Otorhinolaryngology Guidance Material

Implementing Rules (IRs), Acceptable Means of Compliance (AMCs) and Guidance Material (GM) on ENT conditions

The following are the requirements for the medical certification of aircrew, including guidance material issued by the UK CAA Medical Department in relation to the otorhinolaryngology system.

Implementing Rules

Acceptable Means of Compliance

Guidance Material

MED.B.080 Otorhino-laryngology

(a) Applicants shall not possess any abnormality of the function of the ears, nose, sinuses or throat, including oral cavity, teeth and larynx, or any active pathological condition, congenital or acquired, acute or chronic, or any sequelae of surgery or trauma which is likely to interfere with the safe exercise of the privileges of the applicable licence(s). Medical reports - ENT
(b) Hearing shall be satisfactory for the safe exercise of the privileges of the applicable
licence(s).
(c) Examination
   (1) Hearing shall be tested at all examinations.
      (i) In the case of class 1 medical certificates and class 2 medical certificates, when an instrument rating is to be added to the licence held, hearing shall be tested with pure tone audiometry at the initial examination and, at subsequent revalidation or renewal examinations, every five years until the age 40 and every two years thereafter.
      (ii) When tested on a pure-tone audiometer, initial applicants shall not have a hearing loss of more than 35dB at any of the frequencies 500Hz, 1000Hz or 2000Hz, or more than 50dB at 3000Hz, in either ear separately.  Applicants for  revalidation or renewal, with greater hearing loss shall demonstrate satisfactory functional hearing ability. 
      (iii) Applicants with hypoacusis shall demonstrate satisfactory functional hearing ability.
Class 1
a) Hearing
   (1) The applicant should understand correctly conversational speech when tested with each ear at a distance of 2 metres from and with the applicant’s back turned towards the AME.
   (2) The pure tone audiogram should cover the 500Hz, 1000Hz, 2000Hz and 3000Hz frequency thresholds.
   (3) An applicant with hypoacusis should be referred to the licensing authority.

A fit assessment can be made if a speech discrimination test or functional flight deck hearing test demonstrates satisfactory hearing ability.  A vestibular function test may be appropriate.

Initial Class 1 with Hearing Loss
INITIAL applicants shall not have a hearing loss of more than 35dB at any of the frequencies 500Hz, 1000Hz or 2000Hz, or more than 50dB at 3000Hz, in either ear separately.

Revalidation/renewal Class 1 with Hearing Loss
For only revalidation or renewal, greater hearing loss can be recertificated following demonstrated satisfactory functional hearing ability.

Speech discrimination test or functional hearing test
This test should be based on the following ICAO guidance:
Hearing loss greater than the requirements may be acceptable provided that there is normal hearing performance against a background noise that reproduces or simulates the masking properties of the flight deck noise in the cockpit upon speech and beacon signals.

It is important that the background noise be representative of the noise in the cockpit of the type of aircraft for which the applicant’s licence and ratings are valid. The frequency composition of the background noise is defined only to the extent that the frequency range 600 to 4 800 Hz (speech frequency range) is adequately represented. In the speech material for discrimination testing, both aviation-relevant phrases and phonetically balanced words are normally used. Alternatively, a practical hearing test conducted in communication environment representative of the one for which the certificate holder’s licence and ratings are valid may be used.

The Functional Hearing Test form should be used.




Implementing Rules

Acceptable Means of Compliance

Guidance Material

   (4) If the hearing requirements can only be met with the use of hearing aids, the hearing aids should provide optimal hearing function, be well-tolerated and suitable for aviation purposes.

Hearing Aids
For initial Class 1 applicants, hearing aids are not usually acceptable.

In an applicant who already holds a medical certificate, any type of hearing aid is acceptable for recertification, e.g. bone-anchored or intra-aural.  Following insertion of the hearing aid, a functional hearing assessment must be performed and if satisfactory a return to certification is possible.  A multi-crew restriction may be required for Class 1 applicants.

Note: For many pilots increasing the volume of the head set may be preferable and enhance hearing more than wearing hearing aids.

For removable hearing aids, audiometry, if required, should be undertaken both with and without hearing aids.

Class 2
(a) Hearing
   (1) The applicant should understand correctly conversational speech when tested with each ear at a distance of 2 metres from and with the applicant’s back turned towards the AME.
   (2) An applicant with hypoacusis should be assessed as fit if a speech discrimination test or functional cockpit hearing test demonstrates satisfactory hearing ability.  An applicant for an instrument rating with hypoacusis should be assessed in consultation with the licensing authority.
   (3) If the hearing requirements can be met only with the use of hearing aids, the hearing aids should provide optimal hearing function, be well-tolerated and suitable for aviation purposes.

(b) Comprehensive otorhinolaryngological examination
A comprehensive otorhinolaryngological examination should include:
   (1) history;
   (2) clinical examination including otoscopy, rhinoscopy, and examination of the mouth and throat;
   (3) tympanometry or equivalent;
   (4) clinical assessment of the vestibular system.

Class 2 with Hearing Loss
Class 2 applicants who fail the conversational test at 2m are required to provide specialist medical reports detailing the cause of hearing loss and the results of pure tone audiometry. Functional testing in flight may be necessary.

Functional Hearing Test form


Profound Hearing Loss (Class 2)
Class 2 applicants who are or become completely deaf may be considered for certification with special restriction of ‘SSL’ – ‘no flights to or from airfields where ATC is provided by radio and remain outside controlled airspace’.




