Diagnostic Assessment — Right Otitis Media
Example 1 of 1 · fictitious patient
Diagnostic Assessment Right Otitis Media BOP Code: 63 of 2022 (Otitis Media) RH Code: 62 of 2022 (Otitis Media)
ADF History
The veteran, date of birth [withheld], Royal Australian Air Force, Aircraft Technician, 2 February 1979 to 18 November 1985
History
The veteran had right otitis media with possible early left otitis media on 8 April 1985 during service at a maintenance squadron.
He presented with a 3-day history of sore throat, blocked sinuses, rhinorrhoea, and painful ears bilaterally
Timeline
08 Apr 1985 — ABSR the veteran, as a young adult, presented with a 3-day history of sore throat, blocked sinuses, rhinorrhoea, and painful ears bilaterally.
Temperature was 36.5°C (afebrile).
Right otitis media was confirmed on examination.
Possible early otitis media on the left was also noted.
The pharynx was red.
Chest was clear.
Keflex 500mg was prescribed for the otitis media and Panadeine for pain relief. "Right otitis media"
Symptoms
Right ear pain with blocked sinuses, sore throat, and rhinorrhoea, consistent with an upper respiratory infection with secondary otitis media
Imaging
No imaging related to this condition
1. What is the formal diagnosis of the condition claimed above?
Right Otitis Media (ICD-10: H66.90).
Otitis media is infection/inflammation of the middle ear, commonly secondary to upper respiratory tract infections.
The condition was diagnosed during ADF service
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Approximately 5 April 1985 (3 days prior to presentation) [CHART REVIEW document] When did the veteran first present to a health / medical provider for this condition? 8 April 1985 When was the condition confirmed / formally diagnosed? 8 April 1985 When did the veteran first present to you (or your practice) for this condition? 14 June 2020
3. How was this diagnosis confirmed?
Clinical diagnosis by the medical officer at a maintenance squadron on otoscopic examination [CHART REVIEW document]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 2 May 1999 (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 Media, No.
63 of 2022) Factor 9(1): having an upper respiratory tract infection within the 14 days before the clinical onset of otitis media — MET - The Outpatient Health Record of 8 April 1985 at a maintenance squadron records a three-day history of sore throat, blocked sinuses and rhinorrhoea with painful ears and, on examination, a red pharynx, with diagnoses of right otitis media and left conjunctivitis.
This was an upper respiratory tract infection, and in the usual course of such an illness the infection of the nose and throat comes first and the middle ear is involved as its complication.
The infection was therefore present at, and on the usual sequence immediately before, the clinical onset of the right otitis media about 5 April 1985, well within the 14-day window.
Factor 9(2): having partial or complete obstruction of the Eustachian tube of the affected side within the 7 days before the clinical onset of otitis media — MET - The record of 8 April 1985 documents three days of blocked sinuses and rhinorrhoea with painful ears.
Swelling of the inflamed nasopharyngeal mucosa in such an infection partially obstructs the Eustachian tube, allowing negative pressure and infected secretions to accumulate in the middle ear; the right otitis media, with early involvement of the left ear, is the clinical expression of that obstruction.
Although tubal function was not formally tested, partial obstruction of the right Eustachian tube within the 7 days before the onset about 5 April 1985 is the probable inference, and his difficulty equalising his ears while diving in September 1980 is consistent with a tendency to tubal dysfunction.
Factor 9(3): having allergic rhinitis or sinusitis within the 7 days before the clinical onset of otitis media — MET - The medical officer recorded blocked sinuses with rhinorrhoea for the three days before 8 April 1985.
Sudden nasal and sinus obstruction with nasal discharge meets the accepted clinical definition of acute (usually viral) rhinosinusitis, and the sinus mucosa is ordinarily inflamed in such infections, although sinusitis was not recorded as a separate diagnosis.
Sinusitis was therefore present within the 7 days before the clinical onset about 5 April 1985.
Allergic rhinitis is not recorded, and the chronic paranasal sinus disease shown on imaging from December 2003 is much later and does not itself fall within this window.
