Diagnostic Assessment — Left Barotrauma
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Barotrauma BOP Code: 87 of 2020 (Otitic Barotrauma) RH Code: 86 of 2020 (Otitic Barotrauma)
ADF History
The veteran, date of birth [withheld], Australian Army, Artilleryman, 28 November 1987 to 13 September 1994
Occupational History
As an Artilleryman in the Australian Army, the veteran was exposed to pressure changes during diving operations, submarine operations, and altitude changes during military transport.
Australian Army service inherently involves exposure to barometric pressure changes that can cause barotrauma to the ears, sinuses, and lungs
History
The veteran experienced left barotrauma during ADF service.
Barotrauma is injury caused by changes in barometric or hydrostatic pressure, commonly affecting the ears and sinuses.
The condition is a well-recognised occupational hazard of naval service.
On 11 July 1989, aboard an artillery regiment, he was diagnosed with middle ear barotrauma, recorded as Grade 3 on the left and Grade 1 on the right.
He had had trouble with Valsalva while diving on the tide pole two days earlier (snorkel only) and had been diving on SCUBA that day; Valsalva was painful and frontal sinus barotrauma was also noted.
He was treated with Panadine as required, with daily review, and made unfit to dive.
Additionally, the veteran has documented chronic paranasal sinus disease with bilateral maxillary sinus disease, ethmoidal mucosal thickening, and sphenoidal mucosal thickening from 2013 onwards, which predisposes to Eustachian tube dysfunction and barotrauma
Timeline
During service (1988 1995) — The veteran served aboard multiple service vessels including an artillery regiment and an artillery regiment (Artilleryman vessels) and at various shore establishments.
Australian Army duties involving pressure changes are inherent to maritime service.
11 Jul 1989 — ABSR the veteran was seen aboard an artillery regiment after diving on SCUBA, having had trouble with Valsalva while diving on the tide pole two days earlier (snorkel only).
Valsalva was painful.
Middle ear barotrauma was diagnosed, Grade 3 on the left and Grade 1 on the right, and frontal sinus barotrauma was also noted.
Treated with Panadine as required, with daily review; unfit to dive. "Middle ear Barotrauma.
Grade 3 (L) Grade 1 (R)"
1. What is the formal diagnosis of the condition claimed above?
Left Barotrauma (ICD-10: T70.0XXA).
Barotrauma is tissue injury caused by a change in ambient pressure, most commonly affecting the middle ear (otic barotrauma).
2 3.
Dates, confirmation: During ADF service: first documented symptoms were trouble with Valsalva while diving on the tide pole about 9 July 1989; first presentation and clinical diagnosis on 11 July 1989 aboard an artillery regiment (middle ear barotrauma, Grade 3 on the left and Grade 1 on the right, after diving on SCUBA).
DRCA legislation.
Occupational exposure to pressure changes during naval service.
100% service-related
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 25 February 2008 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Otitic Barotrauma, No.
87 of 2020) Factor 9(1): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical onset of otitic barotrauma — MET - The Daily Medical Record made aboard the survey ship an artillery regiment on 11 July 1989 records that about 9 July 1989 the veteran had been diving on the tide pole (snorkel only) and had trouble equalising his ears by the Valsalva manoeuvre.
Underwater diving is listed in the definition of a change in ambient barometric pressure as specified, and the largest proportional pressure changes occur in the first few metres of descent.
The pressure change occurred during the dive in which the difficulty arose, within the 24 hours before the clinical onset of his left otitic barotrauma; if the onset were instead taken as 11 July 1989, that day's SCUBA dive would equally satisfy the factor.
Factor 9(2): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical onset of otitic barotrauma — NOT MET - There is no record of exposure to blast from an explosion or a lightning strike in the 24 hours before about 9 July 1989; the injury arose while diving.
Factor 9(3): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical onset of otitic barotrauma — NOT MET - There is no record of mechanical ventilation, anaesthesia or CPAP in the 24 hours before about 9 July 1989; he was diving with a snorkel only.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Otitic Barotrauma, No.
86 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical onset of otitic barotrauma — MET - About 9 July 1989, while serving aboard the survey ship an artillery regiment, the veteran was diving on the tide pole (snorkel only) and had trouble equalising his ears, as recorded in the Daily Medical Record of 11 July 1989.
Underwater diving is a change in ambient barometric pressure as specified, and it occurred during the dive in which the left ear injury began, within the 24 hours before the clinical onset.
Factor 9(2): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical onset of otitic barotrauma — NOT MET - There is no record of exposure to blast from an explosion or a lightning strike in the 24 hours before about 9 July 1989; the injury arose while diving.
Factor 9(3): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical onset of otitic barotrauma — NOT MET - There is no record of mechanical ventilation, anaesthesia or CPAP in the 24 hours before about 9 July 1989; he was diving with a snorkel only.
Other Plausible Links to Service The injury arose out of, and in the course of, the veteran's employment as a member.
A tide pole is a graduated staff fixed in the water to record the height of the tide during an Artilleryman, and diving on it was a surveying task carried out from the survey ship an artillery regiment, in which he was serving.
The ship had arranged his diving medical in May 1989 (chest X-ray and audiogram of 13 May 1989), which shows that diving formed part of his duties in that ship, and the SCUBA dive of 11 July 1989 was also made while he was serving aboard.
Service also aggravated the injury.
