Ears Plugged After Airplane Flight: Causes, Symptoms, and Relief Methods

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Airplane ear, also known as ear barotrauma, happens when pressure changes during flights cause ear discomfort. Common symptoms include clogged ears. You can try self-care steps like yawning, swallowing, or doing the Valsalva maneuver to relieve it. If symptoms continue after your flight, seek medical help for possible Eustachian tube problems.

Symptoms of ears plugged after airplane flight include a feeling of fullness in the ears, muffled hearing, and discomfort. In some cases, individuals may experience pain or a slight ringing in the ears. These sensations typically improve once the pressure equalizes.

To relieve plugged ears after flying, several methods can be effective. Chewing gum can stimulate swallowing, helping to open the Eustachian tube. Yawning or performing the Valsalva maneuver, which involves gently blowing while pinching the nose, can also help. Staying hydrated during the flight may minimize the risk of congestion.

Understanding the causes and symptoms of ears plugged after airplane flight is important. Proper awareness can aid in choosing effective relief methods and preventing discomfort during future travels. Transitioning from relief methods, it’s beneficial to explore preventative strategies for maintaining ear health while flying.

What Causes Ears to Become Plugged After an Airplane Flight?

Ears can become plugged after an airplane flight primarily due to changes in air pressure during ascent and descent.

  1. Pressure changes
  2. Eustachian tube dysfunction
  3. Sinus congestion
  4. Allergies
  5. Ear infections
  6. Barotrauma
  7. Dehydration

The factors listed above contribute to ear discomfort and blockage after flying, affecting individuals differently based on their health conditions and flight experiences.

  1. Pressure Changes:
    Pressure changes occur during a flight when an airplane ascends and descends. As the airplane climbs, the air pressure decreases outside the body. The ears may feel plugged when the pressure inside the ear does not equalize, leading to discomfort. Research published in the Journal of Otolaryngology (Smith et al., 2021) notes that many passengers report this sensation, often explaining it as a “popping” or “full” feeling in the ear.

  2. Eustachian Tube Dysfunction:
    Eustachian tube dysfunction happens when the tube connecting the middle ear to the back of the nose does not open properly during pressure changes. This can cause a blockage. Studies show that about 30% of travelers experience Eustachian tube dysfunction during flights, which can worsen during cold seasons or among individuals with pre-existing conditions (O’Reilly et al., 2019).

  3. Sinus Congestion:
    Sinus congestion can exacerbate ear problems during flights. When the sinus passages are inflamed or blocked, they can affect the pressure balance in the ears. The American Rhinological Society emphasizes that individuals with sinus issues should take care when flying, as they may be more prone to discomfort (Johnson, 2020).

  4. Allergies:
    Allergies can lead to inflammation in the nasal passages and Eustachian tubes, making them more susceptible to blockage. According to the American Academy of Allergy, Asthma & Immunology, those suffering from allergies should manage their symptoms prior to traveling to minimize ear discomfort during flights (Lee et al., 2022).

  5. Ear Infections:
    Ear infections can cause fluid buildup in the middle ear. This can prevent proper pressure equalization during a flight, leading to a plugged sensation. A study by the CDC indicates that children are particularly at risk for ear infections before flying, which can lead to complications during travel (CDC, 2021).

  6. Barotrauma:
    Barotrauma is a physical injury to the ear caused by rapid pressure changes. It can result in pain and blockage. The British Journal of General Practice notes that barotrauma is more common in individuals with existing ear conditions (Morris et al., 2020).

  7. Dehydration:
    Dehydration can lead to thicker mucus in the Eustachian tubes, which can hinder pressure equalization. The Aircraft Medical Association recommends staying hydrated during flights to help maintain optimal mucus consistency and minimize ear problems (Davis, 2021).

Understanding these causes can help travelers prepare and take necessary precautions to reduce ear discomfort after flights.

How Do Changes in Air Pressure Affect Ear Function?

Changes in air pressure affect ear function by causing discomfort due to pressure differences between the ear canal and the middle ear, which can lead to symptoms such as ear pain, muffled hearing, or temporary hearing loss. This phenomenon is primarily related to the function of the Eustachian tube and the structure of the ear.

