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Permanent impairment case study - ear, nose and throat

The following case studies relate to injuries to the Ear, Nose and Throat and Related Structures.

More detailed information regarding the assessment of injuries to the ear, nose and throat may be found at Chapter 6 of the permanent impairment guidelines and Chapter 9 of the AMA4 Guidelines.

We make no warranties or representation about the accuracy or completeness of the information contained in these Case Studies. It should be noted that the information contained herein is not provided as a substitute for legal advice.

Case Study # Brief Description Primary Body System Secondary Body System
ENT1 Tinnitus ENT  
ENT2 Loss of smell/taste and tinnitus ENT  
ENT3 Hearing loss ENT  
ENT4 Nasal obstruction ENT  
ENT5 Facial disfigurement/olfaction and speech ENT Skin
ENT6 Tinnitus and hearing loss ENT  
ENT7 Incisor injury ENT  
ENT8 Anosmia ENT  
ENT9 General dental ENT  
ENT10 Tinnitus ENT  
ENT11 Facial Bruising and Nasal Swelling ENT  
ENT12 Vertigo ENT Spine

Injuries:

Tinnitus

A claimant collided with a telegraph post sustaining multiple major injuries. The claimant experienced a short loss of consciousness, but could recall impact; the next memory was being in the vehicle at the scene.

Since the MVA, the claimant complains of continuous bilateral ‘cicada’ like sound in the ears, and altered hearing. The tinnitus may prolong attaining sleep and sometimes ‘dreaming of tinnitus’ may awaken the claimant.

Clinical Examination

Examination of the ears revealed no abnormality. Pure tone audiometry demonstrated 1.9% binaural hearing loss.

Diagnosis

Symptoms were consistent with traumatic labyrinthitis due to the motor vehicle accident. With reference to Table 3 (page 228) AMA4 Guides, 1.9% binaural hearing loss equates to 1% whole person impairment. A further 1% was allowed for permanent and severe tinnitus. In accordance with clause 6.4 of the MAA Guides, these two impairments were added, equating to 2.9 %. With reference to Table 3, page 228 AMA 4, this would still rate as 1% whole person impairment.

This matter was subject to review by a Medical Review Panel. These are the Review Panel’s findings.

Claimant’s Date of Birth: 30 September 1951

Date of Motor Accident: 1 April 2006

Injuries: Vestibular impairment

Severed olfactory nerve/loss of sense of taste

Tinnitus

Clinical Findings

Injuries: Fractures – occiput and right petrous temporal bone

The claimant was a child who had been run over by a reversing vehicle. The child sustained a head injury with degloving together with fractures of the occiput and right petrous temporal bone. The claimant had complained of right sided deafness since the MVA, but there were no complaints of tinnitus nor vertigo.

Clinical Examination

Examination showed a step in the right posterior canal wall adjacent to the attic region. The Rinne tuning fork test was negative on the right, positive on the left and the Weber was referred to the right ear. Pure tone audiometry demonstrated normal hearing in the left ear and a conductive hearing loss in the right amounting to 5.8% binaural loss in accordance with the 1988 NAL Scale

Diagnosis

The fracture of the right petrous temporal bone is associated with an ossicular chain disruption and an ensuing conductive hearing loss. With reference to Table 3 (page 228) AMA4 Guides, a 5.8% binaural hearing impairment converts to 2.0% whole person impairment.

This matter was subject to review by a Medical Review Panel. These are the Review Panel’s findings

Claimant’s Date of Birth: 2 February 1971

Date of Motor Accident: 24 November 2002

Injuries:

Nasal fracture causing increased nasal obstruction

Scarring – right eyebrow and scalp

Clinical Findings

The claimant’s scalp was almost completely shaved and he had the following scars.

On the left occipital region of his scalp there was a white scar which measured 5.0 X 0.3 cms. This scar was flat, and soft, it did not adhere to the underlying structures; however it was noticeable because it was hairless while the surrounding skin was not.

The scar in the right eyebrow has now settled so well that it could not be seen.

There was a fine, barely visible scar, 1 cm long, on the bridge of the nose; this scar was soft, flat and the same colour as the adjacent skin, and it was quite difficult to see.

The shape of his nose was essentially normal, although the left nasal bone was slightly prominent; the bridge line was straight, the tip was well supported, the nostrils were symmetrical, the septum was essentially straight and air entry through the nostrils appeared equal and adequate.

