Diagnostic Assessment — Right Otitis Externa
Example 1 of 1 · fictitious patient
Diagnostic Assessment Right Otitis Externa BOP Code: 26 of 2021 (Otitis Externa) RH Code: 25 of 2021 (Otitis Externa)
ADF History
The veteran, date of birth [withheld], Australian Army, Combat Engineer, 18 September 1985 to 4 July 1992
History
The veteran experienced right otitis externa during ADF service.
On 20 June 1986, whilst on leave in a field engineer regiment, he was diagnosed with bilateral otitis externa by the treating doctor.
Bayldon and treated with Sofradex (the record gives his unit as a field engineer regiment).
On 25 July 1986, a medical officer recorded that he had been treated by the treating doctor an infected right ear whilst on leave in a field engineer regiment; he was now well, the ear was clear and he was fit for duties.
Australian Army service involves exposure to water, humidity, and confined living conditions that are recognised risk factors for otitis externa (swimmer's ear).
The documented right otitis media on 23 November 1991 involved the right ear, and otitis externa may have occurred concurrently or separately
Timeline
20 Jun 1986 — Whilst on leave in a field engineer regiment, SMNSR the veteran (unit a field engineer regiment) was diagnosed with bilateral otitis externa by the treating doctor.
Bayldon and treated with Sofradex. "Bi-lat. otitis externa" 25 Jul 1986 — SMNSR the veteran was reviewed after treatment by the treating doctor an infected right ear whilst on leave in a field engineer regiment.
Now well, ear clear and fit for duties. "Infected (R) ear" 23 Nov 1991 — ABSR the veteran presented with painful ears bilaterally and right otitis media at a field engineer regiment.
Otitis externa may have been present concurrently with the middle ear infection. "Painful ears"
1. What is the formal diagnosis of the condition claimed above?
Right Otitis Externa (ICD-10: H60.91).
Otitis externa is inflammation of the external ear canal, commonly associated with water exposure and humid environments.
2 3.
Dates, confirmation: Symptom onset during ADF service, on or before 20 June 1986, when he first presented, whilst on leave in a field engineer regiment, and bilateral otitis externa was clinically diagnosed by the treating doctor.
Bayldon and treated with Sofradex.
On 25 July 1986 a Navy medical officer recorded this treatment of an infected right ear whilst on leave, with the ear now clear and fit for duties.
DRCA legislation.
Australian Army service with water exposure and communal living conditions.
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 December 2005 (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 20 June 1986 records otitis externa in both ears, and the right ear was recorded as infected on his return from leave (Outpatient Health Record of 25 July 1986).
His activities in the preceding ten days are not recorded, but he was on summer leave in a field engineer regiment, 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 field engineer regiment in Western Australia on 26 May 1986 and on leave in his home town of a field engineer regiment when treated on 20 June 1986; the leave dates are not recorded, but it is a reasonable inference that he spent the Christmas and New Year period there. a field engineer regiment 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 July 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 right 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 right 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 right 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 right 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 September 1985.
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 right 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 right ear canal is recorded; the infection treated in July 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 right 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 2021, 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 right 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 right, on 20 June 1986, while the veteran was on summer leave in a field engineer regiment, 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 field engineer regiment on 20 June 1986, after he was last recorded at a field engineer regiment on 26 May 1986, and it is reasonable to infer that his leave covered the Christmas and New Year period. a field engineer regiment 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 July 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 right 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 right 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 right 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 right 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 right 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 right 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 right 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 July 1986; it was diagnosed in 2021.
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 right 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 right otitis externa first appeared during his full-time naval service.
No ear disease was recorded at his enlistment examinations in January and September 1985.
The condition was diagnosed on 20 June 1986, while he was a junior sailor on leave from a field engineer regiment, by the treating doctor.
Bayldon, who later treated him aboard a field engineer regiment and during his a field engineer regiment-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 25 July 1986.
His later service kept the previously infected right ear canal exposed to the conditions that promote recurrence of otitis externa, which is common enough in hot, humid climates to be known as 'tropical ear'.