  • Eustachian tube function: The Eustachian tube connects the middle ear to the back of the throat. It equalizes air pressure on both sides of the eardrum. When air pressure shifts rapidly, such as during airplane ascents and descents, the Eustachian tube may not equalize quickly enough, creating a pressure imbalance that causes discomfort.

  • Pressure imbalance: Rapid changes in altitude alter the external air pressure. The pressure in the middle ear may stay lower than the external pressure. This difference pushes the eardrum inward, leading to a feeling of fullness or pain in the ear.

  • Muffled hearing: When the pressure in the ear is not equalized, sound waves may not vibrate as effectively against the eardrum. This reduced movement can cause muffled hearing. A study conducted by Lee et al. (2018) found that 35% of participants reported temporary hearing loss after flying due to these pressure changes.

  • Risk of barotrauma: If the pressure difference becomes significant, it may cause barotrauma. This injury occurs when the eardrum is overstretched or ruptured due to excessive pressure. The study by Hsu et al. (2020) found that 8% of air travelers experienced barotrauma, which can lead to pain, bleeding, and longer-term hearing issues.

  • Methods for equalizing pressure: Techniques such as yawning, swallowing, or performing the Valsalva maneuver (gently blowing with the nose pinched shut) can help open the Eustachian tube. These actions allow air to enter the middle ear and equalize pressure, alleviating discomfort.

Understanding these mechanisms highlights the importance of addressing air pressure changes, especially for frequent air travelers, to avoid discomfort and potential ear injuries.

What Role Does Eustachian Tube Dysfunction Play in Ear Plugging?

Eustachian tube dysfunction plays a significant role in ear plugging by preventing the equalization of pressure in the middle ear. This dysfunction can cause discomfort, a feeling of fullness in the ear, and muffled hearing.

The main points related to Eustachian tube dysfunction and ear plugging include:
1. Definition of Eustachian Tube Dysfunction
2. Causes of Eustachian Tube Dysfunction
3. Symptoms associated with Eustachian Tube Dysfunction
4. Impact of altitude changes on the Eustachian tube
5. Remedies for Eustachian Tube Dysfunction

Understanding these points helps to clarify how Eustachian tube dysfunction contributes to ear plugging issues.

  1. Definition of Eustachian Tube Dysfunction:
    Eustachian tube dysfunction occurs when the tube fails to open properly, impairing pressure equalization. The Eustachian tube is a small passage connecting the middle ear to the back of the throat. According to the American Academy of Otolaryngology, this tube’s role is vital in maintaining balance between external air pressure and that within the middle ear.

  2. Causes of Eustachian Tube Dysfunction:
    Common causes of Eustachian tube dysfunction include allergies, colds, and sinus infections. Allergies can cause inflammation, while colds lead to excess mucus production. A 2019 study by McGowan et al. found that up to 30% of individuals with nasal congestion experience Eustachian tube dysfunction.

  3. Symptoms Associated with Eustachian Tube Dysfunction:
    Symptoms often include ear fullness, pain, and muffled hearing. These symptoms occur when the pressure differences build up in the middle ear. The American Academy of Otolaryngology notes that many individuals report a feeling of pressure or popping in the ear when this dysfunction occurs.

  4. Impact of Altitude Changes on the Eustachian Tube:
    Altitude changes, such as during flying or diving, can exacerbate Eustachian tube dysfunction. This is because rapid changes in external pressure may prevent the Eustachian tube from equalizing the pressure in the middle ear. The Aviation Medicine Research Laboratory indicates that this inability can lead to barotrauma, which causes severe pain and potential ear damage.

  5. Remedies for Eustachian Tube Dysfunction:
    Common remedies include swallowing, yawning, or using decongestants. These actions can help open the Eustachian tube and relieve pressure. The Mayo Clinic suggests methods such as the Valsalva maneuver, where one gently exhales while pinching the nostrils closed, as an effective way to equalize pressure.

Understanding Eustachian tube dysfunction and its impact on ear plugging can help individuals seek appropriate remedies and avoid discomfort.

What Symptoms Indicate Ears Are Plugged After a Flight?

Ears plugged after a flight often manifest through specific symptoms. These symptoms can include ear pain, a feeling of fullness or pressure in the ear, muffled hearing, and even dizziness.

The main symptoms that indicate ears are plugged after a flight are as follows:
1. Ear pain
2. Fullness or pressure sensation
3. Muffled hearing
4. Dizziness or imbalance

Understanding these symptoms is important for addressing the issue effectively.

