Objective examination in ENT medico legal expertise

Prof. Dr. Raymond BONIVER Lige University, Belgium A.P.O. June 2012

In expertise, we have to obtain objective data from the patients complaints. Those, in certain cases, are voluntary exaggerated, either because the subject has a temperament by which he always tends to exaggerate his symptoms, or because he estimates to be injured in his integrity of its physical status and to be entitled to a repair for which he will do the test in the way to have the best advantages. We shall consider three pathologies for which we are most frequently consulted in ENT: - Hearing disorders - Balance disorders - Smell disorders

Hearing disorders
The first evaluation of the patient with hypoacousia can be done easily without any instrument.
How does he understand the voice during the anamnesis?Does he understand the whispered voice? Is it necessary to speak loud or very loud? It is also important to observe the patient: does he have an auditory prosthesis? Is it open? Is it working good? Is the battery good? How does he react to the questions?

Audiometry
In pure tone audiometry, whenever the subject exaggerates his handicap, the audiogram doesnt fit with the responses he gave during the anamnesis. For example, with an average of 80 dB loss on the audiogram, the subject cant understand the whispered voice. Then, in suspected cases, the audiogram can be delivered in two sessions:

- Descending step: from loud to level of perception, decreasing by step of 5 dB

- Ascending step: from 0 dB to level of perception, increasing by step of 5 Db. In the normal subject, the two levels of perception should be the same in the ascending and descending pathways and should correspond to the discrimination level obtained during speech audiometry.

When we suspect a functional hearing loss, further testing is necessary: Historically, the following tests were used in simulation screening : -Lombard or Voice-Reflex test -Azzi test -Stenger test -Bekesy audiometry The DAF test (delayed auditory feedback test) introduced by Demanez can detect hearing losses of sizeable degree but not the minor exaggerations that can occur in medicolegal situations.

Nowadays, several objective tests can be done and are helpful in assessing auditory function in patients who are unable or unwilling to cooperate. The most common used tests are -Acoustic reflex thresholds -Otoacoustic emissions (OAE) -Brain stem evoked-response audiometry (BERA or ABR) -Cortical evoked-response audiometry (CERA)

Acoustic reflex threshold -Normally, the reflex for pure tones is elected at about 90 dB above the hearing threshold. For broad-band noise, it occurs at about 70 dB above threshold. -In patient with cochlear damage, the reflex may occur at sensation levels less than 60 dB above the audiotory pure-tone threshold. (Metz recruitment) -It is absent: . In conductive losses . In case of impairment of the VII-VIII reflex arch. . In case of cophosis Otoacoustic emissions

Evoked otoacoustic emissions may be conceptualised as an echo in response to a sound stimuli. These emissions are generally absent in hearing loss greater than 30 dB from 500 to 2000Hz.
Then, if the subject has a hearing loss of 60 dB in pure-tone audiometry with normal evoked otoacoustic emissions on the same ear, it is a functional hearing loss. Otoacoustic emissions is not a tool to determine the degree of hearing loss by frequency, even with the distorsion product emissions.

BERA
Brain Stem Evoked-Response Audiometry

The test measures electrical peaks generated in the brain stem along the auditory pathways. Testing can be done with pure tones, broad-band noise or clicks. In any case, the brain stem does not react to a determined frequency. The measure is objective, consistent and approximate threshold levels can be determined. In suspected cases of exaggeration, ABR testing is reliable. If the BERA gives you normal peaks at 20 dB and the threshold on pure tone audiometry is 80 dB, it is a functional hearing loss.

CERA
Cortical Evoked-Response Audiometry (CERA) This method focuses on electrical activity at the cerebral-cortex level. The patient must be kept aware with images projection or reading. It is a valuable tool in evaluating thresholds frequency by frequency. The results in normal subjects are in correlation with pure tone audiometry findings.

Tinnitus
Tinnitus is an otological condition in which sound is perceived without any external auditory stimulation. It may be a whistling, ringing, roaring, buzzing, This challenging pathology is difficult to assess in expertise. Tinnitus may be either objective or subjective. Objective tinnitus is comparatively easy to detect and localize because it can be heard by the examiner using a stethoscope. It may be caused by glomus tumor, palatal myoclonus and other conditions. Subjective tinnitus is much more common by far. All the tests described above can be done in the assessment of subjective tinnitus to recognise a causal relationship. Nevertheless, in a large number of cases in which a normal patient with normal hearing complains of head noises, functional tinnitus has to be considered. The expertise of a psychotherapist is helpful to determine the problem with the patients that can sometimes have distressing proportions.

Conclusion
Actually, objective hearing tests are accurate and reliable to define the hearing threshold of the patient with functional hearing loss.
These objective tests are of great value in expertise.

Vertigo
It is important to rule out all the organic causes that can lead to vertigo and dizziness. It is important to keep in mind that the balance is the result of miscellaneous informations collected in the vestibular nuclei arising from proprioceptive, visual, vestibular, cortical and emotional pathways. The cerebellum is regulating the vestibular nuclei. All these informations are integrated and sent to the motor pathways to control eye movement, static and dynamic posture.

