Bilateral Ears - Eustachian Tube Dysfunction — DVA claim example

Diagnostic Assessment — Bilateral Ears - Eustachian Tube Dysfunction

Example 1 of 1 · fictitious patient (Veteran Q)

Diagnostic Assessment

Bilateral Ears - Eustachian Tube Dysfunction

No Statement of Principles applies to this condition (non-SOP claim).

ADF History

Veteran Q, date of birth 11 November 1979, Royal Australian Air Force, Loadmaster (C-130 Hercules), enlisted 02 February 1998, medically discharged 14 July 2021. Operational service: East Timor, 20 September 1999 to 10 February 2000 (warlike); Middle East Area of Operations including Afghanistan, 05 October 2009 to 15 April 2010 (warlike); Middle East Area of Operations, 02 June 2016 to 10 December 2016 (warlike).

Occupational History

As a loadmaster on C-130 Hercules aircraft the veteran flew several sectors a day, often with tactical low-level flying and rapid tactical descents of up to 1,500 metres a minute into forward airfields, which impose large and fast changes in cabin pressure on the middle ear. He loaded and secured cargo, vehicles and passengers in the aircraft hold, handled chains, strap binders and heavy pallets, and worked on airfields among running engines, auxiliary power units, fuel vapour, dust and exhaust.

Aircrew on deployed air mobility operations flew irregular and overnight schedules with broken sleep and irregular meals, lived in crowded accommodation in which respiratory infections spread readily, and worked at bases where open-air burn pits, dust storms and rocket attacks were common. The aircrew culture of the period discouraged reporting colds and blocked ears, because a grounding would leave the crew short.

History

Veteran Q, a loadmaster in the Royal Australian Air Force, developed bilateral obstructive Eustachian tube dysfunction on 14 March 2010 after a rapid tactical descent into a forward airfield in Afghanistan while he had an upper respiratory tract infection, on a background of repeated otic barotrauma, allergic rhinitis, chronic rhinosinusitis, reflux, smoking, a post-traumatic nasal septal deviation, burn-pit smoke exposure and a recent blast. The condition worsened with bilateral middle ear effusions after barotrauma on a further Middle East deployment on 18 November 2016.

Timeline

• 11 Jun 2002 — The veteran presented to the RAAF base health centre with severe right ear pain and muffled hearing after a descent while flying with a head cold. The medical officer found a haemorrhagic, retracted right tympanic membrane and diagnosed otic barotrauma. He was grounded for two weeks. Similar barotrauma of the left ear was recorded on 14 September 2006 and of both ears on 02 April 2008. "otic barotrauma, grounded two weeks"
• 23 May 2005 — While securing a vehicle in the aircraft hold, a tensioned chain binder released and struck the veteran across the nose. CT showed a displaced fracture of the nasal bones and nasal septum. The fracture was reduced, but he was left with a septal deviation to the left and persistent left nasal obstruction. "nasal fracture, septal deviation"
• 19 Aug 2008 — An ear, nose and throat surgeon reviewed the veteran for persistent nasal blockage, post-nasal drip and recurrent barotrauma. CT showed chronic rhinosinusitis, skin prick testing in 2004 had confirmed allergic rhinitis to grass pollens and house dust mite, and flexible laryngoscopy showed posterior laryngeal oedema consistent with laryngopharyngeal reflux. He was smoking 10 cigarettes a day. Intranasal steroid and a proton pump inhibitor were prescribed. "chronic rhinosinusitis, allergic rhinitis, LPR"
• 14 Mar 2010 — On warlike service in Afghanistan the veteran flew a rapid tactical descent into a forward airfield while recovering from an upper respiratory tract infection that began on 05 March 2010. Both ears blocked during the descent and did not clear. He had been within 40 metres of a rocket impact on 20 February 2010 and lived and worked beside an open burn pit. He continued flying with decongestant. "both ears blocked on descent"
• 22 Jul 2010 — After four months of bilateral aural fullness, muffled hearing, popping and inability to clear his ears, an ear, nose and throat surgeon in Australia found bilaterally retracted tympanic membranes that did not move on Valsalva or pneumatic otoscopy. Tympanometry showed type C traces with middle ear pressures of -220 and -245 daPa, and the Eustachian Tube Dysfunction Questionnaire score was 5.1. "bilateral ETD, type C tympanograms"
• 18 Nov 2016 — On warlike service in the Middle East the veteran flew a series of tactical descents with an upper respiratory tract infection and had severe bilateral otic barotrauma. Tympanometry at the deployed health facility showed flat type B traces bilaterally, and audiometry showed a bilateral conductive hearing loss of 25 to 30 dB. No ear, nose and throat surgeon was available in theatre, and he was kept on flying duties with decongestant. "bilateral effusions, type B"
• 09 Feb 2017 — After return to Australia an ear, nose and throat surgeon confirmed persistent bilateral middle ear effusions and inserted ventilation tubes in both ears. The Eustachian Tube Dysfunction Questionnaire score had risen to 6.3. He was permanently restricted from tactical flying. "bilateral grommets inserted"
• 12 Mar 2019 — Because of recurrent effusions after extrusion of the ventilation tubes, the veteran underwent bilateral balloon dilation of the Eustachian tubes with septoplasty. Symptoms improved partially but he continued to have aural fullness on any altitude change and could not return to aircrew duties. He was medically discharged on 14 July 2021. "balloon dilation, partial improvement"

