Ear - Tinnitus (bilateral) — example DVA determination letter

Reference Determination Content

Suggested draft · fictitious patient

Example document — fictitious patient. This is a suggested draft determination prepared by the Veterans Health Centre from the matching example Diagnostic Assessment, to show how a DVA delegate could determine the claim. The veteran is fictitious: names, dates, service details and clinicians have been invented. It is not a decision of the Department of Veterans' Affairs and must not be relied upon as a record of any real claim.

Ear - Tinnitus (bilateral)

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 April 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 April 2025;
An infectious diseases consultation by the infectious diseases physician, dated 12 August 1993;
A neurology admission summary by the neurologist, dated 20 June 1994;
An ENT consultation and histopathology by the ENT surgeon and pathologist, dated 18 July 2001;
CT temporal bones by the radiologist, dated 14 March 2005;
An operation report by the ENT surgeon; radiotherapy summary, Radiation oncologist, dated 14 April 2005;
A pre-deployment audiogram and medical examination by the audiologist and medical officer, dated 16 June 2008;
A role 3 admission and MRI report by the afghanistan, dated 19 August 2008;
A treatment record by the regimental medical officer, Afghanistan, dated 6 September 2008;
An ENT consultation and audiology report by the ENT surgeon and audiologist, dated 15 January 2009;
An operation report by the ENT surgeon, dated 22 May 2017;
A treatment record by the medical officer, Iraq, dated 28 March 2020;
An ENT consultation (audiology and MRI reports) by the ENT surgeon, Audiologist and Radiologist, dated 5 May 2020.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

3 February 1988 and 30 September 2021

Ear - Tinnitus (bilateral)

You have stated that your condition was caused by:

being exposed to a peak sound pressure level at the tympanic membrane of at least 140 dB(C) before the clinical onset of tinnitus
being exposed to a sound pressure level at the tympanic membrane of at least 85 dB(A) as an 8-hour time-weighted average (TWA) with a 3-dB exchange rate for a cumulative period of at least six months before the clinical onset of tinnitus
having blunt trauma, penetrating trauma or surgery to an auditory structure or central auditory neural pathway, within the five years before the clinical onset of tinnitus
having sensorineural hearing loss or conductive hearing loss at the time of the clinical onset of tinnitus
taking a drug from the specified list of drugs within the 30 days before the clinical onset of tinnitus
taking a drug which is associated in the individual with: (a) the development of tinnitus within 30 days of commencing drug therapy; and (b) a decrease in tinnitus within days or weeks of discontinuing or tapering drug therapy; and where treatment with the drug continued for at least the three days before the clinical onset of tinnitus
having smoked at least ten pack-years of tobacco products before the clinical onset of tinnitus, and where smoking has ceased, the clinical onset of tinnitus has occurred within five years of cessation
being exposed to second-hand smoke: (a) for at least 2,500 hours before the clinical onset of tinnitus; and (b) where the first exposure to second-hand smoke commenced at least five years before the clinical onset of tinnitus; and (c) where the last exposure to second-hand smoke occurred within the two years before the clinical onset of tinnitus
having inner ear exposure to a chemical agent from the specified list of chemical agents within the 30 days before the clinical onset of tinnitus
having a vascular, muscular or other anatomical source of sound that can be transmitted to the affected ear at the time of the clinical onset of tinnitus
having a reduced supply of blood to an auditory structure of the affected ear at the time of the clinical onset of tinnitus
having a bone disease from the specified list of bone diseases, affecting the petrous temporal bone or middle ear ossicles of the affected side, at the time of the clinical onset of tinnitus
having osteoporosis at the time of the clinical onset of tinnitus
having an autoimmune disease at the time of the clinical onset of tinnitus
having multiple sclerosis at the time of the clinical onset of tinnitus
having a benign or malignant neoplasm involving the petrous temporal bone, an auditory structure or central auditory neural pathway of the affected ear at the time of the clinical onset of tinnitus
having a haematological disease from the specified list of haematological diseases at the time of the clinical onset of tinnitus
having a cerebrovascular accident within the 30 days before the clinical onset of tinnitus
having concussion or moderate to severe traumatic brain injury within the three months before the clinical onset of tinnitus
being exposed to an explosive blast within the 30 days before the clinical onset of tinnitus
being struck by lightning within the 30 days before the clinical onset of tinnitus
having temporomandibular disorder at the time of the clinical onset of tinnitus
having trigeminal neuralgia at the time of the clinical onset of tinnitus
having migraine or tension-type headache before the clinical onset of tinnitus
having Meniere's disease or delayed endolymphatic hydrops at the time of the clinical onset of tinnitus
having: (a) an episode of otitic barotrauma involving the affected ear; or (b) cerebral arterial gas embolism; or (c) decompression sickness; within the 30 days before the clinical onset of tinnitus
having acoustic shock at the time of the clinical onset of tinnitus
having a bacterial infection from the specified list of bacterial infections within the 30 days before the clinical onset of tinnitus
having a viral infection from the specified list of viral infections within the 30 days before the clinical onset of tinnitus
having meningitis or encephalitis within the one year before the clinical onset of tinnitus
having neurosyphilis before the clinical onset of tinnitus
having tuberculosis involving the nasopharynx, meninges, temporal bone, middle ear or inner ear of the affected side before the clinical onset of tinnitus
having typhoid fever within the 30 days before the clinical onset of tinnitus
undergoing a course of therapeutic radiation for cancer, where the auditory apparatus was in the field of radiation, before the clinical onset of tinnitus
having: (a) a cobalt-containing metal-on-metal hip prosthesis; or (b) a serum cobalt concentration of at least 200 micrograms per litre; for at least the four weeks before the clinical onset of tinnitus
having vitamin B1 (thiamine) or vitamin B12 (cobalamin) deficiency at the time of the clinical onset of tinnitus
having carbon monoxide poisoning within the 48 hours before the clinical onset of tinnitus
having hypothyroidism for at least the three months before the clinical onset of tinnitus
having a clinically significant depressive disorder or a clinically significant anxiety disorder at the time of the clinical onset of tinnitus