Panel Findings

The whole person permanent impairment of the injuries caused by the accident was calculated as follows:
The scars are situated on his scalp and face and thus are assessed under the guidelines in Chapters 9.2, ‘The Face’ and 13.5, ‘The Skin’ of AMA 4.
As the scars on his right eyebrow and on the bridge of his nose do not restrict the claimant in any way and are essentially invisible, they are assessed as having caused 0% whole person impairment.
The scar on his scalp is clearly visible because it is hairless whereas the surrounding skin is hair bearing; however, it does not adhere to the underlying bone, it is not associated with a contour defect, it has a negligible effect on the normal activities of his daily life and it does not require treatment. Under the Guidelines established in the ‘Table for the Evaluation of Minor Skin Impairment’ (TEMSKI), of the Motor Accidents Authority, it is considered that the ‘best fit’ for the whole person impairment caused by this scar is 1%.

In relation to the nasal injury, “Permanent Impairment Guidelines” Motor Accidents Authority, 1 October 2007, the following is written in section 6.22 on page 37, “When Table 5 (p231, AMA4 Guides) is used for the evaluation of air passage defects, these MAA guidelines allow 0-5% whole person impairment where there is significant difficulty in breathing through the nose and examination reveals significant partial obstruction of the right and/or left nasal cavity or nasopharynx or significant septal perforation”.

The claimant’s nasal obstruction was not considered to be very significant as, when he was assessed, air entry though both nostrils was adequate and there was no significant deviation of his nasal septum; under these circumstances, the whole person impairment caused by this injury was considered to lie at the lower end of the prescribed range at 0%.

  Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) Stabilised (YES/NO) Current %WPI (percentage whole person impairment) %WPI* from pre-existing OR subsequent causes %WPI* from pre-existing OR subsequent causes
1 Scalp scarring Chapter 13, Table 2, page 280 AMA4 Yes 1% 0% 0%
2 Facial scarring Chapter 9, Section 9.2, page 229 Yes 0% 0% 0%
3 Nasal obstruction Chapter 6, Section 6.22 page 37 MAA Guides, and Table 5, page 231, AMA4 Guides Yes 0% 0% 0%

Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident

The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 1%.

Injuries:

Fractured Mandible

Multiple facial fractures

Altered smell and taste

Altered vision due to fractures

The claimant was a 30 year old man who was riding a motorcycle and collided with another motorcycle at 60km

The following injuries were sustained:

  • Bilateral peri-orbital bruising
  • Laceration nasal bridge and epistaxis
  • Depression of fronto–nasal region
  • Palatal laceration and oro-antral fistula
  • Reduced sensation over the distribution of both infra-orbital nerves
  • Altered smell and taste
  • Altered vision due to limitation of extraocular muscle movement by fractures of the orbital wall
  • Laceration right ring finger
  • Transient numbness left forearm.

Treatment

Three days after the accident the claimant underwent open reduction and internal fixation of the fractured mandible, suture of the palatal laceration and eye examination under anaesthesia. Six days later he underwent further surgery. This involved open reduction and internal fixation mid-facial fractures and wire mesh reconstruction of the left medial orbital wall and right orbital floor.

Radiographic investigations revealed

  • Displaced fracture of the left anterior body of the mandible
  • Comminuted fractures of zygomas, right zygomatic arch, maxillae, including a split palate and orbital floors
  • Fractured nasal bones.

Clinical Examination

The following symptoms were reported:

  • Reduced sense of smell
  • Reduced sense of taste
  • Facial disfigurement
  • Difficulties with mastication and deglutition. The claimant said he had difficulty opening his mouth widely and could not bite into an apple. Both temporomandibular joints clicked. Sideways movement of his jaw was restricted
  • Difficulties with speech. The claimant had difficulty pronouncing “s”
  • Diplopia, but the claimant had no problems driving at the time of the assessment. He said he had difficulty looking to the left and suffered from eye strain at night.

Reported functional status

The claimant was working full-time at the time of the assessment. He claims that he recently had to forgo a higher paying job because of his loss of sense of smell. The claimant said that he could not use gas appliances because of his loss of smell.
He also stated that although he could taste salt, meat, vegetables and cordial, their taste was not the same as it was before the accident and that cordial tasted “strange”.
He had scarring on his face and inequalities in the position of his eyes. He complained of partial right nasal obstruction.
The claimant said that his bite was not the same as it was before the accident and some of his front teeth were crooked, and his teeth felt loose and that he had reduced sensation of these teeth which were also sensitive to hot and cold.
Although he had some difficulty saying “s” he was able to be understood most of the time but there was some difficulty when he used a telephone or when there was a lot of background noise.
Anterior rhinoscopy revealed deflection of the nasal septum to the left. Posterior rhinoscopy was normal. A horizontal scar across the palate without fistula was well healed.

Face

  • Well healed bi-coronal surgical scar covered by hair for most of its length
  • Well healed bilateral lower eyelid surgical scars, oblique scars of 2 cm long
  • Well healed oblique 1cm long nasal bridge scar with palpable internal fixation material beneath it
  • Well healed horizontal scar 2 cm long sub-mental scar
  • Mild widening of the nasal dorsum
  • Prominent right zygoma and zygomatic arch
  • Mild inequality in the position of the eyes
  • Smiling reveals malocclusion of teeth
  • Maximum jaw opening was 30 mm.

