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Air Force Waiver Guide

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    Air Force Waiver Guide

    ―This document primarily provides guidance for waivers on trained flying class II and III personnel, and where specifically stated applies to flying class I/IA applicants and other special duty personnel. This waiver guide does not cover general military entrance,

    commissioning, or enlistment.‖

    Last Update: 21 Jan 2009

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     Acne (Acne Vulgaris) (Mar 07) ......................................................................................................... 6Acoustic Neuroma ............................................................................................................................ 10 Adjustment Disorders (Nov 07) ...................................................................................................... 13 Alcohol Abuse and Dependence (Aug 06) ...................................................................................... 17 Allergic Rhinitis (Nov 06) ................................................................................................................ 21 Anemia/Blood Loss/Bone Marrow Donation (Dec 08) .................................................................. 25 Ankylosing Spondylitis .................................................................................................................... 30 Anthropometrics (Short Stature, Excessive Height, Weight, & Other Body Measurements)

    (Aug 07) ............................................................................................................................................. 32 Antimalarials (Jul 06) ...................................................................................................................... 40 Anxiety Disorders (Jul 07) ............................................................................................................... 45 Aortic Insufficiency/Regurgitation (Sep 07) .................................................................................. 51 Aortic Valve Stenosis (Sep 07)......................................................................................................... 56 Asthma (May 08) .............................................................................................................................. 60 Atrial Fibrillation and Atrial Flutter (Aug 08) .............................................................................. 69 Atrioventricular Conduction Disturbances (Jun 08) .................................................................... 74 Back Pain (Chronic Low) (Jan 08) ................................................................................................. 77 Bell’s Palsy (Nov 08) ......................................................................................................................... 82 Benign Prostatic Hypertrophy (Dec 05) ......................................................................................... 86 Bicuspid Aortic Valve (Sep 07) ....................................................................................................... 92 Bladder Cancer ................................................................................................................................. 96 Breast Cancer ................................................................................................................................... 98 Breast Implants (May 06) .............................................................................................................. 100 Cancers, Miscellaneous (Nov 08) .................................................................................................. 105 Cardiomyopathy (Dec 07) .............................................................................................................. 107 Cataract, Capsular Opacification, and Intraocular Lens Implant (May 07) ........................... 112 Central Retinal Artery/Vein Occlusion ........................................................................................ 121 Central Serous Chorioretinopathy (Aug 07) ............................................................................... 123 Cervical Cancer .............................................................................................................................. 128 Cholesteatoma (Sep 07) .................................................................................................................. 130 Chronic Obstructive Pulmonary Disease ..................................................................................... 135 Color Vision Deficiencies (Oct 08) ................................................................................................ 137 Colorectal Cancer (Nov 03) ........................................................................................................... 142 Congenital Heart Disease (Aug 08) ............................................................................................... 144 Coronary Artery Calcium Testing (Mar 08) ............................................................................... 150 Coronary Artery Disease (CAD) (Dec 08).................................................................................... 155 Coronary Artery Revascularization (Dec 08) .............................................................................. 161 Cranial Neuralgia ........................................................................................................................... 165 Crohn’s Disease (Nov 05) ............................................................................................................... 167 Cystic & Congenital Abnormalities of the Kidney & Ureters ...................................................... 171 Decompression Sickness and Arterial Gas Embolism (Mar 08) ................................................ 174 Decreased Renal Function .............................................................................................................. 179 Deep Venous Thrombosis/Pulmonary Embolism (May 06) ....................................................... 181 Defective Depth Perception/Stereopsis (Feb 08) .......................................................................... 187 Diabetes Mellitus (Nov 03) ............................................................................................................. 192 Diverticular Disease of the Intestine (Nov 03) ............................................................................. 196 Dysmenorrhea (Feb 08) ................................................................................................................. 198

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     Eating Disorders (May 08) ............................................................................................................ 203Ectopy and Pairing, Superventricular and Ventricular (PACs, PJCs, PVCs) (Mar 07) ......... 208 Eczematous Dermatitis (Eczema) [Atopic & Contact Dermatitis, Nummular, Dyshidrosis]

