P2LT DATU NUR-JHUN A SALIK MC

WEEK 2 (30 NOV - 04 DEC 2020)

08 OF 14 AMEC CL 15-20

OTOLARYNGOLOGY IN AIR EVACUATION

Otolaryngology in Air Evacuation

– Examination of the ear, nose & throat, head and neck
Barotitismedia, Barosinusitis, Hearing, Problems of the Flyer and Cases in Air Evacuation
• Anatomy & Physiology of the Ear
• Spatial Disorientation
• Motion Sickness; Noise and Vibration during Flying
• “The ears, nose and throat are potentially at risk during a flight, but fortunately the majority of symptoms are
mild, and, with some simple precautions, these can often be avoided. “

Barotitismedia, Barosinusitis, Hearing, Problems of the Flyer and Cases in Air Evacuation

Otitic Barotrauma
• Pressure of 5 cm3 to 7 cm3 at 8000 feet
• Eustachian tube is unable to equalize middle ear pressure with ambient pressure during aircraft flight.
• Submucosal edema may develop within the middle ear, leading to haemorrhage and, in extreme cases,
perforation of the tympanic membrane may occur.

Middle ear pressure changes during ascent and descent

Children
• Suboptimal function of the eustachian tube.
• Otitic Barotrauma is common.
• Mothers of babies would be well advised to breast- or bottle-feed their child during descent.

Other factors:
• Middle Ear Surgery (Myringoplasty, Mastoid Surgery, Stapedectomy, Ossicular reconstruction)
– Eustachian tube is suboptimal.
– Blood may occlude to eustachian tube.
• Vertigo
– May aggravate otitic barotrauma

• Middle Ear Ventilating Tube - Treatment of established childhood otitis media with effusion.

Factors:
• Upper Respiratory Tract Infection
– Most common
• Deviated Nasal septum
• Nasal Polyps
• Acute and Chronic Rhinosinusitis

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 P2LT DATU NUR-JHUN A SALIK MC
WEEK 2 (30 NOV - 04 DEC 2020)
08 OF 14 AMEC CL 15-20

NOSE AND SINUSES

• The nose and paranasal sinuses act together as an efficient air conditioner for the rest of the respiratory tract
(humidify and warm).
• Prolonged exposure to excessively dry air, as encountered during a long-haul aircraft flight, may lead to
excessive drying and even crusting within the nasal cavity.

Prevention and Treatment

• As a general rule, flying while suffering from a heavy head cold should be avoided.
• If unavoidable, then decongestants should be used.
• Swallowing during descent
• Sucking
• Air can travel between the nose and the paranasal sinuses, and through which the mucociliary clearance
mechanism can clear mucus and any debris from within the sinuses.
• The paranasal sinuses are air-containing cavities within the facial skeleton - maxillary, ethmoid, frontal and
sphenoid.

Sinus barotraumas

• Like otitic barotrauma, is due to an inability to equalize the pressure within some or all of the paranasal sinuses
with the ambient air pressure.
• encountered typically during descent.
• The sudden onset of negative pressure within the affected sinus results in submucosal haemorrhage resulting
to an EPISTAXIS.
 Direct pressure, Ice packs applied
 Trotter’s Maneuver

• Predisposing Factors:
 Upper Respiratory Tract Infection
 Anatomical Variations:
 Deviated Nasal Septum, enlarged middle turbinates
 Nasal Polyps
 Chronic Rhinosinusitis

• Treatment and Prevention:

 Ideally, individuals with an upper respiratory infection should avoid flying to prevent barotrauma.
 If flying is unavoidable, then systemic or topical nasal decongestants may help to reduce nasal
mucosal edema and so prevent barotrauma.
 Correction of a deviated nasal septum and removal of nasal polyps

PRE-FLIGHT ASSESSMENT
• Toynbee Maneuver
– Swallowing while mouth and nose closed
• Valsalva Maneuver
– Forced expiration with mouth and nose closed
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 P2LT DATU NUR-JHUN A SALIK MC
WEEK 2 (30 NOV - 04 DEC 2020)
08 OF 14 AMEC CL 15-20

Cases in Air Evacuation

• Ear nose & throat (ENT) injuries are usually found more often that accounted for. Although patient stabilization
according to trauma protocols is important for the patients’ life, care of an ear – nose & throat injury is
important for the patient’s quality of life post trauma

Patients with EAR/Temporal Bone TRAUMA

• temporal bone fractures are longitudinal or transverse
• If one suspected cabin altitude should be kept ideally to AE departure level or kept to the minimum possible
and antibiotic treatment administered to counter for the possibility of delayed meningitis.

