F-15 Pilot with ACOUSTIC NEUROMA -...

F-15 Pilot with F-15 Pilot with ACOUSTIC NEUROMA ACOUSTIC NEUROMA

Capt. Nazim ATACapt. Nazim ATA

Aerospace Medicine Specialist Aerospace Medicine Specialist Turkish Air ForceTurkish Air Force

AAMIMO 2013AAMIMO 2013

Disclosure InformationDisclosure Information8484thth Annual AsMA Scientific Meeting Annual AsMA Scientific Meeting

Nazim ATANazim ATA

• I have no financial relationships to disclose.I have no financial relationships to disclose.

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

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Clinical PresentationClinical Presentation• Pilot profilePilot profile• Present illnessPresent illness• HistoryHistory• TreatmentTreatment• Follow-upFollow-up

Acoustic Neuroma OverviewAcoustic Neuroma Overview

Aeromedical Concerns Aeromedical Concerns

Aeromedical Disposition and WaiverAeromedical Disposition and Waiver

ACS EvaluationACS Evaluation

Scope of PresentationScope of Presentation

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Clinical PresentationClinical Presentation

Pilot Profile:Pilot Profile:

• Sex: FemaleSex: Female

• Age: 29 years oldAge: 29 years old

• Rank: Captain Rank: Captain

• Aircraft: F-15Aircraft: F-15

• Flying Hours: 1750 Flying Hours: 1750

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• PPast few years - Preferred to hear conversations ast few years - Preferred to hear conversations

in her left earin her left ear

• Dec 2011 - Hearing loss was discovered on Dec 2011 - Hearing loss was discovered on

routine routine periodic health assessmentperiodic health assessment


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• Fall 2010 - Difficulty with ocular trackingFall 2010 - Difficulty with ocular tracking• Had to stop to read food labels Had to stop to read food labels • Unable to read them while walking Unable to read them while walking

• No other ocular difficulties while flying No other ocular difficulties while flying

• Noticed difficulties Noticed difficulties • After missions when she was fatiguedAfter missions when she was fatigued• Following other heavy physical exertion Following other heavy physical exertion


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• Headaches on awakeningHeadaches on awakening

• Resolved several hours after awakening Resolved several hours after awakening

• Not accompanied by nausea or vomitingNot accompanied by nausea or vomiting

• About 2/10 in intensityAbout 2/10 in intensity

• Dull in characterDull in character

• Diffuse in locationDiffuse in location


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• Around this time, noticed some new clumsiness Around this time, noticed some new clumsiness

when working outwhen working out

• When the hearing loss was noted on periodic When the hearing loss was noted on periodic

health assessment, initially felt to be otitis media and health assessment, initially felt to be otitis media and

was briefly placed on antibiotics. was briefly placed on antibiotics.

• However, the history prompted a more detailed However, the history prompted a more detailed

exam exam


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• Dec 2011- MRI study: Dec 2011- MRI study:

• Right cerebello-pontine angle massRight cerebello-pontine angle mass

• Pressure on the brainstemPressure on the brainstem

• Obstructive hydrocephalus. Obstructive hydrocephalus.


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• Past medical history: Past medical history: Not significantNot significant

• Social history:Social history:Tobacco: NeverTobacco: NeverAlcohol: 2 glasses of wine/week Alcohol: 2 glasses of wine/week

• Family History:Family History:Not significantNot significant


• Dec 2011 - Trans-labrynthine decompressive Dec 2011 - Trans-labrynthine decompressive

surgery with sacrifice of the right acoustic nerve surgery with sacrifice of the right acoustic nerve

and vestibular apparatusand vestibular apparatus

• Pathologic Diagnosis: SchwannomaPathologic Diagnosis: Schwannoma

• Genetic testing for Neurofibromatosis-2 was Genetic testing for Neurofibromatosis-2 was

negativenegative

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TreatmentTreatment

• Postoperatively Postoperatively

• Right facial weaknessRight facial weakness

• Vertigo Vertigo

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TreatmentTreatment

10 days post-op cerebrospinal fluid (CSF) 10 days post-op cerebrospinal fluid (CSF)

rhinorrhearhinorrhea

• Initial unsuccessful lumbar drainage Initial unsuccessful lumbar drainage

surgery surgery

• Jan 2012 - Surgery eliminated Jan 2012 - Surgery eliminated CSF CSF

leakageleakage

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TreatmentTreatment

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• Ocular tracking symptoms and facial weakness Ocular tracking symptoms and facial weakness

gradually resolvedgradually resolved

• Still noted very mild facial asymmetryStill noted very mild facial asymmetry

• Dryness of the right eye that required treatment Dryness of the right eye that required treatment

with artificial tears for a few monthswith artificial tears for a few months

Follow-up After SurgeryFollow-up After Surgery

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• Residual unsteadiness treated with vestibular Residual unsteadiness treated with vestibular

rehabilitationrehabilitation

• Symptoms resolved about four months Symptoms resolved about four months

postoperativelypostoperatively

Follow-up After SurgeryFollow-up After Surgery

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• Mar 2012 - Brain MRI: Mar 2012 - Brain MRI:

