Tinnitus

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.

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 17 June 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 June 2025;
A neurology consultation and MRI brain by the neurologist, dated 6 February 1998;
An operation report (left tympanoplasty) by the ENT surgeon, dated 18 November 1998;
An audiology report and CT temporal bones by the audiologist and radiologist, dated 14 March 2002;
A haematology consultation by the haematologist, dated 21 October 2002;
A pre-deployment medical examination by the medical officer, dated 28 January 2003;
A field medical record and microbiology by the medical officer, Iraq, dated 26 March 2003;
A diving accident record and recompression log by the diving medical officer, Iraq, dated 10 April 2003;
A field medical record by the medical officer, Iraq, dated 12 April 2003;
An MRI brain and internal auditory meatuses by the radiologist, dated 18 April 2003;
An ENT consultation and audiology by the ENT surgeon, dated 15 July 2003;
An operation report (revision tympanoplasty and stapedotomy) by the ENT surgeon, dated 11 September 2007;
A ship's medical record by the ship's medical officer, dated 14 June 2010;
An MRI brain and internal auditory meatuses by the radiologist, dated 30 June 2010;
An ENT consultation and audiology by the ENT surgeon, dated 2 July 2010.

Your service

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

10 February 1994 and 15 March 2013

Tinnitus

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

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 17 June 2025, and is supported by an ENT consultation and audiology by the ENT surgeon, dated 15 July 2003.

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 sudden pain, burning and fullness in the left ear followed by constant high-pitched ringing and hissing in the left ear, with a pulsatile component, difficulty sleeping and poor concentration on 12 April 2003.

The diagnosis was made clinically by an ENT surgeon on 15 July 2003 on the history of constant left-sided ringing and hissing without an external source present every day since 12 April 2003, more than three consecutive months, supported by audiometry showing left sensorineural and conductive hearing loss, a tinnitus pitch match at 6 kHz with a loudness of 8 dB above threshold, and a Tinnitus Handicap Inventory score of 42. This meets the Statement of Principles definition of tinnitus.

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

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 12 April 2003.

Tinnitus (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 17 June 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 June 2025;
A neurology consultation and MRI brain by the neurologist, dated 6 February 1998;
An operation report (left tympanoplasty) by the ENT surgeon, dated 18 November 1998;
An audiology report and CT temporal bones by the audiologist and radiologist, dated 14 March 2002;
A haematology consultation by the haematologist, dated 21 October 2002;
A pre-deployment medical examination by the medical officer, dated 28 January 2003;
A field medical record and microbiology by the medical officer, Iraq, dated 26 March 2003;
A diving accident record and recompression log by the diving medical officer, Iraq, dated 10 April 2003;
A field medical record by the medical officer, Iraq, dated 12 April 2003;
An MRI brain and internal auditory meatuses by the radiologist, dated 18 April 2003;
An ENT consultation and audiology by the ENT surgeon, dated 15 July 2003;
An operation report (revision tympanoplasty and stapedotomy) by the ENT surgeon, dated 11 September 2007;
A ship's medical record by the ship's medical officer, dated 14 June 2010;
An MRI brain and internal auditory meatuses by the radiologist, dated 30 June 2010;
An ENT consultation and audiology by the ENT surgeon, dated 2 July 2010.