Symptoms

At onset the veteran had blocked ears on both sides that would not clear with swallowing, yawning or the Valsalva manoeuvre, muffled hearing, a sensation of pressure, crackling and popping, and pain on every descent. He had difficulty hearing intercom traffic and briefings and was distracted by the discomfort while flying.

After the 2016 worsening he had persistent hearing loss, fluid in both ears, severe pain on descent and dizziness with pressure changes, and he had to stop tactical flying. He now reports constant aural fullness and muffled hearing on both sides, pain and blockage on air travel and driving through hills, tinnitus, and difficulty following conversation in noise.

Imaging

• 23 May 2005 — CT facial bones: "Displaced fractures of the nasal bones and nasal septum."
• 19 Aug 2008 — CT paranasal sinuses: "Mucosal thickening of the maxillary and ethmoid sinuses consistent with chronic rhinosinusitis. Septal deviation to the left with left inferior turbinate hypertrophy."
• 03 Jan 2017 — CT temporal bones: "Bilateral opacification of the middle ear cavities and mastoid air cells consistent with effusions. No cholesteatoma. Ossicles intact."

Onset Date

The most likely date of onset of this condition is 14 Mar 2010.

At that date the veteran was on warlike service in Afghanistan, flying air mobility sorties as a C-130 loadmaster into forward airfields. During a rapid tactical descent, while he had an upper respiratory tract infection, both ears blocked and did not clear, and the bilateral aural fullness and muffled hearing persisted from that date.

This date is appropriate because his annual aircrew medical examination of 15 August 2009 recorded normal tympanic membranes and normal tympanometry, and he first reported persistent bilateral ear blockage to the deployed medical officer on 15 March 2010, the day after the descent. The diagnosis was confirmed on 22 July 2010. It falls within warlike service.

For the barotrauma factor, the episodes of otic barotrauma on 11 June 2002, 14 September 2006 and 02 April 2008 all occurred before onset. For the infection factor, the 2 weeks before onset run from 28 Feb 2010 to 14 Mar 2010, and the infection began on 05 Mar 2010. For the irritant factor, the 2 years before onset run from 14 Mar 2008 to 14 Mar 2010, during which he was exposed to burn-pit smoke and airfield fumes from October 2009. For the blast factor, the 30 days before onset run from 12 Feb 2010 to 14 Mar 2010, covering the rocket impact on 20 Feb 2010. For the smoking factor, the 5 years before onset run from 14 Mar 2005 to 14 Mar 2010, throughout which he smoked 10 cigarettes a day. Allergic rhinitis, chronic rhinosinusitis, laryngopharyngeal reflux and the post-traumatic nasal obstruction were each established before 14 Mar 2010 and present on that date.

