Diagnostic Assessment — Tonsillitis
Example 1 of 1 · fictitious patient (Veteran CZ)
Diagnostic Assessment
Tonsillitis
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran CZ, date of birth 07 April 1990, Australian Army, Signaller (Communications Systems Operator), enlisted 02 February 2009, medically discharged 28 October 2017. Operational service: Afghanistan, 12 March 2011 to 30 September 2011 (warlike); Middle East Area of Operations, 25 November 2014 to 06 March 2015 (warlike, ended by aeromedical evacuation).
Occupational History
As a signaller the veteran operated and maintained radio and satellite communications in field shelters, vehicles and signals centres, often on long shifts with disrupted sleep. Recruit and field training involved crowded barracks and shelters, arduous physical exertion, sleep deprivation, riot-control agent training and exposure to dust and pyrotechnic smoke.
Deployed signallers of the period lived and worked in crowded tents and demountables, close to open burn pits and in frequent dust storms. Streptococcal and viral respiratory infections spread readily through recruit platoons and deployed bases, and smoking rates rose on deployment.
History
Veteran CZ, a signaller in the Australian Army, developed group A streptococcal tonsillitis on 11 June 2009 during an outbreak at recruit training, and the condition became recurrent and then chronic, with seven episodes in the following year. It worsened with a peritonsillar abscess on 03 March 2015 during warlike service in the Middle East, after tonsillectomy had been deferred for service reasons, and he underwent tonsillectomy in June 2015.
Timeline
- 02 Feb 2009 — Enlistment medical examination. No history of recurrent sore throat or tonsillitis. Tonsils small and healthy. Non-smoker. Fit for recruit training. "tonsils normal, non-smoker"
- 14 Jun 2009 — At the recruit training centre the veteran presented with three days of severe sore throat, painful swallowing and fever after the field phase. Temperature 39.2 degrees, bilateral tonsillar exudate and tender anterior cervical lymph nodes. Throat swab grew group A beta-haemolytic Streptococcus. His bunk neighbour had been diagnosed with streptococcal tonsillitis on 06 June 2009. Treated with intramuscular benzathine penicillin and admitted to the sick bay for two days. "exudative tonsillitis, GAS positive"
- 20 Nov 2009 — Fourth episode of acute tonsillitis since June 2009, at his first posting with a signals regiment, living in shared barracks. Enlarged, cryptic tonsils with exudate and halitosis between episodes. Throat swab again positive for group A Streptococcus. Treated with phenoxymethylpenicillin for 10 days. "fourth episode, cryptic tonsils"
- 15 Aug 2010 — An ear, nose and throat surgeon reviewed the veteran after seven documented episodes of tonsillitis in 12 months, each treated with antibiotics and causing time off duty. Examination showed enlarged, scarred tonsils with debris in the crypts and persistent jugulodigastric lymphadenopathy. He diagnosed recurrent acute and chronic tonsillitis and recommended tonsillectomy, which was deferred because of his pending deployment. "chronic tonsillitis, tonsillectomy recommended"
- 18 Jul 2011 — On warlike service in Afghanistan the veteran had two episodes of exudative tonsillitis in six weeks, treated at the role 2 facility with oral antibiotics. He had started smoking on this deployment, about 15 cigarettes a day. Tonsillectomy was again deferred on his return because of a promotion course and a posting. "two episodes deployed, now smoking"
- 12 Apr 2014 — Periodic health examination and medical officer review for a further episode of acute exudative tonsillitis, swab positive for group A Streptococcus. The veteran had had three to four episodes a year since 2011 and was smoking 15 to 20 cigarettes a day. The tonsils were enlarged and scarred with crypt debris. The ear, nose and throat referral for tonsillectomy was renewed but not actioned before his deployment to the Middle East. "recurrent episodes, referral renewed"
- 19 Feb 2015 — On warlike service in the Middle East the veteran had his fifth episode of tonsillitis in a year, with a group A Streptococcus positive swab. He was living in shared tents near an open burn pit and working 12-hour shifts. He was treated with oral amoxicillin. No ear, nose and throat surgeon was available in theatre. "fifth episode in a year"
- 03 Mar 2015 — The veteran presented to the role 2 facility with severe left-sided throat pain, trismus, a muffled voice and drooling. Temperature 39.6 degrees, bulging of the left soft palate with uvular deviation. A left peritonsillar abscess was aspirated, yielding 6 mL of pus that grew group A Streptococcus and anaerobes. He received intravenous antibiotics and was aeromedically evacuated on 06 March 2015. "left peritonsillar abscess, aspirated"
- 18 Jun 2015 — Elective bilateral tonsillectomy. Histology showed chronic tonsillitis with lymphoid hyperplasia, crypt abscesses, fibrosis and tonsilloliths. A secondary post-tonsillectomy haemorrhage on day 8 required return to theatre. "tonsillectomy, chronic tonsillitis on histology"
Symptoms
At onset the veteran had severe sore throat, painful swallowing, fever, swollen tender neck glands and tonsillar exudate. After onset he had recurrent episodes every six to eight weeks, with persistent sore throat, halitosis and tender neck glands between episodes. At the 2015 worsening he had a peritonsillar abscess with trismus, a muffled voice and drooling. Each episode kept him off duty for three to five days, and between episodes he described a constant mild soreness on swallowing and a bad taste in the mouth.