Speech

The claimant was able to read the ‘Smith House’ passage without difficulty and be understood without difficulty (The Smith House – Test Oral Reading Paragraph is contained in Table 8 page 233 AMA 4).

In the course of the interview, the Assessor noted that the claimant occasionally had difficulty pronouncing “s”.

Olfactory tests

Smell Substance Right Side Left side
Peppermint + +
Eucalyptus ++ ++
Cloves + +

+ = detection of smell test substances but not able to identify.

++ = detection and identification of smell test substance.

Sensonic’s 40 Item Smell Identification Test Result

Severe Microsomia (Hyposmia)

Taste Test

Sugar crystals on tongue: detected and identified.

Salt crystals on tongue: detected and identified

The Assessor was of the opinion that the claimant had suffered multiple facial fractures. Despite treatment he had loss of supporting structures of his face, deformity and facial scarring resulting in disfigurement.

He noted that the claimant had a severe loss of olfaction caused by nasal trauma and injury to the olfactory nerves.

The Assessor noted that the claimant had no loss of taste. He felt that the claim that food did not taste the same as before the accident was due to the claimant’s lack of olfaction causing reduced perception of flavour.

The Assessor noted that the claimant was able to eat solids without difficulty, apart from hard or tough foods which caused discomfort.

The Assessor was of the opinion that the claimant was able to speak effectively but he noted his history of having some difficulty being understood on the telephone and when in background noise.

The claimant had a history of partial right nasal obstruction and mild deflection of the nasal septum which did not result in an impairment of respiration.

Whole Person Impairment of all assessed injuries:

Facial Disfigurement

The Criteria for Evaluating Permanent Impairment due to Facial disfigurement is outlined in AMA4 (page 229). The four classes of impairment and their criteria are listed below:

Criteria for Class 1 (0 to 5%):

The facial abnormality is limited to a disorder of cutaneous structures. For example, visible scars or abnormal pigmentation.

Criteria for Class 2 (5 to 10%):

A loss of supporting structure of part of the face. For example, depressed cheek, nasal or frontal bones.

Criteria for Class 3 (10 to 15%):

The absence of a normal anatomic part or area of the face. For example: loss of part of the nose.

Criteria for Class 4 (15 to 35 %):

Facial Disfigurement is so severe that it precludes social acceptance.

The injuries fall into Class 2 (5 -10%) due to the loss of the supporting structure of part of the face, demonstrated by the prominent right zygoma and zygomatic arch and the inequality in the position of the eyes. The Assessor assigned 8% WPI.

Olfaction

The Criteria for Evaluating Permanent Impairment due to loss of Olfaction and Taste differs between the Neurology Chapter and the ENT Chapter. In order to resolve this MAA Impairment Assessment Guidelines clause 6.15 states in order to resolve this, the Assessor may assign a value of whole person impairment from 1%-5% for loss of sense of taste and a value of whole person impairment from 1%-5% for loss of sense of olfaction.

The severe loss of olfaction would therefore attract between 1%-5% WPI. The Assessor assigned 4% WPI.

Taste

The Assessor determined that the claimant had no loss to their sense of taste; the loss of olfaction was leading to reduced perception of flavour. Therefore there was no % permanent impairment attributable.

Mastication & Deglutition

The Criteria for Evaluating Permanent Impairment due to Mastication and Deglutition is outlined in AMA4 (pp 231). The three types of restriction and their classes of impairment are listed below:

Diet is limited to semi solid or soft foods: 0%-19% (see clause 6.20 of the MAA Guides)

Diet is limited to liquid foods: 20% – 39%

Ingestion of food requires tube feeding or gastrostomy: 40% – 60%

Impairment was 0% as although the claimant experienced some difficulty biting into hard foods such as an apple his diet was not limited to semi-solid or soft foods.

Speech

The Criteria for Evaluating Permanent Impairment to Speech is outlined in Table 7 on p233 of AMA4. Five Classes exist and the Classes are differentiated based on Audibility, Intelligibility and Functional Efficiency.

The Assessor considered the impairment met the criteria for Class 1 (0% – 14%). The reasons for this are:

He could produce speech of intensity sufficient for most of the needs of everyday speech communication, although this may sometimes require effort and occasionally be beyond the claimant’s capacity.

He could perform most of the articulatory acts necessary for everyday speech communication, although listeners occasionally ask the claimant to repeat, and the claimant may find it difficult or impossible to produce a few phonetic units.

He can meet most of the demands of articulation and phonation for everyday speech and communication with adequate speed and ease, although occasionally the claimant may hesitate or speak slowly.