Implementing Rules

Acceptable Means of Compliance

Guidance Material

   
   (2) A comprehensive ear, nose and throat examination shall be undertaken for the initial issue of a class 1 medical certificate and periodically thereafter when clinically indicated.
Class 2
(b) Examination
An ear, nose and throat (ENT) examination should form part of all initial, revalidation and renewal examinations.
(d) Applicants for a class 1 medical certificate with:
   (1) an active pathological process, acute or chronic, of the internal or middle ear;
   (2) unhealed perforation or dysfunction of the tympanic membrane(s);
Class 1 & 2
(c) Ear conditions
   (1) An applicant with an active pathological process, acute or chronic, of the internal or middle ear should be assessed as unfit.  A fit assessment may be considered once the condition has stabilised or there has been a full recovery.

Ear Conditions
A fit assessment can be considered after full recovery from a condition affecting the ear following provision of a satisfactory GP or specialist report.  Complex conditions and Class 1 certificate holders will require an ENT specialist assessment.

If there is incomplete recovery from the condition, evidence that the condition has stabilised for an appropriate period of time is required.  The audiogram standards must be met or a satisfactory functional hearing assessment is required.

Medical reports - ENT

   (2) An applicant with an unhealed perforation or dysfunction of the tympanic membranes should be assessed as unfit.  An applicant with a single dry perforation of non-infectious origin and which does not interfere with the normal function of the ear may be considered for a fit assessment.

Perforation
Recertification is possible after a minimum period of six weeks following a single dry perforation of non-infectious origin.  A specialist report is required confirming complete healing and the pilot must be pain free.  A satisfactory audiogram is required for Class 1 or Class 2 Instrument Rating (IR) recertification.


Stapedectomy
To ensure full healing, recertification is only allowed a minimum of three months after surgery, subject to a satisfactory specialist report confirming no complications, the absence of dizziness, spontaneous or positional nystagmus and a satisfactory hearing result.

Grommet insertion
This is acceptable for certification at both initial and revalidation/renewal.

Acoustic Neuroma
On diagnosis, the applicant should be made unfit.  If clinical management is a ‘watch and wait’ policy, the applicant can be recertificated to Class 1 OML/unrestricted Class 2.  Follow-up MRI reports should be forwarded to  the AMS.
An applicant with symptoms, or if a decision is made to treat, should be made unfit pending full recovery from symptoms or treatment.

Following surgery, recertification depends on surgical approach, extent of removal and post op symptoms.  If brain has been retracted during operation the risk of seizure should be considered.  Normally, following full recovery,  a fit class 1 OML or unrestricted Class 2 assessment is appropriate.  Can consider unrestricted Class 1 at 12 months post-operatively if the imaging shows complete resection of the tumour and there are no seizures or balance disturbance.
 
Following radiotherapy, certification is possible as Class 1 OML/unrestricted Class 2 on recovery (minimum 4 weeks following completion of treatment).  Unrestricted certification can be considered 1 year after the completion date of radiotherapy, subject to imaging showing complete resection of the tumour and there being no seizures or balance disturbance.

Medical reports - ENT




Implementing Rules

Acceptable Means of Compliance

Guidance Material

   
   (3) disturbance of vestibular function;
Class 1
(d) Vestibular disturbance
An applicant with disturbance of vestibular function should be assessed as unfit.  A fit assessment may be considered after full recovery.  The presence of spontaneous or positional nystagmus requires complete vestibular evaluation by an ENT specialist.  Significant abnormal caloric or rotational vestibular responses are disqualifying.  Abnormal vestibular responses should be assessed in their clinical context.


Benign Positional Vertigo/Labyrinthitis
In view of the recurrence risk of this condition and the sudden incapacitating nature of the symptoms, the earliest a pilot can be considered for recertification is after they have been symptom-free and off any treatment for at least 4 weeks.  Class 1 holders require an OML for a minimum period of 3 months from recertification.

The use of any medication to treat vestibular symptoms, eg Betahistine is not acceptable for medical certification.

Medical reports - ENT 

Meniere’s Disease
A diagnosis of Meniere’s Disease, untreated or treated is not acceptable for Class 1 or 2 medical initial or recertification.

Class 2
(d) Vestibular disturbance
An applicant with disturbance of vestibular function should be assessed as unfit pending full recovery.

   (4) significant restriction of the nasal passages;
Class 2
(h) Air passage restrictions
An applicant with significant restriction of the nasal air passage on either side or significant malformation of the oral cavity or upper respiratory tract may be assessed as fit if ENT evaluation is satisfactory.

(j) Eustachian tube function
An applicant with significant dysfunction of the Eustachian tubes may be assessed as fit in consultation with the licensing authority.



Implementing Rules

Acceptable Means of Compliance

Guidance Material

   
   (5) sinus dysfunction; 

Class 1 & 2
(e) Sinus dysfunction
An applicant with any dysfunction of the sinuses should be assessed as unfit until there has been full recovery.
   (6) significant malformation or significant, acute or chronic infection of the oral cavity or upper respiratory tract;(f) Oral/upper respiratory tract infections
A significant, acute or chronic infection of the oral cavity or upper respiratory tract is disqualifying.  A fit assessment may be considered after full recovery.

   (7) significant disorder of speech or voice shall undergo further medical examination and assessment to establish that the condition does not interfere with the safe exercise of the privileges of the licence held.
Class 1 & 2
(g) Speech disorder
A significant disorder of speech or voice is disqualifying.

(e) Aero-medical assessment
   (1) applicants for a class 1 medical certificate with the disturbance of vestibular function shall be referred to the licensing authority;

   (2) fitness of class 2 applicants with the disturbance of vestibular function shall be assessed in consultation with the licensing authority.