Factor 9(4): having a space-occupying mass within the nasopharynx at the time of the clinical onset of otitis media — NOT MET - There is no record of a space-occupying mass in the nasopharynx at or about 5 April 1985, and nothing in his history suggests one.
Factor 9(5): undergoing a course of therapeutic radiation for cancer, where the head or upper neck was in the field of radiation, before the clinical onset of otitis media — NOT MET - There is no record of radiotherapy for cancer of the head or neck, or at any other site, and nothing in his history suggests it.
Factor 9(6): having an acute rupture of the tympanic membrane of the affected side within the 3 months before the clinical onset of otitis media — NOT MET - There is no record of an acute rupture of the right tympanic membrane in the 3 months before about 5 April 1985, and nothing in his history suggests one.
Factor 9(7): having chronic perforation of the tympanic membrane of the affected side before the clinical onset of otitis media — NOT MET - There is no record of a chronic perforation of the right tympanic membrane; his right-sided barotrauma of September 1980 was Grade 1, without perforation, and his hearing was normal on 17 June 1982.
Factor 9(8): having an episode of otitic barotrauma involving the affected ear within the 7 days before the clinical onset of otitis media — NOT MET - His only recorded otitic barotrauma was in September 1980, more than four years before about 5 April 1985, and there is no record of diving or flying in the week before the onset.
Factor 9(9): having tuberculosis or nontuberculous mycobacterial disease at the time of the clinical onset of otitis media — NOT MET - There is no record of tuberculosis or nontuberculous mycobacterial disease; his chest was clear on 8 April 1985 and his chest X-ray of 18 July 1980 was normal.
Factor 9(10): having gastro-oesophageal reflux disease at the time of the clinical onset of otitis media — NOT MET - Gastro-oesophageal reflux disease is not recorded at any time, in service or after it, and nothing in his history suggests that it was present in April 1985.
Factor 9(11): having ascariasis or myiasis of the ear, nose or throat at the time of the clinical onset of otitis media — NOT MET - There is no record of ascariasis or myiasis of the ear, nose or throat, and nothing in his history suggests it.
Factor 9(12): having ANCA-associated vasculitis at the time of the clinical onset of otitis media — NOT MET - There is no record of ANCA-associated vasculitis, and nothing in his history suggests it.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Otitis Media, No.
62 of 2022) 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): having an upper respiratory tract infection within the 28 days before the clinical onset of otitis media — MET - The Outpatient Health Record of 8 April 1985 records a three-day history of sore throat, blocked sinuses and rhinorrhoea with painful ears and a red pharynx on examination: an upper respiratory tract infection, of which the right otitis media was a complication.
The infection was present at, and on the usual sequence immediately before, the clinical onset about 5 April 1985, well within the 28-day window.
Factor 9(2): having partial or complete obstruction of the Eustachian tube of the affected side within the 7 days before the clinical onset of otitis media — MET - Three days of blocked sinuses, rhinorrhoea and painful ears before his presentation on 8 April 1985 indicate congestion of the nasopharyngeal mucosa partially obstructing the Eustachian tube, which is the mechanism by which the right middle ear became infected.
Although tubal function was not formally tested, partial obstruction of the right Eustachian tube within the 7 days before the onset about 5 April 1985 is the probable inference.
Factor 9(3): having allergic rhinitis or sinusitis within the 7 days before the clinical onset of otitis media — MET - The medical officer recorded blocked sinuses with rhinorrhoea for the three days before 8 April 1985, which meets the accepted clinical definition of acute rhinosinusitis (sudden nasal obstruction with nasal discharge), although sinusitis was not recorded as a separate diagnosis.
It was present within the 7 days before the onset about 5 April 1985; his chronic sinus disease on imaging from 2004 is outside this window.
Factor 9(4): having a space-occupying mass within the nasopharynx at the time of the clinical onset of otitis media — NOT MET - There is no record of a space-occupying mass in the nasopharynx at or about 5 April 1985, and nothing in his history suggests one.
Factor 9(5): undergoing a course of therapeutic radiation for cancer, where the head or upper neck was in the field of radiation, before the clinical onset of otitis media — NOT MET - There is no record of radiotherapy for cancer of the head or neck, or at any other site, and nothing in his history suggests it.