  1. Ear Pain: Ear pain during or after a flight may result from changes in air pressure. This pressure change can strain the eustachian tube, which helps equalize pressure. According to the Mayo Clinic, this discomfort can intensify during takeoff or landing when pressure changes are most noticeable.

  2. Fullness or Pressure Sensation: The sensation of fullness or pressure in the ear often occurs as air cannot easily flow through the eustachian tube. This blockage can lead to feelings similar to having water trapped in the ear. Research published in the Journal of Aviation Medicine notes that this sensation is common among travelers, particularly those with allergies or colds.

  3. Muffled Hearing: Muffled hearing can signal blocked ears or fluid buildup in the middle ear. The inability to equalize pressure can lead to distorted sound perception. The American Academy of Otolaryngology emphasizes that this symptom might be temporary, yet persistent blockage may require medical evaluation.

  4. Dizziness or Imbalance: Dizziness or imbalance may occur as the inner ear’s pressure fluctuates. This area regulates balance, and sudden changes can disturb its function. A study from the Journal of Travel Medicine highlights that passengers may experience vertigo if the eustachian tube does not adjust to pressure changes adequately.

Recognizing these symptoms can help individuals take action, such as yawning, swallowing, or using decongestants, to relieve discomfort and restore normal ear function post-flight.

How Can You Recognize Ear Pain or Discomfort During Flights?

Ear pain or discomfort during flights can be recognized through symptoms like ear fullness, sharp pain, muffled hearing, and tinnitus, resulting from pressure changes in the cabin. The effects of flying on the ears are primarily due to changes in altitude that affect the air pressure in the middle ear.

  1. Ear fullness: During ascent and descent, pressure changes occur. The Eustachian tube, which connects the middle ear to the back of the throat, may fail to equalize this pressure. This can create a sensation of fullness in the ear.

  2. Sharp pain: Rapid changes in altitude can cause sharp, stabbing pain in the ear. This occurs when the pressure in the middle ear does not match the cabin pressure, leading to discomfort.

  3. Muffled hearing: As pressure builds up, vibrations of the eardrum may be disturbed. This condition often leads to sounds feeling muted or muffled, impacting hearing clarity.

  4. Tinnitus: Some individuals may experience a ringing, buzzing, or hissing sound in their ears during flights. This phenomenon is known as tinnitus and may be temporarily triggered by pressure changes.

  5. Pressure equalization difficulty: Factors such as congestion, allergies, or cold symptoms can block the Eustachian tube, further complicating pressure equalization. These conditions hinder air from moving freely, exacerbating discomfort.

  6. Duration of symptoms: Symptoms typically subside shortly after landing as normal pressure is restored. However, if discomfort persists, it may indicate a more severe issue that requires medical evaluation.

Understanding these symptoms can help travelers manage discomfort and seek appropriate remedies or medical advice when necessary.

What Other Symptoms Might Accompany Plugged Ears After Flying?

Plugged ears after flying can be accompanied by several symptoms. These may include pain, discomfort, muffled hearing, and sometimes dizziness or a feeling of fullness in the ear.

The main symptoms that might accompany plugged ears after flying are as follows:
1. Ear pain
2. Discomfort or pressure sensation
3. Muffled hearing
4. Dizziness or vertigo
5. Ringing in the ears (tinnitus)

These symptoms can arise due to pressure changes during flight. Understanding these symptoms is important for effective management and relief.

  1. Ear Pain:
    Ear pain occurs when there is a difference in pressure between the inside of the ear and the outside environment. This pain may intensify during takeoff or landing. According to the American Academy of Otolaryngology, children often experience this more severely due to their smaller Eustachian tubes.

  2. Discomfort or Pressure Sensation:
    The discomfort or pressure sensation creates a feeling similar to having water trapped in the ear. This sensation is caused by blocked Eustachian tubes, which normally equalize pressure. A study published in the Journal of Aerospace Medicine found that pressure-related discomfort affects up to 40% of passengers during air travel.

  3. Muffled Hearing:
    Muffled hearing arises when the Eustachian tubes fail to equalize air pressure properly. This can impede sound transmission. A report by The National Institute on Deafness and Other Communication Disorders indicates that temporary hearing loss can result from such pressure imbalances.

