Bilateral Ears - Otitic Barotrauma — DVA claim example

Diagnostic Assessment — Bilateral Ears - Otitic Barotrauma

Example 1 of 1 · fictitious patient (Veteran EJ)

Diagnostic Assessment

Bilateral Ears - Otitic Barotrauma

BOP Code: 87 of 2020 (Otitic Barotrauma)
RH Code: 86 of 2020 (Otitic Barotrauma)

ADF History

Veteran EJ, date of birth 07 October 1984, Royal Australian Navy, Clearance Diver, enlisted 16 February 2004, medically discharged 11 October 2019. Operational service: Middle East Area of Operations (maritime security and port clearance), 01 June 2012 to 20 December 2012 (warlike); Middle East Area of Operations (maritime security), 05 February 2016 to 30 June 2016 (non-warlike).

Occupational History

Clearance divers conduct underwater searches, mine countermeasures, explosive ordnance disposal, ship hull searches and salvage, using compressed air and mixed-gas breathing apparatus at depths of up to 50 metres or more. The trade involves repeated compression and decompression, recompression chamber training and treatment, rapid ascents in emergencies, and helicopter and small boat insertion. Divers are exposed to underwater and surface blast from controlled demolitions and from ordnance disposal.

Recognised hazards include middle and inner ear barotrauma, sinus and pulmonary barotrauma, decompression illness, noise-induced hearing loss, blast injury and near-drowning. Divers are expected to continue working through minor upper respiratory infections that impair middle ear equalisation, and on operations access to specialist ear, nose and throat and audiology services is limited.

History

Veteran EJ, a clearance diver in the Royal Australian Navy, sustained bilateral otitic barotrauma on 14 August 2012 on warlike service in the Middle East, when an underwater controlled demolition was followed by an uncontrolled ascent and bag-valve-mask ventilation for near-drowning. He had a left tympanic membrane perforation, right haemotympanum and inner ear injury with hearing loss and vertigo, and the condition worsened on 23 March 2016 on non-warlike service after a rapid helicopter descent, a demolition blast and overnight CPAP use.

Timeline

• 22 Nov 2011 — Annual diving medical examination at a naval base health centre. Both tympanic membranes were intact and mobile, with normal Valsalva equalisation. Pure tone audiometry showed thresholds within 15 dB at all frequencies in both ears. He was certified fit to dive without restriction. "TMs intact, audiogram normal"
• 14 Aug 2012 — On warlike service in the Middle East the veteran was in the water at about 9 metres, 120 metres from a controlled underwater demolition of a recovered limpet mine, when the charge fired early. The pressure wave stunned him and he made an uncontrolled ascent from 9 metres to the surface while holding his breath. He was recovered unconscious and not breathing, and the team medic ventilated him with a bag-valve-mask for about four minutes until spontaneous breathing returned. He then received high-flow oxygen by face mask. "blast, rapid ascent, BVM ventilation"
• 14 Aug 2012 — Assessed by the ship's medical officer three hours later. He had severe pain in both ears, a feeling of fullness, muffled hearing, loud tinnitus and spinning vertigo with nausea. Otoscopy showed a left anterior inferior tympanic membrane perforation with blood in the canal and a right haemotympanum with an intact drum. Rinne and Weber testing suggested a mixed loss on the left. No audiometry or ENT review was available on board. "L TM perforation, R haemotympanum"
• 29 Aug 2012 — Seen by an otolaryngologist after transfer to a coalition hospital. Audiometry showed a left mixed hearing loss with a 30 dB conductive component and high-frequency sensorineural loss of up to 55 dB, and a right conductive loss of 20 dB. Positive fistula testing on the left and CT findings suggested a perilymphatic fistula. The otolaryngologist diagnosed bilateral otitic barotrauma, with middle ear injury on both sides and inner ear barotrauma on the left, and he was returned to Australia. "bilateral otitic barotrauma, L fistula"
• 18 Oct 2012 — Left exploratory tympanotomy and repair of a round window membrane fistula, with myringoplasty. The right haemotympanum had resolved. Vertigo settled over six weeks, but the left high-frequency sensorineural loss and tinnitus persisted. He was restricted from diving for twelve months. "round window fistula repaired"
• 06 Jun 2015 — Polysomnography for snoring and daytime sleepiness showed moderate obstructive sleep apnoea, and a sleep physician commenced nightly CPAP via a full face mask. He used the machine nightly from that date, including on later deployment. "OSA, CPAP full face mask"
• 24 Mar 2016 — Seen by the ship's medical officer on non-warlike service in the Middle East. On 23 March 2016 he had been inserted by helicopter with a rapid descent while recovering from a head cold, assisted with a surface demolition of found ordnance, and used CPAP overnight. On waking he had severe right ear pain, bloody discharge and worse hearing. Otoscopy showed a new right tympanic membrane perforation. No audiometry or ENT review was available on board. "new R perforation, hearing worse"
• 26 Jul 2016 — Otolaryngology review in Australia. Audiometry showed a new right conductive loss of 35 dB and a further 10 to 15 dB fall in the left high-frequency thresholds compared with 2013. The right perforation had not healed. Right myringoplasty was performed on 02 November 2016. He was permanently restricted from diving and was later medically discharged. "worse bilateral loss, R myringoplasty"

