The Boston Center for Refugee Health

1. Head and Neck Sequelae of Torture Christina Di Loreto1; Shaulnie Mohan1; Sondra Crosby, MD2; Jeffrey Spiegel, MD, FACS3 1Boston University School of Medicine, 2Department of Medicine-Boston Center for Refugee Health and Human Rights3Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, Boston, Massachusetts ABSTRACT RESULTS INTRODUCTION DISCUSSION The United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment defines torture as " any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession … and when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.”1 • Torture is a widespread assault of a person's mind, body, and sense of security. • Survivors of torture are rarely forthcoming regarding their history due to feelings of shame and fear. • Physical evidence of trauma may be limited or obvious depending on the methods of torture utilized. • Cautiously approaching a patient and developing rapport is important. • There are refugee health centers that provide comprehensive medical care, mental health care, and ancillary services to survivors of torture. Our goal for this study was to increase awareness and emphasize the importance of establishing rapport, collecting a social history, and determining the method of torture in order to diagnose/treat survivors of head and neck torture. • Trauma to the head is common in survivors of torture, with Rasmussen et al reporting an incidence of 73% among a cohort of survivors.2,3 Survivors may present with obvious injuries such as facial trauma, or with less obvious symptoms such as vertigo, hearing loss, or sinus pain.4 Sinusitis is reported in a survivor subjected to torture methods that utilize water. 5 • Torture may be difficult to identify in the clinical setting, as survivors may be reluctant to offer their histories, and clinicians may not inquire about torture history. • It is important to consider a patient's country of origin, immigration status (refugee or asylum seeker) and flight history when evaluating otolaryngological symptoms. Medical documentation of torture may be required to support an asylum application. Educational Objective: At the conclusion, participants should be able to recognize manifestations of torture of the head and neck. Objectives: Amnesty International reported that torture occurred in 102 countries in 2007, and many torture survivors seek refuge in the United States. Physicians are often not trained to recognize torture, and survivors are often reluctant to discuss their experiences. Our aim is to review common methods and manifestations of head and neck torture in order to provide otolaryngologists and referring physicians with an improved framework for recognizing and treating torture to the head and neck. Study Design: Retrospective chart review of patients who have experienced head and neck torture among a cohort of refugee, asylee, and asylum seekers referred between January 2002 and January 2008. Methods: A case series of torture survivors (using UN definitions of torture) is presented and includes demographics, torture history including political context, medical, and psychiatric history, physical exam, radiologic studies, and diagnosis. Results: Patients who presented with a history significant for head and neck torture were reviewed. Cases of head and neck torture included facial trauma, severed ear, and vestibular damage. Conclusions: Recognition and treatment of the manifestation of head and neck torture are important when treating asylum seeking and refugee populations, including appropriate referrals to specialized centers for survivors of torture. • Case 1 • 35-year-old man from the Middle East who reported that he was detained and beaten in a prison camp because of his Christian religious affiliation. • He presented with complaints of episodic dizziness, difficulty with ambulation, and otalgia. • The patient initially did not inform his physician of his symptoms due to associated feelings of shame. • Physical exam: slower, broad- based gait with closed eyes and an abnormal Romberg tandem. Dix-Hallpike exam revealed right side down horizontal nystagmus without latency. • Vestibular and audiometric testing revealed left sensorineural hearing loss with otherwise negative electrocochleography. • The suspected diagnosis was post-traumatic disequilibrium secondary to left oval window fistula. He was taken to the operating room for exploratory tympanotomy that revealed pooling of fluid around the oval window, confirming the diagnosis. Pretragal tissue was used to repair the defect. • Case 2 • 59-year-old woman who was a member of an opposition