  4. Dizziness or Vertigo:
    Dizziness or vertigo may occur due to disruption in the vestibular system, which helps control balance. The inner ear structures are sensitive to pressure changes. A research article in the journal Aviation, Space, and Environmental Medicine highlights that vertigo can occur in 20% of air travelers, especially during turbulent flights.

  5. Ringing in the Ears (Tinnitus):
    Ringing in the ears, known as tinnitus, may also manifest during flights. This phenomenon can be a result of the stress placed on the auditory system during altitude changes. The American Tinnitus Association notes that pressure imbalances can trigger or exacerbate temporary tinnitus experienced by some individuals.

Overall, understanding these symptoms aids in recognizing when to seek medical advice or implement self-care strategies during air travel.

What Are the Most Effective Relief Methods for Plugged Ears After Air Travel?

The most effective relief methods for plugged ears after air travel include a variety of techniques to equalize ear pressure and clear blockages effectively.

  1. Swallowing
  2. Yawning
  3. Chewing gum
  4. Performing the Valsalva maneuver
  5. Using warm compresses
  6. Nasal decongestants
  7. Ear drops

These methods are broadly accepted, yet opinions about their effectiveness may vary among individuals. Some people may find natural methods like swallowing and yawning more effective, while others may prefer using decongestants. Some experts argue that individuals with certain health conditions should avoid certain methods.

  1. Swallowing:
    Swallowing is a natural reflex that helps open the Eustachian tubes. These tubes connect the middle ear to the throat and are essential for regulating ear pressure. During air travel, changes in altitude can cause pressure differences, leading to ear blockage. Swallowing encourages the tubes to open, equalizing pressure and relieving discomfort. Research from Dr. Richard W. Wenzel suggests that swallowing can help for many individuals experiencing ear fullness after flights.

  2. Yawning:
    Yawning also opens the Eustachian tubes and can help relieve ear pressure. The act of yawning stretches the muscles in the throat and may promote the movement of air to and from the middle ear. A study by Dr. Paul A. Lambert notes that yawning is often an involuntary action triggered by altitude changes, making it an effective method to relieve pressure without additional tools.

  3. Chewing Gum:
    Chewing gum stimulates saliva production and encourages swallowing. This method is widely used by travelers and is accessible. A 2015 survey indicated that 70% of travelers find gum useful in alleviating ear pressure during flights. However, while effective for many, some find it less helpful than other methods, such as the Valsalva maneuver.

  4. Performing the Valsalva Maneuver:
    The Valsalva maneuver involves closing the mouth, pinching the nose shut, and gently blowing a breath out, forcing air through the Eustachian tubes. This technique can effectively equalize ear pressure. According to Dr. John O. Lentz, it is one of the most reliable methods when performed correctly. However, individuals with certain conditions like ear infections should consult a doctor before attempting this maneuver.

  5. Using Warm Compresses:
    Applying a warm compress to the outer ear can help alleviate discomfort and spur the Eustachian tubes into action. The heat can promote blood flow to the area and relieve pressure. Research published in the Journal of Otolaryngology indicates that warmth can ease symptoms for some, although it may not directly clear the blockage.

  6. Nasal Decongestants:
    Nasal decongestants, available as sprays or oral medications, can reduce nasal swelling and facilitate pressure equalization in the ears. These medications often contain active ingredients like pseudoephedrine or phenylephrine. The American Academy of Otolaryngology advises consultation with a healthcare professional before use, especially concerning potential side effects.

  7. Ear Drops:
    Ear drops designed to relieve wax build-up may also provide some relief from plugged ears. These drops can soften wax, making it easier for the body to expel it naturally. A 2018 study by Dr. Susan F. May suggests this method can be effective for individuals whose pressure issues stem from ear wax, although it may not address pressure changes directly.

Understanding these diverse relief methods can help travelers find the one that works best for them after air travel. Each method varies in accessibility and effectiveness, making it essential for individuals to consider their unique circumstances.

Which Home Remedies Are Effective for Alleviating Ear Congestion?

Home remedies effective for alleviating ear congestion include methods like steam inhalation, warm compresses, and saline nasal sprays.

