Chronic Rhinosinusitis with Nasal Polyposis — DVA claim example

Diagnostic Assessment — Chronic Rhinosinusitis with Nasal Polyposis

Example 1 of 1 · fictitious patient (Veteran EI)

Diagnostic Assessment

Chronic Rhinosinusitis with Nasal Polyposis

BOP Code: 74 of 2018 (Sinusitis)
RH Code: 73 of 2018 (Sinusitis)

ADF History

Veteran EI, date of birth 02 February 1974, Royal Australian Air Force, Loadmaster (C-130 aircrew), enlisted 15 January 1993, medically discharged 28 June 2019. Operational service: East Timor, 20 September 1999 to 10 February 2000 (warlike); Middle East Area of Operations, 01 March 2003 to 30 June 2003 (warlike); Middle East Area of Operations, 10 January 2007 to 15 July 2007 (warlike); Middle East Area of Operations, 01 October 2014 to 30 March 2015 (warlike).

Occupational History

As a C-130 loadmaster the veteran planned, loaded, restrained and dispatched cargo and passengers, working on the flight line and on board unpressurised and pressurised aircraft with rapid descents into tactical airfields. Aircrew are prone to sinus and middle ear barotrauma, particularly when flying with upper respiratory tract infections, and loadmasters handle heavy cargo, chains and straps with a risk of facial injury. Long periods on open flight lines in tropical and desert environments give heavy solar ultraviolet exposure.

On operations in the Middle East, loadmasters worked at airfields exposed to fine dust, sand storms, smoke from open burn pits, aviation fuel and exhaust fumes, and on occasion to enemy attack, including chemical-laden improvised explosive devices. Deployed accommodation was crowded and shared, respiratory infections spread readily, smoking in shared accommodation was common, and specialist ear, nose and throat and dental care was not available in theatre.

History

Veteran EI, a C-130 loadmaster in the Royal Australian Air Force, developed rhinosinusitis on 18 May 2007 during warlike service in the Middle East Area of Operations, after a service nasal fracture, radiotherapy to the left face for a skin cancer, a chlorine gas exposure, asthma, allergic rhinitis and sinus barotrauma, and in the setting of a viral infection, a dental abscess and burn pit smoke. The sinusitis did not resolve, chronic rhinosinusitis with nasal polyposis was confirmed on CT and nasendoscopy in November 2007, and it worsened during his 2014 to 2015 deployment.

