Diagnostic Assessment — Nose - Deviated Nasal Septum (Post-traumatic)
Example 1 of 1 · fictitious patient (Veteran P)
Diagnostic Assessment
Nose - Deviated Nasal Septum (Post-traumatic)
BOP Code: 63 of 2024 (Fracture)
RH Code: 62 of 2024 (Fracture)
ADF History
Veteran P, date of birth 14 June 1988, Australian Army, Infantry Soldier (Rifleman, later Section Second-in-Command), enlisted 05 February 2007, medically discharged 11 November 2021. Operational service: Afghanistan, 20 February 2012 to 26 October 2012 (warlike).
Occupational History
As an infantry soldier the veteran carried loads of 35 to 50 kilograms on foot patrols, cleared compounds at close quarters, travelled in protected mobility vehicles exposed to improvised explosive device blast, and fired and maintained weapons with the sight held close to the face. Pre-deployment and unit training included the Army combatives and boxing programme, with repeated full-contact sparring.
Facial and head injuries are common in infantry soldiers from blast, falls, vehicle accidents, close-quarter fighting and contact sport. Deployed infantry also worked in dust, smoke and extreme heat, often with limited access to specialist care, and the service culture of the period normalised smoking on operations.
History
Veteran P, an infantry soldier in the Australian Army, sustained a comminuted fracture of the nasal bones and the bony nasal septum when an improvised explosive device blast drove his face into his weapon sight on warlike service in Afghanistan on 14 August 2012, through a fatigue-type stress fracture caused by months of full-contact boxing training. The fracture could not be reduced on deployment, progressed to non-union in 2013 and left a fixed post-traumatic deviation of the nasal septum with chronic left nasal obstruction.
Timeline
- 05 Feb 2007 — The enlistment medical examination recorded a mild developmental deviation of the external nose to the right, present since childhood, with no history of nasal fracture and a clear nasal airway on both sides. The septum was recorded as midline on anterior rhinoscopy. He was assessed as fit for infantry employment. "external nose deviated right, airway clear"
- 13 Mar 2012 — During warlike service in Afghanistan the veteran reported that he had started smoking on deployment and was smoking about 15 cigarettes a day, which the medical officer recorded. He was also continuing the unit combatives and boxing programme on the patrol base, three sessions a week, which he had begun during pre-deployment training in Australia in November 2011. He reported intermittent tenderness over the left nasal bridge and two minor nosebleeds after sparring. "smoking 15/day, sparring three times weekly"
- 28 Jun 2012 — He presented to the role 1 facility on the patrol base with a four-week history of aching over the left nasal bone, worse after sparring, and localised tenderness without deformity. The medical officer recorded that his developmental rightward nasal deviation caused straight punches to land obliquely on the left nasal bone. He was advised to stop sparring, but the programme continued as part of unit force preparation and he kept training. "left nasal bone tenderness, sparring continues"
- 14 Aug 2012 — During warlike service in Afghanistan his protected mobility vehicle struck an improvised explosive device. The blast threw him forward and drove his face into the sight of the turret-mounted weapon. He had immediate swelling, profuse epistaxis, a visible deformity of the nose and complete left nasal obstruction. CT at the role 3 hospital showed a comminuted fracture of the nasal bones and the bony nasal septum, running through an older left nasal bone fracture line with sclerotic margins consistent with a fatigue-type stress fracture. "comminuted nasal and septal fracture"
- 07 Sep 2012 — At review on the patrol base the fracture remained displaced with the bony septum deviated to the left and near-complete left nasal obstruction. Closed reduction was not available because no otorhinolaryngologist was deployed and he was not released from operations for evacuation, and the 14-day window for reduction passed. On 02 September 2012 he had been diagnosed with acute eosinophilic pneumonia after new-onset smoking and heavy dust exposure, and was commenced on prednisolone 60 mg daily. "reduction unavailable, prednisolone 60 mg"
