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 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

1.HEARING DISORDERS:

1.1 Hearing 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 it
working 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 be
done to the consulting room of any doctor is a control of the hearing by a tuning fork. We use a
512 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 when
it is held beside his hear (by air) or behind his hear directly on the mastoid bone (by bone). If the
fork 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 which
ear 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 Belgium

rue de Bruxelles, 21
B-4800 VERVIERS
BELGIUM
Email : r. boniver@skynet.be
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1.2 Audiometry

1.2.1 Pure tone audiometry consists to deliver via earphones pure tones of determined intensity
and frequency. In ideal conditions, the subject is placed in a sound-proof room and the tester
should be ideally outside of the room.

1.2.2 Speech 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 heard
correctly.
- The discrimination score is the percentage of understood words presented at 35 dB
above 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 audiogram
doesn’t fit with the responses he gave during the anamnesis. For example, with an average
of 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 and
descending pathways and should correspond to the discrimination level obtained during
speech audiometry.

1.2.3 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

1.2.4 The DAF test (delayed auditory feedback test) introduced by Demanez (1) can detect
hearing losses of sizeable degree but not the minor exaggerations that can occur in medico-
legal situations.

1.2.5 Nowadays, several objective tests can be done and are helpful in assessing auditory function
in patients who are unable or unwilling to cooperate.
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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)

1.2.5.1 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 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 cophosis

1.2.5.2 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.

1.2.5.3 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.

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, a
difference in latency between a patient’s two ears of greater than 0,3 ms is often related to an
acoustic neuroma. In multiple sclerosis, when the patient complains of bad hearing with
normal pure tone audiometry, the BERA can demonstrate increasing interwave latencies or
complete desynchronisation.
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1.2.5.4 Cortical Evoked-Response Audiometry (CERA) (Fig.1)

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. (Boniver 2; 3; 4)

1.3 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.

1.4 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.

2. VERTIGO

2.1 It is important to rule out all the organic causes that can lead to vertigo and dizziness.

In case of head trauma, the most common cause of vertigo is the benign positional paroxysmal
vertigo (BPPV) which is related to the liberation in the endolymph of little particules, the otoconias,
that move in certain position of the head and irritate the sensory cells of the ampulla of the semi-
circular canal, creating a sudden vertigo. Imbalance from a trauma, injury or intoxication can be
very variable.

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.
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2.2 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

2.3. Recurrent paroxystic vertigos can occur : (Boniver 5)

2.3.1 The most frequent are the benign positional paroxystic vertigos secondary to
canalolithiasis.

2.3.2 Other conditions such as Ménière’s disease, syncope, vestibular migraine or vascular
lesion as for example the subclavian artery steel syndrome, are possible.

2.4 In some patients victim of injury, psychogenic vertigo can occur:

- Either provoked by a persistent vertiginous sensation linked to well-known organic

lesion but unexplained to the patient that last for months.
- Either induced by the posttraumatic stress.

2.4.1 The interpretation of the dizziness is linked to several factors:

* The knowledge of the affection: Why, How.
* The interpretation of this knowledge
* The previous state of mind of the patient
° Personality disorder
° Anxiety
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° Psychiatric disorder (schizophrenic, bipolar, Hysteric,…)

° The relationship with the physician
(danger of multiple examinations in expertise without a real relation with
the patient)

2.4.2 Vertigo ca also be a symptom in different psychiatric disorders. The list according to the
DSM-IV classification was published by Brandt in 1996 :

* Vertigo as an associated symptom

° Schizophrenia
° Paranoïd Personality Disorder
° Major Depressive Disorder
° Dysthymic Disorder or Depressive Neurosis
° Generalised Anxiety Disorder
° Conversion Disorder or Hysterical Neurosis Conversion Type
° Hypochondriasis
° Somatoform Disorder
° Depersonalisation Disorder
° Factitious Disorder with predominantly Physical Signs and Symptoms
° Adjustment Disorders unspecified (with Physical Complaints)

* Vertigo as a defined syndrome

° Panic Disorder with Agoraphobia

° Agoraphobia without History of Panic Disorder
° Acrophobia

* Impact of the psychological status on the organic vertigo

° Predisposed Personalities
° Evidence of Psychiatric Disorder
° Voluntary exaggeration of existing Symptoms
° Simulation

2.4.3 The frequency of psychogenic vertigo is not well described in the neuropsychiatry
literature. In a cohort of 1370 patients complaining of vertigo, Brandt (6) demonstrated
15 % of postural phobic vertigo.
When the otoneurological examination is normal, a psychiatric work out is then
necessary in case of suspected psychogenic vertigo.
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2.5. Conclusion

The accurate exploration of the dizzy patient is able to find out in the majority of the cases
the organic lesion of the disease.

The intense and paroxystic vertigo with rotational sensation is always from the labyrinth or
sometimes secondary to an acute brainstem lesion but then associated issued with other
neurologic symptoms.

The balance disorders are dependent of many factors. Some of them are psychologic.

When the otoneurologic examination is normal, it is further necessary, in some cases, to ask
for a neuropsychiatric evaluation of the patient.

3. THE OLFACTION

3.1. Introduction:

The smell loss is frequent in head trauma with anteroposterior impulse which create a laceration of
the olfactive fibers or contusion of the olfactive bulb at the skull base. Up to these last years, it was
difficult to do an objective testing of these patients.

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.

3.2. the UPSIT test

Different psychometric tests to evaluate the sense of smell are available.

The UPSIT (University of Pennsylvania Smell Identification Test) test we use is based on the
presentation of 40 different micro crystallised substances that can be released by scratching with a
neutral pencil. All the odours are familiar.

For each item presented, the subject has to choose one between 4 different proposals.

The odorous substances that are presented have been selected on different criteria: pleasant and
repulsive, pure or mixed flavour (chocolate), trigeminal sensitive (menthol) to detect simulators.

The examiner is compelling the good responses and the score is reported in a board according to the
age and sex of the patient. The score is a percentile and the patient is classified as normosmic,
microsmic, anosmic or suspected simulator.
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3.3. 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. (Melon and Boniver, 1972,
unpublished-fig 2).

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.

3.4. 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.

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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BIBLIOGRAPHY

1° DEMANEZ J.P., DITTRICH F.L., LEDOUX A. DAF Test : a new recording and analysing
device. International Audiology. 1966, V ; 91-96.

2° BONIVER R. Intérêt de l’étude des potentiels évoqués corticaux en expertise. Acta Oto-
Rhino-Laryngologica, 1982, 36 : 377-381.

3° BONIVER R. Cortical electric response audiometry (slow vertex response) in forensic

audiology. Acta Oto-Rhino-Laryngologica Belgica, 1994, 48 : 357-361.

4° BONIVER R. Slow auditory evoked potentials. The end of malingering in Audiology.

International Tinnitus Journal. 2002, 8 : 58-61.

5° BONIVER R. Les vertiges paroxystiques récidivants. Revue Médicale de Liège, 2004; 59: 5:
326-330.

6° BRANDT Th. Phobic postural vertigo. Neurology. 1996, 46:1515-1519.

7° BRANDT Th. Psychiatric disorders and vertigo, in Vertigo its multisensory syndrome.
Springer Verlag Ed. 2000, ISBN 3-540-19934-9, 455-468

8° ROMBAUX Ph., COLLET S., ELOY Ph., LEDEGHEM S., BERTRAND B.

Smell Disorders in ENT Clinic.
B-ENT, 2005, Suppl. 1, 97-109.