Chronic Nasal Obstruction — DVA claim example

Diagnostic Assessment — Chronic Nasal Obstruction

Example 1 of 1 · fictitious patient (Veteran DA)

Diagnostic Assessment

Chronic Nasal Obstruction

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

ADF History

Veteran DA, date of birth 11 November 1980, Australian Army, Cavalry Crewman (Armoured Reconnaissance, later Corporal Crew Commander), enlisted 15 February 1999, medically discharged 25 July 2016. Operational service: Iraq, 28 September 2005 to 14 May 2006 (warlike); Afghanistan, 06 February 2011 to 30 August 2011 (warlike).

Occupational History

As a cavalry crewman the veteran operated and commanded light armoured reconnaissance vehicles, standing in an open turret hatch for long periods on unsealed roads and desert tracks. Crews are exposed to heavy dust, diesel exhaust, cordite and gun smoke, fuel and solvent vapours, and in the Middle East to sandstorms and smoke from open burn pits. Working in and around turrets and hatches carries a risk of facial and nasal injury from hatch lids, weapon mounts and sudden vehicle movement.

Field and deployed living involves dry, dusty air, air-conditioned vehicles and accommodation, crowded sleeping quarters with frequent upper respiratory infections, and limited access to specialist ear, nose and throat care. Smoking was common among crews in the period, and over-the-counter decongestant sprays were widely used to keep the nose clear under respirators and headsets.

History

Veteran DA, an Army cavalry crewman, developed chronic bilateral nasal obstruction on 20 February 2006 during warlike service in Iraq, four months after a nasal fracture from a turret hatch strike that healed with septal deviation, on a background of allergic rhinitis, chronic rhinosinusitis with nasal polyps, heavy dust and exhaust exposure, smoking and decongestant spray overuse. The condition was confirmed by an ear, nose and throat surgeon in 2006 and worsened during warlike service in Afghanistan in 2011 after a second nasal injury.

Timeline

• 16 Mar 2004 — Garrison medical officer review for seasonal sneezing, watery rhinorrhoea and nasal itch since recruit training. Skin prick testing was positive to house dust mite and grass pollens. Allergic rhinitis was diagnosed and an intranasal corticosteroid prescribed. Nasal airflow was recorded as normal between flares. "allergic rhinitis, dust mite positive"
• 25 Aug 2005 — Pre-deployment health assessment for Iraq. The veteran reported no persistent nasal blockage. Anterior rhinoscopy showed a straight septum and mildly congested turbinates. He smoked 15 cigarettes a day and had done so since age 16, a history of about 9.4 pack-years. "septum straight, no blockage"
• 22 Oct 2005 — During warlike service in Iraq the veteran's vehicle dropped into a concealed ditch and the turret hatch lid struck his face. He had a deformed, swollen nose and brisk epistaxis that required anterior nasal packing for 72 hours. The medical officer recorded a displaced nasal fracture deviated to the left. Closed reduction within two weeks was recommended but no ear, nose and throat surgeon was available in theatre. "displaced nasal fracture, packed 72h"
• 19 Jan 2006 — The veteran presented with three months of thick nasal discharge, facial pressure, post-nasal drip and reduced sense of smell, worse after sandstorms and turret duty, despite two courses of antibiotics. The medical officer recorded chronic rhinosinusitis. He had bought oxymetazoline spray at the base canteen and had been using it four to six times a day since 02 January 2006. "chronic rhinosinusitis, oxymetazoline overuse"
• 21 Feb 2006 — The veteran reported that since the previous day both sides of his nose had been blocked constantly, day and night, no longer relieved by the decongestant, with mouth breathing, snoring and difficulty wearing his respirator. Anterior rhinoscopy showed a septum deviated to the left, swollen, beefy red inferior turbinates and a pale polypoid mass in the left middle meatus. "constant bilateral blockage, polyp seen"
• 14 Aug 2006 — After return to Australia an ear, nose and throat surgeon confirmed chronic nasal obstruction. Nasal endoscopy showed a post-traumatic septal deviation obstructing the left airway, bilateral inferior turbinate hypertrophy and grade 2 bilateral nasal polyps. Peak nasal inspiratory flow was 45 litres per minute. CT showed bilateral maxillary and ethmoid mucosal disease. Decongestant was stopped and he had septoplasty, inferior turbinate reduction and polypectomy on 03 April 2007, with partial improvement. "septal deviation, polyps, PNIF 45"
• 11 Jun 2011 — During warlike service in Afghanistan the veteran was thrown against a weapon mount when his vehicle braked suddenly, fracturing his nose again. He had been in dust-laden turret duty for four months and his intranasal corticosteroid supply had run out in April. He had been using decongestant spray several times a day since mid-May. Nasal blockage returned on both sides and became constant. "second nasal fracture, steroid lapsed"
• 07 Nov 2011 — Ear, nose and throat review after return recorded marked worsening: complete obstruction of the left airway, partial obstruction of the right, recurrent grade 3 polyps and peak nasal inspiratory flow of 25 litres per minute, down from 95 after surgery. CT showed re-deviation of the septum and pansinus mucosal disease. Revision septorhinoplasty and endoscopic sinus surgery were performed on 22 March 2012. "worsened, PNIF 25, revision surgery"

