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ASSESSMENT OF SIMULATION AND EXAGGERATION IN ENT EXPERTISE
R. BONIVER, M.D.; V. BONIVER, M.D.
INTRODUCTION:
In expertise, we have to obtain objective data from the patients complaints. Those, in certaincases, are voluntary exaggerated, either because the subject has a temperament by which he alwaystends 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 bestadvantages.We shall consider three pathologies for which we are most frequently consulted in ENT:-Hearing disorders-Balance disorders-Smell disorders
1.HEARING DISORDERS:1.1Hearing loss assessment.
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 itworking good? Is the battery good? How does he react to the questions?In the case we suspect a hearing loss from one side or the other, the first measurement which can bedone to the consulting room of any doctor is a control of the hearing by a tuning fork. We use a512 Hz tone to realize the Rinne and Weber tests.In the Rinne test, the patient is asked to tell us whether the vibrating tuning fork seems louder whenit is held beside his hear (by air) or behind his hear directly on the mastoid bone (by bone). If thefork is louder behind the ear, on the patient’s mastoid bone, his bone conduction is considered to be better than his air conduction, and therefore has a conductive deafness.In the Weber test, the tuning fork is placed on the patient’s forehead. He’s asked to indicate in whichear the fork sounds louder. In a conductive hearing loss, the tone will sound louder in his bad hear.In a sensory hearing loss, the tone will sound louder in his good hear. _________________________________________________________________________________ R. BONIVER, M.D., Invited Prof. Liege University Belgiumrue de Bruxelles, 21B-4800 VERVIERSBELGIUMEmail : r. boniver@skynet.be
 
1.2Audiometry
1.2.1Pure tone audiometry consists to deliver via earphones pure tones of determined intensityand frequency. In ideal conditions, the subject is placed in a sound-proof room and the tester should be ideally outside of the room.1.2.2Speech audiometry will be carried out in double soundproof rooms. In a first examination,the tester presents lists of words phonetically gauged, as the list of dissyllabic words of Fournier for the French language to the patient.One can measure the comprehension of the subject and determine some parameters, whose principals are:- The speech recognition threshold: Intensity at which 50% of the items are heardcorrectly.- The discrimination score is the percentage of understood words presented at 35 dBabove the speech recognition threshold.- The hearing capacity index (HCI) is the average percentage of understood words presented at 40 dB, 55 dB and 70 dB. This test is useful in evaluating an auditory prosthesis.These audiometric tests need the active participation of the subject.In pure tone audiometry , whenever the subject exaggerates his handicap, the audiogramdoesn’t fit with the responses he gave during the anamnesis. For example, with an averageof 80 dB loss on the audiogram, the subject can’t 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 anddescending pathways and should correspond to the discrimination level obtained duringspeech audiometry.1.2.3When 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 audiometry1.2.4The DAF test (delayed auditory feedback test) introduced by Demanez (1) can detecthearing losses of sizeable degree but not the minor exaggerations that can occur in medico-legal situations.1.2.5Nowadays, several objective tests can be done and are helpful in assessing auditory functionin patients who are unable or unwilling to cooperate.-2-
 
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)1.2.5.1Acoustic 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 dBabove the auditory pure-tone threshold. (Metz recruitment)-It is absent :
o
in conductive losses
o
in case of impairment of the VII-VIII reflex arch.
o
In case of cophosis1.2.5.2Otoacoustic emissionsEvoked otoacoustic emissions may be conceptualised as an echo in response to a soundstimuli. These emissions are generally absent in hearing loss greater than 30 dB from 500 to2000Hz.Then, if the subject has a hearing loss of 60 dB in pure-tone audiometry with normal evokedotoacoustic 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.1.2.5.3Brain Stem Evoked-Response AudiometryThe 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 stemdoes not react to a determined frequency.The measure is objective, consistent and approximate threshold levels can be determined. Insuspected 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 hearingloss.ABR are also useful in neurologic disorders. Absence or distorsion in latency of peaks, or delays between peaks, can help localize lesions in the auditory pathways. For example, adifference in latency between a patient’s two ears of greater than 0,3 ms is often related to anacoustic neuroma. In multiple sclerosis, when the patient complains of bad hearing withnormal pure tone audiometry, the BERA can demonstrate increasing interwave latencies or complete desynchronisation.-3-
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