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Learning Outcomes?
- • Discuss the aeromedical implications of ENT disorders with respect to:
- • The impact of the condition on the operating environment
- • The impact of the aviation environment on the condition
- • Immediate fitness to fly
- • Outline what clinical information is required, including investigations and referrals, for determination of aeromedical disposition.
- • Describe the aeromedical implications of possible treatments for ENT disorders.
- • Discuss prognostic considerations that may impact on future fitness.
- • Propose a likely MECR process and aeromedical disposition for ENT disorders.
- • Apply an evidence-based aeromedical decision making framework to the aeromedical management of disorders affecting the ENT system.
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Conditions For Discussion?
- • Barotrauma
- • ear (barotitis)
- • sinus (barosinusitis)
- • Allergic Rhinitis
- • Sinusitis
- • Hearing loss
- • Vertigo
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Aviation ENT History?
- • Previous ENT problems/ ENT specialist Rx
- • Ear disorders as child
- • Ears: infections, ear clearing in flight/scuba diving, tinnitus, vertigo, motion sickness, balance(sports), FH hearing loss
- • Nose: obstruction, allergy, epistaxis, sinus trouble
- • Throat: tonsillitis
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Aviation ENT Examination?
- • Otoscopy including valsalva
- • Ant. Rhinoscopy with speculum/otoscope
- • Test nasal airways
- • Mouth, teeth, tonsils, tongue, pharynx
- • Audiology
- • ENT Specialist: AC/BC & impedance audiometry, nasendoscopy including larynx with decongestant/LA, microexam ears
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Most common ENT disorders in ADF?
- • Nasal obstruction and sinus disorders (incl non-sinus facial pain)
- • Snoring and sleep apnoea
- • Tonsillitis, Infectious mononucleosis
- • Otitis externa
- • Others – barotitis, hearing loss, throat symptoms, middle ear problems, epistaxis
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• “Perforations of the tympanic membrane are acceptable”.
- Follow-up Requirements
- • Recurrent barotrauma requires further investigation.
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Sinus Barotrauma?
- Condition Overview
- • 20 times less common than barotitis.
- • Occurs on descent
- • May be acute or chronic
- • Affects the frontal sinuses in 80% of cases
- • Maxillary sinus next most common
- • Persistent pain – sometimes tenderness
- • Epistaxis in 15% of people
- • Usually history of URTI or chronic sinusitis
- Aeromedical Concerns
- The Condition
- • Pain is severe
- • Incapacitating
- The Environment
- Altitude/Pressure profile
- • Boyle’s Law
- • Normally on descent
- Important Clinical Information
- • History of URTI, sinusitis or allergy
- • Sinus trauma or surgery
- • Pressure change profile of flight
- • DDx of headache/facial pain
- • Beware flying with blow-out fracture of orbit
- Investigations and Referrals
- • Nasal swab C&S
- • CT scan sinuses
- • Nasal endoscopy
- • Allergy testing
- Treatment Considerations All have aviation implications
- • AIM: To improve sino-nasal ventilation
- • Nasal and oral decongestants
- • Antibiotics - ?duration
- • Analgesia
- • Nasal and oral steroids
- • Saline sprays, flushing, steam inhalations
- • Treatment of allergy
- • Sinus surgery
- Military Aeromedical Disposition
- • TMUFF while cause determined and treated
- • Return to unrestricted flying if correctable cause is fixed
- • Medication ground trials as required
- • Desensitisation therapy for allergy - TMUFF periods apply
- CASA Perspective
- • Acute sinusitis temporarily unfit
- • Underlying chronic sinusitis must be referred and treated
- Prognostic Considerations
- - Use of hypobaric chamber pressure testing
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Allergic Rhinitis?
- Condition Overview
- • Inflammation of the nasal cavity secondary to a type 1 immune reaction (mast cell mediated).
- • May be seasonal and/or perennial.
- • Patients are atopic or have a history of atopy (ability to produce high levels of IgE directed at common allergens).
- Aeromedical Concerns
- • Common problem for aviators
- • Gas trapping and barotrauma
- Symptoms often recurrent, annoying and distracting.
- • Older treatments often lead to sedation.
- • Unauthorised OTC medications.
- • Not easily cured but can be controlled.
