1Topic 3.9 ENT AVMO 0017

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  1. 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.
  2. Conditions For Discussion?
    • • Barotrauma
    • • ear (barotitis)
    • • sinus (barosinusitis)
    • • Allergic Rhinitis
    • • Sinusitis
    • • Hearing loss
    • • Vertigo
  3. 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
  4. 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
  5. 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
  6. • “Perforations of the tympanic membrane are acceptable”.
    • Follow-up Requirements
    • • Recurrent barotrauma requires further investigation.
  7. 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
  8. 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
  9. 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
  10. 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.
  11. Acquired Hearing Loss?
  12. ADF Hearing Standard?
    • • Pilots and Navigators: HS1
    • • Non-pilot aircrew: HS2
    • • Loss greater than 30db requires hearing aid
  13. 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.
  14. 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
  15. 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)
  16. 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
  17. 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
  18. 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
  19. 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
  20. 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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david_hughm
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1Topic 3.9 ENT AVMO 0017
Updated:
2017-02-25 12:50:34
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