The examination should be directed to the presence of any condition which would impair respiratory functions or pressure equalization during flight. Ear drums should be examined for any pathology, perforations and for the adequacy of pressure equalization. Pressure equalization should be assessed by observation of the drum during a Valsalva maneuver. Vestibular function should be normal. Auricle and mastoid region should be carefully examined for scars and deformities due to past operations. External Auditory Meatus This is inspected by pulling the auricle upwards, backwards and outwards to straighten the external canal. Presence of wax, foreign body, exostosis or discharge is noted. Wax is removed by a blunt hook probe or syringing. While syringing, the stream of water is directed against the posterior-superior wall of the meatus and not against the wax, foreign body or the drum. Syringing is contraindicated in the presence of perforation of tympanic membrane due to