Guidance for medical examiners when assessing a patient for either a general topic or condition – ENT (ear, nose, and throat) - General.
See also ENT - Vertigo / Disequilibrium and ENT - Hearing Impairment conditions.
This applies to:
- Barotrauma of the ears and sinuses. Barotrauma is defined as injury sustained from failure to equalize the pressure of air-containing space in the body with that of the surrounding environment. The most commonly affected areas for aviators of aeromedical significance are the middle ear and sinuses
- Other non-specific ENT symptoms or conditions affected by pressure changes but not presenting as acute barotrauma (eg Otitis media, intermittent mild sinusitis, chronic Eustachian tube dysfunction, nasal polyps)
- Grommet insertion (ventilation tubes, myringotomy)
- Other surgical treatment of ENT systems (Functional endoscopic sinus surgery FESS; sinus balloon dilation, removal nasal polyps).
Effect of aviation on condition
- Changes in ambient pressure inside pressurised and non-pressurised aircraft
- Pure oxygen effect on middle ear and sinuses
- High and abnormal G inputs into vestibular apparatus
Note: Acute ENT barotrauma is easier to prevent than treat.
Effect of condition on aviation
- Severe acute onset symptoms causing potential for overt incapacitation
- acute pain ear or sinuses
- acute deafness
- acute haemorrhage
- acute dizziness, disorientation and loss of situational awareness
- nausea and vomiting
- Distraction due to less severe or subacute symptoms of pain, deafness, vestibular effects.
Approach to medical certification
Based on the condition
- Absence of current active pathological process affecting normal middle ear and sinus function and effective equalization (eg recent perforation, current active infection middle ear, current active sinusitis requiring treatment, post-operative sinus surgery)
- Absence of a permanent pathological condition affecting middle ear function and effective equalization (eg chronic complex perforation)
- Normal vestibular function (established recovery for at least 4 weeks from a temporary disturbance and absence of a permanent disturbance. See also ENT – vertigo/disequilibrium
Based on treatment
- Equalization must be possible without relying on medication. This includes decongestant nasal sprays such as oxymetazoline / xylometazoline (see guidelines on Medication)
- If long course antibiotics required to maintain absence of infection and no other aviation relevant symptoms (see 'Effect of condition on aviation' above) there are no side effects from antibiotics prescribed (see guidelines on Medication)
- Use of non-sedating antihistamines (see guidelines on Medication)
- Intermittent use of topical non-sedating decongestant or more regular use of steroid for intermittent sinusitis symptoms acceptable if meets above conditions
- If Grommets inserted, no complications or pain symptoms
- If sinus or other ENT surgery, no residual bleeding or obstruction due to postoperative swelling that might increase barotrauma risk
- Pressure equalization demonstrated on ground without the requirement for regular medications
- If simple perforation (dry, uncomplicated), fit to return once healing demonstrated – eg. Normal tympanometry. Audiometry may be required (see 'Risk Assessment' below)
- If small, chronic perforation may be assessed as fit following ENT review
- Evidence of recovery from surgery without complication (see "Risk Assessment" below)
- Clearance by DAME is required following confirmation of resolution of any condition
Risk assessment protocol - information required
New cases - ENT specialist or treating doctor report (depending on condition)
- Confirmed diagnosis
- Clinical status
- presenting symptoms (eg deafness, tinnitus, pain, discharge, barotrauma event)
- current symptoms (eg pain, vestibular symptoms, deafness)
- examination findings (eg valsalva maneouvre, tympanic membrane appearance, oropharynx, sinus tenderness)
- Results of relevant investigations
- Tympanometry – for tympanic membrane and middle ear conditions
- Pure tone audiometry – where there are symptoms of deafness or tinnitus
- Radiological imaging (MRI, CT) – where clinically appropriate
- monitoring proposed
- Comment on stability of condition and likelihood of recurrence (eg confirmation of full recovery in case of middle ear perforation)
- Follow-up plan.
Renewal (ENT specialist or treating doctor)
- Current clinical status
- symptoms and signs
- examination findings
- Investigations conducted – where clinically appropriate
- side-effects (if relevant)
- Comment on stability of condition and likelihood of recurrence
- Follow-up plan.
Note: Ability to equalize easily and without pain is essential.
- Healed tympanic membrane post barotrauma event with normal Eustachian tube function at or after 6 weeks
- Chronic tympanic membrane perforation IF small, dry, not associated with pain, hearing loss or other aviation relevant symptoms
- No current active pathology that might predispose to barotrauma event (eg sinus obstruction)
- Grommet insertion if no complications including pain
- Uncomplicated recovery from sinus surgery with favourable report from treating ENT specialist at least 3 weeks after surgery
- Chronic or permanent Eustachian tube dysfunction
- Eustachian tube or sinus obstruction due to any cause where effective equalization not possible and risk of barotrauma (eg: post surgical period, frequent recurrent epistaxis, acute infective sinusitis or middle ear infection)
- Current or recently resolved vestibular symptoms and vertigo within 4 weeks of application even if secondary to acute barotrauma event
Pilot and controller information
- Pain on ascent or descent must be reported to the DAME
- A DAME review and clearance is required for all cases of barotrauma
- Sinus surgery, grommet insertion or any other ENT surgery requires stand down from flying or controlling and clearance from DAME or CASA
- Medications for ENT conditions can have safety relevant side effects. Consult with your DAME or CASA for advice as required (see guidelines on Medication)
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The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.