Symptoms

At onset the veteran had constant blockage of both sides of the nose, worse on the left, that was no longer relieved by decongestant spray, with mouth breathing, dry mouth, loud snoring, thick nasal discharge, reduced sense of smell and difficulty wearing a respirator and headset. He woke frequently at night.

From June 2011 the left side of the nose became completely blocked and the right side partly blocked, with loss of smell, recurrent sinus infections and nightly mouth breathing. After revision surgery he has persisting partial obstruction, worse on the left and in dry or dusty air, nasal crusting, reduced smell and disturbed sleep, and he uses saline irrigation and intranasal corticosteroids daily.

Imaging

• 22 Oct 2005 — X-ray nasal bones: "Displaced fracture of the nasal bones with deviation to the left."
• 14 Aug 2006 — CT paranasal sinuses: "Septal deviation to the left with a spur contacting the left inferior turbinate. Bilateral inferior turbinate hypertrophy. Mucosal thickening of both maxillary sinuses and the anterior ethmoid cells with polypoid soft tissue in the left middle meatus. Healed nasal bone fractures with deformity."
• 07 Nov 2011 — CT paranasal sinuses: "New fracture of the nasal bones and re-deviation of the septum to the left. Recurrent polypoid disease in both nasal cavities. Pansinus mucosal thickening with opacification of the left maxillary and ethmoid sinuses."

Onset Date

The most likely date of onset of this condition is 20 Feb 2006.

At that date the veteran was on warlike service in Iraq as a cavalry crewman, standing in the turret of a reconnaissance vehicle for long patrols in dust and diesel exhaust. His nasal fracture of 22 October 2005 had healed with a deviated septum, he had been diagnosed with chronic rhinosinusitis on 19 January 2006, and he had been using oxymetazoline spray four to six times a day since 02 January 2006. From 20 February 2006 both sides of his nose were blocked constantly and the spray no longer helped.

This date is appropriate because his pre-deployment examination of 25 August 2005 recorded a straight septum and no persistent blockage, his consultations of October 2005 and January 2006 describe intermittent symptoms, and he presented on 21 February 2006 with constant bilateral obstruction beginning the day before, with a deviated septum, turbinate hypertrophy and a polyp on examination. The ear, nose and throat surgeon confirmed the condition on 14 August 2006. The date falls within warlike service and continuous full-time service.

For the nasal trauma and packing causes, the 1 year before onset runs from 20 Feb 2005 to 20 Feb 2006 and contains the nasal fracture and 72 hours of nasal packing of 22 October 2005. For the airborne irritant cause, the 6 months before onset run from 20 Aug 2005 to 20 Feb 2006, during which he spent 8 to 12 hours a day in the open turret in dust, burn pit smoke and exhaust from 28 September 2005. For the decongestant cause, the 1 month before onset runs from 20 Jan 2006 to 20 Feb 2006, during which he used oxymetazoline every day. Allergic rhinitis, chronic rhinosinusitis, nasal polyps and turbinate hypertrophy were each present on 20 February 2006, and his smoking history exceeded 5 pack-years before that date.