Combined WPI

Using the Combined Values Chart on pp.322 – 323 of AMA4, the total WPI = 16%.

Injuries:

Hearing Loss

Tinnitus

The claimant, a 44 year-old woman, was hit from behind by a van, striking her head on the steering wheel and possibly “blacking out”. Injuries sustained included soft tissue injuries to her cervical spine, lumbar spine and right shoulder.

She was taken by ambulance to hospital and discharged later that day to the care of her local GP. Soon after the accident, she complained of a persistent noise in her left ear, describing it as being “like an air conditioner motor”. The noise has persisted, unaltered since onset. A few months after the accident, the claimant also noticed some hearing loss in her left ear.

The claimant reported that before the accident, she had never experienced any significant symptoms in her ears, no history of ear disorders or persistent pain. Hearing was normal; no history of exposure to high levels of occupational or recreational noise was reported.

Treating Doctors identified hearing loss and tinnitus in her left ear beginning soon after the accident. The claimant said that during the day she is aware of the persistent noise in her left ear. At night, she experiences difficulty getting to sleep and leaves the television on to mask the noise.

Clinical Examination

Examination of the ears revealed no abnormality. Tympanometry showed normal middle ear pressures and compliance (tympanometry measures the function of the middle ear by varying the pressures within the ear canal).

Tuning-fork tests indicated a left conductive hearing loss, which was confirmed with pure-tone audiometry (tuning-fork tests are conducted to assess how well sound moves through the ear. Pure-tone audiometry is a test to determine hearing sensitivity using pure tones delivered through headphones, inserted earphones or sound fields).

The MAS Assessor indicated that the results of the pure-tone audiometry indicated a binaural hearing impairment of 10.6%, according to the 1988 NAL Scale (National Acoustics Laboratory of Australia).

The MAS Assessor was satisfied that the claimant was suffering from permanent left conductive hearing loss with accompanying tinnitus. The conductive hearing loss had led to a binaural hearing impairment and the tinnitus as described by the claimant would be assessed as severe. The condition was considered stable. There was no prospect of spontaneous recovery and the tinnitus was likely to persist indefinitely.

Impairment Evaluation

The MAS Assessor determined that the binaural hearing loss and severe tinnitus were permanent and caused by the accident.

An impairment of up to 5% can be added to the hearing loss if tinnitus is permanent and severe (clause 6.4 of the Motor Accident Authority’s Impairment Assessment Guidelines 2007). The Assessor decided the claimant’s tinnitus is severe because she needs to mask it with the sound of a television in order to sleep. He awarded an additional 2% to the binaural hearing impairment (BHI) due to the tinnitus. Therefore, total BHI equates to 12.6%.

Using Table 3, page 228, AMA4 Guides, a BHI of 12.6% converts to a whole person impairment of 4%.

Injuries:

Incisor injuries

At the time of the MVA, the claimant was a 17-year-old front seat passenger (wearing a seatbelt) in a vehicle which lost control, colliding with a wall, becoming airborne and then skidding 50 metres before coming to rest.

The injuries listed by the parties to be assessed included the lower right and left incisors (41 and 31).

While in hospital, the claimant stated that he felt “a roughness” and a gap between the upper anterior and the lower anterior teeth.

Symptoms

The claimant stated that he could not recall any thermal sensitivity to teeth 31 and 41, just a roughness. The claimant did not recall any spontaneous discomfort associated with either the lower or upper anterior teeth and the claimant noted, while in hospital, he was taking significant levels of analgesics due to the extent of other injuries.

Treatment

No treatment was provided to the dentition while the claimant was in hospital. It was noted that the documentation from the hospital did not indicate the specific dental injuries sustained in the subject MVA. X-rays showed thickening of the periodontal ligament of 31 and 41. Treatment involved the positioning of 41 and 31 to allow reshaping and also involved four fixed braces to correct their malocclusion. The claimant stated that he had not seen any other dental practitioners or dental specialists.

Current symptoms and treatment

The claimant stated there was occasional spontaneous “nervy” pain associated with teeth 31 and 41 and that there was no obvious trigger for this discomfort and if and when this occurred, oral analgesia was taken as required. The claimant stated that there was no impairment or loss of taste and his diet had remained the same and was not limited to semi-solid or liquid food. No further treatment was proposed.

