Case Report: Flight-related facial baroparesis and third-window lesion

Background Alternobaric facial palsy (AFP) is an uncommon phenomenon related to changes in ambient air pressure during flight or diving. Most published cases implicate middle-ear barotrauma and dehiscence of the tympanic segment of the facial canal. Inner-ear third-window physiology and mastoid hyperpneumatization have not been previously emphasized in AFP. Case report A 25 years-old woman presented patient with recurrent, transient right-sided peripheral facial palsy occurring exclusively at cruising altitude during commercial air travel. Episodes lasted less than 30 min and resolved spontaneously. Audiometry and middle-ear function were normal. Cervical vestibular evoked myogenic potentials (cVEMP) revealed asymmetric thresholds, with a lower threshold (~80 dB nHL) on the right, consistent with increased labyrinthine compliance. High-resolution temporal bone CT demonstrated marked bilateral temporal bone hyper pneumatization, right cochleo-facial and lateral semicircular canal–facial micro-dehiscence. An in-flight video documented a typical attack. Tympanostomy tube placement prevented recurrence during subsequent flights . Conclusion This appears to be the first case of cruising-altitude AFP supported by combined radiologic, neurophysiologic, and real-time video documentation, implicating third-window phenomena and mastoid hyper pneumatization. High-resolution CT (HRCT) and cVEMP should be considered in recurrent cases.