Statement of Principles concerning otitis externa (Balance of Probabilities) (No. 26 of 2021)

The instrument’s core concepts are set out in a concise framework: the clinical entity covered, the list of causal or contributory factors, the temporal windows for those factors, the relationship to relevant service, and how overlap with other SOPs is to be handled.

1. Definition of the clinical condition (s 7(2)-(4)).

   • Otitis externa is defined as "an infectious or non‑infectious inflammation of the external auditory canal" (s 7(2)(a)) and explicitly includes a non‑exhaustive list of subtypes such as acute diffuse otitis externa, furunculosis, eczematous otitis externa, malignant otitis externa, acquired cholesteatoma of the external auditory canal, and otomycosis (s 7(2)(b)(i)-(vi)). Notes provide that the condition may be acute or chronic, and list typical symptoms (s 7 notes). The instrument also maps the clinical meaning to ICD‑10‑AM codes but expressly states that the definition in s 7(2) governs application (s 7(3)-(4)).

2. Factors that must exist for a connection with service (s 9).

   • Section 9 lists 27 discrete factors. Each factor is a factual circumstance (for example, "participating in aquatic activities within the ten days before the clinical onset" (s 9(1)); "being exposed to hot and humid weather conditions or heavy rains, on at least ten days within the 30 days before the clinical onset" (s 9(2)); "having diabetes mellitus at the time of the clinical onset" (s 9(11))). Some factors apply both to initial onset (s 9(1)-(13)) and to clinical worsening (s 9(14)-(26)); an additional factor is inability to obtain appropriate clinical management (s 9(27)).

3. Temporal thresholds and quantitative thresholds.

   • The SOP specifies narrow time windows (for example ten days, seven days, two weeks, 30 days) and quantitative environmental thresholds (Schedule 1 defines "hot and humid weather conditions" as ambient humidity exceeding 40 per cent and maximum temperature exceeding 30 degrees Celsius). Extrinsic device use is quantified (occlusion of canal for a cumulative period of at least 16 hours within seven days) (s 9(6), s 9(19); Schedule 1).

4. Relationship to relevant service (s 10).

   • Any factor established must be related to the person’s relevant service (s 10(1)). The SOP distinguishes onset factors from aggravation factors: subsections 9(14)-9(27) apply only to material contribution to, or aggravation of, otitis externa where the person’s otitis externa was suffered or contracted before or during (but did not arise out of) the person's relevant service (s 10(2)).

5. Interaction with other SOPs (s 11).

   • If a factor in s 9 refers to an injury or disease covered by another SOP, then the factors in that other SOP apply according to its terms (s 11). This is a mechanism for cross‑referencing and deferring to other SOPs where causation depends on another diagnosed condition.

6. Dictionary/definitions (Schedule 1).

   • The Schedule supplies precise meanings for terms that appear in factors: "aquatic activities", "extrinsic aural device", "exostosis of the external auditory canal", "hot and humid weather conditions", "immunocompromised state as specified", "immunosuppressive drug", "chronic suppurative otitis media", and administrative definitions ("MRCA", "VEA", "relevant service", "terminal event") (Schedule 1).

These concepts together constitute the SOP’s deterministic template: if the claimant can establish one or more of the enumerated factors, and that factor is related to relevant service as required by s 10, then the SOP supplies the medical foundation on the balance of probabilities for a finding of connection between otitis externa (or death from it) and relevant service for the purposes of VEA/MRCA claims.

The instrument applies to persons making claims under the VEA and MRCA where sections referenced in the instrument are engaged: it expressly applies to claims to which section 120B of the VEA or section 339 of the MRCA applies (s 5). The Schedule’s definition of "relevant service" determines which types of service are within scope: eligible war service (other than operational service) and defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA (Schedule 1, definition of "relevant service").

Primary affected groups

• Veterans and former members of the Australian Forces who seek service connection for otitis externa or death from otitis externa in the context of claims under VEA s 120B or MRCA s 339 (s 5; Schedule 1). The SOP is activated only where those statutory claim provisions apply.

Decision‑makers and medical assessors

• The Repatriation Medical Authority (RMA) is the author of the instrument (instrument header; s 3). The SOP is intended for use by the administrative decision‑makers who determine claims under the VEA and MRCA; the instrument itself does not name the decision body but is made under s 196B(3) of the VEA (s 3). Medical assessors and clinicians preparing reports for claims will be expected to address the listed factors and relevant definitions.