- Important Clinical Information
- • On history:
- • Nasal obstruction, sneezing, itchy nose, eyes and palate and clear rhinorrhoea
- • Trapped gas problems
- • On examination:
- • Wet nasal mucosa
- • Swollen “blue” turbinates
- • Allergic crease
- • “allergic shiners”
- Investigations and Referrals
- • Total IgE
- • RAST grass mix, dust/mite mix, animal mix, mould mix, (weed mix)
- • Skin scratch/prick – allergist
- • CT sinuses
- Treatment Considerations
- • Avoidance (incl use mask)
- • Topical inhaled nasal steroids - Nasonex, Rhinocort , Beconase, Avamys – ground trial.
- • Nasal washing – “FESS”
- • Antihistamines – only non-sedating. Ground trial.
- • Decongestants?
- • Oral prednisolone – no flying
- • Desensitisation – TMUFF required
- • Srgery
- Prognostic Considerations
- • Seasonally recurring
- • Ground trial meds then start prophylactically each season
- • Recurrence likely with multiple postings or deployments
- Military Aeromedical Disposition
- • TMUFF while symptomatic
- • Good control of symptoms with approved meds compatible with flying
- • Likely UAMECR
- CASA Perspective
- • Minimal issue for CASA
- • Managed by GP or DAME
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Acute Sinusitis?
- • Vast majority are viral
- • Anatomical abnormalities and allergic swelling may predispose
- • Common bacteria: Strep pneumoniae, Haemophillus influenzae Moraxella catarrhalis,
- • Duration < 3 weeks
- • Maxillary > Frontal >Ethmoid > Sphenoid
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Chronic Sinusitis?
- • Sinus symptoms > 3 months or recurrent episodes
- • Not really bacterial infection, more a mucosal disease
- • Bacteria found in sinuses different from acute (more anaerobes and Staph)
- • Often secondary to anatomical abnormalities and lack of sinus ventilation
- • Some cases due to fungal infection
- Aeromedical Concerns
- • Minimal symptoms at sea level
- • In flight: gas trapping, barotrauma
- • Pain usually on descent
- • Rarely pain on ascent
- Important Clinical Information
- Symptoms
- • Pain directly related to involved sinus (except sphenoid)
- • Nasal obstruction
- • Fever
- • Purulent rhinorrhoea (ant and post)
- • Remember dental causes
- Signs (LOOK IN NOSE)
- • Fever
- • Congested, inflamed nasal mucosa
- • Pus in nose or nasopharynx
- • Other abnormalities (deviated septum, polyps)
- • Facial swelling (ethmoid sinusitis)
- Investigations and Referrals
- • Swab of nasal pus
- • Routine bloods - WCC
- • Nasal endoscopy
- • CT scan if severe or recurrent – best done when acute episode settled
- Treatment Considerations
- • Analgesia
- • Decongestants – nasal and oral
- • Appropriate use of antibiotics – high dose and long duration
- • ?Steroids
- • Sinus surgery must be endoscopic
- Prognostic Considerations
- • After surgery:
- • Much regeneration of mucosa required - takes 6 weeks partic. frontal ostia
- • Postoperative infection common (Staph)
- • Nasal flushing important
- • Return to flying 6 weeks minimum
- Military Aeromedical Disposition
- Acute sinusitis, TMUFF while symptomatic only
- • Chronic sinusitis, TMUFF, MECR required
- CASA Perspective?
- • Same as military.
- • Chronic sinusitis unfit until appropriately referred treated and improved.
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ADF Hearing Standard?
- • Pilots and Navigators: HS1
- • Non-pilot aircrew: HS2
- • Loss greater than 30db requires hearing aid
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CASA Hearing Standard?
- • Person must be free of any hearing defect that is likely to interfere with the safe exercise of privileges or performance of duties.
- • A person must not have a hearing loss in either ear of more than:
- • 35 dB at any of 0.5, 1, 2 kHz, or
- • 50 dB at 3 kHz
- • Unless person passes a speech test or an operational check.
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Acquired Hearing Loss Overview?