For the worsening, the documented clinical worsening began on 11 Jun 2011 during warlike service in Afghanistan, with return of constant bilateral blockage after a second nasal fracture, and was confirmed on 07 November 2011, when peak nasal inspiratory flow had fallen from 95 to 25 litres per minute. The 1 year before the worsening runs from 11 Jun 2010 to 11 Jun 2011 and contains the nasal fracture of that day. The 6 months before the worsening run from 11 Dec 2010 to 11 Jun 2011, during which he was exposed to turret dust and exhaust from 06 February 2011, and the 1 month before the worsening runs from 11 May 2011 to 11 Jun 2011, during which he used decongestant spray every day from 15 May.

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

The formal diagnosis is Chronic Nasal Obstruction (ICD-10 J34.8), due to post-traumatic septal deviation, inferior turbinate hypertrophy and chronic rhinosinusitis with nasal polyps. No Statement of Principles has been determined for chronic nasal obstruction.

Chronic nasal obstruction is persistent blockage of airflow through one or both sides of the nose lasting more than three months. It results from structural narrowing, such as a deviated septum, collapse of the nasal valve or enlarged turbinates, from swelling of the nasal lining, as in allergic, irritant and drug-induced rhinitis and chronic rhinosinusitis, or from masses such as nasal polyps, and these causes commonly coexist. It causes mouth breathing, snoring, disturbed sleep, reduced sense of smell, recurrent sinus infection and difficulty with respirators and masks, and it is a recognised contributor to obstructive sleep apnoea. It is confirmed by nasal endoscopy, peak nasal inspiratory flow or rhinometry and CT of the sinuses.

The condition began on 20 February 2006 during warlike service in Iraq after a service nasal fracture, airborne irritant exposure and decongestant overuse on a background of allergic rhinitis and chronic rhinosinusitis, was confirmed by an ear, nose and throat surgeon on 14 August 2006, and worsened during warlike service in Afghanistan in June 2011.

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

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

20 February 2006.

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

21 February 2006.

When was the condition confirmed / formally diagnosed?

14 August 2006.

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

08 July 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 14 August 2006 on the basis of constant bilateral nasal obstruction for six months, nasal endoscopy showing a post-traumatic septal deviation obstructing the left airway, bilateral inferior turbinate hypertrophy and grade 2 nasal polyps, a reduced peak nasal inspiratory flow of 45 litres per minute, and CT showing septal deviation, turbinate hypertrophy and maxillary and ethmoid mucosal disease. Operative findings at septoplasty, turbinate reduction and polypectomy on 03 April 2007 confirmed the structural and mucosal causes.

The worsening was established on 07 November 2011, when endoscopy showed complete left and partial right obstruction with recurrent grade 3 polyps, peak nasal inspiratory flow had fallen from 95 litres per minute after the 2007 surgery to 25 litres per minute, and CT showed a new nasal fracture, septal re-deviation and pansinus disease. Revision septorhinoplasty and endoscopic sinus surgery were required on 22 March 2012.

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 for chronic nasal obstruction, so the claim is 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 medical literature on nasal obstruction, rhinitis and chronic rhinosinusitis, and each is set out in the form used by the Repatriation Medical Authority.

Legislation: the clinical onset of this condition was on 20 February 2006, after 1 July 2004, during continuous full-time service that included warlike service in Iraq. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. Operational service is relevant to the veteran's warlike service in Iraq in 2005 to 2006, where the condition began, and in Afghanistan in 2011, where it worsened, and his peacetime service covers the allergic rhinitis and smoking history established in garrison. Each cause must be related to 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: having a fracture of the nasal bones or nasal septum, or other trauma to the nose resulting in septal deviation, within the 1 year before the clinical onset of chronic nasal obstruction; — MET

- On 22 October 2005, during warlike service in Iraq, the turret hatch lid struck the veteran's face when his vehicle dropped into a concealed ditch, causing a displaced nasal fracture deviated to the left, shown on X-ray. The fracture was four months before onset, within the 1 year from 20 February 2005 to 20 February 2006, and healed with the septal deviation that obstructs his left airway.

