Critical evaluation of different objective techniques of nasal airway assessment: a clinical review.

Objective tests for the nasal volume flow are needed for the assessment of nasal patency for diagnosis, documentation and medicolegal purposes. Three main techniques are nowadays established: active anterior rhinomanometry (AAR), 4-phase rhinomanometry (4PR) and acoustic rhinometry (AR). Several guidelines and consensus reports and the International Committee on Standardization have clarified the field of interest and the limitations of this technology. In the meantime, technical progress and the development of seemingly new methods have brought up many new facts which necessitate the re-evaluation of the test available. From our method of critical analysis we can conclude that AAR can be still considered as the standard technique for the objective assessment of the nasal airway. AR is a valid technique with limitations and cannot replace AAR because it measures different parameters thus forming a complementary technique. 4PR might provide supplementary information although not yet all open technical and mathematical inconsistencies conjoint with this technique have been clarified. Still the individual subjective sensations of the patient do not always match the objective measurements. In conclusion, a combination of information given by the patient, the rhinoscopic findings and the carefully interpreted results of AAR and AR will increase considerably the success of surgical interventions and the feeling of satisfaction by the patient after surgery, when matched thoughtfully.

[Expert opinion of ORL for private accident insurance]. / HNO-ärztliche Begutachtung für private Unfallversicherungen.

The provisions and the aims of private accident insurance are not comparable to those of the statutory accident insurance. The ear nose throat- (ENT-)specialist is often consulted on the question of a possible causality between an accident and sequelae. Loss of smell, taste disorder and loss of hearing are specified in a table with a fixed percentage for compensation. The individual invalidity for ear ringing, vertigo and other disorders have to be determined separately from this table. In private accident insurance a probability bordering on absolute certainty must be given when establishing a possible causal connection whereby mental reactions are excluded from compensation and all sequelae have to have continued for at least 3 years. The occupation or specific skills of the injured person are not essential for the judgement. The current jurisdiction and conditions of private accident insurance for tinnitus and vertigo have to be taken into consideration.

[Expert assessment of tinnitus in statutory accident insurance]. / Die Bewertung von Tinnitus in der gesetzlichen Unfallversicherung.

Tinnitus is defined as hearing sensation without external noise source. The aetiology contains also occupational causes such as noise industrial pollution and inner ear trauma, nevertheless the origin of tinnitus is vastly unexplained. For the expert assessment in the public insurance a step-by-step procedure is recommended: Is there a tinnitus? Was the accused cause able to provoke tinnitus? How profound is the insured person hindered in his individual work ability by the tinnitus and potential psycho vegetative reactions? In this publication hints for tinnitus-matching and for expert opinion related questions are given: is there a noise-caused tinnitus in the low frequencies? Is it possible that a noise-induced tinnitus worsens after retirement? Can stress be a potential candidate to evoke tinnitus? Under which circumstances a psychiatric assessment can be necessary? In the assessment of tinnitus crucial differences between public accident insurance, civil right, public health and handicap right are explained.

[Compensation for somatoform (psychogenic) tinnitus in private accident insurance]. / Bewertung von Tinnitus als Gesundheitsschaden in der privaten Unfallversicherung - eine Novität.

BACKGROUND: According to special arrangements in private accident insurance, it is now possible that tinnitus as exclusive sequel (psychogenic tinnitus) can be compensated. This new situation leads to the unanswered question of how such a psychogenic (somatoform) tinnitus should be compensated in regard to the valid compensation tables. METHODOLOGY AND RESULTS: The differentiation between an otogenic and somatoform tinnitus allows a judgement as defined by the general terms and conditions of the private accident insurance. An individual compensation of 5 % or of a complex, decompensated tinnitogenic psycho-syndrome 10 % of the sum insured is proposed. CONCLUSIONS: All impairment of the psychic function as exhaustion, nervous excitability, sleeplessness, depression and concentration disturbances are included in this invalidity of 10 %. In case of a tinnitogenic psycho-syndrome, the medical assessment should be done by a neurologist/psychiatrist.

[Compensation tables for tinnitus as a physical defect in private accident insurance]. / Invaliditätsgrade in der Bewertung von Tinnitus als Körperschaden in der privaten Unfallversicherung.

Until 2004, tinnitus was vieved as a psychic reaction according to the provisions of private accident insurance and therefore excluded from compensation. In two recent judgements of the Federal Supreme Court in Germany the assessment of tinnitus in private accident insurance has been newly defined. According to this jurisdiction, the compensation of tinnitus is possible, when a proven physical defect in the inner ear or the auditory pathway (hearing loss) can be established and has a causal connection to the accident. This leads to the question of how a quantitative assessment of tinnitus can be carried out. The compensation should be in accordance to the general terms and conditions of private accident insurance. A compensation table is proposed, which recognises the physical defect of tinnitus and is based on medical and scientific findings of the relation between hearing loss and tinnitus.

[Chance or causality: problems recognizing laryngeal carcinoma as a result of occupational exposition to noxious substances of blue collar worker employed in the rubber industry]. / Zufall oder Kausalität--zur Problematik der Anerkennung von Larynxkarzinomen bei Arbeitern der Gummi-Industrie.