    (Apr 07) ........................................................................................................................................... 213 Endometriosis (Aug 08) ................................................................................................................. 219 Eosinophilic Esophagitis and Gastroenteritis (Dec 07) ............................................................... 222 Gallstones (Cholelithiasis) (Dec 06) .............................................................................................. 226 Gastroesophageal Reflux Disease (Feb 07) .................................................................................. 229 Gilbert’s Syndrome (Nov 06) ........................................................................................................ 233 Gout (Dec 06) .................................................................................................................................. 236 Guillain-Barré Syndrome (Acute Inflammatory Demyelinating Polyradiculoneuropathy)

    (Mar 07) ........................................................................................................................................... 241 Head Injury (Jan 09) ...................................................................................................................... 245 Headache (Mar 06) ......................................................................................................................... 250 Hearing Loss/Asymmetric Hearing Loss/Use of Hearing Aid(s) (Mar 08) ............................... 255 Hematuria (May 07) ....................................................................................................................... 264 Hemochromatosis (Dec 06) ............................................................................................................ 272 Hepatic Cirrhosis............................................................................................................................ 276 Hepatitis (Dec 03) ........................................................................................................................... 278 Herniated Nucleus Pulposus (HNP) and Spinal Fusion (Nov 08) .............................................. 281 Hodgkin Lymphoma (Aug 08) ...................................................................................................... 289 Human Immunodeficiency Virus (HIV) Infection (Apr 07)....................................................... 295 Hyperlipidemia, Therapy (Nov 06) ............................................................................................... 300 Hypertension (Mar 08)................................................................................................................... 307 Hyperthyroidism (Feb 07) ............................................................................................................. 313 Hypothyroidism (Dec 06) ............................................................................................................... 318 Impulse-Control Disorders ............................................................................................................ 322 Irritable Bowel Syndrome (Nov 03) .............................................................................................. 325 Keratoconus (Apr 06)..................................................................................................................... 327 Laparoscopic Adjustable Gastric Banding (LAGB) (Oct 08) .................................................... 330 Lattice Degeneration (Feb 06) ....................................................................................................... 335 Learning Disabilities/Attention-Deficit Hyperactivity Disorder (ADHD) ................................ 338 Left Bundle Branch Block (Sep 06) .............................................................................................. 341 Leukemia ......................................................................................................................................... 343 Liver Function Testing (Transaminases) ..................................................................................... 345 Lyme Disease (Jul 07) .................................................................................................................... 349 Malignant Melanoma (May 08) .................................................................................................... 355 Medullary Sponge Kidney ............................................................................................................. 362 Meningitis and Encephalitis (Oct 08) ........................................................................................... 364 Mitral Regurgitation (Insufficiency) Primary (Aug 07) .......................................................... 369 Mitral Valve Prolapse (Aug 07) .................................................................................................... 374 Mood Disorders (Bipolar Disorder and Depression) (Nov 07) ................................................... 380 Motion Sickness (Nov 06) .............................................................................................................. 387 Multiple Sclerosis and Clinically Isolated Syndrome (Dec 08) .................................................. 391 Neurological Tumors...................................................................................................................... 399 Non-Hodgkin’s Lymphoma (NHL) .............................................................................................. 400 Ocular Histoplasmosis (Presumed Ocular Histoplamosis Syndrome) ...................................... 402 Optic Nerve Cupping (Enlarged), Ocular Hypertension, & Glaucoma (Sep 07) ..................... 404