The assessment of the dizzy patient:

-Anamnesis -Physical examination -How he stands -How he walks -Otoscopy -Audiology testing -Pure-tone audiometry -Acoustic reflex -Otoacoustic emissions -BERA -Vestibular testing -Oculomotor examination -Clinical vestibular evaluation -Index deviation and Romberg -Spontaneous nystagmus and positional nystagmus -Rotational testing with ENG/VNG control -Caloric testing with ENG/VNG control -Vestibular evoked myogenic potentials (VEMP) -Posturography
ENG = electronystagmography VNG = videonystagmography

Objectif Oculomotricity Pursuit Saccades OPK Vestibular Examination Tonic Dviation Romberg Finger Cerebellar test Fingers-nose Adiadococinesy Musculair Tonus Spontaneous nystagmus Positional nystagmus Head Shaking Hamalgyi + + +

Subjectif

+ +

+ +

+ +

Vibratory nystagmus
Rotatory tests Caloric proofs BERA CERA VEMP

+
+ + + +

Recommandations for vestibular testing

Stop for alcohol, any sedative or antidepressive drug 48h before the examination. Control the attention of the patient. Dont speak with the patient during rotatory test because orientation effects disturb the vestibulooculair reflex. With ENG control the calibration before each caloric proof. In case of week response only for one irrigation it is necessary to repeat it.

Positionnal and Spontaneous Nystagmus in ENG or VNG

A spontaneous nystagmus is pathologic if : - slow phase speed is > 7/sec - one nystagmus without artefact is > 14/sec during the registration A position nystagmus is pathologic if : - slow phase speed > 6/sec. - it exists minime in 3 positions - it is a benign paroxystic nystagmus - its direction change during the position

IT IS NECESSARY TO SUSTAIN THE SUBJECT ATTENTION DURING THE TESTS.

Rotatory and Caloric Proofs

Some considerations
ALWAYS SUSTAIN THE SUBJECT ATTENTION Closed Eyes Opened Eyes in ENG Closed eyes Bell phenomen : it means a transitory up movement of the eyes that disturb the nystagmus. Opened eyes in darckness must give. Directionnal Preponderance : + > 26% (meta-analyses) Labyrinthic paresis : + > 25% ENG + > 22% VNG

Objective signs of central lesion of vestibulo-oculomotric pathways (Demanez J.P.)

!!! Alteration of pursuit ocular without spontaneous nystagmus Horizontal OPK asymetry Failure Fixation Index 50 % Hyperreflexy : a average slow speed phase for 4 irrigations > 200/sec. !!! If the 1e irrigation is particularly intense, it is necessary to repeat. Hypo- or hypermetry of saccades. Spontaneous or positional nystagmus abnormal Dissociated nystagmus Slowness of the nystagmus quick phase Slowness of the slow phase Distorted nystagmus One anormality : central lesion possible 2 anormality : central lesion probable 3 anormality : central lesion.

Olfaction
Actually, the tests we use nowadays can confirm the complete loss of smell (anosmia). Unfortunately, it is still a challenging procedure to detect the little variation of smell (dysosmia). Even in a normal subject, the sense of smell is variable, depending on various conditions: digestion, hormonal, metabolic disorder, smoking, The testing must be completed with a detailed interrogatory to have the maximum level of success in defining the diagnosis of anosmia or hyposmia.

Psychophysical test
TESTS PSYCHOPHYSIQUES (SUBJECTIF) SniffinSticks Hummel, ChemSenses 1997

UPSIT (University of Pennsylvania Identification Test) Doty, Physiol

Behav1984

CCCRC (Connecticut Chemosensory Clinical Research Center) Cain,

Laryngoscope 1988

Zrcher Geruchstest Briner, Rhinology 1999 Biolfa Lecanu, Ann ORL Chir Cervicofac 1999 T & T olfactometer Zusho, Auris, Nasus, Larynx 1981 SOIT (Scandinavian Odor Identification Test) Nordin, Acta Otolaryngol
1998

etc.

Smell Identification Test (UPSIT)

The measurement of the time related respiratory flow In this method, we record the variation of nasal air flow with an anterior rhinomanometer and some different olfactive substances are introduced in the airflow channel. Four flavours are tested after a normal air test recording: eau de rose, lavander, pyridine, ammoniac 30%.

We observe the variations of the respiratory rhythm induced by the presentation of the different flavours.
This test is reliable to detect an anosmic: the smell of pyridine is so intense that only the true anosmic patient can breathe it. If the patient block his respiration with pyridine, he still can smell.

Olfactory Evoked Potentials

The olfactometer can stimulate the olfactive fibers and the nasal mucosa with the diffusion of different odorous substances. The patient sits and is administred by a nasal tube during twenty to forty minutes different flavours, some purely olfactive, some sensitive (trigeminal sensitive).

The patient must be relaxed and not disturb.

The computer analyses the results and can tell if the patient has a normal sense of smell. But it is not reliable to detect the quality of the olfaction of an individual subject. This objective test is time consuming and is actually developed by Rombaux at the University of Louvain in Belgium.

Olfactometer OM2s Burghart Medical Technology Wedel-Germany

In a recent paper (Rhinology 2012, 50, 13-21), Rombaux concludes that this technique has a poor signal-to-noise ratio and cancels out stimulus-induced changes in the EEG signal that are not strictly phasedlocked to stimulus onset. The fact that consistent chemosensory event-related brain potentials (CSERP) are not systematically identifiable in healthy subjects currently constitutes a major limitation to the use of this technique for the diagnosis of chemosensory dysfunction.

Conclusion
The development of new technique and the use of more powerful computer assisted technology lead us to reach the diagnosis of most disease more and more objectively. No doubt, it will be even better in the future.

The simulator has a particular psychologic profile that the examiner has to take in account and it needs a lot of patience and tact to tests these patients.
Simulating is a lie, a fraud, and all fraud must be revealed. It is in fact our opinion.

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