Ear, Nose and Throat
Appendix B: Other Standards
- FAA: Inner Ear: 2017 Edition of Guide for Aviation Medical Examiners, p. 49.
- Acute or chronic disease without disturbance of equilibrium and successful myringotomy, if applicable, for all classes, requires submission of all pertinent medical information to FAA, with recommendation to issue medical card if no physiologic effects.
- Acute or chronic disease that may disturb equilibrium, for all classes requires submission of information to FAA, and requires decision on issuance by FAA.
- Motion sickness, for all classes, requires submission of pertinent information to FAA. If occurred during flight training, and resolved, issue card. If requires continued medication, requires FAA decision on issuance of card.
- FMCSA: Benign positional vertigo: Most recent edition of the Medical Examiners’ Handbook states driver may be certified after a 2-month symptom-free waiting period. The Handbook also recommends not certifying a driver taking phenothiazines or benzodiazepines for vertigo, and to individually assess drivers taking antihistamines for vertigo for sedation that would create a safety hazard. (FMCSA Medical Examiner Handbook, pp 149-50).
NFPA 1582, 2018 Edition: Vertigo, impaired balance, ataxia, Meniere’s syndrome, labyrinthitis, tinnitus require restrictions or disqualification.
City of Alexandria, Virg.: pages 12-13. https://www.alexandriava.gov/uploadedFiles/personnel/Police%20Medical%20Standards.pdf
5-3.2 Category B medical conditions shall include:
(e) Meniere’s syndrome or labyrinthitis.
(g) Vestibular neuronitis, vertigo, dizziness, disequilibrium.
Category B Medical Condition. A medical condition which, based on its severity or degree, may preclude a person from performing as a police officer in a training or emergency operational environment. This may be because the condition presents a significant risk to the safety and health of the person or others, or because it prevents the individual from satisfactorily being able to perform an essential function of his/her job. Whether reasonable accommodation can be made must be determined by an individual study of the candidate’s condition and the capabilities of the City of Alexandria to accommodate the disability.
California POST: These standards are silent on the topic of BPPV.
New York State Municipal Police Training Council, Medical and Physical Fitness Standards and Procedures for Police Officer Candidates:
- b) Ears and hearing. Requires a case-by-case assessment of each candidate to determine if the candidate is able to perform the essential functions of the position.
(5) Inner/middle/outer ear disorders affecting equilibrium. If the candidate has historically had episodes of vertigo, he/she may require further evaluation.
Commonwealth of Massachusetts – 2014, Human Resources Division, Physician’s Guide, Initial-Hire Medical Standards:
- Initial Medical Standards for Municipal Police Officers:
(5) Category A and Category B Medical Conditions
(b) A Category B Medical Condition is a medical condition that, based on its severity or degree, may or may not preclude an individual from performing the essential job functions of a municipal police officer, or present a significant risk to the safety and health of that individual or others.
(c) Ears and Hearing
- Category B medical conditions shall include:
- Meniere’s disease, labyrinthitis or any disorder of equilibrium,
The United States Department of Interior Law Enforcement Medical Standards
These standards are applicable to the following positions:
National Park Service Commissioned Park Rangers (Personnel Series 025) Criminal Investigators (Personnel Series 1811) Correctional Officers (Personnel Series 007)
U.S. Fish and Wildlife Service Special Agent (Personnel Series 1812)
The Hearing Standards
Otological conditions which may result in disqualification include, but are not limited to, the following examples:
- Ménière’s disease
- Vestibular neuronitis
- Vertigo and paroxysmal positional vertigo
Any other disease or defect of the ear which adversely affects hearing or equilibrium and which potentially interferes with the safe and efficient job performance is generally disqualifying.
Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology-Head and Neck Surgery. 2017;156(3S):S1-S47.
Verification of diagnosis (Key Action Statements 1a. Diagnosis of posterior semicircular canal BPPV, and 1b. Diagnosis of lateral (horizontal) semicircular canal BPPV.
Posterior semicircular canal (PSC) BPPV accounts for the majority of cases of BPPV. Lateral semicircular canal (LSC) BPPV accounts for 5-22% of cases, while anterior semicircular canal (ASC) BPPV account for only 1-3% of cases. BPPV can be diagnosed reliably by history and physical exam. Accuracy of diagnosis is important in reducing the inappropriate use of additional testing, and in ensuring proper treatment.
PSC BPPV is diagnosed by an appropriate history and a positive Dix-Hallpike maneuver.
LSC BPPV is diagnosed by an appropriate history and a positive supine roll test maneuver.