Factor 9(6): having an acute rupture of the tympanic membrane of the affected side within the 3 months before the clinical onset of otitis media — NOT MET - There is no record of an acute rupture of the right tympanic membrane in the 3 months before about 5 April 1985, and nothing in his history suggests one.
Factor 9(7): having chronic perforation of the tympanic membrane of the affected side before the clinical onset of otitis media — NOT MET - There is no record of a chronic perforation of the right tympanic membrane; his right-sided barotrauma of September 1980 was Grade 1, without perforation, and his hearing was normal on 17 June 1982.
Factor 9(8): having an episode of otitic barotrauma involving the affected ear within the 7 days before the clinical onset of otitis media — NOT MET - His only recorded otitic barotrauma was in September 1980, more than four years before about 5 April 1985, and there is no record of diving or flying in the week before the onset.
Factor 9(9): having tuberculosis or nontuberculous mycobacterial disease at the time of the clinical onset of otitis media — NOT MET - There is no record of tuberculosis or nontuberculous mycobacterial disease; his chest was clear on 8 April 1985 and his chest X-ray of 18 July 1980 was normal.
Factor 9(10): having gastro-oesophageal reflux disease at the time of the clinical onset of otitis media — NOT MET - Gastro-oesophageal reflux disease is not recorded at any time, in service or after it, and nothing in his history suggests that it was present in April 1985.
Factor 9(11): swimming, diving or water-skiing, where such activities allow water to enter the oropharynx, within the 7 days before the clinical onset of otitis media — NOT MET - Although he had dived on survey duties in 1980, there is no record of swimming, diving or water-skiing in the 7 days before about 5 April 1985, and this episode is explained by the upper respiratory tract infection.
Factor 9(12): having ascariasis or myiasis of the ear, nose or throat at the time of the clinical onset of otitis media — NOT MET - There is no record of ascariasis or myiasis of the ear, nose or throat, and nothing in his history suggests it.
Factor 9(13): having ANCA-associated vasculitis at the time of the clinical onset of otitis media — NOT MET - There is no record of ANCA-associated vasculitis, and nothing in his history suggests it.
Factor 9(14): having infection with human immunodeficiency virus before the clinical onset of otitis media — NOT MET - There is no record of infection with human immunodeficiency virus, and nothing in his history suggests it.
Factor 9(15): taking an immunosuppressive drug for organ or tissue transplantation before the clinical onset of otitis media — NOT MET - He has not had an organ or tissue transplant and has not taken an immunosuppressive drug for one.
Other Plausible Links to Service The right otitis media arose during the veteran's service, as the complication of an upper respiratory tract infection contracted while he was serving at a maintenance squadron.
Respiratory viruses, and the bacteria that complicate them, spread readily where service personnel work, train and eat in close daily contact, and his records show repeated respiratory infections at naval establishments: earache with red, swollen ears during an upper respiratory infection at a maintenance squadron on 26 September 1983, painful ears on both sides with purulent tonsillitis at a maintenance squadron on 1 February 1985, this episode (with conjunctivitis of the left eye on the same day), and a further upper respiratory infection on 27 June 1985.
The source of the April 1985 infection is not recorded and exposure outside service cannot be excluded, but on the beneficial approach his service environment is a probable source, and service contributed to the infection and to its complication in the right ear.
Conclusion the veteran's right otitis media of April 1985 was a complication of an acute upper respiratory tract infection with blocked sinuses and rhinorrhoea, which obstructed the Eustachian tube and allowed the middle ear to become infected; the factors for upper respiratory tract infection, Eustachian tube obstruction and sinusitis are met for clinical onset.
The infection was contracted while he was serving at a maintenance squadron, where respiratory infections spread readily among personnel in close contact, and it followed earlier respiratory infections with ear pain during service in September 1983 and February 1985.
Smoking, about five cigarettes a day in 1985, may have added to his susceptibility but is not a factor in the Statements of Principles, and no later worsening of the otitis media is recorded.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's right otitis media is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (about 5 April 1985) aggravated it or contributed to it in a material degree.
The record documents a single acute episode, diagnosed and treated on 8 April 1985, with no later recurrence or complication recorded before his discharge on 18 November 1985.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Otitis Media, No.