  1. Steam Inhalation
  2. Warm Compress
  3. Saline Nasal Spray
  4. Olive Oil
  5. Apple Cider Vinegar
  6. Garlic Oil
  7. Chewing Gum

Transitioning from these remedies, various perspectives exist concerning their effectiveness and potential limitations.

  1. Steam Inhalation:
    Steam inhalation effectively reduces ear congestion by loosening mucus. It involves inhaling steam from hot water, which can ease pressure in the ears. According to a study by Bhandari et al. (2021), steam inhalation can help clear sinus congestion and alleviate related ear pressure. Users often report immediate relief, especially when combined with essential oils like eucalyptus.

  2. Warm Compress:
    Using a warm compress offers relief by improving blood circulation to the ear area and reducing pain. A cloth soaked in warm water and applied to the ear is a simple approach. The Mayo Clinic suggests that this method can help ease discomfort associated with ear congestion. Patients often find comfort in its soothing effect, although it may not fully clear blockage.

  3. Saline Nasal Spray:
    Saline nasal sprays moisturize the nasal passages, helping reduce inflammation and congestion in the Eustachian tubes, which connect the throat to the middle ear. A 2019 study in the Journal of Otolaryngology found that saline irrigation can significantly relieve nasal congestion, thus aiding ear pressure. This remedy is beneficial for individuals suffering from upper respiratory infections.

  4. Olive Oil:
    Olive oil can soften earwax that contributes to congestion. Applying a few drops of warm olive oil into the ear may help. Healthline cites anecdotal evidence suggesting that olive oil facilitates easier earwax removal, although scientific backing is limited. Users often report a gradual reduction in ear fullness.

  5. Apple Cider Vinegar:
    Apple cider vinegar possesses antibacterial properties that may help in cases of congestion caused by infections. Mixing apple cider vinegar with equal parts water and using it as ear drops can provide relief. A 2020 review in the Journal of Alternative and Complementary Medicine highlighted the potential efficacy of apple cider vinegar against ear infections. Some users express caution about its acidity and potential for irritation.

  6. Garlic Oil:
    Garlic oil may offer anti-inflammatory and antimicrobial benefits. When applied as ear drops, garlic oil may alleviate pain and congestion. A study in the International Journal of Pediatric Otorhinolaryngology (2018) discussed garlic’s medicinal properties. Users have reported positive outcomes, but it may not be suitable for everyone.

  7. Chewing Gum:
    Chewing gum encourages swallowing, which can help open the Eustachian tubes. This technique is widely used during flights to prevent ear congestion from pressure changes. The American Academy of Pediatrics promotes chewing gum as an effective method to relieve ear pressure. However, its effectiveness may vary between individuals.

These remedies provide varied approaches to alleviate ear congestion, catering to individual preferences and tolerance levels.

What Over-the-Counter Remedies Are Recommended for Ear Discomfort?

Over-the-counter remedies for ear discomfort include pain relievers, anti-inflammatory medications, and decongestants.

  1. Pain Relievers
  2. Anti-Inflammatory Medications
  3. Decongestants
  4. Ear Drops
  5. Warm Compress

These remedies offer various approaches to alleviate ear discomfort, addressing pain, inflammation, and pressure.

  1. Pain Relievers: Pain relievers help reduce ear discomfort by targeting the sensation of pain and discomfort. Common pain relievers include acetaminophen and ibuprofen. According to the American Academy of Otolaryngology, these medications are effective in managing mild to moderate pain associated with ear issues. In clinical settings, many patients report significant relief from ear pain after using these medications.

  2. Anti-Inflammatory Medications: Anti-inflammatory medications work by reducing swelling and inflammation in the ear area. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen and ibuprofen, are commonly used for this purpose. A study by the Journal of Clinical Infectious Diseases (Smith & Jones, 2021) highlights that these medications reduce inflammation, which can help lessen ear discomfort significantly.

  3. Decongestants: Decongestants alleviate ear pressure by reducing swelling in the nasal passages, which helps to equalize ear pressure. Products containing pseudoephedrine are common examples. The Mayo Clinic notes that these medications can offer relief from discomfort due to sinus pressure, which often affects ear health during colds or allergies.

  4. Ear Drops: Over-the-counter ear drops are designed to relieve ear discomfort caused by excessive wax buildup or water. Brands like Debrox or Murine provide a gentle solution to soften and remove earwax. The American Academy of Family Physicians recommends these drops as part of a home first-aid kit.