Cause 2: having nasal packing or nasotracheal intubation for at least 48 hours within the 1 year before the clinical onset of chronic nasal obstruction; — MET

- The epistaxis from the 22 October 2005 fracture required anterior nasal packing for 72 hours at the deployed health facility in Iraq. Prolonged packing injures the septal and turbinate mucosa and contributed to the mucosal swelling present at onset.

Cause 3: having allergic rhinitis at the time of the clinical onset of chronic nasal obstruction; — MET

- Allergic rhinitis was diagnosed on 16 March 2004 with positive skin prick tests to house dust mite and grass pollens, after symptoms began in recruit training and in barracks accommodation. It was active at onset, aggravated by dust in Iraq, and the intranasal corticosteroid that controlled it could not be used consistently on deployment.

Cause 4: having chronic rhinosinusitis at the time of the clinical onset of chronic nasal obstruction; — MET

- The veteran had thick nasal discharge, facial pressure, post-nasal drip and reduced smell from October 2005, recorded as chronic rhinosinusitis by the medical officer on 19 January 2006 after three months of symptoms despite two antibiotic courses, and confirmed on CT on 14 August 2006. It developed during warlike service in Iraq after the nasal fracture and heavy dust exposure, and was present at onset.

Cause 5: having nasal polyps at the time of the clinical onset of chronic nasal obstruction; — MET

- A pale polypoid mass in the left middle meatus was seen on anterior rhinoscopy on 21 February 2006, the day after onset, and grade 2 bilateral polyps were confirmed on endoscopy and removed in April 2007. The polyps arose from the chronic rhinosinusitis that developed on warlike service.

Cause 6: being exposed to airborne dust, smoke, fuel vapour or vehicle exhaust in an occupational setting for at least 4 hours per day on most days for at least 3 months within the 6 months before the clinical onset of chronic nasal obstruction; — MET

- From 28 September 2005 to 20 February 2006, during warlike service in Iraq, the veteran spent 8 to 12 hours a day in an open turret hatch on desert tracks in fine dust and diesel exhaust, with frequent sandstorms and smoke from the base burn pit, recorded in patrol logs and in the medical officer's note of 19 January 2006. This exposure lasted almost five months within the 6 months before onset and causes irritant rhinitis and turbinate swelling.

Cause 7: using a topical nasal decongestant for at least 10 consecutive days within the 1 month before the clinical onset of chronic nasal obstruction; — MET

- The veteran used oxymetazoline spray four to six times a day every day from 02 January 2006 to onset, recorded on 19 January 2006, including throughout the 1 month before onset, from 20 January 2006 to 20 February 2006. He used it to keep his nose clear under his respirator and headset on turret duty. Rebound congestion (rhinitis medicamentosa) produced the beefy red, swollen turbinates seen on 21 February 2006.

Cause 8: having hypertrophy of the inferior turbinates at the time of the clinical onset of chronic nasal obstruction; — MET

- Swollen inferior turbinates were seen on 21 February 2006 and bilateral inferior turbinate hypertrophy was confirmed on endoscopy and CT on 14 August 2006, requiring surgical reduction. The hypertrophy resulted from the allergic, irritant and decongestant-induced rhinitis of his service.

Cause 9: having smoked at least 5 pack-years of cigarettes, or the equivalent in other tobacco products, before the clinical onset of chronic nasal obstruction; — MET

- The veteran smoked 15 cigarettes a day from age 16, about 9.4 pack-years by his pre-deployment assessment of 25 August 2005, and continued through his deployment to Iraq, increasing to 25 a day on operations. Smoking began before enlistment but more than 5 pack-years accrued during service, where smoking was encouraged by the culture and supply of the period.