Third parties and record keepers

• Employers, unit commanders, medical practitioners, allied health providers, treating hospitals, and other record‑holders are implicitly implicated because the evidentiary requirements (temporal windows, device usage, environmental exposure) require contemporaneous records, clinical notes, operational logs, radiation treatment fields and dates, and possibly meteorological data (see s 9; Schedule 1). For example, proving "undergoing a course of therapeutic radiation for cancer, where the affected ear was in the field of radiation" (s 9(3), s 9(16)) will typically rely on radiotherapy records.

Those not covered

• Persons whose service does not fall within the Schedule 1 definition of "relevant service" will not be covered by this SOP for VEA/MRCA claims. The SOP does not itself create entitlements outside the scope of s 120B VEA or s 339 MRCA (s 5). The SOP is silent on non‑service‑related claims brought in other schemes or jurisdictions.

Who pays and who decides

• The SOP does not itself establish payments. It is a determinative medical instrument to be applied in adjudicating claims under the VEA and MRCA; entitlements and payments derive from those Acts and their administrative processes (s 5, s 3). The RMA makes the SOP; administrative decision‑makers applying the VEA and MRCA will use it to determine whether the medical causal link to relevant service exists for benefit entitlement purposes (s 3, s 5).

In short, the instrument principally affects claimants under the VEA and MRCA asserting otitis externa or death from it, and the clinicians and administrative decision‑makers who must marshal, lodge and assess the evidence against the specific factors and definitions in the SOP.

This instrument does not create criminal duties, civil tort obligations, direct rights enforceable in private law, or express duties to third parties. It is an instrument that prescribes medical causation criteria to be applied in administrative decisions under the VEA and MRCA. The principal operative legal effects are:

Duties for decision‑makers applying the SOP

• Use the SOP’s definition of otitis externa and the listed factors when determining whether otitis externa or death from otitis externa is connected with relevant service on the balance of probabilities (s 7, s 8, s 9). The RMA states its view that "it is more probable than not that otitis externa and death from otitis externa can be related to relevant service" on the basis of sound medical‑scientific evidence (s 8). Administrative decision‑makers applying the Acts are expected to take the SOP into account when making causation findings for claims captured by s 120B VEA or s 339 MRCA (s 5).

• Apply the Schedule definitions where those terms are used; where a factor refers to another SOP’s covered disease or injury, give effect to that other SOP’s factors in accordance with that SOP (s 11; Schedule 1).

Duty to relate factors to relevant service

• Even where a factor listed in s 9 exists, the instrument requires that the existence of the factor "must be related to the relevant service rendered by the person" (s 10(1)). That imposes a causal link test between the presence of the factor and the person’s service, proceduralised via the SOP’s factors.

Rights of claimants

• Claimants have, in effect, a procedural right to have their claim assessed against the SOP where it applies (s 5). If one of the enumerated factors is established and related to relevant service in the required manner (s 9; s 10), that establishes the medical basis on the balance of probabilities for a finding of service connection for the purposes of the relevant claim provisions.

Evidentiary consequences

• The SOP sets necessary factual predicates: at least one of the enumerated factors must exist to say that, on the balance of probabilities, otitis externa is connected to service (s 9). The SOP’s structure therefore changes the shape of evidence required: claimants must demonstrate the existence of at least one factor and its relationship to service. For aggravation claims, s 10(2) narrows the circumstances in which factors 14-27 apply.

No penalties or sanctions in the instrument

• The SOP does not create enforcement penalties or offences. It is a medical standard to be used administratively (see s 3 and absence of any penalties provision). Procedural remedies or penalties for false claims or misrepresentation would be matters for the VEA/MRCA administrative framework or for general law, not the SOP itself.

Practical interpretation duties

• Where terms are defined in Schedule 1, decision‑makers must apply those definitions (e.g., "aquatic activities", "hot and humid weather conditions", "extrinsic aural device", "immunocompromised state as specified") when determining whether a factor is present (Schedule 1). The SOP also makes explicit that the ICD‑10‑AM codes are referenced for classification but that the statutory meaning is the definition in s 7(2) (s 7(3)-(4)).