Clinical examination

  • The claimant had a Class One occlusion, with midline symmetry
  • The gap between the incisor edges of the upper right and lower right central incisors (11 and 41) were measured as 46mm, 44mm and 43mm respectively
  • Nil restorations were noted.
  • Palpation of the buccal and palatal hard and soft vesting tissues adjacent to teeth 13 to 23 (upper right to upper left canine) elicited no abnormality at assessment.
  • Palpation of the buccal and palatal hard and soft vesting tissues adjacent to teeth 41 to 32 (lower right lateral incisor to lower left lateral incisor) elicited no abnormality at assessment.
  • Teeth 31 and 41 exhibited no signs of sensitivity to percussion at assessment and nil colour change was noted on these teeth.
  • Nil sinus was apparent on either the buccal or palatal soft tissues adjacent to teeth 41 or 31.
  • There was incisor wear and exposure of the dentine, commensurate with the trauma sustained to these teeth and the discing and reshaping of them.
  • Palpation of the facial and temporo-mandibular musculature at assessment elicited no discomfort.
  • Palpation of the left and right temporo-mandibular joints at assessment elicited no discomfort.
  • Nil crepitius, locking or deviation of the mandible was noted on the movements of the mandible.
  • Nil other soft or hard tissue abnormality was noted.

Impairment Evaluation

The Assessor referred to Table 6 “Relationship of Dietary Restrictions to Permanent Impairment” at page 231, chapter 9.3b Mastication and Deglutition of Ear, Nose and Throat Related Structures (AMA4). There was a 0% whole person impairment, as the claimant is able to partake in a full range of foodstuffs without dietary restriction. The claimant stated that there was also no impairment or loss of taste.

Injuries:

Hearing Loss

Tinnitus

Anosmia

The claimant, a woman in her 60s, was a pedestrian hit by a vehicle reversing out of a driveway. The vehicle struck her left side and threw her a distance of three metres. She landed on her right side on the bitumen roadway. Injuries included bruising, swelling and a laceration to the right side of her head. A brief loss of consciousness was reported to ambulance officers and she did not go to hospital. Later the same day, she attended a Medical Centre and had head x-rays which did not reveal any fractures.

After the accident, she complained of a ‘buzzing’ sound and hearing loss in both ears, with the hearing loss being worse in her right ear. A loss of smell and the sensation of having a blocked nose was noted.

The claimant told the Assessor that she had no previous problems with hearing loss and no history of direct ear, skull or blast trauma. The Assessor found that the claimant suffered from bilateral tinnitus (in her case, a hissing sound, which was worse in her right ear). She complained that, during the day the tinnitus makes her nervous but does not affect sleep at night. It was noted, however, that she took sedatives every night.

She was also assessed as having hearing loss which was worse in her right ear. At home, she has a loud ring for the telephone and can hear her doorbell but has difficulty hearing her husband’s conversation and needs the volume on the television set high to hear comfortably.

The claimant reported she cannot smell food, perfume or flowers, but can smell “a little” on her left side. Family members have complained that the food she cooks is “too salty”.

Clinical Examination

Ears

The right and left external auditory canal and tympanic membranes were normal. Weber Test using the 512 Hz tuning fork lateralised to the left. Rinne Test using the 512 Hz tuning-fork was positive bilaterally. Pure-tone audiometry results confirmed the clinical findings.

Nose

Her nasal airway was patent (open and unobstructed) on both sides with minor septal deflection to the right. Normal mucosa was present.

Smell

  • Not able to detect orange, tea tree or vanilla.
  • Able to detect but not identify coconut, strawberry, frangipani, lavender, rose, lime, eucalyptus, lemon and ammonia

Taste

  • Able to detect and identify salt but not sugar.
  • On the Sensonics Smell Identification Test, she fell within the class of anosmia (loss of sense of smell).

The Assessor was satisfied that the claimant had suffered a significant head injury with brief loss of consciousness and that this injury had caused hearing loss, severe post-traumatic tinnitus and damage to the olfactory nerves at the skull base causing anosmia.

Impairment Evaluation:

Hearing Loss and Tinnitus

The Assessor determined that the traumatic hearing loss and post-traumatic tinnitus was permanent and caused by the accident. An impairment of up to 5% can be added to the hearing loss if tinnitus is permanent and severe (clause 6.4 of the 2007 MAA Impairment Assessment Guidelines).

Tinnitus was assessed as severe because it interfered with daily activities and required treatment with sleeping medication. He awarded an additional 2% to the binaural hearing impairment (BHI) for tinnitus. Using the MAA Guidelines (Chapter 6) and the 1988 NAL (National Acoustic Laboratories of Australia) Tables, the Assessor determined that her total binaural hearing impairment was 22.3%.

The Presbycusis correction (for age-related hearing changes) was 0%, so the assessed BHI was unchanged

The addition for severe permanent tinnitus was 2% BHI. Using Table 3, page 228, AMA4 Guides, the resultant BHI of 24.3 % translates to 8% whole person impairment (WPI).