- 12 Feb 2013 — An endocrinologist in Australia reviewed the effects of prolonged high-dose prednisolone, which had been continued for two relapses of the eosinophilic pneumonia. HbA1c was 7.6 per cent and fasting glucose 9.1 mmol/L, confirming steroid-induced diabetes mellitus, and metformin was commenced. DXA showed a lumbar spine T-score of -2.8 and the endocrinologist diagnosed glucocorticoid-induced osteoporosis. Serum 25(OH)D was 34 nmol/L. Weight 127 kg, height 1.76 m, BMI 41.0, up from 84 kg in 2011. He was still smoking 15 cigarettes a day. "steroid diabetes, osteoporosis, BMI 41.0"
- 20 May 2013 — An otorhinolaryngologist confirmed non-union of the fracture of the left nasal bone and the bony septum, nine months after the injury. CT showed persisting fracture gaps with rounded sclerotic ends and no bridging bone, and examination found a mobile left nasal bone segment. The septal deviation to the left had increased, with about 80 per cent obstruction of the left nasal airway. Repeat 25(OH)D was 38 nmol/L, HbA1c 7.9 per cent and BMI 41.3. "nasal and septal fracture non-union"
- 18 Nov 2013 — He underwent open septorhinoplasty with resection of the deviated bony septum, nasal osteotomies and fixation of the non-united left nasal bone. He improved but was left with a residual deviation of the septum to the left and persisting left-sided nasal obstruction. He was referred for long-term nasal steroid spray and saline irrigation. "septorhinoplasty, residual septal deviation"
- 04 Mar 2021 — At his separation medical examination he reported constant left nasal blockage, mouth breathing at night, reduced exercise tolerance under load and recurrent sinus infections. Examination confirmed a fixed deviation of the septum to the left with a bony spur and reduced left nasal airflow on peak nasal inspiratory flow testing. "fixed septal deviation, left obstruction"
Symptoms
At onset the veteran had severe nasal pain, swelling, deformity, profuse epistaxis and complete left nasal obstruction after the blast. After the fracture failed to unite he had persisting left nasal blockage, mouth breathing, snoring, a reduced sense of smell and recurrent sinus infections, and the obstruction worsened as the non-union developed in 2013.
He now reports constant left-sided nasal obstruction, nightly mouth breathing and dry mouth on waking, difficulty breathing through the nose during exertion, recurrent sinusitis two to three times a year, and difficulty tolerating a close-fitting respirator or mask.
Imaging
- 14 Aug 2012 — CT facial bones: "Comminuted fractures of both nasal bones and of the bony nasal septum (perpendicular plate of the ethmoid and vomer), with the septum displaced to the left. The left nasal bone fracture line has sclerotic margins indicating an older incomplete fatigue-type stress fracture."
- 20 May 2013 — CT facial bones: "Non-union of the left nasal bone and bony septal fractures, with persisting fracture gaps, rounded sclerotic fragment ends and no bridging callus. Increased deviation of the bony septum to the left narrowing the left nasal cavity."
- 12 Feb 2013 — DXA bone densitometry: "Lumbar spine T-score -2.8, total hip T-score -2.2, consistent with osteoporosis."
- 04 Mar 2021 — CT paranasal sinuses: "Post-surgical changes of septorhinoplasty. Residual deviation of the bony septum to the left with a bony spur abutting the left inferior turbinate, and mucosal thickening of the left maxillary sinus."
Onset Date
The most likely date of onset of this condition is 14 Aug 2012.
At that date the veteran was on warlike service in Afghanistan with an infantry battle group, travelling in a protected mobility vehicle on a route patrol. The vehicle struck an improvised explosive device and the blast drove his face into the weapon sight, causing an immediately deformed and obstructed nose.
This date is appropriate because the enlistment examination of 05 February 2007 recorded a midline septum and a clear nasal airway, and the role 1 review of 28 June 2012 recorded tenderness of the left nasal bone without deformity or obstruction. The fracture and the septal deviation were first documented on CT at the role 3 hospital on 14 August 2012, the day of the blast. The date falls within warlike service.