Timeline

• 14 Aug 2002 — While restraining a cargo pallet on the flight line a tensioned strap released and struck the veteran across the nose. He had epistaxis and nasal deformity, and a displaced nasal bone fracture was managed by closed reduction. He was left with a deviated septum to the right and partial right nasal obstruction. He had smoked about 15 cigarettes a day since enlistment in 1993, and allergic rhinitis to house dust mite and grasses had been confirmed on skin prick testing in 1998. "nasal fracture, septum deviated"
• 22 Jun 2006 — A dermatologist excised a squamous cell carcinoma of the left cheek with perineural invasion of the infraorbital nerve, attributed to long-term solar exposure on open flight lines, including on deployment. Adjuvant radiotherapy of 60 Gy in 30 fractions was given from 14 August to 25 September 2006, with the left maxillary sinus and left nasal cavity within the radiation field. Asthma, diagnosed after his 2003 deployment, had required repeated courses of oral prednisolone, and frontal sinus barotrauma on descent had grounded him twice in 2005 and 2006. "cheek SCC, radiotherapy 60 Gy"
• 10 Apr 2007 — During warlike service in the Middle East Area of Operations a chlorine-laden vehicle-borne improvised explosive device detonated about one kilometre upwind of the forward airfield where he was unloading an aircraft. Within an hour he had burning of the nose and throat, profuse rhinorrhoea, epistaxis and cough. The deployed medical officer recorded inflamed, ulcerated nasal mucosa. In March 2007 a dental officer had recorded a non-vital upper left first molar awaiting completion of root canal treatment. "chlorine exposure, nasal mucosal ulceration"
• 18 May 2007 — At a deployed air base he presented with nasal congestion, purulent discharge, left facial pain and pressure, reduced smell and fever, which began that day, three days after a head cold spread through his accommodation. Over the previous two days, 16 and 17 May 2007, he had worked through a dust storm and dense smoke from the base burn pit. He had an acute asthma exacerbation and had started prednisolone 50 mg daily on 13 May 2007. The upper left first molar was tender with a periapical abscess. Acute rhinosinusitis was diagnosed and antibiotics were given. "purulent rhinosinusitis, left facial pain"
• 20 Nov 2007 — Four months after his return to Australia an ear, nose and throat surgeon reviewed persistent nasal obstruction, discharge, facial pressure and loss of smell continuing since May 2007. Nasendoscopy showed bilateral grade 2 nasal polyps, septal deviation and mucosal synechiae and scarring of the right septum and inferior turbinate. CT on 05 November 2007 showed pansinus opacification with a Lund-Mackay score of 16. Chronic rhinosinusitis with nasal polyposis was diagnosed and endoscopic sinus surgery recommended. "CRSwNP, grade 2 polyps"
• 05 Mar 2013 — The upper left first molar was extracted after recurrent abscess, complicated by an oro-antral fistula into the left maxillary sinus that persisted. Severe asthma now required maintenance oral prednisolone 10 mg daily, prescribed by a respiratory physician. The endoscopic sinus surgery recommended in 2007 had been postponed repeatedly because of flying and deployment commitments. "oro-antral fistula, prednisolone 10 mg"
• 12 Jan 2015 — On warlike service in the Middle East Area of Operations he reported marked worsening, with complete nasal obstruction, total loss of smell, thick discharge and severe facial pain. In the preceding week he had a viral respiratory infection, flew a tactical descent with left maxillary sinus barotrauma on 09 January 2015, worked beside the burn pit on 10 and 11 January 2015, and had taken ibuprofen 400 mg three times daily for back pain since 02 January 2015. No ear, nose and throat care was available in theatre. "total anosmia, complete obstruction"
• 15 Apr 2015 — After his return, CT of the sinuses showed progression, with a Lund-Mackay score of 22, and nasendoscopy showed grade 3 polyps filling both nasal cavities. The ear, nose and throat surgeon recorded clear worsening of the chronic rhinosinusitis with nasal polyposis. Aspirin-exacerbated respiratory disease was confirmed on history and he was advised to avoid nonselective anti-inflammatory drugs. Endoscopic sinus surgery was performed in June 2015. "Lund-Mackay 22, grade 3 polyps"

Symptoms

At onset the veteran had nasal congestion, purulent nasal discharge, left-sided facial pain and pressure, reduced sense of smell and fever. After onset the symptoms persisted beyond twelve weeks, with constant nasal blockage, postnasal drip, headaches and a progressive loss of smell.

He now reports constant nasal obstruction, total loss of smell and taste, postnasal drip, recurrent sinus infections several times a year and sleep disturbance from mouth breathing. He has had two endoscopic sinus operations and uses daily saline irrigation and steroid rinses.

Imaging

• 14 Aug 2002 — CT facial bones: "Displaced fracture of the nasal bones with septal deviation to the right."
• Jul 2006 — MRI face (radiotherapy planning): "Post-excision changes of the left cheek with thickening of the left infraorbital nerve. No sinus invasion. Radiation field planned to include the left maxillary sinus and left nasal cavity."
• 05 Nov 2007 — CT paranasal sinuses: "Pansinus mucosal thickening and opacification, worst in the left maxillary sinus, with obstruction of both ostiomeatal complexes. Polypoid soft tissue in both nasal cavities. Septal deviation to the right with a right concha bullosa. Periapical lucency at the upper left first molar root projecting into the floor of the left maxillary sinus. Lund-Mackay score 16."
• 15 Apr 2015 — CT paranasal sinuses: "Progression with near-complete opacification of all sinuses and polyps filling both nasal cavities. Bony defect in the floor of the left maxillary sinus at the site of the oro-antral fistula. Lund-Mackay score 22."

Onset Date

The most likely date of onset of this condition is 18 May 2007.

At that date the veteran was on warlike service as a C-130 loadmaster at an air base in the Middle East Area of Operations. He had a viral upper respiratory infection, an acute asthma exacerbation treated with high-dose prednisolone, a periapical abscess of the upper left first molar, a deviated septum from his 2002 nasal fracture, nasal mucosal scarring from the chlorine exposure of 10 April 2007, and a left maxillary sinus that had been irradiated in 2006. He had worked through a dust storm and burn pit smoke over the previous two days.