As a Combat Engineer on the a field engineer regiment-based survey ship a field engineer regiment he worked in the water, diving on a tide pole with a snorkel and on SCUBA (Daily Medical Record of 2 May 1987); he served in the tropics from November 1986 to January 1989; and shipboard life involved sea spray, wet decks, humid living spaces and shared showers.
Repeated wetting strips the canal of its protective wax and macerates its skin; the left ear recurred in these conditions in November 1986, and the right ear was again red and swollen in May 1990.
Conclusion the veteran's right otitis externa began, together with the left, during his full-time naval service, while he was on leave in a field engineer regiment 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.
His later service, with survey-ship water work including tide-pole snorkelling and SCUBA diving and two years in the tropics, kept the previously infected canal exposed to water and humidity, and the right ear was again inflamed in May 1990 and painful in November 1991 without investigation, specialist referral or preventive advice.
The condition therefore arose during his service, and its later course was shaped by the conditions of that service and by the lack of appropriate management.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's right 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 20 June 1986) aggravated it or contributed to it in a material degree.
After the first episode cleared he served for six more years, including survey-ship and tropical service from November 1986 to January 1989, and his right ear was again recorded as red and swollen in May 1990 and painful, with right otitis media, in November 1991.
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 — NOT MET - No worsening of the right ear canal is recorded within ten days of an aquatic activity; the diving of May 1987 caused middle-ear barotrauma rather than otitis externa, and in May 1990, when his ears were next inflamed, he was recovering from foot surgery.
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 - No worsening of the right ear is recorded during his tropical service from November 1986 to January 1989; its later inflammation in May 1990 occurred in a Sydney spring and is not 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 2025 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 right ear canal is recorded in the ten days before any worsening; the barotrauma of May 1987 affected the middle ear and was not followed by otitis externa.
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 right ear canal in the ten days before a clinical worsening, and no basis to infer it.
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 right 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 right ear canal is recorded after the onset, and his hearing was within the service standard on audiograms in 1986 and 1988 and at discharge in July 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 right 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 right ear canal is recorded; the illness of May 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 right otitis media of 23 November 1991 was an acute infection 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 2021, 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 2018 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); no fungal infection of the right ear canal has been diagnosed.
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.
After the first episode, in which the right ear was recorded as infected, his ears were red and swollen with earache on 12 May 1990 and painful on 23 November 1991; the first was treated only as a respiratory infection, and neither led to a swab, specialist referral or advice to protect the ears during the diving and water work of his survey duties.
Survey-ship postings and the loss of his medical record (PM168) in August 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 — NOT MET - No clinical worsening of the right otitis externa is recorded within ten days of an aquatic activity; the diving of May 1987 produced middle-ear barotrauma, not otitis externa.
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 - No worsening of the right ear is recorded after ten days of hot and humid weather or heavy rain within the preceding 30 days, including during his tropical service from 1986 to 1988.
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 right 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 right external auditory canal in the ten days before a clinical worsening.
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 right ear canal is recorded in the ten days before a clinical worsening.
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 right 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 right 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 right 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 right 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 right middle ear is recorded; the otitis media of November 1991 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 2021, 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; no fungal infection of the right ear canal has been diagnosed.
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 right otitis externa.
His recurrent right ear presentations (July 1986, May 1990 and November 1991) led to no swab, specialist referral or advice to protect the ears during his diving and water work, while survey-ship service and the loss of his medical record in August 1991 impeded continuity of care
Sequelae, Unintended Consequence, Inability
No specific sequelae.
Not an unintended consequence.
Loss of PM168 records constitutes systemic barrier — MET
Date of Clinical Onset
Right 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: 20 June 1986 — bilateral otitis externa treated with Sofradex by the treating doctor.
Bayldon whilst on leave in a field engineer regiment [ [CHART REVIEW document], pages 82, 84].
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 20 June 1986.
This date falls within the veteran's ADF service (18 September 1985 4 July 1992).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