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     Optic Nerve Head Drusen (Nov 07) .............................................................................................. 410Optic Neuritis (Dec 08) .................................................................................................................. 416 Osteoporosis/Osteopenia (Feb 07) ................................................................................................ 423 Otosclerosis/Stapedectomy/Stapedotomy..................................................................................... 431 Pancreatitis (Mar 06) ..................................................................................................................... 434 Peptic Ulcer Disease (Dec 08) ........................................................................................................ 437 Pericardial Disorders including Myopericarditis (Jul 07) ......................................................... 444 Personality Disorders ..................................................................................................................... 449 Pituitary Tumors (Sep 08) ............................................................................................................. 452 Pneumothorax................................................................................................................................. 461 Pregnancy (Feb 08)......................................................................................................................... 464 Prostate Cancer .............................................................................................................................. 466 Prostatitis (Jul 08) .......................................................................................................................... 468 Proteinuria & IgA Nephropathy (Nov 08) ................................................................................... 473 Psoriasis and Psoriatic Arthritis (Jan 08) .................................................................................... 479 Psychological Factors Affecting Medical Conditions .................................................................. 485 Psychotic Disorders ........................................................................................................................ 488 Radiofrequency Ablation (RFA) of Tachyarrhythmias (Jun 08) .............................................. 490 Raynaud’s Phenomenon (Apr 08) ................................................................................................. 496 Reactive Arthritis (Reiter’s Syndrome) (Jun 08) ........................................................................ 501 Refractive Errors (Myopia, Hyperopia & Astigmatism) & Anisometropia (May 08)............. 507 Refractive Surgery (RS) (May 08) ................................................................................................ 515 Renal and Ureteral Stones (Nephrolithiasis) (Mar 07) ............................................................... 525 Retained Orthopedic Hardware and Joint Replacement (Dec 07) ............................................ 533 Retinal Breaks (Holes and Tears), Retinal Detachment and Retinoschisis (Jan 07) ............... 540 Rheumatoid Arthritis (Jan 08) ...................................................................................................... 545 Right Bundle Branch Block and Fascicular Blocks (Sep 06) ..................................................... 553 Salivary Gland Disorders (Apr 08) ............................................................................................... 556 Sarcoidosis (Jul 08)......................................................................................................................... 565 Seizures/Epilepsy/Abnormal EEG (Mar 06)................................................................................ 575 Sexual Dysfunctions, Paraphilias, Gender Identity Disorders ................................................... 578 Sexual Dysfunctions due to a General Medical Condition ......................................................... 578 Sickle Cell Disease/Trait (Mar 07) ................................................................................................ 581 Sinusitis, Hypertrophic Sinus Tissue, and Nasal Polyps (Sep 08) .............................................. 585 Sleep Disorders (Sep 08) ................................................................................................................ 593 Somatoform and Factitious Disorders.......................................................................................... 602 Spinal Curvature, Abnormal (Kyphosis, Scoliosis, and Lordosis) (May 08) ............................ 604 Spinal Fracture ............................................................................................................................... 609 Splenectomy (Nov 05)..................................................................................................................... 611 Spondylolysis and Spondylolisthesis (Aug 08) ............................................................................. 615 Subarachnoid Hemorrhage, Non-Traumatic (Mar 06) .............................................................. 620 Suicide Attempt .............................................................................................................................. 623 Supraventricular Tachycardia (Sep 07) ....................................................................................... 626 Syncope (Feb 07)............................................................................................................................. 631 Systemic Glucocorticoid (Steroid) Treatment (Dec 06) .............................................................. 636 Testicular Cancer (Sep 08) ............................................................................................................ 639 Testosterone Replacement for Hypogonadism (Jan 07) ............................................................. 647 Thalassemia (Mar 08) .................................................................................................................... 653

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     Thrombocytopenia, ITP, and TTP (May 07) ............................................................................... 658

    Thrombocytosis (Feb 08) ............................................................................................................... 665 Thyroid Cancer (Nov 08) ............................................................................................................... 673 Transient Ischemic Attack (TIA) and Stroke (CVA) (May 08) ................................................. 682 Ulcerative Colitis and Primary Sclerosing Cholangitis (Feb 08) ............................................... 688 Uterine Fibroids (Leiomyomas) (Jun 07) ..................................................................................... 695 Uveitis (Jul 08) ................................................................................................................................ 699 "V" Code Diagnoses....................................................................................................................... 703 Valve Surgery - Replacement or Repair (May 07) ...................................................................... 706 Valvular Heart Disorders Miscellaneous (Aug 07) .................................................................. 710 Ventricular Tachycardia (Jul 07) ................................................................................................. 714 Vertiginous Disorders, Peripheral (Ménière’s disease, benign paroxysmal positional vertigo,

    vestibular neuronitis [labyrinthitis]) (Apr 07) ............................................................................. 719 Wolff-Parkinson-White (WPW) and Other Pre-Excitation Syndromes (Feb 07).................... 728