Worsening factors

Worsening 1: having a fracture of the nasal bones or nasal septum, or other trauma to the nose resulting in septal deviation, within the 1 year before the clinical worsening of chronic nasal obstruction; — MET

- On 11 June 2011, during warlike service in Afghanistan, the veteran was thrown face-first against a weapon mount when his vehicle braked suddenly, fracturing his nasal bones again. CT on 07 November 2011 showed the new fracture and re-deviation of the septum. The injury was at the start of the worsening, within the 1 year from 11 June 2010 to 11 June 2011.

Worsening 2: being exposed to airborne dust, smoke, fuel vapour or vehicle exhaust in an occupational setting for at least 4 hours per day on most days for at least 3 months within the 6 months before the clinical worsening of chronic nasal obstruction; — MET

- From 06 February 2011 to 11 June 2011, during warlike service in Afghanistan, the veteran spent 8 to 10 hours a day in the turret on dusty roads and tracks in diesel exhaust, a period of four months within the 6 months before the worsening, from 11 December 2010 to 11 June 2011.

Worsening 3: using a topical nasal decongestant for at least 10 consecutive days within the 1 month before the clinical worsening of chronic nasal obstruction; — MET

- When his intranasal corticosteroid supply ran out in April 2011 and could not be replaced in theatre, the veteran used oxymetazoline spray several times a day every day from 15 May 2011 to the worsening, 27 consecutive days within the 1 month before the worsening (11 May 2011 to 11 June 2011), recorded by the medical officer on 11 June 2011.

Worsening 4: inability to obtain appropriate clinical management for chronic nasal obstruction. — MET

- On warlike service in Afghanistan in 2011 the veteran's intranasal corticosteroid could not be resupplied for two months, no ear, nose and throat assessment was available after his second nasal fracture, and reduction of the fracture within the recommended two weeks was not possible. The septum healed deviated again and the polyps recurred, and revision surgery was not possible until March 2012. 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

The chronic nasal obstruction is a sequela of the veteran's accepted nasal fractures sustained on warlike service in Iraq in 2005 and Afghanistan in 2011, and of his accepted allergic rhinitis and chronic rhinosinusitis. It has in turn contributed to snoring and obstructive sleep apnoea, diagnosed on polysomnography in 2013, to chronic mouth breathing with dry mouth, and to difficulty using a respirator and CPAP mask.

Unintended Consequence

Met. The nasal fracture of October 2005 could not be reduced within the recommended two weeks because no specialist was available in theatre, and the 72 hours of anterior nasal packing applied by ADF health providers injured the nasal mucosa (section 6A of the DRCA and the equivalent provisions of the MRCA). Both were features of the treatment provided and paid for by the Commonwealth and contributed to the onset.

Inability to Attain Appropriate Medical Management

MET. After both nasal fractures, in Iraq in 2005 and Afghanistan in 2011, no ear, nose and throat surgeon was available to reduce the fracture within the recommended two weeks, and in 2011 the veteran's intranasal corticosteroid could not be resupplied for two months. The septum healed deviated on each occasion, the polyps recurred and he resorted to decongestant spray, and the obstruction worsened until revision surgery in March 2012. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the absence of specialist treatment and regular medicines in the operational area amounted to an inability to obtain appropriate clinical management.

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

See attached report.

References

1. 16 Mar 2004, Outpatient health record and skin prick testing, Medical Officer, Garrison health centre
2. 25 Aug 2005, Pre-deployment health assessment, Medical Officer, Garrison health centre
3. 22 Oct 2005, Deployed trauma record and X-ray nasal bones report, Medical Officer, Iraq
4. 19 Jan 2006, Deployed health record, Medical Officer, Iraq
5. 21 Feb 2006, Deployed health record, Medical Officer, Iraq
6. 14 Aug 2006, Ear, nose and throat consultation and CT sinuses report, ENT surgeon and Radiologist
7. 03 Apr 2007, Operation report, ENT surgeon
8. 11 Jun 2011, Deployed health record, Medical Officer, Afghanistan
9. 07 Nov 2011, Ear, nose and throat review and CT sinuses report, ENT surgeon and Radiologist
10. 22 Mar 2012, Operation report, ENT surgeon