• Postoperative changes Postoperative changes

• Resolution of hydrocephalus Resolution of hydrocephalus

• Minimal residual mass effectMinimal residual mass effect

• Mar 2012 - Full Spine MRI:Mar 2012 - Full Spine MRI:

• No evidence of tumorsNo evidence of tumors

Follow-up MRIFollow-up MRI

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• Residual deafness Residual deafness

• Very minimal right facial asymmetry Very minimal right facial asymmetry

• Rare right eye dryness Rare right eye dryness

• Artificial tearsArtificial tears

• Minimal unsteadinessMinimal unsteadiness

• No other neurologic symptomsNo other neurologic symptoms

Follow-upFollow-up

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• Acoustic NeuromaAcoustic Neuroma

• Benign Schwann cell derived tumorsBenign Schwann cell derived tumors

• Arising from the inferior vestibular branch of the Arising from the inferior vestibular branch of the

CN-VIIICN-VIII

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• The overall incidenceThe overall incidence

• 1:100,0001:100,000

• Appears to be increasingAppears to be increasing

• IncidenceIncidence

• Peaks in the fifth and sixth decadesPeaks in the fifth and sixth decades

• Both sexes are affected equallyBoth sexes are affected equally

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• Generally slow growing tumorsGenerally slow growing tumors

• Symptoms Symptoms

• Hearing lossHearing loss

• TinnitusTinnitus

• Dizziness/balance issuesDizziness/balance issues

• Facial nerve paralysisFacial nerve paralysis

• Trigeminal nerve disordersTrigeminal nerve disorders

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• Its treatments (surgery and radio-surgery) can Its treatments (surgery and radio-surgery) can

provoke complicationsprovoke complications

• CSF leakCSF leak

• Facial palsyFacial palsy

• Hearing lossHearing loss

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• Tumors are classified based on size:

Grade 1: small tumors measuring 1-10 mm

Grade 2: medium tumors measuring 11-20 mm

Grade 3: moderately-large tumors measuring 21-30 mm

Grade 4: large tumors measuring 31-40 mm

Grade 5: giant tumors those measuring more than 40 mm

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• Primary aeromedical concerns relate to the

neurologic deficits’ potential negative effects on

flight safety and mission effectiveness

• Secondary concerns relate to future risk of tumor

recurrence

Aeromedical ConcernsAeromedical Concerns

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Acoustic Neuroma - not specifically addressed in Acoustic Neuroma - not specifically addressed in USAF Instruction USAF Instruction

Can be covered under several other headings that Can be covered under several other headings that include: include: History of tumor involving the brain or its coverings History of tumor involving the brain or its coverings History of surgery involving the middle ear, History of surgery involving the middle ear,

excluding cholesteatomaexcluding cholesteatoma Any conditions that interfere with the auditory or Any conditions that interfere with the auditory or

vestibular functionsvestibular functions Hearing loss greater than H-1 profile (25 dB for Hearing loss greater than H-1 profile (25 dB for

500,1000 and 2000 Hz; 35 dB for 3000hz, 45 dB 500,1000 and 2000 Hz; 35 dB for 3000hz, 45 dB for 4000 and 6000 Hz), or asymmetric hearing loss for 4000 and 6000 Hz), or asymmetric hearing loss

USAF Aeromedical USAF Aeromedical DispositionDisposition

• Waiver requests Waiver requests

Submitted six months after successful treatment of the Submitted six months after successful treatment of the

acoustic neuroma acoustic neuroma

Provided any post-treatment sequelae are within Provided any post-treatment sequelae are within

acceptable respective flying-class limitsacceptable respective flying-class limits

• The tumor must be unilateral, and there must be The tumor must be unilateral, and there must be

complete resolution of vertigo after treatmentcomplete resolution of vertigo after treatment

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USAF Waiver PolicyUSAF Waiver Policy

• Residual cranial nerve deficits Residual cranial nerve deficits

• Should allow full ocular movements without tracking Should allow full ocular movements without tracking

deficits or strabismusdeficits or strabismus

• Allow for acceptable protective mask sealingAllow for acceptable protective mask sealing