Diagnosis for posterior semicircular canal BPPV is based on: 1) a history of vertigo provoked by changes in head position relative to gravity; and 2) characteristic nystagmus (torsional/upbeating) on the Dix-Hallpike maneuver, with a latency period between the completion of the maneuver and on-set of nystagmus, and the nystagmus increases and then resolves within 60 seconds. Diagnosis for lateral (or horizontal) semicircular canal BPPV consists of 1) a history of vertigo provoked by changes in head position relative to gravity, and 2) horizontal or absent nystagmus on the Dix-Hallpike maneuver, and characteristic lateral nystagmus on the supine roll test.
Both types of BPPV can be successfully treated by canalith repositioning procedures (CRP), though different procedures are used for each type. This underscores the need for accurate diagnosis. A 2010 meta-analysis showed a 6.5 O.R. for improvement, and a 5.19 O.R. for conversion to a negative Dix-Hallpike maneuver, following CRP.
While treatment is effective, recurrence rates are relatively high. While there are only a few quality studies with longer term follow-up, the BPPV recurrence rate is reported to be in the 5-13.5% range at 6 months, and 10-18% at one year. The rate of recurrence is reported to increase with time and may be as high as 36%. Individuals with trauma induced BPPV appear to be at a somewhat higher risk of recurrence.
In general, routine use of antihistamines and/or benzodiazepines is discouraged. Studies have not shown a significant effect on shortening duration of BPPV symptoms, and were inferior in this regard to CPR. However, their use can be considered for symptomatic relief of nausea and vomiting, in a severely symptomatic individual. Given the potential side effects of these medications, this is a significant consideration in LEOs.
USAF Waiver Guidelines:
Notes that BPPV is waiverable for class II and III flying duties, Air Traffic Controller/Ground Based Controller, and Mobile Ordinance Disrupters duties. It is not waiverable for class I/IA flying duties.
The guidelines stress having an accurate diagnosis, as do the guidelines above, as prognosis for recurrence and incapacitation are dependent on diagnosis. BPPV is noted to have short duration episodes, usually less than 30 seconds, are typically brought on by predictable head movements or positions. This of course would cause less risk of sudden incapacitation. “The symptoms of BPPV pose a definite risk of incapacitation which may jeopardize flying safety, although the brief duration of symptoms (less than 20-30 seconds) and the fact that symptoms are provoked by only very specific head maneuvers may permit recovery from an in-flight occurrence and safe return if such provocative maneuvers can be avoided. BPPV may therefore pose more risk to mission completion that to flying safety, unless symptoms occur during particularly critical phases of flight. Therefore, waivers are usually only recommended for multi-crew aircraft.” BPPV is stated to account for about 50% of cases of peripheral vertigo. Lifetime prevalence is cited at 2.4%, with recurrence rates of 15-18% in the first year, and up to 50% within 5 years. Response to CRP are reported at 70-95%. It is also noted that BPPV is self-limited, with spontaneous resolution, though remission can take months.
Candidates: Verify diagnosis and appropriate treatment (CRP) by review of records and/or physical exam. Candidates with vertigo that cannot be ascribed to BPPV (or resolved vestibular neuronitis) with a high degree of confidence should not be certified. Diagnosis for posterior semicircular canal BPPV is based on: 1) a history of vertigo provoked by changes in head position relative to gravity; and 2) characteristic nystagmus (torsional/ upbeating) on the Dix-Hallpike maneuver, with a latency period between the completion of the maneuver and on-set of nystagmus, and the nystagmus increases and then resolves within 60 seconds. Diagnosis for lateral (or horizontal) semicircular canal BPPV consists of: 1) a history of vertigo provoked by changes in head position relative to gravity; and 2) horizontal or absent nystagmus on the Dix-Hallpike maneuver, and characteristic lateral nystagmus on the supine roll test. Do not certify if active symptoms, or requiring medications to control symptoms on a regular or frequent basis. Given the risk of recurrence, the candidate should be free from symptoms off medications for 6 months (FMCSA recommends 2 months symptom free off medications prior to certification for commercial driving duties).
Incumbents: For incumbents who experience an episode of BPPV, remove from safety sensitive duties where sudden incapacitation would cause unacceptable risk to the officer or others, until symptoms are resolved off medication for at least 2 months. Ensure an accurate diagnosis and appropriate treatment as noted above. If attacks are frequent, require regular or frequent medications to control symptoms, or are unusually severe, consider permanent restrictions from safety sensitive duties.