Diagnostic Assessment — Left Otitis Externa
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Otitis Externa BOP Code: 26 of 2021 (Otitis Externa) RH Code: 25 of 2021 (Otitis Externa)
ADF History
The veteran, date of birth [withheld], Royal Australian Navy, Steward, 17 January 1986 to 2 November 1992
History
The veteran experienced left otitis externa during ADF service.
On 19 October 1986, whilst on leave in a supply ship, he was diagnosed with bilateral otitis externa by the treating doctor.
Bayldon and treated with Sofradex (the record gives his unit as a supply ship).
On 12 April 1987, aboard a supply ship, left otitis externa and pharyngitis were diagnosed and treated with capsules and Sofradex drops.
As per the right otitis externa, naval service involves exposure to water, humidity, and conditions predisposing to otitis externa.
On 23 March 1992, possible early left otitis media was documented alongside confirmed right otitis media, indicating bilateral ear involvement
Timeline
19 Oct 1986 — Whilst on leave in a supply ship, bilateral otitis externa diagnosed by the treating doctor.
Bayldon (unit a supply ship).
Treated with Sofradex. "Bi-lat. otitis externa" 12 Apr 1987 — Left otitis externa and pharyngitis diagnosed aboard a supply ship.
Treated with 250 mg capsules four times daily and Sofradex drops three times daily. "(L) otitis externa" 23 Mar 1992 — Bilateral painful ears.
Right otitis media confirmed.
Possible early left otitis media also noted. "Possible early left otitis media" 1 3.
As per Right Otitis Externa above, applied to left side.
Left Otitis Externa (ICD-10: H60.92).
Symptom onset on or before 19 October 1986, when he first presented and bilateral otitis externa was clinically diagnosed by the treating doctor.
Bayldon whilst he was on leave in a supply ship; left otitis externa was diagnosed again on 12 April 1987 aboard a supply ship.
DRCA legislation.
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 16 April 2006 (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 Otitis Externa, No.
26 of 2021) Factor 9(1): participating in aquatic activities within the ten days before the clinical onset of otitis externa — MET - Aquatic activities include swimming and anything that submerges the ear opening or leaves water in the canal.
The Daily Medical Record of 19 October 1986 records otitis externa in both ears, including the left, treated with Sofradex ear drops.
His activities in the preceding ten days are not recorded, but he was on summer leave in a supply ship, a tropical coastal city, and simultaneous inflammation of both canals is the typical pattern of water retained after swimming.
It is more probable than not that he swam within the ten days before the clinical onset; the absence of a record is not evidence that he did not.
Factor 9(2): being exposed to hot and humid weather conditions or heavy rains, on at least ten days within the 30 days before the clinical onset of otitis externa — MET - Hot and humid weather conditions means a maximum temperature above 30°C with humidity above 40 per cent.
The veteran was at a supply ship in Western Australia on 24 September 1986 and on leave in his home town of a supply ship when treated on 19 October 1986; the leave dates are not recorded, but it is a reasonable inference that he spent the Christmas and New Year period there. a supply ship is then in its wet season, with average maximum temperatures of about 31 to 32°C, afternoon humidity of 60 per cent or more and heavy rain, so it is more probable than not that he was exposed to such conditions on at least ten of the 30 days before the clinical onset.
Factor 9(3): undergoing a course of therapeutic radiation for cancer, where the affected ear was in the field of radiation, before the clinical onset of otitis externa — NOT MET - There is no record of cancer or of radiotherapy before the clinical onset in October 1986, when he was a healthy junior sailor, and nothing in his history suggests it.
Factor 9(4): having trauma to the external auditory canal of the affected ear within the ten days before the clinical onset of otitis externa — NOT MET - No injury to the left ear canal, such as a blunt or penetrating injury, surgery or blast, is recorded in the ten days before the clinical onset, and nothing in his history suggests one.
Factor 9(5): having a foreign object or implement inserted into, or removed from, the external ear canal of the affected ear within the ten days before the clinical onset of otitis externa — NOT MET - There is no record of ear syringing, cotton-bud use or any other object being inserted into or removed from the left ear canal in the ten days before the clinical onset, and no basis to infer it.
Factor 9(6): blocking the external auditory canal of the affected ear with an extrinsic aural device for a cumulative period of at least 16 hours within the seven days before the clinical onset of otitis externa — NOT MET - the veteran was on leave at the time, and there is no record that he wore ear plugs, headphones, hearing protection or a hearing aid on the left ear for 16 hours in the seven days before the clinical onset.
