Federal Air Surgeon’s Medical Bulletin Aviation Safety Through Aerospace Medicine Vol. 45, No. 1 For FAA Aviation Medical Examiners, Office of Aerospace Medicine Personnel, U.S. Department of Transportation 2007-1 Flight Standards Inspectors, and Other Aviation Professionals. Federal Aviation Administration

QUICK FIX has a spam blocker, please add us to your 4 Answering the E-Mail acceptable mail list (If you missed my HEADS UP By Richard ‘Dick’ Jones, MD article in the last Bulletin about how to program your spam blocker to not reject 2. Editorial: Tough Acts... PROBLEM our E-mails, go to the FAA Web site 3. FAAMedXPress Delayed We (the FA A) need a quick, effective www.faa.gov/library/reports/medical/ way to communicate information to fasmb/archives/. Click on the Fall 2006 3. Distance Learning Problems Aviation Medical Examiners (AMEs). issue for complete information). For example, the most recent issue of the 4. Letters to the Editor If the address we have is one you rarely Federal Air Surgeon’s Medical Bulletin check or if you don’t recall ever giving us 5. OAM News contained some incorrect Theme Semi- an address, please provide the best address Achievers nar dates. We really wanted to inform to your Regional Flight Surgeon’s office, AMEs of the correct dates before anyone so we can update your information. The made plans or incurred expenses book- regions now have a list of the names of ing non-refundable flights on the wrong AMEs falling into the undeliverable, 5. Who’s Who in AME Services dates. It was decided to try using our list unopened, and deleted categories. Your of E-mail addresses for AMEs to find region may contact you for a more viable 6. Case Report: Meniere’s out how useable E-mail notifications address. We will do another test when Disease might be and to detect problems in use the dust settles. of such a system, by sending an E-mail Dr. Jones manages the Civil Aerospace Medi- 8. Case Report: Venous to everyone on November 3, 2006. cal Institute’s Aerospace Medical Education Angioma We found 1036 (22.9%) of our 4,517 Division. AMEs had not provided us E-mail ad- 4 10. Why I Became an AME dresses, so we could only send 3,481 Tulsa AME Killed In messages. Our system indicated 80.4% Crash 11. AME Seminar Schedule (2,797) of sent messages were received, Called ‘Consummate meaning 691 (19.9%) of the addresses we Contributor’ by Friends 12. 2006 Index of Articles had been given were inaccurate. Worse By David Hale yet, of the 2,016 messages received, only 781 had been opened by one month after they were sent. Guy Baldwin, DO, AME, ATP, RESULT CFII, died October Only 17.3% of our AMEs had seen REMINDER 4, 2006, in an air- this important E-mail message within plane accident at the Please order your FAA forms one month of being sent. Clearly this Rotary Club Air- before running out. This will is not a quick, efficient means of com- show in Tucumcari, save considerable embarrassment munication! We need to improve if New Mexico. He was killed when his and will better serve your airman technology is to help us streamline. fully aerobatic, German-made Extra applicants. Contact the shipping SOLUTION 300L crashed while performing a loop department if you need supplies: at the air show. Guy “Doc” Baldwin, [email protected] Please evaluate why you might have was 60 years old. (405) 954-4831 failed to receive our message if you do not recall getting one. If your computer Continued on page 4 ‘Tough Acts…’

David Millett, MD, recently retired, a lways c a ll on in a pinch. On more t ha n and in January 2007, the FAA Office one occasion, Joel volunteered to spend of Aerospace Medicine and all of you several months in Oklahoma City to waved farewell to two other colleagues as help the Certification Division when they moved on to the next phase in their they were short of sta f f. Somehow, even lives: Joel Dickmann, DO, and Doug though he was several hundred miles Burnett, MEd. These three gentlemen away from his home office, he managed have accumulated more than 74 years to keep his region running smoothly; of federal service. indeed, a real tribute to his skill as a manager and leader.

DAVID MILLETT, MD By Fred Tilton, MD DOUGLAS BURNETT, MED avid came to the OUG B URNETT joined DFAA in 1990, having Dthe FAA in 1987. He served around the world Surgeon for the Southern Region, and it came to us from the U.S. as a flight surgeon in the was immediately apparent that he really Postal Service, where he United States Air Force “knew the business,” so all of us looked was a manager in their and as the medical director to him for advice and counsel. He is a Technical Training In- for Eastern Airlines, so he came to us Fellow and active member of the Aero- stitute. One of his responsibilities as with a wealth of aviation experience. space Medical Association where he has the manager of our Aviation Medical He was hired as the Regional Flight received many awards and accolades, Examiner Program was making the ar- a nd he is a rec og ni z ed le ader in bot h t he rangements for all of the seminars that Civil Aviation Medical Association and you have attended over the years. Federal Air Surgeon’s the Airlines Medical Directors Associa- On some occasions, the hotels we Medical Bulletin tion. Whenever I needed some help or contracted with did not live up to their Library of Congress ISSN 1545-1518 a volunteer for a special project, Dave agreements, but we could always count Secretary of Transportation was always there with his “hand up.” on Doug to “recover.” He had a smile Mary E. Peters He especially loved to make presenta- and a good word for everyone, and he FAA Administrator tions, and his resonant voice, which could magically find a solution to every Marion C. Blakey he honed as a radio announcer when problem. Federal Air Surgeon he was a young man, made him a very As you can see, all three of these Fred Tilton, MD effective speaker. gentlemen have been major contributors Editor to the Office of Aerospace Medicine’s Michael E. Wayda JOEL DICKMANN, DO success, and we will miss them a lot. oel Dickmann also ar- Selfishly, I tried my best to get each of The Federal Air Surgeon’s Medical Bulletin rived on the FAA scene them to stay around until after I retired, is published quarterly for aviation medical J examiners and others interested in aviation in 1990 when he was but they all said, “It was their time.” safety and aviation medicine. The Bulletin is hired as the Assistant Re- We have already filled prepared by the FAA’s Civil Aerospace Medical gional Flight Surgeon for in behind Joel with Larry Institute, with policy guidance and support from our Northwest Mountain Wilson, who was a mem- the Office of Aerospace Medicine. An Internet Region. He was appointed Regional ber of our certification staff on-line version of the Bulletin is available at: www.faa.gov/library/reports/medical/fasmb/ Flight Surgeon for our Central Region in Oklahoma City, and we in 1992. will be filling the other two Authors may submit articles and photos for Joel was a pharmacist before at- positions in the near future. publication in the Bulletin directly to: tending medical school, and he came However, all three of them will be Editor, FASMB to us from private practice where he tough acts to follow and difficult to FAA Civil Aerospace Medical Institute AAM-400 also served as a flight surgeon for the replace. I know you will all join me in P.O. Box 25082 Army National Guard. Joel’s broad wishing them success, happiness, and Oklahoma City, OK 73125 experience, coupled with his “can do” a safe journey. e-mail: [email protected] attitude, made him the person I could –Fred