Diagnosis: Tinnitus (bilateral)

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 22 April 2025, and is supported by an ENT consultation and audiology report by the ENT surgeon and audiologist, dated 15 January 2009.

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Tinnitus (Reasonable Hypothesis) (No. 84 of 2020)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

being exposed to a peak sound pressure level at the tympanic membrane of at least 140 dB(C) before the clinical onset of tinnitus
being exposed to a sound pressure level at the tympanic membrane of at least 85 dB(A) as an 8-hour time-weighted average (TWA) with a 3-dB exchange rate for a cumulative period of at least six months before the clinical onset of tinnitus
having blunt trauma, penetrating trauma or surgery to an auditory structure or central auditory neural pathway, within the five years before the clinical onset of tinnitus
having sensorineural hearing loss or conductive hearing loss at the time of the clinical onset of tinnitus
taking a drug from the specified list of drugs within the 30 days before the clinical onset of tinnitus
taking a drug which is associated in the individual with: (a) the development of tinnitus within 30 days of commencing drug therapy; and (b) a decrease in tinnitus within days or weeks of discontinuing or tapering drug therapy; and where treatment with the drug continued for at least the three days before the clinical onset of tinnitus
having smoked at least ten pack-years of tobacco products before the clinical onset of tinnitus, and where smoking has ceased, the clinical onset of tinnitus has occurred within five years of cessation
being exposed to second-hand smoke: (a) for at least 2,500 hours before the clinical onset of tinnitus; and (b) where the first exposure to second-hand smoke commenced at least five years before the clinical onset of tinnitus; and (c) where the last exposure to second-hand smoke occurred within the two years before the clinical onset of tinnitus
having inner ear exposure to a chemical agent from the specified list of chemical agents within the 30 days before the clinical onset of tinnitus
having a vascular, muscular or other anatomical source of sound that can be transmitted to the affected ear at the time of the clinical onset of tinnitus
having a reduced supply of blood to an auditory structure of the affected ear at the time of the clinical onset of tinnitus
having a bone disease from the specified list of bone diseases, affecting the petrous temporal bone or middle ear ossicles of the affected side, at the time of the clinical onset of tinnitus
having osteoporosis at the time of the clinical onset of tinnitus
having an autoimmune disease at the time of the clinical onset of tinnitus
having multiple sclerosis at the time of the clinical onset of tinnitus
having a benign or malignant neoplasm involving the petrous temporal bone, an auditory structure or central auditory neural pathway of the affected ear at the time of the clinical onset of tinnitus
having a haematological disease from the specified list of haematological diseases at the time of the clinical onset of tinnitus
having a cerebrovascular accident within the 30 days before the clinical onset of tinnitus
having concussion or moderate to severe traumatic brain injury within the three months before the clinical onset of tinnitus
being exposed to an explosive blast within the 30 days before the clinical onset of tinnitus
being struck by lightning within the 30 days before the clinical onset of tinnitus
having temporomandibular disorder at the time of the clinical onset of tinnitus
having trigeminal neuralgia at the time of the clinical onset of tinnitus
having migraine or tension-type headache before the clinical onset of tinnitus
having Meniere's disease or delayed endolymphatic hydrops at the time of the clinical onset of tinnitus