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WAIVER GUIDE

    Updated: Mar 07

    By: Dr Karen Fox

CONDITION:

    Acne (Acne Vulgaris) (Mar 07)

I. Overview.

Acne is a disease of the pilosebaceous unit which typically appears at puberty and becomes less active 2, 6 It can persist into middle as adolescence is ending. 85% of adolescents are affected by this disease.

    age in 12% of women and 3% of men. It appears to be influenced by stress. The role of diet in acne is controversial. Cosmetics may contribute to the development of acne; water-based products are less comedogenic. Soaps, detergents and astringents remove sebum from skin surface but do not alter sebum production. Repetitive mechanical trauma caused by scrubbing with these agents may promote 6 the development of inflammatory lesions.

    There are four recognized pathogenic factors: hyperkeratinization (plugging) of the pilosebaceous follicles, increased testosterone levels which induces hyperseborrhea, colonization with the bacterium Propionibacterium acnes, and inflammation.

Acne lesions are divided into inflammatory and noninflammatory lesions: noninflammatory-open

    (blackheads) and closed (whiteheads) comedones; inflammatory-papules, pustules, and nodules/cysts.

    The primary pathologic site for acne expression is the face and less frequently the back, chest, and shoulders. There are numerous classification systems for acne but generally they describe the following categories:

    Mild Mainly comedones with occasional small inflamed papule or pustule; no scarring.

    Moderate Comedones and more numerous papules and pustules (mainly facial); mild scarring.

    Moderately Severe Numerous comedones, papules and pustules, spreading to the back, chest

    and shoulders with an occasional cyst or nodule; moderate scarring.

    Severe - Numerous large cysts on the face, neck and upper trunk; severe scarring.

    Treatment modalities for acne include cleansing, topical agents, systemic therapy, hormonal therapy, acne surgery, and intralesional glucocorticoids. Adverse effects of some topical agents include development of an irritant reaction. Systemic agents such as erythromycin, tetracycline, or doxycycline may cause gastrointestinal disturbance. The resistance of P. acnes to erythromycin approaches 50%

    and tetracycline inhibition by food is 46 % and with dairy intake inhibition increases to 65%. Minocycline is not approved for aviation usage secondary to an elevated incidence of vertigo and a myriad of central nervous system anomalies. Isotretinoin (Accutane?), a synthetic oral retinoid, can cause a sudden onset of decreased night vision, and is associated with corneal opacities, inflammatory bowel disease, elevated lipids, hepatotoxicity, musculoskeletal symptoms, pruritus, epistaxis, and dryness of skin, nose, and mouth. It is also highly teratogenic and requires a rigorous documentation process for any child-bearing age female.

    Generally noninflammatory lesions are treated by extraction or gentle expression and topical therapies, such as topical retinoid, benzoyl peroxide, or salicylic acid. Mild inflammatory is usually treated with a gradation of topical retinoid, benzoyl peroxide, azelaic acid or salicylic acid. Moderate inflammatory is usually treated with a gradation of topical retinoid, benzoyl peroxide, topical antibiotic or combination.

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    Moderately severe acne usually adds to the previous regime oral antibiotics. Oral antibiotics are also used when acne is on back, chest and shoulders or when inflammatory acne is not controlled/tolerated with topical combinations. Severe/nodulocystic (cysts/tracts/abscesses) acne requires aggressive treatment usually best evaluated and treated by a dermatologist. Typical treatment options in severe acne include isotretinonin (Accutane?), oral corticosteroids, intralesional steroid injection and oral antibiotics. Hormonal therapies are used in women only and include estrogen-containing oral contraceptives and spironolactone. Spironolactone is not an approved medication. Oral contraceptives low in androgenic progestin (e.g. Ortho tri-cyclen?, Yasmin?) are preferred.

