flight experience. Nevertheless, as subjects are likely
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to under-report transitory experiences of being
unwell while on military duty, our study results
certainly stress the need for combat flight training
programs to specifically and accurately address the
issue of alternobaric vertigo.
Acknowledgements
For personal use only.
The authors wish to thank Dr Paulo Borges Dinis for
his help in reviewing the manuscript.
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