Bilateral Ears - Sensorineural Hearing Loss — DVA claim example

Diagnostic Assessment — Bilateral Ears - Sensorineural Hearing Loss

Example 1 of 2 · fictitious patient (Veteran D)

Diagnostic Assessment

Bilateral Ears - Sensorineural Hearing Loss

Statement of Principles (SoP) concerning sensorineural hearing loss (Reasonable Hypothesis) (No. 98 of 2019) - applies to operational and peacetime service Statement of Principles (SoP) concerning sensorineural hearing loss (Balance of Probabilities) (No. 99 of 2019) - applies to peacetime service

ADF History

The veteran, Airfield Defence Guard, enlisted 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran would have been exposed to significant noise hazards inherent to the role. These include exposure to weapons firing (small arms and potentially heavier calibre weapons), aircraft operations (fixed-wing and rotary aircraft), and vehicle movements. Health Surveillance Questionnaires consistently note exposure to noise, including proximity to flightlines and weapons range activities. Post-deployment health screens also indicate daily exposure above normal duty levels to "Excessive Noise and Vibration" with comments such as "Proximity to flightline; periodic noise exposure" and "A/C noise".

History

The veteran an Airfield Defence Guard in the RAAF, has developed bilateral high-frequency sensorineural hearing loss due to repeated exposure to excessive noise from weapons firing and aircraft operations throughout his service career since 1997.

Timeline

• 13 Jun 1996: A Hearing Conservation Report noted a hearing standard of HS1. His audiogram showed some minor high-frequency loss, particularly a 30dB loss at 4000Hz in the left ear and 30dB at 6000Hz in the right ear, compared to a reference audiogram from May 1998.
• 31 Jun 1999: An Annual Health Assessment recorded his hearing standard as HS1. The audiogram showed some high-frequency loss, for example, 15dB at 3000Hz and 4000Hz in the left ear, and 15dB at 6000Hz in the right ear. A comment noted: "Threshold shift >10db between Ears detected. Possible ACOUSTIC NEUROMA. Member should be reviewed by MO."
• 13 Apr 2009: An audiology report from Attune Hearing noted a history of tinnitus in the right ear. The audiogram showed a mild sensorineural notch at 4kHz in the right ear and a mild sensorineural hearing loss from 3-6kHz in the left ear. His hearing was classified as HS2 (Worse Ear).
• 26 Jun 2011: Follow-up audiology report from Attune Hearing indicated that previously occasional tinnitus was now present more often, predominantly in the left ear. Pure tone audiometry showed: "Hearing thresholds are within normal limits in the right ear with a mild sensorineural notch centred at 4 kHz. Results for the left ear indicate normal hearing acuity across to 2 kHz, sloping to a mild sensorineural hearing loss from 3-6 kHz, recovering to normal levels at 8 kHz."Referral to ENT was recommended due to slight asymmetry and tinnitus.
• 19 May 2016: An audiology assessment by an audiology provider Hearing Care Professionals. Pure tone audiometry showed: "Right Ear: Essentially normal hearing, with a mild sensorineural loss from 4-6 kHz. Left Ear: Essentially normal hearing, with a mild sensorineural loss from 3-6 kHz." Tinnitus Functional Index (TFI) Score was 14.8 (None/Slight).

Symptoms

At the time of initial identification, the veteran exhibited minimal symptoms beyond the measurable hearing threshold shift. Over time, he developed tinnitus in the right ear and subsequently in the left ear as well. The tinnitus progressed from occasional to more frequent, though it remained manageable (TFI score of 14.8, categorized as None/Slight).

Currently, the veteran experiences bilateral high-frequency sensorineural hearing loss, characterized by diminished hearing acuity in the 3-6 kHz range. He also experiences bilateral tinnitus that can interfere with sleep to a slight degree but does not significantly impact daily activities. His tinnitus is described as "heard occasionally or in quiet, easily masked."