having: (a) an episode of otitic barotrauma involving the affected ear; or (b) cerebral arterial gas embolism; or (c) decompression sickness; within the 30 days before the clinical onset of tinnitus
having acoustic shock at the time of the clinical onset of tinnitus
having a bacterial infection from the specified list of bacterial infections within the 30 days before the clinical onset of tinnitus
having a viral infection from the specified list of viral infections within the 30 days before the clinical onset of tinnitus
having meningitis or encephalitis within the one year before the clinical onset of tinnitus
having neurosyphilis before the clinical onset of tinnitus
having tuberculosis involving the nasopharynx, meninges, temporal bone, middle ear or inner ear of the affected side before the clinical onset of tinnitus
having typhoid fever within the 30 days before the clinical onset of tinnitus
undergoing a course of therapeutic radiation for cancer, where the auditory apparatus was in the field of radiation, before the clinical onset of tinnitus
having: (a) a cobalt-containing metal-on-metal hip prosthesis; or (b) a serum cobalt concentration of at least 200 micrograms per litre; for at least the four weeks before the clinical onset of tinnitus
having vitamin B1 (thiamine) or vitamin B12 (cobalamin) deficiency at the time of the clinical onset of tinnitus
having carbon monoxide poisoning within the 48 hours before the clinical onset of tinnitus
having hypothyroidism for at least the three months before the clinical onset of tinnitus
having a clinically significant depressive disorder or a clinically significant anxiety disorder at the time of the clinical onset of tinnitus

I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with loud, constant high-pitched ringing in both ears, worse in the right, with ear fullness, sensitivity to everyday sounds, dizziness and difficulty hearing speech on 6 September 2008.

The diagnosis was made by an ENT surgeon and audiologist on 15 January 2009, who documented constant bilateral tinnitus present since 6 September 2008, more than three consecutive months, with a Tinnitus Handicap Inventory score of 48, a tinnitus pitch match at 4 kHz and bilateral high-frequency sensorineural hearing loss. This meets the Statement of Principles meaning of tinnitus.

This has then led to further investigations and the diagnosis of your condition of Tinnitus (bilateral). I have accepted your condition of Tinnitus (bilateral).

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your wartime service.

I have therefore accepted that this condition is related to your service with effect from 6 September 2008.

Ear - Tinnitus (bilateral) (Worsening)

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 April 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 April 2025;
An infectious diseases consultation by the infectious diseases physician, dated 12 August 1993;
A neurology admission summary by the neurologist, dated 20 June 1994;
An ENT consultation and histopathology by the ENT surgeon and pathologist, dated 18 July 2001;
CT temporal bones by the radiologist, dated 14 March 2005;
An operation report by the ENT surgeon; radiotherapy summary, Radiation oncologist, dated 14 April 2005;
A pre-deployment audiogram and medical examination by the audiologist and medical officer, dated 16 June 2008;
A role 3 admission and MRI report by the afghanistan, dated 19 August 2008;
A treatment record by the regimental medical officer, Afghanistan, dated 6 September 2008;
An ENT consultation and audiology report by the ENT surgeon and audiologist, dated 15 January 2009;
An operation report by the ENT surgeon, dated 22 May 2017;
A treatment record by the medical officer, Iraq, dated 28 March 2020;
An ENT consultation (audiology and MRI reports) by the ENT surgeon, Audiologist and Radiologist, dated 5 May 2020.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

3 February 1988 and 30 September 2021

Ear - Tinnitus (bilateral) (Worsening)