After first having trouble equalising, he dived again on SCUBA two days later, before any medical assessment, and the left ear progressed to a Grade 3 injury with frontal sinus barotrauma, after which the ship's medical sailor made him unfit to dive.
Both the injury and its aggravation came from pressure exposures encountered while he was serving in the ship, and no cause unrelated to service is identified; his chronic paranasal sinus disease was first shown on imaging in October 2012, more than 23 years later.
Conclusion the veteran's left otitic barotrauma was caused by diving in the course of his duties as an Artilleryman aboard an artillery regiment: he had trouble equalising while diving on the tide pole about 9 July 1989, and a further SCUBA dive two days later, before any medical assessment, produced a Grade 3 injury of the left middle ear, with Grade 1 on the right and frontal sinus barotrauma.
The change in ambient barometric pressure factors are met for both clinical onset and clinical worsening, and no cause unrelated to service is identified.
The injury therefore arose out of, and in the course of, his service.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's left otitic barotrauma is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (about 9 July 1989) aggravated it or contributed to it in a material degree.
The Daily Medical Record of 11 July 1989 records a Grade 3 injury of the left middle ear after a further dive on SCUBA, two days after he first had trouble equalising.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Otitic Barotrauma, No.
87 of 2020) Factor 9(4): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical worsening of otitic barotrauma — MET - Two days after first having trouble equalising, and before any medical assessment, the veteran dived on SCUBA while serving aboard an artillery regiment on 11 July 1989.
That day's Daily Medical Record found the Valsalva manoeuvre painful, graded the left middle-ear barotrauma as Grade 3 (on the standard grading, gross haemorrhage within the eardrum), with Grade 1 on the right and frontal sinus barotrauma, and made him unfit to dive.
SCUBA diving is a change in ambient barometric pressure as specified; it occurred within the 24 hours before this clinical worsening, in which the left ear progressed from difficulty equalising to a Grade 3 injury.
Factor 9(5): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical worsening of otitic barotrauma — NOT MET - There is no record of exposure to blast from an explosion or a lightning strike before any clinical worsening of his left otitic barotrauma; the worsening on 11 July 1989 followed diving.
Factor 9(6): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical worsening of otitic barotrauma — NOT MET - Breathing from a SCUBA demand regulator on 11 July 1989 is not mechanical ventilation, and no ear symptoms were recorded after his operations under anaesthesia in 1990 to 1992 or with any later CPAP use.
Factor 9(7): inability to obtain appropriate clinical management for otitic barotrauma — NOT MET - the veteran was assessed aboard an artillery regiment on 11 July 1989, the day he reported the injury, and received the essential management (removal from diving, analgesia and daily review); it resolved, with normal hearing in April 1991 and at discharge and a positive Valsalva manoeuvre in both ears on 13 September 1994.
Although at sea he was treated by the ship's medical sailor rather than a medical officer, applying the objective and subjective test in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there is no evidence that he was unable to obtain appropriate management or that this worsened the injury.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Otitic Barotrauma, No.
86 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(4): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical worsening of otitic barotrauma — MET - On 11 July 1989, two days after first having trouble equalising and before any medical assessment, the veteran dived on SCUBA while serving aboard an artillery regiment; the same day the left middle-ear barotrauma was recorded as Grade 3, with a painful Valsalva manoeuvre, and he was made unfit to dive.
The SCUBA dive was a change in ambient barometric pressure as specified within the 24 hours before this clinical worsening.
Factor 9(5): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical worsening of otitic barotrauma — NOT MET - There is no record of exposure to blast from an explosion or a lightning strike before any clinical worsening of his left otitic barotrauma; the worsening on 11 July 1989 followed diving.
Factor 9(6): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical worsening of otitic barotrauma — NOT MET - Breathing from a SCUBA demand regulator on 11 July 1989 is not mechanical ventilation, and no ear symptoms were recorded after his operations under anaesthesia in 1990 to 1992 or with any later CPAP use.
Factor 9(7): inability to obtain appropriate clinical management for otitic barotrauma — NOT MET - the veteran was assessed aboard an artillery regiment on 11 July 1989, the day he reported the injury, and received the essential management (removal from diving, analgesia and daily review); it resolved, with normal hearing in April 1991 and at discharge and a positive Valsalva manoeuvre in both ears on 13 September 1994.
Although at sea he was treated by the ship's medical sailor rather than a medical officer, applying the objective and subjective test in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there is no evidence that he was unable to obtain appropriate management or that this worsened the injury
Sequelae, Unintended Consequence, Inability
No sequelae are documented, and the injury is not an unintended consequence of medical treatment.
Inability to obtain appropriate clinical management: NOT MET.
The veteran was assessed aboard an artillery regiment on 11 July 1989, the day he reported the injury, and was made unfit to dive, given analgesia and placed on daily review; the injury resolved, with normal hearing in April 1991 and a positive Valsalva manoeuvre in both ears at discharge.
The loss of his medical record at an artillery regiment in October 1993 occurred more than four years later and did not affect his management
Date of Clinical Onset
Left barotrauma is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: approximately 9 July 1989 — difficulty equalising (Valsalva) whilst diving on the tide pole, with middle ear barotrauma (Grade 3 left, Grade 1 right) diagnosed aboard an artillery regiment on 11 July 1989 [CHART REVIEW document].
Date of clinical onset: approximately 9 July 1989.
This date falls within the veteran's ADF service (28 November 1987 13 September 1994).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