2 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 45, No. 1 • Certification Distance Learning Don’t Be Fooled Course Procedures for Update The Aircraft Owners and Pilot’s Association (AOPA) has a benefit for AMEs Information About its members called TurboMedical that By Ridge Smith Current Issues allows a member to log on to the AOPA Web site and complete the front side of N OPTION AVAILABLE to aviation By Warren S. Silberman, DO, MPH a simulated Form 8500-8 (medical his- medical examiners to com- tory). TurboMedical looks just like the Aplete their required refresher FAAMedXPress Update FAA medical form. Until just recently, training is by distance learning FAAMedXPress is a new addition to it had the imprint of the FAA airmen through two interactive, Internet- the Aeromedical Certification Subsys- medical certificate in the upper left- based AME courses: Multimedia tem that will allow an airman to go to hand corner and a certificate number Aviation Medical Examiner Refresher a Web site and electronically input his at the top. Course (MAMERC) and Clinical or her history data, thereby eliminat- Some AMEs have mistaken Turbo- Aerospace Physiology Review for ing the need to submit a paper history Medical for the new FAAMedXPress. AMEs (CAPAME). form. In the last edition of the Bulletin, TurboMedical is not FAAMedXPress, These courses may be substituted I informed you that we were going to and TurboMedical is not an FAA-ap- for attendance at an AME seminar at make this system available to airmen proved form. the three-year point between seminar by November 15, 2006. However, we If an airman reports to your office attendance. Specifically, AMEs must encountered a medical-legal issue that with a completed TurboMedical form, perform refresher training every three caused us to delay the implementation we prefer that you have the airman years to maintain their designation. of this new system element. The prob- transfer the information onto a valid This requirement may be satisfied lem centers on the airman’s ability to FAA Form 8500-8. However, to ac- by attending one of the AME seminars change the Form 8500-8 (FAA Flying commodate our airmen, we will accept held six times yearly at various locations Examination) after having submitted the TurboMedical form if it is signed or by completing one of the on-line it to us. in the presence of you or your staff AME courses. However, no more than To assure that the history is accurate and then attached to a blank 8500-8 six years can elapse between attendance and for us to document that any changes that bears the number consistent with at “live” seminars. were actually made by the airman, he the number on the medical certificate Quirky Technical Problems or she will not be able to make any or medical/student pilot certificate We need to make you aware of some changes until first discussing them that is issued to the applicant. Both problems we are currently experiencing with you. If you and the airman agree the TurboMedical form and 8500-8 with these on-line courses to help you that changes are necessary, you will should be sent to the Aerospace Medical avoid frustration if you choose to use have to submit a paper version of the Certification Division (AMCD) after them. form that documents the changes. We the examination data are electronically The on-line instructional courses will then take the paper form and scan transmitted to the AMCD. were put into operation in 2002 and it into our system. Unfortunately, the Suggestion since that time, a combined total of over consequences of this issue will result in This subject was covered in a previous 1,700 AMEs have successfully com- your having to submit a paper 8500-8 in Bulletin [ e.g., AOPA’s ‘ Tu rboMe d ic a l ’ i s pleted these courses. A problem has been the event of changes, but it is the only Not Approved as a Substitute for Form reported by some AMEs that the inter- method we have to assure the accuracy 8500-8,” by Richard Jones, MD; Vol. active course has not correctly recorded of the data and to protect the integrity 43, No. 2, p.1). Each Bulletin is filled their progress in the course. Sometimes of the system. with pertinent information designed to credit for individual modules of the These proposed additions will be keep you and your office staff informed course was dropped or completion of completed by the end of January 2007, and up to date. Once you have read it, the final test was not recorded. We in and we will then make the Web site please share it with your staff, and keep the Education Division have not been available. I apologize for this delay. it on file for reference. able to determine the exact cause for this problem, or why some AMEs are affected while others are not. If you experience any of the above Dr. Silberman manages the Civil Aerospace Medical Institute’s Aerospace Medical Continued on page 11 Certification Division.