In sum, the primary "duties" created by this SOP are administrative and evidentiary: decision‑makers must use the SOP’s definitions and factors when assessing causation for otitis externa claims under the specified claim provisions, and claimants must adduce evidence to establish at least one of the enumerated factors and the requisite relationship to their relevant service.

The instrument itself contains no express penalties, criminal offences or civil fines. It is a Statement of Principles made under subsection 196B(3) of the VEA and functions as a statutory medical framework to be applied in administrative adjudication of claims. The instrument’s text does not prescribe enforcement mechanisms, pecuniary penalties or sanctions for non‑compliance by claimants or third parties (see s 3, s 5-11; Schedule 1).

What this means for enforcement in practice

• Administrative application: Enforcement in the sense of compliance is operationalised through the administrative decision‑making processes of the VEA and MRCA claim systems. The SOP is intended to be relied upon by the decision‑makers who determine entitlement under those Acts (s 5). Any consequences from an adverse finding (for example, denial of a claim) arise from the application of the VEA or MRCA, not the SOP itself.

• Evidentiary effect: The SOP has evidentiary force. If a claimant cannot establish any of the factors in s 9, the SOP provides a basis, on its terms, for concluding that the medical link to relevant service has not been established on the balance of probabilities. Conversely, if a claimant can establish at least one qualifying factor and its relation to relevant service (s 9, s 10), that supports a finding of connection for the purposes of claim adjudication.

• Interaction with other legal remedies and processes: The SOP does not specify appeal, review or enforcement procedures. Appeals against administrative decisions under the VEA or MRCA would proceed under the review and merits appeal regimes established by those Acts and by general administrative law, but those procedural pathways are outside the SOP text (the SOP does not itself set review rules).

• No sanction for non‑observance by third parties: The SOP does not impose duties on employers, clinicians or third parties that carry statutory sanctions if breached. Where a factor requires records or proof (for example, radiotherapy records, device usage), lack of cooperation by third parties will affect evidentiary proof but the SOP does not prescribe penalties for failure to produce records.

Summary statement on penalties and enforcement

• The instrument is an administrative medical standard; it prescribes criteria for causation determinations in claims under VEA/MRCA but contains no independent enforcement regime, penalties or criminal sanctions. The practical enforcement effect lies in how the SOP affects claim outcomes when applied by the relevant decision‑makers under the VEA and MRCA.

The instrument is not a standalone statute of entitlements; it is a subordinate, statutory Statement of Principles made under s 196B(3) of the Veterans' Entitlements Act 1986 (s 3). Its interactions with other laws and instruments are explicit in several provisions.

Interaction with the VEA and MRCA

• Statutory basis: The SOP is made under s 196B(3) of the VEA (s 3). It applies to a claim to which s 120B of the VEA or s 339 of the MRCA applies (s 5). Therefore its legal operation is as a medical causation template for claims determined under those specific provisions. The SOP itself does not alter the substantive entitlement provisions of those Acts; it provides a determinative evidentiary framework to be used in applying them.

Interaction with other Statements of Principles

• Cross‑SOP references: Section 11 provides that if a factor in s 9 refers to an injury or disease that is the subject of another SOP, then the factors in that other SOP apply according to its terms. This creates a legal interaction: where causation depends on a co‑morbid or causative condition (for example, chronic suppurative otitis media is a defined term in the Schedule and may be the subject of its own SOP), decision‑makers must apply the relevant SOPs in combination (s 11).

Interaction with the International Classification of Diseases

• Clinical classification: Section 7(3) and (4) reference ICD‑10‑AM codes (H60, H62.0-H62.4) but clarify that, in applying the SOP, the meaning of otitis externa is the definition in s 7(2). The instrument ties the clinical description to the ICD classification system (s 7(3)-(4)). This interaction matters for how clinicians and administrators map clinical records and coded diagnoses to the SOP’s definition.

Interaction with medical and clinical records

• Evidentiary dependencies: The SOP’s factors invoke clinical procedures and records that intersect with other regulatory regimes. For example, proof that a person was "undergoing a course of therapeutic radiation for cancer, where the affected ear was in the field of radiation" (s 9(3), s 9(16)) will involve radiotherapy records, which are subject to health records legislation and confidentiality regimes. The SOP does not change those regimes but presupposes access to such records for claim assessment.

