Diagnostic Assessment — Left Eyebrow - Epidermal Cyst
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Eyebrow — Epidermal Cyst BOP Code: N/A (there is no Statement of Principles for this condition) RH Code: N/A
ADF History
The veteran, date of birth [withheld], Australian Army, Transport Driver, 2 October 1989 to 18 July 1996
Occupational History
Epidermal cysts (epidermoid cysts) are benign subcutaneous cysts that can develop spontaneously or following trauma to the skin.
The service records document facial trauma during service, including a blow to the left forehead with swelling above the left eyebrow in a rugby scrum on 28 October 1989; boxing is recorded only in the veteran's own account in 2019 and is not documented in the service records
History
The veteran had a lesion excised from the left eyebrow during ADF service on 2 January 1994 under general anaesthetic at RANH a logistics unit by the treating doctor.
The discharge summary documented this as a "mole" (ICD diagnosis: mole left eyebrow).
The DVA claim is for "Left Eyebrow Epidermal Cyst." Histopathology of the specimen (labelled "mole left eyebrow"), reported on 5 January 1994, showed a dermal naevus and an underlying benign epidermal cyst, confirming an epidermal cyst of the left eyebrow; the lesions were benign.
The excision was performed during ADF service at Commonwealth expense.
Five sutures were removed from the left eyebrow at a logistics unit on 9 January 1994
Timeline
02 Jan 1994 — Excision of lesion from left eyebrow performed by the treating doctor general anaesthetic at RANH a logistics unit.
Uneventful recovery.
Suture removal in 7 days. "Excision mole left eyebrow" 05 Jan 1994 — Histopathology report (Hanly Moir Pathology, the treating doctor.
Feain) on the specimen labelled "mole left eyebrow": an ellipse of skin 13 x 10 mm with a raised tan lesion 8 x 7 mm.
Diagnosis: dermal naevus and epidermal cyst of the left eyebrow skin; the lesions were benign. "The sections show a dermal naevus and an underlying benign epidermal cyst" 09 Jan 1994 — Removal of sutures (x5) from the left eyebrow at a logistics unit. "Sutures removed.
Lt eyebrow. x5"
Symptoms
The veteran had a visible lesion on the left eyebrow that was significant enough to warrant surgical excision under general anaesthetic
Imaging
No imaging related to this condition
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Eyebrow Epidermal Cyst (ICD-10: L72.0).
A lesion at the left eyebrow was excised during ADF service on 2 January 1994.
The discharge summary documented this as a "mole"; however, histopathology reported on 5 January 1994 showed a dermal naevus with an underlying benign epidermal cyst of the left eyebrow skin, confirming the diagnosis of epidermal cyst
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Prior to 2 January 1994 [ [CHART REVIEW document], pages 112 113] When did the veteran first present to a health / medical provider for this condition? Prior to 2 January 1994 (referral to surgeon) When was the condition confirmed / formally diagnosed? 5 January 1994 (histopathology: dermal naevus and underlying benign epidermal cyst of the left eyebrow; lesion excised by the treating doctor on 2 January 1994) [CHART REVIEW document] When did the veteran first present to you (or your practice) for this condition? 12 February 2021
3. How was this diagnosis confirmed?
The lesion was excised surgically on 2 January 1994 by the treating doctor, Consultant General Surgeon, at RANH a logistics unit [ [CHART REVIEW document], pages 112 113].
Histopathology reported on 5 January 1994 by the treating doctor.
Feain (Hanly Moir Pathology) showed a dermal naevus and an underlying benign epidermal cyst of the left eyebrow skin; the lesions were benign [CHART REVIEW document]
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 30 December 2009 (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.
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.
There is no Statement of Principles for an epidermal (epidermoid) cyst of the skin, and no other Statement of Principles describes it closely enough to be applied by analogy.
The question under the DRCA is whether the cyst arose out of, or in the course of, the veteran's service, or was contributed to by his service to a significant degree.