The Federal Air Surgeon's Medical Bulletin • Vol. 45, No. 1 • 3 Dr. Baldwin from page 1 SPORT PILOT WANT ADS Dr. Baldwin was a physician and avia- MEDICALS WANTED tion medical examiner who performed more than 2,000 flight physicals each Dear Editor: Dear Editor: year in Tulsa, Okla. He had logged more I would like As a non- than 4,000 flight hours during his 35 clarification regarding the answer senior AME who gets repeated re- years of piloting acrobatic, sea, warbird, given Dr. Lewis in the most recent quests to do class-I physicals, I would and helicopter aircraft. issue of Federal Air Surgeon’s Medi- love to move to senior AME status. Guy Baldwin was a flight instructor, cal Bulletin [Letter to the Editor, The major limiting factor is purchas- physician, and consummate contributor, Vol. 43 No. 3, p. 9]. He had asked ing a very expensive EKG machine constantly giving to multiple charities and about LSA [Light Sport Pilots] capable of transmitting the ECG to other endeavors. Guy worked with Chal- pilots self-certifying for conditions the FAA AMCS. lenge Air, helping physically challenged considered disqualifying and Dr. I have often wondered: Why not children. He supported US-TOO, an Silberman had answered that they have a classified section in the Federal international group of cancer survivors. could be considered “safe to fly” by Air Surgeon’s Medical Bulletin where He began performing at air shows in their personal physician. an AME could buy/sell action medi- 2002, flying under the banner of the There are two problems that I cal equipment pertinent to aviation Make-A-Wish Foundation, and he often see with this approach. First, the medical exams, such as the trans- personally fulfilled the wishes of children LSA class allows these pilots to mitting ECG machines, vision test with terminal illnesses. self-certify so they might not ask equipment, Welch Allyn pan optic He served on The Experimental Air- their physician for advice or will ophthalmoscopes, etc. The classifieds craft Association’s aeromedical advisory ignore negative advice and fly with would give a great opportunity for board, the Tulsa Air and Space Museum’s the idea that their driver’s license AMEs to upgrade equipment and board, and he rebuilt Oklahoma Chapter gives them carte blanch to fly. improve the quality of the exams. 10 of the International Aerobatics Club, Secondly, the non-AME physicians I discussed this with my Regional attracting international aviation figures may approve their flying without Flight Surgeon, who thought this was like Patty Wagstaff and General “Chuck” fully understanding the risks. I’ve a good idea. I hope you do too. Yeager. had applicants angry about being Fred C. Hollar, MD He was a contributing editor for several denied certification and had stated, Auburn, Mass. aviation publications, including General “My Doctor said he would fly with Aviation News, EAA Sport Aviation, and me!” Dear Dr. Hollar: The Oklahoma Aviator. He was also at What should we advise these Your idea about creating a classified the forefront of pilot advocacy. In 2003, applicants with considerable risks? section in the Bulletin is a good idea, albeit an unusable one for us. When we Guy was named Oklahoma Aviator of Self-certify or PCP [Primary Care the Year. Provider] approval? looked into this several months ago, we were told by the legal department that Dr. Baldwin is survived by his wife, Joseph Kennedy, MD the Federal government is prohibited Felice; daughter, Brittny; and son, Cedar Rapids, IA from entering into this type of activ- Hunter. ity because it is considered a form of GUY BALDWIN: PHYSICIAN, PILOT, SERVANT Dear Dr. Kennedy: advertising for private individuals. • Guy was an avid flyer, a tremendous sup- You are correct in your assumptions. As an alternative, we can refer you to porter of the (EAA) medical council, and a This is the intent of the medical aspect the Civil Aviation Medical Association tremendous advocate for pilot certification. for space in their newsletter to advertise He worked very hard on improving the pro- of sport pilot. Technically, all the air- as you suggested. We have discussed man needs to do is to check with their cess, helping pilots with the special issuance this with Mr. Jim Harris, Vice President process, getting through the snags and delays respective state drivers’ license boards of the association, and he has agreed of aeromedical certification. to see what is actually unacceptable to to provide limited advertising space in —Jack Hastings, MD drive an auto with. I doubt that many their Flight Surgeon newsletter. You • can contact Mr. Harris at: I know of few AMEs who had the patience of them will do so. Currently, airmen of and took the time to find out information on any class must “self certify” each time Civil Aviation Medical Association his specific airmen other than Guy. He knew P.O. Box 23864 they fly. It is really up to the non-AME our policies quite well. He was what a ‘good Oklahoma City, OK 73123 aviation medical examiner’ should be. physician to “get smart” on what he is E-Mail: [email protected] —Warren Silberman, DO telling his Sport Pilots. Thanks for the suggestion. Warren Silberman, DO, MPH David Hale is the executive director of Pilot Michael Wayda Medical Solutions, a Tulsa, Okla., pilot aeromedical advisory firm. 4

4 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 45, No. 1 • OAM NEWS Ms. Corbett Named Office of Aerospace Medicine 2006 CAMI Employee of Year CAMI Researcher Passes ABPM Board Exam YNTHIA L. CORBETT, a Research RNOLD ANGELICI JR., MD, MS, hired by CAMI after completing a post- Human Factors Specialist on Team Lead for the Environmen- doctoral fellowship at CAMI through C A CAMI’s Cabin Research Team, tal Physiology Research Team at the the National Academy of Sciences. He was chosen as the 2006 Employee Civil Aerospace Medical Institute is an associate Fellow of the Aerospace (CAMI) in Oklahoma City, received Medical Association and a senior avia- of the Year. notification from the American Board tion medical examiner. He is a member of Preventive Medicine that he suc- of the Commemorative Air Force and cessfully passed both the Core and the consults with their Flight Safety and Aerospace Medicine portions of the Operations Department. exam. The ABPM has awarded him As a member of the Oklahoma Wing Diplomate status. of the Commemorative Air Force, Dr. A graduate of Angelici qualified Mexico’s Autono- to fly the Wing’s mous University Fairchild PT-19. Last CAMI Director Melchor of Guadalajara, year, he shared his J. Antunaño, MD, Dr. Angelici re- enthusiasm for fly- congratulates Ms. Corbett for ceived his Master ing with others by her accomplishments for the Cabin Safety Team. of Science in Aero- donating rides in space Medicine the PT-19 during Ms. Corbett was cited as “a CAMI from Wright State the 2006 Combined rising star, radiating accomplish- University. He was Federal Campaign. ment and illuminating paths of UP AND AWAY. Dr. Angelici at the controls of the PT-19 opportunity” in the workplace. In addition to her job as a prin- cipal Cabin Research investigator, Contacts in the CAMI Aerospace Medical Division statistician, and research author, Below is a current list of whom to call or E-mail for various functions related to aviation medical examiner services. she volunteered her time as the Federal Women’s Program manager NAAMEME TIITLETLE//RREESPONSIBILITIESSPONSIBILITIES EE-M-MAAILIL ADDDRESSDRESS PHHONEONE ((405)-405)- at the Mike Monroney Aeronautical Deanie Davis AME Program Assistant: [email protected] 954-4257 Center and ser ved as co-chair of the AME records Federal Women’s Program Council Gail Gentry Supply Clerk: distribution [email protected] 954-4831 on the Federal Executive Board. of all FAA AME forms Ms. Corbett further distin- and brochures guished herself by earning a Masters Sharon Holcomb Training Assistant: all Dis- [email protected] 954-4829 tance Education (MCSPT, degree in her “spare” time. CAPAME, & MAMERC) Each year, employees at the Insti- for AMEs tute nominate commendable fellow Leah Olson Training Analyst: Theme [email protected] 954-4258 workers for the award. An employee AME seminars committee reviews the nominations Denise Patterson Training Assistant: Basic [email protected] 954-4830 AME seminars and selects the winner. Bobby Ridge Program Analyst for the [email protected] 954-4832 4 International and Military/ Federal Region Ridge Smith Instructional Systems Spe- [email protected] 954-4379 cialist: AME seminars

