Diagnostic Assessment — Right Ear - Impacted Cerumen
Example 1 of 1 · fictitious patient (Veteran DB)
Diagnostic Assessment
Right Ear - Impacted Cerumen
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran DB, date of birth 09 November 1979, Royal Australian Navy, Clearance Diver, later Petty Officer, enlisted 18 January 1999, medically discharged 27 September 2019. Operational service: Middle East Area of Operations (Iraq, maritime), 10 February 2005 to 30 August 2005 (warlike); Middle East Area of Operations (maritime), 12 March 2014 to 25 October 2014 (warlike).
Occupational History
As a clearance diver the veteran conducted frequent open-water and cold-water dives, often several hours a day, as well as mine clearance, demolitions, weapons training and boat operations. He wore foam earplugs or in-ear communication earpieces for long periods in machinery spaces, on weapons ranges, in boats and during demolitions, and worked on deck and ashore in hot, humid, dusty and sandy conditions.
Divers have high rates of external ear canal problems, including otitis externa, exostoses from repeated cold-water exposure, and cerumen impaction, together with noise-induced hearing loss from blast, weapons and machinery noise. Ships at sea had no access to ear, nose and throat services or microsuction.
History
Veteran DB, a clearance diver in the Royal Australian Navy, developed impacted cerumen of the right ear on 20 July 2014 while on warlike maritime service in the Middle East, after months of daily diving, wearing a hearing aid and in-ear protection in a canal narrowed by diving-related exostoses, in hot, humid and dusty conditions. The impaction worsened in March 2017, with complete occlusion, conductive hearing loss and otitis externa that required specialist microsuction and later canal surgery.
Timeline
- 12 Sep 2012 — An ear, nose and throat surgeon recorded bilateral exostoses of the external ear canals, worse on the right, narrowing the right canal by about 60 per cent, attributed to repeated cold-water diving. He also had seborrhoeic dermatitis of the ear canals and scalp and had been treated for right otitis externa twice in the previous year. "R canal exostoses, 60 per cent"
- 14 May 2013 — Audiology confirmed bilateral noise-induced high-frequency sensorineural hearing loss, worse on the right after demolitions and weapons noise. A right receiver-in-canal hearing aid was fitted, and he was advised to use foam earplugs or in-ear communication earpieces whenever exposed to noise. He wore the hearing aid all day off duty. "NIHL, R hearing aid fitted"
- 20 Jul 2014 — On warlike maritime service in the Middle East the veteran had been diving most days and wearing an in-ear communication earpiece or foam earplug in the right ear for six to eight hours a day, and the hearing aid at other times. Temperatures on deck exceeded 40 degrees with high humidity, and he worked ashore and on deck in windblown sand and dust. He had been cleaning water from his ears after each dive with cotton buds. "daily diving, earpiece 6-8 hours"
- 23 Jul 2014 — He presented to the ship's sick bay with three days of a blocked right ear, muffled hearing, a feeling of fullness and itch, and whistling from his hearing aid. Otoscopy showed hard impacted cerumen fully occluding the right canal lateral to the exostoses. The tympanic membrane could not be seen. Olive oil drops were started; irrigation was not attempted because of the exostoses and his diving duties. "R canal occluded, impacted wax"
- 02 Dec 2014 — After return to Australia a general practitioner partly cleared the right canal with irrigation and confirmed residual impacted cerumen against the exostoses. Microsuction by an ear, nose and throat surgeon was requested, but the referral was not completed before he was posted to a ship. Recurrent partial impaction was recorded at medical reviews in 2015 and 2016. "residual impaction, ENT requested"
- 03 Mar 2017 — During a diving exercise off northern Australia he had a sudden complete loss of hearing in the right ear after a dive, followed by pain. He had used a cotton bud to clear water the evening before. Otoscopy showed complete occlusion by swollen impacted cerumen, an abrasion of the canal skin and inflamed, discharging canal walls. Audiometry showed a 30 dB air-bone gap on the right. "complete occlusion, otitis externa"
- 20 Mar 2017 — An ear, nose and throat surgeon removed a large impacted cerumen plug and debris by microsuction under the microscope and treated the otitis externa. The right canal was narrowed to about 75 per cent by exostoses, trapping wax and water. A right canaloplasty was performed on 06 Jun 2018. He was medically discharged on 27 Sep 2019. "microsuction, canal narrowed 75 per cent"
Symptoms
At onset the veteran had a blocked right ear with muffled hearing, fullness, itch and feedback whistling from his hearing aid. After onset the right ear blocked repeatedly, especially after diving, and in March 2017 he had complete loss of hearing in the right ear with pain and discharge.
He now reports recurrent right ear blockage every two to three months, requiring microsuction, intermittent itch and fullness, difficulty using his hearing aid and avoidance of swimming.
Imaging
- 02 May 2018 — CT temporal bones: "Multiple broad-based exostoses of the right external auditory canal narrowing the canal by about 75 per cent, with retained soft tissue debris medial to the narrowing. Smaller exostoses on the left. Middle ears clear."
Onset Date
The most likely date of onset of this condition is 20 Jul 2014.