Imaging

No specific imaging of the auditory system is noted in the records. Diagnosis was made through audiological assessments:

13 Jun 1996: Audiogram showed some minor high-frequency loss, particularly a 30dB loss at 4000Hz in the left ear and 30dB at 6000Hz in the right ear.

31 Jun 1999: Audiogram showed high-frequency loss, including 15dB at 3000Hz and 4000Hz in the left ear, and 15dB at 6000Hz in the right ear.

13 Apr 2009: Audiogram showed a mild sensorineural notch at 4kHz in the right ear and a mild sensorineural hearing loss from 3-6kHz in the left ear.

26 Jun 2011: Pure tone audiometry showed hearing thresholds within normal limits in the right ear with a mild sensorineural notch centred at 4 kHz, and for the left ear, normal hearing acuity across to 2 kHz, sloping to a mild sensorineural hearing loss from 3-6 kHz, recovering to normal levels at 8 kHz.

19 May 2016: Pure tone audiometry showed essentially normal hearing in the right ear with a mild sensorineural loss from 4-6 kHz, and essentially normal hearing in the left ear with a mild sensorineural loss from 3-6 kHz.

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

The formal diagnosis is Bilateral High-Frequency Sensorineural Hearing Loss (ICD-10: H90.3) with associated Bilateral Tinnitus (ICD-10: H93.13). This condition is covered under the DVA Statement of Principles for Sensorineural Hearing Loss (Reasonable Hypothesis - No. 98 of 2019 and Balance of Probabilities - No. 99 of 2019).

Sensorineural hearing loss is defined as acquired hearing loss due to a defect in the cochlea or auditory nerve, with a permanent shift to a hearing threshold level of 25 decibels (dB) or more at 500, 1000, 1500, 1998, 3000, 4000 or 6000 hertz (Hz). This type of hearing loss results from damage to the sensitive hair cells of the inner ear or to the nerves that supply the inner ear. When these structures are damaged, the ability to transmit sound signals to the brain is affected.

High-frequency sensorineural hearing loss is particularly common with noise exposure, as the hair cells that detect higher-frequency sounds are typically the first to be damaged. This pattern is often referred to as a "noise notch" and is characteristic of noise-induced hearing loss, with the most significant threshold shifts appearing in the 3000-6000 Hz range, as seen in the veteran audiograms.

Tinnitus, the perception of sound (often described as ringing, buzzing, or hissing) when no external sound is present, frequently accompanies sensorineural hearing loss. It results from the same damage to the auditory system and can be a significant source of distress for affected individuals.

In the veteran case, the bilateral high-frequency sensorineural hearing loss developed progressively over his period of service, with initial documentation of threshold shifts as early as 2000, and progression noted through 2020. The tinnitus also progressed from unilateral (right ear) to bilateral, and from occasional to more frequent over time.

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

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

Based on the available records, the veteran first demonstrated measurable hearing loss by August 1998, when an audiogram showed a 30dB loss at 4000Hz in the left ear and 30dB at 6000Hz in the right ear. The onset of tinnitus is not clearly documented until the 2013 audiology report, which noted a history of tinnitus in the right ear.

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

The first documented assessment of the veteran hearing was during a Hearing Conservation Report dated 13 June 1996, when minor high-frequency hearing loss was noted. This appears to be part of routine hearing monitoring rather than a presentation for symptoms. The records do not indicate a specific date when he first sought medical attention specifically for hearing symptoms.

When was the condition confirmed / formally diagnosed?

The condition of high-frequency sensorineural hearing loss was first formally documented in the 13 June 1996 Hearing Conservation Report. Tinnitus was formally documented in the 13 Apr 2009 audiology report from Attune Hearing.

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

06 December 2017

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

The diagnosis of bilateral high-frequency sensorineural hearing loss was confirmed through multiple audiological assessments over many years (2000-2020). Key findings included:

• Consistent pattern of hearing threshold shifts in the high-frequency range (3000-6000 Hz)
• Progression of hearing loss over time, documented through serial audiograms
• Development of tinnitus, initially in the right ear and later bilaterally
• Classic "noise notch" pattern characteristic of noise-induced hearing loss

Specialist opinions from audiologists confirmed the diagnosis, including assessments from Attune Hearing (2013 and 2015) and an audiology provider Hearing Care Professionals (2020). These assessments consistently demonstrated mild sensorineural hearing loss in the high frequencies, with the 2015 assessment specifically noting a "mild sensorineural notch centred at 4 kHz" in the right ear and "mild sensorineural hearing loss from 3-6 kHz" in the left ear.