For the worsening factors, the documented worsening is 18 Nov 2016, when tympanometry showed bilateral type B traces and audiometry a new conductive hearing loss. The 2 weeks before the worsening run from 04 Nov 2016 to 18 Nov 2016, during which the infection began on 10 Nov 2016, and the 2 years before it run from 18 Nov 2014 to 18 Nov 2016, during which he was exposed to burn-pit smoke and airfield fumes on deployment from June 2016.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is bilateral obstructive Eustachian tube dysfunction (ICD-10 H68.1, obstruction of Eustachian tube), complicated by bilateral otitis media with effusion. No Statement of Principles has been determined for this condition.

The Eustachian tube connects the middle ear to the nasopharynx. It normally opens briefly with swallowing and yawning to equalise middle ear pressure with the atmosphere and to drain the middle ear. In obstructive Eustachian tube dysfunction the tube fails to open adequately, usually because of mucosal inflammation and swelling from infection, allergy, chronic rhinosinusitis, reflux or irritants, or because of structural obstruction in the nose and nasopharynx. Negative pressure develops in the middle ear, causing aural fullness, muffled hearing and pain, particularly with changes in ambient pressure, and it leads to tympanic membrane retraction, middle ear effusion, conductive hearing loss and, in the long term, chronic otitis media.

In this veteran the condition began on warlike service in Afghanistan on 14 March 2010, after repeated barotrauma from flying and in the presence of several inflammatory and structural causes. It was confirmed on 22 July 2010 and worsened with bilateral effusions on 18 November 2016.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

14 March 2010.

When did the veteran first present to a health / medical provider for this condition?

15 March 2010.

When was the condition confirmed / formally diagnosed?

22 July 2010.

When did the veteran first present to you (or your practice) for this condition?

02 April 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was made by an ear, nose and throat surgeon on 22 July 2010 on a history of more than three months of bilateral aural fullness, muffled hearing and inability to equalise pressure, with retracted tympanic membranes that did not move on Valsalva or pneumatic otoscopy, bilateral type C tympanograms with middle ear pressures of -220 and -245 daPa, and a Eustachian Tube Dysfunction Questionnaire score of 5.1. These findings meet the consensus clinical criteria for obstructive Eustachian tube dysfunction, which require symptoms of pressure dysregulation together with objective evidence of negative middle ear pressure.

The worsening was confirmed on 18 November 2016 by flat type B tympanograms and a new bilateral conductive hearing loss of 25 to 30 dB, and on 09 February 2017 by bilateral middle ear effusions requiring ventilation tubes. CT of the temporal bones on 03 January 2017 showed bilateral middle ear and mastoid opacification. A rise in the questionnaire score from 5.1 to 6.3 recorded the increase in symptoms.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

No Statement of Principles has been determined by the Repatriation Medical Authority for Eustachian tube dysfunction. The claim is therefore decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits a Statement of Principles would impose. The recognised causes below are drawn from the otolaryngology and aviation medicine literature, and each is addressed against the veteran's service and clinical history.

Legislation: the clinical onset of this condition was on 14 March 2010, after 1 July 2004, during warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. Where a Statement of Principles exists, the Reasonable Hypothesis instrument applies to operational service and the Balance of Probabilities instrument to peacetime service; here the condition arose on warlike service and worsened on warlike service in 2016, and the earlier peacetime flying, injuries and exposures also contributed. Each cause must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Recognised causes on the medical-scientific evidence (no Statement of Principles)

Causative factors

Cause 1: experiencing repeated rapid changes in ambient pressure from flying or diving, with at least two episodes of otic barotrauma, before the clinical onset of Eustachian tube dysfunction; — MET

- As a loadmaster the veteran flew several sectors a day with frequent rapid tactical descents. Otic barotrauma was documented on 11 June 2002 (right ear, haemorrhagic retracted drum, grounded two weeks), 14 September 2006 (left ear) and 02 April 2008 (both ears), each after descents in the course of his flying duties. Repeated barotrauma injures the middle ear and tubal mucosa and leads to persistent tubal dysfunction. All three episodes occurred before onset on 14 March 2010, and the onset itself followed a rapid tactical descent on warlike service.

Cause 2: having an upper respiratory tract infection within the 2 weeks before the clinical onset of Eustachian tube dysfunction; — MET

- The veteran developed an upper respiratory tract infection with nasal congestion, sore throat and cough on 05 March 2010, recorded by the deployed medical officer, during an outbreak in the crowded aircrew accommodation at his base in the Middle East. It was still present nine days later, within the 2 weeks before onset, when he flew the descent on 14 March 2010. Viral inflammation of the nasopharyngeal and tubal mucosa is the commonest trigger of Eustachian tube dysfunction.