For the significant force factor, the force was applied on 14 Aug 2012 itself, at the time of onset. For the stress fracture factors, the repetitive loading occurred before onset, from the start of pre-deployment boxing training on 14 Nov 2011 to 14 Aug 2012, about nine months, three full-contact sessions a week. The abnormal direction of force, caused by the developmental rightward nasal deviation recorded on 05 Feb 2007, was present throughout that period and on the date of onset.
For the worsening factors, the treatment period before the fracture non-union runs from 14 Aug 2012 to 20 May 2013, when non-union was confirmed. The veteran smoked about 15 cigarettes a day throughout that period. Diabetes mellitus (confirmed 12 Feb 2013), osteoporosis (confirmed 12 Feb 2013), vitamin D deficiency (34 nmol/L on 12 Feb 2013 and 38 nmol/L on 20 May 2013) and a BMI of 41.3 were each present on 20 May 2013, the date of the non-union. The inability to obtain reduction occurred between 14 Aug 2012 and the closing of the reduction window on 28 Aug 2012, before the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Deviated Nasal Septum (Post-traumatic) (ICD-10 J34.2), the result of a fracture of the nasal bones and the bony nasal septum (ICD-10 S02.2) that progressed to non-union, assessed under the Statements of Principles concerning fracture, Balance of Probabilities No. 63 of 2024 and Reasonable Hypothesis No. 62 of 2024.
The nasal septum divides the nasal cavity into two passages. Its rear and upper part is bone (the perpendicular plate of the ethmoid and the vomer) and its front part is cartilage. A blow to the face can fracture the nasal bones and the bony septum and displace them to one side, narrowing one nasal passage. Displaced nasal fractures need reduction within about two weeks, before the fragments set. If they are not reduced, or if the fracture fails to heal, the septum remains deviated, causing chronic nasal obstruction, mouth breathing, snoring, recurrent sinusitis and reduced exercise tolerance. A post-traumatic septal deviation is a bony injury and is assessed under the fracture Statements of Principles.
The condition began with the blast on 14 August 2012 on warlike service in Afghanistan, through a fatigue-type stress fracture from repetitive boxing loads, and worsened with fracture non-union confirmed on 20 May 2013.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
14 August 2012.
When did the veteran first present to a health / medical provider for this condition?
14 August 2012.
When was the condition confirmed / formally diagnosed?
14 August 2012.
When did the veteran first present to you (or your practice) for this condition?
17 June 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 CT of the facial bones on 14 August 2012, which showed comminuted fractures of the nasal bones and the bony nasal septum with the septum displaced to the left, through an older fatigue-type stress fracture line. This is an acquired break of bone from an applied force that ordinarily would break a healthy bone, and so meets the Statement of Principles definition of fracture, including a comminuted fracture and, for the older component, a stress fracture of the fatigue type.
Non-union was confirmed by an otorhinolaryngologist on 20 May 2013 on examination and CT, which showed persisting fracture gaps with sclerotic ends and no bridging bone nine months after injury. The fixed septal deviation with left nasal obstruction was confirmed at septorhinoplasty on 18 November 2013 and again on CT and peak nasal inspiratory flow testing on 04 March 2021.
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 14 August 2012, after 1 July 2004, during warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan, where the fracture, the repetitive loading, the smoking and the delay in reduction occurred. The Balance of Probabilities instrument applies to peacetime service, which covers the pre-deployment boxing training in Australia from November 2011 and the treatment in Australia from October 2012, during which the fracture went on to non-union.
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 Fracture, No. 63 of 2024
Causative factors
Factor 9(1): having significant physical force applied to or through the affected bone at the time of clinical onset; — MET
- On 14 August 2012 an improvised explosive device blast threw the veteran forward and drove his face into the sight of the turret-mounted weapon. This is a significant physical force applied directly to the nasal bones and bony septum, and the comminuted fracture was shown on CT the same day. The injury was sustained in the course of his duties as an infantry soldier.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- From 14 November 2011 the veteran undertook the Army combatives and boxing programme as compulsory pre-deployment training in Australia, three full-contact sparring sessions a week, with repeated blows to the nose. He reported left nasal tenderness and nosebleeds after sparring, and the CT of 14 August 2012 showed a fatigue-type stress fracture with sclerotic margins in the left nasal bone. The repetitive loading was imposed by required military training and occurred before the onset.