The pattern and progression of the hearing loss, along with the development of tinnitus, are consistent with noise-induced sensorineural hearing loss, which aligns with the veteran occupational exposure to significant noise hazards as an Airfield Defence Guard.

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.

being exposed to a sound pressure level at the tympanic membrane of at least 85 dB(A) as an 8-hour time-weighted average (TWA) with a 3-dB exchange rate for a cumulative period of at least six months, before the clinical onset of sensorineural hearing loss - MET

• The veteran has been an Airfield Defence Guard in the RAAF since 1997, which involved routine exposure to significant noise hazards including weapons firing, aircraft operations, and vehicle movements. Health Surveillance Questionnaires consistently note exposure to noise, and Post-deployment health screens indicate daily exposure above normal duty levels to "Excessive Noise and Vibration." This exposure has occurred over many years, far exceeding the minimum six-month requirement.

being exposed to a peak sound pressure level at the tympanic membrane of at least 140 dB(C) before the clinical onset of sensorineural hearing loss - MET

• As an Airfield Defence Guard, the veteran would have been routinely exposed to weapons firing (small arms, and potentially heavier calibre weapons), which typically generate peak sound pressure levels exceeding 140 dB(C).

being exposed to an explosive blast within the 30 days before the clinical onset of sensorineural hearing loss - NOT MET

• There is no specific documentation of exposure to an explosive blast directly preceding the onset of hearing loss.

having an episode of otitic barotrauma involving the affected ear within the 30 days before the clinical onset of sensorineural hearing loss - NOT MET

• There is no documentation of otitic barotrauma in the records.

inability to obtain appropriate clinical management for sensorineural hearing loss - MET

• While the veteran has had his hearing monitored through annual assessments, the Full Federal Court in Brew v Repatriation Commission (14 May 1993) establishes that "inability" to obtain appropriate clinical management can include many factors beyond simple lack of access. The military environment often creates barriers to seeking treatment for conditions like hearing loss, which may be perceived as common or inevitable in certain roles. The progression of the veteran hearing loss over many years despite monitoring suggests that there may have been barriers to accessing interventions that could have prevented further deterioration.

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

Sequelae

The bilateral tinnitus that the veteran experiences is a sequela of his sensorineural hearing loss. Tinnitus often accompanies noise-induced hearing loss and results from the same damage to the auditory system. It is not a separate condition but rather a consequence of the damage to the inner ear structures that also causes the hearing loss.

Unintended Consequence

There is no evidence in the provided records that the sensorineural hearing loss is an unintended consequence of medical treatment.

Inability to Attain Appropriate Medical Management

The veteran condition demonstrates an inability to attain appropriate medical management for his hearing loss. Despite regular hearing assessments showing progressive deterioration in his hearing thresholds from 2000 through 2020, the records do not indicate implementation of effective hearing conservation measures beyond basic monitoring.

According to the Full Federal Court in Brew v Repatriation Commission (14 May 1993), "inability" to obtain appropriate clinical management encompasses both objective and subjective factors. The military environment often normalizes conditions like hearing loss, creating psychological and institutional barriers to seeking more aggressive intervention. Additionally, the operational demands of the veteran role as an Airfield Defence Guard, including multiple deployments, likely limited his access to consistent, comprehensive hearing protection and management strategies.

This inability to obtain appropriate clinical management has caused a permanent worsening of his condition, as evidenced by the progression from minor threshold shifts in 2000 to established bilateral high-frequency hearing loss with tinnitus by 2020. Effective interventions could have included specialized hearing protection, limitation of exposure to hazardous noise, or earlier modifications to duty.