The Federal Air Surgeon's Medical Bulletin • Vol. 45, No. 1 • 5 An Aviator With Meniere’s Disease fullness, hearing loss, and tinnitus over unpredictable nature of Meniere’s and the ensuing weeks, despite a low-salt the possibility that the disease could Case Report, by Kelly N. West, MD, diet and maximal diuretic therapy. recur in any patient treated with subtotal MPH Two months after the initial episode ablation, the consultant recommended of vertigo, he underwent elective left that issuance be denied. He further Abstract endolymphatic sac decompression and recommended that, should the airman ENIERE’S DISEASE CAN cause shunt placement. In the weeks follow- pursue total ablation (either surgical or Msudden, debilitating, and ing surgery, his dizziness and auricular pharmacologic), medical reinstatement unpredictable attacks of vertigo, pressure resolved, but some left-sided would be a reasonable consideration. and, as such, is of great concern hearing loss persisted. Six months Based upon the consultant’s recommen- when seen in an aviator. This article after his surgery and free of dizziness, dations, special issuance was denied. presents the case of a pilot afflicted the airman was issued a time-limited, with Meniere’s disease. A review of special issuance medical authorization Aeromedical Implications the epidemiology, pathophysiology, letter by the FAA. Meniere’s disease is disqualifying treatment, and prognosis is provided. Two months later, the airman again under the general condition provision The aeromedical implications of the began to experience episodes of severe of Title 14 CFR §61.53. Current FAA disease and of the available treat- dizziness and consulted his ENT medical certification policy holds that ment options are also discussed. again. When the FAA became aware medical certification for any class shall of the recurrent symptoms, the special not be issued until vertigo, due to any Clinical History authorization was withdrawn, and the cause, is fully resolved. No medication The case airman, a 46-year-old Air- airman voluntarily surrendered his is acceptable for continuous daily use in line Transport Pilot with approximately medical certificate. the treatment of vertigo while perform- 13,000 hours’ flying time, presented The episodic symptoms continued ing pilot duties, and pilot duties must to his aviation medical examiner for over the following months, and, after be discontinued while on medication. renewal of his first-class medical cer- discussing further therapeutic options In the specific instance of Meniere’s tificate. The FAA Form 8500-8 reflects with his ENT, the airman elected to disease, certification should not be is- that he was occasionally using Dyazide, undergo intratympanic gentamicin sued to any airman with active disease. A a thiazide diuretic, for control of “tin- therapy for nerve ablation. A single in- certificate may be issued if the condition nitus and plugging of his ears.” The jection of gentamicin was administered has been in remission for a period of 3 AME advised the airman that he would into the middle ear via myringotomy. months, with a complete ENT evalu- “need to have his potassium checked if The dose used was intended to provide ation to document remission. Medical he ever used Dyazide for a period longer partial ablation so as to control the certification should not be issued for any than three weeks.” The airman was then Meniere’s symptoms without unduly class if there is a recurrence of vertigo issued a first-class medical certificate affecting normal hearing and balance. after initial remission. Complicated by the AME. Following the pharmacologic nerve cases should be referred to the FAA’s One week after his visit to the AME, ablation, the airman had no further Aeromedical Certifications Division the airman suffered an attack of diz- dizziness episodes and had sufficient for consideration. ziness, described as a sensation of the hearing function to discern a whispered room spinning, and which lasted for voice. Case Outcome several hours. He subsequently was Three months following the partial Following FAA denial, the case air- seen by an ENT specialist and admit- a bl at ion proc e du re, w it h no f u r t her epi- man appealed to the office of the Federal ted to a 3½ year history of fullness and sodes of dizziness, the airman reapplied Air Surgeon. With supporting evidence inflammation in his left ear, as well as for medical certification. Supporting provided by his ENT and recent meta- a progressive decrease in hearing in the documentation included an audiogram analyses of the medical literature regard- same ear. The airman was then referred that demonstrated mild hearing loss in ing the comparable efficacy and relapse for a battery of tests—audiometry, the left ear and ENG results showing rates of partial versus complete nerve electronystagmography (ENG), brain partial suppression of the left vestibular ablation, his appeal met with favorable and head MRI, and blood work (CBC, system. The Aerospace Medical Certifi- consideration. The airman was granted TSH, RPR), all of which were within cation Division referred the case to one a time-limited, authorization for special normal limits. of its otolaryngology consultants for issuance of a class-I medical for a period The airman continued to suffer review and recommendations regard- of 6 months. episodes of intermittent dizziness, ear ing aeromedical disposition. Citing the Continued on page 9