Your service

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

10 February 1994 and 15 March 2013

Tinnitus (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 (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. On 14 June 2010, on warlike maritime service in the Middle East, a 12.7 millimetre machine gun was fired without warning about two metres from you during a warning-shot serial, a peak level above 140 dB(C), before the worsening that day. Your exposure to compressors, boat engines, machinery spaces and small arms above an 8-hour TWA of 85 dB(A) continued at sea from 2003 to 2010, a cumulative period of years before the worsening on 14 June 2010. On 11 September 2007 an ENT surgeon performed a left revision tympanoplasty and stapedotomy, surgery to the left middle ear within the five years before the worsening, which run from 14 June 2005 to 14 June 2010. Audiometry on 2 July 2010 showed worse left sensorineural hearing loss (70 dB at 4 kHz) with a residual conductive component, present at the worsening on 14 June 2010. After fracturing two ribs on 20 May 2010 you took oxycodone 5 mg up to four times daily until 10 June 2010, and azithromycin for typhoid from 25 May 2010, both on the specified list and within the 30 days before the worsening on 14 June 2010. You continued smoking about 25 cigarettes a day to 2010, about 18 pack-years by the worsening on 14 June 2010. Your exposure to second-hand smoke in enclosed messes and shore-base smoking rooms exceeded 4,000 hours by 2010, began in 1994, and last occurred in an enclosed smoking room at a Gulf port in March 2010, within the two years before the worsening. For chronic suppurative otitis media through a persisting left perforation the ship's medical officer prescribed chloramphenicol ear drops from 28 May to 10 June 2010, within the 30 days before the worsening on 14 June 2010. The left glomus tympanicum, enlarged to 6 millimetres on MRI of 30 June 2010, was present and producing pulsatile tinnitus at the worsening on 14 June 2010. Venesection was not available at sea and your haematocrit was 0.61 on 29 May 2010, with hyperviscosity reducing blood supply to the left inner ear at the worsening, shown also by the cerebellar infarct of 28 May 2010. Left otosclerosis, only partly corrected by the 2007 stapedotomy, affected the left ossicular chain at the worsening on 14 June 2010. Osteoporosis persisted, with a T-score of -2.9 in 2009, at the worsening on 14 June 2010. Hashimoto thyroiditis and pernicious anaemia were present at the worsening on 14 June 2010. Multiple sclerosis was present at the worsening on 14 June 2010, with a new pontine lesion on MRI of 30 June 2010. The left glomus tympanicum involving the middle ear was present at the worsening on 14 June 2010. Polycythaemia vera with hyperviscosity syndrome was present at the worsening on 14 June 2010, with a haematocrit of 0.61 at sea. On 28 May 2010, on warlike maritime service in the Middle East, you developed sudden vertigo and ataxia, and MRI on 30 June 2010 showed a new right cerebellar infarct, a cerebrovascular accident within the 30 days before the worsening. On 20 May 2010, during a boarding on warlike maritime service in the Middle East, you fell from a pilot ladder into the boarding boat, striking your helmeted head and fracturing two ribs, with loss of consciousness for one minute. On 8 June 2010, on warlike maritime service in the Middle East, the ship's diving team destroyed a drifting sea mine with a demolition charge, and you, in the boat about 300 metres away, was exposed to the explosive blast, within the 30 days before the worsening. On 3 June 2010, on warlike maritime service in the Middle East, you were struck by a side flash through the guard rail during an electrical storm while on the upper deck, with a burn to the left hand, within the 30 days before the worsening. Bilateral temporomandibular disorder persisted and was present at the worsening on 14 June 2010. Left trigeminal neuralgia persisted on carbamazepine and was present at the worsening on 14 June 2010. Migraine with brainstem aura from 1996 was present before the worsening on 14 June 2010. Left Meniere's disease remained active, with an attack in April 2010, at the worsening on 14 June 2010. On 11 June 2010, on warlike maritime service in the Middle East, after repeated hull search dives you developed decompression sickness with joint pain and paraesthesia, and left otitic barotrauma, within the 30 days before the worsening. The unexpected machine gun burst on 14 June 2010 was followed immediately by burning pain, fullness and muffled hearing in the left ear, recorded by the ship's medical officer, which were acoustic shock symptoms at the time of the worsening. Chronic suppurative otitis media of the left ear, with a central perforation and discharge since 2008, was active in the 30 days before the worsening on 14 June 2010. On 1 June 2010, on warlike maritime service in the Middle East, you developed herpes zoster of the left geniculate ganglion (Ramsay Hunt syndrome), with vesicles in the left ear canal and left facial weakness, within the 30 days before the worsening. In October 2009 you were admitted with enteroviral meningitis, within the one year before the worsening, from 14 June 2009 to 14 June 2010. Neurosyphilis was diagnosed and treated in 2000, before the worsening on 14 June 2010. Tuberculous otitis media of the left middle ear in 1996 was before the worsening on 14 June 2010. On 25 May 2010, after a port visit on warlike maritime service in the Middle East, blood cultures again grew Salmonella Typhi, within the 30 days before the worsening on 14 June 2010. The 1999 radiotherapy with the left ear in the field was before the worsening on 14 June 2010. The left metal-on-metal hip resurfacing remained in place, with a serum cobalt of 210 micrograms per litre in February 2010, for years before the worsening. Your vitamin B12 injections could not be given at sea from January 2010, and your B12 was 140 pmol/L on 29 May 2010, deficient at the worsening. On 13 June 2010, on warlike maritime service in the Middle East, you were in the attack team at a machinery space fire and your carboxyhaemoglobin was 18 per cent, carbon monoxide poisoning within the 48 hours before the worsening. Hypothyroidism had been present since 2001, more than three months before the worsening, with a raised TSH at sea in May 2010. Major depressive disorder, with chronic posttraumatic stress disorder diagnosed in 2005, was present and under monthly review at the worsening on 14 June 2010. MET.

This has then led to further investigations and the diagnosis of your condition of Tinnitus (Worsening). I have accepted your condition of Tinnitus (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 14 June 2010.

Tinnitus — example determination letter

See the letter exactly as it is delivered

Reference Determination Content

Tinnitus

Evidence

Your service

Tinnitus

Tinnitus (Worsening)

Evidence

Your service

Tinnitus (Worsening)