Aeromedical evacuation of post-operative otologic patients

• Post myringotomy
– 1 day
• For post tympanoplasty or stape surgery
– 10 days mimimum
• CSF leak, AE should not be allowed for two weeks

Patients with facial & RHINOLOGICAL trauma

Facial trauma has been typically classified by Le Forte (Figure 4). However, the sinuses may also be involved in
an “irregular” fashion, with/without identifiable depression on the patient face, although haematomas, nasal bleeding
with congestion may also occur. Orbit involvement may also add diplopia, blurred vision, anopsia or difficulty in
ophthalmokinetic muscle activity due to their involvement in orbit fractures (Figure 5), as well as blood content in tears.
Sinuses with fractured walls are unlikely to present problems during AE either due to the flaccidity of their walls which
allows them to accommodate possible pressure changes, or due to their filling with blood, rendering them immune to
pressure changes. When air has entered the orbit via a fractured sinus wall, care to provide air passage out and monitor
visual acuity should be taken to avoid compression injury to the optical nerve.

Aeromedical evacuation (AE) of post-operative rhinological patients

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 P2LT DATU NUR-JHUN A SALIK MC
WEEK 2 (30 NOV - 04 DEC 2020)
08 OF 14 AMEC CL 15-20

THE CASE OF EPISTAXIS PATIENT

• All patients with anterior packing may not face problems during AE, care should be given to the patient bearing
posterior packing.
• Posterior nasal bleeding is usually controlled via balloon catheters (i.e. In case of severe bleeding (e.g. elderly
patient receiving anti-coagulants) AE should be best avoided for a week after bleeding settles. Otherwise, during ascent
to altitude over-inflation of the balloon catheter will result in discomfort and during descend under-inflation may result
in bleeding recurrence.
• In case of severe bleeding (e.g. elderly patient receiving anti-coagulants) AE should be best avoided for a week
after bleeding settles. Otherwise, during ascent to altitude over-inflation of the balloon catheter will result in discomfort
and during descend under-inflation may result in bleeding recurrence.

The patient with mandible fracture

• Patients with mandible fractures often carry intermaxillary fixation (IMF).
• wire cutters should be readily available (kept secure and attached to the patient), or the wire IMC fixation
system should be replaced by a rubber one, in order to facilitate doffing.

Patients with OROPHARYNX or SOFT TISSUE NECK TRAUMA

Patients with oropharynx of neck soft tissue trauma (Figure 8) should not present with difficulty in AEv,
provided that their surgical field has dried off properly (that is adequate haemostasis techniques were used), all drains
have been removed and the patient remains complication free. This may demand a 10 day period before AEv,
depending on general patient condition.

Post-op care for the tonsillectomy patient

• Tonsillectomy may range from a simple surgical procedure to a vigorous intervention. Its most common
complication, other than pain, is haemorrhage form the surgical bed.
• Some bleeding may normally occur during the 4-5 th post-operative day, due to eschar separation from the
tonsillar fossae.
• Consider safer for a tonsillectomy patient to AEv in 2 weeks post-operation.

The patient with laryngeal trauma

Cricothyrotomy or tracheostomy should be preferred

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 P2LT DATU NUR-JHUN A SALIK MC
WEEK 2 (30 NOV - 04 DEC 2020)
08 OF 14 AMEC CL 15-20

Laryngeal trauma presents a challenge in management because fracture and subsequent instability of the
laryngeal apparatus may be concealed during first evaluation, specially in the unconscious. In such cases, patient history
(trauma mechanism, skin marks: i.e. clotheslines, characteristics of the insulting force, etc) may help. When in doubt,
cricothyrotomy or tracheostomy should be preferred. In extreme trauma cases, a complete separation of tracheal rings
may be unnoticed. An oronasal/nasotracheal tube by mere insertion force can cause the soft tissue keeping tracheal
together to tear and the central trachea to retract into thorax.

• Laryngeal cancer
– a patient with a laryngectomy who is to undertake a prolonged flight should wear a humidifying bib to
prevent excessive drying and crusting.

Care for the tracheostomised patient during AEv

• Tube cleaning facility, incorporating air suction pump to remove tracheal secretions,
• Air humidifier and adequate hydration
• Respiratory Oxygen
• Tube replacement and obturator (in case tube looses fixation)
• If tracheostomy has been performed recently, a week should be at best allowed before air travel.

ENT Trauma is common in modern operations and still remains lethal due to the nature of its site.

Following all trauma management general guidelines, in order to treat it effectively, one must be aware of trauma
mechanism and its relative clinical signs. ENT trauma patients may be evacuated by air safely, keeping simple guidelines
which – within flight – require a fundamental understanding of the underlying basic aeromedical principles and laws of
physics.

Anatomy & Physiology of the Ear

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 P2LT DATU NUR-JHUN A SALIK MC
WEEK 2 (30 NOV - 04 DEC 2020)
08 OF 14 AMEC CL 15-20

THE EAR
• The middle ear or tympanic cavity is an aircontaining space within the petrous temporal bone and is in
continuity with the nasopharynx via the Eustachian tube.
• The volume of air within the middle ear and mastoid system varies between 2.5 and 13 cm3
• This tube is 3.5 cm long
• HEARING LOSS -Not contraindication to flying

SPATIAL DISORIENTATION AND EFFECTS/COUNTERMEASURES

Motion Sickness; Noise and Vibration during Flying

MOTION SICKNESS
• airsickness
• caused by the brain receiving conflicting messages about the state of the body can occur in visually,
otologically, neurologically, psychologically normal persons
• anxiety and stress is contributory
• The vestibular system appears to be the source of the symptoms of motion sickness (airsickness).
• Any pilot, subjected to the right combination of unusual attitudes or flight conditions, can become airsick.
• Passengers (or pilots not in control of the aircraft) are easy subjects. New pilots are also susceptible. Some of
the additional common causes include heat discomfort, anxiety, observing or smelling someone else who is
airsick, and eating foods that are nauseating.

