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membrane may be
obstructed
Tympanic membrane
landmarks accentuated
Tympanic membrane landmarks obliterated
Rupture of vessels Diffuse erythema
No thickening of
tympanic membrane
Thickening of tympanic membrane May be thickening of
tympanic membrane if
visible
Usually no fever Fever usually present May be fever
White blood cell count
normal
White blood cell count elevated White blood cell count
elevated
Serosanguineous fluid in
middle ear
Serous or seropurulent fluid in middle ear No fluid in middle ear
Hearing normal or
slightly reduced
Deafness profound Hearing normal if
canal not obstructed
No pain on pressure over
tragus and movement of
auricle
No pain on pressure over tragus and movement of auricle Pain on pressure over
tragus and movement
of auricle
No swelling of canal Slight if any swelling of canal Swelling of canal
Table 12-2. Differential diagnosis of aerotitis media, otitis media, and external otitis
Chemotherapeutic agents and broad-spectrum antibiotics often prove effective in treating diseases of the
middle ear. Serious complications such as mastoiditis, sinus thrombosis and brain abscess are now rarely seen.
However, the incidence of deafness has not decreased since the advent of antibiotics. Antibiotics may not
resolve these infections completely and a "smouldering" otitis may persist for weeks, with the only symptoms
being stuffiness in the ear and deafness.
ICAO Preliminary Unedited Version — October 2008 III-12-6
Before an applicant for flight training is selected, it is essential that the function of the Eustachian tubes be
examined by clinical means, such as the Valsalva manoeuvre. Applicants with chronic inflammatory diseases
of the nose or paranasal sinuses should be carefully screened. Any chronic suppurative disease of the middle
ear should be carefully evaluated. A slow but progressive erosion of the bony labyrinthine capsule resulting
from an expanding cholesteatoma - the so-called fistula-symptom - should be excluded. An applicant may be
assessed as fit following an acute process once it has completely subsided and the examination reveals no
signs of the disease. Table 12-2 presents a differential diagnosis for aerotitis media, otitis media and external
otitis.
POST-SURGICAL ASSESSMENT
Ear surgery may affect fitness for aviation duties. After an uncomplicated simple myringotomy and simple
mastoidectomy, if the applicant is free of vertigo and his hearing is in accordance with Annex 1 requirements,
there should be no restrictions. A post-operative radical mastoidectomy should be carefully assessed as it
causes severe monaural hearing loss and carries a risk of subsequent infection, vertigo and intracranial
complications. The examiner should refer the applicant for a complete otological consultation before a final
assessment is made.
Otosclerosis is one of several causes of conductive hearing loss in adults. The medical examiner will face the
problem as to whether an applicant who has had ear surgery for otosclerosis may be assessed as fit. The
physical examination may show no evidence of previous ear surgery. A careful history and possible otological
examination should be in order before an assessment is made. After about 1960, nearly all surgery for
otosclerosis has consisted of a procedure referred to as stapedectomy. The stapes is removed and a prosthesis
is placed, re-establishing a connexion between the incus and the open oval window. The prosthesis most often
used is a stainless steel wire with one end attached to the incus and the other end extending into the oval
window. It has a gel foam or fat pad attached and fits into the oval window. In selected cases the percentage
of success is high. More recently, stapedectomy has been superseded by a “small fenestra technique.” This is
a stapedotomy where a small hole is drilled or made with a laser, and a small piston prosthesis is attached to
the long process of the incus. A “close-window-technique” is common, involving a sealing of the shaped
fistula using vein or fascia graft to avoid lateral displacement at an accidental opening during a sudden
decompression which might induce incapacitating vertigo.
Applicants should not fly for a period of one to three months following stapes surgery to allow complete
healing to take place. Thereafter, a specialized ENT assessment should be made to ascertain Eustachian tube
patency and the absence of vertigo, past pointing, nystagmus or unsteadiness during the Valsalva manoeuvre
and while blowing the nose forcibly.
An applicant who, after this three-month period, has not had vertigo and has post-operative acceptable
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Manual of Civil Aviation Medicine 2(74)