BACKGROUND: Laryngeal cancer as an occupational disease in the rubber industry is under subject of continuous epidemiological research because of the lack of stable statistical data. METHOD: Epidemiological studies published in the period between 1982 and 2006 were analysed in regard of the risks employment and laryngeal carcinoma. 23 own cases of medical expert opinion and the documentation of the German Occupational Cooperatives were analysed. RESULTS: A significant statistical correlation between a specific exposition to cancerogenics in the rubber industry and a development of laryngeal carcinoma could not be found in the literature, still there is evidence for an increased mortality. It points to asbestos, talcum, dust as one risk factor. CONCLUSION: Recognition and compensation for laryngeal carcinoma according to [section sign] 9 Abs. 2 SGB VII is possible after intense individual investigation, although up to now no clear statistical evidence for the coincidence between employment in the rubber industry and general could be proven.

[Occupational head and neck cancer. Part I: Registered occupational diseases]. / Berufliche Krebserkrankungen im HNO-Fachgebiet. Teil I: "Listen-Berufskrankheiten".

Head and neck cancer can be caused by the occupational contact with cancerogenic substances, which contribute to the formation of cancer. The knowledge about those cancer entities which are frequently found under similar circumstances and working conditions, helps for getting compensation and alternatively for a realistic view when other influences--particularly lifestyle factors like smoking, alcohol and nutrition--have mainly contributed for the origin of the cancer disease. Our knowledge increases and therefore it is helpful from time to time to keep up to the state-of-art of cancer genesis. This article has two parts: part I deals with occupational cancer diseases, which are listed in a decree of the German government and part II deals with the cancer diseases, which could likely be caused by occupational factors according to latest scientific findings and are not yet listed.

[Compensation for tinnitus in private accident insurance]. / Zur Bewertung von Tinnitus als Körperschaden in der privaten Unfallversicherung.

According to the provisions of private accident insurance, mental or psychic reactions are excluded from compensation. Until now, tinnitus was taken as fully psychic and therefore excluded. In two recently published judgments of the Federal Supreme Court in Germany the assessment of tinnitus in private accident insurance and particularly the exclusion clause section sign 2 Abs. 4 AUB 88 has been newly defined. According to this actual jurisdiction the compensation of tinnitus could be possible, when as physical underlying reason a proved harm in the inner ear or the auditory pathway (hearing loss), which can be traced back to the accident according to the rules of causality. This leads to the question how Tinnitus could be compensated without modification of the general terms and conditions of the private accident insurance. A compensating table is proposed, which recognizes the somatic (physical) part of tinnitus and is based on medical and scientific findings of the relation between hearing loss and tinnitus.

[Bearing of costs for in-patient treatment of sudden deafness: what the physician should know in the light of the actual jurisdiction]. / Zur Kostenübernahme des stationären Hörsturzbehandlung: Was der Arzt vor dem Hintergrund der aktuellen Rechtsprechung beachten sollte.

In Germany, the in-patient treatment of sudden deafness is possible according to the indications given in the guide-lines of the Association of the Scientific Medical Societies. But public and private health insurances often reject bearing the costs later. Their arguments are that there is no rational justification for an in-patient treatment for lack of evidence and that any treatment could be done also on an out-patient basis. Hospitals sued these insurances and now judgments - particular of the Federal Supreme Court (FSC) - are published which strengthen the legitimacy of an in-patient treatment under certain circumstances. According to the law suits, the hospital doctor is mainly responsible for the indication of hospitalization. Also the FSC stressed that the chosen treatment in the hospital can not be questioned retrospectively by the insurance company as long as it is within good medical practise (see guide lines). The grade of evidence is not the decisive factor. The only institution, which can exclude treatments from being practiced in a hospital, according to the German Social Security Code, is the Federal Joint Committee Hospital. The treatment protocol itself must reveal the necessity of hospitalization (need for surveillance, side effects etc.).

[Assessment of tinnitus in private accident insurance]. / Zur Beurteilung von Tinnitus in der privaten Unfallversicherung.

In two recently published judgments of the Federal Supreme Court in Germany dating June 23rd, 2004 (IV ZR 130/03) and September 29, 2004 (IV ZR 233/03) the assessment of tinnitus in private accident insurance and particularly the exclusion clause section sign 2 Abs. 4 AUB 88 has been newly defined. This exclusion clause is still valid according to the actual jurisdiction in the case a tinnitus is asserted following an accident without any organic (physical) damage. In this case tinnitus has to be regarded as mental (psychic) reaction in the meaning of paragraph 2 AUB. According to the actual jurisdiction the compensation of tinnitus could be possible, when as physical underlying reason a proved harm in the field of the inner ear or the auditory pathway is found, which can be traced back to the accident according to the rules of causality.

[Expert assessment within the scope of the sudden deafness disease picture]. / Begutachtungsfragen im Rahmen des Krankheitsbildes Hörsturz.

Claims for medical liability mostly arise when a patient believes that his sudden deafness was not accurately diagnosed, diagnosed too late or insufficiently or was not well treated. Guided by seven expert opinions potential problems in indemnity were depicted. A clear misdiagnosis of sudden hearing loss (e.g., a hearing loss taken for eustachian tube disorder) will lead to an accusation of malpractice if the doctor cannot prove an accurate otological examination and appropriate diagnostic studies. The burden of proof lies with the doctor. A further consequence of a missed diagnosis is a delay in treatment. In the literature the good prognostic factor of early treatment has been stressed but without delineating a clearcut line between "in time" and "too late". An accusation of malpractice by insufficient treatment (pills instead of infusions) has risen. Since an unequivocal treatment is not established and various modalities of therapy are still controversial, disputes could be settled more easily. The validity of "no treatment" may be considered but requires accurate diagnosis and the patient must give informed consent. Such a procedure is justifiable, even from an ethical standpoint, when the patient fully understands and agrees.