At that date the veteran was on warlike maritime service in the Middle East with a clearance diving team embarked on a ship, diving most days and wearing in-ear protection or a communication earpiece for six to eight hours a day in hot, humid and dusty conditions.
This date is appropriate because his pre-deployment medical examination of 20 Feb 2014 recorded clear ear canals apart from the known exostoses, and he first presented to the ship's sick bay on 23 Jul 2014 with a blocked ear of three days' duration. It falls within continuous full-time service.
For the causes relying on duration of exposure, the 3 months before onset run from 20 Apr 2014 to 20 Jul 2014; throughout that period he wore an in-ear earpiece or earplug for six to eight hours a day, wore his hearing aid at other times, dived on most days and cleaned his ears with cotton buds after dives. The 4 weeks before onset run from 22 Jun 2014 to 20 Jul 2014, filled by work in heat, humidity and windblown sand. The 12 months before onset run from 20 Jul 2013 to 20 Jul 2014, during which he had otitis externa in November 2013. The exostoses and seborrhoeic dermatitis were present on 20 Jul 2014.
For the worsening causes, the documented clinical worsening is on 03 Mar 2017. The 4 weeks before it run from 03 Feb 2017 to 03 Mar 2017, and the 1 week before it from 24 Feb 2017 to 03 Mar 2017, during a diving exercise.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Impacted Cerumen of the Right Ear (ICD-10-AM H61.2), associated with right external auditory canal exostoses. No Statement of Principles has been determined for impacted cerumen.
Cerumen (ear wax) is normally produced in the outer third of the ear canal and migrates outwards. Impaction occurs when wax accumulates and occludes the canal, causing a blocked feeling, muffled hearing, itch, tinnitus, dizziness and, in hearing aid users, feedback. It is caused by anything that obstructs the natural migration or pushes wax inwards, including hearing aids, earplugs and earpieces, cotton buds, a narrowed canal from exostoses, repeated water immersion, dusty environments and skin conditions of the canal. Complete impaction can cause conductive hearing loss and otitis externa.
The condition followed months of daily diving and in-ear device use in a canal narrowed by diving-related exostoses, in hot, humid and dusty conditions on warlike maritime service. It began on 20 July 2014, was confirmed on otoscopy on 23 July 2014 and worsened in March 2017.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
20 July 2014.
When did the veteran first present to a health / medical provider for this condition?
23 July 2014.
When was the condition confirmed / formally diagnosed?
23 July 2014.
When did the veteran first present to you (or your practice) for this condition?
09 September 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on otoscopy in the ship's sick bay on 23 July 2014, which showed hard impacted cerumen fully occluding the right ear canal so that the tympanic membrane could not be seen, with the known exostoses medial to it. This was confirmed again by a general practitioner on 02 December 2014.
The clinical picture was consistent: a blocked ear, muffled hearing, fullness and itch, and hearing aid feedback. The worsening was confirmed on 03 March 2017 by complete occlusion with otitis externa and a 30 dB air-bone gap, and by the ear, nose and throat surgeon's microsuction findings on 20 March 2017. CT on 02 May 2018 confirmed canal narrowing of about 75 per cent from exostoses.
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.
No Statement of Principles has been determined by the Repatriation Medical Authority for impacted cerumen. The claim is therefore decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits a Statement of Principles would impose, and the causes below are those well recognised in the medical literature.
Legislation: the clinical onset of this condition was on 20 July 2014, after 1 July 2004, during continuous full-time service on warlike maritime service in the Middle East. The worsening in March 2017 occurred during full-time peacetime service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. Each cause must be related to the person's 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.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: wearing earplugs or in-ear communication earpieces in the affected ear for at least 4 hours per day on most days for at least the 3 months before the clinical onset of impacted cerumen; — MET
- On warlike maritime service the veteran wore foam earplugs or an in-ear communication earpiece in the right ear for six to eight hours a day, in boats, machinery spaces, on weapons ranges and during demolitions, on most days throughout the 3 months before onset, from 20 April 2014 to 20 July 2014. In-ear devices block the outward migration of wax and push it towards the bony canal.
Cause 2: using a hearing aid in the affected ear for at least the 3 months before the clinical onset of impacted cerumen; — MET
- A right receiver-in-canal hearing aid was fitted on 14 May 2013 for noise-induced hearing loss caused by demolitions and weapons noise in service, and he wore it daily off duty throughout the 3 months before onset. Hearing aid users have a markedly increased rate of cerumen impaction.
Cause 3: having exostoses, stenosis or other narrowing of the external auditory canal of the affected ear at the time of the clinical onset of impacted cerumen; — MET
- An ear, nose and throat surgeon recorded exostoses narrowing the right canal by about 60 per cent on 12 September 2012, caused by repeated cold-water diving in service, and they were present at onset. A narrowed canal traps wax and debris medial to the narrowing.
Cause 4: immersing the affected ear in water, including by swimming or diving, for at least 4 hours per week for at least the 3 months before the clinical onset of impacted cerumen; — MET
- He dived on most days, typically for two to four hours a day, throughout the 3 months before onset on warlike maritime service in the Middle East. Water causes cerumen and desquamated skin to swell and become trapped, and repeated wetting impairs normal wax migration.