II. Aeromedical Concerns.

    The main concerns are interference with the wear of protective aviation equipment; exacerbation of acne due to rubbing, pressure, and/or exposure to hot and humid environments; psychological factors; use of acne medications that are incompatible with flying duties; and extended grounding due to a difficult or prolonged treatment course. Lesions on the face may interfere with mask or respirator seal and helmet wear (chin straps). Lesions on the shoulder, chest, and back may cause discomfort and distraction when wearing restraint or parachute harnesses or with prolonged sitting. Repeated or prolonged rubbing or pressure against the skin can produce or exacerbate an eruption (mechanical acne) with striking inflammation.

Tropical acne may occur, typically after several months‘ exposure to a hot, humid environment and can

    be a major cause of disability. Patients often feel quite ill with tropical acne, antibiotic therapy is not effective, and removal from the environment is often necessary as the only effective treatment.

III. Information Required for Waiver Submission.

    Waiver is required if acne is controlled on oral antibiotics, oral contraceptives or if the acne interferes with the wearing of flying equipment. Waiver is not required if acne is controlled on only topical antibiotics, benzoyl peroxide, topical salicylic acid, azelaic acid and/or topical retinoids (tretinoin, adapalene, tazarotene). Waiver will not be granted if acne is controlled on isotretinonin (Accutane?) or minocycline.

The aeromedical summary should include the following:

    A. Extent of lesions, locations, and a description of current therapy - all medications including

    dosage, and frequency, and side effects.

    B. Comments addressing interference with use of aviation equipment.

    C. Dermatology consult if individual has recalcitrant moderate to severe inflammatory or

    severe/nodulocystic acne.

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IV. Waiver Considerations.

    The table below is a summary of the waiver requirements based upon flying class and treatment of acne.

    POTENTIAL

    WAIVER TREATMENT WAITING

    FLYING CLASS TREATMENT OF ACNE PERIOD AND SPECIAL

    WAIVER REGULATIONS

    AUTHORITY

    FC I, IA Topical treatment topical N/A No documented adverse

     retinoids (tretinoin, adapalene, effects from medication and

    tazarotene), benzoyl peroxide, no difficulty with wearing

    salicylic acid, azelaic acid, topical of aviation equipment

    antibiotics (clindamycin,

    erythromycin, sulfacetamide-sulfur)

    Oral contraceptive (female only) Yes 7-day ground trial

     AETC No documented adverse

     effects from medication and

     no difficulty with wearing

     of aviation equipment

    Oral antibiotics - tetracycline, Yes No documented adverse

    erythromycin, doxycycline, and AETC effects from medication and

    trimethoprim-sulfamethoxazole.* no difficulty with wearing

    of aviation equipment

FC II As above Yes As above

    FC III MAJCOM

FC IIC Usually related to scarring from Yes Usually granted so aviator

    severe/nodulocystic acne AFMOA does not have to wear

    helmet/mask on routine

    basis

    *Minocycline is not approved for flying duties.

    Treatment with approved topical agents does not require a waiver. The local flight surgeon must confirm, however, there are no adverse effects and the disease itself does not interfere with use of aviation equipment or safe mission completion. Systemic maintenance agents such as oral erythromycin, tetracycline, doxycycline, and trimethoprim-sulfamethoxazole require a waiver. They are compatible with flying once it is confirmed that side effects are absent or acceptable in severity. Isotretinoin therapy is not compatible with flying duties and would require prolonged grounding (usually 20 weeks) if used when clinically indicated. Therapy with oral contraceptives may be considered for women. In rare cases severe nodulocystic acne or scarring may require a categorical waiver to avoid routine use of a helmet or mask.

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    Review of AIMWTS from October 2003 through October 2006 showed 64 cases of acne. All received waivers except one and that was due to another medical condition; the vast majority being for the use of doxycycline.

Reviewed by Maj Sylvia Parra, Dermatologist at Wilford Hall Medical Center.