political party in Central Africa. She was captured and beaten unconscious on two separate occasions in 1998 and 2002. • She presented with significant facial scarring and complaints of excessive tearing, rhinorrhea, and a collapsed left nostril. • Physical exam: Scarring of the left eyelid with retraction and mechanical lagophthalmous, multiples scars with right medial canthus splitting, fractures of the left orbital rim, & abnormal occlusion. Nasal exam revealed nasal dorsum flattening, near total stenosis of the left nasal vestibule, and nasolabial fold scarring. Neurological exam revealed decreased mobility of the left frontalis and paresthesias over V1 and V2 distribution. • The patient was offered surgical repair for of the nasal vestibular stenosis and scar revision of lower eyelid and right alar area. After discussing her options, the patient chose to defer treatment until the resolution of her legal issues and has not yet returned to clinic. • Case 3 • 49-year-old man who was a member of an opposition political party in Eastern Africa. He was captured and tortured on several occasions, sustaining multiple injuries including avulsion of his auricle with a sharp object. Initially, he had reported that his injuries were incurred in a motor vehicle accident. • Physical exam: Severed left ear with approximately two-thirds of the superior helix and triangular fossa absent. The superior aspect of his external auditory canal was stenotic. • He underwent auricular reconstruction with a Medpore framework, temporalis fascia flaps, and split thickness skin graft from the lower extremity. CONCLUSIONS • This report serves to increase the awareness of survivors of torture in clinical practice, and to advance the clinical understanding of the otolaryngological sequelae of torture. • As awareness increases, we hope to define the most common forms of otolaryngologic torture, acute/ long term sequelae, and the prevalence of these injuries. • In the future, we may be able to improve the identification and access to care offered to survivors of torture from around the world. METHODS AND MATERIALS We reviewed the medical records of patients referred to the Department of Otolaryngology from the Boston Center for Refugee Health and Human Rights from January 2002 through January 2008. Eligibility criteria included women and men greater than or equal to 18 years of age who were survivors of torture by the UN definition, and who had suffered otolaryngologic injury as a result of the torture in their home countries. Of the six cases reviewed, three cases were identified where the head and neck pathology was related to their reported experiences and was consistent with the UN criteria. The following cases describe the symptoms, physical exam, diagnosis, and treatment of these patients. The Institutional Review Board at Boston Medical Center approved the study. REFERENCES The Boston Center for Refugee Health and Human Rights (BCRHHR) is a member of the National Consortium of Torture Treatment Programs and operates as an interdisciplinary collaboration providing comprehensive medical, psychiatric, and dental care coordinated with legal and social services to individuals from 67 countries. The center refers patients with special needs to tertiary providers within Boston Medical Center. • 1. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment Punishment, Office of the High Commission for Human Rights, United Nations Web site. [June 2, 2008]. Available at: http://www.ohchr.org/english/countries/ratification/9.htm. • 2. Iacopino V, Allden K, Keller A. Editors. Examining Asylum Seekers: A Health Professional’s Guide to Medical and Psychological Evaluations of Torture. Boston: Physicians for Human Rights, 2001. • 3. Rasmussen, O. V. (1990). Medical aspects of torture. Danish Medical Bulletin, 37 Suppl 1, 1-88. • 4. Moreno, A., & Grodin, M. A. (2002). Torture and its neurological sequelae. Spinal Cord: The Official Journal of the International Medical Society of Paraplegia, 40(5), 213-23. doi: 10.1038/sj.sc.3101284.  • 5. Moisander, P. A., & Edston, E. (2003). Torture and its sequel--a comparison between victims from six countries. Forensic Science International, 137(2-3), 133-40.  • 6. Vogel, H., Schmitz-Engels, F., & Grillo, C. (2007). Radiology of torture. European Journal of Radiology, 63(2), 187-204. doi: 10.1016/j.ejrad.2007.03.036.  • 7. “Physical Health: Types of Torture.” Boston Center for Refugee Health and Human Rights. <http://www.bcrhhr.org/pro/course/physical/Types.html> .Accessed 16 Dec 2008. Name: Christina Di Loreto Organization: Boston University School of Medicine Email: cmd@bu.edu