This date is appropriate because his aircrew medical examination of 15 January 2007 recorded a normal nasal examination with no polyps or sinus symptoms, apart from his known septal deviation, and on 18 May 2007 he presented with purulent rhinosinusitis that began that day and never resolved. It falls within uninterrupted full-time service and within his warlike deployment.

For the airborne dust and smoke factor, the 48 hours before onset run from 16 May 2007 to 18 May 2007, during which he worked through a dust storm and burn pit smoke. For the irritant factor, the chlorine exposure on 10 Apr 2007 produced acute nasal symptoms within an hour and mucosal ulceration, which healed with scarring before onset. For the smoking factor, he smoked about 15 cigarettes a day from January 1993, about 10.7 pack-years by onset, and had not stopped. For the second-hand smoke factor, his exposure in shared deployed accommodation began in September 1999, more than one year before onset, totalled about 1,400 hours, and last occurred in the week before onset, within the three months from 18 Feb 2007 to 18 May 2007. The radiotherapy was completed on 25 Sep 2006, before onset. Impaired drainage, the viral infection, the immunosuppressive prednisolone, asthma, allergic rhinitis, reflux, sinus barotrauma and the dental abscess were each present on 18 May 2007.

For the worsening factors, the documented worsening was on 12 Jan 2015 on warlike service. The 48 hours before the worsening run from 10 Jan 2015 to 12 Jan 2015, when he worked beside the burn pit. The three months before the worsening run from 12 Oct 2014 to 12 Jan 2015, during which he was exposed to second-hand smoke in shared accommodation on deployment and continued smoking. He was taking ibuprofen and maintenance prednisolone, had a viral infection, sinus barotrauma, an oro-antral fistula and polyps at that date.

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

The formal diagnosis is Chronic Rhinosinusitis with Nasal Polyposis (ICD-10-AM J32.4, with J33.8), under the Statements of Principles concerning sinusitis, Balance of Probabilities No. 74 of 2018 and Reasonable Hypothesis No. 73 of 2018.

Rhinosinusitis is inflammation of the lining of the nose and paranasal sinuses, causing nasal blockage, nasal discharge, facial pain or pressure and reduction or loss of smell. When it persists for more than twelve weeks it is chronic, and in one form the inflamed lining forms polyps that obstruct the nasal passages and sinus openings. It is promoted by obstructed sinus drainage, infection, airway allergy and asthma, smoking and irritant inhalation, radiation damage to the sinus lining, dental infection near the maxillary sinus and immune suppression, and in some patients is aggravated by aspirin and other nonselective anti-inflammatory drugs.

The diagnosis followed a service nasal fracture, radiotherapy for a service-related skin cancer, chlorine exposure, asthma and allergic rhinitis, and arose on deployment with a viral infection, dental abscess and burn pit smoke. It began on 18 May 2007, was confirmed as chronic with polyps in November 2007 and worsened in January 2015.

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

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

18 May 2007.

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

18 May 2007.

When was the condition confirmed / formally diagnosed?

20 November 2007.

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

02 October 2025.

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

The diagnosis was confirmed by an ear, nose and throat surgeon on 20 November 2007. The veteran had nasal obstruction, discharge, facial pressure and loss of smell persisting for more than twelve weeks from 18 May 2007, nasendoscopy showed bilateral grade 2 nasal polyps, and CT on 05 November 2007 showed pansinus mucosal thickening and opacification with ostiomeatal obstruction and a Lund-Mackay score of 16. This meets the Statement of Principles definition of sinusitis as inflammation of the nasal cavity and paranasal sinuses, in its chronic form, with nasal polyps.

The acute onset on 18 May 2007 was documented by the deployed medical officer, with purulent discharge, left facial pain and fever. Progression was confirmed on 15 April 2015, with a Lund-Mackay score of 22 and grade 3 polyps, and histology from endoscopic sinus surgery in June 2015 showed eosinophilic inflammatory polyps.