You have stated that the worsening of your condition was caused by:

being exposed to a peak sound pressure level at the tympanic membrane of at least 140 dB(C) before the clinical worsening of tinnitus
being exposed to a sound pressure level at the tympanic membrane of at least 85 dB(A) as an 8-hour time-weighted average (TWA) with a 3-dB exchange rate for a cumulative period of at least six months before the clinical worsening of tinnitus
having blunt trauma, penetrating trauma or surgery to an auditory structure or central auditory neural pathway, within the five years before the clinical worsening of tinnitus
having sensorineural hearing loss or conductive hearing loss at the time of the clinical worsening of tinnitus
taking a drug from the specified list of drugs within the 30 days before the clinical worsening of tinnitus
having smoked at least ten pack-years of tobacco products before the clinical worsening of tinnitus, and where smoking has ceased, the clinical worsening of tinnitus has occurred within five years of cessation
being exposed to second-hand smoke: (a) for at least 2,500 hours before the clinical worsening of tinnitus; and (b) where the first exposure to second-hand smoke commenced at least five years before the clinical worsening of tinnitus; and (c) where the last exposure to second-hand smoke occurred within the two years before the clinical worsening of tinnitus
having inner ear exposure to a chemical agent from the specified list of chemical agents within the 30 days before the clinical worsening of tinnitus
having a vascular, muscular or other anatomical source of sound that can be transmitted to the affected ear at the time of the clinical worsening of tinnitus
having a reduced supply of blood to an auditory structure of the affected ear at the time of the clinical worsening of tinnitus
having a bone disease from the specified list of bone diseases, affecting the petrous temporal bone or middle ear ossicles of the affected side, at the time of the clinical worsening of tinnitus
having osteoporosis at the time of the clinical worsening of tinnitus
having an autoimmune disease at the time of the clinical worsening of tinnitus
having multiple sclerosis at the time of the clinical worsening of tinnitus
having a benign or malignant neoplasm involving the petrous temporal bone, an auditory structure or central auditory neural pathway of the affected ear at the time of the clinical worsening of tinnitus
having a haematological disease from the specified list of haematological diseases at the time of the clinical worsening of tinnitus
having a cerebrovascular accident within the 30 days before the clinical worsening of tinnitus
having concussion or moderate to severe traumatic brain injury within the three months before the clinical worsening of tinnitus
being exposed to an explosive blast within the 30 days before the clinical worsening of tinnitus
being struck by lightning within the 30 days before the clinical worsening of tinnitus
having temporomandibular disorder at the time of the clinical worsening of tinnitus
having trigeminal neuralgia at the time of the clinical worsening of tinnitus
having migraine or tension-type headache before the clinical worsening of tinnitus
having Meniere's disease or delayed endolymphatic hydrops at the time of the clinical worsening of tinnitus
having: (a) an episode of otitic barotrauma involving the affected ear; or (b) cerebral arterial gas embolism; or (c) decompression sickness; within the 30 days before the clinical worsening of tinnitus
having acoustic shock at the time of the clinical worsening of tinnitus
having a bacterial infection from the specified list of bacterial infections within the 30 days before the clinical worsening of tinnitus
having a viral infection from the specified list of viral infections within the 30 days before the clinical worsening of tinnitus
having meningitis or encephalitis within the one year before the clinical worsening of tinnitus
having neurosyphilis before the clinical worsening of tinnitus
having tuberculosis involving the nasopharynx, meninges, temporal bone, middle ear or inner ear of the affected side before the clinical worsening of tinnitus
having typhoid fever within the 30 days before the clinical worsening of tinnitus
undergoing a course of therapeutic radiation for cancer, where the auditory apparatus was in the field of radiation, before the clinical worsening of tinnitus
having: (a) a cobalt-containing metal-on-metal hip prosthesis; or (b) a serum cobalt concentration of at least 200 micrograms per litre; for at least the four weeks before the clinical worsening of tinnitus
having vitamin B1 (thiamine) or vitamin B12 (cobalamin) deficiency at the time of the clinical worsening of tinnitus
having carbon monoxide poisoning within the 48 hours before the clinical worsening of tinnitus
having hypothyroidism for at least the three months before the clinical worsening of tinnitus
having a clinically significant depressive disorder or a clinically significant anxiety disorder at the time of the clinical worsening of tinnitus
inability to obtain appropriate clinical management for tinnitus