Factor 9(7): having an acquired, persistent narrowing or obstruction of the external auditory canal of the affected ear at the time of the clinical onset of otitis externa — NOT MET - No narrowing or obstruction of the left ear canal, such as impacted wax, exostosis or a growth, is recorded at the time of the clinical onset, and his hearing was within the service standard on his enlistment audiogram of January 1986.
Factor 9(8): having an inflammatory skin disease at the time of the clinical onset of otitis externa, where the skin disease involves the external auditory canal of the affected ear — NOT MET - No eczema, dermatitis, psoriasis or other inflammatory skin disease involving the left ear canal is recorded at the time of the clinical onset or at any other time.
Factor 9(9): having an infectious, autoimmune or granulomatous disease at the time of the clinical onset of otitis externa, where the disease involves the external auditory canal of the affected ear — NOT MET - No herpes zoster, relapsing polychondritis, sarcoidosis or other infectious, autoimmune or granulomatous disease involving the left ear canal is recorded; the infection treated in October 1986 was the otitis externa itself.
Factor 9(10): having chronic suppurative otitis media, involving the middle ear of the affected side, within the 30 days before the clinical onset of otitis externa — NOT MET - There is no record of chronic suppurative otitis media (a perforated eardrum with aural discharge) in the left middle ear in the 30 days before the clinical onset, or at any other time.
Factor 9(11): having diabetes mellitus at the time of the clinical onset of otitis externa — NOT MET - Diabetes mellitus was diagnosed in 2022, some 35 years after the clinical onset, and urinalysis in service was normal.
Factor 9(12): being in an immunocompromised state as specified at the time of the clinical onset of otitis externa — NOT MET - There is no record of immunosuppressive treatment, malignancy, chronic renal failure, HIV infection, severe malnutrition or transplantation at the time of the clinical onset, and nothing suggests an immunocompromised state.
Factor 9(13): for otomycosis only, taking a course of oral antibiotic therapy or having ototopical therapy for the treatment of otitis externa of the affected ear within the two weeks before the clinical onset of otitis externa — NOT MET - This factor applies only to otomycosis (fungal otitis externa); the veteran's left otitis externa was not diagnosed as fungal, and no antibiotic or ear-drop treatment is recorded in the two weeks before the clinical onset.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Otitis Externa, No.
25 of 2021) 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): participating in aquatic activities within the ten days before the clinical onset of otitis externa — MET - Otitis externa was diagnosed in both ears, including the left, on 19 October 1986, while the veteran was on summer leave in a supply ship, a tropical coastal city.
Simultaneous inflammation of both ear canals is the typical pattern of water retained after swimming, and although his activities are not recorded, it is a reasonable hypothesis that he participated in aquatic activities such as swimming within the ten days before the clinical onset.
Factor 9(2): being exposed to hot and humid weather conditions or heavy rains, on at least ten days within the 30 days before the clinical onset of otitis externa — MET - The record places the veteran on leave in a supply ship on 19 October 1986, after he was last recorded at a supply ship on 24 September 1986, and it is reasonable to infer that his leave covered the Christmas and New Year period. a supply ship is then in its wet season, with maximum temperatures usually above 30°C, humidity well above 40 per cent and heavy rain, so it is a reasonable hypothesis that he was exposed to hot and humid weather conditions or heavy rains on at least ten of the 30 days before the clinical onset.
Factor 9(3): undergoing a course of therapeutic radiation for cancer, where the affected ear was in the field of radiation, before the clinical onset of otitis externa — NOT MET - the veteran had no cancer and no radiotherapy before the clinical onset in October 1986, and nothing in his history suggests it.
Factor 9(4): having trauma to the external auditory canal of the affected ear within the ten days before the clinical onset of otitis externa — NOT MET - There is no record of trauma to the left external auditory canal in the ten days before the clinical onset, and nothing suggests it.
Factor 9(5): having a foreign object or implement inserted into, or removed from, the external ear canal of the affected ear within the ten days before the clinical onset of otitis externa — NOT MET - No object or implement inserted into, or removed from, the left ear canal is recorded in the ten days before the clinical onset, and there is no basis to infer one.
Factor 9(6): blocking the external auditory canal of the affected ear with an extrinsic aural device for a cumulative period of at least eight hours within the seven days before the clinical onset of otitis externa — NOT MET - There is no record that he blocked the left ear canal with ear plugs, headphones, hearing protection or a hearing aid for eight hours in the seven days before the clinical onset, while he was on leave.
Factor 9(7): having an acquired, persistent narrowing or obstruction of the external auditory canal of the affected ear at the time of the clinical onset of otitis externa — NOT MET - There is no record of an acquired, persistent narrowing or obstruction of the left ear canal at the time of the clinical onset, and nothing suggests one.