Symptoms

At onset the veteran had severe pain in both ears, a sensation of fullness and blocked ears, bleeding from the left ear, muffled hearing, loud tinnitus and spinning vertigo with nausea and unsteadiness. The vertigo settled over about six weeks after the left fistula repair.

After the 2016 worsening he had right ear pain, bloody discharge and reduced hearing in that ear. He now reports constant bilateral tinnitus, worse on the left, difficulty following conversation in background noise, sensitivity to loud sounds, intermittent unsteadiness in the dark and an inability to fly without ear pain. He has been fitted with bilateral hearing aids and is permanently unfit to dive.

Imaging

• 28 Aug 2012 — CT temporal bones: "Opacification of the left middle ear and mastoid air cells with a small locule of gas in the left vestibule (pneumolabyrinth), suggesting a perilymphatic fistula. Right middle ear fluid. Ossicular chains intact bilaterally. No temporal bone fracture."
• 12 Nov 2013 — MRI internal auditory meatuses: "No vestibular schwannoma or other retrocochlear lesion. Normal inner ear fluid signal bilaterally."
• 20 Jul 2016 — CT temporal bones: "Right middle ear fluid with a defect of the right tympanic membrane. Left post-operative changes. No ossicular disruption."

Onset Date

The most likely date of onset of this condition is 14 Aug 2012.

At that date the veteran was on warlike service in the Middle East with a clearance diving team conducting port clearance and ordnance disposal. At about 10:20 he was in the water at 9 metres when a controlled underwater demolition fired early 120 metres away. He made an uncontrolled ascent to the surface, was recovered unconscious and was ventilated with a bag-valve-mask. His ear pain, bleeding, hearing loss and vertigo were present when he was assessed three hours later.

This date is appropriate because his diving medical examination of 22 November 2011 showed intact tympanic membranes and normal hearing, and he had dived without symptoms throughout the deployment until that day. He first presented the same day, at 13:30 on 14 August 2012, and bilateral otitic barotrauma was confirmed by an otolaryngologist on 29 August 2012.

For the change in pressure, blast and ventilation factors, the 24 hours before onset run from 10:20 on 13 Aug 2012 to 10:20 on 14 Aug 2012, extending to the time of first presentation. Within that period he was exposed to the underwater blast pressure wave, made a breath-hold ascent from 9 metres to the surface, a rapid reduction in ambient pressure from about 1.9 to 1.0 atmospheres, and was ventilated by bag-valve-mask through a face mask, all within minutes of one another and within three hours of presentation.

For the worsening factors, the documented worsening occurred on waking on 24 Mar 2016 on non-warlike service in the Middle East, with a new right tympanic membrane perforation and later audiometric deterioration. The 24 hours before the worsening run from about 06:00 on 23 Mar 2016 to 06:00 on 24 Mar 2016. Within that period he made a rapid helicopter descent from about 1,500 metres while congested, was 80 metres from a surface demolition at about 14:00, and used CPAP through a full face mask from 22:00 to 06:00.

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

The formal diagnosis is Otitic Barotrauma of both ears (ICD-10 T70.0), comprising left tympanic membrane perforation and inner ear barotrauma with a round window perilymphatic fistula and mixed hearing loss, and right middle ear barotrauma with haemotympanum and, from 2016, tympanic membrane perforation, under the Statements of Principles concerning otitic barotrauma, Balance of Probabilities No. 87 of 2020 and Reasonable Hypothesis No. 86 of 2020.