The % contribution of the causes is 100% and significant

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

-see attached report

Diagnostic Assessment — Bilateral Ears - Sensorineural Hearing Loss

Example 2 of 2 · fictitious patient (Veteran U)

Diagnostic Assessment

Bilateral Ears - Sensorineural Hearing Loss

Balance of Probabilities SOP: No. 97 of 2019 Reasonable Hypothesis SOP: No. 98 of 2019

ADF History

The veteran served as an Aviation Technician (Avtech) in the Royal Australian Air Force from Mar 1983 to September 2015.

Occupational History

As an Aviation Technician, the veteran was routinely exposed to significant occupational hazards including high-intensity noise from aircraft engines, maintenance equipment, and flight line operations. His role involved working in hangars, on flight lines, and around sophisticated RAAF aircraft, all environments with substantial noise exposure. Additional exposures included chemicals such as aviation turbine fuel, solvents, hydraulic fluids, and various maintenance compounds. The occupation required physical demands including heavy lifting, awkward postures, and prolonged standing in challenging environments.

History

The veteran an RAAF Aviation Technician, developed bilateral sensorineural hearing loss due to prolonged occupational noise exposure from aircraft engines and maintenance equipment during his service from 1986 to 2018. The condition was first detected through audiometric testing in 1999 and formally diagnosed in 2007.

Timeline

• 27 Feb 1993: Audiometric testing revealed significant threshold shift of 15dB or greater, indicating early sensorineural hearing loss. The assessment noted no coryzal illness or wax present, with no recent noise exposure documented at the time of testing. This marked the first objective evidence of hearing deterioration, prompting comparison with a 1987 baseline audiogram and establishment of an amended baseline.
• 12 Jan 2001: Failed audio test during health examination for reserve posting, with wax in ear canals noted. The test failure indicated progression of sensorineural hearing loss, necessitating ear cleaning and retesting. This assessment was conducted as part of medical evaluation for continued service fitness.
• 18 Jan 2001: Repeat audiogram post-wax removal showed no significant threshold shift, but the prior failed test confirmed the presence of sensorineural hearing loss. The clinical assessment noted no coryzal illness or recent noise exposure, with findings consistent with occupational noise-induced hearing damage.
• 14 Dec 2014: Health records documented sensorineural hearing loss - bilateral with hearing standard classification of HS1, confirming the ongoing nature of the condition. The documentation reflected the permanent nature of the hearing impairment resulting from cumulative noise exposure during military service.

Symptoms

Initial symptoms included difficulty hearing in noisy environments and possible high-frequency hearing loss, though specific symptomatic presentations were not detailed in the early records. The condition was primarily detected through routine audiometric screening rather than symptomatic presentation. Current symptoms include bilateral hearing impairment with hearing standard classification of HS1, indicating permanent hearing loss that impacts daily functioning and communication abilities.

Imaging

• 27 Feb 1993: Audiogram revealed significant threshold shift of 15dB or greater • 12 Jan 2001: Audio test showed failed audio test with wax in ear canals • 18 Jan 2001: Repeat audiogram demonstrated no significant threshold shiftpost-wax removal

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

Bilateral Ears - Sensorineural Hearing Loss (ICD-10: H90.3), DVA SOP No. 98 of 2019 (Reasonable Hypothesis) and No. 97 of 2019 (Balance of Probabilities).

Sensorineural hearing loss is acquired hearing loss due to a defect in the cochlea or auditory nerve, with a permanent shift to a hearing threshold level of 25 decibels (dB) or more, at 500, 1000, 1500, 1997, 3000, 4000 or 6000 hertz (Hz). This condition results from damage to the inner ear structures or the auditory nerve pathways, leading to permanent hearing impairment. Unlike conductive hearing loss, sensorineural hearing loss cannot be corrected through medical or surgical intervention and typically requires hearing aids or other assistive devices.

The temporal relationship shows progressive hearing loss with initial detection in 1999, confirmed diagnosis in 2007, and ongoing documentation through 2021, indicating a chronic progressive condition consistent with occupational noise exposure.