Factor 9(3): for stress fracture only, having significant chronic repetitive loading stress to the affected bone due to abnormal force intensity or direction of application, at the time of clinical onset; — MET
- The developmental rightward deviation of the external nose recorded at enlistment on 05 February 2007 caused straight punches during sparring to land obliquely on the left nasal bone, as the medical officer recorded on 28 June 2012. This abnormal direction of loading continued through the training programme and was present at the onset on 14 August 2012, when the stress fracture was found in the left nasal bone.
Worsening factors
Factor 9(4): smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union; — MET
- The veteran smoked about 15 cigarettes a day from March 2012, a habit taken up on deployment, and continued throughout treatment of the fracture from 14 August 2012 to the confirmation of non-union on 20 May 2013, as recorded on 12 February 2013. Smoking reduces blood flow to healing bone and is a recognised cause of non-union.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- Steroid-induced diabetes mellitus was confirmed on 12 February 2013 with an HbA1c of 7.6 per cent and a fasting glucose of 9.1 mmol/L, and was present with an HbA1c of 7.9 per cent on 20 May 2013, when the non-union was confirmed. The diabetes resulted from high-dose prednisolone prescribed by Defence medical officers for eosinophilic pneumonia that arose on deployment.
Factor 9(6): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- The displaced nasal and septal fracture of 14 August 2012 needed closed reduction within about 14 days. No otorhinolaryngologist was deployed and the veteran was not released from operations for evacuation, so the reduction window closed on 28 August 2012 without treatment, as recorded on 07 September 2012. The unreduced fracture went on to non-union, confirmed on 20 May 2013.
Reasonable Hypothesis — Statement of Principles concerning Fracture, No. 62 of 2024
Causative factors
Factor 9(1): having significant physical force applied to or through the affected bone at the time of clinical onset; — MET
- On warlike service in Afghanistan on 14 August 2012 an improvised explosive device blast drove the veteran's face into his weapon sight, fracturing the nasal bones and bony septum, as shown on CT at the role 3 hospital the same day.
Factor 9(2): for stress fracture only, having significant repetitive loading stress to the affected bone prior to clinical onset; — MET
- The veteran continued the unit combatives and boxing programme on the patrol base during warlike service in Afghanistan from February 2012, three full-contact sessions a week, and kept sparring after nasal bone tenderness was recorded on 28 June 2012 because the programme was part of unit force preparation. CT on 14 August 2012 showed the resulting fatigue-type stress fracture of the left nasal bone.
Factor 9(3): for stress fracture only, having significant chronic repetitive loading stress to the affected bone due to abnormal force intensity or direction of application, at the time of clinical onset; — MET
- During sparring on warlike service the developmental rightward nasal deviation directed blows obliquely onto the left nasal bone, as recorded on 28 June 2012. This abnormal loading was ongoing at the onset on 14 August 2012.
Factor 9(4): smoking at least 5 cigarettes per day, or the equivalent thereof in other tobacco products, during treatment for fracture prior to fracture non-union; — MET
- The veteran began smoking during warlike service in Afghanistan, recorded at 15 cigarettes a day on 13 March 2012, and continued at that level throughout treatment from 14 August 2012 to the non-union confirmed on 20 May 2013.
Factor 9(5): having diabetes mellitus at the time of the fracture non-union; — MET
- Diabetes mellitus was caused by prednisolone 60 mg daily commenced on 02 September 2012 for acute eosinophilic pneumonia, which arose on warlike service in Afghanistan from new-onset smoking and dust exposure. It was confirmed on 12 February 2013 and was present at the non-union on 20 May 2013, with an HbA1c of 7.9 per cent.