Interaction with meteorological or environmental data

• Quantitative definitions: The Schedule defines "hot and humid weather conditions" in quantifiable terms (ambient humidity exceeding 40 per cent and maximum temperature exceeding 30°C). Establishing the presence of this factor may require external meteorological data or service records showing local environmental conditions; the SOP cross‑references non‑medical evidence sources by implication (s 9(2), s 9(15); Schedule 1).

Interaction with clinical practice standards and ENT procedures

• Clinical definitions and findings: Several factors (for example, acquired persistent narrowing or obstruction of the external auditory canal; chronic suppurative otitis media; exostosis) are clinical diagnoses. Their establishment will typically require specialist ENT assessment, imaging, or operative reports. The SOP interacts with medical practice standards in that administrative decision‑makers will look to clinical documentation generated in accordance with accepted practice to determine factor presence (s 9; Schedule 1).

No express conflict or displacement mechanisms

• The SOP does not state that it displaces other law nor does it create new rights outside the VEA/MRCA framework. It expressly repeals the earlier 2012 SOP on otitis externa (s 4). The SOP’s operation is limited to the statutory claim framework where it applies.

In essence, the SOP functions as a statutory medical standard that interfaces with (1) the VEA and MRCA claim provisions, (2) other SOPs where factors overlap, (3) the ICD classification system for coding, and (4) clinical, environmental and administrative record systems needed to prove the enumerated factors. It does not amend the substantive entitlement provisions of the VEA/MRCA but provides the medical foundation for causation findings under those Acts.

This instrument records limited amendment history within its text. Key dated events and replacement of prior instruments are specified.

• Instrument made and dates: The Statement of Principles is dated 24 December 2020 and commences 25 January 2021 (instrument header; s 1; s 2). These dates document the making and commencement schedule.

• Repeal of prior SOP: Section 4 expressly repeals the Statement of Principles concerning otitis externa No. 59 of 2012, identified by Federal Register of Legislation No. F2012L01803, which was made under subsections 196B(3) and (8) of the VEA. The 2021 instrument therefore supersedes the 2012 SOP for the purposes of claims falling within its application (s 4).

• Authority provision: The instrument is made under subsection 196B(3) of the Veterans’ Entitlements Act 1986 (s 3). The instrument does not show subsequent amendments after commencement; there are no in‑text amendment notes or schedules adding further amendments.

• No in‑instrument modification power or sunset clause: The SOP contains no express provision for incremental amendment by reference or review timetable within its text. Any subsequent amendments would be recorded by the RMA and published in the Federal Register of Legislation in accordance with the RMA’s statutory processes, but such later amendments are not present in the current instrument’s text.

• Definitions consistent with contemporaneous clinical classification: The instrument references ICD‑10‑AM Tenth Edition, effective 1 July 2017, in s 7(4). That is part of the instrument’s internal linkage to a contemporary clinical classification schema at the time of drafting.

What is not in the amendment history

• The instrument does not record earlier versions other than the 2012 SOP it repeals, and it contains no record of interim amendments between the 2012 instrument and the 2021 instrument. It also does not record any judicial or administrative decisions amending its interpretation; those would appear in external case law or administrative decisions not reproduced in the text.

For practitioners advising clients or maintaining compliance registers, the amendment history in the instrument consists of the 2012 SOP’s repeal and the 2021 SOP’s commencement on the dates stated. Any later changes should be verified against the Federal Register of Legislation and the RMA’s published instruments, as this instrument itself records only the replacement of the 2012 instrument and the commencement date.

The instrument as presented contains no litigation history, case references, or judicial interpretations. It cites no court decisions and names no cases. The SOP is a technical medical instrument issued by the Repatriation Medical Authority and, within its text, does not record or reference litigation.

Implications for practitioners

• Absence of in‑instrument case law: Because the SOP does not include any judicial citations, legal arguments about the SOP’s application , for example, whether a particular factual pattern satisfies a listed factor or whether a factor is "related to relevant service" under s 10(1) , will need to be tested against administrative decisions under the VEA/MRCA or in courts and tribunals where those decisions are reviewed. Those sources are not reproduced in the SOP.

• Need to check external authorities: For practical casework, lawyers and advocates must consult administrative decisions, VEA/MRCA review tribunal decisions, and any relevant Federal Court or High Court judgments that have interpreted the operation or evidentiary weight of RMA SOPs generally. The SOP itself does not contain such materials and so cannot be relied on to indicate how tribunals or courts will interpret the listed factors or their evidentiary sufficiency.