63 of 2022) Factor 9(13): having an upper respiratory tract infection within the 14 days before the clinical worsening of otitis media — NOT MET - No clinical worsening of the right otitis media is recorded after its treatment on 8 April 1985; his later upper respiratory tract infection of 27 June 1985 was not accompanied by any recorded ear symptoms or findings.
Factor 9(14): having partial or complete obstruction of the Eustachian tube of the affected side within the 7 days before the clinical worsening of otitis media — NOT MET - No clinical worsening of the right otitis media is recorded after April 1985, and there is no later record of Eustachian tube obstruction; the Valsalva manoeuvre was positive in both ears at discharge on 18 November 1985.
Factor 9(15): having allergic rhinitis or sinusitis within the 7 days before the clinical worsening of otitis media — NOT MET - No clinical worsening of the right otitis media is recorded after April 1985; his chronic paranasal sinus disease on imaging from December 2003 was not accompanied by any recorded otitis media, and the MRI of 15 April 2014 showed no temporal bone lesion.
Factor 9(16): having a space-occupying mass within the nasopharynx at the time of the clinical worsening of otitis media — NOT MET - There is no record of a nasopharyngeal mass at any time, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(17): undergoing a course of therapeutic radiation for cancer, where the head or upper neck was in the field of radiation, before the clinical worsening of otitis media — NOT MET - There is no record of radiotherapy for cancer of the head or neck, or at any other site, and nothing in his history suggests it.
Factor 9(18): having an acute rupture of the tympanic membrane of the affected side within the 3 months before the clinical worsening of otitis media — NOT MET - There is no record of an acute rupture of the right tympanic membrane at any time, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(19): having chronic perforation of the tympanic membrane of the affected side before the clinical worsening of otitis media — NOT MET - There is no record of a chronic perforation of the right tympanic membrane; his hearing was normal at discharge on 18 November 1985, and no worsening of the otitis media is recorded.
Factor 9(20): having an episode of otitic barotrauma involving the affected ear within the 7 days before the clinical worsening of otitis media — NOT MET - His only recorded otitic barotrauma, in September 1980, preceded the otitis media, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(21): having tuberculosis or nontuberculous mycobacterial disease at the time of the clinical worsening of otitis media — NOT MET - There is no record of tuberculosis or nontuberculous mycobacterial disease at any time, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(22): having gastro-oesophageal reflux disease at the time of the clinical worsening of otitis media — NOT MET - Gastro-oesophageal reflux disease is not recorded at any time, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(23): having ascariasis or myiasis of the ear, nose or throat at the time of the clinical worsening of otitis media — NOT MET - There is no record of ascariasis or myiasis of the ear, nose or throat, and nothing in his history suggests it.
Factor 9(24): having ANCA-associated vasculitis at the time of the clinical worsening of otitis media — NOT MET - There is no record of ANCA-associated vasculitis, and nothing in his history suggests it.
Factor 9(25): inability to obtain appropriate clinical management for otitis media — NOT MET - A medical officer at a maintenance squadron diagnosed and treated the right otitis media at the veteran's first presentation on 8 April 1985, three days after the onset (Keflex and analgesia), despite the loss of his medical record in December 1984; no recurrence is recorded, and at discharge on 18 November 1985 the Valsalva manoeuvre was positive in both ears and his hearing was normal.
Applying the objective and subjective test in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there is no evidence of an inability to obtain appropriate management of this acute, promptly treated and resolved infection.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Otitis Media, No.
62 of 2022) 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(16): having an upper respiratory tract infection within the 28 days before the clinical worsening of otitis media — NOT MET - No clinical worsening of the right otitis media is recorded after its treatment on 8 April 1985; his later upper respiratory tract infection of 27 June 1985 was not accompanied by any recorded ear symptoms or findings.
Factor 9(17): having partial or complete obstruction of the Eustachian tube of the affected side within the 7 days before the clinical worsening of otitis media — NOT MET - No clinical worsening of the right otitis media is recorded after April 1985, and there is no later record of Eustachian tube obstruction; the Valsalva manoeuvre was positive in both ears at discharge on 18 November 1985.