He now reports occasional sore throats and a sensation of dryness and catching in the throat since tonsillectomy, and he remains anxious about bleeding after the secondary haemorrhage in 2015.
Imaging
No imaging is required to establish this diagnosis.
Onset Date
The most likely date of onset of this condition is 11 Jun 2009.
At that date the veteran was a recruit in the final weeks of recruit training, living in a 30-bed open-plan barracks after a 14-day field phase. A streptococcal outbreak was running through his platoon, and his bunk neighbour had been diagnosed five days earlier. From 11 June 2009 he had a severe sore throat, painful swallowing and fever, and he presented on 14 June 2009.
This date is appropriate because his enlistment medical examination on 02 February 2009 recorded no history of tonsillitis and healthy tonsils, and his first presentation on 14 June 2009 dated the symptoms to three days earlier. The condition then recurred seven times in 12 months and was diagnosed as recurrent and chronic tonsillitis on 15 August 2010. It falls within continuous full-time service.
For the causes, the 7 days before onset run from 04 Jun 2009 to 11 Jun 2009, when he lived in crowded barracks and field shelters and had close contact with a recruit with streptococcal tonsillitis (06 Jun 2009). The 14 days before onset run from 28 May 2009 to 11 Jun 2009 and match the field phase with 3 to 4 hours of sleep a night, and the viral upper respiratory tract infection of 01 Jun 2009. The 30 days before onset run from 12 May 2009 to 11 Jun 2009 and contain the CS chamber test (21 May 2009), field dust and smoke, and the prednisolone course (18 to 27 May 2009). The 1 year before onset runs from 11 Jun 2008 to 11 Jun 2009 and contains more than 200 hours of second-hand smoke exposure from 09 Feb 2009.
For the worsening factors, the documented worsening was the left peritonsillar abscess of 03 Mar 2015. The 1 year before it runs from 03 Mar 2014 to 03 Mar 2015 and contains five episodes of acute tonsillitis, continuous smoking of at least 15 cigarettes a day and more than 380 hours of burn-pit smoke exposure from 25 Nov 2014. The 14 days before it run from 17 Feb 2015 to 03 Mar 2015, during which he worked 12-hour shifts with about 4 hours of sleep a night, and the 7 days before it run from 24 Feb 2015 to 03 Mar 2015, during which he lived in crowded shared accommodation on deployment.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Tonsillitis, recurrent acute and chronic tonsillitis complicated by a left peritonsillar abscess (ICD-10-AM J35.0). No Statement of Principles has been determined for tonsillitis.
Tonsillitis is inflammation of the palatine tonsils, usually caused by infection with group A beta-haemolytic Streptococcus or respiratory viruses such as adenovirus and Epstein-Barr virus. Acute tonsillitis causes sore throat, painful swallowing, fever and tender neck glands. Repeated episodes scar the tonsils, trap debris and bacteria in the crypts and lead to chronic tonsillitis, with persistent sore throat, halitosis and lymphadenopathy. Infection can spread into the space around the tonsil to form a peritonsillar abscess (quinsy). Tonsillectomy is recommended when episodes are frequent (for example seven in one year), and it is the definitive treatment of chronic tonsillitis.
The condition began on 11 June 2009 in a streptococcal outbreak at recruit training, was diagnosed as recurrent and chronic tonsillitis on 15 August 2010 and worsened with a peritonsillar abscess on 03 March 2015 on warlike service.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
11 June 2009.
When did the veteran first present to a health / medical provider for this condition?
14 June 2009.
When was the condition confirmed / formally diagnosed?
15 August 2010.
When did the veteran first present to you (or your practice) for this condition?
21 October 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically and microbiologically: the first episode on 14 June 2009 showed fever, bilateral tonsillar exudate and tender cervical lymph nodes with a throat swab positive for group A Streptococcus, and seven documented episodes followed in 12 months. An ear, nose and throat surgeon diagnosed recurrent acute and chronic tonsillitis on 15 August 2010, with enlarged, scarred, cryptic tonsils and persistent lymphadenopathy, meeting the accepted frequency criteria for tonsillectomy.
The worsening was confirmed by aspiration of pus from a left peritonsillar abscess on 03 March 2015, and the histology of the tonsils removed on 18 June 2015 confirmed chronic tonsillitis with crypt abscesses and fibrosis. No imaging was needed for diagnosis.
