Otorhinolaryngology guidance material GM

1. Examination
   1. Applicants’ hearing shall be tested at all examinations.
      1. For a class 1 medical certificate, and for a class 2 medical certificate when an instrument rating or en route instrument rating is to be added to the licence, hearing shall be tested with pure-tone audiometry at the initial examination, then every 5 years until the licence holder reaches the age of 40 and then every 2 years thereafter.
      2. When tested on a pure-tone audiometer, initial applicants shall not have a hearing loss of more than 35 dB at any of the frequencies 500, 1 000 or 2 000 Hz, or more than 50 dB at 3 000 Hz, in either ear separately. Applicants for revalidation or renewal with greater hearing loss shall demonstrate satisfactory functional hearing ability.
   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.
2. Applicants with any of the following medical conditions shall undergo further examination to establish that the medical condition does not interfere with the safe exercise of the privileges of the applicable licence(s):
   1. hypoacusis;
   2. an active pathological process of the internal or middle ear;
   3. unhealed perforation or dysfunction of the tympanic membrane(s);
   4. dysfunction of the Eustachian tube(s);
   5. disturbance of vestibular function;
   6. significant restriction of the nasal passages;
   7. sinus dysfunction;
   8. significant malformation or significant infection of the oral cavity or upper respiratory tract;
   9. significant disorder of speech or voice;
   10. any sequelae of surgery of the internal or middle ear.
3. Aero-medical assessment
   1. Applicants for a class 1 medical certificate with any of the medical conditions specified in points (1), (4) and (5) of point (b) shall be referred to the medical assessor of the licensing authority.
   2. The fitness of applicants for a class 2 medical certificate with any of the medical conditions specified in point (4) and (5) of point (b) shall be assessed in consultation with the medical assessor of the licensing authority.
   3. The fitness of applicants for a class 2 medical certificate for an instrument rating or en route instrument rating to be added to the licence with the medical condition specified in point (1) of point (b) shall be assessed in consultation with the medical assessor of the licensing authority.

CLASS 1 - AMC1 MED.B.080

(a) Hearing

(1) Applicants 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) Applicants with hypoacusis may be assessed as fit if a speech discrimination test or functional flight deck hearing test demonstrates satisfactory hearing ability. A vestibular function test may be appropriate.

(3) 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.

CLASS 2 - AMC2 MED.B.080

(a) Hearing

(1) Applicants 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) Applicants with hypoacusis may be assessed as fit if a speech discrimination test or functional cockpit hearing test demonstrates satisfactory hearing ability.

(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.

(4) Applicants with profound deafness or major disorder of speech, or both, may be assessed as fit with an SSL, such as ‘limited to areas and operations where the use of radio is not mandatory’. The aircraft should be equipped with appropriate alternative warning devices in lieu of sound warnings.

CLASS 1 - AMC1 MED.B.080

(b) Comprehensive ENT examination
A comprehensive ENT examination should include:

(1) history;

(2) clinical examination including otoscopy, rhinoscopy, and examination of the mouth and throat;

(3) tympanometry or equivalent;

(4) clinical examination of the vestibular system.

CLASS 2- AMC2 MED.B.080

(b) Examination

An ENT examination should form part of all initial, revalidation and renewal examinations.

CLASS 1 - AMC1 MED.B.080

(c) Ear conditions

(1)Applicants with an active pathological process 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.

CLASS 2 - AMC2 MED.B.080

(c) Ear conditions

(1) Applicants with an active pathological process of the internal or middle ear should be assessed as unfit until the condition has stabilised or there has been a full recovery.

CLASS 1 - AMC1 MED.B.080

(c) Ear conditions

(2) Applicants 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.

CLASS 2 - AMC2 MED.B.080

(c) Ear conditions

(2) Applicants 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 which does not interfere with the normal function of the ear may be considered for a fit assessment.

CLASS 1 - AMC1 MED.B.080

(i) Eustachian tube(s) dysfunction

Applicants with permanent dysfunction of the Eustachian tube(s) may be assessed as fit if ENT evaluation is satisfactory.

CLASS 2 - AMC2 MED.B.080

(i) Eustachian tube dysfunction

Applicants with permanent dysfunction of the Eustachian tube(s) may be assessed as fit if ENT evaluation is satisfactory.

CLASS 1 - AMC1 MED.B.080

(d) Vestibular disturbance

Applicants 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 specialist. Applicants with significant abnormal caloric or rotational vestibular responses should be assessed as unfit. Abnormal vestibular responses should be assessed in their clinical context.

CLASS 2 - AMC2 MED.B.080

(d) Vestibular disturbance

Applicants with disturbance of vestibular function should be assessed as unfit pending full recovery.