• No express judicial gloss in the text: The SOP establishes thresholds and definitions but leaves application to the decision‑maker under the VEA/MRCA and to any reviewing courts or tribunals. Potential litigation issues (for example, proof of environmental exposure, the meaning of "inability to obtain appropriate clinical management", or the sufficiency of device‑use evidence) are not addressed by the SOP text and therefore must be developed through case law and administrative practice.

Summary statement

• There is no litigation history provided within the instrument. Practitioners should therefore search administrative and judicial decisions outside the SOP when preparing arguments on borderline factual questions or contested interpretations of the SOP’s factors and definitions.

The instrument contains multiple features that create potential evidentiary and practical pitfalls for claimants, advisers and decision‑makers. These are not value judgements but observations of how the SOP’s structure creates precise, sometimes narrow, requirements.

Temporal and quantitative precision

• Narrow time windows: Many factors require proof within short, fixed time frames: e.g., participation in aquatic activities within ten days before clinical onset (s 9(1)), foreign object insertion within ten days (s 9(5), s 9(18)), extrinsic aural device use for a cumulative period of at least 16 hours within seven days (s 9(6), s 9(19)), and prior ototopical or oral antibiotic therapy within two weeks for otomycosis (s 9(13), s 9(26)). These narrow windows impose a strict temporal burden of proof and may exclude evidence of exposures outside those windows even if plausibly related.

• Quantified environmental threshold: "Hot and humid weather conditions" is defined numerically (ambient humidity > 40 per cent and maximum temperature > 30°C) and requires exposure on "at least ten days within the 30 days before" onset/worsening (s 9(2), s 9(15); Schedule 1). Practically, claimants must produce contemporaneous meteorological or operational records showing such conditions on ten separate days in the thirty‑day window , this is a high evidentiary bar in some circumstances.

Definitions that widen or narrow scope unexpectedly

• Extrinsic aural devices: The definition of "extrinsic aural device" is broad and includes ear buds, plugs, hearing aids, headphones and stethoscopes (Schedule 1). Ordinary consumer headphone or earbud use can meet the "occludes the external auditory canal or creates a seal over the ear" element and, if use totals 16 hours within seven days, trigger a listed factor (s 9(6), s 9(19)). Claimants or respondents may be surprised that everyday audio device use may be capturable by the SOP.

• Aquatic activities definition: "Aquatic activities" means activities in which the external ear opening is submerged or which cause retention of water in the ear canal; the note includes examples such as swimming and underwater diving (Schedule 1). A claimant needs to show ear submersion or water retention within ten days before onset; casual water exposure that did not submerge the ear may not qualify (s 9(1), s 9(14)).

Interplay between onset and aggravation factors

• Limitation in s 10(2): Factors in subsections 9(14)-9(27) apply only to material contribution to, or aggravation of, otitis externa where the person's condition was "suffered or contracted before or during (but did not arise out of) the person's relevant service" (s 10(2)). That means these factors are not a route to connection where the otitis externa arose out of service itself , the SOP distinguishes between causation for onset and for aggravation and constrains aggravation factors to pre‑existing conditions. Advisers need to assess the chronology of disease relative to service carefully.

Ambiguity in "inability to obtain appropriate clinical management"

• Factor 27: The factor "inability to obtain appropriate clinical management for otitis externa" (s 9(27)) is potentially broad and the SOP provides no definition of "appropriate clinical management". Proving this factor will hinge on external evidence (referrals, waiting lists, lack of access to ENT care) and the SOP does not specify which threshold of effort or availability suffices. That creates evidentiary uncertainty.

Cross‑reference issues

• Other SOPs: Section 11 requires that where a factor refers to another injury or disease that has its own SOP, the other SOP applies according to its terms (s 11). This can produce layered causation tests and potential inconsistencies; claimants may need to meet factors in multiple documents.

Death claims

• Death from a terminal event: The SOP treats otitis externa as including death from a terminal event or condition that was contributed to by the person’s otitis externa (s 7(5)). The Schedule defines "terminal event" by listing proximate causes such as pneumonia and respiratory failure. For death claims, advisors must link otitis externa to those terminal events on the balance of probabilities and produce the necessary clinical evidence of contribution , a substantive evidentiary challenge.