6 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 45, No. 1 • MEENIERENIERE’S DIISEASESEASE Meniere’s disease, also known as Clinical presentation. As in the Initial, conservative medical therapy endolymphatic hydrops, accounts for case airman, the typical presentation usually attempts to diminish the approximately 5% of adults present- of Meniere’s disease is with the con- production and/or accumulation of ing clinically with dizziness.1 Classi- stellation of vertigo, tinnitus, aural endolymph. Salt restriction and use cally, Meniere’s syndrome is typified fullness, and ipsilateral hearing loss. of diuretics is the most commonly by the clinical tetrad of vertigo, Symptoms may not occur simultane- used, first-line medical therapy and tinnitus, hearing loss, and aural full- ously. One study showed that 50% has been reported to control vertigo ness. Idiopathic Meniere’s syndrome of patients presented with vertigo in up to 58% of patients.8 Steroids, (i.e., those cases not attributable to and hearing loss, while 19% had either taken orally or administered an identifiable cause like syphilis) is vertigo alone and 26% had isolated, via intratympanic injection, have also referred to as Meniere’s disease. unilateral hearing loss.5 been used as initial treatment. Epidemiology. The incidence of The vertigo associated with For those patients who fail medi- Meniere’s disease in the US is ap- Meniere’s disease can be both de- cal therapy, surgical intervention to proximately 150 cases per 100,000 bilitating and unpredictable. Attacks decompress the vestibular sack is population. Onset typically occurs m ay be sepa r ate d by mont h s or ye a r s, often the next step. Decompression in middle adulthood with mean age or may occur in rapid succession. may be accompanied by placement of onset ranging from 46-67 years.2 The vertiginous symptoms may be of a shunt to prevent reaccumulation Women are affected with a higher so profound as to cause total inca- of excessive endolymph. Success rates frequency than men by a proportion pacitation and spatial disorientation. of 50-75% have been reported with of 1.3:1.3 Roughly 50% of suffer- These features of the disease clearly surgical decompression.3 ers have a positive family history raise great concern in the aviation Surgical therapies have been used of Meniere’s disease, suggesting a and aeromedical communities. to some effect in Meniere’s patients. genetic predisposition. Diagnosis. There is no single, Selective vestibular neurectomy has Etiology. Current thinking holds pathognomonic finding for making shown up to a 90% success rate in that Meniere’s disease is caused by a the diagnosis of Meniere’s disease. providing relief from intractable distortion of the membranous laby- Presumptive diagnosis is often made Meniere’s-associated vertigo but does rinth due to endolymphatic hydrops. based upon the constellation of risk complications like facial nerve This excess of the potassium-rich symptoms. The American Academy paralysis, hearing loss, CSF leak, and endolymph may be from overpro- of Otorhinolaryngology recom- chronic headache. Labyrinthectomy duction or impaired absorption. The mends specific criteria for diagnosis also provides excellent control of ver- association between hydrops and (Table 1).6 tigo, albeit at the expense of hearing Meniere’s is not absolute, insofar as Other causes of dizziness and loss in the operated ear. not all instances of hydrops are as- or hearing loss should also be con- Intratympanic administration of sociated with Meniere’s symptoms.4 sidered in the differential. The list aminoglycoside antibiotics, employ- Rupture of the membranous laby- of possibilities is long and includes ing their ototoxic properties to ablate rinth is thought to be a key element labyrinthitis, neoplasm (e.g., acoustic vestibular neurons, has proven effec- in the pathophysiology of Meniere’s. neuroma), transient ischemic attack/ tive in treating vertigo in Meniere’s Rupture allows the potassium-rich stroke, multiple sclerosis, migraine, sufferers. The hearing loss rates noted endolymph to mix with the potas- thyroid disease, drug toxicities (e.g., in early trials have been reduced in sium-poor perilymph around cranial salicylates, aminoglycosides), and subsequent trials using regimens of nerve VIII and the basal surfaces of vestibular neuronitis.7 multiple, smaller doses of the drugs. the hair cells, leading to nerve excita- Treatment and Prognosis. Recent studies of partial ablations tion and the sequelae of the disease. Currently, there is no recognized using gentamicin have shown success Healing of the membrane rupture cure for Meniere’s disease. Therapy rates comparable to selective surgical allows restitution of the normal is largely directed at controlling ablation, with better residual vestibu- potassium milieu and resolution of symptoms, especially vertigo, the lar and auditory function.9 the attack. Chronic deterioration in most distressing of the sequelae. inner ear function is, presumably, due Table 1: American Academy of Otorhinolaryngology Diagnostic Criteria for to the effects of repeated hyperkale- Meniere’s Disease mic insults upon the hair cells. • Inflammation of the endolym- Two or more episodes of vertigo, each lasting 20 minutes or longer phatic sac, either due to viral infec- •Hearing loss documented on audiogram on at least one occasion tion or autoimmune processes, has •Tinnitus and/or fullness in the affected ear also been implicated in the patho- physiology of Meniere’s. •All other causes excluded (usually by gadnolinium-enhanced cranial MRI)

The Federal Air Surgeon's Medical Bulletin • Vol. 45, No. 1 • 7 Venous Angioma in an Cerebral venous angioma generally has a benign clinical course; how- Airman ever, it might cause cerebral hemorrhage or seizure. On evaluation of an Case Report, by Shino Hara, MD applicant with cerebral hemorrhage due to venous angioma, ruling out other primary diseases is important to consider about the potential of incapacitation. ISTORY. A 42-YEAR-OLD male commercial airline pilot VENOUS ANGIOMA Hwith more than 4,000 hours EREBRAL VENOUS ANGIOMAS are assumed to be congenital lesions presented to renew his first-class resulting from arrested or disordered venous maturation. medical certificate. He had been CThey are thought to be anomalies of normal venous involved in a motorcycle accident 8 drainage (1, 2). The lesions have been described as “venous angioma,” years ago in which he was struck by a “venous malformations,” or “developmental venous anomalies.” Of car. He seemed to be otherwise intact, the four recognized cerebrovascular malformations, which include but a computerized tomography (CT) cerebral venous angiomas, arteriovenous malformations, cavernous scan was done to see if he had a brain malformations, and capillary telangiectasias, venous angiomas are injury. the most frequent ones documented by brain imaging. Autopsy series A small, low-intensity area was seen document a prevalence that may be as high as 3% (3, 4). Imaging in the white matter of the left frontal studies show characteristic caput medusae in the late venous phase lobe. A magnetic resonance imaging of angiography with a normal circulation time and a normal arterial (MRI) and magnetic resonance phase. On MRI, they appear as a stellate vascular or contrast-enhanced angiography (MRA) were performed masses. They are composed entirely of thickened and hyalinized veins, the following month, and a venous containing minimal smooth muscle and elastic tissue interspersed within angioma was diagnosed in the left normal brain parenchyma. frontal lobe. The angiomas are most frequently located in the frontal lobe (55.6%), An electroencephalogram (EEG) followed by the cerebellum (27%), temporal lobe, parietal lobe, basal and neurological examination were ganglia, and pons (5). The association of venous angiomas with other normal. He was issued a special vascular malformations is well documented. issuance (SI) to resume first-class Although patients with venous angiomas have been considered to aviation activities. He had had annual be at risk for hemorrhage, Naff et al. reported (5) that the annual risk of neurological examinations and brain hemorrhage was 0.15% in 92 patients with radiographically confirmed MRIs, and there had been no significant venous angiomas, and the few hemorrhages that did occur were not change for 6 years. The latest brain MRI associated with mortality or permanent damage. Therefore, any hem- was performed 7 years after the first orrhage in the setting of a venous angioma should prompt a search M R I. It showe d a n old hemor rh a ge t h at for another cerebrovascular lesion that is more likely to be the cause was approximately 7mm in diameter in of the hemorrhage. A second cerebrovascular lesion was identified in the left frontal lobe for the first time. 19%; the most common associated lesion was cavernous malforma- The venous angioma had tion (12.7%), followed by aneurysm (4.8%). Some authors assert that not changed at all and no other a hemorrhage in the context of venous angiomas was likely related cerebrovascular disease was seen. The to an associated cavernous malformation (6, 7). The most common new findings were compatible with an symptom was headache (50.8%), followed by focal neurologic deficit old bleed related to the known venous (39.7%), and seizure (30.2%). In some cases, a relationship between angioma. The onset of bleeding was headache and venous angioma could not be proven. The prevalence of suggested to be at least 1 year ago, but headache and seizure decreased as the length of follow-up increased, it was not seen on the previous MRI. without treatment. The neurologist commented that the According to recent reports, a benign natural history is suggested reason it was not seen in the previous for venous angiomas in general. Conservative therapy and observation MRI seemed to be the difference in are recommended because intervention risks probably greatly exceed equipment. The total neurological the low risk that venous angiomas present.