Loss of sense of smell (Anosmia)

The Assessor determined that the anosmia was permanent and caused by the accident. He cited clause 6.15 of the MAA Guidelines that notes the discrepancy in the way the AMA4 treats the assessment of olfaction and taste in the Neurology chapter and the ENT Chapter. The Assessor is advised that they may assign between 1% and 5% WPI for loss of olfaction or taste

The Assessor considered her anosmia was due to the contra-coup injury to the olfactory nerves at the base of the skull. As she could not detect and identify any odorant, the Assessor awarded her 5% impairment for loss of olfaction.

Whole Person Impairment

The impairments for hearing loss (8%) and loss of smell (5%) were combined to give a total WPI of 13%.

Injuries:

Lost Teeth

The claimant was a 16 year old pedestrian who was knocked over by a car that had mounted the footpath. The claimant’s top front two teeth were knocked out and two other top teeth were loosened, one of which was taken out at the hospital after the accident, and the other several months later. The claimant sustained other soft tissue lacerations and minor injuries.

Clinical Examination

The claimant was wearing a plastic denture, but was having root canal therapy before a fixed bridge was to be made to replace the four missing teeth. Despite this impending further treatment, the MAS Assessor considered the injury had stabilised (as the teeth were never going to grow back).

Impairment Evaluation

The AMA4 Guides and the MAA’s Guidelines to evaluating permanent impairment do not prescribe any impairment for missing teeth. However, if the missing teeth impair mastication, breathing or other functions of the mouth, there is an allowance for an impairment percentage.

For example, under Table 6 (p.231), Chapter 9, of the AMA Guides, if the diet is limited to semisolid or soft foods then the whole-person impairment is assessed between 0 and 19% (refer to clause 6.20 MAA Guides).

Another example is Table 7 (p.233), Chapter 9, Speech Impairment Criteria. Should the claimant have difficulty producing speech of intensity or if the claimant has difficulty articulating or if speech is discontinuous, interrupted, hesitant or slow, then the whole person impairment is assessed between 15% and 34% speech impairment. This would then need to be converted to whole person impairment using Table 9, page 234 AMA Guides (see clause 6.23 MAA Guides).

Whole Person Impairment

In this case, the claimant was able to ingest a full range of food and beverages and her diet had not been in any way affected by the loss of teeth or by the denture she was wearing. Her teeth injury did not affect her speech or other functions and she was therefore assessed as having 0% whole person impairment.

Injury:

Bilateral Tinnitus

In 2008, the claimant was a driver when struck by another car on the front right side. The front airbags were deployed. The claimant said they had no bruising or lacerations to their head. The claimant advised they did not hit their head and had no loss of consciousness. At the scene the claimant had hearing loss at first for 1-3 seconds then the hearing improved. The claimant said they had ringing in both ears.

Clinical Examination

The claimant said the tinnitus is about the same since the accident and has an intermittent ringing and humming on both left and right sides, which is very faint, but fluctuates. The claimant said it occurs once a day and lasts for 1/2 - 2 hours. This does not interfere with their day time daily activities, although it can sometimes interfere at night. The claimant said the tinnitus is heard every night and advised it could take between 20-60 minutes to get to sleep due to tinnitus and stress.

On examination the Assessor observed that the nose, ears and throat were all normal and the Weber Test using the 512Hz tuning fork was central and the Rinne Test using the 512Hz tuning fork was positive bilaterally.

The Assessor performed a pure tone audiometry which showed no hearing loss. The Assessor determined that the claimant had suffered tinnitus in their right and left ear.

Impairment Evaluation

The Assessor found in accordance with Chapter 6, clause 6.3-6.10 of the MAA Impairment Guidelines and Chapter 9, Table 3 p228 of the AMA 4 the following:
  • Total Binaural Hearing Impairment (BHI) is 0.0%
  • Presbycusis Correction is 0.0%
  • Addition for Severe Tinnitus is 0.0%
  • The Resultant BHI is 0.0%
  • A Resultant BHI of 0% equals 0% Whole Person Impairment using AMA 4, Chapter 9, Table 3, p228.

The Assessor felt that the claimant’s tinnitus did fall within the class of severe because he has symptoms of interference with concentration and sleep, and he has discussed it with his General Practitioner.

Chapter 6 of the MAA Impairment Guidelines, clause 6.4, states “Tinnitus is only assessable in the presence of hearing loss. An impairment of up to 5% can be added, not combined, to the percentage binaural hearing impairment prior to converting to whole person impairment hearing loss if tinnitus is permanent and severe."

As the claimant has no hearing loss, the criterion for making an addition for severe tinnitus is not met. Accordingly, there is no addition for severe tinnitus, and 0%WPI. The Assessor determined that the total degree of permanent impairment of those injuries caused by the motor accident was 0%.

This matter was subject to a review by a Medical Review Panel. These are the Review Panel’s findings.