CLASS 1 - AMC1 MED.B.080

(h) Air passage restrictions

Applicants 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.

CLASS 2 - AMC2 MED.B.080

(h) Air passage restrictions

Applicants 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.

CLASS 1 - AMC1 MED.B.080

(e) Sinus dysfunction

Applicants with any dysfunction of the sinuses should be assessed as unfit until there has been full recovery.

CLASS 2 - AMC2 MED.B.080

(e) Sinus dysfunction

Applicants with any dysfunction of the sinuses should be assessed as unfit pending full recovery.

CLASS 1 - AMC1 MED.B.080

(f) Oral/upper respiratory tract infections

Applicants with a significant infection of the oral cavity or upper respiratory tract should be assessed as unfit. A fit assessment may be considered after full recovery.

CLASS 2 - AMC2 MED.B.080

(f) Oral/upper respiratory tract infections

Applicants with a significant infection of the oral cavity or upper respiratory tract should be assessed as unfit. A fit assessment may be considered after full recovery.

CLASS 1 - AMC1 MED.B.080

(g) Speech disorder

Applicants with a significant disorder of speech or voice should be assessed as unfit.

CLASS 2 - AMC2 MED.B.080

(g) Speech disorder

Applicants with a significant disorder of speech or voice should be assessed as unfit.

CLASS 1 - AMC1 MED.B.080

(j) Sequelae of surgery of the internal or middle ear

Applicants with sequelae of surgery of the internal or middle ear should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication is minimal.

CLASS 2 - AMC2 MED.B.080

(j) Sequelae of surgery of the internal or middle ear

Applicants with sequelae of surgery of the internal or middle ear should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication is minimal.

Initial Class 1 with Hearing Loss

Initial applicants with 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 should have an assessment carried out by a consultant ENT specialist to identify or exclude underlying pathology, assess stability of hearing loss and establish suitability for a hearing aid. The application should then be referred to a medical assessor.

A newly diagnosed hearing loss at an initial medical, with no evidence of stability, may require a number of months to elapse and then repeat audiometry to be undertaken before certification can be considered.

Class 1 applicants, with hearing aids that are well tolerated and suitable for aviation purposes and which enable them to meet the audiogram requirements, should follow the guidance below.

Initial Class 1 applicants with hearing outside the standards set out in MED.B.080 (a)(1)(ii), who can demonstrate stability and no significant underlying pathology, may be considered for Class 2 certification initially with a satisfactory report from a functional hearing test (see Profound Hearing Loss below). Following the issue of a Class 2 medical certificate, the successful completion of PPL training will be considered to demonstrate that hypoacusis does not interfere with the safe exercise of the privileges and Class 1 certification will be considered with SSL (Special Restriction as Specified) limitation “Functional Hearing Assessment Required within 3 months of renewal/revalidation medical”.

Speech discrimination test or functional hearing assessment

For Class 1, this test should be based on the following ICAO SARPs found in Annex 1 Chapter 6:

Hearing loss greater than the requirements may be acceptable provided that there is…
“6.3.4.1.1….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.

Note 1. - 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.

Note 2. - In the speech material for discrimination testing, both aviation-relevant phrases and phonetically balanced words are normally used.”

For all classes (1, 2 and 3) there is the alternative that a practical hearing test conducted in a communication environment representative of the one for which the certificate holder’s licence and ratings are valid may be used. 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.

The Functional Hearing Assessment (FHA) form should be used.

Hearing Aids

For initial Class 1 applicants, hearing aids may be acceptable and will be considered on an individual basis with accompanying specialist reports.

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-pilot restriction may be required for initial or existing Class 1 applicants. Consideration should also be given to carrying spare aids and batteries where appropriate.

Note: For many pilots increasing the volume of the head set may be preferable and enhance hearing more than wearing hearing aids. In increasing the volume, pilots should be aware of the risks to their residual hearing from noise exposure and seek advice from their AME or company occupational physician.

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

• Medical reports - ENT

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 Assessment (FHA) form

Profound Hearing Loss

Applicants who are or become completely deaf will not be able to gain or renew/revalidate a Class 1 medical certificate.

Class 2 applicants 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’.

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 

Acoustic Neuroma

On diagnosis, the applicant should be made unfit. If clinical management is a ‘watch and wait’ policy, the applicant can be recertified to Class 1 OML/unrestricted Class 2. Follow-up MRI reports should be forwarded to CAA Medical Department. 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. Unrestricted Class 1 at 12 months post-operatively can be considered 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

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.

• Medical reports - ENT

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 4 months from symptom resolution.

The use of any medication to treat vestibular symptoms, for example, 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.

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.