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 for tonsillitis, so the claim is decided on the sound medical-scientific evidence of what causes the condition, without the limits a Statement of Principles would impose. The recognised causes below are drawn from the medical literature on streptococcal and recurrent tonsillitis, including the military literature on outbreaks in recruits and deployed personnel, and are set out in the style of a Statement of Principles so that each can be tested against the facts.
Legislation: the clinical onset of this condition was on 11 June 2009, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The onset occurred during peacetime recruit training, and the worsening occurred on warlike service in the Middle East in 2015, following recurrences on warlike service in Afghanistan in 2011. 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: having an infection of the tonsils with group A beta-haemolytic Streptococcus or another pathogen that infects the tonsils at the time of the clinical onset of tonsillitis; — MET
- A throat swab taken at the recruit training centre on 14 June 2009 grew group A beta-haemolytic Streptococcus (Streptococcus pyogenes), and the medical officer recorded fever of 39.2 degrees, tender cervical lymph nodes and exudate on both tonsils. The infection was present at clinical onset on 11 June 2009 and was acquired during an outbreak among recruits in the same platoon.
Cause 2: living or sleeping in crowded shared accommodation for at least the 7 days before the clinical onset of tonsillitis; — MET
- From 09 February 2009 the veteran lived in a 30-bed open-plan recruit barracks with beds about one metre apart, shared ablutions and a common mess, and from 28 May 2009 he slept in two-person shelters on a field exercise. He had lived in this crowded accommodation continuously for four months, including the 7 days before onset, from 04 June 2009 to 11 June 2009. Crowded military accommodation is a well-established setting for the spread of streptococcal and respiratory infections.
Cause 3: having close contact with a person who has streptococcal pharyngitis or tonsillitis within the 7 days before the clinical onset of tonsillitis; — MET
- The veteran's bunk neighbour and field-shelter partner was diagnosed with swab-positive streptococcal tonsillitis on 06 June 2009, five days before the veteran's onset, and eleven recruits in the platoon were treated for streptococcal pharyngitis between 01 and 20 June 2009, as recorded in the training centre's outbreak report.
Cause 4: undertaking sustained arduous physical training with sleep restriction to less than 5 hours a night for at least the 14 days before the clinical onset of tonsillitis; — MET
- From 28 May 2009 to 10 June 2009 the veteran completed the field phase of recruit training, with daily loaded marches, section attacks and night routine. The training programme and his recruit diary record sleep of 3 to 4 hours a night throughout these 14 days. Sustained heavy exertion and sleep deprivation suppress mucosal immunity, and outbreaks of streptococcal and adenoviral infection in recruits cluster after field phases.
Cause 5: being exposed to second-hand smoke for at least 200 hours within the 1 year before the clinical onset of tonsillitis; — MET
- During recruit training the only break area outside the lines was the designated smoking area, where recruits gathered between lessons and in the evenings. The veteran, a non-smoker at that time, spent about two hours a day there from 09 February 2009, a total of more than 200 hours by onset on 11 June 2009, all within the 1 year before onset. Tobacco smoke impairs mucociliary clearance and increases colonisation of the tonsils by pathogenic bacteria.
Cause 6: being exposed to airborne irritants, including riot-control agents, smoke or fine dust, within the 30 days before the clinical onset of tonsillitis; — MET
- On 21 May 2009 the veteran completed the respirator confidence test in a chamber filled with CS riot-control agent, recorded in his training record with coughing and a burning throat for two days afterwards, and from 28 May 2009 he was exposed to fine dust and smoke from training pyrotechnics during the field phase. Both exposures fell within the 30 days before onset on 11 June 2009 and irritated the pharyngeal mucosa.
Cause 7: taking a systemic corticosteroid for at least 7 days within the 30 days before the clinical onset of tonsillitis; — MET
- On 18 May 2009 the medical officer prescribed prednisolone 25 mg daily for 10 days, to 27 May 2009, for severe contact dermatitis from vegetation encountered on a navigation exercise. The course was taken within the 30 days before onset on 11 June 2009. Systemic corticosteroids impair the local immune response to streptococcal infection.
Cause 8: having a viral upper respiratory tract infection, including adenovirus infection, within the 14 days before the clinical onset of tonsillitis; — MET
- On 01 June 2009, during the field phase, the veteran was seen by the platoon medic with a runny nose, cough and mild sore throat, recorded as a viral upper respiratory tract infection. Adenovirus was confirmed by PCR in nine recruits of his platoon in the training centre's outbreak report. This viral infection occurred 10 days before onset on 11 June 2009, within the 14 days before it, and viral damage to the pharyngeal mucosa predisposes to secondary streptococcal tonsillitis.