Injury:

Facial bruising and nasal swelling

At the time of the accident the claimant, a 45 year old driver, was stationary, waiting to make a right hand turn, when her vehicle was struck on the driver’s door by another vehicle that had suddenly tried to overtake from two cars behind her. She was thrown against the windscreen and driver’s door and sustained lacerations to the bridge of her nose and her forehead, as well as bleeding from her nostrils.

She became aware of the loss of sense of smell and taste a week or so after the accident. The claimant initially thought her sensation of taste and smell would return once the nasal swelling resolved. As it did not resolve, she was referred to several Ear Nose and Throat (ENT) specialists and eventually had a nasal septoplasty and surgery to her sinuses, but this did not result in any return of her sense of smell.

Clinical Findings

The Panel noted the claimant had suffered from hay-fever 25 years previously but had no prior history of ENT injuries. The claimant described being unable to smell any of the odours (good or bad) that others can, and really feels the loss. She was also worried about being unable to detect dangerous gases and fumes.

In regard to her appreciation of taste, the claimant reported she finds all food bland and has lost her enjoyment of food, although she is able to detect between sweet, sour, salty and bitter.

Examination of the ears and throat was unremarkable; there was no nasal deformity or obstructing lesions and the nasal mucosa was consistent with chronic rhinitis (inflammation of the nasal passages).

The Sensonics Smell Identification Test was carried out. This is a very reliable internationally used and recognised objective scratch-and-sniff test for assessment of loss of smell. The claimant scored 12 correct responses out of a possible 40, which equates to a diagnosis of anosmia, total loss of sense of smell.

Impairment Evaluation

The Panel noted there was no imaging to confirm reports of undisplaced nasal fractures around the para-nasal sinuses, but were satisfied that there was evidence of soft tissue injury to her nose to relate this injury to the motor accident. The Panel assessed 0% WPI for air passage defect (Table 5, p.231, AMA 4).

The Panel considered the claimant had provided a compelling account of her impairment, which was consistent with a diagnosis of anosmia. Objective testing confirmed anosmia and so total loss of sense of smell due to the motor accident was rated at the maximum 5% WPI.

In regard to the loss of taste, the Panel noted that alteration of the sense of taste is a common complaint in people who have lost smell, and relates to their description of partial loss of the sense of flavour. The sensation of flavour involves the appreciation of gustatory (from the taste buds in the tongue), olfactory (sense of smell), tactile and thermal sensations. The Panel determined that as a result of her complete loss of sense of smell (the olfactory component of flavour), the claimant has partially lost her appreciation of taste, however her basic ability to detect the taste modalities of salt, sour, sweet and bitter remains unchanged. Thus from an anatomical point of view she has not lost her sense of taste, however she has lost part of the subjective enjoyment of what she perceives or understands to be her sense of taste, but this loss is inherent, and so not separate, to the loss of the sense of smell. The gustatory, thermal and tactile components of the sense of flavour remain intact. The Panel found therefore that the motor accident was not a cause of her (subjective) loss of sense of taste.

The Panel determined a total of 5% WPI for ENT injuries.

This matter was subject to a review by a Medical Review Panel. These are the Review Panel’s findings.

Injuries:

Vertigo

Cervical Spine – musculoligamentous injury

The 68 year-old claimant confirmed his involvement in a motor accident when he was struck by a reversing vehicle. He fell to the concrete striking the left side of the forehead with resultant bruising. At hospital, he complained of dizziness. Ever since the accident, he has experienced dizziness. Through the interpreter, it became clear that he experiences a constant feeling of imbalance or disequilibrium with superimposed “strong” attacks of “spinning”. The problem is not resolving over time.

Clinical Findings

In relation to the ENT component of the examination, there was scarring of the left tympanic membrane consistent with old healed central perforation. The right tympanic membrane was normal.

The fistula test was negative bilaterally. There was no spontaneous or gaze evoked nystagmus. Examination of the nose revealed old traumatic deviation of the nasal septum. Throat examination was unremarkable. Tonsillectomy was noted.

The claimant’s gait was notably unsteady. He could not perform a tandem gait due to lack of balance. Significant unsteadiness was noted on the Romberg’s test. Unterberger’s test could not be performed due to poor balance.

The Hallpike manoeuvre was positive on left head turn with evocation of rotary nystagmus associated with acute vertigo. There was a definite fear/startle reaction with the left-sided Hallpike manoeuvre. On the other hand, the Hallpike was clearly negative on the right. There was no nystagmus corresponding with the claimant’s comment that turning his head to the right was “not too bad”.

Prior to the neck and shoulder examination, he was asked to remove his shirt, vest and singlet. His wife went to assist. However, it was explained that we wanted to see what he could do for himself. During this “informal” component of the examination, he was observed twice to elevate his left arm to approximately 110 degrees without discernible signs of discomfort. During the interview, he was also observed reaching around to his back with the left arm to indicate a site of pain overlying the left rib cage.

