APPENDICES TO PART ONE

SCALE FOR ASSESSING THE DEGREE OF DISABILITY OF VICTIMS OF MEDICAL ACCIDENTS, IATROGENIC CONDITIONS OR NOSOCOMIAL INFECTIONS REFERRED TO IN ARTICLE D. 1142-2

IV. - STOMATOLOGY

A. - Loss of teeth

These rates will be reduced by half in the case of replacement by a mobile prosthesis and by two-thirds in the case of replacement by a fixed prosthesis.

In the event of complete loss of a tooth replaced by an implant-supported prosthesis: 0%.

Pulpal mortification of a tooth: 0.50%.

B. - Mandibular dysfunctions

Permanent limitation of mouth opening (measured between the free edge of the central incisors) :

Temporomandibular joint disorders :

Mild form :

C. - Post-traumatic dental articulation disorders

(in proportion to the loss of masticatory capacity): 2 to 10%.

D. - Sensory neurological disorders

E. - Motor neurological damage (see also ENT section)

Facial paralysis (not including ophthalmological complications) :

F. - Bucco-sinus or bucco-nasal communication

Depending on the site, surface and functional discomfort, including the consequences on swallowing and the impact on the quality of phonation: 2 to 15%.

G. - Salivary pathology

V. - OTOLARYNGOLOGY

I. - Hearing and otology

A. - Hearing loss

Hearing loss is determined on the basis of a thorough and meticulous clinical assessment and a paraclinical assessment, which must include at least a complete impedancemetry (tympanometry with a search for the stapedial reflex threshold), an initial subjective tone audiometry and a voice audiometry.

If necessary :

- the quality of the auditory field above 8,000 Hz will be assessed by high-frequency audiometry;

- the reality of the deficit may be confirmed by objective tests (acoustic otoemissions, early auditory evoked potentials).

Post-traumatic hypoacusis does not progress beyond 12 months.

Complete bilateral hearing loss: 60%.

Partial hearing loss.

The assessment should be carried out in two stages:

a) Assessment of the average hearing loss (AHL) in relation to the air conduction tonal deficit measured in decibels at 500, 1,000, 2,000 and 4,000 Hz by assigning weighting coefficients of 2, 4, 3 and 1 respectively. The sum is divided by 10. Please refer to the double entry table below to assess the rates:

These are indicative rates which must be correlated with any previous condition and the physiological ageing of the hearing.

b) Comparison of this gross rate with the results of a voice audiometry to assess any auditory distortions (recruitment in particular) which aggravate functional discomfort.

The following table suggests the rates of increase which may be discussed in relation to the results of the preliminary pure-tone audiometry:

If hearing aids have been prescribed, the expert must describe the functional improvement obtained. This usually reduces the degree of disability by at least 25%.

B. - Tympanic lesions

An isolated dry perforation does not justify any specific PPI apart from that linked to the hearing loss.

In the case of otorrhea, a rate of 2 to 4% may be retained in addition to that caused by hearing loss.

C. - Tinnitus and painful hyperacusis

The intensity felt does not depend on the extent of the hearing loss.

There is no test to objectivise this disorder. The expert may, however, use subjective tinnitus measurement and recognised tests: DET questionnaire (measure of psychological distress), SEV questionnaire (subjective SEVérité scale).

In most cases, a cerebral habituation phenomenon occurs within 12 to 18 months. We can then propose a rate of up to 3% (to which must be added any rate adopted for hearing loss).

When the psycho-affective repercussions are severe, the disability rate must be determined within a multidisciplinary framework.

II. - Balance disorders

Balance is a multi-modal function that involves the vestibular, visual and proprioceptive systems. The aetiology of the disorder cannot therefore be stated unequivocally from the outset.

Balance disorders are often among the complaints expressed after cranial and/or cervical trauma.

The expert must carry out a methodical interview and a full clinical examination, looking in particular for iatrogenic orthostatic hypotension.

Videonystagmography is the complementary examination of choice. More recently introduced, the Equitest provides a global approach to a subject's balancing strategy, and can also be used to detect the "anorganic" component of a balance disorder.