Diagnosis: Tinnitus (bilateral) (Worsening)

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Tinnitus (Reasonable Hypothesis) (No. 84 of 2020)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

being exposed to a peak sound pressure level at the tympanic membrane of at least 140 dB(C) before the clinical worsening of tinnitus
being exposed to a sound pressure level at the tympanic membrane of at least 85 dB(A) as an 8-hour time-weighted average (TWA) with a 3-dB exchange rate for a cumulative period of at least six months before the clinical worsening of tinnitus
having blunt trauma, penetrating trauma or surgery to an auditory structure or central auditory neural pathway, within the five years before the clinical worsening of tinnitus
having sensorineural hearing loss or conductive hearing loss at the time of the clinical worsening of tinnitus
taking a drug from the specified list of drugs within the 30 days before the clinical worsening of tinnitus
having smoked at least ten pack-years of tobacco products before the clinical worsening of tinnitus, and where smoking has ceased, the clinical worsening of tinnitus has occurred within five years of cessation
being exposed to second-hand smoke: (a) for at least 2,500 hours before the clinical worsening of tinnitus; and (b) where the first exposure to second-hand smoke commenced at least five years before the clinical worsening of tinnitus; and (c) where the last exposure to second-hand smoke occurred within the two years before the clinical worsening of tinnitus
having inner ear exposure to a chemical agent from the specified list of chemical agents within the 30 days before the clinical worsening of tinnitus
having a vascular, muscular or other anatomical source of sound that can be transmitted to the affected ear at the time of the clinical worsening of tinnitus
having a reduced supply of blood to an auditory structure of the affected ear at the time of the clinical worsening of tinnitus
having a bone disease from the specified list of bone diseases, affecting the petrous temporal bone or middle ear ossicles of the affected side, at the time of the clinical worsening of tinnitus
having osteoporosis at the time of the clinical worsening of tinnitus
having an autoimmune disease at the time of the clinical worsening of tinnitus
having multiple sclerosis at the time of the clinical worsening of tinnitus
having a benign or malignant neoplasm involving the petrous temporal bone, an auditory structure or central auditory neural pathway of the affected ear at the time of the clinical worsening of tinnitus
having a haematological disease from the specified list of haematological diseases at the time of the clinical worsening of tinnitus
having a cerebrovascular accident within the 30 days before the clinical worsening of tinnitus
having concussion or moderate to severe traumatic brain injury within the three months before the clinical worsening of tinnitus
being exposed to an explosive blast within the 30 days before the clinical worsening of tinnitus
being struck by lightning within the 30 days before the clinical worsening of tinnitus
having temporomandibular disorder at the time of the clinical worsening of tinnitus
having trigeminal neuralgia at the time of the clinical worsening of tinnitus
having migraine or tension-type headache before the clinical worsening of tinnitus
having Meniere's disease or delayed endolymphatic hydrops at the time of the clinical worsening of tinnitus
having: (a) an episode of otitic barotrauma involving the affected ear; or (b) cerebral arterial gas embolism; or (c) decompression sickness; within the 30 days before the clinical worsening of tinnitus
having acoustic shock at the time of the clinical worsening of tinnitus
having a bacterial infection from the specified list of bacterial infections within the 30 days before the clinical worsening of tinnitus
having a viral infection from the specified list of viral infections within the 30 days before the clinical worsening of tinnitus
having meningitis or encephalitis within the one year before the clinical worsening of tinnitus
having neurosyphilis before the clinical worsening of tinnitus
having tuberculosis involving the nasopharynx, meninges, temporal bone, middle ear or inner ear of the affected side before the clinical worsening of tinnitus
having typhoid fever within the 30 days before the clinical worsening of tinnitus
undergoing a course of therapeutic radiation for cancer, where the auditory apparatus was in the field of radiation, before the clinical worsening of tinnitus
having: (a) a cobalt-containing metal-on-metal hip prosthesis; or (b) a serum cobalt concentration of at least 200 micrograms per litre; for at least the four weeks before the clinical worsening of tinnitus
having vitamin B1 (thiamine) or vitamin B12 (cobalamin) deficiency at the time of the clinical worsening of tinnitus
having carbon monoxide poisoning within the 48 hours before the clinical worsening of tinnitus
having hypothyroidism for at least the three months before the clinical worsening of tinnitus
having a clinically significant depressive disorder or a clinically significant anxiety disorder at the time of the clinical worsening of tinnitus
inability to obtain appropriate clinical management for tinnitus