Factor 9(18): having allergic rhinitis or sinusitis within the 7 days before the clinical worsening of otitis media — NOT MET - No clinical worsening of the right otitis media is recorded after April 1985; his chronic paranasal sinus disease on imaging from December 2003 was not accompanied by any recorded otitis media, and the MRI of 15 April 2014 showed no temporal bone lesion.
Factor 9(19): having a space-occupying mass within the nasopharynx at the time of the clinical worsening of otitis media — NOT MET - There is no record of a nasopharyngeal mass at any time, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(20): undergoing a course of therapeutic radiation for cancer, where the head or upper neck was in the field of radiation, before the clinical worsening of otitis media — NOT MET - There is no record of radiotherapy for cancer of the head or neck, or at any other site, and nothing in his history suggests it.
Factor 9(21): having an acute rupture of the tympanic membrane of the affected side within the 3 months before the clinical worsening of otitis media — NOT MET - There is no record of an acute rupture of the right tympanic membrane at any time, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(22): having chronic perforation of the tympanic membrane of the affected side before the clinical worsening of otitis media — NOT MET - There is no record of a chronic perforation of the right tympanic membrane; his hearing was normal at discharge on 18 November 1985, and no worsening of the otitis media is recorded.
Factor 9(23): having an episode of otitic barotrauma involving the affected ear within the 7 days before the clinical worsening of otitis media — NOT MET - His only recorded otitic barotrauma, in September 1980, preceded the otitis media, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(24): having tuberculosis or nontuberculous mycobacterial disease at the time of the clinical worsening of otitis media — NOT MET - There is no record of tuberculosis or nontuberculous mycobacterial disease at any time, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(25): having gastro-oesophageal reflux disease at the time of the clinical worsening of otitis media — NOT MET - Gastro-oesophageal reflux disease is not recorded at any time, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(26): swimming, diving or water-skiing, where such activities allow water to enter the oropharynx, within the 7 days before the clinical worsening of otitis media — NOT MET - There is no record of swimming, diving or water-skiing after the onset in April 1985, and no clinical worsening of the right otitis media is recorded after its diagnosis and treatment on 8 April 1985.
Factor 9(27): having ascariasis or myiasis of the ear, nose or throat at the time of the clinical worsening of otitis media — NOT MET - There is no record of ascariasis or myiasis of the ear, nose or throat, and nothing in his history suggests it.
Factor 9(28): having ANCA-associated vasculitis at the time of the clinical worsening of otitis media — NOT MET - There is no record of ANCA-associated vasculitis, and nothing in his history suggests it.
Factor 9(29): having infection with human immunodeficiency virus before the clinical worsening of otitis media — NOT MET - There is no record of infection with human immunodeficiency virus, and nothing in his history suggests it.
Factor 9(30): taking an immunosuppressive drug for organ or tissue transplantation before the clinical worsening of otitis media — NOT MET - He has not had an organ or tissue transplant and has not taken an immunosuppressive drug for one.
Factor 9(31): inability to obtain appropriate clinical management for otitis media — NOT MET - A medical officer at a maintenance squadron diagnosed and treated the right otitis media at the veteran's first presentation on 8 April 1985, three days after the onset (Keflex and analgesia), despite the loss of his medical record in December 1984; no recurrence is recorded, and at discharge on 18 November 1985 the Valsalva manoeuvre was positive in both ears and his hearing was normal.
Applying the objective and subjective test in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there is no evidence of an inability to obtain appropriate management of this acute, promptly treated and resolved infection
Sequelae, Unintended Consequence, Inability
No specific sequelae.
Not an unintended consequence.
Inability to obtain appropriate clinical management: NOT MET.
The infection was diagnosed and treated with an antibiotic and analgesia at the veteran's first presentation on 8 April 1985, no recurrence is recorded, and the Valsalva manoeuvre was positive in both ears at discharge
Date of Clinical Onset
Right otitis media is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: approximately 5 April 1985 — onset of painful ears three days before his presentation at a maintenance squadron on 8 April 1985 [CHART REVIEW document].
Date of clinical onset: approximately 5 April 1985.
This date falls within the veteran's ADF service (2 February 1979 18 November 1985).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