Continued on page 9

8 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 45, No. 1 • VENOUS from page 8 MENIERE’S from page 6 References evaluation with EEG was performed References with normal results. He has never 1. Garner TB, Curling OD Jr, Kelly DL 1. Kroenke K, Hoffman RM, Einstadter had any symptoms or any significant Jr, Laster DW. The natural history of D; “How common are various causes neurological findings. He had no intracranial venous angiomas. J Neuro- of dizziness? A critical review.” South- other complications and was taking surg 1991;75:715-22. ern Medical Journal; 93(2), 2000. no medications. 2. Huang YP, Robbins A, Patel SC, Chaud- 2. Li J. “Inner ear, Ménière disease, EROMEDICAL CONCERNS. For all hary M. Cerebral malformations and a surgical treatment.” www.emedicine. Aclasses of medical certificates, new classification of cerebral vascular com. airmen with cerebrovascular disease malformations; in Kapp JO, Schmidek 3. Minor LB, Schessel DA, Carey JP. should be deferred by an AME (8). HH, eds. The Cerebral Venous System “Meniere’s disease.” Curr Opinion The aeromedical concerns are mainly and Its Disorders. New York; Grune & in Neurol February 2004, 17(1), pp the applicant’s present physical status Stratton, 1984; 373-74 9-16. and the potential for incapacitation. 3. McCormick WF, Hardman JM, Boulter 4. Rauch SD, Merchant SN, Thedinger For consideration of a special issuance TR. Vascular malformations (“angio- BA. “Ménière’s syndrome and endo- (SI), the case must be forwarded mas”) of the brain, with special reference lymphatic hydrops: Double-blind to those occurring in the posterior fossa. to the FAA Aerospace Medical temporal bone study.” Ann Otol J Neurosurg 1968;24:241-51. Certification Division (AMCD). The Rhinol Laryngol 1989; 98:873-83. medical history is required, to include 4. Sarwar M, McCormick WF. Intracere- 5. Kitahara M. “Bilateral aspects of current status mentioning medications bral venous angioma. Case report and Ménière’s disease: Ménière’s disease review. Arch Neurol 1978;35:323-25. and complications, MRI and/or with bilateral fluctuant hearing angiography, and EEG. For cases with 5. Naff NJ, Wemmeer JRN, Hoenig- loss.” Acta Otolaryngol (Stockh) 1991; stroke, cardiac evaluations are also Rigamonti, K, Rigamonti DR. A 485:74-77. required. A neurological specialist's longintudinal study of patients with 6. Monsell EM, Balkany TA, Gates venous malformations: Documenta- evaluation should also be submitted GA, et al. “Committee on hearing tion of a negligible hemorrhage risk and equilibrium guidelines for the to the AMCD. Upon their review, the and benign natural history. Neurol applicant may be granted an SI when the diagnosis and evaluation of therapy 1998;50(6):1709-1714. in Ménière’s disease.” Otalaryngol applicant has no sequelae of hemorrhage 6. Spetzier RF. Radiosurgery and ve- Head Neck Surg 1995; 113:181-5. and the potential of incapacitating nous malformations. J Neurosurg rebleeding, seizure, or other symptoms 7. Lorenzo N, “Meniere’s Disease.” 1994;80:173-4. www.emedicine.com. is considered to be low. 7. Wilms G, Bleus E, Demaerel P, et al. UTCOME. This applicant 8. Klockhoff I, Lindblom U. “Ménière’s Simultaneous occurrence of develop- disease and hydrochlorothiazide Ohad no symptoms, and the mental venous anomalies and cavern- neurological examination was totally (Dichlotride®): A critical analysis of ous angiomas. AJNR Am Neuroradiol symptoms and therapeutic effects.” normal. He did not have any associ- 1994;15:1247-54. Acta Otolaryngol (Stockh) 1967; ated malformations (such as cavernous 8. Federal Aviation Administration. Guide 63:347-65. malformations or hypertension) and for Aviation Medical Examiners. [Ac- was taking no medications. It had 9. Chia S, Gamst A, Anderson J, Harris cessed from the Internet on 10/25/06]: J. “Intratympanic gentamicin therapy been more than 1 year since the www.faa.gov/about/office_org/head- for Meniere’s disease.” Otology & onset of bleeding, and the specialist quarters_offices/avs/offices/aam/ame/ Neurotology; 2004 July; 25 (4): 544- concluded his possibility of rebleeding guide/ 52. or other symptoms, such as seizure, was rare. After review, he was granted Shino Hara, MD, is a visiting physician from Dr. West was on a clinical rotation at a special issuance of first-class medical the Japanese Aeromedical Research Center in the Civil Aerospace Medical Institute as certificate. An annual neurological Tokyo. She was at the Civil Aerospace Medi- a Resident in Aerospace Medicine when evaluation was stipulated, with MRI, cal Institute learning about how the Fed- he wrote this case report. He held the eral Aviation Administration conducts pilot rank of major, USAF, SFS. and a current status report from his medical certification so these policies can be neurologist were required. Any adverse applied to Japanese medical certification in 4 changes in his clinical course should be the future. She wrote this case report while promptly reported and flying activity at CAMI. ceased. 4