Cause 3: having allergic rhinitis at the time of the clinical onset of Eustachian tube dysfunction; — MET

- Allergic rhinitis was confirmed by skin prick testing on 06 October 2004, with strong reactions to grass pollens and house dust mite, after the veteran developed persistent rhinitis while posted to an RAAF base surrounded by grassland. It was treated with intranasal corticosteroid and antihistamine and was active at onset on 14 March 2010, aggravated by dust in theatre. Allergic inflammation causes oedema of the tubal opening and is an established cause of tubal obstruction.

Cause 4: having chronic rhinosinusitis at the time of the clinical onset of Eustachian tube dysfunction; — MET

- CT of the paranasal sinuses on 19 August 2008 showed maxillary and ethmoid mucosal thickening, and an ear, nose and throat surgeon diagnosed chronic rhinosinusitis after more than 12 weeks of nasal obstruction and post-nasal drip. It persisted, with a Lund-Mackay score of 9 on repeat CT in 2011, and was present at onset on 14 March 2010. Post-nasal drainage of inflamed secretions over the nasopharyngeal tubal opening impairs tubal function.

Cause 5: having gastro-oesophageal reflux disease with laryngopharyngeal reflux at the time of the clinical onset of Eustachian tube dysfunction; — MET

- Reflux symptoms began in 2006 with irregular meals and overnight flying, and flexible laryngoscopy on 19 August 2008 showed posterior laryngeal oedema with a reflux finding score of 11, consistent with laryngopharyngeal reflux. He was taking a proton pump inhibitor irregularly at onset on 14 March 2010. Pepsin and acid reaching the nasopharynx inflame the tubal mucosa, and pepsin has been found in middle ear fluid.

Cause 6: smoking an average of at least 10 cigarettes per day for at least the 5 years before the clinical onset of Eustachian tube dysfunction; — MET

- The veteran took up smoking during initial training in 1998 and smoked an average of 10 cigarettes a day, recorded at each annual aircrew medical, continuously from 1998 to 2012. He therefore smoked at that level throughout the 5 years before onset, from 14 March 2005 to 14 March 2010. Tobacco smoke impairs mucociliary clearance and causes chronic inflammation of the nasopharyngeal and tubal mucosa.

Cause 7: being exposed to airborne irritants, such as smoke from burning waste, fuel combustion products or fine dust, for at least 500 hours within the 2 years before the clinical onset of Eustachian tube dysfunction; — MET

- From 05 October 2009 the veteran lived and worked at a base in the Middle East Area of Operations within 800 metres of an open burn pit, whose smoke regularly drifted over the accommodation and flight line, and he spent 10 to 12 hours a day on airfields among aircraft exhaust, auxiliary power unit fumes and fine dust. In the five months to onset this amounted to more than 1,500 hours of exposure, all within the 2 years before onset on 14 March 2010, on warlike service.

Cause 8: having a fracture of the nasal bones or nasal septum resulting in chronic nasal obstruction before the clinical onset of Eustachian tube dysfunction; — MET

- On 23 May 2005 a tensioned chain binder released while the veteran was securing a vehicle in the aircraft hold and struck his nose, causing displaced fractures of the nasal bones and septum on CT. After reduction he was left with a septal deviation and left inferior turbinate hypertrophy, confirmed on CT on 19 August 2008, causing chronic nasal obstruction. Nasal obstruction alters nasopharyngeal pressures on swallowing and impairs tubal ventilation. The injury occurred in the course of his duties, before onset.

Cause 9: being exposed to blast overpressure within the 30 days before the clinical onset of Eustachian tube dysfunction; — MET

- On 20 February 2010, on warlike service, a rocket struck within 40 metres of the veteran while he was on the flight line. He had immediate bilateral ear pain and tinnitus, and the medical officer recorded injected tympanic membranes without perforation. Blast overpressure injures the middle ear and tubal mucosa. The blast was 22 days before onset on 14 March 2010.