Factor 9(8): having an inflammatory skin disease at the time of the clinical onset of otitis externa, where the skin disease involves the external auditory canal of the affected ear — NOT MET - There is no record of an inflammatory skin disease involving the left ear canal at the time of the clinical onset.
Factor 9(9): having an infectious, autoimmune or granulomatous disease at the time of the clinical onset of otitis externa, where the disease involves the external auditory canal of the affected ear — NOT MET - There is no record of a separate infectious, autoimmune or granulomatous disease involving the left ear canal at the time of the clinical onset.
Factor 9(10): having chronic suppurative otitis media, involving the middle ear of the affected side, within the 30 days before the clinical onset of otitis externa — NOT MET - No chronic suppurative otitis media of the left middle ear is recorded in the 30 days before the clinical onset.
Factor 9(11): having diabetes mellitus at the time of the clinical onset of otitis externa — NOT MET - the veteran did not have diabetes mellitus at the clinical onset in October 1986; it was diagnosed in 2022.
Factor 9(12): being in an immunocompromised state as specified at the time of the clinical onset of otitis externa — NOT MET - the veteran was not in an immunocompromised state as specified at the clinical onset; none of the specified conditions or treatments is recorded.
Factor 9(13): for otomycosis only, taking a course of oral antibiotic therapy or having ototopical therapy for the treatment of otitis externa of the affected ear within the 30 days before the clinical onset of otitis externa — NOT MET - This factor applies only to otomycosis; the left otitis externa was not diagnosed as a fungal infection, and no antibiotic or ototopical treatment is recorded in the 30 days before the clinical onset.
Other Plausible Links to Service the veteran's left otitis externa first appeared during his full-time naval service.
No ear disease was recorded at his enlistment examinations in January and January 1986.
The condition was diagnosed on 19 October 1986, while he was a junior sailor on leave from a supply ship, by the treating doctor.
Bayldon, who later treated him aboard a supply ship and during his a supply ship-based service; it was recorded on a naval Daily Medical Record, and on his return to duty a service medical record officer recorded the sickness on shore and cleared him for duty on 23 November 1986.
The left otitis externa recurred on 12 April 1987 aboard the survey ship a supply ship, in the course of his duties at sea as a Steward, and required oral erythromycin and Sofradex ear drops.
That service carried the conditions that promote recurrence of otitis externa, which is common enough in hot, humid climates to be known as 'tropical ear': work in the water (tide-pole diving with a snorkel and SCUBA diving, recorded on 31 August 1987), sea spray, wet decks, humid living spaces and shared showers.
He remained in tropical service in a supply ship until May 1989.
Repeated wetting strips the canal of its protective wax and macerates its skin, so a canal once infected is prone to further episodes, and both ears were again red and swollen in August 1990.
Conclusion the veteran's left otitis externa began, together with the right, during his full-time naval service, while he was on leave in a supply ship in the tropical wet season, and is best explained by water retained in the ear canals and hot, humid weather, the two onset factors met by analogy.
It recurred in the left ear on 12 April 1987 aboard the survey ship a supply ship, where his duties involved work in the water, and both ears were inflamed again in August 1990; these recurrences arose in the course of his service and were managed without investigation, specialist referral or preventive advice.
Service was therefore the setting of its onset, and service conditions caused or contributed to its recurrence and worsening.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's left otitis externa is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (on or before 19 October 1986) aggravated it or contributed to it in a material degree.
The left otitis externa recurred aboard the survey ship a supply ship on 12 April 1987, both ears were red and swollen in August 1990, and possible early left otitis media was recorded in March 1992.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Otitis Externa, No.
26 of 2021) Factor 9(14): participating in aquatic activities within the ten days before the clinical worsening of otitis externa — MET - The left otitis externa recurred on 12 April 1987 aboard the a supply ship-based survey ship a supply ship and required oral erythromycin and Sofradex ear drops (Daily Medical Record of that date), a measurable worsening.
His duties there as a Steward involved work in the water: the Daily Medical Record of 31 August 1987 records him diving on a tide pole with a snorkel and on SCUBA, and a diving medical was arranged in July 1987.
His activities in the ten days before 12 April 1987 are not recorded, but it is more probable than not, from these documented duties at sea in tropical waters, that his ears had been submerged in water during that period.
Factor 9(15): being exposed to hot and humid weather conditions or heavy rains, on at least ten days within the 30 days before the clinical worsening of otitis externa — NOT MET - Neither the recurrence of 12 April 1987, in the north Queensland dry season (when temperatures above 30°C are uncommon), nor the inflammation of August 1990 in a Sydney spring is shown to have followed ten days of hot and humid weather or heavy rain.