The Federal Air Surgeon's Medical Bulletin • Vol. 45, No. 1 • 9 Why I Became an AME letter addressed to me. After a week in Our vocation is a privilege with great rewards beyond all Oklahoma City, that was it — I had material wealth and prestige become an AME! By Parvez Dara, MD The author earned his wings in 1992 and became an aviation medical examiner in 2000. He have enjoyed this privilege, earn- describes what motivated him to seek the designation and why he cherishes it. — Ed. I ing the respect of fellow pilots and getting to know a fair number of aviators. This is a select version of HY DID I WANT to become an To be honest, I could not even begin humanity: intelligent, gifted, desir- Waviation medical examiner? to counter his stories with any of mine. ous; a group that constantly strives to The short answer: My AME. He had His were deliciously appetizing, kind expand the envelope of knowledge built the scaffolding of my desire and of made you go into a dream mode, the muscle of want flexed its need, cryptic and satisfying. But through it ‘He showed up again in and there I was, thinking of ways to all, in those twenty minutes of conver- my office two years later in be a part of this elite group. sation, he would make sure to inquire complete remission after When? I think I can nail the timing about my aspirations in aviation. The to the day of my first flight physical. It examination was thorough, while he battling stage-II seminoma.’ was four in the afternoon when I sat in kept me involved with questions about my AME’s office. He was a congenial the “dos and don’ts” of flying. and expertise. fellow, full of smiles and easy talk, com- I passed my medical without a hitch From airline pilots to student pilots, fortable in his demeanor. He sat behind and from then on, each time I left his all have a story to tell, especially the lat- office, I felt good about myself, aviation, ter, whom I call the “innocents.” They ‘Doing AME’s work was and for being a physician. I wanted to be bring a blank slate where words, images the best part of his day, like him. I was already a physician, so and their meanings can be assimilated that hurdle was crossed, but to become for the future. It is a delight to clear he would say.‘ an aviation medical examiner— now them medically (if they qualify) to face that was going to be challenging. those challenges. After an initial inquiry with the a desk with his arms folded behind his FAA, I found out that of all the dif- NE SUCH twenty-something neck, beaming with energy. We got to ficulties I faced, the biggest hurdle O airline-captain-wannabe sat talking and it was all about airplanes. was... NEED. in my office one afternoon, all ani- His chariot was a Piper with a speed that On my fifth medical examination mated while extolling his desires in could transport him from the East to with my AME, I finally asked him how the field of aviation. However, his the West Coast in two or three days. His I could become an AME. He did not expression changed following the description of those multiple journeys miss a beat and answered, “I have been examination when I told him the is chronicled in my brain because his waiting for this question for a while.” grim truth about his testicular growth attention to detail was exquisite. He Oh really, I thought. What gives? and the differential diagnoses. I never flew in the clouds, and if they Turns out he was planning to retire shepherded him to the urologist for hampered his progress, he either sat from his practice and wished to submit more fact-finding. them out or got out of the way. a name to the FAA for his successor in He showed up again in my office Doing AME’s work was the best part the area. Well now, I thought, had I two years later in complete remission of his day, he would say. After his busy stepped into the fields of my desire by after battling stage-II seminoma. He OB-GYN practice, he would relax and accident or was this a carefully crafted wanted to fly now more then ever, enjoy a conversation with a fellow pilot scenario to lure me in? and his desire was to command a large about their various escapades. This was Turns out it was neither. It was a commercial jet. his escape from reality three times a coincidence, and I was the recipient He had restarted his training with a week. His was a demanding occupation, of the proverbial pot at the end of the local CFI, and as he sat there on the edge and we were interrupted several times rainbow. He had thought of me as of his seat, half out of breath describing by the minutia of the daily practice of a potential successor if I showed an his introductory flight, you could not medicine, but through it all, he kept his interest. And now I had. What it took but wonder at the blessings of fearless- smile and soldiered on with his stories was an endorsement from him, and ness in his tone. At the end of his story, while encouraging a dialogue. the FAA identified the need with a his eyes narrowed as he came up for air Continued

10 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 45, No. 1 • AME from page 10 DISTANCE from page 3 completed the test, in case we do not problems, we recommend the following receive your score electronically. and asked if I could help him his get his procedures: Fortunately, most AMEs are able medical certificate. • When taking one of these courses, to successfully complete these on-line Absolutely, I would. After all, how complete each module during a courses without difficulty, but we rec- could you not? Getting the Aviation single, uninterrupted session. ognize the frustration of those who have Medical Examiner-Issued Special Issu- • When you complete a module, temporarily lost credit for their work. ance for a third-class student medical exit from the course and re-enter the Let us know about the problem, and was easy. I told him to continue with course to begin the next module. we can correct your record. his training, though, before deciding to • Finally, when you have success- If you have any questions about these expend resources and energy for higher fully completed the final test, make courses or if you experience any of the a screen print of your final score by problems mentioned, contact Ridge Smith at: ‘Our vocation is a privilege pressing “Ctrl-P” and keep this print- out as positive proof that you have Ridge.Smith @faa.gov with great rewards...’ goals. I would have to obtain the FAA’s Aviation Medical Examiner Seminar Schedule approval. 2007 He walked out carrying a new stu- February 2 – 4 San Diego, Calif. NPN (2) dent pilot certificate with an expanded March 5 – 9 Oklahoma City, Okla. Basic (1) chest and a proud smile of achievement. (He is currently working on his com- March 16 – 18 Bellevue, Wash. CARDIO (2) mercial pilot rating.) The joy of seeing May 14 – 17 New Orleans, La. (AsMA) AP/HF (3) him complete his goals has made me July 13 – 15 Oklahoma City, Okla. NPN (2) realize that helping someone achieve August 17 – 19 Washington, D.C. OOE (2) a dream is a reward devoutly to be cherished. August 27 – 31 Oklahoma City, Okla. Basic (1) A psychiatrist colleague of mine hap- September 14 – 16 Savannah, Ga. CARDIO (2) pened to be in my office the same day December 10 – 14 Oklahoma City, Okla. Basic (1) and wistfully said that he would give a ny t h i n g to m a ke a per son t h at h appy i n CODES such short a period of time. I told him, “Those are the perks of this trade, but AP/HF Aviation Physiology/Human Factors Theme it takes effort and commitment.” CARDIO Cardiology Theme “True,” he said, “but I would love to be in your shoes.” OOE Ophthalmology - Otolaryngology - Endocrinology Theme “Commitment and effort.” I reversed N/NP/P Neurology/Neuro-Psychology/Psychiatry Theme the word flow. (1) A 4½-day basic AME seminar focused on preparing physicians to be Then, he asked, “How do I become designated as aviation medical examiners. Call your regional flight surgeon. an AME?” Had I done it? Become one like my (2) A 2½-day theme AME seminar consisting of 12 hours of aviation medical former AME? I don’t know, but it felt examiner-specific subjects plus 8 hours of subjects related to a designated theme. Registration must be made through the Oklahoma City AME Programs good to be asked that question. Man, staff, (405) 954-4830, or -4258. did it feel good. Embodying my former AME’s pas- (3) A 3½-day theme AME seminar held in conjunction with the Aerospace sion has allowed me the discourse of Medical Association (AsMA). Registration must be made through AsMA at (703) this vocation. Now I am able to assist 739-2240. A registration fee will be charged by AsMA to cover their overhead others in achieving their desires as, years costs. Registrants have full access to the AsMA meeting. CME credit for the FAA seminar is free. ago, he had fueled mine. Our vocation is a privilege with great The Civil Aerospace Medical Institute is accredited by the Accreditation Council rewards beyond all material wealth for Continuing Medical Education to sponsor continuing medical education and prestige. It rests upon the wings for physicians. of passion. 4 The Federal Air Surgeon's Medical Bulletin • Vol. 45, No. 1 • 11 Index of Articles Published in the Bulletin During 2006