After the condition arose, it was worsened during your service. The rocket attack on warlike service in Iraq on 22 March 2020 exceeded 140 dB(C), before the worsening. Generator and vehicle noise above 85 dB(A) TWA on warlike service in Iraq from August 2019 added to well over six months of exposure before the worsening. The right tympanoplasty of May 2017 was within five years before the worsening on warlike service. Bilateral hearing loss was present at the worsening on warlike service in Iraq. On warlike service in Iraq you took azithromycin and tramadol within 30 days before the worsening. You smoked 20 cigarettes a day through your warlike service in Iraq, about 34 pack-years, and had not stopped. Second-hand smoke exposure in enclosed spaces exceeded 2,500 hours from 1988, more than five years before the worsening, and continued in Iraq in 2020. Aminoglycoside ear drops entered your inner ear through a perforation on warlike service from 18 March 2020. The right vestibular schwannoma was present at the worsening on warlike service. The infarct of 10 March 2020 on warlike service, with hyperviscosity, reduced inner ear blood supply at the worsening. Left otosclerosis was present at the worsening on warlike service. Osteoporosis, on DXA in 2019 (T-score -3.0), was present at the worsening. Your autoimmune diseases were present at the worsening on warlike service. Multiple sclerosis was present at the worsening on warlike service. The right vestibular schwannoma was present at the worsening. Hyperviscosity syndrome was present at the worsening on warlike service. On warlike service in Iraq you had a stroke on 10 March 2020, within 30 days before the worsening. The rocket attack on warlike service on 22 March 2020 caused concussion, six days before the worsening. On warlike service in Iraq a rocket exploded near you on 22 March 2020, within 30 days before the worsening. On warlike service in Iraq you were struck by lightning ground current on 3 March 2020, 25 days before the worsening. Temporomandibular disorder was present at the worsening on warlike service. Trigeminal neuralgia was present at the worsening, still requiring carbamazepine. Migraine with brainstem aura and tension-type headache preceded the worsening. Delayed endolymphatic hydrops was present at the worsening on warlike service. On warlike service you had otitic barotrauma on 14 March 2020, within 30 days before the worsening. Acoustic shock from a headset shriek on warlike service on 22 March 2020 was present at the worsening. On warlike service you had right chronic suppurative otitis media from 18 March 2020, within 30 days before the worsening. On warlike service in Iraq you had COVID-19 from 20 March 2020, within 30 days before the worsening. Herpes simplex meningitis in September 2019, on warlike service, was within one year before the worsening. Neurosyphilis from 1994 preceded the worsening. Right tuberculous otitis media in 2001 preceded the worsening. On warlike service in Iraq typhoid fever was confirmed on 6 March 2020, within 30 days before the worsening. Radiotherapy with the auditory apparatus in the field in 2005 preceded the worsening. The metal-on-metal hip, serum cobalt 230 micrograms per litre, was in place throughout your warlike service in Iraq. B12 deficiency was present at the worsening, your injections unavailable on warlike service. Carbon monoxide poisoning in a bunker on warlike service on 27 March 2020 was within 48 hours before the worsening. Hypothyroidism was present for 14 years before the worsening. Clinically significant depression and PTSD under monthly management were present at the worsening on warlike service. On warlike service in Iraq in 2020 audiology, ENT care and replacement hearing aids were unavailable and COVID-19 restrictions delayed review for six weeks while the tinnitus worsened.

This has then led to further investigations and the diagnosis of your condition of Tinnitus (bilateral) (Worsening). I have accepted your condition of Tinnitus (bilateral) (Worsening).

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your wartime service.

I have therefore accepted that the worsening of this condition is related to your service with effect from 22 March 2020.

Ear - Tinnitus (bilateral) — example determination letter

See the letter exactly as it is delivered

Reference Determination Content

Ear - Tinnitus (bilateral)

Evidence

Your service

Ear - Tinnitus (bilateral)

Ear - Tinnitus (bilateral) (Worsening)

Evidence

Your service

Ear - Tinnitus (bilateral) (Worsening)