Factor 9(16): undergoing a course of therapeutic radiation for cancer, where the affected ear was in the field of radiation, before the clinical worsening of otitis externa — NOT MET - There is no record of radiotherapy to the head or ears at any time; his skin cancer of the left hand in 2026 was treated by excision.
Factor 9(17): having trauma to the external auditory canal of the affected ear within the ten days before the clinical worsening of otitis externa — NOT MET - No injury to the left ear canal is recorded in the ten days before the recurrence of 12 April 1987 or the inflammation of August 1990; the barotrauma of August 1987 affected the middle ear.
Factor 9(18): having a foreign object or implement inserted into, or removed from, the external ear canal of the affected ear within the ten days before the clinical worsening of otitis externa — NOT MET - There is no record of ear syringing, cotton-bud use or any other object in the left ear canal in the ten days before the recurrence of March 1987 or the inflammation of August 1990.
Factor 9(19): blocking the external auditory canal of the affected ear with an extrinsic aural device for a cumulative period of at least 16 hours within the seven days before the clinical worsening of otitis externa — NOT MET - There is no record that he wore ear plugs, headphones, hearing protection or a hearing aid on the left ear for 16 hours in the seven days before a clinical worsening, and he has never had a hearing aid.
Factor 9(20): having an acquired, persistent narrowing or obstruction of the external auditory canal of the affected ear at the time of the clinical worsening of otitis externa — NOT MET - No narrowing or obstruction of the left ear canal is recorded after the onset, and his hearing was within the service standard on audiograms in 1987 and 1989 and at discharge in October 1992.
Factor 9(21): having an inflammatory skin disease at the time of the clinical worsening of otitis externa, where the skin disease involves the external auditory canal of the affected ear — NOT MET - No dermatitis (including contact dermatitis from the Sofradex drops), eczema, psoriasis or other inflammatory skin disease of the left ear canal is recorded at any time.
Factor 9(22): having an infectious, autoimmune or granulomatous disease at the time of the clinical worsening of otitis externa, where the disease involves the external auditory canal of the affected ear — NOT MET - No herpes zoster, relapsing polychondritis, sarcoidosis or similar disease involving the left ear canal is recorded; the illness of August 1990 was a respiratory infection.
Factor 9(23): having chronic suppurative otitis media, involving the middle ear of the affected side, within the 30 days before the clinical worsening of otitis externa — NOT MET - No chronic suppurative otitis media is recorded; the possible early left otitis media of 23 March 1992 was acute, without recorded perforation or discharge.
Factor 9(24): having diabetes mellitus at the time of the clinical worsening of otitis externa — NOT MET - Diabetes mellitus was diagnosed in 2022, about 30 years after the in-service episodes, and no worsening of otitis externa has been recorded since then.
Factor 9(25): being in an immunocompromised state as specified at the time of the clinical worsening of otitis externa — NOT MET - No immunosuppressive treatment, malignancy, chronic renal failure, HIV infection, severe malnutrition or transplantation is recorded at the time of any worsening; the local corticosteroid injections of 2019 were not followed by any recorded ear infection.
Factor 9(26): for otomycosis only, taking a course of oral antibiotic therapy or having ototopical therapy for the treatment of otitis externa of the affected ear within the two weeks before the clinical worsening of otitis externa — NOT MET - This factor applies only to otomycosis (fungal otitis externa); the recurrence of March 1987 was not diagnosed as fungal and came about six months after the Sofradex treatment of October 1986, well outside the two-week window.
Factor 9(27): inability to obtain appropriate clinical management for otitis externa — MET - Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic.
The left otitis externa recurred aboard the survey ship a supply ship in March 1987, and his ears were red and swollen with earache in August 1990 and painful in March 1992, yet these presentations received only short courses of drops, antibiotics or symptomatic treatment, without a swab, specialist referral or advice to protect the ears during the diving and water work his survey duties required.
Sea postings and the loss of his medical record (PM168) in December 1991 further impeded continuity of care.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Otitis Externa, No.
25 of 2021) 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(14): participating in aquatic activities within the ten days before the clinical worsening of otitis externa — MET - The left otitis externa recurred on 12 April 1987 aboard the survey ship a supply ship, requiring oral erythromycin and Sofradex drops.
His survey duties on that ship involved immersion in water, including tide-pole work with a snorkel and SCUBA diving recorded in August 1987, so it is a reasonable hypothesis that he participated in aquatic activities within the ten days before this worsening, although the activity itself is not recorded.
