84rd AsMA Annual Scientific Meeting German Panel Chicago...

84rd AsMA Annual Scientific MeetingGerman Panel

Chicago, Illinois May, 2013

Title

Sudden Incapacitation secondary otolaryngological Events

Author: LtCol Dr. Andreas KnoefflerHead of the ENT Department

German Air Force Institute of Aviation MedicineCommander: Col Dr. Franz Grell

AsMA Annual Meeting 2013, Chicago

Sudden Incapacitationsecondary Otolaryngological Events

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I have no financial relationships to disclose.

I will not discuss off-label use and/or investigational use in my presentation

Disclosure Information

84th Annual AsMA Scientific MeetingLtCol Dr. Andreas Knoeffler



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Agenda:• Introduction• Literature Review• Risk Assessment following special Examinations

• Sleep Apnea• Sinus • Middle ear surgery

• Conclusion



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• Noise• Vibrations• Changes of athmospheric pressure• Spatial disorientation• Psychic factors• Climatic factors

Factors



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• Ears• Vestibular organ• Nose and paranasal sinuses• Oropharynx• Larynx and Pharynx• Neck

Aims of interest



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“……Incapacitation:A medical event that resulted, or would have had the propensity to result in an inability to act as flight crew for at least 10 min….

…… Impairment:A partial incapacitation associated with symptoms that resulted, or would have had the propensity to result in a reduction of function …………..” *

* The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9



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Handlungsunfähigkeit



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Beeinträchtigung



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• Conclusion



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Name Country Year Affected Systems Results N

Evans Radcliff UK 2012

Causes of Episodes of temporary Unfitness (not SI)

720ENT 46 (6%)

Accidents (highest) 131 (18%)

In Flight Medical Events Resulting in Notification of Unfitness16

ENT 2 (12,5%)

Rosenquist L et al. Denmark 2008

Barotrauma ear 356 (37.6%)

958Barotrauma sinus 185 (19,3%)

Incapacitated 2%

Zadik et al. Israel 2007Barodontalgia 29 (100%) 27 Patients, 29

EventsBarosinusitis 5 (18,5%)

James an Green UK1967

Sudden incapacitation, Earache/-block153 (7%) 2295

1988 186 (8%) 2209

Newman GATSB

Australia2007

Medical events affecting Accidents and Incidents

98

acute Pain 5 (5,10%)

Pressure Effects 3 (3,06%)

Motion sickness 3 (3,06%)

Spatial disorientation 1 (1,02%)

Gastrointestinal Illnes (highest Score) 21 (21,43%)

Incapacitation /Unfitness following ENT problems – Review:



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The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9

Evans and Radcliff 2012

• Mandatory Occurence Reporting System (MORS) since 1976• 16145 UK/JAR Professional Pilot Licence Holders (2004)• 36 in Flight incapacitations• 4 sudden deaths in Flight• Male Pilot in the 60`s, 5 time higher risk than a male Pilot in the 40`s• Incapaciation Rate 40/16145 = 0,25%



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The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9The annual incapacitation rate of commercial pilots. Evans S, Radcliffe SA Aviat Space Environ Med 2012 Jan; 83 (1): 42-9



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Evans and Radcliff 2012

Following ENT Events:• Causes of temporary Unfitness 46/720 = 6%• Professional Pilot Incapacitation 1/36 = 2,8%• Causes of Unfit Episode compared to other medical events 3/16 = 19%



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James M Green R Airline Pilot Incapaciation survey Aviat Environ Med 1991 62: 1068-72

• Questionaire 4345 Aircrew Members• 16 countries• 97 airlines

• Ranking (R) Incidence Incapacitation in flight:• R 1 bowel action 15,2%• R 5 Ear Block 8,5%• R 7 Headache 4,9%• R 10 Nosebleed 1,9%• R 14 Sneezing Attack 0,68%



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C DeJohn et al. 2004

• Incapacitations and Impairments 1993 -1998• 39 Incapacitations and 11 Impairments aboard 47 aircrafts• Only male Pilots• In Flight Medical Event Rate 0,058/100000 flight/hrs• In flight medicial event would result in an A/C accident is 0.04%• one Impairment following Sinus and Ear Barotrauma (Diversion)• one Incapacitation F/O getting up for Aspirin second. Ear Ache - LOC

In Flight Medical Incapaciation an Impairment of U.S. Airlinbe Pilots: 1993 to 1998C A DeJohn, A M Wolbrink, J G Larcher DOT / FAA /AM-04/16



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FILES DS, WEBB JT, PILMANIS AA. Depressurization in military aircraft: rates, rapidity, and health effects for 1055 incidents. Aviat Space Environ Med 2005; 76:523–9.

Depressurization in Military Aircraft

• 1055 incidents Rate per Million h: 10,8• 235 Tanker 6,8• 55 Bomber 30,3• 444 Fighter 13• 300 Trainer 6,4• 3 Rcon. /U2 9,5• 18 hours unknown

• 350 incidents with adverse health effects (33,2%)



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FILES DS, WEBB JT, PILMANIS AA. Depressurization in military aircraft: rates, rapidity, and health effects for 1055 incidents. Aviat Space Environ Med 2005; 76:523–9.

