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In Belgium and in France, tinnitus has to be considered together with the study of hearing loss to determine a degree of disability.
Otolaryngologists can be called on as expert witnesses in a legal case for any number of reasons. In our countries, tinnitus must be considered as a symptom linked to a disease or an injury to the auditory system. The language used by affected patients, their linguistic competence, and intellectual degree are the most crucial impediments to obtaining reliable results in vocal audiometry. Brainstem evoked response audiometry (BERA) examination does not provide evaluation for separate frequencies.
The late cortical auditory evoked potentials technique allows one to examine each frequency. Cortical audiometry appears to be an indispensable complement if the classic examinations fail to define an exact threshold.
In cases of occupational diseases, a special scale is applied (criteria for indemnification of occupational hearing loss and deafness).
A common practice in calculating the loss of hearing ability in Belgium is to take the average of loss in excess of 1,000 Hz, 2,000 Hz, and 3,000 Hz, while ignoring the 500-Hz reading, as this can create an error in the evaluation of the level of industrial hearing loss.
A maximum rate of 80% can be allowed, because a patient with total deafness loses virtually all possibility of finding employment in the job market. Clearly, in most evaluation scales of industrial disability, the degree of disability varies linearly with that of functional deterioration of the organ; however, in reality, it is not so. Disability categories should in fact take into considerations that a simple raising of the voice is sufficient to produce understanding by a patient with 50- to 70-dB hearing loss.
Evidently our decibel scale does not correspond truly to the progression of the degree of ability for social communion. In the other cases, an official Belgian disability scale (BOBI) is used legally for certain allowances for handicap people, war victims, and people injured in the military.
The actual aim of the commission of the Belgium Otorhinolaryngology Society is to ask for standardization of these different scales, but doing so necessitates new legislative dispositions that are not the concern of the medical world. The evaluation of disability resulting from a hearing loss is based on pure-tone audiometry by air conduction, carried out in a sound-proofed room with headphones worn on naked ears and performed by a calibrated audiometer according to the ISO's latest regulations. According to article 712, the percentage of disability of a hearing deficiency is calculated by transposing the average loss in decibels of each ear (calculated by the following formula) on the x and y axes of the Pythagorean table (Table 2). According to article 713, speech audiometry and, more particularly, the auditive capacity index (ACI) can show a social hearing lower than indicated by tonal average loss. Special scales are in use for the personnel of the NMBS (Belgian Railway) and for civil flying personnel. In case of occupational diseases in France, high-pitched traumatisms are compensated within the framework of industrial accidents.
Losses are not taken into account unless the average hearing loss of the best ear is equal to or greater than 35 dB.
In Belgium and France, tinnitus by itself is considered a weakly important symptom of invalidity. La delivrance et le remboursement sont soumis a prescription medicale prealable et obligatoire. Le meilleur suivi et le meilleur entretien sont assures pendant toute la duree de vie des aides auditives. Aucun frais pour vous lors de l achat de vos protheses auditives, nous supportons les interets a votre place.Si votre mutuelle audition ne prend pas bien en charge le prix de votre appareil auditif, cette formule peut etre pratique. Plus d'information :Prix du xino tinnitus 110 (acouphene) starkeyAvec la technologie multiflex, l'appareil auditif xino tinnitus 110 genere un stimulus sonore adapte aux preferences du patient pour but de le le soulager.
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Despite these operational criteria, the interface between vertigo and headache is complex (7) and the discrimination between MD and VM remains a challenge, in particular in the early course of the disorders (8–11). The development of internationally accepted diagnostic criteria is quite recent in the vestibular field (2, 4). The aim of this study is to systematically assess accompanying symptoms of vestibular attacks in patients fulfilling current criteria for VM, pVM, and MD to enhance the phenotypic description of these episodic vestibular disorders.
Four hundred and twenty-three patients presenting with an episodic vestibular syndrome were recruited between August 2013 and March 2014 in a prospective multicenter study performed in Italy, Luxembourg, Germany and Spain in six clinical centers.
All patients were examined by clinical testing for spontaneous and positional nystagmus, smooth pursuit, saccades, and head impulse test.
To characterize the type of headache during the attack, the interview included specific questions concerning localization (unilateral?), quality (pulsating ?), intensity of headache (moderate to severe?), and aggravation of headache by activity. This study demonstrates, quite expectedly, that patients with VM and pVM have mostly migraine symptoms during their attacks while patients with MD have mostly auditory symptoms. A second finding of our study is that a subset of patients with VM also experience auditory symptoms, especially tinnitus, during the attack.