Plausible Links to Service The lesion excised from the veteran's left eyebrow at RANH a logistics unit on 2 January 1994 was described clinically as a mole, and the specimen showed a raised tan lesion 8 by 7 mm; histology reported on 5 January 1994 showed a dermal naevus with an underlying benign epidermal cyst.
Most epidermal cysts arise spontaneously from the upper part of a hair follicle, and a cyst lying beneath a dermal naevus may arise from obstruction of a follicle within the naevus.
Trauma to the skin, particularly an injury that disrupts the hair follicles or carries epidermis into the dermis, is also a recognised cause of epidermal (inclusion) cysts, which may become apparent months or years after the injury.
The records do not state the cause of this cyst, and nothing in the enlistment records refers to a lesion of the left eyebrow.
The only recorded trauma to that site is the injury of 28 October 1989, when the veteran was an adult Transport Driver at a logistics unit.
The Daily Injury Record of that date records that he was struck on the left forehead by an opponent in a rugby scrum and the scrum collapsed on top of him; he may have lost consciousness, vomited three times and had a left frontal headache, and on examination there was slight swelling above the left eyebrow.
He was admitted to sick quarters for neurological observation and discharged to light duties on 30 October 1989.
The signal of 29 October 1989 described the game as organised rugby league, whereas the Compensation Supporting Report records that he was on day leave and playing with a civilian team, so the service character of the game is not clear-cut.
His other facial injuries in service, a blow to the upper jaw in a fight on 8 August 1990 with a fractured front tooth and a cut upper lip, and on 12 April 1992 a nosebleed after a fight and, in the dental record of the same day, a cricket ball to the face that broke lower teeth, involved other parts of the face and are not relied on.
The cyst was diagnosed and treated during service.
The elective excision under general anaesthetic at RANH a logistics unit, the histology and the removal of five sutures at a logistics unit on 9 January 1994 were provided and paid for by the Commonwealth, and the permanent scar at the left eyebrow is a consequence of that treatment.
There is no record that the cyst became inflamed or infected, or was otherwise aggravated by his duties, before it was removed, and no recurrence is recorded.
Conclusion The records do not state the cause of the veteran's left eyebrow epidermal cyst.
The only causal factor identified in his history is the blow to the left forehead, with swelling above the left eyebrow, sustained in organised rugby league while he was a Transport Driver at a logistics unit on 28 October 1989: trauma is a recognised cause of epidermal cysts, the site corresponds, there is no record of the lesion before service, and it was found and removed during service.
Although a spontaneous cyst beneath the naevus cannot be excluded, on the evidence available the cyst is attributed to that in-service injury, and its excision and scar are consequences of treatment provided and paid for by the Commonwealth.
The % contribution of the causes is 100% and significant
Sequelae
No specific sequelae documented.
A surgical scar at the left eyebrow is a permanent consequence of the excision, which was provided and paid for by the Commonwealth
Unintended Consequence
The excision and resulting scar were part of treatment provided and paid for by the Commonwealth during service; no complication or other unintended consequence of that treatment is recorded — NOT MET
Inability to Attain Appropriate Medical Management
The lesion was referred, excised and examined histologically during service, and the sutures were removed within a week, so there is no evidence of inability to obtain appropriate clinical management — NOT MET
Date of Clinical Onset
Left eyebrow epidermal cyst is a chronic condition.
Its date of clinical onset is the date on which the condition first manifested clinically.
It is not the date on which the condition was first imaged or formally diagnosed
Imaging
And specialist diagnosis record when an established condition was confirmed; a chronic condition is present, and usually symptomatic, for a considerable period before it is investigated, so the date of imaging must not be taken as the date of clinical onset.
First documented: 2 January 1994 — excision of the left eyebrow lesion at RANH a logistics unit (histopathology on 5 January 1994: dermal naevus with an underlying benign epidermal cyst) [ [CHART REVIEW document], pages 112 113, 115].
As the condition was already present when it was first documented, its clinical onset was no later than that date.
Date of clinical onset: on or before 2 January 1994.
This date falls within the veteran's ADF service (2 October 1989 18 July 1996).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