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 18 May 2007, after 1 July 2004, during continuous full-time service and on warlike service in the Middle East Area of Operations. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to his warlike service in East Timor and the Middle East, where the chlorine exposure, dust, burn pit smoke, second-hand smoke, viral infection and dental abscess occurred and where the condition began in 2007 and worsened in 2015. The Balance of Probabilities instrument applies to his peacetime service, including the 2002 nasal fracture, his radiotherapy and his flying duties in Australia.

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 Sinusitis, No. 74 of 2018

Causative factors

Factor 9(1): having impaired drainage of the sinus at the time of the clinical onset of sinusitis; — MET

- The nasal fracture sustained on 14 August 2002, when a cargo strap struck his face on the flight line, healed with a septal deviation to the right, and CT on 05 November 2007 also showed a right concha bullosa and ostiomeatal obstruction. The scarring of the nasal mucosa from the chlorine exposure added soft tissue narrowing. These anatomical and soft tissue abnormalities obstructed the sinus openings at onset on 18 May 2007.

Factor 9(2): having a viral, bacterial or fungal respiratory tract infection at the time of the clinical onset of sinusitis; — MET

- A viral upper respiratory tract infection spread through his shared accommodation and he developed a head cold on 15 May 2007, three days before onset. The infection was present at onset on 18 May 2007, when the deployed medical officer recorded coryzal symptoms progressing to purulent rhinosinusitis.

Factor 9(3): being in an immunocompromised state as specified at the time of the clinical onset of sinusitis; — MET

- The veteran was taking prednisolone 50 mg daily, an oral corticosteroid and immunosuppressive drug, from 13 May 2007 for an acute exacerbation of his service-related asthma, prescribed by the deployed medical officer. He was taking it at onset on 18 May 2007.

Factor 9(4): having a specified medical condition at the time of the clinical onset of sinusitis; — MET

- At onset on 18 May 2007 the veteran had asthma, diagnosed after his 2003 deployment and requiring repeated oral corticosteroids; allergic rhinitis, confirmed on skin prick testing in 1998; gastro-oesophageal reflux disease, confirmed on gastroscopy in 2005; and sinus barotrauma from flying, which grounded him in 2005 and 2006. Each is a specified medical condition.

Factor 9(5): undergoing a course of therapeutic radiation for cancer, where the nasal cavity and paranasal sinuses were in the field of radiation, before the clinical onset of sinusitis; — MET

- After excision of a squamous cell carcinoma of the left cheek on 22 June 2006, caused by years of solar exposure on open flight lines, the veteran received adjuvant radiotherapy of 60 Gy in 30 fractions from 14 August to 25 September 2006, with the left maxillary sinus and left nasal cavity in the radiation field. This was completed before onset on 18 May 2007, and the left maxillary sinus was the most severely affected sinus on CT.

Factor 9(6): smoking at least one pack-year of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of sinusitis, and: (a) smoking commenced at least one year before the clinical onset of sinusitis; and (b) where smoking has ceased, the clinical onset of sinusitis has occurred within three months of smoking cessation; — MET

- The veteran began smoking about 15 cigarettes a day after enlistment in January 1993, in a service culture where cigarettes were cheap and smoking breaks were routine, and had smoked about 10.7 pack-years by onset. Smoking commenced more than 14 years before onset on 18 May 2007 and had not ceased.

Factor 9(7): being exposed to second-hand smoke: (a) for at least 1 000 hours before the clinical onset of sinusitis; and (b) where the first exposure to second-hand smoke commenced at least one year before the clinical onset of sinusitis; and (c) where the last exposure to second-hand smoke occurred within the three months before the clinical onset of sinusitis; — MET

- From September 1999 the veteran shared enclosed tents and demountable accommodation with smokers on deployment and on field exercises in Australia, where smoking inside was common. His cumulative exposure was about 1,400 hours by onset. The first exposure was more than seven years before onset, and the last was in the week before onset, within the three months from 18 February 2007 to 18 May 2007.

Factor 9(8): inhaling a drug or irritant substance which results in: (a) acute nasal symptoms or signs within 48 hours of the inhalation; and (b) scarring or erosion of the nasal or sinus mucosa; before the clinical onset of sinusitis; — MET

- On 10 April 2007 the veteran inhaled chlorine gas from a chlorine-laden improvised explosive device that detonated upwind of his airfield. Within an hour he had burning, profuse rhinorrhoea and epistaxis, and the medical officer recorded inflamed, ulcerated nasal mucosa. The ulceration healed with scarring, shown as mucosal synechiae of the right septum and inferior turbinate on nasendoscopy on 20 November 2007. Both events occurred before onset on 18 May 2007.