Factor 9(15): being exposed to hot and humid weather conditions or heavy rains, on at least ten days within the 30 days before the clinical worsening of otitis externa — NOT MET - Neither the left-sided recurrence of March 1987, in the north Queensland dry season, nor the inflammation of August 1990 in Sydney is shown to have followed ten days of hot and humid weather or heavy rain.
Factor 9(16): undergoing a course of therapeutic radiation for cancer, where the affected ear was in the field of radiation, before the clinical worsening of otitis externa — NOT MET - the veteran has never undergone a course of radiotherapy with the left ear in the field of radiation, and nothing suggests it.
Factor 9(17): having trauma to the external auditory canal of the affected ear within the ten days before the clinical worsening of otitis externa — NOT MET - There is no record of trauma to the left external auditory canal in the ten days before the recurrence of March 1987 or the inflammation of August 1990.
Factor 9(18): having a foreign object or implement inserted into, or removed from, the external ear canal of the affected ear within the ten days before the clinical worsening of otitis externa — NOT MET - No object or implement inserted into, or removed from, the left ear canal is recorded in the ten days before the recurrence of March 1987 or the inflammation of August 1990.
Factor 9(19): blocking the external auditory canal of the affected ear with an extrinsic aural device for a cumulative period of at least eight hours within the seven days before the clinical worsening of otitis externa — NOT MET - There is no record that he blocked the left ear canal with ear plugs, headphones, hearing protection or a hearing aid for eight hours in the seven days before a clinical worsening.
Factor 9(20): having an acquired, persistent narrowing or obstruction of the external auditory canal of the affected ear at the time of the clinical worsening of otitis externa — NOT MET - There is no record of an acquired, persistent narrowing or obstruction of the left ear canal at the time of any clinical worsening.
Factor 9(21): having an inflammatory skin disease at the time of the clinical worsening of otitis externa, where the skin disease involves the external auditory canal of the affected ear — NOT MET - There is no record of an inflammatory skin disease involving the left ear canal at the time of any clinical worsening.
Factor 9(22): having an infectious, autoimmune or granulomatous disease at the time of the clinical worsening of otitis externa, where the disease involves the external auditory canal of the affected ear — NOT MET - There is no record of a separate infectious, autoimmune or granulomatous disease involving the left ear canal at the time of any clinical worsening.
Factor 9(23): having chronic suppurative otitis media, involving the middle ear of the affected side, within the 30 days before the clinical worsening of otitis externa — NOT MET - No chronic suppurative otitis media of the left middle ear is recorded; the possible early otitis media of March 1992 was acute.
Factor 9(24): having diabetes mellitus at the time of the clinical worsening of otitis externa — NOT MET - No clinical worsening of otitis externa is recorded at or after 2022, when diabetes mellitus was diagnosed.
Factor 9(25): being in an immunocompromised state as specified at the time of the clinical worsening of otitis externa — NOT MET - the veteran was not in an immunocompromised state as specified at the time of any recorded worsening of otitis externa.
Factor 9(26): for otomycosis only, taking a course of oral antibiotic therapy or having ototopical therapy for the treatment of otitis externa of the affected ear within the 30 days before the clinical worsening of otitis externa — NOT MET - This factor applies only to otomycosis; the left recurrence of March 1987 was not diagnosed as fungal and came about six months after the ototopical treatment of October 1986, outside the 30-day window.
Factor 9(27): inability to obtain appropriate clinical management for otitis externa — MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), which requires inability to be assessed objectively and subjectively, the veteran was unable to obtain appropriate clinical management of his left otitis externa.
Its recurrence on a survey ship in March 1987 and his further ear presentations of August 1990 and March 1992 led to no swab, specialist referral or advice to protect the ears during his diving and water work, while sea postings and the loss of his medical record in December 1991 impeded continuity of care
Sequelae, Unintended Consequence, Inability
As per Right Otitis Externa
Date of Clinical Onset
Left otitis externa is an infective condition.
Its date of clinical onset is the date on which it first appeared, which is no later than the date on which it was first recorded in the service medical records.
Later treatment, investigation or imaging does not alter the date of clinical onset.
First documented: 19 October 1986 — bilateral otitis externa treated with Sofradex by the treating doctor.
Bayldon whilst on leave in a supply ship [CHART REVIEW document].
The later records, including the further episode of left otitis externa aboard a supply ship on 12 April 1987, do not alter the date of clinical onset.
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 19 October 1986.
This date falls within the veteran's ADF service (17 January 1986 2 November 1992).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