A third point to mention from our data is that anxiety and palpitations and nausea are more common symptoms during the attack in patients with VM compared with MD. A subset of patients with MD, who showed hearing loss in the audiogram after the episode, did not perceive hearing loss during the attack. The MRS is a composite score aiming to estimate the probability that a headache has a migrainous character based on four questions.
All of the accompanying symptoms studied here (except visual aura) may occur in these three disorders but with different frequencies. In conclusion, the present study shows that differences in accompanying symptoms during attacks in MD, VM, and pVM are present in a group comparison, but the considerable overlap of symptoms renders the differential diagnosis in the individual patient challenging. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Either the case is designed in common law, or the cases involve work accidents or work-related diseases.
In the scope of forensic examinations, what has to be emphasized is that BERA does not permit a definition with exact and reliable thresholds.


However, the threshold obtained by late cortical evoked potentials has to be brought into correlation with the other data of the examination [2]. This scale has been elaborated by a study group composed of university professors, other otolaryngologists, and medical doctors of the fund itself. On the contrary, a screaming voice is necessary to bring about understanding in a patient with 80- to 100-dB hearing loss. If affected patients use a well-tolerated hearing aid, the industrial disability rate can be fixed in a category immediately below that obtainable without a hearing aid.
In certain cases, experts may apply other guidelines as long as they can provide acceptable medical reasons for doing so. In other cases, this scale serves as a reference but is not obligatory and usually is questionable. The official Belgian disability scale has just been revised, and the commission has put forward certain new criteria for compensation of hearing loss. The ACI is the mean of speech intelligibility measured at 40,55, and 70 dB SPL, respectively. The sum of this article with those of articles 712 and 713 should not be greater than a disability rate of 80%. Also, for granting a driver's license and for military service, special scales are applied. Compensation is evaluated by taking into account not only the physiological disability but the age, the general condition, and the professional qualifications of the individual being evaluated.
Rebattu [1] makes use of four different compensation scales in his article about medicolegal assessment. Including it in a determination of a degree of invalidity necessitates combining it with the determination of certain hearing loss.
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This means that you will not need to remember your user name and password in the future and you will be able to login with the account you choose to sync, with the click of a button. This page doesn't support Internet Explorer 6, 7 and 8.Please upgrade your browser or activate Google Chrome Frame to improve your experience. The current diagnostic criteria for the two disorders are mainly based on patients’ symptoms, and no biological marker is available. In the absence of a diagnostic gold standard and confirmatory tests, the diagnosis is largely based on the history, including the duration of vestibular symptoms, accompanying cochlear and neurologic symptoms and exclusion of other causes (2, 3).
Of note, patients with MD have a disproportionally high prevalence of headache, including migraine (12–14). At an early stage, the development of disease classifications and of diagnostic criteria is mainly based on expert opinions rather than on robust data (17). As a result, the features, which discriminate best or least between the two, should become clearer and help to guide the clinician in his history taking and diagnostic decisions. All patients were interviewed by experienced neuro-otologists (three neurologists and three otolaryngologists) with at least 12 years of clinical practice. A pure tone audiogram was performed in all patients to determine bone and air conduction hearing thresholds. The questionnaire was designed to collect all vestibular symptoms reported by patients (vertigo, dizziness, vestibulo-visual symptoms, postural symptoms), the frequency, and duration of the attacks and the intensity of the symptoms. Summary of the structured questionnaire designed to characterize symptoms in the vestibular episodic syndrome. Each question could be answered as never, sometimes or mostly and scored as 0, 1, or 2, respectively.
Absolute and relative frequencies were calculated for each accompanying symptom occurring during the attacks. Accompanying symptoms reported by patients with definite and probable VM during the attack. The definition of VM requires that at least 50% of the attacks are accompanied by migraine features (2, 4), but auditory symptoms are not considered except phonophobia.
This observation applies especially to patients with a constant severe sensorineural hearing loss on the affected ear, which temporarily got worse during the vertigo attack. However, this score does not consider the number of headache attacks and it cannot replace the IHS criteria for the diagnosis of migraine (4).