Factor 9(9): for sinusitis affecting the maxillary sinus only, having a specified dental condition affecting the tissues adjacent to the affected maxillary sinus at the time of the clinical onset of sinusitis; — MET

- The upper left first molar was non-vital in March 2007, with root canal treatment left incomplete because of his deployment, and on 18 May 2007 it had a periapical abscess. CT on 05 November 2007 showed periapical lucency projecting into the floor of the left maxillary sinus, the most severely affected sinus. The non-vital tooth and periapical abscess were present at onset.

Worsening factors

Factor 9(10): having impaired drainage of the sinus at the time of the clinical worsening of sinusitis; — MET

- At the worsening on 12 January 2015 the septal deviation from the 2002 fracture persisted and polyps obstructed both ostiomeatal complexes, as confirmed on CT on 15 April 2015.

Factor 9(11): having a viral, bacterial or fungal respiratory tract infection at the time of the clinical worsening of sinusitis; — MET

- The veteran had a viral respiratory infection, acquired in shared accommodation, in the week before and at the time of the worsening on 12 January 2015.

Factor 9(12): being in an immunocompromised state as specified at the time of the clinical worsening of sinusitis; — MET

- From 2013 a respiratory physician had prescribed maintenance oral prednisolone 10 mg daily, an immunosuppressive drug, for his severe service-related asthma, and he was taking it at the worsening on 12 January 2015.

Factor 9(13): having a specified medical condition at the time of the clinical worsening of sinusitis; — MET

- At the worsening on 12 January 2015 he had severe asthma, allergic rhinitis and gastro-oesophageal reflux disease, and he had sustained left maxillary sinus barotrauma on a tactical descent on 09 January 2015.

Factor 9(14): undergoing a course of therapeutic radiation for cancer, where the nasal cavity and paranasal sinuses were in the field of radiation, before the clinical worsening of sinusitis; — MET

- The radiotherapy of August to September 2006 for his service-related skin cancer, with the left maxillary sinus and nasal cavity in the field, was completed before the worsening on 12 January 2015, and the irradiated lining had persisting impaired mucociliary clearance.

Factor 9(15): smoking at least one pack-year of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of sinusitis, and: (a) smoking commenced at least one year before the clinical worsening of sinusitis; and (b) where smoking has ceased, the clinical worsening of sinusitis has occurred within three months of smoking cessation; — MET

- The veteran continued to smoke about 15 cigarettes a day, about 16 pack-years by January 2015. Smoking commenced 22 years before the worsening on 12 January 2015 and had not ceased.

Factor 9(16): being exposed to second-hand smoke: (a) for at least 1 000 hours before the clinical worsening of sinusitis; and (b) where the first exposure to second-hand smoke commenced at least one year before the clinical worsening of sinusitis; and (c) where the last exposure to second-hand smoke occurred within the three months before the clinical worsening of sinusitis; — MET

- His cumulative exposure to second-hand smoke in shared service accommodation exceeded 2,000 hours by January 2015, the first exposure began in 1999, and he shared accommodation with smokers on deployment from October 2014, within the three months before the worsening, from 12 October 2014 to 12 January 2015.

Factor 9(17): inhaling a drug or irritant substance which results in: (a) acute nasal symptoms or signs within 48 hours of the inhalation; and (b) scarring or erosion of the nasal or sinus mucosa; before the clinical worsening of sinusitis; — MET

- The chlorine inhalation of 10 April 2007 caused acute nasal symptoms within an hour and mucosal ulceration that healed with scarring, documented on 20 November 2007, all before the worsening on 12 January 2015.

Factor 9(18): for sinusitis affecting the maxillary sinus only, having a specified dental condition affecting the tissues adjacent to the affected maxillary sinus at the time of the clinical worsening of sinusitis; — MET

- Extraction of the upper left first molar on 05 March 2013 was complicated by an oro-antral fistula into the left maxillary sinus, which persisted at the worsening on 12 January 2015 and was shown as a bony defect on CT on 15 April 2015.