V. References.

     th ed., 1. Habif TP. Acne, Rosacea, and Related Disorders. In: Habif TP, ed. Clinical Dermatology, 4

    Mosby; 2004: 162-194.

2. James WD. Acne. New England Journal of Medicine. 2005; 352: 1463 1472.

    3. Lamberg SI. The course of acne vulgaris in military personnel stationed in Southeast Asia. Cutis. 1971; 7: 655.

4. Omohundro C, Taylor JS. Occupational acne. In: English JSC, ed. Color Handbook of

    Occupational Dermatology. London: Manson Publishing; 1998:121-34.

5. Strauss JS, Thiboutot DM. Diseases of the sebaceous glands. In: Freedberg IM, Eisen AZ, Wolff K, thet al, eds. Fitzpatrick’s Dermatology In General Medicine, 5 ed. New York: McGraw Hill; 1999:769-

    84.

    6. Wirth FA. Approach to Acne Vulgaris. UpToDate. Online version 14.3, August 15, 2006.

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WAIVER GUIDE

    Upated: Mar 00

    By: Dr Lisa Black

CONDITION:

    Acoustic Neuroma

I. Overview.

    Acoustic neuroma (AN) is a histologically benign lesion felt to be the result of over-proliferation of Schwann cells, covering the vestibular branch of the eighth cranial nerve as it passes through the internal auditory canal. Two distinct clinical presentations exist for ANs, unilateral sporadic, and bilateral hereditary tumors found in individuals with neurofibromatosis type 2, an autosomal dominant disorder with a high degree of penetrance. The more common type of AN, unilateral sporadic, accounts for more than 95% of ANs and usually later in life. Annual incidence of AN is one case in 100,000 persons with a female to male ratio of 1.5:1. A recent study of 164 patients undergoing surgery for AN found no clear relationship between tumor size, signs and symptoms, and level of hearing loss. This variation in growth rate makes it difficult for clinicians to predict how long a tumor has been growing or how fast it will grow in the future. The axial cross-sectional diameter of an AN usually falls into one of three growth patterns: slow (0.02cm/year), medium (0.2cm/year), or fast (1.0 cm/year). The majority of individuals will have either a slow or medium growth rate; however, the fast growth rate may be underrepresented because many patients become symptomatic and require surgery. The AN typically compresses the cochlear (acoustic) branch, causing hearing loss, tinnitus and dysequilibrium. Further growth of the lesion results in expansion into the cerebellopontine angle, where the trigeminal and facial nerves may be affected. Inferior extension leads to compression of the glossopharyngeal, vagus, and spinal accessory nerves. Larger tumors may encroach upon the brain stem and cerebellum, resulting in signs of increased intracranial pressure. While asymmetric sensorineural hearing loss is the classic presentation of AN, about 15% have normal audiograms, while up to a third of patients initially present with symptoms of unilateral tinnitus, imbalance, headache, fullness in the ear, otalgia, or facial nerve weakness.

    The traditional treatment for AN is surgical removal via a middle fossa, translabyrinthine or suboccipital approach. Middle fossa surgery is best reserved for small tumors that are limited to the internal auditory canal, while a suboccipital approach allows removal of larger tumors with less risk to the facial nerve. The translabyrinthine approach necessitates sacrifice of hearing on the operated side. The ACS now has experience with an aviator that elected to undergo Fractionated Stereotactic Radiosurgery (FSR), a promising non-invasive treatment modality. His vestibular system was well compensated. Hearing was adequate for all flying duties except those that would require stereo acusis in future cockpits.

    Our outlook on this landmark case is very positive and supported by the literature that reports that the vast majority of patients treated non-invasively maintain hearing, avoid facial trigeminal neuropathy and remain in remission years after treatment. Johns Hopkins experience of treatment of over 85 patients over the span of 6 ? years, have had no failures.

    AN growth has been divided into three stages: intracanalicular, cisternal, and brain stem compressive. The intracanalicular stage is typified by hearing loss, tinnitus, and vertigo. In the cisternal stage, auditory symptoms are worsened, vertigo transitions to dysequilibrium, and

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