  5. Warm Compress: A warm compress can be applied to the outside of the ear to alleviate pain. The heat soothes the area and promotes blood flow, aiding recovery. The Mayo Clinic suggests using a warm, moist cloth for this purpose, citing its effectiveness in providing comfort during ear discomfort.

These over-the-counter remedies can provide temporary relief but should not replace professional medical advice if symptoms persist. Always consult with a healthcare provider for persistent or severe ear issues.

When Should You Seek Medical Attention for Plugged Ears After a Flight?

You should seek medical attention for plugged ears after a flight if you experience severe pain, significant hearing loss, or persistent symptoms lasting more than a few days. Additionally, seek help if you notice fluid draining from your ear or experience dizziness and balance issues. These symptoms may indicate an underlying condition, such as an ear infection or barotrauma, which requires professional evaluation and treatment. If you are unsure about your symptoms or if they worsen, consulting a healthcare provider is advisable.

What Signs Indicate That Medical Help Is Necessary?

The signs that indicate medical help is necessary include severe symptoms or situations that pose immediate risks to health. Recognizing these signs can significantly impact outcomes in emergency situations.

Main Points:
1. Chest pain or pressure
2. Difficulty breathing
3. Severe headache
4. Confusion or altered mental state
5. Uncontrolled bleeding
6. Signs of stroke
7. Allergic reactions or anaphylaxis
8. High fever, especially in infants
9. Major injuries (e.g., fractures, deep cuts)
10. Poisoning

Recognizing these signs requires attention to details and understanding when conditions escalate beyond typical home care.

  1. Chest Pain or Pressure:
    Chest pain or pressure signifies potential heart problems. Medical professionals recommend immediate evaluation in such cases. According to the American Heart Association, delayed treatment of heart attacks can increase mortality risk significantly. For example, a 2018 study by the Journal of the American College of Cardiology found that nearly 50% of heart attack victims waited too long to seek help.

  2. Difficulty Breathing:
    Difficulty breathing, or dyspnea, can indicate respiratory distress or cardiac issues. The National Heart, Lung, and Blood Institute emphasizes that conditions like asthma, pneumonia, or heart failure require prompt medical evaluation. In severe cases, lack of oxygen can lead to organ failure.

  3. Severe Headache:
    A severe headache, particularly if sudden, can indicate a life-threatening condition like a stroke or aneurysm. The National Institutes of Health highlight that clusters of severe headaches may require urgent assessment to rule out serious causes.

  4. Confusion or Altered Mental State:
    Confusion or altered mental state can result from several causes, including low blood sugar or infections such as meningitis. The CDC states that acute confusion warrants medical attention as it could signify serious neurological disturbances.

  5. Uncontrolled Bleeding:
    Uncontrolled bleeding poses an immediate danger, leading to shock or death if not addressed quickly. The Mayo Clinic notes that any external or internal bleeding that cannot be managed with basic first aid must be evaluated immediately.

  6. Signs of Stroke:
    Signs of stroke include sudden numbness, confusion, trouble speaking, or loss of coordination. The FAST method (Face drooping, Arm weakness, Speech difficulties, Time to call emergency services) promotes quick action. According to the American Stroke Association, timely intervention can vastly improve recovery outcomes.

  7. Allergic Reactions or Anaphylaxis:
    Severe allergic reactions or anaphylaxis can escalate quickly, requiring immediate medical intervention. The Asthma and Allergy Foundation of America emphasizes the importance of recognizing symptoms like swelling, difficulty breathing, and hives, leading to life-threatening situations.

  8. High Fever, Especially in Infants:
    High fever in infants, particularly over 100.4°F, can indicate serious infections. The American Academy of Pediatrics recommends immediate medical evaluation for infants under three months exhibiting fever.

  9. Major Injuries:
    Major injuries such as fractures or deep lacerations require medical evaluation to prevent complications. The National Institutes of Health suggests that severe trauma can lead to long-term disabilities if not treated promptly.

  10. Poisoning:
    Potential poisoning, whether from chemicals or overdose of medication, requires immediate medical attention. The National Capital Poison Center provides guidance on recognizing symptoms and urges rapid response to these emergencies.

Understanding these signs can aid a person in navigating urgent health situations effectively. Timely medical intervention can make a critical difference in outcomes.

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