Factor 9(19): for sinusitis with nasal polyps only, using a drug belonging to the nonselective (COX-1 and COX-2 inhibitors) nonsteroidal anti-inflammatory class of drugs, at the time of the clinical worsening of sinusitis; — MET

- The veteran has chronic rhinosinusitis with nasal polyps. He was taking ibuprofen 400 mg three times daily for back pain from 02 January 2015 and was taking it at the worsening on 12 January 2015, and aspirin-exacerbated respiratory disease was subsequently confirmed.

Factor 9(20): inability to obtain appropriate clinical management for sinusitis. — MET

- Endoscopic sinus surgery recommended on 20 November 2007 was postponed for more than seven years because of flying and deployment commitments, and the root canal treatment of the upper left first molar was left incomplete when he deployed in 2007. On deployment in 2015 no ear, nose and throat care was available as the disease progressed, and he was given a nonselective anti-inflammatory drug. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Sinusitis, No. 73 of 2018

Causative factors

Factor 9(1): having impaired drainage of the sinus at the time of the clinical onset of sinusitis; — MET

- At onset on 18 May 2007, on warlike service in the Middle East Area of Operations, the sinus openings were narrowed by the septal deviation from his service nasal fracture and by mucosal scarring from the chlorine exposure on that deployment.

Factor 9(2): having a viral, bacterial or fungal respiratory tract infection at the time of the clinical onset of sinusitis; — MET

- The viral respiratory infection that spread through his shared deployed accommodation in the Middle East Area of Operations began on 15 May 2007 and was present at onset on 18 May 2007.

Factor 9(3): being in an immunocompromised state as specified at the time of the clinical onset of sinusitis; — MET

- Prednisolone 50 mg daily was prescribed on warlike service from 13 May 2007 for an asthma exacerbation triggered by dust and burn pit smoke, and he was taking it at onset on 18 May 2007.

Factor 9(4): having a specified medical condition at the time of the clinical onset of sinusitis; — MET

- Asthma that developed after dust and burn pit smoke exposure on warlike service in the Middle East in 2003 was present at onset on 18 May 2007, together with allergic rhinitis, reflux disease and recurrent sinus barotrauma from tactical flying.

Factor 9(5): undergoing a course of therapeutic radiation for cancer, where the nasal cavity and paranasal sinuses were in the field of radiation, before the clinical onset of sinusitis; — MET

- The squamous cell carcinoma of the left cheek resulted from solar exposure on open flight lines, including during warlike service in East Timor and the Middle East. It was treated with radiotherapy from 14 August to 25 September 2006 with the left maxillary sinus and nasal cavity in the field, before onset on 18 May 2007.

Factor 9(6): smoking at least one pack-year of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of sinusitis, and: (a) smoking commenced at least one year before the clinical onset of sinusitis; and (b) where smoking has ceased, the clinical onset of sinusitis has occurred within three months of smoking cessation; — MET

- The veteran smoked about 15 cigarettes a day from 1993, increasing to 25 a day on his warlike deployments in East Timor and the Middle East, more than 10 pack-years by onset on 18 May 2007. Smoking began more than one year before onset and had not ceased.

Factor 9(7): being exposed to second-hand smoke: (a) for at least 1 000 hours before the clinical onset of sinusitis; and (b) where the first exposure to second-hand smoke commenced at least one year before the clinical onset of sinusitis; and (c) where the last exposure to second-hand smoke occurred within the three months before the clinical onset of sinusitis; — MET

- On warlike service in East Timor in 1999 to 2000 and in the Middle East in 2003 and 2007 he shared enclosed tents and demountables with room-mates who smoked inside, about 1,400 hours in total. The first exposure was in September 1999, more than one year before onset, and the last was in the week before onset, within the three months before 18 May 2007.

Factor 9(8): inhaling a drug or irritant substance which results in: (a) acute nasal symptoms or signs within 48 hours of the inhalation; and (b) scarring or erosion of the nasal or sinus mucosa; before the clinical onset of sinusitis; — MET

- On warlike service in the Middle East Area of Operations on 10 April 2007 he inhaled chlorine gas released by an improvised explosive device, with acute rhinorrhoea, burning and epistaxis within an hour and ulceration of the nasal mucosa that healed with scarring, before onset on 18 May 2007.