Depressurization in Military Aircraft

350 Incidents involving:• Hypoxia 221 (63,1%)• DCS 83 (23,7%)• Barotrauma 71 (20,2%) Barotrauma alone 57 (16,3%)



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• 450 Questionairs; 331 answered (73,6%) • Aircrew Israelian Air Force• Fighter (12 case/Resp. 133 ), Heli (9/112), Transporter (6/86)

• Recent dental Restoration 8 (29,6%) • Pulp necrosis / per-apical Peridontitis 5 (18,5%)• Barosinusitis 5 (18,5%)• Irreversible Pulpitis 2 (7,4%)• Faulty Amalgam Rerstauration 1 (3,7%)• Vertical Root Fracture 1 (3,7%)• Impacted Tooth 1 (3,7%)• Unknown 4 (14,8%)

ZADIK Y, ZAPNICK L, GOLDSTEIN L. In-flight barodontalgia: analysis of 29 cases in military aircrew. Aviat Space Environ Med 2007;78:593– 6.



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Rosenkvist L, Klokker M, Katholm M Upper respiratory infections (URI) and barotraumas in commercial pilots: a retrospective survey. Aviat Space Environ Med 2008 Oct;79(10):960-3.

• Questionaire 920 men / 28 women• 6 month period• Professional Pilots• 356 ≥ 1 ear barotromas (37,6%)• 185 Sinus barotrauma (19,5%)

• frontal Sinus 70-80%• maxillary Sinus 20-30%

• 169 Allergies (17,8%)• Climb (7,1%) Level (2%) Descend (90,9%)• 42,8% went to work in spite of URI

Medical events



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Dr David G. Newman Pilot Incapacitation: Analysis of Medical Conditions Affecting Pilots Involved in Accidents and Incidents 1 January 1975 to 31 March 2006

ATSB TRANSPORT SAFETY REPORT Aviation Research and Analysis Report - B2006/0170

• Accidents• person dies or• serious injury

• Serius incidents• vehicle destroyed or• seriously damaged

• Incidents• property is destroyed or• seriuosly damaged



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1975 – 2006:Events: Medical:Accidents 8302 16 (0,19%)Serious incidents 95 1 (9,5%)Incidents 151 941 81 (0,05%)Total 160 338 98 (0,061%)



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Type of Medical event or Incapacitation(98):Gastrointesinal 21 (21,43%)Heart attack 8 (8,16%)Pressure effects 3 (3,06%)Motion sicknes 3 (3,06%)



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• Conclusion



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0

5

10

15

20

25

30

35

40

HELI FW JET Other

A/C

OSAS vs. A/C

N

BMI

AHI

AHI = 10/h



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Screening - Special Examaniation - Therapy - Survey



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Therapeutic Effect* on av. AHI (n/h)

2.88

17.43

0

2

4

6

8

10

12

14

16

18

20

Pretherapeutic Posttherapeutic

Therapeutic Effect on O2-Saturation

81.3

93.3

90.1

95.2

70

75

80

85

90

95

100

AV SaO2 (%) Min SAO2(%)

Pretherapeutic Postherapeutic



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• Conclusion



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Typical findings of the paranasal sinus: Blocked OMC

MRI - Scan CT - Scan

http://ctscans.hawkelibrary.com/album04/AED_1_47?full=1



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fit for flying; 71.92%

unfit for flying; 2.69%

unfit for flying untill sucessfull

treatment; 9.23%

fit for flying with slight signs;

16.15%

Results of first ENT – examination of ever first candidates Results of first ENT – examination of ever first candidates Sinus findings Sinus findings (11/ 2005 – 11/2006; N=429)(11/ 2005 – 11/2006; N=429)



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Results after treatment N = 28

sucessfullsurgical treatment (FESS)

50%

sucessfullnon-surgical

treatment 32%

remaining unfit for flying

18%

Results of first ENT – examination of ever first candidates Results of first ENT – examination of ever first candidates Sinus findings Sinus findings (11/ 2005 – 11/2006; N=429)(11/ 2005 – 11/2006; N=429)



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• Conclusion



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http://de.wikipedia.org/w/index.php?title=Datei:Stapes_laser3.jpg&filetimestamp=20061226133142

http://de.wikipedia.org/w/index.php?title=Datei:Stapes_prothesen.jpg&filetimestamp=20070106134848



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Electronystagmography

Tympanometry

ENG - Tympanometry



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• Conclusion



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Sudden incapacitations causes by ENT problems in flight are rare (2-8,5%) Male pilots in the 60’s have a 5x higher risk than male pilots in the 40’s ENT events compared to other incapacitating medical events ~ 19%. In flight medical events leading to an a/c accident ~ 0,04% Special risk assessment preventing SI in ENT

Risk assessment sleep apnea:Screening-examination-therapy-survey

Risk assessment sinus:Imaging-endoscopy-hypobaric chamber

Risk assessment ear/middle ear:Otoscopy-tympanometry



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LtCol Dr. Andreas KnöfflerGerman Air Force Institute of Aviation MedicineENT DepartmentPB 1264/KFM82242 FürstenfeldbruckTel.: 08141 5360 2015Fax: 08141 5360 2989E-Mail: [email protected]

Thank you for your attention !

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