Ear - Tinnitus (bilateral) — DVA claim example (Diagnostic Assessment)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Ear - Tinnitus (bilateral)

Example 1 of 1 · fictitious patient (Veteran D)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

EAR - TINNITUS (BILATERAL)

SOP Bulletin No. 85 of 2020 - Tinnitus (Balance of Probabilities) SOP Bulletin No. 84 of 2020 - Tinnitus (Reasonable Hypothesis)

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 a range of occupational hazards. This occupation involves providing security and ground defence for RAAF assets, personnel, and installations. Significant exposure to noise is a major hazard, particularly from 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 note daily exposure to excessive noise and vibration with the comment "Proximity to flightline; periodic noise exposure" and "A/C noise". The physical demands of this role also include manual handling of heavy equipment, environmental exposures (sun, heat, dust), and potential chemical exposures from fuels, oils, and solvents.

History

The veteran an Airfield Defence Guard in the RAAF, has developed bilateral tinnitus associated with bilateral high-frequency sensorineural hearing loss. This condition is linked to his occupational exposure to noise from weapons firing and aircraft operations throughout his military service career.

Timeline

13 Jul 1993. During his enlistment Medical History Questionnaire, the veteran answered "No" to "Ringing in the ears", indicating no pre-existing tinnitus condition.
31 Jun 1999. An Annual Health Assessment recorded his hearing standard as HS1. The audiogram showed some high-frequency loss, and 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. The veteran reported that previously occasional tinnitus was now present more often, predominantly in the left ear, but not currently bothersome. Referral to ENT was recommended due to slight asymmetry and tinnitus.
19 May 2016. An audiology assessment by an audiology provider Hearing Care Professionals. Tinnitus Functional Index (TFI) Score was 14.8 (None/Slight). Tinnitus was described as heard occasionally or in quiet, easily masked, with slight sleep interference but no interference with daily activities.

Symptoms

At the time of initial onset, the veteran experienced intermittent tinnitus primarily in the right ear. Over time, the tinnitus progressed to affect both ears, becoming more frequent but remaining at a relatively mild level of severity.

Currently, the veteran experiences tinnitus that is heard occasionally or in quiet environments. It is described as easily masked by other sounds, with slight sleep interference but no significant impact on daily activities. The Tinnitus Functional Index score of 14.8 indicates a mild level of impact on quality of life. The tinnitus is associated with bilateral high-frequency sensorineural hearing loss.

Imaging

13 Apr 2009. Pure tone audiometry 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 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."
19 May 2016. 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."

1. What is the formal diagnosis of the condition claimed above? The formal diagnosis is Bilateral Tinnitus, ICD-10 code H93.13, which falls under DVA SOP Bulletin No. 85 of 2020 (Balance of Probabilities) and SOP Bulletin No. 84 of 2020 (Reasonable Hypothesis).

Tinnitus is the perception of sound in one or both ears or in the head when no external sound is present. These sounds can include buzzing, hissing, ringing, whistling, and clicking. It is often associated with hearing loss but can occur in individuals with normal hearing. Tinnitus is categorized as subjective (heard only by the patient) or objective (can be heard by an examiner). The vast majority of cases, including the veteran, are subjective.

In this case, the veteran has developed bilateral tinnitus that is associated with bilateral high-frequency sensorineural hearing loss. The condition began in the right ear around 2013 and later progressed to affect the left ear as well, becoming more frequent over time while remaining at a mild to moderate level of severity.

The temporal relationship between the veteran military service as an Airfield Defence Guard and the development of tinnitus is significant. His occupational exposure to excessive noise from weapons firing, aircraft operations, and other military activities is a well-established risk factor for both hearing loss and tinnitus. The pattern of high-frequency hearing loss documented in his audiograms is typical of noise-induced hearing loss, which commonly co-occurs with tinnitus.

2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms of tinnitus around or before June 2011, when it was initially documented in his medical records. At that time, it was noted to be present primarily in the right ear. The records do not specify exactly when the tinnitus first began, but the audiology report from June 2011 refers to it as a history of tinnitus, suggesting it had been present for some time before this documentation.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider for this condition no later than 13 Apr 2009, when he was seen at Attune Hearing for an audiology evaluation following a referral from the treating doctor evaluation documented the presence of right ear tinnitus along with mild sensorineural hearing loss.

When was the condition confirmed / formally diagnosed? The condition was confirmed/formally diagnosed on 13 Apr 2009 by an audiologist at Attune Hearing, who documented tinnitus in the right ear in association with a mild sensorineural notch at 4kHz in the right ear and mild sensorineural hearing loss from 3-6kHz in the left ear.