Anxiety and depression are comorbid conditions with MD and VM, and we did not use a specific instrument for their diagnosis since this study was not designed to estimate the comorbidities of these psychiatric conditions. In summary, subjective hearing loss, tinnitus, and fullness of the ear are much more common in MD. Future studies may address the question whether VM and MD just overlap with regard to clinical phenomenology or if they represent variant phenotypes of a broad clinical spectrum disorder. They also can be asked to stand for insurance companies as an expert or as a consultant by colleagues who themselves are experts and require an ear, nose, and throat (ENT) specialist's opinion on a particular point. In common law, victims have to receive restitution integrally to their states before an accident: Experts have to consider the state of victims before an accident and to compare it with the new situation.
In Belgium, the Royal Society of Otorhinology, Laryngology, Head and Neck Surgery in 1986 proposed recommendations for forensic ENT examination.
Also used are pure-tone threshold audiograms, defined by increasing or decreasing intensity (or both) of the test tone, and measurement of the impedance and of the threshold of the stapedial reflex. A BERA threshold obviously better than the threshold of pure-tone audiometry (difference > 15 dB) is an indication for exaggeration without being able to define its degree. However, the threshold can vary as much as 10 dB from one examination to another and this depends on the sometimes unclear morphology of the curves at threshold, the experience of the examiner in identifying the curves, and the level of alertness and the fluctuations in the basic electroencephalogram. However, in certain cases, the subjective evaluation of the degree of deafness proves not to correspond to figures cited in Table 1. These criteria, which were defined by an organization called Fonds des Maladies Professionnelles en Belgique, have been accepted by the forensic committee of the Belgian ENT Society.
In numerous cases, insurance companies have their own scale and, in assessments concerning railway workers. They consist of tonal audiometry by bone conduction, supraliminal tests, study of the stapedius reflex, vocal audiometry, electrophysiological confirmation tests of threshold, and measurements (evoked response audiometry, electrocochleography).
The legal audiometric techniques are tonal audiometry by air and bone conduction and speech audiometry executed by applying lists of disyllabic words in silence. The double-entry chart of industrial accidents and occupational diseases published in the official journal of the French Republic on December 30, 1982, enables the percentage of disability to be calculated on the basis of average hearing loss in each ear. Convient a la majeur partie des protocoles de traitement des acouphenes et notamment la Tinnitus Retraining Therapy TRT. When applying these criteria, an overlap of the two disorders is occasionally observed in clinical practice. Furthermore, cochlear symptoms are not exclusive to MD but may similarly occur during attacks of VM (15, 16).


The data could also contribute to the discussion if VM and MD are clearly different entities or rather part of a clinical spectrum. The centers were tertiary referral outpatient clinics or vertigo clinics in general hospitals. Additional tests to exclude other differential diagnoses were performed at the discretion of each clinician to establish the diagnosis.
A composite migraine risk score (MRS) was calculated for the patients suffering from headache as the sum of these four items. Our findings suggest that both VM and pVM are more commonly found in women (four to eight times), which does not apply to MD. In this study, we excluded patients fulfilling the criteria for both MD and VM, so we are probably underestimating the prevalence of headache, including migraine, and hearing loss in our series compared to an unselected patient population presenting with episodic vertigo. This shows that hearing loss can be missed by history taking and underlines the importance of audiometric testing in all patients with episodic vertigo to prevent a delay in the diagnosis of MD. Our data demonstrate that the MRS can be useful to differentiate MD from VM, since VM patients reached a higher score than patients with MD or pVM. We did not assess severity of symptoms, which may further aid the differentiation of VM and MD. In social matters (work accident or work-related disease), an important step is to consider the value of a victim in the job market. Depending on the case, examiners have access to testing with delayed stimulus (vocal or pure tone), the Azzi test of apparent modulation, a frequency sweep with constant intensity, the Stenger test, vocal audiometry- speech discrimination testing, and Bekesy audiometry. In such cases, examining doctors can grant disability percentages in excess to the established limits, provided they can offer sufficient justification based on more detailed examinations.
These tests are performed after 12 hours' exposure of the patient to the usual noisy working environment.
However, actually this scale does not have much authority, and different versions of it are found in different schools. Therefore, the present prospective multicenter study aimed to identify accompanying symptoms that may help to differentiate between MD, VM, and probable vestibular migraine (pVM). A previous version of these operational criteria has shown high reliability and validity (5). Only patients who have two different types of attacks, one fulfilling the criteria for VM and the other for MD, should be diagnosed with both disorders (4).
For the present analysis, we selected a total of 268 patients fulfilling either the diagnostic criteria for MD according to the American Academy of Head and Neck Surgery (6) or the diagnostic criteria for VM or pVM (2, 4) to characterize the clinical symptoms during the episodes of vertigo.