Worsening factors

Worsening 1: experiencing further rapid changes in ambient pressure from flying or diving, with an episode of otic barotrauma, before the clinical worsening of Eustachian tube dysfunction; — MET

- On warlike service in the Middle East in 2016 the veteran flew repeated tactical descents with his Eustachian tube dysfunction, and on 18 November 2016 he had severe bilateral otic barotrauma. Tympanometry that day showed flat type B traces bilaterally, compared with type C traces in 2010, and audiometry showed a new conductive hearing loss of 25 to 30 dB.

Worsening 2: having an upper respiratory tract infection within the 2 weeks before the clinical worsening of Eustachian tube dysfunction; — MET

- An upper respiratory tract infection began on 10 November 2016, recorded at the deployed health facility, during his warlike service in the Middle East, eight days before the worsening on 18 November 2016.

Worsening 3: being exposed to airborne irritants, such as smoke from burning waste, fuel combustion products or fine dust, for at least 500 hours within the 2 years before the clinical worsening of Eustachian tube dysfunction; — MET

- From 02 June 2016 the veteran again worked 10 to 12 hours a day on deployed airfields among exhaust fumes and dust, with burn-pit smoke over his accommodation, more than 1,500 hours of exposure within the 2 years before the worsening on 18 November 2016, on warlike service.

Worsening 4: inability to obtain appropriate clinical management for Eustachian tube dysfunction. — MET

- When the condition worsened on deployment on 18 November 2016 no ear, nose and throat surgeon was available in theatre, and the veteran was kept on flying duties with decongestant until his return on 10 December 2016. Ventilation tubes were not inserted until 09 February 2017. Continued flying with obstructed tubes and established effusions caused further barotrauma. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

The % contribution of the causes is 100% and significant.

Sequelae

Met. The Eustachian tube dysfunction has caused bilateral otitis media with effusion and a bilateral conductive hearing loss, documented on 18 November 2016 and requiring ventilation tubes, and it has contributed to his tinnitus. The conductive hearing loss and chronic otitis media should be considered for separate claims. The condition is itself in part a sequela of the service-related nasal fracture, allergic rhinitis and chronic rhinosinusitis.

Unintended Consequence

Met. The veteran was returned to flying duties on 15 March 2010 and again on 18 November 2016 with decongestant, on the advice of the deployed medical staff, and the continued tactical descents caused further barotrauma. This is an unintended consequence of medical management provided by the Commonwealth while he was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. On both deployments the veteran was in a setting with no ear, nose and throat specialist or audiological testing, and on each occasion he was kept on flying duties with decongestant rather than grounded and referred. After the worsening on 18 November 2016 he continued tactical flying with bilateral effusions until 10 December 2016, and ventilation tubes were not inserted until 09 February 2017. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational isolation and the pressure to keep aircrew flying amount to an inability to obtain appropriate clinical management. The four-month delay between onset in March 2010 and specialist diagnosis in July 2010 is also indicative of barriers to care.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 11 Jun 2002, Outpatient health record, Medical Officer, RAAF base health centre
2. 06 Oct 2004, Skin prick test report, Immunologist
3. 23 May 2005, CT facial bones and emergency department record, Emergency physician
4. 14 Sep 2006, Outpatient health record, Medical Officer, RAAF base health centre
5. 02 Apr 2008, Outpatient health record, Medical Officer, RAAF base health centre
6. 19 Aug 2008, CT sinuses, laryngoscopy and specialist consultation, Ear, nose and throat surgeon
7. 15 Aug 2009, Annual aircrew medical examination, Medical Officer
8. 20 Feb 2010, Deployed health record, Medical Officer, Middle East Area of Operations
9. 15 Mar 2010, Deployed health record, Medical Officer, Middle East Area of Operations
10. 22 Jul 2010, Tympanometry and specialist consultation, Ear, nose and throat surgeon
11. 18 Nov 2016, Deployed health record, tympanometry and audiogram, Medical Officer
12. 03 Jan 2017, CT temporal bones report, Radiologist
13. 09 Feb 2017, Operation report, bilateral ventilation tubes, Ear, nose and throat surgeon
14. 12 Mar 2019, Operation report, Eustachian tube balloon dilation and septoplasty, Ear, nose and throat surgeon