Should Pilots with Acoustic Neuroma Fly?

D Schramm MD SM FRCSC FACSE Brook MD MPH BA DABPM

D Salisbury MD MHSc FACPM FRCPC CD

Civil Aviation MedicineTransport Canada

Disclosure Information84th Annual AsMA Scientific Meeting

David Schramm MDEdward Brook MD

David Salisbury MD

We have no financial relationships to disclose.

We will not discuss off-label use and/or investigational use in our presentation

Acoustic NeuromaAcoustic Neuroma

• Vestibular schwannoma – benign, slowly Vestibular schwannoma – benign, slowly growinggrowing

• Incidence: 1 / 100,000Incidence: 1 / 100,000

• Compression of vestibulocochlear nerve:Compression of vestibulocochlear nerve:– Hearing loss Hearing loss

– TinnitusTinnitus

– Disequilibrium/VertigoDisequilibrium/Vertigo

• Larger tumors:Larger tumors:– Facial numbnessFacial numbness

– Brainstem compression symptomsBrainstem compression symptoms

Acoustic NeuromaAcoustic NeuromaPresenting SymptomsPresenting Symptoms

• Hearing LossHearing Loss 95 %95 %

• TinnitusTinnitus 60 %60 %

• HeadacheHeadache 50 %50 %

• Balance DisturbanceBalance Disturbance 45 %45 %

• Facial NumbnessFacial Numbness 25 %25 %

• Facial ParesisFacial Paresis 1 % 1 %

Acoustic Neuroma:Acoustic Neuroma:Hearing LossHearing Loss

• SensorineuralSensorineural

• Typically high frequencyTypically high frequency

• Poor discriminationPoor discrimination

• Sudden or fluctuating: 10 %Sudden or fluctuating: 10 %

Acoustic Neuroma ManagementAcoustic Neuroma Management

• ObservationObservation

• SurgerySurgery– TranslabrynthineTranslabrynthine

– Retrosigmoid/SuboccipitalRetrosigmoid/Suboccipital

– Middle FossaMiddle Fossa

• RadiotherapyRadiotherapy– Stereotactic radiosurgeryStereotactic radiosurgery• Single doseSingle dose

• FractionatedFractionated

Acoustic Neuroma Acoustic Neuroma ManagementManagement

• Surgery typically recommended previouslySurgery typically recommended previously

• Observation and radiotherapy have become Observation and radiotherapy have become more commonmore common

Aeromedical ConcernAeromedical Concern

• 10% incidence of significant 10% incidence of significant dizziness/vertigo with untreated acoustic dizziness/vertigo with untreated acoustic neuromaneuroma

Aeromedical DispositionAeromedical Disposition

• FAA / JAA / ICAO / Transport Canada - FAA / JAA / ICAO / Transport Canada - VariableVariable

Transport CanadaTransport CanadaAcoustic Neuroma ReviewAcoustic Neuroma Review

• Civil Aviation Medical Information SystemCivil Aviation Medical Information System

10 year review (2002-2012)10 year review (2002-2012)

• Acoustic Neuroma specific diagnostic codeAcoustic Neuroma specific diagnostic code

• Chart review:Chart review:– Demographic informationDemographic information

– Presenting symptomsPresenting symptoms

– Tumor sizeTumor size

– Medical management and complicationsMedical management and complications

– Aeromedical dispositionAeromedical disposition

Acoustic Neuroma Review:Acoustic Neuroma Review:ResultsResults

• 19 pilots19 pilots Male Male

• Mean Age:Mean Age: 52.3 years (31 – 74) 52.3 years (31 – 74)

• Medical Certificate:Medical Certificate:– Category 1 - CommercialCategory 1 - Commercial 88

– Category 2 – ATCCategory 2 – ATC 11

– Category 3 – PrivateCategory 3 – Private 88

– Category 4 – Recreational / Ultralight / GliderCategory 4 – Recreational / Ultralight / Glider 11

– Ab initio applicantAb initio applicant 11

Acoustic Neuroma ReviewAcoustic Neuroma Review• Presenting symptoms:Presenting symptoms:– Hearing lossHearing loss 94%94%– TinnitusTinnitus 24%24%– DizzinessDizziness 12%12%– VertigoVertigo 6%6%– Facial numbnessFacial numbness 6%6%

• Tumor size:Tumor size: 1.6 cm (0.3 – 3.5)1.6 cm (0.3 – 3.5)

• Medical DispositionMedical Disposition– Surgery Surgery 88– ObservationObservation 88– RadiotherapyRadiotherapy 33

Surgical RemovalSurgical Removal

• 8 pilots8 pilots

• Translabyrithine or suboccipital approachTranslabyrithine or suboccipital approach

• No hearing preservationNo hearing preservation

• Complications:Complications:

– Facial paresisFacial paresis 22

– Cerebrospinal fluid leakCerebrospinal fluid leak 11

Aeromedical DispositionAeromedical Disposition• SurgerySurgery 88– FitFit 66

– Restricted (with accompanying pilot)Restricted (with accompanying pilot) 11• Incomplete excisionIncomplete excision

– SuspendedSuspended 11• Medical information not providedMedical information not provided

• ObservationObservation 88– FitFit 22

– Restricted (with accompanying pilot)Restricted (with accompanying pilot) 44

– UnfitUnfit 11• Multiple medical issuesMultiple medical issues

– SuspendedSuspended 11• Medical information not providedMedical information not provided

Aeromedical DispositionAeromedical Disposition

• Stereotactic RadiotherapyStereotactic Radiotherapy 33

– Restricted (with accompanying pilot)Restricted (with accompanying pilot) 11

– UnfitUnfit 22• DizzinessDizziness• Ab initio applicantAb initio applicant

Unrestricted Medical CertificateUnrestricted Medical Certificate

• Complete surgical excisionComplete surgical excision

• Partial removal, Radiotherapy, Partial removal, Radiotherapy, ObservationObservation– No vestibular functionNo vestibular function

on electronystagmography (ENG / VNG)on electronystagmography (ENG / VNG)

– Evidence of central compensationEvidence of central compensation

Normal Caloric TestNormal Caloric Test

Left Caloric Weakness Left Caloric Weakness (uncompensated)(uncompensated)

Caloric Weakness 80% Left

Directional Preponderance 70% Right

SummarySummary

• Trend towards more conservative Trend towards more conservative acoustic neuroma management affecting acoustic neuroma management affecting medical dispositionmedical disposition

• Small but significant risk of Small but significant risk of disequilibrium or vertigo affecting flight disequilibrium or vertigo affecting flight safetysafety

• Unrestricted medical certificate if Unrestricted medical certificate if complete surgical removal without complete surgical removal without complicationscomplications

• Consider unrestricted flight after partial Consider unrestricted flight after partial excision, radiotherapy, observation:excision, radiotherapy, observation:– No vestibular function on No vestibular function on

electronystagmographyelectronystagmography– Evidence of central compensationEvidence of central compensation