Clinical diagnosis vs ICD coding

• ICD‑10‑AM codes are noted (s 7(3)-(4)) but s 7(3) makes clear that the statutory meaning is the definition in s 7(2). An ICD code on a record (e.g., H60) will not alone satisfy the SOP if the clinical facts do not align with the statutory definition. Practitioners must ensure documentation describes the clinical features referenced in s 7(2) and Schedule 1.

Reliance on clinical sub‑diagnoses

• Some factors require coexisting clinical disease (e.g., inflammatory skin disease involving the canal, infectious/autoimmune/granulomatous disease involving the canal) (s 9(8), s 9(9), s 9(21), s 9(22)). These require precise specialist documentation; general practitioner notes may be insufficient to establish the specific involvement of the external auditory canal.

In sum, the SOP’s precision creates litigation and evidentiary traps: short windows, numerical thresholds, cross‑SOP interactions, broad device definitions that may capture normal behaviour, and undefined terms such as "appropriate clinical management". Advisers must structure evidence‑gathering to match the precise language and thresholds in the SOP.

This section draws on the SOP’s specific words to outline practical steps for claimants, legal advisers and clinicians preparing or assessing claims. All propositions are grounded in the instrument’s text and the Schedule definitions.

1. Confirm applicability

   • Verify that the claim falls within the SOP’s scope: it must be a claim to which VEA s 120B or MRCA s 339 applies (s 5). Confirm the claimant’s type of service as defined by "relevant service" in the Schedule (eligible war service (other than operational), defence service (other than hazardous and British nuclear test defence service) under the VEA, or peacetime service under the MRCA).

2. Establish the clinical diagnosis per s 7(2)

   • Obtain clinical records that specify otitis externa as an "infectious or non‑infectious inflammation of the external auditory canal" (s 7(2)(a)). Where applicable, document the subtype (acute diffuse, localized/furunculosis, eczematous, malignant, acquired cholesteatoma, otomycosis) as the SOP includes those (s 7(2)(b)(i)-(vi)). Do not rely solely on an ICD code: s 7(3) states the statutory meaning is the s 7(2) definition.

3. Identify which factor(s) in s 9 are claimed

   • The SOP requires at least one of the factors listed in s 9 to exist. For each factor you intend to rely on, gather targeted evidence matching the element language and time frames:
     • Aquatic activities (s 9(1), s 9(14)): Collect contemporaneous accounts, unit logs, swim/diving records, buddy statements and dates showing ear submersion or water retention within ten days before onset or worsening. Refer to the Schedule 1 definition of "aquatic activities".
     • Hot and humid exposure (s 9(2), s 9(15)): Compile meteorological records or unit/operational environmental logs demonstrating ambient humidity exceeding 40% and maximum temperature exceeding 30°C on at least ten days in the relevant 30‑day period (Schedule 1).
     • Therapeutic radiation (s 9(3), s 9(16)): Obtain radiotherapy treatment records indicating field mapping showing the affected ear was in the field and dates relative to onset/worsening.
     • Trauma or foreign object events (s 9(4)-(5), s 9(17)-(18)): Secure outpatient notes, emergency department records, surgical notes, or incident reports documenting trauma (blunt, penetrating, surgical, blast) or insertion/removal of foreign objects within ten days of onset/worsening.
     • Extrinsic aural device use (s 9(6), s 9(19)): Produce device usage logs, contemporaneous statements, occupational health records or duty rosters demonstrating occlusion/seal of the external auditory canal by earbuds, plugs, hearing aids, headphones, stethoscopes, etc., for a cumulative period of at least 16 hours within seven days before onset/worsening (Schedule 1).
     • Narrowing/obstruction (s 9(7), s 9(20)): Provide ENT clinical assessment, otoscopy findings, imaging or operative reports showing acquired persistent narrowing or obstruction (e.g., exostosis, cerumen accumulation, neoplasm, granuloma). The Schedule defines exostosis.
     • Inflammatory skin disease and infectious/autoimmune/granulomatous disease (s 9(8)-(9), s 9(21)-(22)): Obtain dermatology or ENT specialist notes confirming involvement of external auditory canal.
     • Chronic suppurative otitis media (s 9(10), s 9(23)): Provide clinical documentation confirming CSOM within 30 days before onset/worsening. The Schedule defines CSOM.
     • Diabetes mellitus and immunocompromised states (s 9(11), s 9(12), s 9(24), s 9(25)): Produce medical records, pathology, medication lists that confirm diabetes mellitus or an immunocompromised condition as per Schedule 1 (which lists specific circumstances constituting immunocompromise).
     • Otomycosis and prior therapy (s 9(13), s 9(26)): For otomycosis claims, document a course of oral antibiotics or ototopical therapy for treatment of otitis externa of the affected ear within two weeks before onset/worsening.
     • Inability to obtain appropriate clinical management (s 9(27)): Prepare documentary evidence of attempts to obtain treatment, referrals, waitlist information, communications with health services, and contemporaneous records showing lack of access, to substantiate this factor.