Worsening factors
Worsening 1: having repeated acute infections of the tonsils with group A Streptococcus or another pathogen within the 1 year before the clinical worsening of tonsillitis; — MET
- In the year before the worsening, from 03 March 2014 to 03 March 2015, the veteran had five documented episodes of acute exudative tonsillitis, three with swabs positive for group A Streptococcus, on 12 April 2014, 30 June 2014, 18 September 2014, 08 December 2014 and 19 February 2015. The last two occurred on warlike service in the Middle East. Each episode left the tonsils more scarred and crypt-filled.
Worsening 2: living or sleeping in crowded shared accommodation for at least the 7 days before the clinical worsening of tonsillitis; — MET
- From 25 November 2014 the veteran lived in a 12-person tent and then shared demountable accommodation at a coalition base in the Middle East, with shared ablutions and dining. He lived in this crowded accommodation throughout the 7 days before the worsening, from 24 February 2015 to 03 March 2015, during which respiratory infection was circulating through the base.
Worsening 3: smoking at least 10 cigarettes per day for at least the 1 year before the clinical worsening of tonsillitis; — MET
- The veteran began smoking during his first deployment to Afghanistan in 2011 and smoked 15 to 20 cigarettes a day from then on, recorded at his 2013 and 2014 periodic health examinations. He smoked at least 15 a day throughout the 1 year before the worsening, from 03 March 2014 to 03 March 2015, rising to 25 a day on deployment.
Worsening 4: being exposed to smoke from open-air burning of waste or other airborne irritants for at least 100 hours within the 1 year before the clinical worsening of tonsillitis; — MET
- At the coalition base in the Middle East the veteran's signals centre was 300 metres downwind of an open burn pit used for waste disposal, and smoke drifted over the work area on most days. His deployment health surveillance record estimates exposure of about 4 hours a day from 25 November 2014 to 03 March 2015, more than 380 hours, all within the 1 year before the worsening. He also worked in fine dust storms during this period.
Worsening 5: undertaking sustained shift work or operational duties with sleep restriction to less than 5 hours a night for at least the 14 days before the clinical worsening of tonsillitis; — MET
- From 10 February 2015 to 03 March 2015 the veteran worked 12-hour shifts in the signals centre during a period of heightened operations, with frequent rocket alarms at night. His shift roster and the deployed medical record show sleep of about 4 hours a night throughout the 14 days before the worsening.
Worsening 6: inability to obtain appropriate clinical management for tonsillitis. — MET
- An ear, nose and throat surgeon recommended tonsillectomy on 15 August 2010, after seven episodes in 12 months met the accepted criteria for surgery. The operation was deferred because of his deployment to Afghanistan in 2011, deferred again for courses and a posting, and had not been performed when he deployed to the Middle East in November 2014. On that deployment he was treated with repeated oral antibiotics without access to an ear, nose and throat surgeon, and the peritonsillar abscess of 03 March 2015 developed before he could be evacuated. Under Brew v Repatriation Commission (1999) treatment withheld because of service requirements is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The tonsillitis resulted in a left peritonsillar abscess, tonsillectomy and a secondary post-tonsillectomy haemorrhage requiring return to theatre. Time lost from duty and repeated antibiotic courses also followed from the condition. These are sequelae of the accepted condition.
Unintended Consequence
Met. The secondary haemorrhage on day 8 after the tonsillectomy of 18 June 2015, which required a return to theatre and blood transfusion, is an unintended consequence of treatment provided and paid for by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. Tonsillectomy was recommended by an ear, nose and throat surgeon on 15 August 2010, when the accepted criteria for surgery were met, but it was deferred for his 2011 deployment to Afghanistan, then for a course and a posting, and had still not been performed when he deployed to the Middle East in November 2014. In theatre he had no access to an ear, nose and throat surgeon and was managed with repeated oral antibiotics until the peritonsillar abscess developed on 03 March 2015. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), definitive treatment withheld for more than four years because of service requirements amounts to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 02 Feb 2009, Enlistment medical examination, Medical Officer
- 14 Jun 2009, Outpatient record and throat swab, Medical Officer, Recruit training centre
- 30 Jun 2009, Outbreak report, Recruit training centre health centre
- 20 Nov 2009, Outpatient health record, Medical Officer, Signals regiment health centre
- 15 Aug 2010, Specialist consultation, Ear, nose and throat surgeon
- 18 Jul 2011, Role 2 consultation, Medical Officer, Afghanistan
- 12 Apr 2014, Periodic health examination and outpatient record, Medical Officer
- 19 Feb 2015, Deployed medical record and throat swab, Medical Officer, Middle East
- 03 Mar 2015, Role 2 record, abscess aspiration and microbiology, Medical Officer, Middle East
- 18 Jun 2015, Operation report and histopathology, Ear, nose and throat surgeon
- 26 Jun 2015, Return to theatre operation report, Ear, nose and throat surgeon