Factor 9(6): having osteoporosis at the time of the fracture non-union; — MET
- DXA on 12 February 2013 showed a lumbar spine T-score of -2.8 and the endocrinologist diagnosed glucocorticoid-induced osteoporosis, caused by the prolonged prednisolone treatment for the eosinophilic pneumonia contracted on warlike service. The osteoporosis was present at the non-union on 20 May 2013.
Factor 9(7): having vitamin D deficiency, with a serum 25(OH)D level of less than 50 nanomoles per litre at the time of the fracture non-union; — MET
- Serum 25(OH)D was 34 nmol/L on 12 February 2013 and 38 nmol/L on 20 May 2013, the date of the non-union. The deficiency followed months of indoor convalescence and glucocorticoid treatment after his return from warlike service in Afghanistan.
Factor 9(8): having a Body Mass Index (BMI) of 40 or greater at the time of the fracture non-union; — MET
- The veteran's weight rose from 84 kg in 2011 to 127 kg by 12 February 2013 (BMI 41.0) on high-dose prednisolone prescribed for the eosinophilic pneumonia that arose on warlike service. His BMI was 41.3 on 20 May 2013, the date of the non-union.
Factor 9(9): inability to obtain appropriate clinical management for fracture before clinical worsening. — MET
- On warlike service in Afghanistan the veteran could not obtain closed reduction within the 14-day window after the fracture of 14 August 2012, because no otorhinolaryngologist was deployed and he was not released for evacuation. The unreduced fracture progressed to non-union, confirmed on 20 May 2013.
The % contribution of the causes is 100% and significant.
Sequelae
The deviated nasal septum is a sequela of the fracture of the nasal bones and bony septum sustained on warlike service in Afghanistan on 14 August 2012 and of the non-union that followed. It has caused chronic left nasal obstruction, mouth breathing, snoring and recurrent left maxillary sinusitis, shown on CT of 04 March 2021. These conditions should be considered for acceptance as sequelae of the accepted fracture.
Unintended Consequence
Met. The steroid-induced diabetes mellitus, glucocorticoid-induced osteoporosis, vitamin D deficiency and obesity present at the fracture non-union were unintended consequences of high-dose prednisolone prescribed and paid for by the Commonwealth for eosinophilic pneumonia that arose on deployment. Each is a recognised cause of impaired fracture healing, and together they contributed to the non-union and the fixed septal deviation (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. The displaced fracture of the nasal bones and bony septum sustained on 14 August 2012 required closed reduction within about 14 days. On warlike service in Afghanistan no otorhinolaryngologist was available and the veteran was not released from operations for evacuation, so the window closed on 28 August 2012 without reduction, as documented on 07 September 2012. The unreduced fracture went on to non-union, confirmed on 20 May 2013, and left a fixed septal deviation. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent timely, clinically indicated treatment amount to an inability to obtain appropriate clinical management. The further delay of 15 months from injury to definitive septorhinoplasty on 18 November 2013 is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 05 Feb 2007, Enlistment medical examination, Medical Officer, Recruit health centre
- 13 Mar 2012, Outpatient health record, Medical Officer, Role 1 facility, Afghanistan
- 28 Jun 2012, Outpatient health record, Medical Officer, Role 1 facility, Afghanistan
- 14 Aug 2012, Trauma admission and CT facial bones report, Role 3 hospital, Afghanistan
- 02 Sep 2012, Respiratory assessment, Medical Officer, Role 2 facility, Afghanistan
- 07 Sep 2012, Outpatient health record, Medical Officer, Role 1 facility, Afghanistan
- 12 Feb 2013, Endocrinology consultation and DXA report, Endocrinologist
- 20 May 2013, Otorhinolaryngology consultation and CT facial bones report, Otorhinolaryngologist
- 18 Nov 2013, Operation report, septorhinoplasty, Otorhinolaryngologist
- 04 Mar 2021, Separation medical examination and CT paranasal sinuses report, Medical Officer and Radiologist
- Statement of Principles concerning Fracture (Balance of Probabilities) No. 63 of 2024, Repatriation Medical Authority
- Statement of Principles concerning Fracture (Reasonable Hypothesis) No. 62 of 2024, Repatriation Medical Authority