4. Link factors to relevant service (s 10)

   • The SOP requires that any established factor "must be related to the relevant service rendered by the person" (s 10(1)). Provide documents showing the timing and context of the factor in relation to service. For example, if aquatic exposure occurred during a unit activity or exercise in service, produce unit movement orders, activity logs or witness statements connecting the exposure to service. For aggravation claims, confirm the chronology: the pre‑existing condition must have been suffered or contracted before or during (but did not arise out of) relevant service for factors in s 9(14)-(27) to be available (s 10(2)).

5. Cross‑reference other SOPs where applicable (s 11)

   • If a factor points to another injury or disease governed by a different SOP, identify that SOP and ensure evidence satisfies both instruments per s 11. For example, if reliance is placed on chronic suppurative otitis media which has its own SOP, assemble the necessary evidence to meet the CSOM SOP’s factors as well.

6. Address death claims carefully (s 7(5); Schedule 1)

   • For death claims, establish that otitis externa contributed to a terminal event listed in the Schedule (for example, pneumonia or respiratory failure) or another proximate cause. Obtain cause‑of‑death documentation, hospital records, and death certificates that link otitis externa to the terminal event. The Schedule defines "terminal event" and the SOP includes death from otitis externa as within scope where there was contribution (s 7(5)).

7. Prepare clinical statements that map to SOP language

   • Specialist opinions should explicitly address whether the SOP factors are present and whether they are related to relevant service. Where possible, opinions should mirror the SOP wording (e.g., "the affected ear was in the field of radiation"; "occlusion of the external auditory canal for a cumulative 16 hours within seven days") to avoid interpretive gaps.

8. Anticipate evidentiary weaknesses and gather corroboration

   • Where direct records are unavailable, obtain witness statements, service diaries, group rosters, meteorological records, photographs and other contemporaneous material to corroborate exposure and timing. For device use, contemporaneous device‑usage metadata (where available) or workplace rules on headset use may help.

9. Address the ICD coding issue

   • If clinical records contain ICD‑10‑AM codes, also include clinical narrative confirming the s 7(2) statutory definition elements, because s 7(3) and (4) state that the SOP’s meaning of otitis externa is that in s 7(2) rather than simply the code (s 7(2)-(4)).

10. Document attempts to obtain medical care (where factor 27 is relied on)

• Record attempts to seek treatment, dates of appointments, referral rejections, travel issues or systemic barriers to care. The SOP does not define "appropriate clinical management", so detailed and contemporaneous evidence of impediments will be important to support reliance on s 9(27).

11. Use chronological and issues‑based claims folders

• Prepare a tight chronology aligning exposures, medical events, service duties and symptoms to the SOP’s time frames. Map each piece of evidence to the enumerated elements in s 9 and the Schedule definitions.

12. Be alert to prior SOP replacement

• The 2012 SOP was repealed by s 4. For any claim straddling the repeal date, confirm which SOP is applicable based on claim timing and administrative practice, and ensure evidence is aligned with the 2021 instrument’s thresholds if it is the operative SOP.

13. Consider expert evidence that addresses causal linkage and s 10 relationship

• Experts should explicitly address not only the presence of factors but how they are related to the claimant’s relevant service. Where an aggravation factor is relied upon, experts must position the chronology to satisfy s 10(2).

In short, compliance requires a fact‑specific evidentiary approach that mirrors the SOP’s precise language: assemble clinical, service, environmental and documentary evidence that matches the time windows and definitional thresholds in s 9 and Schedule 1, and ensure that the nexus to "relevant service" required by s 10(1) is demonstrably established.