On examination of the neck, his posture was somewhat protracted. Active flexion was 40 degrees, extension 40 degrees, left-sided rotation 15 degrees, right sided rotation 30 degrees, left lateral tilt 10 degrees and right lateral tilt 20 degrees.

On palpation of the neck, he indicated tenderness over the mid cervical spine and base of neck. He also described tenderness over the left sided paravertebral and strap muscles. There was lesser tenderness over the left trapezius. Tenderness was noted over the left lateral pillar but not the right. There was no associated muscle spasm or guarding.

There was bilateral reduction of muscle bulk (spinati) around the shoulders more marked on the left. The right arm measured 26 cm in girth and the left 25.5 cm. The right forearm measured 21 cm and the left 20 cm. An old surgical scar was noted over the volar left forearm, apparently a site of vein harvest during his CABG’s.

Neurological examination of the upper limbs in respect of tone, strength, and reflexes was normal. However, strength testing around the left shoulder was not performed due to associated pain with improbability of obtaining useful information. There was generalized reduction in pinprick sensation over the entire left arm, including all of the fingers. In this context, there was also reduced pinprick sensation noted over the left side of the face in the V1 and V2 distribution.

Neurological examination of the lower limbs was normal in respect of tone, strength (excepting left sided hip flexors, the hip being a site of discomfort) and reflexes. A global sensory deficit was noted to pinprick over the left leg. There was no visible wasting of the lower limbs. Great toe proprioception was normal bilaterally. A positive Babinski response was observed on the left whereas there was a normal flexor response on the right.

Active range of motion of the shoulders is shown in the following table:

  Right Left
Abduction 130 60
Adduction 50 30
Flexion 160 50
Extension 60 40
Internal rotation 50 60
External rotation 80 40

There was significant pain behavior observed whilst he was being asked to move his left shoulder. There was frequent grimacing and pain complaints. He also rubbed the arm on several occasions.

There was marked tenderness over the anterior joint line and subacromial region of the left shoulder. Impingement tests were not performed because he could not abduct the left arm to a level at which impingement would occur.

There was a clear discrepancy in the observed range of motion of left shoulder movement between the formal and informal components of the examination. Informally, the movement was considerably greater.

Panel Deliberations

The Panel concluded there is 5% WPI of the cervical spine based on the demonstration of non-uniform loss of range of motion or dysmetria (L<R motion). There is no objective evidence of pre-existing impairment of the cervical spine. Specifically, the claimant was working until a few months before the accident, having then retired on medical (cardiac) grounds. Accordingly the presence of any preexisting impairment can be ignored (paragraph 1.33 page 6 of the MAA Guidelines). The Panel has not applied any deduction from the present 5% WPI of the cervical spine.

The Panel concluded that the claimant suffers from benign positional vertigo (BPPV). He gives a typical history of episodic vertigo worse with left head turn. The Hallpike manoeuvre on left head turn was also positive, constituting objective evidence of vestibular impairment. Of note, other medical assessors from time to time have also noted a positive Hallpike test. In this case, the criteria are met for Class 2 Vestibular impairment (pages 228-9 AMA4). The Panel concluded that 9% WPI for vestibular impairment was appropriate based on a typical history of BPPV, his ADL limitations due to vertigo and the presence of a positive left-sided Hallpike manoeuvre.

There is restriction of ADL’s including driving due to intermittent vertigo with left head turn. His current restrictions in ADL’s are related to the combined effects of pain and vertigo which are difficult to distinguish from one another, each of the pain and vertigo making a significant contribution to his lack of independence in ADL’s. However, the Panel concluded that his ADL limitations due to vertigo do not warrant categorization as Class 3. There is no objective evidence of any pre-existing vestibular condition.

Panel Decision

The degree of whole person permanent impairment of the injuries caused by the accident was calculated as follows:
Following combination of 9% WPI for vertigo and 5% WPI for the cervical spine, there is 14% WPI.
  Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) Permanent (YES/NO) Current %WPI* %WPI* from pre-existing OR subsequent causes %WPI* due to motor accident
1. Cervical spine Table 4.1 page 22 MAA Guides Yes 5% Nil 5%
2. Vertigo Pages 228-9 AMA4, paragraph 6.11 page 36 MAA Guides Yes 9% Nil 9%

* %WPI = percentage whole person impairment

Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident

The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 14%. Therefore the total whole person impairment is greater than 10%.

Any queries in respect of the methodology used in assessing permanent impairment may be directed to the WPI e-mail enquiry service at wpienquiry@maa.nsw.gov.au. This service is operated by the Injury Management Branch of the MAA who are responsible for the content and publication of the MAA Permanent Impairment Guidelines.