ARTICLE VOLUME PAGE AAM Awards for Excellence and Achievement Presented ------44-2 ------10 Abbas, Dr. Raad: International Exchange Physician Program Participant ------44-2 ------9 Aerospace Standards Guide Published, by Mike Wayda ------44-1 ------5 Airman Address Problems, Quick Fix, by Richard F. Jones, MD ------44-1 ------5 AirVenture 2006: 6 Hot Days in July, by Nestor Kowalsky, MD ------44-3 ------11 Alaska by Air, by Focus FAA ------44-3 ------11 Al-Deleamy, Dr. Louai: International Exchange Physician Program Participant ------44-2 ------9 AME Resources: 3 Ways to Order Pilot Safety Brochures, by Mike Wayda ------44-2 ------4 Boren, Dr. Henry: Retires from CAMI ------44-2 ------10 Certification Issues, by Warren Silberman, DO ------44-3 ------4 Certification Update, by Warren Silberman, DO ------44-1 ------3 Certification Update, by Warren Silberman, DO ------44-2 ------3 Dara, Dr. Parvez: AME Profile, by Mike Wayda ------44-2 ------7 Dumstorf, Dr. Matthew: Appointment to Great Lakes Region, by Nestor Kowalsky, MD ------44-3 ------10 Editorial: THANKS, by Fred Tilton, MD ------44-2 ------2 Editorial: What’s Up, by Fred Tilton, MD ------44-3 ------2 Editorial: When in Doubt…by Fred Tilton, MD ------44-1 ------2 E-Mail Is Coming, Quick Fix, by Richard F. Jones, MD ------44-3 ------1 Fraser, Dr. James: New AAM Deputy Selected ------44-2 ------1 Getting More CME for Your Money at AsMA, by Richard F. Jones, MD ------44-1 ------6 Hypertension: AME Tips, by Glenn R. Stoutt, MD ------44-2 ------4 I Passed My Flight Physical, So I Must Be Healthy!, by David Bryman, DO ------44-3 ------3 Index of Articles Published in 2005 ------44-1 ------12 Internet Address for AME Guide Changes, by Mike Wayda ------44-2 ------4 Invitation Letters, Quick Fix, by Richard F. Jones, MD ------44-2 ------1 Is FAA’s Web-Based Technology Investment Justified? by Mike Wayda ------44-3 ------1 Jackson, Dr. Marvin: Appointment to Great Lakes Region, by Nestor Kowalsky, MD ------44-3 ------10 Laser Eye Surgery Brochure now Available, by Mike Wayda ------44-1 ------5 Letter to Editor: Congratulations to Doug Burnett ------44-1 ------7 Letter to Editor: Email Addresses Needed (and Supplied) ------44-1 ------7 Letter to Editor: Heart Statistics ------44-1 ------7 Letter to the Editor re Light Sport Aircraft ------44-3 ------9 Migraine Headaches: Case Report, by Kimberly R. Bradley, DO, MPH ------44-3 ------8 Millett, Dr. David: Receives AsMA Tamisiea Award, by Janet Saner ------44-2 ------10 Myasthenia Gravis: Case Report, by Nidal El Rimawi, MD ------44-1 ------8 New Pilot Safety Brochure Available: Laser Eye Surgery ------44-1 ------5 New Version of the AME GUIDE Coming, by Kelly Spinner ------44-1 ------1 Peripheral Vascular Disease: Case Report, by Donald Christensen, DO ------44-1 ------10 Perspectives of ‘the New Guy’ in AMCD, by Dennis Deakins, MD ------44-2 ------11 Post-Impact Seizure: Case Report, by Lynn K. Flowers, MD ------44-2 ------8 Primary Cerebral Lymphoma: Case Report, by Patrick R. Storms, MD, MPH ------44-3 ------6 Profile of a Manager: Steve Smiley ------44-1 ------5 Sarcopenia, by Glenn R. Stoutt, MD ------44-2 ------5 Sen, Dr. Ahmet: International Exchange Physician Program Participant ------44-2 ------9 Severe Asthma: Case Report, by R. Shane Day, DO ------44-2 ------6 Tilton, Dr. Fred: Selected as Federal Air Surgeon ------44-1 ------1 Whinnery, Dr. James: Honored by AsMA ------44-2 ------10 Wilson, Dr. Larry: Chosen for Central Regional Flight Surgeon ------44-3 ------11

12 T h e F e d e r a l A i r Su r g e o n's M e d i c a l B u l l e t i n • Vol. 45, No. 1 •