The investigation of balance is inseparable from that of hearing.

In some cases, a neurological or ophthalmological opinion may be necessary.

The key to assessing functional discomfort is not the identification of a lesion, but the quality of the compensation strategy developed by the patient.

A. - Benign paroxysmal positional vertigo (BPPV)

Cure can be obtained by Alain Sémont's liberatory manoeuvre (although 5 to 10% of recurrences occur in the following year).

Some sensation of "floating" or "instability" may persist.

Depending on the extent of clinical signs and paraclinical abnormalities: up to 4%.

B. - Unilateral peripheral vestibular disease

The rate of PPI cannot depend solely on the extent of the deficit, apparently quantified by a single caloric test:

areflexia, simple hyporeflectivity or ductal irritative syndrome. It is not the lesion itself that needs to be assessed, but its functional impact.

Using rigorous complementary investigations, the expert must assess the level and quality of central compensation for vestibular asymmetry and the reliability of the new balancing strategy adopted by the patient.

Depending on the results of these investigations: 3 to 8%.

C. - Bilateral peripheral destructive vestibular disease

This is very rarely post-traumatic. It most often occurs following the use of ototoxic drugs.

The subject is left with only vision and proprioception to manage balance.

The result of the new strategies used by the patient will be assessed by the quality of the optokinetic nystagmus and by the Equitest.

Depending on the results of these explorations: 10 to 20%.

D. - Otolith deficiency

When confirmed by videonystagmography and otolith evoked potentials: 3 to 5%.

E. - Central vestibular syndrome

This diagnosis must be confirmed in a multidisciplinary setting: oto-neuro-ophthalmology.

No specific ENT rate can be offered.

F. - Further investigations

When all further investigations are negative, the ENT expert must reject any specific PPI rate. Instability complaints should be considered in the context of a possible post-concussion syndrome.

III. - Facial motor impairment

A. - Facial paralysis

The expert may use House and Brackmann's 6-grade classification to assess the degree of damage:

- unilateral; depending on its degree: 5 to 15% ;

- bilateral (exceptional); depending on its degree: 15 to 25%.

Any ophthalmological complications should also be assessed.

Cosmetic damage will be assessed independently.

B. - Facial haemispasm

Not amenable to treatment; depending on the extent of the contracture and the frequency of spastic attacks: up to 10%.

IV. - Phonation disorders

Phonation involves several effectors: pulmonary bellows, glottic vibrator, supralaryngeal resonators.

Assessment must be global.

Any associated problems with swallowing and respiratory function will be assessed separately.

Complete aphonia: 25%.

Isolated partial dysphonia: up to 10%.

V. - Nasal ventilation disorders

Assessment will be based essentially on questioning and clinical examination, looking for any previous condition.

Examination with a Glaetzel mirror provides only very fragmentary and incomplete information. Only rhinomanometry can provide a more accurate assessment.

A. - Respiratory discomfort

Permanent unilateral (including possible repercussions on the sense of smell) depending on the extent of nocturnal repercussions: up to 3%.

Permanent bilateral according to the same criteria: up to 6%.

B. - Septal perforation

This may cause functional discomfort independent of respiratory problems.

If persistent: up to 3%.

C. - Sinusitis

Post-traumatic sinusitis is exceptional.

Depending on whether it is uni- or bilateral: up to 8%.

VI. - Olfaction disorders

Exploration of this sense currently involves only subjective odour perception and recognition tests.

These tests must be carried out on each nasal cavity.

A deficit of this type may or may not affect the subject's eating behaviour. The loss of smell itself is sometimes associated with odour perceptions without external stimuli (parosmia), which are generally unpleasant (cacosmia).

Total anosmia (loss of alert and pleasure functions).

Depending on whether or not there is an eating disorder: 5 to 8%.

Hyposmia, depending on its intensity and whether it is unilateral or bilateral: up to 3%.

The existence of parosmia may justify an additional specific rate of 2%.

The impact on taste is not added to the above rates.