CASE OF THE MONTH

IN THIS FEATURE WE WILL PRESENT A NEW CASE FOR YOUR REVIEW EACH MONTH.  THIS MONTH'S CASE WAS KINDLY REFERRED BY LTCOL DANA RAWL OF THE SCANG. THANKS DANA!

Perilymphatic Fistula Secondary to Barotrauma from a Valsalva Maneuver

  This case is about a 45-year-old highly experienced F-16 fighter pilot in the South Carolina Air National Guard.  In December of 1998, our pilot in question was completing a routine low-level training mission at McEntire Air National Guard Base and on rollout he performed a Valsalva maneuver.  The Valsalva maneuver resulted in a "ringing" in his right ear that lasted for approximately four hours.  The ringing in his ears progressed to a complete hearing loss in his right ear and mild vertigo.  He sought treatment from a flight surgeon the following day.  On examination, the pilot had no discernible pain but had complete hearing loss in his right ear.  There was no physical deformity of the tympanic membrane. There was no nystagmus and a Rhomberg test was negative. The pilot was referred urgently to a private ear, nose, and throat specialist who confirmed an idiopathic sensineuronal hearing loss secondary to barotrauma suspicious for a perilymphatic fistula.  He was placed on 60 milligrams of prednisone a day, a diuretic, and Acyclovir to cover for any Herpes Simplex etiology.

  Consultations were made with fellow flight surgeons, civilian otolaryngologists, HQ ANG/SGP, and the ENT consultant to the USAF/SG in Bolling AFB, D.C.  It was thought that our pilot would best benefit from an immediate evaluation from an experienced neuro-otologist.  A consultation by a neuro-otologist in the Department of Otolarygology at the Medical University of South Carolina was achieved in late December of 1998.  The neuro-otologist evaluation revealed no physical abnormalities except for complete hearing loss in his right ear.  It was recommended that he continue with his steroid and diuretic treatment. The neuro-otologist also recommended that early surgical repair of a perilymphatic fistula would yield the best results. During this time frame the pilot underwent an MRI on his head to rule out an acoustic neuroma.  The MRI was normal.

  Interestingly, the pilot took Christmas vacation with his family to North Carolina. He had an episode of vertigo while on a stair well and fell. He sustained an open comminuted fracture to his left wrist adding a major complication to the equation. He was eventually treated by our orthopedic flight surgeon and received an external fixation device. After several months of treatment and therapy for this injury, he regained full strength and functional mobility.

  Exploratory and reparative surgery for a perilymphatic fistula was performed in mid January of 1999 at the Medical University of South Carolina.  Through the post operative course, the pilot experienced varying levels of vertigo but progressed well.  In March of 1999, the pilot was noted to have a small polyp that had developed in his right ear canal that was removed. By that visit his hearing had improved in the low frequencies and he did not experience vertigo with the tympanogram test. By 28 April 1999, the pilot had had no vertigo for the previous six weeks and his hearing in the lower frequencies continued to improve.  The neuro-otologist proposed that he begin the process to return to flying.  He recommended that the pilot take an altitude chamber ride and some functional flights as a passenger to evaluate any symptoms of vertigo and to evaluate his hearing comprehension.

  After discussions with HQ ANG/SGP, the pilot accomplished a chamber flight on 10 May 1999 accompanied by the State Air Surgeon of South Carolina.  The chamber flight parameters were consistent with a physiologic training refresher flight.  He experienced no symptoms during the flight.  On 12 May 1999, the pilot completed a functional flight from the back seat of an F-16D with an instructor pilot in the front seat. Another F-16D with a senior flight surgeon in the back seat was the number 2 ship as an observer.  The pilot was subjected to a full variation of flying scenarios to test his inner ear sensitivity and ascertain his functional hearing capability.  The subject pilot flew the aircraft with precision and his radio communication was appropriate and exact.  The sortie included high G turns, aileron rolls, inverted flight, and rapid altitude changes.  Wingtip formation flying in the weather was also accomplished with the subject pilot on the wing. A "leans" situation was intentionally produced and the subject pilot transitioned to instrument flying without difficulty.  On 13 May 1999, the pilot flew an air-to-air mission with an instructor pilot in the back seat of the F-16D. He was number 4 in the four-ship flight.  All parameters of the flight went normally.  Routine high G and basic fighter maneuvers were accomplished.  The HUD tape of the flight was reviewed by a senior flight surgeon and revealed no difficulty in aircraft control or communications.

  A physical exam for waiver was accomplished and May of 1999 and revealed the pilot to be in good physical condition and on no medications.  His examination revealed mild retraction of his right tympanic membrane without perforations and good movement on a Valsalva maneuver.  He had normal eye movements without nystagmus and his Rhomberg test was negative.  His audiogram revealed hearing loss in the right ear in the higher frequencies with some return of the lower frequency hearing.  A waiver was granted for impaired hearing AD and for status post corrective surgery for a perilymphatic fistula.  There was no waiver request needed for his fracture of his left wrist since his functional capability had returned to normal and he had no internal fixative devices.

  This pilot has since completed his career at McEntire Air National Guard Base and has moved on to become a commercial pilot for a major packaging service.  I believe that this pilot's dedication, determination, and motivation to continue his flying career as an F-16 fighter pilot and the relationship between him and his flight surgeons greatly enhanced his recovery.  I have no doubt that some other pilots with less fortitude would have completed their career flying a desk!