The most common symptoms in patients with MD (total frequency) were nausea (94%), vomiting (84%), and tinnitus (83%). The most frequent accompanying symptom in both groups was headache (95% in VM and 66% in pVM), followed by nausea, anxiety, phonophobia, and photophobia (Table 2). Migraine is three times more common in women and it typically occurs in young patients with a peak prevalence in the fourth decade, regardless of the presence of vestibular symptoms (20).
Neither headache nor migraine is considered as an exclusion criterion in MD in the current definition of the AAO-HNS (6), nor do the instructions warn the clinician to carefully consider VM as a differential diagnosis.
However, our results indicate that lack of certain auditory symptoms, especially hearing loss, are suggestive for a diagnosis of either VM or pVM. Vomiting may be part of migraine as such, as well as a consequence of vertigo, vomiting in association with auditory symptoms may help to discriminate between MD and VM. A second limitation is the fact that the family history of migraine or MD was not considered for the diagnosis and both VM and MD have a strong trend for familial clustering (22).
According to our clinical experience, we would expect that hearing loss or tinnitus during attacks of MD were more pronounced than during attacks of VM, which needs to be investigated in further studies. Experts have to evaluate the loss of physical integrity of function as it relates to the working capacity of the victim. If one suspects exaggeration (or stimulation), the application of several tests is advised to define as closely as possible the real threshold. Articles 712-714, expanded here, are new readings and, as of March 1998, were not yet being officially applied.
Many books have been published on this subject, among which we mention those of Courtat and Elbaz (Table 4 [2]), Derobert [3], and Melennec [4]. Patients fulfilling the criteria for both MD and VM (either VM or pVM) were excluded from the study. Accompanying hearing loss was reported in 77% of cases, headache was found in 41% of patients with MD, and migraine-type headache was observed in 8.4% of MD patients during the attack (Figure 1). Of note, no patient in our series with a diagnosis of MD or pVM had a MRS = 8, and only patients with a diagnosis of VM reached the maximum score. In fact, the presence of headache, including migraine, during the vertigo attack does not rule out the diagnosis of MD (7, 12). Nevertheless, a high MRS score may point to VM, in particular when hearing loss is absent since only patients with VM reached the maximum score (MRS = 8). Since there is a frequent association between episodic vertigo, migraine, and MD in close relatives, including identical twins, it is possible that MD and VM can share a common genetic link with variable expression of hearing loss, episodic vertigo, visual aura, and migraine in the same families (23). Tinnitus gives a maximum handicap of 5%, with an exception in cases of military injury, for which special evaluation scales give an invalidity percentage up to 30%. For probable vestibular migraine (pVM), either a history of migraine or migraine symptoms during the attack are sufficient (2, 4). Although we did not study the relationship between perceived hearing loss and hearing threshold in the audiogram systematically, we noted that some patients with MD, who did not report hearing loss during attacks, had a profound chronic sensorineural hearing loss on the audiogram (>70 dB normal hearing level). Although this finding should be validated in a larger cohort of patients with MD, VM, and pVM, the application of the MRS in clinical practice to improve the diagnostic accuracy of VM seems promising. Finally, for the diagnosis of definite VM, the diagnosis of migraine was made according to IHS criteria, but regarding the quality of the headache accompanying the vertigo episodes, our questionnaire only allowed to establish how many migraine features were present, but not if it fulfilled a migraine diagnosis according to IHS criteria. Although both, photophobia and phonophobia, are more frequent in VM than in MD, they do not seem to have strong discriminating power between pVM and MD, while headache performs slightly better and favors a diagnosis of VM. However, it has to be noted that a subset of MD patients also experienced (migraine-type) headache during the attacks. The criteria for MD by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) require accompanying auditory symptoms and audiometrically documented hearing loss on at least one occasion (6).
It is likely, although unproven, that migraine symptoms during the attack are more useful for distinction of VM from other causes of recurrent vertigo, such as benign paroxysmal positional vertigo, vertebrobasilar TIA, or vestibular paroxysmia.
The frequency of migraine-type headache was significantly higher in VM as compared to both pVM and MD. In conclusion, the present study confirms a considerable overlap of symptoms in MD, VM, and pVM.
In particular, we could not identify any highly specific symptom for one of the three entities. The identification of common symptom patterns in VM and MD may help to refine future diagnostic criteria for the two disorders.



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