Otitic barotrauma is injury to the middle or inner ear caused by a difference between the pressure of the surrounding environment and the pressure of the air in the middle ear. It occurs when the Eustachian tube cannot equalise quickly enough during diving, flying, rapid ascent or descent, or when a blast wave or forced ventilation drives a sudden pressure change. It causes ear pain, bleeding into the middle ear, rupture of the eardrum and, in inner ear barotrauma, rupture of the round or oval window with sensorineural hearing loss, tinnitus and vertigo. Some injuries heal, but inner ear damage and recurrent perforations often leave permanent hearing loss and tinnitus.

The condition began on 14 August 2012 on warlike service in the Middle East, was confirmed by an otolaryngologist on 29 August 2012 and worsened on 24 March 2016 on non-warlike service.

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

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

14 August 2012.

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

14 August 2012.

When was the condition confirmed / formally diagnosed?

29 August 2012.

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

03 June 2025.

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

The diagnosis was made clinically on 14 August 2012, when otoscopy showed a traumatic left tympanic membrane perforation and right haemotympanum immediately after a blast, a rapid ascent and forced ventilation, and was confirmed by an otolaryngologist on 29 August 2012. Audiometry showed a left mixed hearing loss and a right conductive loss, the left fistula test was positive and CT showed pneumolabyrinth, indicating rupture of the round window membrane. Injury to the middle and inner ear arising from inequalities in barometric pressure between the surrounding atmosphere and the middle ear meets the Statement of Principles definition.

The diagnosis of inner ear barotrauma was confirmed at tympanotomy on 18 October 2012, when a round window membrane fistula was found and repaired. MRI excluded a retrocochlear cause for the asymmetric hearing loss. The worsening was confirmed by otoscopy on 24 March 2016 showing a new right perforation and by audiometry on 26 July 2016 showing a new right conductive loss and further left high-frequency loss.

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.

Legislation: the clinical onset of this condition was on 14 August 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in the Middle East in 2012, where the condition began, and non-warlike service in the Middle East in 2016, where it worsened. The Balance of Probabilities instrument applies to peacetime service, including routine diving, chamber training and flying, and its factors are in the same terms.

Each factor must be related to the person's relevant 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.

Balance of Probabilities — Statement of Principles concerning Otitic Barotrauma, No. 87 of 2020

Causative factors

Factor 9(1): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical onset of otitic barotrauma; — MET

- At about 10:20 on 14 August 2012 the veteran made an uncontrolled breath-hold ascent from 9 metres to the surface, a rapid reduction in ambient pressure from about 1.9 to 1.0 atmospheres, during a clearance diving task. Underwater diving and ascent are specified circumstances in the definition. His ear pain, bleeding and vertigo were recorded three hours later, well within 24 hours.

Factor 9(2): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical onset of otitic barotrauma; — MET

- Immediately before the ascent, the veteran was 120 metres from an underwater demolition charge that fired early. Water transmits blast pressure efficiently, and the pressure wave stunned him. This exposure occurred minutes before the onset of his ear injuries on 14 August 2012.

Factor 9(3): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical onset of otitic barotrauma; — MET

- After he was recovered unconscious and not breathing, the team medic ventilated him with a bag-valve-mask device through a face mask for about four minutes on 14 August 2012, forcing air into his lungs and nasopharynx. This is mechanical ventilation as defined and occurred within three hours of presentation.

Worsening factors

Factor 9(4): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical worsening of otitic barotrauma; — MET

- On 23 March 2016 the veteran was inserted by helicopter with a rapid descent from about 1,500 metres while he was congested from a head cold. Flying is a specified circumstance. On waking on 24 March 2016, within 24 hours, he had a new right tympanic membrane perforation, and audiometry later showed a new right conductive loss of 35 dB.

Factor 9(5): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical worsening of otitic barotrauma; — MET

- At about 14:00 on 23 March 2016 the veteran assisted with a surface demolition of found ordnance and was about 80 metres from the charge when it fired, as recorded in the team's demolition log. This was about 16 hours before the documented worsening.

Factor 9(6): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical worsening of otitic barotrauma; — MET

- The veteran used CPAP through a full face mask from 22:00 on 23 March 2016 to 06:00 on 24 March 2016 for obstructive sleep apnoea diagnosed in June 2015. CPAP is included in the definition of mechanical ventilation, and positive pressure in the nasopharynx with blocked Eustachian tubes contributed to the right perforation.