- • NIHL – discussed in Topic 2
- • Presbyacusis
- • Otosclerosis
- • Cholesteatoma
- • Trauma
- • Ototoxicity
- • Meniere’s disease
- • Acoustic neuroma
- Aeromedical Concerns
- • Safety issue
- • Noisy environment
- • Communications
- • Warnings
- • Aircraft sounds – normal and abnormal
- • Situational awareness
- Important Clinical Information
- • Bilateral vs unilateral
- • Temporary vs permanent
- • Presence of tinnitus or vertigo
- • Social impact
- Work impact
- • Functional capacity
- Investigations and Referrals
- • Use the tuning fork – diagnoses otosclerosis
- • Audiogram – AC and BC
- • Speech discrimination testing
- • Tympanogram
- • CT/MRI
- • ENT/neuro referral
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Otosclerosis?
- • Progressive uni- or bilateral hearing loss
- • Tympanic membranes normal
- • Detected with tuning fork
- • Requires AC/BC Audiogram
- • Difficult to diagnose in early stages
- • Best treated by surgery (stapedectomy)
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Cholesteatoma?
- • Associated with TM retractions, perforations, conductive hearing loss, CNS complications, infection.
- • Treatment by surgical excision
- • Aeromedical concerns:
- • Postoperative recovery
- • Conductive hearing loss
- • TM perforations
- • Facial nerve function
- • Vestibular function
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Acoustic Neuroma?
- • 80% of cerebellopontine angle tumours
- • Surgery vs stereotactic radiation
- • Aeromedical concerns:
- • Surgical recovery
- • Unilateral sensorineural hearing loss + tinnitus
- • Facial nerve function
- • Vestibular function
- Treatment Considerations
- • Hearing aids if >30dB loss
- • Stapedectomy treatment of choice for otosclerosis
- • Risk of perilymph fistula post-op
- • Complications affecting cranial nerves, vestibular function, hearing
- • Posterior cranial
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Vertigo?
- Condition Overview
- • Peripheral or Central
- • Motion sickness
- • Vestibular Neuronitis
- • Ischaemic
- • Benign Positional Vertigo – Hallpike test, Epley
- • Perilymph fistula, trauma, congenital
- • Endolymphatic hydrops
- • Cervical
- Aeromedical Concerns
- The condition:
- • Incapacitating
- • Many possible diagnoses
- • Impairs balance and movement
- • Impairs vision
- The environment:
- • Acceleration forces
- • Head movements
- • Spatial disorientation
- • Loss of aircraft control
- Important Clinical Information
- • Otologic symtoms and signs
- • Neurologic findings
- • Balance and cerebellar testing
- • Hallpike test and Epley Manoeuvre
- • Response to vestibular sedatives (jQuery1101024488213094862776_1488027016969?Serc)
- Investigations and Referrals?
- • Vestibular Function Tests
- • ElectroNystagmoGraphy (ENG)
- • Caloric
- • CT temporal bones
- • MRI head
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Benign Positional Vertigo?
- • Aeromedical Concerns:
- • Most common cause of vertigo
- • Head movements in flight
- • High G manoeuvring and otoliths
- • Spatial disorientation risk – nystagmus and vertigo
- • Loss of control in flight
- Treatment?
- • Epley and Semont manoeuvres
- • Vestibular sedatives?
- • Beware effects
- Prognostic Considerations?
- • Course is variable
- • May take weeks to settle
- • Epley manoeuvre 95% successful
- • Recurrence rate 15% in 1 yr, 50% in 5 yrs
- Military Aeromedical Disposition?
- • TMUFF while symptomatic
- • Period of observation
- • Return multicrew before solo
- • IAMECR
- CASA Perspective?
- • Case by case, based on frequency and severity
- • Must be fully investigated
- • Possibly multicrew or safety pilot while observed
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Meniere’s Disease?
- • Aeromedical concerns
- • Diagnosis of exclusion
- • Vertigo - disorientation risk
- • Hearing loss/tinnitus – communications
- • Diagnosis and treatment often difficult
- • Medication side effects
- Treatment Considerations
- • Vestibulosuppressants
- • Prochlorperazine
- • Benzodiazapines
- • Diuretics
- • Steroids
- • Betahistine
- Prognostic Considerations
- • Recurrent exacerbations and remissions
- • Progressive disorder
- • May eventually “burn out”
- • Chronic disequilibrium and hearing loss
- Military Aeromedical Disposition
- • IAMECR/CAMECR
- • Unfit for flying duties, A4
- CASA Perspective
- • Full investigation, specialist reports required
- • Case by case, but likely unfit for flying
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