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

When did the veteran first experience symptoms attributable to this condition? The veteran likely first experienced symptoms prior to 27 February 1993, though specific symptomatic onset was not documented.

When did the veteran first present to a health/medical provider for this condition? The veteran first presented for audiometric assessment on 27 February 1993 as part of routine military medical screening, where the hearing loss was initially detected.

When was the condition confirmed/formally diagnosed? The condition was confirmed and formally diagnosed on 12 Jan 2001 during a failed audio test, with subsequent confirmation on 18 Jan 2001 following wax removal and retesting.

When did the veteran first present to you (or your practice) for this condition? 21 November 2014

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

The diagnosis was confirmed through serial audiometric testing showing progressive sensorineural hearing loss. Key investigation results included the 27 February 1993 audiogram demonstrating a significant threshold shift of 15dB or greater compared to baseline, and the 12 Jan 2001 failed audio test during routine medical examination. The 18 Jan 2001 repeat audiogram post-wax removal confirmed the hearing loss was not due to cerumen impaction. No specialist ENT opinion was documented, with diagnosis based on objective audiometric findings consistent with occupational noise-induced sensorineural hearing loss. The hearing standard classification of HS1 documented in 2021 confirms the permanent nature of the condition.

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.

Being exposed to a sound pressure level at the tympanic membrane of at least 85 dB(A) as an 8-hour time-weighted average (TWA) with a 3-dB exchange rate for a cumulative period of at least six months, before the clinical onset of sensorineural hearing loss - MET. The veteran role as an Aviation Technician from Mar 1983 involved continuous exposure to aircraft engines, maintenance equipment, and flight line operations significantly exceeding 85 dB(A) for periods far longer than six months over his 32-year career.

Being exposed to a peak sound pressure level at the tympanic membrane of at least 140 dB(C) before the clinical onset of sensorineural hearing loss - MET. Aircraft engine startup, jet blast, and maintenance operations routinely produce peak sound levels exceeding 140 dB(C), which the veteran would have been exposed to throughout his Avtech career.

Smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of sensorineural hearing loss - MET. Documentation shows the veteran smoked 10-15 cigarettes per day for 11 years (approximately 1988-1999) and later 3-4 cigarettes per day for 19 years, totaling well over 10 pack-years before diagnosis.

Having hypertension at the time of the clinical onset of sensorineural hearing loss - MET. Blood pressure readings from 1998 (140/95) and confirmed hypertension by 2007 with ambulatory monitoring showing average 151/103 mmHg, present at the time of hearing loss diagnosis.

Being obese for at least five years within the ten years before the clinical onset of sensorineural hearing loss - MET. BMI progression shows obesity from 2003 (BMI 30.2) continuing through diagnosis period and beyond, meeting the five-year requirement within ten years of clinical onset.

Inability to obtain appropriate clinical management for sensorineural hearing loss - MET. No specific treatment or hearing protection measures were documented following initial detection in 1999, and no hearing aids or assistive devices were provided despite confirmed diagnosis in 2007, representing inability to obtain appropriate clinical management as defined in Brew v Repatriation Commission.

Sequelae

This condition is not a sequelae of another compensable condition but rather a primary occupational injury from noise exposure.

Unintended Consequence

This condition is not an unintended consequence of medical management but rather resulted from occupational exposures during military service.

Inability to Attain Appropriate Medical Management

MET. Following initial detection of hearing loss in 1999 and formal diagnosis in 2007, there is no documentation of appropriate clinical management including hearing protection counseling, hearing aids, or audiological rehabilitation. The period between initial detection and formal diagnosis (1999-2007) exceeded reasonable timeframes for appropriate management. As established in Brew v Repatriation Commission, the inability to obtain appropriate clinical management can include both objective and subjective barriers, and the lack of documented intervention despite confirmed hearing loss constitutes inability to attain appropriate medical management, resulting in permanent worsening of the condition.

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

5. Please provide a Health Summary and a medication/prescribing history. -see attached report