Factor 9(9): inhaling airborne dusts, smoke from fires, or fumes or vapours from fuel or a chemical agent within the 48 hours before the clinical onset of sinusitis; — MET

- On 16 and 17 May 2007, within the 48 hours before onset on 18 May 2007, the veteran worked on the flight line of a deployed air base through a dust storm and dense smoke from the open burn pit, together with aviation fuel vapour and exhaust fumes.

Factor 9(10): for sinusitis affecting the maxillary sinus only, having a specified dental condition affecting the tissues adjacent to the affected maxillary sinus at the time of the clinical onset of sinusitis; — MET

- A periapical abscess of the non-vital upper left first molar, whose root canal treatment could not be completed before or during his warlike deployment, was present at onset on 18 May 2007, adjacent to the left maxillary sinus that was most severely affected.

Worsening factors

Factor 9(11): having impaired drainage of the sinus at the time of the clinical worsening of sinusitis; — MET

- On warlike service at the worsening on 12 January 2015 his sinus drainage was obstructed by polyps and the persisting septal deviation, as confirmed on CT on 15 April 2015.

Factor 9(12): having a viral, bacterial or fungal respiratory tract infection at the time of the clinical worsening of sinusitis; — MET

- A viral respiratory infection acquired in shared deployed accommodation in the Middle East Area of Operations was present at the worsening on 12 January 2015.

Factor 9(13): being in an immunocompromised state as specified at the time of the clinical worsening of sinusitis; — MET

- Maintenance oral prednisolone 10 mg daily for asthma arising from his warlike service was being taken at the worsening on 12 January 2015.

Factor 9(14): having a specified medical condition at the time of the clinical worsening of sinusitis; — MET

- Asthma from his Middle East service and left maxillary sinus barotrauma sustained on a tactical descent on warlike service on 09 January 2015 were present at the worsening on 12 January 2015.

Factor 9(15): undergoing a course of therapeutic radiation for cancer, where the nasal cavity and paranasal sinuses were in the field of radiation, before the clinical worsening of sinusitis; — MET

- The 2006 radiotherapy for the skin cancer caused by solar exposure on warlike service, with the left maxillary sinus and nasal cavity in the field, preceded the worsening on 12 January 2015.

Factor 9(16): smoking at least one pack-year of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of sinusitis, and: (a) smoking commenced at least one year before the clinical worsening of sinusitis; and (b) where smoking has ceased, the clinical worsening of sinusitis has occurred within three months of smoking cessation; — MET

- He continued to smoke, more heavily on warlike service in the Middle East from October 2014, about 16 pack-years in total by the worsening on 12 January 2015. Smoking had begun 22 years earlier and had not ceased.

Factor 9(17): being exposed to second-hand smoke: (a) for at least 1 000 hours before the clinical worsening of sinusitis; and (b) where the first exposure to second-hand smoke commenced at least one year before the clinical worsening of sinusitis; and (c) where the last exposure to second-hand smoke occurred within the three months before the clinical worsening of sinusitis; — MET

- Cumulative exposure in shared accommodation on warlike service exceeded 2,000 hours by January 2015, beginning in 1999, and continued in shared accommodation in the Middle East Area of Operations from October 2014, within the three months before the worsening on 12 January 2015.

Factor 9(18): inhaling a drug or irritant substance which results in: (a) acute nasal symptoms or signs within 48 hours of the inhalation; and (b) scarring or erosion of the nasal or sinus mucosa; before the clinical worsening of sinusitis; — MET

- The chlorine inhalation on warlike service on 10 April 2007, with acute nasal symptoms within an hour and mucosal scarring, occurred before the worsening on 12 January 2015.

Factor 9(19): inhaling airborne dusts, smoke from fires, or fumes or vapours from fuel or a chemical agent within the 48 hours before the clinical worsening of sinusitis; — MET

- On 10 and 11 January 2015, within the 48 hours before the worsening on 12 January 2015, he worked beside the burn pit at his deployed air base in the Middle East Area of Operations, inhaling dense smoke, dust and aviation fuel vapour.