When did the veteran first present to you (or your practice) for this condition? The veteran first presented to my practice for this condition on 15 November 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 tinnitus was confirmed through:

Subjective reporting of tinnitus symptoms: The veteran reported experiencing intermittent ringing or buzzing sounds, initially in the right ear and later bilaterally. This is documented in multiple audiology reports beginning in June 2011.
Audiological assessments: Serial audiograms performed on 13 Apr 2009, 26 June 2011, and 19 May 2016 consistently demonstrated a pattern of high-frequency sensorineural hearing loss consistent with noise exposure. These findings correlate with and support the tinnitus diagnosis, as hearing loss and tinnitus frequently co-occur, particularly when noise-induced.
Specialist evaluation: Audiologists from Attune Hearing (2013, 2015) and an audiology provider Hearing Care Professionals (2020) documented the presence of tinnitus and its characteristics. In the 2015 assessment, referral to an ENT specialist was recommended due to the asymmetry of hearing loss and presence of tinnitus.
Tinnitus impact assessment: A formal Tinnitus Functional Index (TFI) assessment performed on 19 May 2016 yielded a score of 14.8, categorized as None/Slight impact, providing objective quantification of the condition's severity.
Persistence criteria: The documentation confirms that the tinnitus has persisted for well over the three consecutive months required by the SOP definition, having been present from at least 2013 to 2020 (and presumably to the present day).
Temporal association with noise exposure: The development of tinnitus in the context of military service with significant noise exposure from weapons and aircraft further supports the diagnosis and its likely etiology.

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 peak sound pressure level at the tympanic membrane of at least 140 dB(C) before the clinical onset of tinnitus - MET

The veteran occupation as an Airfield Defence Guard involved weapons firing, which typically generates peak sound pressure levels exceeding 140 dB(C). The Health Surveillance Questionnaires consistently document exposure to noise, including weapons range activities.

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 tinnitus - MET

As an Airfield Defence Guard since 1997, the veteran had prolonged exposure to aircraft noise and military operations. Post-deployment health screens specifically note daily exposure above normal duty levels to "Excessive Noise and Vibration" with comments like "Proximity to flightline; periodic noise exposure" and "A/C noise." This exposure would easily exceed the six-month cumulative period required.

having sensorineural hearing loss or conductive hearing loss at the time of the clinical onset of tinnitus - MET

Audiological evaluations consistently documented bilateral high-frequency sensorineural hearing loss, which was present at the time tinnitus was first reported. The pattern of hearing loss (notch at 4kHz) is typical of noise-induced hearing damage.

being exposed to second-hand smoke - NOT MET

There is no documentation of significant second-hand smoke exposure in the medical records.

having a vascular, muscular or other anatomical source of sound that can be transmitted to the affected ear at the time of the clinical onset of tinnitus - NOT MET

No evidence of such conditions is present in the medical records.

having an autoimmune disease at the time of the clinical onset of tinnitus - NOT MET

No autoimmune conditions are documented.

inability to obtain appropriate clinical management for tinnitus - NOT MET

The records show appropriate and timely clinical management with audiological assessments and monitoring.

Based on the comprehensive review of the veteran medical records and relevant SOPs, the primary causes of his tinnitus are:

Prolonged occupational exposure to hazardous noise levels from weapons firing and aircraft operations during his service as an Airfield Defence Guard in the RAAF.
The presence of bilateral high-frequency sensorineural hearing loss, which is strongly associated with tinnitus development and is itself likely noise-induced.

These factors meet multiple criteria in the Statement of Principles concerning tinnitus. There is no evidence of pre-existing tinnitus prior to service, as indicated by the negative response to "ringing in the ears" on his enlistment medical questionnaire.

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

Sequelae

There is no evidence that the tinnitus is a sequela of another primary condition. While the tinnitus co-exists with sensorineural hearing loss, they are both likely direct consequences of noise exposure rather than one being secondary to the other.

Unintended Consequence

There is no evidence that the tinnitus is an unintended consequence of medical management. The available records do not indicate any medications or treatments that would have caused or exacerbated tinnitus.

Inability to Attain Appropriate Medical Management

There is no evidence of inability to attain appropriate medical management for tinnitus. The medical records demonstrate appropriate audiological evaluation and monitoring of the condition over time. The fact that the condition has remained mild (TFI score of 14.8) suggests that management has been reasonably effective.

The Full Federal Court in Brew v Repatriation Commission (14 May 1993) (see the judgement of Merkel J) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. In this case, there are no objective or subjective barriers to treatment identified in the records, and the veteran has received appropriate audiological care.

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

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

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