Cause 5: inserting cotton buds or other objects into the affected ear canal on most days for at least the 3 months before the clinical onset of impacted cerumen; — MET
- He used cotton buds to remove water from his ears after each dive, on most days, throughout the 3 months before onset. Cotton buds push wax medially and compact it against the canal and exostoses.
Cause 6: working in a dusty or sandy environment for at least 4 weeks before the clinical onset of impacted cerumen; — MET
- Throughout the 4 weeks before onset, from 22 June 2014 to 20 July 2014, he worked on deck and ashore in windblown sand and dust in the Middle East. Airborne particles adhere to cerumen and increase its bulk and hardness.
Cause 7: working or living in a hot and humid environment for at least 4 weeks before the clinical onset of impacted cerumen; — MET
- Temperatures on deck exceeded 40 degrees with high humidity in the Persian Gulf summer throughout the 4 weeks before onset, and he wore an earpiece or hearing aid for most of the day. Heat and sweating under occlusive devices increase cerumen production and maceration of the canal.
Cause 8: having seborrhoeic dermatitis, eczema or psoriasis involving the affected ear canal at the time of the clinical onset of impacted cerumen; — MET
- Seborrhoeic dermatitis of the ear canals and scalp was recorded on 12 September 2012 and was present at onset. Increased scaling of the canal skin adds to the bulk of the wax.
Cause 9: having otitis externa of the affected ear within the 12 months before the clinical onset of impacted cerumen; — MET
- He was treated for right otitis externa after diving in November 2013, within the 12 months before onset, from 20 July 2013 to 20 July 2014. Inflammation and debris from otitis externa impair wax clearance.
Worsening factors
Worsening 1: wearing a hearing aid, earplugs or in-ear communication earpieces in the affected ear for at least 4 hours per day for at least the 4 weeks before the clinical worsening of impacted cerumen; — MET
- Throughout the 4 weeks before the worsening, from 03 February 2017 to 03 March 2017, he wore his hearing aid daily and an in-ear communication earpiece for about six hours a day during a diving exercise.
Worsening 2: immersing the affected ear in water, including by swimming or diving, within the 1 week before the clinical worsening of impacted cerumen; — MET
- He dived daily in the week before the worsening, from 24 February 2017 to 03 March 2017, and the complete loss of hearing followed a dive on 03 March 2017, when water swelled the retained wax.
Worsening 3: inserting cotton buds or other objects into the affected ear canal within the 1 week before the clinical worsening of impacted cerumen; — MET
- He used a cotton bud to clear water from the right ear on the evening of 02 March 2017, within the 1 week before the worsening, abrading the canal skin and compacting the wax.
Worsening 4: having exostoses, stenosis or other narrowing of the external auditory canal of the affected ear at the time of the clinical worsening of impacted cerumen; — MET
- The diving-related exostoses had progressed to narrow the right canal by about 75 per cent at the worsening, recorded on 20 March 2017 and confirmed on CT on 02 May 2018.
Worsening 5: having otitis externa of the affected ear at the time of the clinical worsening of impacted cerumen; — MET
- Otitis externa with inflamed, discharging canal walls was present at the worsening on 03 March 2017.
Worsening 6: inability to obtain appropriate clinical management for impacted cerumen. — MET
- After onset no microsuction was available on board ship, irrigation was unsafe because of the exostoses, and the ear, nose and throat referral requested on 02 December 2014 was not completed because of sea postings. The residual impaction was never fully cleared and progressed to complete occlusion with otitis externa and conductive hearing loss on 03 March 2017. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The right impacted cerumen is a sequela of the veteran's right external auditory canal exostoses, caused by repeated cold-water diving in service, and of his noise-induced hearing loss, which required a hearing aid in the affected ear.
Unintended Consequence
Met. The use of a receiver-in-canal hearing aid and Defence-issued in-ear hearing protection, provided and required by the Commonwealth to manage his service-related hearing loss and noise exposure, contributed to the impaction as an unintended consequence (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. From onset in July 2014 the veteran could not obtain microsuction at sea, irrigation was unsafe because of his exostoses, and the ear, nose and throat referral requested on 02 December 2014 was not completed for more than two years because of successive sea postings. The residual impaction was never fully cleared and on 03 March 2017 progressed to complete occlusion with otitis externa and a 30 dB conductive hearing loss. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), service postings that prevent appropriate treatment amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 12 Sep 2012, Specialist consultation, Ear, nose and throat surgeon
- 14 May 2013, Audiology assessment and hearing aid fitting, Audiologist
- 20 Feb 2014, Pre-deployment medical examination, Medical Officer
- 23 Jul 2014, Sick bay record, Medical Officer, ship's company
- 02 Dec 2014, Consultation, General practitioner
- 03 Mar 2017, Outpatient health record and audiometry, Medical Officer
- 20 Mar 2017, Microsuction procedure note, Ear, nose and throat surgeon
- 02 May 2018, CT temporal bones, Radiologist
- 06 Jun 2018, Operation report, Ear, nose and throat surgeon
