If in doubt, consult the waiver guide.
http://www.nomi.med.navy.mil/Nami/WaiverGuideTopics/ent.htm#Sinusitis
6.2 CHRONIC SINUSITIS / SINUS SURGERY
Rev Jan 2001
AEROMEDICAL CONCERNS: Sinus barotrauma with potential for in-flight incapacitation, prolonged periods of grounding, symptoms affecting performance.
WAIVER: Civilian applicants with a history of chronic sinusitis are NPQ. A waiver shouldn’t be requested unless he or she is free of disease, as indicated by a recent ENT consultation and (in most cases) a sinus CT. If surgery has been done, enclose any pre- and postoperative notes as well as the operation report. In addition, some evidence of the applicant’s ability to handle pressure changes should be documented. Low pressure chambers are not generally accessible to civilians, so look for a history of, say, recent successful SCUBA diving or aerobatic flying. If the applicant is military, make every attempt to have him or her perform a barofunction run in a low pressure chamber. Students and designated aviation personnel who are diagnosed with chronic sinusitis while on active duty are also NPQ, and a waiver will only be considered after the disease has been successfully treated. If surgery (usually FESS, or Functional Endoscopic Sinus Surgery) is performed, the patient must be healed and free of active disease. The surgeon should state that the patient is cleared for evaluation in a low-pressure chamber before the flight surgeon schedules a chamber run. If the patient successfully completes the run without pain or significant facial pressure, a waiver is generally recommended and usually granted. A common waiver stipulation: for the first 2-3 years after surgery the patient must have an ENT consultation before waiver continuation.
INFORMATION REQUIRED: Submit an aeromedical summary, to include: the events that led to the diagnosis, the findings on physical examination and x-ray studies, the operation performed, and the surgeon’s postoperative findings and recommendations. If copies of the pre- and post-op notes and dictated operation report are available, include them as well. A post-op CT is not required, but if done, include the results. Also include documentation of a successful post-surgical barofunction run in a low pressure chamber. In many cases it is appropriate for a Local Board of Flight Surgeons to return the member to a flying status while awaiting the waiver, but it is best to consult with the NAMI Otolaryngology Department before doing so.
TREATMENT: Chronic sinusitis can be relatively asymptomatic, and may only come to the attention of the flight surgeon because the member suffers an episode of sinus barotrauma. On the other hand, there may be no history of barotrauma, but there may be persistent cough, purulent postnasal drainage, facial pressure, nasal congestion, and low-grade malaise for many months before the flight surgeon is consulted. The symptoms may date back to a particularly severe upper respiratory infection, or even to an episode of acute sinusitis. The symptoms may be dismissed as allergic (although sneezing, clear rhinorrhea, and lacrimation are usually absent) and the patient may have been treated for allergies on multiple occasions, usually with little or no relief. By definition, chronic sinusitis is a condition that is present for more than three months, although in reality most patients have a considerably longer history of waxing and waning symptoms that often are mistakenly treated as multiple episodes of acute sinusitis. Broad spectrum antibiotic therapy with activity against anaerobes is recommended for three weeks. Decongestants, mucolytics, nasal saline and topical steroid sprays are often prescribed, but there is no consensus as to their effectiveness in shortening the course of chronic sinusitis. If antibiotics fail to eliminate the symptoms, and the X-rays don’t improve, surgery is often the next step. Surgery may be done sooner in aircrew than in others because flying personnel are unable to do their jobs until the disease is eliminated.
DISCUSSION: Although early surgery may seem a bit extreme, it is quite effective in eliminating disease and returning aircrew to flying. Not all ENT surgeons are comfortable with doing early surgery, especially if the patient is asymptomatic and the CT shows only minimally diseased mucosa, but when the “minimal” disease is in the area of the ostiomeatal complex, it can have a profound effect on the sinuses ability to ventilate. The Air Force studied 50 pilots and navigators who were found to have chronic sinusitis during an evaluation following an episode of sinus barotrauma. They all underwent FESS, and 47 returned to flying without further problems. The other three, because of barotrauma in the chamber post-op, needed a minor revision of the original surgery. They eventually returned to flying too. The post-op chamber run is invaluable in proving that the member will do well upon returning to flying. Although it seems obvious that the chamber run is necessary in someone who had suffered barotrauma previously, it is also necessary in post-op patients who never had barotrauma, because it is possible for the surgery itself to cause scarring that can compromise sinus ventilation. An uneventful chamber run puts those concerns to rest. Chronic sinusitis can recur in spite of successful treatment in the past, so the flight surgeon should have a relatively low threshold for treatment or for referral back to ENT if typical symptoms (or barotrauma) should resurface. There is one circumstance in which neither a waiver nor a chamber run would be necessary for an aircrew who has undergone FESS. Occasionally this surgery is done to open a maxillary sinus in order to decompress a mucus retention cyst. In such a case there is no chronic sinusitis, and the surgery itself has little chance of leading to barotrauma. But virtually all other patients who undergo FESS will need a waiver.
473 Chronic Sinusitis
P22.60 Endoscopic Sinus Surgery