Factor 9(7): inability to obtain appropriate clinical management for otitic barotrauma. — MET

- Neither in 2012 nor in 2016 was audiometry or ENT assessment available on board ship, and in 2016 the right perforation was not reviewed by an otolaryngologist until 26 July 2016, four months later, by which time it had failed to heal and required myringoplasty. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Otitic Barotrauma, No. 86 of 2020

Causative factors

Factor 9(1): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical onset of otitic barotrauma; — MET

- On warlike service in the Middle East on 14 August 2012, the veteran made an uncontrolled breath-hold ascent from 9 metres during a port clearance task, a rapid change in ambient pressure while diving, within three hours of the onset of his ear injuries.

Factor 9(2): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical onset of otitic barotrauma; — MET

- On warlike service in the Middle East on 14 August 2012, the veteran was exposed to the underwater blast of a demolition charge on a recovered limpet mine that fired early 120 metres from him, minutes before onset.

Factor 9(3): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical onset of otitic barotrauma; — MET

- On warlike service in the Middle East on 14 August 2012, he was ventilated by bag-valve-mask for about four minutes after near-drowning following the blast and ascent, within three hours of presentation.

Worsening factors

Factor 9(4): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical worsening of otitic barotrauma; — MET

- On non-warlike service in the Middle East on 23 March 2016, the veteran made a rapid helicopter descent from about 1,500 metres during insertion to a vessel, within 24 hours of the documented worsening on 24 March 2016.

Factor 9(5): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical worsening of otitic barotrauma; — MET

- On non-warlike service in the Middle East he was about 80 metres from a surface demolition of found ordnance at 14:00 on 23 March 2016, about 16 hours before the worsening.

Factor 9(6): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical worsening of otitic barotrauma; — MET

- On non-warlike service in the Middle East he used CPAP through a full face mask from 22:00 on 23 March 2016 to 06:00 on 24 March 2016, immediately before the worsening was found on waking.

Factor 9(7): inability to obtain appropriate clinical management for otitic barotrauma. — MET

- On warlike service in 2012 and non-warlike service in 2016 no audiometry or ENT assessment was available at sea, and the 2016 right perforation was not reviewed by a specialist for four months and failed to heal.

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

Sequelae

The veteran has developed bilateral hearing loss, mixed on the left and conductive on the right, and chronic bilateral tinnitus as sequelae of the otitic barotrauma, together with intermittent imbalance from the left inner ear injury. These have been confirmed on serial audiometry and have required bilateral hearing aids. The hearing loss and tinnitus have also contributed to sleep disturbance and irritability recorded by his general practitioner.

Unintended Consequence

Met. A persisting alteration of taste on the left side of the tongue, from stretching of the chorda tympani nerve during the left tympanotomy and fistula repair on 18 October 2012, is an unintended consequence of treatment provided and paid for by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA). The contribution of prescribed CPAP to the 2016 right perforation is a further unintended consequence.

Inability to Attain Appropriate Medical Management

MET. On both occasions the veteran was at sea on operational service where no audiometry, otomicroscopy or ear, nose and throat review was available. In 2012 his inner ear injury was not assessed by an otolaryngologist for 15 days, during which he remained on board with vertigo. In 2016 the new right tympanic membrane perforation was managed with dry ear precautions only, he continued duties including helicopter transfers, and he was not seen by a specialist until 26 July 2016, four months later, when the perforation had failed to heal and required myringoplasty. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent timely specialist assessment and protection of the injured ear amount to an inability to obtain appropriate clinical management.

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

See attached report.

References

1. 22 Nov 2011, Diving medical examination and audiogram, Medical Officer, Naval base health centre
2. 14 Aug 2012, Diving incident report and resuscitation record, Clearance diving team, Middle East
3. 14 Aug 2012, Ship's medical record, Medical Officer
4. 28 Aug 2012, CT temporal bones, Radiologist
5. 29 Aug 2012, Otolaryngology consultation and audiogram, Otolaryngologist
6. 18 Oct 2012, Operation report, Otolaryngologist
7. 12 Nov 2013, MRI internal auditory meatuses, Radiologist
8. 06 Jun 2015, Polysomnography report and sleep consultation, Sleep physician
9. 24 Mar 2016, Ship's medical record, Medical Officer
10. 26 Jul 2016, Otolaryngology review and audiogram, Otolaryngologist
11. 02 Nov 2016, Operation report, Otolaryngologist
12. Statement of Principles concerning Otitic Barotrauma (Balance of Probabilities) No. 87 of 2020, Repatriation Medical Authority
13. Statement of Principles concerning Otitic Barotrauma (Reasonable Hypothesis) No. 86 of 2020, Repatriation Medical Authority