Symptoms
• Nausea and vomiting
• General discomfort
• Dizziness
• Paleness
• Sweating

Treatment
• Most people know if they are prone to airsickness.
• There is no known prevention technique or adequate treatment to help.
• Some suggest that there is more chance of becoming airsick if one flies on an empty stomach;
• Training to help pilots break the cycle of airsickness is becoming more popular.

NOISE
• The term noise is commonly used to designate an annoying or unwanted sound
• the term has come to mean any excessively loud sound that has the potential to harm hearing
• noise induced hearing loss is one of the most common adult hearing problems encountered by
Otolaryngologists
• in 1990, the US Veterans Administration paid out $ 206M in pensions to veterans who incurred hearing loss
during their military service.

• Types of noise
– steady-state and
– impulse

Steady-state is a type encountered around and in an operating aircraft, often during flight.
– Here is where duration of exposure becomes important because there is a direct correlation between
intensity, duration, and amount of damage to the ear
– Sources include prop noise, which ranges from 90 to 113 dB, ven- tilation sounds in small aircraft and
even in the new glass cockpits, and the turbulence of air around the fuselage.

Impulse noise is the short burst type that can be produced by a backfiring engine, switching to a
communication channel already turned up to full volume, or other short-term (often lasting only a few
milliseconds) but loud sounds.
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 P2LT DATU NUR-JHUN A SALIK MC
WEEK 2 (30 NOV - 04 DEC 2020)
08 OF 14 AMEC CL 15-20

– Often these sounds come as a surprise, and there is no way to anticipate the need for added
protection; however, within the middle ear, where the ossicles are located, there is a small muscle
attached to one of the bones that functions like a “bungee” protection against sudden and extreme
movement of the joints.

• At the very least, noise is annoying and distracting in flight and can seriously interfere with concentration,
communication, and performance.
• Noises greater than 140 dB SPL may cause pain
• long exposure to noises over 90 dB SPL may eventually harm hearing
• ear protection helps to prevent noise-induced hearing loss by reducing the level of exposure to loud sounds by
putting a barrier between the noise and the inner ear where the damage occurs
• ear muffs, custom-fitted plugs, or disposable ear plugs each provide 20-40 dB of sound attenuation

SOUND DECIBELS
Rocket launching pad 180
Jet plane 140
Gunshot blast 140
Riveting steel tank 130
Automobile horn 120
Sandblasting 112
Woodworking shop 100
Average factory 80-90
Computer printer (dot matrix) 85
Noisy restaurant 80
Busy traffic 75
Conversational speech 66
Average home 50
Quiet office 40
Soft whisper 30

OSHA Standard for Noise Exposure

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 P2LT DATU NUR-JHUN A SALIK MC
WEEK 2 (30 NOV - 04 DEC 2020)
08 OF 14 AMEC CL 15-20

Allowable Noise Exposure

C-130

dB during cruise
105 112 105 110

Vibration
• is related to the physical displacement of parts of the body, some parts moving more and easier than others
(bone, soft tissues, internal organs, etc.).

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 P2LT DATU NUR-JHUN A SALIK MC
WEEK 2 (30 NOV - 04 DEC 2020)
08 OF 14 AMEC CL 15-20

• Vibration is noticed more in helicopters, less in reciprocating engines, a little less in turboprops, and minimally
in jet aircraft.
• A common component is the fact that vibrations are communicated directly to the subject via a solid medium,
or through direct contact with the vibrating aircraft.
• These waves of vibration are transmitted to various body parts, each of which reacts differently.
• Only very intense vibrations disrupt normal cellular and organ function; however, generally speaking, all
vibrations can cause body discomfort, chest pain, diminished visual acuity, and distractions. Vibration is also an
important cause of fatigue.
• The most important frequency range associated with adverse effects lies between 1 and 40 Hz.
• Different parts of the body oscillate with the vibratory frequency but at different levels.
• There is little one can do to change the causes of vibration, because once the aircraft is designed, little can be
changed to reduce vibration.
• The most important modification is in the seats; the more the body is cushioned, the more the vibration is
dampened.
• Shoulder and lap belts tend to transmit some vibration.
• The healthy body is more tolerant of the effects of vibration; however, because vibration is fatiguing, this
fatigue now allows the vibration to be more of an impairment, a vicious circle.
• This fatigue is probably the most noteworthy result of vibration.
• Awareness of this source of fatigue allows the pilot to be more suspicious of substandard performance.

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