• ENT and neurology consultations are required for ENT and neurology consultations are required for

waiver considerationwaiver consideration

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• *Must be at least 6 months after definitive *Must be at least 6 months after definitive

treatment and no aeromedically significant new or treatment and no aeromedically significant new or

residual symptoms.residual symptoms.2727


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Turkish AF (TUAF) RegulationTurkish AF (TUAF) Regulation

•History of central nervous system tumors are History of central nervous system tumors are

disqualifying for flying for any military pilotdisqualifying for flying for any military pilot

•Moderate diseases or their sequelae of central Moderate diseases or their sequelae of central

nervous system nervous system are disqualifying for flying for any are disqualifying for flying for any

military pilotmilitary pilot

•Deafness in one ear isDeafness in one ear is disqualifying for flying for disqualifying for flying for

any military pilotany military pilot

TUAF Aeromedical TUAF Aeromedical DispositionDisposition

TUAF does not grant waivers for any disqualifying TUAF does not grant waivers for any disqualifying

conditioncondition

But if the pilot objects to the decision pilot can But if the pilot objects to the decision pilot can

appeal to the TUAF. There are 4 Aeromedical appeal to the TUAF. There are 4 Aeromedical

Examination Centers and TUAF may refer the pilot Examination Centers and TUAF may refer the pilot

to another one. If the second center decides pilot to another one. If the second center decides pilot

condition is not disqualifying, pilot will be sent to condition is not disqualifying, pilot will be sent to

another aeromedical center for the final decisionanother aeromedical center for the final decision2929

TUAF Waiver PolicyTUAF Waiver Policy

Oct 2012 Oct 2012

Ophthalmology: NLOphthalmology: NL

Internal Medicine: NLInternal Medicine: NL

Psychiatry: NLPsychiatry: NL

Neurology: Needs further information about in-Neurology: Needs further information about in-

flight communication assessment and flight communication assessment and

assessment of vestibular toleranceassessment of vestibular tolerance

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She participated in three operational sorties with She participated in three operational sorties with

two different pilots two different pilots

One sortie was at night and included night-vision One sortie was at night and included night-vision

equipmentequipment

Both pilots reported no difficulty with in-flight Both pilots reported no difficulty with in-flight

communication or speech discrimination communication or speech discrimination

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She had no difficulties with G-tolerance up to She had no difficulties with G-tolerance up to

7.5G, including one prolonged “check six” 7.5G, including one prolonged “check six”

position with turns and G-exposure position with turns and G-exposure

During the night mission she wore night-vision During the night mission she wore night-vision

goggles for two hours and reported no goggles for two hours and reported no

problems, successfully performing the mission problems, successfully performing the mission

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1. Surgically resected right acoustic 1. Surgically resected right acoustic Schwannoma, surgically resected Dec 2011 Schwannoma, surgically resected Dec 2011

2. Postoperative right-sided permanent 2. Postoperative right-sided permanent deafnessdeafness

3. Postoperative right facial weakness, 3. Postoperative right facial weakness, essentially resolved, with no apparent essentially resolved, with no apparent current clinical findings current clinical findings

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ACS Evaluation - DiagnosesACS Evaluation - Diagnoses

4. Ocular tracking dysfunction with associated 4. Ocular tracking dysfunction with associated nystagmus, resolved, with no functional nystagmus, resolved, with no functional impairmentimpairment

5. Postoperative CSF leakage, surgically 5. Postoperative CSF leakage, surgically repaired, no recurrencerepaired, no recurrence

6. Unusual genetic variant noted on NF2 6. Unusual genetic variant noted on NF2 mutation analysis, felt to be clinically mutation analysis, felt to be clinically insignificant, not disqualifyinginsignificant, not disqualifying

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ACS Evaluation - DiagnosesACS Evaluation - Diagnoses

1. Recommend FC-IIC waiver for diagnoses #1 1. Recommend FC-IIC waiver for diagnoses #1 through #4 (restricted to aircraft and settings that through #4 (restricted to aircraft and settings that do not require stereoacusis), valid for two yearsdo not require stereoacusis), valid for two years

2. Local Neurosurgery and ENT follow-up every year2. Local Neurosurgery and ENT follow-up every year

3. Follow-up brain and internal auditory canal 3. Follow-up brain and internal auditory canal imaging studies imaging studies

4. At time of waiver renewal request, specialist 4. At time of waiver renewal request, specialist notes, report and images from any neuroimaging notes, report and images from any neuroimaging studies, and results of current neurologic and studies, and results of current neurologic and otolaryngologic examination to ACS for reviewotolaryngologic examination to ACS for review

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ACS RecommendationsACS Recommendations

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AAMIMO 2013AAMIMO 2013 USAFSAMUSAFSAM

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