Factor 9(20): for sinusitis affecting the maxillary sinus only, having a specified dental condition affecting the tissues adjacent to the affected maxillary sinus at the time of the clinical worsening of sinusitis; — MET

- The oro-antral fistula from the 2013 extraction of the upper left first molar, whose abscess began on warlike service in 2007, was present adjacent to the left maxillary sinus at the worsening on 12 January 2015.

Factor 9(21): for sinusitis with nasal polyps only, using a drug belonging to the nonselective (COX-1 and COX-2 inhibitors) nonsteroidal anti-inflammatory class of drugs, at the time of the clinical worsening of sinusitis; — MET

- The deployed medical officer prescribed ibuprofen 400 mg three times daily from 02 January 2015 for back pain from cargo handling on warlike service, and he was taking it at the worsening on 12 January 2015. His sinusitis is with nasal polyps.

Factor 9(22): inability to obtain appropriate clinical management for sinusitis. — MET

- On warlike service in the Middle East in 2007 his dental treatment could not be completed, and in 2015 no ear, nose and throat care was available as the disease worsened. The endoscopic sinus surgery recommended in November 2007 was deferred for seven years because of flying and deployment commitments. 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 rhinosinusitis with nasal polyposis is a sequela of the veteran's accepted conditions: the nasal fracture, the radiotherapy for squamous cell carcinoma of the left cheek, asthma, allergic rhinitis, sinus barotrauma, the dental abscess and oro-antral fistula, and the chlorine inhalation injury. The condition has in turn led to total loss of smell, recurrent acute infective exacerbations, worsening control of his asthma and two endoscopic sinus operations.

Unintended Consequence

Met. The worsening of the polyposis is in part an unintended consequence of ibuprofen prescribed by the deployed medical officer, and the immunosuppression present at onset and worsening is an unintended consequence of prednisolone prescribed for his service-related asthma, all provided and paid for by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. The endoscopic sinus surgery recommended on 20 November 2007 was postponed for more than seven years because of flying and deployment commitments, the root canal treatment of the abscessed upper left first molar was left incomplete when he deployed in 2007, and on warlike service in 2015 no ear, nose and throat care was available while the disease progressed. The Lund-Mackay score rose from 16 to 22 and his loss of smell became total. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), service demands and the absence of specialist and dental care on deployment that prevent recommended treatment amount to an inability to obtain appropriate clinical management. The prescription of a nonselective anti-inflammatory drug on deployment to a patient with nasal polyps is also indicative of barriers to appropriate care.

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

See attached report.

References

1. 1998, Skin prick test report, Allergy clinic
2. 14 Aug 2002, Emergency attendance and CT facial bones, Medical Officer and Radiologist
3. 2005, Gastroscopy report, Gastroenterologist
4. 2005 and 2006, Aviation medicine records of sinus barotrauma, Medical Officer (Aviation Medicine)
5. 22 Jun 2006, Histopathology and dermatology report, Dermatologist
6. Sep 2006, Radiotherapy treatment summary, Radiation oncologist
7. 15 Jan 2007, Aircrew medical examination, Medical Officer (Aviation Medicine)
8. Mar 2007, Dental record, Dental Officer
9. 10 Apr 2007, Deployed health record and chemical exposure report, Medical Officer, Middle East Area of Operations
10. 18 May 2007, Deployed health record, Medical Officer, Middle East Area of Operations
11. 05 Nov 2007, CT paranasal sinuses, Radiologist
12. 20 Nov 2007, Ear, nose and throat consultation and nasendoscopy, Ear, nose and throat surgeon
13. 05 Mar 2013, Dental extraction record, Dental Officer
14. 2013, Respiratory medicine consultation, Respiratory physician
15. 12 Jan 2015, Deployed health record, Medical Officer, Middle East Area of Operations
16. 15 Apr 2015, CT paranasal sinuses and ear, nose and throat review, Ear, nose and throat surgeon
17. Jun 2015, Operation report and histopathology, Ear, nose and throat surgeon
18. Statement of Principles concerning Sinusitis (Balance of Probabilities) No. 74 of 2018, Repatriation Medical Authority
19. Statement of Principles concerning Sinusitis (Reasonable Hypothesis) No. 73 of 2018, Repatriation Medical Authority